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The Caribbean Accreditation Authority for Education in Medicine and Other Health Professions (CAAM-HP) and the World Federation For Medical Education (WFME) successfully hosted an Invitational Conference on Accreditation of Medical Education Programmes in the Caribbean, May 13-15, 2007 in Montego Bay, Jamaica. The Conference brought together leading regional and international experts (80 persons from over 20 organisations/institutions/governments) from the Caribbean, South America, North America and Europe to reflect on the process of accreditation regionally and worldwide and to examine efficient and effective options for maintaining and improving the accreditation system established thus far.
The official welcome was made by the Minister of Education and Youth Honourable Maxine Henry-Wilson and the Minister of State in the Ministry of Education and Youth, Senator the Honourable Noel Monteith. Introductory Remarks were made by Assistant Secretary-General of CARICOM, Professor Edward Greene, Chairman of the CAAM-HP, Professor E.R. Walrond, Dr Hans Karle, President of the WFME and Dr Bernadette Theodore-Gandi, Caribbean Programme Coordinator of the Pan American Health Organisation, PAHO/WHO.
Presenters at the Conference included the Executive Director of the CAAM-HP, Dr Hans Karle, WFME, Professor Leif Christensen, WFME, Dr Ian Bowmer, Executive Director of the Medical Council of Canada (MCC), Professor Sir Graeme Catto, President of the General Medical Council (GMC) of the UK, Dr Pablo Pulido, Executive Director and CEO of the Panamerican Federation of Association of Medical Schools (PAFAMS), Dr Stacy Lankford Chair, Board of Directors, Federation of State Medical Boards of the United States (FSMB).
Dr James Hallock, President and CEO of the Educational Commission for Foreign Medical Graduates (ECFMG) presented a summary of the Plenary Presentations and Discussions and served as Moderator of the Reactor Panel.
One of the aims of the Conference was to identify the needs of the CAAM-HP and opportunities for its support details of which will be released at a later date. An important observation of the Conference was that the CAAM–HP could serve as a model of regional collaboration in medical education accreditation.
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Welcome by Senator the Honourable Noel Monteith
Minister of State in the Ministry of Education and Youth
Madam moderator - Sister Elizabeth Davis, Dr. Hans Karle - President of the World Federation for Medical Education, Professor “Mickey” Walrond -Chairman of the Caribbean Accreditation Authority, Dr. James Hallock -President of the Education Commission for Foreign Medical Graduates, Dr. Edward Greene -Assistant Secretary-General of CARICOM, other distinguished participants from Europe, United States, Canada, South America and the Caribbean, Ladies and Gentlemen,
On behalf of the Government of Jamaica, I take great pleasure in welcoming you to Jamaica and to this Invitational Conference on the Accreditation of Medical Education Programmes in the Caribbean.
It is with a great sense of pride that I welcome you, as it was just about four years ago that I presented to the Heads of Government of CARICOM, on behalf of the University of the West Indies, the proposal to establish the Caribbean Accreditation Authority for Education in Medicine and other Health Professions. I am especially pleased at the number of overseas organizations and regional governments represented here.
Dynamic changes world wide are altering traditional concepts of higher education. In particular, the growth of new information technologies, the prospective liberalization of trade in educational services and the emergence of various forms of borderless or transnational education have posed new challenges to governments, institutions, policy makers, educators, and students. Nation states are no longer the sole providers of higher education and the education community no longer holds the monopoly on the provision of education. The Caribbean has seen the establishment of national universities, and the incursion of foreign providers, particularly in medicine, business and education.
The Caribbean Community has established a Single Market and Economy (CSME), which facilitates the free movement of skilled personnel within the Community. All these developments have brought into sharp focus the importance of quality assurance and accreditation.
Regional governments must be assured that our young doctors have graduated from appropriately accredited medical education programmes. Of course, young medical graduates do go overseas to further their studies and/or to practise and the regulatory bodies need to be assured of the quality of their certification.
I note with great satisfaction the CAAM’s collaboration with the WFME in hosting this Conference. This partnership, will undoubtedly lead to further international cooperation in accreditation of medical education, such as mutual recognition of accrediting systems.
I hope time will permit you to be charmed by the beauty of our island the warmth and hospitality of our people.
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Opening Remarks Prof. The Hon. E.R.Walrond; Chairman of CAAM
Let me on behalf of CAAM add my welcome to this distinguished gathering brought together for this conference by the hard work of Mr. Seeling and the staff at the Educational Commission for Foreign Medical Graduates. CAAM’s primary purpose is to ensure regional and international acceptance of the qualifications of persons trained in the health fields at participating universities in the region, and to ensure the maintenance of standards of education programmes and the portability of qualifications within the region. It is therefore of particular importance that we showcase what we are doing to an audience such as yourselves.
The need for CAAM arose from two separate factors; the UWI which has been established 60 years ago initially as a College of the University of London, had been fully accredited by the General Medical Council of the UK over those years. Regulatory changes related to the accession of the UK into the European Community meant that the GMC could no longer fulfill that accreditation role. At the same time CARICOM was on the verge of implementing a proposal for the free movement of professionals within the region and wanted to satisfy its member governments that the doctors trained at the many other schools in the Caribbean had acceptable standards of training which would entitle them to move freely in the region - a kind of regional visa.
There was a previous effort at agreeing on the qualifications for registration in the region with the formation of the Caribbean Association of Medical Councils, [CAMC]. What has emerged from that is an agreement to set an examination to be taken by doctors whom the individual country council was not satisfied as to their standard of training. Shortly after CAAM got under way with our work we were approached by Mr. Seeling about holding a conference such as this. After some reflection we set about fleshing out our ideas and your response has been beyond our expectations, which means that our direction is of some importance to you in one way or the other.
Later this morning you will have an overview of medical education in the Caribbean. Of the many schools you will hear about only one, the UWI, has as its purpose the training of doctors for the CARICOM region. The vast majority of schools are training US and other citizens for the US market, with regional students as a tiny minority. You will also hear about the structure of CAAM and the incorporation into its structure of representatives from internationally recognised accreditation bodies. We have had the privilege of starting off with the chairman of the GMC Sir Grahame Catto and the former executive director of the LCME Dr. David Hawkins, their contribution to CAAM has been invaluable and I am delighted that they could join us here.
In setting up a system of accreditation CAAM was all too aware that suitable training of doctors for practise in the Caribbean can come from a variety of sources, and that there may be political, economic, as well as educational objectives in setting up training programmes. After looking at the processes of the GMC and of the LCME, the authority opted for the more detailed standards format so that any queries could be answered by the documentation that was generated.
I would like to thank the reviewers from the UK, the USA, from Canada and from within the region for the excellent job they have done, and are doing., in the three schools they have examined so far. Our authority has also embarked on its wider mandate, for at the just concluded meeting in Kingston we initiated the process of looking at the dental and veterinary schools in the region. The authority has limited resources and we hope that we will be able to garner support from this most impressive gathering in strengthening the secretariat and its various activities. Once again welcome and I hope we have a very successful conference.
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Introductory Remarks
Prof Edward Greene
Assistant Secretary General
CARICOM COMUNINITY SECRETARIAT
ACCREDITATION STRIVING FOR QUALITY AND RELEVANCE
It is my great pleasure to represent the Caribbean Community Secretariat and to bring you greetings on behalf of the Secretary-General, H.E. Edwin Carrington and indeed the entire Caribbean Community.
When the Caribbean Accreditation Authority for Education in Medicine and other Health Professions (CAAM-HP) was inaugurated on July 14, 2004 in Kingston, Jamaica it marked a watershed in a process that engaged the entire Caribbean Community and the medical professionals in finding a formula to achieve an internationally recognized accreditation mechanism. Of course, this process involved in- depth research, collaboration with international experts in this area and the political will of our education and health officials, in particular the Ministers of Health and Education, the region’s universities and the CARICOM Heads of Government.
Today, almost three years after its inauguration, this Authority, in partnership with the World Federation for Medical Education has brought together leading regional and international experts to reflect on the process and to examine efficient and effective options for perfecting the accreditation system.
TAKING COGNIZANCE OF CSME AS THE FLAGSHIP FOR ACTION
This Conference is being held at a time when the Caribbean region is engaged in one of the most challenging and exciting enterprises, that of establishing a CARICOM Single Market and Economy (CSME). The enterprise is anchored in the revised Treaty of Chaguaramus 1973. It manifests the unfolding of regulations and activities deigned to achieve free movement of goods, capital and people. Each of the elements of these factors is guided by rules and procedures and common standards that would lead to orderly and transparent policies that in turn promote a viable regional movement; one that is capable of competing with its counterparts in the global arena. The Caribbean Court of Justice is a fundamental pillar for adjudication in this rules based CSME system. In this regard this Conference will benefit from learning of the experiences in multilateral systems of which the Europe Community is a regional integration system from which lessons may be learned.
When our regional education and health professionals advocated for a Caribbean accreditation mechanism, it was in full recognition of the need for our medical and other health professionals to be capable of functioning effectively within the global arena where ultimately the competition for skills continuously contend. It was also in full recognition that the CARICOM Community had already initiated a process for an umbrella accreditation mechanism that would involve all professions, networking with national accreditation authorities. This wider umbrella mechanism has been evolving. In the meantime Heads of Government agreed that preserving the status of our medical and other health professionals was so critical, that a mechanism to specifically cater to the requirements of these professionals was actually accelerated from concept to reality Indeed CAAM jumped the regional cue. It just could not await the gradually unfolding umbrella regional system. So here we are today discussing the role and future of the Caribbean Accreditation Authority for medical and health professionals.
Credit must be given to the Interim Committee that pioneered this venture, the Authority chaired by Prof Walrond, and in particular Mrs. Lorna Parkins Executive Director, for her efficient management of the process.
CONTEXTUAL FACTORS
Accreditation issues however cannot be discussed in a vacuum. Currently in the Community, as it is for most of the developing world, several pertinent issues must be addressed simultaneously, streamlining and perfecting the accreditation mechanism. Perhaps the most important of these, is how to contain the out-migration of our medical doctors and particular our nurses.
Migration of skilled resources
A CARICOM background paper prepared for UN High-Level Dialogue on “Migration and Development” 14-15 September 2006, showed that over the past 10 years approximately 50,000 nurses migrated from the region at an estimated loss of approximately US S2. 2M from the investment in training at the public’s expense.
The Report of the Caribbean Commission on Health and Development Chaired by Sir George Alleyne directly associated the shortage of nurses in the CARICOM region to shortages of trained personnel. It is also directly linked to the current rate of vacant nursing positions in the USA estimated at 12 percent of the total workforce demand and the decline in graduating nurses by 23 percent. Indeed, the shortfall in nurses predicted by the US Department of Health and Human Services (2002) is 800,000 by 2020.
Similar studies for medical doctors, medical technicians, teachers and other trained personnel reveal startling statistics especially for countries like Jamaica and Guyana where an IMF study (2005) estimates that over 40 percent and 75 percent of trained personnel in these countries respectively migrated between 2000-2004. As a result, at the Twenty-Seventh Meeting of the Conference of Heads of Government held in July 2006 in St. Kitts and Nevis it was “agreed that special attention be paid to establishing policies in specific areas such as:
i. the development of migration policy;
ii. the verification of strategies for the retention of skilled labour;
iii. the establishment of a reliable information system/database;
iv. the use of information to enhance national capacity; building social support systems to respond to the requirements of voluntary and involuntary return migrants.”
With special reference to medical doctors and nurses, the Council for Human and Social Development has called for an overall policy of managed migration which is also a subject to be pursued at the Conference on the Caribbean in June 2007, an engagement between CARICOM and the US stakeholders including governments, private sector and philanthropic interests as well as the Diaspora.
Liberalisation of Tertiary Education
Another relevant area is the liberalisation of tertiary education and its impact on the Universities of the region, including the Faculties of Medicine and other health specialisations. The issue of the liberalisation of higher educational services falls directly under the World Trade Organization (WTO). The General Agreement on Trade in Services (GATS) has particular implications for UWI as a regional higher educational institution.
Liberalisation of higher education according to a study by UWI would result in a diversion of public funding from UWI and other national universities. In the context of the proliferation of off-shore universities only a few CARICOM states have established appropriate legislation and administrative arrangements for regulation and ensuring quality assurance. There is need to strike a balance between the advantages to be gained from increased direct foreign investment in the higher education sector and the need to protect the viability of the region’s tertiary level institutions and the learning integrity of Caribbean citizens.
TRIPS Agreement related to pharmaceuticals
Related to liberalisation in the global arena is the TRIPS Agreement and its implications for access to cheaper pharmaceuticals for the Caribbean and other developing countries.
CARICOM with the assistance of its Caribbean Regional Coordinating Mechanism is currently examining how to exploit the flexibilities of TRIPS along with other developing countries in an effort to reduce the burden of the high cost of medicines under the rigidities of the General Agreement on tariffs within the WTO conditionalities
It has been agreed within CARICOM to adopt a regional position on these issues which may require renegotiations based on the principle of safeguarding the quality of medical and health education.
CAAM-HP RESPONDING TO GLOBAL AND REGIONAL TRENDS
Any discussion within accreditation authorities such as CAAM, must relate to the overpowering elements of globalisation that could have deleterious consequences for the medical and health professionals whose qualifications they assess and regulate in the context of a global arena.
The question that must be answered in a forum such as this one is the extent to which accreditation programmes actually contribute to sustainability within the health sector when both internal and external pressures adversely affect the pool and quality of the trained personnel.
In this regard there are some other initiatives in the form of functional cooperation in health that are of importance to this accreditation council and of which it needs to take particular cognizance:
First there is the emphasis that Caribbean governments are placing on strengthening the Caribbean Cooperation in health with priorities on the Non-Communicable Diseases, HIV/AIDS, mental health, health information systems and new modalities for training health professions. The accreditation programmes if they are to be relevant, must take into consideration and relate to these functional cooperation areas in health.
Second, emphasis is being given to strengthening and rationalisation of the regional health institutions. Chief among these are the Caribbean Health Research Council (CHRC), the Caribbean Environmental Heath Institution (CEHI), the Caribbean Epidemiological Research Centre (CAREC) and Caribbean Food and Nutrition Institute (CFNI). In this regard CAAM must seek to be part of the thrust and to monitor this trend toward integration of the programmes of our regional health institutions.
Third, there has been a very cogent argument put forward in the report of the Caribbean Commission for Health and Development for moving with dispatch to institutionalise health tourism in the region as a mechanism for attracting foreign direct investments. This in turn would call for new modalities in the functioning of medical and other health professions with implications for accreditation procedures.
Fourth, a most recent initiative approved by CARICOM Heads of Government is the examination of the feasibility of a regional health insurance system with the support of the Caribbean Development Bank. This is a direct response to the need for portability of social security and other facilities in a CARICOM Single Market and Economy to which I have previously referred.
In considering the implications of all these contextual issues attention must be given to the role of information and communications for development as a way of increasing connectivity, facilitating the more effective use of distance education and the harmonisation of programmes across the medical and other related disciplines.
As this Conference addresses the essential aspects of accreditation, it therefore has to keep in perspective the overall environment of its remit, failing which its policies and the activities which it supports could have limited impact.
However, to achieve its objectives CAAM needs the support of several stakeholders: both technical and financial. I am glad to note that CAAM has established a strategic plan for moving forward. Hopefully this meeting will identify the next steps and assist CAAM-HP in advancing the quality and relevance of medical and health related education. Such a plan needs to be funded. Already the regional governments contribute to the basic functioning of CAAM. If it is to survive and make the desired impact, CAAM needs other donor partners to come on Board.
The CARICOM Community is pleased to be associated with this noble enterprise which is a direct response to the 2001 Nassau Declaration of our Heads of Government that: the Health of the region is the wealth of the region.
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OVERVIEW AND STATUS OF THE CARIBBEAN ACCREDITATION AUTHORITY FOR EDUCATION IN MEDICINE AND OTHER HEALTH PROFESSIONS
Background
Medical education in the Caribbean Community (CARICOM) began in 1948 at the foundation of the University College of the West Indies (UCWI), then a constituent part of the University of London. From then onwards and even after full university status was achieved in 1962, the medical education programme was accredited by the General Medical Council (GMC) of the UK meaning that graduates of this programme could register without further examination, to practise or pursue postgraduate training in the UK. This practice continued over the years, with periodic visits, as various changes took place in medical education at the University of the West Indies (UWI).
The University of Guyana was established in 1963 and its School of Medicine in 1985 within the Faculty of Health Sciences. Prior to October 2006 the School of Medicine had not undergone an accreditation process.
The St George’s University School of Medicine began in mid January 1977 and over the years has been evaluated by a number of agencies including the New York State Department of Education, New Jersey State Board of Medical Examiners, Florida Commission for Independent Education and The Medical Board of California.
In the year 2002 the UWI received formal notification of the GMC’s intention to abolish the concept of recognized overseas qualifications effective December 31, 2003. This therefore meant that the GMC would no longer continue with the accreditation of the overseas medical education programmes, including those of the UWI, leaving a void of accreditation by an internationally recognized body. This development came about because of the UK’s membership in the European Union and the need for compliance with the EU’s accreditation regulations regarding academic and professional training programmes.
For medical schools in the Caribbean Community to remain attractive to regional and international students their programmes must be recognized to be of international standard both at home and abroad. Consequently, on the initiative of the UWI and with the collaboration of CARICOM, steps were taken to establish an independent regional accreditation authority to replace the GMC.
This initiative is an integral component of the regional thrust to ensure quality education and training in the context of the Caribbean Single Market and Economy (CSME). The CSME entails the creation of a single large economic space without restrictions on cross-border movement of goods, services, capital, technology and skilled persons and without discriminatory access to the region’s resources for CARICOM nationals.
The movement of skilled personnel has implications in terms of ensuring that across the region, people are appropriately certified. Accreditation therefore has an important role in affirming the quality of education and the validity of certification. Free movement is linked to the quality of qualifications which in turn reflects on the educational programmes pursued by professionals. Hence, when persons are accepted to work in other countries, such countries need to be assured that the quality of education and training received meet their requirements, underscoring the need for an accreditation authority such as the CAAM.
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