This May, after seven years of rigorous education, I am officially departing the hallowed halls of the UP College of Medicine. My departure coincides with the end of the deanship of Dr. Alberto Roxas, who served for two 3-year terms and oversaw major improvements in infrastructure and the landmark institutionalization of the return service agreement, which mandates all students of the College to stay for three years after graduation.
Certainly, the parting of one ushers the coming of another. Three of my professors were nominated to succeed Dr. Roxas for the deanship – Dr. Joey Lapena from the Department of Otorhinolaryngology, Dr. Agnes Mejia from the Department of Medicine, and Dr. Arlene Samaniego from the Department of Anatomy. All three have impressive credentials and wide experience in medical education – Dr. Lapena is an accomplished medical journal editor; Dr. Mejia is currently chair of internal medicine; and Dr. Samaniego is a former Vice President of UP.
Why am I concerned about the new leadership? Of course, I owe my holistic formation as a doctor to my alma mater, that’s why I care. More importantly, I believe in the key leadership role the College plays in medical education and in Philippine health in general – sothe leadership of the College is ever crucial in the fulfillment of its work.
Being not affiliated to any of the three in any manner, I leave it to the Chancellor to recommend the best candidate and to the Board of Regents to seal the appointment. But because I firmly believe that the selection of the dean should be based on merits and not familial, disciplinary, organizational, or any affiliation, here I list ten major areas of reform that should serve as guide in choosing the right candidate for the top job.
1. Transforming Philippine medical education to produce doctors that meet the needs of the people.In 2010, in commemoration of the centennial of the Flexner Report that launched the scientific orientation of medical education, a Lancet Commission headed by Julio Frenk, dean of Harvard School of Public Health,published a report entitled “Health professionals for anew century: transforming education to strengthen health systems in an interdependent world.”(1) In summary, the Commission called schools of medicine, nursing, and public health to shift to transformative learning, whose purpose is not just to transfer knowledge and skills, but to cultivate leadership attributes among students to become enlightened change agents. This is in contrast to current informative and formative learning approaches, which are geared towards producing experts and professionals. This overarching recommendation sprang from the realization that despite advances in medicine and public health, glaring inequalities in health care access and health outcomes even widened within and between countries, and contributing to the status quo is the mismatch of competencies of health professionals to patient and population needs.
The Philippines is certainly not an exception. Here, medical graduates are more equipped for hospital settings in cities and even abroad than for the local health system. Furthermore,the estimated generalists-to-specialists ratio is 1:3, while we know that the bulk of the national disease burden – common infectious and noncommunicable diseases – can be easily managed by general practitioners. (2)Given this current paradigm of medical training in the Philippines, the Commission’s report should definitely be first in the reading assignment of the next dean and her/his team.
2. Adopting social accountability as a new measure of success.Certainly the board exam passing rate is one indicator of a medical school’s success. In 2010 however, nearly a hundred institutions and individuals (including the dean of the UP School of Health Sciences, Dr. Jusie Lydia Siega-Sur) drafted and signed the Global Consensus for Social Accountability of Medical Schools, which proposes 10 strategic directions for reorienting education, research, and service priorities of medical schools across the globe. (3) Some of the strategies include anticipating society’s health needs, fostering outcome-based education, and inclusion of social accountability in accreditation schemes. Somehow related to the Lancet Commission’s findings, the Global Consensus however requires commitment from medical schools to implement the recommendations to meet local health needs.
Certainly, UP has contributed a great deal in shaping Philippine medicine and health at large, but hopefully in the 21st century UP will continue to be measured not just for the technical quality of its graduates, but also for the unfading relevance both of its programs and its people, especially to underserved communities in the country.
3. Leading the APMC towards substantial reforms and setting the example for others.The College is a proud and active founding member of the Association of Philippine Medical Colleges (APMC) – I even remember attending its annual conference which the College hosted four years ago. APMC, as the elite collegial body of medical schools in the country, is a fitting place if we want to substantially transform the direction of Philippine medical education and the practice of medicine as a whole.
The new dean of UP should possess the charisma as well as the political force to push for reforms and lead the way for other medical schools. While the College pursues internal changes, the new dean can use our case to demonstrate the need and the feasibility of reforms across the board.
One area of reform needed in many Philippine medical schools is allowing the flourishing of student organizations. Having worked in the Philippine chapter of the Asian Medical Students’ Association, I have listened to many students from other schools who have not been allowed to establish their local chapters because such organizations are not seen as beneficial to the holistic formation of doctors-in-training. This is a stark contrast with UPCM, with nearly 20 organizations spanning diverse interests and advocacies and catering to every type of medical student.
4. Internationalizing the College by promoting global competence. Oftentimes we talk about enhancing the global competitiveness of our students in the health workforce market. What the College should embrace is the paradigm of producing not globally competitive, but globally competent doctors who can harness global knowledge and networks for local and national good.
Global health education should be embedded in the curriculum in order to let students understand local health problems in the context of the global social, economic, and physical environment(4, 5).Furthermore, research partnerships with reputable institutions abroad should be pursued in order to encourage joint learning and discovery to address shared health challenges. More exchange and elective programs with institutions in other countries aside from the United States, especially in fellow developing countries (as part of the growing trend towards South-South cooperation) should also be promoted. In return, the College should open new opportunities for visiting professors and students to further enrich our existing academic portfolio. The construction of a separate medical school catering to international students, however,is not the right measure towards this direction.
5. Thinking beyond return of service in solving the health workforce crisis.The outgoing dean is laudable for instituting the return service agreement (RSA), which was replicated last year in other colleges of UP Manila. While the immediate effects of this policy are still yet to be measured, clearly 160 doctors (or, when all five batches have already graduated, 800 doctors at any point in time) cannot solve the health needs of more than 90 million people within just a short period.
The workforce crisis is more than just a problem of shortage – there is maldistribution and pooling of doctors in urban centers, overproduction, skillmix imbalances, declining work conditions especially of general practitioners, inadequate salaries in the public sector but exorbitant user fees charged by private doctors, and perceived limited opportunities for professional growth, hence the desire to go abroad. (6)While the RSA is operational in the coming years, I wish the next dean will elevate the discussions beyond the contract, and the College begin to take leadership in formulating a national response to the lingering challenges in the management of human resources for health – from recruitment and training to certification and deployment.
6. Uphold College’s commitment to community oriented medical education and primary health care. Unique among schools of medicine is UP’s adoption of the primary health care (PHC) approach in the conduct of community-oriented medical education, which is even enshrined in its vision statement.I remember the WHO Director-General, Dr. Margaret Chan, respond in wonderment when I told her in 2008, during the 30th anniversary conference of the Alma Ata Declaration on PHC in Kazakhstan, that the first document our medical students learn in UP is the declaration itself. Now, WHO is advocating for a “return to Alma Ata” (7) and has been constantly reminding health leaders that PHC is much needed and feasible “now more than ever” (8).
The College does not need to make a full turn back to Alma Ata – I believe we are still in the road towards that direction. However, progress has been slow, with community medicine occupying only 3.75% of the time spent for the entire UP medical education. (9) The community medicine section’s decade-long work in Pasay City, which is celebrated in a book launched last year (9), is of course commendable –and the College needs to support more initiatives like this, even those coming from students, until community action becomes deeply ingrained in the soul of the College.
7. Embarking on interprofessional education.Another critique of the current health workforce set-up is the lack of synergy among different health professionals, when in fact, most of the health problems today can only be addressed through collaborative practice.Therefore, WHO has called for interprofessional education in order to prepare health workers for working in health teams, whether in the hospital or in the field. (10)
The San Juan-UP Community Health and Development Program is a good example of providing spaces for interprofessional learning. When I rotated in San Juan last April, I was blessed to have worked with physical therapy and pharmacy students in managing patients and teaching health workers about rational drug use and herbal medicine. More venues for collaborative learning in classroom and community settings should be fostered among colleges in the university. Since medical doctors naturally serve as leaders in health teams in real practice, the College therefore should also take the lead in designing interprofessional learning programs and in encouraging other disciplines to participate and join.
8. Addressing the basic survival needs of clerks and interns.Having been a clerk and intern myself, I experienced first-hand the challenges of life in the Philippine General Hospital (PGH) – from doling out syringes and test tubes to sleeping in a dilapidated callroom. Of course I do not complain, as on one hand these conditions can be seen as “baptism of fire” for developing resilience and leadership especially in poor resource settings. (But from my conversations with a few classmates, the situation further ignites them to go abroad, seek greener pastures, and experience first-world clinical hospital care.)
However, on the other hand, both personal learning and patient care quality could be enhanced if these pressures are minimized, if not eliminated. The time that can be spent reading a chapter of Harrisons is instead used to purchase needed materials, run blood samples to the laboratory, and track missing results and charts. Oftentimes, the lack of basic resources becomes the spark of petty conflicts, thereby affecting team dynamics and patient interaction. Reducing these problems, therefore, is not only good for ensuring team harmony and work efficiency inside the hospital; it is also good for the health and wellbeing of our medical students, who are already bombarded with heavy workload and intense academic demands to begin with.
9. Asserting UPCM’s leadership in the universal health care movement.The idea of universal health care (UHC) was first brought to public awareness by the UHC study group of the National Institutes of Health. The study grouped analyzed the state of our nation’s health, and came up with a grand master plan that will provide Filipinos with the “highest possible quality of health care that is accessible, efficient, equitably distributed, adequately funded, fairly financed, and appropriately used by an informed and empowered public.” (11)
Most of the stalwarts of the group originated from the College, such as former dean Dr. Alberto Romualdez and former UP Manila chancellor Dr. Ernesto Domingo. However, the voice of the College as a whole on this most ambitious health reform policy is still yet to be heard. The next dean should open more spaces for discussion and debate, take a clear stand in behalf of the College based on broad consultation, and mobilize the entire community towards contributing in the shaping and realization of UHC.
The Organ System Integration (OSI) curriculum should be enhanced to include education about the health system and its building blocks(12), so that our graduates can be better prepared for service and practice in a universal health care system. Furthermore, the College can harness its intellectual and motivational resource to participate in advocacy, lobbying, and policy formulation and implementation. Finally, the College should work with the PGH directorship in order to simulate universal health care in the hospital level and use the PGH as a living example.
10. Expanding our approach to health by including action on social determinants.Even as early as Alma Ata in 1978, there has been a call for the health sector to lead intersectoral collaboration for addressing social factors affecting health. In 2008, thirty years after Alma Ata, the WHO Commission on Social Determinants of Health released the report “Closing the Gap in a Generation” which calls for action on both downstream and upstream determinants of health to reduce health inequities (13).
Two years later, when I was the Philippine representative to the International Federation of Medical Students’ Associations (IFMSA), a global network of 1.2 million medical students from 101 countries, I authored a policy statement calling medical schools to incorporate education, research, and service activities pertaining to social determinants in the curriculum and overall work. (14) Since then, I have been leading the Federation’s worldwide efforts on social determinants and health equity; for months now, we have been meeting with WHO, World Medical Association, and renowned schools of medicine and public health around the world about creating a global consortium for capacity building among health professionals for action on social determinants.
I am sure that the social determinants approach to health for long has been rooted, albeit implicitly, in the overall fabric of the College. I remember that during the second year, we listened to a lecture about the social determinants of health, while the Section of Community Medicine frequently reiterates this perspective in our rotations in Pasay and San Juan, Batangas. Unfortunately, these little efforts cannot substantially transformthe whole of Philippine society, which still suffers from health inequities brought about by myriad social forces that lie beyond our sector (15). Furthermore,in contrast to health sector-initiated programs, whole-of-government approaches like the “Health in All Policies” (16) being implemented now in some countries have not emerged yet in the Philippine public policy arena. I hope the UP College of Medicine will eventually stand in the forefront of this movement, and even set an example to our Asian neighbors for the global consortium we are creating now.
Much of theten aforementioned criteria actually overlap, but they can constitute the scorecard that the decision makers can use in determining who should be the new dean of the College. These standardscan be used to gauge the commitment of the candidates to these reform areas, or measure the contributions the candidates made on these areas even prior to running for deanship. Definitely, these new specific criteria can supplement the more usual and traditional ones such as leadership and teaching experience, commitment to knowledge, devotion to student and faculty welfare, and capacity to manage and even augment existing resources.
Now more than ever, we need a dean who will lead the nation’s premier medical school with anoverflowing spirit of innovation, undying passion to effect radical reforms, and unwavering commitment to social justice and nation building. Ultimately, the greatest challenge of the new dean is to lead a significant culture change in medical education, in the medical community, and in the Philippine health system at large.
Rudolf Virchow, the Father of Social Medicine, once said that medical schools “do not exist to provide students with a way of making a living, but to ensure the health of the community.”The new dean should ensure that the UP College of Medicine is and will remain the full realization of this vision.
References
1. Frenk J, Chen L, et al. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. The Lancet. 2010; 376(9756): 1923-58.
2. Domingo E. Reforms in the Health Human Resource Sector in the Context of Universal Health Care. Acta Medica Philippina. 2010; 44 (4): 43-57.
3. Global Consensus for Social Accountability of Medical Schools.December 2010. Available from: http://healthsocialaccountability.org/.
4. Novak S. Taking a More Holistic Approach to Global Health Education. New York Times, February 19, 2012.
5. Johnson O, Bailey S, et al. Global health learning outcomes for medical students in the UK. The Lancet online version, October 20, 2011. DOI: 10.1016/S0140-6736(11)61582-1
6. Lorenzo FM and Dayrit M. Global Perspectives on Human Resource Development, Migration and the Philippine Situation. Powerpoint presentation delivered on August 10, 2011.
7. Chan M. Return to Alma Ata. Lancet 2008; 372: 865-866. Available from: doi:10.1016/S0140-6736(08)61372-0.
8. World Health Organization. World Health Report 2008: Primary Health Care - Now More Than Ever. Geneva: World Health Organization, 2008.
9. Marcelo P.(ed.)Partnership Matters: Lessons from a Decade of Community-University Collaboration in Community and Local Health Systems Development. Manila: University of the Philippines Manila, 2010.
10. World Health Organization.Framework for Action on Interprofessional Education & Collaborative Practice. Geneva: World Health Organization, 2010.
11. Universal Health Care Study Group. Executive Summary of the Special Issue on Universal Health Care for Filipinos: A Proposal. Acta Medica Philippina. 2010; 44 (4): 9-11.
12. World Health Organization. Everybody's business: strengthening health systems to improve health outcomes - WHO's framework for action. Geneva: World Health Organization, 2007.
13. Commission on Social Determinants of Health. Closing the gap in a generation: health equity through action on the social determinants of health. Geneva: World Health Organization, 2008.
14. International Federation of Medical Students' Associations. Policy statement on health inequity and the social determinants of health. Jakarta, Indonesia, 60th March General Assembly of the International Federation of Medical Students' Associations. March, 2011. Available from: http://www.ifmsa.org[Accessed 26th September 2011].
15. Guinto R. Social Determinants of Health. Philippine Daily Inquirer, March 25, 2012.
16. Kickbusch I. “Health in all policies: The evolution of the concept of horizontal health governance.” In: Kickbusch I, Buckett K. (eds.) Implementing Health in All Policies: Adelaide 2010. Adelaide: Department of Health, Government of South Australia, 2010: pp. 11-23.
About the Author
A member of the UP College of Medicine Class of 2012, Ramon Lorenzo Luis R. Guinto is the current Regional Coordinator for the Asia-Pacific of the International Federation of Medical Students’ Federation, former president of the Asian Medical Students’ Association-Philippines, and former chairperson of the UP Manila University Student Council. Last February, he was appointed Youth Commissioner of the Commission on Global Governance for Health convened by The Lancet, University of Oslo, and Harvard Global Health Institute.
