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Mendis Report
FACULTY OF MEDICINE, UNIVERSITY OF GEZIRA
Susirith Mendis, Dean Faculty of Medicine University of Ruhuma, Galle,
Sri Lanka
The Republic of Sudan, situated in northeastern Africa, is the largest country of the African continent. Its total area of 2.5 million sq. km and population of 30 million is divided into 26 states. The economy of Sudan depends mainly on agriculture. The University of Gezira Faculty of Medicine (UGFMS) is situated in Wad Medani, the capital of the state of Gezira, a fertile area between the White Nile and the Blue Nile with a population of about 3.2 million (Population Data There are 13 faculties of medicine in Sudan and UGMS is the second oldest. It was established in 1975 and students were first admitted in 1978. It adopted an innovative community-oriented, problem-based integrated curriculum from its inception - the first of its kind in Sudan. Four other medical schools in Sudan have designed their curricula on the Gezira model. In the words of its vice-chancellor, not only the medical school, but the University of Gezira itself is based upon a philosophy of "community orientation". Each year, 100 students are admitted on rank order based upon the results of the National University Entrance Examination conducted by the Ministry of Education and Scientific Research. Students apply to the Admission Committee for Higher Education at the Ministry of Education and Scientific Research in Khartoum. In their applications, candidates list their preferences in order of priority. Final placement decisions are based upon examination scores and the preference stated by the student. Therefore, UGMS has no authority over the selection of its students. Generally, Sudanese students prefer to gain admission to the oldest medical school in Sudan, the Faculty of Medicine, University of Khartoum, which has a traditional curriculum. Nevertheless, there are some who specifically opt for NGMS due the recognition it has received for its community-oriented curriculum and as a result, admission to UGMS is increasingly being sought. Since UGMS is a state-owned institution, fees are not charged to selected students; however, a few fee-paying students are admitted, usually children of expatriate Sudanese. Training Sites
UGMS uses the state hospitals and research institutes in Wad Medani as its clinical training institutes. The three main institutions are: 1- The 900-bed Medani Teaching Hospital serves as the referral hospital
Sudan (al Gezira, Sennar, Blue Nile, White Nile and al Gedaref states). It has 50 specialist consultant staff members, including ten general physicians, eleven gynaecologist/obstetricians, seven general surgeons, six dermatologists, three pulmonary physicians, two psychiatrists, two otolaryngologists, two urologists, one orthopaedist and one anaesthesiologist. It offers renal dialysis, endoscopic care and intensive care. An endoscopy unit for diagnostic purposes and a renal transplantation unit are being planned. 2- The Medani Children's Teaching Hospital was established in 1987. The hospital admits
10,000 children per month with a total annual patient turnover (outpatients and in-patients) of about 50,000 children. Both general paediatric and paediatric surgery services are available in hospital. Training of paramedics in immunization, diarrheal and respiratory nutrition and maternal/child health programmes (including infant mortality reduction) are carried out for the major national programme of Integrated 3- The Blue Nile Research & Training Institute is a continuation of the Blue Nile Health
Project established in 1980 with international funding from the United States, the United Kingdom, Japan and Kuwait as well as with funding from the government of Sudan. The institute was initially established with the intent of containing water-borne diseases, i.e., malaria, bilharzias and diarrheal diseases. These diseases are common in the highly irrigated Gezira region. Today, the institute mainly offers training and research in malaria with a higher diploma (postgraduate) in malariology for medical graduates and public health officers. The University of Gezira confers these degrees. Other training institutes include the Faculty of Laboratory Sciences, the Department of Nuclear Medicine, and the Department of Oncology & Radiotherapy. In addition, two World Health Organization collaboration centres contribute to the overall training of medical and health care personnel at UGMS. The Educational Development Centre (EDC) conducts workshops in medical education and curriculum development. The Primary Health Care & Health Education Centre of the Department of Community Medicine conducts master's level and diploma courses in primary health care management. The EDC has been the resource centre for curriculum design for several medical schools in Sudan and Yemen. Workshops on curriculum design have been conducted for the faculties of medicine at al Fasher (West Sudan), Sennar and al Gedaref (Central Sudan), University of Africa (Khartoum) and the Faculty of Medicine at the University of Sciences and Technology in Sanaa, Yemen. The EDC supports regional programme activities in Saudi Arabia, Bahrain and Iraq. It has also been providing assistance and materials for curriculum innovation in Aambia and introducing community-oriented, problem-based learning The UGMS postgraduate studies programme was initiated in 1993 and is coordinated by the Department of Postgraduate Studies. The department offers five doctors of medicine (MD) progammes (general medicine, general surgery, obstetrics/gynaecology, pathology and paediatrics) and five master of science (MSc) programmes (dermatology, sexually transmitted diseases, Parasitology, physiology and biochemistry). At present, all candidates have been from Sudan and many of the junior specialist faculty members at UGMS have obtained their postgraduate qualification through these programmes. It is planned to extend the postgraduate programmes so students from the African region and beyond can be The Curriculum
The curriculum is described by faculty members as a community-oriented and community- based, student-centered and problem-based, integrated learning programme. The basic, clinical and social sciences have been integrated into the curriculum from its inception. Hence, the UGMS has twenty years experience in community-oriented medical education (COME), community-based education (CBE) and problem-based learning (PBL) and has been the pioneer institution in the region. The success of this curriculum is reflected by the fact that many regional medical schools seek to emulate UGMS. UGMS has assisted in the PBL curriculum design of several medical schools in Sudan as well as a few in the WHO East Mediterranean Region. UGMS has found that its curricular approach has much merit in the Sudanese and Wad Medani settings. During the early years, UGMS had to contend with and overcome sustained opposition from the university administration as well as other medical schools in Sudan and the region. Further, while implementing its curriculum and teaching programme, it confronted the negative attitudes of the medical profession and the community, poor co-operation from health authorities, and resource Medical students are exposed to experiences in the community throughout their course of study. The course consists of two semesters per year conducted over a period of five years, totaling ten semesters. The second semester each year is the summer semester. The Community Course
CBE accounts for about 30% of all curriculum activities and is expected to serve two main functions: provide opportunities for collaboration with the community and government, thereby facilitating university-government partnerships; and prepare students for a community-oriented career in medicine. Though CBE is included throughout the curriculum, a greater emphasis is made during certain modules (See Table 1). The learning methods used in this course are didactic lectures, seminars, PBL, fieldwork and group exercises with student presentations. Table1. Modules in which community-based education is emphasized No. of weeks
Credit hours
Field Training & Rural Research Development Rural Residency
The ten-semester programme is implemented in three phases: Phase I, introductory
course; Phase II, system courses; and Phase III, clerkships. The ten semesters are
completed in a total of 105 weeks. CBE is emphasized during 78 of these weeks (74%).
At UGMS, the CBE approach is longitudinal: Students are assigned to village at the beginning of the curriculum. They will remain in their assigned village for the duration of the programme. Three areas in Gezira have been selected as field training sites. Each area represents a different stage of development and together they provide a spectrum of rural development and its inherent problems. This allows comparative studies to be performed. Community-based sites * Villages across the Blue Nile River that are seriously underdeveloped and where basic
amenities are poor. There is hardly any development activity in these villages.
* Villages in the Rahad area where development is just beginning.
* Villages in the Gezira and el Managil areas where development has taken place over many
years. These areas have now generated specific problems of their own.
Module I: Introduction to medicine
students are introduced to the underlying philosophy of the UGMS training programme. Each student has to collect basic information and data about a health or a health-related problem facing their village. They are expected to write a descriptive report on a selected problem, giving their evaluation and view of how it affects the well being of the family and the community. They are also expected to list in general terms the skills and attitudes they need to acquire so as to be able to identify and manage the problem. During this period, students are also exposed to a variety of teaching and learning methods. These include: the rationale and concepts of PBL and the systematic approach to problem solving: principles of group dynamics that contribute effectively and positively to group activity; use of the library to extract material and information to support their investigation; and the use of available audio-visual teaching material. Students are provided with the required facilities and are supervised by the faculty as well as by specialists from disciplines outside of medicine (i.e., agronomist or economist). At the end of the course, their attitudes are assessed by an opinion questionnaire whereas their knowledge is assessed by multiple choice questions (MCQ), written essay questions (WEQ) and student reports. Module II: Field training research and the rural development programme
This programme is conducted in three blocks during the summer semesters of the first, second and third years. The objectives of this programme are to provide practical field training for students in rural areas; develop an understanding of the multi-sectoral nature of health and disease; give students experience in interdisciplinary activity and team work; open up research opportunities for students and faculty; and engage the university in rural development efforts. During Block 1: Students collect basic demographic information and other data from the village
(location, environment, available amenities, agricultural and socio-economic conditions, customs and traditions); identify specific problems; and plan and design projects to investigate the problems In Block II: They collect data for their projects; statistically analyse their data; draw conclusions
and plan, using all resources available of them. In Block III: They follow up on their action plan, make a preliminary evaluation of outcomes; and
submit a project report that will be evaluated during their final semester. Students arrange seminars during these semesters so that information, ideas and experiences are discussed and exchanged. Financial resources needed for this programme have been obtained from the Regional Ministry of Health, local government entities, community organisations and international agencies. The Field Training Research and Rural Development Programme is evaluated by the students and the people in the villages through 'opinionaires' and discussions. The students are evaluated by assessing their attendance, self-evaluation, peer evaluation, seminar performance, presentations, supervisor reports and final reports. Magzoub & Schmidt (1998) developed a causal model for CBE and after minor adaptations it was tested on a group of 106 students and the teaching staff. The students rated each other on leadership, interaction with the community, subject-matter contributions and effort. Teaching staff assessed the readiness of the community to collaborate. Student achievement (or measured outcomes) was assessed by short essays and judgment from the staff and the community. The results of the survey showed that "leadership had a potent effect on the measured outcomes" and to a lesser extent on "the readiness of the community to collaborate with the students" (Magzoub & Module III: Doctor and society
During this module, students are introduced to the basics of medical sociology; introduction to psychology; family, marriage and their effects on disease; socio-economic aspects of disease; traditional medicine in Sudan; functions and responsibilities of health personnel; and the medico- legal aspects of the practice of medicine. Ethics in medicine including the doctor-patient relationship, the Hippocratic Oath and the Geneva Convention are also covered. Learning methods include didactic lectures, seminars, group work and field visits. Evaluation methods include written essay questions (WEQs) (80%), seminars (10%) and attendance & participation (10%). Module IV: Family health & primary health care centre practice
This module is a continuous programme conducted in four phases over four semesters beginning with the fourth semester. It is offered to enable students to play an active role in the delivery of primary health care (PHC) at the level of the family The health visitor is an elderly woman trained in all aspects of antenatal 20-30% of the blood samples screened by the health centre laboratories daily are found to be positive for falciparum malaria and to ensure continuation of that service at the health centre. The aim of this module is not only to improve the quality of service provided, but also to specifically intervene at the "atrogenic gap" between the family - where medical problems can be detected early - and the health centre - where active intervention with social and therapeutic management is instituted. The module is structured on 30 detailed objectives that include the basic principles of PHC, epidemiological principles, statistical concepts, study of common tropical African diseases, sanitation, preventive health, social-cultural- economic variables affecting health, health education and community participation in health. Each phase of the module has three instructional components; students perform increasingly more complex clinical procedures; students practice these competencies during the continuing family visits; and students follow lecture schedules and participate in seminar programmes and presentation of family health reports. The health centres are important clinical settings during this module. The health centres consist of eight interdependent sections that serve different needs of patients who visit the centres. They are: doctor's consultation room, medical assistant's consultation room, 0the antenatal clinic managed by a health visitor,1 the infant/child health clinic, a diagnostic laboratory with basic amenities including a binocular microscope, special 3-4 bed male and female rooms for intravenous quinine treatment,2 medical insurance and documentation section, and a dispensing pharmacy with antimalarials, anthelminthics, antipyretics and antibiotics. The students participate in the health centre activity initially as observers, the as assistants and later in direct clinical assessments and patient care services. Also during the fourth module, students are assigned to a family for an extended period of time. The student looks after the health needs of the family, following them until the end of the clinical Module V: Rural residency
This module is conducted during the sixth semester and is four weeks in duration. The main objective of this course is to expose the student to the "real environment of a rural hospital and community". The students obtain first-hand knowledge and experience in meeting the challenges of working in an environment that has constraints in physical (health care facilities and equipment) and human resources (doctors and trained paramedical personnel). In addition to understanding the organizational structures and administrative aspects of a rural hospital and health care centre, students also see how laboratories, wards and operating theatre facilities are maximally utilized. They are also exposed to "off-hospital" field activities such as medico-legal functions and community activities that include collecting demographic and statistical data regarding economic and social profiles and political, historical and cultural backgrounds that are useful in conducting a KAP (Knowledge, Attitudes, Practices) study on a selected topic. The instructional methods include guided learning, self-learning, and practical training and community surveys. The students are evaluated based upon the report of the rural hospital doctor, final reports submitted and presentations made by students. Module VI: Primary health care clerkship
The Primary Health Care Clerkship is conducted during the last four semesters of the medical course and occurs concurrently with the clerkships in clinical subjects - medicine, surgery and obstetrics/gynaecology. During the clerkship, students apply their clinical knowledge and skills acquired during their clinical training. The students are expected to participate in maternal & child health (MCH) and family planning services, immunization programmes, assessment of nutritional status of "at risk" groups in the community, identifying endemic and communicable diseases and assessment of environmental, sanitation and water supply issues that affect health. The instructional settings are the PHC unit, dispensaries and health centers. Community physicians, paediatricians, obstetricians and even sociologists and economists from the University of Gezira are recruited to assist the students in their learning activities. Evaluations are based upon the products of group and individual work and performance (10%), report of individual students on their work in the PHC setting (40%) and written examinations that consist of WEQs, MCQs and Table II. Modules with a substantial component of community-based education Semester(s)
No. of weeks
Credit hours
Modules with a Substantial CBE Component
There are other modules that include substantial components conducted in a community setting. Each of the modules listed in table II is designed to accentuate community aspects as appropriate. This is done when dealing with the theoretical aspects of environmental factors, human growth and development, blood disorders and gastrointestinal tract problems. This CBE is in addition to the community-based clinical clerkships. In summary, the overall course time (in weeks allocated), taken together with the credit hours assigned to CBE modules and activities as listed in tables I and II, show unequivocally that UGMS conducts a comprehensive community-based and community-oriented medical course. Student and Graduate Perception
UGMS graduates interviewed expressed the view that the Regional Ministry of Health prefers UGMS graduates to others from Sudan as they are more enthusiastic in serving the rural areas of Gezira. Medical graduates from other schools tend to be more hospital-oriented and less inclined to serve in the community or in rural hospitals or health centres. Medical students expressed similar sentiments. The students enjoyed the medical course as it was "not confined to lectures within walls". They also said that they learn to "work with minimum facilities". They discovered a "new image of being a doctor - helping people and decrease suffering"; it made them "think about people not about ourselves"; and they got a "better understanding of socio-economic factors in ill-health". Thirteen of the 22 medical students (60%) interviewed said that they wish to pursue a community medicine-based career. They were nevertheless aware that "more realistic expectations may change their views later". They also commented that the sense of achievement in a community medicine career is long term and not felt Doctors participating in UGMS postgraduate training programmes spoke of their impressions of the curriculum and its vision in more elaborate terms. They found the exposure to the rural communities a new experience as many came from urban areas. Besides the epidemiological skills they developed during their community course, they found that the course provided them with a unique opportunity to "get to know the life of the people" and interact with many persons from other health-related academic disciplines. The postgraduates said that they developed awareness that "doctors can serve patients better when they understand the problems of patients" and also that "medicine cannot solve all health problems of the people". They also reported that participation had increased their sense of commitment to help uplift the health of the community and enhanced the "hard-working socially-responsible doctor image" of UGMS graduates. They also said that UGMS graduates can be distinguished from other Sudanese medical graduates even in a clinical hospital setting as they "go deeper into the socio-economic history of the patients" admitted to the wards and dedicate more of their time to talk with a patient and convince him/her of a necessary course of treatment of alleviate his/her medical condition. Only one out of the 11 postgraduates interviewed wanted to be a community physician but the other ten said that they routinely take more in-depth social histories of their patients, a quality they developed due to their community-oriented medical This interaction with this cross-section of UGMS students, graduates and postgraduates brought out a general consensus that the community-oriented, community-based UGMS curriculum has been able to create a more 'community-conscious' doctor. The UGMS graduates were particularly gratified with these positive attitudinal achievements of the curriculum. Their sense of satisfaction was reflected in the spontaneity and exuberance with which they expressed their views. Cooperation with the Regional Ministry of Health
Though it had its early problems, UGMS now has the full co-operation of the Regional Minister of Health. The minister observed that graduates of UGMS contribute more to the health needs of Gezira Province than graduates from other medical schools, as they are more committed and concerned about the community and preventive aspects of health. Therefore, they were more inclined to recruit UGMS graduates to the service of the Regional Health Ministry. The confidence of the Regional Health Ministry in the UGMS faculty is such that UGMS clinical academic staff hold leadership positions in the main hospitals in Wad Medani; the professor of medicine is the director of the Blue Nile Research & Training Institute; the associate professor of paediatrics is the director of the Wad Medani Paediatric Hospital; and the head of the department of medicine is the director of the Medani Teaching Hospital - all of which are administered under the Regional This co-operation between the medical school and the Regional Health Ministry has facilitated an increasingly important role played by the UGMS faculty in the delivery of health services and in the definition and administration of health policy in the province. Further, there is majority representation of UGMS faculty in the Regional Ministry Health Advisory Board. The new health programmes for the region developed by the ministry are mostly managed and implemented with leadership provided by the UGMS faculty. The ministry and UGMS faculty members jointly manage many current Regional Health Ministry ventures. These include the new WHO- recommended approach to 'Integrated Management of Childhood Illnesses' (IMCI), the Council for Psychiatric and Mental Health and the Emergency Unit for Epidemics and Catastrophes. The Minister of Health as well as UGMS academics emphasize that this 'co-operation, collaboration and co-ordination' between UGMS and the Regional Ministry of Health in the delivery of health care services to the community has been made possible because of the strongly community-oriented Visit to el Managil
A separate section is dedicated to documenting the visit to el Managil as it epitomises the lengths to which the UGMS vision of social commitment and community consciousness is carried out by the faculty. El Managil is an area 80 kilometres from Wad Medani that had been devastated by floods two months before our visit. It is a field training area for UGMS medical students and consists of three villages with a total population of about 10,000. The floods had subsided but most of the mud brick houses had been completely destroyed. The temporary refugee camps set up by the Sudanese Red Crescent were in need of urgent humanitarian support and were threatened with disease and starvation of epidemic proportions. UGMS stepped in to give leadership to the massive relief effort and also to galvanise the UGMS academics initiated and organized the relief effort, mobilizing physical and human resources from all possible public and private sector agencies. A convoy of 20 trucks with medical and health support staff, food (grain and live protein) and building materials was financed and mobilized through the commitment of the UGMS faculty under leadership of the vice-dean. The enthusiasm of the UGMS faculty and students in participating in this urgent and critical community rescue Endeavour was a revelation. It was an unequivocal expression of community consciousness and commitment and a unique example of the UGMS mission in action. The faculty and students who participated in the distribution of the food and building materials stayed on in the camps for two more days. Under these extremely grim and austere conditions, they conducted health camps and attended to the medical needs of the affected people. The tumultuous welcome received by the rescue convoy when they reached the refugee camps, the merging and intermingling of the rescuer and the refugee, the faculty and the people and the enthusiasm shown by the faculty and students during this effort was an authentic social measure of the success of the community-oriented, community-based medical education at UGMS. Conclusion
Sudan is a very large country with a relatively small population. The State of Gezira has vast tracts of arable land and water as a main natural resource from one of the largest rivers and irrigation projects (the Gezira scheme) in the world. It is, nevertheless, an underdeveloped poor country. Therefore, it is to be expected that UGMS will have severe constraints in financial resources and infrastructure. These constraints are observable in the medical school library (a large new library building is under construction and nearing completion), laboratories and other facilities. The UGMS faculty does not seem to be the least bit intimidated by these deficiencies. They have maximally utilized the facilities available to them and in that process they have inculcated in the students a 'culture of determination' that has had beneficial and positive effects on their attitudes. Student concern for poor patients and commitment to their community and field training activities were clearly observable. Sudan, as other countries in the region, has many serious and challenging health problems. The Gezira region is seriously affected by chloroquine-resistant falciparum malaria. Every health centre has a special room for intravenous administration of quinine. The poor literacy rates are a major impediment to the implementation of effective health education and promotion of healthy lifestyles. Superstitions and tribal beliefs are still prevalent and affect health education and medical treatment outcomes. The challenges that have to be met by the health services are clearly daunting. UGMS faculty has realistically assessed them and is equal to the task. The distinctively community-based and community-oriented curriculum at UGMS and the co- operative, collaborative and consultative partnership that the UGMS faculty has developed with the regional health authorities are together what make the UGMS experience unique. In addition, one finds a sense of communion and brotherhood that seems to contribute to the community consciousness of UGMS students and staff, a finding that may be attributable in part to their Islamic cultural heritage and traditions. UGMS can be considered as a beacon for its approach to medical education not only for underdeveloped Africa, but also for other third-world nations and more

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