|ORIGINAL RESEARCH PAPER
|Year : 2007 | Volume
| Issue : 3 | Page : 65
Capacity Building in Medical Education and Health Outcomes in Developing Countries: The Missing Link
WP Burdick, PS Morahan, JJ Norcini
Foundation for Advancement of International Medical Education and Research, Philadelphia, PA, USA
|Date of Submission||30-Jun-2007|
|Date of Web Publication||27-Nov-2007|
W P Burdick
Foundation for Advancement of International Medical Education and Research, Philadelphia, PA
Source of Support: None, Conflict of Interest: None
Background: Finding evidence for the link between capacity building in medical education and improved health outcomes in developing countries is an important challenge. We describe the Foundation for Advancement of International Medical Education and Research (FAIMER) Institute, a two year, part-time fellowship in medical education methodology and leadership and its evaluation as a model to bridge this gap by collecting quantitative and qualitative data on intermediary outcomes.
Methods: FAIMER has used the following framework of human capacity building programs: 1) identify young and talented individuals with potential to become agents for change; 2) organize and deliver an effective learning intervention that is relevant for the environment; 3) facilitate the opportunity for real-life application of acquired knowledge and skills with support; and 4) promote development of a sustainable career path with opportunities for growth and advancement.
Results: Twenty-three percent of curriculum innovation projects were directly related to community health. Of the 35 fellows in the first three classes of the Institute, there have been 11 promotions, 9 peer-reviewed publications and 14 international poster presentations, indicating development of the medical education field. Other qualitative and quantitative program evaluation data are presented.
Discussion: The link between capacity building in medical education and improved health can be demonstrated in several ways: align curriculum with local health needs, place learners in community clinical settings, teach basic healthcare workers, become involved in national policy development and develop the field of medical education.
Conclusion: While experimental models may not be possible to evaluate the effect of capacity building, methods described may help support the connection between improved medical education and health.
Keywords: Faculty development, program evaluation, community health, international medical education
|How to cite this article:|
Burdick W P, Morahan P S, Norcini J J. Capacity Building in Medical Education and Health Outcomes in Developing Countries: The Missing Link. Educ Health 2007;20:65
Capacity building is defined as an increase in the ability of systems to function on their own to meet local needs. This is accomplished by developing a physical infrastructure or by increasing the number and ability of individuals who can function autonomously after the trainer has gone or funding has stopped. It can be a challenge, however, to evaluate capacity building programs and demonstrate the link between the intervention and improved health outcomes. The Foundation for Advancement of International Medical Education and Research (FAIMER) aims to build quality capacity in medical education for developing countries by strengthening the medical school faculty. In this paper, we describe the FAIMER Education program and its evaluation as a model to bridge the missing link between capacity building and health outcomes.
FAIMER has used the following framework of human capacity building programs: 1) identify young and talented individuals with potential to become agents for change; 2) organize and deliver an effective learning intervention that is relevant for the environment; 3) facilitate the opportunity for real-life application of acquired knowledge and skills with support; and 4) promote development of a sustainable career path with opportunities for growth and advancement (Nchinda, 2002).
Capacity building in the healthcare sector has emphasized capacity building in research (Lansang & Rodolfo, 2004). One of the most prominent and sustained examples is the International Clinical Epidemiology Network (INCLEN). Since around 1980, INCLEN has set up 18 epidemiology resource and training centres and 30 clinical epidemiology units around the world (MacFarlane et al, 1999).
In developing countries, fewer initiatives have been taken to build capacity generally in higher education, and particularly in education for health professions. This may be due in part to the immediacy of direct health needs and the less direct link to the effect of education for health professions on these needs. The short cycle from intervention to expected outcome that is required by some program evaluation schemes may also contribute to the lack of enthusiasm for this type of development, because effects of improved education are often difficult to demonstrate and may take years to have an impact on long-term goals (Richardson, 1998). Concern over the loss of newly trained researchers and health providers through emigration, may also contribute to the secondary role of education capacity building in development (Pang & Lansang, 2002).
FAIMER has created programs for capacity building in medical education in order to improve the health of communities, using indicators for intermediary outcomes to develop evidence to support this investment. This paper focuses on the challenge of developing evidence to test the link between capacity building in medical education and improved population health.
FAIMER Education programs
The FAIMER Institute is a two-year, part-time fellowship in medical education methodology and leadership. It is conducted in four sessions: a three-week residential session in the U.S., followed by an eleven month distance-learning and co-mentorship component; a second two-week residential session; and finally another distance-learning and co-mentoring experience (Norcini & Burdick, 2005). Two Regional FAIMER Institutes, built on the same model but with shorter residential periods, are located in India, with several others to be developed. Institute alumni may apply for funding to obtain a masters degree in health professions education. All programs have been fully supported by FAIMER, (approximately $2 million since 2001) with more than 100 fellows trained across the various programs and regions. In the first three years of the Philadelphia FAIMER Institute, 35 fellows completed the fellowship. Follow up and feedback data from this cohort is described below.
Figure 1. Concept map for FAIMER Education.
The first goal of the human resource capacity building programs is to identify young and talented individuals who have the potential to become agents for change. An important criterion for selection for FAIMER Education programs is the analysis of the required curriculum innovation project proposal for feasibility, local relevance, clarity of goals and plans for project evaluation.
The second goal is to organize and deliver an effective learning intervention that is relevant for the environment. A group of education leaders from developing countries was convened to help design the curriculum and ensure its relevance in environments with limited resources. Twelve medical school leaders from Chile, China, Egypt, Indonesia, Kenya, Mexico, Malaysia, Nigeria, Pakistan, Philippines, Spain and Zimbabwe who were familiar with existing ECFMG programs were convened. Through a series of brainstorming sessions, consensus was reached on goals and organizational framework that would be relevant in resource limited environments. Program effectiveness is enhanced by using fellows’ curriculum innovation projects as authentic motivation for learning during educational sessions that are highly interactive. Sessions on leadership, conflict management, managing change, project planning and program evaluation, all use the innovation projects as focal points for discussion and analysis. Fellows also acquire basic skills in medical education, including deepening students’ critical thinking skills and student assessment. Many faculty members are from countries with limited resources who reinforce concepts relevant to participants’ environments.
Curriculum projects also facilitate the third human capacity building goal which encourages an opportunity for real-life application of acquired knowledge and skills. During the distance-learning component, fellows report their progress implementing their projects, and seek information and guidance from other members of the FAIMER network. Real issues that implement change are discussed on the Institute listserv and recent examples from fellows’ institutions are frequently cited.
Table 1. Community-oriented curriculum innovation projects
Finally, FAIMER education programs promote development of a sustainable career path with opportunities for growth and advancement. Fellows are involved in a variety of methods to build a strong community of practice (Wenger et al., 2002), including sharing their professional “stories” (Wheatley, 2005), learning about how such communities are built and maintained (Baker, 2000) and being involved in co-mentoring. By educating a critical mass of medical school faculty in education methodology, helping them to produce scholarship related to their projects and promoting diffusion of this scholarship through conferences and journals, a field of medical education may gradually emerge. Advocacy by members of that field may lead to changes in academic promotion policies with recognition of education as a legitimate pathway for advancement in the medical school.
Results of evaluation
Several models for program evaluation have been combined (Kirkpatrick, 1994; Stufflebeam, 2000; Grove, 2006; Kellogg, 2006) to assess achievement of short and long-term outcomes of capacity building through the FAIMER Institute. Quantitative evidence for capacity building includes: 1) course feedback, 2) self-report surveys of changes in knowledge and attitudes, 3) quantitative analysis of professional networks, and 4) tabulation of professional accomplishments. Qualitative evidence for program effectiveness includes: 1) individual structured interviews at the end of one year and subsequent periodic interviews and questionnaires; and 2) analysis and follow-up of curriculum innovation projects. We use these data to assess our success, our intermediate goals of selecting change agents, delivering an effective, relevant learning intervention, facilitating authentic applications of knowledge and promotion of a sustainable career path. Longer term goals related to improving the health of communities will take several more years to attain and will have many confounding variables, which is why identification and measurement of intermediate goals is important.
Of the 35 fellows in the first three classes of the Institute, there have been 11 promotions, 9 peer-reviewed publications, and 14 international poster presentations. All individual session evaluation scores were 5 or higher on a 7-point Likert scale, where 7 = most effective. When participants were asked to rate perceived importance of and knowledge of medical education and leadership before and after the Institute experience, effect size increases ranged from 1.1 to 2.5 (all significant at p < 0.0001). Longitudinal data also supported evidence of increases in the size and diversity of professional networks of participants. Thirteen of 35 (37%) curriculum innovation projects were directly related to health of the community (Table 1).
Several major themes emerged from the initial interviews that provided evidence for effectiveness in building a community of practice. All fellows recognized and praised the program’s uniqueness, its broad view, its ability to gather fellows from throughout the world and the experiences that create profound bonding. One fellow’s statement captures the sentiment of many, “The networking, the family concept and the friendships that have evolved from the FAIMER Institute…All this is extremely positive and extremely valuable.”
The link between capacity building in medical education and improved health can be demonstrated in several ways. First, the link between medical education and the long term outcome of improved health outcomes can be strongly supported by a medical school curriculum that is aligned with population health needs (Supe & Burdick, 2006) viewed broadly in the curriculum to include fundamentals of clean water, adequate sanitation and nutrition. Authentic curriculum reform projects by change agents in a capacity building program such as the FAIMER Institute can help create this link.
Second, education innovations by change agents can put learners into clinical settings, thus directly increasing access to care for the local population and potentially increasing the interest of learners to practice in that environment (Sherrill et al., 2005). Supervised medical students can also be an effective work force multiplier for delivering care. Placing students in rural environments has been shown to increase interest in such practice settings (Dunbabin & Levitt, 2003). Third, medical schools can be effective institutions for interdisciplinary education so that nurses, pharmacists, social workers and others can add to the work force as well as learn to work together more effectively and better understand economic, social and cultural issues (Gordon et al., 1996). Fourth, medical school faculty may also teach basic healthcare workers, creating not only a larger health work force, but also one with a potentially closer connection of the medical school to the community and better health outcomes (Dawson & Joof, 2005). Finally, medical schools can become more involved in national policy development, especially those in rural settings and contribute more to population-based health research (Centeno, 2004).
An intermediate goal in the connection between capacity building in health professions education and improved population health is the development of the field of medical education. Development of a field implies creation of a critical mass of individuals involved in the production of new knowledge, scholarly debate, and generating a pathway for career advancement. An academic field nested within a region is more likely to generate scholarship that will have an impact on diffusion of knowledge than scholarship from outside the region (Page et al., 2003). Measuring output of scholarship, number of regional and national meetings in education, and development of associations dedicated to medical education, will provide evidence to support the hypothesis of field development.
The limitations in the FAIMER Institute intervention and evaluation methodology are common to other education interventions. Our paradigm for the identification and strengthening of potential change agents applies substantial resources to a limited number of individuals. In addition, while the distance-learning emphasis allows participants to work from their home country during most of the program, it also reduces face-to-face contact, which limits the strength of the relationship between participants and with faculty. The main limitation of this program evaluation method is that causal relations cannot be definitively proved due to the large number of confounding variables.
FAIMER Education programs are attempting to build medical education capacity through faculty advancement in developing countries to improve population health. Evaluation of intermediate goals and use of qualitative and quantitative data yield preliminary support for effectiveness of these programs and offer a model for demonstrating the link between capacity building in medical education and health. Data on professional achievement can provide evidence to participants becoming change agents. Qualitative data analysis can generate evidence for utilization of acquired leadership and medical education skills and knowledge, and the development of enhanced professional networks.
While experimental models testing the hypothetical link between capacity building in medical education and improvement in health outcomes may not be possible due to the “open system” context of the intervention, the use of innovative evaluation methods incorporating quantitative and qualitative data on intermediary outcomes may help support the link between capacity building in medical education and health.
No ethical clearance was required for this paper and no funding was required for this paper. The authors declare no potential conflicts of interest.
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