Evolução da Política de Educação Médica em Cabo Verde

Resumo Cabo Verde e um dos Pequenos Estados Insulares em Desenvolvimento do mundo, com especificidades e desafios proprios. Independente ha 43 anos, com meio milhao de habitantes, a formacao dos seus medicos tem sido feita no exterior, incrementando a forca de trabalho do pais, mas nao o suficiente, em numero e diferenciacao, para sustentar os desafios da saude, nomeadamente a extensao da cobertura universal. Em 2015 as autoridades decidiram implantar a educacao medica local, tornando necessario reformular a Politica de Educacao Medica enquanto politica de educacao e de saude, envolvendo os varios atores, organizacoes e instituicoes. O objetivo deste artigo e analisar a percepcao de varios informantes-chave sobre a implantacao da educacao medica em Cabo Verde e propor subsidios a reformulacao da sua Politica de Educacao Medica. Um estudo qualitativo que resulta da analise de conteudo de entrevistas e discussoes em grupo, bem como de noticias na media cabo-verdiana, identificou elementos-chave da reformulacao de politicas em termos de conteudo, contexto, processos e principais atores envolvidos na reconsideracao do curso de medicina. Os entrevistados consideraram essencial ter uma politica de educacao medica envolvente que oriente o desenvolvimento do curso e identifique os principais impulsionadores de sua implementacao.


Abstract
Cabo Verde is one of the world's Small Island Developing States, with its own specificities and challenges. Independent 43 years ago, with half a million inhabitants, the education of its physicians has been done abroad, increasing the country's workforce but not enough in number and differentiation to support the challenges of health care, namely the extension of universal coverage. In 2015 the authorities decided to implement local medical education, making it necessary to reformulate the Medical Education Policy as an education and health policy involving the many actors, organizations, and institutions. The objective of this article is to analyze the perception of several key informants of the Cabo Verdean society about the medical education in the country and to propose means to reformulate its Policy of Medical Education. A qualitative study that results from the content analysis of interviews and group discussions, as well as news in the Cabo Verdean media, identified key elements of policy reformulation in terms of content, context, processes and main actors involved in the reconsideration of the medical course. Respondents considered essential to have an engaging medical education policy to guide the development of the course and identifies the key drivers for its implementation. Keywords: Cabo Verde; Medical Education; Doctors; Human Resources in Health.

Resumo
Cabo Verde é um dos Pequenos Estados Insulares em Desenvolvimento do mundo, com especificidades e desafios próprios. Independente há 43 anos, com meio milhão de habitantes, a formação dos seus médicos tem sido feita no exterior, incrementando a força de trabalho do país, mas não o suficiente, em número e diferenciação, para sustentar os desafios da saúde, nomeadamente a extensão da cobertura universal. Em 2015 as autoridades decidiram implantar a educação médica local, tornando necessário reformular a Política de Educação Médica enquanto política de educação e de saúde, envolvendo os vários atores, organizações e instituições. O objetivo deste artigo é analisar a percepção de vários informanteschave sobre a implantação da educação médica em Cabo Verde e propor subsídios à reformulação da sua Política de Educação Médica. Um estudo qualitativo que resulta da análise de conteúdo de entrevistas e discussões em grupo, bem como de notícias na media cabo-verdiana, identificou Introduction Cabo Verde (CV) -a small island country that became independent just over 40 years ago (in 1975), with half a million inhabitants scattered over nine islands and with a relatively large diaspora (Buchan;Connel;Rumsey, 2011) -has always provided the upper education of its technicians abroad, in countries that accepted their students with scholarships or, more recently, offered student positions under bilateral cooperation agreements. These specificities of Small Island Developing States (SIDS) have fueled the recurrent debate in vulnerable island countries (Briguglio, 2003;Negin;Martiniuk, 2012) about whether it is more worthwhile to invest locally in training health care human resources (HHR), particularly of doctors, or continue to educate them abroad.
The policy of higher education in CV was developed within the scope of an education reform. The creation of the Escola de Formação de Professores (School for Teacher Education) in 1979 was a milestone in the process of establishing higher education provision in the country and in the emergence of universities (Tolentino, 2007). The first institution to emerge was private in nature, Jean Piaget University (Uni-Piaget), in 2001, followed by the Public University of Cabo Verde (Uni-CV) in 2006. In 2014, there were 11 institutions of higher education in Cabo Verde, including universities (6), institutes (3) and schools (2).
The training of doctors followed the model of training abroad, and this was how the country increased its medical workforce. However, the results obtained in the area of HHR are insufficient in number and variety (Delgado, Tolentino;Ferrinho, 2017) to support the new health challenges, namely the aim of extending universal coverage (Campbell et al., 2013;Chan, 2008) to all the islands and places. As of 2015, the country's political and academic institutions began to reformulate the Medical Education Policy (MEP) and experiment with a model (complementary to the previous one) of domestic training, assisted by the Faculty of Medicine of the University of Coimbra (FMUC).
This decision aims to combine an increasing number of physicians with the improvement of specialized and continuous training, as well as with good working conditions and distribution of doctors throughout the country and advancing the management, the motivation and the satisfaction of these, as a means of increasing health services performance (Cabral et al., 2013). The measure also aims to bring to the country the side effects that such a measure has on professional practice and on the performance of health services and care.
The MEP (re)formulation, as an education and health policy, should be inserted in its own context, which involves several actors, organizations and institutions in designing and implementing measures that affect the health system as a whole, as suggested by Buse, Mays and Walt (2012). The objective of this article is to analyze the perception of several key informants of Cabo Verdean society regarding the implementation of medical education (ME) in CV and contribute to the reformulation of the MEP.

Materials and method
A qualitative study was conducted (Creswell, 2003;Yin, 2003) on the opinion of a sample of 52 key informants purposively chosen. Semi-structured questionnaires were applied (Annexes 1 and 2) in which the main issue common to all was: "There is a lot of talk about establishing a college/medical school in CV. What's your opinion? Is it necessary? Is it a priority? Is it viable?" Nineteen interviews Lakatos, 2003Lakatos, , 2012 were collected in 2014 with government members (GOV), former public officials with involvement in health and education (FOR), academic leaders (ACA), leaders of professional bodies (BOD) and managing health professionals (MAN) 1 , featured in Table 1.
Also in 2014, 18 physicians active in the public and private health sectors, at three levels of health care and in the three most populous islands (Table 2), participated in focus groups (FG) (Backes et al., 2011).
In early 2015 a focus group was held with five journalists from state-owned and private media at the three levels of health care and in the three most populous islands (Table 3).
Secondary data from interviews conducted in Praia in 2012 with practicing Cabo Verdean physicians working in the public sector, in the private sector or in both, as part of a survey on medical multi-employment in economy sectors of three African cities (Praia, Maputo and Bissau), performed by Russo et al. (2014), which are identified in Table 4.
Interview and FGs scripts were pretested in a purposive sample with personalities for interviews and physicians for focus groups (Table 5).
continues...      Responses to the interviews and discussions in FG were recorded with prior consent, transcribed and analyzed in their content (Hsieh;Shannon, 2005), according to a category grid for content analysis (Annex 3), to obtain the challenges to the implantation of local ME based on the opinions expressed by the institutions' representatives interviewed and the peer discussion in the FG.
An analysis of the content of articles published in the Cabo Verdean press between April 2010 and July 2016 was also carried out in order to identify the level of support and the arguments for the development of medical education in CV in the media and identify the most active actors in this debate (Bowen, 2009).
In this article we analyze the opinions expressed by the key informants, adopting as a logical framework the model proposed by Walt and Gilson (1994), called "health policy triangle", to subsidize an approach to the reformulation of MEP in CV, focused on the intended content of this policy, but also on the context, process and identified actors, which are the significant elements of the policies, which need to be considered in interconnection ( Figure 1).

Content Process
Actors:

Context
Source: Walt and Gilson, 1994 Given the relevance of an ME policy, we used an analysis of the public policy models suggested by some authors (Brooks, 2002, Souza et al., 2006Wiktorowicz;Deber, 1997) to better understand the expectations -both regarding government's decisions and the opinions of key informants -about the local ME model and its implementation and consolidation.

Results
The presentation of the results will follow the logical framework of the triangle of Walt and Gilson (1994), which forces us to adopt a synchronic look at the analysis of policy development, beginning with clarifying the content of the MEP in the arguments of the key informants. We will next address the context that led to the establishment of medical education in 2015 and the most important processes identified. Then, we will list the main actors involved in this process and the respective roles and measures taken by them to arrive at the results.

Content and results
The whole debate focused on the objective of developing a MEP that addresses the establishment of medical education in CV, complementary to the existing model of training abroad. This objective found a broad consensus among the key informants, who argued that the best response to the inadequacies of physicians seems to be the training of medical personnel in CV (FOR_E12) and that the medical school should be a public school (GOV_E5), based on the agreement that includes the government of Cabo Verde, the Government of Portugal and FMUC, in a shared responsibility to establish the medical school, seeking to form a doctor with ample capacities to work here or in another part of the world (MAN_E4), temporarily resorting to a logic of sandwich training [i.e. partly done abroad] (GOV_E9), domestically [offering] certain disciplines that do not require many technical-scientific resources (MAN_E3), followed by an intermediate phase in Coimbra, and the final part again in CV (ACA_E14) .
Thus, institutional developments should be available: a defined curriculum for the course; a defined physician profile; a guaranteed level of quality for the teachers recruited; approved regulations; [availability of] places for practical classes and teaching materials (MAN_E3); students selected according to predefined criteria; financial capacity of the country and the families to pay the monthly fees. There should also be a broad, consensual reflection on the meaning of the ME, [and] a training plan (GOV_E8); as well as [ensuring] course accreditation, stimulating and seeking financing, organizing, contacting the main actors of the system, having the support of the Ministry of Health and the Medical Association (ACA_E10).

Context
The key informants referred to elements of the context that condition the process, namely: specific conditions of the country; the need to affirm national sovereignty; strengthening citizens' rights; perception of the necessity and priority of medical education in CV; perception of available or mobilizable means; feasibility of different options; political will; and the situation of secondary education. We will address some of these issues in more detail.

National sovereignty, development and the right to health care
The need to establish a ME in the country (MAN_E7; FOR_22) faced, in the early years of independence, the challenge of a small market that could later lead to unemployment, but also there were no human resources, equipment, teaching hospital and no partnership with a foreign college with the capacity to support us -a significant number of doctors in CV (GOV_E8). But CV cannot contemplate not having a medical course (MAN_E3), based on the sovereign assumption of the country's responsibility of training its cadres, and the local medical education should be framed within the country's strategic development plan (GOV_E9), because there is a need to accelerate the process of modernizing the entire national health system (FOR_E22). The development success that we have at the moment is due in large part to this attention to health and education (GOV_E5), and a ME can help to systematize the extraordinary practice and school that was created in forty years of independence, CV could be an example of health care provision using basic means, which are primary care, population mobilization, [and] the health perspective [present] in all policies (GOV_E8).
A medical and higher education institution will support more advanced steps in both education and in ensuring the right to health (FOR_E1). This effort is also made in order to qualify a Cabo Verdean labor force for employability in general, here and abroad; we are in a position to take a new leap in the overall functioning of the health system, but the training pillar did not function completely -we lacked physicians (FOR_E22).

The need to establish medical education
All key informants and participants in FG discussions (doctors and journalists) advocated the establishment of a local ME, arguing that it would help increase the number of doctors, acquire a greater internal capacity to think about the practice of the medical profession, establish an interaction between the academy, hospitals and health centers where medicine is practiced, but [it would] also constitute the base for other important components such as research, articulation between the health care system and the training and research systems, access to databases, a strategy for permanent scientific updating, continuing education or postgraduate training. (GOV_E9) Additionally, there is a need for strengthening the mission of universities as a source of knowledge, learning and excellence (FOR_E2). Besides being necessary, it is urgent -based on a decision on the matter, due to the well known fact of the country's deficit of professionals in the health sector at all levels and in all branches -to ensure a qualitative leap forward with the creation of the medical school (GOV_E11).
Some informants argue for a certain caution in its implementation because we have been training our medical staff abroad in several countries, and nothing tells us that suddenly starting to train doctors in CV will be more efficient or safer (FOR_E12), recognizing that there is many factors involved; we have to know what to do to adjust medical education in CV, starting with secondary education, which is not functioning as it should, to certain determinants that would lead us to give a concrete objective answer (FOR_E15, ACA_E16).

Priority
The give priority to the establishment of medical education divides the opinions of key informants among those who privilege political aspects in the decision to move forward, favoring an incremental model (Souza et al., 2006) of policy implementation, and the ones that, closer to the rational-comprehensive model (Rua, 1997), argue for a more cautious approach to the pace of the process. Among the former, there are opinions that the process depends on the priority given in relation to other pressing political needs, with a view that it is a political priority for the country in the current context (FOR_E1), reinforced by the statement that there is political will to move forward with the medical course (MAN_E4) and that there is a very clear directive of the Head of the Government to launch, devise, develop and strengthen a course of medicine in CV on the occasion of the 40-year anniversary of our independence, as one of the milestones to be announced (GOV_E9). Amongst the latter, most of them key informants and participants in the FGs, it is stated that priority should be given to continuing to anticipate needs, compare our needs with our possibilities, namely financial or regarding cooperative relations, continue to train a number of specialists as close as possible to the number corresponding to the foreseeable need (FOR_12), in order to give a better response to health problems and to ensure a 'brain gain' (FOR_E1).
Most interviewees and almost all FGs participants prefer to focus on the preconditions, because we face a challenge in CV that is to continually improve health care, and to highlight the pressure of the insufficient number of doctors because we have very few people, there are people retiring and not many people are being trained (MAN_E6), and also the countries where doctors are trained have less capacity to do so. It is necessary to fill this gap, take advantage of the opportunities that may still arise, but also to create conditions to train our doctors here in CV (GOV_E11).
Others, in the minority, suggest that establishing ME is not a priority in the near future due to a lack of sufficient data to reach a decision, and they recommend, alternatively, to study and make a better choice of models to decide what will be the more efficient approach, that is, how we would achieve this same level of quality at a lower cost (FOR_12); or it may not be a priority, but [I think] in the medium or long term it will be a necessity, so we should start preparing for the training of these doctors (BOD_E13).

Feasibility
The establishment of ME in a country with CV characteristics is a complex process of enormous responsibility that poses obstacles to its viability and requires prudence because of the enormous challenges imposed on it. The absence of a prepared faculty is pointed out by key informants as the main challenge. Another challenge is the quality of the education system, especially regarding the connection between basic and higher education, in view of guaranteeing the learning of necessary linguistic or logical skills, which requires a great investment in this matter (GOV_E5); the precariousness of the links between health and education systems, which does not facilitate the necessary involvement of medical staff in the process (ACA_E10); and the financing of ME, which lacks some clarification regarding sources and sustainability (FOR_E2), so we have to find and seek the necessary financing abroad (ACA_E16). Therefore, some argue that we should take the time necessary to prepare ourselves well, avoid false starts, ensure the credibility of this education and start with the minimum conditions already in place (FOR_E15).

Processes
The various processes that the interviewees identified as indispensable involve: (1) strategic elements -definition of the main guidelines, strategies and policies for higher education, definition of the profile of the doctor for CV, development of proposals for medical education, establishment of standards and course certification criteria; (2) factors related to its management, leadership, articulation and partnership; (3) factors related to the materialization of the educational process -teaching-learning, selection and follow-up of students, recruitment, initial and continuous training of teachers; (4) allocation of resources -budget approval and financing; and (5) mobilization of Cabo Verdean public opinion. The most thoughtful ones put the emphasis on studies to support the decision-making process, arguing that it is necessary to conduct more refined prior studies (FOR_E1; FOR_12) and to enlist the help of people with experience (MAN_E6, BOD_E13) to create a proper institution (GOV_E8) and develop the specific health care knowledge, regarding the academy as serving not only CV, but a wider African region, both geographic and linguistic (GOV_E5), favoring the investigation and confrontation of critical thinking to create a new ecosystem with new requirements (GOV_E9).
Quality medical education requires investing in cadres, qualifying, diversifying (GOV_E15), having local trainers (MAN_E4), organizing pedagogical training processes to upgrade doctors who will want to be teachers, with gains in both their medical and academic practice (GOV_E9) -because the interaction with the teachers who are [coming from Portugal] favors the internationalization in CV, which is a precondition of the quality of a course of this nature (GOV_E9) -stricter requirements for admission (FOR_E2), adapting the course's curriculum according to the expected professionals' profile, without being limited to traditional education, since the general profile of the doctor is changing (MAN_E3), and paying institutional attention to continuing training, lifelong training, because we cannot have a society where a person graduates in medicine and then spends ten years without going back to school (GOV_E8). Other processes will be addressed below in relation with the actors who are identified by the key informants as responsible for their execution.

Actors
The identified actors were: president of the republic, parliament, government, public and private universities, the Cabo Verdean Medical Association (OMC), healthcare institutions, international partners, civil society organizations (CSOs) and economic agents. Leadership, stakeholder articulation and accountability issues should be clearly (re)defined, considering that the process will be politically led by the Government, and it is essential to articulate the ministries involved (BOD_E13), and that the necessary technical leadership must be integrated into the University of CV for the implementation process (FOR_E2, ACA_E10).
Some respondents advocated a national political consensus around the decision to create this course (BOD_E13), taking into account that the parliament is the space par excellence for the political debate on and validation of policies and major national issues and, given the relevance of the creation of a medicine school, it cannot remain indifferent (GOV_E11, FOR_E1). They recognized that ME depends, first and foremost, on the government, which must endorse and have a very strong involvement [with it] (GOV_E11, FOR_E1), having the obligation to indicate a strategy or lead the way (FOR_E12), through the involvement of crucial governmental sectors: the Ministry of Education defines the main guidelines, strategies and policies for higher education, establishes standards, defines criteria and guarantees the certification process of the courses, while the Ministry of Health has a leading role in the definition of the doctor's profile expected in CV (MAN_E3, MAN_E4, MAN_E6 and ACA_E10)those ministries were highlighted among others with specific roles, such as the Ministry of the Environment (climate change) and the Ministry of Finance (GOV_E8).
The materialization of an MEP will require a very strong involvement of the public university, to which medical teaching should be more associated (GOV_E11, MAN_E3, GOV_E5). There is a need for involving all universities, even if the course is conducted in a single one, so that this course is solid and adequate to public needs (FOR_E1).
CV is a small country, with a relatively small population, and any project has to promote partnerships and interinstitutional collaborations and synergies of a public-private partnership (GOV_E11, MAN_E6, FOR_E2) required for a medical school to be truly a reference at the national level and, perhaps, at the regional level (ACA_E10).
The OMC is identified as an unquestionable and fundamental partner, an organization of experts in the subject (FOR_E1, MAN_E4, FOR_E12), with the role of granting or endorsing diplomas (MAN_E3), seeking partnerships within the Portuguese speaking medical community and raising the medical class awareness of the need for a medical course in CV (BOD_E13).
Managing the course requires focus on the issues of regulation and quality (Ferrinho et al., 2010) and on the first steps to build a credible project, considering the infrastructure needs but allowing the development of a university education in phases in our health institutions (FOR_E2), taking advantage of the network of health care providers with the capacity to serve internship purposes (GOV_E11), with adaptations in the organization and management to receive medical students in need of practice (MAN_E4 and ACA_ E10), and the National Institute of Public Health, because of its vocation of research (ACA_E10). MEP also requires the involvement of nurses' and other professionals' associations, in a team perspective of integrating those professionals with physicians, not only in the provision of care but also, possibly, during training (GOV_E8).
In addition, a process of this nature requires involving civil society, convincing it that this course is indeed relevant and necessary in CV (ACA_E10), but also requires involving several partners, making it a cherished project by society, discussed in the academy, businesses and media, besides being considered a catalyst to awaken and sensitize people (POL_E11) and having a good base of support.
The media have had and will play an important role in listening to and mobilizing society. The documental analysis of the news published in the Cabo Verdean press in the period between April 2010 and July 2016 showed the attentive way television, newspapers, news agencies and Cabo Verdean radios accompanied and publicized the issue of the establishment of medical education in the country, clarifying public opinion with statements, decisions or contributions, sometimes controversial but beneficial, of various actors such as the OMC, the head of government, the Ministry of Higher Education, Science and Innovation (Mesci), Uni-CV, FMUC, Uni-Piaget and the University of Mindelo.
The communication agents gave prominence to OMC positions by organizing in 2010 the First International Congress of the Cabo Verdean Medical Association, which included the conference "Continuing Medical Education and Quality of Health Care" 2 , or the subsequent statements of the association's Regional Director of Barlavento in 2012 who viewed medical education in CV as "a very relevant subject", but "within a horizon of fifteen to twenty years" because of the absence of "all the conditions, both material and human, for the establishment of a medical course in the country" (RTC, 2012). However, the Uni-Piaget administrator stated that he could launch the medical course -he was "just waiting for the 'yes' of the Cabo Verdean authorities" 3 -and the OMC president said he was ready to involve the Medical Community of Portuguese Speaking Countries "in working with Uni-Piaget in the establishment of its Faculty of Medicine" (Expresso das Ilhas, 2013). These are statements that reflect the importance of the theme and some differing opinions within the society.
The press widely publicized the government's decision announced by the prime minister in 2014 that it would "work with […] Uni-CV to shortly launch the medical course in the archipelago in cooperation with Portuguese universities and hospitals" in order to create and develop new medical specialties (Expresso das Ilhas, 2014a), as well as the OMC reaction, once again warning that the country "does not yet have the technical conditions to start a medical course" (Mendes, 2014).
Government communication came to be a major political milestone in this process. A partnership was signed between FMUC, a Portuguese institution designated to carry out "a preliminary study for the launch of a medical course", and the Uni-CV, which would administer it, with the consent of the Portuguese and Cabo Verdean governments. Such a partnership would be important to accelerate the local establishment of the course and win the support of the population. The publication of the "Document on the framework of medical training" and the "auscultation of various members of the government, the president of the Cabo Verdean Medical Association, those responsible for public and private institutions, physicians and personalities of Cabo Verdean society" (Expresso das Ilhas, 2014b) will be important in accepting the course, according to the general coordinator. This was announced by the Uni-CV's Dean on the beginning of the 2015/2016 academic year with the "objective of preparing general practitioners to work in any country" (A Nação, 2015). The medical course started with 25 students, selected amongst more than a hundred competitors, evidencing a high demand.
Other private institutions were identified as potential actors: Would the company Aeroportos e Segurança Aérea (ASA S.A.) and other companies in the transport sector have no role to play in this? Tourism companies -we are already behind in health tourism -large hotel chains, [should] be involved as potential partners that can participate [in the process], because it is also daring to move forward with training of such a scale. (GOV_E11) Of course, it will be necessary the support of international cooperation, identifying partners who have already taken this path and acquired a know-how, because the creation of the medical school in CV should have behind it an entity with international credibility, a kind of supervisor that gives credibility to the diploma (GOV_E11). It would also be necessary to look for partners at the national level (FOR_E2, ACA_E10) to ensure there would be an experienced faculty (FOR_E2 The collaboration of WHO is indispensable because it is an institution that has focused on ME and can be of benefit in defining the profile of the courses (MAN_E3). Obviously, we should rely on our people, our structures, and allocate the resources necessary for this (financial), not only through budgeting, but also through cooperation and [human] resources, and benefit from [members of] our diaspora trained in these areas (FOR_E1).

Discussion
This is a unique study, because in the literature on the subject there is no text that focuses specifically on the evolution of medical teaching from the very beginning: the birth of an independent State, counting with no ME and dealing with other specific characteristics and challenges of a vulnerable state, one of the SIDS. This study was designed to take the pulse of decision-makers in this matter before the public decision to establish a local model.
The frame of reference of Walt and Gilson (1994) served well to expose the complexity of the (re) formulation of a MEP, by ensuring a synchronic approach to the content, the analysis of the decision processes, the understanding of the use of power in health and education policies, the way in which these influences are exercised and the context in which the different actors and processes interact (Buse;Mays;Walt, 2012).
For this article, we selected from the interviewees' and FGs participants' opinions the key elements of each of the essential components for the reformulation of a MEP, as part of higher education and health policies, showing the need for it to cover basic education, continuing professional training, specialized education and interprofessional health education, besides addressing the measures and strategies to guide the consolidation of medical education within the country's specific context.
The National Health Policy (NHP) reflects the concern with the improvement of the health care workforce and its capacity to serve the Cabo Verdean population, without referring explicitly to local medical training (Cabo Verde, 2007). To fill this gap in the NHP on the subject of medical education, the higher education system sponsored the issue and carried it forward.
Higher education policy has been responding to the pressure of a growing secondary education body of students seeking higher education opportunities. Governments have responded through the institutionalization of higher education, with an initial focus on technical and managerial issues, in order to overcome the dependence on training professionals abroad. The financial effort for this training abroad has always been very high for the possibilities of the country, since CV has been paying about 60% of the expenses with scholarship students scattered about more than a dozen of foreign countries. The intention was always to develop in the country the capacity to train and qualify cadres, in order to be able to enroll as many as possible of the students seeking this level of education. It is noteworthy the strong political and social will to use higher education as a lever for development -quoting Corsino Tolentino (2007): "the political will to integrate the higher education project into the national Purpose of cultural and economic affirmation of CV" (Tolentino, 2007, p. 314).
This development has been pursued seeking the insertion of the Uni-CV in university networks within the Community of Portuguese Language Countries (CPLP), with emphasis on Portugal and Brazil (Alves, 1998), which led to an operational support plan of Portugal to the development of the public university in Cabo Verde and, in a certain way, explains the option for Portugal as a partner in the launching of medical education in CV rather than rely on Cuba, which trained most Cabo Verdean doctors since independence (Delgado, Tolentino and Ferrinho, 2017).
The development of higher education in CV has been more incremental than rational (Brooks, 2002;Wiktorowicz;Deber, 1997). This experience, thus, explains the admonitions about the "low level of qualification of teachers", the "poor qualification of a high number of candidates for higher education, due to the massification of secondary education" (Varela, 2014, p.12), and about the strong scientific and curricular dependence on foreign countries, both with regard to the curricular conception of the courses, whose curricula and programs are, in general, copied or adapted from those adopted by Portuguese university institutions, and to pedagogical (especially bibliographic) resources, usually imported from abroad, and also in terms of the teaching staff required for the courses. (Varela, 2012, p.465) This cautions attitude was reflected in many of the comments collected in the interviews analyzed, but they went unheeded in face of the challenge of the head of government's call to to launch, devise, develop and strengthen a course of medicine in CV on the occasion of the 40-year anniversary of our independence, as one of the milestones to be announced (GOV_E9) to affirm the national sovereignty. The political arguments won and imposed the adoption, once again, of an incremental model of development for the MEP against those that appealed for a more rational approach. The timing of this decision is important to contextualize it. The date for the establishment of medical education in CV was set by the Order No. 77, dated October 6, 2015, with which the Minister of Higher Education, Science and Innovation authorizes the accreditation and registration of the master's degree in medicine program at Uni-CV for the academic year 2015/2016. It was a decision taken by a lame-duck government with its popularity in decline, representing a party in turmoil; a decision which was probably seen as yet another opportunity to please an electorate that a few months later would judge the government's performance (Afrobarometer , 2015). The timing also coincides with a large investment in ME both in African countries and globally, which did not exclude the Portuguese-speaking African Countries (Palop) (Fresta et al., 2016).
In our interviews and FGs, the incrementalists and rationalists converged unanimously on the need to develop medical training in CV. Both recognized that key drivers (Lueddeke, 2012) included: recognition of a lack of health personnel; the poor diversity and quality of medical care; the loss of associated benefits of a structured training process such as the development of health research and science; the insularity of the country; the demographic trends in CV and the necessity to adapt to a changing epidemiological profile and to the social determinants of health; the financial costs of training abroad and the brain drain.
They diverged, however, on how to conduct the process. The rationalists argued for ensuring the institutional developments necessary for launching a ME: a identified course curriculum; defining the expected doctor profile; teachers recruited with a guaranteed level of quality; regulations approved; places defined for theoretical and practical classes; libraries, laboratories and health units to accommodate students in a didactic way; a critical mass of students selected according to predefined criteria, considering they come from a secondary education that did not prepare them properly to study at the university; the country's ability to respond in terms of households' financial capacity to pay tuition; an affordable monthly fee. They identified the most important strategic, leadership and partnership processes, the materialization of the educational process, the allocation of resources, the participation of society and, also, the main players, essential to the results.
In the decision-making process, the incrementalist model for advancing the establishment of ME, while at the same time defining the strategies and promoting the conditions, prevailed over the rationalist, which recommended the previous improvement of strategies and creation of conditions for success . This choice left much to be done in the elaboration of a MEP adjusted to the country's characteristics, thus constituting a great challenge to the short-term consolidation of ME in CV.

Conclusion
The need for the establishment of a local medical education was not questioned at any time by the key informants. There were, however, recommendations as to the conditions and priorities, which would require more consideration, time and assurance of the feasibility of a complex, rigorous process of high responsibility. Therefore, having a MEP designed with the guidelines of the health policy triangle (Walt, Gilson, 1994) and covering graduate, continuing and specialized training is of vital importance for the process, ensuring scientific, technical and financial sustainability.
The responsibility is political, technical and social. The MEP should be designed to involve all actors, in accordance with the requirements of universal health, the evolution of science and medical technology in the 21st century, national health and education policies in the context of an island and vulnerable country, with a dispersed population, but with a great potential for tourism. A reflection within the academy, businesses and social media on this matter is indispensable for ensuring the support of the Cabo Verdean society. This will imply reconsidering the medical education in CV with the perspective of accompanying this experience, analyzing it and consolidating the project with the required institutional developments.
The consolidation of the course will probably require a compromise between the arguments of both models of decision-making for the formulation of public policies, mentioned above, by a mixedscanning approach of composition between the two -a conception advocated by Etzioni (1967) broadening the range of alternatives to better deal with the structuring decisions of a necessary public policy in an adverse context. The continuity of the course of medicine, with the admission of a new class each year, shows that this compromise between the models is possible and beneficial.

Annex 1 -Interview script
This script was developed to conduct the interviews carried out in this study with the aim of gathering opinions from policy makers, academics, physicians and personalities on the challenges of establishing medical education in Cabo Verde and how to overcome them, and also on the advantages and disadvantages that may exist.
The objective of the study is to evaluate the feasibility of medical education in Cabo Verde in its own context, from various angles -political-strategic, social and economic -based on appropriate models and on the expected profile of the physicians, yet to be defined, and also on the knowledge of the required local foundations for the establishment and development of medical education in particular.
The interviews will be conducted by me, and participation is entirely voluntary. If you so choose, you may refuse to respond to any question or at any time decline your participation. Responses will be recorded after the informed consent of the interviewee, to ensure the legitimacy of the opinions expressed, and will be transcribed with the probity required, treated by the technique of content analysis by categories and codification of the results to obtain blocks of opinions about the various aspects of the study. The information collected will be treated anonymously and confidentially.
Thank you for your willingness to answer the questions and to collaborate in the study and for your time.
There is an increasing debate about moving forward with the establishment of a Faculty/School of Medicine in Cabo Verde. What is your opinion? i. In what time frame?
ii. Phased? In partnership with another training institution? Local preclinical part and clinical part abroad (model of the Azores/Madeira?)