How the mobile phone will soon help Kenyans find a Doctor

This is very cool – set to launch on October 1 this could really change the playing field of mhealth – next on deck is using mobile phones to enable training in the rural sites.

“medAfrica from Kenyan startup Shimba is a phone-based medical reference and real-time public health tool meant to dramatically increase the well being of Kenyans, and eventually people throughout the developing world. Similar in many ways to Indian company mDhil, the smart phone version of the app allows a sick individual to check his or her symptoms against an encyclopedia of ailments, such as fever, swelling or other maladies, and the tool will allow them to call a relevant medical professional with a single click.

There are 40 million people in Kenya, and only 7,000 doctors nationwide. There’s too much knowledge locked up in too few heads, as co-founder Mbugua Njihia quipped from the stage during his presentation. Their app helps to narrow this knowledge gap in many important ways. And while smart phone penetration is steadily rising throughout Kenya and Africa as a whole, the real power comes from medAfrica’s ability to deliver health information to remote areas through the use of SMS.

What works in Africa can work anywhere, in terms of scale and internationalization, and the team believes that if they can reach 200 million downloads, at $10 of revenue per customer per year, they will be a billion-dollar company within five years.”

How do you incentivize resource-strapped medical schools to embrace open access?

It sounds obvious that medical schools in developing countries should share curricula. That open access is the way to go to address the severe shortage of doctors, and especially of faculty to train doctors. In fact I think there’s a real opportunity out there for someone to create a destination site that would have  comprehensive collection of lectures, articles, curricula for a complete medical education.  I’ve seen a number of potential sites recently – Science Supercourse and even OER has a few courses posted under ‘medicine’, but there doesn’t seem to be a definitive leader in this space.

And as I understand it, to create open access material you need to have your material licensed so that it can be shared, reused etc…I haven’t done it myself but expect that it does take some time to deliberately prepare your material to share. Enough time and effort that this is one of the primary services offered by OER.

So the challenge, in my opinion, is how do you incentivize resource-strapped medical schools in Africa to go through this process and make their material open access? I don’t doubt their intentions,  but why should they spend the time it takes to obtain the licenses and make their material ready for open access when they have more pressing challenges on their minds? There may be exceptions such as Stellenbosch University, who already have elearning material ready to share and do so, but most schools are still trying to develop content for their elearning programs.

This might be an opportunity for a grant, a competition or for partner schools in developed countries to take on as their social mission. Given the shortage of doctors, the shortage of faculty and the fast pace of new medical schools in Africa, increasing open access material and establishing a definitive destination could make a huge contribution to the field.

The question is – how do you get this done?

 

Medical education programs in Africa should follow the trend and start doing homework in the classroom.

The Khan Academy is changing the way the world approaches education. Sal Khan (an MIT grad) provides 10-minute online tutorials on thousands of topics. He makes complicated topics easy to understand. He’s a gifted teacher, he doesn’t charge tuition and you can listen to him at your own pace. You can stop, rewind, fast-forward or replay.  This is revolutionary. While the traditional model is you go to school to hear the lecture and then go home to apply the knowledge, Bill Gates and Sal Khan, through the Khan Academy are suggesting that we should switch those activities around.  We should get the best teachers in the world to provide lectures online, then students can listen at their own pace. Students come to the classroom to do problems, apply their knowledge and get tutored/mentored by the teacher when they get stuck.  It’s already being tested in schools across America.

Now think about this in the context of medical education in Africa. Throughout Africa the biggest challenge is the lack of faculty…not enough teachers. In Ethiopia the government plans to train 20 thousand doctors by 2020 so medical schools are challenged by trying to teach upwards of 300 students in a class. In Zambia though the classes are not so big, there just aren’t enough basic science faculty to teach in the pre-clinical years.  So what if we apply this model. Take the best teachers in the school, city or region and tape the lectures. Give students access to these lectures by video, CD, intranet or internet. If the resources are really limited, you can just give them the reading material but expect them to come to class prepared.

Then when students gather in the class, they spend their time doing what used to be their homework, i.e. solving problems. Working through a case. Teaching each other and trouble-shooting together. The strong students will help the weak students. Together they will make their knowledge come alive. They don’t need experts in the room to teach, they just need facilitators to answer questions – these could be post-graduate students, senior students, junior faculty etc.

This model is already being used in some schools referred to as Team-Based Learning (TBL). At my institution, George Washington University, we use TBL in Anatomy. There are already schools in Africa such as the Kilimanjaro Christian Medical School using it in medical education.

As countries throughout Africa try to train more doctors with few faculty, they need to consider new models of delivery. It’s learner-centered, team-based and efficient on faculty time and expertise.  The Khan Academy is really on to something….

Can community-based training convince medical graduates in Africa to stay?

How effective is community-based education in retaining graduates in rural service?  The literature on retention focuses mainly on approaches that are in the hands of the government – increased financial incentives, housing, good work environment, opportunities for professional growth and development and more. So what can medical schools do to address the issue of retention? Most of the literature supports rural recruitment programs – suggesting that students recruited from rural or remote areas are more likely to return to work there.

That said, Ethiopia is one example where recruiting is centralized. High school students take a national exam, those with the highest grades can attend medical school but there is no specific rural recruitment quota. The government does have a compulsory service program where graduates are required to do public service after graduate. For those who choose to go rural, they can complete their rural service in a shorter time.

So what can the medical schools do to encourage rural service? According to a WHO technical document on rural retention strategies training in the community can work. But how much community training and what kind of community training is effective? Does one short rotation work or do students need a longer experience of several months duration to really appreciate the impact they can have? Many medical students do one community-health rotation where they do both clinical and public health research.  Other medical schools like Jimma University in Ethiopia, have threaded community training throughout their curriculum, facilitated by their location closer to community/rural clinic.

So for medical schools based in urban settings, is a short community rotation enough to convince students to work there or are the scant accommodations, the social isolation and the lack of IT connectivity a deterrent?

As I survey medical programs across Africa, the majority of schools have some form of community training yet the literature has very little about the impact of this training on rural retention. Given the continent-wide crisis accessing a physician in rural areas, training programs should do a better job of evaluating the impact of these experiences and publishing the positive and negative results. Is it frequent short-bursts of exposure or one long-term exposure that has a better chance of retaining medical graduates? Time to figure this out….

Should the US pay Ethiopia for each doctor that chooses to move to the States?

I heard a great BBC podcast on the brain drain in Ethiopia and it got me thinking about creative solutions to old problems.  I’m in Ethiopia right now and fascinated by the country’s approach to flood the market with doctors to retain the numbers they need.

The brain drain of physicians trained in Africa to the US, Canada and other developed nations is an on-going challenge. In Ethiopia, a country of over 80 million people, there are only 3000 physicians. To address this challenge, the country plans to scale up in large scale the number of medical schools and therefore physicians trained in the country. In essence, they plan to flood and retain. At public medical schools (which are the majority), medical education is free, then graduates are expected to complete compulsory service of 2-4 years in country. After that, physicians are free to go wherever they want. Many go to western countries to complete residency training, others go to NGOs in-country and others go in to private practice – all options that pay more than public service where then need is most acute.

So if Ethiopia is investing in to provide medical education to thousands of students each year, only to supply richer countries where access is not nearly in as much a crisis, shouldn’t we pay for their service?

Medical education for a US student costs around 250K – now granted a good portion is paid by students but States often subsidize higher education, so shouldn’t we pay back some of Ethiopia’s investment, especially given the huge deficit it leaves behind?

The issue of retaining doctors should clearly be addressed by the Ethiopian Ministries of Health, Education and the medical schools but perhaps it’s time the West takes some responsibility for the brain drain?

3 Ways to Fix Africa’s Healthcare Workforce Shortage

There is a severe health care workforce shortage in Africa. The solution is not to build a western-style system, rather we need to leverage new technologies and low-cost alternatives to build an African-style medical education system that will help train and retain providers and bridge gaps in access to care.

The first is to invest in tele-education given the scant resources.  There are many tele-education programs in the West and there is even a trend to expand these services to developing countries. Having been a part of such a program where US health professionas teach remotely I would suggest that these models are not ideal. The best model of tele-education would be one that is based in the host country itself. Fore example, a tele-education program for East Africa could be based in Nairobi, building local capacity to teach to more remote areas of Africa.  While daunting to set up, this would help build even supporting infrastructure such as IT support.

The second solution is to train more paraprofessionals. A recent McKinsey report nicely summarizes the benefits of such a model.  This will minimize the brain drain, provide more providers in less time and cost less. The model of the community health volunteer has worked in so many countries – this model needs to be scaled up so that they can refer to mid-level providers who ultimately refer to secondary and tertiary centers that are staffed by physicians. These paraprofessionals would complement not replace much needed physicians and nurses.

Lastly, medical education in developing countries needs to capitalize on mHealth. In the next few years over 90% of Africa will have a cell phone. It makes perfect sense to use this technology to bridge gaps in access and knowledge.  For example, geographically isolated providers could complete modules on their cell phone on topics that are relevant to their patient population e.g. HIV, TB, NTDs. 

While I’m sure the solution to the health care workforce shortage is much more complicated, I do feel these three areas are worth prioritizing and funding in these areas should be scaled up.

McKinsey Report Describes a Bright Future for Sub Saharan Africa

The McKinsey Quarterly Report suggests that Africa is on the rise and in particular, Sub-Saharan Africa is a land of economic promise.   The region is weathering the global downturn better than Latin America, Europe and Central Asia. The article suggests this is largely due to macroeconomic and political stability, in particular private investment into infrastructure and education.  Average years of schooling are catching up to developed countries which means this growth has hopes of being sustained by an educated and progressive younger generation. Natural resources and renewable resources will be some of Africa’s most valuable assets as it is positioned well to develop solar and hydro energ.

Of particular interest to me, given my interest in eHealth is the fact that Africa’s mobile market has grown to 400 million and that 65% of the population lives within reach of a mobile phone network. I had previously heard at Med-e-Tel that by 2013 98% of the world would have a mobile phone so this number did not surprise me. The article makes an important point that despite the increased and impressive access to wireless technology, other sectors have been slow to capitalize on this access for development.

For so long we only heard of Africa in the context of civil unrest or corruption in the government. By allowing private investment, Africa is changing its reputation and prognosis, it’s exciting to hear African countries being referred to as ‘emerging markets’.