Lessons from studies in South Asia and Sub-Saharan Africa on improvement of basic medical education and related health services

Abstract

South Asia and Sub-Saharan Africa are facing rapid proliferation of medical schools especially in the private sector stimulated by demand for doctors in the mainly curative private health sector. Accreditation has failed to stem declining standards of basic medical education and its increasing irrelevance to national health care needs. Medical graduates tend to opt for careers in high paying specialties and frequently migrate to Western countries for career progression and a better organized lifestyle. However, some recent developments hold promise for improvement and are potential solutions to the problem: (a) the trend towards decentralization of health systems favours strengthening of district health services that hold the key to serve populations equitably, with district hospitals as hubs for integrating clinical care and Primary Health Care; (b) the trend towards diversification of basic medical education to district health services is potentially beneficial for both as they are interdependent; and (c) the realization that accreditation of health professional education must influence health outcomes through practice provides the impetus to improve related health services. The aim of the present review was to find evidence of successful implementation of these measures in South Asia and Sub-Saharan Africa. Evidence of improvements in performance and health outcomes from decentralization of health systems and strengthening of district health services is forthcoming, although provision and management of human and financial resources are challenging. Similarly, there is growing evidence from Sub-Saharan Africa that improvement of health professional education and quality of health care occurs when experiential learning is based at district level hospitals and its related health services; albeit the evidence is presently limited to externally supported projects. Accreditation based on successful integration of medical education and health services, is the weakest link. Although there is growing pressure for national accreditation agencies to implement global standards of basic medical education, without the context of professional development associated with coordinated improvement in related health services the notion that global standards will improve health care lacks credibility. Eventually, effective convergence of these measures is required if the daunting health challenges in South Asia and Sub-Saharan Africa are to be addressed sustainably.