Where there’s a will there’s a way

Lesotho Times - - Opinion & Analysis - Dr Tholang Maqutu

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 min­iste- rial 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 stu­dent­doc­tors’ 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 ac- cred­i­ta­tion or qual­ity as­sur­ance au­dit of LSOM.

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.

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 in­ter­dis­ci­pli-

nary 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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