Establishing new medical schools in medically under-served areas

Author: Sneha Kirubakaran

Kirubakaran, Sneha, 2022 Establishing new medical schools in medically under-served areas, Flinders University, College of Medicine and Public Health

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Medically under-served areas might seek to establish a new medical school in their region to improve the quantity and quality of their local medical workforce, as well as their population’s health outcomes and educational opportunities. Establishing a new medical school is a significant venture involving many complex political, social, economic, educational, and organisational considerations. Most founders go about the process intuitively, drawing from their prior knowledge and experiences; guided by accreditation standards; and utilising project management strategies. There is substantial value in this experience-based, intuitive approach, but a stronger evidence-base could increase the efficiency and efficacy of academics, clinicians, administrators, politicians, universities, health facilities, health systems, and communities seeking to establish a new medical school.

The published literature on the process of establishing a new medical school is, however, empirically and theoretically under-developed. There are several clear gaps including no prior published reviews; no explicit reference to applicable theory; minimal research on the establishment process; poor reporting of strategies to obtain initial approval from governing authorities; and minimal discussion regarding the personal costs and burnout commonly experienced by founders of new medical schools. My thesis addresses each of these gaps through Critical Realist Multiple Case Study research with a social accountability ethos. I conducted a scoping review of the published literature; I developed a strong theoretical basis by adapting concepts from Institutional Entrepreneurship theory; and I provided a suite of strategies for use by various stakeholders at all stages of the process, particularly in medically under-served regions.

The research question I sought to answer was, “How are new medical schools successfully established in medically under-served areas?” To answer this question, my Multiple Case Study research spanned three continents, in medically under-served contexts of Australia, Canada, and Botswana. Multi-source data was collected for each case study including site visits, observational data, semi-structured interviews, documents, and audio-visual materials. Using Institutional Entrepreneurship theory and my empirical findings, I derived a novel conceptual framework – the Eight C’s Framework (8CF) –that unpacked the various aspects of successful new medical school establishment: Context, Catalysts, Conducing, Convincing, Collecting, Connecting, Challenges, and Consequences.

My research aimed to understand the critical success factors for the process of establishing a new medical school in medically under-served regions. These success factors are encapsulated in 8CF and can be used to answer my research question:

New medical schools are successfully established in medically under-served areas when Catalysts act within their Contexts to undertake various tasks of Conducing, Convincing, Collecting, and Connecting in order to produce desired Consequences and overcome Challenges.

Catalysts are the human agents of change and innovation. They are creative, visionary leaders who use mechanisms of agency and power to collectively and individually effect change. They identify the field conditions of their environmental Context that are either beneficial or detrimental to their venture and utilise them to their advantage. They use entrepreneurial skills and processes when Conducing (making more favourable) the Context for their venture. They use socio-political devices such as power, persuasion, trust, symbiosis, sharing, and bricolage when Convincing all the stakeholders with various arguments and rationales, Connecting with various partners and collaborators, and Collecting all the required resources. Catalysts harness the utility of both field structure and human agency to produce the desired macro-level, meso-level, and micro-level Consequences or outcomes and to overcome foreseen and unforeseen Challenges or problems and obstacles. Underlying mechanisms that contribute to successful establishment include elements of human agency, contextual structure, power dynamics, and political diplomacy. Furthermore, my research identified that socially accountable motivations and methods can unite these factors into an even stronger force for successful establishment of a new medical school, particularly in medically under-served areas.

My research makes several original theoretical, methodological, empirical, and practical contributions. Critically, it provides stakeholders such as academics, clinicians, administrators, politicians, universities, health facilities, health systems, and communities with an evidence-informed framework for establishing a new medical school. Even though building a new medical school and teaching hospital is not a panacea to addressing doctor shortages, the empirically and theoretically supported 8CF guides medical school founders to consider the elements of human agency, contextual structure, power dynamics, political diplomacy, and social accountability that underpin successful establishment, especially in medically under-served areas. Future research could test application of the 8CF in practice, in establishing other new medical schools.

Keywords: new medical schools, establishing, starting, critical realism, multiple case study, institutional entrepreneurship, strategic framework, Eight C Framework, 8CF

Subject: Health Service Management thesis

Thesis type: Doctor of Philosophy
Completed: 2022
School: College of Medicine and Public Health
Supervisor: Jennene Greenhill