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October 2013, Volume 63, Issue 10

Original Article

Public health and the undergraduate medical curriculum: Are we preparing physicians for the 21st century?

Ali Yawar Alam  ( Shifa College of Medicine, Bahria University, Islamabad, Pakistan. )
Syed Muslim Abbas  ( Shifa College of Medicine, Bahria University, Islamabad, Pakistan. )
Mohammad Raees Malik  ( Shifa College of Medicine, Bahria University, Islamabad, Pakistan. )

Abstract

Objective: To investigate the adequacy of the undergraduate medical curriculum in Pakistan to address primary healthcare and public health needs of the community at national level.
Methods: The cross-sectional study used standardised pilot-tested instruments from January 12 to July 14, 2010. Stratified purposive sampling technique was employed to include public and private-sector medical colleges in the study. A total of 174 faculty members were interviewed at 11 medical colleges. Data entry and analysis was done using SPSS 17.0.
Results: Of the 174 faculty members, 93(53%) were male. The age of the respondents ranged between 26 and 68 years (Mean: 43±9 years). Of the participants, 64(37%) had worked in a primary healthcare facility at some point in their career. Various aspects of maternal, newborn and child health are not covered by the medical curriculum as reported by the faculty members.
Conclusion: There is disconnection between academia, primary healthcare providers, policymakers and the regulators. The primary healthcare providers have inadequate representation in the curriculum design. There is a need to re-direct financial resources, medical education, and medical practitioners with a focus on addressing the needs of the rural areas.
Keywords: Undergraduate medical curriculum, Pakistan, Policymakers. (JPMA 63: 1241; 2013).

Introduction

Health is an integral part of human life and has important consequences in the quality of life spent by an individual. Its significance has been highlighted by various studies1-3 which highlight and argue the concepts of \\\'health related quality of life\\\'. Moreover, \\\'health\\\' has now been incorporated in indicators for measuring development, such as the human development index,4 which was in fact devised by Pakistani economist Mahbub-ul-Haq in 1990s, and is found in United Nations Development Programme\\\'s (UNDP) Human Development Reports.5 Moreover, three of the Millennium Development Goals (MDGs), which are a part of a global action plan that most countries, international financial institutions and development organisations recognise, are directly related to health.6 Despite this universal recognition of the importance of health, easily preventable diseases are still widespread, especially in developing countries such as Pakistan. According to the Pakistan Millennium Development Goals Report (2010),7 Pakistan is lagging far behind in its goals to reduce child mortality, improve maternal health, and combat Human Immunodeficiency Virus/Acquired immunodeficiency syndrome (HIV/Aids), Malaria and other diseases.7
The healthcare delivery system in Pakistan is unable to address the health problems of the majority of population, particularly due to a mismatch between human resource in health (HRH) training and the requirements of healthcare delivery system. Although HRH appears to be one of the points of focus in the National Health Policy, there is no specific National HRH policy and strategy in Pakistan. The World Health Report 2006 indicated that 57 countries, including Pakistan, have a critical shortage in their health workforce.8 Similarly, the World Health Report 2008 presented the same issues in more detail while emphasizing that "Primary care requires team of health professionals: physicians, nurse practitioners and assistants with specific and sophisticated biomedical and social skills. It is not acceptable that in low-income countries primary care would be synonymous with low-tech, non-professional care for the rural poor who cannot afford any better."9 Furthermore, this report distinguished \\\'Conventional health care\\\' from \\\'People-centered Primary Healthcare.\\\'9
The objective of this study was to investigate the adequacy of undergraduate medical curriculum in Pakistan to address primary healthcare (PHC) and public health (PH) approaches. Similarly, studies have been conducted internationally which signify deficiencies in curriculum.10,11 This was done through a survey of a representative sample of public and private-sector medical colleges in Pakistan and also reviewing the undergraduate medical curriculum of the Pakistan Medical and Dental Council (PMDC).

Methods

The cross-sectional study was used to standardised pilot-tested instruments through interviewer-administered questionnaires in the four provinces of Pakistan from January 12 to July 14, 2010. The principal investigators in Islamabad were responsible for data collection and supervision in the twin cities of Rawalpindi-Islamabad, while the co-investigators in the four provinces were responsible for data collection and supervision in the provinces. Training of the co-investigators on tools and instruments was done at a day-long workshop in Islamabad. Sampling flow chart (Figure-1)

was discussed. Stratified purposive sampling was used to include public and private-sector medical colleges in the study. The first stratum consisted of the provinces and the second stratum consisted of public and private medical colleges.
The sample size considerations were as follows: overall, 17.8% of the medical colleges were sampled, which is good enough for a national level survey. This came to be 11 medical colleges in all. More weightage was given to the province with higher number of medical colleges.

Therefore, from Punjab 5 medical colleges, Sindh 3 medical colleges, Khyber Pukhtoonkhwa (KPK) 2 medical colleges and 1 medical college from Balochistan was included in the study. The sample size was further stratified to get a representative sample from both the public and private-sector medical colleges. As a result, 5 public-sector medical colleges were recruited in the study which constituted 17.8% of the public-sector medical colleges in the country, while 6 private sector medical colleges were included in the study which constituted 17.7% of the private-sector medical colleges in the country. Total of 174 faculty members were interviewed which was a random sample from the available pool of faculty members. It consisted of a mix of senior and junior faculty members. Data entry and analysis was done using SPSS 17.0.

Results

A total of 174 faculty members participated in the study of which 93(53%) were male. The age of the respondents ranged between 26 and 68 years (Mean: 43±9 years). The study participants were in the medical field for 4 to 54 years (Mean: 17±9 years).
The number and percentage of faculty members taking part in the study according to province were: Punjab — 85 (49%); KPK - 38 (22%); Sindh - 28 (16%); Balochistan — 23 (13%).
Out of the participants, 122 (70%) were senior faculty members (Assistant Professor and above), while 52 (30%) were senior registrars and senior instructors in Basic and Clinical Health Sciences. Public-sector medical colleges were represented by 92 (53%) faculty members, while 82 (47%) belonged to the private sector. From Basic Health Sciences, 44 (25%) faculty members participated, while participation from the Clinical Health Sciences was 130 (75%).
From the total number of participants, 64(37%) had worked in a primary healthcare facility (basic health unit [BHU]/rural health centre[RHC]) at some point in their career, while the remaining had no such experience.
The responses of the faculty members were collected and analysed (Tables-1 and 2).



Various aspects of maternal, newborn and child health (MNCH), particularly Emergency Obstetric and Newborn Care (EmONC), post-natal care (PNC), Neonatal care, family planning, common diseases of under-5 children, knowledge and skills in child growth monitoring, integrated management of childhood illnesses (IMCI) are not covered as reported by 25-33% of the faculty members. Community outreach activities, such as health promotion activities, screening for common and uncommon diseases and effective communication and counselling skills are not priority areas in undergraduate medical curriculum. Disaster preparedness response and management, capability of assessing and using information, research methodology and analytical skills, managerial skills, monitoring and evaluation skills, rational drug use, recognition, prevention and management of common mental conditions, knowledge and prevention and management of sexually transmitted infections and diseases (STIs/STDs) are other less emphasised areas in undergraduate medical curriculum. Knowledge about some of the most important international commitments in public health, such as MDGs, current stages of the different indicators of MDGs in Pakistan and required stages of the different indicators of MDGs for Pakistan were also reportedly not well emphasized.
The areas of public health significance/primary healthcare which are not even covered in the PMDC/Higher Education Commission (HEC) curriculum include community outreach activities, such as screening programmes, health promotion of the communities, identification of when and where to refer patients, capability of assessing and using information, keeping abreast with current medical literature, ability to solve Community Health problems, managerial skills, monitoring and evaluation skills, malnutrition (under and over-nutrition), knowledge about MDGs, current stages of the different indicators of MDGs in Pakistan, required stages of the different indicators of MDGs for Pakistan and advocacy for deserving and needy patients.

Conclusion

The healthcare delivery system in Pakistan should address the health problems of the majority of population, particularly due to a mismatch between HRH training and the requirements of the system. There are severe gaps in the curriculum of undergraduate medical education as far as PHC and PH approaches are concerned. Such gaps need to be filled. Moreover the PMDC curricular guidelines need to be streamlined to address PHC and PH approaches which have certain deficiencies. The future medical doctors of Pakistan are not prepared to address PHC and PH challenges. There is a need to re-direct financial resources, medical education, and medical practitioners with a focus to addressing needs of the rural areas.

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