Sm. .Sci. Med. Vol. 17, No. 22. pp. 1819-1825, 1983 Printed in Great Britain

0277-9536183 S3.00 + 0.00 Pergamon Press Ltd

TRAINING HEALTH WORKERS: WHAT NEEDS TO BE

TAUGHT AND WHO SHOULD TEACH IT

PETER GODWIN

Educational OfYicer, African Medical and Research Foundation, P.O. Box 30125, Nairobi, Kenya

Abatraet-The training of many health workers has been inadequate in producing workers who can function effectively in rural health sexvices. This inadequacy is seen in two areas. While health workers are well drilled in technical procedures, operational strategies for applying these procedures in the conditions of rural health services are often lacking; and much of what they are taught is inappropriate in terms of the , practicalities ofworking in rural areas. Two aspects of training are then discussed. What is taught and who teaches it. A distinction is made between teaching routine technical procedures and teaching cognitive strategies for problem-solving. These need to be distinguished and both considered when training health workers. The use of health workers themselves as trainers of other health workers is then considered. They often do not have the confidence necessary to teach in open participatory, discussion-centred ways. These ideas are then briefly considered in the light of a training scheme in Kenya, and how it has been used for training in Primary Eye Care.

Rural Health Workers in East Africa have a demanding job: delivering high quality care, with chronic resource constraints, to an often unresponsive population. Are they, in fact, trained to do this? In this article I intend to suggest that in many ways training of health workers is inadequate. Much of what they do, they learn from colleagues once they have gone to work; there is little control of what and how they learn under these conditions. It is not intended, however, to offer a detailed analysis of what is wrong with training programmes. Rather some principles for training will be examined and comments offered on how these can be interpreted to improve training and correct the dis- crepancy betyeen what is taught and what needs to be done. Brief reference will be made in support of these suggestions to a major training programme in Kenya and how it has been used for training in Primary Eye Care.

PRINCIPLES FOR TRAINING

Training should be carefully designed to prepare health workers to do their jobs under the actual conditions that prevail.

In this training, a clear distinction must be made between training for procedural, task-oriented leam- ing, and training for higher-order problem-solving skills.

Where trainees have not already developed problem- solving skills from their school education, particular care must be &ven specifically to developing these skills, if they are considered necessary.

Teachers of health workers should be specifically selected, not only for familiarity with the jobs their students are later to do, but also for personal characteristics of professional and intellectual capacity.

Teachers should be trained as teachers. These principles are not new, nor do they mean much

in themselves. The crucial issue is in how they are used practically to produce actual training. It is suggested, however. that there is a new emphasis in them, firstly regarding what needs to be taught, and secondly, concerning who is to do the teaching.

This new emphasis lies in considering the actual conditions under which the health worker’s job is to be performed, and then in ensuring that the problem- solving skills as well as the procedural skills needed are learned. Secondly, importance of selecting the best to be teachers needs to be emphasized. As shown later, a crucial factor in the type of teaching needed is the confidence of the teacher: he must be able to risk the limitations of his own knowledge in the interests of his students’ gain in learning and thinking skills.

As I have said, much of this is not new; everyone agrees that health workers should be trained to do their job, and that the selection of teachers to do this training is important. The problem, however, is that important factors in deciding just how this is to be done have been ignored. These factors arise from some of the psycho- logical and educational analyses of training that fields outside medicine have to contribute. It is the essentially educational analysis of how people learn, and what makes a good teacher, to which attention is drawn in this article. This will, I trust, show not how wrong all previous training has been, but rather how it can be improved.

TRAINING FOR WORKING IN REAL CONDITIONS

Studies carried out in Kenya in 1971 stated that “The present training of para-medical staff is of particular concern to the Ministry of Health since it is not relevant to the actual conditions under which some of the trained staff are destined to work” [l]. Specifically, the studies noted a number of factors contributing to this : “Technical Procedures were found in need both of specification and standardiz- tion . Operating Procedures were either lacking in precision or absent and not based on best possible use of epidemiological knowledge . .“.

Among community nurSes for example it was noted that: “The basic training for community nurses in general provides adequate technical training in the specific tasks

1819

1820 PETER GODWIN

outlined in the job description of this category of staff. prevent him scratching! Even if gloves were common However, given the time available for basic training and the requirement to simultaneously produce nursing staff for the

and available in Sudan. the sort of people they would be

hospital services, the basic training cannot adequately treating in general could never afford to buy them.

prepare nurses to work as a member of a team in a rural This concern with what health workers are taught *is

environment striving to achieve specific operational targets”. closely related to how they are taught. On the one hand. the content of teaching must derive from sound

Similar problems are hinted at for other cadres. The “Technology Analysis” section of this study noted :

“In summary, technology analysis proved more useful in evidencing the extreme degree of variability of the current practice, as compared with what staff are trained for, than in establishing its central tendencies. The shortest summary on current health technology would be that whatever staff available at any time in a health facility adjusts its technical performance to the available resources and to the pressure of demand”.

The studies quoted above were part of a “Proposal for the Improvement of Rural Health Services and the Development of Rural Health Training Centres in Kenya” [l]. The problems identified will sound common to most who are involved in the training of health workers. But how does this relate to training? Are health workers not being trained in the right things? Are they not being taught properly? Are they expected to learn too much? Or too little? The Kenya example is an interesting one in that a determined analytical attempt was made to identify the role and effect of training. The central problem identified was that basic training, though sound and adequate in terms of individual technical procedures, did not adequately prepare health workers for their real task of delivering appropriate health services in rural areas, where they are most needed, within existing practical andresourceconstraints[2].Essentially, healthworkers leaving basic training were not equipped with skills in solving problems arising from the actual application of what they had learned in the variable conditions of rural services, particularly when resource shortages produced the need for improvization. This situation is common to many cadres of workers in many countries, though few have analysed the problem as closely as in Kenya.

What is the reason for this? What is wrong with the training? There seem to be two main causes. One is that the technical procedures taught to health workers are often learned as discrete, isolated clinical or nursing procedures, and seldom linked together in overall operational frameworks. Medical Assistants for ex- ample, are taught the diagnosis and management of a wide range of diseases. They are seldom effectively taught, however, how to run a clinic, or how to diagnose and manage the wider picture of disease and ill health in the community they serve. The second reason concerns the parcticability, or suitability of what they are taught. Nurse Tutors 1 met on a recent course in Uganda, for example, were concerned about how to teach ward procedures when they knew the wards their students would go into would have no equipment or supplies at all. Do you teach students how to give a

technical procedures and an effective operational framework, taking into account the rural situation in which the procedures are to be carried out: a precise job-description related to epidemiological needs. On the other hand, the process of teaching must help to develop improvizing and problem solving skills in health workers, so that theycanadjust theiroperational and technical procedures to meet the vagaries of resource constraints, and constantly review and adjust their priorities and strategies.

Towards the end of this article I describe in a little more detail a project for the improvement of rural health services in Kenya that attempted to deal with these problems. First we examine some of the factors that affect the sort of training suggested.

PROBLEM-SOLVING AND PROCEDURAL LEARNING

Simple views of learning see problem-solving and procedural learning on a continuum from psycho- motor skills to higher-order cognitive skills [3]. They suggest that there is no great qualitative difference in these forms of learning. Gagne [4], on the other hand, has argued that there are five distinct varieties of learning, the outcomes, conditions and activities of which are quite different. They are: intellectual skills, cognitive strategies, verbal information, motor skills and attitudes. Many human job-tasks, he maintains, are ‘procedures’ built up of chains of intellectual and motor skills. While the ‘part-skills’ that make up these chains may be learned separately, it is essentially motor-skill learning that puts together and practices the whole skill, under an ‘executive routine’ or ‘movement plan’. This, Gag& insists, is a very different form of learning from that of the ‘cognitive strategies’ that are learned in problem-solving. The great importance of this for training or education, in GagnC’s eyes, is in selecting the appropriate instructional method to produce appropriate learning. Whether we accept Gagnt’s absolute distinctions or not, it is clear that the practice of both part-skills and the overall procedure involved in motor skill learning is a very different activity to the challenging, independent trials in novel situations that characterize the develop- ment of cognitive strategies for problem-solving. In terms of teaching it is fairly well agreed that different strategies are needed for learning higher order skills: group discussions, ‘discovery’ and independent leam- ing are crucial. These are not on the whole appropriate for the final development of procedural skills where massed or distributed practice of the skill are necessary for precision, smoothness and confidence in carrying it out.

It should be noted that problem-solving skills alone, bed bath, using soap, powder, towels, etc., when you without competence in the procedures indicated as know that the hospitals do not even have sheets for their solutions, are not sufficient. Being able to do what he beds? In another case I have seen Medical Assistants has decided needs to be done is necessary for the rural who are to work in rural health centres in Southern health worker. Solving actual problems requires com- Sudan being taught that part of the management of petence in both areas. For example, analysing a village chicken pox is to put gloves on the child’s hands to situation and deciding that more, cleaner water would

Training health workers in Kenya 1821

prevent much of the ill-health occurring in it is not very helpful unless you know how to provide more, cleaner water. Equally, however, knowing how to dig a well, protect a spring, chlorinate a well or repair a hand-pump is not much use unless you can analyse and decide which of these alternatives is the sensible and feasible one to choose.

EXISTING CURRICULA FOR HEALTH WORKERS

Typically, curricula for para-medical training start with large blocks of background learning of anatomy, physiology, pharmacology, etc. For clinically oriented workers it then usually proceeds to a systemic examina- tion of disease conditions. Trainees are expected, both through theoretical exposition and clinical practice, to acquire self-sufficient, deductive skills of diagnosis and management of ill-health. The management of preventive and community health is usually tacked on at the end of training as an application of the skills learned. in a wider setting. For nursing cadres the picture is different: theory is interspersed with large blocks of practical activity in wards, reinforcing specific and rigorous technical procedures in controlled situations under strict supervision-the matron’s eagle eye. Environmental cadres get the worst of both worlds: theoretical introduction to, for example, ‘sources of water supply and contamination’ without any actual practice in improving sources in different village settings, and supervised practice in specific procedures such as ‘Meat Inspection’ and ‘Inspection of Premises’. where rigorous legal requirements are emphasized. albeit based on sound principles, which are often not adequately grasped. The effects of such curricula are familiar. The deductive approach to training (common among clinically oriented workers) assumes that trainees are already equipped with problem-solving skills. In the absence of specific training in these, the diagnosis and management of ill- health becomes a stereo-typed. theoretical pattern for learning about diseases rather than a genuine analytical procedure for identifying interventions. The procedural approach on the other hand tends to stifle problem- solving. by its very nature. The ranges of variation allowed in carrying out a procedure are strictly limited. The routine practice of procedures in con- trolled settings. while ensuring that they are carried out correctly. does not make allowance for improvisation, and fails to teach flexibility. Improvization, aproblem- solving skill in itself, is considered an unfortunate necessity rather than essential precondition for the realities of rural health practice.

HO\\ SHOULD TRAINING PROGRAMMES AND CURRICULA BE DESIGNED?

The preface to the WHO public health paper devoted to the topic, “Development of Educational pro- grammes for the Health Professions”, started thus:

“Until recentI> medical faculties concerned themselves marnl! with II,/W/ is taught and little with honk it is tau_ght or what 1s done with the kno\\ledge acquired. The chief aim of education for health workers has been to instil as much information as possible. largeI> b! means of lectures .“[5].

Somedefinite improvement on ths situation has been

seen in the last few years. Summing up the discussion on training of medical assistants at a Conference on Medical Assistants. the moderator said : “Several themes were emphasized in this discussion: training should be based on a careful definition of the role and functions to be performed and in relation to the various other types of health workers Training is based on a different principle than the training of physicians. It is task and technique oriented .“[6].

One example of such ‘functional’ training is the competency based curriculum developed by the MEDEX programme working out of the Medical School at the University of Hawaii [7].

Competency based curriculum development follows a pattern through job description, fie!d observation and task analysis, to the setting of learning objectives. Without wishing to be diverted by the red herrings of the value and practicability of task analysis and setting learning objectives, it is suficient to note that few local training schools and programmes have the time, let alone the inclination or competence, to indulge in these activities with any real hope of success. This does leave, however, the problem ofhow training is to be designed.

Some of the difficulties are clearly shown in a recent summary of experiences in health worker training, the APHA Monograph No. 3 “Training and Use of Auxiliary Health Workers: Lessons from Developing Countries”:

“Most auxiliary training (except that of physician assistants) takes place in a relatively short period of time. Teachers can choose from a variety of teaching methods. However, instructors should select teaching methods appropriate to the educational objectivesoftheauxiliary trainingprogramme. In most cases this will mean a concentration on demonstration, discussion and supervised practical assignment rather than an emphasis on theoretical material. . The instructor should concentrate on increasing the student’s capacity to solve problems. . Some programmes have used explicit protocols to instruct students and later guide their activities. . Such protocols provide guidelines for care and performance of tasks” [8].

Reference to a taxonomy of learning [9] as well as what has already been said, reveals the potential conflict between training for such activities as ‘solving problems’ and for following procedures for ‘care and performance of tasks’. Training that is ‘task and tech- nique oriented’ is likely to be quite different to that aimed at the development of the higher order skills of problem solving.

To suggest that problem-solving is merely one of the tasks of a health worker is no way out. The failure to distinguish between these two very different approaches to training can lead to an unhealthy emphasis on pure knowledge during training, (assumed to be the data necessary for problem solving) or to expectations of problem-solving from workers who are in no way trained for it. There seem to be two factors that need to beconsidered when choosing between these two sorts of training: the background education of the trainee, in so far as this determines how much he has already been taught problem-solving strategies; and the length of training, in so far as this will give him time to become sufficiently familiar with the cognitive strategies he has to handle in problem solving, and to practice the problem solving skills in independent and relevant situations [4].

1822 PETER GODWIN

It is important for curriculum designers to appreciate and to tackle the problem. If a problem-solving approach is required, specific training in problem- solving is needed. If, on the other hand, training is to be purely procedural, it is unfair to expect workers to do other than follow procedures; these must then be standardized in terms of the real availability of resources and the actual situations at rural level. It must be noted that “protocols to provide guidelines for care and performance of tasks”, mentioned earlier, are the very opposite of problem-solving; training based on them will have a distinctly negative effect on attempts to introduce problem-solving.

What has been argued so far suggests that the main problem in training health workers is the design of appropriate curricula. As the Kenya Rural Health Development Project saw, however, the situation has wider implications : the provision of teachers who can use the curricula effectively is equally important.

WHO SHOULD BE RESPONSIBLE FOR TRAINING

To answer this question we need first to consider the learning process and its implications for the role of the teacher. This may offer some guidelines to suggest who is best suited to carry out the training of health workers.

. The learning process

Interest in education and training has, in recent years, increasingly tended to stress the importance of the process by which students or trainees learn :

“Learning. . is a dynamic and interactive process, in which the role and experience of the student are vital components, in which he should contribute as well as receive, in which his perception of what is happening is quite as important as the perception of his teachers, and in which his assessment of its value may be more relevant than that of his examiners” [lo].

Such a description of the learning process is quite different to that of older models, such as the student as an ‘empty vessel’ to be filled with knowledge, or the ‘communication-learning fallacy’, which assumes that “information transmitted to the student is always learned” [l 11. Further interest in the learning process is shown in a recent WHO paper “Student Helping in the Teaching/Learning Process” [12]. This paper describes recent thinking about ‘peer group learning’ and suggests its importance in such aspects as reducing anxiety, increasing personal involvement of students, learning higher-order thinking skills, co-operating and accepting responsibility in learning and increasing motivation. The significance of this new emphasis on the learning process is profound as far as teachers are concerned : it suggests a new role for the teacher.

The role qf’the teacher

Primarily the teacher is there to facilitate the learning process. Depending on the aim of the learning and an understanding of the process, teachers can adopt different strategies and different roles. Stenhouse has distinguished three main strategies: Instruction-, discovery- and inquiry-based teaching.

“instruction-based teaching implies that the task in hand is the teacher’s passing on to pupils knowledge or skills of

which he is the master. In discovery-based teaching the teacher introduces his pupils into situations so selected or devised that they embody in implicit or hidden form principles or knowledge which he wishes them to learn Instruction or discovery are appropriate in the classroom whenever the desirable outcome of teaching can be specified in some detail and is broadly the same for every pupil When a curriculum area is in a divergent rather than a convergent field. i.e. where there is no simple correct or incorrect outcome, but rather an emphases on the individual responses and judgements of the students. the case for an inquiry-based approach is at its strongest [13].

In practical terms. these three approaches can be taken to be points on a continuum, from a highly disciplined transmission of knowledge. through a structured. less directive, manipulation of students, to an unstructured, equal sharing and directing. After all, teachers are there to be used by students, if and when they are needed during the learning process [ 121.

The provision of teachers-for health workers

A report prepared by the Commonwealth Health Secretariat showed that in the English-speaking coun- tries of East, Central and Southern Africa in 1973, there were 571 teachers in health worker training schools. Only 394 (69%) of these were nationals of the countries concerned. Of the 394, only 125 (32%) had any training in educational methods. 114 of the 125 (91%) were working in nursing schools [14j.

In 1972 a WHO Study Group on the Training and Preparation of Teachers for Schools of Medicine and Allied Health Sciences noted:

“There is widespread evidence of serious deficiencies in present educational practices, some of which can be corrected by training teachers in the sound application of educational principles” [ 151.

The WHO study group was a response to increasing concern with the provision of trainers for health workers. Fendell had noted in 1972:

“The proper selection and training of teaching personnel (for auxiliaries) is as important as the selection of educators for university. It is, or should be, an essential prerequisite for the establishment of auxiliary cadres. Too often it is not- teachers are simply drafted into such occupations or are self-selected for reasons other than a desire and ability to teach. Specific training in educational methods should be mandatory” [ 161.

Training of teachers must, however. go far beyond an introduction to teaching techniques and aids. Experi- ence and competence in the job, as well as competence in educational planning, teaching methods and evalua- tion is necessary [17]. The report of a WHO expert committee on the training of auxiliaries noted the greater preparation needed by teachers where the students have limited education. Among other require- ments, such teachers need special skills in planning, organizing, implementing and evaluating the teaching/learning process [ 181.

Apart from the issue of training of the teachers, we must consider who would best be a teacher of health workers. As Fendell [16] and Storms [S] noted, trainers of auxiliaries need not be well grounded in theories of teaching, but it is imperative that they are conversant with the conditions in which their trainees will have to operate. Teachers with field experience have a special advantage.

Training health workers in Kenya 1823

A common response to these requirements has been the best way may stretch’their confidence beyond its to use experienced health workers themselves as limits. An important point should be noted here, how- teachers. Some doubts about the efficacy of this are ever. The earliest cadres of paramedicals were often raised, however, by Beeby’s penetrating analysis of trained more by apprenticeship than by formal teachers and teaching [19]. training. They were usually chosen and trained on the

Beeby’s great contribution has been the theory of job for particular tasks by doctors who realised their “stage IV” teaching which implies: own limitations, and the usefulness of assistants. Once “meaning and understanding stressed variety of content the great expansion of paramedicals came about in the and methods: individual differences catered for; activity 60s and 7Os, however, and training became formalized, methods, problem-solving and creativity. relaxed and much of the apprenticeship nature of their training was positive descipline; emotional and aesthetic life, as well as intellectual; closer relations with community . ”

lost. Apart from nurses, few paramedical health workers nowadays have any real apprenticeship or

This, in essence, means that it is as important for the internship. This creates problems both in terms of

teacher to have emotional security as it is to be curricula, where this practical experience, under super-

intellectually prepared for that will determine the vision and in actual working conditions, has been

quantity and quality of learning among the students. largely lost, and in terms of teachers: those older health

While Beeby was describing the development of workers trained under apprenticeship may find the

primary schools and the teaching therein, much of his formal training of institutions extremely difficult. Their

analysis is valid as an indicator in looking at all great strength is their experience, yet this is the element

teaching. Beeby described the development of primary least drawn upon in their teaching.

teaching from a notional ‘Stage 1’ in which teaching is It is interesting to note here that one of the major

concerned with “relatively meaningless sym- criticisms of Nurse Educator training made by other

bols . . . memorizing all important” to the “Stage IV” health professionals engaged in training, is that such

described above: the “stage of meaning”. He stressed courses give more emphasis to learning about nursing

the importance of the teacher’s “ability” as well as than to education. Yet this may, in fact, bean important

“adaptability” in using teaching methods appropriate benefit in terms of Beeby’s analysis: ‘better’ nurses are

to the different stages. Adaptability covers the more secure in using open, participatory teaching

teacher’s willingness to teach at a level beyond that at methods.

which he is teaching now. Ability indicates “the So far little research evidence is available to prove

highest level in the four stages at which a leacher b or disprove Beeby’s hypothesis of stages and teachers’

capable of operating (emphasis added).” The main abilities, let alone to extend it to levels of teaching and

factors limiting a teacher’s ability are essentially his training beyond the primary school. It is suggested,

emotional and intellectual confidence, arising from his however, that it must be considered an important

own background education and his training. As noted contribution to a consideration of the selection of

above, Beeby is concerned with primary schooling; his teachers of health workers.

concern with the teacher’s own education and the gap So far two broad subjects, have been discussed, what

between what the teacher knows and what his students needs to be taught and who should teach it. In the

know is thus confined to the importance of teachers absence of hard data about what actually happens in

having more than primary education themselves. The health training schools, this general discussion must‘

concept of this gap, and its importance can, however, remain in the realm of speculation. Little hard data is

be usefully employed at a variety of teaching levels. It available. Indeed, students pass exams and graduate,

seems particularly appropriate in considering the yet this tells us relatively little. In spite of, or perhaps

training of health workers. because of, external examiners, the burden of teaching

As has been noted, it is often health workers and learning is directed towards curricula and examina-

themselves who are responsible for training other tions rather than towards performance. Little sys-

health workers. Although there may be many good tematic attempt is made regularly to correlate curricula,

reasons for this. in terms of Beeby’s analysis the exams, and performance in the field. It is only

problem is clear: the health worker teacher knows no investigations such as that of the Kenya Rural Health

more in terms of general education, than the class he is Development Project that can assess the effectiveness

teaching; even in the subject he is teaching, the class of these curricula and examinations; and the findings

will. intentionally, reach the same level as himself. It is of that investigation have been mentioned. Existing

suggested that this can easily produce the lack of curricula and teachers were not, in Kenya at least,

confidence noted by Beeby as a major contraint on the producing appropriately trained rural health workers.

teacher’s use of more open, meaningful teaching: The following is a brief description of what was

“The teacher is afraid of any other questions in the classroom intended under the Project and notes one particular

but those he himself asks, for they are the only ones to which occasion in which the Training Centres and the teachers

he can be sure of knowing the answers”. established have been used for training in Primary Eye

This is particularly important in view of the desire for Care. It is noted how the broad speculations made

training in problem-solving noted earlier, and the above can be seen affecting what was achieved.

increased emphasis on learners’ ‘participation in the learningprocess’. Teachersin health workerschoolsare THE KENYA RURAL HEALTH DEVELOPMENT

frequently the older, more experienced workers. PROJECT

Many of them learned in less participatory, less open Under this project, six Provincial Rural Health classrooms themselves. To admit that the way that they Training Centres have been established in Kenya. learned and graduated in their day was not necessarily These consist both of a health centre and of facilities for

1824 PETER GODWIS

training rural health workers: dormitories, class- rooms. dining rooms, kitchen, etc. The teachers who run these training centres are drawn from among health workers themselves. They are Clinical Officers, Public Health Nurses and Public Health Officers, who have received 9-month teacher-training courses. Of the 9 months, roughly one third is given to epidemiology and practice in how to make a Community Diagnosis. Roughly another third is given to learning about teaching and teaching practice. The teaching practice covers classroom teaching, teaching community diag- nosisinthefieldandpracticeinarrangingandmanaging teaching situations. The rest of the course covers management, both in theory andin relation to the actual provision of rural health services, and a number of other subjects, including some professional up-dating.

After this training, these teachers run 3-month in- service courses for health workers already in the field. The course is based on the Health Unit Team: the full staff of a health centre. Several of these teams, compris- ing clinical officers, community nurses, public health technicians, family health field educators and statistical clerks, are asked at one time to attend. The course is aimed both at improving problem-solving skills related to the realities of rural health practice, and at standardizing proficiency in technical procedures. Half of the three months is given to learning how to make a community diagnosis for each team’s area, and then planning, implementing and evaluating strategies for the provision of health services, based on this diagnosis. The rest is largely given to review of proficiency in technical procedures. Thus both the details of what to do, and how to apply this in the context of particular rural health services, are covered. Emphasis through- out the course is on practical work, both in the field and in the health centres attached to the Training Centres.

An important aspect of these Training Centres is that they run only two 3-month courses a year. This leaves them free to develop, co-ordinate and run a variety of other continuing education and training courses in their provinces.

By 1982 the Kenya Rural Blindness Prevention Programme (KRBPP) had decided to use these Training Centres for the training of all rural health workers in Primary Eye Care (PEC). The KRBPP had already developed a short PEC course which they had been using as ‘district seminars’ for health workers in Kenya. Their primary objective in now using the Rural Health Training Centres (RHTCs) was in line with the Ministry of Health’s intention to co-ordinate rural health training through the RHTCs; KEPI (The Kenya Expanded Programme on Immunization) had already incorporated its training into the RHTC 3 month course. This was to avoid the development of multiple vertical training programmes, and rather to integrate all rural health training as a coherent whole. In June of 1982, therefore, the KRBPPconvened a four day work- shop of the RHTC teachers to design a curriculum for Primary Eye Care which could be integrated with the existing RHTC curriculum.

The Kenya Rural Blindness Prevention Project. envisaged a curriculum based on four simple tasks :

Recognise the problem Test Vision Treat or Refer Prevent

and four simple rules : The cornea should be clear The white part should be white The pupil should be black The lids should open and close properly. The curriculum produced at the end of the work-

shop, however. covered some fifteen conditions, and was arranged in terms of Disease, Cause, Diagnosis. Management and Administration of drugs. and Prevention, and was to be given one day in the cur- riculum.

Evidence of the presence of the first of our specula- tions can be immediately seen : the distinction between procedural and problem-solving training. The organ- isers of the workshop, the KRBPP, had intended to reduce problem-solving to a minimum: their aim was to teach to ‘protocols’-the four tasks and four rules. The RHTC tutors, on the other hand. rejected the ‘protocols’ in favour of a traditional. medical, problem- solving approach involving history taking and differ- entialdiagnosis. Which group assessed more accurately the existing problem-solving skills of the trainees they are to teach. and the length of time necessary and available, remains to be seen. Only evaluation of the performance of their trainees at a later date can say. While it is arguable that the Tutor’s experience, both as health workers and as trainers, would justify their choice, what little data there is available suggests that problem-solving skills in all areas of rural health care are less well-developed than had previously been thought.

Suffice it to say that the failure to distinguish between these two forms of training before the work- shop began caused considerable difficulties. The RHTC Tutors were suspicious of the KRBPP’s limit- ing approach to training; they suspected the KRBPP of under-rating their students. The KRBPP was con- cerned that their simple. easily applicable protocols had been lost in a welter of conventional disease conditions.

The second of our speculations was also apparent in the workshop. The curriculum was designed very much by group work by the participants. Conventional lecturing was eschewed, and the facilitators insisted on open, participatory discussion and learning. Crucial to this discussion was the presence of the Provincial Ophthalmologist and other highly trained members of the KRBPP. whose level of technical competence ensured no Beebyan lack of confidence. How far the RHTC Teachers will themselves be able to use equally open, participatory teaching for their curricu- lum remains to be seen. The KRBPP do intend to evaluate just such aspects as these. One further point should be made. As far as the training of health workers in PEC in Kenya is concerned, the contrast between what the Kenya Rural Blindless Prevention Programme expected and what the RHTC Tutors wanted to do, has already been noted. On the occasion of the workshop, the RHTC tutors prevailed. As far as the KRBPP was concerned, they had asked the tutors to design their own curriculum; they gracefully conceded to the tutors’ design. This is an- other and particularly important aspect of training: that teachers should feel concerned with, responsible for, and in control of what they are to teach. This aspect may even, at times, outweigh reservations about the appropriateness of what is to be taught.

Training health workers in Kenya 1825

CONCLUSIONS

AS has been stressed, much of this paper is speculatory.

Little hard evidence exists either to support or reject my 8’ speculations. Indeed, one of the great difficulties in training health workers is to collect acceptable evid- ence of is effect and effectiveness. The current interest 9.

of WHO and others in ‘Performance Assessment’ [20]

is an attempt at this. Health Care Systems too often 10.

divorce training from service; while teachers may be drawn from service, it is seldom seen as part of their duties to follow-up their ex-students and evaluate 11.

their performance once training has finished. Attempts at establishing continuing education programmes for health workers arein their infancy, yet much important 12. data can be collected by these.

REFERENCES 13.

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