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Learning from other countries 

Learning from other countries
Chapter:
Learning from other countries
Author(s):

Geoff Meads

DOI:
10.1093/med/9780199234219.003.0013
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date: 17 October 2019

Purpose

The theme of this chapter is transferable learning. The perspective of the chapter is global and contemporary. Its principal aim is to identify alternative international approaches to medical education that can be applied appropriately to developments in the UK, and possibly elsewhere. A framework of ‘Modernization’ is used to help ensure that there is an authentic comparability between the UK and the other countries so that they may be regarded as relevant resources for this purpose. Accordingly, in each case the democratic nation states referenced are undertaking reforms of their health systems during the post-Millennium period, which are characterized by such common characteristics as new forms of clinical and corporate governance, participation and regulation, and stewardship strategies for public health. In each ‘modernizing’ health system the model of medical education is itself undergoing significant change. Indeed, despite the strong professional resistance that is internationally a consistent factor in such change, the development of novel curricula is usually an important and integral element of a state’s overall policies for the positive transformation of health and healthcare relationships.

Specifically for medical education the ‘modernizing’ principles of decentralization and partnership are those which have the most powerful impact. Together they pave the way for the much wider involvement of different community interests and non-professional groups in curricula design and delivery. These principles have also been the most prominent and explicit in successive policy statements in the UK since the incoming central government of June 1997 declared its intention of re-creating a new and dependable National Health Service (NHS).13 In the pages that follow we shall therefore focus particularly on those countries where there are both novel forms of local resource management and collaboration, and educational innovations designed deliberately, or sometimes by default, to support the new organizational developments. Because the emphasis on decentralization and partnership often finds its expression in primary care agencies, as practice-based commissioning and primary care trusts in England readily illustrate, many of the international initiatives cited below will be derived from this service sector.

The data for this chapter are mostly derived from a 2007 literature review and international fieldwork over the 2001–06 period. This took place in 24 countries where new forms of primary care were being developed in response to national policies that emphasized the benefits of both decentralization and new cross-boundary partnerships. This research was commissioned by the UK Health Foundation and Department of Health, which were keen to identify and draw on global best practice in those areas of the NHS where central policymakers recognized significant shortfalls. One of these was in the area of community-based healthcare education. The whole research programme has been widely reported elsewhere, with the peer-reviewed publications,4,5 including those specifically dedicated to relevant ‘modernizing’ educational developments in other countries.6,7

Context

The essential values expressed in this chapter are those of parity and reciprocity. They represent the normative context for transferable learning between countries in relation to medical education. They also constitute important contemporary values for those learning to become doctors today. As such they belong to the modern international idiom of relational healthcare, which views the quality of relationships as the conduit for converting formal health status into an actual sense of well-being.

This is a view frequently expressed by those leading the development of medical education in economically disadvantaged countries, where financial stringencies serve to restrict the growth of specialist scientific disciplines. Cost containment is, for example, a critical factor at the University of San Jose in Costa Rica where students at the Medical School are taught Social Development as a statutory responsibility, and the director of postgraduate studies is also titled Head of Social Action. The relational viewpoint is also, however, growing in its influence in the UK and some of the more economically developed and market-oriented countries. Here too there are growing pressures for increased financial controls over the use of expensive new therapies and clinical techniques, and these pressures coincide with an understanding that such therapies and techniques can only be managed effectively by doctors who acquire skills of communication with not just individual patients but with whole communities as well. In Costa Rica virtually all of its 1800 community-based doctors have attended one of the San Jose Medical School’s five local campuses to gain a 14-module local healthcare management qualification. This underpins not only the contracts for medical provision in nationwide Social Action Development agreements between the university and the central Department of Social Security, but also their joint development of telemedicine as a community-oriented training resource. This is available daily to trainee doctors and their supervisors at the local ebais clinics throughout the country. For an NHS of foundation trusts and Public–Private Partnerships (PPPs) in England, the future parallel with this development in Central America may well lie in the relationship between university medical and business schools and the joint development of social marketing and community development modules for their combined students.

This comparison of Costa Rica and the UK points to the pivotal principle of international exchange in relation to any aspect of health systems development. Always adapt; never adopt. Seek to emulate; do not try to imitate. Context is all important, and this is especially true for medical education where sensitivity to cultural constraints – and opportunities – is overwhelmingly important. The case example of Costa Rica may stimulate new ideas, or it may act as a warning sign. It may even inspire; but it cannot simply be copied. The model of medical education of one state cannot successfully be imposed in the different environment of another. A vivid illustration of this statement is that within 5 years of the Berlin Wall being dismantled the Soviet Semashko model was almost unrecognizable throughout many of the former Russian satellite states.

This imperial reference is especially relevant to the UK where colonial traditions cast a long shadow over the mindsets of those leading medical education, even in the ‘modernizing’ post-Millennium era. The historical legacy is that of an independent sovereignty, which has often bordered on a sense of overweening superiority. For the NHS as an institution, and for British medical schools in particular, there is still the risk in the future of this past bequeathing an insularity that inhibits genuine two-way learning with other countries. Such an attitude, for instance, would be unthinkable at their Costa Rican counterparts where the Millennium Development Goals of the United Nations and World Health Organization8 are formative influences in the shaping of learning objectives. In the UK Global Health remains a foreign subject9 and, indicatively, even since 2000 standard texts for general medical practice trainees and trainers from one of the country’s most established healthcare publishers contain virtually no international references beyond those to WONCA.10,11 A popular official handbook for medical course organizers, issued long after the General Medical Council signalled its intention of ensuring that tomorrow’s doctors would be more multifaceted and primary care oriented,12 continues to refer to international settings solely in terms of a final chapter’s set of warnings on the risks faced by medical students if they should venture into Africa, Eastern Europe or, as the worst scenario, any of the countries of the Middle East.13 Much of the text reads as if it could have been written, if not in Victorian times, at least half a century ago.

For the UK medical education has been a one way street. Other countries learn from us. The medical schools of London, Manchester, Southampton, and Edinburgh have been seen in the UK as the basic reference points for the rest of the world: setting the standards and sustaining a professional infrastructure of Royal Colleges in the many different specialities of medicine that has spawned successor bodies across the world, from Thailand to Latvia and from Portugal to the West Indies. A willingness to be open to ideas and innovations from other countries has only come relatively recently. Ironically, this change of attitude has in part taken place among the British as a reaction to a new imperialism represented by the USA and the export of its health maintenance and managed healthcare models. The educational requirements needed for effective performance within these are no longer derived from vocational or personal orientations with self or internal regulatory mechanisms. Rather they follow what has been identified as a growing trend in Western countries towards learning as certificated ‘repeat production’ with external regulation that is bureaucratic in character and focused on details and procedural compliance.14

With the mantra of ‘evidence-based medicine’ the new American service models have their academic origins in Californian, Minnesota, and New England medical universities, where there has been the backing of powerful pharmaceutical and life science corporate interests. In the UK many medical professionals and educationalists, and central policy makers, have felt an urgent need to counterbalance these. A new interest in alternative approaches to community participation, combinations of health and social care services, health promotion, and interprofessional practice has arisen as a result as part of this reaction. With this new interest has come a willingness to learn from those countries where these components of contemporary health systems appear to be more advanced and, of course, effective in terms of maintaining medical status.

Transferable learning

Systems of medical education and healthcare do not automatically align. Indeed a creative tension between the two can generate a powerful and positive dynamic. In Chile, for example, there are some of the most multiprofessional healthcare teams in the world and the Catholic University in Santiago has been instrumental in their development. Its crucial role over 2003–06 was to redesign medical curricula to support six initial zonal health centres in which nutritionists, dentists, physical and occupational therapists, drugs dispensers and psychologists train and work alongside general medical practitioners, all responding to referrals triaged by an integrated community welfare and nursing team. The university role only crystallized, however, after the country had withstood two general strikes in which medical unions played a leading role; and significantly, the chief academic architects of the new curricula include immigrant medical educators from such countries as Germany, Ecuador, Bolivia, and even the UK. In a similar fashion the San Jose Medical School of Costa Rica cited (p. 182) drew on the legitimacy and stimulus provided by its enduring external links with McGill University in Canada and the Karolinska Institute in Sweden to help push through the quality assurance arrangements and primary care placements required for the implementation of its Social Action educational and ethical research programmes.

Without such levels of support and skilled facilitation the political balance between medical education and practice can easily be lost. In modern Britain there has been the danger of a cultural dissonance between the two comparable with that of New Zealand in the 1990s. Here the attempts to promote market competition in both the healthcare and higher educational sectors in tandem backfired as universities forged ahead while Crown Enterprise hospitals and mixed public–private status primary health organizations, sensitive to the needs of the indigenous Maori and other minority populations, lagged far behind. The result was a reversion over time to a more localized and less market oriented model of medical education, although with a stronger continuing emphasis on workplace learning.15

A similar gap between the curriculum and clinic has undermined successive attempts in Canada to roll out several otherwise internationally impressive developments in social medicine. The professional control of the former at provincial level, where the interests of independent practices and specialist consultants in hospitals tend to prevail, has successfully checked both local and national attempts to disseminate, for example, Quebec’s approach to community health centres and Ontario’s family health networks.16 Indonesia, Zambia, and Thailand are among the other countries that have endured parallel experiences,17 while the paramount importance of integrating major structural developments in medical education and healthcare practice has been demonstrated by the highly successful Ugandan Sector Wide Approach to both AIDS/HIV and malaria epidemics. In Uganda policymakers have consciously sought to adhere to the tenets of the World Bank’s Comprehensive Development Framework, by establishing universal primary education as the platform for universal health promotion.18,19

The danger of medical education and medical practice being in not only a dissonant but also even a destructive relationship because of a lack of alignment with national health systems points to the need to define clearly the latter and their development. Even for parallel national systems being re-engineered in accordance with the ‘modernizing’ principles of partnership and decentralization there are substantial variations in organizational form. From a primary medical care organizational perspective the recent Warwick University research was able to recognize five types worldwide,20 and with each of which a specific style of medical education can be associated as an appropriately applied pedagogy. These are set out below with examples of universities where medical educators are internationally – but not exclusively – recognized as leaders in the particular mode of learning.

For the UK the extended general practice would seem at first glance to be the organizational model that is most evident in the NHS environment. Certainly such medical schools as those of Leicester, Sheffield, and Exeter Universities have been closely associated with both the development of interprofessional practice based teams and the adoption of problem-based learning (PBL) approaches.2123 The two are mutually reinforcing. The PBL approach is to focus on the person of the patient, not just the symptoms; and the perception of the patient of his or her illness, rather than more narrowly on a scientific definition of the clinical condition. This opens the way for a range of professionals to contribute from their different sources of expertise and experience to the negotiation of diagnostic meaning and alternative intervention options. PBL is very much in the British tradition of family doctoring with loud echoes of one of its founding fathers, Michael Balint, who was writing at the time when the first Department of General Practice was established in a UK university medical school in Edinburgh.24

Closer examination of the organizational models in Table 13.1, however, quickly leads to the appreciation that the extended general practice is not the only modern international health system rooted in decentralization and partnership relevant to the UK. Indeed, it soon becomes apparent that they all are. Indeed, on reflection, it may well appear that the educational approaches attached to some of the newer primary care organizations are likely to exert the most powerful influences over future curriculum developments in medicine. As a result there is a clear logic in suggesting that they may well then also lead to more efficacious processes in healthcare delivery itself for collaboration and local resource management.

Table 13.1 International systems of healthcare delivery and education.

Primary care organization

Educational model

Curriculum leaders

Host nations

Extended general practice

Problem-based learning

Maastricht, Kuopia, Linjöping Universities

The Netherlands, Finland, Sweden

Managed care enterprise

Evidence-based medicine and management

Minneapolis, Metropolitan (Mex), Auckland Universities

USA, Mexico, New Zealand

Polyclinic

Transdisciplinary/values-based

Londrina, Santiago (Catholic), Newcastle (NSW) Universities

Brazil, Chile, Australia

Community development agency

Civil society/citizenship approach

Chiclayo, El Alto, San José Universities

Peru, Bolivia, Costa Rica

District health system

Community based education and service

Moi, Gezira, Western Cape Universities

Kenya, Sudan, South Africa

It is not difficult, for example, to recognize that the managed care enterprise finds its expression today in the NHS primary care and foundation trusts and the promulgation of practice-based commissioning. Given the strong political and economic ties of the two countries a two-way relationship between the UK and the USA is scarcely a surprise, with the latter already claiming to possess by the turn of the century over 28 000 scientifically endorsed clinical guidelines as a teaching resource for the evidence-based medicine, and management approach.25 Similarly, the hybrid organizational developments that characterize healthcare franchises in such countries as the Philippines and Colombia, where institutional outreach services are often the norm, have their Western counterparts now in the growing number of mixed public–private status social enterprises.

For both the growing movement towards values-based education in medicine (VBM), at such universities as far apart as Warwick in England and Newcastle in Australia, helps underpin and legitimize the often commercially oriented changes taking place. At the heart of VBM is a liberal educational impulse that seeks to ensure that new doctors are more sensitive than their predecessors to very different ethnic, social, and generational expectations of what comprises health, who constitutes an effective healthcare practitioner and where treatments take place. It is an impulse designed to help those involved in both the teaching and learning of medicine acquire the skills and mental attitudes required to practice successfully in a globalized and multicultural society. Its logic of tolerance also paves the way for novel organizational models in which, for example, hospitals are no longer largely closed institutions but hub and spoke models and patients are consumers and customers as well. Greece offers a role model for such a style of development with its multiple forms of healthcare in its 17 geographic health regions, in all of which the Presidents also hold academic appointments in university medical and healthcare faculties.26

Both VBM and evidence-based medicine are pedagogic developments that internationally have a particular appeal to medical schools in the private sector. They can both be understood as market oriented and focused on the individual user. As such they are attractive to sponsors, from the pharmaceutical industry and elsewhere, and are still seen as socially responsive and responsible. Globally such educational developments are paving the way for a major growth in the number of private medical schools, in relatively few of which is general medical practice or family medicine included in the curriculum. The figure for example is less than 50% in four of the countries cited above: Chile, Colombia, Greece, and the Philippines; and similarly low proportions apply in such other countries as Slovakia, Mexico, and Thailand where the private sector expansion of medical education seems synonymous with additional profit-oriented medical specialties.

For the UK some of the most interesting developments in medical education are taking place in the ‘modernizing’ countries of Sub-Saharan Africa and Latin America. Their relevance to the UK arises from their peculiar strengths in relation to participation, not least in terms of course design. In both parts of the world the relationship between medical education and medical practice is more interactive than it is in either Europe or North America. The development of service and curricula go hand in hand. Doctors do not simply train and then do medicine. Education and practice are in a concurrent not consecutive relationship. They are not seen as sequential. They continuously shape each other. The outcome can be a real dynamism in medical teaching and learning.

The community development agency has been the principal organizational model recently espoused by most ‘modernizing’ policy makers in Latin American healthcare. Its most obvious characteristic is the inclusion of substantial and sometimes majority lay representation on the management boards of medical service units. Among these representatives, almost invariably, are university academics from a range of healthcare and non-medical disciplines. In return university decision making structures are heavily weighted in favour of local community representatives. These changes need to be understood in the cultural context of a continent in which the regeneration of professions and the relationship between professions is part of a widespread move to create new civil societies, often in response to catastrophic civil conflict and breakdown.

The community development model can be found as part of the Progresa programme in Mexico aimed at extending primary care to five million more people partly through 1-year rural training and work placements for final year medical students; as part of the nationwide Misiones in Venezuela where voluntary local health cooperatives have been instrumental in the development of a new 5-year integrated family and social medicine qualification; and, of course, in Brazil with its 5000 new local community health and welfare centres where the transdisciplinary approach to medical education is most apparent in the mix of health and social care students training together. Among the various initiatives taking place in Latin America Peru, however, remains the exemplar of the modern civil society approach to medical education and practice.

By 2003 there were 760 Comunidades Locales de Administracion de Salud (CLAS) in Peru responsible, under the terms of the Ministry of Health’s 2002 decentralization laws, for the management of over 1200 local clinics and hospitals.27 A CLAS managing committee usually consists of a medical director and six lay members, of whom three are elected by the local community and three selected by local social organizations, including educational establishments. Each member has a designated lead role for a community health education priority. Nationally the CLAS come together in the regional and national assemblies of ForoSalud, a forum for civil society development that promotes holistic health and well-being principles and cross-sectoral collaborations. Its intellectual leadership comes from the social sciences, and much of its funding from liberal grant making foundations in the USA. The outcome for medical education is a national ‘Future Generations’ programme based on ‘Social Managerialism’, with medicine inextricably linked to issues of social control.

Existing Peruvian doctors did not originally want this. The changes only came after the debate about medical practice and its educational prerequisites was brought together in what were termed ‘Service circles’ that embrace, in particular, local women’s movements and seniors’ groups alongside health and education professionals. A supportive policy and financial framework was provided from 1991 to 1997 by the government’s National Fund for Social Development and Cooperation, which sought explicitly to ‘overcome medical opposition and resistance’. This has had its counterparts in Nicaragua, Bolivia, Mexico, Chile, and Costa Rica. In each of these today university medical schools have ownership of and accountability for up to 10% of the countries’ healthcare facilities, with local community support. These facilities are the sources of ongoing curriculum change and testify to the scale of change taking place in Latin America through the implementation of a global ‘Towards Unity for Health’ (TUFH) paradigm that postulates a five-way equivalence and interdependence between local communities, medical professions, national politicians, higher education, and private businesses.28

The TUFH philosophy has been endorsed by the World Health Organization. In Sub-Saharan Africa this has worked alongside the World Bank and the UK Department for International Development to support the district health system model and sector-wide approach to strategic aid and development. Based usually on population units of about 500 000 both demand a new multistakeholder approach to medical education, with non-governmental organizations especially influential because of the economic reliance on external charities and benefactors. In Uganda, for example, the creation of a combined curriculum for nursing, pharmacy, dentistry, and medicine through the local outreach training centres of Makerere University has been dependent on generosity of the Rockefeller Foundation, CAFOD, Action Aid and other donors. Parallel developments for trainee doctors can be identified throughout South Africa, Kenya, Tanzania, Malawi, and the Sudan. In each there are differences of emphasis in curriculum development. In South Africa the subject of rehabilitation is a recurrent feature of, for example, the ‘Shared Community Based Practice’ programme of the Western Cape University where trainee doctors and physiotherapists undertake placements together, while at the Durban Medical School a PBL approach is utilized in trainees’ community attachments across Kwa-Zulu, Natal in which budding occupational therapists are especially prominent. In the Sudan meanwhile, at Gezira University’s Faculty of Applied Medical Sciences in Khartoum, it is health psychology that supplies the topic on which medical students come together to learn as undergraduates with counterparts from all the other healthcare disciplines.

The African model of medical education with the widest international reputation is that of the ‘Community Based Education and Service’ pioneered in northern Kenya by Moi University. Based on a series of partnership arrangements between the medical school and the people of Eldoret, after an initial induction visit, students spend from year 2, a minimum of 3 weeks a year located in a community health facility as part of an interprofessional team working with local people to identify needs and to develop programmes to address specific healthcare priorities. The focus is on disease prevention and neighbourhood capacity building. Medical and other healthcare students do not simply have the chance to test and extend their learnt clinical skills outside hospital settings, they also learn as doctors how to become integral to the process of defining health, planning services, and locally respond to identified needs, which can range from new vaccination campaigns to freshwater jars and daycare schemes. As a result in Kenya the concept of medicine in Kenya is genuinely multistakeholder, incorporating not just intra- and interprofessional learning but community education as well.

Conclusions

The examples from Sub-Saharan Africa illustrate again the importance of locating medical education in its cultural context, even at a time when there is greater scope for transferable learning between countries because of the comparability of contemporary healthcare reforms based upon organizational principles of partnership and decentralization. Sensitivity to particular context remains still of crucial significance in medical education, where developments ‘precipitated’ by top-down structural initiatives are often counter productive. As the recent experience of many countries, including both the UK and Canada indicates, an awareness of the ‘enabling’ historic, social, geographic, and, above all, political determinants of a health system continues to be the platform on which progressive interprofessional and community-oriented changes in curricula can be built.29,30 However, it is now evident that this awareness should incorporate international perspectives, sometimes from previously unlikely locations; and that there is clearly a potentially rich resource for UK medical schools to draw upon in other countries.

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