Table 4 Programmatic Issues in Implementation

Organization and Coordination

· Lack of coordination between the ministry, institutions, health departments and WHO (95%).

· Lack of coordination between the ministry, institutions, health departments and WHO (4/16 all principals).

· Faculty not informed of the progress on COME (71%).

· Not sure of the time lines on implementation (9/16).

· Faculty not informed of proposed time of implementation (68%).

· Why did the faculty not think about the evaluation issue earlier on (4/16 – administrators at provincial level).

· Transfer of trained faculty caused delays in implementation (55%).

· The assessment system by the university is not congruent with the PBL and COME curricula (20%).

Financial support

Lack of financial support for photocopying, books, petrol for students’ community visit, secretarial support and faculty incentives (99%).

· The concerned Ministry was willing to provide financial support however they needed official documentation from the principal (5/16 administrators at provincial and federal level).

Political Commitment

· The principals were not in favour of COME (57%).

· They felt that the principals were not complying (5/16 administrators at provincial and federal level).

· Lack of political commitment (30%).

· Frequent change of administrator at all levels (35%).

· No lack of political commitment, government is fully supportive (5/16 administrators at provincial and federal level).

· Lack of ownership by the provincial government (35%).

· Frequent change of administrator at all levels (10/16).

Lack of directive from the federal ministry (4/16 all principals).

Effect on Health System of the Country

· No effect on health system of the country (54%).

· The health system of the country will improve with implementation (9/16).

· The senior faculty does not have time to go the field site and are not trained to go in the field (47%).

· The senior faculty will come in contact with the service providers at the peripheral level with a hope to improve their competencies (3/16).

· The community comes to the tertiary care teaching hospitals; hence the students are adequately trained (45%).

· The cost of in-training of medical doctors after posting to Basic Health Units will be decreased (3/16).

· Tertiary care teaching institutions will be linked with the community health services (3/16).

Need and Usefulness of COME

· We do not need to send the students to the community because the community comes to our hospitals (74%).

· Unless the infrastructure in Community health services is organized to receive students for medical training, it will be difficult to implement COME in Pakistan (3/16).

· Infrastructure of the community is not developed and the staff is not trained in the peripheral centers (92%).

· Presence of students will have beneficial effect on the practices of the health providers at the primary care level (3/16).

Faculty readiness and knowledge of the program

· Lack of acceptance by the faculty at large for the change (12%).

· Not sure of the abbreviation and concept of COME (3/16 administrators).

· Some faculty members did not know what the abbreviation COME stood for (8%).

· COME means taking students to the community by the department of community Medicine (6/16 administrators).

· We are ready to take the students to the community for learning (64%).