Assist.Prof Thamer Kadum Yousif Al Hilfy
Email: thamer_sindibaad@yahoo.com
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Community based education is defined as a means of implementing community oriented learning programs (which is the type of training that focuses on both population groups and individuals taking into consideration community health needs) as defined by (WHO -1987) which consists of learning activities that take place within the community where students, teachers, members of the community and other sectors are engaged actively through this educational experience, i.e the learning activities that take place in particular community settings.

These activities may or may not be relevant to community health needs as the curriculum can be community oriented without being community based. On the other hand we can have a community-based curriculum without being community oriented.

Our college has tried since establishment, to implement relevant curriculum, which is both community oriented as well as community based.

TUCOM (Tikrit University College of medicine)/CBE program (in its ideal times) constitutes a community based curriculum including an acceptable balance of community based activities throughout the duration of educational settings (6 years of study).

The curriculum of TUCOM constitutes community-based settings for 2 days/week (field work) under supervision for the 1st, 2nd and 3rd years, in addition to community projects for the 2nd and 3rd year. Training is done in small groups throughout the academic year in coordination with the theoretical knowledge they gain at college.

Training is not limited to PHC centers, but extends through a detailed scheduled plan to include schools, kindergartens, communicable disease centers, factories (mainly in the 4th year) and family visits.

The main objectives of field work are to give students contact with relevant community heath problems, systems of health care at different levels, units of PHC, how to take proper medical histories from healthy people, acquisition of essential medical skills, geographical and demographical characteristic factors of community, scientific analysis of health problems and team work with other members and health staff.

The 4th year curriculum is based on community settings through this year. The activities include problem solving, lectures and clinical training related to the following topics which include medicine, surgery, pediatrics, community medicine (including environmental and occupational health), basic and behavioral sciences.

The settings are connected and implemented in the primary health care center (PHC) which is mainly Al Razi health center, in addition to the outpatient clinic in Tikrit teaching hospital (which is a general hospital including the main departments of medicine, surgery, pediatrics and gynecology departments, family medicine and family planning centers) in addition to occupational sites, in addition to a community project at the end of the academic year.

The 5th year constitutes 2 days/week work in PHC (and other sites), while the rest will be spent in outpatient and hospital wards. (Field projects are necessary at the end of the academic year).

6th year constitutes an 11 week/course including 2 days (ideal) in PHC and the rest spent in hospital wards, theatre, emergency and outpatient clinics of the teaching hospital.

FIELD PROJECT

The general and specific objectives are based mainly on community health needs and priority relevance. The program tries to adopt HFA goals (adhering to the values of quality, equity, relevance and cost effectiveness and maintaining a balance among them) through PHC commitment.

The activities are related to well planned educational goals and objectives and are introduced throughout the whole educational program.

The training is done appropriately and in an acceptable balance covering the primary, secondary and tertiary health centers, as it is focused mainly on the community rather than the teaching hospital (this point is moot now and, the reliance is mainly shifting toward the hospital side not because of the current situation but mainly due to vague policies caused by lack of knowledge and beliefs.

The training tries to make use of the available good resources in the community.

The main issue related to this CBE program is to graduate students with the ability and conviction to serve the community and handle community health needs through self confidence and problem-solving skills they gained as thus they will be able to evaluate and realize their strength and limitations.

The rationale behind TUCOM/ CBE program is mainly summarized in the following points:

• It will provide better future involvement of the newly graduated students in resolving health priority problems through proper linking of theoretical knowledge gained in the college (CBE) curriculum with associated proper practical training.
  
• Being PBL, application of CBE program provides better elaboration on in formation which will be better understood and processed as CBE facilitates PBL, providing more control on community health problems, with better chances to learn in an environment that is close to future real professional life in the community, in addition to the value of appreciation and recognition of team members' roles in sharing respect and understanding.
  This will provide the newly graduated students with a better sense of social responsibility and understanding of their community and its related factors.
  
• It will help to remove obstacles between the newly graduated students and community members and improve their assessment competencies including communications, management, ability to work in a team and leadership skills.
  
• The CBE program will ensure relevant educational processes that help students and new graduates to acquire the main competencies needed for better future professional performance (5 star doctor), including curative, promotive, preventive, and research based competencies, besides other managerial and leadership skills.
  
• It will provide a multidisciplinary approach toward improving the quality of health services and health status, through achieving the concept of health for better physical, mental and social wellbeing.
  
• Being in more contact with community and political leaders it will provide more opportunities for partnership with the community, university and the government.
  
• It will help students and graduates to better recognize the relationship between risk factors, diseases and defense mechanisms and through better understanding of the natural history of disease.
  
• Finally CBE is bringing important contacts with important international organizations (e.g. WHO) and societies concerned with innovative education.

CBE program constitutes specific perspectives including ethical issues related to individual patient health care in respect to respecting peoples thoughts (autonomy), regardless of our personal philosophy, politics and religion; providing effective, relevant education and training to provide medical benefit with less harm; providing the chance for active involvement of the community and achieving justice in the form of equity and equality of health care services provision. It fosters appreciation and recognition of social characteristics through being exposed to community problems. It fosters recognition of people's rights and basic social services ate more guaranteed.

The other issue to be discussed here is classifying community-based programs. This issue is important for 2 reasons: firstly this will encourage a systematic approach to the study of CBE and secondly it helps in developing guidelines and improved implementation as stated by (Schmidt and Magzoub 2000).

There are 3 categories regarding the aspect of trying to differentiate the CBE program according to whether it is mainly a service oriented program which is found mainly in developing countries or if it is concerned with and further subdivided into community development and health intervention programs.

The services range from curative services in the primary care unit to broader aspects related to community mobilization.

In health intervention it is concerned with mainly curative and preventive health services while if it is to be applied in community-based services, it needs more organization, more time and to be continuous and provide follow up for many years as it needs more active involvement and partnership between the different sectors.

The second approach is the research-oriented program which is found more in developed countries where both students and staff are involved in community health problem studies. This type is further subdivided into community based and health facility based programs according to the site of research.

The third approach is the training focused program which focuses mainly on student training in their community whether on primary care, or other working environments, and is further subdivided into primary case based program where primary health care facilities are the proper places for training and community exposure program.

In regard to the TUCOM /CBE program, although many activities are shared in the various 3 categories, it is more shifted (for the last 4 years) toward the first category, focusing mainly on curative and preventive health services and with more approximation to the second subdivision, that is health intervention program.

All these activities are provided by TUCOM/CBE program with one obvious problem which is mainly related to lack of clear vision in implementation of this program, a defect mainly related to managers and authorized staff as they are losing faith in this program (lack of orientation) leading to confusion in implementation of the activities and educational objectives and intended learning outcomes.

Community Based Learning Activity (CBLA) is the activity that can take place in the community and/or in a variety of health service settings whether primary or secondary. (Tertiary care services cannot be included).

This participation could be in the form of community surveys, community oriented programs, health education etc.

These communities include workplaces, families, social societies and schools.
The following example is related to one of our CBL activities in TUCOM.

Community -Based education/ Learning Activity /year 5

Anemia in 1st year primary school/in Al Alam district/Salahaldeen governorate.

Activities performed by the faculty:

• Seminar on Anemia in children: This seminar will cover the following branches (biochemistry, physiology, pathology, pediatrics and community medicine/school health services.
  
• Skill lab: Clinical examination of anemic child (signs and symptoms)
• Field work activities:
  a) Examination of 1st school children/350
  b) Suspected diagnosis (the indication for referral) through referral to field tutor.
  c) Referral to PHCC for necessary hematological examination as indicated.
  d) Analysis of the results (statistical analysis)
  e) Final reporting (presentation of data through tables, charts etc).

Faculty members will be responsible for providing and assessing the competencies of 5th year students regarding their knowledge, attitudes and practice performance through the clinical, written examination and the final report submitted.

Many of the challenges TUCOM is facing regarding assessment are related to lack of observational methods, peer evaluation and attendance of students, which are only practiced by a few tutors.
The intended plan is to build a triangular relationship between the academic college, health care system, including PHCC and the community.

To fulfill these competencies and activities, we need to have a committee of believers in the CBE program and learning activities.

The Triangular relationship

There is good coordination between the community based education program of TUCOM and health services in spite of the difference of the organizational pattern, as the latter is controlled by MOH.
This collaboration extends to a degree of collaboration in that the personnel of MOH are involved in training of students including PHCC.

On the other hand reliance on multi professional teamwork at local primary health care in spite of being a vital issue, needs to be ensured during the whole education process.

The local health system which is the product of collaboration of professions, health services provided and the community, constitutes many activities, including health promotion, student (pupil) care and basic health care beside health education and preventive care and the referral to main PHCC and hospitals as secondary level is provided and ensured.

Both systems are centralized as regards planning and administration resources, as well as both being fully nationalized.

Still it is evident that success of this cooperation depends more on the personalities of those who are in charge, than the process and structure that regulates this relationship, which represents our last defence mechanism against the objectors and those who oppose.

As the declaration of Alma-Ata outlines the importance of other sectors such as agriculture, animal husbandry, food industry, education, housing, public works and communication for PHC in addition to health sectors, the Non Governmental Organizations (NGOs) are of vital importance toward better collaboration and more successful program achievements.

The involvement of different health careers is of importance for better health profession education of undergraduates. The participation of nurses, and teachers of various health professions in these activities, including our example, will positively contribute more to the CBE program and learning activities.

Political situation: (It is said that the best way to solve a problem, is to face it.) is a major issue in Iraq, especially for the last few years, mainly due to an unstable socio-political situation, vague vision toward clear policy, hesitation in empowering and enhancing the CBE program, violence and lack of security, restricted movement and transportation, beside the current threats to community unity, which leads to isolation of creative people and reluctance of many sectors for social participation; all this represents a major challenge.

Tradition and cultural aspects play another important role that should be considered, as some of the health events, for example, tuberculosis in women, still represents a social stigma in rural and even urban communities, in addition to (physical) examination of women.
This needs to be considered when planning for the CBE program and learning activities.

Community involvement is considered essential in community educational program decision-making and its success.

The program that steps gradually from bottom to the top will be more acceptable for community participation and involvement. CBE program should consider inter-societal action as a tool for empowerment.

The facts are that intra-sectoral coordination is more evident than inter-sectoral coordination.

The practice and implementation was obviously deficient and mostly issued for publicity and propaganda rather than scientific reasons, as it was not structured toward specifying educational learning and administration purposes. And the results were disappointing.

This involvement should include creative, enthusiastic members composed of teachers and administrators, voluntary organizations like NGOs and graduates, different social class sectors of the community, effective community leaders and industrial and commercial sectors.

The religious organizations could play an important rule also, although our simple experience in Iraq for revealed many negative impacts regarding this part (personal view and experience).

TUCOM/CBE program intended to achieve a community involvement that implies the sharing of power relying on regulations and means, or at least community reaction and expressions.

But on the ground the type of involvement is more or less nominal and more likely to be passive.
The information flow is more likely to be one way, and even attendance of meetings (at least for the past few years) is more likely a routine process, and is called the 10 dollar meetings (where the attendants are paid this sum of money for their participation irrelevant to the kind of qualification they possess).

Creation is a matter of fiction and those attending are receiving a one-way flow of information.
We can classify the degree of community initiatives in the best situation by way of innovations that are initiated by administration rather than community induced.

We need community involvement that deals with the educational process from different aspects, related to community diagnosis, setting of objectives, and selection of methods, as well as
the planning, organization and evaluation of educational activities.

This could be achieved through endorsement from decision policy makers by strengthening and enhancing the concept of decentralization as a prerequisite for effective community involvement.

Tikrit University College of Medicine (TUCOM) is among establishments aiming at responding to the Iraqi community through identification and prioritisation of health problems and needs.

This could be done by adopting a student centred problem based curriculum, which relies on the CBE program.

In order to identify and prioritize the main health problems and needs of our community according to the college vision, there are several indicators, which we can rely on for prioritizing health problems. These include factors related to the prevalence and rate of the disease i.e. the rate of existing cases among the community and whether it currently represents a burden on peoples' health, the preventability and treatability possibilities and how much burden could be relieved by achieving this and the degree of disability caused by that health problem, and its socio-economic impact on the community besides its medical aspects, as well as the possibility of an emerging outbreak.

The availability of a national program against the disease under study, and in addition to these points, the curriculum considers the prototype value and interdisciplinary input for pedagological purposes.

As there were many trials to involve the faculty specialist and faculty students through surveys and research, including field work and community projects, still the main dependable records regarding morbidity, mortality and other indicators measures were obtained from MOH and related centers records, so the main strategy the college relied on in regard to prioritizing health problems was based on the existing health data in addition to the new data, whether quantitative or qualitative, for possibility of modification when needed.

Before listing these health priorities, I should stress one important point. According to the current situation in Iraq, and due to the absence of a committee that takes responsibility for updating the health priorities for more than 4 years now, many priority health problems were raised and recognized but were not included among this list .

For example, Environmental pollution, violence, increased rate of congenital anomalies and cancer cases, and psychological trauma.

Our educational curriculum is Problem - Based curriculum, where prioritized health problems form the major core. The curriculum is composed of 3 phases: Pre pathogenesis, for the 1st academic year, pathogenesis phase for the 2nd and 3rd academic year and the clinical (clerkship) for the following academic years (4th, 5th and 6th).

By using the 'circus tent' (when a curriculum is based on 3 main pillars, the objectives, priority health problems and discipline content, they all actively share a dynamic inter-relationship) bipolar approach as dependable curriculum design, the health priorities will be studied in all aspects and more than just once as our curriculum is supposed to be of a spiral nature.

At the same time being objective oriented curriculum, this will guarantee that each health problem is distributed in a horizontal manner including the 3 phases of our curriculum and involving all the 6 academic years according to their place in the phase and objectives of each block.

In this case these objectives will deliver the pre-set objectives.

These pre-set objectives (through discipline matching and cross matching) will be important in ensuring coverage of the non priority health topics for Academic issues, thus avoiding possibility of creating gaps on one hand and overlapping on the other hand and will help convert individual planning to more central planning.

This kind of curriculum relies on the bi polar theory which tries to accomplish both the intended college objectives upon which the program was initiated and the required faculty content which should be filled properly and related to the subject base.

The following diagram illustrates the design supposed to be followed.

In reality and regarding TUCOM priority health problem issue, there is one major defect which is related mainly to absence of a committee that takes responsibility for revising and updating the PHP (priority health problems) which is supposed to be done each year and at least every 3 years.

This in fact has not been done for many years (more than 4 years) which is affecting the prioritization process, leading to lack of ability to modify the PHP list and is really representing a big burden on Iraqi community health, leaving these topics to be studied as pre-set objectives as before.

The reason behind this major defect relates mainly to changing of some qualified staff, and the dominance of some faculty staff members who are reluctant to any change or real participation.

Another problem facing the curriculum as do other similar program designs, is related to imbalance between supply side thinking (crowded lecture theatres and didactic lecture orientation) and the demand side thinking which prioritizes community health needs, public expectations and societal trends and the balance should be on this side (which is not the current case) as illustrated below.

Moving to another aspect which is related to CBE activities, and toward implementing these PHPs, as mentioned previously each topic will be discussed thoroughly from different aspects (anatomy, physiology, medical etc) during the different phases of the academic study (3 phases constituting the program) and each PHP will be handled more than once through the 6 year of academic study. The above discussions are guaranteed being CBE/ problem based learners, using different tools.

The students meet in small groups twice per week and are presented with PHP under study (discussing the causes, mechanisms, developing hypotheses and strategies) and reach conclusions, under the supervision of the tutor (here acting as a facilitator), and involving them in seminars, and skill labs when indicated.

This will be accompanied by field work, spending 2 days/week in the field, which involves
Primary Health Care Centers (PHCC) where most of the national programs are implemented and provide 80% of total services.

Students will be in direct contact with national programs implemented in PHC centers like TB programs, ARI, ORT, vaccination program and so on, besides MCH units with all related activities, family planning centers etc.

Field work will also involve factories, schools and according to community health priorities.

Another activity will be applying community projects where each group of students take responsibility for visiting the field and undertaking small studies in one of the PHPs.

These activities, as well as related steps, will ensure strengthening the relationship between college students and community health centers, shifting their direction toward community

The supply-demand balance in medical education
(Neufeld et al.1993)

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