East and Central African Journal of Surgery Association of Surgeons of East Africa and College of Surgeons of East Central and Southern Africa ISSN: 1024-297X EISSN: 2073-9990 Vol. 9, Num. 2, 2004, pp. 96-102

East and Central African Journal of Surgery, Vol. 9, No. 2, Dec, 2004, pp. 96-102

M Galukande, N K Sewankambo, E T Katabira, S Luboga, SC Kijjambu, S. Kiguli, E Kiguli-Malwadde, A Mwanika.

Faculty of Medicine, Makerere University, P.O. Box 7072 Kampala, Uganda.
Correspondence to: Dr. Moses Galukande, Department of Surgery E-mail address: mosesg@img.co.ug

Code Number: js04049

Background: Makerere University introduced a new policy¹ on the minimum qualification for appointment to a lecturer teaching position and eligibility for subsequent promotions. The highlight of the policy is a requirement for a PhD or equivalent as the minimum qualification necessary for appointment to a lecturer position and above. As a result of this policy fewer and fewer members have shown interest or indeed joined the Faculty of Medicine teaching staff roll.
Objectives: This study set out to investigate the perception of the faculty and the impact of the policy on staffing.
Methods: Literature review, oral and a questionnaire interviews were used to gather data. Participants included current members of teaching staff (of biomedical sciences and clinical disciplines) postgraduate students and visiting overseas academic staff and adjunct staff employed by the Ministry of Health at teaching hospitals.
Data collected was analyzed and summarized in tabular form.
Results: A PhD or equivalent is required as a minimum qualification to join academic positions at lecturer level and above at Faculty of Medicine and subsequent promotion to higher positions. There was a significant lag in promotions and recruitment in the Faculty of Medicine compared to counterparts employed by the Uganda Ministry of Health at the teaching hospitals. Participants expressed strong views that a PhD or equivalent should not be a minimum requirement nor should it be a prerequisite for promotions though it should be encouraged. Policy documents from other universities did not require a PhD or equivalent qualifications as a minimum requirement for appointment to the academic ranks of those institutions.
Conclusion: Whereas it is desirable for the academic staff to acquire a PhD, it should not be a mandatory requirement. The policy was not in the best interest of the Faculty of Medicine and may not be for other medical schools to impose that requirement for appointment or promotion.
University policy makers should consider schools of medicine as an exception to the policy requiring a PhD or equivalent as minimum requirement for teaching at a Medical School.

The University and therefore the Faculty of Medicine (FoM) have the obligation to be creatively responsive to changing needs and priorities of health services in Uganda and the region, since the East Africa community is reviving. The promise to be responsive while striving for excellence is embedded in medical school vision and mission, which are:

Vision: “To be a center for academic and health service excellence.”
Mission: “We are dedicated to improving the health of the people of Uganda and beyond and promoting health equity by providing quality education, research ad health services. We achieve this by enhancing capacity and participation of stakeholders; strengthening systems and partnerships; and harnessing the power of new sciences and technology so as to build and sustain excellence and relevance”

In order to appropriately respond, Faculty of Medicine should have a well-trained, motivated and adequate staff that works in a conducive and supportive environment.

Makerere University introduced a new policy¹ requiring a PhD or equivalent as a minimum for a lecturer position and above at the University in all academic departments. The university policy on promotions and recruitment was intended to stimulate academic growth of its teachers with the intent to enhance the academic and professional students of its programme. The policy has been in effect for the past 6 years i.e. since 1999. There has been a need to determine the impact of this policy on the Faculty of Medicine regarding recruitments, retention, promotions and morale in general of teaching staff has been clearly negative.

The purpose of this study was to investigate the perception of faculty, compare recruitment and promotions policy of Makerere University with other medical schools internationally and assess impact on staffing levels in the Faculty of Medicine, Makerere.

Subjects and Methods

Participants included teaching Faculty from both basic and clinical sciences, postgraduate students, Heads of Departments and a few visiting professors from South Africa who were present at the time of the study. Data was obtained from; Literature review: Including the 1999 Makerere University Recruitment and Promotions policy document, the Faculty annual report of 2002, Common-wealth year books 1997/8 and 2002, other medical schools’ policy documents on appointments and promotions which were obtained through websites, prospectuses and direct contact on phone and emails. Additional information and data were obtained from two Faculty board meetings which were called in a space of 6 months. These were attended by representatives from all 21 medical school departments and debated the university Recruitment and promotions policy extensively. Minutes from these meetings were reviewed. Twenty other teaching staff and postgraduate students were approached at random and interviewed about their perception on the policy relating to the PhD or its equivalent requirement for appointment to academic positions in the medical school.

A questionnaire was sent out to the 21 heads of departments to obtain further understanding into the staffing situation and human resource flows in their respective departments over a 6 year period of between 1999 and 2004. The questionnaire included issues of recruitment over the 6 years for academic positions at all levels, promotions, resignations, retirement and deaths. It also included details of who had enrolled for PhD over past 6 years and number of persons who had been approached about possibility of joining the Faculty of Medicine academic staff but had declined. Permission to conduct this survey was obtained from the Faculty board.

Results

Makerere Recruitment and Promotions Policy Document and Other Documents

A PhD or equivalent is the minimum requirement for the appointment to lecturer position and for subsequent promotions. The academic promotional ladder at the entire university including Faculty of Medicine has the following levels: Teaching assistant, Assistant Lecturer, Lecturer, Senior lecturer, Associate Professor and Professor.

Since its inception the teaching staff at this Medical school is of two major categories. First there are those directly employed by the university at various academic ranks. Second are others who are under employment of the public service under the Ministry of Health (MoH) and positioned at the two major teaching Hospitals of Mulago and Butabika.The Faculty of

Medicine and Ministry of Health had a working understanding of contributing 50% each for teaching and clinical service duties in the National referral and teaching hospital. Mulago Hospital that is the biggest centre for clinical teaching. Only 40% of the teaching positions at the Faculty of Medicine, Makerere were filled. At the moment the MoH staff account for over 50% of the teaching staff at the FoM but they can only take on honorary titles.

From Heads of Departments

Over the past 6 years, the departments of Anaesthesia, Radiology, Orthopaedics, General Surgery and Obstetrics & Gynaecology approached 23 newly qualified Masters degree holders (M. Med) or equivalent of Membership of Royal Colleges in UK to interest them to join Faculty of Medicine academic staff. All turned down the offer, citing uncertainties over a successful career growth through the ranks given the tortuous path, unreasonable doctoral requirement and relatively much lower pay. Ministry of Health staff enjoys higher pay and better other working terms and conditions. Table 1 shows data comparing MoH and FoM, overall staffing situation over past 6 years at the Medical School/Mulago Teaching hospital. The agreement was for the Faculty of Medicine to contribute 50% of Mulago Hospital clinical staff.

From The Oral Interviews

Categories of the FoM personnel interviewed ranged from teaching assistants to Professors while senior Registrars, consultants and senior consultants were interviewed from the MoH. Others included postgraduate students and visiting Professors from South African universities. They provided extremely similar views as summarized below:

• PhD should not be mandatory requirement for Faculty of Medicine teaching staff for the clinicians.
• Undergraduate and postgraduate training in Medicine is significantly longer compared to some other programs offered at the University. A career path following an MBChB basic medical degree (5 years), Internship (1 year), Mandatory service (1-2 years).
• Postgraduate training in a clinical discipline at Masters level (3-4 years). PhD (3 – 5 years) would take 13 to 17 years before one attaining a PhD so as to be eligible for the position of lecturer. Whereas a career path for some fields like in the humanities and some sciences would be Bachelors degree (3 years), Masters (1-2 years) and PhD (2-3 years) taking 6-8 years in total. Medical training in the region (East Africa) is academic and is extremely hands on; i.e. providing both professional and academic grounding.
• A PhD in a clinical discipline tends to be in an extremely limited field and may not be very useful for teaching broad subjects and day-to-day clinical practice.
• It is recognized that doctoral education prepares one for a deeper knowledge and skills for a research career.

International comparators

It was necessary to learn as to what was happening in other institutions in Sub-Saharan region and elsewhere in the world. We thus undertook a comparative study to identify the criteria for appointments and promotions as shown in Table 3a, 3b. The institutions studied were: Universities of Nairobi (Kenya), Moi (Kenya), Mbarara (Uganda), Zambia, Malawi, Zimbabwe, Dar es Salaam (Tanzania), Wisconsin, Alabama, New Mexico, Harvard, London, John Hopkins do not require PhDs or equivalents for clinical academic staff on entry as lecturers and promotions to Professor^4-13. North American Medical Schools do not require PhD for clinical Sciences¹⁴ though they encourage them. For Makerere the path to the pinnacle of an academic career is tortuous, its 6 tiered, in the US and Canada is mostly 3 tiered.

(Table 2)

Discussion

There are 3 major responsibilities and obligations at the core of Faculty of Medicine mission: Teaching - dissemination of knowledge, research -the creation of new knowledge and clinical service - practice and advancement of application of knowledge. The staff employed by the FoM executes theses responsibilities. It is the fulfillment of these responsibilities that is the basis for recruitment and promotion.

With the ever-increasing volume of information, advances in new methods and techniques and the increasing patient volumes and expectations, it is increasingly difficult and impractical to excel in all the 3 responsibilities equally or satisfactorily.

So must one excel in all the 3 areas to deserve a promotion or should it be any of the two or even one? Is any more important than the other?

Makerere University requires a PhD as a minimum requirement for appointment as a lecturer in the faculty of Medicine. The findings from the Medical schools sampled mostly required a terminal degree (which is the highest in a field for example M. Arch (architecture), MFA (Masters of Fine Arts, M. Med (Masters of Medicine) for appointment and subsequent advancement. Advancement is based on Clinical and professional activity, scholarly activity, teaching and servicing in amounts consummate with the track pursued. The American medical schools faculty pursues any one of the three mentioned responsibilities for purposes of promotion.

The Faculty of Medicine has experienced unprecedented stagnation and retardation, in terms of recruiting, retaining and promotion of teaching staff over the past 6 years the recruitment and promotion policy has been in effect. The reasons for potential Faculty of Medicine staff opted to join the MoH staff were that the advancement path in the latter is ‘shorter’. After acquiring a terminal degree one is eligible for appointment as Medical officer Special Grade and after a further 3 years would be eligible for promotion to a consultant position and a further 5 years, senior Consultant position.

The advancement path for FoM staff is a lot ‘longer’ it goes through six tiers: Teaching Assistant, Assistant Lecturer, and lecturer, senior lecturer, Associate Professor and Professor. A terminal degree without a PhD starts one at Assistant lecturer, with a PhD one starts at lecturer position. The speed at which one moves after entry is a function of not only the number of publications I peer reviewed journals, which averages 3-5, but also time. It takes at least 3-5 at each tier.

The other possible reason was pay; the Ministry of Health pays more depending on rank. The impact of remuneration could be further investigated.

The justification for not having a PhD as a minimum requirement is that a PhD is not the highest degree in a Field. A master’s degree is one, the latter has the advantage of covering a broader area in much detail and depth making it more relevant to teaching and service as far as many clinical Medicine disciplines are concerned. Besides the context of a developing country is that we need more generalists than super specialists.

A PhD exposes one to a narrower field but at greater depth and understanding. The generation of new knowledge can occur without having to do PhD studies. This does not mean PhD studies should be abandoned, on the contrary they should be encouraged, funds should be sourced and attractive conditions created for the faculty to take on PhD studies for example catering for spouses in case the time away from home is long. The absence of a PhD should not be in the way for appointment and advancement.

The current trend at the Faculty of Medicine threatens to erode teaching standards and competitiveness in the Health Professional Education sector. A sector that is increasingly finding it difficult to attract new comers to the field ¹⁶.

Conclusion

PhD studies should be encouraged for many reasons; generation of new knowledge, academic growth, generation of income for schools and universities however PhD studies should not stand in the way of recruitment and promotion. Policy makers show reconsidering the reward system in academic by coming up with situation specific solutions. .

References

1. Promotions and Recruitment policy approved by council on 16^th, 17^th Aug 1999, 81^st meeting
2. Makerere University Prospectus, College of Health Sciences, 2002
3. Faculty of Medicine Annual Report 2002
4. Common Wealth year book; 1997, 1998 and 2002
5. Duke University Medical Center. Criteria and Promotion. Appendix C; February 6, 2001 17. ies, BMJ Oct 2004; 329:752-753.
6. John Hopkins University, Bloomberg School of Public Health Policy and Procedure Memorandum Faculty – 1. Appointments, Promotions, and Professional Activities of the Faculty; January 5, 2004
7. University of Illinois College of Medicine. Criteria and Guidelines for Appointment and Promotion of Faculty
8. McMaster University. Revised Policy and Regulations with respect to Academic Appointments, Tenure and Promotion (1998) Approved by Board of Governors; April 27, 2000
9. The University of Alabama at Birmingham. Faculty Hand book and Policies
10. University of Wisconsin Medical School. Policies Governing Faculty Appointments; August 1996
11. Case Western Reserve University. Faculty Handbook. Summer 2004
12. Harvard Medical School. System of Titles and Appointments, criteria and procedures for making permanent term and annual Appointments. August 2004
13. University of Colorado Health Sciences center. Criteria for Appointment and promotion under the three-track system. Appendix 2
14. Distribution of US Medical School Faculty by degree andDepartment, AAMC DATA BOOK 2004
15. V Narasimham, H Brown, A Pablos-Mendez et al. responding to the global human resources crisis. Lancet. 2004; 363: 1469-1472
16. N Sewankambo, Academic Medicine and global health responsibilit

© 2004 East and Central African Journal of Surgery

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