3 Reasons to use e-Learning in African Medical Schools

eLearning is a trendy topic. More and more funding is being channeled into technology-related infrastructure, training, and faculty development. Medical education in Africa is no exception. In fact, as internet access improves in Africa, more medical schools are integrating e-learning into their curricula.

The challenge lies in developing an e-learning strategy that responds to local needs. In the US, the driving force to use technology is to improve the quality of the education. We use it to improve communication skills, physical exam skills and have more opportunities to practice cases. These uses appropriately respond to recognized deficits in our students.

Medical education in Africa has different challenges. According to the Sub-Saharan African Medical School Study, the biggest challenges are lack of faculty and inadequate infrastructure. Now that more countries in Africa are scaling up training of health workers, including physicians, it is critical to address the bottlenecks. So here I suggest there should be 3 explicit goals of e-learning programs in Africa, and I list them in order of priority:

1. Reducing the need for faculty time: Despite inadequate faculty, medical schools in Africa are increasing enrollment. They need to figure out how to teach more students with limited faculty. Technology should be used to meet this need. Self-study curricula (like what the Khan Academy has done for K-12 would be great). Medical schools should select courses to pilot e-learning based on their faculty needs – if there are not enough anatomists, then the anatomy course should be prioritized for integrating e-learning. As schools are testing e-learning in their curricula, one explicit indicator that should be measured is faculty-time required. If it takes faculty more time to upload their curricula, engage in on-line discussions and evaluate – is it really meeting the acute needs?

2. Cost-effectiveness: It takes money to provide educational supplies, classrooms, housing and supervision for the growing number of medical students in Africa. As the enrollment increases, schools will be looking for ways to make their dollars stretch. If we can use technology to provide online access to resources (instead of buying textbooks), give laptops to students so they can study more often at home, reduce the number of faculty it takes to run a school – we most certainly will find cost-savings. To prove this, schools that are pioneering the use of technology must include cost-analysis in their evaluation.

3. Quality – This tends to be the most obvious reason to use technology and is often the driving force, but I put this deliberately third because it is sometimes over-stated. Sure you can use technology to connect a school in Uganda with a US school to watch a lecture on HIV, and sure it will give yet another perspective on a condition commonly seen. But is that really meeting the acute and critical needs of the system? The use of technology to improve the quality of training in Africa should be competency and need-based. By first being explicit about the skills all graduates need, evaluating their competency, and then using technology to provide additional teaching where gaps exist.

Developing an e-learning strategy that prioritizes the reduction of faculty time and cost are increasingly important as technology becomes a more common tool in African medical schools.

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Too many African doctors lost to local NGOs – we need to fix the ‘internal’ brain drain.

A recent article in the British Medical Journal brought to the world’s attention the significant financial cost of the external brain drain. It studied 9 African countries that typically export doctors, and 3 western countries that tend to import doctors and assessed the cost. The final tally – African countries lost $2.6billion dollars training doctors who are now living in western countries. According to this article 25-50% of African-born doctors are now living and working abroad. These numbers are impressive and concerning. If we are to address the severe shortage of physicians in Africa we certainly need to plug this leak and encourage western countries to find ways to become self-sufficient in producing enough doctors.

There’s another brain drain that doesn’t seem to get as much attention – the internal brain drain. Of those medical graduates who chose to stay in-country after training, many don’t go on to clinical practice – they get lured into non-clinical jobs by governments or local NGO’s. Foreign NGO’s pay better and offer better benefits. I remember when I was in a hospital in Tanzania a few years ago talking to the one internist working there – he complained that so many of the residents he trained would go off to do a Masters in Public Health because then they could get a job with the Clinton Foundation – have a good salary and still feel like they were improving the health of their country.

The Sub-Saharan African Medical School Study examined the plight of faculty in medical schools. These faculty often see patients in public hospitals along side their teaching responsibilities. This study found that in a 5-year span, 25% of faculty were lost to internal brain drain (either working for the government or NGOs).

Ironically, when I’ve talked to physicians in Africa who have moved from clinical to policy or public health work, they miss their patients. In fact, in a recent trip to Ethiopia some of these docs say they would be happy to see patients on a part-time basis or in the University clinic with residents but their jobs would not allow them that option.

There are two questions that need to be addressed:

– What are the real numbers of this internal brain-drain? A brief look at physician tracking systems in Africa reveals that these numbers are likely not being captured. We need tracking systems that gather this data and we need more research done to understand the breadth and scope of this problem.

– What can NGOs do to address this issue? Can they allow or even require their physician on staff to do some amount of clinical work? Can they partner with governments or Universities to allow their employees to work in public clinics or medical schools? If NGO’s made this a policy, it could apply to all doctors working in the country – not just the African-trained doctors. Imagine if all doctors who come to Kenya for research or policy work were required to spend even one day a month in a clinic – access to specialists would certainly improve! 

Both quantifying the internal brain drain and finding innovative ways to address it must be on the table if we are to scale up the physician workforce in Africa.

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How many doctors does Africa need?

According to the 2006 WHO World Health Report, there were 54million health care workers – which includes service providers and administrative/support staff. Still there was a deficit of 4.3million. Of the 57 countries with critical shortages, 36 are in Africa – leaving the continent with the biggest crisis of healthcare workers. In 2008 the WHO published a document called ‘Scaling up, Saving Lives’ which advocates for scaling up low and middle level providers to improve access. This scale up has already started with 15,000 health extension workers trained in Ethiopia alone. With improved access, comes more demand for higher-level care and an increased need for supervision of these low- and middle level workers. Hence the need for more doctors in Africa. The WHO has estimated that African needs 167,000 more doctors to meet the basic health needs of the continent. With less than 170 medical schools in the country, and an annual throughput estimated at around 11,000, where will all these doctors come from? Looking at the pipeline for physician training in Africa, we need to plug the leaks. The in-country brain-drain to NGOs and ministerial jobs is a challenge. Another leak in the pipeline is the out-of-country brain drain that ranges from 25-50% depending on the country. Image

As we invest in health system strengthening in Africa, we must invest in strengthening the physician pipeline, putting more students through the pipeline and fixing the brain drain both within and outside the country.

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Successful examples of mHealth applications in Africa…from the mHealth Summit

As promised, here are a few examples of innovative mhealth applications in Africa from the mHealth Summit last week in DC:
  • In Tanzania, D-Tree with Harvard faculty tested eIMCI with significant impact on the sickest kids because full guidelines were followed. Interestingly, patients felt they were getting better care (with use of PDA vs. paper) because clinical officers were referring to a phone/guidlines.
  • MoTeCH in Ghana provides pregnancy information for women and their families using $40 phones, and using an open source software Open MRS for their platform. Interestingly, most families preferred getting their information using voicemail rather than text messages (due to literacy rates)
  • Operation Asha in India uses fingerprints/biometrics to track TB treatment, sending an SMS if missed doses. Good results and the cost is $3/patient.
  • Wired Mothers Project in Zanzibar  reported a 4 fold increase in skilled birth attendants present at birth when mobile phones connect midwives.
  • In India, lactation consultants providing cell-phone consultations resulted in increased rates of exclusively breast fed infants

With African having 60% penetration of mobile phones (and growing…) and South Africa with 20% penetration of smart phones (compared to 50% in the US) there is certainly a lot of potential for real impact using mhealth.

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5 Highlights from the mHealth Summit in DC

I thoroughly enjoyed the mHealth summit. The crowd was a mix of people from different sectors, all energized about the potential of mhealth and clearly everyone felt we are on the verge of a major transformation in medicine. A few messages came through:

1. There are many, many pilots in mhealth – globally. What’s needed now is a focus on interoperability, scalability and sustainability.

2. Financing is a challenge – there was little talk about how physicians will get reimbursed for services related to mhealth. Incentivizing physicians is going to be a challenge.

3. Multiple stakeholders – clearly there is a need for inter-sectorial collaboration to make mhealth scalable, and successful. The government needs to provide oversight and the private sector needs to drive the innovation. There were many examples of successful private-public initiatives from around the world. The Switchboard partnership with Vodafone in Ghana is my favorite.

4. Data, data, data – with home monitoring and 24-7 data being created, there is going to be a need to analyze this data, and present it both to the patient and the physician in a meaningful way that drives appropriate treatment.

5. Training – there was really not much talk about this, but I think it’s critical that we start thinking about training physicians in technology and change management. This next decade will see radical transformations in medicine by technology, yet medical school curricula and their developers are not even thinking about providing in ehealth. While it may be difficult to train on specific technologies because the winners are not yet clear, we should certainly be thinking about training doctors in change management. Our next generation of doctors should be able to adapt to a rapidly evolving environment when they graduate.

I’m very energized by the conference and definitely hope to return next year. I will be writing about specific highlights in the days to come.

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An Innovative and Profitable Venture that Keeps Track of Doctors in Ghana

Given the increasing brain drain of doctors leaving Africa, the issue of retention is a top priority for Ministries of Health (MOH) and medical schools in Africa. The MOHs want to incentivize physicians to both stay in country and go to the rural parts of the country. The medical schools are trying to entice students to practice in rural settings by increasing the quality and quantity of training in the community. The challenge is the measure of their success cannot be determined without a physician tracking system. There are few countries in the world with a physician tracking system.

That said, I heard at the mHealth Summit in Washington DC this week an innovative public-private initiative that has created a tracking system in Ghana, as an indirect benefit of a business venture. Vodafone (who only has 18%) of the market share in Ghana, teamed up with the Switchboard (a US company) and the Ghana medical association. They gave each of the 2200 doctors in the country (public and private) a sim card with which all the doctors could talk freely to each other. They were already spending minutes and money consulting each other – now these minutes were free. All the rest of their calls to non-physicians are charged. Vodafone got 100% of the physician market, making 1.3M in the process and the doctors got free calling to one another. When they distributed the SIM card, they collected names, specialty and place of practice – so now the MOH even has a tracking system to know where all their doctors are. They are now expanding to Tanzania.

That is mHealth at it’s best – innovative, scalable and sustainable. I like it.

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A great resource for teaching doctors in Africa how to find, organize and use information….

I came across an interesting group African Medical Librarians and Deans – who have put together a number of online courses and presentations addressing internet literacy among medical students. This is an example of how the approach to ehealth in Africa will most certainly be different in Africa compared the America. Most people in the US are computer and/or web-literate. Certainly medical students have the skills to use both. But in Africa where students come from different backgrounds, including rural areas, computer literacy is variable. Starting from the basics is essential not only for students but for faculty alike. This particular website has seven modules addressing finding, organizing and using health information. Interestingly, there’s a module here called Scholarly communication in which the latter part discusses how to write a journal article. Ironically, this type of information/training would even be helpful for American medical students!

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