1. Health Systems Strengthening Competencies for medical graduates Prof Lilian Dudley SURMEPI Health Systems Strengthening Focus Division of Community Health This research has been supported by the President’s Emergency Plan for AIDS relief (PEPFAR) through HRSA under the terms of T84HA21652 SURMEPI Stellenbosch University Rural Medical Education Partnership Initiative

2. Health needs Health system Competencies Outcomes Curriculum Assessment Competency-based education model Lancet report on training health professionals for the 21 st century, Frenk et al 2011

3. What is a competency? A competency is an observable behavior that combines knowledge, skills, values, and attitudes related to a specific activity

4. Process of curriculum development Curriculum in context of general needs Overall goals of the curriculum Specific Goals and Measurable Outcomes Educational Strategies and Content Learning experiences (incl. assessment) in order to reach outcomes Learning experiences (incl. assessment) in order to reach outcomes Evaluation and feedback      

5. STEP 1: Curriculum in context of general needs 1)Context of community needs 2)Institutional context 3)Expectations, context and interaction between role players 4)Process to be followed

6. Social Accountability Medical schools ‘‘to direct their education, research and service activities towards addressing the priority health concerns of the community, region and the nation that they have a mandate to serve’’ Boelen 1995

7. Which HSS competencies do graduates require? Literature review of competencies in Health Systems Strengthening areas (PH, HSSR, EBHC, IPC) National & faculty workshops on HSS competencies – Burden of Disease – Health system challenges and needs – National policies e.g. HR Strategy, NHI, Re-engineering of PHC, Quality of Care Key informant interviews – Provincial health service managers – Public Health experts Refinement of competencies through dissemination of documents for comment

8. SU Faculty of Medicine and Health Sciences 3877 enrolled students participating in five undergraduate programmes (MB,ChB, Physiotherapy, Occupational Therapy, Human Nutrition and Speech, Language and Hearing Therapy); 80 postgraduate programmes 1430 staff 96% throughput of undergraduates Expanding rural community based education platform

9. Current status of HSS teaching & learning? Document review Survey of recent graduates Interviews with lecturers

10. Curriculum review: Key Lessons HSS competencies not adequately integrated into curriculum Poor continuity and progression of learning More practical and experiential learning in ‘working’ context needed Role models across disciplines needed Greater inter-disciplinary collaboration required Faculty lack clear understanding of ‘health systems’ Capacity and willingness of faculty an issue

11. STEP 2: Overarching goal of the curriculum The recently graduated Stellenbosch doctor must possess the necessary knowledge, skills and attitudes to optimally utilise the opportunities available during the internships as to be able to function autonomously in the primary health care sector thereafter, and must also be equipped with the necessary ability and insight to develop further personally and professionally. FMHS Stellenbosch University, 2009

12. Knowledge (14) includes Necessary medically applicable scientific and mathematical concepts. The maintenance of health and prevention of disease (physical, mental and social). Factors in the community environment that can influence health. Finances, management and structures of health care The interaction between biological, psychological and sociological factors that play a role in health. The principles of research.

13. Skills (12) 1.The ability integrate, interpret and apply knowledge. 2.The ability to think and act in a problem solving fashion. 3.The ability to function holistically within the context of family and community. 4.The ability to establish and manage a primary health infrastructure. 5.The ability to interpret and apply relevant literature. 6.The ability to function optimally within the interdisciplinary health care team. 7.The ability to take part in and guide continuous and inservice training as well as community education. 8.The ability to effectively utilise relevant technological resources (e.g., computers) in the health environment

14. Attitudes (8) A loyal and ethically accountable disposition towards the profession, patients and community An empathetic disposition towards the patient, their family as well as the community and a willingness for accessibility. The willingness to set a positive example regarding social responsibilities and obligations.

15. Graduate Attributes Faculty of Medicine and Health Sciences, Stellenbosch University, 2012

16. STEP 3: Specific goals and measurable outcomes 1)Are the goals clear and in line with community needs? 2)Are the learning outcomes (knowledge, skills, attitudes) clearly described and in line with the goals BLOOM’S TAXONOMY

17. HSS Learning Outcomes 1. Determinants of health – To manage patients holistically within their context (individual to population perspective) – To advocate for health improvements 2. Health Systems Organisation, management and financing – To identify, analyse and solve health system problems – To manage health resources efficiently 3. Evidence and information – To use evidence to inform practise – To identify or create, appraise, and utilise data to improve health and health care

18. Detailed outcomes Knowledge, Skills and Attitudes for each learning outcome Levels of learning in each outcome according to different phases of the curriculum

19. Evidence and information EXIT LEVEL OUTCOMES:Blooms TaxonomyBLOCK Phase 1 MB,ChB I 1.Describe the fundamentals of Epidemiology:  Explain the value of research  Describe the principles of EBHC  Identify how to search the literature  Describes an approach to conducting a study  Describes approaches to conducting a study  Describes bias, error and confounding  Defines the benefits and weaknesses of quantitative study designs  Defines the benefits and weaknesses of qualitative study designs 2.Describes the fundamentals of Biostatistics:  Describe different types of data  Estimate the characteristics of a test and a sample (diagnostic accuracy)  Describe measures of occurrence Comprehension (Evidence) Health in Context

20. STEP 4: Educational strategy and content Learning strategies – Where is the curriculum positioned on the SPICES model? – Is it relevant to the community context, goals and outcomes?

21. STEP 4: Educational strategy and content Overall organisation – Integration: to what extent does the aim, goals, learning outcomes and educational strategies dictate vertical and horizontal integration? – Which part of the curriculum is compulsory. Are there options within the curriculum which allow student choice? – Is there a spiral of learning which promotes on-going academic and professional development.

22. STEP 4: Educational strategy and content Teaching design – What is the understanding of and approach to Assessment? – How is the theory of translated/ transitioned into practice? – To what extent are human resources adequate: Support and Supervision? Experienced teachers / mentors? Support personnel? Capacity building programmes?

23. STEP 5: Learning Experiences Effective teaching and learning methods and materials? Positive learning environments? Encouraging extra curricular activities? Does the hidden curriculum affect learning? Deep learning encouraged

24. STEP 6: Evaluation of curriculum Is there complete alignment of goals, objectives, outcomes, learning strategies, content, learning experience including assessment.

25. STEP 6: Evaluation of curriculum Approach effective? Evaluation of lecturers - self and peer? Documentation? Management of concerns? Student and lecturer feed back / experience of module? Outcomes assessed? Improvements made?

26. Next steps Revise curriculum content to align with outcomes Revise learning strategies to support acquisition of competencies Update assessment methods (portfolio’s) to support formative and summative assessments. Evaluate!

27. “Education is the most powerful weapon which you can use to change the world.” Nelson Mandela

28. Acknowledgments Dr Stefanus Snyman, SURMEPI and CHPE Dr Kalay Moodley, SURMEPI Project Manager Division of Community Health, FMHS SURMEPI HSS team Ms Anke Rohwer, Dr Taryn Young, Prof Lilian Dudley, Dr Bart Willems, Dr Fidele Mukinda, Dr Neil Cameron, Prof Shaheen Mehtar, Dr Frederick Marais, Dr Angela Dramowski, Ms Charlyn Goliath, Dr Miranda Voss SURMEPI PI’s, Prof’s Jean Nachega and Marietjie De Villiers This research has been supported by the President’s Emergency Plan for AIDS relief (PEPFAR) through HRSA under the terms of T84HA21652