We want you to enjoy this booklet and we want you to find it interesting, helpful and a stimulus to your work, so that you can help others who are engaged in health care to enjoy their work. This then will make it probable that, amidst all the great changes that are happening in health care and in disease and its treatment, you and your health team, or if you are a teacher, your students, will be better equipped to meet the challenges of your work. Health care systems are changing but also the way teachers teach and students learn. We will give a small overview of these changes abd than answer the question why Problem Based Learning is a promising educational method to meet he new challenges in work.

The changing pattern of disease

Some old diseases are much less important than they used to. An example is guinea worm which used to disable so many fit and strong farmers, but, now that the world wide campaign to obliterate this crippling infection has begun to be effective, whole communities are free of the worm. The campaign against yaws has removed this disease from those that are widespread in the tropics, so that is now only a minor occasional problem. Similarly, the obliteration of small pox is a triumph of preventive medicine.

In countries where the Expanded Programme of Immunisation has been successful, and is systematically being maintained, measles and pertussis are now rare so that the infant and under 5's mortality rates have been sharply reduced. And even where malaria continues to kill infants and young children, the introduction of bed nets impregnated with permethrin has had a dramatic effect on mortality. Nor is the improvement on children's health solely due to creating a barrage against malarial infection by the net, or preventing others with the appropriate vaccine: potentially one of the greatest advances has been the discovery that Vitamin A can significantly reduce the deaths and disease among children if it is given routinely to all children. New and more effective remedies have been developed against helminths of the gut, parasites which have so undermined the health of whole communities that they could not do a day on the farm. Blinding diseases have been tackled too: teams of health workers, specially trained to deal with cataract, have given sight to thousands and thousands wait for this sight-saving surgery. There is now effective treatment against trachoma, if it is given before this disabling and blinding disease is not to far advanced.

These are some of the advances, and yet all those who read this will know only too well how depressing the burden of sickness and ill health can be where they work. Where the women are hidden away during pregnancy and do not receive adequate antenatal care, mothers and babies die and mothers may be left with appalling childbirth injuries. In the hospitals on the main roads, the needless injuries due to motor vehicle accidents, and the permanent disabilities that follow, could have been prevented. Chloroquine resistance has reduced the commonest drug for treatment of malaria to a spectator in the battle against malaria.

Structural adjustment and health

The World Bank has made its demands on countries that were and may still be terribly in debt. They are told to cut the cost of health care and to charge the sick for admission to the hospital, for drugs, for dressings, and for the materials necessary for basic health procedures. The burden of this falls on the poor who are unable to go to the hospital and are unable to consider the level of charges demanded. Women fail to get antenatal care, while for others there is no money for attendance when their disease is early-so the delay brings its own complications. These are the realities and, if there is not enough for the poor to endure, there is the growing resurgence of tuberculosis; this ancient killer now kills almost six people every minute and is the leading cause of death in those who are infected with the HIV virus. No mention of disease can be complete without time to pause and consider this ancient and now again this resurgent killer. No programme of health care can fail to take account, now, of the sexually transmitted diseases. The health care worker should not be totally gloomy, however: there is evidence that, if other sexually transmitted diseases are treated, the incidence-that is the reporting of new cases-of HIV infection is cut by half. There are powerful drugs to treat tuberculosis, but is there an adequate health system to deliver them? Knowledge may be not matched by the administrative infrastructure.

The Changing Demography

The great advances in immunisation and the rise in relative prosperity in many countries have meant that more children have survived the rigours and disease of infancy and childhood. Perhaps fifty percent of the population is under the age of twenty years. But, just as more of the young have survived, so too have the adults live longer. A generation ago the life expectancy in may of the poorer countries was much less than fifty years, now it over sixty in some of these countries so that the demands on the health service are increasing.

The educational background.

This then is the health care background of this booklet. But what of the educational background? What have been the changes in the approach to education for those who work in health care? Has there been any attempt to change the methods of the past? Have those who teach been prepared to adapt their methods to the challenges of new problems in health care? Have any new ideas been introduced which can make students enjoy their learning and make learning more effective?
The answer is Yes! New methods, or rather new understanding of what has always been the preferred method of helping a student to learn, have gripped those who are responsible for teaching.

Training workers for health care has to prepare them for the challenges of the new problems they will meet. Those who were trained fifteen years ago did not even hear of AIDS in the developing countries and yet now this disease is spreading more vigorously there and is causing an incalculable burden of disease. This will confront their health services soon. Traditionally, most teaching for health care has been didactic-that is the teacher stands up in front of the class and the students write down every word. But, if there are such great changes, it is enough therefore to rehearse the old facts to such students? Surely it would be better to equip them with the ability to think for themselves so that they are ready to confront the usual and the unexpected?

This is the reason behind this booklet: it is not a theoretical treatise: it is written so that health workers, you-the readers-can be ready to meet the changing patterns of disease and can be ready for the unexpected in the old diseases that you will be called on to treat.

It is written so that you can learn to learn without the help of a teacher at your side and so that you can learn to think, rather than merely to repeat a lot of things that you were told and were forced to remember.

We do not want the readers to be put off by the term Problem Based Learning (PBL); this is a technical term. We would prefer that you thought of the reason for the method that this booklet discusses. The term is one thing, the reason and the result for the work of the health worker and the enjoyment of that work is something quite different and so much more important. Besides, the concept of PBL in medicine is neither new or unique. It has its roots in old teaching methods in which teachers know how to raise good questions and insight in how doctors and other health personnel solve problems. In the booklet you will find many examples of these. Medical schools are finding that their students enjoy this method and, later, when they are active in practice, we hope that these students are better able to take responsibility for their own learning. They do not depend on their teachers any more. They have learned to be life long learners. Now you will agree that, in such a time of change in disease and method of care, it is essential for the health worker to be able to learn again and again, new things upon new things. The method prepares the worker for the field: for the city: for the problem that has never been met before: and equips the health worker to be a life long learner.

It is because we found during training's courses that PBL is popular and valuable for trainers in leprosy and tuberculosis , that we have written this booklet. We hope it will be a help for the life long learning process of the trainees as well, if they mastered the self guided learning techniques.

How to read the booklet?

This booklet contains of two parts; Part I and Part II.
Part I, the most important one describes the PBL method. First of all the different steps are illustrated, that are needed to work through a problem in order to get a better understanding of the problem. A small paragraph is spend to the small learning group. The self guided learning takes place in libraries, but the gained knowledge and insights must be shared with other students during small group sessions as well. The students recieve feedback on these study results, of other students and the tutor. The role of the tutor is of extreme importance. The role of the tutor is not longer "sage at the stage" but much more "guide by the side". A tutor must help the student to become an independent learner.
Becoming an independent learner is a difficult proces, that must be developed step by step. In part I all kind of techniques are discussed to help the tutor to facilitate or strengthen the learning of good study skills. Using these techniques will help the students to enjoy their learning more fully and get better results in their understanding.
Since PBL is different from the traditional learning approach, not every health worker is convinced of the benefits of the new method of PBL. Its implementation is rather difficult in courses that were successful in the past. Therefor we highlight some reasons for the conversion to PBL, how to deal with resistance to change and how to help the tutors in their training to become good facilitators.

Part II, on Assessment and Evaluation, is not related directly to the PBL method. However, we like to spend paragraphs to these subjects. If Health workers like to use PBL in their courses, these courses must also be effective. Good assessment procedures and evaluation are prerequisites to show that PBL is worthwhile for reaching the goals. We hope trainers will benefit from these chapters in order to get new programmes on their feet and are able to improve the programmes if weaknesses are found.