PHN-8714 PHYSICIAN EDUCATION IN THIED WORLD COUNTRIES (With special reference to sub-Saharan Afric-' by Professor Sir Kenneth Stuart June 1987 Population, Health and Nutrition Department World Bank The World Bank does not accept responsibility for the views expressed herein which are those of the author(s) and should not be attributed to the World Bank or to its affiliated organizations. The findings, interpretations, and conclusions are the results of research supported by the Bank; they do not necessarily represent official policy of the Bank. The designations employed, the presentation of material, and any maps used in this document are solely for the convenience of the reader and do not imply the expression of any opinion whatsoever on the part of the World Bank or its affiliates concerning the legal status of any country, territory, city area, or of its authorities, or concerning the deliminations of its boundaries, or national affiliation. FILE COPY PHN Technical Note 87-14 PHYSICIAN EDUCATION IN THIRD WORLD COUNTRIES (with,special reference to sub-Saharan Africa) ABSTRACT The report reviews reasons for current inadequacies in third world physician education. These include the global economic recession; fall-off of recruitment of overseas workers; inappropriate western educational models and curricula; inadequate educational and research emphases on local health issues; resistance to curricular change and a relative lack of emphasis on the promotive and preventive aspects of health; poor cooperation between national medical schools and ministries of health; an imbalance in the mix, training and utilization of health team professionals; and aspects of the working environment in third world countries. Examples are given of countries where effective models for meeting some of these inadequacies had been introduced. Recommendations are made for (i) the development of "teaching community" units comparable to "teaching hospital" units; (ii) strengthening of capabilities for joint medical school/health ministry interaction; (iii) integration of the entire medical faculty and of the university as a whole in community health development initiatives; (iv) closer attention to the management and economics of health team development; (v) additional emphasis on .continuing education and self-directed learning; and (vi) student selection and qualifying examinations. Guidelines and conditions for international agency support, particularly from the World Bank, were also proposed. The appendix sets out examples of relevant physician training programmes from Central and East Africa - Zimbabwe, Tanzania, Zambia, Kenya, Uganda, Malawi, Ethiopia, Sudan, Equatoria, Mozambique, Niger, Cameroon; from West Africa - Nigeria, Ghana; from eastern European States - Russia, Yugoslavia; from other countries - Papua New Guinea, Fiji, Malaysia, Thailand, Cuba. Prepared by: Professor Sir Kenneth Stuart Consultant to the World Bank June 1987 -＿心 CONTENTS SUMMARY Page No. 1. Intent Conclusions Recommendations 6 INTRODUCTION 1. Some general issues 11 2. Educational cul-de-sacs 13 3. Institutional models 19 SOME CHARACTERISTIC AFRICAN PROBLEMS 1. Inherited curricula 20 2. Difficulties with community programmes 21 3. Resistance to curricular change 22 4. Staffing difficulties 23 5. The elusive pursuit of relevance 24 ASSESSMENT OF THIRD WORLD NEEDS 25 1. Coordination between medical schools and 27 ministries of health 2. Appropriateness of educational programmes 31 for national health needs 3. A balanced hospital/community health care curriculum 32 i) possible negative effects of conventional 32 university departments of community medicine ii) the concept of a "Teaching Community Unit" 34 iii) An integrated community/hospital orientation for 38 all members of the medical faculty 4. An appropriate health team 40 i) selection and training 40 ii) inter-professional training prog.rammes 42 iii) administration 43 iv) the economics of healt, team development 44 5. An adequate educational focus on preventive medicine 46 6. The strengthening of capabilities for continuing education and self-directed learning 48 SOME OTHER INFLUENCES ON PHYSICIAN EDUCATION AND UTILIZATION 1. Within medical schools 50 i) selection of students 50 ii) medical qualifying examination 52 iii) other university departments 53 2. Outside medical schools 54 i) community values and development 54 ii) the working environment 55 INTERNATIONAL AGENCY SUPPORT 1. Areas of greatest need 57 2. Guidelines and conditions for international 58 agency support OPTIONS FOR THE BANK 1. Introduction 61 2. Constraints 62 3. Priorities for support 63 4. Mechanisms for support 63 i) direct ii) through recognised international health agencies like WHO iii) A corps of international experts (via i or ii above) 5. Malawi, a credible recipient for initial support 64 6. Proposals for funding collaborative review and 65 revision of health care and education systems REFERENCES 66 APPENDIX SOME RELEVANT PHYSICIAN TRAINING PROGRAMMES Central and East African Commonwealth countries 1 Zimbabwe, 1 Tanzania, 2 Zambia, 3 Kenya, Uganda, 4 Malawi 5 East Africa - Non-Commonwealth 7 Ethiopia, 7 Sudan, Equatoria, 8 Mozambique, 9 Niger, Cameroon 10 West Africa (Commonwealth) 12 Nigeria, 12 Ghana 14 EASTERN EUROPEAN STATES 15 Russia, 15 Yugoslavia 18 OTHER COUNTRIES 19 Papua New Guinea 19 Fiji School of Medicine 21 Malaysia 24 Thailand 26 Cuba 27 REFERENCES 30 卜 , 、 翻 、 ,. 6 SUMMARY Intent Conclusions - Recommendations The Report presents a review of the many factors which have contributed to the present unsatisfactory state of health care in the developing world. uch of the information it contains has been gathered from country visits, from exchange of information with colleagues and from experi ences gained over a number of years. It also draws on published reports which were themselves produced over a span of years. In essence the development of effective health care has been constrained by the imposition of a disease oriented model of health which was developed in and for industrialised countries some one hundred years ago. The concentration on high technology, centred on complex and expensive hospitals, makes the viability of this model dependent on the availability of sophisticated, country-wide infrastructures and substantial financial resources which are not available in all parts of the developing world. In seeking to safeguard "standards", developing countries have often followed too closely the curricular models inherited from other countries - and sometimes long after some of these 7 countries have themselves made innovative modifications in their own programmes. The result has been a failure to adapt their curricula to meet their own health needs; to modify them in the light of new or emerging health hazards; to relate what the student is taught to what his tasks are likely to be after graduation; to train him to identify and tackle community health problems in addition to hospital diseases; to develop a capacity for sustaining his own self-education; to establish linkages between health educators and those responsible for the delivery of health care. The development of affordable and effective health care systems, that are suited to the specific needs, strengths and constraints of a developing country, requires sensitive and creative collaboration between politicians, public servants and health care professionals. The recruitment or selection, the education and training, and the subsequent maintenance of health care personnel will depend entirely on the prior determination of the overall health care system, the tasks to be performed within the system and the types of personnel who are best suited to undertake specific tasks most acceptably, effectively and efficiently. These analyses lead on to planning ways and means; that is, how and with what resources the education and deployment of health professionals should be effected. 8 The present report describes some of the many educational systems and institutions that have mounted innovative and successful programmes to deal with their health care and manpower problems. These programmes seem to have certain common features, the most important of which appear to be: (i) the formulation of clear-cut national educational and health care policies; (ii) the introduction of mechanisms for achieving joint action between governments and educational institutions; (iii) the training and utilization of appropriate cadres of health professionals. There are clearly many difficulties to be overcome in the large scale application of such programmes. The reality, however, is that models for them exist and are working. The report stresses the need for the provision of both the national and international leadership which will encourage and enable ministries and medical schools, for example, to come together and re-examine the fundamental principles on which the health care of their population should be based. The result should be a plan for a tailor-made, affordable system of health care and the tactical steps to implement it. 9 Further international support will be essential to ensure that these tactics, including suitable education, can be translated into action. Thus, for example, suitable expert teachers from other countries cannot be recruited until it has become clear what roles they are to play and what tasks they are to undertake. It will then be equally important to ensure that the financial, social and career obligations of such teachers are properly safeguarded. One of the proposals for the Bank is that a steering committee of international experts be established which would assist it in the development of guidelines and conditions for financial support and how such support would be administered and evaluated. Existing international health agencies and institutions may be able to provide the necessary administrative facilities as an appropriate channel between the Bank and recipient countries. There are difficulties in arriving at country-specific recommendations for Bank financed support. For a number of reasons, however, Malawi, East Africa, might be an appropriate country in which a model might be introduced for Bank assistance towards the resolution of third world physician problems: 1. a new medical school is being planned for Malawi which would make it possible for most of the educational initiatives outlined in this paper to be planned and introduced at its inception; 10 2. the country is neither too large nor too small - some 6.5 million - a size which would facilitate the introduction, monitoring and evaluation of the programmes undertaken; 3. it is politically stable and has a record of progressive education and of sound fiscal management. In addition it is suggested that the Bank might invite certain sub-Saharan countries to submit proposals for financial support for the review and revision of their health care and education systems through close collaboration between ministries and educational institutions. 令 - b k ,. INTRODUCTION Some general issues As long ago as 1976, Dr H. Mahler, Director General of the World Health Organization, warned "...if the developing countries continued to base their health manpower development on the professional, medical and nursing patterns of the affluent world, no attempt at social planning will avail. The social revolution in public health will remain a paper revolution". 1 Although it achieved dramatic global publicity, and in spite of .the ground swell of international resolve and activitiy to which it has undoubtedly given rise, the Declaration of Alma-Ata (1978) has remained not much more than an optimistic statement of purpose by the world community. A real breakthrough has yet to be achieved; the revolution in public health is still largely a 11paper revolution". A widening world economic recession, with the all pervasive global poverty to which it has given rise, is undoubtedly an important reason for the slow pace of progress. But it is by no means the only one, and is probably not the most critical. If the funds of most countries of the developing world had been doubled in the past decade, it is still unlikely that commensurate progress would have been made in the health field in the absence of revised national concepts about the teaching and practice of medicine which are even more urgently needed than additional financial resources. 12 An important adverse effect of the global economic crisis on third world educational capabilities has been its reduction of the recruitment of skilled workers from the developed world. The last twenty years have witnessed a rapid fall in the numbers of overseas researchers and teachers working in third world countries.2 Through formal and on-the-job training such personnel have in the past played pivocal roles in the development of medical education, service and research in such countries - in Nigeria, Kenya, Uganda, the Caribbean and others. Local salaries, however, no longer attract overseas workers and, even if they did, falling career prospects when they return home is a substantial deterrent. A North-South transfer of medical skills and resources is now even more needed by developing countries. Special measures are required if this source of assistance is to be made available to them again - with safeguards, of course, to ensure appropriate commitment of the individuals recruited and the relevance of the skills they transfer. As a reflection of the importance they attach to this issue, Commonwealth Health Ministers made it one of the central agenda items at their triennial meeting held, in the Bahamas in October 1986, and approved the setting up of a steering group of Commonwealth officials to advise them and Heads of Commonwealth 13 Governments on the requisite measures for tackling it.3 Commonwealth Heads of Governments themselves, recognizing that such interchange will not be achieved by any groups of professionals, not only doctors, in the absence of wider mobility for all students, have already set up a permanent Committee of Commonwealth Officials to advise on how opportunities for such mobility might be expanded.4 Educational cul-de-sacs In some of the Western models of health sciences education, which many third world medical schools have uncritically followed, the goal of biomedical excellence takes priority over relevance to national health problems; graduates trained in the relatively inflexible academic orthodoxies that commonly characterise such models are less flexible and adaptable to the needs of their own countries than they would have been had their training been more directly related to them. It is also an ironic commentary that these models continue to be followed long after more progressive Western institutions have made bold revisions in their own systems of medical education. The McMaster5 curriculum with its problem oriented approach, the recently introduced new curriculum at Edinburgh6 with its emphasis on helping students to take 7 responsibility for their own education, the Newcastle University modifications in New South Wales with emphasis on small group teaching, the practice of medicine in the community and the more recent "new pathway" Harvard Medical School curriculum8 14 experiment with its emphasis on active, rather than passive roles of learning for the student, on problem solving and independent study, are examples of such initiatives in developed countries. As a product of a major medical centre whose special emphasis is commonly on tertiary care and as an apostle of teachers, most of whom are specialty oriented, the third world graduate often places disproportionately greater emphasis on the biomedical and curative aspects of disease than on the behavioural and socio- cultural factors that are frequently the true determinants for loss or maintenance of health. -This does not deny the importance of curative health services. Indeed, it is on their curative health services that much of the credibility of national health care systems depends. Nor is there anything pejorative in the comparison between the bio- medical and sociocultural aspects of health. Both are essential. A sound understanding of the biomedical aspects of medicine is a basic scientific requirement that is essential for good patient care. An equally essential basic scientific requirement, however, for the protection and maintenance of the health of communities is sound knowledge of the natural history of disease, its social and cultural influences, its epidemiology, the value of controlled trials, and the preventive and the promotive aspects of health. 15 In many countries of the developing world chronic disorders like hypertension, diabetes and obesity, the consequences of smoking, alcoholism and other disorders dependent on changes in lifestyle have now become major health hazards. It is an ironic commentary on "progress" in these countries that the increase in the prevalence of disorders which are characteristically associated with affluence is often greater than the fall of diseases like tuberculosis, malaria, hookworm, diarrhoea, malnutrition and respiratory infections that stem from poverty and under- development. In their approach to these lifestyle disorders third world physicians, again following the patterns set by their developed country colleagues, to which they have been conditioned by their training, place greater emphasis on measurements of their laboratory and biomedical characteristics than on their behavioural, sociocultural and epidemiological aspects. The latter would logically be expected to be more rewarding in the search for methods for their prevention and control. In this context it is of interest that students in the conventional course at the Harvard Medical School take only 6 of their 134 required credits from courses listed under Behavioural Sciences, Social Science or Preventive Medicine.9 The consequences of this "follow-my-leader" trend by the third world physician are equally seen, but are even more critical, where the disorders that are characteristic of his own country 16 are concerned - the infectious and communicable diseases. It is almost certainly because these receive no special priority in the curricula of the medical schools of the developed world that the curricula of third world medical schools so commonly fail to reflect their local importance. This is the reason why so much of the responsibility for even basic teaching about these disorders, and more so for research, still falls to overseas centres. Even for such routine but critical local public health issues as diarrhoea control, nutrition, vaccination and the like, the stimulus for national action is commonly external rather than internal. A further indictment of current third world physician education rests not only in its inability to motivate graduates towards the community aspects of health but also in its failure to adapt its training methods to the utilization of available community resources. It is the highly developed and sophisticated social structures that exist in many third world countries - the extended family, the role of women, special interest groups, tribal bonds, village links - that have made the use of non-qualified assistants and village workers as feasible and practicable as it has become. The potential of these structures for linking medical schools and ministries of health with effective community health programmes is substantial. The curricula of only a few third world medical schools (Papua New Guinea,10 the Fiji School of Medicine,11 the Institute of Health Sciences in the Phillipinesl2 are examples) reflect their 17 importance or seek to capitalise on them, despite the efforts of the World Health Organization in supporting the Network of Community-oriented Educational Institutions for Health Sciences. 13 When the medical school of the University of the West Indies was first opened in 1946 the degrees it gave were those of the University of London under whose aegis it was established. The medical school of the University of Ibadan in Nigeria was established around the same time and under the same arrangements. The Medical School of the University of Zimbabwe had Birmingham as its foster-parent. The academic value of these arrangements has never been in question. It was not surprising, however, that the early medical graduates of these Universities were better equipped to work in London or New York than in their own countries. Despite the "tinkering" with the curriculum that has occurred in recent years, this basic shortcoming persists in the curricula of most medical schools that have shared this pattern of development. They continue to reflect their initial emphasis which was to qualify students to meet "international" standards rather than to identify and deal with local health priorities. 18 Although having an academic medical school foster-parent may be initially beneficial it has some in-built shortcomings. If continued too long, as possibly occurred in the Caribbean, it tends to delay the introduction of imaginative curricular reforms and makes it more difficult for the new medical school to diversify its links with universities in other places. But prouably the greatest difficulty is the one referred to by Dr Alexander Brown,14 the first professor of medicine of the University of Ibadan: "I think we should have taken more time in developing our new curricular pattern. Instead of merely thinking of the "chess board" approach and the "horse-trading" between heads of departments for blocks of time, we should have given more time to fundamental analysis of the local needs in Nigeria. Too much attention tends to be given to expensive educational exploits in Europe and the United States. A fundamental reappraisal of content and presentation in the African context is long overdue. We have been too good as imitators". Many of the difficulties that now beset third world medical schools must be attributed directly or indirectly to the heavy reliance placed on the expatriate assistance that was so generously given in their earlier days. This resulted in a reduced emphasis on the strengthening of indigenous skills and accounted for the disarray and, sometimes, inertia that followed the withdrawal of overseas staff and assistance. 19 Institutional Models Until World War II, the principal "export" systems of medical education were European - British, French and German. The London hospital medical schools place their emphasis on the study of the patient at the bedside through the clinical clerkship. The British system is followed today in India, Pakistan, Egypt, the Sudan and in the new schools that have beer. established in the Caribbean, Malaysia and the former African British colonies - Uganda, Nigeria, Zimbabwe, Kenya, Zambia, Tanzania and Ghana. The French system places special emphasis on the academic aspects of medicine with proportionately less on the clinical. Since World War II the American model of medical education, a synthesis of the basic science philosophy of the German schools and the clinical clerking of the London hospital schools, has had a growing global impact - at the University of the Philippines, the American University of Beirut, Mahidol University in Thailand for example. A number of countries in sub-Saharan Africa have also been influenced by Eastern European models during this period - by Eastern European teachers in African medical schools and by the training of African students in Eastern European institutions. Brief descriptions are given in the Appendix of the medical school programmes of a number of sub-Saharan African countries and also of some third world countries outside Africa. They 20 have been selected only as examples and are intended to be neither comprehensive nor complete. Descriptions are also given of some of the Cuban and Eastern European educational systems in which a number of African physicians were trained. SOME CHARACTERISTIC AFRICAN PROBLEMS There are a number of problems characteristic of but by no means common to sub-Saharan medical schools. Some of the more important concern curricula and staffing as well as educational relevance: 1. Inherited curricula The early medical schools in the Commonwealth countries of Africa were closely modelled on the prevailing pattern in t)Te United Kingdom, for three reasons: the university was a daughter of a British university which, therefore, had to approve courses and award degrees; medical education in the United Kingdom was rigidly structured and its curricular design was dominated by individual and often technical subjects; public health was taught in the context of an industrialised society with highly developed public services. The architects of these first schools, therefore, did not have much chance to innovate, even if they had wanted to. The local pressures to produce a prestige school precluded any thought about relevance to local health needs except the production of graduates "who could work anywhere in the world". 21 2. Difficulties with community programmes It was not long, however, before attempts were made to develop community outposts; the Rockefeller Foundation, for example, sponsored the Ibarapa projectl5 for the University of Ibadan. Although this gave students rural experience, it did not succeed because it was grafted on to a host curriculum and soon became a curricular victim of graft versus host disease! The problem of trying to add more community work to an established curriculum met opposition, because such work was not seen to be necessary by teachers whose training had been in Europe or North America, or because it would take time from other subjects and could thus threaten "standards". An added difficulty was the inability of most schools to find adequate numbers of their own people who were committed to relevant community work. Most, if not all, had been educated in Europe and North America and few had specialised in community health. Foreigners were often needed to run community health departments which gave lower status and less financial reward to their members. These difficulties continue and have been compounded by the international agencies which have sought to recruit African community health doctors, thus robbing their medical schools and countries. But, in fairness, it must be added, that the appeal of an international salary in dollars has been irresistible when family and social demands have pressed hard. 22 3. Resistance to curricular change Determined efforts have been made to be more relevant by reducing the dominance of the central teaching hospital (Ife, Nigeria),16 encouraging much community based work and arranging a first year common to all health care trainees (Centre Universitaire des Sciences de la Sante, Yaounde, Cameroon),17 starting with a Department of General Practice (Calabar, Nigeria), 8 developing a problem oriented curriculum with substantial external aid (Suez Canal, Egypt and Gezira, Sudan)19 and, most innovative of all, developing a community oriented and problem solving curriculum (Ilorin, Nigeria).20 However, there is not one of these innovations which has been able to continue unscathed. Each institution has regressed towards the mean of a conventional curriculum, often on account of the indifference or antagonism of faculty members to a community directed programme. Where there has not been opposition, the sheer logistical problems of a community based programme have been weakening and sometimes fatal. In addition, when budgets are limited it is hard to sustain the case for much spending on a community programme. Work in the community is generally popular and exciting for students, but staff members can find its demands, particularly absence from home and urban comforts, irksome and unwelcome. No medical school can make any significant allowance for field work and so no financial incentive exists. 23 4. Staffing difficulties The major influences on staffing during the last 20 years have been: i) The growth of medical schools in size so that faculty members had greater responsibilities in supervising/ teaching a larger number of students. ii) The opening of new medical schools for whom staff had to be recruited from overseas, which is financially burdensome and culturally inimical. iii) Political instability which compelled many people to leave their home country and so be lost absolutely to the teaching staff. iv) Financial inadequacy so that faculty members have sought posts where their earnings could be safe- guarded - often outside the country. v) Family financial pressure and the pursuit of status through private medical practice. This is not allowed in most, if not all, schools but it cannot be controlled. Therefore, in many schools, much time and energy are lost through diversion to private practice. vi) The increasing gulf between medicine in the 'North' and medicine in the -South'. There is decreasing 24 prospect of work in an African country being of any help towards the career' of someone from the U.S.A. or Europe unless a secondment is arranged, which is unusual and difficult to find. vil) Staffing has also been weakened by (a) the absence overseas of younger men and women receiving further training - which often takes 3-4 years, (b) the transfer of more senior people to posts in government, (c) the departure of foreigners whose overseas service, often for nany years, is concluded. 5. The elusive pursuit of relevance The relevance sought at first was the relevance of the curriculum to the English or French educational pattern, so that local graduates could continue their training and be registered and acceptable overseas. The relevance sought now is to relate the training a student receives to the tasks he will be required to perform in the health services of the country. This demands a wholesale change of emphasis in the curriculum of most schools. This has-not been adopted with much enthusiasm, nor has any noticeable success been achieved for it. 25 ASSESSMENT OF .THIRD WORLD NEEDS There have been a number of innovative third world educational programmes, but on the whole they have tended to be limited in scope, local in influence and experimental in nature. They do not represent major coordinated national efforts in solving problems of health care and physician education. Unusual local conditions have appeared to favour the coordinated approach to health care and education that some of them achieved: but their overall impact on national policies and mechanisms has been limited. They are "prescriptions" for what national educational systems should be doing but not reflections of what they are in fact doing. None of them are operating in a sufficiently comprehensive fashion or on a sufficiently broad scale to bring about the wide changes called for in a credible time-frame. The questions to be answered are: why has there not been a broader response to these initiatives? What conditions would favour such responses? What can be done by all of the partners in health care - health professionals, educators, government officials, community members - to bring about more favourable educational responses? 26 These persistent shortcomings and unanswered questions are indicative of how many tasks remain. They will naturally vary from country to country, but certain basic common elements can be identified. They include: 1) the need for more effective cooperation between national medical schools and other health professional training institutions on the one hand and ministries of health on the other; 2) ensuring that the design and content of the health professional educational programmes are appropriate to the health needs of the community; 3) the production of a physician capable of and motivated towards providing service in an integrated hospital/community health care system; 4) ensuring the selection of the appropriate numerical mix of health professionals, the facilities and resources for their training and the administrative framework in which they would be utilized; 27 5) ensuring an appropriate focus on and a rational approach to the preventive and promotive aspects of health; 6) the strengthening of capabilities for continuing education and self-directed learning. Each of these elements is discussed separately below. It must be emphasized, however, that they are inter-related and would have to be tackled more or less simultaneously, if the requisite results are to be achieved: 1) Coordination between medical schools and ministries of health Closer association between medical schools and ministries of health is a special need. There could hardly be two more important elements in national systems of health care than health ministries and the community services they support on the one hand and medical schools, their teaching hospitals, and their research laboratories on the other. Although each of these groups has distinct ana broadly separate responsibilities they have complementary roles to play in the development and implementation of their countries' health programmes. It is surprising how slender have been the links and how marginal the associations between them in several countries - in the Caribbean21 and in the Pacific22 for example. There is 28 relatively little coordination of their activities in identifying or implementing national health objectives. The training of health professionals commonly proceeds independently of the qualitative and quantitative health needs of their communities, and there is often wide divergence between academics and their training goals on the one hand and health service requirements on the other. Categories of health professionals are trained often without provision of the posts, the career structure or the legislative instruments that would be required to make them effective. For example, the provision of posts and enabling legislation to utilize them lagged far behind the training of nurse practitioners in Thailand and Jamaica; .this information is based on personal observation. Medical schools are, of course, traditional institutions and guardians of painstakingly acquired academic excellence; so change comes slowly. This is as it should be. There can hardly be any doubt, however, about the value of their role in helping governments to examine community health issues and to train people to deal appropriately with them. They might question whether participation in community health activities would detract from their established academic roles. Probably a more urgent and important question would be whether they could sustain academic leadership in the health field while disengaging from some of its most pressing challenges. 29 One of the best examples of collaboration between a medical school and a ministry of health is from the University of the 23 Negev in Beer Sheba, Israel. Here the Dean of the medical school and the Regional Director of Health are the same individual. At the recently established Aga Khan Medical School24 in Pakistan the medical faculty accepts responsibility for both academic teaching and medical service to the community. Similarly at Xochimilco, Mexico25, the University faculty accepted responsibility for the care of a section of the population, in the southern part of Mexico. The Institute of Tacloban iDhilippines)12 provides the health manpower for a whole region, and most academic teachers have responsibilities in the health service. In Papua New Guineal0 the College of Allied Health Sciences is responsible for the care of 110,000 people in two such provinces. This in turn ensures that the trainees participate in clinical, administrative and public health activities. Most recently, the new medical school in Oman has established cross-appointments with the Ministry of Health, so that senior ministry officials are also teachers in the medical school and vice versa. The introduction of a service element into teaching and research increase their relevance, while the introduction of the academic element into national health care delivery systems improves services. This does not mean that medical schools should simply become passive appendages of the health ministries. The real purpose of a link with the government would be to enable medical 30 schools to contribute not only through teaching and research, but also as consultative resources to their governments. This would not only establish them as integral parts of their national health care delivery systems, it would confirm their validity and legitimacy as contributors to national health development. It is becoming increasingly evident that it is on national and governmental perceptions of their validity and legitimacy that sustained support for third world universities eventually depends. Julius Nyerere26 had this to say about the then University of East Africa: "For let us be quite clear, the University has not been established for prestige purposes. It has a very definite role to play in development in this area, and to do this it must be in, and of, the community it has been established to serve." Several individual third world countries have recognised and addressed this need; but no major international movement in this direction has established itself. Even within countries where initiatives have been taken they have remained limited. The University of Xochimilco in Mexico25 had as one of its primary aims the establishment of links between the educational process and the community health care delivery system. Joint responsibility of the university and health ministry for the health care of about 2,000,000 people was achieved. However, the initiative achieved only local, not national, implementation. Nepal27 recognised how essential cooperation between its Ministry of Health and its Institute of Medicine was for its physician 31 training programme but experienced difficulties in achieving it. In designing its community oriented M.D. course the Institute of 12 Tachloban in the Philippines established linkages between itself, the Department of Health and the Department of Local Government and Community Development and gave practical but limited expression to the principle that the development of health manpower cannot be the sole responsibility of a university but is best pursued through inter-agency cooperation. 2) Appropriateness of educational programmes for national health needs Two of the principal reasons for the continuing irrelevance of physician education systems to the tasks to be carried out have been: (i) the reluctance of educational instructors to ensure that training programmes are appropriate to the future functions of their graduates; (ii) the continuing separation of universities from the governmental agencies that are responsible for providing health care. Curricular modifications for achieving relevance have varied. Their introduction was found to be easiest in new universities. It has been achieved in the University of Newcastle in 7 Australia , in the developed world, whose foundation professors 32 were able to spell out in reasonable detail the objectives towards which the undergraduate programmes should be directed. The University of Beer Sheba in Israel23 and the University of McMaster in Canada5 also had the opportunity of designing and introducing a new curriculum. The greater difficulty of achieving the requisite modifications in established medical schools is being addressed by an increasing number of institutions in both the developed and developing worlds. By intioducing an innovative curriculum in parallel with the conventional one, the Medical School of New Mexico25 and the 9 28 Harvard Medical School as well as Mozamibque have set challenging examples. 3) A balanced hospital/community health care curriculum There are several issues, that must be critically examined before this can be widely achieved. High among these are: i) A possible negative impact of conventional university departments of community medicine Conventional university departments of community medicine are the main academic avenues for introducing and motivating medical students towards community health needs. They have unquestionably given impetus to training in community health and have attained significant degrees of success. The overall extent, however, to which such departments have achieved their objectives and, indeed, the need 33 for them in their current form in medical education merit re-examination. It is possible that their importance for bringing a special-focus to community health and for motivating students towards it might have been over-estimated. They might even have had a contrary effect. Far from opening up new horizons the new departments might have distracted attention from the need for more radical and more basic medical educational reforms. Their presence has sometimes given their faculties an apparent up-to-date image obscuring the need for overdue basic curricular reform. The reality is that the academic requirements for the faculty's role in community medicine cannot be met by a single department of community medicine. Community medicine is more appropriately conceived as the basis for each and the unifying concept for all of the-departments of the medical school. In spite of their obvious value and the role many of them have played in expanding the concepts of community medicine and primary health care, academic departments of community medicine have tended to "polarise" rather than narrow the gap between community and curative medicine and to increase rather rather than to diminish the tension between them. 34 The tension is automatically eased where the responsibility for community involvement is shared throughout the entire faculty as at the University of the Negev, the University of Xochimilco in Mexico - and where, as at the University of Kuopio in Finland29 and the University of Brasilia30 the joint faculty intention is to develop a health care oriented education rather than focusing on the care of disease. ii) The concept of a teaching community unit The effectiveness of a health practitioner depends not only on appropriate technical 'Knowledge and skills, but also on his understanding of his society and his acceptance by.it. The medical school can no longer reasonably be considered to consist of a faculty of medicine in a university and its teaching hospital(s). A substantial proportion of the resources and efforts of the schools should be devoted to introducing the undergraduate to medicine outside the hospital. The medical school needs to face the statutory responsibility of providing facilities in the community just as it does in teaching hospitals. The place of the clinical student is with those medical issues, largely unselected, which derive from the society of 35 which he is a member; that society for whose service the medical school has a duty to prepare him. It is only by its formal recognition of this need that the medical school can confirm the essential role that community medical services must play in undergraduate education in the future. The increasing range of non-medical personnel and organisations that play a role in a community's health makes it logical that the setting for medical education should become the total system of medical care rather than only the teaching hospitals. In this way medical students can be led to appreciate the contribution of non-medical members of the health team to medical care, as well as the ways in which medical services and other community services complement each other. However, as student training extends to the community outside the medical school and the teaching hospital it becomes necessary to specify more precisely the role of the doctor and thus the objectives of such training, to develop new forms of association between medical schools and community health and social services and to reach agreement on the content of the curriculum that would be appropriate for achieving these objectives. 36 It is by identifying practical problems in the community that appropriateness and relevance of physician education are to be achieved - not by still more conferences, seminars or studies, nor by merely addressing more money to them. It is through genuine community programmes that undergraduates can be trained and motivated towards involvement in national health concerns; programmes in which academics, government health officials, the professions and community members can all have responsible and legitimate roles. This is the setting in which an appropriate balance is to be sought by the faculty between scholarship and community service. In this setting the faculty's role in relation to national health service needs can be best perceived and met. In this environment a problem orientated curriculum could be best developed and implemented. Simple agreement by medical schools and health ministries to cooperate, however, is not enough. Coordination would be best achieved in the framework of some mutually agreed on-going projects or set of objectives. Local circumstances and needs could determine the choice of project. One might be, for 37 instance, an acceleration of the national programme of immunization; another might be a national project for the reduction of infant mortality; another might be targeted on the health problems of young adults. The curriculum for each could be structured to involve the practical utilization by the student of the principles of epidemiology and public health and bring him to a broad appreciation of the values and methods of community/health professional/health ministry interaction. In time, such interaction could come to involve the entire range of national health issues. Experience has shown that close organisational arrangements are necessary to ensure continuing close collaboration between ministry and medical school. This is likely to be achieved most effectively through cross-dual-appointments, where academics hold part- time ministry appointments and ministry staff are part-time academics31. The latter can contribute to teaching and research in relation to health administration, economics and planning, while the former can contribute through clinical epidemiology and research in appropriate technology. 38 It is in this setting also that the antagonisms, rivalries, territorial jealousies and, sometimes, the indifference that tend to characterise relationships between ministries of health, medical schools and community professional and lay groups would be best dealt with. The current professional imbalance will not be corrected until medical curricula come to reflect the truism that "hospitals treat diseases; they don't solve health problems". The need is to imbue the medical student with the same degree of commitment and responsibility for the health of community members as of hospital patients. It is a need that has been 32,33 emphasized as much for developed ' as for developing countries.34,35 iii) An integrated community/hospital orientation for all members of the medical faculty New universities - in developed and developing countries - have the opportunity to plan their curricula in conformity with current concepts of community medicine and primary health care. The University of Newcastle, N.S.W., the University of the Negev and McMaster University all had this opportunity. It is the established universities, however, and they 39 are the majority, that for the most part determine the content and direction of third world physician education. It is precisely these institutions that - have the greatest difficulty in introducing such curricular innovations. This is why it is so critical that a coordinated initiative be mounted to motivate the staff of these institutions, and particularly of their clinical faculties, towards the need for their participation in an integrated community/hospital curriculum. Changes in government or health ministry policy alone will not suffice. It is today's teaching and dogma that determine tomorrow's practices and traditions. That is why today's teachers are so critical to future developments in medicine. Guilbert (1974)36 emphasised that "real change can on.ly be achieved by direct and sustained efforts to influence the current generation of medical teachers." Until they are convinced about the need for change, the rate of change will continue to be slow. 40 Special initiatives to influence them must be undertaken if the attitudes of future generations of practitioners and teachers are to be changed; and these initiatives would have to be comprehensive, not piecemeal, and of the scope that would enable them to have the wide global impact that would be essential if they are to have long-term effects. 4) An appropriate Health Team i) Selection and training The concept of the health team is based on the collective efforts of its members rather than on their individual skills. It is not merely bringing together groups of people with special interests or training. In spite of wide global acceptance of this concept many health workers still work, and most are trained, in isolation. The consequences of this apartheid in the training an utilization of health team workers are professional inefficiency and economic waste. Doctors trained at great expense spend much of their time in the performance of tasks for which a lesser level of training would be appropriate; nurses and medical assistants assume responsibilities for which their training is inadequate. Reference up and 41 down the ladder of health care responsibility is difficult in the absence of awareness of the limits df each other's capabilities. The qualitative and quantitative ratios that should mark the utilization of team members is seldom achieved. Categories of non-medically qualified health professionals vary widely in number and function throughout the developing world - medical assistants, public health nurses, nurse practitioners, post orderlies, village assistants, etc. Each country would need to identify and work towards its own appropriate mix. Many have already moved in this direction and with varying levels of success. What is by no means certain, however, is that a proliferation of special types of health professionals is the best r-sponse to new health care needs and functions. The modification of classical roles for the diverse functions thrown up by new needs is probably more apposite, e.g. nurse practitioners trained for more advanced and specialist work in Canada, in Thailand and in Jamaica. It has been pointed out that for many countries in both the developed and developing world a more judicious means for using existing personnel would seem to be the best option. In Papua New Guinea the training programme for health 42 extension officers was a direct response to a locally prevailing need and the recognition that the most beneficial service could be rendered by non-physicians working at the village and health-centre level. In Tanzania priority was given to the study of health manpower needs, to the orientation of physicians' education to national needs and to the training of paramedics whose special contribution here and in other countries of the region - Kenya, Zimbabwe, Uganda and Zambia - has been widely acknowledged. A programme of expansion for the production of medical auxiliaries for Tanzania was outlined in 1972 in a 34-point training plan for changing the health manpower structure in the country from its top-heavy form (a doctor/medical assistant/rural medical aid ratio 2:1:2) to the more appropriate pyramidal structure (a ratio of 1:2:4).37 ii) Inter-professional educational programmes Obviously all students cannot share all educational experiences at all times. There are differences in duration of courses, level of expertise required, educational backgrounds, professional curricula, etc. between students preparing for the different professions. The issue, therefore, centres on the selection and timing of common educational experiences. 43 At present, common educational experiences for students entering different professions - doctors, nurses, physiologists, medical assistants - are exceptions rather than the rule. Even when they have learning experiences in the same institution, (e.g. university hospital), common educational interactions between health professionals are infrequent. Mechanisms and opportunities, however, for interaction between health professional groups would help to develop a common language and a common understanding of their mutual roles and abilities. Centre Universitaire des Sciences de la Sante, (C.U.S.S.).Yaoundel7 was established so that different cadres of health science students could learn together. The programme thrust them into the community early with increasing responsibility for health care, at first supervised and later largely unsupervised. Whether it is still achieving its objectives has yet to be evaluated. iii) Administration The existence of separate administrative structures for the training of each type of professional health worker has been another constraint against the integration of their training; and is one of the reasons why their work and training continue to be separate. Experiments 44 like the integrated programme for the training of nurses, dentists, physicians and other health personnel at Xochimilco, Mexico, and the ladder-type programme to a Doctorate in Medicine which is shared by all grades of community health professionals at the University of the Tacloban in the Philippines, are limited but important signposts towards a more rational inter-professional administrative structure. iv) The economics of health team development It is gaps in knowledge about the economics of health team training that provide one of the greatest constraints against rational health manpower, planning and development. Abel-Smith38 has pointed out how difficult it is to arrive at true costs of training for individual categories of the health team in most African countries where medical education is heavily subsidised, where the costs of medical services, research and medical education may be met from the same budget, where costs may vary widely from region to region, where undergraduate and postgraduate training are commonly carried out together, and where a variety of other health professionals may be trained concurrently with physicians. 45 The relative neglect of the economics of health man.power planning has also been noted by Abel-Smith 38 who pointed out in the same paper that of 17 national reports commissioned for a WHO conference on health manpower, only three countries even attempted an estimate of the costs of training of even two categories of health professionals, and only two gave information on the salary levels which the different categories could command once trained. He also referred to information from Pakistan on the annual training costs of different levels of health manpower which shows-that it would cost about the same to train six auxiliaries or two and a half nurses as it would to train one doctor. In Sri Lanka it was shown that it is possible to train nearly three nurses, or seven midwives, or eight pharmacists or eight and a half assistant medical officers. Moreover, in Sri Lanka, where 41 per cent of doctors emigrate, it is possible to get 14 assistant medical officers working within the country for the cost of training one doctor who will remain at home. "Of even greater importance than the training costs were the implications of the difference in salary levels. It could be shown that in Sri Lanka two nurses or assistant medical officers, could be employed for 46 what would be one doctor's salary."38 In other countries the difference in salary levels might be even wider. Not only the economics, but also the planning of health manpower could be materially improved, if the education of all health professionals commenced with a common one year of basic training. This would provide a pool from which different branches of the profession would recruit as demand dictated. Supply could be regulated through phased recruitment for a series of relatively short courses, leading to progressively more responsible or more specialised tasks in the system of health care delivery. 5) An adequate educational focus and rational approach to preventive medicine There are several reasons why, in spite of wide global acceptance of the importance of preventive medicine and in spite of the examples of the educational initiatives already cited, progress in both the teaching and practice of preventive medicine has been slow in both developed and developing countries. One is that concern about prevention commonly finds expression in generalities about it rather than in specific action programmes to achieve it. Specific questions such as the prevention of what and how must be constantly asked: What should be the precise curricular content of a community education programme for disease 47 prevention? What are the disorders in the community that can be prevented? What specific action can be taken to achieve their prevention?- What incentives can be identified and offered that will make research into, and application of preventive measures seem worthwhile to doctors, particularly when the outcome may not become manifest for some considerable time? The six disorders against which the W.H.0. expanded programme of immunisation is aimed will make up a large proportion of such disorders. What, then, should be the content of community education programmes for prevention? Special focus might well be on community participation and public health procedures; on the principles underlying the development and use of vaccines; on the basic principles of sanitation, nutrition and oral rehydration; on the use of anti-microbial and anti-malarial drug therapy; on epidemiology, not solely as a tool for research but as an essential guide for health planning and for community education which must include the application of persuasion to ensure compliance by individuals and community groups. Similarly, with the disorders considered to be due to inappropriate life styles, there needs to be a clear under- standing of the extent of the threat posed by each of them in any given community - drug abuse, obesity, smoking, hypertension, ischaemic heart disease, alcoholism, traffic accidents and the like. What should be the specific content of physician educational curricula for their prevention and what precise community action would be required to cope with them? 48 Projects can be designed in which students play an integral part and in which the principles of epidemiology, public health and prevention can be introduced in the curriculum in the context of such specific public health and preventive initiatives. This is the lesson to be learned from the curricula of the University of Beer Sheba, the University of Newcastle and the Medical School of the Cameroons39. It is real, not theoretical, health hazards that form logical bases for "problem-oriented" curricula and give credibility to academic teaching on prevention. 6) The strengthening of capabilities for continuing education and self-directed learning Although continuing education has become a fashionable term it is one to wh-ch greater lip service is paid.than effective action. In most developing countries, as also in many of the developed, emphasis is still placed on the acquisition of postgraduate qualifications for clinical specialties rather than on continuing education. Many, however, like Sri Lanka and Zimbabwe40 are placing increasing emphasis on the latter and have developed programmes for the continuing education of community oriented physicians. The success of such programmes depends most of all on the attitudes and perspectives of doctors themselves. That is why it is of such critical importance that during his undergraduate training the student should be inculcated in the habit and skills of self-learning and self-assessment. He would then be motivated to making use of opportunities 49 for informal learning as provided by lectures, discussion groups, demonstrations, seminars and workshops. He would have gained experiences with the use of learning materials such as journals, tapes, correspondence courses, radio and television programmes and the newer techniques of distance learning. The important principle, is that the knowledge and skills required of students, particularly in community-oriented work, cannot be exclusively dealt with in formal teaching. One of the main objectives of the McMaster curriculum and of the curriculum recently introduced at the Universities of Edinburgh and Newcastle (N.S.W.) in the developed world, at the Ben Gurion University of the Negev, The Nepal Institute of Medicine and the University Centre for Health Sciences in the Cameroons in the developing world, is to help the student take life-long responsibility for his own education. The adoption of this type of self-study programme requires commitment on the part of the teaching staff, and is essential for progress. The Wellcome Tropical Institute41, based in London, has recently been set up to assist developing countries to design relevant postgraduate and continuing education programmes for physicians, to develop distance learning techniques, innovative teaching methods and to prepare appropriate teaching materials. s0 SOME OTHER INFLUENCES ON PHYSICIAN EDUCATION AND UTILISATION There are a number of other determinants for change in physician education and utilisation. Some are to be found within, others outside medical schools. Within medical schools The importance of the attitudes of the "clinical" medical faculty has already been mentioned. Other aspects of the medical school that have a bearing on the quality of physician education include: i) Selection of students: Selection criteria in most third world medical schools are based, as are their counterparts in the developed countries, on academic criteria rather than on the qua ities that would be likely to make a man a "good doctor". Such criteria are unlikely to identify the students that would best meet contemporary national health challenges. It is the quality of the student selected, not his school leaving examination results, which will largely determine the quality of the graduate that will emerge from the educational system. 51 Critical as his selection is for the developed world it is even more critical for the developing world. There is an urgent need for rich and poor countries alike to review their criteria for selection of students with a view to ensuring that the potential for their development should be as much "social" as "scientific". Certain approaches to selection from both the developed and developing world are of interest. The McMaster student selection is by extensive interviews - not based only on school leaving academic performance. Students are evaluated on their ability to interact as a group, to solve problems, to think clearly to express themselves. Academic performance alone was seen to be an inadequate criterion for student selection at the University of Newcastle (Australia). This medical school admits one half of its students on academic criteria and the other half partly on academic performance and partly on personal characteristics, in order to establish by experiment how to select students for effective practice in the next century.41a Selection of the student from the community to which he is expected to return together with his training in the 52 community in which he is expected to work - at Tacloban in the Philippines and at Xochimilco in Mexico, at Papua New Guinea's College of Allied Health Services while ideally suited to small communities is unlikely to be widely applicable to larger ones. ii) Medical gualifying examinations What is not commonly appreciated is the influence of medical qualifying examinations themselves in retarding modifications of physician education in Third World countries. Although many teachers are keen to develop experimental curricula they are inhibited from doing so by genuine fear of the possible adverse effects on students' chances in examinations. Revision of examination procedures and requirements must be an integral part of curricular revision and is as urgently needed. The University of Newcastle, Australia, has pointed the way by selecting tests which expect students to demonstrate their competence in each of five clusters or domains of the medical school's programme objectives, that is in the competences which the school expects students to have attained by the time of graduation. These five domains are concerned with: 53 Self-directed Learning, Critical Reasoning, Professional Skills and Doctor-Patient Relationship, Clinical Practice, and Population Medicine.42 iii) Other university departments It was in recognition of the wider role of the university in national health development that the 1984 World Health Assembly selected "the role of universities in the strategies for Health for All" as the subject for their technical discussion. The reach of primary health care and community medicine extends beyond the medical faculty to the entire university. Although the medical faculty has special obligations, the responsibilities for achieving relevance in physician education. extend beyond it to the entire university. Many of the academic areas that have greatest bearing on health - agriculture, planning, housing, education, social sciences, economics - are catered for in faculties other than medicine. Similarly, on the government front, many of the sectors that have the closest relationships with health - agriculture, housing, sanitation, education, planning and others - lie outside normal areas of responsibility of health ministries and within government departments that have no primary responsibility for health. 54 The first steps and the leadership role within the university must be taken by the medical faculty itself. Other faculties would not be convinced of the value of their roles in community health if departments within the medical faculty itself could not reach agreement about theirs. This would pre-suppose, of course, that the Faculty has a viable quantity and quality of staff with sufficient time and energy to think and act. Outside medical schools i) Community values and development The general working background for the physician in the third world is formed by the existing health practices, governmental policies on health, the community's expectations, demands and lifestyle, attitudes of protessional groups, political stability or instability, levels of educational, social and economic development, as well as family and community organization. This background is the constraint on national health development that is the least responsive to medical "prescriptions" for change. Medical faculties can play no more than modest supplementary roles. Only governments can devise the 55 policies and introduce the measures needed. Indeed it has been shown in Latin America and the Caribbean that the extent to which adverse economic factors affects health as a whole depends mainly on how governments respond.44 This emphasises once more the overriding importance of the closest possible collaboration between ministries and educational institutions. ii) The working environment The more immediate working environment for the third world physician is in either government institutions - hospitals or clinics, academic centres, private practice or in combinations of the three. It is the more or less independent operation of these systems that makes difficult the achievement of integrated and harmonious systems of professional education and national health care - particularly in the larger developing countries. The proportions of doctors employed in each of these environments vary widely. In the Commonwealth Caribbean, for instance, 71-80 per cent would be in private practice; in the countries of sub-Saharan Africa the proportion of doctors in private practice varies from an estimated 10 per cent in Lesotho to 80 per cent in Kenya45 56 The working conditions in most government hospitals are unsatisfactory. Poor pay, shortages of staff and drugs. Inadequate equipment and overcrowding contribute to frustration and low morale. Many of these doctors supplement their government income by private practice, further lowering the standards of health care provided by government institutions. It is the poor quality of existing services, and the resulting health workers' dissatisfaction with their status and working conditions that are the main reasons why many workers leave government service to go into private practice. In particular all health personnel require greater incentives, both material and psychological, to work in the government service in rural areas. A retatively small but privileged elite work as consultants in major hospitals and clinics where the financial rewards are high. This is also the group that has the easiest access to travel opportunities and fellowships for further studies, commonly abroad. It is another factor that widens the gap between hospital specialists and general and community practitioners. 57 INTERNATIONAL AGENCY SUPPORT 1. Areas of greatest need The areas of greatest need for support have been referred to in the text of the report. They include: i) Measures for ensuring coordination of the roles of medical schools and ministries of health To review and restructure national health care systems in accordance with the country's needs, strengths and constraints; to evolve appropriate manpower structures and related education. ii) Curricular development for (a) undergraduate education (b) postgraduate education (c) distance learning programmes for continuing education iii) The development of community health education units iv) Special attention to the composition, training and use of the health teams v) Support for major national programmes, in which medical schools and ministries of health would collaborate at all levels of implementation, e.g. vaccination. 58 vi) The institutional strengthening that would be required for the above developments. vii) The commissioning of an advisory corps of international experts, drawn from both the developed and developing world, which could be a consultative resource on which the Bank might draw for formulating its own policies for support in this field and for guidelines for action. 2. Guidelines and conditions for International Agency supoort There has possibly been too little rather than too much "conditionality" which partly explains why proportionate benefits have not been derived from the enormous amounts of international support already channelled to third world countries, not only in the health field but in other sectors of national development. Some of the guidelines and conditions for support might thus include:- i) Agreement on the respective roles of universities and ministries of health and a precise mechanism for achieving government/university interaction in any major supporting educational initiative undertaken by the Bank. ii) If Governments were to be invited to seek support (in collaboration with their medical schools and/or 59 universities) for major health initiatives, they would be expected to specify how they intended to collaborate with medical schools and how this would facilitate the introduction of new trends in physician education and utilization. The achievement of universal immunisation of children could be an example of such an initiative. Apart from beir a major national health objective it could involve such practical issues as motivation of the public, the dispensing, preservution and distribution of vaccines and assessment of results; it could provide an opportunity and a model for collaboration between the ministry and medical school and for student involvement in a major community health problem. iii) Measures could be agreed upon for strengthening the commitment of the university as a whole, and of the entire faculty of the medical school, to the promotive. and preventive aspects of health, and for ensuring their active participation in such programmes. iv) Priority for support should be given to curricular revisions leading to more community oriented teaching methods, problem-oriented approaches and the development of "community teaching units". 60 v) Support for any major project might also be made conditional upon a precise statement of the parts that medical students would play and the contributions which faculty or university academic departments would make to it. vi) Because of the rapid urbanisation that is taking place in the developing world, an increasing proportion of the population will be living in urban settings. Agreed programmes should contain measures for both urban and rural implementation of the measures proposed. vii) All submissions should specify, and budget for, an external, critical and ongoing evaluation of the project. viii)Due to the importance attached to harmonizing the roles of medical schools and ministries of health, the setting up of mechanisms for such interaction might be made a condition for support for any major programme. A permanent high level university/ministry coordinating committee for health policy development might be a minimal requirement. 61 OPTIONS FOR THE BANK 1. Introduction In view of the essentially "human resource" nature of the major needs it is envisaged that the major portion of any financial support provided by the Bank would not be utilized for massive capital construction. Although some capital costs might be entailed for operational activities like accommodation, major emphasis should be on support for staff salaries, transport and subsistence for students and teachers, curricular reform, institutional strengthening, administrative arrangements, staff recruitment and training, the preparation and distribution of teaching materials, data collecting systems, etc. Individual national prescriptions for meeting agreed targets will clearly vary with local needs and resources. Nigeria and Fiji, for instance, might have common needs, but the individual national requirements for meeting them might have only limited relevance for each other. For this reason, the recommendations set out below are presented in general rather than in specific terms. 62 The overriding emphasis should be on encouraging and assistin-g ministries and institutions of health professional education to collaborate in reviewing and revising their country's health care system. Additional support should also be made available to ensure that the necessary steps can be taken to implement related revisions in the organisation, administration, recruitment, education and deployment of health professionals. 2. Constraints Financial implications apart, measures for meeting the needs outlined above would require supervision, management and evaltation on a scale which it would be difficult for the Bank to undertake. At the international level the country-specific adaptations that would be required for any agreed project would be so variable as to limit direct involvement by the Bank in individual countries. For these reasons, the Bank might consider thi desirability of channeling its support (for specific developments) through an established international health planning agency such as WHO, PAHO, the Commonwealth Secretariat, or the Wellcome Tropical Institute. 63 3.. Priorities for support Priority for.Bank support might be particularly directed to assisting health ministries and health manpower training institutions i) to set up the academic and administrative instruments that would facilitate coordination of roles of health professional training institutions and ministries of health; ii) to quantify through sector analysis the numerical needs for varying categories of health professional and their costs, to set up the appropriate programmes of training for them and to introduce the requisite administrative and supervisory arrangements for their employment once the most appropriate health care system has been identified; iii' to identify and achieve the curricular revisions and modifications best suited to their health needs. 4. Mechanisms for support Bank support for these priorities might be given: i) directly by the bank, ii) through a recognised international health agency, or iii) through a corps of international experts, (via i or ii above) possibly 10 in number, drawn from both the developed and developing world. It might have the following roli ;: 64 a) As a "think-tank" it could provide advice on health development and professional education to the Bank. Its findings could also be made available to universities and governments; b) it could be the third world counterpart, although on a more sustained basis, of the international group of experts appointed in 1975 by the Secretary General of the O.E.C.D. group of countries "to identify major possibilities for innovation in health education in O.E.C.D. countries in the context of the organisation and sanagement of health care systems, and to study alternate ways and means of meeting such needs through international cooperation..." 46 c) it could provide to the South Commission a comparable service to that provided by the O.E.C.D. expert group to O.E.C.D. member countries. The South Commission is a body which was recently established under the Chairmanship of Dr. Julius Nyerere to facilitate collaboration in development among third world .47 countries. 5. Mal4wi, a credible recipient for initial support There are difficulties of arriving at country-specific recommendations for Bank financed projects in ths field. As a pilot project, however, Malawi, East Africa, might be an appropriate country in which a beginning might be made of Bank assistance towards the resolution of third world physician problems: 65 i) a new medical school is being planned for Malawi48 which would make it possible for most of the educational initiatives outlined in this paper to be planned and introduced at its inception. ii) the country is neither too large nor too small - some 6.5 million - a size which would facilitate the introduction, monitoring and evaluation of the programmes undertaken; iii) it is politically stable and has a record of progressive education and of sound fiscal management. 6. Proposals for funding collaborative review and revision of health care and education systems In addition or alternatively, the Bank may wish to issue an invitation for certain sub-Saharan countries to submit proposals for financial support. Such proposals would be expected to identify how a national review and revision of the health care and health professional educational systems would be conducted and implemented through collaboration between ministries and institutions of health professional education. 鱸 66 REFERENCES 1 Mahler, H., A social revolution in public health. (1976). WHO Chronicle 30, pp.475-480. 2. Duggan, A.J., Goodwin, L.G. and Williams P.O. The present state of tropical medicine in Britain and its future prospects. Conclusions. Trans.Royal Soc. of Trop.Med. and Hygiene. (1981). Volume 75 (supplement), pp.59-60. 3. Report of Eighth Commonwealth Health Ministers Meeting held in Nassau, Bahamas, October 1986. 4. 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WHO Series No.71. pp.71-80. 26. Nyerere, J.K. Freedom and Unity: A selection from writings and speeches, 1952-65. Dar-es-Salaai. Oxford University Press 1966. p.218. 27. Shato, M. Tribhuvan. University Institute of Medicine, Nepal (1980) in Personnel for Health Care. WHO Public Health Series No.71. pp.81-96. 28. Marzagao, C. Mecanismes de development des personnels de sante - 1'experience Mozambicalne: in Conferences biomediqales, Cycle 1976-1977. Brazzaville, W.H.0. Cahiers techniques AFRO. No.13, 1978. pp.38-42. 70 29. Vanha - Perttula, T. University of Kuopio, Finland: Reforms of the health care system in Finland - A challenge' for a new university (1980) in Personnel for Health Care. WHO Public Health Series No.71. pp.47-70. 30. Lobo, L.C.G. Faculty of Medical Sciences, University of Brasilia in Medical Schools for the modern world. Report of a Macy Conference 1970 edited by J.Z. Bowers, John Hopkins Press. pp.69-92. 31. Thompson, K.W., and Fogel, Barbara R. in Higher Education for Social Change. Volume 1: reports, Praeger Publishers, Inc. New York, 1976. p.59. 32. Querido, A. The Functions of Medical Schools and Universities in Education for Health Care Delivery: Proc. 1st International Conference on Education in the Health Services. 8-12th October, 1972. The Hague. 33. Ebert, R.H. The Medical School: Scientific American. September 1973. 229. pp. 139-148. 34. Bryant, J. Health and the Developing World. Cornell University Press. Ithaca, 1969. p.142. 35. Stuart, K. Health for all: its challenge for medical schools. Lancet, 1984, 1. pp.441-442. 71 36. Guilbert, J.J. Teacher Training for medical schools in Africa. 'Lancet 2 (7880). 7th September, 1974. pp.570-573.' 37. Gish, 0. Swedish International Development Authority, Stockholm. Medical Auxiliaries: a programme of expansion. Stockholm. SIDA, Health and Nutrition Unit. 10th May, 1972. p.11. 38. Abel-Smith, H. The World Economic Crisis: health manpower out of balance. Oxford University Press. Health Policy and Planning. 1986, 1(4): 309-316. 39. Monekosso, G.L. and Quenum, C.A.A. University Centre for Health Sciences, Yaounde, United Republic of Cameroon: Training in Health Team: in Personnel for Health Care. W.H.O. Public Health Series, 1978. No.71. pp.169-184. 40. Stuart, K.L. Information from official visits. Sri Lanka and Zimbabwe, 1984. 41. Wellcome Tropical Institute: Statement of institutional objectives. 1986. 41(a). Vinson, T., Cooney, G and Turnbull, J. Admission to medical-school: The Newcastle experiment. (1979). Programmed Learning and Educational Technology. 16. pp.277-287. 72 42. Feletti, G.I., Saunders, N.A. and Smith, A.J. Comprehensive assessment of final-year medical students' performance based on undergraduate programme objectives. (1983). The Lancet, 2, pp.34-37. 43. W.H.O. Report of Technical Discussions on the Role of Universities in the Strategies for Health for all. 1984. 44. Musgrove, P. The impact of the economic crisis on health and health care in Latin America and the Caribbean (1986). WHO Chronicle. 40 (4). pp.152-157. 45. Stuart, K.L. Information from discussions on visits to Lesotho and Kenya, 1979, on behalf of Commonwealth Secretariat. 46. New Directions in Education for changing health care systems: Report by Centre for Educational Research and Innovation to OECD, 1975. p.13. 47. South Commission: A Commission set up under Chairmanship of Mwalimu Nyerere, 1986. 48. A plan for Medical Education in Malawi: Private Report to the President of the Republic of Malawi of the Tripartite Project - Identification Study for the Establishment of a Medical School in Stages. August 1986. s APPENDIX SOME RELEVANT PHYSICIAN TRAINING PROGRAMMES Central & East African Commonwealth Countries Zimbabwe The Medical School was first a daughter of the University of Birmingham and so its training and curriculum developed along the lines determined by Birmingham. The isolation of the country to 1980 meant that there were few opportunities for its academic staff to exchange ideas or to enjoy new ones. A conservative Faculty developed which has not been eager to allow time for community work - away from its established teaching hospital. This, together with the stark contrast between the quality of the clinical staff and the dearth of enthusiasts in community medicine, has not helped. But there is in the country a sophisticated rural/district hospital pattern through which the graduates, after school, pass. The rural framework is therefore available but the orientation of training is still towards hospital work. In 1982, Zimbabwe's Institute of Medical and Allied Professions introduced a number of specialty training courses for physicians in order to reduce the amount of time and money lost when doctors take such courses abroad, to discourage emigration and to make physician training more relevant to the needs of the country. These include 4-5 year in-service training programmes in areas such as pathology, medicine, surgery, obstetrics and gynaecology and paediatrics, with a two-year course in public health and a one-year course in clinical pharmacy. In addition, because the need for specialists is limited, there are eight diploma courses, most of one year's duration in various areas of primary health care. Tanzania From the first there was a commitment to training the doctor for the country, and the entry each year of seasoned men who had been clinical officers gave their student colleagues a broad and relevant experience. Priority was given to the study of health manpower needs, to the orientation of physicians' education to national needs and to the training of paramedics whose special contribution here and in other countries of the region - Kenya, Zimbabwe, Uganda and Zambia - has been widely acknowledged. A programme of expansion for the production of medical auxiliaries for Tanzania was outlined in 1972 in a 34-point training plan for changing the health manpower structure in the country from its top-heavy form (a doctor/medical assistant/rural medical aid ratio 2:1:2) to the more appropriate pyramidal structure (a ratio of 1:2:4).1 Implicit in the plan was that priority be placed on auxiliary rather than physician training. The process would involve the construction of 11 new schools for training such medical aids and full production on the part of the four existing medical assistant schools; the language of instruction would be Swahili instead of English: and the whole medical assistant and rural - medical and training programmes could be organised under the auspices of a director of medical auxiliary services. The feasibility of the entire programme, however, is considered to be conditional upon the country's capacity to contain expenditures on hospitals and curative services. The programme in community health at the University of Dar es Salaam is continuous throughout the five years of the medical course. Students have to work in the field after pre registration/internship appointments. The Medical School is trying to embark on a two year M.P.H. programme also. The current appalling economic plight of Tanzania, despite massive and often inappropriate aid, leaves little room for manoeuvre and none for educational adventure into the community with all its additional costs. Zambia Zambia has not been fortunate. At first it had a number of Russians in a largely multinational expatriate staff, who knew little of the relevance to Zambia and could merely reproduce the pattern prevailing in their home country (see below). Financial collapse and a dearth of well trained Zambians has left the school precarious and able only to survive rather than develop and innovate. Kenya The Medical School in Nairobi, where every international organisation seeks a foothold and embarks on projects, suffers from being in a capital city where wide health care demands are made on well trained doctors. This, together with the building of the Kenyatta National Hospital, has turned the medical school into a hospital centred institution. The problems of health care are those of the urban dwellers. The staff of the Medical School are in a most difficult position, many have the problems of private practice and of urban living. This makes a mould for the graduates which will be very hard to break as they see what their teachers do and inevitably seek to emulate them later. There have been vigorous community health projects but the background is hostile. Uganda Health care and medical education in Uganda, once the best in black Africa, have been adversely affected by the economic, political and social upheavals during the past two decades. Inadequate public health measures, shortages of medical equipment and essential drugs, and lack of sufficient medical school faculty have resulted in crisis. Substantial aid from the developed countries and an adequate period of social.stability and ecooomic recovery would be required to restore medical practice and education to their former levels. As in Nairobi, there are also the potential constraints imposed by a central massive teaching hospital in a capital city. It is likely, however, that with appropriate support and an adequate period of social and political stability, the rural and community work which has been started will be strengthened and extended. Malawi This East African country of 7.08 million has been independent for 22 years and in the absence of a national medical school has had to rely on foreign medical training for both its local and expatriate doctors. A "tripartite project identification study for the establishment 2 of a medical school in stages" in Malawi is now in progress . The current medical staffing situation here is precarious. There are only 71 doctors (52 per cent) who are in posts out of an establishment of 136 and only 26 (55 per cent) out of 47 in the Private Hospitals Association of Malawi. It has been pointed out that "the Malawian students trained in European medical schools have more experience in the degenerative disorders of the elderly than in the predominantly infectious and nutritional diseases that effect the population of Malawi. Moreover, they often initially lack the'wider range of practical skills that are necessary for district practice and are often inadequately prepared for the community, preventive and managerial work of a district medical officer." The curriculum proposed for the new school would be of two years pre-medical and 5 years medical training with three main themes- community health, clinical practice and the basic medical services. Represented on the "tripartite" study group are the British Overseas Development Administration, the Deutsche Gesellchaft fur Technische Zusammienarbeit, of the Federal Republic of Germany and representatives of the Ministry of Health and the University of Malawi. The proposals, if implemented, promise to make significant contributions to the health educational capabilities not only of Malawi but of the East African region as a whole. 7 East Africa - Non-Commonwealth Ethiopia 1. Addis Ababa The course at Addis Ababa is only four years in duration. It ha- had to accommodate a large intake of students - about 110, for the last 3-4 years and so the teaching staff are hard pressed. Also, the school grew up on a British model and was not able to get a strong community orientation or commitment into its curriculum. It is trying to do this now, largely in the fourth year when, it could be argued, students' attitudes are already shaped and it is too late to change them. The two years rural hospital or clinic work which are now compulsory after internship give a rich experience, for which rural and community preparation has been scanty. The four-year programme also will not allow additional field work as this would be at the expense of time in other subjects which few teachers would be prepared to allow. 2. Gondar The pattern of Gondar follows that of Addis. Gondar has been, and will be for another five years, sustained by East German teachers, who each come for a year from a different technical and hospital background and know little of the wider environment of the country. Technically competent, they are short stay, and would innovate if they were told to do so. But there are not enough Ethiopian physicians to sustain such an initiative. 3. Jimma The school at Jimma is under the Ministry of Health; Addis Ababa and Gondar are under the University. It was established almost as a protest against the hospital orientation of the first two Schools, but its growth has not been easy and it is being reassessed. Cuban faculty members help it. The idea of a school much more orientated to the community was good, but the realisation of its aim has been almost impossible to achieve. Sudan There are three schools, Khartoum, Wad Medani and Juba. Khartoum was established as a Kitchener School of Medicine in 1923. It has continued as a traditional school ever since. Wad Medani developed under an enthusiastic Sudanese Dean who has since gone to the regional headquarters of the WHO at Alexandria. It was dedicated to being a problem-solving, community oriented school. The early loss of its Dean may be lethal to this philosophy. Equatoria Africa's most recent medical school is located in Juba, the capital of Equatoria, an isolated and underdeveloped area of the Sudan. The teaching and hospital facilities for the first class 3 of 16 students are described by Woodruff (1982)3. There are shortages of everything except patients. The school's present and future needs are considerable. Located as it is in the embattled South this medical school depends on foreigners for its survival, and it is unlikely to be able to provide much of a lead as long as the war continues. There are few options open to its staff. Mozambique Mozambique has fashioned and begun implementing a plan to shift health care emphasis from cure to prevention and to provide services to the rural majority. Its efforts to model its medical curriculum on the needs of the population is one of the major adjustments that this country made after achieving independence to strengthen its national health care systems. The national health policy that was designed to achieve this had as central objectives: (i) that medicine taught should be social rather than clinical in orientation; (ii) that the curriculum should be designed to meet the characteristics and functions of the physician to be trained; (iii) that the various categories of health personnel who work in the health team should be catered for; (iv) that continuous education should be a central feature of the system and that clear-cut directions of career advancement should be open to the different categories of health workers.4 Niger In 1974, on WHO's recommendation, Niger opened a school of health services within the University of Niamey. The purpose of the school was to train physicians, pharmacists, dental surgeons and public health technicians with a view to fostering a team spirit among them: to participate in the continuing education and continuous evaluation of all health workers: and to continue scientific and operational research into African Pharmacopoeia and public health. The medical curriculum has been designed to produce a doctor who will be suited to practice in Niger. The integrated approach to medicine and patient care is emphasised, and theoretical and practical content are chosen to complement each other. Because of its innovative approach the progress of this school will be of interest to other African national health planners. Cameroon Like most Francophone schools, Cameroon has a relatively stronger basis of theoretical rather than of clinical skills. It is, however, moving rapidly towards greater emphasis on clinical medicine and on community orientated studies. It is attempting to achieve a broader distribution of basic: medical services and to revise its medical education to provide appropriate health manpower. Monekosso5 (1977) introduced a new twelve month integrated internship programme: for four months they treat outpatients in a satellite rural health centre: for one month - each they provide emergency care in hospital medical, surgical, paediatrics and obstetric departments, and for four months they practice general medicine in a district hospital in one of the country's seven provinces. In the district hospital the intern assists the District Medical Officer in all aspects of his work: administration, technical, clinical and public health, The District Officer, in turn, evaluates the intern on every aspect of his performance. Joseph6 has recently reviewed the progress of the university's plans for the training of workers in locally relevant skills. He considers that pressures to continue more traditional forms of medical education are posing major obstacles to achieving the school's original objectives and concludes that "both health services and medical education reforms are necessary in order to provide broader distribution of appropriate care." Centre Universitaire des Sciences de la Sante, Yaounde (C.U.S.S.) was established so that different cadres of health science students could learn together and could have a programme in which they were thrust into the community early and learned to take increasing responsibility for health care, at first supervised and later largely unsupervised.7 While the philosophy persists, few of the early pioneers remain and in particular those who were largely responsible for the community programme. From the early days there was some conflict between the aspirations of the founders and their strong supporters in North America and the traditions of the French trained faculty staff. C.U.S.S. continues and its community direction is admirable; whether it is still achieving its objectives in training has yet to be evaluated. West Africa: Commonwealth Nigeria To comment accurately and briefly on the medical schools of Nigeria is impossible. 1. The early schools, Ibadan principally, and Lagos followed a traditional mould and Ibadan as a University College of the University of London gave London degrees at first. When Ife developed in 1963-64 it resolved to break the pattern of the teaching hospital, but it nevertheless produced an academic BSc over three years as pre-clinical training and did nothing to make pre-clinical studies relevant or to develop a vigorously community oriented school. The Ibarapa community project at Ibadan has been in action for 20 years but during these years clinical powers have increased in Ibadan, the clinical/pre-clinical schism has continued and little impact has been made on students' attitudes and behaviour. This is probably due to the artificiality of a well equipped rural centre (where students could eat imported rice!). The recent determination of Lagos to involve its students in urban primary health care was largely due to the initiative of Professor K Ransome-Kuti, Professor of Child Health, who is now Federal Minister of Health. The pressures against rural involvement of students in Youmba society, which is essentially and culturally urban, are great. The challenge of urban Lagos and its primary health care may not now be met on account of the departure of Professor Ransome-Kuti to government. 2. Benin, Nigeria (Enugu), and Ahmadu Bello (ABU) (Zaria) followed and in all three the inevitable pattern of work dominantly around a teaching hospital prevailed, although ABU developed a small district hospital at Malumfashi where students went during their clinical years. As more students were admitted, so the problems of adequate work in the field supervised by indigenous doctors increased. The professors of community health at Zaria were almost exclusively expatriate and although there was much desire to develop a vigorous community oriented approach, this did not materialise and community health did not rise much above the theoretical. 3. The newer schools, Jos, Maiduguri and Port Harcourt, made no special provision for an imaginative approach to primary health care in medical education. Calabar, however, emphasised the need for students to be associated with family health through its Department of General Practice. The University of Ilorin had a widely acclaimed community oriented and problem-based programme. It began strongly but the pressures of convention and of a shortage of committed staff made it less strong and geographically less advantageous, despite the great enthusiasm of the students. It could have been, together with C.U.S.S. and Yaounde, a model for Africa - but both are in their early days. Ghana Accra The University of Ghana Medical School was established as a typical classical medical school. Community health and primary care, therefore, have had to be grafted onto an existing conventional and rather rigid curriculum. The latest Head of Department has recently joined UNICEF in New York and the School lacks staff seriously - but this is the common fabric of Ghanaian Universities. Its strongest threads are drawn into the world of the international company and it becomes bare. Kumasi A theoretical commitment to community work, embodied in the establishment of the School, has not been matched by results. The chronic crises since 1975 when the School began have made it a beggar for staff and resources, and it has also lacked any dynamism in its community health department. EASTERN EUROPEAN STATES Descriptions are included of Cuban and certain Eastern European educational systems because of the large number of African students that were trained in them and also because of the relatively large numbers of doctors from these countries who worked and taught in Africa. Russia: (A) First and Second Moscow Medical Institutes In the USSR health manpower planning and the planning of medical education are the responsibility of the Ministry of Health. Training syllabuses are implemented and evaluated and new ideas suggested or approved in an elaborate system of training system panels that link the Medical Institute to the Ministry of Health. At present there are more than 800,000 physicians working in the Soviet Union and training is carried out at 83 medical institutes and 9 university faculties.8 The First and Second Moscow Medical Institutes are among the largest higher medical establishments in the Soviet Union and physicians are trained in the faculties of general medicine, paediatrics, sanitation, hygiene and pharmacology. A biomedical faculty has been developed in the Second Moscow Institute which trains specialists in biophysics and biochemistry to work in faculties of other medical and health institutions. These two institutes also play the roles of educational devel'Opment and participate in the preparation and modification of curricular. They also do research on educational methods. They have been responsible for the creation of a network of specialist medical facilities throughout the country and an accompanying curriculum reform designed to prepare large numbers of physicians for their main specialties. A 1976 curriculum reform sought: i) to introduce students early (in the first year) to the nature and practice of medicine and to general clinical medicine; ii) to prolong the teaching of biomedical subjects in the senior years; and iii) to strengthen the students' practical skills by early exposure/introduction to polyclinic. It is difficult to evaluate the extent and nature of the clinical teaching referred to in descriptions of Soviet curricula: it is difficult also to assess the effectiveness of training in epidemiology, the national history of disease, community health issues, prevention of disease and health promotion. Questions have been raised about the clinical competence of the Soviet doctor in comparison with Western countries. What seems to be certain is that there is considerable variation between the "have" and "have not" states both in university standards and in the quality of health professionals. (B) Patrice Lumumba People's Friendship University This university was founded in 1960 to train mainly African, Asian and Latin American students, although many of its students are Russian.9 It is the university to which a large number of African students from both Anglophone and Francophone countries went for their medical education. The language of instruction is Russian and there is a strong emphasis on political indoctrination. Although its degrees and diplomas are the same as those awarded by other Soviet universities, most of the medical graduates of this university from Commonwealth African countries have been found to be deficient by Western standards in both the theoretical and practical aspects of medicine; and few of them have been able to undertake the usual clinical responsibilities of hospitals or health centres without a period of additional training. Yugoslavia The Medical Faculty at Novi Sad This medical faculty was founded in 1960 and in 1974 its educational system was reformed with the basic principles that science, education and health care should be linked into a single functional system,10 In the past the medical faculty had been responsible for pre- clinical studies, the hospitals provided medical care and the scientific research had been done in research institutes. Following the reorganisation of the medical faculty a reform of the educational plan and programme was undertaken. The task set the reorganised faculty was that its undergraduate courses were "to prepare students to be general practitioners and enable them, both theoretically and practically, to solve the health problems of the local communities in which they will work".10 A scheme of study for the purpose of defining the role of the general practitioner as well as the education plan and programme necessary to train physicians was worked out. The conclusion of the evaluation undertaken of the effectiveness of the programme to achieve this purpose was that health workers were much better at theory than at practice, that they were more at home in dealing with individual than community work and that, taken as a whole, they lacked a sufficient preventive orientation. The revised curriculum included a markedly increased emphasis on - preventive and social medicine. "Seminars, workshops, field visits and field practice are the main methods of instruction. The management of health services based on the principles of primary health care are taught as part of general practical, occupational health, school medicine and management and planning in health services".10 OTHER COUNTRIES Papua New Guinea The population of this Pacific island is approximately 3.2m. There are 19 provinces, four of which are main inhabited islands. The Papua Medical College was founded originally to train students from the region for the Diploma in Medicine and Surgery. In 1972 the Medical Faculty of the university evolved from this College with a curriculum of training towards MBBS degrees. There is a clear demarcation of responsibilities for the training of health professionals in Papua New Guinea. The University has the responsibility for the training of doctors, the Ministry of Health for the training of health extension officers, health inspectors, aid-post orderlies, nurses, laboratory technicians, radiographers and dispensers. Although there is some collaboration between the Ministry of Health and the Medical Faculty in these training roles they are virtually carried out in isolation. In a country like PNG, where 85 per cent of the population is rural and might.only infrequently ever see a doctor, the non- medically qualified health professionals carry a greater overall responsibility than doctors, both functionally and in numerical terms, for the manning of the country's health care delivery systems. The Ministry of Health centralises the training of health professionals as a national responsibility. The operation of hospitals, pharmacies, health centres, etc, has been decentralised and is a provincial responsibility. The medical school of the University of Papua New Guinea has major problems. The staff is largely expatriate and its regional role has been constrained to date for geographical and socio cultural reasons. Its national role needs consolidation before any significant regional role can be undertaken. Physician training follows the basic patterns of contemporary western models. It is in the training of health extension officers at the College of Allied Health Services at Madang and the reliance placed on them that are the unique features of this country's training programmes for health professionals. Health extension officers are the middle-level health workers who are in charge of health centres supervising curative, preventive and promotive health care of from 5,000 to 20,000 people with the help of community health nurses and post orderlies. Their training is of three years duration followed by a year of supervised internship. Most of their training is in field training situations at general and public health administrative tasks. Their training programmes are more extensive and sophisticated than in any other country in the region. They have proven their national worth; this and the national reliance placed on them have given them a deep sense of professional commitment and pride. The Fiji School of Medicine The school, founded in 1885, is now one hundred and one years old. It has played a crucial role in the training and supplying of medical officers for the region during this period. It still has a key role to play for the future. The manning of the health services of the Cook Islands, Fiji, Kiribati, Nauru, Niue, Solomon Islands, Tokelau, Tonga, Tuvalu, Vanuatu and Western Samoa has been highly dependent on this institution for nearly a century. In spite of its regional importance, however, it is administered entirely by Fiji; and, as far as Fiji itself is concerned, in spite of the close ties between the Health Ministry and the School there is still little functional coordination or harmonisation of their roles. Up to 1985 the qualification awarded to its graduates was a Diploma in Medicine and Surgery which qualified them to practice anywhere in the Pacific. During the past: year it has been agreed, although the academic and administrative arrangements are still being worked out, that for the future the University of the South Pacific would award external degrees in medicine and surgery to the graduates of this school. Apart from the course for the external degree of Bachelor of Medicine and Bachelor of Surgery of the University of the South Pacific, for which students are now being prepared, there are other courses at the Fiji School of Medicine for students from Fiji and other Pacific countries - Bachelor of Dental Surgery; certificate courses in medical laboratory technology, radiography, physiotherapy; and health irispection training. The uncertainties that currently surround the future of this institution will not be resolved until clear-cut regional agreements are reached about its future in the Pacific. It is at present in transition between its past role as the Fiji School of Medicine and its projected role as the Medical School of the University of the South Pacific. Its difficulty is that it is now not sti.11 the one and not yet the other.10 These uncertainties are also reflected in its curriculum. The School cites the following as its institutional objectives for its graduatesl3 1. a broad knowledge of medicine, extending from basic to sound implications of health and disease; 2. competence in the basic essentials of primary health care; 3. ability to work as a leader of the health team and to possess the necessary qualities and attributes; 4. greater appreciation for preservation of health and prevention of disease; 5. desire for continuing education and self learning and commitment to the profession; The curriculum that followed this statement of objectives, with its disproportionate emphasis on propositional clinical knowledge and bedside medicine, is unlikely to achieve them. Malaysia Malaysia is a country of approximately 15 million people. Its medical training needs are met by the medical faculties of its three universities: Universiti Kebangsaan Malaysia (UKM); the University of Malaysia (UM) in Kuala Lumpur and Universiti Sains Malaysia (USM) in Penang. The medical faculty of University of Malaya is the oldest and was started in 1963. The faculty of Universiti Kebangsaan was started in 1973 with an annual intake of 44 students. Its expansion in the twelve years since its commencement has been rapid. It has already reached an annual intake of 192 students. Its first graduates were produced in 1979. The Universiti Sains Malaysia is the most recent of the medical schools - its first graduates are not expected until 1986. Technical assistance in the form of overseas experts has been provided to the Faculty of Universiti Kebangsaan by the Commonwealth Secretariat since 1978 and shows the value of sustained assistance with skilled professionals for institution strengthening. A total of 25 professional man years have been provided since 1979 in psychiatry, paediatrics, radiology, pharmacology, general and orthopaedic surgery, ophthalmology and obstetrics and gynaecology.14 The unique features of this assistance programme was that local people retained the posts of Departmental Chairman, while the role of the overseas experts, some of whom were recruited from the developing world, was to provide: i) assistance to departmental heads with the organisation and planning of their undergraduate curricula; ii) help with the administration and development of their departments; iii) contributions as resource persons to the academic training and development of a relatively young and inexperienced local academic Malaysian staff; iv) support to the University as a whole as members of its administrative, research, planning, curriculum, senate and other committees. It is not the fault of these experts that in spite of eight years of continuous Commonwealth support most departments in the faculty are still vulnerable in terms of the number and seniority of their permanent staff. This is due mainly to the recent rapid loss of academic faculty members to the private sector. In addition to contributions to the University and its undergraduate teaching programmes a special benefit of the assistance of the Commonwealth experts has been with the development of the faculty's postgraduate programmes. There are now eleven established graduate programmes in the faculty - all in clinical subjects - the development of which has been largely the responsibility of overseas experts. Apart from their role in the development of these programmes the experience and seniority of the experts have given credibility to their departmental programmes and have influenced enrolment in them. The purpose of these programmes has been to train medical specialists not only for the faculty's academic posts but also for posts in the Ministry of Health and to meet other national needs. Their success will probably be the best measure eventually of the value of the Commonwealth Secretariat's contribution to medical school. A discouraging feature of this assistance programme, however, has been how little institutional emphasis has been placed on community health and on the preventive and promotive aspects of medicine. Thailand After a few initial experiments Chulalong Korn University was founded in 1916 during the reign of King Rama VI, and Sirraj Hospital was then incorporated as a medical faculty of the University. The medical course was extended to six years in 1951. Aid for the Faculty of Medicine was obtained from the Rockefeller Foundation in 1921 and Professor A.E. Ellis was sent to Thailand to organise the medical curriculum (with a strong Harvard emphasis), the first examination leading to the MB degree.18 A third medical school was established in Chiengmai in 1959. This school was largely sponsored by the American U.S.O.M. (United States Operation Mission) and was affiliated with the University of Illinois. A fourth medical school, the Faculty of Medicine of Ramathibodi Hospital was started in Bangkok in 1965 and is now the University of Mahidol.(18) The United States system of medical education has continued strongly in all of these institutions. As in many other countries there is a lack of doctors in rural areas in Thailand and nurses working in rural clinics had to provide curative care for which they have not been appropriately trained and often not legally protected. The planned response of the Health Ministry and Mahidol University to meet this need was of interest. Instead of training a new cadre of health professional, they gave additional training to public health nurses in the field. The resultant programme for the training of public health nurse practitioners is an excellent example of the value of good Ministry of Health - Medical School cooperation.(19) Cuba Cuba is a country of some nine million inhabitants. There are approximately nine thousand medically qualified doctors, with a resultant doctor/population ratio of around 1:1,200. There are few general practitioners and the delivery of medical care is almost entirely through the services provided by the Ministry of Health. The doctor/paramedical ratio of the health care pyramid is higher than in most other developing countries. The health centre (polyclinic) is the functional unit both for training and delivery of health care at the community level throughout the island. The functions of the ministry of health and of the universities are closely integrated. The health of the population is a government responsibility and the health services are available to the total population. Much emphasis is placed on preventive services. The community through its mass organisations collaborate extensively in the planning and the organisation of the health services; and an exceptionally high level of patient compliance in personal and public health programmes has been achieved. Cuba is particularly suited to such programmes for a number of reasons. The health services have achieved a coverage of nearly one hundred per cent of the population; the party machinery, special community groups and existing mass organizations provide unique opportunities for community propaganda and education; sustained participation in programmes requiring patient compliance over long periods is achieved; the health communication network is excellent; certain socio-cultural and socio-political features of the community ensure high levels of national discipline.14 Although it may be impossible to reproduce all of these circumstances in other countries they might be useful models for approoriate areas., Workers in community programmes elsewhere might benefit from information on the organisation of the country's network of health centres and polyclinics and of *methods by which its high level of community participation in large-scale health care delivery programmes has been achieved. Apart from providing a beneficial background for physician education good community participation also facilitates effective community utilization of physicians. t4 APPENDIX REFERENCES 1. Gish, 0. Swedish International Development Authority, Stockholm. Medical Auxiliaries: a programme of expansion. Stockholm. SIDA, Health and Nutrition Unit. 10th May, 1972. p.11. 2. A plan for Medical Education in Malawi: Private Report to the President of the Republic of Malawi of the Tripartite Project - Identification Study for the Establishment of a Medical School in Stages. August 1986. 3. Woodruff, A.W. New Medical School in Central Africa. Lancet, 4th September, 1982, pp.545-546. 4. Marzagao, C. Mechanismes de development des personnels de sante - 1'experience Mozambicalne: in Conferences biomedicales, Cycle 1976-1977. Brazzaville, W.H.O. Cahiers techniques AFRO. No.13, 1978. pp.38-42. 5. Monekosso, G.L. Organization of an integrated medicine internship in tropical district hospitals. Tropical Doctor. 1977, 7 (2). pp.76-80. 6. Joseph, S.C. Innovation and constraints in health manpower policy: a case history of medical education development in Cameroon. Social Science and Medicine (Aberdeen, U.K.). 13 (2) June 1979. pp.137-142. 7. Thompson, K.W. and Fogel, Barbara R, in Higher education for social change, Volume 1: reports, Praeger Publishers, Inc. New York, 1976. p.38. 8. Isakov, A.Y. and Uryvaev, Y.V. Development in medical education in the U.S.S.R. in the last decade. Medical Education, 1984, 18. pp.3-6. 9. Patrice Lumumba People's Friendship University: International Handbook of Universities, 1983. 10. Jakovljevic, D. The Medical Faculty of Novi Sad, Yugoslavia: in Personnel for Health Care, 1980: W.H.0. Public Health Series No.71. pp.191-202. 11. Stuart, K.L. Roles of Medical Schools in National Hetlth Development. Report of a Survey in Commonwealth Caribbean countries to Commonwealth Secretariat 1985. 12. Banam, J. College of Allied Health Sciences, Madang, Papua New Guinea (1980) in Personnel for Health Care. WHO Public Health Series No.71. pp.97-114. 13. University of the South Pacific/Fiji School of Medicine. Affiliation Arrangements and Memorandum of Understanding. December 1981. p.19. 14. Stuart, K.L. Medical Faculty: Universiti Kebangsaan, Malaysia. Report to Connonwealth Secretariat. October 1985. 15. Stuart, K.L. Cuba: Hypertension Control Progranne: Assignment Report to W.H.O. April 1975. 10