As President's Emergency Plan for AIDS Relief (PEPFAR) delegates its operations on the African continent to local providers, close attention should be given to appropriate capacity building and strengthening of health care systems by nurturing partnerships between institutions on the subcontinent. Health infrastructures originally crafted for treating HIV will also need to be expanded to cope with the coming wave of chronic diseases. Given the alarming discrepancy between the small health workforce and the burden of disease, such workforce capacity will likely only be achievable through sharing partnerships—or “networks, alliances and consortia” as suggested in a recent article in The Lancet (2010). Medical schools, as the training ground of the emerging workforce, will be at the forefront of this change. How global donors allocate funding to emerging medical and nursing schools will be crucial to the ultimate success of a sustainable health workforce development.
A 2011 publication identified 168 medical schools in Africa.1 With scores of new medical schools likely to open in Africa over the next decade (by some estimates, more than 100 schools), the need for sharing of ideas, faculty, and resources will become more pressing.2 Compatible with current global financial exigencies, donor nations should consider making available smaller grants to complement the current strategy of awarding multimillion dollar funding to a few schools.
This is where the Medical Education Partnership Initiative (MEPI) should have a decisive role to play. MEPI was established by PEPFAR in partnership with the National Institutes of Health Fogarty International Center to strengthen health care systems in Africa by training an additional 140,000 new health care workers through $133 million in grants to established African schools of medicine and nursing over a 5-year period (2010–2014). The strategy by which MEPI decided to disburse this funding has been perplexing.
MEPI funds were largely awarded to just 11 medical schools – mostly well-established schools rather than to new schools. (The University of Botswana was an exception, a new school that did garner MEPI support.) These were competitive awards and a number of variables went into the complex decision-making process. Nonetheless, we believe that a broader distribution of funds to more African medical schools would have been more equitable and ultimately also have achieved a wider range of sustainable goals in terms of health-care strengthening and capacity building. Smaller awards to more medical schools could serve a vital role in developing novel medical school curricula, context-appropriate competencies, and training programs.
Such an MEPI funding strategy might also have been better aligned with the proposals of the recent landmark report in The Lancet (2010) by a panel of distinguished global health leaders (Health Professionals for a New Century: transforming education to strengthen health systems in an interdependent world) that proposed a series of critical reforms in global health education.3 The Lancet report points to a “slow-burning crisis” in global medical education that is in serious need of innovation.3 It is uncertain that such innovation can be effectively driven from within established medical schools.1 The Lancet report comments on how established schools can be saddled with “fragmented, outdated, and static curricula that produce ill-equipped graduates” with a “mismatch of competencies to patient and population needs.” It suggests that new schools may be more adept at adapting to “rapidly changing local conditions drawing on global resources” than are the established schools, being encumbered by “curricular rigidities, professional silos, static pedagogy [and] insufficient adaptation to local contexts.” To be sure, MEPI seeks in some ways to overcome these obstacles, but limited engagement of new schools may paradoxically remove key innovators in medical education and health care improvement from this process. In the world of business, it is recognized that innovation often emerges from the start-up companies in contrast to the more established firms.4
The Lancet report proposes that the process of achieving the goals of health care strengthening and capacity building should be guided by 2 desirable outcomes: “transformative learning” and “interdependence.” Transformative learning is essential for producing “enlightened change agents” that are needed to change and improve health care and education. A correlate of transformative learning suggested in the report is “transprofessional” education that aims to enhance teamwork between health professionals, administrators, policy makers, and community leaders as a way of breaking through the current “rigid tribalism…hyperspecialisation…[and] overly rigid accreditation standards that restrict opportunities for collaboration.” (A recent WHO report also called for such “transdisciplinary” approaches in medical education as a way of engaging health care workers in tackling social determinants of disease within the context of primary health care. See: World Health Organization Commission on Social Determinants of Health. Closing the Gap in a Generation: Health Equity Through Action on the Social Determinants of Health. Final Report of the Commission on Social Determinants of Health. Geneva, Switzerland: World Health Organization; 2008:1–256.) Interdependence is emphasized in the report as a way of strengthening health care systems rather than leaving them to flounder in isolation. These goals, the reports suggest, are best achieved through the creation of “global networks, alliances and consortia.”
Such a consortium was recently created through the founding of CONSAMS—the Consortium of Southern African Medical Schools. As of early 2012, CONSAMS represents a partnership among currently 5 southern African medical school partners located at the University of Namibia (Windhoek, Namibia), Copperbelt University (Ndola, Zambia), Universidade Lúrio (Nampula, Mozambique), the University of Botswana (Gaborone, Botswana) and, most recently, Lesotho University Medical School. The founding meetings between the deans of these medical schools were held in 2011 in Ndola, Zambia and Nampula, Mozambique, with the second meeting in early 2012 in Windhoek, Namibia. We envisage the Consortium expanding soon to include other new schools in Africa that are keen to explore a “south-helping-south” model.
Currently, the 5 CONSAMS medical schools all face similar challenges in terms of critical faculty shortages and constrained resources. The goal of CONSAMS is for these schools to maximize their potential and strengthen their education systems by sharing faculty and ideas to develop their competency-based curricula, their graduate training programs, and promote faculty development. Also, in the CONSAMS partnership are 2 northern hemisphere “twinning” partners—Vanderbilt University School of Medicine (Tennessee) and Oulu University School of Medicine (Finland)—that have helped secure start-up funding and will continue to facilitate meetings and provide advice and expertise.
Continued funding for CONSAMS is uncertain and yet modest funding is critical for the success of the consortium. Indeed, at this vulnerable stage of their development, it may be a determining factor in the ultimate success of the schools. New medical schools, particularly those willing to work together in “global networks, consortia and alliances,” deserve the attention of global funding organizations. Two reasons why new medical schools (like those in CONSAMS) deserve such funding are the following. First, these new schools are in a tenuous financial situation and need the south-to-south support that even modest funding could support. Second, while the established schools have a track record of graduating doctors and nurses, new schools within a south–south consortium may, paradoxically, be better positioned to introduce many of the transformative and health system strengthening changes that the 2010 Lancet report encouraged.3
The new schools that decided to form CONSAMS were generally not competitive for MEPI awards, which were aimed mostly at well-established medical schools as a seemingly safer and more efficient option for growing the health workforce. As a cross-national organization, CONSAMS has not yet captured the imagination of in-country PEPFAR coordinators for funding. In-country coordinators tend to focus their concerns on their pressing national AIDS treatment programs and specific education agendas within the countries where they are deployed. The multilateral structure of PEPFAR does not facilitate cross-border initiatives. Given the current tight funding climate and national priorities, it seems that a new funding model may be needed to support “global networks, alliances and consortia.” We would therefore urge that MEPI reconsider aspects of its current funding strategy so as to include more of the new African medical schools particularly those willing to partner and share their limited resources in “networks, alliances and consortia.”
1. Mullan F, Frehywot S, Omaswa F, et al.. Medical schools in sub-Saharan Africa. Lancet. 2011;377:1113–1121.
2. Crisp N. Global health capacity and workforce development: turning the world upside down. Infect Dis Clin North Am. 2011;25:359–367.
3. Frenk J, Chen L, Bhutta ZA, et al.. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. Lancet. 2010;376:1923–1958.
4. Christensen CM. The Innovator's Dilemma: When New Technologies Cause Great Firms to Fail. Boston, MA: Harvard Business School Press; 1997.