Realizing the Social Mission of Universities and training institutions
There are many stories of poorly planned health workforce programs in our countries. There are also many meeting taking place on health professionals education and training. at the same time, there are strikes and reported cases of suicide resulting from failure to get employed after graduation and completion of internship.
Here below are my thoughts on long term solutions. Looking forward to seeing your responses.
There is a lot of renewed activity in Africa and globally on the subject of health professionals’ education and training. A meeting took place at the beginning of February, 2023, in Kigali, Rwanda, of the Governing Council of the African Forum for Research and Education in Health (AFREhealth). In November, 2022, two meetings took place; in Miami, USA and in Accra Ghana on this topic. In May 2022, there was a Forum in Canada; McGill University School of Population and Global Health on “Nurturing Leadership for Health: are Universities Stepping Up?” Another meeting took place last week of February, 2023 in Pretoria, South Africa. So, what is going on? Are we making any progress? Are health professional training institutions contributing to better health globally, regionally and nationally? Are they just about themselves?
The Lancet Commission on the Education of Health Professionals for the 21st Century issued its report ten years ago recommending a new generation of reforms in health professionals’ education. Universities, especially university leaders, are called upon to become the change agents among the people that they serve. These leaders should demonstrate social accountability and teach their students to be societal change agents by exemplary lives; engaging with their ministers of health, cultural, religious and civil society leaders. The purpose of this engagement is to ensure that better population health is visible in practice as a result of teaching and research. Failure to achieve this qualifies universities to be described as ivory towers that are disconnected from their communities.
University leadership, including all Faculty should engage proactively with politicians and the public to ensure that knowledge, research and training are aligned with efforts to improve the performance of health systems and advocate and guide investments in health. This requires reviewing incentives for promotion of university lecturers that are currently skewed towards research and publications with insufficient emphasis on teaching and service. When students see this as a dominant role model, they also aspire to become researchers resulting in a gap in service and teaching.
Clinical excellence through services delivery is a pre-requisite for clinical teaching followed by the need to undertake research to address identified gaps in knowledge for improved services and teaching. This was described at Makerere Medical School as the three-legged African stool. If the legs of the stool are not of equal length or one of the legs is missing, the stool is unstable and unsafe. Growing up at Makerere, it was a requirement for all heads of clinical departments to be university employees alongside many non-university employees at the Mulago referral and teaching hospital. These university leaders were also advisors to the Ministry of Health in their respective clinical specialties.
In order for universities to have a social mission and be change agents, it is important for them to track and follow the performance of their graduates. Graduate tracking is a source of feedback that improves teaching and contributes to improved quality services delivered by the graduates. This is also needed to improve health workforce planning and management. There are many reports from African countries where graduates remain unemployed for long periods of time and many migrate especially to the developed countries at a huge cost to the source countries of migrant health workers. Tracking graduates by universities in partnership with their governments can also be an entry point into negotiating bilateral and multi-lateral agreements with other countries on managed migration, guided by the WHO Code on the International Recruitment of Health Personnel adopted by the World Health Assembly in 2010.
The Sub Saharan African Medical Schools Survey that looked at all Medical Schools in Sub Saharan Africa, found that many private medical and nursing schools have emerged with the primary business aim to make money with questionable attention to the quality of graduates. Regulation and accreditation of these schools is challenging because many have connections to politicians who interfere with the roles of regulatory and accreditation agencies. In some cases, Regional accreditation mechanisms are in place which help to protect the independence of the regulatory bodies and assure quality of the training institutions and graduates.
Another set of key players are the professional associations in the countries. These have a key role in ensuring the universities and training institutions are supported to play their rightful roles and that the standards of teaching and service, including ethics are responsive to societal health needs. The Global Health Workforce Alliance recommended a tool known as Country Coordination and Facilitation (CCF); a forum that creates partnership structures in countries comprising, Ministries of Health, Education, Public Service and Finance along with Professional Associations, to develop National Health Workforce Plans and ensure that these are implemented to scale. Effective CCF committees would guarantee the achievement of the required competencies, skill mix, numbers and budget so that all graduates get employed. This will make it possible for every person, in every village, everywhere have access to a motivated, skilled and supported health worker responding to population health needs.
This is a call to action to universities and training institutions. They should commit to pursuing social accountability by engaging with health professional associations in all disciplines and advocate with political leaders and the public for the creation of CCFs in the countries as vehicles for realizing their social mission and achieve better health of the people.
What do you all think?
Prof. Miriam Khamadi Were
How great to see your name in my inbox! Thank you for writing.
I haven't even read what you have sent. I see "It is not short"!. I will go through it as
soon as I can and get back to you.
Thanks a lot and stay well.
Your Sister Miriam.
Prof. Miriam Khamadi Were
Prof. Francis Omaswa
So nice to hear from you Sister Miriam. I hear that doctors in Kenya are among those affected and go for years without getting employed even when there are vacancies in the health services.
Looking forward as always for your wise comments.
Prof Lovemore. Gwanzura
Greetings and welcome back Prof Omaswa !!! I was just touched with your continued sharp memory on health issues in Africa . I thought you are now retired and enjoying the peace of the storm after all you have done to influence efficiency and ethical health related professional education training and practice. I am also now retired and had gone silent but after this presentation I have now have changed my mind. I also want to keep on being heard and will reactivate issues I had left for the young.
The issues of poorly planned Health work force programs is critical and your current views are indeed right , critical and need specific country attention and orientation and thus adoption of resolutions and initiation of new directions on which way to do after the workshops and conferences. Soon when we have one United Africa things will be different.
For now Prof "keep walking" and of course Talking. We lost Prof Hakim here and the link to East Africa seems to have dwindled. Down.
Prof Lovemore. Gwanzura
Prof. Francis Omaswa
Very nice to hear from you. I will never forget your forthright and eloquent submissions to our discussions. I retired from one role into another new one and so it goes until the systems will call for a halt and society stops asking for our services.
We were in Harare last August 2022 for the annual AFREhealth conference and should have looked you up and other colleagues such as Chris Samkange etc.
We miss James Hakim. In his memory, AFREhealath has established James Hakim leadership development program for early career health professionals.
All the best.
you touch (as always) on a vital issue and a current subject of debate, health professions education (HPE) and its impact.
I agree that there are numerous HPE conferences and meetings and through participating in a number of them, I can confirm that the deliberations and outcomes are inward looking. Issues around the impact of HPE and its relationship to health systems and health care are not addressed and when it is the case, this is usually done in a shallow manner.
Despite an inventory of reforms and recommendations coming out of literature sources such the Lancet Commission Report, the Sub-Saharan African Medical School Study, the Global Consensus for Social Accountability, and the WHO Transformative HPE program; some dimensions such as system level governance and the mechanisms to ensure synergy with health systems are not well covered. Some academic circles (e.g. Gordona and Karle, 2012) are skeptical about whether HPE has to follow health systems and respond to their realities. They persist that HPE should lead and be more futuristic in a liberal approach. The movement of competency based education though widely embraced and more appealing to the HPE-health system synergy is still criticized by some academic circles, and impact of accreditation is also questioned. When you attend these conferences and read the academic literature, you feel that the dichotomy between education and health is still rampant.
Yet, there are emerging voices like your calling for this synergy between HPE and health systems/health care to realize the desired impact of generating the health workforce. I think the discussion needs to be taken miles further to delve into the important question of how to practically realize this??. I think more joint activities between HPE and health systems leaders and professionals are needed to look into governance of HPE and what are the effective approaches and mechanisms to ensure the synergy and realize the potential of the health workforce in pursuit of population health improvement.
I like the discussion and hope that it opens avenues for a true movement in this respect
Prof. Francis Omaswa
It is so nice to hear from you and to read your very incisive analysis of diverse aspects of this debate. My desire is to bring the HPE community to agree that their core role is to produce HWF that is accountable to society. The health system leaders also need to provide incentives for the HWF to that enjoy their work as they serve their communities.
Let us hear what others will contribute to this discussion.
All the best.
Adamson S. Muula
Good morning HRH champions. As usual, cutting thoughts from Dr Omaswa.
Sadly for us in Malawi, I had to write the following editorial as even our nominal supply of HRH is an oversupply in a constrained market. The editorial can be accessed here: https://www.mmj.mw/?tag=editorial
I cannot agree more, it is really bewildering to see some international strategies meant to alleviate the HRH crisis producing damage rather than solutions. I served in the WHO Expert Group on the effectiveness of the Global Code and I reflected to the meetings on this odd situation in our countries where production is there but employment is lacking due to governmental failure...yet international instruments come in to punish health professionals by restricting their chances of being recruited in a place that value them and instead pushing them into idle situations inside their countries..
Understanding the real dynamics inside our countries should be the basis for solution and not the generalized impressions on the health workforce crisis..
So many circles belive that our problem is the shortage while it is not!
Adamson S. Muula
Incase we still have unemployed doctors, the openings for two months towards cholera are still available. The focus is for those fully registered and please express your interest to this email email@example.com or by directly texting me on +265994642331.
Those that attended walk in interviews have all be considered already.
Okong Pio (Prof)
You rightly highlight the challenges of Universities and training Institutions in fulfilling their "social" roles. I would probably split this at three levels:
1) Responsibilities to the trainees. graduates are largely head knowledge individuals, a result of parotting what they have read. They are largely devoid of relevant technical and BEHAVIOURAL COMPETENCES. Behavioural competences are acquired by modeling on role models and many teachers/consultants are rarely available in a 24 hour cycle when curative services are needed. For nursing, the tutors have completely stopped "practicing" in the clinical settings. What is the way forward? A sobering review and appraisal of the status and honest changes to the practice of training to ensure behavioural competencies are also critically modeled and assessed.
2) Responsibilities to the Universities/training Institutions: A significant number of teachers hop around in more than one Institution not because their skills are RARE but for economic reasons. This is now a chronic problem. How can this be addressed? I have no immediate thoughts on this.
3. Responsibilities to Society...social roles. Ensure production of competent, SAFE and COMMITTED healthcare practitioners.
However, in the course of your writing, you highlight the issues of employment and deployment of the health workers. In many countries, I have come to the conclusion that terms of service for health workers, their employment and deployment is largely a political issue. In the Public sector, it was long removed from the purely civil service or technical sense; hence the chronic strikes and industrial actions, "absenteeism"; "presenteeism". In one country, we cannot streamline internship,no honest appraisal and accreditation of sites for internship. All "graduates must be absorbed into internship" irrespective of the capacity to train them. Hence slowly, we are eroding the quality of internship and the outcomes less than satisfactory.
For human resource planning, in Uganda, the framework is there, Human Capital Development is under one programme, but weak implementation. The National Planning Authority is often ignored, There is an Interministerial committee: MOH, MOES, .....professional Councils, and others on/off. Little technical work and true engagement which leads me to the next subject.
Lastly, the issue of CCF just like the WHO Code on health workforce movements is an excellent piece but countries have largely paid lip service and tno viable national frameworks have been developed. If we struggle hard we might just reach the level of organization like dealing with Global Health Security issues. In this light, the epidemics and global threats energised this concept and all nations are on the " starting line" at the same time. However, the health workforce, one of the pillars ensuring global security, is left behind at the whistle! Some health workers claim they have not yet been paid for some of this work.
How do we get political commitment for CCF?