This speech was given by professor Bart Criel (ITM) at the graduation ceremony of this year’s MPH students (July 3rd).
Dear Ladies and gentlemen, dear colleagues, dear MPH graduates,
This ceremony for the 50th anniversary of our Master of Public Health (MPH) course is a time to celebrate, to acknowledge the achievements of the course, to thank a great many people, but also to reflect on the way forward …
It is with humility that I stand here. My role in and contribution to the MPH is relatively recent and therefore limited. But it is an honor for me to be addressing you on this occasion, and I like to see myself as a spokesman of the many people who have contributed to this Masters…
I would first like to briefly take you through the highlights of the history of the MPH from 1964 till today; discuss some of the most important recent changes; but also reflect on the future…
The Antwerp MPH has a long and passionate story. Describe it as an opportunity to pay our respect to the late Harrie Van Balen and the late Pierre Mercenier, the founding fathers of the course.
The International Course in Health Development (or ICHD) – the initial name of the MPH – was organized for the first time in 1964 resulting from a joint initiative of Dutch and Belgian authorities, more specifically the Tropical Institutes in Amsterdam and Leyden/Rotterdam in the Netherlands, and the Institute of Tropical Medicine here in Antwerp. The course was launched at a very important and radically new time, i.e. the period immediately following the gulf of decolonization and independencies in most of the developing world.
From the start on, the course was organized around two basic assumptions (both still very relevant today): first, to consider health and health care as part of a more comprehensive human and societal development and wellbeing; and second, the need to take into account cultural, social and economic factors in the endeavor to bridge policies and implementation.
Initially the ICHD started as a 5-month course, one in English (ICHD) and one in French (CIPS), which took place simultaneously, one year in Amsterdam and the other in Antwerp, and targeting medical personnel from developing countries with a number of years of experience. In 1967, the 5-month programme was complemented with a second semester and a thesis was added at the end of the course.
In 1969 Harrie Van Balen joined ITM as course coordinator – the function that Marjan Pirard and Marlon Garcia occupy today. Pierre Mercenier joined the institute in 1971 and teamed up with Van Balen. Both had been active overseas, but were also very much involved in a think tank reflecting on health policies in Belgium… A great deal of their inspiration came from their work in the Groupe d’Etudes pour une Réforme de la Médecine (GERM) – they had the genius to bridge the thinking on public health and health services organization in developing countries with the one in high-income countries. Ivan Beghin, professor in nutrition, joined the tandem a couple of years later.
Already from these early times, the option was to go for an international student audience with maximum 2-3 people from the same country and not more than 3-4 Europeans. It was seen as appropriate to organize the course in Europe, because a critical analysis of one’s own health system would be less threatening and benefit from the exposure to the experience of people coming from different contexts.
The launch of the Kasongo research project in eastern Zaire in the early 70s contributed to the enrichment of the concepts on Health Services Organisation. The commendable academic triad of research, teaching and service delivery was operating at its full potential by then – with tremendous synergies.
It is also in the seventies that the concept of a ‘critical mass’ appeared in the discourse of the public health department. The hypothesis was that a number of motivated ICHD graduates in a given country could make a difference. The cases of Thailand and Mali are noteworthy: in the former, the Rural Doctors Association led by former ICHD students contributed to shaping national PHC policies; and a number of ICHD alumni contributed in Mali to steer the health sector reform process.
At the end of the 80s, another Masters course was created: the Master of Science in Tropical Biomedical Sciences that focused on the control of tropical diseases – this course later evolved into the current masters in Disease Control. One of the privileged areas of collaboration between the ICHD and this new course focused on the vertical analysis, well known to many of you, that was developed by Mercenier a couple of years earlier.
In the 80s, the ICHD course coordinators also started with organizing study visits to health systems in high-income countries: a first visit was to Italy, later visits were organized to Scotland, France, the Netherlands, Canada, and the Maisons Médicales in Belgium. The aim of these visits, which we still have today in our MPH, was to apply the acquired knowledge to a real-life situation, but also to illustrate that the frameworks and concepts discussed during the course are relevant to study health systems in high-income countries as well.
The early nineties were an important transition period with the departure of Pierre Mercenier and Harry Van Balen. Their legacy was a successful course, with a great international reputation, that since then of course has evolved a great deal, but where the core views and values of its founding fathers still play a key role.
After their retirement, Jean Pierre Unger, Patrick Van der Stuyft and Wim Van Lerberghe took over the ICHD course; they were later joined by Guy Kegels. Steps were taken to adapt the teaching curriculum to a changing international context. Important in that respect was the fact that more room was given in the course to the study of health policies at national and international level – beyond the operational district level. Another major change in the MPH landscape was the launch – at the end of the 90s – of the MDC focusing on training disease control programme managers – and with special attention for HIV/AIDS, tuberculosis and malaria, but also reproductive health.
In 1993, upon the initiative of Wim Van Damme, the MPH alumni network was created, implementing the wish of the Institute to maintain privileged relationships with former students. By now more than 1300 MPH students have been trained at ITM… The alumni network responded to the demand of our alumni to keep in touch with the Institute, with new scientific developments and to share their professional experiences with other alumni. A number of regional meetings have been organized with alumni – these have been powerful opportunities to get feedback on the relevance of the course. The list of meetings held is impressive: a first one took place in Ayutayyah (Thailand) in 1999 with a selection of participants from South-East Asia; this meeting was followed by other regional meetings in Cuba, Morocco, Uganda and together with the MDC in the DRC and India. Today the alumni network funds the participation of former students in international conferences with side-events where alumni and staff can interact more informally.
In the last 10 years we have again implemented a number of important changes in our Masters architecture. I want to highlight two of them.
A first was the launch of two options in the ICHD and in the MDC. The ICHD was relabeled HSMP (Health Systems Management and Policy) and its participants were offered the option in the third trimester to attend the short course strategic management of health systems or the short course health policy. The establishment of these short courses was accompanied by more flexibility in the intake of students. External participants, other than the ones who started with the MPH in September, can now also attend these short courses. This “flexibilisation” fits well in current developments at European level where the Troped program overlooks the organization of modular MPH courses. The creation at ITM of the MPH in International Health is an exponent of this dynamic.
A second development has been the “rapprochement” between the HSMP and the MDC courses. In 2010-2011 the decision was taken to go for one single MPH with two study orientations – HSMP and MDC respectively, each one with its specific identity. The rationale for this was straightforward: ITM over the years built clear conceptual views on how to structure the often tense interface between “horizontal” systems and “vertical” programs, going for integration whenever there is an added value to do so, but also recognizing the potential contribution of control programmes in improving service delivery to people. In real-life situations, systems managers and disease control specialists need to interact and collaborate… In this context, it makes a lot of sense to foster such a dialogue during the training of our MPH participants. In the same vein, in the academic year 2011-12, a common core was created for HSMP and MDC participants – covering more than a third of the total number of credits of the MPH. This experience so far has been extremely positive.
It is time now, I believe, to say a word on the future. What developments can we expect for our MPH in the years to come? There is as of yet of course no blueprint lying on the table but a number of important contextual elements must be taken into account nevertheless…
There is the steady increase in MPH courses in the global South, not in the least organized by some of ITM’s partner academic institutions in Africa, Asia and Latin America – however, most of these MPHs only reach a national audience of health professionals. There is also uncertainty whether donors will still be willing (or even able) to fund fellowships for people from the South wishing to attend the ITM Masters for much longer. Our alumni however continue to appreciate the field knowledge of our teaching staff – or to put it in their words “you people know what you are talking about”…
The case of Thailand, a middle-income country, where a number of national MPH programs have been set up, is illustrative in that respect. The Thai government has recently expressed the demand to go on sending selected Thai health professionals to Antwerp for their Masters, despite the fact that their people can’t get Belgian cooperation fellowships. Thailand has accepted to fund the participation of their people to our course itself. That is a major recognition from a middle-income country that has made great advances in its own health system over the last decades… This may very well become a scenario that spreads to other MICs.
The alleged end of development cooperation in the coming years, be it in Belgium or in other HIC, is a possible scenario, but not necessarily the only one. Low income countries, some of them fragile states, will not soon be in a position to go without international solidarity – also when it comes to training their national health professionals. We therefore need to safeguard equitable and needs-based access to our MPH.
Having said all this, is there a reason to be complacent and to go on with business as usual? Of course not. The future of our MPH lies in innovation, as well in terms of content as in terms of teaching methodologies, without therefore throwing overboard the good things – even if they are “old”. Flexibility is definitely welcome and needs to be further encouraged, although we should refrain from turning it into a fetish – flexibility should be carefully balanced with coherence. I am also convinced of the need to find a sound balance between specialisation and a comprehensive generalist view on systems to make sure that the oversight is not lost. And we should also go on making explicit the values that guide and drive us (solidarity, participation, equity) without ignoring the realities from the field and without hampering the freedom of our students to make their own choices.
But perhaps the main challenge and opportunity ahead lies in the close collaboration of our MPH with the teaching programs of our overseas framework agreement partners. The Framework Agreement between DGD and ITM is a powerful opportunity, and the Switching the Poles philosophy a great mobilizing idea. We are grateful that it is there, it may very well be a game-changer for our MPH… I am thinking more in particular of the programme Alliance of Schools of Public Health.
In order to illustrate this, let me briefly share with you the findings of a recent mission by Marjan Pirard, our departmental academic coordinator, and myself, to the Institute of Public Health (IPH) in Bangalore in South India. The demand from IPH was to reflect on how we could collaborate in terms of teaching.
The current MPH landscape in India is very fragmented, with a booming offer of MPHs in a mostly market-driven logic, and operating in the virtual absence of regulation and accreditation policies – with all the negative consequences one can expect in terms of financial accessibility of the course and quality of the teaching. Moreover, there is hardly a focus in these MPHs on the organizational and managerial dimensions of health care delivery systems; they are often built around ex cathedra teaching and hardly rooted in the day-to-day realities at the grassroots level. IPH is currently developing a number of stand-alone short courses or modules of a couple of weeks each that could then be nested in some of the most promising of these existing MPH courses. IPH would be interested to obtain accreditation and visibility for these short courses – perhaps TropEd can play a role in this? – but is also keen on joining the teaching in our own MPH: as trainees, in order to learn how to teach and to organize training programmes, but also as lecturers in order to contribute to the enrichment of our own teaching portfolio (and where we can learn from them!). Since a couple of years, IPH Bangalore offers internships to young health professionals from the Netherlands and the USA who wish to get acquainted with the realities of an under-resourced health system… Perhaps this could also be an avenue for our own postgraduate students or something to fit within the MPH-IH… ?
Our MPH has strongly evolved over the last decades in an environment that has dramatically changed – with important social, political, technological, epidemiological transitions. In addition, keeping up with the (increasing) pace of changes is a challenge. The quasi monolithic public health care delivery systems of the 60s and 70s have been replaced by complex pluralistic systems operating in a globalized world.
If we go back 20 or 30 years, we recall the MPH as a rather peaceful and traditional course, operating in a relatively stable environment, focusing very much on the operational levels of the health system, with a student population that almost exclusively comprised medical doctors, most of them men, coming from LICs and receiving mostly traditional teaching in a class room environment, with a significant dose of well-intentioned hand holding…
In 10 years from now we can imagine a course that might and will probably have a more diverse student population in terms of professional background and gender, originating from Low-Income, Middle Income but also High Income Countries, using a greater variety of teaching methods, with a more international, colored and multidisciplinary teaching staff, with modules organized (in Antwerp or overseas) by experienced staff from partner institutions in the South, with a greater focus on getting research into policy and practice, on making optimal use of social media and global knowledge management platforms, and with enhanced student abilities to take decisions in rapidly changing environments characterized by a great deal of uncertainty.
At the same time we see a course where values will still matter very much and where past achievements are not thrown overboard just because they are from the past, but are optimally integrated in new course formats.
Our course is flexible enough to adapt to changing circumstances, I hope that my brief historical account has illustrated that. This ability will be challenged for sure. At the same time past changes have always been the result of thorough and careful thinking, never blindly following the market or the fad of the day… That is definitely a culture to nurture… Reflexivity and flexibility will remain key in a context of growing uncertainty about what the future will bring. We hope that our most faithful donor, the Belgian cooperation, will further accompany us on that journey.
Let me conclude with the following: ITM’s Master is first of all about training health workers, yet, it is also a project that can contribute to “linking” staff within the public health department, that constitutes a forum to discuss rapidly evolving views on public health, and that contributes to shaping a common professional identity. It therefore deserves to be handled with due care.
I thank you for your attention.