A model for the transfer of new education methodologies to improve capacity development for low-income countries

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• Anthony D. Falconer, DM FRCOG

• President, Royal College of Obstetricians and Gynecologists, London, UK

Anthony D. Falconer graduated from the University of Bristol, UK, in 1972 with an MB ChB degree. After a year in psychiatric medicine training at Edinburgh University, UK, he began training in obstetrics and gynecology at the Simpson Memorial Maternity Pavilion in the Royal Infirmary of Edinburgh. He was appointed Consultant in Obstetrics and Gynecology at Plymouth Hospitals, Devon, UK, in 1986. He has made a major contribution, within the region, to the development of cancer services and hysteroscopy, and was a coauthor on the first paper supporting the use of the latter in an outpatient setting. Dr Falconer has been active in the Royal College of Obstetricians and Gynecologists (RCOG) for 20years, was elected to Council in 2001, and was Senior Vice President and International Officer from 2007 to 2010. During this time, he drew on his experiences of working in Zambia and South Africa to push forward an educational and advocacy agenda concerning issues surrounding Millennium Development Goals 4 and 5. He spent considerable time raising further the international profile of the RCOG and, in 2010, was elected President of the organization. He became a member of FIGO's Executive Board in the same year.

The RCOG was founded in 1929 to further the standard and quality of women's reproductive health care both within the UK and overseas. Very quickly, it became apparent that this aspiration could be linked closely to excellence in education. Today, the RCOG is an international organization of over 12000 specialists who work in over 90 different countries. Nearly 50% of its global membership is based outside the UK and it has developed close relationships with other countries and specialists through the historical links of its own country. The organization has 29 representative groups overseas, each of which supports the needs and aspirations of its own members. Historically, RCOG education and training focused on postgraduate training within the UK and preparation for the MRCOG examination. Recently, however, the RCOG has undergone a transformation in diversifying into other areas of education activity.

The evolution of advocacy and the power of the media and contemporary communication have awakened many clinicians in high-income countries to the enormous disparities in global health provision. Such a change has allowed the RCOG to rethink some of its education strategies, including adapting some of its products for use in under-resourced communities.

Education involving both learning and evaluation is at the heart of this professional organization. The developments in e-learning have facilitated distance learning. Traditionally, teaching would be conducted at the RCOG and learners would have to travel to the College to benefit from the experience. However, this is no longer the case; learning strategies can now be transferred long distances without the need for travel. There has also been a large increase in the number of methodologies for teaching and assessment. The introduction of the National Health Service (NHS) Modernising Medical Careers and Foundation Programme was accompanied by new assessment tools—the mini-clinical evaluation exercise (Mini-CEX), case-based discussion, and objective structured assessment of technical skills (OSATS), for example, are techniques that are well established within the repertoire of the College.

Each country has its own particular health needs, and the challenges in maternity care faced by high-income countries are very different from those faced by low-income countries. In response to such global needs, FIGO has developed 5 principal initiatives: adolescent sexual and reproductive health; maternal and newborn health; prevention and treatment of fistula; prevention of unsafe abortion; and saving mothers and newborns. Through the leadership of Lord Naren Patel, Chair of the FIGO Committee on Fistula, strategies have been introduced to try to improve facilities and services for those with obstetric fistula in Africa and Asia. Until recently, there was no conformity in the provision of care for the large numbers of women experiencing obstetric fistula—instead, individual practices were the norm. FIGO was committed to reversing this behavior with the introduction of a universally accepted manual of care for the management of obstetric fistula, which would be accompanied by a training resource. The education division of the RCOG, a group well versed in contemporary education methodology, was approached by FIGO to establish whether an education manual and a set of evaluation systems to assist with in-country acquisition of fistula management could be developed. The specific objective was to develop a resource that was not based on the traditional didactic model from the center to the periphery, but instead could be delivered in-country by local teachers to local trainees.

The first responsibility of this project was standardization of the curriculum, with each learning module containing clear aims and objectives. The components for learning were classified under 5 domains: knowledge criteria; clinical competency; professional skills and attitudes; training support; and evidence and assessment. Each module covers independent, yet interrelated, subjects within the overarching framework of fistula; for example, management of simple fistula and management of rectovaginal fistula are 2 separate modules. Knowledge is tested through formal assessment, using multiple-choice questions, single best-answer questions, and extended matching and short-answer questions.

A fundamental shift in postgraduate clinical training in the UK has been the transition from a time-based apprenticeship model to a competency-based framework where progress relies on acquisition and demonstration of skills. Competency is assessed though workplace-based assessment in an attempt to introduce a quantifiable evaluation of skills in the workplace. Mini-CEX and case-based discussions are 2 examples that are now standard within the NHS learning environment. However, within the surgical field, the development of OSATS has allowed for more rigorous assessment. OSATS contains both generic and specific identifiers of surgical skill. A ranked assessment of the observed procedure will enable the trainee to pass through a hierarchy of increasingly complex processes. These evidence-based evaluations are performed on a regular basis and form a significant part of the evaluation of surgical competency.

The introduction of such education methodology to trainers in low-income countries was challenging. Using computer modeling for the recording of data was not practical, necessitating the continued use of paper. In addition, the methodology requires reinforcement through “training the trainers” courses to facilitate the process for future trainers.

This project, which is strongly supported by the International Society of Obstetric fistula Surgeons, has now reached the pilot phase, with appropriate feedback received from 6 centers in Africa and Asia. The format has been simplified at request and it will be translated into French prior to further evaluation.

Satisfactory completion of such a program, with built-in competency frameworks, could lead to certification from major stakeholders.

Quality assurance is a vital component of this process and it is essential that this is built into the program to guarantee a sustainable product of an appropriate standard. This model for transferring education methodology could be repeated in many other areas of obstetrics and gynecology. High-income countries must share their rich resources with healthcare workers in low-income countries who experience daily difficulties in providing medical care to those in need.