Abstract
Medical educators have a responsibility to train physicians and other health professionals in the core competencies needed to improve the sexual and reproductive health of their communities. Yet sexual and reproductive health care is significantly under-represented in the basic educational curriculum for medical and other health professionals, as well as in continuing medical education and professional development programmes for practising physicians and other health professionals. The Commonwealth Medical Association Trust is developing a model curriculum on sexual and reproductive health that can be integrated into undergraduate medical education and used with appropriate amendments for continuing medical education. This paper outlines topics for inclusion in the curriculum and three strategies for incorporating core components of sexual and reproductive health in the curriculum—by developing themes that can be integrated into the general curriculum in a multi-disciplinary fashion, adding free-standing modules as electives, and delegating cross-cutting issues such as gender issues and adolescent reproductive health to courses run by other departments. It argues for the use of problem-solving and case-based learning methodologies, as well as lectures, as the best way to teach health professionals how to provide information, counselling and support for sexual and reproductive health, as well as to cover the range of prevention and treatment needs of women and men seeking these services.
Résumé
Les éducateurs médicaux doivent doter les médecins et autres professions de la santé des compétences nécessaires pour améliorer la santé génésique de leurs communautés. Pourtant, les soins de santé génésique sont nettement sous-représentés dans le programme d'études des personnels médicaux et de santé, ainsi que dans l'éducation permanente et les programmes de perfectionnement professionnel pour les médecins et autres personnels de santé en activité. Le Commonwealth Medical Association Trust prépare un modèle de curriculum en soins génésiques pouvant être utilisé par les écoles de médecine et, avec quelques changements, par l'éducation permanente. L'article décrit une méthodologie de définition du curriculum et trois stratégies pour inclure des éléments essentiels de santé génésique dans le curriculum—en développant des thèmes qui peuvent être intégrés dans le programme général de manière multidisciplinaire, en ajoutant des modules indépendants comme options, et en incluant des questions transversales comme les spécificités de chaque sexe et la santé génésique des adolescents dans des cours dispensés par d'autres départements. Il préconise l'utilisation de méthodologies d'apprentissage fondées sur la solution de problèmes et les études de cas, ainsi que les conférences, comme la meilleure manière d'apprendre aux professionnels de la santé à fournir des informations, des conseils et un appui en santé génésique, ainsi que de couvrir l'éventail des besoins de prévention et de traitement des femmes et des hommes recherchant ces services.
Resumen
Los educadores en medicina tienen la responsabilidad de capacitar a los médicos y otros profesionales de la salud para atender y mejorar la salud sexual y reproductiva de sus comunidades. Sin embargo, la atención en salud sexual y reproductiva está sub-representada en los planes de estudio básicos de medicina y las otras profesiones de la salud, y en los programas de desarrollo profesional y de perfeccionamiento para médicos y otros profesionales de la salud. The Commonwealth Medical Association Trust está elaborando un plan de estudios modelo de salud sexual y reproductiva que puede ser integrado en la educación médica de pregrado y adaptado para los programas de perfeccionamiento. Este artı́culo describe una metodologı́a para elaborar un plan de estudios y tres estrategias para incorporar los componentes centrales de la salud sexual y reproductiva en dicho plan, al desarrollar temas que se pueden integrar en el plan de estudios general de manera multidisciplinaria, agregando módulos independientes como materia electiva, y delegando los temas transversales —tales como la perspectiva de género y la salud reproductiva adolescente— a cursos impartidos por otros departamentos. Aboga a favor del uso de metodologı́as de aprendizaje basadas en la resolución de problemas y el estudio de casos, además de exposiciones orales, como las mejores formas de enseñar a los profesionales de la salud cómo prestar servicios de información, consejerı́a y apoyo, y cubrir además la gama de necesidades de prevención y tratamiento de las mejores y hombres que acuden a los servicios de salud sexual y reproductiva.
Medical educators have a responsibility to train physicians and other health professionals in the core competencies needed to improve the sexual and reproductive health of their communities. One of the distinguishing features of the International Conference on Population and Development (ICPD) in Cairo in 1994,Citation1 and its five-year follow-up by a special session of the UN General Assembly in 1999 (ICPD+5)Citation2 is that they moved beyond rhetoric to define reproductive health, including sexual health, in the context of primary health care and to provide countries with specific goals, objectives, and targets, in order to provide quality sexual and reproductive health information and services. These reflect an international consensus on what needs to be achieved, requiring a combination of programme initiatives, public health policies, legislation, educational capacity building and community-wide efforts.
Until recently, little interest has been expressed by medical educators in integrating sexual and reproductive health in the medical curriculum. Significantly, no international group that is representative of medical educators or the medical profession attended either ICPD in 1994 or the 1999 Special Session of the UN General Assembly, with the exception of the Commonwealth Medical Association.
Sexual and reproductive health, as defined by ICPD and ICPD+5, is significantly under-represented in basic educational curricula for medical and other health professionals and in the continuing medical education programmes for established practitioners in many developing countries. For the necessary instruction in sexual and reproductive health to be given, most existing curricula for undergraduate, post-graduate and continuing professional development must be altered. This is not an easy goal, as proposals for changing the medical curriculum usually take considerable time and effort to implement, especially with so many competing priorities for a place. The attitudes of some educators in subjects such as obstetrics and gynaecology, moreover, may be expected to be conservative and difficult to change.
To support change, the Commonwealth Medical Association Trust (Commat)Footnote* is developing a model curriculum on sexual and reproductive health that can be integrated into undergraduate medical education and used with appropriate amendments for continuing medical education. This paper describes a methodology for curriculum development and strategies for incorporating core components of sexual and reproductive health. It argues for the use of problem-solving and case-based learning methodologies, in addition to lectures, as the best way to teach health professionals how to provide information, counselling and support for sexual and reproductive health, as well as to cover the range of prevention and treatment needs of women and men seeking these services.
Methodology for curriculum development
The development of a curriculum can be divided into four phases—assessment of needs, design of the curriculum, testing and implementation, and evaluation.
The ICPD Programme of Action calls for sexual and reproductive health information and services to be provided as part of primary health care, while maintaining and ensuring access to existing specialist and tertiary level services at regional centres for the more complex procedures and conditions. It follows that traditional courses in obstetrics and gynaecology should continue as specialist clinical subjects while sexual and reproductive health care is also fully incorporated in the basic undergraduate medical curriculum. At the same time, cross-cutting issues such as gender discrimination, human rights, ethics and adolescent health are appropriate for cross-disciplinary inclusion at undergraduate level.Citation4
It is equally important that nurses, midwives and other mid-level and primary health care workers should receive appropriate instruction in sexual and reproductive health care, as they are more likely to attend the majority of women and adolescent girls in developing countries than are doctors. Indeed women living in isolated rural areas with low doctor–patient ratios are unlikely to receive treatment directly from a doctor. Nevertheless, doctors working in centres near remote areas are usually expected to be available to provide specialist advice and assistance to nurses and midwives, and should therefore have received adequate instruction in this area.
In March 2001, Commat organised a consultation at the Royal College of Obstetricians and Gynaecologists in London which brought together 27 heads of university departments of obstetrics and gynaecology, experts in sexual and reproductive health, specialists in family planning and preventive health care, key non-governmental organisations and specialists in areas such as gender, HIV/AIDS and adolescent health from Commonwealth countries, including Kenya, Uganda, Nigeria, Ghana, Tanzania, India, Singapore, UK and Canada, and also from the USA.Citation5
The consultation reviewed medical curricula that cover sexual and reproductive health that have been developed in Nigeria, the USA and UK,Citation6 Citation7 and initiated preparation of an interdisciplinary reproductive health curriculum and mechanisms for its inclusion in undergraduate medical training. The key components for instruction, including the needs of students, modes of curriculum delivery and potential constraints, together with a variety of approaches for promoting stakeholder support and collaboration, were also discussed.Citation5 A follow-up workshop was held in Kampala in March 2002, at which educational consultants and representatives of medical schools from Uganda, India and Papua New Guinea, who were selected to pilot the revised curriculum, further elaborated the proposals made at the consultation. The outcomes of both meetings are discussed in this article.
Strategies for incorporating sexual and reproductive health into the curriculum
Almost all developed countries and an increasing number of developing countries have national or provincial statutory licensing bodies which issue guidance on the content of the curriculum they require medical schools to follow. This guidance is usually fairly general and is often based on the clinical disciplines involved, with preventive medicine being included under the heading of public health. It is significant that sexual and reproductive health is not regarded for this purpose as a priority preventive health discipline and is usually covered only indirectly. Hence, one of the first steps needed at country level is to review and seek to amend this guidance. This was the strategy adopted by the Association of Professors of Obstetrics and Gynecology in 2000 for promoting the inclusion of knowledge in women's health into medical school curricula in the USA and Canada.Citation4
Three approaches were identified at the Commat consultation for the introduction of sexual and reproductive health into the basic curriculum. Each has advantages and disadvantages, but all three have been found to be effective in Canada and the USA. These approaches include:
developing sexual and reproductive health themes that can be integrated into the general curriculum in a multi-disciplinary fashion;
adding free-standing modules to the existing curriculum as electives; and
delegating aspects of sexual and reproductive health such as gender issues and adolescent reproductive health to courses run by other departments, such as those teaching gender studies and paediatrics.
Integrated model
The integrated model was considered preferable at the consultation, as it maintains continuity in planning, instruction and assessment across the range of medical educational programmes.Citation6 Citation7 Citation8 In this model, students would begin to interact with patients from their first day at medical school, developing skills in communicating with patients and their families, and in clinical history-taking. They would also participate in courses on clinical skills so as to become proficient in the physical examination of patients and be able to correlate their findings with what they are learning in anatomy and physiology. Initially, learning would begin in ambulatory settings, e.g. dealing with non-emergency cases such as routine antenatal evaluation, breast examination and cervical cancer screening, at outpatient clinics in the community, and in due course progressing to deal with emergency conditions such as ectopic pregnancy or obstructed labour in hospitals.
Basic reproductive health sciences should be taught throughout, in parallel with clinical subjects. For example, the contraception module would involve disciplines as diverse as pharmacology, primary care and gynaecology, using inter-disciplinary educators such as those teaching basic sciences, physicians, nurse practitioners, and family planning counsellors. In addition, relevant aspects of contraception, including associated disciplines such as community health and epidemiology, as well as gender issues, would be taught concurrently.
Free-standing model
The Reproductive Health Model Curriculum, designed by the American Medical Women's Association, has spurred considerable interest in the development of free-standing reproductive health modules that senior students can choose as electives as part of their clinical training.Citation7 Citation8 Elective modules would be limited to specific aspects of sexual and reproductive health that have been covered more briefly in the general curriculum, such as HIV/AIDS, recognition of cases of domestic violence and prevention and treatment of reproductive cancers, and would be attached to a specific period of training, usually the final year of undergraduate or post-graduate education. One advantage of this model is that students are exposed in depth to specific major issues before they commence clinical practice. While free-standing modules are easy to introduce using an elective format, they are more appropriate for either medical students or practising health professionals who are seeking advanced training or a career in sexual and reproductive health care.
Delegated model
The delegation of specific topics in sexual and reproductive health to individual departments for instruction across established classes has been adopted by a number of medical schools and has been promoted by several professional organisations as particularly suitable for the continuing medical education of practising health care providers. The University of Massachusetts model takes such an approach to domestic violence education in the clinical clerkship year, for example.Citation9 During two sessions, family physicians, paediatricians, gynaecologists, nurses and social workers present a comprehensive approach to domestic violence, addressing behaviours of both victims and perpetrators, as well as issues of safety in the home. Similarly, the American College of Obstetricians and Gynecologists (ACOG) has developed a module on female genital mutilation (FGM) for the training of interns and as a component of continuing medical education programmes.Citation10
Delegating aspects of sexual and reproductive health to existing courses has the advantages of simplicity, rapid adoption by stakeholders and ease of implementation. However, Nelson at Harvard University found that the assignment of women's health topics to existing department-based curricula may diffuse responsibility for instruction and coordination, leading either to the omission of important material or unnecessary repetition, or both.Citation8
The main difference between the integrated model and the other two models is whether or not sexual and reproductive health becomes integrated throughout the entire educational experience or only into portions of it. The concept of integration involves restructuring the entire curriculum so that sexual and reproductive health is included from the very beginning, starting at the basic science level. For example, a course in the anatomy of the female pelvis would include a demonstration of how to carry out a pelvic examination, and teach a woman how use a diaphragm or the female condom.
The initial cost of introducing the integrated model, including faculty, student time, support and infrastructural resources, may be higher than the other models. The cost would also be dictated by the method of teaching, e.g. whether problem-based learning, didactic lectures or a combination. The Commat consultation thought that the integrated approach may be more effective in the long term as it represents the most in-depth introduction of ICPD concepts.
The MCP Hahnemann University in Philadelphia, USA, pioneered an integrated, multi-disciplinary approach to women's health that is centrally coordinated across the curriculum,Citation11 and is an example of how different models may be appropriate to the needs of each institution and its students. The programme is interdisciplinary for the first two years of basic medical sciences and takes on more of a delegated model in the clinical years. The latter involves departments such as community health and epidemiology, family medicine, paediatrics, internal medicine and obstetrics and gynaecology, which each participate in teaching specific areas of reproductive health.
When efforts are centrally coordinated through an educational institution's academic and administrative structures, it is more likely that effective sharing of learning objectives, together with evaluation involving educators from other departments and agencies, will occur, thereby ensuring more effective implementation of the curriculum. This requires the clear identification of course coordinators from the different departments who are responsible for various aspects of the curriculum. The course coordinators need to meet regularly with the overall director of undergraduate education to discuss student evaluation and learning objectives, to ensure that the desired competencies are being attained and that the curriculum is regularly updated.
Two Nigerian Federal University Schools of Medicine are already piloting a sexual and reproductive health curriculum within their undergraduate medical courses.Citation12 The Medical School in Papua New Guinea is in a unique position to ensure that sexual and reproductive health is integrated not only within the undergraduate medical curriculum but also the training of nurses and midwives, as all the health sciences and disciplines have been brought together for educational purposes (Personal communication, January 2003).
Topics in sexual and reproductive health in the curriculum
The respective needs of students who aspire to both general and specialist practice should be borne in mind in the design of curricular modules. Topics that are relevant to reducing the burden of sexual and reproductive health problems in developing countries proposed by the consultation were family planning, maternal health, complications of pregnancy, infertility, sexually transmitted infections, HIV/AIDS, abortion, sexuality, prevention of and problems following the treatment of reproductive tract cancers, prevention of harmful practices, adolescent reproductive health and communication skills.
Issues not always considered relevant in medical education, but which should be addressed, include counselling and communication skills, sometimes involving the disclosure of intimate personal matters; when and how to involve partners and family members of patients, including in STI/HIV testing and partner tracing and notification; the impact of socio-economic status and poverty on access to services; provider attitudes towards different types of patients (e.g. non-literate and uneducated); the effects of social and cultural factors on health-seeking behaviours; the social, emotional and psychological consequences of problems such as infertility or unwanted pregnancy; the impact of violence against women on health and the introduction of support and referral; the role of dependence-forming drugs, e.g. in STI/HIV transmission; the need for cross-cutting attention to adolescent health needs; the importance of a sympathetic approach as opposed to one that is critical and judgemental; and the differences in presentation of certain conditions in women and in men. Finally, the gender aspects of each of these topics need to be covered. It is also essential that students should understand the ethical and rights-based approach to providing information and services.
Medical ethics and guidelines on conscientious objection should also be included. Ethical guidance in such areas as respect, right to information, confidentiality (including in relation to reporting clandestine abortions) and informed consent are particularly important in providing sexual and reproductive health services. Guidance on the relationship of health professionals with traditional healers, who will frequently be consulted by their patients before or even at the same time as they are under the active clinical care of a health professional, should also be provided.
As part of their professional responsibilities it is important that doctors, nurses and midwives should be fully informed about the laws and policies in their country and international documents and instruments that relate to sexual and reproductive health. Abortion laws are the most obvious example, but equally important are the age of consent for providing a young person with contraceptive information and other services, whether sterilisation is legal, STI/HIV screening requirements for sex workers, which procedures mid-level providers are permitted to carry out, approved indications for certain drugs, and many others.
Traditional courses in obstetrics and gynaecology rarely give students adequate education in sexuality throughout the life cycle. There should be a module on sexuality that develops students' awareness of their own sexuality and its impact on their care of patients, and an understanding of the physiology of male and female sexual responses. In addition, it should help students to understand social, physiological and emotional influences on sexual function and dysfunction, different modes of sexual expression and the implications of body image and self-esteem.
Students should also be informed of the boundaries that should be observed in the conduct of physicians towards their patients and other relevant issues affecting the doctor–patient relationship in providing sexual and reproductive health information and services. It is particularly important that they develop the appropriate skills needed to communicate effectively with patients on sexual matters.
Students must be able to identify and monitor harmful practices against women in their communities, including female genital mutilation, gender-based violence and abuse of sexual and reproductive rights, all of which are strongly related to unequal power relations between men and women. Students should be fully aware of the local resources available to assist the victims or how to locate them.
Insufficient attention has been paid to instruction in adolescent health in medical schools, particularly in developing countries, where a much higher proportion of the population is under the age of 25. Students should be taught that young men and women face specific social and economic pressures, which can have adverse effects on their ability to adopt a responsible approach to sexuality and reproductive issues. They need to acquire attitudes and skills to encourage adolescents to make use of sexual and reproductive health information and services, including an understanding of the physiological and emotional changes associated with puberty and adolescence. Adolescents need to be helped to understand the importance of avoiding unwanted pregnancy and the risk of contracting STIs, in particular HIV infection, and students need to develop appropriate skills for counselling adolescents within the socio-cultural context of the community in which they live.
Medical practitioners are in an exceptionally strong position to influence their patients and the community against behaviour that can adversely affect sexual and reproductive health, and to encourage them to adopt safe patterns of sexual behaviour.Citation13 Therefore they need to develop the ability to recognise behaviour that is potentially damaging and effective means of influencing such behaviour. This is why students should come into contact with patients from the beginning of their studies, mainly under the guidance of experienced teachers and clinicians, and not just attend lectures.
Lastly, students must learn to avoid verbal and non-verbal behaviour that is rude, arrogant or patronising and to resist making denigrating remarks or otherwise humiliating patients, which many women seeking sexual and reproductive health services complain of.
Evidence-based best practice
The current approach to medical education seeks to promote the effective use of evidence from clinical research and information technology to improve sexual and reproductive health care delivery. Students and practising health professionals need to demonstrate an ability to locate, analyse and use current clinical and prevention information, and to acquire an overview of the different types of evidence that are useful to health management and policymaking.
Although many medical schools have recognised the need for instruction in evidence-based medicine, the best way to teach these skills to students remains uncertain. Departments of community health, epidemiology and biostatistics, demography, gender studies and computer science should play an important role in showing how the principles of evidence-based medicine can be introduced into the teaching of components of sexual and reproductive health that focus on reproductive biology, and on medical and surgical interventions from both a therapeutic and preventive perspective.Citation14
Problem-solving and case-based learning for curriculum delivery
Information overload is considered the bane of the current undergraduate medical curriculum in most countries. There is a move towards reducing the content of the curriculum by eliminating the esoteric, focusing only on those conditions that contribute to the burden of illness and suffering in the population. This can be achieved by reducing the number of hours of classroom lectures through clinical case presentation and problem-solving, with emphasis on common conditions that students will be dealing with in their careers.
With sexual and reproductive health care, in many instances the student will be dealing not so much with patients who are very sick, as with those who are seeking information or services that can protect or improve their sexual and reproductive health and prevent problems occurring, such as unwanted pregnancies, STIs or infertility. At other times, however, e.g. in the management of obstetric emergencies or the complications of unsafe abortion, different skills are required. Together, these add up to a different way of interacting with patients. Hence, there is a need to draw upon the skills and expertise of a variety of health care educators and administrative leaders concerned with medical education, in order to promote and facilitate the introduction of new concepts into the curriculum.
In addition to the traditional lecture format, the use of problem-solving methods should be promoted, such as case-based learning, small group teaching and concept mapping.Citation15 The latter highlights relationships between concepts and across disciplines, connecting the competencies to enable meaningful learning at various points of training, so that learners can adapt their knowledge to multiple settings.
Figure 1 Anatomy class, Osmania Medical College students, Hyderabad, 2000
These approaches are particularly relevant to sexual and reproductive health care education and community health education. Unfortunately, their use for these purposes was reported to be highly inconsistent in the countries represented at the Commat consultation.
Problem-based learning is an educational technique that enables students to develop problem-solving skills and to acquire knowledge about the basic and clinical sciences through the use of problems presented by patients. It is a core curriculum in the new pathway of educational reform that many institutions are adopting, together with case-based presentations, in their traditional pre-clinical and clinical courses. Available evidence shows that graduates educated through a problem-based learning curriculum felt a high degree of satisfaction with their undergraduate training and the acquisition of clinical, diagnostic and therapeutic skills.Citation16
At the Commat workshop in Uganda, the Chair of the Department of Obstetrics and Gynaecology from Makerere University described the skills that a doctor working in a remote area might need in order to be able to save a woman's life in an obstetric emergency. No trained obstetrician or gynaecologist would have been available for a considerable time, and the fate of both woman and child would be entirely dependent on the doctor at the nearest health centre, who would have had to be able to cope with a very wide range of emergencies. The challenge, therefore, is how to ensure that medical students get practical experience of the problems encountered in providing services under such conditions. Whereas in most developed countries, the great majority of deliveries are in hospitals or within easy reach of a hospital, the opposite is the case in most developing countries.
It is necessary, therefore, for students to spend periods of time attached to health centres in remote areas in order to get adequate training and experience in dealing with day-to-day problems and emergencies when there is effectively no access to a properly equipped hospital. Allocating sufficient time for such attachments is difficult within the basic curriculum of medical schools in developing countries.
It may also be necessary to supplement training for students intending to work in remote areas with additional advanced vocational training, provided in small groups. Vocational training for general practice (i.e. primary health care) was introduced in the UK 30 years ago; the prescribed course lasts for three years, including a one-year attachment to a general practitioner who is accredited as a trainer.Citation17 Vocational training in primary health care in developing countries (of which sexual and reproductive health is one of the important components) is a relatively new concept.
The Dean of the Medical School in Papua New Guinea believes that a doctor going to a remote rural area should, at the minimum, be able to carry out a caesarean section and a hysterectomy as well as to administer the necessary anaesthesia (Personal communication, January 2003). One way to accomplish this is to allow first- and second-year medical students to assist at such surgical procedures, thereby improving their knowledge of reproductive anatomy and helping them to feel more confident when carrying out surgery. With graded participation in surgery during their senior years, their surgical skills can be further refined.
Obstetrics and gynaecology pioneered the use of “standardised patients”, who are individuals trained to act as patients in teaching situations; they simulate various clinical presentations and agree to be examined physically, e.g. breast and pelvic examinations. For teaching communication skills, different clinical scenarios can be role-played, with students acting particular roles, or students can conduct interviews using a standardised patient for five to seven minutes, followed by feedback from peers, standardised patients and facilitators. These activities provide students with the opportunity to develop skills prior to working with real patients.Citation18
Continuing medical education and professional development
The knowledge base of established practitioners and awareness of what constitutes best practice should be updated regularly through continuing medical education.Citation19 Contrary to the situation in developed countries, the health sector in many developing countries is beset with under-developed continuing medical education programmes because of lack of resources, shortage of professional staff, lack of locum cover for those absent on continuing medical education courses and problems arising from the long distances involved in travelling to institutions where training can be delivered effectively and follow-up carried out.
National medical associations, in particular, have a traditional role to keep their members up to date by providing opportunities for continuing medical education. Some professional organisations, such as the International Confederation of Midwives and the Malaysian Medical Association, have excellent programmes for their members, including publication of relevant information in their newsletters. Others, such as the Medical Association of Jamaica, organise conferences on aspects of sexual and reproductive health, including adolescent health, for their membership.
Established professionals also regularly need to learn new skills, for example, technical aspects of inserting new contraceptive devices or performing vasectomies, new techniques for cervical cancer screening and the use of new information technology. Outmoded practices such as routine episiotomy and dilatation and curettage (D&C) for early abortion also need to be challenged and replaced with proven, safer techniques.
Motivating teachers and promoting change
One of the major challenges to introducing the curricular changes needed to ensure that medical students receive adequate instruction in sexual and reproductive health is how to motivate medical teachers to accept, promote and adopt the changes involved. Sexual and reproductive health is particularly suited to the newer methods of instruction described here. But many have never received formal training in using them and will need assistance to become familiar and gain confidence in using them, e.g. through faculty development workshops. Teachers also have the general perception that their teaching skills are less valued than their research and publications. Hence, the motivation to learn new skills and update their knowledge is often lacking. The need to reward good clinical teachers by promotion and improved tenure cannot be over-emphasised.
Obstetrics and gynaecology are specialist subjects and are not synonymous with sexual and reproductive health. Yet traditional textbooks, even the most recent editions, give little if any attention to the ICPD concept of sexual and reproductive health as a component of primary health care. Medical teachers will therefore need to adopt a paradigm shift in moving towards an interdisciplinary sexual and reproductive health curriculum.
It is uncommon to find such issues mentioned specifically, if at all, in the curriculum requirements of licensing bodies (which medical schools are bound to observe if the degrees and diplomas they confer are to be recognised for purposes of obtaining a license to practise). Similar considerations apply to continuing medical education, which is becoming an important requirement for renewal of the licence to practice medicine in many developed countries.
Making the necessary changes to the medical curriculum therefore requires preparation and consultation with all the stakeholders concerned with health care education. While increasing attention is being paid to improving access to services and other health systems issues, integration of services and other health sector reforms, and adoption of a rights-based approach, there has been less progress in improving the teaching of sexual and reproductive health care in the medical curriculum and in continuing medical education. Greater efforts are needed in order for targets for sexual and reproductive health to be met by 2015.
Acknowledgements
The authors gratefully acknowledge the assistance of Dr John Havard, Chairperson, Commat, and participants in the London consultation and Uganda workshop for their assistance.
Notes
* Commat's activities take an ethical and rights-based approach to the promotion of health (in particular sexual and reproductive health) and the prevention of disease and disability in developing countries.Citation3
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