Reports in Brief
fragmented mental health system: The main psychiatric hospital is located 75 kilometers from UBSOM. By necessity, the eight-week rotation was split between disparate clinical sites. MEPI funds allowed the introduction of several high-tech innovations to address these challenges. All students received tablet computers, and wi-fi Internet access was installed at the psychiatric hospital, ensuring that students had access to online tools, such as psychiatric journals through EBSCO Host, the ICD-10, and course lectures. Low-tech innovations included improving communication with other behavioral health services at training sites to create new experiences for students, such as clinical placements in psychology clinics and inpatient interdisciplinary team meetings. Such placements have had the added benefit of strengthening interdisciplinary relations and patient care. • Step 3: Emphasize a future-focused approach. Developing a futureoriented approach to learning has been fundamental to the department’s educational mission. Botswana’s limited formulary of psychiatric medications and laboratory constraints make the use of drugs such as lithium and atypical antipsychotics difficult. Given these challenges, the curriculum focuses on integrating evidence-based knowledge and reality-based best practice, framing psychiatry training within an evolving paradigm of what is feasible and what is preferable.
Author affiliations: M. Pumar, P. Opondo, Department of Psychiatry, School of Medicine, University of Botswana, and Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania; J. Ayugi, Department of Psychiatry, School of Medicine, University of Botswana; M. Reid, Department of Medicine, Perelman School of Medicine, University of Pennsylvania
Outcomes: While the full impact of psychiatric training to reduce Botswana’s neuropsychiatric disease burden is years away, the fact that 70 students have successfully completed the clerkship is evidence of the department’s early success in recruiting faculty and developing a curriculum despite considerable constraints. A nascent program of research projects, including international research collaborations, also demonstrates the department’s maturing ambitions.
Moses C. Simuyemba, MD, Damen H. Mariam, MD, MPH, PhD, Charles Michelo, MD, MPH, MBA, PhD, Gaonyadiwe G. Mokone, PhD, Kalay Moodley, MD, MMED, Kintu Mugagga, BCM, MSc, Katie Nolen, MPH, Dykki Settle, Joslin Dogbe, MD, MPH, Yakub Mulla, MD, MMED, and Candice Chen, MD, MPH
Comment: By leveraging the experience of partner institutions and employing innovative learning solutions, UBSOM has made substantial early progress in preparing a new generation of doctors to provide mental health care in Botswana. Correspondence should be addressed to Dr. Pumar, PO Box AC 157, ACH Riverwalk, Gaborone, Botswana; e-mail: [email protected].
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Acknowledgments: The authors acknowledge colleagues at the School of Medicine at the University of Botswana and thank them for their unwavering commitment to improving medical education in Botswana. They also acknowledge the enthusiasm of MEPI-funded partners at the University of Pennsylvania. Special thanks to Katie L. Bryant for assistance with drafting and revising this manuscript. Funding/Support: This publication was made possible through support provided by the Medical Education Partnership Initiative (Health Resources and Services Administration [HRSA] T84HA21125)and through support from the Penn Mental Health AIDS Research Center. Other disclosures: None reported. Ethical approval: Reported as not applicable. Disclaimers: The content is solely the responsibility of the authors and does not necessarily represent the official views of HRSA.
Reference 1 Saxena S, Thornicroft G, Knapp M, Whiteford H. Resources for mental health: Scarcity, inequity, and inefficiency. Lancet. 2007;370:878–889.
Graduate Tracking Systems for the Medical Schools in Africa: Processes for Developing an Implementation Framework
Background: Human resources for health are critical for effective health systems. In Africa, the number of doctors and nurses required to provide essential health services will be deficient by an estimated 800,000 in 2015.1 Numerous interventions have been implemented to mitigate these shortages, including educational reforms aimed at retaining medical graduates in areas of need by both increasing the number of graduates and by adapting training to match the needs of local populations.2 Tracking
graduates from African universities is critical to determine whether interventions are effective. However, most African medical schools do not track their graduates; only 18% of Sub-Saharan African medical schools reported having a graduate tracking system in 2012,3 and the data obtained from these systems are generally inadequate.4,5 Intervention: Based on a community of practice theory, a Graduate Tracking Technical Working Group (GT-TWG) was established within the Medical Education Partnership Initiative (MEPI) network comprising representatives from MEPI schools and the MEPI Coordinating Center. The GT-TWG, with CapacityPlus, a USAID-funded health workforce strengthening project, developed graduate tracking requirements for MEPI institutions and countries through a collaborative process, including structured interviews of 12 key individuals from 11 MEPI schools. Interviewees included deans, physician leaders, and monitoring and evaluation program officers identified by their schools as being central to graduate tracking. The GT-TWG and CapacityPlus also convened a workshop in October 2013 where representatives from 10 MEPI schools and from various country ministries of health, education, and health professional councils explored the MEPI landscape for tracking. Outcomes: Tracking systems varied widely among schools and countries. Most were paper based, although five schools reported having tracking systems in electronic formats or using electronic resources such as e-mail or social networking for communication and data gathering from graduates. No country among the MEPI-sponsored network had a single collaborative tracking system that involved all key stakeholders. The workshop allowed participants to validate findings and define a way forward to develop systems. Underlying principles included (1) clear goals and objectives to ensure that systems and data elements match the needs of schools and health systems; (2) medical school systems should be integrated with other health professional tracking systems when possible to enhance cooperation and information sharing; (3) early and meaningful stakeholder engagement is needed to define goals and objectives, establish integrated systems, and ensure
Academic Medicine, Vol. 89, No. 8 / August Supplement 2014
Reports in Brief
sustainability; and (4) tracking systems should be sufficiently flexible to match data collection to local contexts and available resources. Participants designed a framework to guide the establishment of graduate tracking systems consisting of seven core processes or elements: (1) general requirements; (2) locate graduates; (3) collect/update information; (4) search and view information; (5) create tracking survey tools; (6) manage tracking survey response data; and (7) generate reports. Objectives, business rules, triggers, and other elements were developed for each core process. Comment: The framework and its requirements may provide a tool for institutions developing graduate tracking systems of their own and highlight opportunities for partnerships nationally and globally to establish sustainable systems. Correspondence should be addressed to Dr. Chen, George Washington University, School of Public Health and Health Services, Department of Health Policy, 2121 K St., NW, Suite 210, Washington, DC; e-mail: [email protected]. Author affiliations: M.C. Simuyemba, C. Michelo, Y. Mulla, University of Zambia; D.H. Mariam, Addis Ababa University; G.G. Mokone, University of Botswana; K. Moodley, Stellenbosch University; K. Mugagga, Kampala International University; K. Nolen, Public Health Informatics Institute; D. Settle, IntraHealth International; J. Dogbe, Kwame Nkrumah University of Science and Technology; C. Chen, George Washington University Funding/Support: Funding and support for this work came from the Office of the U.S. Global AIDS Coordinator (OGAC), National Institutes of Health (NIH), Health Resources and Service Administration (HRSA), CapacityPlus, and USAID. Other disclosures: None reported. Ethical approval: Reported as not applicable. Disclaimers: The content is solely the responsibility of the authors and does not necessarily represent the official views of OGAC, NIH, or any other agency or organization.
References 1 Scheffler RM, Mahoney CB, Fulton BD, et al. Estimates of health care professional shortages in sub-Saharan Africa by 2015. Health Aff (Millwood). 2009;28:849–862. 2 Mullan F, Frehywot S, Omaswa F, et al. Medical schools in Sub-Saharan Africa. Lancet. 2011;377:1113–1121. 3 Chen C, Buch E, Wasserman T, et al. A survey of Sub-Saharan African medical schools. Hum Resour Health. 2012;10:4.
4 Pemba S, Macfarlane SB, Mpembeni R, et al. Tracking university graduates in the workforce: Information to improve education and health systems in Tanzania. J Public Health Policy. 2012;33:202–215. 5 Stilwell B, Diallo K, Zurn P, et al. Migration of health care workers from developing countries: Strategic approaches to its management. Bull World Health Organ. 2004;82:595–600.
Cancer Service Delivery in Malawi: Impact of a MEPI Pilot Award Tamiwe Tomoka, FCPath
Background: Malawi is a densely populated developing country in SubSaharan Africa. With a population of 15 million, Malawi suffers from a high burden of HIV/AIDS, with an estimated HIV prevalence of 15% for those aged 15 to 49. This high prevalence has resulted in an increase in HIV-associated malignancies. Kaposi’s sarcoma and cervical cancer are the most common cancers in males and females, respectively.1 Contributing to the challenge is a paucity of data on the matter which has been attributed to the lack of diagnostic capacity and inadequate cancer services at different levels and disciplines throughout the country. In addition to inadequate infrastructure, only three pathologists and three oncologists are available to serve the entire nation. The nation also lacks adequate support staff including laboratory technicians, pharmacists, and nurses with expertise in cancer care. Intervention: Motivated by the lack of capacity in cancer service delivery, in 2010 the University of Malawi applied for and received a Medical Education Partnership Initiative (MEPI) award. The goal was to use the MEPI award to expand physical resources for cancer diagnosis and treatment and assemble a limited group of trained Malawian doctors, scientists, and personnel to strengthen the diagnosis, treatment, epidemiologic surveillance, and research on HIV-associated malignancies in Malawi. Eighteen individuals were identified to pursue specialized training in various disciplines in cancer service delivery, including anatomical pathology, histotechnology, epidemiology, oncology nursing, and palliative care. In addition to increasing human resources for health, there was the need to renovate cancer wards and establish chemotherapy preparation rooms and anatomical
Academic Medicine, Vol. 89, No. 8 / August Supplement 2014
pathology laboratories at the country’s two major referral hospitals—Queen Elizabeth Central Hospital (QECH) and Kamuzu Central Hospital (KCH). Outcomes: Five oncology nurses, four palliative care nurses, one histotechnologist, and one epidemiologist have completed their specialized training and are now working in Malawi. In addition, there have been several in-house trainings for clinicians in colposcopy and for pharmacists, clinicians, and nurses in the handling of chemotherapeutic agents. The QECH cancer ward has also been renovated, and a chemotherapy preparation room has been established at KCH. Two functional anatomical pathology laboratories have been established, and a retired pathologist has been called back into service. Three technologists who plan to undergo specialized training are working in these laboratories, and one technologist is in training in Uganda. Two doctors are training in anatomical pathology in South Africa and are expected to finish in 2016, while one physician is preparing to attend a master’s program in public health. Comment: We anticipate improved surveillance, timely diagnosis, and treatment of HIV-associated malignancies. The oncology and palliative care nurses and clinicians are all working in Malawi. The majority of cancer patients present in late stages and are benefiting from additional palliative care services. Previously, Malawi had only one pathology laboratory with one histotechnologist. The establishment of the two new laboratories and recruitment of technologists has significantly decreased specimen turnaround times from more than six months to less than two weeks. Beyond the pilot phase, the long-term goal is to create a sustainable program having a high likelihood of success in attracting resources to care for cancer patients and conduct independent research into HIVassociated cancers. It is expected that the trained personnel will take a leading role in this research. The Malawi Ministry of Health has included cancer in its noncommunicable disease strategic plan with the goal of improving cancer service delivery at all levels. Correspondence should be addressed to Dr. Tomoka, University of Malawi College of Medicine, P/b 360, Blantyre3, Malawi; e-mail: [email protected].
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fragmented mental health system: The main psychiatric hospital is located 75 kilometers from UBSOM. By necessity, the eight-week rotation was split between disparate clinical sites. MEPI funds allowed the introduction of several high-tech innovations to address these challenges. All students received tablet computers, and wi-fi Internet access was installed at the psychiatric hospital, ensuring that students had access to online tools, such as psychiatric journals through EBSCO Host, the ICD-10, and course lectures. Low-tech innovations included improving communication with other behavioral health services at training sites to create new experiences for students, such as clinical placements in psychology clinics and inpatient interdisciplinary team meetings. Such placements have had the added benefit of strengthening interdisciplinary relations and patient care. • Step 3: Emphasize a future-focused approach. Developing a futureoriented approach to learning has been fundamental to the department’s educational mission. Botswana’s limited formulary of psychiatric medications and laboratory constraints make the use of drugs such as lithium and atypical antipsychotics difficult. Given these challenges, the curriculum focuses on integrating evidence-based knowledge and reality-based best practice, framing psychiatry training within an evolving paradigm of what is feasible and what is preferable.
Author affiliations: M. Pumar, P. Opondo, Department of Psychiatry, School of Medicine, University of Botswana, and Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania; J. Ayugi, Department of Psychiatry, School of Medicine, University of Botswana; M. Reid, Department of Medicine, Perelman School of Medicine, University of Pennsylvania
Outcomes: While the full impact of psychiatric training to reduce Botswana’s neuropsychiatric disease burden is years away, the fact that 70 students have successfully completed the clerkship is evidence of the department’s early success in recruiting faculty and developing a curriculum despite considerable constraints. A nascent program of research projects, including international research collaborations, also demonstrates the department’s maturing ambitions.
Moses C. Simuyemba, MD, Damen H. Mariam, MD, MPH, PhD, Charles Michelo, MD, MPH, MBA, PhD, Gaonyadiwe G. Mokone, PhD, Kalay Moodley, MD, MMED, Kintu Mugagga, BCM, MSc, Katie Nolen, MPH, Dykki Settle, Joslin Dogbe, MD, MPH, Yakub Mulla, MD, MMED, and Candice Chen, MD, MPH
Comment: By leveraging the experience of partner institutions and employing innovative learning solutions, UBSOM has made substantial early progress in preparing a new generation of doctors to provide mental health care in Botswana. Correspondence should be addressed to Dr. Pumar, PO Box AC 157, ACH Riverwalk, Gaborone, Botswana; e-mail: [email protected].
S112
Acknowledgments: The authors acknowledge colleagues at the School of Medicine at the University of Botswana and thank them for their unwavering commitment to improving medical education in Botswana. They also acknowledge the enthusiasm of MEPI-funded partners at the University of Pennsylvania. Special thanks to Katie L. Bryant for assistance with drafting and revising this manuscript. Funding/Support: This publication was made possible through support provided by the Medical Education Partnership Initiative (Health Resources and Services Administration [HRSA] T84HA21125)and through support from the Penn Mental Health AIDS Research Center. Other disclosures: None reported. Ethical approval: Reported as not applicable. Disclaimers: The content is solely the responsibility of the authors and does not necessarily represent the official views of HRSA.
Reference 1 Saxena S, Thornicroft G, Knapp M, Whiteford H. Resources for mental health: Scarcity, inequity, and inefficiency. Lancet. 2007;370:878–889.
Graduate Tracking Systems for the Medical Schools in Africa: Processes for Developing an Implementation Framework
Background: Human resources for health are critical for effective health systems. In Africa, the number of doctors and nurses required to provide essential health services will be deficient by an estimated 800,000 in 2015.1 Numerous interventions have been implemented to mitigate these shortages, including educational reforms aimed at retaining medical graduates in areas of need by both increasing the number of graduates and by adapting training to match the needs of local populations.2 Tracking
graduates from African universities is critical to determine whether interventions are effective. However, most African medical schools do not track their graduates; only 18% of Sub-Saharan African medical schools reported having a graduate tracking system in 2012,3 and the data obtained from these systems are generally inadequate.4,5 Intervention: Based on a community of practice theory, a Graduate Tracking Technical Working Group (GT-TWG) was established within the Medical Education Partnership Initiative (MEPI) network comprising representatives from MEPI schools and the MEPI Coordinating Center. The GT-TWG, with CapacityPlus, a USAID-funded health workforce strengthening project, developed graduate tracking requirements for MEPI institutions and countries through a collaborative process, including structured interviews of 12 key individuals from 11 MEPI schools. Interviewees included deans, physician leaders, and monitoring and evaluation program officers identified by their schools as being central to graduate tracking. The GT-TWG and CapacityPlus also convened a workshop in October 2013 where representatives from 10 MEPI schools and from various country ministries of health, education, and health professional councils explored the MEPI landscape for tracking. Outcomes: Tracking systems varied widely among schools and countries. Most were paper based, although five schools reported having tracking systems in electronic formats or using electronic resources such as e-mail or social networking for communication and data gathering from graduates. No country among the MEPI-sponsored network had a single collaborative tracking system that involved all key stakeholders. The workshop allowed participants to validate findings and define a way forward to develop systems. Underlying principles included (1) clear goals and objectives to ensure that systems and data elements match the needs of schools and health systems; (2) medical school systems should be integrated with other health professional tracking systems when possible to enhance cooperation and information sharing; (3) early and meaningful stakeholder engagement is needed to define goals and objectives, establish integrated systems, and ensure
Academic Medicine, Vol. 89, No. 8 / August Supplement 2014
Reports in Brief
sustainability; and (4) tracking systems should be sufficiently flexible to match data collection to local contexts and available resources. Participants designed a framework to guide the establishment of graduate tracking systems consisting of seven core processes or elements: (1) general requirements; (2) locate graduates; (3) collect/update information; (4) search and view information; (5) create tracking survey tools; (6) manage tracking survey response data; and (7) generate reports. Objectives, business rules, triggers, and other elements were developed for each core process. Comment: The framework and its requirements may provide a tool for institutions developing graduate tracking systems of their own and highlight opportunities for partnerships nationally and globally to establish sustainable systems. Correspondence should be addressed to Dr. Chen, George Washington University, School of Public Health and Health Services, Department of Health Policy, 2121 K St., NW, Suite 210, Washington, DC; e-mail: [email protected]. Author affiliations: M.C. Simuyemba, C. Michelo, Y. Mulla, University of Zambia; D.H. Mariam, Addis Ababa University; G.G. Mokone, University of Botswana; K. Moodley, Stellenbosch University; K. Mugagga, Kampala International University; K. Nolen, Public Health Informatics Institute; D. Settle, IntraHealth International; J. Dogbe, Kwame Nkrumah University of Science and Technology; C. Chen, George Washington University Funding/Support: Funding and support for this work came from the Office of the U.S. Global AIDS Coordinator (OGAC), National Institutes of Health (NIH), Health Resources and Service Administration (HRSA), CapacityPlus, and USAID. Other disclosures: None reported. Ethical approval: Reported as not applicable. Disclaimers: The content is solely the responsibility of the authors and does not necessarily represent the official views of OGAC, NIH, or any other agency or organization.
References 1 Scheffler RM, Mahoney CB, Fulton BD, et al. Estimates of health care professional shortages in sub-Saharan Africa by 2015. Health Aff (Millwood). 2009;28:849–862. 2 Mullan F, Frehywot S, Omaswa F, et al. Medical schools in Sub-Saharan Africa. Lancet. 2011;377:1113–1121. 3 Chen C, Buch E, Wasserman T, et al. A survey of Sub-Saharan African medical schools. Hum Resour Health. 2012;10:4.
4 Pemba S, Macfarlane SB, Mpembeni R, et al. Tracking university graduates in the workforce: Information to improve education and health systems in Tanzania. J Public Health Policy. 2012;33:202–215. 5 Stilwell B, Diallo K, Zurn P, et al. Migration of health care workers from developing countries: Strategic approaches to its management. Bull World Health Organ. 2004;82:595–600.
Cancer Service Delivery in Malawi: Impact of a MEPI Pilot Award Tamiwe Tomoka, FCPath
Background: Malawi is a densely populated developing country in SubSaharan Africa. With a population of 15 million, Malawi suffers from a high burden of HIV/AIDS, with an estimated HIV prevalence of 15% for those aged 15 to 49. This high prevalence has resulted in an increase in HIV-associated malignancies. Kaposi’s sarcoma and cervical cancer are the most common cancers in males and females, respectively.1 Contributing to the challenge is a paucity of data on the matter which has been attributed to the lack of diagnostic capacity and inadequate cancer services at different levels and disciplines throughout the country. In addition to inadequate infrastructure, only three pathologists and three oncologists are available to serve the entire nation. The nation also lacks adequate support staff including laboratory technicians, pharmacists, and nurses with expertise in cancer care. Intervention: Motivated by the lack of capacity in cancer service delivery, in 2010 the University of Malawi applied for and received a Medical Education Partnership Initiative (MEPI) award. The goal was to use the MEPI award to expand physical resources for cancer diagnosis and treatment and assemble a limited group of trained Malawian doctors, scientists, and personnel to strengthen the diagnosis, treatment, epidemiologic surveillance, and research on HIV-associated malignancies in Malawi. Eighteen individuals were identified to pursue specialized training in various disciplines in cancer service delivery, including anatomical pathology, histotechnology, epidemiology, oncology nursing, and palliative care. In addition to increasing human resources for health, there was the need to renovate cancer wards and establish chemotherapy preparation rooms and anatomical
Academic Medicine, Vol. 89, No. 8 / August Supplement 2014
pathology laboratories at the country’s two major referral hospitals—Queen Elizabeth Central Hospital (QECH) and Kamuzu Central Hospital (KCH). Outcomes: Five oncology nurses, four palliative care nurses, one histotechnologist, and one epidemiologist have completed their specialized training and are now working in Malawi. In addition, there have been several in-house trainings for clinicians in colposcopy and for pharmacists, clinicians, and nurses in the handling of chemotherapeutic agents. The QECH cancer ward has also been renovated, and a chemotherapy preparation room has been established at KCH. Two functional anatomical pathology laboratories have been established, and a retired pathologist has been called back into service. Three technologists who plan to undergo specialized training are working in these laboratories, and one technologist is in training in Uganda. Two doctors are training in anatomical pathology in South Africa and are expected to finish in 2016, while one physician is preparing to attend a master’s program in public health. Comment: We anticipate improved surveillance, timely diagnosis, and treatment of HIV-associated malignancies. The oncology and palliative care nurses and clinicians are all working in Malawi. The majority of cancer patients present in late stages and are benefiting from additional palliative care services. Previously, Malawi had only one pathology laboratory with one histotechnologist. The establishment of the two new laboratories and recruitment of technologists has significantly decreased specimen turnaround times from more than six months to less than two weeks. Beyond the pilot phase, the long-term goal is to create a sustainable program having a high likelihood of success in attracting resources to care for cancer patients and conduct independent research into HIVassociated cancers. It is expected that the trained personnel will take a leading role in this research. The Malawi Ministry of Health has included cancer in its noncommunicable disease strategic plan with the goal of improving cancer service delivery at all levels. Correspondence should be addressed to Dr. Tomoka, University of Malawi College of Medicine, P/b 360, Blantyre3, Malawi; e-mail: [email protected].
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