Aisha Mehnaz ( Department of Medical Education, CPSP & LUMHS. Jamshoro, Hyderabad. )
Health System of Pakistan is facing a number of challenges which is of critical importance to the whole nation. The utmost priority is the identification of resources and effective delivery of health care to the society. The recent Demographic survey of Pakistan1 has identified a number of health indicators and determinants, the picture is all too gloomy for Pakistan. The figure is particularly disturbing as regards paediatric population of Pakistan .The Neonatal mortality rate (NMR), infant mortality rate (IMR) and under five years mortality rates in children (<5 MR) is disturbingly high (40.4, 54.2, and 65.2 per 1000) respectively .This coupled with a large population (approx. 220 million with 34% being less than 14 years old2 compounds the problem. Pakistan is now labeled as the most dangerous place to be born, as first day mortality is highest in Asia. Most of these deaths are preventable with skilled manpower.
It is imperative that Pakistan sets its priority, the top being health and health care of our children. At the same time it is also the need of time to bring medical education and training in line with the nation’s priority and global demand and make our medical universities responsible for social accountability.3,4The medical schools need to shoulder the responsibility with the Government for developing a healthier society.4 At present what is disturbing the effective delivery of health care to the community is the shortage of trained health care providers. Considering the large paediatric population of Pakistan2 with myriads of health and protection issues, the paediatricians plays the most important role. The competencies desired in each paediatric resident need to be aligned with the changing needs of the society and the global demand.5,6 Post graduate medical education in Pakistan is currently facing a lot of challenges .At present it is more context based and does not lay much emphasis on educating students in professionalism, ethics, communication skills, leadership skills and other competencies like prioritizing the need of the community and developing skills to manage it e.g. our residents are not well trained to manage and overcome the consequences of natural or man created disasters or deal with the real life problems faced by the community in a more competent manner. The residents training in most specialties does not involve rotation in rural or a peri-urban set up where more than 70% of our paediatric population resides. Social accountability is still an alien concept.3 Post graduate training in paediatrics is being offered in almost all teaching hospitals .There are wide inconsistencies in the quality of training and attainment of desired competencies in postgraduate residents of paediatrics in the country. As a result the paediatrics residents have different “pace of learning”, yet they are expected to achieve the desired outcome at a specified time. There also exists no standardized curricula or methods of assessment. Direct observation of their performance during work (work based assessment) is not given weightage in the present system, beside it has its own issues. The retention of residents in some centers are also a big issue.7 As a result residents are graduating with various levels of competencies and their overall performance is poor. The International competency based medical education (ICBME) outlined three fundamental principles of training.8 First the education must be based on the identified health needs of the population being served. Secondly the primary focus of education and training should be the desired outcomes for post graduate residents rather than the structures of the educational system and lastly the formation of physicians should be seamless across the continuum of education and practice.
The globalization of medicine has also influenced post graduate medical education in the East.Following the Can Meds model,9 a number of countries in the east like Singapore, UAE and Qatar7 have restructured their residency programme from time-based to out-come based. The paediatric residents training too in a number of countries has now moved from Time –based to out-come based CBME module. As the latter module has taken into account the societal need of the country. The competencies involved problem solving and decision making, critical analysis, creativity and autonomy. Thus it is multidimensional and dynamic, it changes over time, experience and setting and does not follow a fixed time period.10
In Pakistan political and socio-economic instability and existing inertia to initiate change by redefining the goals of medical education and revising the curriculum in the context of existing health problems amid poor socio-economic conditions are some of the issues of paramount importance, Fortunately there are sizeable number of professionals in medical schools with sound educational backgrounds who can accept the challenges and initiate the changes to bring the present medical curriculum and training in line with the need of time and in accordance with global standards .
In country which has an unacceptable NMR/IMR and under five mortality rate(<5 MR) in children, the quality and quantity of graduating paediatrician is of paramount importance and should be considered a national issue that mandate a wide scale educational reform. The transition of training of paediatric residents from traditional time bound approach to learner centered, outcome based training organised around the desired competencies may be the first step in the right direction. The end product (paediatricians) will be better trained to address and deliver health care to a large paediatric population.
Addressing the priority areas in Paediatrics including health and related social issues, faculty development, assessment to determine whether students have achieved the benchmark levels of competence and work based assessment should be reflected upon. Collaboration with the other concerned departments, inclusion of ambulatory Paediatric training programme and encouraging students to work in a cost effective primary care and prevention will have a positive impact on the development of nation’s health care workforce. Accreditation council and key stakeholders need to give serious consideration on the issue.
1. Pakistan Demographics profiles [Internet] 2018.Aailable from http//:www.indexmundi.com/Pakistan/demographics_people.html cited on Sept 2, 2022.
2. Pakistan Population aged 0-14 years, 1960-2021 - knoema.com available at https://knoema.com/atlas/Pakistan/Population-aged-0-14-years cited on 30/8.22)
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