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The Emerging Role of Medical Assistant Training Schools in Bangladesh A 1 The Emerging Role of Medical Assistant Training Schools in Bangladesh A Situation Analysis Dr. Kawkab Mahmud, MBBS, MPH James P Grant School of Public Health (JPGSPH) BRAC University Dr. Lal B Rawal, MPH, PhD icddr,b and James P Grant School of Public Health (JPGSPH) BRAC University Working paper series No. 2 September 2015 2 The emerging role of medical assistant training schools in Bangladesh Published by Centre of Excellence for Universal Health Coverage, icddr,b and James P Grant School of Public Health (JPGSPH), BRAC University 68, Shahid Tajuddin Ahmed Sharani Mohakhali, Dhaka 1212, Bangladesh URL: http://www.coeuhc.org First published 2015 Copyright© 2015 CoE-UHC The views expressed and the choice of the presentation of the facts both in the text and illustrations are entirely those of the authors. Editing Hasan Shareef Ahmed Cover design and page layout Muhammad Abdur Razzaque ISBN: 978-984-33-9529-0 Printed by 3 RESEARCH PARTNERS Centre for Medical Education and Health & Manpower Development (HMPD) Unit, DGHS Human Resource Management Unit Ministry of Health and family Welfare (MOHFW), Ban 4 The emerging role of medical assistant training schools in Bangladesh ADVISORS Prof. ABM Adul Hannan Centre for Medical Education, DGHS Dr. Ashadul Islam Ministry of Health and Family Welfare Professor Dr. Md. Ismail Khan Dean, Faculty of Medicine, Univ. of Dhaka Prof. Dr. Shah Abdul Latif Medical Education and HMPD, DGHS Dr. Timoty Evans, Health Population and Nutrition, The World Bank Dr. Khaled Hassan WHO, Bangladesh Dr. Aftab Uddin Technical Training and Learning Unit, icddr,b Dr. Md. Shah Nawaz Directorate General of Health Services (DGHS) Dr. M A Abdus Sabur Sajida Foundation, Bangladesh Farzana Momtaz Human Resource Management Unit, Ministry of Health and Family Welfare (MoH&FW) Dr. Zahidur Rahman the State Medical Faculty of Bangladesh (SMFB) 5 Dr. Md. Mizanur Rahman World Health Organization (WHO) Ms. Taslima Begum Directorate of Nursing Services (DNS), Bangladesh Ms. Shuraiya Begum Bangladesh Nursing Council (BNC) OVERALL SUPERVISION AND REVISION Prof. Syed Masud Ahmed Centre of Excellence for Universal Health Coverage icddr,b and James P Grant School of Public Health (JPGSPH) BRAC University 6 The emerging role of medical assistant training schools in Bangladesh PREFACE Improving health of general population has been a major challenge worldwide, particularly in developing countries like Bangladesh, where majority of the people live in rural areas. While the Government of Bangladesh is making significant efforts in producing adequate number of trained health care providers, it has recognized the important roles of private sector in producing trained medical assistants in the country and also providing quality health services to the people of Bangladesh. This study assessed the current situation of medical assistant training schools (MATS) and also examined their roles in producing adequate number of quality mid-level health cadres in the country. Because this study has identified a number of key strategies for improving medical assistant training in Bangladesh, which will help the Government and relevant national/international agencies to improve existing situation and also develop new strategies that will particularly emphasize institutional governance, MATS curriculum, teaching workforce, financing, infrastructure and quality assurance of medical assistant training programme in Bangladesh. I would like to congratulate the research team for successfully conducting this comprehensive study. World Health Organization, Bangladesh has been playing a vital role in producing trained health cadres in Bangladesh. I would like to thank Dr. Thushara Fernando, WR to Bangladesh for agreeing to support this study and also Dr. Khaled Hassan, WHO MO-HRH and his team for the technical support throughout the study. This study was conducted in collaboration between HRM unit MoHFW, DGHS, and James P Grant School of Public Health, BRAC University. I would like to thank everyone who was involved with the study and their industrious effort making this study happen. Prof. Dr. ABM Abdul Hannan Director, Medical Education and HMPD DGHS, MoHFW, Government of Bangladesh 7 ACKNOWLEDGEMENTS This study was conducted jointly by Human Resource Management Unit, Ministry of Health and Family Welfare (MOHFW), Directorate General of Health Services (DGHS) and James P Grant School of Public Health (JPGSPH), BRAC University. It was funded and technically supported by the World Health Organization (WHO) Bangladesh under the BAN HRH programme. We are grateful to the research team who made significant contribution at the inception phase of this study particularly late Dr. Khaled Samsul Islam, Dr. Timoty G Evans of JPGSPH, Dr. Shah Abdul Latif of DGHS, Dr. Ismail Khan, Faculty of Medicine, University of Dhaka, Md. Nuruzzaman of WHO, and Dr. ASM Nurulla Awal. We would like to extend our sincere gratitude to Dr. Khaled Hassan, WHO MO-HRH for his technical support and valuable comments/feedback on the draft report. We are also grateful to Dr. Mizanur Rahman and Md. Nuruzzaman of WHO HRH team for their valuable comments/feedback on the draft report. We would like to thank Prof. Syed Masud Ahmad of ICDDR,B and BRAC University, Prof. Dr. ABM Abdul Hannan of DGHS, Dr. Aftab Uddin, ICDDR,B and Dr. Timoty G Evans for their overall guidance/supervision while conducting this study and valuable comments/feedback on the draft report. Thanks to the field research team including Md. Tarek Hossain, Iffat Nowrin Tuly and Md. Mahmodul Haque Chowdhury of JPGSPH, BRAC University, and Hosne Nur Rob, Syaket Ahmed Shakil, Md. Bilal Hossain, and Md. Habibullah Fahad of ICDDR,B for data collection. We also like to thank Md. Tarek and Tuly for their additional contribution in data management. We also thank others who directly or indirectly supported in the accomplishment of this study. Thanks are also due to Mr. Hasan Shareef Ahmed for editing the manuscript. Our sincere gratitude goes to those participants and key informants, whose valuable time and active participation was vital for us in determining the current situation of medical assistant training programme in Bangladesh, aiming to promote roles of private MATS in the country. 8 The emerging role of medical assistant training schools in Bangladesh TABLE OF CONTENTS Preface Acknowledgements Acronyms Executive summary i Chapter 1. Introduction 1 1.1 Objectives 3 Chapter 2. Methods 5 2.1 Study design 5 2.2 Study methods 5 2.3 Tools development 6 2.4 Sample selection and sample size estimate 7 2.5 Training of the field research team 8 2.6 Field data collection 8 2.7 Data management 9 2.8 Ethics approval 9 2.9 Quality assurance 10 Chapter 3. Results 13 Part A. Findings of the institutional level study 13 A1 Institutional governance 13 A2 Educational services 17 A3 Teaching worksforce 24 A4 Financing in MATS teaching and learning 30 A5 Infrastructure and technology 32 A6 Information for policy-making 35 A7 Accreditation and quality assurance in MAT education 35 9 Part B. Graduate students survey 38 B1 General characteristics of the MATS students 38 B2 Perception and attitudes towards working in rural, remote or hard to reach areas 40 B3 Competency self-assessment in medical assistant training and skills 43 B4 Infrastructure and other facilities 44 Chapter 4. Discussion 49 Chapter 5. Conclusion and Recommendations 59 References 61 Annex A. Name and address of the sample schools 64 Annex B. Basic Information of the MATS Curriculum 66 Annex C. List of small roundtable stakeholders 74 TABLES Table 2.1 Summary of study methods used to fulfill each study objectives 6 Table 2.2 Sample selection of MAT school and students included in the study 8 Table 3.1 Representation for different constituencies in the governing body 14 Table 3.2 Preference of admission in the MATS program 17 Table 3.3 Percentage of MAT schools using different off-site exposure opportunities 19 Table 3.4 Assessment methods used to assess students performance in Public and Private MATS schools 20 10 The emerging role of medical assistant training schools in Bangladesh Table 3.5 Percentage of MAT Schools assessing different type of student competencies 21 Table 3.6 Comments of Institute heads on further improvements of admission process in Public and Private Schools (%) 23 Table 3.7 Number and percentage distribution of teaching workforce by age categories and current employment status 25 Table 3.8 Formal appointment of health service provider and other (e.g. service users) as adjunct faculty 26 Table 3.9 Criteria for staff recruitment by type of MAT schools 26 Table 3.10 Staff retention strategies/mechanism in public and private MAT schools 27 Table 3.11 Major reasons for staff resignation of the staff left in public and private MAT schools 28 Table 3.12 Main places staff left for after resignation 29 Table 3.13 Nature of the continuous staff development and formal evaluation mechanisms 30 Table 3.14 Availability of information on unit of cost for Medical Assistant production 31 Table 3.15 Availability of School Facilities in Public and Private MATS schools 33 Table 3.16 Interactive dialogue between MATS schools and other related institutions 35 Table 3.17 Quality assurance and External evaluation of the school 36 Table 3.18 Focus of the school accreditation 38 Table 3.19 General characteristics of the MATS students 3 11 Table 3.20 Perception/attitudes towards rural, remote or hardship areas by students from public and private MATS 41 Table 3.21 Job preference of the students upon graduation 42 Table 3.22 Main reasons for intention to work at different places after MATS graduation 42 Table 3.23 Competency self-assessment by Public and Private MATS 43 Table 3.24 Availability of school facilities in public and private MATS 45 Table 3.25 Students assessment on available school facilities by public and private MATS 47 Table 3.26 Financial hardship/suffering while undertaking MATS study 48 FIGURES Figure 3.1 Average percentage of time students spend in different study methods estimated by the institutional heads 19 Figure 3.2 Number of students’ entered into MAT programme through different criteria over the past 10 years 21 Figure 3.3 Percentage graduated/dropped out of those students who entered into the MATS in 2008 22 Figure 3.4 Number of students admission, graduation and dropout in the past 10 years 24 Figure 3.5 Number of staff at private MAT schools in the past 6 years 28 Figure 3.6 Procedure of establishing private medical assistant training school (MATS), SMFB, 2010 37 12 The emerging role of medical assistant training schools in Bangladesh ACRONYMS BMRC Bangladesh Medical Research Council CME Centre for Medical Education DGHS Directorate General of Health services GoB Government of Bangladesh HRH Human Resources for Health HRM Human Resource Management HSC Higher Secondary Certificate ICDDR,B International Centre for Diarrheal Disease Research, Bangladesh JPGSPH James P Grant School of Public Health LMIC Low and Middle Income Countries MA Medical Assistant MAT Medical Assistant Training MATS Medical Assistant Training School MDG Millennium Development Goals MOHFW Ministry of Health and Family Welfare SMFB The State Medical Faculty of Bangladesh SSC Secondary School Certificate UHC Upazila Health Complex UHFWC Union Health and Family Welfare Center WHO World Health Organization i EXECUTIVE SUMMARY Introduction Shortages of health care providers in low and middle income countries (LMICs) like Bangladesh, have significant impact on access to health services and achieving health outcomes. In recent years, the importance of developing functional health workforce that can meet the current challenges of health system has been recognized and been documented extensively. The Ministry of Health and Family Welfare (MOHFW), Government of Bangladesh (GoB) has making significant efforts in producing enough quality health professionals in the past few decades. However, in recent years, GoB has recognized the roles of private sector in producing trained human resources for HRH including medical assistants (MA). While the public sector, for a long time, has been providing medical assistant training in Bangladesh, the emerging roles and contribution of the private medical assistant training schools (MATS) to provide quality health services is explored. Objective This study aimed to assess the current scenario of private MATS and examine their roles in producing competent medical assistants in Bangladesh. Methods Both qualitative and quantitative methods were used to get a clear understanding on the current situation of MATS in Bangladesh. This was conducted both at institutional and student level. Data were collected from both public and private MATS (5 public and 30 private) and medical assistant students (238 public and 732 private). Findings A. From institutional level Almost all private schools have governing body to look after overall management of the school, however the number and representation ii The emerging role of medical assistant training schools in Bangladesh of members from different sectors in the committee were not uniform. On the other hand, all public schools have academic council to look after the academic aspects of the school. For public schools, the students are admitted in the Medical Assistant Training (MAT) programme through national entrance exam conducted by the Directorate of Medical Education, DGHS. However, in private schools, the students are admitted mainly through entrance examination conducted by the respective schools. Our findings show that the students in both private and public MATS spent majority of their time in classroom teaching (42% private and 45% public). Regarding the methods of assessment, the written essay exam was ranked first as a common method of assessment for both type of MATS followed by oral exam which ranked second, and assignments and class test ranking third. These MATS also used other assessment methods including term paper, students’ classroom attendance, overall clinical performance, etc. The number of students admitted and timely graduation rate in both private and public MATS have been increasing over the past decade. The timely completion rate of the students is almost similar in both private and public schools (67% public and 60% private), however the delayed graduation was three-fold greater in private compared to public schools (30% vs. 10%). Twenty percent of the students’ information in public school was not available. The age of majority of the teaching staff in public schools was 50 years or older (65%), which is more than double of those in private schools (28%). Majority of the teachers in both the schools were on full time basis, however the proportion of part-time teachers in private schools was double (31%) than those in public schools (15%). Regarding the financing, majority of the private schools considered tuition fees as a major source find come. For public schools, the budget is allocated from the DGHS. None of the private or public schools found any kind of financial hardship at the time of the study. Majority of the public and private schools reported that they had moderate level of infrastructure including building, library, teaching facilities, computer lab, internet, accommodation, field training, etc. However, almost all schools did not have facility for conference call, video conferencing, and tele-medicine facilities. iii None of the public schools reported having any kind of unit within the school to maintain the quality, whereas 10% of the private schools had a quality assurance unit within the school. However, majority of both public and private schools reported having provision of conducting external evaluation of the schools. In terms of major indicators for quality assurance both private and public schools used students’ annual performance (results), teachers’ competency in teaching, and students’ class attendance. As maintained by MOHFW through DGHS, the main focus of the private school accreditation is the entire institutional performance (77%), followed by institutional infrastructure (53%) and the course curriculum (27%). B. Graduate student survey The majority of the current students in both types of schools were from rural areas (61% private, 66% public). Majority of their parents, particularly fathers, were engaged in service or business. Majority of the students were aware of not having enough amenities and entertainment in rural, remote and hard to reach areas. However, they perceived that working in these areas could have several other benefits, such as opportunities to use skills learned at MATS, rural people are friendly, MAT programme is helpful in preparing students working in rural/remote areas, and opportunities for real-life problem solving experience, etc. After graduating from MATS, majority of the students preferred to work in the public sector health services. According to the students, the facilities available at the schools are relatively sufficient in both private and public schools. In terms of total cost for medical assistant training, the reported average cost was Tk. 66,000 in public schools and Tk. 168,000 in private schools. Conclusion Both private and public MATS in Bangladesh have similarity in using standard curriculum, governance under the same ministry, modes of delivering the educational activities, and accreditation process. However, differences exist in terms of modes of admission, source of financing, and unit cost for medical assistant training. Our findings Executive Summary iv The emerging role of medical assistant training schools in Bangladesh suggest that the policy guidelines have been developed to guide the establishment of private MATS and also to improve quality of training. However, lack of strategies to effectively monitor the implementation process of these guidelines in private schools could be matter of concern. Since the students in both types of schools spend majority of their time in more traditional mode of teaching, particularly classroom teaching, this also may be the matter of concern in optimizing the quality of MAT. Further, while the number of private MATS is increasing, the high turnover rate of teachers, and their part-time involvement in schools and less experience in teaching can also jeopardize the production of competent medical assistants in the country. Recommendations Given the need for producing adequate number of competent medical assistants to serve high demand of the country, there has been a need for formulating a comprehensive strategic plan to address all possible aspects of producing medical assistants and assuring their quality, their deployment, health service delivery, etc. Based on the findings the following recommendations are made: With the government’s stewardship, a comprehensive assessment system could be developed to effectively monitor the MAT programme in Bangladesh and also to facilitate private MATS to produce adequate number of competent medical assistants as per demand of the country. The strategies need to be developed to reinforce government stewardship role with more attention towards effective monitoring and evaluation of private MAT programme. The MAT curriculum could be reviewed with particular focus on pedagogic methods of teaching, such as practical learning, field-based learning, problem-based learning and also more emphasis on rural population health, etc. A comprehensive and evidence-based guideline needs to be developed giving more emphasis on using rigorous methods for faculty recruitment, job description, incentives, in-service training, career development of teachers, etc. so that it could help reduce the high turnover rate as well as optimizing the quality of the MAT programme. Emphasis needs to be given to strictly maintain regulation of existing accreditation mechanism. This also needs to be comprehensive v including aspects of quality assurance, infrastructure development, governance and evaluation of faculty, etc. Standard protocol could be developed to effectively monitor financing of the MATS and also to standardize admission/tuition fees and other charges across all private MATS. Executive Summary vi The emerging role of medical assistant training schools in Bangladesh This page internationally left blank 1 Chapter 1 INTRODUCTION The policy-makers around the world, particularly in low and middle income countries (LMICs), are facing significant challenge in meeting the health needs of general population [1, 2]. The main underlying factor is the shortage of qualified health care providers and also the migration (internal/international) of skilled human resources for health (HRH), which has a profound impact on equitable distribution of health care providers and also delivery of quality health services [3, 4]. It is now well understood that the adequate number of skilled and motivated health care providers in LMICs is critically important to deliver health services effectively, thereby improving health outcomes [4-6]. Shortages of health care providers in LMICs like Bangladesh, has a significant impact on access to health services as well as the impact on achieving health-related Millennium Development Goals (MDGs) by 2015 [7]. In recent years, the importance of developing functional health workforce that can meet the current challenges of health system including shortages of HRH has been recognized and been documented extensively [2, 5, 8]. In the hope of providing minimum level of health services, the World Health Organization (WHO) has recommended a set of standard density of health care providers (doctors, nurse and midwife) to be at least 23 per 10,000 population [2]. However, Bangladesh is one of the 57 countries worldwide, which do not meet the WHO-recommended standard and has big imbalance in skilledmix health care providers. There are around five physicians and two nurses per 10,000 populations [7]. In addition, there is also a widespread shortages of key mid-level health cadres, such as medical assistant (MA), laboratory technician, pharmacist, radiographer, physiotherapist, etc. The density of these health cadres in the country is 1 per 10,000 population [9]. Given the fact that majority of the skilled health professionals tend to remain in urban health facilities or at the secondary/tertiary level health care facilitates, the shortages are 2 The emerging role of medical assistant training schools in Bangladesh more prevalent in rural and hard to reach areas [7, 9]. By default, there has been almost a quarter (22%) vacant posts of para-professionals, particularly MAs, in health care facilities having greater vacancy rates in rural areas compared with urban areas [10]. Given the shortages of skilled HRH, particularly physicians, in the country the importance of producing mid-level health cadres such as medical assistants has been significant importance [9]. The Medical Assistant Training (MAT) in Bangladesh first began in 1979 with the establishment of public Medical Assistant Training Schools (MATS). The purpose of the training was to produce mid-level health cadres who will serve government health facilities such as Upazila Health Complexes (UHCs) and Union Health and Family Welfare Centres (UHFWCs) [9]. The UHCs and UHFWCs are the first point of health care in the community and the MAs play significant role in providing quality primary health care through these health facilities [11]. The MAs in general assist doctors in clinical and administrative procedures and are supervised by doctors. However, in rural health facilities they perform these activities independent of doctors’ supervision [11, 12]. The trained MAs are recruited by MOHFW for the position of SubAssistant Community Medical Officer (SACMO) at the UHC (2 positions sanctioned) or at the UHFWC (1 position sanctioned) [10, 12]. Like as many LMICs, in recent years Bangladesh government has recognized the importance of private sector in producing trained HRH including MAs [13-16], and has given approval to establish private sector MATS since 2007/8. Currently, there are 103 MATS in the country with 93% schools run by private sector. The number of seats allocated for these schools are 6,730 per annum (private MATS 6,030 and public MATS 700 seats)[10]. The MA training both in public and private MATS is offered for four years duration with three years theory and one-year internship at district hospitals or UHCs. In general, there is greater availability of information and more direct and extensive regulations in public sector MATS as they are regulated and monitored by the Directorate General of Health Services (DGHS). However, for most cases, less information is available about how the private MA training is designed, implemented, monitored, and evaluated. In addition, little attention is given on the accreditation, quality assurance, and standardization of the programmes in these educational institutions [17, 18]. These issues have been recognized and given emphasis in a number of ongoing health related policies/plans including National Health Policy, 2011 [16], Health, Population and Nurtition Sector Development Progamme (HPNSDP), 2011-2016 [14] and Bangladesh 3 Health Workforce Strategy 2008 [13]. Emphasis is also given to reform the health professional training in both public and private sectors to optimize the quality of training. The needs were realized to understand different aspects of MA training and performance in Bangladesh. Using six ibuilding blocks of the health system management [2] as conceptual framework, this study comprehensively assesses the important aspects of MAT in Bangladesh. These include institutional governance, educational services, financing, infrastructure and technology, information for policy-making, and accreditation and quality control of MA training in Bangladesh. This study also has a particular focus on the private sector to provide evidence base for the policy-makers to make informed decision in terms of planning and implementation, and also developing monitoring and evaluation mechanisms for future MAT programmes in Bangladesh. 1.1 Objectives This study aimed to assess the current situation of the private MATS and also to examine their roles in producing adequate number of quality MAs in Bangladesh. The specific objectives, at the national level were to: 1. Explore and compare, between 1990 and 2010, the number of public and private medical assistant training schools and their production capacity, enrolments, and graduations; 2. Explore at institutional level the issues such as governance, source of financing, recruitment of teachers, MATS curriculum, quality assurance, student recruitment, and exposure to clinical and community practices; and 3. Explore the students’ perspective on study experiences, financing for the course, and employment opportunities. Chapter 1 | Introduction 4 The emerging role of medical assistant training schools in Bangladesh This page internationally left blank 5 Chapter 2 METHODS 2.1 Study design This study used a mix of qualitative (key informant interviews and roundtable discussion) and quantitative (survey questionnaire) methods to understand the current situation of medical assistant training schools in Bangladesh. 2.2 Study methods The study was conducted at two levels - one at the institutional level and the other at the students level. The institutional level was designed to have better understanding on institutional governance and its implementation, curriculum, financing and infrastructure, human resources, and quality assurance mechanism of the MAT programmes. These study components were identified based on the WHO six building blocks [2]. Key informant interviews were conducted with the institutional head or the responsible person nominated by the head of the institution. Self-administered survey questionnaires were completed by the final year MAT students. The students’ survey was to assess the output of the programme from the students’ perspective in terms of their perception and attitude towards the programme, self competencies and future career path. The key informant interviews were conducted with the institutional heads or their representatives by trained field research officers and research assistants. In addition, we did a thorough literature review of published documents, grey literature (particularly government policies, acts, statues, etc.) relevant to the MATS in Bangladesh. Table 2.1 summarizes how each study objective was fulfilled through different study methods. The preliminary findings of the study were shared with the key stakeholders and the relevant personnel involved 6 The emerging role of medical assistant training schools in Bangladesh with MAT programme at national level in a roundtable meeting. The feedback from the roundtable meeting was used as qualitative data for this study. The key stakeholders are listed in Annex A. Table 2.1 Summary of study methods used to fulfill each study objectives Objectives Methods 1. Assess and compare, over the period between 1990 and 2010, the number of public and private MATS Document review, key informant interviews, roundtable meeting 2. To investigate the sources of financing, teachers’ recruitment, MATS curriculum, quality assurance, student recruitment, exposure to clinical and community practices etc. Documents review, in-depthinterview with the institutional heads, roundtable meeting 3. The final year students - to examine their general characteristics, their study experiences, financing for the course, and employment opportunities Students’ survey with self administered questionnaire 2.3 Tools development A number of study tools were used for this study. The tools for institutional level assessment consist of both open-ended and closed questions and also some Likert scales. The questions were developed to assess the situation according to the WHO health system building block conceptual framework, including Institutional governance; Educational services; financing; health workforce/faculty; infrastructure and quality assurance [2]. The study tool for students’ survey was developed as a self-administered questionnaire focused on assessing students’ perception on the training programme, self competencies, attitude and perception of future career path and towards working in rural and remote areas, availability of 7 infrastructure and services. Closed questions and some Likert scales were used in the questionnaire. All assessment tools were thoroughly reviewed and consulted with relevant experts. Prior to data collection, the study tools were pretested in one of the MATS located in Dhaka city. Necessary revision and amendment of the tools were done. 2.4 Sample selection and sample size estimate Purposive sampling was done to determine the institutions as well as the key informants. The representations of the institutions by their ownership (public or private) and geographical (rural or urban) and divisional locations were considered to maintain equal representation of MATS. The aim was to select one-third of the existing MATS and a representative number according to the division-wise distribution of the existing schools. Selection of at least one private and one public MATS from each division was considered. If there were two or more MATS in each division, the preference for selecting one old and one new school was also given. For students’ survey, the classroom census of the selected schools was used. Primarily the final year students were selected for the survey. However, in those schools which did not have final year students yet, the groups of students closer to final year were selected. Table 2.2 shows the number of MATS and the samples included in the study. Of the total 101 private and 8 public MATS in Bangladesh, 30 private and 5 from public MATS were purposively selected. These consist of 7 MATS (all private) located inside the capital city and 28 (public 5, private 23) outside the capital city in Bangladesh. Annex A shows the list of sampled MATS and their details. Altogether 732 students from private and 238 from public MATS were surveyed. Chapter 2 | Methods 8 The emerging role of medical assistant training schools in Bangladesh Table 2.2 Sample selection of MAT school and students included in the study Divisions Public Private Total no. of schools Schools selected No. of students sampled Total no. of schools Schools selected No. of students sampled Dhaka 2 2 100 49 14 310 Khulna 3 1 27 6 1 31 Rajshahi 1 1 72 24 5 148 Chittagong 2 1 39 6 2 40 Sylhet 0 0 0 3 2 58 Rangpur 0 0 0 10 4 134 Barisal 0 0 0 3 2 11 Total 8 5 238 101 30 732 2.5 Training of the field research team The field researchers were trained for two days before data collection. First day of the training was focused on the theoretical aspect of the project including study concept, methods, and study tools. A comprehensive participatory discussion was done to have better understanding about the project and data collection process. They were also given information about how to build rapport, engage participants in the study, and also follow the ethical aspects of the research while involving human participants. In the second day, a simulation exercise was done among the training participants. Altogether six field researchers were given training, and the training was facilitated by one of the co-investigators and the project coordinator. 2.6 Field data collection Three field data collection teams, each composed of two field researchers, were dispatched in different parts of the country during February to June 2013. They spent, on average, three days in each institution to complete institutional assessment and students’ survey of the respective institute. They were closely supervised by the project 9 coordinator and co-investigators. During data collection, a debriefing session with the field researchers was conducted to obtain their feedback and to facilitate the data collection process. 2.7 Data management Quantitative data management After completion of checking and double-checking of the questionnaire, data were coded and entered into SPSS programme for Windows. With the close supervision of the project coordinator, data were entered by the research assistants having background of public health and also having previous experience of data entry. Data analysis template also was developed and was followed while performing data analysis. One of the study team members, having advance knowledge and skills on biostatistics, performed data analysis using SPSS version 12.0 for Windows. Qualitative data analysis Upon completion of key informant interviews, the notes written in Bangla were translated into English and was prepared a soft copy according to the interview guidelines. Two research officers went through this procedure and identified themes with the close supervision of the principal investigator and project coordinator. The translated contents of the interviews were entered into the Atlas Ti software for qualitative data analysis for preparing a transcription according to the identified themes. Clustering of data on each theme was done by aggregation, contrast and comparison. These qualitative data were used in the study findings to triangulate with the findings obtained from the quantitative study and documents review. 2.8 Ethics approval Ethical approval of this study was obtained from the Bangladesh Medical Research Council (BMRC). Before the interviews, the key informants were fully informed of the project objectives, confidentiality of the information, and how the collected information would be used. The same procedure was performed with the MATS students. Chapter 2 | Methods 10 The emerging role of medical assistant training schools in Bangladesh Informed verbal consent was obtained prior to all interviews. In order to maintain privacy of the information, the information, documents and scripts were stored securely. All interviews were applied with the identification numbers. The ID code and name of interviewee were kept confidentially. Report and quotes were applied with the ID number and the type of institution (public or private) the informant represented. 2.9 Quality assurance In order to assure quality of the data following activities were performed: At data collection phase 1. Two members of each team were responsible for taking notes to ensure accuracy of data during the interview 2. Debriefing sessions were arranged with the field investigators to clarify any outstanding issues related to the field data collection Before data entry 1. Checked each and every completed survey tools at the end of the day of data collection 2. Reviewed each of the filled-in tools and survey questionnaires and rejected if more than 30% questions were incomplete 3. Review meeting held with data collection team to obtain clarification on any confusion or misinterpretation 4. Checking hard copies and soft copies and also cross-checking with attached document collected from the institutions 5. Final checking done by the project coordinator before the data being entered into the database At the data analysis phase 1. The data were checked by at least two researchers during analysis 11 2. Reviewed the interview with relevant person at national and institute level for further information or cross-checking of the data 3. Presented the preliminary findings and obtained feedback from the national policy-makers in a roundtable meeting before finalizing the report Chapter 2 | Methods 12 The emerging role of medical assistant training schools in Bangladesh This page internationally left blank 13 Chapter 3 RESULTS This chapter presents qualitative findings obtained from the KIIs of institutional head and the quantitative findings obtained from MATS graduate students. Part A primarily contains results of the institutional level study, supplemented by the findings obtained from the documents review. Part B contains findings of MATS graduate students and supplemented by the findings from the document review. PART A. FINDINGS OF THE INSTITUTIONAL LEVEL STUDY A1. Institutional governance Policy steering committee - roles and responsibilities in private MATS According to the establishment of Private Medical Assistant Training School Policy, 2010 [19], each school should have a governing body of seven members for two years. Representation from DGHS and The State Medical Faculty of Bangladesh (SMFB) in the governing body is mandatory. If the newly-formed committee fails to conduct the first meeting of the steering committee within 30 days, then the principal of the institute, with the approval from DGHS, can form the ad-hoc committee and send to DGHS for further approval within 6 months to transform ad-hoc committee into a regular one. The study findings show that all private schools have their governing bodies formed to maintain overall management of the school. All schools also seem to be well aware about the existence of national guidelines for establishment of private MATS in Bangladesh. In most cases the principal of the school takes initiatives to appoint the members in the committee. In general, the number of committee members is seven as 14 The emerging role of medical assistant training schools in Bangladesh suggested by the national guidelines, but in few cases some schools have greater or less number of members in their committee. Despite the policy for private schools suggesting having mandatory representation of DGHS in the steering committee, just above half of them (53%) said that they had a member representing DGHS in the committee. Similarly just over a quarter (27%) said that they had a member representing SMFB which is also a mandatory provision. There seems to have rare representation from the civil societies, health care providers, and associated partner institutions. Table 3.1 Representation for different constituencies in the governing body Representation in the governing bodies Public % (n=5) Private % (n=30) DGHS, MOHFW representative 0 53 SMFB representatives 0 27 Own institution 60 40 Health care providers 40 10 Associated partner institutes 0 13 Civil society/professional organizations 0 10 Academic council in the public MATS The public schools are under the direct governance of the directorate of medical education. They normally have academic council formed by the members of the school which is responsible for managing academic aspects of the school. In one school they also have a disciplinary committee formed looking after moral aspects of the students. Roles and responsibilities of the steering committee and academic council Majority of the private schools were not aware of the mandate and roles of the steering committee. However, some schools mentioned the roles of the committee as academic development, financial and administrative management, appointment of teachers and decisions 15 for salary scale, student admission, management of class routine, timeline, students performance, etc. According to the guidelines, it is mandatory for private schools to conduct committee meetings at least four times a year with three months interval. In line with this provision, most of the respondents from the private schools said that they have been conducting meetings at least four in a year with some schools saying even six times a year with two or one month interval. For public schools, as suggested by the rules, most of the schools were organizing meetings at least once a month. The duration of the council seems to be not fixed as it was considered as the management of the public school is a continuum process. Extent of directing power of the body Almost all private schools (94%) said that the governing body had executive power for implementing as well as changing the policies within the institutions, whereas only two out of five public schools thought that academic council had such executive power for policy change in the organization. The qualitative findings in this regard suggest that the private schools in general have more liberty in making any kind of decisions for school management, which the public schools may face. In most cases, the chairman of the governing body with the agreement from other members has authority in making decisions for different issues including students’ admission, examination, recruitment, staff welfare, promotion, financial management, etc. Different sub-committees are also formed to look after specific issues in the schools. For public medical schools, they normally follow the government guidelines to make any kind of decisions related to academic and administrative aspects of the education programme. But the students’ admission and faculty recruitment are maintained as a central national process. Partnerships with other related institutions Almost all private and public schools mentioned that they had some level of collaboration with other related institutions in order to enhance the quality of medical assistant education and also to complete the courses. Chapter 3 | Results 16 The emerging role of medical assistant training schools in Bangladesh For public schools, in addition to having their own hospital, they also have partnerships established with other public hospitals for the clinical practice as well as internship for their students. All schools reported that the partnership has been able to improve clinical competency of the students. All private schools reported that they had established informal agreement with the private hospitals or clinics for clinical practices and internships of their students. They also reported having partnership with the public hospitals and UHCs. The partnership with these institutions was mentioned mandatory in case the private institutions did not have their own hospital for their students’ clinical practices and internship. Majority of the schools reported that the partnership had positive impact on improving hands on training for the students, increasing the competency level and also broadening the areas of their works. Students’ admission and eligibility criteria All private schools acknowledged that they are following the SMFB guideline for students’ admission. They also have 5% seats allocated for poor and meritorious students, which is mandated by the SMFB [19]. Some schools stated of having other preferences while recruiting the students. Some of them include quotas for female students, orphans, ethnic minorities, and children of freedom fighters. For public schools, the students are entered into the programme through the national entrance exams conducted by directorate of medical education, DGHS with the close coordination with respective schools. In addition, the students with different background are also recruited, such as quota for ethnic minority and for children of freedom fighters. Table 3.2 shows additional preferences for the MATS recruiting students. The socioeconomic background of the students and the history of being children of freedom fighters seem to be the major preferences for private schools, whereas ethnicity and history of being children of freedom fighters for public schools. Regarding the existence of any criteria for getting these students into the programme through these additional preferences, we did not obtain any detail information. 17 Table 3.2 Preference of admission in the MATS programme Admission preference by Public % (n=5) Private % (n=30) Gender 0 12 Geography 33 8 Socioeconomic status 0 64 Ethnicity 80 8 Religion 0 0 As per Govt. Rule 20 17 Freedom Fighter 80 33 Others (institution/oral viva) 0 6 Students’ retention in MATS Despite having no formal student retention strategies for all private schools, the common informal strategies employed by these schools include participatory teaching learning activities, students counseling and motivation, financial support, extra class for relatively poorly performing students, meeting with guardians, regular follow-up and lessons for career development, etc. For public schools, the retention was not a problem at all and they also reported of not having used any strategies for students’ retention. A2. Educational services Medical assistant training programme in Bangladesh The current State Medical Faculty was established in 1914 to offer diploma programme such as LMF doctors. The current medical assistant course was started in 1976 [20, 21]. Since then, the SMFB has been holding examinations and awarding diploma. They are responsible to maintain the quality of the paramedics programme in Bangladesh. Bangladesh government established the first MATS in 1979 to produce medical assistants to serve at government health facilities like UHC, UHFWC and Union sub-centers [9]. Since then other government medical assistant training schools have been established. However, in recent years a number of privately run MATS are also established, the Chapter 3 | Results 18 The emerging role of medical assistant training schools in Bangladesh first one being in 2008 [10]. To date, there are altogether 8 public and 103 private MATS in Bangladesh [10]. Our review of documents show that the MATS were first established in 1979 with the support of Dutch government. At the early phase of MATS establishment, the duration of the course was three years (2 years of course work and 1 year internship). This programme continued until 1986 before it was suspended with no reason from 1987 to 1993. However, the MATS programme restarted in 1996 with revised course (3 years of course work only). In 2009, the MATS curriculum was revised and the course duration was extended to four years (thre years of course work and one year internship. This programme is now well standardized for private as well as public MATS in Bangladesh. MATS curriculum Majority of the respondents of both public and private schools said that MATS curriculum was a standard programme inclusive of medical and general education, and it also covered almost all aspects of medical assistant training that they should learn. For example, general English, computer course, and a 12-month internship programme with 9 months at district hospital at 3 months at UHC were included in the new curriculum. However, few responded reported that “The curriculum covers all aspects of medical education like MBBS course, but the duration is not enough to cover all contents.” In addition, there is a lack of quality textbooks recommended in the curriculum. Annex B gives the basic information on MATS curriculum. With regard to review of the MATS curriculum, one KI from the SMFB stated that, “There is no specific mechanism to review the MATS curriculum and it is in general based on needs of the time and course and the CME normally takes the lead for this revision of the curriculum.” Medium of teaching As indicated by majority of the respondents, the main language used in the textbook is English, however, some books are also available in Bangla to facilitate students’ teaching learning activities. For teaching, the medium of communication is a mix of English and Bangla and the examinations are held in English language only. Pedagogic methods The teaching approach in majority of both private and public MATS is lecture-based learning. Team-bsed learning i.e. intra- or inter- 19 professional learning almost does not exist. However, problem-based learning has been used by most of the public and private MATS frequently. Figure 3.1 shows that students of both public and private MATS spent majority of their time at classroom, followed by laboratory studies, clinical practice and community practice. Students also spent almost one-fifth of their time in self-study. Figure 3.1 Average percentage of time students spent in different study methods estimated by the institutional heads Table 3.3 shows that majority of the private and public schools has a provision of off-site exposure as mandated by the curriculum followed by exposure to the rural hospital/health centers and local communities. Table 3.3 Percentage of MAT schools using different off-site exposure opportunities Off-site exposure Public % (n=5) Private % (n=30) Mandatory in curriculum 60 57 Local communities 20 20 Rural hospitals/health centres 40 30 Related organizations 0 3 Others (clinics, nursing homes, hospitals) 0 30 Public 45 42 21 14 13 14 20 5 6 19 Percentage Private Classroom 50 45 40 35 30 25 20 15 10 5 0 Laboratory studies Clinical practice Community practice self-study Chapter 3 | Results 20 The emerging role of medical assistant training schools in Bangladesh Regarding the existence of any innovative approaches of teaching such as didactic faculty lecture, small students groups learning, early patient or population exposure, longitudinal relation with communities, etc., almost all private and public schools reported non-existence of such means of teaching learning activities. Despite non-existence of any formal mechanism to review or update the MATS curriculum teaching method, one public and 14 private schools informed that they reviewed and updated the curricula. They also used different strategies for curriculum review, such as students feedback, monitoring of classroom teaching, interaction with different teachers, etc. Assessment methods Regarding the methods of assessment, the essay exam was ranked first as a common method of assessment for both types of MATS, followed by oral exam ranked second, and assignments and class test ranked third. These MATS also used other assessment methods including modified essay question, term paper, students’ classroom attendance, overall clinical performance, etc. Table 3.4 Assessment methods used in both public and private MATS Type of MATS Highest reported methods of assessment 1st ranked 2nd ranked 3rd ranked Public MATS Essay exam (60%) Oral exam (100%) Assignment & class test (40%) Private MATS Essay exam (60%) Oral exam (77%) Assignment & class test (27%) As reported by three public and 12 private schools, the other innovative approaches they have been using for students’ competency tests were interdisciplinary working competency, evidence-based practice, skills on the use of new informatics and understanding of health systems, etc. 21 Table 3.5 Percentage of MATS assessing different types of student competencies Innovative methods Public (n=3) Private (n=12) Interdisciplinary working competency 33 25 Evidence-based practice 33 33 Skills on the use of new informatics 33 25 Understanding of a thorough health system 33 8 Integration with public health 0 8 Ethical principle 0 8 Others tests such as assignment, class test, surprise test, tutorial, etc. 67 75 Figure 3.2 shows that the number of students admitted through all different types of entry criteria is increasing over the past decade in both private and public MATS. Since the private schools were established only after 2008, the data for previous years were not available. Figure 3.2 Number of students entered into MAT programme through different criteria over the past 10 years 99 99 101 100 101 101 100 305 407 407 408 389 81 289 427 658 723 148 255 407 480 622 Public national entrance exam Private institutional exam Private previous academic performance No. of students 800 700 600 500 400 300 200 100 0 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Chapter 3 | Results 22 The emerging role of medical assistant training schools in Bangladesh The timely completion rate of those students who entered into the MATS in 2008 was similar for both private and public schools. However, the delayed completion rate was quite higher in private MATS than the public MATS. Similarly, the attrition rate in private schools was more than double than that of the public schools. The information for onefifth of the MAT students entered in public schools was not available (Fig. 3.3). Figure 3.3 Percentage graduated/dropped out of those students who entered into the MATS in 2008 Table 3.6 shows that majority of the participants from both private and public schools suggested to introduce and continue national entrance examination system for admitted into the MATS. Similarly, the participants from both types of schools also suggested continuing previous academic performance, special quota for talented students and the students from under-served background as some other bases for getting into the programme. The qualitative data collected in this regard also support the suggestions made by the participants. This data adds on increasing the CGPA into 3.0 as another admission criterion from the current criteria CGPA 2.50. 20 2 8 3 30 10 60 67 Percentage Public (n=306) Private (n=336) Info not available Delay Dropout completed Timely completed 70 60 50 40 30 20 10 0 23 Table 3.6 Comments of institutional heads on further improvement of admission process in MATS (%) Different components Public % (n=5) Private % (n=30) Improved Continued Scale up Improved Continued Scale up National entrance examination 20 80 0 10 27 3 Previous academic performance 20 20 20 40 23 17 Special quota for talent 0 40 0 0 37 0 Community work hours 0 0 0 3 7 0 Special quota for students from underserved areas 0 20 0 0 10 0 Selection by local community 0 0 0 0 10 0 Others (Institutional exams) 0 0 0 10 7 0 Figure 3.4 depicts the number of students admitted into the MATS programme over the past 10 years is increasing in the public schools. Similarly the number of students regularly graduated is also increasing, with some students having delayed graduation and some students dropped out from the programme. In private schools, the number of students admitted into the programme in 2008 and 2009 is almost similar, having observed almost similar trend on number of students graduating regularly and delayed. There were also some students dropped out from the programmes. Due to unavailability of a complete set of data, the result presented in this figure should be used with particular caution. Chapter 3 | Results 24 The emerging role of medical assistant training schools in Bangladesh Figure 3.4 Number of students admission, graduation and dropout in the past 10 years As reported by few respondents, the major causes of student dropout were personal reasons, interest in developing career in different areas, poor academic performance, and inability to pay tuition fees, etc. A3. Teaching workforce General characteristics of the teaching workforce Majority of the teachers’ age in public schools was ≥50 years (65%), which is more than double of those in private schools (28%) (Table 3.7). More than three quarters of the teachers were males in both the schools. Currently 30% of the teachers in private schools are employed on a part-time basis. However, the establishment policy for private MATS 2010 suggests having provision of no more than 25% part-time teachers if full-time teachers are unavailable (19). The proportion of part-time teachers in public school is 15%. 49 49 51 50 51 51 101 204 205 226 224 30 10 40 19 13 39 76 172 180 133 150 2 20 11 68 66 9 11 10 8 Attrition Delay graduated Public schools Private schools Timely graduated Total admission 250 200 150 100 50 0 No. of students admission 2001 2002 2003 2004 2005 2006 2007 2008 2009 2008 2009 25 Table 3.7 Distribution of teachers by age and employment status Age and employment status Public Private Age Age

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