Recent developments in the current medical and nursing curricula
The medical and nursing curricula at MakCHS are each organized in three phases. Phase I is interdisciplinary and conducted jointly for the first two years of the medical and nursing programs. It emphasizes the pre-clinical sciences and the acquisition of knowledge. Phase II and III gradually build upon this initial knowledge foundation with clinical skills training as well as rotations, and are organized around organ systems. Teaching and learning of the biomedical sciences (anatomy, physiology, and biochemistry) is integrated. There is some minimal clinical integration in this early phase through basic clinical exposures, case studies and some basic clinical skills training. During Phase I, students also get introduced to behavioral sciences, epidemiology and biostatistics. For the medical program, Phase II occurs in the third year and Phase III in the fourth and fifth. Phase II addresses abnormal body structure and function, and emphasizes pathophysiology of systemic disorders, as well as pharmacology. Phase III of the medical program emphasizes both knowledge and clinical outcomes. This phase involves students rotating through different clinical disciplines. For the nursing program, Phase II and III occur during the third and fourth years of the program.
The curricula are delivered mainly through student-centered learning approaches including problem-based learning, early clinical contact with patients, clinical experiences with patients during clinical clerkships, and community-based education and service (COBES). COBES starts during Phase I of both programs, and continues through Phase II of the nursing program and Phase III of the medicine program.
Current core competencies
The curriculum analysis revealed that that the core competencies that medical and nursing students are expected to achieve by the end of the training were clearly outlined for both programs (Table 1). While the core competencies outlined by the two curricula were similar, nursing puts more emphasis on research skills, management, education and professional development competencies than the medicine curricula. These stated core competencies as well as the clinical content were, in general, well aligned with those identified by KI and FGDs as necessary to meet HSSP targets in maternal and child health, mental health, environmental health, and infectious diseases .
However, the curriculum analysis also revealed that the core competencies were not systematically integrated into all the course objectives and learning activities. Furthermore, the course objectives of Phase I and II were mainly designed in the cognitive domain and generally reflected lower cognitive levels of knowledge and comprehension (i.e. “to describe” and “to explain” were the most common verbs used in the objectives for the biomedical sciences, in contrast to those which would reflect knowledge acquisition at higher domain levels, such as “to apply” and “to analyze”). Even in the instances where the language was more explicit, the metrics and processes by which faculty evaluated student competencies were not outlined. Furthermore, the link among core competencies, coursework, and expected student outcomes during their progression through the program, was difficult to establish.
The observations recorded from the KIIs and FGDs provided further insights into the strengths and weaknesses of curricula implementation. A district health officer explained that “the current curriculum for Medical Officers mostly covers clinical aspects, specifically patient management. This aspect of the training is well done. Even the internship that medical officers go through before they are registered mainly covers clinical skills.” However, the concerns raised by study participants indicated that the current teaching and learning strategies did not adequately address some of the stated core competencies, for example, leadership and management, interpersonal communication, professionalism, and primary care.
As an MoH official explained, “Management is one of the things that we lack in this country and really to be able to use available data but that is all management. Management is a very key issue in Africa managing the available resources and being able to produce results in the area key issues. How do you manage available resources? How do you manage the money available to you?” On a related note, the district officials and international agencies interviewed noted that all health professionals, not just doctors and nurses, needed some leadership skills to manage and create the change necessary to meet the HSSP targets. They also emphasized the need for team building to facilitate cooperation both within and among the different health system operational levels. In general, most participants agreed, as a MoH director stated, that “ The modern doctor also needs good management and leadership skills.”
Respondents also expressed repeated concerns that the health professionals did not have the necessary interpersonal skills to communicate well with staff, community and patients. This finding resonates throughout the curriculum analysis, which also found that most of the course objectives targeted cognitive and psychomotor outcomes, with less emphasis on affective outcomes and other competencies. A representative of the Health Consumers Organization affirmed: “There is need to train people in humanistic skills which will help them to learn how to interact with people whether patients or not patients, respect, treat people with empathy, have a listening ear, listen and understand people, learn to deal with human beings as human beings and understand them as human beings.”
Lack of professionalism in practice, including ethics, integrity, and physical presence in the health facilities, was another gap identified in the core competencies of the medicine and nursing graduates. Respondents said that ethical conduct of health workers was a key issue and argued that MakCHS students should be sensitized on human and patient rights.
Other key respondents raised the issue of faculty and student integrity as well as their attitudes toward medical and nursing practice. These respondents emphasized the role of faculty in modeling good behavior and mentoring students. According to alumni who participated in FGDs, the issue of professionalism was compounded by the lack of role models within the faculty to model this competency. One alumnus posited: “Now the ethics, well, it has to be in you, the integrity. So if the person who teaches it doesn’t behave that way then I also wouldn’t really have the guts to follow unless I have that personal, you know touch. I know what it means to have integrity, respect and all that. So you find that everyone is taught ethics but some of the seniors don’t even behave in the ethical way.”
A final major gap in the current curricula that was emphasized throughout the findings was an insufficient emphasis on primary prevention, which includes both health promotions and disease prevention. As one of the district health officers stated, “There is little emphasis on preventive and promotion of health service delivery. There is a lot of emphasis on curative, investigative, good clinical history and examination which are more expensive.” In a separate KII, a MakCHS Dean agrees: “Even another thing that we have also realized is needed for achieving the Health Sector Strategic Plan targets is actually people going out for preventive services. They tend to be ignored in the training. I think it is not focused on a lot. You find that even a clinical officer does not prioritize going out to focus on hygiene and sanitation so that he educates; he knows a lot, but he doesn’t see it as his role.”
Whereas the MoH official emphasized the clinical skills for quality patient management was a very important core competency for MakCHS graduates, the district health officers as well as officials from the development partners put leadership and management as the main key competency health professionals had to possess in order meet the HSSP targets. Representatives of health consumers’ organization put the emphasis on the need for health professionals to empower communities to promote their health and to possess the competency of good communication skills. However, the importance professionalism, communication and good interpersonal skills as core competencies of graduates of MakCHS were highlighted by all the study participants.
Guidance for the future
In addition to shedding light upon some of the critical gaps in the medical and nursing curricula at MakCHS, respondents offered several solutions for improving medical and nursing education at MakCHS and for increasing the alignment of the curricula goals and objectives to the needs of the Ugandan population. These solutions concentrated primarily around decentralization of training, strengthening partnerships with the MoH and other key stakeholders, and filling the highlighted gaps in the curricula.
Several respondents suggested that training should be decentralized to lower level health units in order to strengthen the critical linkages needed between the community and the health system and to better prepare students to deliver the Minimum Package of Health Services of cost effective interventions high impact interventions to serve the primary needs of the Ugandan population . A faculty member who participated in FGDs suggested that MakCHS explore the “use of resources surrounding us and changing the model; the students should be able to go to the City Council clinics (lower level health facilities) in order for them to learn better for example students in year one should not go to the wards of a tertiary hospital, but to the City Council clinics. Tutorials should be done at the health centers so they actually see patients with minor problems.” One of the MakCHS Deans explained that: “Mulago as the National Referral Hospital is sometimes too specialized for undergraduate training. College of Health Sciences could do better by affiliating and sending our students to regional hospitals where there are interns as well as Faith-based hospitals around Kampala to make learning interactive and the teachers would give supervisory support to these centers and offer continuous professional development. This would move a large part of teaching and learning to the community and increase the accountability of College of Health Sciences to the community.”
Not only would increased training in the community strengthen the linkages between the future health workforce and the Ugandan population, but also improve the relevance of the students’ learning experiences to their needs.
Internal stakeholders also highlighted the need to strengthen curricula by involving the MoH and other stakeholders. One key informant from the MakCHS leadership recommended to “work closely with MoH in planning the training program so that the curricula satisfy the need for the MoH. Work closely with MoH to define competencies once the MoH has defined the roles.” Several other respondents also emphasized that all stakeholders, internal and external, should jointly develop training programs in order to optimize the set of competencies that graduates acquire and to ensure that they meet the needs of the Ugandan population.
When discussing opportunities to enhance the core competencies present in the curricula, addressing the gaps in leadership, management, communication and interpersonal skills, and professionalism were identified as high priorities for MakCHS in the next 10 years. In addition, respondents emphasized the need to strengthen students’ experiences within the community-based health care system. One of the district health officer interviewed emphasized the need “ to train people in the areas where they are going to be posted like to have an attachment because I’ve noticed when we get people who have come during their training and get attached through rural districts they tend to stay.”
Other respondents highlighted the need to enhance supervision of students and teamwork. For example, a MakCHS leader thought that “supervision should be a factor too because it brings in mentoring. The team approach should be emphasized not only to learning but to solving problems so that as people move on, they move as teams but not as individuals.” In addition to these issues, the need to emphasize training in ethics and human rights was also highly emphasized in discussion. According to a representative of the Health Consumer Organization, “the providers should also know what the rights of patients are. And accountability and efficiency will come out if the users know what they need and how to demand for it and how to get it and how to hold providers and policy makers, it is not just the health workers they need to be able to demand from policy makers”.
Respondents also highlighted the need of reviewing the existing curricula in order to accommodate the gaps in the competencies and learning experiences of the current programs. According to a MoH Department Head, “ curriculum reviews to improve, training should involve more community training, teachers to go in community with students which will be a spin off for continuous professional development.”