Q&A: Cause of death course to boost medical education in Africa

Medical professionals in Kenya. Photo by: SIM USA / CC BY-SA

CANBERRA — As the Bloomberg Philanthropies’ Data for Health Initiative enters the final year of its four years of funding, implementing partner Vital Strategies has launched a new e-learning course to help collect data on cause of death — one of the initiative’s goals and an important part of developing better health policies.

The medical certification cause of death course is the first of its kind designed specifically for Africa. It will be used for physicians in Ghana, Tanzania, Rwanda, Kenya, Zambia, and Malawi, and aims to provide wider availability and flexibility for medical training in the continent.

Speaking with Devex, Philip Setel, vice president and director of the civil registration and vital statistics program at Vital Strategies, discussed the new program and how the training’s been tailored to meet the specific needs and challenges of medical services in Africa.

The interview has been edited for length and clarity.

What was the research and consultation process in creating the e-learning course?

We began with a curriculum that has been taught for many years by a master trainer from Tanzania, who has been teaching proper cause of death certification using the international classification of diseases standard medical certificate of cause of death. And we carried out consultations with the ministry of health and other stakeholders from the countries that have endorsed the course to get their buy-in — Ghana, Tanzania, Kenya, Rwanda, Malawi, and Zambia.

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We felt it was important to educate physicians not just about how to properly certify cause of death, but also why it is important to do so carefully and correctly. We added content at the beginning of the course to explain that good quality national cause of death statistics cannot be derived based on deaths that are poorly certified. As we developed the script and content for the course, we also sought informal peer review from ICD experts both in our network and from the World Health Organization.

What was the process of gaining government buy-in for the training?

Before we started work on the e-learning course, we gathered relevant authorities from each of the countries for a stakeholders meeting. The purpose of the meeting was to assess the need and desire of national stakeholders from the six countries for such a course, and their willingness to endorse the course if it were to meet their standards for continuing medical education.

Once that was obtained, we had periodic check-ins with the group to update them and share the course at intermediate stages of development to ensure continued buy-in and support.

Are there unique challenges in Ghana, Tanzania, Rwanda, Kenya, Zambia, and Malawi you had to accommodate for?

There were not any particularly unique challenges to developing the course for these different countries. In all cases, we were seeking to ensure that the instructional content and length of course would qualify physicians successfully completing the course, and would meet the standards necessary to award continuing medical education credit. Because this course teaches to an international standard, the content needed to be consistent across these countries.

But one common local barrier that does need to be addressed, is the tendency to succumb to pressure from families not to write “stigmatizing causes of death” on the certificate, primarily HIV/AIDS. Though it is not possible to measure the scope of the problem, we know anecdotally from several countries that this is an issue. In place of entering HIV/AIDS as the underlying cause of death, it is reported that physicians may enter causes such as “chronic malaria,” “TB,” or “cancer.”

“In place of entering HIV/AIDS as the underlying cause of death, it is reported that physicians may enter causes such as ‘chronic malaria,’ ‘TB,’ or ‘cancer.’”

— Philip Setel, vice president and director of the civil registration and vital statistics program at Vital Strategies

Are there challenges in certifying and recording causes of death that cannot be solved through training?

While good cause of death data begins with physician training on proper certification, several things need to be in place to derive good cause of death data for a country.

First, in African countries the official medical certification of cause of death captures only deaths taking place in health facilities. Assigning and recording causes of death in the community, where there is no doctor and, which often represent a large majority of deaths taking place, needs to be addressed by developing a nationally representative system for conducting and collecting verbal autopsies. This is a structured interview carried out with the family or caregivers of the deceased to determine signs and symptoms experienced in the period before death.

The pattern of responses to the questionnaire is used by a computer algorithm to assign the most likely cause of death, which can be used in the tabulation of mortality statistics. At present we have supported governments in five of the six countries endorsing the course to establish and scale a permanent, sustainable, and nationally representative system for collecting verbal autopsies.

Considering only those deaths that can be medically certified — such as deaths in health facilities — it is ideal to have an overall strategy to strengthen the entire process of certification and reporting. This includes inserting certification into medical school curricula, face-to-face training at high volume hospitals, the use of smartphone apps that physicians can refer to when certifying a death, and training or retraining programs including the e-learning course launched by the Data for Health Initiative.

Finally, governments should establish quality assurance measures at the hospital and national levels, ideally with some form of incentive for good performance. We have helped to establish mortality review committees at these levels and equipped them with access to a tool that assesses the quality of certification practices. This information is fed back to doctors and hospitals and can be used to identify the need for retraining.

In implementing this for other countries in Africa or elsewhere, are there specific elements of the training you would change to suit local conditions and circumstances?

Because the course teaches an international standard, the bulk of it is applicable to any setting.  However, if adapted to other regions or countries, the introductory section that displays and discusses regional issues in the quality of cause of death and certification would need to be contextualized. We are currently in discussions with the Ministry of Health in Colombia to do just that.

What are the next steps for training and how will you go about monitoring its effectiveness?

Our next steps in supporting governments to reach a higher standard of medical certification are to support governments to develop and implement such national strategies, using all the modalities previously discussed. Unfortunately, only face-to-face training of physicians — where we can see the before and after effects of the training over time — lends itself well to rigorous monitoring. Measuring the impact of distributed methods like e-learning or cell-phone apps on the performance of individual physicians is not practical.

Over time, we are counting on the combination of pre-service and in-service training, plus feedback loops and incentives where possible to lift the overall quality of cause of death statistics, which countries measure annually using another assessment tool developed by the Initiative.

How is the training accessed?

Although the course was designed with the physicians of Anglophone Africa in mind, it can be accessed free online by anyone. We have tried to keep bandwidth requirements low, but being an e-learning course, it is currently available only to those with an internet connection. We intend to explore making the course available offline as well via USB.

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