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The case for specialized medical universities – Part 3

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Indeed, the Tokyo Medical Women University in Japan, which I visited in October 2018, is one of the highest performing Universities in Japan. Established in 1900, the University currently ranks 151st among Universities in the world and has some of the most sophisticated medical facilities for research and teaching in Japan.

To my knowledge, the establishment of UNIMED was fortuitous rather than purposefully designed. The journey began in June 2014 when I paid a courtesy call on the then Governor of Ondo State, His Excellency, Dr. Segun Mimiko. In the usual manner of showcasing his achievements as Governor of the State, he drove in his car with me in the owner’s seat, and the then Commissioner of Justice and Attorney General of the State, EyitayoJegede, SAN in the front seat.

Without telling me, he drove incognito to the Medical Village in Ondo City, an edifice that he had completed two years previously and which was then functioning very well. The Medical Village, as it was then called, consisted of state-of-the-art facilities in trauma care, general and specialized surgical care, kidney specialist care, obstetrics and gynecology, and child health. On inspection of the facilities, I immediately divulged to Mr. Governor that those were the most ultra-modern and well equipped comprehensive medical facilities that I had seen anywhere in the country at that time. I then spontaneously recommended that based on the vast expanse of adjoining land, and the comprehensiveness of the services available, the Village could form the nucleus of a Medical University. I reminded him that Ondo State was the only State in South-West that did not have a medical school in any of its existing Universities.

Indeed, Ondo State despite being an oil-producing zone was then the only State in Southern Nigeria that did not have a Medical School. This is despite the fact that Ondo State had one of the highest numbers of professors in medicine, some of the most accomplished professors of medicine (such as Professor Oladipo O. Akinkugbe), and indeed about five professors that had been honored with the National Order of Merit in the Medical Sciences (NNOM) in the country. I decided to push his ego further by telling him that as a medically qualified Executive Governor, he will be making a grave mistake if he did not consider establishing a medical school in his State during his tenure as Governor. I further quipped that the medical village facilities were excellent points of reference where a comprehensive Medical University could be established.

As usual, when I ramble on like that, Dr. Mimiko listened to me attentively and did not alter a word, but quietly padded me on the back signifying his recognition and appreciation of the points I had made. About two weeks after this meeting, Dr. Mimiko called me on the phone to ask whether I was familiar with the NUC criteria for establishing new Universities and then asked me to help him identify someone who could advise on how a Medical University could be developed in Ondo State. My colleague, Professor Eugene Okpere was then on sabbatical leave working as an adviser to the Executive Secretary of the NUC, Professor Julius Okojie. I immediately recommended Professor Okpere as the ideal person to contact.

Subsequent events led to the presentation of a bill for the establishment of the University to the Ondo State House of Assembly and the passage of the bill into law in October 2014. In March 2015, I was appointed the Vice-Chancellor of the University while the Dr. (Mrs.) EF Oyebade, mni, of blessed memory was appointed the Registrar.

I accepted this appointment for two main reasons. First, the encouragement and goodwill that I received from principal stakeholders in the Ondo Kingdom at the time were gargantuan. Specifically, these were 1) the Osemawe of Ondo Kingdom, himself a medical doctor with whom I attended the Obafemi Awolowo University Medical School (then the University of Ife), HRM Oba (Dr.) Victor AdesimboAdemefunKiladejo, Jilo III; and 2) Emeritus Professor Oladipo O. Akinkugbe, the doyen of Medicine in Nigeria. I spoke to both of them about the Vice-Chancellorship appointment, and they gave encouraging words of advice and urged me to accept the offer. I later found out that the Osemawe and the Governor had tremendous respect for me. The three of us were both at the University of Ife (now Obafemi Awolowo University) in the ‘70s as a medical student. They were familiar with my propensity for hard work and ethical values; traits that make up my core till today. Indeed, the Osemawe assured me at the time that he knew me more than I know myself, and that he will give me stupendous support in administering the University. I can confirm without hesitation that he has not departed from this promise till this day.

The second reason that I accepted the appointment as Vice-Chancellor was the consideration of the unique opportunity and high confidence that Ondo State was offering me to develop the first Specialized Medical University in the country. A task that I considered monumental and will forever go into the history books. My not being a citizen of Ondo State propelled me to prove the point that high profile academic appointments should never be based on ethnicity or other primordial factors, but on competence, and the ability to deliver standard outcomes. I immediately conducted a SWOT (strengths, weaknesses, opportunities, and threats) analysis of the prevailing situation and convinced myself that I had the temerity, depth of knowledge, and connections to take on the big task with positive outcomes. The analysis also helped me early to identify the barriers that impact the training of healthcare professionals.

The University commenced with seven Faculties: Natural Sciences, Basic Medical Sciences, Basic Clinical Sciences, Clinical Sciences, Dental Sciences, Nursing Sciences, and Allied Health and added a School of Postgraduate Studies in October 2017. A Department of Herbal Medicine designed to train Nigeria’s first set of professional herbal medicine practitioners, and an international School of Public Health named after a Nigerian Health visionary and former Minister of Health – the Professor Mohammed Pate School of Public Health – will commence in the 2018/2019 academic session. The pioneer Departments of the University (Anatomy, Biochemistry, and Physiology) currently offers a Master of Science (MSc), Master of Philosophy (MPhil), and Doctor of Philosophy (Ph.D). Also, the Department of Anatomy offers the Doctor of Medicine (MD) degree program. UNIMED already has an approved national and regional clinical fellowship program in trauma and emergency medicine which started in December 2015. Presently, 15 students are enrolled in the fellowship program.

UNIMED now offer degree programs in Medicine, Dentistry, Nursing, Medical Laboratory Sciences, Physiotherapy, the Basic Medical Sciences (Anatomy, Physiology, and Biochemistry), and the Natural Sciences (Biology, Chemistry, Physics, and Mathematics). We are now set to offer academic programs in Occupational Therapy, Medical Radiography, Pharmacy, Pharmacology, Biomedical Engineering, and Herbal Medicine. It is anticipated that our efforts will significantly increase the number of medical and allied health professionals produced to serve in the nations’ health care system. I have so far served four years as Vice-Chancellor and our other accomplishments will be discussed later in this presentation.

The Specialized Place of Medical Universities to Address Developmental Challenges in the Health Sector Since the establishment of UNIMED, the passion for Specialized Medical Universities has gained popularity in the country. The next wave of such Universities came with the approval given by the NUC for the establishment of PAMO Medical University, and the Eko University for Medicine and Health Sciences in Lagos – both of which are private universities.

Recently, the Bayelsa State Government has established the Bayelsa Medical University and the appointment of the Governing Council, Vice-Chancellor and the primary university administrators.

In 2017, the Senate has also approved the Federal University of Health Sciences, Otukpo, but this is yet to take off. On another note, I recently had a conversation with Governor Nassir El-Rufai, during which he promised to establish a Medical University in Kaduna State in the not too distant future.

Thus, a relevant question is: why the sudden interest in the establishment of Specialized Medical Universities in Nigeria? Many reasons may explain this trend. First, is the proven success of UNIMED – the first Specialized Medical Universities in Nigeria. The experiment revealed that with the right leadership and support, a lot could be achieved in developing the Natural Sciences, Basic Medical Sciences and some of the professional programs within a short period. The NUC approved UNIMED in April 2015, and the first cohort of students was able to enroll by January 9, 2016. Since then, we have recorded critical successes that include 1) NUC accreditation of the first cohort of Medical, Dentistry, Biochemistry, Anatomy and Physiology programs, and 2) accreditation of the second cohort of Medical and Dentistry programs by the Medical and Dental Council of Nigeria (MDCN). The accreditation of our Pathology and Pharmacology programs by the MDCN is pending. We anticipate graduating our first cohort of Anatomy, Physiology, and Biochemistry students by December 2019. Most significantly, we are on track to graduate our first set of students in December 2019, and our first Medical Doctors and Dentists by late 2020.

Indeed, based on the resounding success of UNIMED, I am aware that the NUC has been promoting Specialized Medical Universities to various stakeholders in the country. I will not be surprised if the medical schools housed in the traditional Universities are in the minority very soon.

The second reason, which is apparent from the exceptional performance of UNIMED, is that having medical schools as part of a full-fledged traditional Universities have hitherto not proven to be effective. The failure is because many of our traditional Universities consistently grapple with lack of resources and funding to support their academic programs. Given that medical and health sciences programs are capital intensive, traditional Universities in Nigeria are often unable to provide adequate resources needed to launch and operate a world-class medical school. Based on my academic experience at Obafemi Awolowo University and the University of Benin, I can unequivocally confirm that the annual budgetary allocations to the conventional Universities do not adequately fund the medical schools.

There was an attempt in the past to solve this challenge with the recommendation by the MDCN that Universities should consider establishing independently administered Colleges of Medicine as a way to partly decentralize power and garner additional resources for the medical schools. To date, of all the Colleges of Medicine in Nigeria, perhaps only the Universities of Ibadan and Lagos have been able to address this concern realistically and purposefully.

The third reason why Specialized Medical Universities have become very important and epic in the country is the high demand for medical and allied health professionals in the country. Many reports suggest that the number of doctors, dentists, physiotherapists, occupational therapists, and bachelor’s degree-prepared nurses in the country are just not adequate to deal with the increasing population growth and the high burden of disease in the country. The rising wave of external migration of medical and allied health professionals seeking greener pastures in more developed countries further compounds the problem. Furthermore, some critically needed health professionals such as physical and occupational therapists, medical engineers, psychotherapists, and others are just not adequately produced in the country. Indeed, some of the disciplines are on the verge of extinct due to the mass emigration of the professionals. Universities of Medical and Health Sciences have an excellent chance to train the critically needed health professionals as they will have flexibilities for creative program expansion. The shortage of critical health professionals due to migration has become more chronic in recent years. For example, more than 5,000 Nigerian trained medical doctors have migrated to the USA. Similarly, Nigeria has produced more than 3,000 physiotherapists in our universities, but less than 700 are currently practicing in the country. For a leading country in Africa such as Nigeria, the mass exodus of our health professionals to other countries is dangerous to the development of our healthcare system.

Advantages and Disadvantages of Specialized Medical Universities
Currently, traditional Universities in Nigeria are restricted by the NUC and the MDCN in the number of students each academic program, including Medicine and Dentistry, can admit. NUC attributes the restriction to inadequate facilities and the limited number of lecturers available to teach medical and health-related courses in those Universities. With adequate physical and human resources, the Specialized Medical Universities will be well positioned to admit more students into various academic programs. A case in point is the dedicated Women Medical University in Tokyo, Japan, which enrolls 500 students each year, and ditto for Specialized Universities in Egypt and South Africa. With the increasing pre-eminence of Medical Universities in the country’s educational landscape, the well-funded institutions will soon be able to admit 300 medical students annually.

The interprofessional educational model used by UNIMED and other Medical Universities around the world provides a unique opportunity to educate all health professionals in tandem. This approach promotes collaboration and a better understanding, among the students and faculty, the roles and responsibilities of the members of the health care team. The interprofessional model of educating healthcare professionals has the potential to reduce the current intra-and inter-professional rivalry among health professionals in the country. Therefore, it is worth the investment for other medical schools in Nigeria to explore this global best practice of educating healthcare professions.

With the advantages so far discussed, there are potential drawbacks in Specialized Medical University education. The absence of other non-medical professional programs on campus may limit the educational exposure and skills of students in Medical Universities. For example, traditional Universities have lecturers and students in Faculties of Law, Social Sciences and Agriculture, with which medical and health sciences students and lecturers in conventional medical schools often interact during their training. The out of class interaction enables the medical students to gain life-long experiences and friendships which can serve them well after graduation. However, a purposeful and deliberate design of the Medical Universities’ curriculum that provides leadership and community engagement activities would reduce this drawback as a substantive weakness.

Lessons, Outcomes and Recommendations
The new trend in the establishment of Medical Universities provides the opportunity for a paradigm shift in medical education in Nigeria. This move will correct the inadequacies that previously bedeviled the training of medical and health sciences professionals, thereby leading to quality improvement and the onset of a new cohort of health professionals that will be better trained to address the health care needs of our people. At this juncture, I would like to discuss some of the curriculum related experiences that we have gained at UNIMED which I believe will be useful lessons for newly established Medical Universities in Nigeria.

1). Natural Sciences and Basic Medical Sciences Conundrum. One of the initial contentious debates and challenges that emanated was whether we should focus exclusively on the Basic Medical Science courses and not be buoyed down by the Natural Science courses such as Biology, Chemistry, Physics, and Mathematics. This line of reasoning championed by some of our stakeholders was that we should not include a Faculty of Natural Sciences since other Universities in Ondo State were offering degree programs in the Natural Sciences. We are grateful that those who supported having the Faculty of Natural Sciences won the day. After all, medical and allied health students in the traditional medical schools are often admitted at the 100 level after they have passed all the examinations in the natural sciences. This position reaffirmed the fact that medicine and other health sciences disciplines emanated as offshoots of the natural sciences.

Without a solid foundation in the arts and natural sciences, medical and allied health students are unlikely to do well in the clinical and professional courses. Our experience at UNIMED indicates that students who passed all the examinations in the natural sciences are more discerning, more conscientious and more amenable to training as they progress faster in their medical education. Attempting to train medical and allied health professionals without a sound foundation in the natural sciences is akin to growing a tree with its branches rather than with its roots. Although some trees are known to blossom this way, it is often with great difficulties, and indeed, many withers away within a short period.

My first recommendation is that Medical Universities should include a Faculty of Natural Sciences that include Departments of Biology, Chemistry, Physics, Mathematics, and Computer Science in their curricular planning – This is the model that we fashioned at UNIMED with excellent learning outcomes, including the attraction of external grants from international agencies. Any Medical University that fails to have a Faculty of Natural Sciences will eventually find out that they have made a grave mistake which will be difficult to correct at a later date. Indeed, I have reviewed the curricula of many Medical Universities around the world and have not found one that does not include the Natural Sciences as foundational courses.

A unique aspect of the UNIMED education is the integration of General Studies and Entrepreneurship (business aspect of medicine) courses into our medical, dentistry and allied health curricula. In addition to these unique courses, our students are encouraged to participate in rigorous clinical and community-based internships as part of their training. These experiences have the potential for liberating our graduates and not make them solely dependent on government jobs after graduation.

2). Name and Diversity: Another argument posited by some of our stakeholders is that Medical Universities should exclusively be for medicine and dentistry professions and not include any other health-related disciplines. Again, this is a short-sighted position as there are only a few universities in the world that focus on just one or two programs. In any case, such Universities will be costly as the number of students enrolled will be unable to adequately pay for the educational and residential services needed to run the institution effectively. The academic and financially sound approach is that Medical Universities should offer an abundance of health disciplines, to provide for diversity in courses, and expansive learning and research experiences for the faculty and students. At inception, a Medical University should start with a few disciplines, and diversify by offering other disciplines at a later stage when resources become more available.

With diversity comes the debate about the name of the university. Should it be called a Health Sciences University rather than a Medical University? Naming it a Health Sciences University, some argue will provide a sense of ownership for all health professions. Others contend that the name Medical Sciences University embraces all aspects of medicine and other health professions. In my view, the onus should be left entirely to the proprietors to decide on the name of the University. As long as the mission, vision and core value statements of the Medical University are well defined, useful time should not be spent on wrangling on a name.

3). Contextual and Strategic Measures: Establishing a Medical University (indeed, any new University) should be with a specific mission and end-points in mind. Such a University must have a unique purpose that will differentiate it from the existing Universities in the country. The curriculum of the new Medical University should be designed to conform to global trends in medical education. The typical curriculum of a Nigerian medical school is deficient in the following non-clinical related contents: patient-centered care, interdisciplinary teams, evidence-based practice, quality improvement, informatics, organization and leadership theories, program administration, health care financing, essential drugs, supplies and human resource management, entrepreneurship, and pedagogy. The new Medical University must address these curricula deficits for its graduates to be able to practice effectively in the 21st-century healthcare system. It must never be “business as usual.”

Far too often Universities in Nigeria are established on sentiment and with sensational underpinnings, without concerted efforts made to align the expected outcomes to address the existing medical, societal and environmental challenges. This omission can lead to failure, creating a pathway that does not allow the new institution to grow substantively. It is essential that a new Medical University is academically guided by sound scientific principles and administratively embrace transparency, accountability, and anti-corruption philosophy. Otherwise, the institution will have no justification for its existence, and will likely not survive the current national and global academic competitiveness for program quality and efficiency.

It is essential that before establishing a specialized Medical University, the proprietors must devote sufficient time for consultation, stakeholders’ engagement, strategic planning, physical and environmental scanning, curriculum planning, and resource mobilization. It is heart-warming and commendable that the NUC currently insists that these initial efforts are in place before applying for a license to establish a new University. Concerning strategic planning, a detailed SWOT analysis must be completed in consultation with experts in tertiary education, and the results widely published.

In a favorable academic milieu, both the teaching and non-teaching personnel are drawn typically from different cultural and socioeconomic backgrounds. These expectations do not always align with the vision of the University founders. Given this schism, it is essential that the strategic mission and vision of the University be made known at the onset, and efforts made to continually remind all internal and external stakeholders about the primary expectations of the University.

At UNIMED, our stakeholders value transparency and to actualize this treasure, I organize weekly consultative meetings with all senior teaching and non-teaching staff. Despite this effort, there are still some stakeholders who frequently fall prey to dissension and who do not support the University in its quest for academic excellence. Nevertheless, we have continued with the weekly consultations to ensure that the new University is on a solid foundation for future growth and development.

4) Medical Universities and Teaching Hospitals: The advent of medical universities has provided the opportunity to rethink the relationship that should exist between universities that teach health sciences professionals and their corresponding teaching hospitals. In traditional Universities, the two institutions (universities and teaching hospitals) have often been administered in parallel fashion, a situation which has tended to delimit the training component attributable to the teaching hospitals. Most teaching hospitals affiliated to traditional Universities are presently run as commercial outlets with little consideration for the teaching, training and clinical experience for students and post-graduates that were intended for the hospitals in the first place.In many cases, teaching hospitals often fail to include teaching and research in their annual budgets, with many arguing that these are supposed to be provided by the parent Universities. In some cases, acrimony has emanated from the use and sharing of resources between the teaching hospitals and the parent universities, a situation which has tended to severely reduce the quantum and quality of clinical training of health professionals in many traditional Universities/Teaching hospitals.

Medical Universities provide an opportunity to correct this incongruity. This can be done easily since it would be expected that in Medical Universities, both the University campus and the Teaching Hospital complex should be in one location. Ideally, they should never be on different sites. This unified location allows for the development of a harmonized administrative structure for both institutions, which will help to improve efficiency and effectiveness, and also prevent the unnecessary duplication of resources.

At UNIMED, we have proposed the adoption of a unified administrative structure under the leadership of the Governing Council of the University. The Governing Council will include individuals from the University and the Teaching Hospital components, external members, and internal members from both the University and the Teaching hospital. The Vice-Chancellor will work under the supervision of the Council. He/She will have two Deputy Vice-Chancellors, one of whom will oversee the teaching hospital as the Chief Medical Director, as is presently practiced in traditional teaching hospitals. The other DVC will be in charge of academic matters, while other functionaries of the Teaching Hospital and the University, including the Chairman of the Medical Advisory Committee, Senate, Deans and Heads of Departments will perform roles that are assigned for them in traditional universities and teaching hospitals. We believe that this will significantly reduce the cost of running the University and teaching hospitals as separate institutions and will also increase the impact of medical universities. I have reviewed the administrative patterns of several Universities of Medical Sciences in many parts of the world, and I have not found one where the university and the teaching hospital components are administered as separate institutions.

5) Funding and Accountability Issues: One of the significant challenges of all Universities, especially the new institutions are funding. A Medical University is costly to establish, and in our estimation, it is more expensive to develop one than a traditional university. The NUC and the MDCN recently pronounced that individuals wishing to establish medical and dental programs must first build a functioning teaching hospital with the appropriate level of academic and non-academic personnel. This policy has enlivened the debate on the cost of developing a Medical University.

A Medical University (or any university for that matter) must never be established for the sole purpose of profit-making because financial gains are typically not realized in the first ten years. Profits will come from grants, possibly fees paid by the increasing number of undergraduate and post-graduate students, patents from research findings, and clinical service provision, etc., and will only manifest when the University has entirely taken off and is fully operational. Thus, efforts must be made by the proprietors at the onset to make substantial provision for funds, especially for infrastructure, equipment, staffing, and related matters. Such projected funds should cover ten years and should be done possibly with a bank guarantee to ensure continuous availability of funds.

Even with the best intentions, a proprietor may not always be able to provide all the funds required to run such a University. Therefore, the university administration must not leave the issue of resource mobilization to the proprietor. Hence, the administration must begin a fund-raising drive right from the very onset to augment the funds from the proprietor.

At UNIMED, we established a Resource Mobilization Unit within the Vice-Chancellor’s office right from the inception of the University. The Unit has now grown in leaps and bounds, raising considerable funds and other physical assets for the University. These include the donation of a Faculty of Basic Clinical Sciences building to the University by Chief IF Akintade, an indigene of Ondo State. This gift is in addition to a grant from Seedling Lab based in the USA that donated 200 pieces of ultra-modern laboratory equipment. Recently, Hon Akinlaja, a member of the Federal House of Representatives, gave a Faculty of Clinical Sciences building to the University.

Our unique innovation at fund-raising is through the Friends of UNIMED Fund (FUF) established in July 2016, to “raise small amounts of money from various stakeholders each year for the sustained development of the University.” The initial goal set was to raise at least one billion Naira from our stakeholders annually. We anticipate our one million Friends of the University members will donate at least N1,000.00 (one thousand Naira) each. The FUF has raised substantial funds dedicated to building an edifice on campus to be named the “Friends of UNIMED Building.” Every donor will have his/her name inscribed on a billboard that will be installed in the building, to honor such donors in perpetuity.

Donations to the University can only happen when stakeholders believe that their funds will be used judiciously just for the designated purposes, and solely for the advancement of the growth and development of the University. To facilitate donation, UNIMED has come up with the TEA – Transparency, Effectiveness, and Accountability – agenda which affirmed that all our projects would be handled based on the principles of openness and anti-corruption. We have demonstrated this in many ways, which has helped our stakeholders to continue to make donations to the University.

Indeed, I believe very firmly that substantial funds can be raised in many ways when the donors are convinced that their gifts will be judiciously used to address some of the University’s developmental challenges in a meaningful and realistic manner.

Conclusion
I want to conclude my presentation by averring that the recent establishment of Specialized Medical Universities is one of the most significant developments in the training of health professionals in Nigeria. The concept is an enormous paradigm shift from the traditional medical education that focuses on silo-experience of the different professionals to an interprofessional, multi-system approach that focuses on healthcare systems improvement for the sustainable reduction of the burden of disease and disability.

For a Specialized Medical University to be successful and impactful, it must be driven by visionary, selfless and purposeful leadership that embraces accountability and transparent use of available resources. Similarly, the university administration must systematically engage all its stakeholders in the health and education sectors and the power brokers in the local communities.

The establishment of more Specialized Medical Universities in Nigeria will positively change the trajectory of our healthcare system. Hopefully, it will correct some of the curriculum deficits in traditional medical schools in Nigeria. I anticipate that when UNIMED graduates are produced a year from now, they will be clinically competent practitioners ready to deliver high-quality healthcare services to diverse populations. They will have the entrepreneurial skills needed to start their private practice after registering with the MDCN. They will also be more collaborative and less combative in their approach to the practice of medicine because they will have the skills needed to work in interdisciplinary teams, organizations, or systems. Furthermore, and most importantly, they will be in a unique position to prevent illnesses of the type that resulted in the sudden death of Professor Sofoluwe. Thank you very much for giving me your undivided attention!
Professor Okonofua is Vice-Chancellor, University of Medical Sciences (UNIMED), Ondo City, Ondo State . Being aeynote address delivered at the Seventh Professor Sofoluwe Memorial Lecture, organized by the Alumni Association of the University of Lagos, recently


In this article:
Segun MimikoUNIMED
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