Evaluation of PEPFAR's Contribution (2012-2017) to Rwanda's Human Resources for Health Program (2020) / Chapter Skim
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5 Institutional Capacity for Health Professional Education
5 Institutional Capacity for Health Professional Education
Pages 125-166
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From page 125... ...
and the Global Health Workforce Alliance (GWHA) calls for a rapid and significant scale-up of education and training of health workers and highlights 125
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From page 126... ...
Increased institutional capacity for health professional education during the HRH Program included training a new cadre of health professionals and educators, expanding the skills of existing faculty, and building capacity within the University of Rwanda to continue to produce these professionals in the future. Although the 2013 integration brought together students in the health professions, U.S.
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QUALITY OF TEACHING HRH trainees, University of Rwanda faculty, and USI faculty respondents in this evaluation all concurred that the quality of teaching improved dramatically during the HRH Program, in terms of the teaching methodologies and the approaches. However, these improvements were reported solely in reference to USI faculty members.2 HRH trainees did not report observed improvements in Rwandan faculty members' teaching abilities or competencies, partly due to challenges in recruiting HRH faculty to participate in the twinning initiative, and partly owing to the lack of availability among existing faculty members at the University of Rwanda to teach HRH trainees.
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Some University of Rwanda faculty also reported a clear difference in the quality of teaching after the HRH Program. USI faculty and HRH trainees attributed this increase to USI faculty members' holding HRH trainees to a "higher standard" in terms of what was expected in class and during rotations: There's a difference, especially if you see how the practical teaching and learning was done before and how it is done and was done during this period where HRH Program started, and even today.
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Government of Rwanda HRH Program administrators, students, and staff highlighted more practical, hands-on experience with patients because of the exposure to the high standards for quality of education USI faculty members implemented at the clinical teaching sites. HRH trainees and USI faculty also identified the value and importance of the more informal and interactive teaching approaches USI faculty employed, which treated HRH trainees as colleagues, rather than students.
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(85, University of Rwanda Former Student in Pediatrics) At the facility level, particularly in the nursing program, some HRH trainees reported being better teachers and mentors to their colleagues.
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In surgery, one HRH trainee respondent did not feel the USI faculty had contributed to his education, although when speaking of teachers more broadly, he referred to them as "family" (57, University of Rwanda, Former Student in Surgery)
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Although the HRH Program may have facilitated improved teaching skills while it was fully funded and running, the decline in teaching quality following a drop in investment indicates that the effect of the Program may have been a shortterm injection of faculty. RECRUITMENT AND RETENTION OF HEALTH PROFESSIONAL EDUCATORS Recruiting HRH Trainees to University of Rwanda Faculty The University of Rwanda had mixed results in retention of Rwandan faculty, but showed early progress in recruiting those trained under the HRH Program.
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Current and former HRH trainees also reported significant challenges to continuing their careers in the health profession (in education and in clinical work)
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. With significant increases in overall enrollment across training programs, the production of health workers was not matched by a Rwandan faculty recruitment plan to sustain production (some programs like obstetrics and gynecology were at risk of falling below baseline enrollment with the departure of USI faculty)
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(80, University of Rwanda Faculty in Nursing) University of Rwanda faculty and many of its staff attributed some of these challenges to a lack of building institutional capacity into the HRH Program's original design.
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CURRICULA AND PROGRAMS FOR HEALTH PROFESSIONAL EDUCATION Overall Curriculum Developments Curricula for nursing and midwifery and medical training had developed over the years, with a shift to competency-based curricula and a mix of didactic teaching and more interactive activities becoming evident since the nursing and midwifery education reforms implemented in 2007 (Flinkenflögel et al., 2015c; Uwizeye et al., 2018)
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(15, USI Faculty in the MHA Program) Nursing and Midwifery Training In 2004, the MOH deemed the quality of services delivered by A2 nurses insufficient and initiated plans to cease the A2 training level by 2007 (Mukamana et al., 2015)
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. The HRH Program supported the upgrading of nurses and midwives from A2 to A1 and the development of postgraduate master's programs for eight nurse specialty tracks (alongside a review of the undergraduate physician training curricula and the launch of six new postgraduate residency programs, discussed later in this section)
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USI faculty collaborated with University of Rwanda faculty to develop curricula for eight master's-level nursing specialty tracks in pediatrics, critical care and trauma, nephrology, medical–surgical, neonatal, oncology, perioperative, and education leadership and management. Development of these specialty nursing curricula was cited as a significant contribution of the HRH Program: So, not only they came for the curriculum and improve the exist ing one, but during that time, especially in the nursing department, they created … a relative[ly]
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. This is consistent with reports from HRH trainees and University of Rwanda faculty, who noted that updates to curricula and national protocols were conducted with the support of USI faculty.
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The University of Rwanda reported low dropout rates among students in the undergraduate nursing program (1.43 percent) , with only slightly higher dropout rates in postgraduate programs (3.53 percent)
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. Representatives from professional associations cited that USI faculty were critical in developing clinical content for the curricula, as well as instilling a teaching ethic.
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.7 With the decentralization of health to the district level, health managers trained in public health or management were deemed essential to a functional health facility. The 2-year executive program targeted professionals who were already performing facility management and administration functions in the health system, and focused on increasing the number of trained hospital managers, ensuring equitable distribution of managers, and strengthening institutional capacity to sustain the MHA program locally (MOH, 2016)
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. Similarly, building on their existing partnerships, in February 2012 Partners in Health, Harvard Medical School, and Brigham & Women's Hospital with the MOH launched the first Global Health Delivery course for health professionals in Rwanda, bringing
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Both programs faced challenges with sustainability, and more time is needed to evaluate how these programs will be sustained. Challenges in Curriculum Support Despite notable achievements with the curricula for various health professional education programs, USI faculty reported that those who were recruited as USI faculty often did not have experience in curricula development or that if curricula were developed, they were not formally approved.
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Curriculum Development Adapted from MHA program in Ethiopia: Rwandans were not engaged in the process, but had "final say" before submitting it to the Higher Education Council for approval. (15, USI Faculty in the MHA Program)
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In 2014, there was a shift in focus to develop an MSN program, with the first cohort enrolled in 2015. Adapted from existing curriculum elsewhere: Rwandan and USI faculty collaboratively created curricula in eight specialties, though the extent of curriculum development in each track is unclear.
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(06, USI Faculty in Pediatrics) Sustainability The MHA program was not seen as having been sustained due to: no University of Rwanda faculty taking over; change in MOH priorities; restructuring of leadership in hospitals, which meant that those who were trained were no longer in leadership positions; and not being as well supported as other areas of the HRH Program.
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The MSN program was seen as producing specialized nurses who could provide more complex care and could train others working in their department. Faculty teaching in a master's program were required to have a Ph.D., and there was concern about whether there would be enough Ph.D.-level staff to train the next cohort of students, though a new Ph.D.
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For the MHA program, the curriculum that was developed underwent a lengthy process for approval and was reportedly copied, as noted in the previous section. Indeed, use of the HRH Program–supported curricula seemingly expanded beyond the University of Rwanda and the HRH Program to UGHE, other established schools of medicine or health professional education institutions, and the East African Community for accreditation.
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One University of Rwanda faculty member attributed the university's most recent accreditation by the East African Accreditation Board partly to the HRH Program and suggested that improvements in the quality of education were linked with this accreditation: [T] he program has been upgraded….
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. RESEARCH AND PROFESSIONAL DEVELOPMENT Data from this evaluation show that the HRH Program also increased HRH trainees' research outputs, professional development opportunities, and overall preparation and motivation as they entered the health workforce.
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. Across all respondents for this evaluation, one of the main reported outcomes of the HRH Program was the development of HRH trainees' skills and competencies in research, grant writing, and publication.
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Respondents reported that research collaborations, publications and mentorship with HRH trainees continued after USI faculty left Rwanda (see Chapter 4 for details, in the context of the HRH Program's twinning activities)
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Subsequently, four professional councils (Rwanda Medical and Dental Council, National Council for Nurses and Midwives, National Pharmacy Council, and Rwanda Allied Health Professionals Council) established a joint CPD policy, requiring health professionals to continually update their skills and knowledge as a condition of licensure (Health Professional Councils of Rwanda, 2013)
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HRH trainees from the facility microsystem and the University of Rwanda reported CPD activities hosted by the MOH, Rwanda Biomedical Center, and professional associations as critical to their development. At the facility level, HRH trainees reported that the MOH deployed 2-day to 3-day CPD training courses on topics including tuberculosis, malaria, and hepatitis.
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Chapter 6 expands on student and faculty advancements. CONCLUSIONS In reexaming health professional education, a 2010 Lancet commission identified a series of instructional and institutional reforms for postsecondary education in medicine, nursing, and public health to be not only responsive to local needs, but also connected globally and extended beyond the silos of individual health professions.
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. At the outset of the HRH Program, there was an underestimation of the degree of structural change within the University of Rwanda, and across sectors, that was needed for institutionalized capacity for health professional education and that would occur as a consequence of the HRH Program.
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. Bringing in external faculty and other experts via memoranda of understanding with USIs added value to the quality of health professional education and training, as determined by the development of new programs and curricula or the updating of existing curricula, increased research output, and the provision of high-quality teaching by USI faculty.
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, the HRH Program was likely one of many efforts contributing to a steadily growing body of research output during this period. For HRH trainees, the Program specifically increased their research outputs, professional development opportunities, and overall preparation and motivation as they entered the health workforce, although a cross-sectional descriptive study of interns and pediatric residents at the University of Rwanda identified "barriers to research such as faculty lacking time to mentor, lack of funding, lack of statistical support, and lack of faculty experienced in conducting research" (Habineza et al., 2019)
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. Although experiences with twinning were positive, as described in Chapter 4, the HRH Program's individual twinning approach, as opposed to institutional twinning, resulted in limited improvements in institutional capacity for health professional education.
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2015b. Umuganda for improved health professions education in Rwanda: Past, present and future in the training of health professionals at the University of Rwanda.
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Health Professional Councils of Rwanda.
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2017. Factors influencing retention of health workers in the public health sector in Kenya: A case study of Kenyatta National Hospital.
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2019. Overview of health professional education regulatory oversight for Rwanda and the region, edited by National Academies staff.
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