THE FUTURE OF SURGICAL POSTGRADUATE TRAINING PROGRAMMES ACCREDITATION

Accreditations are performed by many professional bodies as a quality assurance process to audit and improve standards of practice among their member organizations. This ensures a compliance with minimum standards in accredited institutions and programmes for public safety and eligibility to receive government grants.

The American Council on Education (ACE) was the first such body formed almost a hundred years ago to coordinate equivalence and reduce duplication in the accreditation process. By the end of the Second World War, specialized national accrediting agencies coordinating the standardization and efficiency of higher education had replaced the ACE and today, its successors have been described as the most reliable sources for determining the quality of education and training of institutions of higher education. The USA thus extensively utilizes these non-governmental accreditation bodies.

The ideal accreditation body should be an independent, professionally organized entity, free of government interference and a driver of progressive changes. Accreditation of tertiary health institutions where postgraduate specialist doctors are trained also vicariously safeguards and protects the public from negligence by professional health workers while encouraging cost-effective, periodic, adaptive investments. It should minimise window-dressing, be consistent and reproducible. It should not be punitive but should foster growth within the healthcare industry through the promotion of healthy competitions among competing care-giver organizations.

The West African College of Surgeons (WACS) through its accredited training institutions in the Anglophone West Africa, uses objective guidelines in the identification and encouragement of suitable institutions for surgical training through periodic peer-review audits of installed manpower, facilities, services and academic components. National Postgraduate Colleges in Nigeria and Ghana perform similar functions and with largely the same objectives. There is no interference from governments and no government funding is budgeted or given to any accrediting body for this function. Rather, accredited institutions bear the cost of transportation, hospitality and honorarium for each member of the audit team.

Achievements

Surgical training programs in Anglophone West Africa are unmatched in sub-Sahara Africa in terms of scope, uniformity, spread and coverage. The WACS alone examines almost 6000 candidates biannually in surgical disciplines. The National Postgraduate Medical College of Nigeria has a similarly impressive record and the same trend is beginning with the newly established national programme in Ghana. No other sub-region does this locally for postgraduate medical training in Africa. The WACS and two other Anglophone national training programmes as guided by their accreditation process remain cost-effective while retaining trainees and trainers to work in the sub-region. These programmes have discouraged the egress and emigration of scarce trained manpower to greener pastures in the name of brain drain. Other sister organizations and linguistic blocks have understudied these training formats.

Weaknesses

In spite of these laudable achievements, programmes accreditation has remained a thankless exercise, unappreciated and sometimes resented by provincial and national governments in areas served. Reports of visits are seldom if ever requested for budgetary or policy planning by sponsoring authorities of training institutions and, except when training schools were sanctioned or under threat of sanction, accreditation reports have not appreciably influenced statutory funding of training institutions. Till date, enforcement of accreditation reports is largely through partial (or seldom) full denial of training programmes and denial of examination to trainees form barred institutions. This only punishes the un-intended, in the hope that the trainees will mount pressure on their institutions, a daunting task at best. Withdrawn accreditation also attracts strong negative press and unfavourable comments on social media platforms. Such uproar and unpalatable media exposure sometimes forces governments to act to remedy causes of withdrawn training accreditation.

These limitations largely reflect the market forces and economics of an underserved healthcare sector where hundreds of thousands, and sometimes millions, are served by one specialist. Such a milieu cannot promote a discerning, elite middleclass which is the driving engine of economic growth. Pauperization of the masses in many countries of our sub-region thus draws back the growth propensities inherent in accreditation exercises. While in more affluent societies, consumers are influenced by accreditation ratings in making choices from a rich array of existing health care facilities, the patients in our clime have little choice with no luxury of preferences in a sub-region with limited healthcare outlets and manpower. This is also why accreditation processes focus mainly on infrastructure and manpower, with much less emphasis on assessment of service proficiency in our overwhelmed facilities. In spite of the challenging economic realities, nationalistic, linguistic and other considerations have slowed the desirable development of a unified accrediting body for postgraduate medical education in West Africa. Till date only a few accreditations are jointly held among Colleges.

The future?

The success of the West African College of Surgeons must be built upon to forge a collaborative alliance and develop a single, pan-regional accrediting body which will ensure adherence to stipulated training guidelines. This will however wait for an integrated training curriculum as envisaged in the ongoing harmonization process between Anglophone and Francophone West African countries. Since diseases know no borders, trans-border collaboration is more effective in tackling our healthcare needs. Such a body should be independent from government interference and dictates. It should be insulated from political, national and regional pressures. It must also be free from clientele sponsorship and promote ranking of institutions.

To minimize window-dressing, surprise, mystery guest visits should feature prominently in the assessment to make on-the-spot, unannounced snap review of services. Such a body should comprise career accreditation officers within an office well funded by grants agencies. External funding drives have remained a largely unexplored area although there is a paucity of funds specifically budgeted for accreditation in our sub-region. The abundance of international funds for quality control should be tapped for this purpose.

Carefully harnessed, programmes accreditation can become innovative and create a healthy competition among member training institutions and in the manner by which governments’ economic profiles are ranked internationally. This however will have to await the much needed improved national investment in medical services and an equitably fair redistribution of the dividends of the national health insurance programmes. Sub-regional governments should also endeavour to better the lot of their populace through the creation of a robust middle-class and sustainable job creation. It takes good leadership, collaboration and a strong political will to succeed.

PROFESSOR CHRISTOPHER BODE FWACS Immediate Past Secretary General, WACS.
Professor of Surgery & Consultant Paediatric Surgeon,
College of Medicine
University of Lagos & Lagos University Teaching Hospital,
Lagos, Nigeria.
E-mail: cobode@yahoo.com

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