562024 research-article2014

APHXXX10.1177/1010539514562024Asia-Pacific Journal of Public HealthKarunathilake and Liyanage

Original Article

Accreditation of Public Health Education in the Asia-Pacific Region

Asia-Pacific Journal of Public Health 2015, Vol. 27(1) 38­–44 © 2014 APJPH Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1010539514562024 aph.sagepub.com

Indika M. Karunathilake, MBBS (Col), DMedEd (UK), MMedEd (UK), FHEA (UK), FCGP (SL, Hon)1, and Chiranthi K. Liyanage, MBBS (Col)1

Abstract There has been dramatic advancement in health status in the Asia-Pacific region (APR) over the past 50 years. This ever-changing paradigm of public health calls for continuous review and quality improvement of public health education (PHE). Since its founding in 1984, the mission of the Asia-Pacific Academic Consortium for Public Health (APACPH) has been to improve the quality and relevance of PHE to combat the diverse, dynamic, and unique challenges in the APR. Prof Walter Patrick was a forerunner in this movement and played an instrumental role in establishing APACPH’s position in accreditation and improvement of PHE. Keywords education (public health), curricular, medical education, health management, primary health care, health equity, health policy

Introduction There has been dramatic advancement in health status in the Asia-Pacific region (APR) over the past 50 years.1 Multiple public health interventions have increased life expectancies and reduced morbidities to an extent unseen in previous eras. Overall socioeconomic development that promoted equity and comprehensive measures were central to health improvement at affordable cost.2 With the application of Universal Health Rights, optimum health care for all became more a norm than a notion.3 Public health education (PHE) embedded such values and competencies into professional practice. The ever-changing paradigm of public health calls for continuous review and quality improvement of PHE.

The Diversity of PHE PHE worldwide is a diverse mix of scholastic establishments based on distinct traditions and sociopolitical contexts. A synergistic approach between medicine and community-based public

1Faculty

of Medicine, University of Colombo, Sri Lanka

Corresponding Author: Indika Karunathilake, Medical Education Development and Research Centre (MEDARC), Faculty of Medicine, University of Colombo, Sri Lanka. Email: [email protected]

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health is seen in British, Canadian, and Australian PHE systems.4 There is considerable emphasis on understanding clinical conditions, disease outbreaks, management, and prevention with the inclusion of nonmedical students in MPH programs.5 Although the roots of PHE in North America were similar to those in Britain, they have evolved to become independent institutions—schools of public health.6 Promotion of equity and social values was prompted by the American tradition of PHE. The Asia-Pacific Academic Consortium for Public Health (APACPH) was conceived and born within this tradition 30 years ago and continues to uphold the values of social justice and health equity even today.7 The Asian context is very diverse. The Chinese Health Care and education of health professionals has undergone major reforms over the years, with the adoption of national policies and programs with pragmatic approaches and synergy between traditional and modern health care services. Hong Kong illustrates selective adoption of best practices from both the British and American models while absorbing positive experiences from primary health care (PHC) and Chinese traditions.8 PHC approaches have influenced community health agencies in Japan, where medical and public health systems are closely linked to governmental and local bodies. Taiwan, Thailand, and the Philippines have drawn largely from the US tradition in PHE.9

Trends and Achievements in Health: Challenges for PHE In an earlier era when most births and deaths occurred at home, without institutional care, PHE focused primarily on sanitation and environmental conditions necessary for the control of infectious diseases. In the 1970s, broad frameworks on addressing causal factors such as nutrition and maternal and child health marked the next big shift in PHE, with immunization taking center stage. In the 1980s and 1990s, PHC became the mainstay of public health practice.10 The lesson for PHE from all these endeavors was that the PHC approach, which was comprehensive, collaborative, and covered minimal but essential services, made a significant contribution at these stages of development.11 With the economic boom in the 1980s, along with the demographic and epidemiological transitions that transformed Asian societies, this trend in public health began to shift toward new and high-end technologies from core essential services in health care. The reduction in under-5 mortality caused by vaccination and the invention of “wonder” drugs for upper-respiratory infections validated this shift from more fundamental but slower-yielding strategies. Moreover, dramatic successes in intensive and emergency care and the treatment of HIV/AIDS continue to demonstrate effectiveness of high-tech care. However, over time, these successes, which came at considerable cost, began to expose the overall burden as well as the continued need to manage problems related to secondary and tertiary prevention. Noncommunicable diseases have now become the most frequent cause of death12 in the APR, whereas maternal, perinatal, and nutritional and infectious diseases, injuries, and disasters continue to lay bare vulnerabilities in public health.13 Maintaining PHE in such a complex, dynamic, and rapidly changing environment while preserving affordable health services has become a major challenge.14 As health services get skewed to the more-expensive end of the spectrum, cost-effectiveness of care becomes an increasingly important consideration. Hence there is an urgent need to realign PHE curriculum and focus PHE on health equity and social justice. There is a body of evidence established beyond doubt that the social determinants of health account for major health disparities across all age groups in most countries.15 Therefore, PHE needs to pay far more attention and focus on policies and partnerships to bring larger societal change. Success in health improvement and the PHE experience in the APR provided 3 major lessons for the future. The first is the value of health equity and social justice.16 The second lesson is on

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the balance between technical competency and social responsibility. PHE needs to maintain a balance between high tech (technical skills) and high touch (managerial, cultural, and contextrelated skills). Thirdly, PHE has promoted problem-solving experiences through well-structured public health field practicum. There is a need to be proactive and responsive to meet the new challenges. As a leading public health academic organization, APACPH has a leading role to play in this endeavor.

The Role of APACPH in Improving PHE Since its founding in 1984, APACPH’s mission has been to improve the quality and relevance of PHE to combat the diverse, dynamic, and unique challenges in the region.7 Prof Walter Patrick was a forerunner in this movement and played an instrumental role in establishing APACPH’s position in accreditation and improvement of PHE. Leadership and faculty development in the first decade was in partnership with leading universities through the World Health Organization (WHO) Collaborating Center for Leadership in Primary Health Care at the University of Hawaii and its academic networks in the United States and Australia.17 In the early 1990s, APACPH established a “global,” regional MPH program through collaboration of several universities, including University of Hawaii (USA), Mahidol University (Thailand), and University of Philippines. This program provided well-supervised multicountry MPH training, with field training sites in member universities in Korea and Malaysia catering to World Bank/WHO funded scholars with MD/nursing/management backgrounds. It was geared to produce a prototype of a “Global Health Specialist” with higher-order skills—a “super generalist” with global health competencies for leadership positions in international or national agencies. This was an expensive program funded by 5 universities and funding agencies, and it was conducted over a 6-year period (1990-1996) for 3 cohorts.17 From 1988, over a 5-year period, 10 leading universities engaged in faculty exchanges and self-studies of their own curricula to enhance their MPH programs. Areas such as environmental and occupational health, health education, maternal and child health, health management, and international health were identified as needing additional support. Multiuniversity faculty reviewers identified competencies in certain public health sciences such as epidemiology and biostatistics as being adequate. In the recent decade, since the year 2000, the focus of exchanges has been on disasters (Asian Tsunami, 2004; Cyclone Nargis, 2008; Sichuan Earthquake, 2008) and pandemics (SARS, 2003; avian flu, 2009). Using Web-based learning, the APACPH-Yonsei International Cyber University for Health (ICUH) offered public health courses taught by faculty from 10 leading member universities. The Web-based program enhanced the breadth and depth of the curriculum and timeliness of PHE while providing access to students in hard-to-reach locations such as Mongolia and Vietnam. The next step for APACPH following these achievements was quality improvement through accreditation.

APACPH Accreditation Initiative Accreditation has become a priority area for APACPH since the 1990s. Marking the cross-roads in health development in Asia, the accreditation initiative in PHE was proposed by APACPH with the 80 member universities from 23 APR countries. In March 2011, the first formal steps for accreditation in PHE in the APR were taken at the APACPH Hangzhou Management Board Meeting hosted by President Liming Li and colleague deans from 10 leading schools of public health from China. During this meeting, a committee was set up on accreditation. Prof Phitaya Charuphoonpol and Prof Walter Patrick were appointed as cochairs of the Central Accreditation Committee with Prof Hung-Yi Chiou and Dr Indika Karunathilake as joint Secretaries. Prof

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Patrick’s passion and perseverance has been the driving force in bringing together leading public health institutions in the region for this cause and advancement of this initiative. Later on, with approval of the executive council and endorsement of the general assembly of APACPH, the accreditation committee was mandated to assess issues concerning accreditation of PHE in the region, examine national level accreditation requirements, identify strategies and establish necessary structures—managerial, technical, and funding—and conduct initial accreditation activities, including conferences, workshops, and mock site visits. The Accreditation for Public Health Education Programme was launched on March 29, 2012, at the Faculty of Public Health, Mahidol University, Thailand, sponsored by the president of Mahidol University, Prof Rajata Rajatanavin, and the dean, Prof Phitaya Charupoonphol. In all, 50 international and local experts from 10 APACPH member universities attended this conference. The conference addressed issues related to the need for accreditation, competencies required in the MPH, and the procedures and requirements for institutional accreditation. During this conference, the accreditation procedures of Thailand, Indonesia, Taiwan, Korea, Hong Kong, the United States, Australia, the United Kingdom, and Europe were reviewed. Competency requirements for the MPH in PHE were studied. and a survey on PHE competencies required in the context of the APR was carried out.9 Since then, expert committees have further reviewed those criteria and competencies. The main objectives of these APACPH sponsored multicountry expert consultations were to identify the common competencies for the MPH and to identify characteristics in PHE that are unique to the APR and shaped by regional culture, history, and public health needs. These competencies reflect national and regional priorities, such as universal coverage and cultural and religious values. Surveys and expert consultative meetings provided the consensus, which formed the basis for the PH competencies list for MPH in the APR. Gathering more momentum, the second accreditation meeting was held at the Faculty of Public Health, University of Indonesia, with the support of the rector of the University of Indonesia, Dr Gumilar Somantri, and the dean of Faculty of Public Health, Prof Bambang Wispriyono, from May 21 to 22, 2012. At this meeting, the Jakarta PHE accreditation model was designed and approved. At a follow-up accreditation meeting held at the Faculty of Public Health, University of Indonesia, Jakarta, in June 2012, the PHE accreditation model was presented, and more than 70 participants from the University of Indonesia attended this meeting. The APACPH-Jakarta MPH competency model, competency list, and guidelines serve as the basis for site visits and reviews.18 In September 2012, the progress of accreditation in PHE in the APR was reviewed at a consultative meeting held at the Taipei Medical University sponsored by the Ministry of Health, Taiwan. The review committee considered the APACPH model for accreditation in PHE appropriate and recommended for adoption. Prof Patrick conceptualized and guided development of the 3-circle APACPH model (Figure 1), accentuating that a public health graduate should demonstrate global health competencies gained through the use of different approaches and based on a foundation of core content. He strongly believed that public health graduates should understand the sociocultural and geopolitical context in the APR and its impact on public health approaches and use this understanding in their own practice. With an invitation from Sichuan University, the first APACPH-China MPH Accreditation and Curriculum Conference was held from June 20 to 22, 2013, at the School of Public Health, Sichuan University, Chengdu, China. PHE accreditation guidelines developed by the APACPH accreditation committee with the technical support of the Early Career Network of APAPCH were presented, discussed, and reviewed at this conference. The proposed accreditation process in PHE by APACPH included both institutional and program review.

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Figure 1.  Asia-Pacific Academic Consortium for Public Health (APACPH) competency framework for public health education.

The overall purpose of institutional review is to achieve accountability for quality and standards in public health by using a peer review process to promote sharing of good practice. The focus of the review is on how the academic and organizational structures and systems of the institution contribute to the program implementation to achieve the institutional objectives. It examines 8 main domains—that is, mission of the institution; governance; infrastructure; institutional programs; quality of faculty, staff, and students; research; community service activities; and collaborations and evaluation. In particular, the review should ensure that the key structural elements and financial sustainability of the institution support the mission and that the required institutional policies and procedures are in place.18 The program review investigates how the programs of study in an institution meet content standards and whether there are faculty and other resources to meet the expected accreditation standards. The APACPH PHE accreditation guidelines are focused on, but not limited to, master’s in public health programs. The program review takes into account 8 domains, including aims; learning outcomes and program details; governance; curriculum design, competencies, and content; teaching and learning methods; quality of students; quality of faculty; and assessment procedures and program evaluation.18 The proposed process of accreditation is completely voluntary and involves 3 distinct parts of preparation by the institute and the review team, a review visit, and reporting and discussion of the report and outcomes with the institution before publication. Any institution that wishes to be accredited should initially conduct a self-evaluation and submit a request for accreditation to APACPH, following which the accreditation process will be initiated (Figure 2). A trial “mock” site visit was conducted at the Faculty of Public Health, University of Indonesia, in 2012 to test the conceptual framework of the Accreditation process and to familiarize these institutions with accreditation expectations and procedures. The Faculty of Public Health, Mahidol University, and Faculty of Public Health, University of Indonesia, are the first 2 institutions seeking accreditation under the proposed APACPH accreditation format.

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Recommendations on regional standards

Initiation of Self Evaluation Submission of Institutional/ Programme Accreditation Request

Annual review of accreditations done

Recommendation to Institution/ University

APACPH sends the guidelines and templates Preparation of Self Evaluation documents by the Institution/ University

Accreditation decision

Accreditation report discussed with Institution

Self Evaluation documents are returned to APACPH

Assessment by panel at APACPH and accreditation report sent to Institution

Assessment of Self Evaluation adequacy by review team Site Visit

Figure 2.  Conceptual accreditation process.

Abbreviation: APACPH, Asia-Pacific Academic Consortium for Public Health.

Conclusion The overall contributions of APACPH in Public Heath leadership in academia, in ministries of health, and among international agencies has permitted APACPH to respond to the emerging need and that of interested parties to initiate accreditation in PHE in a progressive manner and on a voluntary basis. Prestigious lead institutions in selected countries have agreed to seek accreditation from an APACPH-sponsored globally established accreditation body in the APR. The key institutions have also agreed to serve as centers for improvement, conducting self-study conferences and workshops in their countries and regionally. In addition ICUH and APACPH collaborating centers will continue to promote the development of PHE in less economically developed countries like Mongolia, Laos, Cambodia, and others. Prof Walter Patrick was an ardent believer in advancement of PHE in the region. Because of his diligence and resoluteness, his initiative in accreditation of PHE has progressed over the years into an object of interest and paramount importance across the globe, which is at the verge of yielding tangible outcomes. His legacy will live on as APACPH continues progress toward a vision conceived by this inimitable public health figure but shared by all others in the APR today. Acknowledgments Contributions of Dr Ashvini De Abrew and Dr Asela Olupeliyawa in developing the APACPH accreditation guidelines are acknowledged.

Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

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Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.

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Accreditation of public health education in the Asia-Pacific region.

There has been dramatic advancement in health status in the Asia-Pacific region (APR) over the past 50 years. This ever-changing paradigm of public he...
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