Improving Quality of Education in Extreme Adversities-The case of Libya

History of medical education in Libya spans over a period of 50 years. Medical education started in faculty of medicine at Benghazi in 1970, and at Tripoli in 1973. Both medical schools performed their main core function and their graduates provided good health services locally and abroad. However, the medical schools did not keep up with the immense changes that medical education experienced over the last two decades with inclusion of research and community services within their main core function [1-3],


Introduction
History of medical education in Libya spans over a period of 50 years. Medical education started in faculty of medicine at Benghazi in 1970, and at Tripoli in 1973. Both medical schools performed their main core function and their graduates provided good health services locally and abroad. However, the medical schools did not keep up with the immense changes that medical education experienced over the last two decades with inclusion of research and community services within their main core function [1][2][3], Education of professionals must be adapted to practice in order to meet needs and demands of the population and the health systems that serve them. Currently, the role of medical schools needs to be redefi ned and regulated in a world where specialization is becoming a requirement to practice. Medical schools need to transform their specialist training into a community-oriented education in accordance with World Health Organization (WHO) and World Federation for Medical Education (WFME) recommendation, to reorient medical education to meet current challenges [3][4][5].
Refl ecting the importance of the interface between medical education and the healthcare delivery sector, the WHO/WFME Strategic Partnership was formed in 2004 to improve medical education. In 2005, the partnership published guidelines for accreditation of basic medical education. The WHO/WFME Guidelines recommend the establishment of proper accreditation systems that are effective, independent, transparent and based on medical education-specifi c criteria [5][6][7].
An important prerequisite for this development is initiation and use of WFME Global Standards program in 1997 in all six WHO/WFME regions as a basis for quality improvement of medical education [7].
Global Standards for quality Improvement divided the standards into basic standards and quality development standards. Basic standards, which are 106,should be fulfi lled by all institutions involved in medical education. Standards for quality development, which are 90, serve as an incentive for development and as a leverage for improvement. Standards are defi ned in these two levels for each of the different domains (Text box 1).

Current status of medical education in libya
In spite of initial promising level, quality of medical education in Libyan universities progressively declined due to many reasons ( Table 1).

Faculty of Medicine in Libyan international medical
university was the only medical school getting a provisional Citation: Nasef

Consequences of declining teaching level
The decline in the quality of medical education led to exclusion of Libyan medical schools from the annual publications of international rankings, to loss of confi dence in Libyan universities, consequent loss of confi dence in Libyan doctors, with further decline in medical services.
Benghazi medical schools achieved 33% of basic standards in an assessment performed in 2018, followed by Tripoli medical schools achieved 22%. Other medical schools achieved less than 5 % of basic standards [9].
Most current medical graduates are under-qualifi ed due to sub-standard medical education, with resulting lack of professionalism, absent scientifi c attitude, weak creativity and inability to play a role in health advocacy. Suboptimal medical education was aggravated by enrolling of large numbers of students despite non-readiness of medical schools. As a result, a lot of Libyans seek treatment in neighboring countries and in Europe with increase of fi nancial costs and economic burden for both patients and government. In addition, patients pay an additional price because of consequent ineffective and/or incomplete management especially for cancer, trauma and rare diseases.

Road map for accreditaion in libya
Road to accreditation composed of two phases. First phase is establishment of a national task force for accreditation prepares for establishment of a national system for accreditation. Second phase is establishment of sound Internal Quality Assurance (IQA) system with clear responsibilities at medical universities ( Figure 1).
Phase one is composed of the following steps to be taken in order to establish a national system for accreditation

Curriculum/ Teaching and Learning Factors
11. Out dated teaching with Teacher-centered didactic unidirectional lectures. 12. Out dated non-competency based curriculum that is lacking recommended inclusion of personal and managerial skills, and that could not meet societal needs (9), (11). 13. No adoption of WFME standards (12). 14. Curriculum lack quality improvement and applied patient safety ( 13 ). 15. Lack of applied learning culture. 16. Language obstacle and minimal student participation. 17. Topics are not representative to current and real problems and nonresponsive to community needs. 18. Lack of and/or non-effective utilization of clinical skills labs. 19. Merging of parallel private educational centers, where excellent new graduates, or good tutors are teaching their own sub-standard curriculum ( 14 ). 20. Absence of research based education and culture. Citation: Nasef

Establishement of internal quality system at medical universities
Quality and innovation of medical education in Libyan medical schools is needed, to identify weak area, to enforce education, to graduate competent care giver medical students, to have an international standards of services to retain public trust, to prevent fi nancial and brain drain. Quality medical education can be established in three steps (Table 2).
Self-study and description through assessment of current status such as; facilities, student's number/staff number,     Citation: Nasef (Table 4).

1-An Endorsed
Auditing should involve evaluation of 10 standards, and result should be ≥ 60% for each standard, and overall result should be ≥ 70% (

Conclusion
Evidence based medicine, clinical reasoning, self-directed critical thinking and problem solving approach are mandatory Steps of establishment of sound IQA system at medical universities.

STEPS Components
Step 1 Conduction of self study 1) Self study: • Self assessment and description.
• Assessment of current status and SWOT analysis. To assess quality and effectivness of services. 2) Bench-marking.

3) Recommendation and Action Plan.
Step 2 Initation of QA in Medical universities 1) Adoption of recommendation and Action Plan For Further Enhancemnt. 2) Having an alternative teaching/ learning approaches and adoption of evidence based medicine (19). 3) certifi cation of quality management systems of educational institutions.
Step 3 Implementation of national quality assurance according to standard guidelines 1) Accreditation of educational institutions (Institutional accreditation). 2) Accreditation of degree programmes (Program accredetation) (20).
Step 4 Auditing Evlauation, supervision of the accredited educational institutions and accredited degree program for of ten standrads (20), (21).   in order to acquire better retained and usable knowledge in a clinical context through student-centered teaching, and team interpersonal skills promotion. Adoption of new and high standards methods of teaching such as 3D models [24,25], along with updated responsive teaching materials are mandatory and represent pre-requirements for accredited medical schools Accreditation, a risk-reduction strategy, is not an aim by itself but it is a tool for self-recognition, continuous improvement of pedagogical skills and a guide to reach out for the standards as a way to achieve academic excellence, which is the real added value of all the operations, we do.
Therefore, the accreditation and continuous quality improvement in medical education is crucial to adjust medical education to improve the current status of health service system and to prepare qualifying doctors for the needs and expectations of their essential clients, i.e the community they serve.
Accreditation and continuous quality improvement are expected to ensure training in era of information technologies in order to help doctors cope with the explosion in medical and scientifi c knowledge and technology, and to be lifelong learners.

Stakeholders in National Center for Quality Assurance and
Accreditation should work urgently to acquire mandatory state of art performance and excellency of execution. It would be advisable, for Quality Assurance and Accreditation center to consider a mandate for issuing practice license for all future public and private medical school, to ensure availability of quality requirements since establishment. Then they should consider closing severely underperforming medical schools.
A check list of standard requirements including inputs, process, outcomes, institutional and program quality, fi nancial cost should be prepared as fi rst step. This should be followed by a review of all medical schools according to these selected criteria. Subsequently, tough but needed decisions are needed to close medical schools with low quality standards in order to ensure effi ciency and effectiveness of medical education.

National
Center for Quality Assurance and Accreditation achieved remarkable progress despite all inconvenient circumstances. However, there is still a long way to go. Auditing own performances and outcomes, implementing standards of quality, hiring competent employees, collaboration with international centers and having a national plan to have medical schools with international standards in near future.