Advice for eLearning programs in Medical Education: Determine the problem first, then find technology

Just read a very interesting post on the World Bank EduTech blog on using technology to gather data in Uganda’s education sector. Below is an excerpt which I think is such an important issue and relates to the use of technology in all contexts but particularly in low-resource settings where the stakes are high:

“On the technology front, the general lesson learned (or re-learned, or reinforced) was to “first identify issues to be addressed, then identify the technology”. (This is a lesson to which the EduTech blog regularly returns!) Other key related lessons (see the related PowerPoint file if you would like these presented in a concise, bullet point format) were to identify appropriate technology tools that can be adapted to address specific needs and to acknowledge that technology is only a tool, and so has various limitations. In addition, in the case of Uganda, the adoption of these specific technology tools was greatly enabled given widespread access to mobile networks, and improving access to the Internet.”

As many medical schools in Africa embark on eLearning programs in partnership with American Universities or other local/international partners, it’s really important to keep in mind that the strategy should be to start with a clear need statement and a clear problem to solve. Since partners often have experience with a particular technology, or in some cases have even developed their own technology that they are eager to use, there is a tendency find ways to make use of a so-called ‘good’ technology.   There might be pressure from the partner, an implicit expectation in the collaboration or simply the assumption that it worked for them so it should work for us. Yet establishing an eLearning program based on technology is dangerous and risky – it can often lead to wasted time and resources as you may be fixing a problem that didn’t exist or scaling something that is not right for your context.

Thanks for the reminder EduTech blog – we will indeed try to choose technology only after we know the issue to address!

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6 Trends in Medical Education in Africa

The Medical Education Partnership Initiative, a multi-million dollar US government initiative, recently held the Annual MEPI Symposium in Kampala Uganda. In it’s third year of a 5-year grant, the MEPI community has clearly lit up with innovations and progress abound. MEPI is now a network of over 26 medical schools in Africa, each investing in building capacity to improve the quality, quantity and retention of their graduates, while also building research capacity. Having seen the evolution of MEPI from it’s inception to this half-way point, I note 6 trends that have emerged.

It’s no coincidence that the trends nicely fit under two categories that were coined by the Lancet Commission for Health Professions Education; Institutional and Instructional trends.

Institutional Trends:

1. Strategic In-Country Partnerships: Gone are the days when medical schools in Africa simply look to the North for support and direction. Instead, African medical schools are partnering with each other, to share limited resources creatively and to have a stronger voice in advocating for national health workforce reform. In Uganda and in Zambia, all in-country medical schools have formed a consortium in their respective countries even bringing together public and private schools. The Ugandan partnership is called MESAU – Medical Education for Equitable Services to All Ugandans.

2. Rapid-Scale Up of Enrollment: In response to the urgent need for health care workers, we are seeing countries and schools across the continent rapidly scale up the enrollment to medical schools. At Addis Ababa University in Ethiopia, the class sizes have increased from just over 100 to now close to 400 students per class. At Kilimanjaro Christian Medical College in Tanzania, class sizes have increased over 50%.

3. Medical Education Units are being established: As schools embrace education innovations there is a trend to establish Medical Education Units (MEUs) to support faculty development, curriculum review and to help evaluate the impact of these education investments.  At the University of Zambia, the MEU is conducting a study to determine the impact of the new Skills Lab. At Stellenbosch University in South Africa the Medical Education Unit has already started a robust evaluation of the rural training program.

At the Instructional level, there are 3 additional trends:

4. Decentralization of medical education: As tertiary hospitals become congested with more and more students, and district hospitals paradoxically struggle to retain staff and provide high-quality service, the decentralization of clinical rotations seems to fill the gap. Sending students out to do core rotations in internal medicine, surgery or OB brings academic rigor and resources to the community. The district hospital docs are incentivized to stay in their jobs by the new teaching responsibilities and the rigor of teaching raises the level of care provided at the district sites. This is the story of both teachers and students at the University of Nairobi. At the University of Jos in Nigeria, they’ve creatively converted the PEPFAR supported district hospitals into teaching sites, offloading the crowded hospitals at urban hospitals.

5. Curriculum reform, embracing competency-based education; Africa is no exception as schools across the globe embrace competency-based education. In Nigeria, they have developed a nation-wide template for a competency-based medical school curriculum that takes into account the local health needs.  In Uganda, all 5 schools in the country met to determine the minimum competencies that should guide all medical curricula. Coming from a western context, I found it interesting that the list included critical inquiry, population health and leadership and management skills. The latter topic of leadership in medicine begs for a global discussion on the definition of leadership as we look to the decades ahead.

6. Last but not least is the trend to embrace technology and establish elearning as a core competency of medical schools. Medical schools across the continent are preparing to embrace technology by investing in infrastructure. We are even starting to see African medical schools implement elearning programs – providing students with tablets for access to e-textbooks and point-of-care decision making tools as they are doing at the University of Botswana and at Kilimanjaro Medical College in Tanzania.

These trends demonstrate that while there certainly is a global health workforce crisis, medical schools in Africa are prepared to rise to the occasion.

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Partnerships in Medical Education – an African Context

As I look across the medical schools involved in the Medical Education Partnership Initiative, it’s interesting to note the different types of ‘partnerships’ that have been stimulated by this investment. As the landscape of medical education evolves to meet the global health workforce crisis, these diverse partnerships should be examined for creative and effective ways to sustain and strengthen health professions education. Medical schools in Africa are partnering with:

1. In-country medical schools – while African schools often turn to schools in the west for technical expertise, they are increasingly looking at each other for creative partnerships that enable efficient use of limited resources and provide a common platform for national and even international advocacy.

2. Ministries of Health and Education – historically, academic institutions have had limited influence on health workforce in Africa, but this gap seems to be getting smaller as academics are now building bridges with politicians. In Uganda, the medical schools have formed a new national body that brings together all the schools along with the government ministries involved in health policy. In many countries the Ministry of Education determines who gets into medical school and the Ministry of Health looks to employ the graduates of medical schools. So these government ministries book-end the pipeline of physician training, making this connection between academics and policy-makers a mutually important relationship.

3. Research institutions – one of the core themes in MEPI is to build local capacity to conduct locally-relevant research. Here again, while the traditional partnerships for research have been north-south, we are now seeing medical schools in Africa are looking at the rich resources in their immediate environment. The University of Zambia early on identified local research partners that provide a cost-effective, locally-relevant way of supporting research capacity-building in an African context.

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Why is it exciting to hear of virtual doctors in Zambia?

I just read about a new service – a virtual doctor service for patients in remote areas of Zambia. Given that Zambia has one of the worst doctor:patient ratios in the world, this is potentially game-changing. This tele-medicine service will connect patients with health professionals around the world for advice on diagnostics and treatment. Tele-medicine has been used in many settings, so why is this particular service interesting?

For one, it speaks to the fact that internet in Zambia is becoming more robust. As someone who is keenly interested in addressing the health workforce gaps in Africa, this is exciting. When the internet reliably reaches remote areas of Zambia, not only will health service be taken to another level, but also health professions education.  Earlier this year, while on a site visit to the medical schools in Zambia, I learnt that the Ministry of Health has plans to exponentially grow the number of physicians trained in the country (something like 10k in 10 years, when until recently the output was around 100/year!) The only way they can conceivably do this, is by using eLearning so that students placed at district or provincial hospitals, have access to the limited number of faculty working at one of the few medical schools in Zambia. So when I read that tele-medicine has arrived in rural Zambia, I felt a twinge of optimism that the next break-through may be a medical school in a remote district of the country, using teachers in Lusaka or even New York!

The other interesting feature of this program is that they are recruiting health professionals from around the world to participate. Last week I ran a course for internal medicine residents interested in global health. All of the residents described a deep desire to maintain some level of global health activity in their career, but none of them were quite sure how to do it.  The opportunity to provide medical consultation to patients in the remote areas of Zambia would certainly be a great way for them to either get involved, or more likely, to stay involved after a medical mission. During our course, we discussed the unclear ethics behind short-term medical missions. One clear take-away from our discussion was the need for short-term missions to be anchored in longer-term relationships with communities. Without knowing the details, this virtual doctor program appears to be a plausible strategy to work remotely and become familiar with a community.

It’s obvious that technology is going to be a game-changer in health care. It’s exciting that even the most remote parts of the poorest countries are starting to feel the benefits of exciting innovations.


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Strengthening the Physician Workforce in Africa

Given the striking paucity of physicians in Africa, investing in medical education is becoming a necessary component of health system strengthening efforts. In the United States we have approximately 1 doctor for 390 people. In parts of Tanzania, there is 1 doctor for 50,000 people! Despite this large gap, Sub-Saharan Africa with a population of 800 million people, has about the same number of medical schools (about 160) as the US with a population of 300 million people. We also know that the schools in Africa lack adequate infrastructure, faculty and resources.

So scaling up the physician workforce in Africa is going to mean a heavy investment in medical schools. The US Government is the first recognize this need and invest in addressing the gaps. The Medical Education Partnership Initiative is a 150million dollar investment over 5 years to primarily 13 medical schools in Africa. Many of the grantees have partnered with other schools so the reach is actually to over 30 African Medical Schools.

Recently, an article we published in Health Affairs, describes this large initiative and  how the different schools are using their funding to scale up their output. The three goals of the grant are to increase the quantity/quality of their graduates, to improve retention rates of graduates and to increase the capacity of the medical schools to do locally driven, and locally relevant research.

This past August in Addis Ababa, was the 2nd MEPI Annual Symposium where all the schools came together to share stories. Some notable trends:

  • All schools are investing in technology to transform learning, to access new content and/or to make management functions more efficient
  • All schools are investing in community-based education in some form. Some in ‘exposure’ type rotations, others in clinical rotations and others are creating rural immersion experiences
  • All schools are scaling up faculty development activities in an effort to recruit and retain more faculty
  • Many of the schools have used this large external investment as a means to bring together government stakeholders (the ministries of education and health) to discuss the pipeline of physician training.
  • Medical schools and African governments are starting to appreciate the urgent need for a physician tracking system that would allow them to see where their physicians go after graduation -an effort to improve their return on investment in medical education.

These are but a few of the innovations in medical education that have been stimulated by MEPI. As we now enter year 3 of a 5 year grant, we are certain to see and hear more about this important initiative.

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Is Community-based medical education a worthwhile investment in Africa?

As medical schools in Africa expand there are a number of reasons why community-based education (CBE) is a common strategy. First let me define that community-based education is training that occurs ‘in the community’, not just training that’s ‘about’ the community (which is community-oriented education). School strategies to train in the community come in different shapes and sizes. Some provide a month-long rotation every year to the same site, others provide long-term experiences in a district hospital. The skill taught, duration, mentorship and type of sites vary in each school.

The challenge with CBE is that it almost all models, it requires a lot of time and financial investment. Preceptors need to be trained, accommodation and/or transport needs to be provided, the community and local stakeholders need to be engaged and a curriculum needs to be developed. So with the limited resources available in Africa, why are schools training in the community? There are a number of reasons:

  1. To provide students with an opportunity to get to know the community, the people of their country and their health needs
  2. To teach competencies that are not easily taught in the tertiary hospital such as primary care, preventative care, management of mid-level providers, health services research. In Uganda for example, their COBERMS program (Community-based Education, Research, Management and Service) teaches students a variety of different competencies required of physicians.
  3. To offload the over-burden faculty at the tertiary institutions. In Ethiopia, for example with the sudden ramp up in enrollment in medical schools, the existing schools are overwhelmed. Newer medical schools necessarily need to use district hospitals to provide opportunities for students to learn and interact with patients.
  4. To provide a curriculum that engages the community and improve their utilization of the health services
  5. To increase the volume, quality and/or scope of health services provided at a district hospital or community clinic.
  6. To ultimately improve graduate retention – by training in the places they are needed to work, the hope is that graduates will feel more compelled and competent to return to under-served areas as physicians.

The million-dollar question is what type of CBE experiences lead to the desired outcome? Interestingly, the current literature on CBE in Africa reveals that most evaluation efforts are focused on student performance, the student experience and the impact on the community. Were these the primary endpoint? Which of this menu of outcomes is the priority? If retention is the real driving force of CBE investments, then how long do students need to spend in the community to really gain confidence, proficiency, a sense of accountability and comfort in order to return?

Given the variety of different strategies used in CBE, the charge to African medical schools is to determine what is the primary end-point for CBE efforts and evaluate accordingly.


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New Global Health Course for Internal Medicine Residents

After many months of preparation, this week I launched the first Global Health Course for Internal Medicine Residents at GWU. This course has three objectives

  1. To prepare residents who will likely go on short-term medical missions abroad either during or after residency
  2. To provide residents with a basic understanding of global health principles and trends
  3. To expose residents to career paths that include global health work

The course was seminar-style for a small group of residents. The list of topics included:

  1. Broad topics – Introduction to global health, vaccine-preventable diseases, health systems, health workforce
  2. Clinical topics – HIV, malaria, parasites, NTDs, malnutrition, chronic diseases, minor trauma, adolescent health and a lab session where we looked at tropical diseases, practiced preparing and reading basic gram and acid-fast stains
  3. Specific perspectives – Health systems after a crisis, using a limited formulary, the ethics of short term medical missions
  4. Spotlight on specific countries – Honduras, Dominican Republic, Haiti and many examples from Ethiopia woven in to the talks.

The one-week intensive course has gone very well. An opportunity for residents to become familiar with common terms used in global health (like MMR, Infant mortality, DALYs, MDGs) and to start to compare countries using values for each of these. The course offered residents an opportunity to meet a number of experts from different fields. We deliberately started each session with a discussion about the speaker’s career path so that residents could get a sense of how careers often evolve into global health. The more clinical discussions were also very well-received. An opportunity for residents to review what they rarely see and to practice skills that have become out-sourced in our system (such as gram staining) but would likely be expected of a doctor practicing in a more resource-limited environment.

All in all, a very successful week. We will certainly run the course again next year and consider expanding it to take more residents and include more topics. As medical missions and global health become more popular, more residency programs will likely be inspired to offer these kinds of experiences for interested residents.

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