The first decade of the Malawi College of Medicine: a critical appraisal
Adamson S. Muula The College of Medicine, P/Bag 360, Chichiri, Blantyre 3, Malawi. E-mail: email@example.com
The College of Medicine of the University of Malawi was opened in April 1991. Over almost a decade it has flourished in the face of economic and political constraints, as well as a change in the philosophy of donor support. We review the past, assess the present and look to the future.
Malawi had no medical school at Independence in 1964. When the Federation of Northern and Southern Rhodesia and Nyasaland (Malawi) broke up in 1963, the already established medical schools of Lusaka and Salisbury (Harare) had previously provided opportunities for potential Malawian doctors. In the acrimony following the dissolution of the Federation, independent Malawi found it difficult to place its candidates with its neighbours and had to rely mainly on sending students abroad to Europe and America through sponsored scholarships. This was expensive and many bright students, most of whom were sent abroad in their late teens and early twenties, did not return to practice in Malawi, either because they had married and settled with a family or because the economic rewards and political climate were not conducive to return. The health service delivery of newly independent Malawi was provided almost entirely by clinical officers and medical assistants trained for two and three years respectively at the Lilongwe School of Health Sciences and at Malamulo School of Health Sciences. The mission hospitals, of which there are 38, also provided care and were administered principally by expatriate doctors. Malawian doctors who remained in Malawi were usually called to serve in senior administrative posts. Aware of this dependence on expatriate medical assistance, Malawi sought to establish its own medical school. Despite two commissions convened to assess the feasibility of a medical school, it was not until 1986 that the Tripartite Commission emphatically endorsed the creation of a School of Medicine ( Grillo & Gilles 1981; Ministry of Health 1984). The Tripartite Commission, so-called because the British, German and Malawian governments were the key movers, resolved that the medical school should be community health-based and that its curriculum should reflect the needs of Malawi ( Ministry of Health 1986).
From 1986, the British Government agreed to sponsor 100 medical students over 4 years to do their basic medical science training and initial clinical year in the UK, while at home preparations would begin to complete their training in Malawi by July 1990. This was delayed by one year and Malawi had its first intake of final year medical students in September 1991 and graduated its first doctors in July 1992. From that time Malawi gradually took on increasing responsibility for training. Through a series of four curriculum conferences with medical educators both from abroad and from Malawi, an integrated, community-based curriculum was developed that sought to reflect the country’s needs and health problems while making the best possible use of its limited resources of academic manpower and facilities.
The academic challenge
From the outset the College of Medicine was determined that the training of its future doctors should reflect the immense medical and social problems of Malawi, one of the world’s 10 poorest countries ( World Bank Report 1998; United Nations 1998). The curriculum pursued this objective by allotting approximately 25% of its contact hours to the teaching of Community Health in all five years of the course. The district hospital at Mangochi, situated some 190 kilometers from Blantyre on Lake Malawi, was adopted as the base for Community Health training because the lakeshore reflected the medical problems of a rural environment and provided a different medical experience from urban Blantyre. The Head of the Department of Community Health moved to Mangochi to supervise the training. A students’ hostel had already been built. A health centre, Lungwena, was developed as a teaching centre with assistance by a Finnish donor, the Mannerheim League. It also provided residential training for medical students, nurses and other health personnel in a remote area on the east side of Lake Malawi.
The curriculum was developed through a series of conferences held in 1990, 1992, 1993 and 1995, and implemented and monitored through the College Curriculum Committee. By and large the College of Medicine has achieved its objectives. Community Health remains the cornerstone of the curriculum. There is a fair degree of integration of teaching, both horizontally through the division of Basic Medical Science and vertically with the clinical departments. The tensions between centrifugal forces of departmental autonomy and centripetal forces for curriculum integration are resolved through the College Curriculum Committee. The students are represented on the Curriculum Committee. As far as the academic manpower allows, the curriculum seeks to stimulate student participation through problem-based learning. Limited resources, however, necessitate pragmatism taking precedence over academic ideology in this regard.
The academic achievements of the College of Medicine have been considerable by any measure. The College of Medicine has been awarded several international prizes for its innovative undergraduate teaching programme. The Department of Community Health received the Association of African Universities’ Prize in 1994 for the introduction of a community-based Objective Structured Clinical Examination (OSCE) assessment for final MBBS exams. In 1998, 1999 and 2000 students have won 1st or 2nd prizes in the Tropical Health Education Trust/Reuter Prize for the best student research projects. A 1999 final year student won the first prize for the best student research project from the Royal Society of Tropical Medicine and Hygiene, London.
The College has, in collaboration with overseas academic institutions and agencies, developed a research base of international repute and academic excellence. Collaborators include the Malaria Research Project linked with Michigan State University, the Johns Hopkins Research project charged with investigating aspects of HIV transmission and the Wellcome Research Unit through the University of Liverpool, where fellows from various countries come to do research in collaboration with Malawian counterparts. Other academic collaborative links are encouraged at individual departmental level.
The College of Medicine is recognized and supported by the World Health Organization for its high standard of training. It is favoured by foreign medical students as a good institution for doing their elective period (WHO 1998).
From the outset the College of Medicine had to combat cynical voices, principally from expatriates, that doubted Malawian doctors would remain in Malawi once qualified. Before the creation of the College of Medicine, the joke was that there were more Malawian doctors practising in Manchester than in Malawi. Where was the incentive to return when graduates trained and registered in the host country could earn so much more, when many had married nationals of their host country, where they could live in security and freedom, none of which could be guaranteed in Malawi at that time? This may have been so in the 1970s and 1980s, but times have changed. Developed countries experience increasing medical unemployment and protectionism for their own graduates. It has become less easy for overseas medical graduates to gain employment, other than on designated training programmes. Malawian-trained postgraduates sent abroad for specialist training are much older than their past undergraduates peers used to be when leaving the country; usually they are married and have dependents.
Since July 1992, 134 medical doctors have graduated from the College of Medicine. Where are those doctors today and what has been their postgraduate training to date? Table 1 shows that the majority of the graduates who are or have been abroad are on designated training programmes either sponsored through the College of Medicine or by overseas sponsors. Most candidates are committed to returning either to the College of Medicine or to Government service. Those who have already received some or all of their training are working for the College of Medicine, the Government and its agencies or nongovernmental organizations (NGOs). The College’s most senior graduate is now Permanent Secretary at the Ministry of Health.
Malawian doctors in postgraduate training
Of the 134 doctors who have qualified since July 1992, 57 have received or are receiving their postgraduate training abroad. Nineteen have returned and are working in the College of Medicine, government service, mission hospitals or other health agencies. Of the other 77 doctors, 20 are undergoing internship/houseman rotation and 18 are either posted to district hospitals or mission hospitals after recent completion of their internship. The remainder are either in early specialist training as staff associates/assistant lecturers in the College of Medicine or are working in other government or nongovernmental organizations. Only four have left Malawi through marriage or for further opportunities. Four doctors have died. This analysis confounds the cynical predictions of many that Malawians would not return to work at home. True, the conditions for working in government service are not good. At present the package of incentives offered by the College of Medicine, other agencies and NGO’s offers more security and better conditions. There is disgruntlement about conditions of service, which are still based on the old British colonial terms of civil service. This issue is currently being addressed.
Most Malawian doctors want to work in their own country and do not wish to remain in permanent exile. Slowly but surely Malawian trained graduates are working their way into all areas of medical influence where they are beginning to effect real improvements in the delivery of health services. No longer will inappropriate solutions to the medical needs of Malawi be imposed in a top down manner by outsiders.
Since Malawi relies on donor support, it has been subject to changes in donor philosophy. The British government, which so imaginatively endorsed the Tripartite Agreement and funded 100 students to study basic medical science, withdrew its support in 1994 because the College of Medicine did not fit in with the new philosophy of ‘programme development’ and emphasis on Primary Health Care. The German government, which had been a signatory to the Tripartite Agreement, withdrew its support to the College of Medicine even before it started because of the poor human rights record under the former autocratic government of President H. Banda. A German-trained neurosurgeon, Dr G. Mtafu, was imprisoned without trial for 2 years in 1987. He later became Minister of Health in the first democratically elected government of President Bakili Muluzi in 1994. The Dutch government, which has long supported Malawi medical services, struck the country from its priority list of nations who receive aid in 1998 and is phasing out its support to the College of Medicine. Other Governments such as those of Australia and South Africa have aided the College of Medicine for specific periods and through special arrangements. But adversity is often the spur to ingenuity. The College has entered into various academic links with institutions and agencies abroad which aid the College’s development in a rich network of academic relationships.
At present the College of Medicine trains only 18–22 graduates per year. There are several reasons for this. Initially, there were limited manpower and teaching resources such as student accommodation, library facilities and laboratory space. However, a new students’ hostel, and fine new teaching laboratory facilities, which are half-finished and partly in use, will enable the College to double its student intake from 2001. As set out in the Tripartite Agreement, some students will be drawn from neighbouring countries, especially Botswana, Namibia, Lesotho, Swaziland and the Seychelles, who have no medical school of their own. The fees will generate income for the College of Medicine.
The low general literacy rate in Malawi and the limited opportunities for secondary and tertiary education limit the number of potentially eligible students of the College. The present government plans to redress this situation.
Looking to the future
July 1999 saw the first group of graduates who had received their entire training in Malawi – a major achievement as the College of Medicine had kept to its timetable of phased development despite political and financial constraints dictated by the emergence of democracy.
The 1999 graduation was immediately followed by the 5th Curriculum Conference whose objectives were to review what had been established and look to the future. Many past members of staff and advisors who had been in at the College’s foundation came to Malawi, some at their own expense, to take part. Medical educators, past and present members of staff, graduates and students, Malawi government and donor representatives, reviewed the curriculum year by year. Their recommendations and resolutions essentially endorsed the principle of integration with community health as its corner stone. The completion of new hostels will allow the College of Medicine to increase its intake of medical students recruited both from home and abroad.
Looking to the future, delegates endorsed the College of Medicine’s resolve to begin its own postgraduate programme. Five elements were identified as essential ( Malawi Medical College 2000): Firstly, the postgraduate programme should be of the highest academic standard and strive for international recognition. Secondly, the postgraduate programme should be firmly rooted in research, which should strengthen the academic collaboration with our existing international research partners as well as actively develop new academic research links, in order to develop the academic capacity of the College of Medicine. Thirdly, an independent library and academic resource centre for the College of Medicine is necessary. The learning environment of the teaching hospital, Queen Elizabeth Central Hospital, must be improved, especially for clinical disciplines. Lastly, although a start should be made as soon as possible, departments should be given the autonomy to develop at a pace that was sustainable.
The College of Medicine has endorsed and implemented the recommendations and resolutions of the 5th Curriculum Conference of July 1999. The modifications have been introduced into the undergraduate curriculum and internship programme. Postgraduate development has already started with three separate initiatives; the Tropical Health and Education Trust (THET), a UK based charity, has sourced funding through the Royal College of Physicians of London to initiate bilateral academic exchanges for visiting experts to Malawi and graduates in training from Malawi to the UK.
The Government of Norway, through the Norwegian Agency for Development (NORAD), has donated an initial sum of US $1.4 million towards strengthening postgraduate training in the Basic Medical Sciences, the first stages of a medical library and academic resource centre, and to improving the student facilities at the teaching hospital. The Dutch government’s ‘exit strategy’ provides funding of nine Dutch academic members of staff over a three-year transition period for four clinical departments, after which it is hoped that the postgraduate training would be self-sustaining.
The first formal postgraduate training will start in 2001. This will comprise core modules deemed essential for all clinical disciplines and will run through one calendar year. This will be followed by a second year where individual departments will run modules more orientated to their specialty, however a degree of integration with the Basic Medical Sciences and other clinical departments will be encouraged where appropriate. These first two years will be followed by a Part I barrier examination. Organization of the final 2 or more years of specialist training has yet to be fully developed. An elective period should be mandatory, during which graduates can be exposed to the discipline and standards of their specialty in centres of medical excellence. How long and in what form this will take place has yet to be determined. Pragmatically, the College hopes to capitalize on existing academic research collaborations, and is actively pursuing new links.
Challenges and opportunities
The College’s future holds exciting challenges and opportunities. The communications revolution and innovations introduced into medical education offer opportunities to participate internationally while deepening our experience at home in Malawi. This can be through new formal learning techniques and through collaborative research. The economic constraints of a very poor developing country like Malawi can be a stimulus to ingenuity rather than a hindrance to academic development. The wide clinical experience, sadly but inevitably present, can be used to hone clinical skills and provide great research opportunities. A new college has the advantage of setting academic precedents without being bound to the past. This allows for academic flexibility and initiatives on the basis of need rather than ideology at the same time as maintaining academic excellence in the face of limited resources. The College of Medicine of Malawi will be a pioneer in this and is committed to succeed.