The Value and Feasibility of South-South Medical Elective Exchanges in Africa

Abstract


Background
Global health issues, the need to understand health disparities and equip students appropriately are increasingly relevant (1) in light of globalisation.Educators need to ensure students are prepared for such challenges and electives can help achieve this.
An elective is part of the curriculum where students choose both study topic and location, often in another country.International medical electives (IME) are well-established within curricula at most medical schools in high-income countries (HIC) (2)(3)(4) because of the learning students gain, which broadly includes: clinical knowledge and skills, attitudes, personal and professional development and global perspectives (5-8) (Fig. 1).They also provide signi cant transformative experiences for many and reignite the vocational drive that led many to enter the medical profession (9), whilst potentially recruiting trainees to primary care and underserved areas (8).
Of British students undertaking an IME approximately 40% of them choose a developing country (3).In Australia, this can be as high as 59% (4).Based on medical electives alone, universities and healthcare institutions in Africa receive thousands of students yearly from HIC (10).
Increasing consideration is being given to the ethics of electives, including the positive and negative consequences for host communities (5,9).International students undertaking electives can bene t the host institution by enhancing the host's reputation (5,11,12); bringing opportunities for international training for local staff, equipment donation and nancial gain (5,12); bringing international collaboration opportunities (11), and providing clinical services (11,13) which sometimes lls gaps in healthcare provision (11).Their presence enriches the educational environment due to varied backgrounds (1), allowing the exchange of ideas and experiences (11).In this setting, learning can become bidirectional between host staff and elective students (13).Elective students can increase supervisors' motivation to continue professional learning (11).Finally, some hosting institutions see elective students as a potential source of future staff (13).
However, students undertaking IME in under-resourced settings potentially exacerbate the lack of resources (5,11).Such electives can also include cultural voyeurism and replicate colonialist practices, promoting the 'West knows best' attitude, cultural insensitivities and power imbalance (7,14).As such, host communities in low-middle income countries (LMIC) often experience that the burdens outweigh the bene ts.
An awareness of the need for change exists (5, 7) with sending institutions, government reports (15) and importantly, elective host communities in LMICs (11,15,16) recognising that reciprocity should be increased in current elective systems.Students in LMIC rarely get such elective opportunities according to the staff at the medical schools participating in this research.We expect that African medical students have as much to gain from studying internationally as their HIC colleagues, and there is some evidence consistent with this (10,17).However, there are numerous constraining factors for IME for African students including limited funding, visa restrictions and the lack of organisational support (10).Some elective opportunities exist, through institutional partnerships with bilateral exchange programmes, where LMIC elective host institutions are given elective opportunities in other countries, typically HIC (18,19).However, they are limited in number and organising them on a larger scale is di cult and costly.The International Federation of Medical Students Associations (IFMSA) 'SCOPE' programme creates elective opportunities by providing bilateral exchanges using a network of locally and internationally active students in both HIC and LMIC (20,21).However, costs such as exchange fees and international travel make even these programmes unaffordable for the majority of students in LMIC.
South-South Medical Elective Exchanges (SSMEE) is an alternative elective model that aims to create IME opportunities for African medical students in another African country for several reasons.Firstly, students should experience healthcare systems similar enough to their own that learning will be transferable back to their own context, secondly, such electives have a reduced risk of brain-drain and thirdly costs could be lower than an elective further a eld, which would increase nancial sustainability.
The concept of SSMEE was presented at the 2015 The Network: Towards Unity for Health conference in South Africa.This international conference was an opportunity to share the concept to gauge existing interest in SSMEE.Several African medical schools expressed interest so a pilot with four African medical schools (Malawi, Rwanda, South Africa, and Uganda) was developed.
Despite the evidence of the value of electives for students from HIC, there remains little evidence for undergraduate students in LMIC.The evaluation of SSMEE aimed to explore how South-South medical electives are valuable and/or feasible in sub-Saharan Africa.

Methods
A qualitative case study approach was used to gain a detailed understanding of SSMEE through evaluation (22).Being an instrumental case (23) it sought to gain insight into speci c issues and problems in one bounded case to determine how SSMEE was valuable and feasible.
The subjects were eight nal year medical students, selected by their respective medical schools to participate in SSMEE, and composed of two students each from the College of Medicine, Malawi; University of Rwanda, Rwanda; University of Witwatersrand, South Africa and Makerere University, Uganda (Fig. 2).The organisation of this pilot was supported by the Global Educational Exchange in Medicine and the Health Professions (GEMx) program, a service of Educational Commission for Foreign Medical Graduates' and the Foundation of Advancement in Medical Education (ECFMG®│FAIMER®) (24).GEMx provided the web-based elective application platform that allowed the centralisation and operationalisation of the student electives, a coordination center to oversee activities and mobility of the students, as well as a 1000USD grant for each student as they went on electives to help reduce costs.Students were advised that SSMEE was part of a research project and so they would be invited to participate in the evaluation of the programme in line with the good ethical practice that involved gaining of written informed consent (25).

Data Collection
Electives took place between June 2017 and January 2018 and were of 4 weeks duration.Two methods of data collection were used: rstly, a pre-elective questionnaire and secondly a post-elective semistructured interview.
The questionnaire obtained helpful background information regarding the student, previous travel, why they wanted to participate, desired learning objectives and any concerns they had about the elective.The questionnaire was administered via email and completed before the elective.
Semi-structured interviews were conducted within a few weeks of the elective to allow the researcher to evaluate participants' learning and gather information about their experiences whilst enabling clari cation, further questioning and probing of answers (26).With participants in four African countries and the interviewer (KD) in Scotland, face-to-face interviews were not feasible.Anticipated internet challenges discounted internet-based interviews and so interviews were conducted using WhatsApp instant messenger.The credibility of responses was sought by giving participants control of the interview such as selecting the time of the interview, the ability to leave the interview and come back to it if required, putting them at ease and then giving an invitation to share their thoughts (27).The transcripts were downloaded and anonymised.

Data Analysis
Framework analysis (28) was undertaken of both questionnaire and interview data.Inductive analysis was used following the six steps described by Braun & Clarke (29).Two of the six interview transcripts were analysed and coded independently by a second analyst for triangulation, then as a thematic framework was constructed, discussion of coding and discrepancies took place between analysts thus adding rigour to the analysis.Ethical approval was granted by research ethics committees at the University of Dundee, Scotland, College of Medicine, Malawi, the University of Rwanda and the University of Witwatersrand, South Africa.Local ethical approval was not required in Uganda.

Results
All eight medical students in SSMEE agreed to participate in the research.However, the two students from the University of Rwanda had not undertaken their elective within the intended time frame due to delayed student selection by the university and restrictions as to when their elective could take place within the academic calendar.As such, data from six of the eight students is presented, each identi ed by a letter from A-F.The six students undertook an elective in Malawi, Rwanda or South Africa, however, the elective destination is not speci ed as this could breach student con dentiality.

Value of the Elective
Interview data highlighted the perceived value for students, which has been grouped into four categories: clinical knowledge and skills, personal and professional development, attitudes and global perspectives.
Although the data was independently analysed, the same themes emerged as presented in Figure 1(5-8) hence the same themes were used.

Clinical knowledge and skills
All six students described the elective as providing opportunities to apply and develop their clinical knowledge and skills, such as: history taking and examination skills, communication skills, diagnostic capabilities, and practical procedure skills.Sometimes this was by exposure to diseases, such as schistosomiasis and malaria not encountered in their own hospital setting and in other cases it was the application of previous learning.Some students felt more independent in patient management, such as examination of the neurological system, cardiac murmurs and placing central lines, chest drains, using sonography for trauma assessment and use of a de brillator, not readily available in their own institution.This also led some to re ect on differences between their elective experience and how things were done in their home institution as well as the application of their learning: "I realised that patients were being explained everything and being involved in every step of the way including them to write in the le what they had understood and sign against it.I found this very striking since back home, we mostly talk to rather than talking with the patients.I am going to practice this and share it with my colleagues" (B) All students felt their learning was applicable to their home context.

Personal and Professional Development
The elective resulted in students' personal and professional development in areas such as vocational drive, meeting their own goals and improving con dence: "In terms of myself, it rea rmed me that I was in the right profession and that I was becoming the competent doctor I've always wanted to be... Before the elective, I didn't think I'd be comparable with a student in a different institution but now I know I can be and there's no excuse for not dreaming big." (F) Attitudes Personal attitudes were challenged resulting in a desire to change, e.g.be kinder to patients or less wasteful of resources.
"I am advantaged compared to my peers to know some more but I also share with them the ideas and knowledge."(A)

Global Perspectives
Students experienced different languages, cultures, healthcare systems, beliefs/values and diet allowing them to re ect how this impacts local populations and look at their own background and healthcare system from another perspective.
"The culture had a toll on health-seeking behaviour.Most of the patients believe in traditional medicine and therefore would visit traditional healers and only come to hospital when everything failed, therefore they would present late to hospital!" (A) Students recognised that teaching methods vary between countries and highlighted their positive experiences of elective-based teaching: "I observed that the professors and lecturers (at least the ones that taught me) are not intimidating and always want to teach students.It is somehow different to [home country] where sometimes you feel intimidated."(E)

Feasibility
The feasibility of SSMEE was explored by considering student's perceptions of an IME in another African country and the challenges they anticipated or encountered.

Student Perceptions
Students described their feelings about IME in another African country.Initial attitudes among the six students varied, with some changing over time.Students A and B were happy to have the opportunity to go anywhere.Students D and E initially preferred to go out of Africa.With hindsight, however, student E recognised the elective undertaken provided him/her the opportunity to see something different, as s/he had desired, and student D is now motivated to visit more African countries rather than leave Africa because "there is a lot more to learn especially in Africa with regards to resource constraints and the burden of disease."Student C, also favoured the elective within Africa: 1. "The disease burden within Africa is similar, …, by staying here you are learning similar things just in a different way and different place.
2. From my understanding, African countries have more hands-on learning opportunities because medical students are more hands-on.
3. Charity begins at home, so why travel across an entire ocean for something you can achieve in your own backyard.
4. Africans should build and support other Africans, and this is a good way to do that." Student F initially associated 'elective' with leaving Africa, however, had "such an amazing experience… can't imagine having the experience I had in an outside [of Africa] country" Challenges Anticipated or Encountered In the pre-elective questionnaire, ve of the six students identi ed potential concerns such as: getting lost, communication, cultural awareness, the potential for culture shock, insu cient personal knowledge and skills, safety and money shortages or non-functional bank cards.Actual challenges encountered were discussed in post-elective interviews: Finance Each student received a 1000USD bursary towards elective expenses.Students were asked how much their elective cost and ve of the six students provided gures.Costs ranged from 900USD to 1600USD.At least four out of six students required further funding.Four of the six students supplemented the bursary with their own nance obtained via family or friends.Only two students had additional costs covered by their own University.For those covering their own additional costs, limitations of funds had a considerable impact: "I mainly faced a shortage of funds.I had no stipend to cater for meals especially in the last week.Most of the money for upkeep I got from home and it was not really enough." (A) Student D described few opportunities to pay by bank card in their elective country resulting in high bank charges to withdraw money which could have been avoided had they known to expect this.

Language Barrier
The language barrier was a concern expressed by students prior to their elective.Two students revisited the language barrier during post elective interviews.One student mentioned that discussions took place in English and the [local] language was easy to learn.Student D however found: "It was quite challenging to talk to patients and examine because of the language barrier.I had to learn some [local language] words to ease the consultation.I also asked for help from one of the doctors or nurses to translate" (D) Student D declared s/he would increase efforts to learn different languages used in his/her country to improve communication with patients.

Practical issues
A range of practical issues were encountered by students.South African students wanted to travel to Rwanda however were unable to due to political reasons.Another student encountered visa problems because the allowed time was inadvertently overstayed.
Student E encountered logistical challenges because the accommodation was not as close to the hospital as expected, incurring transport costs.Other unexpected issues arose in terms of electricity supply and supervision: "I was not aware about the electricity cuts.I would have been better prepared for them."(D) An additional gain described in this study, not mentioned in existing literature was the exposure to alternative teaching methods.It could be expected that this can encourage one to reconsider their own education system through different lenses.
Attitude changes can occur through an IME (5,13,30,31) and similar attitudinal changes were identi ed in SSMEE participants.This study provides evidence that such learning can be gained within Africa and students often share this learning with others, spreading the bene ts further a eld.Therefore, students do not need to travel as far as HIC to gain this learning, which could reduce costs, a recognised barrier to electives (9,32,33).

Challenges
The SSMEE pilot identi ed challenges discussed under the themes of nance, harm to patients and practical issues.

Finance
The most signi cant challenge is the funding of electives.With elective costs a potential challenge for students in HIC (9,32) it is unsurprising this was also an issue for SSMEE participants from LMIC.With the cost of a four-week elective exceeding the 1000USD grant in most instances, covering costs beyond this was a challenge for the students involved.Other sources of funding or bursaries are often not available to African medical students.Apart from the one university covering additional costs for their two students, other students did not have access to other bursaries.Addressing the nancial costs of an elective remains the biggest hurdle for SSMEE and without the grant offered by GEMx programme nancing the elective would have been a bigger hurdle for students.Though SSMEE will cost less, due to lower travel costs and lower living expenses, and so is a more nancially viable and sustainable option if the desire is to create international elective opportunities with reciprocity.

Practical issues
A few minor practical challenges were encountered by students, some of which might have been prevented with more pre-departure information and better planning on the part of students.
One student had expressed concern pre-elective of encountering potential hostile attitudes, such as xenophobia, in elective host countries.Although this was not encountered it does highlight the need to consider equity and diversity issues with respect to electives.

Strengths and Limitations of the Study
The small size of the study could be seen as a limitation, however, being a pilot it was intentionally small aiming to explore the value and feasibility of the model.Financial support was another key reason for the study size as student bursaries were only available for two students from each institution at this stage.
Despite being small, the study has involved four different medical schools, each in a different country and with their own curricula and timetable demonstrating the feasibility of a multicentre model.
Selection bias may have occurred as participating institutions were self-selected and the institutions designated the students to participate in the electives, only excluding students who previously did an international elective.This selection process might have resulted in potential positive bias due to the positive attitudes towards the study from the outset.Additionally, this research project provided participants with an IME that they otherwise would not have had, which means they may have exaggerated the bene ts of their elective, as a sign of gratitude.

Conclusion
The SSMEE model provides valuable learning for participating students and their peers/colleagues.This pilot has shown that the SSMEE model is feasible with four countries participating.Financing electives remains the biggest challenge.Since this pilot in 2017/18, SSMEE has continued and has now merged with another GEMx pilot project forming a regional elective exchange network in Africa with an additional four institutions in three other countries.More funding through GEMx, has been given to each institution to help offset elective costs.As such SSMEE has resulted in increased opportunities for African medical students and better educational outcomes that are likely to have a positive effect on healthcare systems in Africa.The value for host institutions and impact on patients has not been explored during this study and would warrant further research.Declarations MF -involved in the conception and design of the pilot project, gained ethical approval in Rwanda, reviewed and edited initial draft.Approved nal version and agrees to be accountable for it ET -involved in the conception and design of the pilot project, was the second analyst, contributed to the review and revision of the article.Approved nal version and agrees to be accountable for it FN -facilitated the elective exchange process, contributed to the review and revision of the article.

List Of Abbreviations
Approved nal version and agrees to be accountable for it Figures