Posted by: davidjolson | 03/11/2011

Transforming education to strengthen global health systems

NOTE: This is a guest blog by Homira Nassery, the HNP Knowledge, Learning, & Fragile States coordinator for Health, Nutrition and Population at the World Bank.

The diminishing stock and shifting balance of health care workers globally has become an increasingly pressing issue that development actors are struggling to address. Hence, it was with great anticipation that a packed house attended Julio Frenk’s discussion of “Transforming Education to Strengthen Health Systems.” As articulate as ever, Dr. Frenk quickly set the stage by referring to the Flexner Report of 1910 and the Welch-Rose report of 1915 as defining documents for medical education in the 20th century. And he referred to the report “Health Professionals for a New Century: Transforming Education to Strengthen Health Systems in an Interdependent World,” upon which his presentation was based.

Key points he made that we can all generally agree upon were:

·     The focus should be on all health professions from doctors to nurses to dentists to pharmacists to public health specialists to avoid the creation of the traditional silos that exist between these positions.

·     The long-term perspective on post-secondary education includes developed and developing countries – i.e. all income levels.

·     An integrative framework is used to match people who have needs with people who respond to these needs with services.

Here is Dr. Frenk’s presentation.

The key challenge that emerged from this discussion is the mismatch of skills competencies of health care professionals with the skills most needed by the market of health care users. This mismatch creates the labor market distortion in the health sector that plagues all countries. The proposed solution is to link the education system more closely with the health system via close coordination and collaboration between ministries of health and education, as well as bringing in ministries of finance to lend a reality check to the sectors.

Teamwork is the competency that Dr. Frenk singled out as not being part of the basic medical or public health curriculum, but essential to the effectiveness of the health system. He suggested that there is no instruction in how to function as a team or lead a team in our current health education model.

If one defines teamwork as work done by several associates with each doing a part but all subordinating personal prominence to the efficiency of the whole, I would venture to ask, what professional field DOES specifically target team-building skills in the preliminary education of its workers?  The only sectors that that quickly come to mind are the military and athletics, in which teamwork and leadership are heavily branded as part of basic training.

But at the same time, when I think of my clinical work and how effortlessly and smoothly the medical professionals on a code team worked together as one organism, each part knowing its function and not questioning tasks, I think the public policy arena could learn a lot from clinical care.

Code team: a specially trained and equipped team of physicians, nurses, and technicians that is available to provide advanced cardiac life support when summoned by an emergency code set by the institution. A code team usually includes a physician, registered nurse, respiratory therapist, and pharmacist.

Even in non-emergency medical cases, the roles and responsibilities in hospital care are far more concrete and focused on the patient than I have experienced working in project management or public policy, so perhaps we should be looking closely at what we can learn from clinical care that could be applied to health systems.

Of course that cohesion inevitably breaks down in resource-poor settings such as the environment that a community health worker (CHW) works in. CHWs are a category of health care worker  in lower-income settings that has no direct counterpart in high-income countries aside from possibly the role of the social worker. CHWs are often overlooked by health education planners in lower income and middle-income countries since they are recruited at the community level and receive on-the-job training.

Indeed, GHC President & CEO Jeffrey L. Sturchio raised this salient issue at the conclusion of the panel by stating that the codified knowledge of health professionals should go beyond the traditional nurse and doctor classifications to include CHWs, who should be trained, paid and able to make referrals.

Unfortunately, this is often not the case, particularly the payment of CHWs. In many systems, donors expect them to work for free with the assumed respect of the community as the major incentive to continue performing the role.  With all of our emphasis on PBF/RBF now, this approach is increasingly irrational as most of the CHW’s primary responsibilities are preventive health care and education, hence these activities would be replaced by those that they can charge people for, thus eroding the primary purpose of CHWs.

I hope that Dr. Sturchio’s perspective will be taken seriously as the CHWs are the spine of community level care, and could contribute substantially to prevention of both infectious and non-communicable diseases.

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