Africa Interprofessional Education Network (AfrIPEN)

Interprofessional Education and Collaborative Practice (IPECP) is not well established in developing countries (Sunguya, Hinthong, Jimba, & Yasuoka, 2014), even though the needs are greater. The burden of disease, lack of resources, the influence of poverty on health, and workforce shortages in developing countries mean that the availability and composition of health-care teams are vastly different from those in developed countries.

This issue of the Journal of Interprofessional Care publishes for the first time a collection of papers from Sub-Saharan Africa. We are pleased to have contributed to coordinate this issue and write this editorial, which has emerged from a collaborative effort to build a movement around interprofessional practice and education as one way of tackling challenges facing all health and social care professionals in Sub-Saharan Africa.

Africa, of course, is a huge continent with widely varying economies. The burden of disease, the determinants of health, the overlap of different worldviews, the response to colonialism, the shortage of a trained health workforce – particularly in under-resourced and rural areas – and the ongoing higher education crisis, place unique challenges on the health profession educator sector. In the context of a global undersupply of health-care professionals, it is a concern that 75 countries have fewer than 2,5 health workers per 1000 population, which is the minimum number necessary to deliver basic health services. A large majority of these countries are located in Africa (Aluttis, Bishaw, & Frank, 2014; Crisp & Chen, 2014). Therefore, the importance of interprofessional care in Africa has to be seen in the context of the challenges it faces, notably Africa has only 10% of the world’s population, yet bears 25% of the global burden of disease and has only 3% of the total global health workforce (Aluttis et al., 2014). Furthermore, Sub-Saharan Africa, with the lowest density of doctors and nurses, has the highest burden of disease in the world (Crisp & Chen, 2014).

Emergence of new roles in Africa

Superimposed on these workforce challenges is the pull of migration from low/middle to high-income countries, which inevitably exacerbates problems and has an impact on universal access to health care. In response to this, government policy has promoted the development of new roles to meet gaps and workforce shortages, for example, community health workers, clinical associates, and assistants in pharmacy, physiotherapy, occupational therapy, counseling, and nursing (Barr, 2015). Tasks have been shifted to these cadres of health professionals who have often received less training, have a lower level of skills or have a narrow focus to their work (Fulton et al., 2011). These changes in the workforce skill mix raise questions about identity, redistribution of work, role blurring and communication across professional boundaries (Thistlethwaite, 2012) – all issues that are covered by the papers in this issue of the Journal.

Culture and worldviews in Sub-Saharan Africa

Health professions educators in Africa acknowledge the value of globalization and the associated development and prosperity that goes with it, but many resent the loss of typical African socialization and learning. For example, Mosweunyane (2013) has argued that pre-colonial teachers were viewed as custodians of knowledge by the recipients of their training. The culture supported assumptions that what was taught was never questioned. Even today, educators are seen as persons of authority and power and are seldom challenged. Most African cultures are patriarchal with strict hierarchical systems that are compounded by the Western version of a ranked health-care system. Although most African cultures rely on collective decision-making, the chief or the patriarch makes the final decision. This essential top-down traditional culture of acquiescence before one’s superiors (Mosweunyane, 2013) may hinder the implementation of shared decision-making and collaborative leadership. This may explain why educators often verbally and cognitively acknowledge curricular innovations like IPECP but have been slow to implement changes (Botma & Nyoni, 2015).

In Sub-Saharan Africa, the first contact with health care is often through the traditional healers and not the primary health-care clinic (Barr, 2015). Belief in ancestors is widespread in many areas. For example, more than 80% of the health-care consumers in South Africa consult the traditional healer (sangoma) before or during the use of “Western medicine”. The spirits of ancestors are believed to be intermediaries between God and humankind, and should not be dismissed as unimportant as they are thought to play an important role in taking and restoring health (Mosweunyane, 2013). The recognition of traditional healers in South Africa has added another important element to this discourse (Republic of South Africa, 2007).

Interprofessional education and collaborative practice in Sub-Saharan Africa

The goal of health professional education is to produce a cadre of well-trained and appropriately skilled health workforce for the continuum of the health-care system, persons who can collaborate effectively to ensure universal health-care coverage and advance health for all. Dramatic changes in education reflect patient demands and developing systems for health and technologies (Academy of Science of South Africa, 2018). The refocus of governments in Sub-Saharan Africa on primary health care and community engagement has catalyzed offering new training programmes aimed at supplementing traditional health-care approaches. With the emergence of community health workers, clinical associates and assistants in pharmacy, rehabilitation, counseling, and nursing, has come the need to re-examine professional identities and explore opportunities for task shifting and task sharing. These developments have already spurred some changes in health profession education programmes, including problem-based learning, interprofessional education and collaborative practice (IPECP), community-based education and service-learning (Academy of Science of South Africa, 2018).

IPECP presents great potential for transformative learning and reforming systems for health, for improving health outcomes, as well as cost-effective health care (Frenk et al., 2010). It also facilitates health equity and universal access by addressing the challenges posed by shortages of human resources for health (World Health Organization, 2010). Equipping students and the health workforce with the necessary competencies to render people-centered care and contribute to health-care reform are already receiving significant attention in Sub-Saharan Africa. However, this momentum will need to be sustained and advanced through bold political and professional leadership to make IPECP the new paradigm of health professions education and clinical practice. This issue of the Journal shares insights, learning, and the impact of interprofessional education innovations on professional attitudes and ways of working. Papers are mostly from South Africa. We hoped to have a wider spread from Sub-Saharan Africa and recognize this is a limitation, which perhaps reflects the maturity of the discipline and lack of resources available in higher education. We hope in future there will be a greater spread of quality contributions.

Working together for a way forward

Working together across professions, we are currently assessing, developing, and implementing interprofessional strategies with impetus from the Africa Interprofessional Education Network (AfrIPEN). AfrIPEN is a consensus-based partnership between various institutions and individuals with the vision to establish IPECP as an integral part of training for the health workforce to promote effective functioning of health systems.

Following a consultative process over five years, AfrIPEN agreed on the following priorities to advocate for, collaborate on, promote, and share good practice of IPECP in Sub-Saharan Africa (Africa Interprofessional Education Network, in press):

1. Develop organizational capacity and structure to support AfrIPEN’s aims, namely to:

   • Recruit and mobilize policy makers, professional bodies, institutional leadership, faculty, service providers, funders and other stakeholders to advance IPECP;

   • Collaborate in identifying, developing, adapting, and sharing IPECP resources for the Sub-Saharan African context;

   • Utilize relevant global, regional, and national networks and platforms to create an awareness of and mobilization around IPECP;

   • Advocate for and facilitate the inclusion of IPECP into scopes of practice of all professions represented in the health workforce;

   • Advocate for and facilitate the integration of interprofessional collaborative competencies into health workforce curricula offered by higher education institutions;

   • Advocate for, promote, and facilitate the cultivation of IPECP values and competencies among faculty, preceptors, health, and social care workers;

   • Participate in international networks informing best practice models; and

   • Conduct collaborative research to inform IPECP.

2. Conduct a survey on what Institutions in Africa have available on IPE and what is needed regarding IPE;

3. Compile a collection of our IPE stories from Sub-Saharan Africa;

4. Produce generic policies and guidelines that can be adapted by various authorities to promote and endorse IPECP;

5. Create a web-based platform to share IPECP learning and teaching resources

6. Develop a short course for IPE facilitators;

7. Develop a collaborative research framework.

Five Working Groups are collaborating on plans to realize these priorities. This themed edition of the Journal of Interprofessional Care on IPECP in Sub-Saharan Africa is giving effect to AfrIPEN’s priority to encourage collaborative research in the region to demonstrate the impact of IPECP on transformative learning, patient outcomes and the strengthening of systems for health.