A curriculum can be designed, developed and implemented using different approaches, according to the needs and circumstances in each setting. In Vietnam, when the curriculum needed to be changed, traditionally a small core team, consisting of medical school leaders, training department leaders and a few medical teachers with experience in curriculum development was established by the MoH to participate in revising the old curriculum [8
]. There were many limitations to this approach. Firstly, few of the teachers who implement the curriculum were involved and teaching methods were not considered. However, as pointed out by French [7
], the classroom teacher is the crucial ingredient for the success of any educational innovation. Secondly, non-university stakeholders such as local authorities and lay community members are not medical experts but are the consumers of health care services and have vested interests in ensuring optimal health care for themselves, their families and their communities [9
]. They can, therefore, make meaningful contributions to facilitate choices in medical education. With the support of a project, eight Vietnamese medical schools used a participatory approach to work with a wide range of stakeholders to change their curriculum and consequently the teaching and learning methods and materials.
It was complicated, costly, time consuming and can be tricky to motivate all of the stakeholders involved in the process, but it was quite successful with the application of a participatory approach. Although Herzberg's theory has made a wide impact on the field of job attitudes and motivation, it still has significant number of critics [18
]. Among those critical of the use of this theory, Whitsett and Winslow suggested that many investigations were characterized by methodological flaws, misrepresentation of results and gross misunderstanding of the theory [21
]. Herzberg's theory is widely cited in the business literature, but less often in education, especially for teachers [22
]. When Bellott and Tutor conducted a study among elementary and secondary school teachers, they reported that salary was an important factor to motivate teachers, while according to Herzberg, money would be a hygiene factor, not a motivation one [23
]. The motivation of medical teachers and of clinicians was compared by Schormair [24
]. Among ten statements on the motivation of medical teachers to teach, financial incentive played a small role in comparison with other incentives, such as teacher of the year award or student rating. Motivation for practising clinicians to teach medical students was due to intrinsic issues such as altruism, intellectual satisfaction, personal skills and truth seeking; reasons for clinicians not to get involved in teaching included lack of involvement in course design, or a heavy clinical workload [25
]. In Vietnam, the situation may be similar in some ways to other countries, but local regulations and culture may also influence the motivation. For example, medical schools can accept health professionals outside the university as teachers if they contribute enough to teaching students in their working location. The status conferred on the professionals by their association with the university can motivate non-university stakeholders to teach. A Vietnamese saying, "Salutation is more appreciated than a party." reflects the importance of respect and appreciation compared to material benefits. Indeed, community-level health staff in Vietnam were found to be motivated mainly by appreciation of employers, colleagues and the community, as well as job stability and training opportunities; financial issues were less important [26
Looking at the activities that were applied to involve and motivate the different stakeholders, the following strategies appear to have been crucial.
Firstly, it was observed that involving stakeholders outside the university, such as health service staff, part-time teachers, FT preceptors and communities, actively in the process of curriculum development and implementation in itself contributed to their motivation. Many of them were pleased to contribute to forming future doctors. They felt flattered and proud that their expertise and opinions were appreciated by the university.
Secondly, there was a strong focus on interaction between the different stakeholders
, e.g. between teachers and school leaders, part-time lecturers and FT preceptors, and between school leaders and the ministries. Opportunities for different stakeholders to meet, to discuss and to share medical education experiences and health care needs motivated all of them to work towards a better medical curriculum to provide good doctors. It was proposed by Schormair that reforms in medical education must consider the interaction between medical teachers and their students [24
], but this project went beyond that interaction to promote a broader process of exchange.
Thirdly, the process combined bottom-up and top-down
approaches. Government policy and the authority of the two Ministries and the school leaders were combined with contributions from many stakeholders who were not usually given a chance to express their views on the subject. Both fulltime and part-time teachers were motivated by respect for their inputs. Not involving them in curriculum development could result in poor implementation due to lack of motivation on the part of teachers [25
], while excluding authorities would weaken the project with respect to realizing an impact on curriculum change, which would have discouraged school leaders and teachers.
Learning is motivating in itself, and that strategy was highly motivating especially for the part-time teachers, like clinicians, researchers, laboratory technicians and field preceptors. They received training in technical topics from the university teachers, but were also trained in teaching and learning methods. When the university teachers joined the students in the field or practice sites, the part-time teachers could also learn from participating in teaching for students, thereby strengthening their own capacity and providing additional motivation.
Last but not least, it is important to note that the project put a strong emphasis on self-motivation factors
for stakeholders, like learning-by-doing or working for recognition and appreciation, while minimizing motivation by monetary incentives. The main factors influencing motivation for clinical teachers have been reported to be intrinsic issues, such as altruism, intellectual satisfaction and personal skill development [25
]; the same appeared to apply here. According to Coleman, two components underlie this kind of motivation: altruism and personal gain. Altruism meant providing service to the community and repaying the system, while personal gains included improved knowledge, improved self-esteem and relationships [27
Not every stakeholder was equally motivated; there were part-time teachers who could or would not find time to improve their capacity to teach the students and there were teachers who did not want to accept feedback from the students. A detailed discussion of their lack of response to the factors discussed here is beyond the scope of this paper but will be necessary to complete the picture.
One limitation of Herzberg's Theory of Motivation is that it was originally developed to manage staff motivation inside an organization [11
], rather than motivation of a range of stakeholders from different organizations. That meant that several of the factors found in Herzberg's theory, especially hygiene factors like salary, job security, company policy and administration, would be less relevant for some of the stakeholders described here, especially those from outside the university. Therefore these factors were not included in Table . In this particular situation, a factor like 'relationships with colleagues' acted not only as a hygiene factor, as Herzberg found, but also as a motivator. The repeated mention of the opportunities to meet and exchange experience with colleagues from other medical schools during this participatory process showed the importance the teachers gave to such exchanges. Because Herzberg focused on the employees within an organization, the theory also may not have considered the factors that may motivate those who are outside the university to become involved in the cycle of change within the university.
An interesting question is whether this attention to motivation of various stakeholders contributed to sustainability of the results of the change process. There are indications that this is indeed the case. Many interventions that started with the support of this project can be expected to last, especially because many of the factors that motivated the stakeholders still remain when the project was completed, such as responsibility, recognition, advancement, job interest, personal growth and achievement. Although the financial incentives during the project period could play a role in motivating the stakeholders, such incentives would no longer be available when the project finished. Therefore, payment was not given for just participating in project activities; financial rewards focused on products and skills that could be used for a long time, such as the KAS book, joint curriculum, teaching/learning materials, student assessment tests and active teaching methods. The part-time teachers working outside the universities were trained and as described above, were motivated to continue to learn once they had become involved.
"You ask about sustainability of activities that this project supported for our university? I don't think there is any problem. Development of teaching, learning and assessment materials are activities we have to do anyway, so teachers have to update materials to teach and produce student assessment tools. Now the project already supported them to develop, why not use them?"
(Teacher, Internal Medicine department)
Collaboration among the different stakeholders was based on a win-win approach. For example, once teachers benefited from exchanging materials among identical departments in different schools and communicating with their colleagues about their teaching experience, they were motivated to continue producing and exchanging TLM in that network. Some of the project-funded opportunities, such as big inter-school workshops and regional study visits or conference attendance might be difficult to sustain giving the limited budgets of the MoH and the medical schools. One solution was to create a new project that will use advances in information technology to establish online forums, teleconferencing and distance learning to support continued networking activities among the various stakeholders.