|Year : 2014 | Volume
| Issue : 3 | Page : 277-282
Overcoming challenges to develop pediatric postgraduate training programs in low- and middle-income countries
Lakshmi Ganapathi1, Yolanda Martins2, David Schumann3, Christiana Russ4
1 Division of Infectious Diseases, Boston Children's Hospital, Boston, MA, USA
2 Division of General Pediatrics, Boston Children's Hospital, Boston, MA, USA
3 Division of Computer Science, University of Potsdam, Potsdam, Germany
4 ivision of General Pediatrics; Division of Medicine Critical Care Program, Boston Children's Hospital, Boston, MA, USA
|Date of Web Publication||26-Feb-2015|
Division of Infectious Diseases, Boston Children's Hospital, 300 Longwood Avenue, Boston, Massachusetts - 02115
Source of Support: None, Conflict of Interest: None
Background: Interest is growing in strengthening postgraduate medical education in low-income countries. The purpose of this study was to understand how postgraduate pediatric training programs are developed in countries with no or few pediatric training opportunities. The authors sought to describe and compare a purposive sample of such new programs, and identify challenges and solutions for successful program establishment and sustainability. Methods: The authors queried national pediatric email lists and the Accreditation Council for Graduate Medical Education (ACGME) accredited pediatric residency programs in the United States to identify four pediatric training programs that met study criteria. All four programs responded to a questionnaire with quantitative and qualitative components. Qualitative responses were analyzed for themes. Results: Four centers - in Kenya, Laos, Eritrea and Cambodia - met study criteria. Reported challenges to program development and sustainability centered on faculty development and retention, training in pediatric subspecialties, creating pipelines for applicants and graduates, and funding. These themes were used to develop a logic model, which provides a framework for planning, implementing and evaluating new postgraduate general pediatric training program in low-income countries. Discussion: This study compares four postgraduate general pediatric training programs that were recently established and now continue to graduate pediatric residents in low-income countries. Lessons derived from these programs may help guide practice and research for other centers seeking to establish similar programs.
Keywords: General pediatric, low- and middle-income, postgraduate, residency training
|How to cite this article:|
Ganapathi L, Martins Y, Schumann D, Russ C. Overcoming challenges to develop pediatric postgraduate training programs in low- and middle-income countries. Educ Health 2014;27:277-82
|How to cite this URL:|
Ganapathi L, Martins Y, Schumann D, Russ C. Overcoming challenges to develop pediatric postgraduate training programs in low- and middle-income countries. Educ Health [serial online] 2014 [cited 2020 Feb 21];27:277-82. Available from: http://www.educationforhealth.net/text.asp?2014/27/3/277/152189
| Background|| |
The world has a lot of children in need of medical care and limited numbers of providers with expertise in child health. As of 2012, there were 1.9 billion children under the age of 15 in the world, comprising 26% of the world's population. In 43 low- and middle-income countries, greater than 40% of the population is under age 15.  An estimated 15% of children live with disabilities.  The international community has long recognized the dearth of subspecialist physicians across several disciplines in medicine and surgery in low-income countries. , Initial solutions have sought to improve access to medical care largely by focusing on short training courses or task shifting.  When these trainings combine with innovative strategies for moving resources into communities, they are often successful.  Health providers trained in the World Health Organization (WHO) Integrated Management for Childhood Illness are provided guidelines for when to refer patients to a physician. While there are no data available on number of pediatricians or pediatric training programs in developing countries, even general medical education is often lacking. As of 2008, 31 countries had no medical school and 44 countries had only one.  Some countries have funded a small number of physicians to receive specialty training abroad; however, this strategy risks exacerbating brain drain, where the best trained medical professionals do not return to their country of origin.  This study sought to explore how pediatric residency training programs are developed in countries with few pediatricians. Based on a sample of four recently developed general pediatric residency training programs in low- and middle-income countries, our goal was to identify challenges that were overcome for their successful establishment and continuation. From these findings, we developed a logic model that could provide a useful framework for others seeking to build similar programs.
| Methods|| |
As there is no listing of pediatric training programs around the world, we used established contacts to identify new pediatric training programs for purposive sampling. The programs of interest were general pediatric postgraduate training programs in countries designated by the World Bank as low- or low middle-income.  The programs were either the first or second such program in their country, and had been established for less than 20 years but long enough to have graduated residents.
We identified programs by asking about institutional or individual collaborations among all pediatric residency programs in the Association of Pediatric Program Directors (APPD), and the American Academy of Pediatrics Section of International Child Health (AAP SOICH). We emailed the list serves of both groups, and through this process identified seven general pediatric residency training programs in various stages of development in low- and middle-income countries. Three of these programs (Princess Marina Hospital in Botswana, JFK Hospital in Liberia and Mirebalais, Haiti) had either not yet matriculated or graduated trainees.
We surveyed the remaining four programs via a quantitative and qualitative survey with follow-up phone calls for clarification. At least one person in program leadership from within the country and someone from the US partner institution or a supporting in-country expatriate physician provided responses jointly to the survey (seven individuals overall). Due to the dissolution of the partnership between George Washington University and Orotta Children's Hospital in Eritrea, we were able to obtain survey responses only from the US partner. This study received an exemption status from the institutional review board of Boston Children's Hospital.
Program descriptions and themes
All four pediatric graduate medical education programs that met study criteria participated in the survey [Table 1].
Angkor Hospital for Children, Cambodia
Approximately 20% of the population was killed or died from starvation and disease while the Khmer Rouge controlled Cambodia (1975-79). There were only 40 doctors and no infrastructure for physician training remaining for a population of seven to eight million people at the end the regime.
Angkor Hospital for Children, Cambodia (AHC) was first established as a hospital in 1999, having been founded by a Japanese photographer, KenroIzu. The hospital began a three-year pediatric residency program in 1999, initially with support from expatriate physicians and volunteers. The program is considered a nongovernmental organization (NGO).
Interestingly, pediatric residents who matriculate at AHC came from various countries including Cambodia, France, Vietnam, Russia and Cuba. As a result, the program is challenged by lack of uniformity in prior medical training of its residents, and the need for English lessons for some trainees.
Laos Faculty of Medical Sciences, Laos
In the years following 1975, approximately 10% of the Laotian population, largely the educated middle class, left the country in objection to the new communist government. From 1975 through 1996, all postgraduate training for Lao doctors occurred in other countries. In 1996, Laos had only seven pediatricians for a population of approximately five million people.
In 1991, the University of Health Sciences, then called the Faculty of Medicine in the National University of Laos, began an informal collaboration with the US nonprofit, Health Frontiers, run by a husband-wife team from Case Western Reserve University.  After years of discussions with various government departments, the first class of six residents enrolled in the Lao Pediatric Residency Program in 1997.
The curriculum was developed primarily by Lao faculty members with consultation by Health Frontiers. Initially the curriculum followed a Western model; however, subsequent adaptations to local needs include longer inpatient blocks, no continuity clinics, and English classes for some trainees.
Orotta Children's Hospital, Eritrea
Eritrea has a population of approximately six million people, half of whom are children under the age of 14. Despite its young population, the country previously had only a handful of pediatricians. In 2006 the Eritrean Minister of Health invited a NGO called Physicians for Peace and George Washington University Medical Center (GWU) to partner with the Ministry in developing a graduate medical education program at the Orotta School of Medicine, beginning with residency programs in pediatrics and surgery.
In January 2008, this 'Partnership for Eritrea' enrolled its first class of eight physicians into a three-year pediatric residency program. The curriculum, developed following a needs assessment and consultative process with local pediatricians, focused on three aims: (i) To develop clinicians, (ii) to produce leaders in medical education and (iii) to produce doctors with expertise in public health issues.
A change in leadership in the Health Ministry resulted in the dissolution of the partnership in mid-2010. The early focus on residency education proved prescient as the pediatric residency was able to continue after 2010 with program graduates stepping into the role of faculty.
Moi University Teaching and Referral Hospital
Kenya has a population of about 40 million, of whom 20 million are children and adolescents, with a ratio of only 14 doctors per 100,000 individuals. Since 1989, the Indiana University School of Medicine and Moi University School of Medicine in Kenya have worked in partnership to develop leaders in health care for the US and Africa through several key programs. In 2005, this partnership established a three-year pediatric residency program at Moi University Teaching and Referral Hospital. Prior to this, the only postgraduate pediatric training program in Kenya was at the University of Nairobi.
The curriculum was developed with assistance provided by U.S. consultants for subspecialty areas in which local faculty members did not have expertise. It was designed as a master's program with the first year focused on basic sciences and the second and third years focused on clinical sciences.
Challenges in program initiation
From our survey results, we identified several common challenges to initiating and maintaining a residency program. Lack of precedence and a poor understanding of what pediatric postgraduate education entails was a challenge cited by all the programs, with achieving a balance between clinical work and education as a common theme. In Laos, the program struggled with bureaucratic changes resulting from the shifting of the medical school from the Ministry of Health to the Ministry of Education. Orotta and Moi both noted the breadth of stakeholders, from government officials to hospital staff, whose participation and cooperation was required.
Lack of faculty was another challenge noted by all programs. While program leadership remained with local faculty, all programs initially had some expatriate physician committed to spending a year or more as faculty in country. The programs also hosted volunteer visiting physicians to assist with teaching. Drawbacks to this system included difficulty identifying volunteers to teach certain subspecialities and challenges in scheduling short-term volunteers, resulting in a curriculum, which one respondent described as initially "disjointed and haphazard". All four programs eventually moved from reliance on volunteers to building local faculty primarily with their own graduates.
Providing training in pediatric subspecialty areas presented unique challenges as there often were no practicing subspecialists in country. Most of the programs relied on short-term volunteers to provide such subspecialty training. At AHC the senior faculty members undertook self-study programs to teach subspecialty topics for which consistent volunteers had not been found. Moi University developed a four-month subspecialty rotation for its residents at its partner institution (Indiana University). The residents at Laos did subspecialty rotations in two-month blocks in KhonKaen, Thailand. These solutions are all currently challenged by the need for ongoing funding.
Challenges in program sustainability
Funding was an early and ongoing challenge for all of the programs. Inconsistent funding from donors and governments provide ongoing challenges, particularly for funding subspecialty rotations and adequate trainee and faculty stipends. Several of the programs wrote about the need to protect time for faculty to teach, an issue directly related to the structure of faculty reimbursement.
All the programs continued to work toward effectively developing and retaining faculty. They sought to provide training in medical education for their junior faculty, including training in feedback and evaluation, problem-based teaching, bedside teaching and preparation of lectures. One program described the challenge of "providing consistent and direct oversight of pediatric residents so that clinical work translates into increased knowledge base". Developing faculty to provide quality research mentorship was another noted need.
Faculty retention was a specific concern in the countries with mandatory government service, as they were frequently unable to retain trainees who were naturally adept at teaching. However, many of the graduates in all of these programs have been hired as faculty, a practice that builds toward program sustainability. A few programs sought to obtain subspecialty training for their junior faculty in order to continue expanding clinical services and academic expertise.
The final theme elicited from the survey was the need for pipelines for applicants and graduates. The Lancet Commission on Education of Health Professionals detailed the complex interactions between supply and demand in the healthcare workforce.  Postgraduate education in pediatrics requires a context where there are competent physicians seeking pediatric training, and opportunities for pediatric graduates resulting in paying jobs and satisfying careers. The quality of the applicant pool was a concern of several programs with disagreement about whether to matriculate residents directly after medical school versus those already in practice.
Government support is requisite to help develop a mandate for pediatrics training, and to recognize program graduates as specialists equipped with unique skills. Recognition by the government was achieved by all the programs except AHC in Cambodia, which at the time of the survey was working toward obtaining formal national recognition. In Cambodia, there is no requirement for postgraduate training to practice pediatrics, and resident salary limitations at AHC with the alternative of lucrative practice in the private sector without residency training has resulted in attrition of trainees.
Of the residency graduates from all four pediatric programs in the past three years, 96% have continued to remain and practice in their respective countries. This is notable given the known challenges of "brain drain". The mandatory government service requirement following residency in three of the programs keeps the graduating residents initially in the country. Our conversations with program leadership indicated that even after mandatory service was completed, most graduates continued to practice in country. Further study with surveys of program graduates will help to elucidate their work experiences and practice decisions.
Lessons learned: A program model
In comparing these four pediatric programs, we found common challenges to program development and sustainability centered on faculty development and retention, being able to provide subspecialty training, funding and creating a pipeline for applicants and graduates. We used the identified themes to develop a logic model for developing pediatric training programs in under-resourced countries [Figure 1]. We believe this may be useful as a guide to individuals and institutions working to develop pediatric postgraduate programs in places where few or none exist. Though focused on pediatric training, a similar model may be applicable for postgraduate training in other specialties.
The logic model describes resources needed for program initiation, particularly focusing on faculty comprised of local pediatricians, expatriates providing in-country support and possibly volunteers for subspecialty training. Subspecialty training may also be provided by rotations at regional or partner institutions. Government support is essential to provide a mandate for the program, qualified applicants, postresidency career tracks and funding. Partnerships may help bridge funding gaps, but only on a temporary basis.
Necessary activities include curriculum development with ongoing revision, and clear evaluation processes. If required, short-term volunteer faculty should be carefully incorporated into the curriculum and phased out over time. Early training in medical education is warranted as a program's sustainability is largely dependent upon effective faculty development. It may be that offering an academic track and potential for further advancement provides incentive to retain motivated graduates as faculty.
All of the programs met the short- and medium-term outcomes in our model, by producing pediatricians to provide care to children locally and junior faculty to teach subsequent pediatric trainees. Supporting graduates in subspecialty training so that they may pursue academic careers in their local context is a long-term outcome in our model. Further studies are needed to assess how well programs attain these outcomes and improve child health in their countries.
The study is based on a small, limited sample selected by identifying newly developed pediatric residencies in low- and middle-income countries through email lists of U.S. institutions, thus limiting the study's findings to programs that developed either in partnership with U.S. institutions or with the involvement of US-based pediatricians. In addition, the findings may or may not be applicable to postgraduate training in other medical specialties. Despite these limitations, we believe our small sample was adequate as a beginning exploration of the challenges that newly developed residencies in such countries face.
| Conclusions|| |
Expanding the number of pediatricians and pediatric subspecialists in low- and middle-income countries is crucial to the long-term goal of improving child health worldwide, particularly with the epidemiologic shift toward noncommunicable pediatric diseases. Dedicated individuals and partnerships helped the studied programs establish sustainable general pediatric residencies in countries with few pediatricians, successfully graduating pediatricians who continue to work in their respective countries. Lessons learned from their experiences can help to inform pediatric and other specialties seeking to develop graduate medical education programs in countries where there are none. Further studies are needed to evaluate how such specialty training programs improve child health outcomes.
| Acknowledgments|| |
The authors wish to thank Dr. Neou Leakhena (Angkor Hospital for Children), Dr. Varun Kumar (Angkor Hospital for Children), Dr. Ellie Hamburger (George Washington University and DC Children's Hospital), Dr. Karen Olness (Case Western Reserve University and Health Frontiers), Dr. Melanie Anspacher (Health Frontiers), Dr. Jill Helphinstine (Indiana University) for their participation and contributions. The authors also wish to thank Dr. Amy Sullivan for valuable assistance in data analysis, and Dr. Judith Palfrey and Dr. Frederick Lovejoy for reviewing and advising on this work.
Other Disclosures: None
Ethical Approval: This study was exempted from review by the Boston Children's Hospital IRB
Previous Presentations: Results were presented as a poster at Pediatric Academic Societies meeting, Boston, MA, April 2012.
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