Establishing an African Association for Health Professions Education and Research: Workshop in Brief (2016)

WORKSHOP IN BRIEF

Establishing an African Association for Health Professions
Education and Research—Workshop in Brief

Africa faces a severe shortage of human resources for health (WHO, 2006). Over the past 5 years, the President’s Emergency Plan for AIDS Relief (PEPFAR), in partnership with the National Institutes of Health (NIH), has sought to address this problem by supporting health professional education and research in Africa through the Medical Education Partnership Initiative (MEPI) and the Nursing Education Partnership Initiative (NEPI).¹ These programs have been widely recognized for their success at strengthening research capacity and advancing health professional education (Kristiansen, 2012). MEPI in particular, led by its Principal Investigator (PI) Council, has been a catalyst for collaboration, innovation, and the exchange of best practices (PEPFAR, 2015).

As funding for MEPI and NEPI comes to an end, there is interest in finding a way to institutionalize the knowledge and networks that have developed. At the request of the NIH Fogarty International Center, the National Academies of Sciences, Engineering, and Medicine’s Board on Global Health convened a workshop just outside Kampala on February 1–4, 2016, to discuss the establishment of a permanent African association for health professions education and research that would build on the achievements of MEPI and NEPI and expand their reach across the continent and the spectrum of health professions. The workshop brought together a diverse group of leaders in health professions education, representing 11 African countries and a range of professions including dentistry, laboratory sciences, medicine, nursing, pharmacy, and public health.

NIH staff referred to the workshop as a consultation designed to help the U.S. government assess the value and feasibility of supporting a PI Council–like activity. They emphasized that this activity would not be a continuation of MEPI or another round of large grants, and that both the activity’s form and necessity were still up for debate. If funding were available, it would be relatively modest and designed to jumpstart an activity, such as an association, that would ultimately sustain itself. Unlike MEPI, NEPI, and many other health and science networks in the region, which have been the direct outcomes of non-African donor support, this activity would be African-developed and African-led. Participants of the workshop were invited to consider where they would like to see health professions education in 10 years and how best to achieve that vision.

In his opening remarks, Nelson Sewankambo² described the workshop as an opportunity for participants to think deeply about how they could work interprofessionally to advance health education and research on the continent. He urged the group to explore whether there were compelling reasons to come together in an association.

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¹ For more information, see http://www.pepfar.gov/partnerships/initiatives/index.htm (accessed March 19, 2016).

² Nelson Sewankambo, MBChB, MMed, MSc, FRCP, is professor of medicine, former dean of Makerere Medical School, and past principal of Makerere University College of Health Sciences. He is president of the Uganda National Academy of Sciences.

RATIONALE FOR AN INTERPROFESSIONAL ASSOCIATION FOR HEALTH EDUCATION AND RESEARCH

Throughout the workshop, the group returned to the question of whether an association of this kind would be valuable. Onesmo ole-MoiYoi³ explained that those who come together would share information and resources, as well as a vision. An association could serve as a platform for exchange and relationship building, similar to the networks developed through MEPI and NEPI. A few participants spoke of those networks as the most valuable outcome of the initiatives.

The beauty of an association lies in knowing what others are doing on the continent, suggested Sewankambo. Even this workshop gave participants the opportunity to learn about each other’s initiatives. For example, Abdel-Karim Koumare⁴ shared how the African Malagasy Council for Higher Education (CAMES) has been training young teachers and scientists on pedagogy and research through its African Institute of Training in Pedagogy, Research, and Evaluation in Health Sciences (IAFPRESS).⁵ Marietjie de Villiers⁶ pointed out that Koumare’s group was doing on a regional level what many in the room were trying to do in a single school. By providing a link to people and organizations who are working on the same things, an association could generate efficiencies, Sewankambo said. For instance, rather than each institution or profession developing its own approach to e-learning or accreditation, members of an association could combine their efforts and learn from one another. Even within areas of care, like HIV/AIDS, there are opportunities to transfer lessons, Tom Kariuki⁷ said, and an association could facilitate this. It could also help set the agenda.

Lonia Mwape⁸ and Kariuki stressed that the association’s niche must be clear: how would such an organization relate to existing ones? Ole-MoiYoi suggested that the uniqueness of the association would come from joining research and education; in Africa, there tends to be a divide between universities and research organizations. This association could find ways for them to work together.

Some participants suggested that it would not compete with, but would instead complement more traditional professional associations. Other participants pointed out that it would strengthen the education pipeline that feeds into those organizations.

Interprofessionalism

Flora Katz⁹ pointed out that at the core of this discussion was an assumption that the association would be interprofessional in nature. She challenged the participants to consider the value proposition for interprofessionalism and why an organization of that kind does not exist already.

Referencing the landmark 2010 Lancet commission paper that called out the problem of tribes among health professions, Sewankambo suggested that moving beyond a fragmented approach could result in stronger outcomes and spur the continent’s development (Frenk et al., 2010). Citing a recent report that attributed 20–25 percent of economic growth to health improvements, another participant made a similar point later in the workshop, saying that building a cadre of health professionals in Africa would be an investment in society that could generate growth and substantial returns (Jamison et al., 2013).

Quoting the founder of the African Academy of Sciences, Kariuki observed that Africa’s problems cannot be solved by one discipline alone. Integrating health professions education can improve quality of care and people’s health. Address Malata¹⁰ acknowledged that from the start of NEPI, it was clear nurses alone could not change the system; they must work with other health professions.

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³ Onesmo K. ole-MoiYoi, MD, is a senior visiting scientist at the International Center of Insect Physiology and Ecology (ICIPE) in Nairobi.

⁴ Abdel-Karim Koumare, MD, MSc, is director of the surgery and anatomy departments at the Faculty of Medicine, Bamako, Mali. He is also director of the African Institute of Training in Pedagogy, Research, and Evaluation in Health Sciences, and manager of the General Surgery Department at University Hospital Point G Bamako.

⁵ For more information, see Koumare’s presentation: http://ow.ly/10FOU6 (accessed April 14, 2016).

⁶ Marietjie de Villiers, MBChB, MFamMed, FCFP, PhD, is professor in family medicine and primary care and Deputy Dean: Education at the Faculty of Medicine and Health Sciences of Stellenbosch University in Cape Town, South Africa.

⁷ Tom Kariuki, PhD, is senior research scientist and director of the Institute of Primate Research and director of the Alliance for Accelerating Excellence in Science in Africa (AESA).

⁸ Lonia Mwape, PhD, MSc, BSc, is lecturer and head of the department of nursing sciences at the University of Zambia School of Medicine.

⁹ Flora Katz, PhD, is the acting director of the Division of International Training and Research at the National Institutes of Health (NIH) Fogarty International Center.

¹⁰ Address Malata, PhD, MScN, is the vice president of International Confederation of Midwives, current principal of Kamuzu College of Nursing (KCN) in the University of Malawi, and director of the World Health Organization Collaborating Centre for Interprofessional Education and Collaborative Practice.

An interprofessional approach can also optimize training in an environment where human resources are scarce. Doreen Mloka¹¹ described how, as Muhimbili University of Health and Allied Sciences (MUHAS) transitioned to competency-based education, they were forced to bring all the schools together and integrate training. This integration has allowed for the harmonizing of competencies across professions. An association might foster such harmonization regionally and facilitate migration, in effect regionalizing education, treatment, and research. Integrating the curriculum also allowed MUHAS to leverage the comparative advantage of different professions—for example, nurses can teach vital signs. She cautioned that segregating health professionals in their training hinders their ability to practice together later.

Pierre Claver Kayumba¹² called the idea of an interprofessional association overdue, noting the lack of communication between medical and pharmacy education programs despite a necessarily close relationship in practice. This siloed approach causes problems—for example, conflict about the rational use of medicine. To address this tension, Kayumba explained that Rwanda has been working to better integrate medical and pharmacy education programs through joint basic science courses and clinical placements. At Moi University, a course called clinical pharmacy has similarly brought the two professions together. The improved communication enables the professions to build on each other’s strengths, according to Sylvester Kimaiyo.¹³ Adding his support for this approach, ole-MoiYoi observed that the animosity among professions is not limited to medicine and pharmacy; such undercurrents are widespread.

Peter Donkor¹⁴ came across many of the same difficulties in his tenure as provost of the College of Health Sciences at Kwame Nkrumah University of Science and Technology. But he said there is a desire for the professions to come together, building on what MEPI has tried to do.

BUILDING ON MEPI

Milliard Derbew,¹⁵ the current chair of the PI Council, gave a brief presentation about the Medical Education Partnership Initiative (MEPI), focusing on the lessons learned over the past 5 years. The initial grants were awarded to 13 universities in 12 African countries. Derbew explained that an additional 29 African consortia universities and more than 20 US-based schools were involved through collaborations in different areas across five themes:

• Increasing the number and improving the quality of graduates
• Promoting retention of graduates where they are most needed
• Improving capacity for regionally relevant research
• Building communities of practice within Africa and globally
• Ensuring sustainability

Reflecting on the lessons learned, Derbew noted the importance of awarding the grants directly to African institutions. In his opinion, this gave the institutions greater ownership and the upper hand with partners, so the African institutions actually led the activities. The initiative, he said, stimulated educational capacity development; innovative teaching and learning methods, such as modular curricula and tablets for e-learning, have been taken as models by other universities and governments. He noted that MEPI has improved retention, both at medical schools themselves (through training and opportunities in research) and in rural and underserved areas (through community-based training).

Another important contribution, according to Derbew and other participants, was the initiative’s focus on south-south partnerships.¹⁶ Sewankambo observed that, before MEPI, such partnerships were not routinely a part of medical education in sub-Saharan Africa. As a primary grantee, Makerere University partnered with other medical schools in the country—in effect, sharing its resources with competitors. But, according to Sewankambo, the school saw benefits in these partnerships and would do the same again. Derbew, too, reflected on the particular value of partnerships within countries, as well as across the continent.

As it prepares for the conclusion of MEPI, the PI Council has developed recommendations for the way forward, which Derbew shared with the workshop participants. One recommendation already being implemented is the

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¹¹ Doreen Mloka, MSc, PhD, is a Medical Education Fellow, the university curriculum chair, and the director of Continuing Education and Professional Development at Muhimbili University of Health and Allied Sciences, Tanzania.

¹² Pierre Claver Kayumba, BPharm, MSc, PhD, is an associate professor of pharmaceutical technology and deputy dean of the School of Medicine and Pharmacy at the College of Medicine and Health Sciences of the University of Rwanda.

¹³ Sylvester Kimaiyo, MBChB, MMed, OGW, is associate professor in the department of medicine at Moi University School of Medicine, the Ag CEO for Academic Model for the Providing Access to Health Care (AMPATH), and chief of party for AMPATHPlus.

¹⁴ Peter Donkor, BDS, MDSc, MSc, FWACS, FGCS, is a professor of oral and maxillofacial surgery and director of the Office of Grants and Research at the Kwame Nkrumah University of Science and Technology (KNUST), Kumasi, Ghana.

¹⁵ Milliard Derbew, MD, is currently project director for the Medical Education Partnership Initiative project for Ethiopia and president of the College of Surgeons East, Central and Southern Africa. (COSECSA).

¹⁶ South-south partnership or collaboration refers to the exchange of knowledge, skills, and resources between two or more entities in developing countries.

expansion of the PI Council to include other health professions. One of MEPI’s main limitations, according to Donkor, was its exclusivity. Its focus was too narrow, he said, noting that the program was not even talking to NEPI.

Derbew and other members of the MEPI PI Council—Marietjie de Villiers, Peter Donkor, James Hakim,¹⁷ and Nelson Sewankambo—reflected on the evolution of the initiative from one that was funder-driven and physician-focused to one that was more inclusive and African-owned. It was the schools themselves that decided to implement grants focused on medical education in a much broader way. Recalling the funder’s initial reluctance to take an interprofessional view, de Villiers observed that MEPI had been an opportunity for a few to blaze a trail, which could be widened now that they had demonstrated what could be achieved.

Starting around the program’s third year, the PI Council began to discuss how it could maintain the momentum and continue the fruitful collaborations of MEPI; its members were no longer viewing the program in the narrow terms of a grant. Hakim spoke about the empowerment that the initiative brought to the schools involved and the importance of spreading the lessons and vibrancy beyond the original grantees. According to Sewankambo and Roger Glass,¹⁸ it was clear from the first meeting of MEPI that other schools yearned to benefit from the mutual learning; the PIs brought deans from other schools in their countries, and the initiative ended up involving about a quarter of the medical schools in Africa. MEPI changed the direction of health professions education on the continent, and even those on the sidelines were cross-pollinated, according to Kimaiyo, himself not a beneficiary.

Kimaiyo, Derbew, and others urged that any new association for health professions education and research not lose sight of MEPI’s experience. But this association would not be MEPI 2.0, Donkor and Hakim added. As the PI Council thinks about the future, Hakim asserted that its focus is not on sustaining itself or the funding, but on sustaining the knowledge, skills, and attitudes that emerged from the initiative. He expressed the desire to create a movement that would impact the whole breadth of health professions and crisscross the continent.

Derbew referred to MEPI as a pilot project to test whether institutions can change; having seen the results, the participants and other stakeholders can now think more widely about how to improve health professions education and research capacity. Hakim, Sewankambo, and others suggested that a new association could build on MEPI’s good ideas and achievements while taking a broader approach, one that encompasses more institutions, professions, and countries.

CONSIDERATIONS FOR ESTABLISHING AN ASSOCIATION

In thinking about establishing an association, participants considered what it might do, how it could be organized and governed, and how it could be sustained. De Villiers led the group in thinking about the purpose of the association, encompassing both the why and the what. She suggested that the raison d’être for an association of this kind is the desire to make a difference in the health of Africa by impacting health systems. As an association for health professions education and research, it would focus on the human resources aspect of health systems, which Glenda Gray¹⁹ broke down into three pieces: education, optimization for care, and involvement in research. Derbew proposed that the association should address the quantity, quality, and relevance of human resources for health in Africa. Many organizations focus on certain diseases, he said, but human resources provide the cornerstone for improving the continent’s health in the long term.

Participants discussed whether the association should be pan-African or focus on sub-Saharan Africa only. A number of them felt strongly that it should encompass all of Africa. The whole continent, Kariuki said, faces the same challenges. Gray added that North Africa has more resources and less stigma than sub-Saharan Africa does.

Individual participants offered their thoughts on what success might look like. Ole-MoiYoi suggested that a successful association would be the partner of choice on the continent. Hakim saw success as all health professions working together and benefiting equally from an association. Hester Klopper²⁰ wanted to see young faces, representing a transfer of capacity. For Gray, success would take the form of government buy-in and political leverage. Other signifiers of success suggested by individual participants included sharing of best practices, locally relevant research, south-south partnerships and inter-African collaboration, extensive networking, and improvements in the quantity and quality of health care personnel.

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¹⁷ James G. Hakim, MBChB, MMedSci, FRCP, is a professor of medicine and former chair of the Department of Medicine at the University of Zimbabwe College of Health Sciences.

¹⁸ Roger I. Glass, MD, PhD, is the director of the Fogarty International Center and Associate Director for International Research at NIH.

¹⁹ Glenda Gray, MBBCh, FCPaed (SA), DSc (honoris causa), is president of the South African Medical Research Council, a professor of pediatrics in the Faculty of Health Sciences at the University of the Witwatersrand, and a professor in the Vaccine and Infectious Disease Division at the Fred Hutchinson Cancer Research Institute.

²⁰ Hester Klopper, PhD, MBA, is CEO of the Forum for University Nursing Deans in South Africa (FUNDISA).

Potential Activities and Functions

Over the course of the workshop, individual participants shared many ideas for what an association might do to accomplish its goals, centered around sharing best practices; developing research leaders; promoting the use of research in policy, practice, and education; facilitating south-south partnerships; and advocating for investments in health professions education and research. The following are a sample of activities that individual workshop participants suggested an association could consider undertaking²¹: host an annual meeting; create a website; publish a newsletter and/or journal; serve as a repository of data, scientific articles, or other information; facilitate site visits; hold workshops and webinars; develop e-learning tools; provide training on research skills or leadership; establish an innovation challenge; produce topical reports, manuals, and/or guidelines; develop curricula or standards; support accreditation; provide opportunities for faculty development; offer mentorship programs; maintain a clearinghouse for trainings and internships; encourage knowledge translation (e.g., policy briefs); supply expertise to the government in emergencies; lobby or engage stakeholders; and serve as a repository of expertise in health professions education and research.

Education for Research, Research for Education

Like MEPI, this association would address both health professions education and research. In every session, participants discussed the relationship between those two components and how they might come together in an association. The two are connected, Mloka observed; for people to do research, their education must include research training. Educational methods themselves may also be the subject of research. She and Mwape described the trail from education to producing researchers who then influence policy, practice, and education. Malata, similarly, saw the role of research in guiding policy, practice, and education as an important agenda for the association to push.

Some participants thought that the association’s main focus should be on education, with research as a component of that. In Sewankambo’s opinion, the research component would be more than theoretical or classroom-based: to learn it, one must do it. Another participant noted that focusing on education would allow for the participation of younger or smaller schools that do not yet have the capacity for research. As rapporteur for the one of the breakout groups, Mloka suggested that supporting multidisciplinary research and researchers through capacity building (e.g., training, grant writing, information literacy) could be one of the main aims of the association.

Mloka identified two ways that the association could incorporate research: building research capacity and strengthening education through research on best teaching practices, etc. Supporting health education research as a discipline could be an important role for the association, she said; other participants mentioned this as a major gap in current research. The association could also act as a repository and dissemination platform for research that promotes best practices in health education and clinical practice. Kimaiyo endorsed the value of a data repository, adding that the data must be integrated into the whole system so that it becomes a normal part of the working process for both the researcher and the clinician.

Ole-MoiYoi saw the association as uniquely positioned to address the weak research capacity in sub-Saharan Africa where the current curriculum often does not emphasize research, and the quality of science teaching is poor. Other participants suggested that this makes it hard to get young people interested in hard science and research. Mentorship could play a role in encouraging an interest in research. Kariuki recommended that the association focus on the development of research leaders and empower them to be agents of change at the institutional level. This could include training on skills like grant writing, as well as grants management.

Sewankambo, Gray, and others talked about educating public health and health care workers on research so they can embed research in their work; this could produce much-needed locally relevant research. Some participants mentioned barriers that keep health care workers from engaging in research, including the lack of training, protected time, and incentives. Kariuki pointed out that current systems of career advancement reward only publications, not this type of local research or innovation. Mloka said one idea might be to establish a challenge program that rewards researchers at all levels of health care for introducing innovations in practice, health education, and research.

As with education and practice, a few participants saw the need for a more interprofessional approach to research. They noted that, too often, nurses are invited only at the implementation stage, rather than early in the grant writing or data analysis.

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²¹ This list was compiled by the rapporteurs from examples suggested by individual workshop participants. It is not meant to construe consensus views.

Potential Vision, Mission, and Objectives

Kariuki then led the participants in thinking about how they might give some structure to the ideas discussed in the previous sessions. He emphasized that an organization must be able to produce three key elements:

1. A charter, constitution, or other foundational document
2. A business and/or strategic plan
3. Regular outputs, such as an annual report or meeting

Referencing slides developed by Patrick Kelley,²² Kariuki briefly introduced participants to these elements before turning their attention to the vision and mission statements.

Kariuki called on the participants to think about the key ingredients or words that might go into the vision and mission statements of an association focused on health professions education and research in Africa. Hearkening back to Derbew’s point, de Villiers said she would like to see a vision statement that incorporates the quantity, quality, and relevance of human resources for health in Africa. Sewankambo imagined a world in which Americans and Europeans came to Africa for health care, instead of vice versa. Malata suggested that the interprofessional aspect be emphasized, along with the idea of research that influences policy, practice, and education. Some participants mentioned the possibility of linking the association’s goals to global campaigns, like the Sustainable Development Goals²³ and UNAIDS 90-90-90 targets.²⁴ In order to maintain long-term relevance, however, Hakim cautioned against including specific diseases like HIV/AIDS in the vision or mission statement; these might be better suited as objectives or metrics. Kariuki agreed, reminding the group that the association’s vision should be broad and encompassing.

A vision statement communicates where the organization wants to be; it describes an idealized state. For example, a vision statement might be “no diseases in Africa” or “no one suffers from food insecurity,” Kariuki explained. He observed that crafting a good vision statement is a balancing act: an organization does not want to be too broad nor does it want to close itself off to future opportunities. Individual participants suggested possible vision statements for the association under discussion. Koumare proposed, “The African health workforce is adequate in quantity, quality, relevance, and innovation.” Another participant put forward, “A healthy Africa through health professions education and research.”

Kariuki explained that a mission statement is more concrete. It explains how the organization will get to that ideal world, describing what the organization is about (its purpose) and what it does (its business).²⁵ It often includes a brief list of activities through which the organization achieves its purpose. Using the example from Kelley’s slides, one participant suggested the association’s mission statement could be something like the following: “The association, based on principles of innovation, excellence, sustainability, and interprofessional collaboration, seeks to enhance health professional education research across Africa through networking, sharing of best practices, advocacy, and research.”

In breakout sessions, participants considered possible objectives that could move the association’s agenda forward. Kimaiyo presented some suggestions raised during his group’s discussions, including to increase the number of health care workers across professions engaged in high-quality, relevant research; to promote exchange of evidence-based innovations in health professions education and research; to promote collaboration among relevant stakeholders to achieve a common goal for health care worker training/education; and to promote evaluation, standards, and accreditation. Klopper then shared a few potential objectives for the association as mentioned by individual workshop participants in her group. These included sharing innovations and best practices in health professions education to improve interprofessional care; developing research leaders and innovators to transform health professions education; promoting the use of research evidence in practice and in policy formulation and implementation; advocating to increase resource investment to improve the quality of health care education and, ultimately, the quality of care; and serving as a platform for south-south partnerships.

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²² Patrick W. Kelley, MD, DrPH, is director of the Board on Global Health of the National Academies of Sciences, Engineering, and Medicine.

²³ For more information on the Sustainable Development Goals, see http://www.un.org/sustainabledevelopment/sustainable-developmentgoals (accessed March 19, 2016).

²⁴ For more information on the 90-90-90 targets, see http://www.unaids.org/en/resources/documents/2014/90-90-90 (accessed March 19, 2016).

²⁵ For more information, see Kelley’s presentation: http://ow.ly/10FP5t (accessed April 14, 2016).

Elements of a Charter

In his overview, Kariuki explained that a charter lays out the rationale and key aspirations of the organization while also addressing how the organization will govern itself. An organizational charter establishes:

• Legal authority for operations
• Rules for participation
• Rules for election, service, and dismissal of leaders
• Governance and accountability structures
• Authority for resource mobilization
• Mechanisms for amendment of the charter

Guided by Malata, individual workshop participants discussed elements that could be included in a draft charter. The conversation started by considering the legal authority for such an association. Donkor explained that legal authority refers to the registration of an organization. There are different ways an organization could be registered—for example, as a company, a trust, or a nonprofit organization. Speaking from her experience in South Africa, Klopper advised staying away from companies and trusts and suggested that, for a pan-African organization, registration as a nonprofit could be a good choice. One consideration in deciding where to register is the ease and security of transferring money. De Villiers noted that the association should be registered in a country where the relevant legislation is enabling, rather than restricting.

For legal and financial reasons, one place—probably the location of the secretariat—would be considered the domicile of the association. After it is registered, other countries may sign on to the charter, though it could take a while, said ole-MoiYoi.

A few participants suggested that another option for launching this association would be to house it within an existing organization, like the African Academy of Sciences, the New Partnership for Africa’s Development (NEPAD), or the African Union Commission for Social Affairs. In the future, the association might choose to become a legal entity in its own right, but in the short term, it could more easily raise funds and work across the continent, they said. But this raised the concern of ownership. Describing how other successful groups, like the Great Neglected Disease Network, were undone by the easy rider problem, ole-MoiYoi emphasized the importance of choosing partnerships carefully, ensuring that there is a shared vision, commitment, and equal footing. Sewankambo described how the organic development of the PI Council led to a strong sense of ownership in MEPI; the governance of the association should instill a sense of ownership. It should also provide accountability through checks and balances, added Kariuki.

Structure and Governance

Donkor and Klopper described a basic governance structure for an association:

• Board or governing council
• Executive committee
• Secretariat or coordinating center
• Chapters

Overarching governance and strategic direction comes from the board; de Villiers described it as a panel of elders. A few officers from the board, including the chief executive officer (CEO) or chairperson make up the executive committee, which manages the daily affairs. Supporting the management committee is a secretariat. The secretariat is responsible for day-to-day running of the organization, including communication and finances. Depending on the involvement of the CEO, the secretariat might take instruction from the executive committee, rather than making decisions about how to allocate resources. Chapters or subcommittees might be based on functionality (e.g., research, education, clinical) or regions, and their coordinators would serve as a link to the board. De Villiers advocated for interprofessional representation in these lower level groups; they should not all be chaired by medical doctors.

Some participants identified the secretariat as the most important piece. Sewankambo agreed that a secretariat was key to a well-functioning association; he noted that it should be based in Africa, unlike the coordinating centers of MEPI and NEPI. Having seen organizations fail for lack of a strong secretariat, Kariuki recommended making at least the director a full-time position.

Other participants urged making the CEO a full-time paid position as well. Malata suggested it would be difficult for that person to concentrate on the association if he or she must look for money elsewhere. Individual participants debated whether the president and the CEO would be the same person, how they would be chosen, and how they

would interact with the board. Klopper noted that they are often two separate individuals, allowing the president to focus on strategy and the CEO on operations. The CEO, she noted, sits on the board, but he or she may or may not have a vote.

Donkor explained that in most associations, members elect their leadership and may also decide who can be on the board. Klopper added that the board can have some non-elected members serving as non-executive directors, who would be appointed from outside the organization and bring other expertise—e.g., legal, financial, marketing.

Bringing in interprofessional and regional representation is critical, said Hakim, and should be built into the structure. He also advocated for ensuring linguistic representation, implementing technical work in at least the four major languages of Africa—Arabic, English, French, and Portuguese. This would also help with membership, according to Donkor: Francophone members could more easily approach Francophone schools to recruit them. Koumare echoed the call for better linguistic representation, which some participants considered a major weakness of the MEPI program. Regional representation posed some difficulty, however. Various participants considered how to balance large and small countries, as well as countries with a single public university like Rwanda. One model, shared by Donkor, is that of the West African College of Surgeons council: every country is represented, and decisions are made through consensus.

Some participants suggested that the subcommittees be included in the charter, but not functional from the start. At the beginning, it might be too cumbersome. Once the association has become more established, subcommittees could be added. Working groups, if desired, could be appointed on an ad hoc basis by the subcommittees. One participant suggested that multiple organograms could be produced, showing the evolution of the association as it becomes more established and able to support more complexity.

Membership

Throughout the workshop, participants discussed the proper level of inclusivity for an association of this kind. There is a tension between keeping it open and allowing it to get unwieldy, many participants noted. Some did not want the association to exclude anyone, while others argued that it was necessary to start small. Donkor cautioned that being everything to everyone reduces the clarity of an association’s goals. He suggested that an association should clearly define those goals and, accordingly, its membership while remaining open to working with others. It is possible to leave room in the charter for others to be added later, he stated.

One participant suggested that the association would have a bigger impact by working with institutions than with individuals; the downside is that strong individuals may be left out because their organization cannot or will not join. Including a mechanism for individual members to join might be a good idea, even if the association does not use it at the beginning, suggested Malata. Donkor noted that the Consortium of Universities for Global Health (CUGH) initially restricted its members to organizations and has recently created individual memberships. As with individual members, there was some debate about what types of organizations ought to be permitted as members; possibilities mentioned by individual participants included universities, research organizations, and health professions training programs outside of academia (e.g., ministry of health, missionary hospitals) or below the bachelors level. Kayumba suggested that it not be limited to academic or research institutions, provided the organization has some involvement with health professions education.

Membership might include different categories for individuals, such as students, foreign associates, and honorary or emeritus members; there could be another category or set of categories for institutional members. Some participants pointed out that different categories could have different benefits and voting status. De Villiers shared the example of the Association for Medical Education in Europe (AMEE), which has different tiers of membership for individuals and organizations and opens certain activities (like its yearly conference) to all, for a fee. Hakim agreed that certain activities, like the annual meeting, should be kept open, while those that are expensive to develop or deliver (like e-learning opportunities) could be limited to members as an incentive.

Business Plan and Sustainability

Early in the workshop, Kariuki urged the group to keep sustainability at the forefront of the discussion, and participants returned to the subject often. In considering objectives, a few participants were reluctant to include anything about sustainability for fear it would sound self-serving. Others disagreed, saying that the goal is not to sustain the association for its own sake, but to sustain the innovations and best practices that emerge from it. Donkor acknowledged that sustainability might not be a stated objective, but he urged that it be considered early. He described how, when the MEPI coordinating center shut down its website, the PI Council no longer had a platform to share its fifth year report.

One way to think proactively about sustainability is by developing a business plan, Kariuki explained. This plan lays out the business of an association and its value proposition. While Kelley’s presentation described the business plan as separate from the strategic plan,²⁶ Kariuki noted that an association could choose to combine them into one document. When thinking about its business goals and the strategies it will use, an association should pay attention to capital requirements and prioritize, he warned. When funding is limited, crosscutting programs can be an efficient way to achieve business goals. In breakout groups, participants considered possible elements of a business plan for the association including costs and expenditures; sources of income; beneficiaries; timeline and budget (including prioritization); products and services; and communications strategy and marketing.

Funding plays an obvious role in an organization’s sustainability and was brought up by many participants throughout the workshop. A few participants recommended pursuing untapped resources in the form of public–private partnerships—for example, engaging the mining industry in the area of occupational health. Others focused on the public side of the equation, pointing out that government buy-in is essential for success. Some participants disagreed about how much support could be expected from the government, however. Derbew acknowledged that this was a challenge for MEPI at first. But Kariuki pointed out that science-led development is now included in many national plans, and the African Academy of Sciences has received significant funding from certain African governments. Governments can also provide valuable non-financial resources such as land for a secretariat, duty-free privileges, or work permits.

Still, Mwape encouraged the association not to rely too heavily on government funding and to consider membership fees as a source of income. Klopper suggested a formula for balancing funding streams with one-third coming from membership, one-third from support and grants, and one-third from products and programs. Ownership itself can be an important driver of sustainability: Malata described how each NEPI country developed its own agenda and plan for nursing education; because they are self-created, the programs will continue even though the NEPI funding has ended.

Many participants had seen networks that seemed promising fail, even when individual units remained active. Koumare and de Villiers pointed out that, if the association focuses on capacity building, it would leave value even if it collapsed after 5 years. But there are lessons in why certain organizations survive and others do not. According to Sewankambo, if the units outlive the network, it indicates that the network did not make its value clear or that it did not have value any longer. This could happen to MEPI. Without the substantial funding of MEPI, an association might find it even more difficult to attract and retain members. Some participants recommended that the association foster champions who could communicate its value and advocate for resources.

Communications

As the workshop came to a close, participants discussed how they could communicate the value and role of an association for interprofessional health education and research to groups and individuals not in attendance. Donkor explained that an effective communication strategy requires absolute clarity about the message. He encouraged the participants to identify people who might be interested in this idea and engage them to build a broad coalition of support. This should include competitors, he said; constructive engagement will require listening to them and asking whether the idea for this association is actually new and important. If the message is clear and targeted correctly, funders and other stakeholders will be able to understand the agenda and how it advances their own, Donkor said. Mloka suggested compiling the best practices and showcasing the achievements of MEPI, NEPI, and other groups.

Kimaiyo added that communication among members of the proposed association is also key. He described how, after 14 years, the Academic Model Providing Access to Healthcare (AMPATH) still meets every week to keep everyone abreast, gather complaints, and share news. Mwape echoed this sentiment, underscoring the importance of transparency and a good flow of information among all health professions.

According to Sewankambo, existing organizations might pose the biggest communication challenge. He suggested that the solution lies in champions at the country, regional, and African levels, as well as within each profession. It is easy to say that an interprofessional association is necessary, Sewankambo reflected, but the challenge comes in having to articulate its complementarity. He encouraged the participants to think about two or three issues on which the health professions, working together, could have the greatest impact.

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²⁶ For detailed information on the elements of strategic and business plans, see Kelley’s presentation: http://ow.ly/10FP5t (accessed April 14, 2016).

REFERENCES

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.

Jamison, D. T., L. H. Summers, G. Alleyne, K. J. Arrow, S. Berkley, A. Binagwaho, F. Bustreo, D. Evans, R. G. A. Feachem, J. Frenk, G. Ghosh, S. J. Goldie, Y. Guo, S. Gupta, R. Horton, M. E. Kruk, A. Mahmoud, L. K. Mohohlo, M. Ncube, A. Pablos-Mendez, K. S. Reddy, H. Saxenian, A. Soucat, K. H. Ulltveit-Moe, and G. Yamey. 2013. Global health 2035: A world converging within a generation. Lancet 382(9908):1898–1955.

Kristiansen, C. 2012. Africa transforms its medical education with Medical Education Partnership Initiative (MEPI). Global Health Matters 11(5):8–13. http://www.fic.nih.gov/News/GlobalHealthMatters/september-october-2102/Documents/ghmsept-oct2012.pdf (accessed April 14, 2016).

PEPFAR (President’s Emergency Plan for AIDS Relief). 2015. Medical Education Partnership Initiative (MEPI): 2010-2015: Moving forward together towards an AIDS-free generation. Washington, DC: World Health Organization. http://www.pepfar.gov/documents/organization/250333.pdf (accessed April 14, 2016).

WHO (World Health Organization). 2006. The world health report 2006: Working together for health. Geneva, Switzerland: World Health Organization.

DISCLAIMER: This Workshop in Brief was prepared by Rachel Pittluck, Louise Flavahan, and Bridget Callaghan as a factual summary of what occurred at the meeting. The statements made are those of the authors or individual meeting participants and do not necessarily represent the views of all meeting participants, the planning committee, or the National Academies of Sciences, Engineering, and Medicine.

PLANNING COMMITTEE FOR THE WORKSHOP ON SUPPORTING THE ESTABLISHMENT OF AN AFRICAN ASSOCIATION FOR HEALTH PROFESSIONAL EDUCATION AND RESEARCH*

Fred Binka, University of Ghana; Wafaa M. El-Sadr, Columbia University Mailman School of Public Health; Eric P. Goosby, University of California, San Francisco, School of Medicine; Glenda E. Gray, South African Medical Research Council; James Hakim, University of Zimbabwe; Isaac Kibwage, University of Nairobi; Address Malata, University of Malawi; Lyn Middleton, Training for Health Equity Network and University of KwaZulu-Natal; and Nelson K. Sewankambo, Makerere University.

*National Academies of Sciences, Engineering, and Medicine planning committees are solely responsible for organizing the workshop, identifying topics, and choosing speakers. The responsibility for the published Workshop in Brief rests with the institution.

REVIEWERS: To ensure that it meets institutional standards for quality and objectivity, this Workshop in Brief was reviewed by Peter Donkor, Kwame Nkrumah University of Science and Technology, and Sylvester Kimaiyo, Moi University School of Medicine. Lauren Shern, National Academies of Sciences, Engineering, and Medicine, served as the review coordinator.

SPONSOR: This workshop was supported by the National Institutes of Health.

For more information, visit http://www.nationalacademies.org/hmd/Activities/Education/AfricanAssociationHealthEducationAndResearch.aspx.

Copyright 2016 by the National Academy of Sciences.
All rights reserved.