Kadum Yousif Al Hilfy
Director Health For All Center (NGO)
Assistant Professor / Alkindy College
The health professions
in Iraq in general include physicians,
dentists, pharmacists, nurses and
The documents prevail
that the already existing health system
is based on curative side and shifted
toward hospital orientation.
The total number of
health centers in Iraq according to
the latest reports prevail the presence
of 1285 health centers among which
only 50% have a health professional.
There are 20 colleges
of medicine in Iraq, seven colleges
of nursing, 10 colleges of dentistry
and 8 colleges of pharmacy in addition
to 6 technical colleges and 20 colleges
of sciences which take the responsibility
for supporting health care services
We are in great need
to reform our health professional
education through following the global
standards toward unity of agreed standards.
Tikrit college of medicine has followed
since 1987, competency based education
programs/problem based learning. This
paper provides a comparison to evaluate
Iraq's experience against global standards.
The WFME recommends the following
set of global standards in basic medical
education. The standards are structured
according to 9 areas with a total
of 36 sub-areas. The TUCOM (Tikrit
University College of Medicine) was
established many years before the
production of the WFME standards (1988).
Nevertheless, it is a valuable exercise
to compare and evaluate the college's
performance against these global benchmarks.
STATEMENTS OF MISSION AND OBJECTIVES
In the self-study of
TUCOM the statement of mission was not adequately
addressed. Looking into the main curriculum
document, it appears that a statement of
mission does exist however; however the
self-study has ignored it. As for the institutional
objectives TUCOM has 5 clearly stated objectives,
addressing 5 main issues. These are:
- Role of the college
in improving the health of the targeted
- Preparation of competent
and responsive graduates to manage individual,
family, and community health problems
- Adoption of educational
program focusing on priority and primary
- Adoption of life-long
learning and assessment strategies.
- Focusing on population
The self-study concentrated
only on the educational objectives and ignored
other institutional objectives like role
in research, providing services, social
accountability and contributing to professional
development. Aldabbagh (2003)
ignored areas should be revisited and well
1.2 PARTICIPATION IN
FORMULATION OF MISSION AND OBJECTIVES
The self-study mentioned
the participation of a few stakeholders
who participated in the formulation of mission
and objectives. These included university
authorities, international organizations
and staff from the Ministry of Health. However,
the study ignored the contribution of important
stakeholders like: community leaders, students
and professional organizations.
part of a routine periodic revision all
stakeholders are to be approached and actively
1.3 ACADEMIC AUTONOMY
Medical education in
Iraq is totally run under the patronage
of the ministry of higher education and
scientific research. The medical school
is almost totally funded by two types of
governmental budgets; a yearly regular budget
and a project-based developmental budget.
Both budgets are granted according to a
request from the college based on real needs
and future projection. All academic departments
and centers participate in such an exercise
based on the requirement of implementing
the curriculum. Once the budget is granted
the college authority is autonomous in distributing
and spending the allocations according to
priorities. However such an arrangement
depends on the financial status of the government
revenues and budgets could vary accordingly.
In recent years, TUCOM as well as all other
medical schools in Iraq started to compete
in attracting foreign students to be enrolled
against paying tuition fees in hard currencies.
The greater part of such income is used
by the college for developmental purposes.
(TUCOM curriculum document)
TUCOM should make the best of its innovative
educational program to attract more funds.
1.4 EDUCATIONAL OUTCOME
The competencies at graduation
are clearly defined in the TUCOM curriculum
document. The level of performance of these
competencies at graduation are closely related
to the job description for the two years
foundation residency program that each graduate
should pass before being allowed to start
any kind of practice and postgraduate training.
It is also unique to note that the competencies
include all those required by a general
practitioner with emphases on primary health
care and family medicine in addition to
all other clinical disciplines.
future revisions of educational program,
the graduates' competencies should be revisited
to align with the new development in professional
practice and health system development including
postgraduate training schemes.
2.1 CURRICULUM MODELS AND INSTRUCTIONAL
TUCOM is the first medical
school in Iraq to introduce problem-based
learning curriculum and still the only one
among the 19 operating medical schools at
the present time. The curriculum document
clearly defines and describes the learning
strategies based on the following characteristics
- Community oriented
program responding to priority health
- Full integration of
subjects and disciplines at both horizontal
and vertical levels
- Curriculum is divided
into 3 phases : healthy life, pathogenesis
and clinical and primary care clerkship
- Organ-system modules.
- Self-learning strategies
- Community-based training
in and outside college campus.
future revisions the problem-based learning
methodologies should be modernized to match
the new developments in learning strategies
including the case presentation curriculum
(CPC) with the use of clinical flow charts
and scripts. Meanwhile, new advances in
e-learning should also be considered
2.2 SCIENTIFIC METHOD
The program adopted by
TUCOM is based on analysis of common problems.
Also the six years program contains a curricular
research project assignment in 4 years (years
2-5) where groups of student learn by doing
scientific thinking and research methodology
that usually has each project ending in
producing a scientific, publishable article.
in-depth evaluation of the program is needed
to identify strengths and weaknesses.
2.3 BASIC BIOMEDICAL
The first 3 years of
the program are devoted to address basic
medical sciences in integrated modules,
based on health problems.
It is usually claimed
by opponents of the PBL program that graduates
of such program are somehow deficient in
basic knowledge. However several research
studies showed that PBL graduates are better
in applying knowledge in their professional
studies are needed to examine this issue
2.4 BEHAVIOURAL AND SOCIAL
SCIENCES AND MEDICAL ETHICS
The curriculum document
does not show clearly separate modules on
behavioral sciences. It is apparent that
such elements are deeply embedded within
the whole curriculum. For example the weekly
student self-evaluation and group peer evaluation
are based on behavioral performance of students.
Such exercise provides students with actual
practicing of behavioral and ethical issues.
comprehensive analysis of the curriculum
is needed to identify the behavioural and
ethical practices experienced by the students
during their 6 years of the study and to
add what would be seen as missing elements.
2.5 CLINICAL SCIENCES
The students are given
the opportunity to get in contact with the
community including patients as early as
the first week of the program. In addition
all training in hospitals, primary health
care centers and community setting is done
from a systematic and pre determined list
with clear students' objectives and tasks.
However, many of the clinical teachers go
beyond the schedule training to concentrate
on their personal interests.
supervision and monitoring of students training
outside teaching facilities under the control
of the college is needed to ensure systematic
training with full use of standard operation
procedures (SOPs) and checklists.
2.6 CURRICULUM STRUCTURE,
COMPOSITION AND DURATION
The six year curriculum
follows the natural history of health and
disease. It starts with promotive and protective
health and passes through the stage of early
detection of disease and the history of
pathogenesis to prepare the student for
the interventional stage of diagnosing,
managing and rehabilitating individuals,
families and communities. During all these
stages special emphasis is made on community
priority health problems and targeting the
state of population wellbeing.
population health is dynamic by its nature,
new challenges are to be periodically followed
up and to be incorporated into the curriculum
on regular bases.
2.7 PROGRAMME MANAGEMENT
In TUCOM the curriculum
committee and its structural curriculum
unit is headed by the dean. In addition
to secretary and administrative staff, the
committee is composed of members representing
different academic departments and the coordinators
of each year. The committee is responsible
for managing all the learning and student
assessment activities. Departments are only
responsible for teaching and training of
students according to the schedules and
time-tables organized and supervised by
the curriculum committee.
evaluation of the work of the committee
is needed to ensure efficiency and effectiveness.
learning outcome is to be measured using
two strategies. Formative assessment is
used for feedback and continuous development.
Students are verbally fed-back at the end
of every week during the face-to-face peer
and tutor evaluation at the end of each
problem. At the same interval, each student
reports on the week's learning achievement.
The report is reviewed by tutor and written
feedback is provided and discussed if necessary.
The second strategy is the summative method
for scoring, passing and ranking.
First, Continuous assessment
(10%): This assessment takes place during
almost all learning activities in the form
of quizzes, peer evaluation (negative marking
only), reporting, attitude, tasks during
field, practical and clinical sessions.
Assessment: At the end of each block, there
is one integrated MCQ paper (10%) and a
10-15 stationed OSCE (10%).
Final Assessment at the
end of the year, a grand block/subject is
assessed through assessing two blocks together
using an integrated single paper of MCQ
(20%) and an integrated OSCE (20%). So,
final marks for each subject are calculated
as Continuous Assessment in 2 blocks (10%x2)
+ End -of-Block Assessment (20%x2) + Final
Assessment (40%) = 100%.The criteria for
passing any part of the assessment is to
score at least 50%. All assessments are
organized and conducted by the curriculum
committee and in collaboration with the
concerned department. Accordingly the test
questions are evaluated before and after
the test and students are given a feedback.(TUCOM
technologies should be looked for to enhance
and ensure validity, reliability and objectivity
of the test.
3.2 RELATIONSHIP BETWEEN
ASSESSMENT AND LEARNING
The aim of assessment
is to be always based on the educational
objectives. Teachers and trainers are asked
to submit several questions and training
tests based on the specific objectives they
followed during teaching and training. The
curriculum committee will evaluate the material
submitted and choose the final sets to be
administered for the students' assessments.
All tests, theoretical and practical, are
based on sets of integrated subjects. However,
during the last few years several teachers
in different departments started to administer
subject based guises and mini-tests.
of the integrated assessment is of a high
priority to maintain and ensure a close
relationship between assessment and learning
ADMISSION POLICY AND SELECTION
policy for admission to higher education
institutes is uniform for all institutes
in Iraq. This policy is based on competitive
application for enrollment in different
colleges based on demand and number of seats.
The major criteria are the academic scoring
in the secondary school final examination
after 12 years schooling. However, enrollment
in medical schools in particular is conditioned
on passing a special interview selection
by a special committee headed by the dean
to ensure characteristics other than the
academic record. The role of this exercise
is unfortunately a limited one.
and decisive role should be given to the
interview plus introduction of new psychological
and social tests.
4.2 STUDENT INTAKE
Students' intake is decided
annually by the ministry of higher education
and scientific research and is tied to the
national need, as submitted by the ministry
of health. In general terms, not all capacities
at the college are seriously considered.
The college is usually consulted on the
already decided number of the student intake
and an approximate number is compromised
between the different colleges so that the
total national number of intake is made.
number of intake in the college is to be
determined and maintained, according to
the real capacity and size of teaching and
training opportunities available.
4.3 STUDENT SUPPORT AND
Limited support and counseling
is available as part of a national policy.
Some support is provided in respect of housing,
transport and cafeteria services. Social
and psychological counseling is unavailable.
Suggestion: This important aspect of support
to the students should be seriously considered.
Also, financial support and grants should
be extended to cover students with distinction
as was done prior to 2003.
4.4 STUDENT REPRESENTATION
In TUCOM the student
union is active in several ways. Each year
the central committee is formed of two representatives
from each year, freely elected by all students.
One representative of students is present
as a member in the college council and one
in each department council. In addition
the student union establishes each year
several committees in different activities
in arts, athletics, poetry, literature and
other non-curricular activities.
Such activities need to be supported
financially, logistically, and morally.
5.1 RECRUITMENT POLICY
A central policy exists
at the national level. However, eligible
staff can choose to submit their application
to each medical college and will be considered
according to their qualification and experience.
Each application will be considered by the
college according to the vacancies available
and approval of university and ministry
of higher education authority.
that scientific criteria is met, the college
should have a policy to be given the right
and authority, to recruit the needed staff
and decide the appropriate salary and motivation
without submitting the application for approval
by the university and the ministry.
5.2 STAFF POLICY AND
As part of career development,
each member of staff should pass a course
in principles of medical education during
the first two years of service. In order
to be promoted to the title of professorship,
staff members should pass through three
stages of promotion with certain criteria
to be met, including teaching, research
and service, with annual appraisal.
of the shortage of qualified candidates
willing to work in the medical college,
the ratio of teachers to students varies
from one department to another. Salary scale
and motivations should be reconsidered to
encourage qualified people to work in different
departments of the college. Also incentives
should be given to encourage attracting
qualified staff from the ministry of health
to train medical students.
6.1 PHYSICAL FACILITIES
The learning, training
and teaching activities are conducted in
1. Inside college campus,
- Lecture halls, small
group face to face discussion rooms.
- Practical laboratories.
- Skills laboratories.
- Computer laboratories.
Interactive Learning Laboratory.
- Audio-Visual laboratory.
- Teacher-Student contact.
2. Outside college campus
and includes: Tikrit teaching hospital,
primary health care centers and other community
Suggestion: The learning environment
for the students should be improved by regular
updating and extension of the facilities
to match developments in educational practices.
6.2 CLINICAL TRAINING
The medical school must ensure adequate
clinical experience and the necessary resources,
including sufficient patients and clinical
420-bed Tikrit General Teaching Hospital
belonging to Ministry of Health.
Health Care Centers in Tikrit City (3
in number) and in Tikrit suburbs and rural
surroundings (4 in number)
settings including both urban and rural
settings including schools, factories,
farms and clubs
Students should be provided with support
to get training outside Tikrit, for example
in Baghdad specialized hospitals.
6.3 INFORMATION TECHNOLOGY
The computer interactive
lab provides excellent opportunities for
students and staff to use simulated training
programs and internet connection.
update and to increase the number and improve
the quality of the information technology
facilities at regular periodic bases.
TUCOM is the only medical
school in Iraq that adopts a curricular
research program extending over four years
(years 2,3,4,5). Groups of students plan,
choose topics, implement, data collect and
analyze, discuss and write a publishable
field interventional research. Each year
this curricular research is presented by
the students in front of an examining committee
with a continuous appraisal and scoring
by a faculty staff supervisor. The resulting
overall score system has a pass or fail
mark for each student.
monitoring and evaluation of all projects
by the supervising committee is needed.
6.5 EDUCATIONAL EXPERTISE
The college employs an
educationalist who acts as a member and
adviser to the medical education unit in
the college. The unit plans, implements
and evaluates the medical education activities.
These activities include a weekly journal
club on medical education, staff development
workshops (at least one a year) and publication
of research on medical education.
Activities and publications related to medical
education need to be more encouraged and
motivated. Research in medical education
should be treated in a similar way to scientific
and clinical research in the process of
The curriculum includes
a strategy to evaluate the programme through
the following activities (internal and external):
- End-of-block evaluation
where the Block Committee meets and evaluates
the performance and reports back to the
- Development Committee
chaired by the dean.
Tutors report back evaluation remarks
to the Block Committee at the end of each
- The College Council
discusses educational events with evaluations
under a fixed item of agenda.
- Year Committee evaluates
problems and performance at the end of
each year and feedback to the Educational
- External evaluation
by invited experts from outside the college.
The college, for example, was visited
several times by the late Professor Jacobus
Greep (Maastricht), Late Professor Zohair
Nooman (Suez Canal), Professor Othman
K. Othman (Gezira), Professor Wagdi Talaat
- The college organizes
workshops for evaluation and performance
- The staff are encouraged
to conduct research to evaluate educational
process and outcomes for publication in
journals and in a special serial document
every 5 years entitled "Programme
Evaluation Studies" (TUCOM, 2000).
- The Educational Development
Committee regularly conducts studies to
evaluate graduates (Alsheikh et al 1999).
evaluation should always and periodically,
be revisited and generated to ensure new
blood in the life of the college
7.2 TEACHER AND STUDENT
Teacher annual appraisal
is done in two ways; firstly through the
supervisor and secondly through students.
Feedback from both is given to the teacher
on the one hand and to the medical education
unit and college council on the other hand.
Expansion of the process of feedback needs
to be elaborated
7.3 STUDENT PERFORMANCE
Student performance is
poorly dealt with.
is a very important subject that needs attention
as it leads to significant results
7.4 INVOLVEMENT OF STAKEHOLDERS
This is poorly dealt
with as program evaluation is only sent
to the university and the ministry of higher
To be seriously revisited.
GOVERNANCE AND ADMINISTRATION
The governance of the
college is well documented by law and roles
8.2 ACADEMIC LEADERSHIP
The dean leads the college
activities and chairs the medical education
committee and unit and college council with
clear authority, delegation and job description
of heads of departments and members of committees.
8.3 EDUCATIONAL BUDGET
AND RESOURCE ALLOCATION
The total budget of the
college is allocated according to uniform
chapters including clear parts devoted for
8.4 ADMINISTRATIVE STAFF
The college is regarded
by law as an independent administrative
entity headed by the dean and other senior
managers. The educational process is at
the top of the college priorities.
administrative staff should be motivated
and link to educational achievements.
8.5 INTERACTION WITH
This is a very important
aspect. TUCOM is very closely related to
ministry of health for example:
- Dean is member of
the national health planning board chaired
by the minister of health
- Chief medical officer
of the governorate is a vice chairman
of the college council
- Dean is vice chairman
of the governorate board of health care
- Dean is chairman of
the governorate board of continuing professional
- All training
of students takes place in health facilities
belonging to the ministry of health.
The college performs
a comprehensive program evaluation every
five years. Both external and internal experts
participate in this exercise. A special
document is produced on such occasion. In
addition, the ministry of higher education
conducts an annual performance evaluation
for the college covering inputs, process,
and outputs. According to the result of
this annual appraisal all colleges of higher
education are ranked according to specialty
and the first three colleges in each profession
is declared and awarded a certificate of