Rest-Hec Pres.

“REST” Model-Indigenous Approach, for bridging the gap
between Academicians and Learners

By
Dr. Minhaj A. Qidwai
MBBS, MPH, MBA, CMC
Program Director
Healthcare Management
Institute of Business Administration,
Karachi-Pakistan
Goal: To Share with participants an indigenous transformational
Strategy for Structuring Curriculum and meeting the challenges in
healthcare and development in Pakistan.
Objectives: By the end of the session, participants should be able to
understand:
• The priority issues related to Healthcare and Development.
• Where a developed nation was in 1900?
• What it did, to reach, where it is today?
• Issues in terms of Medical Education and Reforms?
• How a Transformational Strategy, can be applied to structure the
curriculum, to meet challenges in healthcare and development?
As, per W.H.O., Health is a complete
state of “Physical, Mental, and Social ISSUES ISSUES ISSUES
wellbeing” and not merely, the absence
of disease or infirmity.
Healthcare Issues-Probable Reasons?
• Healthcare-Designed, Developed and Maintained by Politicians and
Bureaucrats-Strategies-Results!
• Healthcare-Marred by Fragile System, Policies and Regulations-Uncontrolled
Delivery-Results!
• Healthcare-Delivered by Healthcare Professionals-Trained Clinically, Lack of
Primary Care Professionals, Researchers and Evidence Based Practice-Neglect
of Health Promotion and Disease Prevention-Results!
• Healthcare-Effected by Lack of Public Funding, Costs of Medicines and
Procedures-Increased Out of Pocket Costs-Results!
• Healthcare-Influenced by Clergy, Literacy, Poverty and Security-Birth
Spacing/Polio-Results!
Development Issues
Millennium Development Goals (MDG)
• Slow progress on 1990s’ summits of United Nations (UN).
• MDGs’ were formulated by UN with a combination of goals set by the
Organization for Economic Cooperation and Development (OECD) at
Millennium Summit in September 2000.
• The signatories were all 189 countries and 23 Organizations.
• MDG’s emphasized 3 core areas:
• Human Capital;
• Human Rights; and
• Infrastructure.
8 Goals, 18 Targets & 48 Indicators
http://www.undp.org/content/dam/pakistan/docs/MDGs/MDG2013Report/UNDP-Report13.pdf
MDGs’ Status-Pakistan
• Indicator Status--Pakistan followed 33 out of 41 indicators-Status:
• Lagging behind-20;
• Slow-4;
• Off track-1;
• Unmet-5; and
• On Track-3.
• Goal # 1: Poverty-Unlikely to Achieve:
I. Level of poverty dropped from 34.5 in 2001-2, to >12.4 in 2010-11.
II. All Employed- Unlikely and
III. Malnutrition-Plan (P)=20%-Achieved (A)=35%.
• Goal # 2: Education-Way Off track-Pakistan among 10 countries with least investment.
I. Primary Education Enrollment (P=100%-A=50%).
II. Literacy Rate: P=88%-A=58%.
• Goal # 3: Gender Parity-Unlikely to Achieve-Women Employment: P=24%-A=10%
• Goal # 4: Reduce Child Mortality-Unlikely to Achieve:
I. Under 5 Mortality-P=52-A=89,
II. IMR-P=40-A=74,
III. Immunization Coverage-P=90%-A=80%,
IV. Children with diarrhea P=10%-A=8%.
• Goal # 5: Improve Maternal Health-Unlikely to Achieve:
I. MMR-P=140-A=276;
II. Contraception usage-Trippled-35.4%.;
III. Births by TBAs’ has doubled 52.1%;
IV. ANC quadrupled-68%; and
V. TFR-P=2.1-A=3.8.
• Goal # 6: TB, HIV/AIDS, Malaria and Others-Unlikely to Achieve:
I. TB-P=45 Cases/10K -Actual=230 Cases/10K;
II. HIV/AIDS-+ve Trend; and
III. Malaria-P=40%-A=75%
• Goal # 7: Environmental Sustainability-Likely to Achieve:
I. Wildlife Conservation-P=12-A=11.6,
II. Safe Drinking Water-P=93-A=89 ----.
• Goal # 8: Develop Global Partnership for Development-Collaboration
is Ongoing in different sectors.
MDGs’ Status-Pakistan-Summary
• Pakistan lacks investment in Human Capital and Human Rights.
• Indicator Status—Only 3 out of 33 are ON TRACK.
• MDG’s Status:
• Only 7th MDG will be achieving its targets.
• The 2nd MDG is WAY OFF TRACK.
• The 8th, is an on-going process.
• Goals 1, 3. 4, 5 and 6 are unlikely to be achieved.
• Maternal and Child Healthcare (MDGs’ 4&5) currently
emphasized at the national level.
MDGs’ 4-5 and Related Data-Pakistan 2014
• Maternal Mortality Rate: 276 deaths/100,000 Live Births (LBs).
• Fertility rate at 3.8 remains higher, despite of all out efforts.
• Neonatal Mortality Rate: 42 death/1000 LBs.
• Infant Mortality Rate: 57.48 deaths/1000 LBs.
• < 5 Mortality Rate: 89 death/1000 LBs (2/3rd are preventable)
• 1/3 of <5 deaths are caused by treatable diseases (40%) and 60% by
water/sanitation/hygiene related diseases (eg. Typhoid).
• Malnutrition contributes to 1/3 of < 5 deaths-> 40% of children are stunted.
• Diseases associated with poor nutrition (e.g., pellagra and goiter).
http://www.indexmundi.com/pakistan/demographics_profile.html
http://www.unicef.org/infobycountry/pakistan_pakistan_statistics.html
Healthcare Issues in USA in 1900
• Infectious diseases associated with poor hygiene and poor sanitation
(e.g., typhoid).
• Diseases associated with poor nutrition (e.g., pellagra and goiter),
• Poor maternal and infant health.
• Diseases or injuries associated with unsafe workplaces or hazardous
occupations.
• Rising chronic diseases (e.g., cardiovascular disease and cancer).
• Life expectancy: 47 years.
• No Health Insurance.
• National disease monitoring initiated in 1850.
Interventions were needed in healthcare management
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm4850a1.htm
American Healthcare in 1900
• In 1904, American Medical Association created the Council on
Medical Education (CME) to restructure American medical education.
• In 1908, CME asked Carnegie Foundation to survey American medical
education.
• Abraham Flexner was chosen to conduct a survey for the 155 medical
schools in North America, which differed greatly in their curricula,
assessment, and requirements for admission and graduation.
• 1910 Flexner Report Recommended reforms for Medical Education;
and Modern Science teaching.
Flexner Report
Recommendations of Flexner led to

doubling of life span in 20th century
Ref: Commission Report on “Education of Health Professionals for the 21 st century-www.thelancet.com Published online
November 29, 2010 DOI:10.1016/S0140-6736(10)61854-5
Flexner Report-Pakistan?
• US Medical schools were "proprietary", and run to make a profit.
• Regulation of the medical profession-minimal or nonexistent.
• American doctors varied in scientific understanding and word "quack"
flourished.
• Medical Schools were high in number (155), giving unstructured medical
education.
• Flexner examined the situation. Using the Johns Hopkins School of Medicine
as the ideal and issued the ensuing recommendations:
http://en.wikipedia.org/wiki/Flexner_Report
Flexner Report-Recommendations-
Pakistan?
• Reduce # of medical schools (from 155 to 31) and poorly trained
physicians;
• Proprietary medical schools should either close or be incorporated
into existing universities;
• Increase the prerequisites to enter medical training;
• Train physicians to practice in a scientific manner and engage medical
faculty in research;
• Give medical schools control of clinical instruction in hospitals;
• Strengthen state regulation of medical licensure;
Flexner Report-
Recommendations-Pakistan?
• Medical schools should be part of a larger university; and
• Medical schools appoint full-time clinical professors and they
become the "true university teachers, barred from all but charity
practice, in the interest of teaching."
• Medical schools in Canada and USA have followed Flexner's
recommendations down to the present day.
• Recently, however, schools have increased their emphasis on
public health matters.
Flexner Report-What Next?
Education &
Systems
Recommendations of Flexner Implemented,

leading to doubling of life span in 20th century
Pakistan-At Cross-Roads
• Healthcare compromised and challenged at almost all levels.

• Most of MDGs’ unachieved.
• Four Tiered Healthcare Approach?
• Health Systems-Struggling, Complex and Costly.
• Health Management-Part of Medical Curriculum?
• Medical Education and Curriculum need reforms as per demands.
Pakistan-Medical Education
Recognized Medical and Dental Colleges
Province Public Private Public+Private
Medical Dental Total Medical Dental Total Grand Total
Punjab 18 03 21 28 12 40 61
Sindh 09 04 13 13 12 25 38
K.P.K 08 02 10 09 05 14 24
Baluchistan 01 01 02 01 00 01 03
AJ&K 02 00 02 01 00 01 03
Total 38 10 48 52 29 81 129
http://www.pmdc.org.pk/MedicalandDentalColleges/tabid/333/Default.aspx
Pakistan-Where Doctors Go?
• Surgery and its associated sub-specialties (50.3%)
• Internal medicine (26.8%),
• Pediatrics (23.2%),
• Dermatology (16.7%),
• Gynecology and obstetrics (16.7%),
• Psychiatry (13.1%),
• Radiology (10.8%),
• ENT (8.8%),
• Anesthesiology (8.7%),
• Administrative medicine (8.6%),
• Orthopedics (8.2%),
• Ophthalmology (7.5%), and
• Laboratory medicine (6.1%).
http://www.jpma.org.pk/full_article_text.php?article_id=2881
Pakistan-Medical Education
• Dr. per 1000 pt. ratio: Europe-3.5, Third world countries-1.3, Pakistan-0.7.
• Approx. 14,150/year seats for Drs. Total 165,307 Drs. in Pakistan
• 5,004-Balochistan.
• 3,079-AJK, 19,792-NWFP.
• 64,975 in Sindh.
• 68,790 in Punjab.
• 3,101 doctors are foreign degree holders.
http://www.studyinpakistan.info/medical-education
• Teacher-Student ratio: For 300 medical students:
•1 professor,
•2 associate professors,
•3 assistant professors, and
•16 demonstrators.
IS IT PRACTICED?
http://www.dawn.com/news/634487/teacher-student-ratio-changed-pmdc-step-meant-to-fill-private-coffers
Problems of Medical Education in Pakistan
Problems of Medical Education in Pakistan
Problems in Medical Education
• Impaired Mismatch of Per patient ratio;
• Mismatch of competencies to patient and population needs;
• Poor teamwork;
• Persistent gender issues;
• Narrow technical focus without broader understanding;
• Episodic encounters rather than continuous care;
• Predominant hospital orientation at the expense of primary care;
• Quantitative and qualitative imbalances in research & labor market;
• Weak leadership to improve health-system performance; and
• Tribalism of the professions—i.e., the tendency of the various
professions to act in isolation or even in competition with each other.
Redesign of professional education is

necessary and timely
November 29, 2010 DOI:10.1016/S0140-6736(10)61854-5
Medical Educational Reforms
• Three generations of educational reforms:
-First generation: At beginning of the 20th century
Science-based curriculum
-Second generation: Mid century
Introduced-problem-based instructional innovations.
-Third generation: Currently Needed-Systems based approach
Improve performance of health systems.
Universal Coverage-health professionals need to be educated to:
• Mobilize knowledge;
• Engage in critical reasoning; and
• Ethical conduct
Health Professionals-competent to participate as members
in patient and population centered health systems.
November 29, 2010 DOI:10.1016/S0140-6736(10)61854-5
Medical Educational Reforms
•Types of Reforms Needed:
A. Institutional reforms and
B. Instructional reforms.
• Proposed outcomes:
I. Interdependence in education and
II. Transformative learning.
November 29, 2010 DOI:10.1016/S0140-6736(10)61854-5
A. Institutional Reforms
• Establish joint education and health planning mechanisms that

take into account crucial dimensions, such as:
• social origin,
• age distribution, and
• gender composition, of the health workforce;
• expand academic centers to academic systems
encompassing hospitals & PHC units;
• Link together through global networks, alliances, and
consortia; and
• Nurture a culture of critical inquiry.
November 29, 2010 DOI:10.1016/S0140-6736(10)61854-5
B. Instructional Reforms
• Adopt competency-driven approaches;

• Adapted to changing local conditions;
• Promote inter-professional and trans-professional education to
break down professional silos;
• Enhance collaborative & non-hierarchical relationships;
• Exploit the power of information technology for learning;
• Strengthen educational resources, with special emphasis on
faculty development;
• Promote a new professionalism using competencies as objective
criteria for classification of health professionals;
• Develop a common set of values around social accountability; and
• Focus on Evidence based and transformational learning.
November 29, 2010 DOI:10.1016/S0140-6736(10)61854-5
Proposed Outcome:
I. Interdependence in Medical Education
• Involves three fundamental shifts from:
• Isolated  harmonized education and health systems;
• Stand- alone institutions  networks, alliances, and
consortia; and
• Inward-looking institutional preoccupations  harnessing
flows of educational content, teaching, resources, and
innovations.
November 29, 2010 DOI:10.1016/S0140-6736(10)61854-5
Proposed Outcome:
II. Transformative Learning
• Transformative learning-Proposed outcome of
instructional reforms;
• Involves three fundamental shifts:
• From fact memorization  searching, analyzing, and
synthesizing information for decision making;
• From seeking professional credentials  achieving core
competencies for effective teamwork in health systems; &
• From non-critical adoption of educational models 
creative adaptation of resources to address local needs and
priorities.
November 29, 2010 DOI:10.1016/S0140-6736(10)61854-5
Evolution of Learning
for Professional Medical Education
Transformative Learning
 Developing
Leadership Attributes
Producing Enlightened
Change.
“REST” Model
Considering the recommended reform for transformation, for education in
general and Medical Education in particular, a “REST” model based curriculum is
being followed and recommended for teaching purposes.
A. Research:
a. Enable the students to learn the fundamentals of research.
b. Undertake research on issues related to healthcare management,
policy, practice and education.
c. Write publishable research articles and reports.
B. Education:
a. Enable the students to communicate (verbal and written)
effectively and learn the concepts of Public Health.
b. Understand the principles of adult learning, developing and
evaluating educational activities and student assessment.
REST Model
C. Systems:
a. Enable the students to adopt systems based approach towards
management of healthcare organizations and teaching institutions.
b. Focus on various components of Healthcare Systems through
structured learning.
D. Training and Development:
a. To apply learnt concepts for improving management at their work
place under supervision.
b. Document the changes implemented along with justification
for changes, resistance encountered and measures taken to
overcome the change.
c. Grow professionally and bring the desired changes in the organization.
“REST” Model-Application for
Diploma Program in Hospital Management at IBA
• Research: Epidemiology, Demography, Biostatistics and Research
Methodologies.
• Education: Communication Skills, Leadership and Strategic Management.
• Systems: Organizational Behavior and Human Resources; basics of Hospital
Design; Aligning Hospital Operations; Supply Chain, Information, Financial
and Quality Management.
• Training: Participants will be provided an opportunity of first hand learning
in research, report writing and management skills.
Recommendations
- Instructional and Institutional reforms are important.
- “REST” model-a “SKELETON” Formula-Universal Teaching application.
- Enabling actions are required For transforming Medical Education:
• First: The Leadership has to come from within the academic and
professional communities, but it must be backed by political leaders in
government and society.
• Second: Focus on producing health/managers at all levels.
• Third: The individuals being taught, have to shoulder the responsibility
of taking the message to their organizations and masses for making the
necessary changes in the healthcare system management. and practices.
Recommendations
• Medical Education and Curriculum need reforms as per demands.
• Health Management should be incorporated as a part of Medical
Curriculum.
• Structure Healthcare System-Four Tiers?
• Political Will and Leadership Commitment for health and education.
• Poverty Alleviation by investment in Human Capital and education.
• Gender Indiscrimination.
• Integration among various healthcare providers, organizations and
institutions.
Summary
• Pakistan’s healthcare status is more than a century behind USA.
• MDGs’ need to be revisited for a practical and pragmatic approach.
• Flexner Report-A beacon of light for Medical Educational Reforms.
• Reforms in Medical Education in particular and Education in general:
- Institutions to focus on their Interdependence; and
- Instructional reforms to bring transformational learning.
• Regulating authorities can take forward the recommendations and play a
pivotal role in achieving the institutional and instructional reforms to achieve
the outcome.
• “REST” model-a transformational and innovative approach can be
recommended for following a structural pattern of curriculum development
and teaching for bringing the instructional reform.
Back Up Slides
How To Deal with the Unachieved MDGs’?
• Goal #1: Poverty-Unlikely to Achieve:
I. How to reduce level of poverty, II. Ensuring All Employed and III. Reduce
Malnutrition.
• Goal #2: Education-Way Off track:
Increase Investment and literacy rate.
• Goal #3: Gender Parity-Unlikely to Achieve.
• Goal # 4: Reduce Child Mortality, IMR-Unlikely to Achieve.
• Goal # 5: Improve Maternal Health-Unlikely to Achieve-Despite of Tripple
Contraception usage, Doubled Births by TBAs, and Uncontrolled TFR.
• Goal # 6-TB and Malaria and Others-Unlikely to Achieve
POST-2015-Agenda For Pakistan
• Peace and Security

• Governance
• Equitable Economic Growth
• Controlling Population Growth
• Engaging Pakistani Youth in Positive Activities
• Shift towards Qualitative
• Realization of Individual Social Responsibilities
• Short and Medium Term Goals, rather Long Term
• Investment in Education, Healthcare, and Human Capital Development.
POST-2015-Agenda For Pakistan
• Mushroom Growth of NGOs’ in Pakistan
• Lack of Inter-sectoral Collaboration
• Vertical approach of Programs
• Aid and Donor driven Programs
• Lack of Quality Data
•Establishing an affordable, available and

accessible healthcare is a challenge for
Pakistan.
•Public Private Partnerships may be able to
respond.

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Rest-Hec Pres.

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“REST” Model-Indigenous Approach, for bridging the gap

between Academicians and Learners

Recommendations of Flexner led to

Recommendations of Flexner Implemented,

• Healthcare compromised and challenged at almost all levels.

Medical Dental Total Medical Dental Total Grand Total

Redesign of professional education is

• Establish joint education and health planning mechanisms that

• Adopt competency-driven approaches;

• Peace and Security

•Establishing an affordable, available and

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