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Distance Learning for Health: Potential and Problems Explored at Workshop

The benefits and drawbacks of open and distance learning for the health community working in developing countries were discussed at a two-day event. Successes shared at the workshop organised by LIDC included programmes for nurses in Kenya and India. Challenges identified included low completion rates and inappropriate technologies for poor settings. Speakers also ventured beyond health education to explain how competence does not necessarily equate to performance, and how health outcomes are dependent upon many factors, such as politics, pay and job satisfaction.
Conditions for success
Dr Hilary Perraton, a Visiting Fellow at LIDC and the Institute of Education, drew on his fifty years of experience working in open and distance learning to emphasise how these methods can be used effectively to strengthen capabilities and promote development. He set out six requirements for progress at the workshop on 26 and 27 October:

• Respond to the needs and circumstances of learners (including their ability to pay)
• Devote resources to formative research and evaluation
• Get the instructional design right (mixed media, face-to-face support, well-designed materials)
• Make sure the logistics work
• Seek integration
• Get political support and teach your learners how to pursue it

Perraton questioned the impact of fees of UK-administered courses, which are typically two or three times the salary of professionals in developing countries, and also warned that improving health involves more than just educating health professionals. He added: “We need to include politics in our health curriculum”, pointing out that health workers need a practical understanding of the policies and strategies that underpin the national health systems they work within.
Demand for health education among primary care providers
Dr Tana Wuliji, of research institute Integrare, highlighted the “staggering” shortage of four million health workers required to provide basic health services in 57 developing countries. She described positive results from e-learning, but said these were mixed or limited when compared to the impact of classroom-based learning.  The key issues identified by Wuliji included the need for strengthened health systems that can support the work of primary health workers. As part of this, she highlighted the need for competent health managers and educators.  Wuliji also stressed the importance of enhancing the working environment to ensure health workers improve performance, particularly the role of supervision and feedback, granting autonomy, job satisfaction, pay, and the monitoring of outcomes.
Discussing these issues further, Caroline Mbindyo, e-learning programme manager for the African Medical and Research Foundation (AMREF) in Kenya, described how “extraordinary pressures” within the Kenyan health system, including a moratorium on hiring new nurses, have led to the use of e-learning to upgrade nursing skills. This partnership, involving AMREF and Accenture, has rapidly increased access to health education; more than 7,000 nurses are enrolled at 34 schools and there are 108 e-learning centres across the country, including centres which run on solar energy. Mbindyo said many of the nurses had not used computers before starting the course, but that resistance to change is being overcome, and further innovation is planned. She added: “We are looking at other devices which are more available, including mobile phones.”

Issues in training health workers at a distance
Petra Boynton, Lecturer in International Health Care Research at University College London, spoke about her experiences delivering the distance learning MSc in International Primary Health Care. She said the course and e-learning methods create opportunities for cheaper learning, an ability to share experiences beyond borders online, and a chance to reflect on neglected health issues. However, Boynton also mentioned the educational challenges, including lack of confidence among students, a reluctance to ask for help, students unable to complete courses because of major life events disrupting study, and NGO employees being constrained in their discussions by their organisation’s priorities. Jessica Sheringham, Public Health Tutor for Peoples-Uni (which provides capacity building in public health via open educational resources available online) echoed many of these observations, and said that many students do not complete assignments, although in unaccredited programmes, this can be because they have acquired the skills they required through study and so do not need to submit for marks.

Training approaches for strengthening health systems
Bimla Kapoor, Director of the School of Health Sciences at Indira Gandhi National Open University in India, discussed the ways in which her institution works in close collaboration with national and regional health administrations, as well as local hospitals and clinics, in order to facilitate the delivery of their programmes. This approach was presented partly as a necessity, given the scale of IGNOU’s health programmes in providing training to over three  million learners across India.  However, it was also seen as an approach which ensures that programmes meet localised priorities.

Karen Chio, of the US-based NGO Management Sciences for Health, described the approach their Virtual Leadership for Development Programme takes in training health managers in low- and middle-income countries. Distinctive features of this programme include the training of institutional teams of health managers rather than individuals, and the central objective of identifying and solving issues within local health systems. This localised approach to problem-solving and service improvement through project-based activities was also highlighted by Ralf Graves, describing the international Foundation for Advancement of International Medical Education and Research (FAIMER)  programme, and by Anand Zachariah, describing the India-wide Fellowship in HIV Medicine at Christian Medical College (CMC), Vellore. In addition, both highlighted the value of using distance learning programmes to create national and international networks of practitioners. Such networked approaches were presented as a further contribution to the strengthening of health systems.

Issues in evaluating programmes and providing evidence of impact
The evaluation of distance learning for health (DL4H), and the difficulties in providing evidence of programme impact, were recurrent themes at the workshop. The issues discussed included evaluating the impact of training programmes on learner practice, on the strengthening of health systems, and on the achievement of wider health outcomes.

Among the points raised during an open discussion with a panel of experts included the need for programme designers to see programme evaluation as a core programme activity, rather than as an additional or final task. It was argued that responsibility for evaluation design should rest with the programme developers, and that the evaluative process should be outlined at the point where programme objectives were being agreed. Many were interested in identifying the means by which this could be achieved. It was also pointed out that the training of health workers may not necessarily be the most appropriate input for health systems strengthening or the achievement of wider health outcomes, although it was often assumed to be so. Given this, it was recommended that a broad set of guidelines for an evaluation framework should be developed.

Delegates’ concluding remarksAt the conclusion of the two days of discussion and analysis, many delegates highlighted the fact that, as professionals in a field as specialist as distance learning for health, they had often felt as if they were operating in isolation. Many expressed their enthusiasm for the opportunity to meet practitioners from around the world, and to compare expertise and experience. It was noted that despite the diversity of approaches to DL4H on show, ranging from highly localised programmes to those with a global reach and an international student body, a number of common approaches and practices emerged. These included the importance of accommodating,  and an awareness of, localised and contextual approaches to health service delivery within programme content and delivery, and the value of blending distance learning and self-study with face-to-face and work-based training.

Finalising the DL4H review
The DL4H International Workshop was an important component within the DL4H review of distance learning for health workers in low- and middle-income countries. Many of the findings presented and discussions held during the two days will be an important supplement to the information gathered to date. They will be incorporated into the final report and recommendations, due to be completed by the end of 2010. It is anticipated that this review will also form the basis of a number of further activities to be undertaken by LIDC in collaboration with a range of partners during 2011.

By Chris Joynes, Project Officer for DL4H at LIDC, and Guy Collender, Senior Communications Officer at LIDC

Powerpoints presentations delivered at workshop