The lancet commissions THE LANCET EDUCATION OF HEALTH PROFESSIONALS FOR THE 2IST CH A GLOBAL INDEPENDENT COMMISSION Health professionals for a new century: transforming education to strengthen health systems in an interdependent world Julio Frenk*, Lincoln Chen*, Zulfiqar A Bhutta, Jordan Cohen, Nigel Crisp, Timothy Evans, Harvey Fineberg, Patricia Garcia, Yang Ke, Patrick Kell Barry Kistnasamy, Afaf Meleis, David Naylor, Ariel Pablos-Mendez, Srinath Reddy, Susan Scrimshaw, Jaime Sepulveda, David Serwadda, Huda Zura Executive summary Redesign of professional health education is necessary nd timely, in view of the opportunities for mutual go, a series of studies about the education of learning and joint solutions offered by global 6736(10)61854-5 health professionals, led by the 1910 Flexner report, interdependence due to acceleration of flows of sparked groundbreaking reforms. Through integration knowledge, technologies, and financing across borders, DOt101016/50140- of modern science into the curricula at university-based and the migration of both professionals and patients. 6736(10)62008-9 schools, the reforms equipped health professionals with What is clearly needed is a thorough and authoritative Dot10 1016/50140- the knowledge that contributed to the doubling of life re-examination of health professional education, 6736(10)61968-x span during the 20th century. matching the ambitious work of a century ago " Joint first authors 4 By the beginning of the 21st century, however, all is not That is why this Commission, consisting of Harvard School of Public alL. Glaring gaps and inequities in health persist both 20 professional and academic leaders from diverse (Prof Frenk MD): China Medical within and between countries, underscoring our countries, came together to develop a shared vision and a Board, Cambridge, MA,USA collective failure to share the dramatic health advances common strategy for postsecondary education in medicine,(Chen MD)AgaKhan equitably. At the same time, fresh health challenges loom. nursing, and public health that reaches beyond the University, Karachi, Pakistan New infectious, environmen tal, and behavioural risks, at confines of national borders and the silos of individual(Prof ZA Bhutta PhD); George a time of rapid demographic and epidemiological professions. The Commission adopted a global outlook, a Center, Washington, DC, Us transitions, threaten health security of all. Health systems multiprofessional perspective, and a systems approach. ( Prof Cohen MD); Independent more complex and costly, placing additional demands on between education and health systems. It is centred on tondo UK N SChp kof: health workers people co-producers and as drivers of needs and Health,Dhaka, Bangladesh Professional education has not kept pace with these demands in both systems. By interaction through the (ProfT Evans MD): US Institute ted, outdated, and labour market, the provision of educational services licine, Washington, DC, static curricula that produce ill-equipped graduates. The generates the supply of an educated workforce to meet the PKelley MD: sch problems are systemic: mismatch of competencies to demand for professionals to work in the health system. To Health Universidad Peruana patient and population needs; poor teamwork; persistent have a positive effect on health outcomes, the professional Cayetano, Heredia, Lima, Peru gender stratification of professional status; narrow education subsystem must design new instructional and (Pro P Garcia MD): Pekin technical focus without broader contextual understand. institutional strategies g: episodic encounters rather than continuous care (ProfY Ke MD): National Health predominant hospital orientation at the expense of Major findings Laboratory Servic primary care; quantitative and qualitative imbalances in Worldwide, 2420 medical schools, 467 schools or johannesburg. the professional labour market; and weak leadership to departments of public health, and an indeterminate (KIstnasamy MD);School of Nursing, University of improve health-system performance. Laudable efforts to number of postsecondary nursing educational instit- Pennsylvania, Philadelphia, PA, address these deficiencies have mostly foundered, partly utions train about 1 million new doctors, nurses, USA(Prof A Meleis PhD) because of the so-called tribalism of the professions-ie, midwives, and public health professionals every year. unversity or oronto, toronto, the tendency of the various professions to act in isolation Severe institutional shortages are exacerbated by The Rockefeller foundation from or even in competition with each other. maldistribution, both between and within countries. New York, NY, USA ww.thelancet.com
The Lancet Commissions www.thelancet.com 5 Published Online November 29, 2010 DOI:10.1016/S0140- 6736(10)61854-5 See Online/Comment DOI:10.1016/S0140- 6736(10)62008-9 DOI:10.1016/S0140- 6736(10)61968-X *Joint first authors Harvard School of Public Health, Boston, MA, USA (Prof J Frenk MD); China Medical Board, Cambridge, MA, USA (L Chen MD); Aga Khan University, Karachi, Pakistan (Prof Z A Bhutta PhD); George Washington University Medical Center, Washington, DC, USA (Prof J Cohen MD); Independent member of House of Lords, London, UK (N Crisp KCB); James P Grant School of Public Health, Dhaka, Bangladesh (Prof T Evans MD); US Institute of Medicine, Washington, DC, USA (H Fineberg MD, P Kelley MD); School of Public Health Universidad Peruana Cayetano, Heredia, Lima, Peru (Prof P Garcia MD); Peking University Health Science Centre, Beijing, China (Prof Y Ke MD); National Health Laboratory Service, Johannesburg, South Africa (B Kistnasamy MD); School of Nursing, University of Pennsylvania, Philadelphia, PA, USA (Prof A Meleis PhD); University of Toronto, Toronto, ON, Canada (Prof D Naylor MD); The Rockefeller Foundation, New York, NY, USA Health professionals for a new century: transforming education to strengthen health systems in an interdependent world Julio Frenk*, Lincoln Chen*, Zulfiqar A Bhutta, Jordan Cohen, Nigel Crisp, Timothy Evans, Harvey Fineberg, Patricia Garcia, Yang Ke, Patrick Kelley, Barry Kistnasamy, Afaf Meleis, David Naylor, Ariel Pablos-Mendez, Srinath Reddy, Susan Scrimshaw, Jaime Sepulveda, David Serwadda, Huda Zurayk Executive summary Problem statement 100 years ago, a series of studies about the education of health professionals, led by the 1910 Flexner report, sparked groundbreaking reforms. Through integration of modern science into the curricula at university-based schools, the reforms equipped health professionals with the knowledge that contributed to the doubling of life span during the 20th century. By the beginning of the 21st century, however, all is not well. Glaring gaps and inequities in health persist both within and between countries, underscoring our collective failure to share the dramatic health advances equitably. At the same time, fresh health challenges loom. New infectious, environmental, and behavioural risks, at a time of rapid demographic and epidemiological transitions, threaten health security of all. Health systems worldwide are struggling to keep up, as they become more complex and costly, placing additional demands on health workers. Professional education has not kept pace with these challenges, largely because of fragmented, outdated, and static curricula that produce ill-equipped graduates. The problems are systemic: mismatch of competencies to patient and population needs; poor teamwork; persistent gender stratification of professional status; narrow technical focus without broader contextual understanding; episodic encounters rather than continuous care; predominant hospital orientation at the expense of primary care; quantitative and qualitative imbalances in the professional labour market; and weak leadership to improve health-system performance. Laudable efforts to address these deficiencies have mostly floundered, partly because of the so-called tribalism of the professions—ie, the tendency of the various professions to act in isolation from or even in competition with each other. Redesign of professional health education is necessary and timely, in view of the opportunities for mutual learning and joint solutions offered by global interdependence due to acceleration of flows of knowledge, technologies, and financing across borders, and the migration of both professionals and patients. What is clearly needed is a thorough and authoritative re-examination of health professional education, matching the ambitious work of a century ago. That is why this Commission, consisting of 20 professional and academic leaders from diverse countries, came together to develop a shared vision and a common strategy for postsecondary education in medicine, nursing, and public health that reaches beyond the confines of national borders and the silos of individual professions. The Commission adopted a global outlook, a multiprofessional perspective, and a systems approach. This comprehensive framework considers the connections between education and health systems. It is centred on people as co-producers and as drivers of needs and demands in both systems. By interaction through the labour market, the provision of educational services generates the supply of an educated workforce to meet the demand for professionals to work in the health system. To have a positive effect on health outcomes, the professional education subsystem must design new instructional and institutional strategies. Major findings Worldwide, 2420 medical schools, 467 schools or departments of public health, and an indeterminate number of postsecondary nursing educational institutions train about 1 million new doctors, nurses, midwives, and public health professionals every year. Severe institutional shortages are exacerbated by maldistribution, both between and within countries
The Lancet commissions (APablos-Mendez MD): Public Four countries(China, India, Brazil, and USA) each have agents. Effective education builds each level on the Health Foundation of India, more than 150 medical schools, whereas 36 countries previous one. As a valued outcome, transformative Deth, india have no medical schools at all. 26 countries in sub. learning involves three fundamental shifts: from fact Colleges, Troy, Ml, USA Saharan Africa have one or no medical schools. In view memorisation to searching, analysis, and synthesis of S Scrimshaw PhD); of these imbalances, that medical school numbers do not information for decision making: from seeking i8 Melinda gates align well with either country population size or national professional credentials to achieving core competencies 0 Sepulveda MD): Makarere burden of disease is not surprising. for effective teamwork in health systems; and from niversity School of Public The total global expenditure for health professional non-critical adoption of educational models to creative (Prof D Serwadda MD); and great disparities between countries. This amount is less Interdependence is a key element in a systems pulation and Health, Faculty than 2% of health expenditures worldwide, which is approach because it underscores the ways in which University of Beirut, Beirut, industry. The average cost per graduate is $113000 for desirable outcome, interdependence in education also Lebanon(Prof HZurayk PhD) medical students and $46000 for nurses, with unit costs involves three fundamental shifts: from isolated to Correspondence to: highest in North America and lowest in China. harmonised education and health systems: from stand of public health office ofthe Stewardship, accreditation, and learning systems are alone institutions to networks, alliances, and consortia; Dean, Kresge Building, Room weak and unevenly practised around the world. Our and from inward-looking institutional preoccupations to 1005, Huntington Avenue, analysis has shown the scarcity of information and arnessing global flows of educational content, teaching Boston, MA O2115, USA research about health professional education. Although resources, and innovations frenk hsph. harvardedu many educational institutions in all regions have Transformative learning is the proposed outcome of Dr Lincoln Chen, China launched innovative initiatives, little robust evidence is instructional reforms; interdependence in education available about the effectiveness of such reforms should result from institutional reforms. On the basis Cambridge, MA O2138, USA of these core notions, the Commission offers a serie Ichenecmbfoundorg Reforms for a second centur!, onal reforms characterise performance. Instructional reforms should:adopt of specific recommendations to improve systems Three generations of educati progress during the past century. The first generation, petency-driven approaches to instructional design; launched at the beginning of the 20th century, taught a adapt these competencies to rapidly changing local science-based curriculum. Around the mid-century, conditions drawing on global resources; promote the second generation introduced problem-based interprofessional and transprofessional education that instructional innovations. A third generation is now breaks down professional silos while enhancing needed that should be systems based to improve the collaborative and non-hierarchical relationships in erformance of health systems by adapting core effective teams; exploit the power of information sional competencies to specific contexts, while technology for learning: strengthen educational drawing on global knowledge resources, with specialemphasis on faculty development; To advance third-generation reforms, the Commission and promote a new professionalism that uses puts forward a vision: all health professionals in all competencies as objective criteria for classification of countries should be educated to mobilise knowledge and health professionals and that develops a common set of to engage in critical reasoning and ethical conduct so values around social accountability. Institutional that they are competent to participate in patient and reforms should: establish in every country joint population-centred health systems as members of locally education and health planning mechanisms that take responsive and globally connected teams. The ultimate into account crucial dimensions, such as social origin, purpose is to assure universal coverage of the high- age distribution, and gender composition, of the health uality comprehensive services that are essential to workforce; expand academic centres to academic advance opportunity for health equity within and systems encompassing networks of hospitals and primary care units; link together through global Realisation of this vision will require a series of networks, alliances, and consortia; and nurture a culture instructional and institutional reforms, which should be of critical inquiry guided by two proposed outcomes: transformative Pursuit of these reforms will encounter many barriers. learning and interdependence in education. We regard Our recommendations, therefore, require a series of transformative learning as the highest of three successive abling actions. First, the broad engagement of leaders at levels from informative to formative to all levels--local, national, and global--will be crucial to transformative learning. Informative learning is about achieve the proposed reforms and outcomes. Leadership acquiring knowledge and skills; its purpose is to produce has to come from within the academic and professional experts. Formative learning is about socialising students communities, but it must be backed by political leaders in around values; its purpose is to produce professionals. government society. Second, present fundin Transformative learning is about developing leadership deficiencies must be overcome with a substantial attributes; its purpose is to produce enlightened change expansion of investments in health professional education www.thelancet.com
The Lancet Commissions 6 www.thelancet.com (A Pablos-Mendez MD); Public Health Foundation of India, New Delhi, India (Prof S Reddy MD); The Sage Colleges, Troy, MI, USA (S Scrimshaw PhD); Bill & Melinda Gates Foundation, Seattle, WA, USA (J Sepulveda MD); Makarere University School of Public Health, Kampala, Uganda (Prof D Serwadda MD); and Centre for Research on Population and Health, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon (Prof H Zurayk PhD) Correspondence to: Prof Julio Frenk, Harvard School of Public Health, Office of the Dean, Kresge Building, Room 1005, 677 Huntington Avenue, Boston, MA 02115, USA jfrenk@hsph.harvard.edu or Dr Lincoln Chen, China Medical Board, Two Arrow Street, Cambridge, MA 02138, USA lchen@cmbfound.org Four countries (China, India, Brazil, and USA) each have more than 150 medical schools, whereas 36 countries have no medical schools at all. 26 countries in subSaharan Africa have one or no medical schools. In view of these imbalances, that medical school numbers do not align well with either country population size or national burden of disease is not surprising. The total global expenditure for health professional education is about US$100 billion per year, again with great disparities between countries. This amount is less than 2% of health expenditures worldwide, which is pitifully modest for a labour-intensive and talent-driven industry. The average cost per graduate is $113 000 for medical students and $46 000 for nurses, with unit costs highest in North America and lowest in China. Stewardship, accreditation, and learning systems are weak and unevenly practised around the world. Our analysis has shown the scarcity of information and research about health professional education. Although many educational institutions in all regions have launched innovative initiatives, little robust evidence is available about the effectiveness of such reforms. Reforms for a second century Three generations of educational reforms characterise progress during the past century. The first generation, launched at the beginning of the 20th century, taught a science-based curriculum. Around the mid-century, the second generation introduced problem-based instructional innovations. A third generation is now needed that should be systems based to improve the performance of health systems by adapting core professional competencies to specific contexts, while drawing on global knowledge. To advance third-generation reforms, the Commission puts forward a vision: all health professionals in all countries should be educated to mobilise knowledge and to engage in critical reasoning and ethical conduct so that they are competent to participate in patient and population-centred health systems as members of locally responsive and globally connected teams. The ultimate purpose is to assure universal coverage of the highquality comprehensive services that are essential to advance opportunity for health equity within and between countries. Realisation of this vision will require a series of instructional and institutional reforms, which should be guided by two proposed outcomes: transformative learning and interdependence in education. We regard transformative learning as the highest of three successive levels, moving from informative to formative to transformative learning. Informative learning is about acquiring knowledge and skills; its purpose is to produce experts. Formative learning is about socialising students around values; its purpose is to produce professionals. Transformative learning is about developing leadership attributes; its purpose is to produce enlightened change agents. Effective education builds each level on the previous one. As a valued outcome, transformative learning involves three fundamental shifts: from fact memorisation to searching, analysis, and synthesis of information for decision making; from seeking professional credentials to achieving core competencies for effective teamwork in health systems; and from non-critical adoption of educational models to creative adaptation of global resources to address local priorities. Interdependence is a key element in a systems approach because it underscores the ways in which various components interact with each other. As a desirable outcome, interdependence in education also involves three fundamental shifts: from isolated to harmonised education and health systems; from standalone institutions to networks, alliances, and consortia; and from inward-looking institutional preoccupations to harnessing global flows of educational content, teaching resources, and innovations. Transformative learning is the proposed outcome of instructional reforms; interdependence in education should result from institutional reforms. On the basis of these core notions, the Commission offers a series of specific recommendations to improve systems performance. Instructional reforms should: adopt competency-driven approaches to instructional design; adapt these competencies to rapidly changing local conditions drawing on global resources; promote interprofessional and transprofessional education that breaks down professional silos while enhancing collaborative and non-hierarchical relationships in effective teams; exploit the power of information technology for learning; strengthen educational resources, with special emphasis on faculty development; and promote a new professionalism that uses competencies as objective criteria for classification of health professionals and that develops a common set of values around social accountability. Institutional reforms should: establish in every country joint education and health planning mechanisms that take into account crucial dimensions, such as social origin, age distribution, and gender composition, of the health workforce; expand academic centres to academic systems encompassing networks of hospitals and primary care units; link together through global networks, alliances, and consortia; and nurture a culture of critical inquiry. Pursuit of these reforms will encounter many barriers. Our recommendations, therefore, require a series of enabling actions. First, the broad engagement of leaders at all levels—local, national, and global—will be crucial to achieve the proposed reforms and outcomes. Leadership has to come from within the academic and professional communities, but it must be backed by political leaders in government and society. Second, present funding deficiencies must be overcome with a substantial expansion of investments in health professional education
The Lancet commissions from all sources: public, private, development aid, and foundations. Third, stewardship mechanisms, including The Flexner report socially accountable accreditation, should be strengthened NURSING AN to assure best possible results for any given level of N THE UNITED STATES funding. Lastly, shared learning by supporting metrics, evaluation, and research should be strengthened to build up the knowledge base about which innovations work 量影露 under which circumstances Health professionals have made enormous contributions to health and development over the past century, but complacencywill only perpetuate theineffective application of 20th century educational strategies that are unfit to tackle 21st century challenges. Therefore, we call for a global social movement of all stakeholders--educators, Hgure Flexner, weidch-kose, and goldmark reports students and young health workers, professional bodies, complementing the importance of social determinants universities, non-governmental organisations, inter- and social movements in health. In these endeavours national agencies, donors, and foundations--that can professionals play the crucial mediating role of applying propel action on this vision and these recommendations knowledge to improve health. Much evidence suggests to promote a new century of transformative professional that coverage and numbers of health professionals have a education. The result will be more equitable and better direct effect on health outcomes. Health professionals performing health systems than at present, with are the service providers who link people to technology onsequent benefits for patients and populations information, and knowledge. They are also caregivers everywhere in our interdepend communicators and educators, team members, managers ders, and policy makers. -1z As knowledge brokers Section 1: problem statement health workers are the human faces of the health system Background and rationale Arguably, dramatic reforms in the education of health professionals helped to catalyse health gains in the past Health is all about people. Beyond the glittering surface century. After the discovery of the germ theory in Europe, of modern technology, the core space of every health the beginning of the 20th century witnessed widespread system is occupied by the unique encounter between one reforms in professional education around the world. In set of people who need services and another who have the USA early in the 20th century, such reports as by been entrusted to deliver them. This trust is earned Flexner. 3 Welch- Rose 4 and Goldmarks transformed through a special blend of technical competence and postsecondary education of physicians, public health service orientation, steered by ethical commitment and workers, and nurses, respectively(figure 1). These efforts social accountability, which forms the essence of to imbed a scientific foundation into the education of professional work, Developing such a blend requires a health professionals extended into other health fields. 6 lengthy period of education and a substantial investment However, in the first decade of the 21st century, glaring by both student and society. Through a chain of events gaps and striking inequities in health persist both fowing from effective learning to high-quality services to between and within countries. -m A large proportion of improved health, professional education at its best makes the 7 billion people who inhabit out planet are trapped in an essential contribution to the wellbeing of individuals, health conditions of a century earlier. Many face conflict families, and communities and violence. Health gains have been reversed by the Yet, the context, content, and conditions of the social collapse of average life expectancy in some countries effort to educate competent, caring, and committed health which in sub-Saharan Africa is attributable to the professionals are rapidly changing across time and space. HIV/AIDS pandemic. uz Poor people in developing The startling doubling of life expectancy during the 20th countries continue to have common infections entury was attributable to improvements in living malnutrition, and maternity-related health risks, which standards and to advances in knowledge. Abundant have long been controlled in more affluent populations evidence suggests that good health is at least partly For those left behind, the spectacular advances in health knowledge not only produces new technologies but also ensure the equitable sharing of health progress. sure to knowledge based and socially driven. 23 Scientific worldwide are an indictment of our collective failure to empowers citizens to adopt healthy lifestyles, improve At the same time, health security is being challenged care-seeking behaviour, and become proactive citizens by new infectious, environmental, and behavioural who are conscious of their rights. Additionally, knowledge threats superimposed upon rapid demographic and anslated into evidence can guide practice and policy. epidem-iological transitions. -7 Health systems are Health systems are socially driven differentiated struggling to keep up and are becoming more complex institutions with the primary intent to improve health, and costly, placing additional demands on health workers. ww.thelancet.com
The Lancet Commissions www.thelancet.com 7 from all sources: public, private, development aid, and foundations. Third, stewardship mechanisms, including socially accountable accreditation, should be strengthened to assure best possible results for any given level of funding. Lastly, shared learning by supporting metrics, evaluation, and research should be strengthened to build up the knowledge base about which innovations work under which circumstances. Health professionals have made enormous contributions to health and development over the past century, but complacency will only perpetuate the ineffective application of 20th century educational strategies that are unfit to tackle 21st century challenges. Therefore, we call for a global social movement of all stakeholders—educators, students and young health workers, professional bodies, universities, non-governmental organisations, international agencies, donors, and foundations—that can propel action on this vision and these recommendations to promote a new century of transformative professional education. The result will be more equitable and better performing health systems than at present, with consequent benefits for patients and populations everywhere in our interdependent world. Section 1: problem statement Background and rationale Complex challenges Health is all about people. Beyond the glittering surface of modern technology, the core space of every health system is occupied by the unique encounter between one set of people who need services and another who have been entrusted to deliver them. This trust is earned through a special blend of technical competence and service orientation, steered by ethical commitment and social accountability, which forms the essence of professional work. Developing such a blend requires a lengthy period of education and a substantial investment by both student and society. Through a chain of events flowing from effective learning to high-quality services to improved health, professional education at its best makes an essential contribution to the wellbeing of individuals, families, and communities. Yet, the context, content, and conditions of the social effort to educate competent, caring, and committed health professionals are rapidly changing across time and space. The startling doubling of life expectancy during the 20th century was attributable to improvements in living standards and to advances in knowledge.1 Abundant evidence suggests that good health is at least partly knowledge based and socially driven.2,3 Scientific knowledge not only produces new technologies but also empowers citizens to adopt healthy lifestyles, improve care-seeking behaviour, and become proactive citizens who are conscious of their rights. Additionally, knowledge translated into evidence can guide practice and policy. Health systems are socially driven differentiated institutions with the primary intent to improve health, complementing the importance of social determinants and social movements in health. In these endeavours, professionals play the crucial mediating role of applying knowledge to improve health. Much evidence suggests that coverage and numbers of health professionals have a direct effect on health outcomes.4 Health professionals are the service providers who link people to technology, information, and knowledge. They are also caregivers, communicators and educators, team members, managers, leaders, and policy makers.5–12 As knowledge brokers, health workers are the human faces of the health system. Arguably, dramatic reforms in the education of health professionals helped to catalyse health gains in the past century. After the discovery of the germ theory in Europe, the beginning of the 20th century witnessed widespread reforms in professional education around the world. In the USA early in the 20th century, such reports as by Flexner,13 Welch-Rose,14 and Goldmark15 transformed postsecondary education of physicians, public health workers, and nurses, respectively (figure 1). These efforts to imbed a scientific foundation into the education of health professionals extended into other health fields.16 However, in the first decade of the 21st century, glaring gaps and striking inequities in health persist both between and within countries.17–20 A large proportion of the 7 billion people who inhabit out planet are trapped in health conditions of a century earlier. Many face conflict and violence. Health gains have been reversed by the collapse of average life expectancy in some countries, which in sub-Saharan Africa is attributable to the HIV/AIDS pandemic.21,22 Poor people in developing countries continue to have common infections, malnutrition, and maternity-related health risks, which have long been controlled in more affluent populations.23 For those left behind, the spectacular advances in health worldwide are an indictment of our collective failure to ensure the equitable sharing of health progress.24 At the same time, health security is being challenged by new infectious, environmental, and behavioural threats superimposed upon rapid demographic and epidem-iological transitions.25–27 Health systems are struggling to keep up and are becoming more complex and costly, placing additional demands on health workers. Figure 1: Flexner, Welch-Rose, and Goldmark reports
The Lancet commissions challenging in poor countries, which are constrained by severely scarce resources. Many countries are attempting to extend essenti service through the deployment of basic health workers, even as millions of people resort to providers without credentials, both traditional and modern 42 In an effort to achieve health goals, many poor countries are channelling external donor funding towards implementation of disease-targeted initiatives. Consequently, in many countries, po professional education is absent from the policy agenda and is overtaken by emergency or urgent action projects and is regarded as too costly, irrelevant, or long term. igure 2: Emerging challenges to health systems A renaissance to a new professionalism--patient centred and team-based-has been much discussed. AL In many countries, professionals are encountering more but it has lacked the leadership, incentives, and power to socially diverse patients with chronic conditions, who are deliver on its promise. Some attempts to redefine the more proactive in their health-seeking behaviour. -3 future roles and responsibilities of health professionals Patient management requires coordinated care across have floundered amid the rigid so-called tribalism that time and space, demanding unprecedented teamwork. afflicts them. Advocacy for specific practitioner groups has Professionals have to integrate the explosive growth of been strong, but without an overall strategy for the broader knowledge and technologies while grappling with health professional community to work together to meet expanding functions--super-specialisation, prevention, individual and population health needs. Several and complex care management in many sites, including meaning recent efforts have attempted to address different types of facilities alongside home-based and fractures, but they have fallen short. community-based care(figure 2). -12 Consequently, a slow-burning crisis is emerging in Fresh opportunities the mismatch of professional competencies to patient Opportunities are opening for a new round of reforms to and population priorities because of fragmentary, craft professional education for the 21st century, spurred outdated, and static curricula producing ill-equipped by mutual leaming due to health interdependence, changes graduates from underfinanced institutions. -1 5-20 In in educational pedagogy, the public prominence of health almost all countries. the education of health and the growing recognition of the imperative for change fessionals has failed to overcome dysfunctional and Paradoxically, despite glaring disparities, interdependence inequitable health systems because of curricula in health is growing and the opportunities for mutual rigidities, professional silos, static pedagogy (ie, the learning and shared progress have greatly expanded. science of teaching), insufficient adaptation to local Global movements of people, pathogens, technologies contexts, and commercialism in the professions. financing, information, and knowledge underlie the Breakdown is especially noteworthy within primary international transfer of health risks and opportunities care, in both poor and rich countries. The failings are and flows across national borders are accelerating. Weare systemic--professionals are unable to keep pace, increasingly interdependent in terms of key health becoming mere technology managers, and exacerbating resources, especially skilled workers. 2 protracted difficulties such as a reluctance to serve Alongside the rapid pace of change in health, there is a marginalised rural communities. 323 Professionals are parallel revolution in education. The explosive increase falling short on appropriate competencies for effective not only in total volume of information, but also in ease teamwork, and they are not exercising effective of access to it, means that the role of universities and leadership to transform health systems. other educational institutions needs to be rethought. Poor and rich countries both have workforce shortages, Learning, of course, has always been experienced outside skill-mix imbalances, and maldistribution of profess. formal instruction through all types of interactions, but ionals 7-In neither rich nor poor countries is professional the informational content and learning potential are education generating high value for money. Difficult to today without precedent. In this rapidly evolving context, design and slow to implement, educational reforms in rich universities and educational institutions are broadenin competencies attempting to develop professional their traditional role as places where people go to obtain countries e responsive to changing health information(eg, by consulting books in libraries or needs, overcome professional silos through inter- listening to expert faculty members) to incorporate novel rofessional education, harness information technology forms of learning that transcend the confines of the (IT-empowered learning, enhance cognitive skills for class lext generation of learners needs the critical inquiry, and strengthen professional identity and capacity to discriminate vast amounts of information values for health leadership. Reforms are especially and extract and synthesise knowledge that is necessary www.thelancet.com
The Lancet Commissions 8 www.thelancet.com In many countries, professionals are encountering more socially diverse patients with chronic conditions, who are more proactive in their health-seeking behaviour.28–31 Patient management requires coordinated care across time and space, demanding unprecedented teamwork.5–11 Professionals have to integrate the explosive growth of knowledge and technologies while grappling with expanding functions—super-specialisation, prevention, and complex care management in many sites, including different types of facilities alongside home-based and community-based care (figure 2).7–12 Consequently, a slow-burning crisis is emerging in the mismatch of professional competencies to patient and population priorities because of fragmentary, outdated, and static curricula producing ill-equipped graduates from underfinanced institutions.5–12,18–20 In almost all countries, the education of health professionals has failed to overcome dysfunctional and inequitable health systems because of curricula rigidities, professional silos, static pedagogy (ie, the science of teaching), insufficient adaptation to local contexts, and commercialism in the professions. Breakdown is especially noteworthy within primary care, in both poor and rich countries. The failings are systemic—professionals are unable to keep pace, becoming mere technology managers, and exacerbating protracted difficulties such as a reluctance to serve marginalised rural communities.32,33 Professionals are falling short on appropriate competencies for effective teamwork, and they are not exercising effective leadership to transform health systems. Poor and rich countries both have workforce shortages, skill-mix imbalances, and maldistribution of professionals.7,32–35 In neither rich nor poor countries is professional education generating high value for money. Difficult to design and slow to implement, educational reforms in rich countries are attempting to develop professional competencies that are responsive to changing health needs, overcome professional silos through interprofessional education, harness information technology (IT)-empowered learning, enhance cognitive skills for critical inquiry, and strengthen professional identity and values for health leadership.36–40 Reforms are especially challenging in poor countries, which are constrained by severely scarce resources.38,40,41 Many countries are attempting to extend essential services through the deployment of basic health workers, even as millions of people resort to providers without credentials, both traditional and modern.42 In an effort to achieve health goals, many poor countries are channelling external donor funding towards implementation of disease-targeted initiatives. Consequently, in many countries, postsecondary professional education is absent from the policy agenda and is overtaken by emergency or urgent action projects and is regarded as too costly, irrelevant, or long term. A renaissance to a new professionalism—patientcentred and team-based—has been much discussed,37,43–47 but it has lacked the leadership, incentives, and power to deliver on its promise. Some attempts to redefine the future roles and responsibilities of health professionals have floundered amid the rigid so-called tribalism that afflicts them. Advocacy for specific practitioner groups has been strong, but without an overall strategy for the broader health professional community to work together to meet individual and population health needs. Several well meaning recent efforts have attempted to address these fractures, but they have fallen short. Fresh opportunities Opportunities are opening for a new round of reforms to craft professional education for the 21st century, spurred by mutual learning due to health interdependence, changes in educational pedagogy, the public prominence of health, and the growing recognition of the imperative for change. Paradoxically, despite glaring disparities, interdependence in health is growing and the opportunities for mutual learning and shared progress have greatly expanded.1,24 Global movements of people, pathogens, technologies, financing, information, and knowledge underlie the international transfer of health risks and opportunities, and flows across national borders are accelerating.48 We are increasingly interdependent in terms of key health resources, especially skilled workers.24 Alongside the rapid pace of change in health, there is a parallel revolution in education. The explosive increase not only in total volume of information, but also in ease of access to it, means that the role of universities and other educational institutions needs to be rethought.49 Learning, of course, has always been experienced outside formal instruction through all types of interactions, but the informational content and learning potential are today without precedent. In this rapidly evolving context, universities and educational institutions are broadening their traditional role as places where people go to obtain information (eg, by consulting books in libraries or listening to expert faculty members) to incorporate novel forms of learning that transcend the confines of the classroom. The next generation of learners needs the capacity to discriminate vast amounts of information and extract and synthesise knowledge that is necessary Figure 2: Emerging challenges to health systems Health system Technological innovation Population demands Epidemiological and demographic transitions Professional differentiation
The Lancet commissions for clinical and population-based decision making. delimit their respective spheres of practice. The division These developments point toward new opportunities for of labour at any specific time and in any specific society is the methods, means, and meaning of education. -12B-20 much more the result of these social forces than of any Like never before, the public prominence of health in inherent attribute of health-related work. general and global health in particular has generated an In most of this report we continue to refer to the health environment that is propitious for change. Health affects professions in a conventional manner. We focus the most pressing global issues of our time: socio- health workers who have completed postsecondary economic development, national and human security, education--typically in universities or other institutions and the global movement for human rights. We now of higher learning that are legally allowed to certify understand that good health is not only a result of but educational attainment by issuing a formal degree. also a condition for development, security, and rights. At Although this definition does not include most ancillary the same time, access to high-quality health care with and community health workers and there has been financial protection for all has become one of the major substantial growth of new occupational categories or domestic political priorities worldwide. specialisations, we focus mostly on the conventional A full and authoritative examination and redesign of professions, with special emphasis on medicine, nursing. the education of health professionals is warranted to midwifery, and public health. Our analyses and match the ambition of reformers a century ago. Such a recommendations are directed at all health professions. eview would necessarily be globally inclusive and multi- However boundaries between health professions are professional, spanning borders and constituencies. delineated, all are subject to educational processes aimed Reform for the 21st century is timely because of the at developing knowledge, skills, and values to improve imperative to align professional competencies to the health of patients and populations. There is, therefore, changing contexts, growing public engagement in a fundamental linkage between professional education health, and global interdependence, including the shared on the one hand, and health conditions, on the other. For aspiration of equity in health. this reason, the Commission developed a framework aimed at understanding of the complex interactions between two systems: education and health(figure 3) The Commission on education of health professionals for By contrast with other frameworks, in which the the 21st century was launched in January, 2010. This population is exogenous to health or education systems independent initiative, led by a diverse group of ours conceives of the population as the base and the driver 20 commissioners from around the world, adopted a global of these systems. People generate needs in both education perspective seeking to advance health by recommending and health, which in turn may be translated into demand instructional and institutional innovations to nurture a for educational and health services. The provision of new generation of health professionals who would be best educational services generates the supply of an educated equipped to address present and future health challenges. workforce to meet the demand for professionals to work in Webappendix pp 1-5 lists the members of the Commission the health system. Of course, people are not only recipients See Online for webappend and its advisory bodies. We pursued research, undertook of services but actual coproducers of their own education deliberations, and promoted consultations during 1 year. and health The brevity of time constrained the scopanalyses.Our and depth of consultations, data compilation, and aim was to develop a fresh vision with practical recommendations of specific actions that might catalyse steps towards the transformation of health professional Supply of heah abour market fo Demand for health education in all countries, both rich and poor. The work of the Commission is intended to mark the centennial of the 1910 Flexner report, which has powerfully shaped medical education throughout the world. rative framework Education system Health The Commission began by defining its object of study th professional educ labour between the various health professions is a social construction resulting from complex historical processes around scientific progress, technological development, economic relations, political interests, and cultural schemes of values and beliefs. The dynamic nature of professional boundaries is underscored by the continuous ruggles between different professional groups to Figure 3: Systems framework ww.thelancet.com
The Lancet Commissions www.thelancet.com 9 for clinical and population-based decision making. These developments point toward new opportunities for the methods, means, and meaning of education.5–12,18–20 Like never before, the public prominence of health in general and global health in particular has generated an environment that is propitious for change. Health affects the most pressing global issues of our time: socioeconomic development, national and human security, and the global movement for human rights. We now understand that good health is not only a result of but also a condition for development, security, and rights. At the same time, access to high-quality health care with financial protection for all has become one of the major domestic political priorities worldwide. A full and authoritative examination and redesign of the education of health professionals is warranted to match the ambition of reformers a century ago. Such a review would necessarily be globally inclusive and multiprofessional, spanning borders and constituencies. Reform for the 21st century is timely because of the imperative to align professional competencies to changing contexts, growing public engagement in health, and global interdependence, including the shared aspiration of equity in health. Commission work The Commission on education of health professionals for the 21st century was launched in January, 2010. This independent initiative, led by a diverse group of 20 commissioners from around the world, adopted a global perspective seeking to advance health by recommending instructional and institutional innovations to nurture a new generation of health professionals who would be best equipped to address present and future health challenges. Webappendix pp 1–5 lists the members of the Commission and its advisory bodies. We pursued research, undertook deliberations, and promoted consultations during 1 year. The brevity of time constrained the scope and depth of consultations, data compilation, and analyses. Our aim was to develop a fresh vision with practical recommendations of specific actions that might catalyse steps towards the transformation of health professional education in all countries, both rich and poor. The work of the Commission is intended to mark the centennial of the 1910 Flexner report, which has powerfully shaped medical education throughout the world. Integrative framework The Commission began by defining its object of study— health professional education. The present division of labour between the various health professions is a social construction resulting from complex historical processes around scientific progress, technological development, economic relations, political interests, and cultural schemes of values and beliefs. The dynamic nature of professional boundaries is underscored by the continuous struggles between different professional groups to delimit their respective spheres of practice. The division of labour at any specific time and in any specific society is much more the result of these social forces than of any inherent attribute of health-related work. In most of this report we continue to refer to the health professions in a conventional manner. We focus on health workers who have completed postsecondary education—typically in universities or other institutions of higher learning that are legally allowed to certify educational attainment by issuing a formal degree. Although this definition does not include most ancillary and community health workers and there has been substantial growth of new occupational categories or specialisations, we focus mostly on the conventional professions, with special emphasis on medicine, nursingmidwifery, and public health. Our analyses and recommendations are directed at all health professions. However boundaries between health professions are delineated, all are subject to educational processes aimed at developing knowledge, skills, and values to improve the health of patients and populations. There is, therefore, a fundamental linkage between professional education, on the one hand, and health conditions, on the other. For this reason, the Commission developed a framework aimed at understanding of the complex interactions between two systems: education and health (figure 3). By contrast with other frameworks, in which the population is exogenous to health or education systems, ours conceives of the population as the base and the driver of these systems. People generate needs in both education and health, which in turn may be translated into demand for educational and health services. The provision of educational services generates the supply of an educated workforce to meet the demand for professionals to work in the health system. Of course, people are not only recipients of services but actual coproducers of their own education and health. Figure 3: Systems framework Labour market for health professionals Population Demand for health workforce Supply of health workforce Provision Provision Demand Demand Needs Needs Education system Health system See Online for webappendix