Curricular review, revisions and modifications have been routine practice in medical institutions of the developed countries. Recently developing countries are also experimenting with different curricular models. However, initiating, implementing and sustaining change has not been easy [1
]. Successful educational improvements require establishing a clear educational vision and a shared institutional mission. According to Bland (2000) [3
] “successful curricular change occurs only through the dedicated efforts of effective change agents”.
The authors report on the process of change and the elements necessary for effective change from the standpoint of a governmental decree for change in multiple (four) medical schools. In addition to the perspective about the country wide and government mandated change process, there is a unique political situation included in the change process; specifically the instability in the government of Pakistan at the time the changes were attempted. This is an aspect of change that is not usually reported in the literature from the developed world.
Of the 35 features of successful curricular change identified by Bland et al. we used organization's mission and goals, internal networking, resource allocation, relationship with the external environment, organizational structure, need for change, scope and complexity of the innovation, cooperative climate, participation by the organization's members, communication, human resource development, evaluation, and leadership to identify the factors that were hindering the smooth implementation of the curricular change [3
We also describe a process that did not work as planned and the reasons for that. There is too little published about what does not work and we hope that our study will provide useful insight into why a planned activity did not work and the lessons that can be learned from the unanticipated outcomes.
A change was instituted by the government of Pakistan in 1992 taking lead from the Edinburgh Declaration asking the faculty and administrators of medical institutions to review the existing medical curriculum and develop a revised/new curriculum for use by all the medical institutions of the country. The World Health Organization (WHO) was contacted for assistance in this regard and a series of deliberations and discussions were held with educational leaders who had successfully introduced curricular innovations in the countries with similar health care problems. In the light of these deliberations and educational philosophies [4
], best evidence medical education practices (BEME), and the health problems and health delivery structure of the country, a Community-Oriented Medical Education (COME) curriculum with Problem-based learning (PBL) as the instructional methodology was finally selected. The COME project (as it was called) was initiated as a pilot in 1994 in collaboration with the WHO by the Government of Pakistan.
Four medical Colleges, one from each province were included in the program. They were Dow Medical College (Sindh), King Edward Medical College (Punjab), Bolan Medical College (Balochistan) and Ayub Medical College (Khyber Pakhtoon Khwah). The faculty of medical colleges and the other stake holders (medical students, representatives of ministry of health and service providers from potential catchment areas who were to become partners in student learning) were involved in revising the traditional curriculum with incorporation of COME in undergraduate teaching [5
].Medical students were also involved in this process and participated in the introductory curriculum development workshops which introduced the participants to the educational principles and PBL process. Members from the ministry of health were invited on the first and last day of the workshops to show their commitment, to know the views of the faculty, review the changes recommended in the curriculum as a result of the workshop process and discuss their own role in the implementation process. Large full day meetings were held in the selected community sites to initiate the process of developing partnership with these communities. These meetings were attended by service providers, community leaders, elected councilors, school teachers and representative from community based organizations (CBOs). These meetings were conducted by the national and provincial COME coordinators, national and international consultants in consultation with the Provincial Minister of Health and Principal1
of the COME College.
The conceptual framework for the curriculum was taken from the spiral curriculum at the medical school of Dundee in United Kingdom [6
]. A consensus was reached by the faculty of COME colleges in the initial workshops that the medical graduate should be a safe, skillful, and humane medical practitioner [5
]. The curriculum was distributed over five years in three phases with horizontal and longitudinal blocks as follows:
Phase 1 consisted of year: 1 and 2 of medical college and included Normal structure and function, abnormal structure and function with clinical relevance.
Phase 2 consisted of year 3 and included abnormal structure, function and patient management with clinical rotations in major disciplines
Phase 3 consisted of rotations and training in the hospital in all required disciplines as per the core competencies: defined by the Pakistan Medical and Dental Council (clerkship)
The two longitudinal blocks were:
Community Experience was over the four year period (1st to 4th year) with the final exam in the fourth year
Clinical skills started in the 1st year and continued till the final year with varying levels of competency training.
A coordinated and integrated approach was adopted for developing the curriculum [2
] learning from the experience of the Interdisciplinary Generalist Curriculum (IGC) Project of North America [9
].A national coordinator (similar to the IGC project officer), international and a national consultant, and four provincial coordinators were deputed to oversee the academic and administrative aspects of the program, and facilitate transition from traditional to innovative curriculum [11
].The provincial coordinators were selected from the medical institutions within the program [11
]. The curriculum was developed during regular meetings of the faculty from these four colleges and launched in 2001. Three out of these four colleges piloted one to two first year blocks. However despite intensive efforts by the consultants, coordinators, and the faculty, the COME curriculum could not be implemented till 2004. Recently some aspects of the curriculum i.e. thematic curriculum using case-based learning (CBL) have been introduced in at least one medical college.
A study was initiated by WHO and Ministry of Health (MOH) in 2004 to look into the factors, which hampered the implementation of the COME curriculum in the selected colleges. The objectives of the study were to identify the reasons for non implementation of the COME Project and to assess the understanding of the stakeholders about COME.