Abstract
Developing and retaining a high-quality medical workforce in low-resource countries is a worldwide challenge. The Filipino Ateneo de Zamboanga University–School of Medicine (ADZU-SOM) has adopted a strong focus on socially accountable health professional education (SAHPE) in order to address the shortage of physicians across rural and urban communities in the Western Mindanao region. A cross-sectional survey of graduates from two Philippines medical schools: ADZU-SOM in the Mindanao region and a medical school with a more conventional curriculum, found ADZU-SOM graduates were more likely to have joined the medical profession due to a desire to help others (p = 0.002), came from lower socioeconomic strata (p = 0.001) and had significantly (p < 0.05) more positive attitudes to community service. ADZU graduates were also more likely to currently work in Government Rural Health Units (p < 0.001) or be generalist Medical Officers (p < 0.001) or Rural/Municipal Health Officers (p = 0.003). ADZU graduates were also less likely to work in private or specialist Government hospitals (p = 0.033 and p = 0.040, respectively) and be surgical or medical specialists (p = 0.010 and p < 0.001, respectively). The findings suggest ADZU-SOM’s SAHPE philosophy manifests in the practice choices of its graduates and that the ADZU-SOM can meet the rural and urban health workforce needs of the Western Mindanao region.
Introduction
In the mid-1990s, the predominantly rural region of Western Mindanao was one of the most disadvantaged regions in the Philippines with respect to socioeconomic and health indicators; with high birth, infant and child mortality rates, a high prevalence of infectious diseases and malnutrition and extremely limited health resources (http://www.ucalgary.ca/ghealth/node/120; Flavier et al. Citation1990); in particular, medical workforce. For example, there were only 250 doctors in an administrative region of 4.5 million people, with 200 of these working in the largest city Zamboanga; thus, over 80% of rural municipalities were without doctors (Cristobal & Worley Citation2012). Sufficient quality and quantity of doctors is essential for regional health systems to function effectively (Wilson et al. Citation2009).
Recruitment and retention of medical graduates to rural areas – often the areas of greatest need – is a problem worldwide (Rabinowitz & Paynter Citation2000; Dussault & Franceschini Citation2006). For Western Mindanao in the 1990s, not having a medical school in the region was its biggest problem in maintaining an adequate rural medical workforce. Without a local medical school, those who wanted to pursue medicine had to relocate to other parts of the Philippines, and typically did not return after graduation; either remaining in the bigger cities or migrating overseas. This led to the establishment in 1994, of the Zamboanga Medical School Foundation Inc. (ZMSFI) a product of an intersectoral community participation efforts of local doctors, civic leaders and academicians, of which 10 years later was absorbed into the Ateneo de Zamboanga University (ADZU) to become the ADZU School of Medicine (ADZU-SOM). ADZU-SOM is still Western Mindanao’s only medical school.
Over time, ADZU-SOM has adopted a strong focus on social accountability in order to fully address the shortage of physicians across Western Mindanao. Social accountability has been defined (Boelen & Heck Citation1995) as: “The social obligation to direct education, research and service activities towards addressing the priority health concerns of the community, region, and/or nation the school has a mandate to serve. The priority health concerns are to be identified jointly by governments, health care organizations, health professionals and the public.” Recent studies have highlighted the importance of addressing the shortage and maldistribution of health workers to reduce health inequities within and between countries, largely by reforming health professional education to include a greater emphasis on social accountability (Neusy & Palsdottir Citation2008; Frenk et al. Citation2010; Larkins et al. Citation2013; Ross et al. Citation2014).
Twelve medical schools worldwide which have an explicit ‘social accountability’ mandate are members of a consortium called the Training for Health Equity Network (THEnet) (Palsdottir et al. Citation2008). A recent study involving five of these schools in different countries showed having a socially accountable curriculum contributed to their graduates having strong intentions to work with under-served populations (Larkins et al. Citation2014). However, there is limited published evidence of “social accountable’ medical school graduates contributing to any significant impact on local health workforce and local health needs (Reeve et al. Citation2016).
Therefore, this study seeks to identify evidence of local health workforce outcomes in the Zamboanga Peninsula region from graduates of the socially-accountable ADZU-SOM, and also from graduates of another Philippines medical school which has a more “conventionally” orientated curriculum. Specifically, the study describes the differences between graduates of a socially-accountable, community-engaged Philippines medical school, with graduates of a conventional Philippines medical school, in regards to practice location, motivation toward community-based service, training in population health and community development and the treatment and prevention of local priority health issues.
This study is part of a series of multi-institutional collaborative research supported by THEnet and its institutional partners to gather evidence on the outcomes and impact of socially accountable health professional education (SAHPE), using the THEnet’s Framework for Socially Accountable Health Workforce Education (http://thenetcommunity.org/social-accountability-framework/; Palsdottir et al. Citation2008; Larkins et al. Citation2013; Ross et al. Citation2014) as a logic model.
Methodology
Study design and protocol
The practice locations of a decade of medical graduates (2003–2012) were collated from the socially-accountable, community-engaged ADZU-SOM based on the Zamboanga Peninsula. Graduate practice locations were also collated from another medical school in the Philippines which has a more conventional curriculum. Graduates included in the study were those who had been employed for six (6) or more months. Ethical approval for the study was obtained from the Ateneo de Zamboanga School of Medicine Ethics Review Committee and the Flinders University Human Research Ethics Committee (number 7042). Ethical approval for inclusion of the conventional school graduates was granted via the ADZU-SOM review board, with the proviso all respondents must complete an informed consent form.
Graduates of both schools were identified from graduate records, personal contact, alumni networking through other graduates, social media, and the Department of Health of the Philippines physician placement data. A variety of methods were then used to send out surveys due to geographical and technological barriers; for example, some surveys were administered face-to-face in paper-based format, while some surveys were sent electronically via SurveyMonkeyTM and Google internet forms ().
Table 1. Strategies used by the medical schools for contacting their graduates, showing the number of surveys collected via each method.
An information sheet was always provided, which included the sentence they were free to decline participation if they wished, with the paper-based method also asking participants to sign a consent form. Similarly, follow up and survey collection was provided by phone call, return post and personal visits.
Survey questions
This survey sought information on the graduates’: background (age, gender, gross family income), undergraduate demographics, financial support during medical school, motivation for medicine, motivation for studying at the respective school, intentions at time of graduation (career, rural practice), and graduate aspects (attitude to community service, current practice discipline, current practice location, current practice facility and specializations). A complete list of the variables as they were considered for statistical analysis is given in .
Table 2. Undergraduate comparisons of graduates from two Philippines medical schools.
Table 3. Postgraduate comparisons of graduates from two Philippines medical schools.
Table 4. Postgraduate comparisons of graduates from two Philippines medical schools with regards responses to questions on current attitude toward community practice (Likert scale questions used from “strongly disagree” (SD) to “strongly agree” (SA)).
Data analysis
A coding template was developed in Microsoft Excel, and all survey data were entered in uniform format using a coding guide. For the bivariate analysis, these data were later imported into the computerized statistical package SPSS, release 19 (Chicago, IL). Bivariate relationships between the dependent variable (“medical graduate” – conventional school/ADZU-SOM school) were assessed using two-tailed Student’s t-tests, Pearson χ2 tests and χ2 tests for trend, as appropriate. Throughout the study, a statistical test was considered significant with a p value < 0.05.
Results
For ADZU-SOM, a total of 223 out of a possible 232 graduates completed the graduate survey; an overall response rate of 96%. For ADZU-SOM’s comparator conventional medical school, a total of 119 out of a possible 464 graduates completed the graduate survey; an overall response rate of 26%. A complete list of the graduate respondents classified by year of graduation is given in .
Table 5. Graduate respondents classified by year of graduation.
Demographic aspects
ADZU-SOM medical graduates had significantly lower gross family incomes (p = 0.001) as opposed to the conventional school graduates.
Medical profession selection aspects
Compared to conventional school graduates, ADZU-SOM medical graduates were more likely to be motivated to join the medical profession due to desire to help others (p = 0.002) and to have chosen their medical school due to its community-orientated curriculum (p = 0.001) and because there was “little option” in the region, its prestige/international standard (p < 0.001), while graduates from the conventional school were more likely to have chosen their medical school due to its prestige/international standard (p = 0.007).
Health workforce intentions at graduation
Compared to conventional school graduates, ADZU-SOM medical graduates were more likely to intend having a career in Family Medicine (p = 0.034) disciplines at graduation, while graduates from the conventional school were more likely to intend pursuing a Surgical career (p = 0.016).
Postgraduate career and location
Significantly more comparator school graduates were found to have pursued advanced studies than ADZU-SOM medical graduates (p = 0.042). Overall, ADZU-SOM medical graduates were more likely to be currently practising in pediatrics (p = 0.018), while comparator school graduates were more likely to be practising in family medicine/GP (p = 0.001).
ADZU-SOM medical graduates were more likely to work in their first position as a Rural/Municipal Health Officer than were comparator school graduates (p = 0.001). ADZU-SOM medical graduates were also more likely to be working in a Government tertiary hospital in their current position as a generalist Medical Officer/Resident/Consultant (p < 0.001) or working in a Rural Health Unit (p < 0.001) as Municipal Health Officers (p = 0.003), while comparator school graduates were more likely to currently working in private hospitals (p = 0.033) or Government specialist hospitals (p = 0.040), often as surgical (p = 0.010) or nonsurgical/medical specialists (p < 0.001).
Attitudes to community service
Compared to conventional school graduates, ADZU-SOM medical graduates were more likely to “strongly agree” that: community physicians should cater holistically to the needs of the community (p = 0.001); community healthcare entails partnership with other stakeholders (p < 0.001); healthcare requires prioritizing community health needs (p = 0.006); community healthcare should promote health equity (p = 0.050); and, working in the community can make an impact on population health outcomes (p = 0.042).
Discussion
Study findings show notable differences in the outcomes of ADZU-SOM graduates with those of the more conventional medical school. Demographically, the conventional medical school graduates generally belong to higher income families compared to ADZU-SOM graduates. Due to its geographical location on the tip of the Zamboanga Peninsula, the ADZU-SOM attracts students mostly from the Peninsula and Sulu archipelago; these regions include some of the poorest provinces in the Philippines. In contrast, the conventional school is more accessible to the major islands groups of the Philippines, which have more affluent populations.
Selecting local applicants from lower socioeconomic strata is used specifically by ADZU-SOM as a means for achieving equity in access to medical education in the Western Mindanao region. There is evidence in the literature suggesting this strategy of selecting local applicants, especially those from lower socioeconomic groups, increases later practice intentions and practice behaviors with regards working in underserved and/or rural areas of Western Mindanao. For example, Hispanic medical students from lower socioeconomic strata were more likely to choose to later practice in communities of similar ethnic and economic status (Fryer et al. Citation2001), while an international study of “socially accountable” medical schools found a selection process aimed at recruiting students from under-served communities produced strong intentions to later work with underserved populations (Iputo Citation2008; Strasser & Neusy Citation2010; Larkins et al. Citation2014).
Indeed, this study also found the ADZU-SOM graduates had more positive attitudes towards community service and health equity than the conventional medical graduates. ADZU-SOM graduates were more likely to “strongly agree” that community physicians should: provide more holistic patient care, partner with other stakeholders for good population health outcomes, prioritize community health needs and promote health equity. Providing more holistic patient care, partnering with other community stakeholders and promoting health equity all improve community health outcomes (WHO Citation2010; Strasser et al. Citation2015; Corbin et al. Citation2016).
This more positive mindset toward holistic and equitable healthcare may be attributed to ADZU-SOM’s philosophy of socially accountable, community-engaged education. Through this philosophy, ADZU-SOM students are taught in the classroom and on community placement about the social and economic factors which determines an individual’s or a community’s health status, and students also practice developing holistic health action plans in collaboration with community stakeholders, based on actual community health needs and real life situations.
Overall, conventional school alumni are more likely to pursue advanced studies than ADZU-SOM graduates, which is likely reflection of that school being located in an area with easier access to training hospitals and universities. This study also found that while ADZU-SOM students had a strong inclination to practice in Family Medicine or General Practice (GP) at time of graduation, significantly more so than the conventional medical students (who were more likely to intend to practicing Surgery), it was the conventional medical school graduates who were more likely to practice Family Medicine or GP after graduation, while ADZU-SOM graduates were more likely to practice in Paediatrics. The majority of the burden of illness in the Western Mindanao region is in the pediatric age group; therefore, there is a strong need in the field for Paediatrics training. In response to this need, the Zamboanga City Medical Center (ZCMC) has developed and maintained a strong Paediatrics Department for many years, which now attracts many ADZU graduates as well as graduates from other medical schools. In contrast, the Zamboanga Peninsula has historically had a less strong Family Medicine and GP training pathway, which appears to be restricting ADZU-SOM graduates’ entry into these professions.
Graduates of both schools were mostly (>70%) working in Government tertiary hospitals, with >50% working in generalist positions as a Medical Officers, Residents or Consultants. However, ADZU-SOM medical graduates were significantly more likely than comparator school graduates to be currently working in a Government Rural Health Unit (17% versus 2%), often as Municipal Health Officers (10% vs. 2%). The ADZU-SOM student scholarship program may be promoting the number of graduates who later choose to work in Rural Health Units, as students who avail of these scholarships are required to serve rurally for 4 years after graduation. In fact, additional analysis of the survey database shows ADZU-SOM scholarship holders stay significantly longer in their first medical position than non-scholarship holders (mean of 3.4 years versus mean of 2.0 years; p < 0.001) and work as a Rural/Municipal Health Officer in both their first medical position (p = 0.029) and in their current medical position (p = 0.013).
In contrast, comparator school graduates were significantly more likely than ADZU-SOM graduates to be working as surgical or medical specialists (36% vs. 11%), often in private hospitals (17% vs. 7%) or Government specialist hospitals (4% vs. 0%). There is growing support in the literature for producing greater numbers of generalist doctors over specialist doctors (Hegde Citation2005; Starfield et al. Citation2005; Duns Citation2013); in particular, to help prevent and manage the growing burden of chronic disease in low-cost community settings. Hegde further states newly qualified Western doctors are often incapable of solo-practising medicine at the community level due to their undergraduate training, which lacks exposure to minor illness syndromes in the community and creates a dependence on hi-tech gadgets for diagnosis. Hegde goes on to recommend medical schools change their curricula to be more patient-centered and community based from the first day and have a strong public health focus – similar to that of the ADZU-SOM. There is also strong evidence (Starfield et al. Citation2005) that health systems with a generalist orientation consistently achieve better outcomes at lower costs, and are also associated with a more equitable distribution of health across the population. Thus, these findings suggest the ADZU-SOM’s graduate profile of more generalists than specialists, and many being Municipal/Public Health Officers, may be more appropriate for the Philippines context.
Limitations
The major limitation of this study is that it compares the ADZU-SOM to the graduate outcomes of only one other medical school. However, the conventional school was deliberately chosen as both schools have been granted level 1 accreditation status, and both have achieved consistently high scores in the national licensure examinations over recent years. In addition, the study is retrospective, with many of the responding doctors having graduated more than 5 years before completing the survey. Thus, recall bias may be a factor for questions on respondent’s initial motivation to undertake a medical degree, why they chose their medical school, and what was their discipline practice intention at time of graduation.
The alumni tracking and networking process of the ADZU-SOM allowed a high proportion (96%) of graduate locations to be identified; however, the response rate for graduates of the conventional medical school was much lower at 26%, most probably because those graduates had weaker connection to the named ADZU-SOM researchers on the project, thus introducing the potential for respondent bias for this particular school.
Since 1993, the Philippine government has also financed the “Doctors to the Barrios” (DTTB) program (http://www.doh.gov.ph/node/1091) to keep physicians in poorer and more remote communities through healthy financial benefits. This external DTTB program would attract both ADZU-SOM and conventional school graduates to community practice in addition to internal scholarship programs, but due to the demonstrated different financial backgrounds of the two schools (with ADZU-SOM graduates being significantly more likely to come from a lower income family than conventional school graduates), it may be that ADZU-SOM have dis-proportionally taken up these financial benefits to practice in rural areas.
Conclusions
Study findings suggest ADZU-SOM’s philosophy of socially accountable, community-engaged medical education manifests in the practice choices of its graduates. Graduates of ADZU-SOM, predominantly recruited from Zamboanga Peninsula and the Sulu archipelago, were more likely to come from lower socio-economic backgrounds, have more positive attitudes to community service and promoting health equity, and upon graduation work in rural health units or as generalists in government hospitals. Findings show that ADZU-SOM is able to meet the local rural and urban health workforce needs of the Western Mindanao region, and suggests SAHPE institutions can produce graduates with the ability, desire and commitment to work in areas that are medically underserved.
Notes on contributors
Dr Servando ‘Ben’ Halili Jr., PhD, previously of Anteneo de Zamboanga University – School of Medicine (ADZU-SOM), now at Zamboanga State College of Marine Sciences and Technology. He is a Fulbright Research fellow and a FAIMER fellow.
Dr Fortunato Cristobal, MPH, a pediatric gastroenterologist is the founding dean of the Ateneo de Zamboanga University School of Medicine. Since 1993, he was worked to develop a medical curriculum that is locally relevant and community engaged. He is also founding member of the board of the Training for Health Equity Network.
Dr Torres Woolley, PhD, is the Evaluation Coordinator for the JCU College of Medicine and Dentistry. Torres has been an active researcher for 20 years using both quantitative and qualitative methodologies, and is experiences in a range of research and evaluation methods, analyses and software.
Simone J. Ross, MDR, is the Project Manager for the Training for Health Equity Network, and Lecturer in General Practice and Rural Medicine, College of Medicine and Dentistry, James Cook University.
Carole Reeve, PhD, previously of Flinders University, now at James Cook University, is a rural general practitioner and public health physician involved in health service and education research in rural and remote areas. Her research and teaching interests are around research translation to improve health equity in disadvantaged populations.
A-J. Neusy, DTM&H, is a retired Professor of Medicine at New York University School of Medicine. He cofounded the Training for Health Equity Network (THEnet) in 2008. He is the Senior Director, Research and Programs and Co-Founder of THEnet and a visiting professor in several universities around the world. His work focuses on health workforce and institutional development.
Acknowledgements
We would like to thank the graduates who completed the surveys, and acknowledge Michael Angelo Filoteo, Diorey Jesse Serrano, Wilster Don Madamba, Vanessa Bolido, and Chereylynn Ruth Ramirez from ADZU-SOM for their support.
Disclosure statement
The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article.
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References
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