Where there’s a will there’s a way

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Dr Tholang Maqutu

THIS opinion piece is in response to the story “End of the road for medical school” (Lesotho Times, 7 April 2016) written by Pascalinah Kabi.

However, as the title of my article suggests, I will argue that where there’s a will there is a way. Former Education and Training Minister Dr Mahali Phamotse made a mistake when she shut down the Lesotho School of Medicine.

From the onset, I should put a disclaimer. This article is purely my personal opinion, as a Mosotho. It does not represent views of any political party, past or present.

There have been momentous developments in Lesotho’s higher education landscape since the dawn of the 21st century. These include the restructuring of the National University of Lesotho (NUL), resulting in its changes in shape and size, the arrivals of international private universities, other public higher education institutions gaining autonomies which enabled them to offer improved qualifications, the establishment of Lesotho’s Council on Higher Education (CHE), etc. All these milestones are commendable.

However, one such innovation, which should have been spearheaded by the Ministry of Education and Training, Ministry of Health and Social Welfare (MoHSW) and the NUL, namely, the Lesotho School of Medicine (LSoM), met with its demise as soon as it “saw the light of a day”. Unfortunately, the NUL Vice-Chancellor referred to LSoM as a “controversial medical school” elsewhere. However, in the same report, he acknowledged that NUL was working to establish a medical school.

The 7 April 2016 edition of the Lesotho Times reported that the Ministry of Education and Training (MoET) abruptly declared that they were shutting down the LSoM. Dr Phamotse premised her decision on a recommendation by Lesotho’s Council on Higher Education (CHE) not to accredit LSoM to continue to train student doctors because they lacked the capacity to produce such specialised personnel. She continued to correctly point out, it was “absurd” that LSoM was placed under the Ministry of Health and not MoET, the rightful custodian of education in Lesotho.

While this may have been the truth at the time, for the reasons that she stipulated, the swift manner in which the decision by the minister was made and implemented is questionable. Clearly, there must have been other underlying reasons that were not disclosed to us as the general public by the decision makers. Nevertheless, whatever these reasons were, they could not negate the gains that the country would make in accomplishing the Basotho’s needs, socially, economically and professionally and otherwise, had the medical school not been closed and been fully supported by that very government. The decision could not have been based on educational, academic or curriculum rationale.

The then MoHSW through the World Health Organisation (WHO) commissioned Prof Desalu to carry out the feasibility and environmental impact study to assess the possibility of establishing a medical school at the NUL jointly with its affiliate, the National Health Training Centre (NHTC). Prof Desalu was a scholarly expert with impeccable credentials. However, it is not clear why Basotho medical sciences and curriculum scholars could not conduct this feasibility and environmental impact study. Nevertheless the necessary stakeholders were consulted, both in government, academia and professionally.

Prof Desalu submitted his report to his sponsors in 2010. In this report he argued that it was possible to commence training of student doctors from 2012. This shows a “disconnect” between the ministerial decision to shut down the medical school and Prof Desalu’s feasibility and environmental impact study report. His recommendations were anchored on the following profound pleading statement: “If there is a political will that this should be done, the government of the Kingdom of Lesotho should take the bull by the horn and do it.” Unfortunately, subsequent events reveal that the plea was not heeded. His recommendations, together with a roadmap for the establishment of a quality medical care that was presented to the NUL, were to be the blueprint for establishing LSoM. Prof Desalu recommended a comprehensive structure to run the LSoM. According to Desalu and the Coordinator’s report, the LSoM would be governed by a Technical Working Group (TWG) assisted by committees that included Curriculum and the Admissions, continuing medical education, research and faculty appointments & promotions committees, until faculty was established. A full structure of departments and the overall organogram suggested. A full framework for implementation strategy clearly marking out the key performance indicators and costing, made part of his recommendations and were included in the proposal and the Coordinator’s report.

The sponsor of Prof Desalu’s feasibility and environmental impact study, namely, the then Minister of MoHSW, presented the first of what became numerous briefs to the cabinet. Ministries of Health, Education & Training, and Finance and Development Planning together with NUL fully participated in these preparatory meetings. However NUL was never given a directive by the Mister of MOET to start the project.

Prof Desalu recommended that LSoM be established at NHTC under the auspices of NUL because of a number of gains over it being at NUL. Firstly, NHTC had requisite facilities such as a well-resourced medical library which Prof Desalu correctly describe as sine qua non to medical education. Secondly, it will enable LSoM to consolidate NUL and NHTC resources, thus eliminating the unnecessary duplication of resources that Lesotho cannot afford. The key to success of the LSoM was commitment of the key stakeholders, namely, the MoET and MoHSW in making the requisite financial resources available and NUL in the provision of curriculum and academic leadership. Thirdly, its (NHTC’s) proximity to two referral hospitals, Queen Elizabeth II (which we will show that although it was being closed down a later government saw the need to re-establish it) and Queen ‘Mamohato Memorial Hospital. These two referral hospitals which would be used for major clinical studies are situated in Maseru, compared to NUL main campus at Roma which is over 34 km away.

A benchmarking exercise revealed the University of Zimbabwe College of Health Sciences (UZCHS) to be the most cost effective regional institution to take Basotho student doctors in this regard. The governments of Lesotho and Zimbabwe signed a Memorandum of Understanding (MoU) where student doctors would spend part of their studies in Zimbabwe and the rest in Lesotho. A comprehensive curriculum for the degrees Bachelor of Medicine and Surgery (MBChB), was designed, clearly showing its structure, aims & objectives, courses and their course contents, modes of delivery, the requisite rules and regulations. This curriculum was in line with Desalu’s recommendation where he proposed: “… the curriculum should be set out as a broad outline of what is obtained in the region with special emphasis on the peculiar nature of the needs of Lesotho and should be in line with international standard.” A word of caution, from a portrait painted by an African scholar on African curriculum evolution. He asserts that curriculum reconstruction in post-colonial Africa represents an accumulating legacy of failure. It is imperative that these student doctors experience this curriculum in the context of Lesotho.

The degree programme was proposed to follow a sandwich approach where the UZCHS would host the away-leg for Basotho student-doctors’ studies and award the Bachelor of Medicine and Surgery (MBChB) degree while the latter stage, the clinical studies, would be taken in Lesotho. MoET and MoHSW were to raise financial resources from fiscus and donor agencies and the NUL and NHTC were to provide infrastructure, curriculum design and development and facilitate accreditation.

According to the Coordinator’s Report, the first three groups of student doctors enrolled at the UZCHS from 2011, a year earlier than the planned implementation date, and before appraisal of the project as well as approval of its budget. The Ministry of Finance needed the project to be approved by an authorising body in its then Planning Section. This approval process was effected in 2013 and was approved in 2014. The Minister of Education was cautioned that the project would be too expensive. The LSoM had to ‘prioritise’ their activities. The explanation given was that the budget for Government projects has to be shared by all projects approved in a particular fiscal year. Because the LSoM was appraised as a project in the Ministry of Health, the Ministry of Finance requested that the project activities be prioritized according to their urgency hence the reduction from R½ billion to 30 million, of which only 3 million was availed (for another feasibility and environmental impact study, not for infrastructure development and establishment of faculty.

Finally, the medical school was advised that the funds were budgeted for and expended on the Prof Desalu feasibility and environmental impact study. Consequently, the activities of LSoM were managed out of pockets of individuals, the ‘Friends of the LSoM’, through the support received from WHO and the University of Columbia. Clearly, this funding model is unsustainable for running such a massive national project.

The life span of the LSoM from feasibility and environmental impact study, its translation into the medical school and subsequent closure traversed three national governments, one being absolute majority single party and the remaining two comprising coalition governments stemming from hung parliaments. As a consequence there were three different ministers in each of the three ministries, namely, Health, Education and Finance, in the respective governments.  Priorities shifted with the changes in governments. Needless to say, the Minister of Health (who sponsored the feasibility and environmental impact study and had been prepared to pilot the LSoM project) together with her ministerial colleagues in MoET and Finance stepped down from their portfolios in 2012. The subsequent ministers of the three ministries had other priorities than establishing the LSoM. For example, the Minster of Health, in the 2012 coalition government had prioritised funds to re-establishing Queen Elizabeth II Hospital in Maseru. In the process she ignored efforts by the then teething LSoM to alter the two-nations MoU, even when the Zimbabwe partners expressed willingness to travel to Lesotho to put the matter to rest. Lastly, although he expressed his support for the closure of the medical school the present Minister of Health insisted that there were more than enough qualified Basotho specialist doctors in South Africa who are capable of teaching in the medical school. All that is required was to mobilise these to return home. However, the enthusiasm that was displayed by the first non-coalition government has completely dissipated by 2016, even though the two parties that form part of the seven-party coalition government are presently in charge of the 3 ministries, Finance, Health, and MoET.

In her explanation for the shutdown of the medical school, the Minister (of MoET) correctly argues that education in Lesotho is the responsibility of her ministry.  LSoM should have been placed under the MoET and not the Ministry of Health. Perhaps the above paragraphs explain how this anomaly arose. She correctly labelled process, or lack thereof, as ‘absurd’.  However, what is ‘absurd’ to me as a citizen is procedure followed during government transitions.

Over the same period, NUL passed through four vice chancellors regimes, albeit two in acting capacities (2009 – 2010 and 2013 – 2015) and the remaining substantive (2011 – 2013 and 2014 – present). These transitions happened over a highly volatile period at the university. It suffices to say that this period had the worst students and staff unions’ strikes ever to be experienced by the NUL including a massive exodus of staff. These resulted in the university experiencing its lowest pass-rates across the board. The transitions together with the respective challenges are well documented in your earlier edition (see Lesotho Times edition of 26 September 2013 also accessed from the NUL Website).

The abovementioned edition of your paper reported: “during the run-up to the 2012 polls, opposition parties rallied support from the electorate by announcing they would fire Prof Siverts (Vice Chancellor 2011 – 2013) upon ascending to power as government.” Prof Siverts is the only substantive female Vice Chancellor ever to be appointed by NUL in its 70 years. Sadly, she did not even complete her term of office. Clearly, both the government and NUL administrations were distracted by these stormy transitions resulting with the LSoM initiative being relegated to the periphery. It had ceased to be the top priority for both government and NUL.

It is well established that the Minister of Education shut down LSoM because CHE had not granted them accreditation. I have gone over CHE reports that are in the public space, but was not able to access their full report on the accreditation or quality assurance audit of LSoM. I found CHE’s literature which included: CHE Annual Report 2014 – 2015; CHE Policy for the Kingdom of Lesotho, approved by Cabinet in November 2013, CHE’s Institutional Audit Framework for Higher Education, Schedule 7. These were informative in understanding the principle in which CHE functioned.

Education is developmental. Accordingly, CHE’s contention that improving the quality of higher education is a prime concern of their policy is compatible with this belief.  According to CHE, quality is a catalyst for positive change, as a result, quality graduates are regarded as a positive return to investment to Lesotho. Therefore, it is not surprising that CHE explains that the institutional audits must lead to the identification of areas in which an institution needs to improve resulting in developing in an improvement plan for the institution. In other words, the developmental aspect of quality in education would be compromised if quality assurance in CHE is premised mainly on accountability and compliance as these may lead to a shallow ‘tick box’ mentality lacking deep and deliberate reflection. It is imperative that it (CHE) functions in a developmental manner but not in punitive and definitive way.

Alternatively, CHE could have used the Appreciative Enquiry paradigm on LSoM. Had CHE used this paradigm, the Minister of MoET would have been persuaded not to close the LSoM and transfer some students to the Copperbelt University School of Medicine and others back to the UZCHS. The Appreciative Enquiry paradigm is a forward thinking paradigm that begins with identifying that which LSoM did well and the strengths enabling them to attain their goals and build on them.

When the audit was completed, CHE and the Minister of MoET ought to have requested LSoM to develop a Quality Improvement Plan (QIP), namely the steps that they will take in order to enhance the quality of their policy frameworks including systems and processes with very clear timelines that are agreed upon between the service provider (LSoM and NUL) and CHE (standing for custodian of quality and advisor to the Minister of MoET). The development and implementation of QIP ought to be integral practices of CHE. In the case of LSoM nothing was ever tried. Closure must be the last resort when all else has failed.

It therefore comes as a surprise that CHE treated the LSoM differently. CHE’s resolution to suspend the medical school was definitive and punitive rather than being forward thinking and developmental, as it (CHE) purports to be. Education is a powerful tool for addressing issues of social justice, and in this case, public health. Clearly, shutting it down is failing the nation in achieving its mandate.

The Minister of MoET and CHE state the MoET is the custodian of Education and Training in Lesotho. It has been pointed out that MoET, MoHSW and NUL together with NHTC fully participated in the numerous briefings of cabinet meetings. Prof Desalu stressed that without exception, all the participants felt that Lesotho is overdue to have a medical school of its own to train medical doctors. MoET was fully aware of the implementation of LSoM. However, it is not clear whether MoET advised LSoM and MoHSW of accreditation requirement by CHE, or if not, then why not. Borrowing from the Minister, what is be ‘absurd’ is the manner in which records are kept and handed over during governments’ transitions.

Prof Desalu specified that the establishment of LSoM in Lesotho was long overdue. LSoM was the best opportunity for Lesotho to strengthen its own public health system by developing its own human capital from within the country. A similar sentiment is shared by the Minster of Health where he pointed out that the medical school was a national priority because of the dire need for doctors.

The Minister said it was not in the best interest of the government for the LSoM to be shut down, bearing in mind that the medical school was about access to education and healthcare. From these strong positions taken by the minister on the government side, the observations made by Prof Desalu, including what today may sound axiomatic, that Lesotho, with its limited natural resources, has to focus their full attention towards developing their most important wealth, the human resources, it is crystal clear that LSoM was not only an essential assert but a “national key point”.

An added gain of offering medical degree is that this would enable LSoM to carryout research that would seek to understand contemporary burning challenges such as HIV/AIDS in the context of Third World countries, in general and in Lesotho in particular. For example, it is not clear why the HI virus in the First World countries spreads predominantly in one group of people while on the other hand in Third World countries such as Lesotho it spreads in both homo- and heterosexual beings.

Associated with this awkward predicament is the need to understand the relationship between the spread of this viral pandemic of unemployment, education, poverty and starvation in communities in Lesotho. For example, in one of Lesotho Parliamentary Sittings reported on TV Lesotho, a Member of Parliament reported on an anecdotal account of an HIV patient in his constituency who pointed out to him that while she religiously collected her antiretroviral (ARV) tablets and would like to strictly observe their protocol, her biggest challenge was that the prescriptions clearly state that the pills must be taken: ‘after meals’. The challenge here is not only medical, but also social. Evidently, the need for interdisciplinary and inter-institutional collaborative research teams comprising Basotho natural and social sciences and medical scholars would be ideal in pursuing studies that would identify the best means of containing this opportunistic virus with the view of ultimately eliminating it all together. It makes sense that Basotho, in this sense would be empowered to seek solutions for Lesotho’s medical challenges in their context.

The swiftness in which a MoU was signed by Lesotho and Zambia, and Basotho student doctors transferred to Zambia’s Copperbelt University School of Medicine is commendable.  Clearly, finding places, enrolling these students and maintaining them over the period of their studies in a foreign country will cost Lesotho fortunes. As Desalu observed, the funds that were used to place these trainee doctors abroad should be used in establishing the medical school. The same energy should have been expended in securing the resources that were required to properly establish the medical schools.

Even more recently, your sister paper, the Sunday Express (posted on 13 September 2016) reported on protests that resulted with the university suspending all academic programmes. The students demanded for the inclusion of 200 first-year students sponsored by the National Manpower Development Secretariat. The government acceded, though with protestations that the NMDS cake is just too small and was shared.

The Government of Lesotho has invested substantially in training of doctors in our neighbouring countries and in the region. The gains for training our own doctors locally outweighed the setbacks. For example, while Lesotho had trained over 350, majority of these doctors (70 percent) remain in their countries of training, especially South Africa. The few who returned were not all retained. Clearly, localising training of doctors to Lesotho would be beneficial to the country in a number of ways. We can, therefore conclude that the findings of Prof Desalu show that while knowledge may be regarded as universal, the context in which it is taught and acquired is crucial.

While some may argue that knowledge is universal, it appears that the context in which it is mediated, that is, acquired and applied is crucial. For example, in the case of these Basotho doctors, whose medical education was paid for by Lesotho Government, predominantly prefer to work in the context in which they were trained, South Africa. Consequently it makes sense that the only solution for Lesotho is to train its own doctors in the context in which the country would like them to work in. This is understandable, because these doctors would have been trained in this environment, using facilities and equipment on patients living in the countries’ university hospitals where they are found. As a result they may not need much adaptation when they acclimatise themselves into the working force.

Prof Desalu argued: “… identification of the problem is half the problem solved and half the solution found.” Related to this is a saying that ‘there is no problem without a solution. If one cannot find the solution, then they are looking in the wrong direction.’ The shutting down of LSoM is an example of where the wrong solution was implemented. For us to attain our set millennium goals, there must be unity of purpose and succession planning amongst key stakeholders, especially government in terms of availing resources and NUL and NHTC in providing meaningful contextualised curriculum in properly structured LSoM. This leads to the common saying that I have chosen as a title here, namely: ‘Where there’s a will, there’s a way!’

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