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:
- To provide students with an opportunity to get to know the community, the people of their country and their health needs
- 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.
- 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.
- To provide a curriculum that engages the community and improve their utilization of the health services
- To increase the volume, quality and/or scope of health services provided at a district hospital or community clinic.
- 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.