Aisha Rafi  ( Department of Anatomy, Shifa College of Medicine, Shifa Tameer e Millat University, Islamabad, Pakistan )
Muhammad Idrees Anwar  ( Department of Surgery, Holy family Hospital, Rawalpindi Medical University, Rawalpindi, Pakistan )

Objective: The accreditation standards developed by the World Federation of Medical Education (WFME) are acknowledged as regulatory mechanism for quality assurance of medical education programmes. The scoping review was planned to collect all the literature for identification of the barriers affecting the implementation of quality curriculum defined by WFME.

Methods: The literature was searched in electronic databases for relevant peer-reviewed studies over the last ten years. The search terms used were, `challenges of WFME accreditation’, `barriers to accreditation’, `challenges to accreditation in healthcare system’, `hindrances to WFME accreditation standards’, and `barriers to WFME standards’, in PubMed, ERIC, PsycINFO databases, and in Google Scholar for grey literature. After screening and assessing for eligibility, 922 publications were retrieved and only 19 articles were included in study. The QualSyst appraisal tool was used to appraise the quality of studies. Data was synthsized to present the findings.

Results: The themes identified after data synthesis broadly described the barriers to implementation in various domains of WFME standards. The themes were social and political support, process of curriculum development, involvement of students in curricular planning, organizational setup, infrastructure, technical issues/ management of curriculum. The social and political support referred to leadership and governance, a prime barrier to address. Similarly, organizational setup, infrastructure and technical issues should also be looked for apart from students and curriculum.

Conclusion: The scoping review will inform and lay the foundation for more empirical studies on quality improvement in health professional education, particularly in low and middle-income countries.

Keywords: Challenges of accreditation, Barriers to accreditation, WFME standards, Challenges of quality curriculum implementation. (JPMA 71:  966; 2021)

DOI: https://doi.org/10.47391/JPMA.795

 

Introduction

 

Global experts in medical education, under the umbrella of the World Federation of Medical Education (WFME), have developed standards to guide development, evaluate and diagnose strengths and weaknesses of the medical education programme along with stimulating quality improvement.¹ The ultimate goal of the reforms is formation of transformative and interdependent professional educational system for providing equitable healthcare.²

The WFME standards are used as a template to focus on acquiring competencies to serve the local needs in the global context. The educational commission for foreign medical graduates announced that by 2023 all medical graduate programmes should be accredited by an authority meeting the WFME or any other global criteria for accreditation.³ There is a need to identify the challenges to accreditation, particularly in low and middle-income countries (LMICs) to improve the medical education curriculum which indirectly will have a positive effect on the healthcare system of the country. The current scoping review was planned to identify the barriers affecting the implementation of quality curriculum defined by WFME.

The scoping review was carried out to explore what the barriers and hindrances are that impede the quality curriculum in medical education related to WFME standards, particularly in LMICs.

Many curricular reformers fail just because they fail to identify the barriers that hinder and hamper the process of curriculum reforms. The factors and elements that impede the achievement of standards in nine areas of WFME can help identify the issues and barriers that can hamper the quality of curriculum and pose a threat to accreditation by the health regulatory authority of the country.

 

Research design and methodology

 

Ethical approval for the review was not necessary because it did not involve patients and interventions. The studies included in the review were traced from different databases.

The scoping review search strategy was applied because it is useful when there is no extensive research for the topic under consideration. It maps the body of all published and grey literature to answer the research question. There are some common processes of research between scoping and systematic review.⁴

After identifying and scrutinising the problem and forming a review team and research questions, the Arksey O’Malley framework of scoping review was used because it provides all the necessary guidelines for educational research.⁵

The review objective was to map the existing literature on barriers and inhibitors to implementation of WFME standards for curricular reforms in LMICs.

 

Eligibility Criteria

 

Relevant studies were identified by using an eligibility criterion made with mutual consensus of the authors. The inclusion and exclusion criteria were developed according to the specific research question. The criteria were modified post-hoc after-literature search.

 

Study designs

 

The literature pre-screening identified a heterogeneity of study designs, and, therefore, search was not restricted to a particular study design. Quantitative and qualitative studies and survey and evaluation reports answering the research question were included in the review. Only those articles were included that were fully available with no payable access.

A deadline was agreed after which no study was included in the review.

 

Search Strategy

 

The reviewers developed the electronic database search strategy by defining the key concepts answering the review question. Later on, the search strategy was peer-reviewed by the librarian of Shifa Tameer-e-Millat University, Islamabad, Pakistan, in compliance with Peer Review of Electronic Search Strategies checklist.⁶

 

Electronic databases sources, key words and phrases

The databases searched for relevant literature were Education Resources Information center (ERIC), Psychological information database (PsycINFO) and PubMed, while Google Scholar was searched for grey literature to look for information yet to be peer-reviewed and avoid missing any relevant article. The key words and phrases used for searching were `challenges to WFME accreditation’, `barriers to accreditation’, `challenges to accreditation in healthcare system’, `hindrances to WFME accreditation standards’, and `barriers to WFME standards’. Grey literature was also searched among technical reports from governmental agencies, communication with personnel involved in self-evaluation study at Shifa Tameer-e-Millat University and the Rawalpindi Medical University along with hand-searching of the key documents were also taken into account.

We employed Boolean operators by joining of multiple keywords as in `Challenges to accreditation’ OR `Barriers to implementation of curriculum’ etc. (Appendix I).

All the included literature was imported in Mendeley citation management software, where duplicate citations were removed.

 

Study Selection

 

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flowchart reports the results of the number of articles identified, screened and finally selected after applying the inclusion and exclusion criteria for review.⁷

One researcher identified 917 records in the electronic databases by using the keywords -- or combinations of keywords – and 5 records were identified through grey literature.

Duplicates were removed in the screening phase after which 19 full-text articles remained. The eligibility of selected articles was carried out by using the validated QualSyst checklist8 to assess the quality of quantitative studies and qualitative studies. The QualSyst contains a 14-item criteria for quantitative studies, and 10-item criteria for qualitative studies. Each item in the study was scored on a three-point scale (0 = NA, 1 = Partial present, 2 = Present), making maximum score 28 for the quantitative (14x2) and 20(10x2) for the qualitative studies. The final score attained by the study was derived by dividing the total score attained by either 28 or 20 or as applicable. The final score of > 80% was chosen as high, 71–79% as good, 50–70% as sufficient, and < 50% as limited quality.⁴ Studies with more than 50% were included in the review. A total of 19 articles score >50% were included in the scoping review. .(Appendix-II).

The bias was controlled by calculating inter-rater agreement using Cohen’s Kappa⁹ (0.682; considered a good agreement) (Appendix III; Figure 1)

A number of studies from different LMICs were included (Figure 2).

Although Saudi Arabia and India are not counted among LMICs, the data extracted from the studies conducted in those countries identified the barriers they share with LMICs.

 

Publication Year

The barriers and inhibitors to implementation of WFME standards became the popular research topic from 2016 to 2018 in LMICs on account of problems of accreditation. The studies in the past ten years were selected.

 

Outcome Measures

The main aim of the systematic review was to identify the economic, cultural, organisational and technical barriers and inhibitors irrespective of whether these were operating at the regional, national or international levels affecting the implementation of quality curriculum defined by WFME.

 

Screening

The results of literature search were assessed by two rounds of screening based on the inclusion-exclusion criteria of the review.

Initially, the screening was carried out by the reviewers independently by applying the inclusion-exclusion criteria to all the citations. It included screening of the titles and abstracts of the studies. All those records that partially fulfilled the inclusion criteria were also kept at this level. when needed, a third reviewer was taken onboard to resolve the difference in opinion of the two reviewers.

In the second round of screening, full text article review was done. Full text articles representing the best fit of the research question were selected for inclusion in the review process. Discrepancies were resolved by consensus or by a third reviewer.

 

Data extraction

The data extraction was preceded by a calibration exercise to pilot test and use the results to refine the data extraction form. The data extracted comprised full reference, study design, objectives, target population, outcome measures and study results.

 

Assessment of risk of bias

Two independent reviewers were involved in each phase of the review. Risk of bias assessment for each study was done by checking the author affiliation, study population, type of questions asked in questionnaire/interviews and reviews.

 

Analysis/synthesis of data

The data was analysed descriptively owing to different study designs, study population, barriers and inhibitors mentioned in the included studies. The same features in each study included in review were summarised. The studies were grouped according to study design, population and outcome measure. The different patterns across the included studies were identified by tabulating the results by study design, risk of bias, or results and any other additional information.

 

Results

 

The reviewers thoroughly read the articles to perform a thematic analysis of the data.⁵ Concepts were identified by open coding and the categories and their related sub-categories were decided by axial coding to give a precise explanation to generate themes and sub-themes.

The themes identified broadly described the barriers to implementation in various domains of WFME standards. These included:

1. Social and political support: This theme deals with the WFME areas addressing the mission and outcome of programme, governance, leadership, evidence-based decisions and institutional autonomy.

2. Process of curriculum development: This broad theme narrates the WFME standards influencing the curriculum model, educational outcome, assessment and linkage with healthcare system.

3. Involvement of students in curricular planning: This theme describes the barrier to WFME standard related to involvement of students in curriculum planning.

4. Organizational setup: The theme relates to academic staff and faculty.

5. Infrastructure: The barrier offered by lack of purpose-built building, playground, common rooms, telecommunication, funds, and sustainable cost.

6. Technical issues/ management of curriculum: Barrier to system design issues, lack of timely reporting, feedback and data analysis tools, issues related to educational environment.

 

Discussion

 

The accreditation standards are used as regulatory mechanisms to ensure the quality of medical education, which, in turn, lead to quality healthcare.  The trend for quality assurance and accreditation of medical schools is growing worldwide.¹⁰ WFME standards are structured under nine areas with 35 sub-areas, at two levels: ‘basic standards’ or minimum requirements; and relatively advanced standards called ‘quality standards’. Basic standards are mandatory while quality standards are optional. The barriers to implementation of quality curriculum conforming to WFME standards in LMICs are discussed under the relevant categories.

 

Lack of social and political Support

 

Every institution is founded on its own set of principles and values. The literature review has identified that adapting to an international educational framework does not pose any threat to institution's vision, mission, goals and objectives and a societal impression. Most institutions already had clearly spelled out vision and mission and only needed minor changes to preserve their identity.¹¹

The long-term maintenance of change is difficult because of change in leadership or there is a shift of priorities.¹¹ Changes in managerial staff and staff at leadership position can result in creating a gap between the top management and the academic staff and can poses another barrier.¹² Government agencies and bureaucracy also have their influence through imposition of certain regulations, like admission policy, faculty promotion and the type of curriculum.¹³ Political support backs the financial support required for hiring more human resource to facilitate overburdened staff and for improving the infrastructure, commodities and governance.¹¹

 

Process of curriculum development

 

The barriers to development of curriculum affect WFME standards dealing with educational programme and assessment. WFME standards mandated early clinical exposure, horizontal and vertical integration of curriculum and integration of behavioural sciences in the curriculum.¹⁴ Providing early clinical exposure require time and availability of the clinical faculty. This warrants allocation of infrastructure of early clinical exposure for first and second years in a teaching hospital.¹⁵

The second barrier identified was faculty apprehension on account of compromising their status as subject specialist in a system-based integrated curriculum. This threat to basic sciences teachers acted as a barrier to implement and adopt integration at its fullest. Also the pedagogical content knowledge, instructional strategy adopted by faculty and curriculum, which was not relevant to the developmental level of learner, acted as the challenge to integrated curriculum. The subjects had inherent differences as how well they could be integrated with other specialties compromised the process of integration.¹⁶

WFME basic standard emphasises the vertical integration of behavioural and social sciences. The impedance to integration of behavioural sciences curriculum is due to lack of faculty available for behavioural and social sciences for teaching and lack of post-graduate training in behavioural sciences in underdeveloped countries.¹⁷

The standards for assessment mandated reliability, validity, standard setting, and scrutiny by external examiners of the process of assessment. The standard setting requires content experts, logistics and data management resources.¹⁸ Reliability and validity are dependent on many factors, including post-hoc analysis, standard setting and faculty training in formulating assessment.¹⁹ Assessment experts are scarce and a lot of institutions do not have a proper examination departments. Scrutiny by external examiners of assessment is time- and resource-intensive.²⁰ A lot of centres are not geared for these pre- and post-exam analysis and can pose a major threat to implementation of these standards.²⁰

 

Students as important stakeholders

 

The WFME standards state that the process of student selection should comply with the mission and targeted outcome of the institution. Medical and dental college admission test is conducted by national agencies where the test relies on cognitive ability only. There is a vast number of educational boards in Pakistan, each having its own criteria for entry test.²⁰ Multiple mini-interview is a useful tool to select students in accordance with the philosophy of curriculum, but regulatory authority has banned this important selection tool.²¹ The rule for transfer of students from other programmes is also defined by the regulatory authority, and the parent institution has no stake in it.²⁰

WFME standards also advocate due stake of students in curriculum, planning and implementation, mission and vision and management of curriculum, but unfortunately student bodies are not involved in any of these.²² Curriculum planning is not as rigorously performed in many underdeveloped countries, as it should be. Improvement in learning is predicted when students are involved in various committees and provide feedback and opinion which, in turn, indirectly affect curricular development by directing the admission policy, curricular content and provision of student selected components.²³

 

Organisational setup

 

The organisational setup of many institutions poses a threat to implementation of quality curriculum mentioned in WFME standard related to academic staff and faculty. There is a dearth of qualified basic science faculty members which indirectly affects curriculum implementation and delivery. The rules and regulation of Pakistan Medical and Dental Council (PMDC) allowing clinical science degree holders to hold faculty position even in basic sciences did a great harm to the teaching of basic sciences.²⁴

Basic science teachers feel threatened with little institutional support and time constraints, which hinder their personal development plans.¹⁷ The significant hindering contributors are lack of training for curriculum development and almost 87% faculty expressed concern in a study conducted in India that addition of new courses through integration affected the basic course they had to teach.²⁵

 Majority of medical schools do not have optimal faculty development programmes which is a difficult task and requires a lot of political commitment, supportive leadership, resource allocation and recognition of excellence in teaching.²⁶ Mushrooming of medical schools in many countries in the last few years have compounded the problem, and qualified well-trained faculty is becoming scarce.

 

Infrastructure

 

Standards for educational resources refer to infrastructure, information technology (IT), research culture, and international collaboration. The resource-constrained countries lack major resources and are allocating very little funds for further development.

The health regulatory body in Pakistan has mandated the clinical training resources according to the number of seats the college has for medical students. A few medical colleges do not possess a hospital with the specified number of beds. Hospital facilities are inadequate with high faculty-student ratio. Many institutions have inadequate learning facilities and unsatisfactory educational environment. Owing to increased cost of healthcare and pressure for free treatment, medical students are left with less patient exposure than required for proper learning.¹⁹

The problem is enhanced by inadequate IT services. The barriers to implementation of IT component can be infrastructure, cost and time, national policies toward health information system, social and cultural, educational, organisational and ethical barriers.²⁷ Also, there is no adequate infrastructure, such as wireless communication channels, internet and skilled professional human resource for inter-organisational and intra-organisational communications.

Also, healthcare users are reluctant to adopt new technology and stick to conventional approach and routine practice. Adjustment with new technological environment causes initial decrease of productivity, which further limits the adaptation of new health technologies.         There is no health informatics education in the undergraduate medical curriculum.²⁸

The WFME standards insist on the promotion of research culture. Most of the research is questionnaire or survey-based, and the students do not show interest in research because of overwhelming curricular content and examination phobia. Most of the curricular time is spent on delivering lectures on how to conduct research rather than hands-on activities for research methodology.²⁹

Practice of evidence-based medicine, although generally lauded, is not yet completely accepted as the standard on which patient care should be based.³⁰

The health regulatory body in Pakistan ensures that every medical college has functional department of medical education, but it does not provide the framework regarding regulations, policy guidelines and technical support for roles and responsibilities of the department of medical education. In most medical colleges of Pakistan, there is no full-time medical educationist. This is due to lack of trained medical educationists in the country.³¹ Many medical schools have un-qualified staff working in medical education departments.

Most colleges have no collaboration with other health institutes. The common barriers to national and international collaboration are language barriers, faculty apprehension to international partnerships, cultural and ethical issues, and difficulty in reaching a consensus on partnership agreements.³²

 

Management of curriculum

 

The WFME standard for programme evaluation clearly states that there should be a proper mechanism for programme evaluation and monitoring, feedback system and a system for evaluating the graduate performance to measure the outcome of a programme, and it also necessitates the involvement of all the stakeholders in programme evaluation. But mostly the evaluation system is not in place. This is due to lack of knowledge, commitment, inadequate policies, strategies and an inefficient management system about evaluations.³³ The formation of evaluation tool in the local context is another challenge that requires efficient and trained personnel and infrastructure.

The barriers to evaluation can be human and contextual factors. The interpersonal skill of evaluators, lack of context and programme knowledge and technical competence is a human factor. The process of evaluation is influenced by trust on the programme evaluator, threat of negative results and a prior negative experience.³⁴

Contextual factors identified in the studies were gaining access to correct data and lack of justifiable and context-specific criteria for evaluation. The contextual factors also include hierarchical structures, political structures, mandate and decision, organisational culture and level of implementation of programme, turnover of staff and accountability.³⁵

The WFME basic standard about analysis of performance of cohorts of students and graduates in relation to mission and intended educational outcomes is difficult to achieve on account of difficulty in data collection from advisory boards, recruiters, employees and graduate surveys.³⁶

The standard for governance and administration encompasses the role of leadership, academic administration, stakeholders and healthcare sector. Evaluation of academic leadership is difficult because of potential backlash because of giving negative feedback. There is no perfect instrument for assessing academic leadership.³⁷

Currently, the healthcare sector lacks trained physician leaders as they do not demonstrate competency in leadership and management skills mandatory for healthcare system.³² Also, the continuous monitoring via self-evaluation and peer appraisal is a time-consuming and laborious job.³⁸ Interaction with government involves bureaucratically administrative boundaries, varying laws and regulations, different information systems and databases.¹³ All these are very crucial barriers to governance and administration standards in health education.

 

Healthy educational environment

 

Change involves time, effort and overcoming challenges. Every institution has its own values defined by staff, skills and styles intertwined with system, structure and strategies and they are reluctant to change. Also, change in any one segment will have its impact on other segments.³⁹ Introduction of a new standard influences the cultural values, beliefs and norms in individuals, groups, departments and institutions.⁴⁰ Change in curriculum and its renewal intensifies the academic work and most organisations are not very keen on it. Lack of a feedback loop between students and the institution to relate its mission and outcomes to subsequent stages of education or practice is recognised as a dilemma rather than a barrier.⁴¹

If all the challenges are categorised with respect to its contribution towards curricular reforms needed for WFME accreditation, it will be clear that problems are similar across LMICs. For example, faculty resistance to change is one of the main issues regarding curricular reforms in Pakistan²⁶ as seen in other parts of the world, like India,²⁵ Rwanda²⁸ and Uganda.³⁵ Similarly, financial constraints and lack of digital technology system in healthcare is another common challenge. The barriers to accreditation owing to lack of research are common in Pakistan,²⁹ Sudan³⁰ and Iran.³⁸

The scoping review has highlighted leadership role as the most important challenge to accreditation in Pakistan,²⁶ Saudi Arabia,³² Iran,³⁸ Sudan³⁰ and South Africa.³⁷ LMICs across the board need a good leadership to combat all the challenges to accreditation and quality curriculum for a better healthcare system.

 

Conclusion

 

The scoping review will provide a guideline to the curriculum planners, policy-makers and government agencies for developing standards in the local context to achieve global objectives. The challenge identified against every WFME standard should be sought out for a smooth implementation of WFME standards for accreditation, thus saving the future of medical and dental graduates.

 

Disclaimer: None.

Conflict of interest: None.

Source of Funding: None.

 

References

 

1.      Tackett S, Grant J, Mmari K. Designing an evaluation framework for WFME basic standards for medical education. Med Teach 2016;38:291-6. doi: 10.3109/0142159X.2015.1031737.

2.      Frenk J, Chen L, Bhutta ZA, Cohen J, Crisp N, Evans T, et al. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. Lancet 2010;376:1923-58. doi: 10.1016/S0140-6736(10)61854-5.

3.      Norcini JJ, Banda SS. Increasing the quality and capacity of education: the challenge for the 21st century. Med Educ 2011;45:81-6. doi: 10.1111/j.1365-2923.2010.03738.x.

4.      Munn Z, Peters MDJ, Stern C, Tufanaru C, McArthur A, Aromataris E. Systematic review or scoping review? Guidance for authors when choosing between a systematic or scoping review approach. BMC Med Res Methodol 2018;18:143. doi: 10.1186/s12874-018-0611-x.

5.      Arksey H, O'Malley L. Scoping studies: towards a methodological framework. Int J Soc Res Methodol 2005;8:19-32. Doi: 10.1080/1364557032000119616

6.      McGowan J, Sampson M, Salzwedel DM, Cogo E, Foerster V, Lefebvre C. PRESS Peer Review of Electronic Search Strategies: 2015 Guideline Statement. J Clin Epidemiol 2016;75:40-6. doi: 10.1016/j.jclinepi.2016.01.021.

7.      Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. [Online] 2015 [Cited 2020 March 18]. Available from URL: http://www.prisma-statement.org/PRISMAStatement/Default.aspx

8.      Kmet LM, Lee RC, Cook LS. Standard Quality Assessment Criteria for Evaluating Primary Research Papers. [Online] 2004 [Cited 2020 February 15]. Available from URL: https://archive.org/details/standardqualitya00kmet_0

9.      Pykes K. Cohen’s Kappa: understanding Cohen’s Kappa Coefficients. [Online] 2020 [Cited 2020 March 02]. Available from URL: https://towardsdatascience.com/cohens-kappa-9786ceceab58

10.    Sethi A, Javaid A. Accreditation System and Standards for Medical Education in Pakistan: It's time we raise the bar. Pak J Med Sci 2017;33:1299-1300. doi: 10.12669/pjms.336.14178.

11.    Shankar PR. Challenges in Implementing an Integrated Curriculum in Xavier University School of Medicine, Aruba. Educ Med J 2014;6:e74-7. DOI:10.5959/eimj.v6i4.290

12.    Ali SK, Baig LA. Problems and issues in implementing innovative curriculum in the developing countries: the Pakistani experience. BMC Med Educ 2012;12:31. doi: 10.1186/1472-6920-12-31.

13.    Köybaşi F, Uğurlu CT, Bakir AA. The factors that influence bureaucracy and professionalism in schools: a grounded theory study. J Educ Pract 2017;8:196–207.

14.    Maccarrick G. A practical guide to using the World Federation for Medical Education standards. WFME 2: educational program. Ir J Med Sci 2010;179:489-91. doi: 10.1007/s11845-010-0574-3.

15.    Cooper T. Curriculum Renewal: Barriers to Successful Curriculum Change and Suggestions for Improvement. J Educ Train Stud 2017;5:115-27. doi:10.11114/jets.v5i11.2737.

16.    Shah N, Tabassum A, Shah N. A needs assessment for faculty development at two medical colleges of Dow University of Health Sciences, Karachi. Pak J Med Sci 2018;34:1386-91. doi: 10.12669/pjms.346.16302.

17.    Tabatabaei Z, Yazdani S, Sadeghi R. Barriers to integration of behavioral and social sciences in the general medicine curriculum and recommended strategies to overcome them: A systematic review. J Adv Med Educ Prof 2016;4:111-21.

18.    Mortaz Hejri S, Jalili M. Standard setting in medical education: fundamental concepts and emerging challenges. Med J Islam Repub Iran 2014;28:34.

19.    Tavakol M, Doody GA. Making students' marks fair: standard setting, assessment items and post hoc item analysis. Int J Med Educ 2015;6:38-9. doi: 10.5116/ijme.54e8.86df.

20.    Khan JS, Biggs JSG, Tabasum S, Iqbal M. Assessment in medical education in Pakistan: Evaluating Evaluation. Biomedica 2012;28:88-94.

21.    Rauf A, Tayyab A, Masrur A. Relationship between Student Performances in Non-Cognitive Skills in Multiple Mini Interview and Integrated Practical Examination. J Coll Physicians Surg Pak 2018;28:270-3. doi: 10.29271/jcpsp.2018.04.270.

22.    Grant J, Marshall J, Gary NE. Pilot evaluation of the World Federation for Medical Education's global standards for basic medical education. Med Educ 2005;39:245-6. doi: 10.1111/j.1365-2929.2004. 02085.x.

23.    Shakil-Ur-Rehman S, Ahmad S, Yasmin R. Study of curriculum of Doctor of Physical therapy programme based on World Federation of Medical Education standards. Pak J Med Sci 2018;34:1582-85. doi: 10.12669/pjms.346.15926.

24.    Pakistan Medical and Dental Council (PMDC). Regulations for the Appointment / Promotions of Faculty / Teaching Staff / Examiners / Principals / Deans/ Vice Chancellors in undergraduate & Postgraduate medical & Dental Institutions / Medical Universities of Pakistan. [Online] 2018 [Cited 2020 February 15]. Available from URL: https://numspak.edu.pk/careers/files/uploads/requirements/2-%20Regulation%20for%20the%20appoinment%20-Promotions%20of%20Faculty%20(PMDC%20Sept%202018).pdf

25.    Bhat D, Pushpalatha K, Kulkarni P. Study of Faculty Viewpoints on Challenges and Factors Influencing Curriculum Development / Revision. J Clin Diagn Res 2017;11:1-4. DOI: 10.7860/JCDR/2017/ 25697.10764

26.    Anwar MI, Humayun A. Faculty development----looking through different lenses. Pak Armed Forces Med J 2015;65:110-7.

27.    Anwar F, Shamim A. Barriers in Adoption of Health Information Technology in Developing Societies. Int J Adv Comput Sci Appl 2011;2:40–5.

28.    Aurore N, Valens M, Lune NJ, Nyssen M. Assessment of health informatics competencies in undergraduate training of healthcare professionals in Rawanda. Rawanda J 2016;3:36-40. doi.org/10.4314/ rj.v3i1.6F

29.    Faiza R, Nisa Q. Perception, attitudes and barriers in undergraduate medical students toward medical research at Rehman Medical College, Peshawar, Pakistan. Khyber Med Univ J 2017;9:146–9.

30.    Osman T. Medical students' perceptions towards research at a Sudanese University. BMC Med Educ 2016;16:253. doi: 10.1186/s12909-016-0776-0.

31.    Latif MZ, Wajid G. Reforming Medical Education in Pakistan through strengthening Departments of Medical Education. Pak J Med Sci 2018;34:1439-44. doi: 10.12669/pjms.346.15942.

32.    Almansour S. The challenges of international collaboration: Perspectives from princess Nourah Bint Abdulrahman University. Cogent Educ 2015;2: e1118201. doi: 10.1080/2331186X.2015.1118201

33.    Zarifraftar M, Aryankhesal A. Challenges of implementation of accreditation standards for health care systems and organizations: A systematic review. J Manag Sci 2016;2:191–201.

34.    Sjöström H, Christensen L, Nystrup J, Karle H. Quality assurance of medical education: Lessons learned from use and analysis of the WFME global standards. Med Teach 2019;41:650-5. doi: 10.1080/0142159X.2018.1536259.

35.    Mijumbi-Deve R, Sewankambo NK. A Process Evaluation to Assess Contextual Factors Associated With the Uptake of a Rapid Response Service to Support Health Systems' Decision-Making in Uganda. Int J Health Policy Manag 2017;6:561-71. doi: 10.15171/ijhpm.2017.04.

36.    Worley P, Esterman A, Prideaux D. Cohort study of examination performance of undergraduate medical students learning in community settings. BMJ 2004;328:207-9. doi: 10.1136/bmj.328.7433.207.

37.    Solomon A, Steyn R. Leadership style and leadership effectiveness: Does cultural intelligence moderate the relationship? Acta Commer 2017;17:a453. doi: 10.4102/ac.v17i1.453

38.    Ghiasipour M, Mosadeghrad AM, Arab M, Jaafaripooyan E. Leadership challenges in health care organizations: The case of Iranian hospitals. Med J Islam Repub Iran 2017;31:e96. doi: 10.14196/mjiri.31.96.

39.    Waghmare LS, Srivastava TK, Tankhiwale SR, Quazi Z. Quality assurance of medical education in India: perspectives and recommendations. Glob J Res Anal 2014;3:3-4. doi: 10.15373/22778160/ January2014/18

40.    Mcleod P, Steinert Y. Twelve tips for curriculum renewal. Med Teach 2015;37:232-8. doi: 10.3109/0142159X.2014.932898.

41.    Davis MH, Harden RM. Planning and implementing an undergraduate medical curriculum: the lessons learned. Med Teach 2003;25:596-608. doi: 10.1080/0142159032000144383.