SW. Su K Med.. Vol. IJC. pp. 137 to 142 Perpamon Press Ltd 1979 Printed m Chat

Bratam

INNOVATION AND CONSTRAINTS IN HEALTH MANPOWER POLICY: A CASE HISTORY OF MEDICAL EDUCATION DEVELOPMENT IN CAMEROUN STEPHENC. JOSEPH Harvard

School

ol Public

Health

Abstract-In attempting to achieve a broader distribution of basic health services. a central policy dilemma arises: how to reform medical education in order to provide appropriate health manpower in reformed health services systems. The University Center for Health Sciences in Cameroun developed a medical education program to train workers in locally relevant skills. However, pressures toward more traditional forms of medical education at the outset of the program posed major obstacles to achieving the school’s original objectives. The author concludes that both health services and medical education reforms are probably necessary for providing broader distribution of appropriate care.

INTRODUCTION-HEALTH POLICY AND MEDICAL EDUCATION

the developing countries since the mid-1960s there has been an increasing emphasis on attempting to achieve a broader distribution of basic health services, especially for the dispersed rural populations and the rapidly growing urban poverty populations of the Third World Cl]. Contemporary efforts in this regard often run counter to earlier attempts to increase the supply of physicians and the supply of urban hospital beds. There is growing recognition that the feasible mechanisms by which to meet the basic health services needs of Third World populations, given the constraints of scarce fiscal, manpower and other resources, are not congruent with traditional patterns of medical education. nor with traditional patterns of hospital-oriented physician practice [2]. However, most of the health ministries and manpower training institutions in developing countries (as elsewhere in the world) are dominated by physicians trained in the traditional Western model of medical education. Also, there has been relatively little awareness on the part of political decision-makers, and others who allocate scarce resources within the health sector, of the alternatives to the investment of resources in physicians and hospitals [3]. Therefore, until relatively recently, most health strategies of developing countries have been closely tied to investments in physicians and hospitals. Newer. trends focusing upon the training of auxiliary workers and the wider distribution of rural health services have created policy dilemmas and policy conflicts within health ministries and between health ministries and medical and other health professional schools. To be sure, the training and utilization of generalist and specialist health auxiliaries. especially for service in rural areas, has been a feature of health services in developing countries since 19th century colonial times: important examples of more recent, but pre-196Os, activities of this nature in Africa include the work of Fendall and others in British East Africa [4], the training of village midwives in the Sudan [.5] and the long tradition of the French “Services des Grandes Endemic?’ in West Africa. But, until the Throughout

137

past decade, few develop:ng countries have. as national policy, placed high priority on achieving a broad distribution of rural health services without dependence on physicians or hospitals. In recent years the reorientation of health policy in these directions in Tanzania in Anglophone East Africa [6] and Niger in Francophone West Africa [7] are important examples. Perhaps the greatest impetus for policy change in this area is a result of the influence of the achievements in health in the People’s Republic of China; the health manpower policy and resource allocation examples of China have made significant impressions upon health policy-makers and planners in both socialist and non socialist developing countries. In many countries in the developing world. where the need for a reorientation of the basic health services strategy has been appreciated, major dilemmas arise about the appropriate forms and content of mkdical education. As early as the 195Os, and continuing well through the late 196Os, the major efforts towards health services reorientation in developing countries were attempts to reform medical education. Llowing the concept that the training and employment of a “new breed” of physicians could provide the most likely route to fundamental changes in health services [8]. In other words, if physicians could be educated to be oriented towards a broader distribution of basic health services, towards ambulatory and community medicine rather than subspecialized hospital medicine, then it ‘was considered likely that significant changes in the patterns of delivery of the health services of a given country would follow. Most of these efforts were undertaken via attempts to create “strong departments of community medicine”, and to develop via this structure a counterbalance to the specialty clinical departments with their hospital and subspecialized orientation [9]. These attempts were especially strongly supported by the Rockefeller Foundation, growing out of the early important work by John Grant at the Peking Union Medical College in China. and flowing into Rockefeller Foundation assistance to the development of community medicine programs in new medical schools in such places as Cali. Columbia; Bangkok, Thailand: and. more recently, in Jogjakarta. Indonesia. Other early (i.e. circa 1960) significant national efforts in this regard

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STEPHEN

were undertaken in such places as Haceteppe Medical School in Turkey and Pahlavi University in Shiraz, Iran. The ideal of reforming health services via fundamental change in medical education, through the development of programs in community medicine and public health within traditional schools, was strongly supported by the World Health Organization in the mid and late 1960% and had significant impact on most medical schools in the Third World during this period [lo]. However, most observers of the results of these efforts conclude that this approach of attempting to reform medical education from within, that is through developing community medicine programs in competition with the clinical specialities, has not demonstrated major success [ll]. Within the medical education hierarchy in individual universities, and within the health services hierarchy in ministries of health, this approach has not been able to gather sufficient interest, talent or fiscal resources to serve as an effective counterbalance. More recently, partly in response to this, the attention of health policy-makers and international organizations (such as the World Health Organization) has shifted away from attempts to reform medical education and rowurds attempts to reorganize the health services systems within individual countries as a prelude to a change in the educational patterns of physicians and other health workers. Thus in many countries one is faced with a chicken and egg dilemma: is educational reform in the health professions (especially physicians) a necessary initial step towards a change in the health service patterns, or must there first occur a changed pattern of health services within a country to provide the climate within which changes in health manpower training and education can flourish? Whichever approach is chosen as the primary mechanism, it is obvious that changes in the traditional pattern of educating physicians will be necessary, since physicians are, and are likely to remain, key personnel in the organization and delivery of health services and in the training and education of new physicians and other health care workers. MEDICAL CONCEPTUAL

EDUCATION INNOVATION

IN CAMEROUNAND CONSTRAINTS

This paper explores the interaction of these policy dilemmas as they appeared in a Central West African country within the last 10 years. The setting described is of particular interest because of the investment of significant national and international resources and the use made of the accumulated experience of previous efforts in medical education reform. This appeared to provide an optimal milieu for constructive innovation in in physician training and national health manpower policy. The basic concepts of the University Center for Health Sciences (UCHS) in Yaounde, Cameroun, were developed in the mid-1960s by the Government of Cameroun, in close collaboration with the World Health Organization [12]. As the program unfolded, the foreign assistance agencies of France, Canada and the United States provided significant financial and technical assistance to the development of the institution. The UCHS, set within the national university

C.

JOSEPH

in Yaounde but directed by an interministerial council (which included both the Ministers of Health and of Education), was conceived as a health manpower training institution to produce health workers, especially physicians, specifically motivated and competent to provide health services in the rural African context [13]. Towards this end the objectives of UCHS were to train various categories of health workers in a multidisciplinary setting, via the use of an integrated curriculum that would mesh the basic sciences. the clinical sciences and public health. The analysis of the UCHS in this paper argues that. viewed against its original objectives, the UCHS suffered from three major “inborn errors of medical school metabolism”. The term “inborn errors of metabolism” is used here to draw the analogy between prenatal genetic conditions that express themselves as fundamental biochemical lesions throughout life, and the conscious or unconscious policy formulations set at the conceptual stage of an institution’s development that shape the future existence of that institution. The three “inborn errors of medical school metabolism” described for the UCHS are common to many other medical education programs in developing countries, including institutions that preceded the UCHS in time, and newer medical schools. The three common decisions which posed major obstacles to achieving the school’s original objectives were the following: 1. The decision was made to begin the institution’s training program with medical (i.e. physician) education and to “add other categories of health workers” in later years. 2. The decision was made to locate the school in the capital city urban area, even though the emphasis of the curriculum was to be on health services for a rural African population. 3. The decision was made to develop a curriculum that would lead to a medical degree which would be accepted as “internationally equivalent” with medical degrees from Europe and North America. While one can criticize these basic policy decisions retrospectively, the direct and indirect policy pressures at international and national levels which led to these choices should also be understood. To the extent that the Government of Cameroun and the international agencies involved viewed health services primarily through the optic of the need for more appropriately trained physicians, it seemed logical to begin the UCHS with a medical education track, especially since the institution’s own aspirations were for fundamental medical education reform. Medical schools in developing countries are a considerable source of national pride and prestige; this appears to have been a strong factor in the decision to begin with physician training and, perhaps more importantly, to seek international equivalence of the M.D. degree. It is particularly difficult for health ministry officials and for medical academicians, who are themselves physicians trained according to the Western bioscience model, to risk their personal and professional investment in a medical curriculum that might be labelled and regarded as “second class” to, or significantly different from, the accepted norms of physician education.

Innovation

and constraints

Locating the school in the urban area was based on the argument that the UCHS needed to be close to other facilities of the university and to the National Ministry of Health and its urban hospital. Also, it was argued that it would be difhcult to attract and support a faculty if the school were placed in a more or less remote rural area. In all probability, national pride in an innovative and showpiece medical school facility in the capital city were also important considerations in this decision. PROGRAM

IMPLEMENTATION-INNOVATIONS

As the medical education program at the UCHS developed, several significant differences between the UCHS program and more traditional medical schools evolved. First. as has already been mentioned, the school was not divided into the usual departments. Rather, the faculty was grouped within three major divisions: the basic sciences; the clinical sciences: and the public health sciences. This was done deliberately as an admin~trat~ve attempt to avoid speciafty fragmentation and competition between the various clinical and preclinical departments. A major issue was resolved with the decision not to build a large specialized teaching hospital but rather to develop for the UCHS a small (250-300 beds) teaching hospital unit that would be reflective of the departmental-level hospital in the rest of the country [143. This facility was designed with teaching and research needs in mind, but an attempt was made to avoid over-s~ciaii~tion and over-soph~ti~tion of facilities. The concept of a small hospital was tied to the idea of selecting a geographic area (on the periphery of the capital city and extending out into surrounding rural areas) which would provide a defioed population base for the health services activity of the UCHS. This approach it was argued, would strengthen concepts of population-based and community medicine and provide the school with a ‘%ommunity laboratory” in which to carry out education. service and research. Within the medical curricuhtm, much greater emphasis than in most other medical schools was placed on training medical students in health centers and rural hospitals. Beginning in their first year, students spend considerable time at a peri-urban health center; later in the curriculum they spend major blocks of time working in rural health center settings [15], engaging in preventive medicine and public health activities in rural districts [16] and undertaking a rural hospital internship [17). The training of other health professionals has been added to the institution, beginning, approximately four years after the medical education program started, with advanced nursing training to prepare nurse supervisors and educators. Four or five years later, i.e. only within the past two or three years, there has been the progressive addition of various streams of param~ical technicians. Programs for students other than medical students were originally added as quite separate curriculum streams; attempts to develop team training and shared educational experiences are only in their earliest stages. These team-training activities have taken two major forms: multidisciplinary student teams

in health manpower policy

139

engaged in clinical and community health activities. especially during a two-month-long clerkship [15], and the mixing of students in basic science and public health didactic activities. This latter activity has proven more difficult than the former, as the faculty have wrestled with problems of different content and levels of knowledge among groups of students. Finally, with regard to the major curriculum and program innovations of the UCHS, it should be mentioned that the medical education track is bilingual. Cameroun is a country with both Francophone and Anglophone traditions. The medical faculty is one of the few truly bilingual higher ~u~tiona1 programs in the country. Because of the profound differences in the health services traditions between Anglophone and Francophone areas of West Africa, it will be interesting to see whether the graduates of the medical program in Yaounde will develop a new synthesis of health policy and practice flowing from their exposure to both traditions. For example, the Anglophone tradition in former West Cameroun emphasized the provision of rural public heafth services fanning out from a well-developed network of nurse-run health centers: in Francophone Cameroun the emphasis was more heavily on a separation between curative services in health centers and dispensaries, and mobile preventive services directed from a more central level. The current health policy of Cameroun aims at an integration of curative and preventive services that plaoes fixed and mobile activities under unified administration. To the extent that UCHS medical graduates hold a “community health” orientation that embraces the best aspects of both Anglophone and Francophone traditions, they will be a powerful force in supporting this policy, and equilibrating the mixture of fixed and mobile, and curative and preventive, services throughout the nation. PROGRAM

IMPLEMENTAT~ON~ONS~AIN~

Thus far this paper has described the conceptual and programmatic innovations of the UCHS, which aimed at an educational reform that would in turn lead to improved and more relevant health services in Cameroun. These innovations were hindered. even before the program began, by a series of policy constraints in the conceptual structure of the institution. There were, in addition, a series of pohcy differences and, at times, policy conflicts which revolved around the ~pIementation of these innovations in medical and health professional education. Some of these issues relate primarily to faculty and students of the school, some to the larger medical community in Cameroun and some to the society at large. The most important of these will be discussed below. There was considerable scepticism on the part of the existing medical community in Cameroun, especially in the first five or six years of the program, concerning the “‘quality” of the UCHS approach. Al1 the then-existing practicing physicians and Ministry of Health officials in Cameroun had been trained in Europe. Some of these individuals were vocal in their doubts as to whether or not the UCHS would produce a “second-class doctor’*. In part, discussion of these issues took place in the arena of Ministry/

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University difference-s, analogous to the town/gown contlicts in many other settings in the world. The students themselves, particularly in the early years of the program, would manifest anxiety as to their future abilities and roles, and would pose questions such as “will I be a real doctor?” or “will I be as good a doctor as Dr. X or Y who was trained in France or Britain?” This scepticism, and sometimes antipathy, on the part of the existing medical community produced strong pressure upon the UCHS to modify its innovations in the direction of more traditional medical education. These same pressures, and sometimes internal ambivalences, were noted on the part of faculty of the medical school. One important obstacle to innovation in medical education lay in the fact that the faculty themselves were the product of the more traditional systems, and in some cases were unable or unwilling to commit their energies to the innovations basic to the concept of the school. Apparently, in the last several years, these problems have diminished greatly. As the first three graduating classes of physicians have gone into Ministry service and worked side by side with physicians trained elsewhere there appears to have been a significant increase in mutual tolerance and respect. Pressures towards more traditional forms of medical education also came from political figures and from society at large. Despite the insight of several key political and Ministry figures into the need to train health workers of various categories in a fashion more appropriate to the actual problems of Cameroun, the most usual interpretation of health services and health manpower needs in Cameroun was similar to that in most other countries, e.g. that the way to the wider distribution of improved health services was to train more doctors and to build more hospitals. Directly and indirectly, through the press and radio and through political. Ministerial and University postures. there was, and remains, constant pressure upon the institution to adopt a more traditional course. A dynamic equilibrium between the forces for innovation and those of traditionalism within the medical education spectrum continues, of course, into the present. It is probably too early to make definitive statements about the balance between them. The author’s preliminary conclusions are that the innovations of the UCHS program will indeed produce significant future changes in the pattern of health services in Cameroun, but far less significant changes than might have been achieved had a more radical approach been adopted in conceptualizing the institution, i.e. had the “inborn errors of medical school metabolism”, described above, been averted. In following the progress of the UCHS and by interviewing its early medical graduates after their first year’s service as physicians in rural areas [lg. 191 it seems clear to the author that the attitudes and behaviors of these young physicians place considerably more emphasis on a preventive and community health approach to the health problems of the districts in which they work then is generally true of the graduates of other developing country medical schools or of physicians who have returned home to developing countries after medical education (with clinical subspecialty emphasis) in Europe or the United States. Though the current evidence is only

anecdotal or impressionistic, UCHS graduates seem to accord both higher priority and higher status to public health, preventive and medical generalist functions. In addition they are, by the nature of their curriculum as students, better attuned to and prepared for the realities of rural practice and administration. and also appear more cognizant of the need to function as teachers and supervisors of nurses and other health personnel. UCHS-THE

BALANCE AT PRESENT

What can one say at this point, ten years after the initial conception of the UCHS, in terms of the outcomes of this experiment in medical education? [18] First of all there is an increasingly stabilized and significantly innovative medical education program which has produced a yearly crop of new physicians for the past three years. How “different” these physicians are because of the kind of training they have received and what impact these differences will have upon future health policy and health services in Cameroun are questions that should be closely followed, for it is probably a decade too early to make an assessment of results [19]. The Government of Cameroun has posted all physicians who have graduated from the UCHS to rural areas (the medical students have a lO-year bond of service to the Government). These physicians, graduates of the UCHS, will continue to enter the clinical and public health services. and some of them will undoubtedly move progressively higher up into the administrative, planning and policy levels of the Ministry of Health itself. With a physician output of approximately 30 per year. within 10 years the majority of physicians practicing in Cameroun will be graduates of its own medical school. A highly significant development has been the recruitment in the last year of several physicians from the first graduating class (1975) as junior faculty within the UCHS itself. Thus, one can look towards the future of the institution as being reinforced by people trained in the tradition of the institution. rather than those whose prior training is less directly relevant to those objectives. At the beginning the faculty of the UCHS was heavily dependent upon expatriates in senior posts; by now the faculty has become almost completely Camerounian and the number of expatriates in senior faculty positions is quite small. The UCHS is developing a teaching, research and service base that is reflective of its own national character. To the extent that this faculty pursues objectives which are relevant to the health needs of Cameroun, they will be a much more potent force for change than any collection of expatriates could ever be. Yaounde itself, because of the development of the UCHS, has become a nucleus for othkr health training and health policy activities, serving as both a stimulus and a center for similar activities elsewhere in West and Central Africa. The advanced nursing training program has been extremely successful, and nurses in senior supervisory and educational positions through Francophone West Africa have had their training at the UCHS. These developments are particularly important with regard to those West African

Innovation and constraints in health manpower policy

countries who have decided to de-emphasize physician manpower and achieve a broader distribution of rural primary care utilizing nurses and auxiliaries [ZO]. It is still too early to comment on the impact that the training of other health professions will have upon the organization and function of health services within Cameroun. This is due. in part. to the decision to begin with medical education and the later addition of more or less separate streams of other health professionals within the UCHS, as described above, and also, in part, to a resistance both within the Ministry of Health and within the University to training health auxiliaries as primary care workers. Biomedical and health services research is also beginning to flow from the UCHS. Most of the biomedical research is clinical and applied, focusing on subjects of particular relevance to West Central Africa such as current research projects of UCHS faculty in sickle cell disease and filariasis. Each medical student must design, carry out and write up an independent research project before graduating; a review by the author of the research projects of the first two graduating classes revealed that the greatest majority of these could not easily be categorized as “basic science”, ‘*clinical” or “public health“ projects. Rather, most cut across two or three of these categories, and included population-based or community epidemiologic surveys of particular disease entities or treatment regimens: the author views this as a piece of corroborative evidence that there is some extent of “community health imprinting” going on in the UCHS medical curriculum. It is important to mention that this t>pe of research being carried out by faculty and students is providing useful info~ation to the Ministry of Health of a kind that virtually did not exist previously. Those who have worked in settings similar to Cameroun know that accurate demographic/disease patterns specific fo national or local settings are seldom available. Some of the research findings of faculty and students have already been used by the Ministry for program planning purposes. Because of the UCHS concept of designing training and service programs. cis-&is defined popuIations (both in Yaounde and in rural areas), many of the school’s programs have involved baseline demographic. epidemiologic and health resources studies in urban and rural communities. These activities have fostered an interest in health services research on the part of UCHS faculty; plans are currently under discussion for the development of a Health Services Research Institute in Yaounde; this would be the first of its kind in Africa. and could prove very important both in balancing the pressures for traditional subspecialty biomedical orientation at UCHS and also in providing useful data for health services and evaluation in Cameroun and elsewhere in subsaharan Africa. Finally. the UCHS has had an important conceptual impact on the development of similar institutions elsewhere in West Africa. For example, the Republic of Niger has started a CUSS (the French acronym for University Center for the Health Sciences). closely modelled on the Yaounde school. and other countries. such as Upper Volta are considering similar developments.

What

is most

interesting

about

these

other

I41

endeavors is that while they have tended to follow closely the conceptual orientation of the UCHS, they may well turn out to be more innovative in their implementation than the template institution. Some of the other countries considering UCHS-like developments have considerably scarcer resources (in both fiscal and trained manpower terms) than does Cameroun. The resource scarcities could provide a positive lever for innovation and more radical curriculum reform. How might one summarize the interactions between health manpower policy innovation and constraints that are displayed against the UCHS background? The following statements seem to the author to be applicable to similar situations in other countries. as well as descriptive of the history in Cameroun: 1. The early conceptual framework of a health training institution contains the seeds of later operational (as well as theoretical) policy choices. For example, one can envisage a quite different scenario of current and future health services priorities in Cameroun, even given the same educational objectives, had the UCHS been built in a ruraf area, begun its training program by producing &ealth auxiliaries and placed the highest priority upon “local standards of relevance” rather than “international standards of equivalence”. 2. Constraints to innovation in health manpower policy arise, nbt only because of formal and conscious priorities of policy-makers in the Ministry and in the University, but also because of the mind-sets of students, faculty, the larger health professional community and the society at large (nationally and internationally) concerning basic definitions of “health services”, “medicine”, “quality/relevance”, etc. 3. Given the above, the answer to the question of whether health services reform is most appropriately a result of. or a condition precedent to, health professional educational reform is probably “both”. This implies a need for functional and collaborative relationships between Health Ministry and University officials that has proven to date to be extremely difficult to achieve in most. if not all, countries.

REFERENCES

1. Newell K. Health by the People. World Health Organization. Geneva. 1975. 2. Joseph S. C. Education for health: The gap between the teaching hospital and the community. Presen:ed at the International Hospital Federation Congress in Tokyo, Japan, 22 May, 1977. In press. 3. Gish 0. P~~nn~ng the Health Secror The Ton:anian Experience. Holmes and Meier. New York. 1976. 4. Fendall N. R. E. Auxiliaries in Health Care. Progrnms in Deueloping Countries. Johns Hopkins. Baltimore, 1972. 5. Bayoumi A. Training and activity of village midrr~tes in the Sudan. Tropical Docror 6 (3). 118-125. 1976. 6. Chagula W. K. and Tarimo E. Meeting Basic Health Needs in Tanzania. In Newell. op. cir.. pp. 145-168. 7. Fournier G. and Djermakoye I. A. Village Health Teams in Niger (Maradi Department). In Newell. op. cit.. pp. t28-144. 8. King M. Medicinein red and blue. Lancer 1, 679-681. 1972.

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142 9. Latham

10. 11.

12. 13.

14.

15.

W. and Newberry A. Communir) Medicine: Teaching. Research and Health Care. AppletonCentury-Crofts, New York. 1970. Third World Conference on Medical Education. World Hlth Ora. Chronicle 21. (11). 451457. 1967. Mahler -H. Tomorrow’s medicine and tomorrow’s doctors. Address at the Centenary Celebration of the Faculty of Medicine of the University of Geneva, October 28, 1976, WHO Mimeo No. 39, November, 1976. Monekosso G. L. A community center for health sciences in Cameroon. Lancet 1. 1105. 1972. N’Chinda T. C. An integrated approach to the training of health personnel for developing countries: The Cameroon experiment. Tropical Docror 4, 41. 1974. Monekosso G. L. A community hospital unit: a general practice teaching facility for tropical medical ,schools. Tropical Doctor 2, 141, 1972. Joseph S. C. The health care team demonstration: an experiment in rural health training for nursing and

16.

17.

18.

19

20

medical students in central Africa. J. mop. Pediarr. Environ. Child Hlth 21, 325. 1974. Guillozet N. Medical education: team training of physicians in Cameroon. J. Trop. Pediat. Enoiron. Child Hith 22, 225, 1976. Monekosso G. L. Organization of an integrated medicine internship in tropical district hospitals. Tropical Doctor 7, 76. 19i7. Joseph S. C. The University Center for the Health Sciences. Yaounde, Cameroun, in September, 1975: the CUSS revisited. Unpublished report, October, 1975. Joseph S. C. Report of a conference of the first medical graduates of the University Center for the Health Sciences. Yaounde. Cameroun. Unpublished report, October, 1976. Joseph S. C. and Scheyer S. C. A strategy for health as a component of the Sahel Development Program. Report submitted to the U.S. Agency for International Development. Washington, DC, May, 1977.

Innovation and constraints in health manpower policy: a case history of medical education development in Cameroun.

SW. Su K Med.. Vol. IJC. pp. 137 to 142 Perpamon Press Ltd 1979 Printed m Chat Bratam INNOVATION AND CONSTRAINTS IN HEALTH MANPOWER POLICY: A CASE H...
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