Title: Netherlands Course in Tropical Medicine and Hygiene (NTC)
Country: Netherlands
Institution: The Netherlands - Royal Tropical Institute (KIT), Amsterdam
Course coordinator: Maaike Flinkenflögel
Fernando Maldonado
Date start: 2018-03-05
Date end: 2018-06-08
About duration and dates: 14 weeks full time study (including 1 examination/ graduation week) next course date: 2018-09-10 to 2018-12-14
Classification: core course
Mode of delivery: Face to face
Course location: Amsterdam, KIT
ECTS credit points: 20 ECTS credits
SIT: Contact time: on average 4 days a week 6 hrs per day (about 304 hrs total excluding about 10 hrs open book exam, opening, closing ceremony etc)
Self study and not facilitated group work: on average one full day a week and several hours on class days (about 290 hrs total)
Language: English
Description:

Introduction Module

- LO 1 Describe and analyse the impact of globalization on health and health systems in L-MIC
- LO 2 Identify relevant literature databases and to search them effectively
- LO 3 Give a clear oral presentation on a topic/issue of interest
- LO 4 Write a scientific paper on a topic/issue of interest
- LO 5 Identify different learning styles
- LO 6 Recognize the principles of self-reflection

Determinants of Health

- LO 7 Identify and analyse the major, interrelated determinants of health and origins of disease
- LO 8 Identify inequalities and inequities and relate them to the determinants of health
- LO 9 Discuss the interaction between socio-cultural, gender, economic, environmental determinants and health
- LO 10 Describe how the current process of globalisation influences health and the pace of change in both health status and health systems in Low and Middle Income Countries

Health problems

- LO 11 Discuss and apply the concepts of Integrated Management of Childhood Illnesses as well as recommended immunization schedules for children
- LO 12 Identify and analyse some key issues in the area of sexual reproductive health, such as contraceptive use, treatment of STI’s, maternal mortality, safe motherhood
- LO 13 Discuss implications for planning, monitoring and evaluation of services at district level of key issues identified such as safe motherhood, contraceptive use for different target groups, and STI prevention and treatment
- LO 14 Identify and analyse key issues concerning major causes of fever, coma, convulsion, cough, diarrhoea and anaemia in low and middle income societies
- LO 15 Identify and analyse key issues concerning common dermatological, ophthalmologic and psychiatric problems in resource-poor settings
- LO 16 Recognize and manage abnormal growth and development in a child, including micro-nutrient deficiencies
- LO 17 Describe the lifecycle and pathology of intestinal bowel parasites
- LO 18 Recognize and analyse key issues concerning the major causes of a blue, yellow or small new-born
- LO 19 Recognise and analyse key issues concerning the major tropical diseases, including HIV/AIDS, tuberculosis and malaria in adults and children
- LO 20 Develop guidelines for non-communicable diseases

Basic research methods

- LO 21 Explain the application of epidemiology in health services delivery and health policy and management; use basic principles and concepts in epidemiology: incidence, prevalence, causation, relative risk and odds ratio, attributable risk, population attributable risk, screening
- LO 22 Differentiate different types of data and variables and describe ways to summarize, tabulate and present these; Explain principles of distributions, sampling confidence Describe and explain different concepts in the dynamics and epidemiology of infectious diseases, with particular reference to HIV/AIDS, tuberculosis, malaria and disease outbreaks intervals and the basic principles of statistical inference; use and interpret basic statistical tests
- LO 23 Critically appraise published epidemiological literature and draw implications for practice and policy
- LO 24 Differentiate between different types (applied, action, participative) and methodologies of qualitative research and identify appropriate application of these methodologies in international health
- LO 25 Appraise qualitative research and interpret results critically for implications in policy and practice
- LO 26 Explain the socio-cultural character of disease and illness and discuss the relevance of medical anthropology in dealing with public health problems and explaining health- and health seeking behaviour
- LO 27 Analyse health problems and develop an approach to investigate these; critically discuss the usefulness and complementary nature of qualitative and quantitative research in this analytic approach

Health systems

- LO 28 Explain how cultural differences in attitudes, values and behaviour may cause misunderstandings in cross cultural relations and communications
- LO 29 Describe the role and functions of health systems
- LO 30 Describe and analyse factors that influence the coverage and utilisation of health services in a district health system and discuss the interrelation between the levels of first line health services, hospitals and the community
- LO 31 Explain and analyse how different health policies and reforms at the national level affect the implementation of health programmes in the district and how they impact on equity, efficiency and quality of service delivery
- LO 32 Describe and appraise different ways of financing a (district) health system; discuss the main criteria for resource allocation and manage financial resources for a more efficient use
- LO 33 Describe the relevance of health promotion, prevention and protection to improving health of communities and discuss the role of health promotion in a community, hospital and district setting Manage the drug supply cycle in a district, including selection, procurement, distribution and the rational use of drugs
- LO 34 Process and analyse data from various sources at district level and use them for planning
- LO 35 Identify managerial aspects of common situations and problems in the hospital; propose and plan improvements for deficiencies in quality of care and/or management problems
- LO 36 Describe human resources issues at a health facility, including training, continuous education, supervision and performance management
- LO 37 Describe and discuss various forms of community involvement in health and describe strategies to enhance community involvement and accountability
- LO 38 Assess the needs of a population in an emergency setting, describe the essential components (organisation and content) of emergency health programmes and identify constraints in their implementation
Focus or specific features:
KITs approach is very practice oriented. Facilitators are active in the field and have up to date knowledge of situations encountered. Therefore we can offer and up-to-date approach to complex public health issues. The course is directed at health professionals (physicians, nurses, midwives etc) and aims to be at the cutting edge of clinical and public health.
Both the facilitators and the students are from various disciplines and countries. This can result in a vivid exchange of viewpoints/ knowledge. The classroom sessions are highly interactive to facilitate this exchange.

The course is organized jointly with the University Hospital of Amsterdam (UvA) and the Vrije Universiteit Medical Centre (VU) in Amsterdam.
Content:

The course in KIT consists of the following five modules: Introduction Module, Determinants of Health, Health Problem, Basic Research Methods and Health Systems. The modules ’Determinants of Health’ and ’Basic Research Methods’ combined cover the content of the category ’Concepts and Research Methods’ as used by tropEd (Table 2). Below the content of each of the modules is described in detail.

Introduction Module

This module has a double aim: on the one hand to introduce students to international health with a particular reference to globalisation and health, on the other hand to help students develop learning and communication skills that will be necessary in their daily practice and for further personal studying. International health finds itself where globalisation operates at the interface between tropical medicine and public health. This module explores how globalisation affects both the health status of individuals in low and middle income countries and the way the health system in these countries operates.
Globalisation is multifaceted and one of its many aspects is the increase of relevant information now available to health professionals. In order to process this information and in order to keeps one’s knowledge updated, one needs to be able to appreciate the value of this tremendous flow in other words to operate a selection according to well chosen criteria. This module will bring to the students the skills to do so. By definition the MIH is international: how to communicate with fellow students will be a first opportunity in the intercultural communication skills that they will need as health professionals in Low and Middle Income Countries. In dealing with the local population, with refugees or with donor agencies graduates of International Health will need to operate in a multicultural environment in which they will have to explain their actions, to lobby or to give well formulated instructions. The sessions on intercultural communication and presentation skills aim to raise the awareness of cultural issues in communication and to prepare students to the rest of their study; to their work and to further self study. Additionally, the module will provide a session about learning styles and self-reflection. This session will be the departing point of a continuous process though the NTC aimed to provide student with tools for professional development (mainly about attitude and behaviour). The follow-up of the process will be done using a system of personal portfolios.

Determinants of health module

Health is highly valued in all societies, though cultures differ in perceptions of causes of health and ill health, and in the action they take to promote or restore health. There is also agreement on the broad categories of factors that influence health. If we analyse the environmental factors that influence health it becomes clear that each of these factors is not only separately related to health, but that they mutually influence each other. Poverty has a clear influence on the health of women and men but ill health also affects the wealth of individuals and families. Gender and age have an impact on the health of individuals and families. While some aspects of the demographic transition have obvious impacts on health, others have more subtle but none the less important health consequences. Moreover, the recent acceleration in population movements within countries and across borders can have dire consequences for the health of displaced population and sometimes that of the recipient population. Changes in the physical environment may not only influence the economy of the country and of individuals; they may also have political consequences, and cause changes in the value attached to the health of individuals, in (health) policy and budget allocations, and therefore in the functioning of the health services. In fact, all factors are mutually related, but in each country the strength and direction of the influences may differ. Many connections may also still be unknown, and some may be so sensitive (e.g. influence of pollution due to industrial 'development' on health) that research into this field is not encouraged by policymakers, or that no action is taken on research findings which would require action in favour of health of large population groups. Policy makers, clinicians and managers therefore need to be conscious of the various factors, which influence health. Finally, all the above mentioned determinants are themselves influenced by the present processes that are intensifying human interactions at all level, i.e. globalisation: determinants of health are not fixed, they evolve and with them, their impact on health.

Basic research Module

Epidemiological studies are crucial in answering questions on the importance of determinants of disease and the effectiveness of interventions. As both epidemiology and statistics are basic knowledge systems to interpret literature, time will be devoted to the critical appraisal of published literature. The statistics part of the module will emphasise the interpretation of statistical tests, confidence intervals, p-values, etc. The emphasis in qualitative and participatory research is on generating knowledge to inform decisions and interventions. Involvement of patients, community groups, grassroots workers and managers help to identify local needs and priorities and places health issues in the context of people's lives, thus giving direction to health programme development and service provision. An introduction to medical anthropology and sociology will help to explain health, illness and health care from a socio-cultural perspective, which is of crucial importance to interpret health- and health care seeking behaviour. The complementary nature of qualitative an quantitative approaches for the planning, development and evaluation of specific interventions and health promotion strategies will be stressed. The use of a combination of qualitative and quantitative methods will be illustrated with examples of specific disease control programmes such as tuberculosis, HIV/AIDS and malaria, but also through problem solving strategies in the management of health systems. The link between evidence-based knowledge and evidence-based decision-making is stressed

Health Problems module

This module builds knowledge and skills to recognise, and analyse key issues regarding diagnosis and management of the most important diseases and health problems occurring under resource-poor conditions. The module consists of three components: curative and preventive care for adults, curative and preventive care for children, and sexual and reproductive health. In the component regarding adults particular attention is given to the three main killer diseases: HIV/AIDS, tuberculosis and malaria. Management of HIV/AIDS, including HAART based on the latest evidence is highlighted. Diagnosis and treatment of opportunistic infections, and related dermatologic problems are discussed. Different forms of malaria, also in relation to other fever related diseases, as well as treatment, differentiating between different resistance patterns are. Best practices in recognition, diagnosis and treatment of tuberculosis are highlighted, including the DOTS strategy. For other diseases emphasis is placed on a syndromic approach, as in resource constraint working conditions not all diagnostic procedures are available. As such the syndromes related to fever, coma, convulsion, cough, diarrhoea and anaemia are discussed, the possible related diagnosis and treatment are dealt with, using an evidence based approach. As mental health problems are often underestimated in low-income countries, basic issues are discussed. Parasitology is taught in several sessions and includes some practical instruction in lab techniques and identification of major parasites.
A large proportion of the patients in resource poor countries are children, therefore a number of clinical and related aspects of children are dealt with in terms of diagnosis and treatment specific for low and middle income settings using a syndromic approach. Because the Integrated Management of Childhood Illnesses is very much propagated and used in low-income countries, the application, use and stimulation of the IMCI approach as well as EPI will be practised.
Safe motherhood is an essential component of this module, looking at the determinants of maternal and perinatal mortality as well as effective clinical and public health interventions to decrease these. As the focus from population control has changed towards sexual health and individual rights, fertility regulation issues and the societal influence on individual reproductive decision-making process is the subject of a session in this module. Sexual transmitted infections, their relationship with the HIV/AIDS epidemic, as well as diagnosis and treatment are dealt with using a syndromic approach. Advice on Post Exposure Prophylaxis for the professional health worker is provided.

Health Systems Module

Health systems in countries all over the world are facing different kind of challenges in order to meet the ever increasing needs and demands of their citizens. Demographic changes, technological developments, a more conscious and assertive demand for quality care compete with requirements of reaching or maintaining universal access and containing costs. This module starts therefore with an introduction on how health systems are defined, their goals, functions and main actors. Basic health economic concepts are explained in order to understand how health systems are financed (through user fees, insurance systems, taxes, or donor funding), how providers of services are paid (fees, salaries, contracting) and how market failures in health influence the choice for public and/or private provision of services. Health economics also provides basic tools for priority setting and resource allocation in the planning process. A short introduction to health promotion links this module to the one on determinants of health, as health systems enclose ’all activities, whose primary purpose is to promote, restore, improve or maintain health’ (WHR 2000) The emphasis in this module is on the practical implementation of health programmes and the organisation of health care at district level. This district level is situated at the crossroads of national health systems and -policies and the community: the community as consumer, target group and partner in health care. In order to make efficient use of the scarce resources available to the health sector, the sector has to be well organised at this operational level. Roles of community initiatives, health centres and hospitals as well as NGO’s and private providers are discussed, and attention is drawn to the importance of other sectors in relation to health. Working within the health system health professionals deal with a number of management issues. Management in district health systems includes the management of resources, drugs, personnel, and information. Therefore resource management, elements of bookkeeping and the use of management information systems are important topics. Management of human resources entails aspects of training and continuous education, performance management and motivation, as well as supervision. Basic skills for the management of projects, as well as in communication and managing oneself are part of this module. Monitoring of quality of care and quality improvement is highlighted. Attention will be paid to the management of drugs, including the drug supply cycle and the rational use of drugs.
National and international policies and initiatives and different health sector reform strategies are discussed in relation to what they imply for equity, efficiency and effective coverage of priority health programmes and their implementation at the district level. What are the implications of decentralization policies, strongly vertically and top-down organised programmes or brain drain and human resources motivation issues on the day to day running of a district health systems? How communities are involved in planning for their health and how are providers and managers held accountable for their performance? Due consideration is given to the specific situation of health care delivery in emergency situations, health issues around refugees and the influence that refugees may have on resident populations. Throughout the module, attention is paid to a pro-poor approach and gender implications of health policies.
Methods:

There are generally two sessions a day. A session consists of three hours including a coffee/tea break. On average 1 day a week is kept free from sessions for self-learning. Sessions usually consist of an introductory presentation combined with other teaching methods as described below.

The content of the course is oriented as much as possible to the working situation of the participants. Participants have intensive contacts with highly qualified staff who are active in the field. Methods are varied and include discussions, group work, lectures, case studies, exercises, serious gaming, self-reflection, giving feedback to others and self-study. Simulations and role plays are used to familiarize participants with problem-solving in cross-cultural management and planning. Reading material is prepared and distributed beforehand via online repositories. Laptops and/or tablets are required. Two days of the course are given in the laboratory.
Prerequisites:
- Academic training at least to the level of a (para) medical bachelor's degree
- Two years of relevant work experience including experience in low/middle income countries
- Proven proficiency in spoken and written English through one of the following:
- Applicant is a native English speaker or completed his higher education in English
- The applicant has a certificate or an English proficiency test (TOEFL or IELTS). The minimum scores required: TOEFL 5.5 or IELTS 6.0.
- Students that completed their higher education in English and Dutch participants who hold a university degree are not required to show proof of English language proficiency.
- A laptop or tablet and computer literacy is required.
Attendance:
Maximum number of students: 30
Selection:
first-come, first-served basis
Fees:
6400 Euro. This fee does not include living expenses, transportation costs, insurance or any other incidental costs.
Scholarships:
There are no special scholarships for the core-course/NTC. Suggestions for financial support can be found on our website www.kit.nl/fellowships or www.grantfinder.nl
Major changes since initial accreditation:
-New sessions were added on topics that the advisory committee and students missed as relevant to international health: ’Dealing with corruption’, Palliative care, extra time for Non-communicable diseases etc. Other sessions were cancelled as they were now integrated in other classes (e.g. urban health).
-Students are encouraged to do self reflective exercises and to keep a self reflection portfolio
-Students prepare an individual 5 minute presentation on an ’a global actor in health’
-In line with these changes two new examinations were added: the self reflection summary and the presentation. These examinations aim to examine whether the student is able to ’clearly communicate and work professionally’
-the course is now mostly ’paperless’ and an online repository is used for distribution of course materials. A laptop or tablet can be used to look up information during the open book exam.
Student evaluation:
Students generally praise the facilitators, especially their knowledge on recent developments in the field. Role plays, games, debates and simulations are most interesting and provide most learning. Students like the opportunity to learn from each other’s experience as well.
Students found that the course was well organised, such as the reading material being on time, and changes in the schedule being announced. It was also commented that the management was easy to approach.
The reading materials are thought to be very good and relevant but integration and connection to the classroom sessions can be improved for some classes.
Some non-medical students have trouble with clinical information in some of the health problem sessions and they would like optional sessions. Others would like more tutoring sessions on their paper. Many facilitators use examples from Africa, and less examples from other continents are given.
In response: teachers are asked to focus less on Africa and more on other continents, they are asked to better integrate the required reading in their classes. Teachers are encouraged to use even more debates/role plays etc. Some optional classes are offered, but time is limited.
Lessons learned:
Student are very positive about the use of online repositories. These are also used to give feedback to individual and group work products and they are used during the open book examination. Note keeping on an electronic device is done by many.
Self reflection portfolio’s often mention the groupwork and presentations as important parts of the course for development of professional skills.
tropEd accreditation:
Accredited in 2004 in Madrid. Re-accredited in 2009 in London and in 2014 in Umea. This accreditation is valid until January 2019.
Remarks: Specific features characterising our core course

Central to KITs approach is the elaboration of practical expertise in policy development and implementation. Most of the facilitators are active in the field and have up to date knowledge of situations encountered. In the Netherlands, the core course (NTC) is also part of a post-graduate training programme for Dutch physicians leading to a diploma in tropical medicine. Other components of the programme include residencies in surgery or paediatrics and in obstetrics and gynaecology. This post-graduate training programme is currently being assessed to see whether it can become an official profile/specialization in the Netherlands. The outcome of this assessment is expected in 2010. About half of the participants are medical doctors who will work on the tropics, often in a clinical setting. Other health professionals also take this course as part of their education, either as a stand alone course, or as the start of their Master in International Health.
Email Address: M.Flinkenflogel@kit.nl
Date Of Record Creation: 2011-06-07 17:26:56 (W3C-DTF)
Date Of Record Release: 2011-06-07 17:35:30 (W3C-DTF)
Date Record Checked: 2017-03-19 (W3C-DTF)
Date Last Modified: 2017-10-10 16:09:25 (W3C-DTF)

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