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Tradition

The University of the West Indies (UWI) began in Mona, Jamaica in 1948 as a peripheral site of the University College of London (Branday and Carpenter ). Despite a humble start with 33 medical students, the UWI has retained its emphasis on serving the Caribbean community (CARICOM) with an array of professionals within the medical, natural and social sciences, and the art fraternities. As three campuses emerged, each specialized in one of the triumvirates of professions: medicine (Mona, Jamaica), law (Cave Hill, Barbados), and engineering (St. Augustine, Trinidad). With time, the needs of our community continue to diversify; globalization reinforces the fact that as professionals, we must also reinvent ourselves and redefine the quality of service being given, and thus today all campuses offer these programs. 

Within the Faculty of Medical Sciences Mona (FMS Mona), community health has linked both students and staff inextricably to patients in rural and underserved populations. In 1948 a student by the name of Kenneth Standard enrolled in medical school. Given his achievements, today he is seen as “the father of social accountability in medical education in the Caribbean.” Social accountability of medical schools was defined in 1995 by the World Health Organization as “the obligation to direct their education, research, and service activities toward addressing the priority health concerns of the community, the region, or nation they have a mandate to serve. The priority health concerns are to be identified jointly by governments, health care organizations, health professionals, and the public” (Boelen and Heck ). More recently the Global Consensus for Social Accountability of Medical Schools (GCSA) defines a socially accountable medical school as one that “responds to current and future health needs and challenges in society, reorientates its education, research, and service priorities accordingly, strengthens governance and partnerships with other stakeholders, and uses evaluation and accreditation to assess their performance and impact” (Global Consensus for Social Accountability of Medical Schools (GCSA)).

Kenneth Standard drew on his experiences pursuing the MBBS degree at UWI and a Master of Public Health at the University of Pittsburgh to improve services offered to patients. As the first Head of the Department of Social and Preventative Medicine at the University of the West Indies, his greatest work was implementing a Community Health Aide program in a community nearby the UWI Mona campus called August Town. In this program, volunteer doctors and nurses trained residents in basic health care geared towards the unique needs of this underserved community. The program set the foundation for a standard to open a community health clinic at UWI where medical students would learn as they served other adjoining communities. This historic action contributed to the high clinical involvement of medical and allied health care students during their training at the Faculty of Medical Sciences (FMS), Mona. These initiatives along with others earned Kenneth Standard a national award from the Jamaican government, Commander Class in The Order of Distinction (1976), and the Order of the Knight Bachelor (1982) from Her Majesty Queen Elizabeth II. While vital, where do these advancements leave us today?

Innovation

The Bachelor’s in Medicine, Bachelor’s in Surgery (MBBS) program at UWI Mona has a high percentage of secondary school graduates matriculating into the program. This reflects in volunteerism of students, who are passionate about service but may lack the clinical and social acumen. To enrich the quality of student volunteerism, over the past two years, the FMS has promoted social outreach among its health professional students. Under this initiative, students travel to rural areas and work under supervision to deliver care to members of these communities. Medical students enter this outreach initiative with different levels of training and expertise given the Bachelor of Medicine, Bachelor of Surgery (MB BS) program is five years long. A model was therefore proposed to supplement students’ abilities prior to outreach and to match these to specific engagements during the outreach. 

Phase 1 of the MB BS program is three years long and is largely pre-clinical followed by two years of clinical clerkships. For the purposes of this model, students are placed into three tiers:  Tier 1: 1st and 2nd year; Tier 2: 3rd Year Pre-clinical; Tier 3: 4th and 5th year. Common social outreach activities were assigned to the different tiers with support including pre-activity training prescribed. 

Consequently, the model stratifies activities according to the level of medical education completed by students. By doing so, faculty members may approximate the abilities of students and facilitate opportunities for supplementary student training. 

Table I

As community outreach activities are being expanded within the FMS’ strategic plan for improving social accountability, this model will be implemented and evaluated over the coming year.

Tradition of Excellence

Service, in the form of volunteerism, has evolved from individual medical students assembling as requested or needed. Through cultivating students’ skillsets, the FMS Mona may increase its efforts to tackle healthcare inequities in underserved and vulnerable populations while simultaneously endowing students with the ability to do the same. Students will benefit from increased clinical exposure, as well as lifelong skills such as healthcare advocacy, ultimately benefitting patients and the health system. 

The model also allows FMS Mona to further adapt its curriculum to develop socially accountable young professionals wholly invested in the wellbeing of their clientele. Implementation of the model may span to include several student organizations which pioneer student led initiatives including the Jamaica Medical Students Association (JAMSA), Jamaica Dental Students’ Association (JADSA), Physical Therapy Students’ Association PTSA), and the University of the West Indies Student Emergency Response Team (UWISERT), an interprofessional student-run Emergency Medical Services (EMS) team trained and supported by the Faculty.

The Interprofessional Future of Social Accountability at UWI, Mona

An international meeting of medical education experts in 1994, called jointly by the World Health Organization (WHO) and the Educational Commission for Foreign Medical Graduates (ECFMG), affirmed that serving the specific needs of populations and individuals is an essential part of the definition of quality of medical education and should be an important goal of all medical schools (Gastel). With more innovations on the horizon, students and staff from the FMS Mona can continue re-defining the range and quality of services delivered locally, regionally, and globally from this generation to the next. Going forward, accrediting bodies for medical schools in promoting standards for medical education must see social accountability as a marker of excellent medical education. 

Perhaps in the future the next innovation could be an interprofessional student-run volunteer clinic solidifying the university’s commitment to its community.

Works Cited

Boelen, C and J Heck. Defining and measuring the social accountability of medical schools. Geneva: World Health Organization, 1995.

Branday, JM and RA Carpenter. "The evolution of undergraduate medical training at the University of the West Indies 1948-2008." West Indies Medical Journal Vol 57(6) (2008): 530-6.

Gastel, BA. "Gastel BA (1995) Toward a global consensus on the quality of medical education: serving the needs of populations and individuals." Acad Med, 70 (7 Suppl) (1995): 73-5.

Global Consensus for Social Accountability of Medical Schools (GCSA). 2010. 23 June 2019. < http://www.healthsocialaccountability.org.>.

Author Bios

Toni-Ann A. Mundle is a fourth-year medical student at the University of the West Indies Mona Campus. She currently serves as the deputy student leader for Social Accountability and Interprofessionalism. She aspires to be an Obstetrician-Gynecologist and a health policymaker in Jamaica, with special focus on Gender Equity and Transplant Medicine.

Dr. Tomlin Joshua Paul is the Dean of the Faculty of Medical Sciences at the University of the West Indies, Mona, Kingston 7, Jamaica. He received his Bachelor of Medicine, Bachelor of Surgery (MB BS) from the University of the West Indies, Mona and did advanced training in Public Health and Epidemiology at the Johns Hopkins University. He is a Diplomat of the Faculty of Public Health Medicine of the Royal College of Physicians, UK, and a Fellow of the Academy of Medical Educators, UK. He has a teaching career of more than 30 years at the University of the West Indies, Mona during which he received the Vice Chancellor’s Award for Excellence in Teaching and the World Organisation of Family Doctors’ Five Star Award for the North American Region. Dr. Paul is an advocate of social mission in health professions’ education and has been a consultant to the Pan American Health Organisation (PAHO) in the development of policies and tools to assist training institutions in capacity building for socially accountable programs. He is a past member of the Board of the Caribbean College of Family Physicians and an executive member of the Consortium for the Advancement of Social Accountability in Health Professions’ Education in the Region of the Americas.

Nikolai J. Nunes is a final-year medical student at the University of The West Indies Mona Campus, where he serves as principal student leader for Social Accountability and Interprofessionalism. He is a future Emergency Medicine physician, and he is a passionate advocate for Universal Health Coverage and Global Health Workforce.

Background

English and French are the two official languages in Canada. The French-speaking population is present all across Canada. The province of Quebec is the only province where French is spoken by the majority (85 percent). The French-speaking population living in a minority setting, however, totals more than one million with percentages that vary in provinces and territories from 1.9 to 33 percent of the total population respectively. In 2001, the Association of Faculties of Medicine of Canada (AFMC) during a strategic planning session under the theme of social responsibility identified that the Francophone minority of Canada was a vulnerable population compared to their Anglophone counterparts. In general, access to health care in their mother tongue was limited or totally absent depending on where they lived. Even though at that time, no research had been done, it was thought that linguistic barriers had a negative impact on health care services and health outcomes. In 2015, Dr. Sarah Bowen  demonstrated by means of an extensive literature review that linguistic barriers had a negative impact on: access to health care services, the experience and satisfaction of users, and, on the equity of services offered. 

As a result of their strategic planning, in 2001, the AFMC established its “Resource Group for French-language minority communities” which undertook the examination of this issue and produced a framework and action plan to address it. This group partnered, from the start, mainly with two community organizations being the Société Santé en français  which is a consortium of 14 health networks based in all provinces and territories where there is a French-language minority population and whose work aims to increase access to health care services in French, and, Médecins francophones du Canada  which encourages doctors to commit to providing quality health care services, gathers them in formal or virtual networks, and offers them resources and tools to support their initiatives and projects as well as their life-long learning. Together, these partners have developed Franco Doc, a socially accountable project to better respond to the needs of the Francophone minorities across Canada. 

Objectives of the Franco Doc Project (2014-2017) Phase One

The main goal of the project was to contribute to the development of Francophone medical resources by working with French-speaking medical students attending English-language faculties of medicine in Canada and having them contribute to the needs of the Francophone minority communities by means of an integrated interdisciplinary approach. The Franco Doc project set specific objectives to make this possible. The objectives were to: 

  • Identify Francophone and Francophile students in the 14 English-language faculties of medicine in Canada; 
  • Provide Francophone and Francophile students with experiential activities by increasing access to community-based hands-on training in Francophone minority settings; and
  • Facilitate collaboration between faculties of medicine and local Francophone community health networks. 

Franco Doc: Action Plan in Action

After having the action plan approved by the board of the AFMC, the Resource Group sought and obtained financial support from the Office of the Official Languages of Health Canada. A project director and coordinator were hired, and the action plan was implemented. Medical school deans were asked to identify a faculty champion for the project and the representative of the Société Santé en français’ Health Networks in the catchment area of the respective medical school were linked with this faculty lead. The medical faculty champion and Health Network community partner with the participation of French-speaking medical students formed the faculty-community liaison committees. These committees were supported by the Franco Doc project coordinator. These 14 committees have been the local drivers of the project. Medical students have been very enthusiastic and have greatly contributed to the activities. Médecins francophones du Canada has offered resources and tools to support the project activities.

Francophone and Francophile medical students have been identified by a self-reporting mechanism through medical school undergraduate secretariats and/or through medical student associations. 550 Francophone or Francophile undergraduate medical students were identified across Canada after the first year of the project and on average, an additional 150 new Francophone or Francophile admissions are occurring yearly. 

A variety of activities have been put in place by the liaison committees ranging from service-learning activities, medical terminology practice sessions, history-taking practice sessions,  networking with French-language communities, webcasting, and even French wine and cheese socials. In 2018-2019, 21 activities have taken place to date. This, all in an effort to inform, engage, and promote networking among faculty, students, and communities. On two occasions, the project offered a one-day leadership event for medical students where students learned about the importance of the increasing need for culturally and linguistically competent human health resources, developed leadership skills, and shared their success stories with Franco Doc. The goal of these two events is to help the participants plan their activities and experiences for the year to come. Attendees are given a certificate of recognition as an “Ambassadocteur” for their participation. We also produced an online toolbox  for students and others interested in the subject.

The project is now in Phase Two (2018-2021). Health Canada was very satisfied with the outcomes of the first phase which helped us secure a further three years of financial support. We are continuing with the same objectives but with some expansion. We hope to ensure sustainability of the objectives that are in place. First, we have established a partnership with the Canadian Federation of Medical Students and the Resident Doctors of Canada that will ensure yearly nomination of their respective member-representatives to our national steering committee. We have expanded the faculty community liaison committees to include postgraduate residents and we are looking at possibly adding student representatives from other programs like nursing, social work, clinical psychology, all in line with the needs of the communities. We are also linking with another project of the Société Santé en français being Franco Professionnel, which is looking at replicating or adapting the Franco Doc strategies to other health educational programs based on the needs of the communities.

We will be supporting the faculty liaison committees to put in place permanent identification measures for Francophone and Francophile students both at the undergraduate and postgraduate levels in order to screen their linguistic competencies. We are moving to identifying Francophone preceptors and linking Francophone and Francohile students through an online catalogue for clinical placements within Francophone communities. We will be supporting a range of activities as described above and continue to offer and encourage knowledge transfer and share best practices through constant communication. This most certainly will generate new ideas and contributions. A new Facebook page has been set up and is managed by Médecins francophones du Canada. The page is open to medical students as well as to other health professional students interested in French-language health services.

Discussion

Placing the Francophone minority community’s needs at the center of the initiative has been a stimulus for all. It gives the faculty an action plan to be more socially responsible towards this population. The faculty champion has the opportunity to reconnect and contribute to his or her community of origin. For the students, who indicated that they felt abandoned by their communities of origin, they are thrilled that they can offer services to their communities and are much more informed and conscious of the latters’ needs. The health networks of the Société Santé en français have a great opportunity to influence and interact with medical schools which is a very rare scenario and helps them to contribute more successfully to health human resources development strategies than they already undertake. Also, the networks of communities take an active part in educating learners and the medical schools about their realities. For Médecins francophones du Canada, they are fully meeting their mandate and have a greater visibility across Canada. 

This project has had major successes but also some challenges. We are working with 14 medical schools and 16 community networks that are different in size, located across a huge land mass, have varying resources, and, have their own priorities. The Francophone minorities need a voice both at the level of the AFMC and at the medical schools. Keeping both the AFMC and medical school managers engaged in the long run is a must. Hopefully, the newly added accreditation standard on social accountability will put to good use all of the strategies and activities of Franco Doc and the faculties will integrate them in their ongoing process. This collaborative approach with community partners, learners, and medical faculties will lead to an increase in linguistic competencies of future clinicians and to the active offer of French-language services in Francophone minority communities. 

Conclusion

Nurturing close ties between communities and faculties of medicine establishes the necessary conditions to better understand the challenges facing patients and better prepare learners to respond to those challenges more efficiently. This hopefully will increase access to improved quality and security in health care delivery as well as increased satisfaction and more equity for Francophone minorities in Canada. This project is a testament to major sustained social innovation and a model for best practices for any educational program looking to better respond to the needs of its respective minority populations.

1 Bowen, S. (2015) Language barriers in access to health care. Health Canada. publications.gc.ca/collections/

2 www.santefrancais.ca/

3 www.medecinsfrancophones.ca/index.fr.html

4 afmc.ca/medical-education/franco-doc/

Author bios

Dr Aurel Schofield is a graduate of Laval University in Family Medecin in 1980. He has worked intensively to develop both French medical services and French medical education in minority settings mostly in New Brunswick but also across Canada. He was the Founding Director at the Centre de formation médicale du Nouveau-Brunswick, Associate Dean for New Brunswick of the Faculty of Medicine and Health Sciences, Université de Sherbrooke and a tenured professor. He was also the Associate Dean for medical education at the Université de Moncton. Since his retirement he has been elected president of la Société Santé en français du Canada, has been project director for Training and mentoring group for Diabetes Action Canada and more recently leads the Franco Doc project of the Association of Faculties of Medicine of Canada. He has been awarded many prize and recognition including the Order of Canada in 2014. 

Danielle Barbeau-Rodrique is the Director of the Northern Ontario School of Medicine's Francophone Affairs Unit, established to ensure the implementation of the School's social accountability mandate and to support its commitment to a culture of inclusiveness and responsiveness to the needs of the Francophone population and communities of northern Ontario. The FrAUnit team is committed to establishing, supporting and increasing collaborative partnerships with Francophone communities and key stakeholders, as well as supporting all NOSM learners in their understanding of Francophone health and culture through academic and non-academic sessions and experiences.

Born in Sudbury, Ontario, Canada, Danielle has a bachelor’s degree in Translation and Interpretation from Laurentian University.  She is currently a M. A. candidate in Sociology (Applied Social Research) with a particular interest in Active Offer and the provision of culturally and linguistically appropriate health care.

Philippe Leblanc is a graduate from the University of Ottawa in communications and French studies. He has been working in the project management office of the Association of Faculties of Medicine of Canada since 2014. Initially, Phillipe’s work focused on the Future of Medical Education in Canada Postgraduate Implementation Project, a project to adapt the postgraduate medical education system to changing societal needs while improving efficiencies to support a more sustainable health care system. Currently he serves as the coordinator of the Franco Doc project, a project aimed at developing French speaking medical human resources in Francophone minority communities in Canada. 

Student nurses demonstrating water purification in a rural community

Problem and Context

Cameroon is located in Sub-Saharan Africa, geographically lying between West and Central Africa. The country has a population of 25 million people (CIA 2019). Health professions education in the country is supervised by three government ministries -- Higher Education (diploma and degree programs); Public Health (diploma programs); and Employment and Vocational Training (diploma programs). Schools that train health professionals in the private sector will have to be accredited by one of these ministries depending on the programs they intend to run. Some of the programs are harmonized (similar curriculum is used across schools) while some others are unique to the institutions running them. Where programs are harmonized, you will see similar activities, including internships taking place in the different institutions.

In the course of their programs in different institutions, students will undertake both clinical and community internships as is the standard. Clinical internships take place in hospitals while community internships take place in communities where primary health services are located. For the community internship to be successful, the school, the primary care health center, and the community leaders must collaborate. In the communities, the students will typically conduct health educations and community health needs diagnoses. These diagnoses usually paint a picture of community needs that are affecting the health of the people. The students will present this in their post-internship reports to receive a grade. The data thus generated was not used as the emphasis was on the internship as an academic activity to be completed by the students. Even though the reports usually included complaints from the communities who expected more than just assessments and health education, the institution didn’t think it could do more for them. The communities wanted intervention projects, but the institution did not have the financial resources that such interventions would warrant. We had to reflect on strategies to make the community-institution partnership more beneficial to the community members in a sustainable and cost-effective manner. 

Innovative Solution

A team from two institutions (Health Research Foundation Buea and Biaka University Institute of Buea) worked to develop a social accountability-based model. Social accountability was first defined by the World Health Organization (WHO) in 1995 as “the obligation of medical schools to direct their education, research, and service activities towards addressing the priority health needs of the community, region, and/or nation they have a mandate to serve. The priority health needs are to be identified jointly by governments, healthcare organizations, health professionals, and the public.” Both institutions have always tried to be socially responsible, i.e. describing social needs implicitly, internally setting their objectives, developing community-orientated programs, and internally assessing their successes (Boelin et al. 2016, 1078-1091). They equally ensured that their programs were socially responsive, i.e. explicitly describing community needs inspired by data from the community, being community-based, and measuring success through actually achieved outcomes (Boelin et al. 2016, 1078-1091). What was lacking was that the concept of social accountability had not been directly incorporated into their philosophy and operations. In this regard, they were more reactive than anticipatory in their projects, defined their success internally, and didn’t strongly consider unique solutions for each context. This critical awareness was essential in developing a model that built on community needs. It had to incorporate community stakeholders in addressing these needs using locally available resources, while at the same time identifying strategies to meet future needs.

The development of the model was influenced by the awareness of three key realities from past experiences: (1) there will be little or no external funding to initiate and sustain any identified projects; (2) rural communities have always demonstrated the ability to address some local problems by themselves; and (3) the presence of student nurses in the communities had always increased the number of service users visiting the health centers. The underlying assumption of the model was that students can be prepared to help communities to implement sustainable initiatives to address health and health-related needs. A special 12-hour orientation curriculum was developed to reinforce key aspects of community dynamics, leadership, and community participation. The goal was to strengthen their competence in managing relationships with communities. Communication, leadership, problem-solving, and team and cultural sensitivity skills were emphasized in this training. The training was designed as a workshop and delivered over three to four sessions during the week prior to their community postings. Students were then randomly assigned to the different rural communities with the students in the same community constituting one group. Each group was allocated a staff advisor whose role was to provide guidance and advise. The groups have their initial meetings on campus before moving to their respective communities where they spend 12 weeks. In the communities, the students are based in the health center where they are involved in all the clinical and outreach activities of the health center. Being final year undergraduate nursing students, they are expected to be able to conduct most of the clinical activities within their scope of practice with minimal supervision from the health center nurses. In the community, the students are expected to meet the traditional leaders, introduce themselves and their objectives in that community. This should help them secure authorization and support to visit homes, groups, and communal facilities and to work with community members. 

While there exists an established relationship between the school, the health centers, and the community leaders, each group of students has the responsibility to secure support and goodwill from community leaders and members. When they obtain the blessings of the community authorities, they start conducting visits to homes and other facilities (schools, markets, water catchments, etc.) within the community. In the course of these, they establish a diagnosis of the health and health-related needs and then coordinate with community members to develop and implement appropriate solutions to a selected problem. The solution must be realistic and require only resources that can be mobilized within the community. 

In summary, this student-led model has the following components: empower, negotiate, assess, collaborate, intervene, evaluate, and report (ENACIER).

Student nurses (in white t-shirts) conducting health screenings in a rural community.

Unique Characteristics of the Model

Many articles on social accountability have focused on medical schools (Boelen, Dharamsi, and Gibbs 2012, 180-194; Pourabbas et al. 2015, 77-80; Boelena et al. 2016, 1078–1091; Abdolmaleki et al. 2017, 55-70). The ENACIER model was tried with nursing students and shows distinct characteristics from other social accountability models used in the health professions. The Training for Health Equity Network (THEnet) advocates for a socially accountable transformative workforce (International Federation of Medical Students Association -- IFMSA and THEnet 2017, 2). Their model provides a value-based process to guide medical institutions to evaluate the level to which they are meeting the needs of the communities they serve (IFMSA and THEnet 2017, 2). This is an in-ward looking system for the members of the institution to assess the institution’s own level of social accountability. The Global Equity Gauge Association (GEGA) in 2003, proposed a framework that was based on social justice and sought to emphasize advocacy, community empowerment, and assessment of health inequities. Another model is the CARE (Clinical activity, Advocacy, Research, Education and training) model. This is a tool for identifying priority health concerns of underserved communities so that the institution can implement cultural and curricular change to help address them (Meili, Ganem-Cucena, Leung and Zaleschuk 2011, 1114–1119). All of these models revolve around improving health access for disadvantaged groups. A model of social accountability that slightly deviates from these examples is the AIDER model. AIDER (assess, inquire, deliver, educate, and response) is a “continuous monitoring process that explicitly incorporates reciprocal education and continuous collaboration with underserved stakeholders, integrating community participation at all levels (Sandhu, Garcha, Sleeth, Yates, and Walker 2013, 1404-1405). The model is cyclical and continuous and though it integrates community participation, it is driven by the physician. Greer et al. (2018, 60-65) describe another community focused model -- NeighbourhoodHELP, in which students in their medical program are assigned a household in medically underserved neighborhoods. For three years they partner with students from other schools to provide home care services to their selected household. 

Community participation is the common factor in the ENACIER and AIDER models. When the community is involved in all aspects of these processes, they become empowered to take on these issues on their own. However, the ENACIER model is unique in that it is student nurse driven and designed to play two major roles: developing specific competencies in the learners and bringing palpable interventions in communities. 

The Empower Model focuses on developing the student nurse’s ability to access the community as professionals with the goal of helping the community develop homegrown solutions to jointly identified health and health-related problems. This is achieved through the intensive 12-hour preparatory curriculum and the input of the staff advisor. This academic staff-led process takes place in school and does not include community members. This explains why it is not included in the cycle of activities that occur in the community.

Negotiate deals with the process of the students navigating power structures and community groups to build trust and secure support. They meet the traditional authorities, group leaders, and other influential members of the community whose help is needed to facilitate their work and stay in the community. A failure of this aspect will result in limited access into the community. This might mean student nurses will not be able to work beyond the confines of the health center.

Assess involves the students identifying first the community structures and persons they need to work with. Once negotiations are done, not every stakeholder will be needed for the next phase of activities. For example, after meeting the traditional ruler of the community and securing his support, the students have to identify the quarter heads that they will need to coordinate with on a daily basis. This will depend on many factors including which part of the community they will want to focus on. Some communities are so large or have inaccessible areas that influence where the students can work. Next, the students with the collaboration of those identified, use appropriate diagnostic tools to identify health and health-related needs of the community. 

Collaborate emphasizes building a coalition of community members, institutions, and the health center staff in the process of developing solutions to the selected problem. 

Intervention refers to the joint implementation of the agreed solution to the identified problem. The students and community choose an intervention that is completely within their capacity to implement. They set their objectives and indicators that will help them gauge the level of success. The students are instrumental in helping the community to identify these resources within themselves and how to use them to solve their health and health-related problems.

Evaluate has to do with the project participants evaluating the level of success in the implementation. This is guided by the objectives they set out at the beginning of the intervention.

Report is where students use a format provided by the school to prepare an academic report on the entire process and its outcomes. Copies of this report are shared with the health center which shares it with other community leaders and structures. The report findings from the previous year usually contribute to the negotiation process for new student groups.

Figure 1: An illustration of the ENACIER model.

 

Figure 2: The ENACIER Model

The ENACIER model considers a three-way partnership between the school, community, and health center. The health center drives primary care in the community but is usually underutilized in the local communities. Utilization significantly goes up during the 12 weeks that students are deployed in the community health centers. Using the student nurses to strengthen the bond between the health center and its community ensures that projects developed as such can continue even during the months when students are not in the community. The model does not require deployment of significant resources as the parties learn to use only what is at their disposal therefore fostering a spirit of self-reliance as well as a new approach to dealing with community challenges. Another significant difference between our model and other models is that it is not disease focused. Any factor that has a direct or indirect effect on health could be addressed if the participants so desire. This allows us to achieve social accountability, empower communities, build networks, turn students into change leaders, and demonstrate that public-private partnerships are possible even in the most peripheral rural settings.

Outcome and Impact 

From the 2010/2011 academic year when this model was first rolled out, right up to the 2016/2017 academic year, a total of 585 final year undergraduate student nurses have taken part in the program as shown on Table 1 

Table 1: Student Participation Rates in the ENACIER Model

SN Academic Year Number of Students
1 2011/2012 88
2 2012/2013 78
3 2013/2014 126
4 2014/2015 82
5 2015/2016 100
6 2016/2017 111


During this time, student-community led interventions successfully took place across 10 communities: 

Type 2 diabetes management (two communities): student nurses used point-of-care testing to screen and diagnose people with diabetes mellitus. They went on develop nursing management plans which were implemented both at the level of the patient’s homes and the health centers. This activity was not part of the routine activities of the health centers in these communities. Treatment and care also included health education on diabetes. 

Water sanitation (six communities): the projects here included laying down pipes to bring water from catchment sources into the community so that communal taps could be available; support construction of a water catchment; and enable the development of a plan for routinely cleaning the central water source.

Teenage pregnancy control (one): in one community with high prevalence of teenage pregnancies and school dropouts, the student nurses worked with young people to increase awareness of reproductive health. The result was a 70 percent increase in the number of teenagers who came to the health center for birth control services in the first year of intervention alone. 

Refuse management (one): in this community the student nurses and the community worked to establish a system of separating refuse. Biodegradable refuse was deposited in the farms to serve as organic manure while plastics and other nondegradable materials were taken to dumps managed by the local council.

All communities reported greater satisfaction with the model. The students too reported increased readiness to work in rural communities and the feeling of fulfilment from helping the communities to realize these projects. Student reports showed significant evidence of leadership competences. Two projects (diabetes management and aged curriculum development) built from this model template have been published as health professions education innovations in the Medical Education Journal. 

The rural diabetes management project used a 12-hour curriculum to prepare student nurses to use point-of-care testing to screen, diagnose, and manage diabetes mellitus in two rural communities (Leke, Portwood, and Maboh, 2013, 1122). During the 12-week internship, the students applied the ENACIER model with significant results. They worked with the health center nurses to screen for, and manage, the care of diagnosed diabetics and high-risk cases. In the first year of implementation, a total of 334 clients were screened; overall diabetes prevalence was 4.89 percent; 11.31 percent were at high risk; and 35.78 percent were at risk (Leke, Portwood, and Maboh 2014, 37-44). The project’s successful implementation in two rural communities benefited the patients, community members, health center staff, and students. This project still operating on the ENACIER model received a three-year World Diabetes Foundation grant in 2017, to expand the project to six rural communities. 

The ENACIER model was also adapted in the development of the first community-based curriculum for geriatric nurse training in Cameroon. Using findings from previous student-led community projects, a one-year post-registration curriculum was designed to train nurses in geriatric care. At the core of the design is the care of older adults within their own homes and communities (Maboh, Leke, and Nyenti 2013, 1121). This curriculum was culturally sustainable because it built on the traditional values and perceptions of aging. Family caregivers and older adults, through interactions with the student nurses learn more about aging and how to provide care and support for the elderly members of the family. Community-based elderly groups are key partners in the program as they provide more extensive access to older adults living in their communities. More than 100 graduates have successfully completed this program between 2011 and 2017. While many of the graduates have gone on to find jobs and further education opportunities, two of them started their own independent community-based elderly care services.

We have seen stronger cooperation ties between the school and communities. The reception of students and the cooperation they receive in the community keeps growing. The project team has received recommendations from beneficiary communities to get other schools that send students for internships to adopt this model. The health center staff and regional health officials of the Ministry of Public Health have also increased their support and cooperation with our school. Most importantly we have graduates from this program working in all the health districts that have been used for this project this far.

Expected Social Impact 

In introducing this model, it was expected that community internships could be transformed from a purely academic exercise where students pick up clinical skills in primary care centers, to a veritable tool in change leadership. The modification of the community internship was a response to local communities’ desire to not only be “used” for student learning but also to see real benefits from that interaction. At the institutional level, we expected to build consensus among academic staff and administrative staff to support a complete overhaul of this component of the curriculum for the final year nursing students. Staff called to play the role of advisors were expected to take a back seat and allow the students to lead their project as it best fit the context of the communities they were assigned to. This primarily advisory role also included potential for the advisor to work with the student groups to develop their reports into publications if they so desired. We also inspected the two institutions involved in the development of the model to adapt and expand the concept of social accountability actively across all other aspects of their services and operations.

At the local level, we expected to see increased satisfaction from the community and health center staff with our new approach. We also expected the health center staff while supervising the student nurses to also learn some new techniques and protocols from the students thus strengthening their connection. The improvement of quality care in the primary health centers was another expectation. Considering that final year student nurses have already acquired significant clinical skills, they were able to expand services in the health center. They could take on many simple routine activities that didn’t need direct supervision, thus giving the usually few nurses more time to improve on the quality of services. In some communities, due to low staffing levels, it is only when students come to the health center that home visits and other outreach services become a weekly routine once more. This strongly contributed to the increased utilization of the health center services during the internship periods. We also expected to see new community-based models being generated to address different aspects of community needs. The project team expected that other institutions will adapt the model to their own programs thereby making social accountability a permanent part of their operations. We also expected that through this model, there will be a general improvement in the overall health of the community.    

Internationally, many poor countries with primary care challenges could find this model as a simple, sustainable tool to use social accountability to achieve positive outcomes in health professions education, community health, and health systems improvement. Advanced countries with more developed health care systems can find aspects that could be incorporated into their systems as they try to move health care back into homes and communities.

Generally, we expected that stakeholders would realize that self-reliance and community cooperation could help communities solve quite a significant number of problems even without government or external support.

Funding of Model

The model did not require extra allocations as it was built into existing structures that were already being funded. The community internship already existed as part of the curriculum. It just needed to be modified to achieve the project goals. Deployment of students to communities including supervision visits by staff advisors were already part of the nursing department’s budget thus requiring little extra funds. In the communities, the stakeholders decided how they will secure the resources needed for the agreed intervention within their community. Student nurses needed only their routine clinical tools required during placements. They did not need any extra tools for this activity. Depending on the nature of the intervention, they could use existing resources in the health centers or work with community members to mobilize resources. For example, in one of the communities where a pipe-borne water project was selected, the students supported the community fundraising through health education on risks and benefits of pipe-borne water. So, community members saw reason to make small financial contributions towards the project. Financial resources are usually the most difficult to come by in these systems and as such, designing the model in such a way that no significant financial resources are needed increased the chances of success.

Scaling and Policy Implications

In centralized government systems like Cameroon, private sector and local communities have very little influence on policy development and implementation. Everything is centrally decided, funded, and implemented. However, the project team kept close contact with regional health authorities as different aspects of this project were implemented in the communities. Reports and data from the field are routinely shared with these regional authorities even as we seek to maintain their cooperation in facilitating access to the regional health structures. It is expected that this data sharing could influence some of their policy decisions. For example, we are expecting to see the diagnosis and management of Type II diabetes become part of the minimum package of activities of the rural health centers since access to specialized treatment centers in urban areas remains a challenge to rural dwellers. One avenue exploited for scaling the model has been other schools that train health professionals in the country.

The project team supported the third author in adapting the model for community health internships in a state-owned nursing school in the region. With support from Health Research Foundation, she was able to prepare students to lead communities with little or no access to pipe-borne water to use locally available resources to treat their drinking water. This project was started in 2015 and is currently in its third year. Another positive sign here is that the students of this second school are working with communities that have not been used for the project before. The students also went further to create a social media page where they shared their experiences in the community.

While this is the first time that the model is being published as designed, projects that were adapted from it have been published. These publications have helped other institutions to develop similar projects. For example, another institution in another part of the country, launched its own geriatric care curriculum four years after the successful implementation of the model developed by the project team. Health Research Foundation has developed a package to support both public and private health professions training institutions to implement the ENACIER model. The rollout of this plan has been stalled by the growing insurgency in that part of the country.

Conclusion 

Nursing schools can use student internships to foster collaboration with local communities to assist them to leverage local resources to meet their needs. Students led communities to see for example that they could take charge of their own clean water supply without government assistance.

Transformational learning that moves students from simply identifying and reporting problems to being resource persons and leaders, improves community health outcomes. The diabetes project for example demonstrated that, students using point-of-care testing, could mobilize individuals and groups, conduct screening, implement individualized care, facilitate referrals, and provide genuine health data. This earned an external three-year funding grant in 2018 to expand the project to six more communities. 

Curriculum designs drawn from local needs can lead to unique but transferrable models of providing culturally and economically sustainable care to individuals and communities. The geriatric program showed that professional aged care could fit into a culture that promotes aging at home. 

Curriculum designs help learners develop a wide range of skills: communication, networking, consensus-building, critical thinking, cultural responsiveness, problem solving, and leadership. This is achieved during the process of negotiating and interacting with community leaders, groups, and individuals. It also makes working in rural settings appealing.

Nursing schools can be the nexus of intersectoral collaboration for health if they adopt social accountability models similar to the ENACIER model.

Works Cited

Adolmaleki Mohammadreza, Yazdani Shahram, Momeni Sedigheh, and Mmtazmanesh Nader. 2017. “A Social Accountable Model for Medical Education System in Iran: A Grounded-Theory.” Journal of Medical Education 16, no. 2 (Spring): 55-70

Boelen Charles, Dharamsi Shafik and Gibbs Trevor. 2012. “The Social Accountability of Medical Schools and its Indicators.” Education for Health 25, no. 3 (December): 180-194

Boelena Charles, Pearson David, Kaufman Arthur, Rourke James, Woolard Robert, Marsh C. David and Gibbs Trevor. 2016. “Producing A Socially Accountable Medical School: AMEE Guide No. 109.” Medical Teacher 38, no. 11: 1078-1091. dx.doi.org/10.1080/

Central Intelligence Agency (CIA). 2019. “The World Factbook: Cameroon” Accessed June 14, 2019. www.cia.gov/library/publications/

Greer J. Pedro Jr, Brown R. David, Brewster G. Luther, Lage G. Onelia, Esposito F. Karin, Whisenant B. Ebony, Anderson W. Frederick, Castellanos K. Natalie, Stefano A. Troy and Rock A. John. 2018. “Socially Accountable Medical Education: An Innovative Approach at Florida International University Herbert Wertheim College of Medicine.” Academic Medicine 93, no. 1 (January): 60-65

International Federation of Medical Students Association (IFMSA) and Training for Health Equity Network (THEnet). 2017. “Student’s Toolkit: Social Accountability in Medical Schools.” Accessed June 18, 2019. https://ifmsa.org/social-accountability/

Leke Z. Aminkeng, Portwood Cheryl and Maboh N. Michel. 2013. “Diabetes Management: Student Nurses Contribute Using Point-of-Care Testing” Medical Education Journal, 47(11): 1122.

Leke Z. Aminkeng, Portwood Cheryl and Maboh N. Michel. 2014. “Breaking Barriers to Diabetes Management in Rural Communities: Student Nurses Make a Difference Using Point-of-Care Testing.” GSTF Journal of Nursing and Health Care (JNHC) 1, no.2 (August): 37-44. DOI: 10.5176/2345-718X_1.2.33

Maboh N. Michel, Leke Z. Aminkeng and Nyenti B. Pauline. 2013. “Curriculum for Community-Based Nurses on Care of Older Adults.” Medical Education Journal, 47(11): 1121. doi: 10.1111/medu.12350

Meili Ryan, Ganem-Cucena Alejandra, Leung J. Wing-sea, Zaleschuk D. 2011. “The CARE Model of Social Accountability: Promoting Cultural Change.” Academic Medicine 86, no. 9 (September): 1114-1119 

Pourabbas Ahmad, Amini Abolghasem, Fallah Farnoush, and Alizadeh Mahasti. 2015. “Management of Social Accountability in Medical Education at Tabriz University of Medical Sciences.” Res Dev Med Educ 4(1): 77-80. doi:10.15171/rdme.2015.012

World Health Organization (WHO). 1995. “Defining and measuring the social accountability of medical schools.” Geneva: World Health Organization.

Author bios

Dr. Maboh M. Nkwati is the pioneer Head of Nursing and Deputy Vice-Chancellor for Academic Affairs at the Biaka University Institute of Buea Cameroon. He has been working for 14 years in health professions education and academic governance. He is passionate about improving individual and community health through education and has been active in the development of health professions education in Cameroon. In this context he has led curriculum development in a wide range of health and nursing subject areas. His primary research interest is in the area of health professions education (and improving health care through education), active learning, and elderly care. This has led to publications in academic journals that include articles on innovative approaches to curriculum development, elderly care, student-led community health improvement projects, and the evolution of professional education. He is also introducing the concept of interdisciplinary clinical simulation in health professions education in Cameroon at Biaka University Institute of Buea.

Maboh is also serving as member of the academic board of Equals Institute Australia. He is co-investigator of a World Diabetes Federation funded project to improve rural diabetes management using a synergy of student nurses and primary care nurses in the South West Region of Cameroon. He is a member of multiple professional associations in Cameroon and internationally. He is actively involved in professional advocacy and the fight against fraud in health professions education and practice. He is also the founder of the Health Research Foundation that provides health research consultancy and training services in Cameroon 

Maboh’s educational background includes a Bachelor of Nursing Science and Master’s in Nursing Education from the University of Buea Cameroon, and a PhD from the University of Essex in the United Kingdom. He is also a 2012 Fellow of the Foundation for the Advancement of International Medical Education and Research (Philadelphia USA).

Dr. Aminkeng Z. Leke is fellow (2011) of the Foundation for International Medical Education and Research (FAIMER)-USA. He holds a BSc. in medical laboratory science and MSc in chemical pathology from the University of Buea-Cameroon; and a PhD in Pharmacoepidemiology from Ulster University-UK.  

Since 2007, he has served in various administrative and academic roles at Biaka University Institute of Buea; his latest (in 2016) being Deputy Vice Chancellor for Research, Cooperation, and Quality Management.  

Dr. Leke has been a lead member of many curriculum development committees on health professions education in Cameroon. His manual “Medical Laboratory Science for Nurses” written in 2008 has been a great educational resource for many nursing students across Cameroon. He has a keen interest in community health and maternal/infant health. He led an innovative project on diabetes management in rural Cameroon that won the TUFH Projects that Work International Award in 2015. This project is currently being funded by the World Diabetes Foundation with potential nation-wide adoption. One of Dr. Leke’s recent projects has produced the first data on maternal medication use and safety in pregnancy in Cameroon. In his past work in Europe, he investigated maternal use of antibiotics and risk of congenital anomalies by analyzing the European Surveillance of Congenital Anomaly (EUROCAT) database. Currently, he is working with the ZikaPlan Global Birth Defects Team to develop an app for the identification and accurate description and coding of congenital anomalies in low-resource settings. He is also involved in the WHO Pregnancy Registry project in Africa. 

Pauline B Nyenti is a nurse educator working with the Training Schools for Health Personnel, Limbe Cameroon. She is adjunct faculty in the departments of Nursing at the Biaka University Institute of Buea and the University of Buea, both in Cameroon. Nyenti holds a Master’s in Nursing Education and a Bachelor of Nursing Science from the University of Buea Cameroon. She is also a 2014 fellow of the Foundation for Advancement of International Medical Education and Research (FAIMER) Institute in Philadelphia, Pennsylvania. She enjoys teamwork and is very passionate about enabling students to discover and develop their capacity to contribute to the health of communities. This has led her to remain active in various community projects involving students both at the Health Research Foundations (HRF) Buea and in schools where she teaches. 

 

Photos taken by the project Tabang MARAWI team during the pilot implementation of the intervention in Marawi City, Philippines. The background is the temporary shelter, the study site where the participants reside as shown with a typical family. The inset photos include a father feeding his child with the complementary foods and a focus discussion with mothers in the temporary Shelter. 

The Social Problem and Context

The current situation of children continuously poses as a social development concern, particularly the problem of malnutrition among children 0 to 5 years of age which has been persistent throughout the years. In the Philippines for instance, among children under five years old, two out of 10 Filipino children are underweight and three out of 10 have stunted growth (DOST-FNRI, ENNS, 2018).

This matter becomes worse in the event of both natural and man-made emergencies and disasters like typhoons, earthquakes, floods, and armed or war conflict, where the groups who suffer the most are young children along with the women, people with disabilities, migrants, youth, elderly, and the communities. In times of disaster and emergencies, vulnerable young children suffered the most because the food packs distributed are intended for a whole family with limited specific foods for young children. Intervention for families are usually extended during the recovery phase of a disaster. There are different stages of emergencies: early or immediately following a disaster lasting one to two days; intermediate or the transition from the initial onset of disaster to rehabilitation; and extended or the recovery phase of the disaster.

This article focuses on a nutrition intervention innovation which will aid and protect vulnerable young children along with their mothers who are mostly women of reproductive age during the recovery phase of a crisis or disaster situation. This nutrition strategy combines complementary feeding of local-based complementary foods (for the children) and nutrition education (for their mothers or caregivers). This type of intervention both responds to the immediate need to address the compromised children who are already undernourished in the community or in temporary shelters in times of disaster, and the education of their mothers/caregivers on basic nutrition and health including sessions on safe pregnancy, breastfeeding, complementary feeding, safe food preparation, and handling and vegetable gardening. 

The nutrition-education component intends to equip mothers/caregivers with knowledge and skills on food, nutrition, and health. It is envisioned to have more lasting effects in terms of improving the women’s knowledge of food, health, and nutrition, and eventually its application to the everyday lives of their families. In brief the intervention components will feed the children’s stomach through the complementary foods and feed the mind of the mothers and caregivers with nutrition education.

In the context of human rights, this approach focuses on the child’s rights which should be addressed without discrimination of any kind. The participation (involvement) of the children in this community program is a contribution towards ensuring healthy survival and development within this age group. On the other hand, on the part of the mothers/caregivers the intervention which involves educating them in terms of food, nutrition, and health are important approaches to empowering these women. 

Specifically, during the recovery phase of a disaster, the mothers/caregivers and households, on the whole, are recovering and adjusting to the effects of a disaster in their lives. Interventions from all sectors of society are usually poured onto the affected population and communities which include psycho-social assistance, health, and programs to support the basic needs of the families. This innovation intends to strengthen these types of assistance by improving the nutritional situation of young children, while at the same time equipping their mothers/caregivers with knowledge and skills on food, nutrition, and health, specifically related to the significance of monitoring the nutrition of their children through nutrition education sessions. The convergence in the nutrition education sessions among the mothers/caregivers will also serve as a form of relaxation after a period of stress and tension brought about by the disaster.

How Will the Innovation Be Implemented? 

The community or the temporary shelters where the affected families are located shall be the setting of the innovation implementation. Initial coordination and orientation with local officials shall be conducted to introduce the intervention. After the orientation with the local officials, the community workers shall be empowered to implement the intervention through skills training on food, nutrition, and health using tailor made modules appropriate for the level and characteristics of the local community workers. It is important to emphasize that the complementary foods and products to be fed to the children shall be made of local-based foods, or indigenous foods in the region, which are rich in protein and energy. It shall also be emphasized that foods from backyard vegetable gardens can be the source of complementary foods for the children and can be prepared as part of the family pot. Thus, vegetable gardening should be strengthened in the temporary shelters where the affected families live. The how’s of vegetable gardening will be taught to the mothers and caregivers in the nutrition education sessions.  

This innovation has been pilot tested in one of the areas in the Philippines which has suffered from a man-made siege in Marawi City. As a case in point, the complementary foods made of rice and mungbean are indigent in the Philippines while the modules used in the nutrition sessions are translated in the Filipino dialect. In the pilot testing, the complementary food products given to the children participants were produced in the processing facilities in the region using the Department of Science and Technology -- Food and Nutrition Research Institute (DOST-FNRI) transferred food technology. In this innovation there are counterpart funds from the Local Government Units (LGUs) in the putting up or building the complementary food facilities and in its operation and maintenance. 

The proposed intervention shall be funded by the Local Government Units (LGUs) where the innovation shall be implemented. In the pilot testing done in the Philippines, the fund for the implementation of the innovation has been part of the research fund from the Department of Science and Technology. The scaling-up of the innovation needs advocacy and an issuance of a policy memorandum for the adoption of the intervention by the Local Government Units and its institutionalization nationwide along with the inclusion of food for young children in the family food pack distributed in times of disasters and calamities. In the Philippines, the national departments which can be tapped for such memorandum issuances are the social welfare and development and the interior and local government.

This innovation is a social development program anchored in the Sustainable Development Goals (SDG) and specifically aligned with SDG #2 which is “End Hunger, achieve food security and improved nutrition, and promote sustainable agriculture,” which is the government’s commitment along with the accountability of local leaders needed to implement and sustain this type of intervention. 

 

This Figure shows the nutrition strategy for young children which combines complementary feeding using local –based foods [rice-mungbean-sesame] and nutrition education for mothers.


Author bios

Julieta B. Dorado is a Supervising Science Research Specialist at the Department of Science and Technology, Food, and Nutrition Research Institute. Her work focuses on food and nutrition intervention assessment and policy-related researches. Her academic background is on sociology, social development and communication. She can be reached at This email address is being protected from spambots. You need JavaScript enabled to view it..

Emily O. Rongavilla is a Science Research Specialist II and a Nutritionist-Dietitian by profession at the Department of Science and Technology, Food, and Nutrition Research Institute in the Philippines. She is engaged in nutritional assessment studies, nutrition intervention, and evaluation and advocacy studies. Emily can be reached at This email address is being protected from spambots. You need JavaScript enabled to view it..

Joanne Jette L. Semilla is a Science Research Specialist I and a Nutritionist-Dietitian by profession at the Department of Science and Technology, Food, and Nutrition Institute. She is involved in nutrition intervention, monitoring, and policy research studies. She can be reached at This email address is being protected from spambots. You need JavaScript enabled to view it..

Rowena V. Viajar is a Science Research Specialist II at the Department of Science and Technology, Food, and Nutrition Research Institute in the Philippines. Her research focuses on nutritional assessment, nutrition intervention, monitoring and evaluation, and policy research. She can be reached at This email address is being protected from spambots. You need JavaScript enabled to view it..

Dr. Mario V. Capanzana is currently the Director of the Food and Nutrition Research Institute, Department of Science and Technology. His contributions to the country’s development in food and nutrition include research and technology development in food fortification, functional foods, technology transfer, food quality and safety, and food product development. He has several patents and utility models credited to his name as inventor. Dr. Capanzana can be reached at This email address is being protected from spambots. You need JavaScript enabled to view it..

 

Authors

Sandra Mendel,1 Karen Beattie,1 Jane Thompson,1 Robyn Vines,1 Kam Wong,1 Jannine Bailey,1 Krista Cockrell,1,2 Buck Reed,2 Tim McCrossin,1 and Ross Wilson1 

1 Bathurst Rural Clinical School, School of Medicine, Western Sydney University, Bathurst NSW Australia

2 School of Science and Health, Western Sydney University, Campbelltown NSW Australia

A farm accident simulation scenario in action: stabilizing the patient and preparing them for transfer to hospital.
Photo credit: Jane Thompson

Collaborative care is the gold standard in effective patient care.1 This is particularly important in the rural context where teams are smaller and there is typically more interaction with colleagues from other professions in the delivery of health care. Rural generalist medicine is shaping up to become the cornerstone of medical care delivery in rural Australia. A rural generalist is described as a “medical practitioner who is trained to meet the specific current and future healthcare needs of Australian rural and remote communities, in a sustainable and cost-effective way by providing both comprehensive general practice and emergency care and required components of other medical specialist care in hospital and/or community settings as part of a rural healthcare team.”2 Such an approach of targeting rural practitioner’s skills to the needs of the community they serve aligns with the World Health Organization’s (WHO) definition of social accountability in medicine.3 Equally important is that rural generalists operate using a multidisciplinary team care approach, drawing on the skills and expertise of clinicians from other professions to provide effective patient-centered care.4

One challenge lies in how to teach effective teamwork and collaboration skills to medical students to ensure they are workplace ready. At the Bathurst Rural Clinical School (RCS) of Western Sydney University’s School of Medicine, we strive to nurture an interest in rural practice in our cohorts of medical students who complete an extended clinical placement in the region and are accountable for contributing to an increase in the rural medical workforce. Students are typically “highly urbanized” and have little prior exposure to life outside of metropolitan city living. The RCS curriculum aims to provide a positive and authentic rural experience and at the same time correct any incorrect notions about what it is like to live and work in a rural community. The end result, ideally, being to foster rural practice aspirations in students, or at least open them up to the possibility of a future rural career by giving them a lived experience and removing the element of the unknown.

In addition to being accountable to rural communities in terms of increasing numbers in the rural medical workforce, the RCS also holds an accountability in terms of the quality and ability of these medical graduates. It is not simply sufficient to provide our rural communities with a medical practitioner; we also need to take responsibility for ensuring that our rural communities are provided with the best possible practitioner capable of working with the local multidisciplinary health team to deliver the best possible care to rural patients. 

A farm accident simulation scenario in action: stabilizing the patient and preparing them for transfer to hospital.
Photo credit: Jo Halloran

Our answer to this is RIPL -- Rural Inter-Professional Learning -- which has recently been integrated into the curriculum of the Bathurst RCS. RIPL is a simulation teaching session that involves several members of the interdisciplinary team; including, but not limited to medical, nursing, social work, and paramedicine students. Students are supported through the scenarios by a multidisciplinary team of facilitating clinicians. Throughout the teaching session, students rotate through a range of complex scenarios that are designed with both medical and social factors in mind to expose students to situations they would be expected to encounter at work in a rural community. Some scenarios are more commonly expected encounters (e.g. an elderly patient with delirium/confusion or a patient who has experienced a stroke) whilst other scenarios may be encountered less frequently but are nonetheless important to working in a rural setting (e.g. a farm quad bike accident). The students are supported to act out the scenarios in full, including travel from the home setting (or other external setting) to the local hospital for admittance. Students practice their skills in clinical handover throughout the scenario with the different health professionals as would be required in a real-life context. Where relevant, students are encouraged and supported to work together as a multidisciplinary team to provide necessary care in the home, thereby preventing hospitalization; the question “to hospitalize or not to hospitalize?” provides an important reflection for students to give consideration to the distance to the nearest facility and what that means for the patient and their family, whilst also considering the need for hospitalization from the viewpoint of avoiding unnecessary hospitalization. This then leads to a consideration of the challenges around coordinating necessary services outside of the hospital environment when working in the rural setting.

Student reflections:

"As a result of this experience, I have more respect towards other disciplines and their specialties."

"Paramedics and nurses take histories in a very similar way to doctors, so I need to take on board what they tell me to avoi overlap."

"Today drummed "social aspects" into my head, so I'll always be assessing the social factors now."

The end goal, or RIPL effect, of inter-professional education is to create a health workforce with improved levels of teamwork, collaboration, knowledge sharing, and problem solving, eventually leading to better client and patient outcomes in the health care setting. This type of shared learning has the potential to deepen the understanding of the layers of care involved in the patient experience and how professional roles and responsibilities complement each other. An informal evaluation that has been conducted to date supports this notion, as evidenced by student and facilitator feedback. Students have described an increased understanding of the role different health professionals play, both in general and as part of the multidisciplinary team. A greater awareness of the importance of social factors was also mentioned. 

Facilitator reflections:

"From my observations of this scenario, I think the students will better be able to draw on each other's skills to meet patient needs in challenging settings such as rural and remote communities."

"Technical skills are only half the story! They learnt how important a team was."

"This RIPL provides a foundation for the students to build on further interprofessional collaboration in their career."

Other important learnings were around communication with the patient and the other health professionals, and how best to collaborate as a team to provide the best care to the patient, regardless of the setting. Of particular importance here from the medical student perspective, was their recognition that within the team care approach, there were critical times when they as the doctors needed to take a step back and allow the other members of the team (e.g. paramedic or nurse) to lead that aspect of the patient’s care. This awareness and recognition of the skillset and strength that these other professionals bring to the team is an important learning objective of RIPL. 

This early feedback demonstrates that inter-professional education activities are a valuable addition to a medical curriculum to foster an understanding and appreciation of the multidisciplinary health care team in medical students. However, informal feedback such as this is not sufficient for firming up the evidence base around inter-professional learning in the rural context. Others have highlighted the rather limited evidence base and have called for more rigorous evaluation of inter-professional education programs to expand the evidence base and show lasting impact beyond the immediacy of the teaching session.5 In light of this, a structured formal evaluation of the RIPL program is currently underway to add to the growing evidence base around inter-professional education.

In conclusion, the incorporation of an undergraduate rural interprofessional education program such as RIPL can enhance medical students’ awareness and recognition of the roles other health professionals play in delivering quality health care to rural patients. This can lead to graduates who are equipped to operate effectively within a multidisciplinary team environment to provide effective patient-centred care to rural patients.

 

 

Works Cited

Holmqvist M, Courtney C, Meili R, Dick A. Student-run clinics: Opportunities for interprofessional education and increasing social accountability. Journal of Research in Interprofessional Practice and Education. 2012 Aug 29;2(3).

 

National Rural Health Commissioner. The Collingrove Agreement. Canberra: Australian Government, 2018. Available from: https://www.health.gov.au/internet/main/publishing.nsf/

Boelen C, Heck J. Defining and measuring the social accountability of medical schools. Geneva: World Health Organization, 1995. Available from: https://apps.who.int/iris/handle/

Murray, R. Cairns Consensus Statement on Rural Generalist Medicine. 2013. Available from: www.acrrm.org.au/docs/default-source/

Anderson ES, Kinnair D. Integrating the assessment of interprofessional education into the health care curriculum. Journal of Taibah University Medical Sciences. 2016 Dec 1;11(6):552-8.

Author bios


Dr. Sandra Mendel is a Senior Lecturer in Rural Health at the Bathurst Rural Clinical School and a General Practitioner in Orange where she has been a Rural Generalist for the last 20 years. 


Karen Beattie is a Critical Care Nurse and Associate Lecturer in Clinical Skills Education at the Bathurst Rural Clinical School. 


Jane Thompson is the Rural Program Coordinator at the Bathurst Rural Clinical School. She is committed to growing the future rural health workforce. 


Dr. Robyn Vines is a practicing Clinical Psychologist and a Senior Lecturer in Mental Health at the Bathurst Rural Clinical School.


Dr. Kam Wong is a local General Practitioner and a Senior Lecturer in General Practice at the Bathurst Rural Clinical School.


Dr. Jannine Bailey is a rural health researcher and Senior Lecturer in Rural Health & Research at the Bathurst Rural Clinical School.


Krista Cockrell is a Research Officer at the Bathurst Rural Clinical School and Casual Academic at Western Sydney University. She is a trained paramedic and has practiced in both the U.S. and Australia in a range of emergency and industrial environments.  


Buck Reed is an Associate Lecturer in Paramedicine and a paramedic who has practiced for more than 20 years in various areas of pre-hospital care including event medical services and industrial paramedicine.


Associate Professor Tim McCrossin has been a consultant paediatrician in Bathurst for more than 20 years and is the Clinical Dean for the Bathurst Rural Clinical School. 


Professor Ross Wilson is the Director of Rural Health at the Bathurst Rural Clinical School and has been a General Practitioner in Bathurst for more than 30 years.  

 

By José Rodrigues Freire Filho, José Francisco García Gutiérrez, Silvia Helena De Bortoli Cassiani & Fernando Antonio Menezes da Silva

Background

In recent years, Interprofessional Education (IPE) has been introduced into policies on human resources for health (HRH) in the countries of the Region of the Americas, predominately in the United States and Canada, but also in Latin America and the Caribbean (LAC). The Pan American Health Organization/World Health Organization (PAHO/WHO) has encouraged its member states to adopt this approach and support policymakers in expanding its use. PAHO’s Strategy on Human Resources for Universal Access to Health and Universal Health Coverage and its Plan of Action 2018-2023 encourages countries to promote the development of interprofessional teams in integrated health services networks using IPE, diversifying learning settings, and promoting collaborative practice. Objective: To present an overview of national IPE plans developed with PAHO/WHO support in 19 countries of LAC during 2017-2019. Method: In 2017, PAHO's Human Resources for Health Unit launched a technical cooperation strategy to support countries of the Region of the Americas in implementing IPE in their HRH policies. The strategy was mainly focused on networking, research, sharing of experiences, and activities such as international meetings, webinars, guidelines, publications, and virtual courses. Results: The Regional Network for IPE in the Americas (REIP) has been established (educacioninterprofesional.org) and 19 countries have submitted national action plans for the implementation of IPE. Overall outcomes derived from the evaluation of those plans will be presented using four dimensions: 1) Dissemination and research; 2) Faculty recruitment and development; 3) Legislation mechanisms; and 4) IPE in permanent education programs. Conclusion: International organizations have an important role to play in articulating and collaborating with countries to incorporate innovative approaches, such as IPE and interprofessional collaborative practice (ICP), directed to transforming and scaling-up health professions education towards the achievement of universal health, and to ensuring its alignment with health services demands and population needs.

Introduction

Since 2010, the World Health Organization (WHO) has promoted interprofessional education (IPE) and interprofessional collaborative practice (ICP) as innovative strategies that hold promise in mitigating the global health workforce crisis (WHO 2010, 7-10).

WHO recognizes IPE “when students from two or more professions learn from each other to enable effective collaboration and improve health outcomes,” and ICP "when different professional backgrounds work together with patients, families, caregivers, and communities to offer the highest quality of care” (WHO 2010, 7-10). 

In recent years, IPE has been introduced into policies on human resources for health (HRH) in the countries of the Region of the Americas, especially in the United States and Canada, but also in Latin America and the Caribbean (LAC). The Pan American Health Organization (PAHO) has supported its member states in adopting this approach and encouraged policymakers in expanding its use (Silva, Cassiani and Freire Filho 2018, 26). In addition, PAHO’s Strategy on Human Resources for Universal Access to Health and Universal Health Coverage and its Plan of Action 2018-2023 endorses the development of interprofessional teams in integrated health services networks using IPE (PAHO 2017, 2-3).

In this regard, IPE is necessary to prepare the health workforce to engage in collaborative efforts; to respond to local health needs in a dynamic environment; to improve human resources for health capacities and outcomes; and to strengthen health systems and services. A high level of synergy between health workforce planning and health education systems is required to facilitate the advancement and sustainability of IPE and ICP (CAIPE 2002, CIHC 2010, IPEC 2016, WHO 2010).

The aim of this article is to present an overview of the development process of national IPE plans in 19 countries of LAC -- with PAHO/WHO technical cooperation -- during the period 2017-2019, as an innovative contribution for the transformation of health professions education in the Region of the Americas.

Methods

The basis for this study was developed through three annual regional IPE meetings (in 2016, 2017, and 2018) and the establishment of the Regional Network for Interprofessional Education in the Americas (REIP).

Bogota Meeting 2016  

In 2016, PAHO/WHO held a regional meeting in Bogota, Colombia that aimed to support countries in the Region in the implementation of IPE and IPC. Participants included representatives from ministries of health and education, academic institutions, schools, and professional associations from 12 countries. They discussed the theoretical, practical, and political rationale for IPE, as well as the individual and institutional attributes, resources, and commitments required for its implementation (PAHO 2017).

Brasilia Meeting 2017 

On December 2017, a second regional technical meeting on IPE was held in Brasilia, Brazil. The event, organized jointly with the Ministry of Health of Brazil, was attended by representatives from 22 countries of the Region of the Americas. The purpose of the meeting was to discuss processes for incorporating IPE into policies on human resources for health, to establish a common agenda for strengthening IPE in the Region, and to foster the preparation of national action plans to implement this approach (PAHO 2018).

During this meeting the Regional Network for Interprofessional Education in the Americas (REIP) -- coordinated by the Ministries of Health of Argentina, Brazil, and Chile -- was formally established and its directives approved in accordance with the principles and lines of action set forth by PAHO’s Strategy on Human Resources for Universal Health (PAHO 2018).

Buenos Aires Meeting 2018 

On December 2018, the City of Buenos Aires hosted the Third Technical Meeting on IPE sponsored by PAHO. The meeting was attended by representatives from 15 countries of the Americas that confirmed their commitment to invest in IPE and shared the results of ongoing activities of their national plans (i.e., mapping of IPE experiences, research studies, workshops, and conferences) as members of  REIP (educacioninterprofesional.org),

The REIP constitutes a technical cooperation strategy for promoting IPE and ICP with a view to improving the quality of health services and enhancing the education of health personnel through interprofessional teams (REIP 2018).

This network supports countries, in collaboration with PAHO, to develop action plans for implementing IPE through intersectoral collaboration between ministries of health and education, academic institutions, and professional associations. It also serves as a platform to exchange and disseminate IPE information, experiences, and scientific evidence; identify common IPE facilitators and barriers; encourage the development of multicenter research; and monitor and support country activities (REIP 2018).

In coming years, REIP hopes to maintain its support for the development of leadership in IPE, increase the number of member countries of the network, and remain affiliated with the main institutions and global bodies working on this topic (REIP 2018).

Results

Using the Regional Network for IPE in the Americas (REIP) (educacioninterprofesional.org), 19 countries of LAC have submitted national action plans for the implementation of IPE. 

 

Figure 1: Countries of LAC and Caribbean with IPE plans (REIP 2018).

These plans have been analyzed using four dimensions:  1) dissemination and research on IPE; 2) faculty recruitment and development; 3) legislation mechanisms; and 4) IPE in permanent education programs.

1) Dissemination and Research on IPE

The first dimension refers to the activities foreseen in the IPE plans of the countries related to the promotion of events, such as meetings, conferences, conducting studies to address the concepts of IPE, its theoretical and methodological basis, and the recognition of its power for the transformation of education health professions. In a survey conducted by PAHO/WHO, several countries in the Americas are unaware of the concept of IPE, as well as its applicability. All 19 countries present IPE dissemination and research activities in their plans.

Argentina, Brazil, Cuba, Chile, and Colombia discuss the importance of creating evidence on IPE. Paraguay, Uruguay, Colombia, and Costa Rica are conducting surveys on the subject at the national level. Argentina, Brazil, Chile, Colombia, Dominican Republic, Guatemala, El Salvador, Panama, Uruguay, and Cuba held events on IPE to disseminate the theme in the countries.

2) Faculty Recruitment and Development

Faculty recruitment and development is a key factor for the implementation of IPE. This refers to the activities that prepare and assist faculty in all educational settings (classroom, clinic, hospital, and community). The initiatives proposed by the countries in this dimension are the development of courses for leaders in IPE who have the knowledge, skills, and attitudes to teach both students and colleagues to work collaboratively.

For IPE faculty development only six countries presented actions in their plans: Bolivia, Brazil, Costa Rica, Honduras, Panamá, and Uruguay.

Brazil held a virtual course in IPE faculty development on July 2018. The IPE course was attended by 300 professors, directors of graduate programs on the health of the country, as well as professionals who work to accompany students in health services (REIP 2018).

3) Legislation Mechanisms

Legislation is fundamental to the effectiveness of IPE and institutionalizes a country's commitment to the implementation of IPE. With this impetus, many countries are in the process of developing and strengthening their legislation for IPE and are embracing effective mechanisms for its incorporation into HRH policies.

In the countries' IPE plans, examples of regulatory mechanisms are the formulation of guidelines, protocols, resolutions, creation of national IPE networks, and other resources that assist in the implementation of IPE.

For the IPE legislation mechanisms, eight countries included activities in this dimension in their plans. Some countries, such as the Dominican Republic and Suriname, are proposing the establishment of National IPE Networks and Brazil and Panama have the proposal to formulate resolutions on IPE to promote changes in the model of the training of health professionals and to include the IPE in curricula.

4)  IPE in Permanent Education Programs

Courses, seminars, and any other educational activity directed to health professionals, aiming to develop skills or knowledge applicable to practice, are considered permanent education programs. With respect to IPE in permanent education programs, 11 countries have activities in their plans, among them Guatemala, Nicaragua, Panama, and Venezuela have presented strategies for the qualification of health service professionals, making use of the theoretical and methodological basis of IPE.

 

Figure 2: Activities of countries' IPE plans according to the dimensions of analysis.

Conclusions

This study showcases ongoing experiences in implementing IPE and ICP as part of HRH policies in the LAC Region. It also stresses the important role that international organizations (such as PAHO/WHO) could play in encouraging countries to incorporate innovative approaches directed to transforming and scaling-up health professions education aligned with health services demands and population needs.

Achieving Universal Health means that everyone, irrespective of their socio-economic background, ethnicity, gender, or race, is covered by a well-financed, well-organized health system offering quality and comprehensive health services, be they curative, preventive, rehabilitative, or palliative. Interprofessional health teams and collaborative practice may contribute to the removal of barriers to the access of health services -- either physical, geographic, cultural, or economic. However, neither IPE and ICP, nor the creation of interprofessional health teams, are ends onto themselves. They are means to increase access to equitable, quality health services, and improving the organization of health systems and the working conditions of the people who work in them.

IPE networks could serve to promote innovation in health and education, but they imply changes in the way professional competencies are taught, regulated, exercised, and shared. For this reason, PAHO/WHO shall continue supporting member states and educational institutions in the Region:

  • To continue carrying out the series of seminars on the IPE and ICP, maintain the IPE virtual course in the Virtual Campus of Public Health, and launch a new course for the IPE faculty development.
  • To incorporate IPE and ICP both in educational academic programs and HRH policies as key strategies to increase access to health and to improve care quality. 
  • To introduce specific IPE standards and indicators as part of the accreditation processes of health professional’s education and programs, as a major driver to promote change.
  • To develop interprofessional teams at the first level of care with combined competencies in comprehensive care, intercultural skills, and social determinants to health. The target would be to have 30 countries with interprofessional health teams at the first level of care, consistent with the model of care, by the year 2023.

Works Cited

Canadian Interprofessional Health Collaborative (CIHC) Competencies Working Group. 2010. A National Interprofessional Competency Framework. Vancouver, BC: Canadian Interprofessional Health Collaborative. Retrieved from www.cihc.ca/files/

Centre for the Advancement of Interprofessional Education (CAIPE). 2002. Interprofessional Education - a definition. Retrieved from: www.caipe.org.uk/about-us/defining-ipe

Interprofessional Education Collaborative (IPEC). 2016. Core competencies for interprofessional collaborative practice: 2016 update. Washington, DC: Interprofessional Education Collaborative.

Pan American Health Organization. 2017. “PAHO cooperates with countries of the Region to incorporate interprofessional education into health education policies.” Privacy & Terms. Las modified December 17, 2017. www.paho.org/hq/

Pan American Health Organization. 2017. Interprofessional Education in Health Care: Improving Human Resource Capacity to Achieve Universal Health. Report of the Meeting. Bogota, Colombia, 7-9 December 2016. Retrieved from: iris.paho.org/xmlui/handle/

Pan American Health Organization. 2017. Strategy on human resources for universal access to health and universal health coverage. [29th Pan American Sanitary Conference, 25-29 September 2017 (document CSP29.R15). [Retrieved from: www.paho.org/hq/

Regional Network for Interprofessional Education in the Américas (REIP). Privacy & Terms. https://www.educacioninterprofesional.org

Silva, F. A. M. D., Cassiani, S. H. D. B., & Freire Filho, J. R. (2018). Interprofessional Health Education in the Region of the Americas. Revista latino-americana de enfermagem, 26. Retrieved from: www.scielo.br/pdf/rlae/v26/

World Health Organization. 2010. Framework for action on interprofessional education and collaborative practice (No. WHO/HRH/HPN/10.3). Geneva: World Health Organization. Retrieved from: apps.who.int/iris/bitstream/handle/10665/

Author Bios

José Rodrigues Freire Filho is an International Consultant on Interprofessional Education and Collaborative Practice in the Department of Health Systems and Services (HSS) at the Pan American Health Organization/World Health Organization (PAHO/WHO). He is responsible for the implementation of interprofessional education and collaborative practice in health and provides technical assistance to countries in the Region of the Americas. He is a Pharmacist with a PhD in Interprofessional Education.

José Francisco García Gutiérrez is a Regional Advisor on Human Resources for Health Development in the Department of Health Systems and Services (HSS) at the Pan American Health Organization/World Health Organization (PAHO/WHO). He holds a PhD in Public health and his work focuses primarily on social accountability in health.

Silvia Helena De Bortoli Cassiani is Regional Advisor for Nursing and Allied Health Technicians in the Department of Health Systems and Services (HSS) at the Pan American Health Organization/World Health Organization (PAHO/WHO). She holds a PhD in Nursing and provides technically cooperation to Member States to advance nursing through education, research, and broadening the scope of nursing practice in Primary Health Care. 

Fernando Antonio Menezes da Silva is Unit Chief in the Unit of Human Resources for Health (HSS/HR) in the Department of Health Systems and Services (HSS) at the Pan American Health Organization/World Health Organization (PAHO/WHO). He holds both a MD and PhD in research and completed a fellowship and post-doctorate in Evaluation of Higher Education. He has extensive experience in management of human resources for health and health systems strengthening. 

In recent decades, medical education has been changing around the world in an effort to improve quality, equity, and relevance among other characteristics. A good example for this is the accreditation process of many medical institutions around the world. Besides this, institutions are also aiming to reach what has been defined as social accountability, and it is the main topic of the must-read, “Global Consensus for Social Accountability of Medical Schools.” 1 Both topics have been widely explored by The Network: TUFH and its members during the last years and are reflected on The Fortaleza Declaration (2014)2 and the Tunis Declaration (2017)3 seeking global learning objectives for health professionals and to enhance health and social justice in the social accountability context respectively.  

Accreditation and social accountability are topics that deserve their own review and discussion, but both are related to an issue I want to highlight, the disparity between what is taught and learned during the undergraduate period and what is really useful and needed to work with, and in, communities. From the accreditation perspective, standards are given in order to develop programs and activities in the communities (depending on the national standard that is widely used), meaning that students will, for sure, be in touch with the communities and their surroundings in non-clinical or outreach activities. On the other hand, social accountability has a much bigger picture of the community and includes relevance, quality, cost-effectiveness, and equity to the activities developed in the community.4,5 

We, as health educators, talk about the relevance of community-based practices and that students must be in touch with the community (even though some students and even teachers may be slightly against it), but community-based practices are not the same as socially accountable actions, neither being a social accountability program. Therefore, students are being taken to communities to perform activities, within accreditation standards, but they might not be socially accountable and it endangers the development of health care students and the reason is quite simple, during and around four to seven years, health care education institutions train students to face and treat health issues in a clinical context (of course this does not apply to all medical institutions but for most it does), and then, they are taken to a more social context where they do not have the tools and environment they are used to, so they must face a completely new reality. This situation can be so deeply entrenched that even the country's health system is not designed to respond to the needs of the community outside the hospital, so what do we expect from students when it comes to commitment and delivery within the community? Why do we proudly say that our students perform activities in the community when we are not really having the desired effect on them nor on the community? Or at least in most communities because even faced with these difficulties, some students actually “fall in love” with the community’s health and that’s what brings us to this discussion. 

Recently in Latin America there was a debate about the voluntary interruption of pregnancy as a right, Argentina6 and Colombia7 just to cite some examples, and many institutions refused to train their students about this type of care. In the specific case of Colombia when the students where asked, many reported that they received little or almost no training about the topic. If this happens with a subject that is specific, what might be happening when we try to teach and inform students around health in the communities, and even more complex, social accountability issues?

Now, from the community context, are they involved in the planning, execution, and follow up of these community-based practices or social accountable activities? Do we even ask them what they need and what is a priority for them? Or do we just assume that we know what is best because we are the health professionals? A highly involved and active community is not a common thing but is not impossible to find or to nurture. Yet it does require time and work and once it is archived, it can basically guarantee the sustainability part of the impact of the intervention. This brings us to the “the elephant in the room,” are we involving the community? Are we working for the community, in the community, or with the community? Most of the community-based activities tend to be focused on building capacities for the students, but not all of them aim for building capacities for the community as well. These activities ended up being used as a means to reach the objectives with the students, instead of being the end itself and forming students along the way.

So, if we combine these factors, students are being formed on a clinical level and then taken to perform community-based practices that do not meet the needs of the community, ultimately we will have newly graduated doctors that do not possess the theoretical and practical knowledge to answer a community’s health needs, and additionally, communities that do not feel like they can identify with these newly graduated doctors. Isn’t this a problem we are facing worldwide? Of course, it has other contributing causes, but this is one we can face now.

The solution can be found in the problem itself once we face it. Building programs and curriculums around the needs of the community -- with the community -- will allow students to face these needs in a much more real scenario, while during classes students will receive education in primary health care. This is a solution that does not require additional funding, it requires a restructuring and prioritization, something that is extensively addressed during the actions of primary health care and community-based primary health care.

There are many programs and institutions that are changing the health related education paradigm and that we all can meet in the next The Network: TUFH Social Accountability: From Evidence to Action Conference in Darwin, Australia, which demands that institutions, teachers, students, and policymakers among others participate in this must attend event.

This is just a short reflection on a subject that requires a wide and rich debate with different perspectives to support primary health care as a reality that will last over time and that will deliver the impact we are looking for -- education and health promotion, disease prevention, early detection and treatment, and the improvement of the quality of life of the entire population. It may sound idealistic, but Ayn Rand stated it best, “Anyone who fights for the future, lives in it today.”

Works Cited

Abdalla, Mohamed Elhassan, y Charles Boelen. “Social Accountability of Medical Schools: The New Frontier For Development”, 2012, 7–31.

Awases, Magdalena, Rebecca Bailey, Charles Boelen, y Mario Dal Poz. “Global consensus on social accountability of medical schools”. Sante publique (Vandoeuvre-les-Nancy, France) 23, núm. 3 (2010): 247–50. www.ncbi.nlm.nih.gov/pubmed/21896218.

Boelen, Charles, Jeffery E Heck, y World Health Organization. Division of Development of Human Resources for Health. “Defining and measuring the social accountability of medical schools”, 1995. apps.who.int//iris/handle/10665/59441.

Cañón, Laura Natalia Cruz. “Facultades de medicina, reprobadas en Interrupción Voluntaria del Embarazo”. El Espectador. 2019. www.elespectador.com/noticias/salud/.

Garcia, Glenn. “Abortion in Argentina”. The Lancet 393, núm. 10173 (2019): 744. doi.org/10.1016/s0140-6736(18)32767-3.

Goñi, Uki. “‘Thousands’ of young girls denied abortion after rape in Argentina”. THe Guardian, 2019. www.theguardian.com/global-development/.

Members of The Network; TUFH. “The Fortaleza Declaration”. Fortaleza, Brasil, 2014. thenetworktufh.org/declarations/.

———. “Tunis Declaration”. Hammamet, Tunisia, 2017. thenetworktufh.org/declarations/.

Footnotes

1 Magdalena Awases et al., “Global consensus on social accountability of medical schools”, Sante publique (Vandoeuvre-les-Nancy, France) 23, núm. 3 (2010): 247–50, www.ncbi.nlm.nih.gov/pubmed/21896218.

2 Members of The Network; TUFH, “The Fortaleza Declaration” (Fortaleza, Brasil, 2014), thenetworktufh.org/declarations/.

3 Members of The Network; TUFH, “Tunis Declaration” (Hammamet, Tunisia, 2017), thenetworktufh.org/declarations/.

4 Charles Boelen, Jeffery E Heck, y World Health Organization. Division of Development of Human Resources for Health, “Defining and measuring the social accountability of medical schools”, 1995, apps.who.int//iris/handle/10665/59441.

5 Mohamed Elhassan Abdalla y Charles Boelen, “Social Accountability of Medical Schools: The New Frontier For Development”, 2012, 7–31.

6 Glenn Garcia, “Abortion in Argentina”, The Lancet 393, núm. 10173 (2019): 744, https://doi.org/10.1016/s0140-6736(18)32767-3; Uki Goñi, “‘Thousands’ of young girls denied abortion after rape in Argentina”, THe Guardian, 2019, www.theguardian.com/global-development/2019/mar/05/.

7 Laura Natalia Cruz Cañón, “Facultades de medicina, reprobadas en Interrupción Voluntaria del Embarazo”, El Espectador, 2019, www.elespectador.com/noticias/salud/.

Author bio

 

Alejandro Avelino Bonilla is a physician and epidemiology postgraduate student from Juan N. Corpas University in Bogotá, Colombia. He is a National Research Leader in the Colombian Medical Student Association ACOME and member of the advisory board of The Network: TUFH. For more than three years he was a student representative for his University, as well as founder and co-president of the Colombian Association of Students Representatives of Higher Education ACREES. Alejandro also previously served as a Latin Americas´ representative and president of SNO.

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