By: Lisa Croucher, Duke Global Health Institute
Three renowned international leaders in medical education offered perspectives on the implementation of the 2010 Lancet Commission Report, Health professionals for a new century: transforming education to strengthen health systems in an interdependent world (http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2810%2961854-5/fulltext).
Dr. Julio Frenk, Dean of the Harvard School of Public Health and co-chair of the initiative that produced the report, introduced the Commission’s work and positioned the resultant report in the context of historical trends in both instructional and institutional development over the past 100 years. With the publication of the landmark Flexner Report in 1910, the instructional focus of medical education shifted to basic and clinical sciences, and the university became the institutional home for medical education. Beginning in the 1970s, the instructional focus shifted to a problem-based curriculum, as academic medical centers were established to provide the institutional foundation for problem-based medical education and research.
The Lancet Commission report espouses the importance of a competency based curriculum that integrates education systems with health systems, on a local, national, regional and global level. Frenk explained that in the new model, “populations,” who previously may have been viewed as clients or consumers of a health system, are now seen as fundamental stakeholders and contributors to the design of an integrated education and health system that addresses real needs in the workforce. To date, systemic failures in the education of health professions have produced a “fundamental mismatch of competencies to needs” leading to an excess of “doctors without jobs and jobs without doctors.”
The Commission report, which has been formally launched in 20 locations worldwide and has been translated into 6 languages, articulates 10 specific recommendations for instructional and institutional reform that links education and health systems. The desired result is an integrated system that produces change agents trained to address real local and global health needs.
Dr. David Serwadda, Professor of Public Health at Makerere University, presented on the distribution and reception of the Commission report in Uganda and its relevance to the Sub-Saharan Africa context. Serwadda predicted that by 2050, 1/5 of the global population will live in Africa, noting that Africa will see “a refugee situation in slow motion” as huge portions of the population migrate from rural to urban areas, resulting in 60% of Africa predicted to be urbanized by 2050. Serwadda observed that, meanwhile, there is a “huge hemorrhage of physicians from Sub-Saharan Africa” to higher-income regions of the world (regions that Dr. Frenk cleverly referred to as the “undeveloping world”).
“Many of the recommendations in this report have been going on at Makerere for many years,” Serwadda said. “The report resonates with what some of these institutions have already been doing and it reinforces that this is something right for us to move forward.”
Dr Zulfiqar A. Bhutta, Chair of Division of Women and Child Health at Aga Khan University, presented the state of health education in Pakistan and summarized the activities related to the Lancet report. Challenges to the training and maintenance of a health workforce in Pakistan include the fact that most medical colleges are in urban centers and that of approximately 6200 physicians trained each year, about 1700 are “lost” due to emigration or decisions not to enter the workforce, namely that many of the female graduates go on to raise families instead of practice medicine.
In the late 2000s, Prime Minister Benazir Bhutto implemented the largest community health worker program in the region which positioned lady health workers as the backbone of community health services. Pakistan now has a health system that bulges with physicians, albeit poorly distributed, and with well-trained lady health workers but with few other intermediary cadres of health workers. The government is focusing its attention on task shifting and on care in rural areas.
The Lancet report has been distributed and discussed widely in Pakistan, in both formal and informal settings, by the leaders of 26 medical schools, universities and postgraduate colleges, with many having discovered and read the report on their own prior to having been invited to discuss it at a national level.
The leaders expressed “intense interest and broad agreement with the report” and identified primary challenges to its successful implementation – lack of resources (faculty, financial, transportation), a “dysfunctional health system,” and clarity and relevance of the competency requirements which address local and global or regional needs. They developed specific action points to address each of the identified challenges.
And then, in June 2010, the Pakistan Ministry of Health was abolished, as curtly noted here: http://www.health.gov.pk/. As a result, all health planning was shifted to the district and provincial levels, which are now embarking on the same planning and analysis that was already conducted at the national level.
Uganda and Pakistan provide enlightening case studies of the potential impact of the Lancet Commission report, as well as acute examples of the challenges involved in implementing its recommendations.