I am grateful to God for the opportunity to deliver this lecture that has come close to the 6th anniversary of an armed-robbery attack on my life. God must have spared my life for various reasons. One of them, I believe, is to enable me fulfill a life-long cherished dream to see foundations laid for Ghana to advance medical education. This dream registered when I was Vice Dean at the University of Ghana Medical School in 1997. To realize the dream, I worked with Prof. Sam Owusu, then Dean at the time, to advocate for a National School of Biomedical Sciences and Postgraduate Biomedical Research. We shared this idea with Professor Kwamena Woode at the University of Virginia, USA who immediately got his University and the WHO involved, convinced that it had the potential of transforming medical education in Africa.
To move the initiative forward, a major conference was held at the Labadi Beach Hotel in 1998, with the late President John Evans Atta Mills (then Vice President) opening the ceremony and Dr. Eunice Brookman-Amissah chairing as Minister of Health. All stakeholders, including the WHO and the University of Virginia, accepted the proposal for a National Biomedical Science Center and Postgraduate Biomedical Research Institute. However, where the Center would be located became an issue and the project was later abandoned. This caused many of us grief. A golden opportunity was lost.
To keep the dream alive, Professor Owusu proposed that the development of the School of Biomedical Sciences and Postgraduate Research should be part of the academic development plans of the University of Ghana. When I was appointed Provost of the College of Health Sciences in 2000, this project became central in the strategic plan. In 2003, Ex-President J.A. Kufuor (then President) became personally interested in that project and had his Chief of Staff, Mr. Kwadwo Mpianim work with us to present a paper on it for the consideration of Cabinet. While that was happening, a team of Canadian medical-institution -planning experts visited Ghana. They produced a Master Plan for Korle Bu and another for the College of Health Sciences to realize a long-cherished vision for a Medical Complex at Legon conceived in 1969 under Prof. Easmon, the first Dean of the Ghana Medical School. The Master Plan featured the Biomedical Center. Today, one of the components of the Medical Complex, the University of Ghana Hospital, has been almost completed under the government of President John Mahama. The Biomedical Center, however, still remains on the drawing boards.
The concept of the Medical Complex was to build human resource capacity for sustainable health delivery in Ghana. It was to promote medical research for progressive advancement in medical services. This was the reason for the establishment in 1979 of the Noguchi Memorial Institute for Medical Research to be a leading institution in biomedical research, with a mandate to conduct research into public health problems. It was also to provide opportunity for postgraduate students in medical research, based on that concept.
If we are to succeed in building a robust medical educational system in Ghana, we must stick to this concept. And we need a home-grown educational policy to implement the concept. This is how Ghana would develop to become an equal player and partner in global health issues. This is also how Ghana would be free to prosecute its own medical education agenda to address national health needs and challenges without relying on other nations for solutions.
Before I turn to the main subject of tonight, let me place on record my appreciation to Prof. Larbi, our indefatigable President, for asking me to speak on a subject which I am passionate about. Actually, it was Professor Larbi who proposed the topic. And I believe he did this from what he had gleaned out of a concept document for a Regent University School of Medical and Allied Sciences produced nine months ago with the help of my colleagues Dr. Stanley Moffatt, Dr. Evelyn Owusu and Prof. Desmond Ayim-Aboagye. When we speak about this school, most people immediately conclude that Regent is setting up a Medical School. No! This is not our primary focus. Regent is not setting up a medical school. Nursing school or school of allied health sciences. The school we are planning for is not an undergraduate school but a postgraduate School with a postgraduate research focus especially in the clinical areas.
I need to also emphasize that what I shall be addressing goes beyond medical education. It covers education in all areas of life for the total development of our nation. In other words, there is also a missing link in our educational system that must be addressed. And this is a matter that should gain the critical attention of government and of Parliament, as it affects the present and future fortunes of Ghana far more than any other factor in national development. We need a national policy that would intentionally scale up education from the first degree to the postgraduate degree level. Ghana should be focusing on producing adequate numbers of postgraduate scholars in all areas including science and technology. We need to build our human resource capacity for innovative research of strategic national issues for accelerated industrialization.
In addressing this matter, we must acknowledge the fact of the very rapid growth in numbers of tertiary institutions in Ghana. From the National Accreditation Board records, there are 10 public Universities, 70 Private Universities out of which 4 are Chartered; 10 Polytechnics, 47 Registered Colleges and others making a total of 183 tertiary institutions. Considering that the University of Ghana was established in 1948; the University of Science and Technology in 1952, and the first private university, Valley View University established in 1979, this growth has been phenomenal and would, likely, continue till we are able to absorb all graduates from second-cycle institutions.
From the 2012/2013 academic year NAB data, there were 228,347 students in the public and quasi-public tertiary institutions; 65,890 students in Private tertiary institutions; 51,169 in the Polytechnics; and 38,409 in registered Colleges (SLIDE 3). However, of this number, only a few are pursuing postgraduate Masters and fewer still the PhD in the public universities. In the private institutions, the focus is on undergraduate programs with very few non-research masters programs (SLIDE 4). If this trend is allowed to continue, Ghana would be flooded with first degree holders who would have little opportunity to advance to the MPhil and the terminal PhD degree level. And it should be noted that it is at the PhD level that quality, sustainability, reproducibility, advancement and innovation in every sector of life is determined.
It is also to be noted that the current crop of professors most of whom had their PhD education in foreign institutions, are ageing and their replacement would be difficult. Considering that in some advanced institutions professors serve even at the age of 80-90, we need a national policy that would allow the engagement of such persons to contribute to academic excellence for as long as they are healthy and able.
1. THE POWER OF THE NEURON
To introduce the topic of the missing link in medical and other areas of education, I would like, Mr. Chairman, to speak briefly about the neuron, the basic cell unit of the nervous system.
Having taught neuroanatomy for several years, I have come to appreciate better the importance of this cell. The progress any individual makes and for that matter a family or community or nation makes, is closely linked to the extent to which this cell is developed and used. The economic life of a nation is proportionally related to the extent to which this cell is used; the strength and sustainability of systems and institutions depends on the neuron; advances we make in technology depend on how effectively we employ these cells.
We need the neuron to protect us from exploitation; we need it to be truly independent and to achieve interdependence; we need it to gain competitive advantage in the global market; we need it for social advancement. The neuron is designed for critical observation, critical thinking and for critical analysis of issues. It is the most important tool we use to explore the universe to discover what is already there and to use it for our advantage. It is therefore the tool that enables effective and efficient business for the best economy of life.
The neuron is a key provision of God for mankind to fulfill the mandate of having dominion over the earth and subduing it (Genesis 1:26-28). In the neuron resides the divine capacity also for love, respect, goodness, justice, morality and ethics.
It is estimated that there are about 86 billion neurons in the human brain. Considering the enormous functional capacity of the neuron to receive, interpret, modify, suppress, enhance, store (memory), integrate and use information to advance knowledge, this huge number of neurons indicates how well-endowed we are with intelligence. But it is not just about the number of neurons. It is about its capacity to influence change and, therefore, to dominate. If it is about numbers, elephants should be dominating the world for they have more - 300 billion, even though most of these are in the cerebellum designed for balance and coordination of movement.
For as long as the earth has been in existence and for as long as all creatures have lived, only human beings have influenced its life substantially and will continue to do so because of the functional capacity of the neuron. This is why we are stewards of the earth, as mandated by God.
The neuron has enabled generations of human beings to push the frontiers of knowledge further and further forward. The foundation laid by one generation propels the next generation to a higher level of knowledge and achievement. Each stage is facilitated by the generation of new ideas through research resulting also in improved technology. From use of simple tools in the days of Adam and Eve to the building of the tower of Babel to the present, mankind has achieved much.
Specifically, what has contributed to the advances that have been made could be traced to the beginning of scientific enquiry. From around 500 BC, Greek Philosophers like Alcameon, Hippocrates, Socrates, Plato, and Aristotle spent time exploring life. The founding of the School of Alexandria in Egypt for studies in mathematics, astronomy and medicine promoted scientific learning and exploration with teachers such as Herophilus and Erasistratus down to Galen. For nearly 1000 years after Galen, scientific approach to studies was arrested but intermediated by Arabic scientists like Rhazes and Hali-Abbas until its renaissance through the establishment of the first University in Bologna, Italy in 1156 AD. From that time to the present (only 860 years ago), there has been an avalanche of growth in scientific thought and investigative processes, with commensurate growth in knowledge and technology.
Today, the knowledge gained has propelled mankind to unimaginable levels including space exploration, genomic studies permitting a full library of the human genes to be established for medical research, and ever expanding growth in Information Communication Technology. This has revolutionized business, making us more efficient, effective and productive. At this rate of progress in research, one cannot imagine what the world would be like in the next 10 or twenty years. These advances are attributable to the effective and efficient harnessing of the creative capacity of the neuron. And we have this neuron in equal measure, whether black or white, rich or poor, strong or weak. The extent to which we invest in the neuron to develop and use it, is the extent to which we advance in life. Countries that make significant investments in higher education are the ones most likely to become problem-solvers. They are also the ones that lead in science and technology and, therefore, in the manufacturing industry.
Countries that invest little to develop and harness the full potential would likely remain “hewers of wood and drawers of water” (Joshua 9:21). They would be exploited; they would be providers of raw materials that will be refined and sold back to them at higher prices; they will have a consumer-driven economy.
With this critical and foundational concept of the neuron in mind, I now address the main topic of the day, “The missing Link in Ghana’s Medical Education: From Guggisberg to the Present”.
2. FIRST, THE MILESTONES IN THE DEVELOPMENT OF MEDICAL EDUCATION IN GHANA:
Ghana has several important milestones in its history of development of medical education.
2.1 In the pre-colonial period and before the advent of Western Medicine, medical education and, hence, medical practice, was offered by local priests and herbalists. Disease was regarded as influenced and precipitated by spiritual events. Evil spirit forces were thought to operate in a manner that affected the physical and mental health of individuals directly or indirectly through the family. These evil forces must be expelled or appeased where offense had been caused. Incantations, prayer, deliverances as well as herbal treatment, combined in some case with animal sacrifices, featured in the management of the patient. Education in this traditional medical business was private and jealously guarded by families. Knowledge was passed from one generation to the other through traditional inheritance patterns. Those who served as health-care assistants to the traditional priests and herbalists learned some of the secrets of the practice. Some of these assistants shared their knowledge about herbs for healing with friends and family. This way, some of the herbs with medicinal value became known to others in the community.
2.2 In the period of the slave trade (1418-1809), western type of medical care was available but benefitted only the slave-traders and colonial masters. According to Prof. S.K. Addae, author of “History of Western Medicine in Ghana”, before the 20th Century, some Africans were trained as doctors but they only served the colonial masters. The establishment of the Basel Mission in 1828 marked the beginning of the effort to introduce scientific medical care to indigenes. The Moravian Brethren from South America, who continued the work of the Basel mission from 1840, introduced elementary health education and health care in Ghana. In 1885, Dr. Rudolph Fisch established the first out-patient clinic at Aburi. This was expanded to provide for in-patient care. It also facilitated the training of medical nursing and dispensing auxiliaries (Larbi). This first local care center collapsed soon after. In 1929, the Scottish Mission began to build a hospital at Agogo, completing it in 1930.
2.3 GOVERNOR HUGH CLIFFORD (First major health policy): On account of rapid growth in the British colonial government administration and high mortality rates among the whites, Governor Hugh Clifford adopted a policy to extend medical services to cover all citizens.
2.4 GOVERNOR GUGGISBERG: Hugh Clifford was succeeded in 1919 by Governor Guggisberg who implemented his policies, building the Gold Coast Hospital in 1923 at Korle Bu. But Governor Guggisberg did more. He introduced a plan for medical education to produce health care professionals. For that reason, he acquired 160 acres of land at Korle Bu. Having served in the Survey Department of the Gold Coast previously to prepare a map for the country and having worked closely with the chiefs and people, he also believed in the capacity of the indigenes to develop the country. He therefore invested in education of the people, establishing principles to ensure quality and encouraging also education of women, The Achimota School was established as a model for those principles to be espoused. Building roads and railways and expanding potable water supply together with his educational policies, Guggisberg laid a strong foundation for economic growth of the Gold Coast. In 1927, his appointment was terminated.
2.5 Ransford Slater: The health care development plan of Guggisberg to produce high caliber health professional staff for the Gold Coast was suspended by his successor, Governor Alexander Ransford Slater. For economic reasons, Slater favored the training of medical auxiliaries (medical assistants, sanitary inspectors and midwives). He also caused retrenchment of medical staff also for economic reasons.
Between 1935 and 1955, six public health schools had been established – the Accra Sanitary School (1935), the Nursing Training School at Agogo under the Presbyterian Church (1935), the School of Nursing, Kumasi (1945), the School of Hygiene at Korle Bu (1948), the School of Nursing at Korle Bu (1948) and the Dispensing School (1953) at Kumasi. All these schools offered programs leading to the award of certificates or the diploma.
In this period (1935-1955), an important policy decision was made to educate and produce high level health professionals in institutions outside the country through Commonwealth Scholarships, the Canada-Colombo plan, Inter African University program and the Eastern European scholarship program. From these, students from the country were placed in institutions in Canada, the UK, Australia and New Zealand among others. A number of the well qualified health professionals educated in the external institutions returned to take up leadership responsibilities in the health sector. They included doctors, nurses and dental practitioners. It was through this crop of professionals that the foundation was laid for growth in medical education in Ghana. Through this crop of qualified health workers, health professional associations also began to emerge.
2.6 The Role of Dr. Kwame Nkrumah in Advancing Medical Education in Ghana: From the time of independence in 1957 to date, rapid advances have been made in medical education with significant impact on health service delivery. Major foundation for this was laid by Dr. Kwame Nkrumah in 1962 when he established the Ghana Medical School which, in 1969, became the University of Ghana Medical School when it was incorporated into the University of Ghana to validate its academic programs and to award degrees.
The significance of this policy-shift under Dr. Kwame Nkrumah should be well noted and appreciated. In establishing the medical school, a major missing link in Ghana’s medical education was provided for. Dr. Nkrumah’s policy marked the beginning of escalation of medical education from the certificate and diploma level to the Bachelor degree level. It marked the beginning of the localization of medical education in other health disciplines with huge economic benefits.
By Nkrumah’s policy, Ghana made significant savings producing its own health manpower at the first degree level - doctors, dental surgeons, nurses, medical technologists and pharmacists at a fraction of the cost of training such professionals in external institutions. Prof. Nii Otu, then Vice Dean of the Dental School and I as Dean of the Medical School noted this when we realized that what it cost the country a year in tuition for 30 dental students for clinical training in the UK (600,000 pounds) was the same amount needed to build and equip the dental school ($1,000,000). More so, many of those who graduated from the external institutions did not return to serve. On the other hand, many of those that have graduated from the Dental School are working in the country. Some have progressed to become teachers at the Dental School.
A research is called for to determine the full economic impact and benefits of Kwame Nkrumah’s policies in medical education.
3. POSTGRADUATE PROFESSIONAL DEVELOPMENT IN GHANA AND WEST AFRICA:
Another important mile-stone in the development of medical education in Ghana was reached in the localization of postgraduate professional programs. This began with the establishment of the West African College of Surgeons in 1975, under the West African Postgraduate Medical College (1973), now an agency of the West Africa Health Community (WAHC, 1978). After the West African College of Surgeons, came the West African College of Physicians in 1976. In 1979, the West African College of Nurses was formed under the same agency. And in 1991, the West African Postgraduate College of Pharmacists was formed. These major historic events bridged yet another missing gap in the development of medical professional practice with significant economic and social benefits.
Before then, postgraduate health professional advancement was provided by external institutions in Europe, Asia, North America, Australia and New Zealand.
4. FORMATION OF NATIONAL HEALTH PROFESSIONAL COLLEGES:
The formation of the West African health professional colleges encouraged the formation of national ones. By an ACT of Parliament, the Ghana College of Physicians and Surgeons was formed in 2003 as the first local postgraduate professional college with a mandate to produce professional medical and dental specialists and consultants. In the year 2013, the Ghana College of Nurses and Midwives was established by ACT 833 of Parliament, enabling the nursing profession to have locally developed postgraduate programs. What remains in the gap to be filled in this area of postgraduate professional development in Ghana is a College of Allied Health Professionals and a statutory Ghana College of Pharmacists.
5. ESTABLISHMENT OF PROFESSIONAL HEALTH TRAINING AND PRACTICING REGULATORY BODIES:
To ensure quality of medical education and of professional development and practice, government established regulatory bodies for the health disciplines beginning with the Nurses and Midwives Council in 1971 (changing to Nurses and Midwifery Council in 2013). The Medical and Dental Council followed in 1972. In 2013, the Allied Health Professions Council was established by ACT 857 of Parliament.
6. THE MISSING GAP IN MEDICAL EDUCATION:
I have pointed out that Ghana has progressed in medical education from the auxiliary level of training to the certificate and the diploma through to the first bachelor degree stage through the initiation of governmental policies. As a country, we have also successfully advanced to the level of postgraduate professional education. What we should now be investing that will drive best the quality of medical education and make it sustainable is postgraduate academic education. There should be a national policy that would ensure advancement in medical education to the postgraduate academic level up to the PhD. This policy should cover all professional disciplines - medical, dental, nursing, medical technology and other disciplines with services that impact health care. In some ways, Ghana has laid a good foundation for this level of academic development to be possible. We must now intentionally move to utilize these initiatives fully supported by a national policy that will drive it.
The following are examples of such health training institutions in Ghana with capacity for PhD programs:
6.1 Health Research Centers of the Ministry of Health: The Ministry of Health has medical research centers at Navrongo (established in 1992) and Kintampo that could readily be used as primary sites for PhD studies with clinical and academic supervisors from other institutions. These centers have strong links also with several universities in the world and with major funding agencies.
Others are The National Cardiothoracic Centre; National Radiotherapy Centers; The National Reconstructive Plastic Surgery and Burns Center at Korle Bu; 6 major Teaching Hospitals; Other Hospitals; Polyclinics; The Center for Scientific Research into Plant Medicine at Mampong, Akwapim.
6.2 The Noguchi Memorial Institute for Medical Research: As noted earlier, this Institute which is part of the College of Health Sciences of the University of Ghana has a huge potential for PhD studies through its biomedical and public health research programs.
6.3 Graduate Schools of Public Health:The School of Public Health at the College of Health Sciences of the University of Ghana was established in 1994 with a concept of a public health school without walls. Through the initiative of Professor Isabella Quakyi, this School has developed into an institution with quality graduate programs including the PhD. The Ensign School of Public Health, a private tertiary institution, runs the Master of Public Health program but could have higher degree programs.
6.4 The Basic Medical and Para-clinical Sciences at our Medical Schools: Academic progression at the Basic and Para-clinical sciences has remained limited for years mainly because of inadequate space and research facilities. It was for this reason the National Biomedical School and Postgraduate Biomedical Research was proposed in 1997. Intercalated BSc programs with research focus for academic staff development for the Ghana Medical School in 1970 grew into a local BSc medical program in 1985 and thereafter into MPhil programs. I am reliably informed by Prof. Fred Addai who has worked very hard at this that there are now more than 30 MPhil graduates from that program. Similar effort has been made at the para-clinical sciences, producing a number of MPhils and now some PhDs, led by Prof Mercy Newman and Prof. Patrick Ayeh-Kumi, the current Provost. I am aware also of Master’s programs at the College of Health Sciences of the Kwame Nkrumah University of Science and Technology under Prof Agbenyega and others. Here again, I call for the National Biomedical Research Institute to be established to drive pre-clinical and clinical research.
6.5 Academic Postgraduate Studies at the Clinical Level: At the clinical level, there has been little effort to invest in MPhil and PhD programs. The result is that although there are professional specialists and consultants, high level clinical research has not been a strong feature in our teaching hospitals and in other hospitals, medical centers and clinics in the country. At the School of Medicine and Dentistry of the College of Health Sciences, University of Ghana and in the other medical and nursing schools in the country, only few on the faculty hold both medical professional and PhD qualifications. More worrying is the fact that the few with professional and PhD qualifications have either retired or are on post-retirement. This is serious for the future of medical education in Ghana. We must take steps as a nation to ensure adequate numbers of well-qualified health professionals with academic degrees are produced to re-populate our medical education institutions.
7. RELEVANCE OF THE ACADEMIC POSTGRADUATE PROGRAMS TO THE PHD LEVEL:
Why is this missing link vital in medical education?
Ghana cannot achieve academic independence in medical education and, for that matter, in any other area without investing in local PhD programs. We need this to build strong medical institutions that would offer quality education at all health professional institutions: nursing, medical, dental, pharmacy and medical technology. Our teaching hospitals should be led by clinicians, nurses, pharmacists and technologists with the PhD degree. A strong health team is needed to deliver the best quality care to the patient. And, as noted already, our medical academic schools should have very experienced PhD faculty to lead in medical research, mentoring MPhil and PhD students.
Ghana should have adequate capacity of health workers to confront emerging diseases and microbial resistance to antibiotics which is of great concern globally. We should be able to research and produce vaccines for tropical diseases. With home-grown policies that would promote localization of postgraduate academic programs in health, Ghana will be improving its health economy beyond that achieved by Dr. Kwame Nkrumah. When we are able to move Ghana to the highest academic level, we shall attract significant grants for international collaborative research. And Ghana would become a destination for advanced medical education for students from other countries.
8. WHAT DO WE NEED AS A NATION TO ADDRESS THIS MISSING LINK?
Having identified the missing link, how do we address it? How do we scale up medical education to the highest level to make it sustainable? And who must be involved in this?
Mr. Chairman, let me state that Ghana has what it takes to address all these questions.
8.1 First, we have history to inform and guide us. The policy of Dr. Kwame Nkrumah to localize training of doctors and to raise the level to the bachelor degree, influenced localization of other health professional programs at the same level. Today, we are still reaping the benefits.
8.2 Second, it requires a shift in mind-set from the bachelor level to the PhD degree level in all areas, and not just in the medical sciences. As the Bachelor programs became an attractive preferred option to the diploma ones, so will the PhD be.
8.3 Third, a national policy. Whatever contributions individuals and public and private institutions are making to introduce the PhD, government has a major role to play by introducing educational reforms that would emphasize postgraduate education to the PhD level. The need for critical observation and critical analysis however should begin even at the preparatory and basic school levels. When students are brought up this way with strong emphasis on logical thinking, they will be better research students at the PhD level. I am, therefore, appealing to His Excellency the President and to our Parliamentarians to seriously consider this.
8.4 Fourth, availability of Resources: It is my belief that Ghana has more than adequate resources for the PhD especially in the clinical areas. We may not have what the advanced nations have. But we have reasonably well-equipped hospitals and research centers; and we have PhDs some of whom are on retirement but who have great experience to share. In my view, the availability of competent faculty is even far more important than availability of equipment. And we have both.
8.5 Fifth, Corporate Business Involvement for Financial Support: We must view this need building a nation and not individual institution. Everyone has a role to play in this and especially the corporate business organizations. The Board of Trustees for an endowment fund for Postgraduate Studies set up at the College of Health Sciences when I was Provost has shown what contributions such organizations can make to development of medical education. Led by Dr. Charles Mensa and followed by Mr. Sam Okudzeto, this fund has provided for postgraduate medical education for staff development for the College. I believe this partnership will grow.
8.6 Sixth, Ghana is well endowed with Brilliant Students: In my mind, this is the best resource of all. We have many young and brilliant first-degree-holding health professionals who are well suited for PhD studies. We should intentionally identify these students and track them into research, just as was done for me when I was a medical student. These professional graduates should be fully sponsored to pursue postgraduate academic degrees to the PhD. They should be encouraged to study at public and private hospitals, public research institutions and at diagnostic centers available in the country. Whilst they are doing this, they should be on their salaries as professional workers. And government should also provide incentives for them to progress professionally and academically when they complete their studies.
8.7 The seventh requirement is the will to do it. We need the political will; we need the will of the people; we need the will of academic leaders; we need the will of health institutional leaders; we need the will of CEOs in corporate business institutions; we need the will of all agencies related to medical education; we need the will of Parliamentarians. I trust that all those listed would say “yes we are willing to do it”; and will add, “yes, we will to do it and we “we will make it happen”, God being our helper.
God grant us grace to pursue this national agenda for Ghana to realize its full potential and capacity, harnessing fully the rich human resource potential for socio-economic advancement. God bless our homeland Ghana and make our nation great and strong.