TOWARDS UNITY FOR HEALTH IN MEDICAL EDATION: a case from the Philippines
The call for “Health for All” articulated in the Alma Ata Charter is a formidable goal but with great potential for triggering convergence towards “Unity for Health”. But 20 years after this charter’s inception, the need for health reforms convergence bringing medical schools on board is still in want. Although medical schools have been highly criticized as isolated “ivory towers”, lacking in proactive contributions to society’s health needs, academic institutions actually have the potential to address the complex issues of health unity and therefore can create synergies between the community, health professionals, health managers, and policy makers towards ‘Unity for Health”. We report here, the convergence of various stakeholders in establishing an innovative medical school in the Southern Philippines.
Health in our Region:
Nearly one third of the Philippines 72 million people live on Mindanao Island. Zamboanga City (pop.0.5 million) is the hub for services in Western Mindanao and Sulu Archipelago (pop.3.5million), one of the most under served areas of the Southern Pacific. Seventy percent of the people live in rural densely populated shorelines of the islands. Travel is predominantly by boat, access to inland areas is mostly by foot.
Neonatal tetanus, measles, typhoid, cholera, dengue fever, tuberculosis, malaria, diarrhea and respiratory infections are major problems. The fertility rate is about 5 and infant mortality is more than 75 per 1000 births. Safe water, balanced nutrition, prenatal care and full immunization remain long term health goals. There are 28 medical schools in the Philippines but none in this region and few physicians are willing to move to this under resourced area.
Planning a Medical school for unity of health and development:
Against this background and aware of the challenge of starting a new school with very limited resource, consultations between the community, the health professionals, and the academic stakeholders were initiated. As a result of these series of intensive intersectoral meeting, a new, private, not for profit medical school was proposed. This was to be a
collaborative efforts between a local university to share the use of teaching facilities (library, modular rooms) for free; the local doctors as volunteer faculty; the community for the student’s community based experiential learning including their entry selection; the local businessmen to do fund raising support; the local Health Department for financial assistance on countryside health researches. A board of 15 members composed of 3 academicians, 5 civic leaders, 7 doctors was established to oversee its governance.
The next issues was to develop an educational program to select and train a new kind of professional: proficient in advanced methods of managing disease, but also with competence to improve the health in the community. We contacted leaders in medical education at WHO (Dr. Charles Boelen), in the U.K. (Dr. Charles Engels), USA (Dr. Arthur Kauffman), Canada (Dr. Clarence Guenter), New Zealand (Dr. John F. Smith) and (Dr. Reynaldo Joson) Philippines. We heard a common call for medical education reform.
Most schools emphasized learning the disciplinary subjects rather than improved health in a community. Students in teaching hospitals worked with patients suffering from complex medical problems. Clinical instruction emphasized complex disorders more than common community health problems. This prepared students to be specialists and to practice hospital medicine in urban centers. (We perform kidney/heart transplants in Manila, but 80% of the rural people of Western Mindanao have no health services). This emphasis on the sick largely ignored disease prevention, health promotion, community development and the social and economic determinants of health. We did not find a model that was ideally suited to our situation, so we crated one.
The Beginnings:
In 1993, we held development seminars on weekends for volunteer faculty, discussing the psychology of learning, problem solving, new methods of evaluating students and curriculum design. The school opened in June 1994 and since then students and faculty learned and modified our new programs together. Mentors from Canada and New Zealand assisted with the faculty development, curriculum planning and some students learning experiences.
Piece by piece we developed an integrated curriculum, with problem based learning, community oriented and based education and competency based evaluations. All basic science and clinical learning is integrated into the problem based approach. Three educational strands are intertwined: a working problem strand, a population strand, and a professional skills strand.
As early as first year, students are exposed to patients both in clinics and communities where the focus on the practice of medicine as applied to a group or population is emphasized (community based). About 18 months are spent studying and working under some supervision in remote rural communities.
As we progressed, two additional dimensions became central in our planning:
i) Faculty Development. We recognized the need to train our faculty , graduates of traditional medical schools, with the tools for this new curriculum. This led to a faculty development program with the option of earning the Master of Medical Educational Degree.
ii) Career Options. Our students needed a career option to medical specialties, which could equip and qualify them to field positions in the Department of Health. This lead to an optional Master of Public Health tract for the fifth (first post graduate) year. This MD-MPH has also become attractive to some members of faculty.
We have enrolled about 15-25 students each year depending on the quality of the applicants. We have seen many changes in some communities where the students work. Ten graduates of the first class (1998) passed the examinations of the Philippine Medical Board in 1999, and majority are now working as physicians in remote regions, equipped in skills of community development.
Dr. Fortunato Cristobal, a Pediatrician, is the founding Dean of Zamboanga Medical School Foundation; ADZ, LRC Bldg, La Purisima Street, Zamboanga City, Philippines 7000.
