TOWARDS UNITY FOR HEALTH IN MEDICAL EDUCATION: a case
from the Philippines
The call for “Health for All” articulated in the Alma Ata Charter is a
formidable goal but with great potential for triggering convergence towards
“Unity for Health”. But 20 years after this charter’s inception, the need for
health reforms convergence bringing medical schools on board is still in want.
Although medical schools have been highly criticized as isolated “ivory towers”,
lacking in proactive contributions to society’s health needs, academic
institutions actually have the potential to address the complex issues of health
unity and therefore can create synergies between the community, health
professionals, health managers, and policy makers towards ‘Unity for Health”. We
report here, the convergence of various stakeholders in establishing an
innovative medical school in the Southern Philippines.
Health in our Region:
Nearly one third of the Philippines 72 million people live on Mindanao
Island. Zamboanga City (pop.0.5 million) is the hub for services in Western
Mindanao and Sulu Archipelago (pop.3.5million), one of the most under served
areas of the Southern Pacific. Seventy percent of the people live in rural
densely populated shorelines of the islands. Travel is predominantly by boat,
access to inland areas is mostly by foot.
Neonatal tetanus, measles, typhoid, cholera, dengue fever, tuberculosis,
malaria, diarrhea and respiratory infections are major problems. The fertility
rate is about 5 and infant mortality is more than 75 per 1000 births. Safe
water, balanced nutrition, prenatal care and full immunization remain long term
health goals. There are 28 medical schools in the Philippines but none in this
region and few physicians are willing to move to this under resourced area.
Planning a Medical school for unity of health and development:
Against this background and aware of the challenge of starting a new school
with very limited resource, consultations between the community, the health
professionals, and the academic stakeholders were initiated. As a result of
these series of intensive intersectoral meeting, a new, private, not for profit
medical school was proposed. This was to be a
collaborative efforts between
a local university to share the use of teaching facilities (library, modular
rooms) for free; the local doctors as volunteer faculty; the community for the
student’s community based experiential learning including their entry selection;
the local businessmen to do fund raising support; the local Health Department
for financial assistance on countryside health researches. A board of 15 members
composed of 3 academicians, 5 civic leaders, 7 doctors was established to
oversee its governance.
The next issues was to develop an educational program to select and train a
new kind of professional: proficient in advanced methods of managing disease,
but also with competence to improve the health in the community. We contacted
leaders in medical education at WHO (Dr. Charles Boelen), in the U.K. (Dr.
Charles Engels), USA (Dr. Arthur Kauffman), Canada (Dr. Clarence Guenter), New
Zealand (Dr. John F. Smith) and (Dr. Reynaldo Joson) Philippines. We heard a
common call for medical education reform.
Most schools emphasized learning the disciplinary subjects rather than
improved health in a community. Students in teaching hospitals worked with
patients suffering from complex medical problems. Clinical instruction
emphasized complex disorders more than common community health problems. This
prepared students to be specialists and to practice hospital medicine in urban
centers. (We perform kidney/heart transplants in Manila, but 80% of the rural
people of Western Mindanao have no health services). This emphasis on the sick
largely ignored disease prevention, health promotion, community development and
the social and economic determinants of health. We did not find a model that was
ideally suited to our situation, so we crated one.
In 1993, we held development seminars on weekends for volunteer faculty,
discussing the psychology of learning, problem solving, new methods of
evaluating students and curriculum design. The school opened in June 1994 and
since then students and faculty learned and modified our new programs together.
Mentors from Canada and New Zealand assisted with the faculty development,
curriculum planning and some students learning experiences.
Piece by piece we developed an integrated curriculum, with problem based
learning, community oriented and based education and competency based
evaluations. All basic science and clinical learning is integrated into the
problem based approach. Three educational strands are intertwined: a working
problem strand, a population strand, and a professional skills strand.
As early as first year, students are exposed to patients both in clinics and
communities where the focus on the practice of medicine as applied to a group or
population is emphasized (community based). About 18 months are spent studying
and working under some supervision in remote rural communities.
As we progressed, two additional dimensions became central in our
i) Faculty Development. We recognized the need to train our faculty ,
graduates of traditional medical schools, with the tools for this new
curriculum. This led to a faculty development program with the option of earning
the Master of Medical Educational Degree.
ii) Career Options. Our students needed a career option to medical
specialties, which could equip and qualify them to field positions in the
Department of Health. This lead to an optional Master of Public Health tract for
the fifth (first post graduate) year. This MD-MPH has also become attractive to
some members of faculty.
We have enrolled about 15-25 students each year depending on the quality of
the applicants. We have seen many changes in some communities where the students
work. Ten graduates of the first class (1998) passed the examinations of the
Philippine Medical Board in 1999, and majority are now working as physicians in
remote regions, equipped in skills of community development.
Dr. Fortunato Cristobal, a Pediatrician,
is the founding Dean of Zamboanga Medical School Foundation; ADZ, LRC Bldg, La
Purisima Street, Zamboanga City, Philippines 7000.