The Lancet commissions In this system approach, the interdependence of the In addition to labour market linkages, the education and health and education sectors is paramount. Balance health systems share what could be thought of as a joint between the two systems is crucial for efficiency, subsystem--namely, the health professional education effectiveness, and equity. Every country has its own subsystem. Whereas in a few countries schools for health unique history and legacies of the past shape both the professionals are ascribed to the health ministry, in others present and the future. There are two crucial junctures in they are under the jurisdiction of the education ministry. the framework. The first is the labour market, which Irrespective of this administrative issue, the health governs the fit or misfit between the supply and demand professional education subsystem has its own dynamic of health professionals, and the second is the weak resulting from its location at the intersection of two major capacity of many populations, especially poor people, to societal systems. After all, health-care spaces are also translate their health and educational needs into effective educational spaces, in which the in-service education of demand for the respective services. In optimum future professionals takes place circumstances, there is a balance between population The linkage between the education and the health needs, health-system demand for professionals, and systems should also address the delivery models that upply thereof by the educational system. Educational determine the skill mix of health workers and the scope institutions determine how many of what type of for task shifting. In addition to the managerial aspects, professionals are produced. Ideally they do so in response there is a political dimension, since health professionals labour market signals generated by health institutions, do not act in isolation but are usually organised as interest and these signals should correctly respond to the needs groups. Furthermore, governments very often influence of the population. the supply of health professionals in response to political However, in reality the labour market for health situation more than tomarketrationalityorepidemiological professionals is often characterised by multiple imbal- reality. Lastly, labour markets for health professionals are ances,o the most important of which are undersupply, not only national but also global. In professionals with unemployment, and underemployment, which can be internationally recognised credentials, migration quantitative (less than full-time work) or qualitative growing occurrence. (suboptimum use of skills). To avoid these imbalances, After specification of the linkages between the health the educational system must respond to the requirements and educational spheres, our framework identifies three of the health system. However, this tenet does not imply key dimensions of education: institutional design(which a subordinate position of the education system. We see specifies the structure and functions of the education educational institutions as crucial to transform health system), instructional design(which focuses on processes ystems. Through their research and leadership and educational outcomes(which deal with the desired functions, universities and other institutions of higher results; figure 4). Aspects of both institutional and learning generate evidence about the shortcomings of instructional design were already present in the original the health system, and about potential solutions. reports of the 20th century, - which sought to answer not Through their educational function, they produce only the question of what and how to teach, but also where professionals who can implement change in the to teach-ie, the type oforganisation that should undertake organisations in which they work. the programmes of instruction. However, by contrast with the reports of a century ago, ours considers institutions Structure Process not only as individual organisations, but also as part of an Institutional design Instructional design inter-related set of organisations that implement the diverse functions of an educational system. By adaptation of a framework that was originally dship and governance formulated to understand health-system performance Channels we can think of four crucial functions that also apply to educational systems:(1) stewardship and governance, Organisational level GlobaHocal which encompass instruments such as norms and policies, evidence for decision making, and assessment of rformance to provide strategic guidance for the various components of the educational system;(2)financing, /Networks and partnerships which entails the aggregate allocation of resources to educational institutions from both public and private roposed sources,and the specific modalities for determining resource flows to each educational organisation, with the in education ensuing set of incentives; (3)resource generation, most importantly faculty development; and (4) service provision which refers to the actual delivery of the educational service igure 4: Key components of the educational system and as such reflects instructional design. www.thelancet.com
The Lancet Commissions 10 www.thelancet.com In this system approach, the interdependence of the health and education sectors is paramount. Balance between the two systems is crucial for efficiency, effectiveness, and equity. Every country has its own unique history, and legacies of the past shape both the present and the future. There are two crucial junctures in the framework. The first is the labour market, which governs the fit or misfit between the supply and demand of health professionals, and the second is the weak capacity of many populations, especially poor people, to translate their health and educational needs into effective demand for the respective services. In optimum circumstances, there is a balance between population needs, health-system demand for professionals, and supply thereof by the educational system. Educational institutions determine how many of what type of professionals are produced. Ideally they do so in response to labour market signals generated by health institutions, and these signals should correctly respond to the needs of the population. However, in reality the labour market for health professionals is often characterised by multiple imbalances,50 the most important of which are undersupply, unemployment, and underemployment, which can be quantitative (less than full-time work) or qualitative (suboptimum use of skills). To avoid these imbalances, the educational system must respond to the requirements of the health system. However, this tenet does not imply a subordinate position of the education system. We see educational institutions as crucial to transform health systems. Through their research and leadership functions, universities and other institutions of higher learning generate evidence about the shortcomings of the health system, and about potential solutions. Through their educational function, they produce professionals who can implement change in the organisations in which they work. In addition to labour market linkages, the education and health systems share what could be thought of as a joint subsystem—namely, the health professional education subsystem. Whereas in a few countries schools for health professionals are ascribed to the health ministry, in others they are under the jurisdiction of the education ministry. Irrespective of this administrative issue, the health professional education subsystem has its own dynamic, resulting from its location at the intersection of two major societal systems. After all, health-care spaces are also educational spaces, in which the in-service education of future professionals takes place. The linkage between the education and the health systems should also address the delivery models that determine the skill mix of health workers and the scope for task shifting. In addition to the managerial aspects, there is a political dimension, since health professionals do not act in isolation but are usually organised as interest groups. Furthermore, governments very often influence the supply of health professionals in response to political situation more than to market rationality or epidemiological reality. Lastly, labour markets for health professionals are not only national but also global. In professionals with internationally recognised credentials, migration is a growing occurrence. After specification of the linkages between the health and educational spheres, our framework identifies three key dimensions of education: institutional design (which specifies the structure and functions of the education system), instructional design (which focuses on processes), and educational outcomes (which deal with the desired results; figure 4). Aspects of both institutional and instructional design were already present in the original reports of the 20th century,13–15 which sought to answer not only the question of what and how to teach, but also where to teach—ie, the type of organisation that should undertake the programmes of instruction. However, by contrast with the reports of a century ago, ours considers institutions not only as individual organisations, but also as part of an inter-related set of organisations that implement the diverse functions of an educational system. By adaptation of a framework that was originally formulated to understand health-system performance,51 we can think of four crucial functions that also apply to educational systems: (1) stewardship and governance, which encompass instruments such as norms and policies, evidence for decision making, and assessment of performance to provide strategic guidance for the various components of the educational system; (2) financing, which entails the aggregate allocation of resources to educational institutions from both public and private sources, and the specific modalities for determining resource flows to each educational organisation, with the ensuing set of incentives; (3) resource generation, most importantly faculty development; and (4) service provision, which refers to the actual delivery of the educational service Figure 4: Key components of the educational system and as such reflects instructional design. Institutional design • Systemic level ✓Stewardship and governance ✓Financing ✓Resource generation ✓Service provision • Organisational level ✓Ownership ✓Affiliation ✓Internal structure • Global level ✓Stewardship ✓Networks and partnerships Structure Instructional design Criteria for admission Competencies Channels Career pathways Process Context Global–local Transformative learning Proposed outcomes Interdependence in education
The Lancet commissions The way that the four functions are structured defines Data and methods the systemic level shown in figure 4. Within a system, The conceptual framework was used to guide the individual organisations will vary according to ownership Commissions research, consultations, and report (eg, public, private non-profit, or private for profit), writing. Webappendix pp 6-10 provides detailed data and affiliation (eg, freestanding, part of a health sciences methods for this work. The data consisted of a review of complex, or part of a comprehensive university), and published work, quantitative estimations, qualitative case internal structure(eg, departmental or otherwise). These studies, and commissioned papers, supplemented by are all important aspects of institutional design. Equally consultations with experts and young professionals. We important is the global level. The stewardship function searched all published articles indexed in PubMed and that should be done nationally has a global counterpart, Medline relevant to postsecondary education in medicine, especially with respect to normative definitions about nursing, and public health. Undergraduate medical common core competencies that all health professions educational institutions were compiled by combining should have in every country. An emerging development two major databases: Foundation for the Advancement of globally refers to new forms of organisation, such as International Medical Education and Research(FAIMER) networks and partnerships, which take advantage of and Avicenna, updated by recent regional and countr information and communication technologies data. We estimated public health institutional counts To have a positive effect on the functioning of health from regional association websites, but nursing. systems and ultimately on health outcomes of patients midwifery did not have comparable international data. and populations, educational institutions have to be Because of definitional ambiguity, estimation of public designed to generate an optimum instructional process. health and nursing institutions was incomplete Instructional design involves what can be presented as The numbers of graduates of medicine and nursing. four Cs:(1)criteria for admission, which include both midwifery were derived from both direct reports(eg, from achievement variables, such as previous academic the Organization for Economic Cooperation and performance, and adscription variables, such as social Development [OECDI) and estimates of yearly flows from origin, race or ethnic origin, sex, and nationality, the modelling of nursing stock reported by WHO. We did (2)competencies, as they are defined in the process of not estimate the number of public health graduates designing the curriculum; (3)channels of instruction, because of data and definitional restrictions. by which we mean the set of didactic methods, teaching Financing estimations were calculated through both technologies, and communication media; and (4)career microapproachesandmacroapproaches Microapproaches pathways, which are the options that graduates have on to estimating the financing of medical and nursing completion of their professional studies, as a result of education were based on unit costs of undergraduate the knowledge and skills that they have attained, the education multiplied by number of graduates. We process of professional socialisation to which they have compared these results with macroapproaches that been exposed as students, and their perceptions of calculated the share of tertiary educational financing pportunities in local or global labour markets devoted to medical and nursing education. Although not re 4 precise, the convergence of microapproaches and Different configurations of institutional and macroapproaches provides some assurance that the broad nstructional design will lead to varying educational order of magnitude of our estimations is robust. outcomes. Making the desired results explicit is an essential element in assessment of the performance of Section 2: major findings any system. In the case of our Commission, two The Commissions major findings are presented in four were proposed for the health professional subsections. The first describes a century of educat education system--transformative learning and reforms, grouped into three generations. The next tw interdependence in education. Transformative learning subsections present our diagnosis based on the major is the proposed outcome of improvements in categories of the conceptual framework. Analysis of instructional design; interdependence in education institutional design relies mainly on quantitative data to should result from institutional reforms(figure 4). present a global analysis of institutions, graduates, and Because they are the guiding notions of our financing, followed by key stewardship functions such recommendations, they will be discussed in the final as accreditation, academic systems, faculty development, section of this report and collaboration for shared learning. We then examine A final component of our framework, shown in instructional design, focusing on the purpose, content, figure 4, is that all aspects of the educational system are method, and outcomes of the learning process. deeply affected by both local and global contexts. Challenges are categorised according to the four Cs Although many commonalities might be shared globally, explained in the conceptual framework: criteria for there is local distinctiveness and richness. Such diversity admission, competencies, channels, and career path- rovides opportunities for shared learning across ways. In the final subsection we cut across institutions ountries at all levels of economic development and instruction by examining the challenges of local ww.thelancet.com
The Lancet Commissions www.thelancet.com 11 The way that the four functions are structured defines the systemic level shown in figure 4. Within a system, individual organisations will vary according to ownership (eg, public, private non-profit, or private for profit), affiliation (eg, freestanding, part of a health sciences complex, or part of a comprehensive university), and internal structure (eg, departmental or otherwise). These are all important aspects of institutional design. Equally important is the global level. The stewardship function that should be done nationally has a global counterpart, especially with respect to normative definitions about common core competencies that all health professions should have in every country. An emerging development globally refers to new forms of organisation, such as networks and partnerships, which take advantage of information and communication technologies. To have a positive effect on the functioning of health systems and ultimately on health outcomes of patients and populations, educational institutions have to be designed to generate an optimum instructional process. Instructional design involves what can be presented as four Cs: (1) criteria for admission, which include both achievement variables, such as previous academic performance, and adscription variables, such as social origin, race or ethnic origin, sex, and nationality; (2) competencies, as they are defined in the process of designing the curriculum; (3) channels of instruction, by which we mean the set of didactic methods, teaching technologies, and communication media; and (4) career pathways, which are the options that graduates have on completion of their professional studies, as a result of the knowledge and skills that they have attained, the process of professional socialisation to which they have been exposed as students, and their perceptions of opportunities in local or global labour markets (figure 4). Different configurations of institutional and instructional design will lead to varying educational outcomes. Making the desired results explicit is an essential element in assessment of the performance of any system. In the case of our Commission, two outcomes were proposed for the health professional education system—transformative learning and interdependence in education. Transformative learning is the proposed outcome of improvements in instructional design; interdependence in education should result from institutional reforms (figure 4). Because they are the guiding notions of our recommendations, they will be discussed in the final section of this report. A final component of our framework, shown in figure 4, is that all aspects of the educational system are deeply affected by both local and global contexts. Although many commonalities might be shared globally, there is local distinctiveness and richness. Such diversity provides opportunities for shared learning across countries at all levels of economic development. Data and methods The conceptual framework was used to guide the Commission’s research, consultations, and report writing. Webappendix pp 6–10 provides detailed data and methods for this work. The data consisted of a review of published work, quantitative estimations, qualitative case studies, and commissioned papers, supplemented by consultations with experts and young professionals. We searched all published articles indexed in PubMed and Medline relevant to postsecondary education in medicine, nursing, and public health. Undergraduate medical educational institutions were compiled by combining two major databases: Foundation for the Advancement of International Medical Education and Research (FAIMER) and Avicenna, updated by recent regional and country data. We estimated public health institutional counts from regional association websites, but nursingmidwifery did not have comparable international data. Because of definitional ambiguity, estimation of public health and nursing institutions was incomplete. The numbers of graduates of medicine and nursingmidwifery were derived from both direct reports (eg, from the Organization for Economic Cooperation and Development [OECD]) and estimates of yearly flows from the modelling of nursing stock reported by WHO. We did not estimate the number of public health graduates because of data and definitional restrictions. Financing estimations were calculated through both microapproaches and macroapproaches. Microapproaches to estimating the financing of medical and nursing education were based on unit costs of undergraduate education multiplied by number of graduates. We compared these results with macroapproaches that calculated the share of tertiary educational financing devoted to medical and nursing education. Although not precise, the convergence of microapproaches and macroapproaches provides some assurance that the broad order of magnitude of our estimations is robust. Section 2: major findings The Commission’s major findings are presented in four subsections. The first describes a century of educational reforms, grouped into three generations. The next two subsections present our diagnosis based on the major categories of the conceptual framework. Analysis of institutional design relies mainly on quantitative data to present a global analysis of institutions, graduates, and financing, followed by key stewardship functions such as accreditation, academic systems, faculty development, and collaboration for shared learning. We then examine instructional design, focusing on the purpose, content, method, and outcomes of the learning process. Challenges are categorised according to the four Cs explained in the conceptual framework: criteria for admission, competencies, channels, and career pathways. In the final subsection we cut across institutions and instruction by examining the challenges of local
The Lancet commissions daptability in an interdependent globalising world. In 1900 Science based Problem based Systems based )200o. view of the huge diversity of health and educational systems, we address the question, how can instructional and institutional design achieve effectiveness in diverse contexts while at the same time harnessing the power of Scientif Problem-based competency driven: local-global global pools and flows of knowledge and other resources institutional Health-education Academic centres Century of reforms To capture historical developments in the past century, we defined three generations of reforms (figure 5. We igure 5: Three generations of reform recognise that, as with all classification schemes, this one simplifies multidimensional realities, so our categories are broad and to some extent arbitrary. Yet, they are informed by historical analyses, and we believe that they have Panel 1: The Flexner, Rose-Welch, and Goldmark reports heuristic value. The word generation conveys the notion that this development is not a linear succession of clear-cut Three seminal US reports( Flexner, Welch-Rose, and Goldmark)had powerful effects reforms. Instead, elements of each generation persist in professional health education in North America, and arguably by extension around the world. All the reports recommended major instructional reforms to integrate the subsequent ones, in a complex and dynamic pattern of change. The first generation, launched at the beginning of modern medical sciences into the core curriculum, and institutional reforms to link the 20th century, instilled a science- based curriculum. education to research and the basing of professional education in comprehensive Around mid-century, the second generation introduced problem-basedinstructionalinnovations. A third generation is now needed that should be systems based The report introduced the modern sciences as foundational for the medical curriculum Most countries and professional institutions have mixed into two successive phases: 2 years of basic biomedical sciences, based in universities, patterns of these reforms. In some countries, most followed by 2 years of clinical training, based in academic medical hospitals and schools are entirely confined to the first generation, with centres. Research was to be viewed not as an end in itself but as a link to improved traditional and stagnant curricula and teaching methods patient care and clinical training. Flexner also changed the doctors education from an and with an inability, or even resistance, to change. I apprenticeship model to an academic model, and his report created the conditions for Many countries are incorporating second-generation the birth of academic medical centres, ushering in a hitherto unknown era of discovery. reforms, and a few are moving into the third generation In 1912, Flexner extended his study of medical education to a group of key European countries. Although the Flexner model of professional education was widely adopted generation. utside the USA and Canada, it has often not been sufficiently adapted to address Although the three generations are bounded in the 20th health in vastly different societal contexts century, we recognise that innovation in medical learning has long and deep historical roots worldwide. Early Welch-Rose report 19154 ystems of medical education were reported in India This report offered two competing visions of public health professional education round 6th century BC in a classical text called Rose s plan was for a national system of public health training with central national Susruta Samhita, and in China with lectureships in schools acting as the focus for a network of state schools, both emphasising public Chinese medicine at the Imperial Academy in 624 AD 7 alth practice. By contrast, Welch s plan called for institutes of hygiene, following the Arab and north African civilisations had flourishing German model, with increased emphasis on scientific research and connections to a medical learning systems, as did the greeks and the medical school in comprehensive universities. Welch's plan was financed by the Mesoamerican civilisations. ,9 In the UK, the Royal Rockefeller Foundation to create the Johns Hopkins School of Public Health and College of Physicians started in the 17th century. Hygiene in 1916, and the Harvard School of Public Health in 1922. Most schools of Educational reforms in the 20th century share roots ublic health in the USA followed the Welch model as independent faculties in going back to social movements and the development of universities Outside the USA and Canada, both institutional models described by Rose the medical sciences in the 19th century. In themid-1800s and Welch were implemented and co-exist to this day. Florence Nightingale l campaigned that good nursing Goldmark report 19236 care saved lives, and good nursing care depended on This report advocated for university-based schools of educated nurses. The first nursing education programme of existing educational facilities for training skilled nu report put nursing on gan in London in 1859, as 2-year hospital-based the same academic trajectory as medicine and public health in the USA, albeit a little training that soon spread quickly in the UK, the USA, later in time. Although major health burdens prevailing at the time-such as infant Germany, and Scandinavian countries. 2 The roots ortality and tuberculosis-had greatly decreased, the importance of an improved modern medicine and public health go back similarly to trained nursing workforce remains, including high standards of nursing educational the mid-1800s, propelled by discoveries that proved the germ theory. By the beginning of the 20th century, the fields of medicine and public health had been left behind www.thelancet.com
The Lancet Commissions 12 www.thelancet.com adaptability in an interdependent globalising world. In view of the huge diversity of health and educational systems, we address the question, how can instructional and institutional design achieve effectiveness in diverse contexts while at the same time harnessing the power of global pools and flows of knowledge and other resources? Century of reforms To capture historical developments in the past century, we defined three generations of reforms (figure 5). We recognise that, as with all classification schemes, this one simplifies multidimensional realities, so our categories are broad and to some extent arbitrary. Yet, they are informed by historical analyses, and we believe that they have heuristic value. The word generation conveys the notion that this development is not a linear succession of clear-cut reforms. Instead, elements of each generation persist in the subsequent ones, in a complex and dynamic pattern of change. The first generation, launched at the beginning of the 20th century, instilled a science-based curriculum. Around mid-century, the second generation introduced problem-based instructional innovations. A third generation is now needed that should be systems based. Most countries and professional institutions have mixed patterns of these reforms. In some countries, most schools are entirely confined to the first generation, with traditional and stagnant curricula and teaching methods and with an inability, or even resistance, to change.18,19 Many countries are incorporating second-generation reforms, and a few are moving into the third generation.52–55 No country seems to have all schools in the third generation. Although the three generations are bounded in the 20th century, we recognise that innovation in medical learning has long and deep historical roots worldwide. Early systems of medical education were reported in India around 6th century BC in a classical text called Susruta Samhita,56 and in China with lectureships in Chinese medicine at the Imperial Academy in 624 AD.57 Arab and north African civilisations had flourishing medical learning systems, as did the Greeks and the Mesoamerican civilisations.58,59 In the UK, the Royal College of Physicians started in the 17th century.60 Educational reforms in the 20th century share roots going back to social movements and the development of the medical sciences in the 19th century. In the mid-1800s, Florence Nightingale61 campaigned that good nursing care saved lives, and good nursing care depended on educated nurses. The first nursing education programme began in London in 1859, as 2-year hospital-based training that soon spread quickly in the UK, the USA, Germany, and Scandinavian countries.62 The roots of modern medicine and public health go back similarly to the mid-1800s, propelled by discoveries that proved the germ theory. By the beginning of the 20th century, the fields of medicine and public health had been left behind Panel 1: The Flexner, Rose-Welch, and Goldmark reports Three seminal US reports (Flexner, Welch-Rose, and Goldmark) had powerful effects in professional health education in North America, and arguably by extension around the world. All the reports recommended major instructional reforms to integrate modern medical sciences into the core curriculum, and institutional reforms to link education to research and the basing of professional education in comprehensive universities. Flexner report 191013 The report introduced the modern sciences as foundational for the medical curriculum into two successive phases: 2 years of basic biomedical sciences, based in universities, followed by 2 years of clinical training, based in academic medical hospitals and centres. Research was to be viewed not as an end in itself but as a link to improved patient care and clinical training. Flexner also changed the doctor’s education from an apprenticeship model to an academic model, and his report created the conditions for the birth of academic medical centres, ushering in a hitherto unknown era of discovery. In 1912, Flexner extended his study of medical education to a group of key European countries.63 Although the Flexner model of professional education was widely adopted outside the USA and Canada, it has often not been sufficiently adapted to address health in vastly different societal contexts. Welch-Rose report 191514 This report offered two competing visions of public health professional education. Rose’s plan was for a national system of public health training with central national schools acting as the focus for a network of state schools, both emphasising public health practice. By contrast, Welch’s plan called for institutes of hygiene, following the German model, with increased emphasis on scientific research and connections to a medical school in comprehensive universities. Welch’s plan was financed by the Rockefeller Foundation to create the Johns Hopkins School of Public Health and Hygiene in 1916, and the Harvard School of Public Health in 1922. Most schools of public health in the USA followed the Welch model as independent faculties in universities. Outside the USA and Canada, both institutional models described by Rose and Welch were implemented and co-exist to this day. Goldmark report 192316 This report advocated for university-based schools of nursing, citing the inadequacies of existing educational facilities for training skilled nurses. The report put nursing on the same academic trajectory as medicine and public health in the USA, albeit a little later in time. Although major health burdens prevailing at the time—such as infant mortality and tuberculosis—had greatly decreased, the importance of an improved trained nursing workforce remains, including high standards of nursing educational attainment. Figure 5: Three generations of reform 1900 Science based Problem based Systems based 2000+ Scientific curriculum Problem-based learning Competency driven: local–global Instructional University based Academic centres Health-education systems Institutional
The Lancet commissions by scientific advances, with no rigorous standards of examples, including several in the Arabian countries and education and practice based on modern foundations. south Asia, show the capacity of public health academic After developments in western Europe, the first institutions to respond to diverse and rapidly changing about the public generation of 20th century reforms in North America local requirements(panel 2) ndation of India see were sparked by such reports as Flexner(1910), In parallel with the increasing engagement of national w-phfLorg/ which launched modern health sciences into classrooms reforms began after World War 2 both in industrialised ro mores althseehttp://www dentistry, respectively(panel 1). These reforms, which were independence from colonialism. 7 School and university bracuniversitynet/&S/sph/ usually sequencing education in the biomedical sciences followed by training in clinical and public health practice, Panel 2: Adaptation of public health education and research to local priorities were joined by similar efforts in other regions. Curricular reform was linked to institutional transformation- Several public health institutes have developed over recent decades in response to very university bases, academic hospitals linked to universities, diverse local contexts. We present inovations in three regions: Arabian countries, closure of low.-quality proprietary schools, and the bringing Mexico, and south Asia. gether of research and education. The goals were to Institute of Community and Public Health, Birzeit University, occupied Palestinian n dvance scientifically based professionalism with high territory, is one of three independent schoolsof public health linked to leading technical and ethical standards American philanthropy, led by the Rockefeller of Alexandria in Egypt is a large institution founded in 1956; and the Faculty of Health Foundation, the Carnegie Foundation for the Advancement Sciences, American University of Beirut(AUB), Lebanon, was established as separate from and other similar organisations, promoted AUB's medical school in 1954 and achieved accreditation of its graduate public health these educational reforms by financing the establishment programme from the US Council on Education for Public Health in 2006. All were of dozens of new schools of medicine and public health uniquely shaped by national contexts, ranging from a strong state in Egypt to civil the USA and elsewhere. 2 years after the publication of conflict in Lebanon, to absent state structures in the occupied Palestinian territory. All his original report, which focused on the USA and Canada ive adopted different approaches to public health: application of evidence-based Flexner"extended his study of medical education to the interventions to improve health-care delivery and environmental health in Egypt: German Empire, Austria, France, England, and Scotland. xpansion of multisectoral developmental public health practice in Lebanon; and focus on infuence went beyond nations in social determinants of health necessitating actions inside and outside the health sector in The so-called flexner model was translated into action through the establishment of new medical schools, the e occupied Palestinian territory earliest and most prominent being the Peking Union National Institute of Public Health of Mexico(NIPH), "founded in 1987, responded to Medical College founded in China by the Rockefeller rapid national economic and social change, striving to balance excellence in its research Foundation and implemented by its China Medical Board and educational mission with relevance to decision making through proactive translation in1917635 of knowledge into evidence for policy and practice. The Institute widely disseminated a In public health, the earlier experiences at the London conceptual base around the essential attributes of public health; developed educational School of Tropical Medicine, Tulane University, and the programmes across diverse areas of concentration; implemented a wide range of Harvard-MIT School for Health Officers were affected by innovative educational approaches, from short courses to doctoral programmes; and the Welch-Rose report, "which paved the way for a major developed sound evidence that supported the design, implementation, and evaluation of growth in new schools starting with the Johns Hopkins the ongoing health reform initiative for universal coverage. The success of the NIPH School of Hygiene and Public Health(1916), the Harvard underscores the crucial importance of national and international networking to School of Public Health(1922), the School of Public thstand local difficulties by sharing of experiences to build a strong health-research Health of Mexico(1922), a renewed London School of system that is able to tackle a vast array of local and global health challenges. Hygiene and Tropical Medicine(1924), and the University The Public Health Foundation of India is a unique private-public partnership to energise of Toronto School of Public Health(1927). The Welch. public health by bringing together pooled resources from the Indian Government and Rose model was also exported through Rockefellers private philanthropy to address Indias priority health challenges. The Foundation is funding of 35 new schools of public health overseas, as crafting partnerships with four state governments to create eight training institutes of amplified by the School of Public Health of Mexico, public health in the country. The BRACUniversity's School of Public Health, named which was established in 1922 as part of the Federal after UNICEF's visionary leader James P Grant, was launched by the worlds largest This mass-scale export and adoption had mixed non-governmental organisation and offers an innovative 12-month curriculum for outcomes, with useful results in some countries but also basic public health skills in the context of rural health action, followed by the remaining evere misfits in others. In 1987, the pioneering Mexican 6 months of thematic and research training. These two public health initiatives in south school underwent major reform when it merged with the Asia were based on the legacy of British colonialism, which focused exclusively on medical Centre for Public Health Research and the Centre for rather than public health schools. Importantly, both these schools are developing new Infectious disease research to form the National institute urricula shaped to national and global priorities, and neither is adopting wholesale the of Public Health--one of the leading institutions of its Welch-Rose model of public health education type in the developing world. Many other innovative ww.thelancet.com
The Lancet Commissions www.thelancet.com 13 by scientific advances, with no rigorous standards of education and practice based on modern foundations. After developments in western Europe, the first generation of 20th century reforms in North America were sparked by such reports as Flexner (1910),13 Welch-Rose (1915),14 Goldmark (1923),15 and Gies (1926),16 which launched modern health sciences into classrooms and laboratories in medicine, public health, nursing, and dentistry, respectively (panel 1). These reforms, which were usually sequencing education in the biomedical sciences followed by training in clinical and public health practice, were joined by similar efforts in other regions. Curricular reform was linked to institutional transformation— university bases, academic hospitals linked to universities, closure of low-quality proprietary schools, and the bringing together of research and education. The goals were to advance scientifically based professionalism with high technical and ethical standards. American philanthropy, led by the Rockefeller Foundation, the Carnegie Foundation for the Advancement of Teaching, and other similar organisations, promoted these educational reforms by financing the establishment of dozens of new schools of medicine and public health in the USA and elsewhere.64 2 years after the publication of his original report, which focused on the USA and Canada, Flexner63 extended his study of medical education to the German Empire, Austria, France, England, and Scotland. But the influence went beyond nations in western Europe. The so-called Flexner model was translated into action through the establishment of new medical schools, the earliest and most prominent being the Peking Union Medical College founded in China by the Rockefeller Foundation and implemented by its China Medical Board in 1917.63,65 In public health, the earlier experiences at the London School of Tropical Medicine, Tulane University,66 and the Harvard-MIT School for Health Officers were affected by the Welch-Rose report,14 which paved the way for a major growth in new schools starting with the Johns Hopkins School of Hygiene and Public Health (1916), the Harvard School of Public Health (1922), the School of Public Health of Mexico (1922), a renewed London School of Hygiene and Tropical Medicine (1924), and the University of Toronto School of Public Health (1927). The WelchRose model was also exported through Rockefeller’s funding of 35 new schools of public health overseas, as exemplified by the School of Public Health of Mexico, which was established in 1922 as part of the Federal Department of Health. This mass-scale export and adoption had mixed outcomes, with useful results in some countries but also severe misfits in others. In 1987, the pioneering Mexican school underwent major reform when it merged with the Centre for Public Health Research and the Centre for Infectious Disease Research to form the National Institute of Public Health—one of the leading institutions of its type in the developing world.67 Many other innovative examples, including several in the Arabian countries and south Asia, show the capacity of public health academic institutions to respond to diverse and rapidly changing local requirements (panel 2). In parallel with the increasing engagement of national governments in health affairs, a second generation of reforms began after World War 2 both in industrialised and in developing nations, many of which had just gained independence from colonialism.71 School and university Panel 2: Adaptation of public health education and research to local priorities Several public health institutes have developed over recent decades in response to very diverse local contexts. We present innovations in three regions: Arabian countries, Mexico, and south Asia. Institute of Community and Public Health, Birzeit University, occupied Palestinian territory, is one of three independent schools of public health linked to leading universities in the Arab region; the High Institute of Public Health (HIPH) at the University of Alexandria in Egypt is a large institution founded in 1956; and the Faculty of Health Sciences, American University of Beirut (AUB), Lebanon, was established as separate from AUB’s medical school in 1954 and achieved accreditation of its graduate public health programme from the US Council on Education for Public Health in 2006. All were uniquely shaped by national contexts, ranging from a strong state in Egypt to civil conflict in Lebanon, to absent state structures in the occupied Palestinian territory. All have adopted different approaches to public health: application of evidence-based interventions to improve health-care delivery and environmental health in Egypt; expansion of multisectoral developmental public health practice in Lebanon; and focus on social determinants of health necessitating actions inside and outside the health sector in the occupied Palestinian territory.68 National Institute of Public Health of Mexico (NIPH),69 founded in 1987, responded to rapid national economic and social change, striving to balance excellence in its research and educational mission with relevance to decision making through proactive translation of knowledge into evidence for policy and practice. The Institute widely disseminated a conceptual base around the essential attributes of public health; developed educational programmes across diverse areas of concentration; implemented a wide range of innovative educational approaches, from short courses to doctoral programmes; and developed sound evidence that supported the design, implementation, and evaluation of the ongoing health reform initiative for universal coverage. The success of the NIPH underscores the crucial importance of national and international networking to withstand local difficulties by sharing of experiences to build a strong health-research system that is able to tackle a vast array of local and global health challenges. The Public Health Foundation of India is a unique private–public partnership to energise public health by bringing together pooled resources from the Indian Government and private philanthropy to address India’s priority health challenges. The Foundation is crafting partnerships with four state governments to create eight training institutes of public health in the country.70 The BRAC University’s School of Public Health, named after UNICEF’s visionary leader James P Grant, was launched by the world’s largest non-governmental organisation and offers an innovative 12-month curriculum for masters in public health that begins with 6 months on its Savar rural campus acquiring basic public health skills in the context of rural health action, followed by the remaining 6 months of thematic and research training. These two public health initiatives in south Asia were based on the legacy of British colonialism, which focused exclusively on medical rather than public health schools. Importantly, both these schools are developing new curricula shaped to national and global priorities, and neither is adopting wholesale the Welch-Rose model of public health education. For more about the Public Health Foundation of India see http://www.phfi.org/ For more about BRAC University’s School of Public Health see http://www. bracuniversity.net/I&S/sph/
The Lancet commissions development was accompanied by expansion of tertiary Before the centennial of the Flexner report, a series of hospitals and academic health centres that trained health initiatives have once again heightened national and professionals, did research, and provided care, thereby global attention about the future of education of health integrating these three areas of activity. Pioneered in professionals. We summarise four sets of major reports the 1950s was the idea of graduate medical education that focus on education of the global health workforce, as postgraduate training, which was similar to an nursing education, public health education, and medical apprenticeship, through residency programmes in education. Recommendations in these reports are ea academ increasingly coalescing into a third generation of reforms The major instructional breakthroughs from the second that emphasise patient ar generation of reforms were problem-based learning and competency-based curriculum, interprofessional and disciplinarily integrated curricula In the 1960s, McMaster team-based education, IT-empowered learning, and University in Canada pioneered student-centred learning policy and management leadership skills. These areas based on small groups as an alternative to didactic lecture. we believe, provide a strong base for formulation of style teaching. Simultaneously, an integrated rather than reform initiatives into the 21st century discipline-bound curriculum was experimentally de- Global workforce education has witnessed a major eloped in Newcastle in the UK and Case Western resurgence of policy attention, partly driven by imperatives Reserve in the USA. 5 Other curricular innovations to achieve national and global health objectives as set out included standardised patients-ie, individuals who are by the Millennium Development Goals(MDGs). Three trained to act as a real patient to simulate a set of major reports are noteworthy in terms of education and symptoms or problemsto assess students on practice, training of the workforce: Task Force on Scaling-Up and trengthening doctor-patient relationships through Saving Lives, World Health Report, and the Joint Learning facilitated group discussions, 7 and broadening the Initiative. These reports all underscore the centrality of continuum from classroom to clinical training through the workforce to well performing health systems to achieve earlier student exposure to patients and an expansion of national and global health goals. All the reports draw training sites from hospitals to communities. - In public attention to the global crisis of workforce shortages health, disciplines expanded along with multidisciplinary estimated worldwide at 2.4 million doctors and nurses in work, and in nursing there was accelerated integration of 57 crisis countries. The crisis is most severe in the worlds schools into universities, with advanced graduate poorest nations that are struggling to achieve the MDGs programmes at the master and doctoral levels particularly in sub-Saharan Africa. The shortages also emphasise associated issues, including imbalances of skill Panel 3: Women and nursing in Islamic societies mix, negative work environment, and maldistribution of health workers. The reports cite imbalanced labour market Women and nursing in Islamic societies has a long and rich dynamics that are failing to ensure adequate rural coverage history. In the Middle East and north Africa, higher education hile generating unemployed professionals in capital nursing started in 1955 when the first Higher Institute of cities, and the international migration of professionals or more about Nursing in the region was established in the Faculty of from poor to rich countries Medicine of the Egyptian University of Alexandria. Endorsed These reports recommend vastly increasing investment WHO, the Institute offered a bachelor of nursing degree. The Institute became an autonomous faculty affiliated to the in education and training. They concentrate on basic workers because of the importance of primary health care University in 1994, offering both masters and doctoral and the long time lag and high costs of postsecondary degrees in nursing sciences. During the past 50 years, the education. Consequently, health professionals, although faculty of nursing has produced more than 6000 graduates, acknowledged, do not receive much attention.These many assuming leadership in the region. rts, however, are sparking growing interest in task nother pioneer is the Aga Khan University School of shifting and task sharing-a process of delegating practical Nursing, which was established in Pakistan in 1980, and tasks from scarce professionals to basic health workers. which began offering a bachelor of science in nursing in 1997 All reports propose increased investment, sharing of and the masters of science in 2001. " The school has devised a resources, and partnerships within and across countries unique curriculum adapted to local contexts but based on the Nursing education is the focus of three major reports in curriculum recommended by the American Association of 2010: Radical transformation, by the Carnegie Foundation olleges of Nursings Essentials of Masters Education in Frontline care. a UK Prime minister commission: 2 and the Robert Wood Johnson Foundation Initiative on the future expanded the bachelors and masters nursing programmes to of nursing, at the US Institute of Medicine. "The Carnegie its campus in east Africa In addition to training nurses, report concluded that although nursing has been effective these advanced degree programmes attract high-quality in promotion of professional identity and ethical candidates in Islamic society, showing societal prestige and comportment, the challenge remains of anticipating value for women entering the nursing profession changing demands of practice through strengthening of scientific education and integration of classroom and www.thelancet.com
The Lancet Commissions 14 www.thelancet.com development was accompanied by expansion of tertiary hospitals and academic health centres that trained health professionals, did research, and provided care, thereby integrating these three areas of activity. Pioneered in the 1950s was the idea of graduate medical education as postgraduate training, which was similar to an apprenticeship, through residency programmes in hospital-based academic centres.72 The major instructional breakthroughs from the second generation of reforms were problem-based learning and disciplinarily integrated curricula. In the 1960s, McMaster University in Canada pioneered student-centred learning based on small groups as an alternative to didactic lecturestyle teaching.73 Simultaneously, an integrated rather than discipline-bound curriculum was experimentally developed in Newcastle in the UK and Case Western Reserve in the USA.74,75 Other curricular innovations included standardised patients—ie, individuals who are trained to act as a real patient to simulate a set of symptoms or problems—to assess students on practice,76 strengthening doctor–patient relationships through facilitated group discussions,77 and broadening the continuum from classroom to clinical training through earlier student exposure to patients and an expansion of training sites from hospitals to communities.78–81 In public health, disciplines expanded along with multidisciplinary work, and in nursing there was accelerated integration of schools into universities, with advanced graduate programmes at the master and doctoral levels. Before the centennial of the Flexner report, a series of initiatives have once again heightened national and global attention about the future of education of health professionals. We summarise four sets of major reports that focus on education of the global health workforce, nursing education, public health education, and medical education. Recommendations in these reports are increasingly coalescing into a third generation of reforms that emphasise patient and population centredness, competency-based curriculum, interprofessional and team-based education, IT-empowered learning, and policy and management leadership skills. These areas, we believe, provide a strong base for formulation of reform initiatives into the 21st century. Global workforce education has witnessed a major resurgence of policy attention, partly driven by imperatives to achieve national and global health objectives as set out by the Millennium Development Goals (MDGs). Three major reports are noteworthy in terms of education and training of the workforce: Task Force on Scaling-Up and Saving Lives, 20 World Health Report, 19 and the Joint Learning Initiative. 18 These reports all underscore the centrality of the workforce to well performing health systems to achieve national and global health goals. All the reports draw attention to the global crisis of workforce shortages estimated worldwide at 2·4 million doctors and nurses in 57 crisis countries. The crisis is most severe in the world’s poorest nations that are struggling to achieve the MDGs, particularly in sub-Saharan Africa. The shortages also emphasise associated issues, including imbalances of skill mix, negative work environment, and maldistribution of health workers. The reports cite imbalanced labour market dynamics that are failing to ensure adequate rural coverage while generating unemployed professionals in capital cities, and the international migration of professionals from poor to rich countries. These reports recommend vastly increasing investment in education and training. They concentrate on basic workers because of the importance of primary health care and the long time lag and high costs of postsecondary education. Consequently, health professionals, although acknowledged, do not receive much attention. These reports, however, are sparking growing interest in task shifting and task sharing—a process of delegating practical tasks from scarce professionals to basic health workers. All reports propose increased investment, sharing of resources, and partnerships within and across countries. Nursing education is the focus of three major reports in 2010: Radical transformation, by the Carnegie Foundation; Frontline care, 9 a UK Prime Minister commission;12 and the Robert Wood Johnson Foundation Initiative on the future of nursing, at the US Institute of Medicine.82 The Carnegie report concluded that although nursing has been effective in promotion of professional identity and ethical comportment, the challenge remains of anticipating changing demands of practice through strengthening of scientific education and integration of classroom and Panel 3: Women and nursing in Islamic societies Women and nursing in Islamic societies has a long and rich history. In the Middle East and north Africa, higher education in nursing started in 1955 when the first Higher Institute of Nursing in the region was established in the Faculty of Medicine of the Egyptian University of Alexandria. Endorsed by WHO, the Institute offered a bachelor of nursing degree. The Institute became an autonomous faculty affiliated to the University in 1994, offering both masters and doctoral degrees in nursing sciences. During the past 50 years, the faculty of nursing has produced more than 6000 graduates, many assuming leadership in the region. Another pioneer is the Aga Khan University School of Nursing, which was established in Pakistan in 1980, and which began offering a bachelor of science in nursing in 1997 and the masters of science in 2001.83 The school has devised a unique curriculum adapted to local contexts but based on the curriculum recommended by the American Association of Colleges of Nursing’s Essentials of Master’s Education in Advanced Nursing (1996).84 Aga Khan University has also expanded the bachelors and masters nursing programmes to its campus in east Africa.83 In addition to training nurses, these advanced degree programmes attract high-quality candidates in Islamic society, showing societal prestige and value for women entering the nursing profession. For more about the Faculty of Nursing at the University of Alexandria see: http://www. alexnursing.edu.eg