Student Participation in
Medical Policy Making and EducationPosition paper for Medicine Meets Millennium
EXPO-2000, Hannover

On behalf of the International Federation of Medical Students’ Associations, IFMSA
Björg Thorsteinsdóttir
IFMSA president 1997/98

Executive Summary
"….that health which is a state of complete physical, mental and social wellbeing, and not merely the absence of disease or infirmity, is a fundamental human right and that the attainment of the highest possible level of health is a most important world-wide social goal whose realisation requires the action of many other social and economic sectors in addition to the health sector.
The existing gross inequality in the health status of the people particularly between developed and developing countries as well as within countries is politically, socially and economically unacceptable and is, therefore, of common concern to all countries."; (Internat. Conf. On Primary Health Care, Alma-Ata, USSR 1978)

The consequences of mismanagement and unequal distribution of goods are nowhere more dramatic or more serious than in the field of health. In industrialised societies, new treatment options have led to escalating prices for health care while at the same time the well fare states are cutting back funding. Developing countries struggle to keep up technical hospital services, but are unable to provide basic health care for most of the citizens. As they fight their immense disease burden they are faced with brain drain from their medical force. This gross inequality of access to health care resources is made worse by a market directed approach to health care management.
To reverse this development in order to ensure that all people have access to necessary health care services, it is imperative that doctors claim a leading role in the development and implementation of a sound health care policy. A thorough understanding of medicine is a prerequisite to set the correct priorities in health care.
Medical education needs to develop methods to prepare doctors for this challenge and ensure their commitment to the general welfare of their societies. The best way to achieve these goals is to nurture initiative and problem solving skills in medical education.
Medical students should be entrusted with their own education in an expert guided but self-directed learning. Active student participation in developing education aims and objectives will result in a greater sense of responsibility. It will also prepare the students for the teaching role that awaits them.
During their formative years, medical students also need to be sensitised to the health care needs of society. Involving medical students in an interactive dialogue on the challenges facing the health care system in their society will increase their understanding and motivate them to seek future solutions.
Medical students are also an important resource for the provision of health care. If properly trained they can act as advocates for disease prevention, especially among their peers. Youth friendly health services could also greatly benefit from the active participation of medical students as advisors and health care providers.
The International Federation of Medical Students Associations, IFMSA, involves medical students in an international debate and advocacy and prepares them for community action. This way it contributes to the development of globally aware and culturally sensitive professionals for medicine.

Situation Analysis
Advances in medical science and technology have changed medicine and medical practice dramatically in the last decades. Increased specialisation and almost unlimited treatment options have increased the expenditure of health-care exponentially in industrialised countries and created a chasm between the rich and the poor both between and within countries. In developing countries minimum public health measures can not be undertaken nor can basic health care be provided to the majority of patients. At the same time the richer classes demand state of the art interventions.
This development has not been without its effect on medical education. As the amount of medical knowledge increases it becomes increasingly difficult for medical professors, let alone students to set the correct priorities in the education. The academic society has not reacted adequately to this problem. With increasing specialisation, every speciality tends to overemphasise its importance as an essential component in the education of the physician.
The time medical students spend on a given speciality during their education becomes one of the measures of importance as every speciality fends for the largest possible share. The limited resources available to health care enhance this struggle between specialities.
Faced with this predicament the medical student is largely left to his own devices in trying to digest all the knowledge handed down to him by his professors. He gets little direction or methodology to guide his quest for knowledge. Unfortunately simple memorisation of facts shortly before the exams is often the easiest way out. This leaves little time for critical thought and integration of the knowledge for overview and balanced judgement.
The attitude of medical students towards their education is affected by this neglect of the academic society to define the core curriculum in a balanced way. Academic achievements are dictated by professors where specialisation is the key to success. The student learns to regard specialisation and factual knowledge as the ultimate measure of quality. He learns all the most complicated and specialised diagnostic, intervention and treatment options for every disease but does not get enough training in clinical reasoning and judgement.
Information overload and demands on the medical student for academic achievements are often overwhelming. The medical hierarchy demands total dedication to the profession irrespective of personal and family needs. Students are therefore often forced to withdraw from active participation in society and family life. The widespread respect for the medical profession perpetuates this situation.
This tendency of the medical profession to isolate itself and nurture a certain arrogance towards other professions, risks blinding the would be doctors to their role and responsibility towards society.
In many ways the medical society has failed to shoulder its responsibility for the development of an equitable and sound health care system. One of the reasons for this is that the young physicians enter independent professional life at a very late stage in their professional development. By that time they already have extensive vested interest in their speciality and the tradition attached to it. This makes them too biased for a leading role in health care policy. To combat this therefore medical students must be reached at an earlier stage. They need to get an understanding of the challenges facing health care and get involved in solving them before they make the choice of their future carrier.
At present, medical student bodies in collaboration with other NGOs and professional bodies, are trying to sensitise medical students to the importance of public health and primary health care. These bodies also provide training in skills necessary for community action and advocacy. This is especially important, as academic medicine has proven to inert to respond to this need.

Desired Development
Doctors have a duty to ensure an equitable and efficient health care policy that provides health for all. A thorough understanding of medicine, its potential and limitations, is imperative to set the correct priorities in health care. To be able to do so doctors need to claim a leading role in health care management and policy making.
To prepare doctors for this leading role leadership and management skills have to become an essential part of every doctor’s education.
The best way to nurture initiative and problem solving skills is by entrusting medical students with their own education. Self-directed learning under expert tutelage will ensure that the young professionals harbour the skills necessary for a life long quest for knowledge.
Active student participation in developing educational aims and objectives is a learning process in itself. It will result in a greater understanding of the challenges of having to choose what to learn and how to approach the overwhelming amount of medical knowledge available. It also increases the students’ responsibility for their own education. Likewise an understanding of different teaching methodologies, their strengths and weaknesses is important since most doctors assume a teaching role be it towards patients and community or medical students and doctors in training.
The formative years of the young professionals in medical schools strongly influence their future carrier choices. Therefore medical education has to encourage a debate on human rights, medical ethics and public health. From that platform it needs to define the role of doctors not only as health care providers but also as advocates and leaders of health care reform. The students also have to be provided with the necessary management tools and leadership skills to address the challenges of making priorities in health care. Real life experiences in social services and community health work have to be an integral part of the education to sensitise the students to the most pressing problems.
Medical students can also be an important resource for the health care system. If properly trained they can act as advocators for disease prevention, especially among their peers. As peer educators they have a unique potential. They are usually respected by seniors as doctors to be, yet close enough to the young people to be seen as peers. Prevention programs and youth friendly health services could therefore greatly benefit from the active participation of medical students.
The International Federation of Medical Students Associations, IFMSA and other NGOs and student bodies are ideal vehicles to encounter the shortcomings of the present educational system and bring about the necessary changes.
IFMSA is a unique vehicle to reach and teach medical students. Currently 69 member countries are active with a potential outreach of over 800.000 medical students in these countries. IFMSA serves as an action platform to formulate policies and to co-ordinate the activities of its member organisation. International workshops and training programs are organised around important topics. Under IFMSA's umbrella national members organise community work, advocacy and peer education programs. All IFMSA’s activities are co-ordinated by a large group of committed young people, spread around the world and working on a voluntary basis. It actively collaborates with other NGOs in the medical field as well as student and youth organisations from other disciplines. It also maintains official relations with various UN agencies and collaborates with them where appropriate.
It is of special importance that IFMSA is run by medical students, catering to the needs of medical students. This encourages initiative and calls them to responsibility and trains the students for future leadership.

IFMSA therefore has an important role to fulfil by:
- Leading and co-ordinating an international debate and policy discussions among medical students;
- Preparing medical students for community action and co-ordinating their efforts;
- Providing leadership training and experiences for medical students;
- Mobilising medical students for grass root advocacy and lobbying;

However, effective mobilisation of the majority of medical students will not be possible without the embrace of the medical education system, whereby community action is encouraged and credited.

Challenges and Strategies
IFMSA has proven through its work that it can reach out to a large number of medical students, prepare and motivate them for action. However there is still a long way to go to release the full potential of the international medical student community. To attain this, international IGOs and NGOs have to join forces in working towards a global agenda for the reform of medical education.
The ultimate evolution and changes have to take place on a national level in the universities. The motivation for the change however can arise through international involvement and participation.
With a strong and independent global student network in place, advocacy for the attainment of global aims and policy will gain increased strength. An interactive dialogue between junior and senior organisations on an international level can rapidly be spread to the grass root through the student organisations. That way, the IGOs and senior/academic organisations can lobby at government and university level while at the same time the students give pressure from below, stressing the same issues with an international endorsement of their effort. Caught between two fires, it will be very difficult for the establishment to resist. Hopefully this will lead to progressive changes.
IFMSA as well as other student NGOs need the endorsement of senior organisations as well as intergovernmental bodies to gain a more widespread national recognition. Where government and political forces work against the formation of youth organisations, it is even more important to use international pressure to support non-political student activities in the community.
It is a formidable challenge to ensure continued growth and development in the face of the rapid turnover in a student organisation. At present IFMSA focuses on strengthening its infrastructure and national constituencies to enable them to effectively carry out the mission of the organisation. To this end, a self-sustainable strategy for the training of trainers is being developed. It will be based on the experience and resources within the organisation as well as external expertise. For this initiative to be effective IFMSA needs both technical and financial support as well as an extended network of collaborators.
To release the full potential of IFMSA an extensive and structured organisational capacity building has to take place. The leadership of IFMSA needs to receive intensive training in how to face the challenge of managing the organisation to its optimum. The leadership also needs a more effective backup of the secretariat and a stable financial basis. With a strong leadership and infrastructure in place, the co-ordination of the work of IFMSA and backup of its national constituencies will be much more effective.
The development of IFMSAs national constituencies depends on an extended strategy of national capacity building. The training on an international level has to focus on the needs of the national leadership on one hand, and on the training of trainers on the other. The training of the majority of the students will then take place nationally and regionally with the backup of international trainers and teaching materials.
IFMSA does not have the expertise or the financial capacity to work alone on this big task. It is also logical that other stakeholders in medical education and global medicine participate in this development.
To ensure the development of the "universal doctor"; IFMSA, WMA, WFME and WHO should work together to define the qualities and skills needed for health leadership, advocacy and community work. With the definition in place the organisations should together develop a coherent training strategy and the course modules needed to implement it. Foundations and youth serving NGOs as well as government funds could then be approached for funding of the effort.
Medical schools should then be encouraged to take on, as part of the core curriculum, the implementation of some of the training. Most of it however should be left to the initiative of the students on a national level but with the endorsement of the international community and necessary support as needed. Only the more advanced modules and training of trainers should take place on an international level.
It is imperative that the academic medical community recognises the importance of this training for medical students. Their participation in policy discussions and community work alongside their studies must be encouraged. The curriculum must allow for it and it should earn the student credit.
To ensure that this strategy will benefit every country, IFMSA has to reach out to all medical students. The Internet gives an unprecedented possibility for an active outreach and rapid spread of information. All teaching materials and methods must be made available through the Internet, giving the medical students around the world direct access to the program. Thus they can become active participants in the work of IFMSA and benefit from the training. Once they are online they also have to have easy access to quality controlled and content specific medical information to support their studies and reduce the cost of medical education in the developing world. Therefore it is one of the biggest challenges for the global medical community to make the net available to medical students in developing countries.
IFMSA aims to reach out to all medical students and through them contribute to the health and development of their communities. It strives to contribute to the development of globally aware and culturally sensitive professionals for international medicine. Given the necessary endorsement and support IFMSA has proved that it can be an important vehicle for change. Let this important international movement develop to its full potential to face the new millennium to the benefit of mankind.