By: David Duong (@DrDavidDuong)
A global shortage of over 4.3 million health professionals poses a major threat to achieving the Sustainable Development Goals (SDGs), Universal Health Coverage (UHC) and a collective vision of health for all. This shortage is more evident in low-and-middle income countries (LMIC). Exacerbating this, health systems face new challenges of rapid demographic and epidemiologic transitions, threats of emerging infectious diseases, such as the most recent COVID-19 pandemic, and environmental and behavioral risks. However, health professional education, especially in LMICs, have not evolved quickly enough to address these challenges.
In LMICs, the majority of health professional curricula, including undergraduate medical education (UME), has not significantly changed since the issuance of the 1910 Flexner Report.1 There continues to be an emphasis on knowledge acquisition rather than on the attainment of professional competencies. Most curricula are static, outdated and fragmented, contributing to ill-equipped graduates lacking skills which corresponding to population, complex globalized healthcare systems, and patient health needs.1
A reform of UME is necessary, with a shift to competency based medical education (CBME). Three contributing factors may account for limited UME reform efforts in LMICs are limited investment, coordination and technical knowledge of CBME. First, investments in health professional education account for less than 2% of global healthcare spending, the majority of which has been concentrated on reform efforts in high-income countries (HICs). This further perpetuates the inequities faced by LMICs.1 Second, there exist limited coordinated leadership in health education within the academic and professional communities. Third, technical knowledge in CBME, which has mostly been driven by HICs, has not been widely shared with and meaningfully transferred to LMICs, to build and sustain local expertise.2 For example, 95% of medical education research publications consist of authors in North America, Northern Europe, Western Europe and Asia, the majority being from HICs.3
The Lancet’s Global Independent Commission: Education of Health Professionals Education for the 21st Century calls for the strengthening of global learning and cooperation to address the daunting health challenges of our time.1 In Viet Nam, the Partnership for Health Advancement in Viet Nam (HAIVN), collaboration between Harvard Medical School (HMS), Brigham and Women’s Hospital (BWH) and Beth Israel Deaconess Medical Center (BIDMC)has partnered with the Viet Nam Ministry of Health and five medical schools to reform UME towards a CBME orientation since 2015.4 This has been done through a multi-year collaboration of technical assistance (i.e. training-of-trainer workshops, immersion trips to HMS, direct faculty-to-faculty mentorship and coaching). This has enabled technical skills transfer, sharing best practices and collaboration in medical education scholarship and research. In 2022, HAIVN has expanded to five additional new medical schools in Viet Nam, and one in Lao PDR and one in Cambodia. The UME reform effort has support from multilateral institutions such as the World Bank (WB), Asian Development Bank (ADB), the US Agency for International Development (USAID) and the China Medical Board, a US-based non-profit.
UME in Viet Nam, Cambodia and Lao PDR is also predominately a six-year program bifurcated by the basic sciences in the initial three years and clinical sciences and rotations in the latter three years.4-7 There exist a learning culture focused on knowledge acquisition instead of the development of competencies and skills. Faculty in the three countries have reported limited skills in new pedagogical methodologies and are further hindered by a high student to faculty ratio, impeding teaching of clinical skills and problem-based learning.4-7 Furthermore, students often cite a lack of access to learning materials and resources as another barrier to obtaining medical knowledge.4-7
The similarities in medical education systems, challenges to UME reform, geographical proximity and socioeconomic development status will enable meaningful collaboration, cooperation and promotion of shared medical education reform goals between Viet Nam, Cambodia and Lao PDR. HAIVN is utilizing a shared learning model of inter-university cooperation in order to promote global south-south collaboration, maximize best practices which are contextually appropriate and align resources. We have found in our work to date that competency-based medical education (CBME) is a key starting point for transformative change of medical education. In contrast with a knowledge acquisition approach to medical education, CBME encourages students to become life-long learners, acquiring broad skills and approaches to ever-evolving clinical and population health challenges. The creation of a regional learning network with meaningful participation from experienced medical schools (i.e. those in high-income countries and those who have undergone CMBE reform such as the University of Medicine and Pharmacy at Ho Chi Minh City) has the exciting potential to promote and sustain medical education reforms. This will enable the world to move closer to a new era of passionate and participatory action to achieve the universal aspiration for equitable progress in health.
About the author: David B. Duong, MD, MPH, is Director of the Harvard Medical School Office for Community-Centered Medical Education, and also Director of the Program in Global Primary Care and Social Change Program. He is the Associate Director for Harvard’s Partnership for Health Advancement in Viet Nam (HAIVN) where he oversees medical education collaborations and projects for Viet Nam, Laos and Cambodia.
References
1. Frenk J, L Chen, ZA Bhutta et al. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. The Lancet. 2010; 376: 1923-1958
2. National Academies of Sciences, Engineering, and Medicine 2020. Evaluation of PEPFAR\’s Contribution (2012-2017) to Rwanda\’s Human Resources for Health Program. Washington, DC: The National Academies Press. (accessed 5/5/2020)
3. Buffone B, I Djuana, K Yang, KJ Wilby, MS El Hajj, K Wilbur. Diversity in health professional education scholarship: a document analysis of international author representation in leading journals. BMJ Open. 2020;10(11):e043970.
4. Duong DB, T Phan, NQ Trung, et al. Innovations in medical education in Vietnam. BMJ Innov. 2021;7(Suppl 1).
5. Amin Z, K Hoon Eng, M Gwee, K Dow Rhoon, T Chay Hoon. Medical education in Southeast Asia: emerging issues, challenges and opportunities. Med Educ. 2005;39(8):829-832.
6. Wittick TA, K Bouphavanh, V Namvongsa, A Khounthep, A Gray. Medical education in Laos. Med Teach. 2019;41(8):877-882.
7. Kilpatrick AL, K Bouphavanh, S Sengchanh, V Namvongsa, AZ Gray. Medical Education in Lao People’s Democratic Republic: The challenges students face in accessing learning resources. Asia Pacific Sch. 2019;4(2):39-47.
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