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Higher education

Expert medical knowledge

by Carolin Kröner
Only half as many mothers die in childbirth in Vietnam as in the mid-1990s: a doctor at work in a village hospital outside Hanoi

Only half as many mothers die in childbirth in Vietnam as in the mid-1990s: a doctor at work in a village hospital outside Hanoi

Medical care can be improved in the world's poorest countries through cooperation with German universities with the goal of training medical specialists. Projects supported by the Else Kröner-Fresenius-Foundation in Laos and Cambodia have successfully taken the “train the trainer” approach. [ By Carolin Kröner ]

Until a few years ago, the training of specialists in developing countries was neglected – for political reasons and because of high costs. University training and specialist medical care were considered too expensive and too technically demanding, therefore, they seemed inappropriate for developing countries.

Nonetheless, university instruction of medical specialists helps to improve medical care in developing countries in South-East Asia. A particularly successful approach is the international cooperation of universities, for instance in gynaecology.

It is important to offer training and education programmes that are adapted to a country’s needs, especially in places with a growing divide between rich and poor. The Else Kröner-Fresenius-Foundation supports programmes in the medical and humanitarian field. In Laos, successful work has been done due to the involvement of the University Hospital Freiburg for Women. Another successful programme involves dermatological training in Cambodia (see box). Both initiatives strive to develop an education system for doctors and medical personnel. As a result, the Laotian Health Ministry, for example, has become increasingly aware of gynaecologists’ training being essential for reducing maternal mortality.

Instructional material

Horst-Michael Runge, head of the Collaborating Centre for Postgraduate Training and Research in Reproductive Health at the University Hospital Freiburg, began cooperating with Vietnam in 1995. Over the past 15 years, this programme has trained more than 1,200 gynaecologists. More than a million people have benefited from better medical care thanks to these efforts. In mid-1990s Vietnam, the ratio of maternal deaths to live births was around 400 to 500 per 100,000. Since then, the ratio has fallen to 180 per 100,000. The German figure is a mere four to five maternal deaths per 100,000 live births.

The successful cooperation model with Vietnam was easily transferable to Laos, one of the poorest countries in the world. Before the cooperation began, the entire country only had 14 gynaecologists and natal-care specialists, and all of them were based in the capital Vientiane. In 2002, 600 to 800 mothers died for every 100,000 live births, mostly due to lack of education and medical care. Around 20 % of the deaths were caused by improper abortions. It is crucial that pregnant women receive not only expert medical care but also information on family planning and contraception.

Scientific expertise is essential to reduce maternal mortality. The Collaborating Centre for Postgraduate Training and Research in Reproductive Health in Freiburg developed 18 text books, 25 CDs with PowerPoint presentations and 14 instructional DVDs on gynaecological procedures and operations. The collection is Europe's largest documentation on gynaecological training – a major accomplishment in itself. The European Union of Medical Specialists and the European Board and College of Obstetrics and Gynaecology have therefore accredited the material for medical training in Europe.

The instructional material was translated into Vietnamese and Laotian, which improved the quality of the training. This is what makes this cooperation programme unique throughout the world.

The material has been approved for teaching in all eight medical colleges of the country. At first, the Else Kröner-Fresenius-Foundation funded the production of the instructional material for all university professors involved. Since 2010, however, the Vietnamese Health Ministry and the universities have paid the costs. In Laos, meanwhile, the material is used by the medical faculty to train specialist doctors and university professors in the field of gynaecology, a process that helped establish a collaborative process with the education and health ministry.

Hands-on training was also improved in Laos. Two Laotian hospitals, in Vientiane and Luang Prabang, set up post-graduate training centres. The centres have state-of-the-art technical equipment such as gynaecological examination units, ultrasound scanners, birthing beds, reanimation units for newborns, and incubators. They also offer daily courses for Laotian doctors, midwives, and nurses. The courses are carried out in cooperation with doctors from the University Hospital Freiburg and other European partner universities.

Measurable success

Six to seven specialists have been trained every year since the Laos programme began in 2002. The country now boasts 33 specialists and five new university professors for gynaecology. As a result, there are now treatments for gynaecological diseases that were previously not taught and therefore neither diagnosed nor treated.

After their training, the specialists frequently take over leading positions and instruct in provincial hospitals, where, in keeping with the “train the trainer” principle, they pass on their knowledge to general practitioners and midwives. They, in turn pass on what they have learned. Thus, in Laos more than 200,000 people now benefit from improved medical conditions, and the number is growing every day. The rural people – 80 % of Laotians – are getting better access to professional healthcare.

Official statistics show that maternal mortality in hospitals has now fallen to 380 deaths per 100,000 live births. Additionally, perinatal mortality – meaning a newborn dies within the first 10 days of birth – has dropped from 67 to 43 deaths per 1,000 births in recent years. The positive trend is also a result of midwife-training programmes carried out by the World Health Organisation (WHO) as well as courses on family planning organised by the United Nations Population Fund (UNFPA).

There is now a network of Laotian-European university partnerships:
– the University of Düsseldorf supports neonatal screening,
– the University of Basel is engaged in HIV/AIDS prevention, and
– Stockholm’s Karolinska University Hospital supports a project for early detection of cancer.
Moreover, the US-based NGO Health Frontiers offers advanced training programmes that also contribute to the improvement of medical care.

Improving medical care

The programmes described above show how to improve the partner countries' medical performance:
– through the “train the trainer” approach, which spreads comprehensive and lasting knowledge,
– by managing the project as partners thus, involving universities and local partners in planning and implementation and
– through a problem-oriented and hands-on education system that is based on medical specialist competence.

The experiences of the Else Kröner-Fresenius-Foundation prove how and why these projects should be implemented over the long-term and with a high level of expertise. The crucial factor driving medical progress, however, remain individual persons: experienced and highly-committed people are the ones who drive change.