Building Health Workforce Capacity Through Community-Based Health Professional Education: Workshop Summary (2015)

Appendix D

Summary of Updates from the Innovation Collaboratives

The Institute of Medicine’s (IOM’s) Global Forum on Innovation in Health Professional Education is complemented by the work of four university- or foundation-based collaborations in Canada, India, South Africa, and Uganda. Known as innovation collaboratives (ICs), these country-based collaborations characterize innovators in health professional education through their demonstration projects that require different health professional schools to work together toward a common goal. The four ICs were selected through a competitive application process. By being selected, these collaboratives receive certain benefits and opportunities related to the forum that include

• The appointment of one innovation collaborative representative to the Global Forum,
• Time on each workshop agenda to showcase and discuss aspects of the IC’s project with leading health interprofessional educators and funding organizations,
• Written documentation of each collaborative’s progress summarized in the Global Forum workshop summaries published by the National Academies Press, and
• Remote participation in Global Forum workshops through a video feed to the collaborative’s home site.

Each collaborative is undertaking a different 2-year program of innovative curricular and institutional development that specifically responds to one of the recommendations in the Lancet Commission report or the

2011 IOM report The Future of Nursing—reports that inspired the establishment of the Global Forum. These on-the-ground innovations involve a substantial and coordinated effort among at least three partnered schools (a medical school, a nursing school, and a public health school). As ad hoc activities of the Global Forum, the ICs are amplifying the process of reevaluating health professional education globally so it can be done more efficiently and effectively, and it is hoped it will increase capacity for teamwork and health systems leadership. The work of the collaboratives is detailed below.

CANADA PROGRESS REPORT FOR THE INSTITUTE OF MEDICINE

Maria Tassone, M.Sc., B.Sc.P.T., and Sarita Verma, L.L.B., M.D., CCFP
University of Toronto

The CIHLC

The Canadian Interprofessional Health Leadership Collaborative (CIHLC) is a multi-institutional and interprofessional partnership whose goal is to develop, implement, and evaluate an evidence-based program in collaborative leadership that builds capacity for health systems transformation. The CIHLC lead organization is the University of Toronto (UofT) partnered with the University of British Columbia (UBC), the Northern Ontario School of Medicine (NOSM), Queen’s University, and Université Laval.

Through the foundational research it conducted, the CIHLC identified unique aspects of collaborative leadership and an existing Canadian program as an exemplar in collaborative leadership for system change. The Canadian Collaborative Change Leadership (CCL) Program housed at the University Health Network (UHN) closely aligns with the CIHLC vision and proposed design and is embedded in a context of interprofessional and relationship-centered care. Rather than launch an additional leadership education program, the CIHLC co-created the Integrated CCL program, adding the evidence and unique CIHLC components—including community engagement (CE), social accountability (SA) content, an online presence, and an enhanced developmental evaluation—to the existing CCL program.

The Program: Design and Delivery

Structured to be context specific, the integrated CCL program is adapted to the individuals, teams, organizations, and communities participating. This program covers a 10-month period with five 2-day face-to-face sessions and blends these intensive sessions with coaching from faculty within and

between sessions. Additional coaching and learning will be promoted via an online platform and community of practice. During and between sessions the participants will develop, design, implement, and evaluate a capstone initiative in their community or organization based on the principles of SA and CE.

The CIHLC introduced a multilingual platform—the Blackboard Learning Management System—to allow the program to provide distance education and online collaboration through tools such as webinars, multimedia, discussion boards, Wikis, and online assessment tools. Blackboard allows the program to use online education to reach learners throughout Canada and, potentially, globally.

Session One

The first program session was held April 11–12, 2014, in Toronto. The session was designed to explore collaborative change leadership theories and practices, develop understanding of social accountability and community engagement in the context of setting up the capstone initiative and organizational inquiry, and initiate the community of practice. The evaluation of the first session and the design of the second session are in progress.

Recruitment and Selection of Participants

The goal of the integrated CCL program is to develop people to lead health system transformation and enable socially accountable change in their community; therefore, the targeted learners were senior and high-potential leaders across practice and education.

The two program partners selected participants by direct recruitment through each of the four CIHLC partner sites outside of Toronto and through the CCL call for applications open to Canadian and international health leaders, largely focusing on Toronto-based organizations affiliated with UHN. A total of 32 participants were selected, with teams representing Anglophone and Francophone Canada, rural and urban leaders, and four provinces, including Alberta, British Columbia, Ontario, and Quebec. Each team brings to the program a capstone initiative that addresses an important issue such as seniors’ health in aboriginal communities; mental health related to child and youth, addictions, rural, and northern populations; models of interprofessional collaborative education and care; and enhancing the accessibility of collaborative leadership education for French-speaking health leaders.

CIHLC Website

The CIHLC project website provides an Internet platform to present information on project activities, program development, and participant recruitment. The full website was translated to French in order to create a truly pan-Canadian forum for the CIHLC project and the program. The website will be updated in parallel in English and French throughout the program, to provide equal access to Anglophone and Francophone participants. The English website can be accessed at http://cihlc.ca; the French website can be accessed at http://cihlc.ca/fr.

Knowledge Dissemination and Knowledge Transfer Strategy

The CIHLC submitted several scholarly pieces for publication in reputable journals and books and is preparing several additional articles and book chapters pertaining to the research and program development for publication. Published scholarly work and other knowledge dissemination and knowledge transfer activities can be found at the following link: http://cihlc.ca/research (English) or http://cihlc.ca/fr/recherche (French).

Next Steps

The upcoming program session themes are outlined in Table D-1. Testing of the program will continue to be conducted during the 10-month period of the program. A final evaluation report will be produced by March 31, 2015, at the close of the CIHLC project.

TABLE D-1 CIHLC Program Overview

INDIA
BUILDING INTERDISCIPLINARY LEADERSHIP SKILLS AMONG HEALTH PROFESSIONALS IN THE 21ST CENTURY: AN INNOVATIVE TRAINING MODEL PROGRESS REPORT (APRIL 2012 TO MAY 2014)

Sanjay Zodpey, M.D., Ph.D.
Public Health Foundation of India (PHFI)

Background

The Lancet Commission report (Frenk et al., 2010) on Education of Health Professionals for the 21st Century discusses three generations of global educational reforms. It elaborates on transformative learning, focusing on development of leadership skills and interdependence in health education, as the best and most contemporary of the three generations. The purpose of this form of education reform is to produce progressive change agents in the field of health care. The Future of Nursing report (IOM, 2011) also strongly focuses on transformative leadership, stating that strong leadership is critical for realizing the vision of a transformed health care system. The report recommends a strong and committed partnership of nursing professionals with physicians and other health professionals in building leadership competencies to develop and implement the changes required to increase quality, access, and value and deliver patient-centric care.

Leadership is a complex multidimensional concept and has been defined in many different ways. In the field of health care, leadership serves as an asset to face challenges and is an important skill to possess. To reach this goal, common leadership skills must be looked for among students applying for health professional education, including medical, nursing, and public health professionals (Chadi, 2009). The Lancet Commission report’s recommendations are targeted at a multidisciplinary and systemic approach toward health professional education. In India, the lack of and need for professional health care providers has been discussed for the past many decades. The education system for health professionals in India is strictly compartmentalized, and there are strong professional boundaries and demarcations among the various health professions (medical, nursing, and public health); there is recognized need for integrating these three streams. Moreover, the current health professional education system in India focuses minimally on the development of leadership competencies to address public health needs of the population.

Rationale for the Initiative

Health professionals have made enormous contributions globally to health and development over the past century. The demand of 21st-century health professional education is mainly transformational, aiming to help the professionals strategically identify emerging health challenges and innovatively address the needs of the population. The need of the hour in India is to amalgamate the skills and knowledge of the medical, nursing, and public health professionals and to develop robust leadership competencies among them. This initiative proposed to identify interdisciplinary leadership competencies among doctors, nurses, and public health experts necessary to bring about a positive change in the health care system of the country.

Objectives of the Initiative

1. Identification of interdisciplinary health care leadership competencies relevant to the medical, nursing, and public health professional education in India
2. Conceptualization and piloting of an interprofessional training model to develop physician, nursing, and public health leadership skills relevant for the 21st-century health system in India

Partners of the Innovation Collaborative

The Innovation Collaborative is a partnership among the following three schools:

• Public Health Foundation of India, New Delhi: public health institute;
• Datta Meghe Institute of Medical Sciences, Sawangi, Wardha: medical school; and
• Symbiosis College of Nursing, Pune: nursing school.

These schools teamed up to further the objective of the Innovation Collaborative. Table D-2 provides basic information for the three schools.

Innovation Collaborative Activities—Update

The three partner institutes collaborated to address the major objectives of this initiative. A formal approval of the proposal was obtained by the IOM, following which the team members conducted various outlined activities.

TABLE D-2 Innovation Collaborative Partners

Constitution of the Collaborative

A team was formed including members from all three partner institutes. Prof. Sanjay Zodpey, Director-PHE, PHFI, represents the Collaborative as the National Program Lead along with Col. Jayalakshmi N., Principal, Symbiosis College of Nursing, and Dr. Vedprakash Mishra, Pro-chancellor, Datta Meghe Institute of Medical Sciences as Regional Program Leads. The team also included other member representatives from each partner institute.

Constitution of a Technical Advisory Group (TAG)

The TAG was formed, comprising renowned experts in the field of health professions education. All these members were contacted to seek their consent to be a TAG member to oversee and provide guidance to the activities of the collaborative. Regular meetings were held with the TAG members, and their guidance was sought on various aspects of the project.

Identification of Interdisciplinary Health Care Leadership Competencies

The initial activity undertaken by the collaborative was an exhaustive literature search by the working group under the guidance of the program leads to understand need for and genesis of leadership competencies as a part of education of health professionals. Published evidence, both global and Indian, was included in the literature search to look for key interdisciplinary leadership competencies, the need for an interdisciplinary training of health professionals, and the current scenarios in interprofessional health education. The literature search strategies included journal articles from electronic databases, medical journals, grey literature, newspaper articles, and papers presented in conferences. The search was not restricted by the period of publication or language. The electronic search was complemented by hand searching for relevant publications or documents in their bibliographies. A process of snowballing was used until no new articles were located.

Expert Group Meetings

Once the literature search was complete, the working group summarized the findings of the search and prepared a formal report. This report was reviewed by all senior members and finalized. This was followed by a consultation with experts from various disciplines of health professional education, where the findings of the literature search were presented.

Development of Training Model

The next activity of the project was the development of the training model for the pilot. The training model was conceptualized based on the findings of the literature search and the recommendations of the expert group at the consultation. A training manual was developed for use in the trainings by the working group along with the team leaders.

The trainings are aimed at health professionals across the country from the medical, nursing, and public health fields. The long-term objective of this training model is its integration into the regular curriculum of the medical, nursing, and public health students, with an aim to develop interdisciplinary leadership skills among them.

To align with the objectives of the Innovation Collaborative, the training model was pilot-tested on some in-service professionals and students across the three streams. For this, a detailed agenda and the training material were prepared based on the content of the training manual.

Piloting the Training Model

The pilot trainings commenced in April 2013 and were completed in the first week of May 2013. These trainings were conducted in batches at three different sites:

• State Institute of Health Management and Communication, Gwalior (SIHMC);
• Indian Institute of Public Health, Bhubaneswar (IIPHB); and
• Datta Meghe Institute of Medical Sciences, Sawangi (DMIMS).

The duration of each training batch was 3 days. Resource faculty from the three partner institutes actively trained the participants. IIPHB had 25 participants for the training, while SIHMC and DMIMS had 16 and 25 participants, respectively. The average age of the participants across all the three batches was 32 years. The total number of males in the three batches was 40, and there were 26 females.

The group for each batch of the training workshop was mixed, with participants from different disciplines. The training was aimed at bringing the three disciplines (medical, nursing, and public health) together to build interdisciplinary leadership skills. Details of participants are shown in Table D-3.

The pilot training workshops included didactic sessions as well as group discussions. The didactic sessions were aimed at giving the trainees an understanding of leadership skills and their importance in health care. The aim of the group discussions was to train them to innovatively apply interdisciplinary leadership competencies in their local health care settings.

At the end of the pilot trainings, the trainees were asked to fill out a

TABLE D-3 Participants at Training Workshop

feedback form about various aspects of the training. Positive responses from the participants were many, ranging from good coordination of the training, suitable content, good pedagogy, to friendly atmosphere. A few negative points, such as short duration of the training, more theoretical, less group discussions/practicum, were also emphasized.

Following the pilot trainings, a formal report was prepared by the working group and shared with the Global Forum at the IOM.

Revision of the Training Model

Based on the feedback of the trainees, the training model was revised. The duration of the training was increased to 4 days. Certain topics—such as ethics of leadership, advocacy, conflict resolution, negotiation, and interpersonal communication—were added to the program. The program was revised to include group discussions and role plays wherever necessary.

This revised model was shared with members of the TAG for their inputs and accordingly finalized.

Taking the Initiative Forward

Following the structure adopted for the pilot trainings and incorporating the lessons learnt from them, PHFI, through its academic institute, the Indian Institute of Public Health Delhi (IIPHD), conducted a 4-day training on Leadership in Health and Development Sectors April 1–4, 2014. This training was attended by 35 participants from across the country. These were professionals working at different levels in the health and development sectors, such as medical, nursing, program management, public health organizations, and academe. Innovative pedagogic techniques were applied during this training to engage the participants.

Prospective Activities Planned

1. The activities undertaken as part of the Innovation Collaborative will be published in a peer-reviewed journal (see Table D-4). A manuscript detailing the activities of the collaborative is under way and will be submitted to a suitable peer-reviewed journal soon.
2. The collaborative will also present the findings of the initiative to the Global Forum on Innovation in Health Professional Education.
3. On the basis of the overwhelming response and the feedback of the participants of the recently concluded training, IIPHD is organizing a second round of the training in August 2014.

TABLE D-4 Innovation Collaborative Activities—Update Summary

SOUTH AFRICA
THE AMAZING RACE FOR HEALTH: A NOVEL INTERPROFESSIONAL COMMUNITY-BASED EDUCATION EXPERIENCE FOR FIRST-YEAR HEALTH PROFESSIONS STUDENTS AT STELLENBOSCH UNIVERSITY PROGRESS REPORT JUNE 2014

Kalay Moodley, M.D., M.Med. Public Health, FCMPH, and
Marietjie de Villiers, Ph.D., M.B.Ch.B., M.Fam.Med.
Stellenbosch University

The Stellenbosch University Rural Medical Education Partnership Initiative (SURMEPI) strives to develop, implement, and evaluate innovative, workable, and effective medical education models in order to strengthen medical education and health systems within rural and resource-constrained environments. This is in keeping with the South African Department of Health Human Resources for Health Strategy 2012/13–2016/17, which seeks to implement a rural health strategy to attract and retain health professionals in rural areas (SA Department of Health, 2011). SURMEPI addresses the pipeline for human resources for health including high (secondary) school learners, undergraduate and postgraduate students, faculty staff, and practicing health care workers.

While the Faculty of Medicine and Health Sciences (FMHS) at Stellenbosch University (SU) has been providing extensive community-based education and training experiences to our students (De Villiers et al., 2014), the challenge is to design and implement such community-based experience for a large cohort of first-year students. As part of strengthening the pipeline in the first year of study, SURMEPI in 2013 facilitated the development of “The Amazing Race for Health,” a new innovation at the FMHS. The underpinning of this innovation is to ensure a transformative educative experience for first-year students by exposing them to the context in which people live and seek health care. By making training more relevant to the South African context through progressive and longitudinal exposures, we aim to adequately prepare graduates for the realities of working in underresourced health care systems.

“The Amazing Race for Health” forms part of the Health in Context module, an interprofessional module for first-year medical, physiotherapy, and dietetic students (see Box D-1 for the educational outcomes for the Amazing Race).

During the first phase of the Health in Context module, the students receive lectures on the social determinants of health and health systems. Students are then divided into 39 groups of 10 students each, and each group is allocated a subdistrict within the Western Cape, South Africa.

The second phase of the module consists of group work, where each Amazing Race team researches their allocated site. This includes understanding the social determinants of health, the burden of disease, and the number and nature of health services provided in the sub-district.

When the students have acquired the background knowledge of the area, they are provided with the opportunity to visit their subdistrict to experience firsthand how the determinants of health affect patients, their families, and communities in the area. This serves to help them to better understand the organization of the health services in the specific community they had been studying for the previous 4 months, as well as to gain a better understanding of the functioning of the facility and the roles of the different professions and the health care team. These activities include joining community care workers on home visits, interviewing patients and health facility staff, visiting local community organizations, and observing health care professionals in local health care facilities.

When they return to FMHS, students reflect on their learning experiences in their groups. They prepare structured feedback and do a formal group presentation to the class. This presentation serves as the summative assessment of the activity.

The Amazing Race has now run for 2 consecutive years, and the feedback received from students is overwhelmingly positive. The following quotes from students’ personal reflections demonstrate that this was a valuable learning opportunity:

• The Amazing Race has taught me a great deal and has opened my eyes to see the bigger picture in health care. I started to see the importance of our careers and the enormous impact it has on a community.

• My appreciation for all health practitioners has grown tremendously. . . . I am inspired to be that passionate about my career and devote myself to give my best each and every day.
• The visit was quite eye-opening and made many of the concepts I had learned in class much more real and easy to identify with.
• One of the biggest lessons I learned upon visiting the town was the great need of health care workers in rural and farm areas, and how much change health care workers such as doctors, dieticians, and physiotherapists can bring to underserved areas.
• It made me realize that being a doctor involves so much more than just treating one patient at a time. When I chose to be a doctor, I also chose to make a difference in every community that I will work in, and going on the Amazing Race really inspired me to realize that.

The early and interprofessional exposure of students to the realities of underserved communities, their social determinants of health, and their health services facilitated consolidation and integration of students’ theoretical knowledge with experiential learning. The experience reinforced the young students’ motivation to be socially accountable and make a difference to their communities.

Acknowledgments

Professor Lilian Dudley, Dr. Stefanus Snyman, Dr. Aziza Bawoodien, and Ms. Maryke Geldenhuys were instrumental in designing and implementing the Amazing Race initiative. We gratefully acknowledge funding from the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) through the Health Resources and Services Administration (HRSA) under the terms of T84HA21652 via the Stellenbosch University Rural Medical Education Partnership Initiative (SURMEPI).

UGANDA

Nelson Sewankambo, M.B.Ch.B., M.Sc., M.D., F.R.C.P., L.L.D. (HC)
Makerere University

Defining competencies, developing and implementing an interprofessional training model to develop competencies and skills in the realm of health professions ethics and professionalism.

Innovation and Motivation for Selection of Innovation

This project is a major innovation aimed at contributing to improvement in the quality of health service. Although there is a lot of discussion about the need to improve professional ethics and professionalism in low- and middle-income countries, there has been very little attempt to develop competency-based interprofessional education programs to address the challenges. Professionalism is defined in several different ways (Wilkinson et al., 2009). The Royal College of Physicians (2005) has defined professionalism as “a set of values, behaviors, and relationships that underpin the trust the public has in doctors.” This definition can be extended to embrace all types of health workers.

Overall Aim: To prepare a future workforce committed to practicing to a high degree of ethics and professionalism and performing effectively as part of an interprofessional health team with leadership skills.

Specific Objectives

1. To define competencies and develop a curriculum for interprofessional education of health professional students (nursing, medicine, public health, dentistry, pharmacy, and radiography) in order to develop their skills in the realm of ethics and professionalism.
2. To pilot a curriculum for interprofessional education of health professional students (nursing, medicine, public health, dentistry, pharmacy, and radiography) to develop their skills in the realm of ethics and professionalism.
3. To develop curriculum for interprofessional education for health workers and tutors in ethics and professionalism and pilot its implementation in partnership with the regulatory professional councils.

Approach to Implementation of the Project

Instructional Reforms

A critical element of this project will be the engagement of major stakeholders, including the Ministry of Health, patients, hospitals and health centers, private practitioners, professional councils, educators, students, alumni, and consumer rights groups nationally. This engagement will ensure the participation of stakeholders in the implementation and the commitment of local resources to support this effort. Through this engagement, the collaborative will define the extent of the problem (unethical and unpro-

fessional practices among nurses, doctors, public health workers, and other health professionals) and identify the necessary interventions, including the required competencies and interprofessional training approaches that will address the gaps as well as the necessary post-training support to ensure the institutionalization of ethics and professionalism among health professionals in Uganda. Stakeholders will participate in the implementation of training and mentoring trainees at their respective places of work. Of particular importance are the students who have initiated the formation of a student ethics and professionalism club. They are advanced in the planning process and will be supported through this project and contribute to the whole process of this project. Right from the beginning, the collaborative plans to align this educational project with the needs of Uganda’s population. Concerns have been raised about ethics and professionalism among health professionals in Uganda, largely by the media. There are, however, only limited, brief reports in publications in the recent past in peer-reviewed literature on the issue of ethics and professionalism among health workers in Uganda (Hagopian et al., 2009; Kiguli et al., 2011; Kizza et al., 2011).

Some national reports highlight the challenges in this area, but few formal studies have been conducted to document the extent of the problem, the contextual factors, and possible interventions (UNHCO, 2003, 2010). Because of the lack of comprehensive evaluations and evidence, the collaborative plans to initiate this project with a systematic needs assessment. The needs assessment will involve the participation of representatives from several key partners mentioned previously. Data will be collected through an analysis of key documents from the professional councils, which are statutory units charged with the responsibility of investigating reports and cases of professional indiscipline among doctors, dentists, nurses, pharmacists, and others. The collaborative will undertake limited surveys and key informant interviews among the above-named groups.

Development and Implementation of the Curriculum

Results from the needs assessments will be used to inform the curriculum development process, which will employ a six-step approach (Kern et al., 2009). Prior to curriculum development, interprofessional competencies will be defined through stakeholder engagement and suggestions, building on the five competencies defined by the 2003 IOM report Health Professions Education: A Bridge to Quality. Trainees will learn not only competencies related to ethical practices and professionalism but also competencies of interprofessional collaboration and leadership (IPEC Expert Panel, 2011). Stakeholder discussions will be held to get a clearer understanding of society’s needs and the challenges of ensuring high standards of ethics and professionalism. This will be followed by a consensus process to

arrive at an agreed-on set of competencies to be acquired during an interdisciplinary course for the students who are the next generation of leaders.

A curriculum will be developed for students and for teachers based on the needs assessment results and the defined competencies.

Institutional Reforms

A number of institutional reforms will be needed as the instructional reforms are implemented. These include a careful review of the linkages and collaboration between the university and the aforementioned stakeholders, and the recognition and the reward system for excellence in demonstrating the desired high standards of ethics and professionalism among both students and staff.

REFERENCES

Chadi, N. 2009. Medical leadership: Doctors at the helm of change. McGill Journal of Medicine 12(1):52-57.

De Villiers, M. R., H. Conradie, S. Snyman, B. B. Van Heerden, and S. C. Van Schalkwyk. 2014. Chapter 8. Community based education in health professions: Global perspectives. In Experiences in developing and implementing a community-based education strategy: A case study from South Africa., edited by W. L. Talaat, Z. Cairo: World Health Organization (WHO) Regional Office for the Eastern Mediterranean.

Frank, J. R., and Royal College of Physicians and Surgeons of Canada. 2005. The canMEDS 2005 physician competency framework: Better standards, better physicians, better care. Ottawa, Ontario: Royal College of Physicians and Surgeons of Canada.

Frenk, J., L. Chen, Z. A. Bhutta, J. Cohen, N. Crisp, T. Evans, H. Fineberg, P. Garcia, Y. Ke, P. Kelley, B. Kistnasamy, A. Meleis, D. Naylor, A. Pablos-Mendez, S. Reddy, S. Scrimshaw, J. Sepulveda, D. Serwadda, and H. Zurayk. 2010. Health professionals for a new century: Transforming education to strengthen health systems in an interdependent world. Lancet 376(9756):1923-1958.

Hagopian, A., A. Zuyderduin, N. Kyobutungi, and F. Yumkella. 2009. Job satisfaction and morale in the Ugandan health workforce. Health Affairs 28(5):863-875.

IOM (Institute of Medicine). 2003. Health professions education: A bridge to quality. Washington, DC: The National Academies Press.

IOM. 2011. The future of nursing: Leading change, advancing health. Washington, DC: The National Academies Press.

IPEC (Interprofessional Education Collaborative) Expert Panel, American Association of Colleges of Pharmacy, and American Association of Colleges of Osteopathic Medicine. 2011. Core competencies for interprofessional collaborative practice: Report of an expert panel. Washington, DC: Interprofessional Education Collaborative.

Kern, D., P. Thomas, and M. Hughes (eds). 2009. Curriculum development for medical education: A six-step approach, 2nd edition. Baltimore, MD: The Johns Hopkins University Press.

Kiguli, S., R. Baingana, L. Paina, D. Mafigiri, S. Groves, G. Katende, E. Kiguli-Malwadde, J. Kiguli, M. Galukande, M. Roy, R. Bollinger, and G. Pariyo. 2011. Situational analysis of teaching and learning of medicine and nursing students at Makerere University College of Health Sciences. BMC International Health and Human Rights 11(Suppl 1):S3.

Kizza, I., J. Tugumisirize, R. Tweheyo, S. Mbabali, A. Kasangaki, E. Nshimye, J. Sekandi, S. Groves, and C. E. Kennedy. 2011. Makerere University College of Health Sciences’ role in addressing challenges in health service provision at Mulago National Referral Hospital. BMC International Health and Human Rights 11(Suppl 1):S7.

Royal College of Physicians. 2005. Doctors in society: Medical professionalism in a changing world. London, UK: Working Party of the Royal College of Physicians of London.

SA (South Africa) Department of Health. 2011. Human resources for health strategy for the health sector 2012/13-2016/17. Pretoria, South Africa: Department of Health.

UNHCO (Uganda National Health Users’/Consumers’ Organisation). 2003. Study on patient feedback mechanisms at health facilities in Uganda. Kampala, Uganda: UNHCO.

UNHCO. 2010. Establishing incidence of health provider absenteeism in Bushenyi District. Kampala, Uganda: UNHCO.

Wilkinson, T. J., W. B. Wade, and L. D. Knock. 2009. A blueprint to assess professionalism: Results of a systematic review. Academic Medicine 84:551-558.