The Lancet commissions clinical teaching. The UK Commission identifies the competencies of different professions. At the same time, requisite core competencies, skills, and support systems they underscore the opportunities for mutual learning for nursing For the National Health Service itrecommends across diverse countries. Taken together, they form a base mainstreaming nursing into national service planning, of convergence around a third generation of reforms that development, and delivery. Pioneering work in nursing promise to address gaps and opportunities in a education is also being pursued in other regions--eg, in globalising world. China and Islamic countries(panel 3) Public health education is the subject of two major Institutional design ports by the US Institute of Medicine in 2002 and 2003, In this subsection, we focus on institutions of both focusing on the future of public health in the 21st postsecondary education that offer professional degrees century. The reports recommend that the core in medicine, public health, or nursing. Such educational curriculum adopt transdisciplinary and multischool institutions might be extraordinarily diverse. They might approaches, and instil a culture of lifelong learning. They be independent or linked to government, part of a also urge that public health skills and concepts be better university or freestanding, fully accredited, or even integrated into medicine, nursing, and other allied health informally established. Their facilities might range from fields, become more engaged with local communities rudimentary field training sites to highly sophisticated and policy makers, and be disseminated to other campuses. And each country, of course, has its ow practitioners, researchers, educators, and leaders. unique legacy because institution building is a long-term Importantly, the reports argue in favour of expanding path-dependent development prod federal funding for public health development. ne major distinction is between public versus private Medical education has received great attention, as shown ownership, with a wide range of patterns in between by a series of four selected recent reports: Future of medical Although some are autonomous, many publicly owned education, by the Associations of Faculties of Medicine of institutions are also publicly operated, usually under the Canada; Tomorrows doctors, by the General Medical oversight of the ministry of education or the ministry of Council of the UK, Reform in educating physicians, by the health. In decentralised countries, state or provincial Carnegie Foundation; and Revisiting medical education at governments might be especially engaged. The oversight a time ofexpansion, by the Macy Foundation. An additional between these ministries and departments often falls report was issued by the Association of American Medical predominantly to one or the other, and coordination Colleges: A snapshot of medical student education in the USA might not be strong because of preoccupation of and Canada. s All reports concur that health professionals competing priorities in the USA, the UK, and Canada are not being adequately Private institutions might be non-profit or for-profit. repared in undergraduate, postgraduate, or continuing Historically, religious and missionary movements have ducation to address challenges introduced by ageing, established many non-profit hospitals and some medical changing patient populations, cultural diversity, chronic and nursing schools. Non-profit institutions have also diseases, care-seeking behaviour, and heightened public been created by philanthropy, charitable organisations expectations and corporations as part of their social endeavours. In The focus of these reports is on core competencies many countries, proprietary for-profit schools are beyond the command of knowledge and facts. Rather, the increasing, especially to produce doctors and nurses to ompetencies to be developed include patient-centred exploit opportunities in the global labour market. 5 86 care, interdisciplinary teams, evidence-based practice, Most institutions possess mixed patterns of public and and integration of public health. Research skills are valued, heavily on public subsidies for research, scholarships as are competencies in policy, law, management, and and services, whereas publicly owned and operate leadership. Undergraduate education should prepare institutions often have distinguished private individuals graduates for lifelong learning. Curriculum reforms serving in leadership and governance roles include outcome-based programmes tracked by In our study, all such institutions have degree-granting assessment,capacity to integrate knowledge and authority. There is a multiplicity of degrees, and the same experiences,flexible individualisation of the learning degree could be acquired with highly variable curricular process to include student-selected components, and content, duration of study, quality of education, and development of a culture of critical inquiry-all for competency achieved. Globally, and even nationally, there ping physicians with a renewed sense of socially is little uniformity with respect to qualification and sible professionalism. competency of degree holders. Medical doctors in China perspectives of these major initiatives between rich for example, might obtain professional practice degrees and poor countries, and between the professions, are very with 3, 5, 7, or 8 years of postsecondary education. These different. These differences reflect the huge diversity of graduates are the credentialed practitioners, compared conditions between countries at various stages of with the nearly 1 million additional village doctors who educational and health development and the core mostly have only vocational training. In public health, ww.thelancet.com
The Lancet Commissions www.thelancet.com 15 clinical teaching. The UK Commission identifies the requisite core competencies, skills, and support systems for nursing. For the National Health Service it recommends mainstreaming nursing into national service planning, development, and delivery. Pioneering work in nursing education is also being pursued in other regions—eg, in China and Islamic countries (panel 3). Public health education is the subject of two major reports by the US Institute of Medicine in 2002 and 2003, both focusing on the future of public health in the 21st century.5,6 The reports recommend that the core curriculum adopt transdisciplinary and multischool approaches, and instil a culture of lifelong learning. They also urge that public health skills and concepts be better integrated into medicine, nursing, and other allied health fields, become more engaged with local communities and policy makers, and be disseminated to other practitioners, researchers, educators, and leaders. Importantly, the reports argue in favour of expanding federal funding for public health development. Medical education has received great attention, as shown by a series of four selected recent reports: Future of medical education, by the Associations of Faculties of Medicine of Canada;11 Tomorrow’s doctors, by the General Medical Council of the UK;8 Reform in educating physicians, by the Carnegie Foundation;10 and Revisiting medical education at a time of expansion, by the Macy Foundation.7 An additional report was issued by the Association of American Medical Colleges: A snapshot of medical student education in the USA and Canada. 85 All reports concur that health professionals in the USA, the UK, and Canada are not being adequately prepared in undergraduate, postgraduate, or continuing education to address challenges introduced by ageing, changing patient populations, cultural diversity, chronic diseases, care-seeking behaviour, and heightened public expectations. The focus of these reports is on core competencies beyond the command of knowledge and facts. Rather, the competencies to be developed include patient-centred care, interdisciplinary teams, evidence-based practice, continuous quality improvement, use of new informatics, and integration of public health. Research skills are valued, as are competencies in policy, law, management, and leadership. Undergraduate education should prepare graduates for lifelong learning. Curriculum reforms include outcome-based programmes tracked by assessment, capacity to integrate knowledge and experiences, flexible individualisation of the learning process to include student-selected components, and development of a culture of critical inquiry—all for equipping physicians with a renewed sense of socially responsible professionalism. The perspectives of these major initiatives between rich and poor countries, and between the professions, are very different. These differences reflect the huge diversity of conditions between countries at various stages of educational and health development and the core competencies of different professions. At the same time, they underscore the opportunities for mutual learning across diverse countries.24 Taken together, they form a base of convergence around a third generation of reforms that promise to address gaps and opportunities in a globalising world. Institutional design In this subsection, we focus on institutions of postsecondary education that offer professional degrees in medicine, public health, or nursing. Such educational institutions might be extraordinarily diverse. They might be independent or linked to government, part of a university or freestanding, fully accredited, or even informally established. Their facilities might range from rudimentary field training sites to highly sophisticated campuses. And each country, of course, has its own unique legacy because institution building is a long-term, path-dependent development process. One major distinction is between public versus private ownership, with a wide range of patterns in between. Although some are autonomous, many publicly owned institutions are also publicly operated, usually under the oversight of the ministry of education or the ministry of health. In decentralised countries, state or provincial governments might be especially engaged. The oversight between these ministries and departments often falls predominantly to one or the other, and coordination might not be strong because of preoccupation of competing priorities. Private institutions might be non-profit or for-profit. Historically, religious and missionary movements have established many non-profit hospitals and some medical and nursing schools. Non-profit institutions have also been created by philanthropy, charitable organisations, and corporations as part of their social endeavours. In many countries, proprietary for-profit schools are increasing, especially to produce doctors and nurses to exploit opportunities in the global labour market.35,86,87 Most institutions possess mixed patterns of public and private governance. Private institutions often depend heavily on public subsidies for research, scholarships, and services, whereas publicly owned and operated institutions often have distinguished private individuals serving in leadership and governance roles. In our study, all such institutions have degree-granting authority. There is a multiplicity of degrees, and the same degree could be acquired with highly variable curricular content, duration of study, quality of education, and competency achieved. Globally, and even nationally, there is little uniformity with respect to qualification and competency of degree holders. Medical doctors in China, for example, might obtain professional practice degrees with 3, 5, 7, or 8 years of postsecondary education.88 These graduates are the credentialled practitioners, compared with the nearly 1 million additional village doctors who mostly have only vocational training.89 In public health
The Lancet commissions bachelor degree holders constitute a large proportion of is associated with low national income, especially professionals worldwide. Many postgraduate degree affecting sub-Saharan Africa; however, abundance is holders have attended independent public health schools, not concentrated only in wealthy countries. Indeed, but many attended medical school departments or several middle- income countries have increased the bunits. Postgraduate public health degree holders number of institutions to deliberately export come from multiple professions--clinical medicine, professionals, because many wealthy countries have nursing, dentistry, pharmacy--or other fields such as chronic deficits since they underproduce below national social sciences, law, humanities, biology, and social requirements. Not surprisingly, the number and pattern policy. Nursing produces postsecondary graduates with a of medical institutions do not match well with national bachelor of science in a nursing degree. An increasing population size, gross national product, or burden number of nurses are continuing on to masters or of disease doctoral training However, substantial numbers, We estimate about 2420 medical schools producing ven the bulk of nt have vocational or on- around 389000 medical gradu population of 7 billion people(table 1). Noteworthy are Our study undertook a quantitative assessment of the large number of medical schools in India, China, ducational institutions in medicine, nursing, and western Europe, and Latin America and the Caribbean, bublic health. To our knowledge, this is the first-ever by contrast with the scarcity of schools in central Asia, mapping of health professional education around the central and eastern Europe, and sub-Saharan Africa. We world. After showing the patterns of institutions, also estimate 467 schools or departments of public health graduates, and financing, we discuss frontier challenges which is 20% of the number of medical schools. Our as key drivers for institutional improvement- count of public health schools is han accreditation, academic centres, collaboration, faculty in definition. We aggregated degree-granting publi health institutions with medical school departments or ibunits offering varying degree titles such as communi Global perspective medicine, preventive medicine, or public health. We Because of restricted data availability, our global estimate that about 541000 nurses graduate every year, erspective focuses on medical education, but when which is nearly double the number of medical graduates. data are available we cite comparable information about Counts of nursing schools are not straightforward nursing, public health, dentistry, pharmacy, and because of few data and ambiguous definitions. Although community health workers. Not surprisingly, we nursing has many postgraduate programmes, there are recorded large global diversity in medical institutions, also many certificate programmes in vocational schools with abundance and scarcity across countries. Scarcity Many are traditional or informal practitioners with Population Estimated number of schools Estimated graduates peryear Workforce( thousands) 13 30 36 Central High-income Asia-Pacific 227 1543 Europe 122 Eastern 82 350 74 2997 Latin America/Caribbean 827 1099 North Africa/Middle East 450 46 Webappendix pp 6-11 shows data sources and regional distribution. Table 1: Institutions, graduates, and workforce by region(2008) www.thelancet.com
The Lancet Commissions 16 www.thelancet.com bachelor degree holders constitute a large proportion of professionals worldwide. Many postgraduate degree holders have attended independent public health schools, but many attended medical school departments or subunits. Postgraduate public health degree holders come from multiple professions—clinical medicine, nursing, dentistry, pharmacy—or other fields such as social sciences, law, humanities, biology, and social policy. Nursing produces postsecondary graduates with a bachelor of science in a nursing degree. An increasing number of nurses are continuing on to masters or doctoral training.9 However, substantial numbers, perhaps even the bulk of nurses, have vocational or onthe-job training. Our study undertook a quantitative assessment of educational institutions in medicine, nursing, and public health. To our knowledge, this is the first-ever mapping of health professional education around the world. After showing the patterns of institutions, graduates, and financing, we discuss frontier challenges as key drivers for institutional improvement— accreditation, academic centres, collaboration, faculty development, and learning. Global perspective Because of restricted data availability, our global perspective focuses on medical education, but when data are available we cite comparable information about nursing, public health, dentistry, pharmacy, and community health workers. Not surprisingly, we recorded large global diversity in medical institutions, with abundance and scarcity across countries. Scarcity is associated with low national income, especially affecting sub-Saharan Africa; however, abundance is not concentrated only in wealthy countries. Indeed, several middle-income countries have increased the number of institutions to deliberately export professionals, because many wealthy countries have chronic deficits since they underproduce below national requirements. Not surprisingly, the number and pattern of medical institutions do not match well with national population size, gross national product, or burden of disease. We estimate about 2420 medical schools producing around 389 000 medical graduates every year for a world population of 7 billion people (table 1). Noteworthy are the large number of medical schools in India, China, western Europe, and Latin America and the Caribbean, by contrast with the scarcity of schools in central Asia, central and eastern Europe, and sub-Saharan Africa. We also estimate 467 schools or departments of public health, which is 20% of the number of medical schools. Our count of public health schools is hampered by variability in definition. We aggregated degree-granting public health institutions with medical school departments or subunits offering varying degree titles such as community medicine, preventive medicine, or public health. We estimate that about 541 000 nurses graduate every year, which is nearly double the number of medical graduates. Counts of nursing schools are not straightforward because of few data and ambiguous definitions. Although nursing has many postgraduate programmes, there are also many certificate programmes in vocational schools. Many are traditional or informal practitioners with Population (millions) Estimated number of schools Estimated graduates per year (thousands) Workforce (thousands) Medical Public health Doctors Nurses/midwives Doctors Nurses/midwives Asia China 1371 188 72 175 29 1861 1259 India 1230 300 4 30 36 646 1372 Other 1075 241 33 18 55 494 1300 Central 82 51 2 6 15 235 603 High-income Asia-Pacific 227 168 26 10 56 409 1543 Europe Central 122 64 19 8 28 281 670 Eastern 212 100 15 22 48 840 1798 Western 435 282 52 42 119 1350 3379 Americas North America 361 173 65 19 74 793 2997 Latin America/Caribbean 602 513 82 35 33 827 1099 Africa North Africa/Middle East 450 206 46 17 22 540 925 Sub-Saharan Africa 868 134 51 6 26 125 739 World 7036 2420 467 389 541 8401 17684 Webappendix pp 6–11 shows data sources and regional distribution. Table 1: Institutions, graduates, and workforce by region (2008)