PERSONAL VIEW

Medical Education in the Developing World - New Approaches Needed

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DAVID MORLEY David Morley, MD, FRCP, iS Professor of Tropical Child Health, Institute of Child Health, 30 Guilford Street, London W C l N I E H , UK.

Existing health care systems fail to reach more than 20 per cent of people in most developing countries. Change of emphasis towards primary health care will be achieved at best slowly, if ever, through the existing university teaching structure. Provision needs to be made for the on-going training of all health personnel who work in rural areas and slums. Developments in distance teaching techniques, if applied to health, should be both effective and cheap. New approaches to improving health in the developing world must take account of three inter-related circumstances: the disparities in the provision of medical care between urban and rural areas; the population structure: and the inappropriateness of existing health services. Urban-Rural Disparity Although three quarters of the population in most developing countries live in rural areas, three quarters of the spending on medical care is in urban areas where three quarters of the doctors live. Three quarters of the deaths are due to conditions that can be prevented at low cost, but three quarters of the medical budget is spent on curative services,many of them provided at high cost. Economists who examine the difficulties that present in the development of countries in the third world no longer place so much emphasis on the limited resources available. Rather, they emphasize that resources have been and are being inappropriately spent. This is particularly true in the health sector. Most of the new capital produced in these countries arises from agricultural production in rural areas. This capital is then mis-spent in construction of inappropriate buildings in major cities, which means that most of the recurrent budget is tied up in running costs. Some of the buildings are used to teach skills to the cities’ better-off citizens. The professionals so trained are inappropriate to the urgent needs of the 258

majority of the people, particularly those in the rural areas (Figure 1). Nigeria has proposed 19 new major teaching hospitals - ‘disease palaces’ - even though the existing four or five have done little except provide an excess of doctors for urban areas. It is time we gave up tinkering with the medical students’ curriculum in the hope that more will go and give a lifelong service in rural areas where health workers are needed. Health workers for rural areas must be trained in those areas and must not be ‘contaminated’by life in the cities. Population Structure In 1970 there were approximately 1,100 million children in the developing world. Early in the 80s there are likely to be 1,400 million. The increase of 300 million is equal to the total population of children in North America and Europe, areas in which the number of children is now static. Together with women of reproductive age, children make up about 70 per cent of the population in developing countries. Comparisons of disease incidence in the second year of life suggest that each child in the developing world will have around five times as many disease episodes as a child in Europe, where serious acute infections and undernutrition hardly exist. About 97 per cent of all child deaths in our world occur in developing countries. In spite of such a different population structure and disease spectrum, it is from Europe that the developing countries have inherited their health services. Rarely do these health services take account of the fact that half of all deaths in third world countries occur amongst children. This is, however, only one reason why existing health services are inappropriate (Morley and Woodland 1979). Inappropriate Health Services In the past decision-making in health services has been largely in the hands of doctors trained in and practising Medical Teacher Vol 1 No 5 1979

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Figure 1. Even ifthe medical student in developing countries comes from a rural area, after spending time in a ‘disease palace’ he is imbued with the material expectations of the city e‘lite. The alternative suggested here is highly desirable, but dqficult to achieve.

curative medicine. These doctors have not considered it their responsibility to teach their patients how to lead healthy lives and become involved in their own health care. As a result, the population becomes more dependent on them (Figure 2). Signs of Change to More Appropriate Health Care About one in seven of the world’s population live in China. The Chinese people have experienced a dramatic improvement in their health over the last 30 years. Visitors to China have rightly emphasized the role that the part-time health workers, locally called ‘barefoot doctors’, have played in this improvement in health, which has come from the grass roots. Unfortunately, the majority of visitors have failed to appreciate that the success of the programme was dependent on these workers breaking the absolute power of the medical profession in health matters (Werner 1977a, b; Rifkin 1978a, b). Small programmes in which local people are involved in identifying their own health problems and looking for resources within their own community have now been developed in many countries. The more successful Medical Teacher Vol 1 No 5 1979

ones accept only limited outside help and themselves evaluate the health care provided. Examples of successful programmes are those in the remote Sierra of Mexico (Werner 1978) and the out of the way barrios of the Philippines (Rural Missionaries 1978). There are also many such programmes in the villages of India, for example that described by Arole and Arole (1975). We need to examine which of the methods used should be encouraged and developed further. Unfortunately, it seems that existing universities are capable of playing only a small part in developing alternative approaches to health care and indeed may be a block to them. If the new programmes are to succeed, members of the medical profession must play their part, even if they are ‘on tap rather than on top’. In every country a proportion of the doctors do work in rural areas; attempting to communicate new concepts to them must be a high priority. Disappointingly, although universities can train doctors to become surgeons, physicians and paediatricians, they have shown little ability to become involved in the far more important ongoing training of the average doctor and his primary health team. Nor do they emphasize sufficiently strongly that learning should be a lifelong process. 259

GIVE A MAN A FISH AND YOU FEED HIM FOR A DAY.

.......

..... ..... he may be a beggar

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Tomorrow

............TEACH A MAN TO FISH AND YOU FEED HIM FOR LIFE Tomorrow

.... if well taught ...

... he will be teaching others

Figure 2 . Treating patients without explaining to them how t o take better care of themselves increases their dependence on doctors (Morley 1977).

Distance Teaching

A more appropriate approach to training health workers than the traditional university/medical school system is to involve students in distance teaching. The basic tenet of distance teaching is that education is taken to where people are, rather than expecting them to come to where the teaching is. Instead of providing educational opportunities in large urban institutions at fixed times, educational materials are delivered to learners who are able to study anywhere and in their own time. As Farnes (1976) has outlined, the materials may consist of selfinstructional texts, programmed learning, reading materials, experimental kits, leaflets, educational games, television and radio broadcasts, self-assessment exercises etc. In addition to self-assessment, learners can complete assignments that are marked and commented on by correspondence tutors. Distance teaching may also be supported by tutorials, self-help groups and counselling. A good example of a distance teaching programme is that mounted by the Open University in the UK. To produce a distance teaching programme for health workers, a developing country would need a carefully chosen team involving an educationalist, a doctor, a 260

nurse, and perhaps a medical assistant with suitable back-up staff including an artist, and someone experienced in layout of material which, in the first place, would be sent out in a duplicated form. Such a team would need training in distance teaching methods, probably in Europe, and then would need to travel fairly widely in their own country finding those health units which were led by a doctor, medical assistant or senior nurse who would be willing to become involved in setting up the programme. The programme would not be aimed primarily at the doctor, but rather at the health team. The doctor or senior medical assistant would act as tutor, utilizing material provided by the distance teaching team, but soon he would find that it was necessary for him to study in order to keep up with the students. At the start of the programme the teaching would involve lectures on subjects like why measles is serious, or how to go about oral rehydration. However, as the course progressed there would be a change in emphasis. Participants would be expected to collect simple figures on what patients they saw, and they would be encouraged to consider why only some patients come forward for care. As the course progressed, it would try to explore the possibility of further involvement with the community Medical Teacher Vol 1 No 5 1979

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and how the community itself could provide more adequate health care services (Morley 1979). After a time, particularly successful units could be identified. Such units would be ideal places for medical students to join, as they would be able to see how a health team with limited resources could muster support from the community in order to provide adequate care. This kind of training would be very much more appropriate than the typical university community health programmes that exist today. Most of the latter utilize the curative approach adopted by the ‘disease palaces’ and add to it something about immunization, and perhaps some health education, and call it community health. It is nothing of the sort. A community health programme must be based and at least in part directed by the community itself. Setting up distance teaching programmes is now quite feasible. Production of the teaching material should be relatively simple as there are books such as Where There is No Doctor by David Werner (1977). and Primary Child Care by Maurice and Felicity King (1977) which, after appropriate adaptation and translating, could be used as a basis for the programme.

References Arole, M. and Arole, R.. A comprehensive rural health project in Jamkhed (India), in Health by the People, (Ed. K . W. Newell.). WHO, Geneva, 1975. Fames, N . , Distance teaching for developing countries, Teaching at Q Dirtance, 1976, 5,34-39. King, M. and King, F., Primary Child Care, Manual for Health Workers, Oxford University Press, Oxford, 1978. Morley, D. C . , Organization of paediatric care, Proceedings of the Royal SocietyofLondon (B), 1977, 199, 161-168. Morley, D. C . , Continuing education for the health team in developing countries, ArnericanJoumal of Pvblic Health, 1979,69.277. Morley, D. and Woodland, M . , See How They Grow, Macmillan, London, 1979. Rifkin, S., Politicsof barefoot medicine, Lancet, 1978, i, 34. Rural Missionaries of the Philippines, Duplicated material available from the Rural Missionaries of the Philippines, 2215. P. Gil. Sta. Ana., Manila, The Philippines. Werner, D., The village health worker - lackey or liberator, International Hospital Federation Congress Sessions on Health Auxiliaries and the Health Team, 22-27 May, Tokyo, 1977a. Werner, D.. Where There is No Doctor, A Village Health Care Handbook, Available from Teaching Aids at Low Cost, c / o Institute of Child Health, 30 Guilford Street, London WClN IEH, UK. 1977b.

Action to Produce More, Better Trained Nurses A medium-term programme in nursing/midwifery has been developed by the European Regional Office of the World Health Organization. It is aimed at better nursing care for the public within the overall national health services and at assisting member states to overcome problems in the provision of nursing services and the education of nursing personnel. The four components of the programme are: (1) the nursing process, (2) the organization and management of nursing/midwifery services, (3) the education of nursing/midwifery personnel, and (4) resource planning, with four phases of implementation over a period of eight years. Nursing activities are also increasing in WHO’SEastern Mediterranean Region, where there is an overall shortage of nursing personnel. According to Regional Director Dr A. H. Taba, every country in the Eastern Mediterranean Region has its own schools of nursing and each year over 30,000 nurses graduate from the 500 schools scattered throughout the Region (Taba 1978). In Egypt, Iran, Iraq and Lebanon several nursing programmes have moved to universities. In others (Democratic Yemen, Jordan, Pakistan and Sudan) nurse training programmes require that girls have nine to twelve years’ general education before admission to nursing schools, and university programmes are being promoted in order to prepare nurses for leadership positions. Saudi Arabia has initiated two university-based Medical Teacher Vol 1 No 5 1979

programmes for nurses and is well on the way to producing its own nurse leaders. Many countries in the Region are experimenting with training programmes during which nursing students learn alongside other disciplines. Such training institutions for health personnel are in existence in Bahrain, Democratic Yemen, Somalia and Yemen. In Jordan too, nursing and medical students take some of their lectures together, and in Schools of Public Health in Egypt, Iran and Lebanon all professionals, including nurses, study together. It is hoped that by doing so they will find it easier to work together. Attempts are being made to produce nursing learning materials in the mother tongue for those who do not understand English. For example, a project in Cairo, which seeks to prepare learning material in Arabic, based on Egyptian examples, will produce material that can be used there and in other Arab countries. Other countries are laboriously preparing their own texts and translations of well-known text books. Syria has its own closed-circuit television so that students can watch themselves performing. Fifty years ago, most professional nurses in the Eastern Mediterranean Region were expatriates, Dr Taba says. Today, the vast majority are nationals. Yet the distribution of nurses remains uneven, and there are still wide geographical areas without any nurses. Taba, A. H.. A changing image, World Health, December 1978.4-7.

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Medical education in the developing world - new approaches needed.

Existing health care systems fail to reach more than 20 per cent of people in most developing countries. Change of emphasis towards primary health car...
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