Original Scientific Articles

Medical Education

National Training Program for Comprehensive

Community Physicians, Venezuela
Eugenio Radamés Borroto Cruz, MD, DrSc, MS, Ramón Syr Salas Perea, MD, MS

ABSTRACT tors and who receive postgraduate training in medical education. This
Introduction Through the 1990s, wide disparities in health status “university without walls” has accredited 5,131 Barrio Adentro clinics
were recorded in Venezuela, a mirror of poor social conditions, de- as teaching institutions; its infrastructure includes other health care
creasing investment in the public health sector and a health workforce delivery facilities plus 855 multipurpose classrooms throughout the
distribution unable to meet population health needs or to staff effec- country. For the 2006-2007 academic year, the pass rate was 82% for
tive, accessible public health services. Venezuelans’ health status first-year students and 94% for second-year students. Some difficul-
deteriorated as a result. In 2003-2004, the Venezuelan government ties persist in student selection, pre-medical preparation, and achiev-
launched Barrio Adentro, a new national public health model aimed ing optimum use of existing resources. Academic, institutional, and
at assuring primary health care coverage for the entire population of external evaluations are ongoing.
an estimated 26 million. Cuban physicians staff Barrio Adentro clinics,
mainly in poor neighborhoods, until enough Venezuelan physicians Conclusion This is the most ambitious example of scaling up of phy-
can be trained to fill the posts. sician training in a single country. The program has been made pos-
sible by considerable political will from the Venezuelan and Cuban
Intervention Cuban experience with community-oriented medical ed- governments; by the experience acquired through development of the
ucation and global health cooperation was drawn upon to develop cur- Cuban health system and medical education programs; by the indi-
riculum and provide faculty for the new National Training Program for vidual commitment of Cuban curriculum developers and physician-
Comprehensive Community Physicians, begun in 2005 in cooperation tutors; and by ever-more-organized Venezuelan communities. The
with six Venezuelan universities. The program differs from previous size of the undertaking, coupled with significant innovations in curricu-
Venezuelan medical education models by adopting a stated goal of lum, present challenges. The Venezuelan experience — emphasis on
training physicians for public service, recruiting students who had no training physicians for a revitalized public health sector, accompanied
previous opportunity for university-level education, and concentrating by a paradigm shift in primary care — warrants attention from the
the weight of their training on a service- and community-based model international community in the context of the global shortage of health
of education, relying on practicing physician-tutors. workers and efforts to achieve a more equitable distribution of health
services worldwide.
Results Over 20,000 students have been enrolled in three years. The
six-year program has been extended to all 24 Venezuelan states, re- Keywords: medical education, human resources for health, community-
lying mainly on Cuban faculty who are practicing Barrio Adentro doc- based medical education, primary care, health equity, Venezuela

INTRODUCTION decentralized and participatory public health system with full gov-
Health Status, Poverty and Human Resources for Health in ernment financing.[4]
Venezuela: Through the 1990s, wide disparities in health status
were recorded in Venezuela, a mirror of poor social conditions, However, Venezuela lacked sufficient qualified human resources
decreasing investment in the public health sector, and a health to fulfill this objective, a reflection of the crisis in human resourc-
workforce distribution that failed to meet population health needs es for health worldwide, especially in developing countries.[5] In
or to staff effective, accessible public health services. From 1980 to 1999, 55% of physicians worked in the five states (out of 24) with
2000, five new patient care facilities were built in the public health the highest per capita income in the country.[1] Approximately half
sector, compared to 400 private clinics constructed during the the country’s 30,000-35,000 employed physicians were working
same period. From 1970 to 1996, government funding for health exclusively in the private sector, while the other half were em-
decreased from 13.3% of the national budget to 7.89%, the latter ployed part- to full-time in the public sector. Only 4,000 physicians
representing just 1.73% of the gross domestic product.[1] In this were practicing in primary care. In the 1990s, Venezuela graduat-
context, public health institutions offered limited services and did ed 1,200-1,500 new doctors annually, with 40-50% directly enter-
not attempt broad coverage.[2] As a report from the Pan American ing the private sector, and approximately 10% leaving the country
Health Organization (PAHO) concludes: “Throughout the 1990s, to practice elsewhere. By 2004, it was estimated that the country
the capability of the public health network to provide health ser- needed 20,000-30,000 new physicians for public service if it was
vices and resolve health problems became critically insufficient.”[1] to aspire to universal coverage.[6]
Venezuelans’ health status deteriorated as a result: in 1999, over
four million children and adolescents suffered malnutrition, 1.2 mil- Barrio Adentro, International Cooperation and Community
lion aged 7-14 years had severe malnutrition; 48.9% of the popula- Health: In 2002, when a national strike by the Venezuelan Medi-
tion was living in poverty.[3] cal Federation shut down most public outpatient and hospital ser-
vices, the mayor of Caracas’ Libertador municipality tried to recruit
That same year, the new Venezuelan Constitution redefined health physicians for a new program to provide vital medical services in
care as a fundamental right of citizens and a responsibility of gov- poor neighborhoods, the barrios. Only 50 doctors responded, and
ernment, and mandated establishment of a universal, integrated, of those, 30 refused posts that would locate them within the bar-

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Original Scientific Articles

rios.[7] An appeal to the Cuban Embassy in 2003 produced the By 2006, an estimated 73% of the Venezuelan population was
first Technical Cooperation Agreement in Health between Vene- covered by Barrio Adentro services. From 2004 to 2005, 150.5
zuela and Cuba, providing Cuban physicians to work in these un- million patient visits were carried out through Barrio Adentro,
derserved neighborhoods and to help develop the Barrio Adentro nearly four times the number recorded by traditional outpatient
(“inside the neighborhood”) plan, in consultation with government services; 40% of these were home visits. Detection of major
authorities and local community representatives. childhood killers such as diarrhea and pneumonia nearly dou-
bled in the same period, while deaths from these conditions
In 2004, the Venezuelan government announced ten policy strate- substantially decreased. According to a PAHO study, Barrio
gies aimed at eliminating social inequities, poverty and exclusion, Adentro has had significant impact on health care throughout
including one for increasing the efficiency of a comprehensive, Venezuela by increasing access and making service delivery
integrated public health system. In this context, Barrio Adentro more equitable.[8]
was extended throughout the country with the main objective of
assuring primary health care coverage for the population of an Drawing from the Cuban Experience in Medical Training: In
estimated 26 million.[1,8] addition to insufficient numbers and problems with motivation
and maldistribution, the medical profession in Venezuela was
Barrio Adentro is based on the principles of the 1978 Alma-Ata fraught with many difficulties common to other countries, which
Declaration,[9] which established the universal right to health became more evident as authorities attempted to address popu-
as a global goal and emphasized the fundamental role of pri- lation health issues and increase equitable service coverage.[5]
mary health care in adequately and equitably meeting popula- In particular, physicians were trained in a curative model of medi-
tion health needs.[10-12] These tenets were reaffirmed in the cine that paid little attention to prevention, the needs of the public
2007 Buenos Aires Declaration issued at a 60-nation World health sector, or the population’s health in general. Students were
Health Organization conference reassessing Alma-Ata.[13] Ar- traditionally drawn from private high schools, and their medical
ticulated as a public health strategy, Barrio Adentro is designed training was primarily classroom-based with some hospital rota-
to transform the public health system from a fragmented, inad- tions. They spent little or no time in poor communities, and de-
equate, underfunded, and inaccessible model into a universal,
veloping a sense of social responsibility was not an objective of
community-based, fully funded model of services providing pre-
the curriculum. This approach coincided with a highly privatized
ventive, curative, and rehabilitative care to individuals, families,
health care system that catered to the concerns of individual
and communities.
patients.[2,14] In short, social accountability of medical schools
Each Barrio Adentro clinic is staffed by at least one physician and was not a working principle.[15]
one nurse, and serves 250-350 families in a specific geographic
area (Community Health Area). These doctor-nurse teams see The situation in Cuba before1959 had been similar, but since
patients at the clinic, make home visits, and cooperate with local the early 1960s, a series of medical education reforms were
Health Committees to organize health promotion activities. Clinic aimed at meeting the needs of what had become a single, uni-
physicians may refer patients to a local Comprehensive Medical versal public health system offering primary, secondary and
Diagnostic Center (CMDC) furnished with essential diagnostic tertiary services free of charge.[16] An early exodus of half its
equipment, laboratories, and treatment facilities; a Comprehen- doctors left Cuba with a scant 3,000 in 1967;[17] but by 2007,
sive Rehabilitation Center (CRC) for physical therapy; a regional 72,416 physicians were registered in the country of 11.2 million
High-Tech Medical Center (HTMC) for more complex diagnostic people.[18]
testing and treatment; and to optometry or dental offices (Figure
1). All Barrio Adentro services are free of charge. Over the decades, Cuban medical students were placed in com-
munity settings during a successively greater proportion of their
Figure 1: Barrio Adentro Infrastructure, 2008 six-year training; the biopsychosocial approach melded basic,
clinical and population health sciences; health promotion be-
• Organized in 335 municipalities and 591 Community Health
came part of the core curriculum; essential competencies were
Areas in all 24 states
• Barrio Adentro Clinics: 6,531 determined on the basis of the country’s priority health prob-
• Comprehensive Medical Diagnostic Centers (CMDC): 420; 106 lems; and humanistic values were emphasized. These transfor-
with surgical facilities mations were underpinned by considerable political will on the
• Comprehensive Rehabilitation Centers (CRC): 502 part of the country’s leadership and a constitutional mandate of
• High-Tech Medical Centers (HTMC): 18 the right to health care.[19-22]
• Optometry offices: 459
• Dental offices: 1,628, with 3,019 dental chairs
• Physicians: 14,000, mainly primary care specialists*
In the 1980s, with the national introduction of the family medi-
• Dentists: 2,900* cine model (a physician-nurse team in every neighborhood),
• University-level nurses: 2,500* Cuban medical students began initiating contact with patients
• Technical-level nurses: 1,658* and communities from their first year of training.[16,23-25] By
• Laboratory, imaging, ophthalmology, and rehabilitation the 1990s, virtually all new medical graduates were required
technicians, etc.: 7,500* to complete a Comprehensive General Medicine (family medi-
cine) residency before opting for a second specialty, as primary
*All personnel listed in Figure 1 are Cuban; additional Venezuelan personnel also care became the backbone of training. This integrated health
participate in the program.
Source: Misión Barrio Adentro. Statistical Report. Caracas: Informática de la system model grounded in primary care was put to the test dur-
Misión Médica Cubana (IMIMEC); 2008. ing Cuba’s economic crisis of the 1990s. It is one of the factors

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 Original Scientific Articles

credited with maintaining, and in some cases improving, critical The National Commission was charged with addressing all major
health indicators under such adverse circumstances, and it is the aspects of the new program:
model adapted for the Cuban contribution to Venezuela’s Barrio
Adentro program.[26,27] By 2007, Cuban indicators were among 1. Goals, principles and general design
the best in the hemisphere, with infant mortality at 5.3 per 1,000 2. Institutionalization and organization
live births and life expectancy at 77 years.[18] Equitable access (Barrio Adentro University)
to health care as a social right and efficient use of resources 3. Student selection and support
are recognized as positive features of the Cuban health system. 4. Curriculum design and competencies
[26,28,29] 5. Faculty preparation
6. Evaluation
In addition to training a workforce for domestic health care delivery,
Cuba has made international service a cornerstone of its medical Goals, principles and general design: The program’s goal is
profession for the last 45 years: since 1963, over 130,000 Cuban to educate and train an adequate number of physicians with the
health professionals have volunteered abroad.[30] In June, 2008, competencies and commitment required to guarantee full primary
care coverage of Venezuela’s population through Barrio Adentro,
36,770 were serving in 70 countries.[31] Such global health coop-
and provide a pool of graduates for other specialties and respon-
eration has provided further experience in human resource train-
sibilities required by the country’s public health system. In this
ing: from 1961 to 2007, the country’s medical schools graduated
context, the objective — to paraphrase the World Health Organi-
8,572 physicians from other countries, nearly all from Latin Amer-
zation (WHO) — is to get the right doctors with the right skills in
ica, the Caribbean and Africa. In 2008, 24,848 students from 108
the right place doing the right things to generate improvements in
countries were studying medicine in Cuba in the Latin American
health status and equity.[34]
Medical School and other programs.[32]
The principles of the program parallel those of the Cuban family
Through bilateral accords, Cuban doctors and educators have doctor system. The NTPCCP aims to graduate community-based
also participated in establishing ten medical schools across the physicians with a solid scientific foundation and the necessary
globe in Yemen, Guyana, Ethiopia, Guinea Bissau, Uganda, clinical competencies to provide comprehensive medical care
Ghana, Gambia, Equatorial Guinea, Haiti and, most recently, through health promotion; disease prevention; treatment and re-
Venezuela.[33] habilitation of individuals, families, communities; and to preserve
and improve the environment. Their training also motivates and
In Venezuela by 2008, 14,000 Cuban physicians were staff- empowers these physicians to work with community residents
ing Barrio Adentro clinics, accompanied mainly by Venezuelan and to resolve an important and particular set of health problems
nurses, although a number of Cuban nurses and allied health at the primary level in a medical practice infused with humanistic
professionals also participate in the program (Figure 1). Cuban values, responsibility, and social commitment.[35,36]
personnel and Barrio Adentro facilities have become essential
to assuring the sustainability of the Venezuelan public health The main setting for implementation of the six-year curriculum is
system as they provide infrastructure for training the healthcare the community itself – through academically accredited Barrio Ad-
workforce, particularly physicians. entro clinics, community-based multipurpose classrooms, and other
Barrio Adentro facilities. Faculty in this “university without walls” are
The objective of this article is to characterize the development Cuban physicians participating in Barrio Adentro who receive peda-
and present preliminary results of the National Training Program gogical training and academic accreditation for their teaching role,
for Comprehensive Community Physicians in Venezuela. and are supported by investments in textbooks, classroom models,
and digital teaching aids. Students are high school graduates, many
INTERVENTION from the communities where they will eventually practice.
In early 2005, Venezuelan authorities launched the National
Training Program for Comprehensive Community Physicians Institutionalization and organization (Barrio Adentro Univer-
(NTPCCP). Over 20,000 students are currently enrolled. The sity): Planning, organization, leadership, monitoring, control and
NTPCCP differs from previous Venezuelan medical education evaluation of the NTPCCP is the responsibility of the National
Commission, which integrates the perspectives and activities of
models by explicitly aiming to train physicians for public ser-
the Cuban-led Barrio Adentro National Academic Coordinating
vice, recruiting students who had no previous opportunity for
Committee and the participating Venezuelan universities, effec-
university-level education, and concentrating their training on a
tively constituting Barrio Adentro University. In each state, the
service- and community-based model of education, relying on
National Commission is supported by Bolivarian Advisory Com-
practicing physician-tutors.
missions in Health (BACH), which coordinate the leadership, im-
plementation and development of the program in their respective
Venezuela’s Ministry of Higher Education (MHE) established territories. Each BACH includes representatives of the Ministry of
a National Commission to develop and oversee the NTPCCP, Higher Education, Ministry of Health, Barrio Adentro’s state-level
chaired by the Vice Rector of the Colegio Universitario Fran- coordinating committee, and the Venezuelan university associ-
cisco de Miranda. The commission includes members from the ated with the NTPCCP in the state, as well as representatives
MHE, its Office of University Sector Planning, the Ministry of from local communities. This organizational pattern is mirrored
Health and six Venezuelan universities, plus a team of six Cu- at the municipal level. The NTPCCP of Barrio Adentro University
ban medical educators from Barrio Adentro experienced in cur- has been officially accredited by the Bolivarian Republic of Ven-
riculum development. ezuela’s National Council of Universities.[37]

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Original Scientific Articles

Student selection and support: Through the 1990s, admis- Figure 2: Essential Elements in the NTPCCP Curricular
sion to Venezuelan universities was limited. Most slots were Design
filled by graduates of private high schools, leaving over half
a million public high school graduates excluded from access • Ensure focus on medicine that is humanistic, holistic and
to higher education.[14] In recent years, however, the govern- biopsychosocial.
ment has instituted several programs to address this social • Integrate medical care and education, with primary health care
debt by providing free education at various levels, including as the foundation.
the NTPCCP.[38] • Identify Barrio Adentro clinics as the main settings for learning,
progressively incorporating other institutions and patient care
facilities.
In April 2005, the Ministry of Higher Education issued a first call • Link students with family and community medicine from their
in the mass media for applicants to the NTPCCP and received first year of training.
over 35,000 responses.[36] Applications were reviewed by • Develop moral, ethical, civic, and professional values.
local, state, and national admissions committees. Applicants • Educate and train by objectives.
were interviewed by a representative from the Sucre Mission • Integrate content of basic biomedical and sociomedical
(a Venezuelan program promoting access to higher education) sciences horizontally and vertically.
and a Cuban physician to ascertain motivation and to provide • Link theory and practice, integrating clinical and basic sciences
applicants with details of the program: full-time nature, dura- in curricular units based on main health problems identified.
• Implement a teaching strategy that integrates orientation of
tion, modalities of study, etc. Each applicant was required to
learning activities, consolidation of knowledge and skills, and
present a written recommendation from the Community Health evaluation of learning results.
Committee in their locale and to sign an affidavit confirming • Develop new roles for students and teachers: students as
their commitment to practice in communities-in-need upon active agents, builders of their learning process; teachers as
graduation. orienters, guides and tutors in the process.
• Structure an evaluation system that integrates academic and
As a result, 24,000 students were admitted into a four-month licensing evaluations.
premedical bridging course. Some 16,000 students success- • Organize systematic curricular evaluation, using action
fully completed this course and began their medical studies in research methodology, to identify and adjust problem areas;
October, 2005.[36] A monthly stipend of 200,000 bolivares was progressively evaluate program impact.
• Ensure effective bridging and updating of knowledge in the
provided (minimum monthly wage in 2006 was 465,000). This is
basic sciences, Spanish language, and study skills through the
especially important given the large percentage of students from premedical course.
low-income families, marginalized indigenous populations, and
poor rural areas.[38,39]
creative problem-solving and decision-making; social interaction;
Curriculum design and competencies: The Barrio Adentro teamwork; and legal responsibility.
National Academic Coordinating Committee developed the
NTPCCP curriculum. They drew fundamentally on the curriculum Patient care: approach to individual and collective health prob-
formulated by Ilizástigui et al.[23,24] in Cuba in the 1980s, based lems using clinical and epidemiological methods; health promo-
on the social mandate of medical schools to contribute to the tion and disease prevention; diagnosis; therapeutic and rehabili-
promotion, conservation and restoration of population health,[16] tation management; environmental health.
which, in turn, determines the type of professionals to be trained,
the health problems they should be capable of diagnosing and Educational: didactic, methodological, technological competen-
treating, the professional competencies required, and the edu- cies; social education; continuous independent study.
cational objectives guiding the process. The Committee also re-
viewed international literature on the vision, role and curricular Administration and management: social participation; adminis-
design of medical education for the twenty-first century,[5,10,40- trative - planning, organization, management and control; self-
44] plus the Venezuelan and Cuban experiences and two key in- evaluation.
ternational documents: Global Standards for Basic Medical Edu-
cation of the World Federation for Medical Education[45] and the Some 60 Cuban medical school professors with considerable ex-
Global Minimum Essential Requirements in Medical Education of perience in various disciplines of biomedical and sociomedical
the Institute for International Medical Education.[46] sciences designed the curricular units and academic calendars.
A six-year curriculum was developed (Figure 3).
As a result, the essential elements listed in Figure 2 were identi-
fied for the NTPCCP curriculum. The discipline of Human Morphophysiology takes an inter- and
transdisciplinary approach, integrating basic biomedical sciences
The curriculum design also took into consideration 205 main such as human anatomy, normal histology, embryology, normal
health problems identified in Venezuela and the competencies and pathologic physiology, cellular and molecular biology, genet-
required of community physicians to address them, given ade- ics and immunology (Morphophysiology I, II, III in first year and IV
quate mandate and appropriate resources. This process yielded in second year). Morphophysiopathology (I and II in second year)
an analysis of necessary core competencies, developed in the takes a transdisciplinary approach to basic sciences related to
following areas: clinical practice: clinical laboratory, imaging, parasitology, micro-
biology, anatomic pathology, genetics, and immunology, as well
General: communication; professional, ethical, moral and civic at- as the main immune, hemodynamic, genetic and neoplasic patho-
titudes; information analysis and interpretation; independent and logical processes.

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Figure 3: Curricular Units of the National Training Program for Comprehensive Community Physicians (NTPCCP), Venezuela*

Period Units
Community Health and Medicine I
Year One Human Morphophysiology Intro to social sciences, Intro to primary health
care (PHC), social communication
1 (16 weeks) Human Morphophysiology I
2 (13 weeks) Human Morphophysiology II Civics
3 (14 weeks) Human Morphophysiology III Introduction to Community Health & Medicine
Primary Health Care:
4 (2 weeks)
Basic Procedures
Community Health and Medicine II
PHC, social & sociomedical sciences, public
Year Two Human Morphophysiology health, history of health, epidemiology &
hygiene, research, community intervention,
community health analysis
1 (14 weeks) Human Morphophysiology IV Family and Community Health (FCH) I
2 (13 weeks) Medical Information Technology I Social Psychology of Health and Illness

Human Morphophysiopathology I, II Medical Information Technology II

3 (16 weeks) FCH II
Intro to Latin American
Political Thought
Community Health and Medicine III
Year Three Clinical Medicine Same themes as Year Two, plus medical
ethics
1 (12 weeks) Clinical Medicine I
FCH III
2 (10 weeks) Clinical Medicine II Pharmacology I
3 (11 weeks) Clinical Medicine III Pharmacology II
FCH IV
4 (10 weeks) Clinical Medicine IV Psychology of Health Care

Community Health and Medicine IV

Normal growth & development, family health,
Year Four Clinical Medicine care of oncology patients, community health
analysis, community rehabilitation, special
environments
1(10 weeks) Pediatrics I: Comprehensive Care
FCH V
2 (13 weeks) Pediatrics II: Comprehensive Care
3 (10 weeks) Psychiatry
FCH VI
4 (10 weeks) Obstetrics & Gynecology I: Comprehensive Care

Community Health and Medicine V

Public health, PHC administration, disaster
Year Five Clinical Medicine
medicine, forensics, toxicology, research,
natural & traditional medicine
1 (10 weeks) General Surgery
2 (8 weeks) Orthopedics, Traumatology & Rehabilitation FCH VII
3 (5 weeks) Pediatrics III: Hospital Care
4 (5 weeks) Obstetrics & Gynecology II: Hospital Care
5 (16 Urology Dermatology FCH VIII
weeks)** Otolaryngology Ophthalmology

Comprehensive Community Medicine

Year Six Internship Year
Rotations
1 (12 weeks) Adult Care
2 (12 weeks) Children’s Care
3 (12 weeks) Care of Women and Pregnancy
4 (9 weeks) Surgical Care

*Does not include elective periods.

**In rotations of four weeks each.
Source: Diaz, P. Barrio Adentro National Academic Coordinating Committee, August 2008.

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Original Scientific Articles

The socio-medical sciences are also taught beginning in the first 2. Institutional evaluation through: a) visits to academic settings by
year, in the discipline of Community Health and Medicine. Medi- methodology advisors with ten or more years experience in medical
cal Information Technology covers data collection, treatment and education, and who participated in NTPCCP curriculum develop-
reporting, as well as essential elements of descriptive and health ment; b) continuing medical education for faculty, including evalu-
statistics. Introduction to Latin American Political Thought pro- ation; and c) academic and attendance assessments of students in
vides context for medical education and practice. From the third their fourth, eighth and eleventh weeks of various courses.
year through internship, the program is structured in two broad
areas: 1) Ambulatory patient care in the Community Health Area; 3. External evaluation consisting of pedagogical research projects
and 2) Inpatient care. by curriculum designers, applying evaluation instruments to
50% of students and 70% of faculty to assess quality of curricu-
This approach relies on problem-based individual and group lum application and satisfaction. These include surprise exams
learning, guiding students through themes (orientation, con- and visits to academic settings and document archives.[48]
solidation, and evaluation of knowledge and skills gained)
along a continuum from simulation towards real practice situ- PRELIMINARY RESULTS
ations. A typical academic week for students through the third A new paradigm of medical education has been introduced
year combines time in the multi-purpose classroom (together in Venezuela to train comprehensive community physicians
with students and faculty from the surrounding Community capable of addressing the majority of the population’s health
Health Area), the Barrio Adentro clinic, and the community it- problems at the primary care level. Barrio Adentro University’s
self (Figure 4). National Training Program for Comprehensive Community Phy-
sicians is underway in all 24 states of the country, with a May
Faculty preparation: The 60 professors mentioned above also
2008 enrollment of 21,902 students: 5,118 in first year; 6,209
developed a national plan to adequately prepare faculty selected
in second year; 10,575 in third year; and approximately 5,000
from Cuban specialists (primarily in family medicine) working in
in the pre-medical course. For the 2006-2007 academic year,
Barrio Adentro, which contemplates three aspects:
the pass rate was 82% for first-year students and 94% for sec-
1. Individual study of the biomedical, clinical, and sociomedical ond-year students. A total of 4,503 students (26% of initial en-
content of each year of the medical education program.[47] rollment) have dropped out of the program since its inception,
mainly due to poor academic performance.
2. Basic preparation in medical education and pedagogy, through
two certificate courses and subsequent master’s program. A total of 6,715 faculty — primary care specialists who also staff
Barrio Adentro clinics — teach in the program; 4,602 (68.5%) of
3. Systematic methodological study to develop specific teaching them have attained the academic rank of at least Instructor or As-
activities and evaluate faculty preparedness. sistant Professor, having met requirements established by Cuba’s
Ministry of Higher Education. An 18 to 24-month master’s program
The main Cuban academic directors of the NTPCCP at the mu- in medical education has been implemented through Cuba’s Na-
nicipal, state, and national level are also enrolled in the master’s tional School of Public Health; 126 faculty and program directors
program in medical education sponsored by Cuba’s National at various levels have obtained MS degrees.[49] Progressively
School of Public Health. more Venezuelan faculty have joined the program, although the
number is still relatively small.
Evaluation: NTPCCP curriculum evaluations include three basic
components: The state-level Bolivarian Advisory Commissions in Health
(BACH) have accredited 5,131 Barrio Adentro clinics as
1. Academic evaluation for each subject taught, including a glob- teaching institutions, according to norms that consider num-
al assessment of student performance, based on nationally ber and level of faculty, available physical infrastructure and
standardized theoretical and practical (clinical) final exams for- resources, audiovisual and digital teaching aids, and proxim-
mulated by the National Academic Coordinating Committee’s ity of one of the 855 multipurpose classrooms in the country.
team of experts. Systematic statistical control of academic re-
sults is maintained, and 30% of test papers for each exam Weekly visits to teaching sites by the Academic Committee’s
receive a second review. methodology group have been systematized for the purpose of

Figure 4: Typical Academic Week Years 1-3, National Training Program for Comprehensive Community Physicians (NTPCCP)
Session Monday Tuesday Wednesday Thursday Friday Saturday
CSBL, CSBL, CSBL, CSBL, CSBL, Faculty
Morning
BA Clinic BA Clinic BA Clinic BA Clinic BA Clinic Consultation, MC
Evaluation Activity Orientation Activity CSBL Consolidation of knowledge CSBL
Afternoon
(previous theme), MC (new theme), MC (in the community) (current them), MC (in the community)

Evening Independent Study

CSBL: community- and service-based learning.

BA Clinic: Barrio Adentro Clinic
MC: multipurpose classroom
Source: Diaz, P. Barrio Adentro National Academic Coordinating Committee, August 2008.

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supervision, control and orientation, as have semi-annual visits primary care focus and within a system based on a universal,
to each Community Health Area by a multidisciplinary team from equitable health service delivery model. Finally, the program has
the National Academic Coordinating Committee itself. Results rested on the integration of medical education into Barrio Adentro
are analyzed at the municipal, state and national level, the latter comprehensive public health services, and of the Barrio Adentro
by the NTPCCP National Commission. delivery model into the fabric of social programs in place in Ven-
ezuela today. No doubt such an array of factors must be present
An action research study by the National Academic Coordinating for this experience to be replicable in another setting.
Committee,[50] carried out in March-April 2008 in all 24 states,
involved 124 faculty teams from 108 Community Health Areas At the same time, the sheer size of the undertaking, coupled with
(18.4% of total), with participation by 100% of students and fac- innovations that have gone beyond reforms hitherto in place ei-
ulty present at the time of the researchers’ visit. As a result, 5,739 ther in Venezuela or Cuba, present significant challenges to the
persons were surveyed: 1,199 faculty (15% of total faculty); 2,552 program’s successful outcomes. These challenges include:
students (12%); and 1,988 community residents (1 per 10,000
population). A total of 3,871 persons participated in group inter- • student selection and retention, given the educational and
views (1,277 faculty and 2,594 students). economic obstacles faced by the mainly low-income, margin-
alized student population;
Results from the study corroborated existence of minimum es-
sential infrastructure to support the program, as well as consis- • use of family medicine specialists as teachers, which has re-
tent implementation of certificate courses and the master’s pro- quired an extra effort organizationally, academically and in-
gram for faculty and program directors. dividually, to assure assimilation and communication of new
pedagogical concepts (hence the early difficulty in integrating
Although the detailed methodology is not within the scope of this content);
paper, it should be noted that qualitative portions of results re-
vealed generalized student satisfaction, a ratified commitment to • the fact that Barrio Adentro itself is still being expanded and
practice in underserved communities, as well as positive NTPCCP articulated as part of the health system reform, reflected in un-
contribution to patient satisfaction. Difficulties were revealed in the even development in different places, changing infrastructure,
following areas: etc.; and

• All faculty did not achieve adequate integration of content in the • growing demands by communities and patients.
various subjects, as prescribed by the curricular guidelines.
The challenge of quality assurance is a permanent one, not only
• Student selection, and the quality and rigor of the pre-medical in traditional academic terms, but also with regard to formulat-
course, continued to be uneven and therefore problematic. ing relevant standards and instruments for measuring the new
program’s success against population health goals, as well as for
• Potential of the community- and service-based learning oppor- developing innovative tools to correct the course where neces-
tunities was not fully realized, and insufficient use was made of sary. The action research study in early 2008 offers one example
diagnostic equipment in Community Health Area institutions. of efforts in this direction.

DISCUSSION Any final measure of the program’s success — its impact on health
The NTPCCP constitutes the design, development, and imple- services and their accessibility, on the health status of the population,
mentation of the most ambitious scaling-up of education of doc- and on the graduates’ future commitment to a career in public ser-
tors for public service in a single country, based on a significant vice — is still several years away. Documentation and assessment
paradigm shift. This has been made possible by considerable po- at every stage are required to reveal the outcomes for Venezuela as
litical will on the part of the Venezuelan and Cuban governments, well as the program’s full range of lessons for other countries.
which have facilitated the necessary investments and human re-
sources; by the individual commitment of Cuban curriculum de- If the goal of “Health for All” is to be reclaimed, a more equitable distri-
velopers and physician-tutors; and by the ever-more-organized bution of health services and health professionals is essential. From
Venezuelan communities. this perspective, the Venezuelan experience — emphasis on training
physicians for a revitalized public health sector, accompanied by a
The program has also been made possible by four decades of paradigm shift in medical education and primary care — warrants
Cuban experience in medical education for public health with a particular attention from the international community.

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