Education and training of health workers: towards systems solutions

1. Education and training of health workers: towards systems solutions July 3, 2012

2. Objectives • To review the Task Force Report • To consider the changes in mortality and the burden of surgical diseases in LMICs • To consider the above as they relate to improving access to high quality obstetrical services in LMICs • To consider the roles of the public and private sectors in system solutions

3. HW make a difference1

4. The maldistribution of HWs1

5. Estimating the HW shortfall1

6. The Task Force Lord Nigel Crisp (Co-Chair) Commissioner BienceGawanas(Co-Chair) Hon. Stephen Mallinga Hon. Marjorie Ngaunje Miriam Were Srinath Reddy Alex Preker Judith Oulton Anders Nordstrom Cathy Cahill Francisco Campos Louise Holt Peggy Vidot Gustavo Gonzalez-Canali Francis Omaswa

7. Types of health workers needed2

8. Prerequisites for successful scaling up2

9. Aligning HHR with system needs

10. Attrition is very high in Uganda3

11. There is an issue of quality5,6 In Tanzania 46% of women deliver in a health facilities. Is it safe?

12. Quality gaps are system wide7

13. Integrate education and health systems

14. New educational models

15. Towards a time table

16. Labor costs of scaling up in SSA a baseline number of HWs is 1.6m b 0.9m if focus on mid-level cadres; 0.4m if focus on hi-level cadres

17. But … Costs for education and training scale up are not included. These costs alone are estimated at $US26.4b! How can you do both within a sharply circumscribed and inadequately funded system? Consider the use of ICTs, measures to decrease attrition and outward migration, modular education, COBES, career paths, changing skill mix.

18. The Zambia scale up example4 Training institutions estimate that they can meet targets of 70% increases. Modest infrastructure ($US60m) and teaching personnel investments (+400) required. Training Plan scale-up targets lead to some cadres meeting their target establishment much earlier than others

19. Recommendations • Reduce attrition and improve accessibility • Integrate pre-service and in-service education and training • Develop common educational platforms for different types of health worker • Move learning to the community, using modular education and action learning • Increase use of information and communication technologies • Improve education through quality assurance programs • Build institutional capacity • Expand teaching capability • Foster twinning and partnerships • Maximize impact through regional approaches • Harness public-private partnerships

20. The increasing burden of surgical diseases

21. The causes of mortality are changing8

22. Global burden of surgical diseases9 15.6 14.6 35 average surgical rate 34.8 r2=0.996

23. Global burden of surgical diseases • Majority of surgical problems in LMICs relate to general surgery and obstetrics10,11 • Compelling shortage of adequately trained surgical and anesthesia HRH • Important lessons to be learned from task shifting and TTR12 • Task shifting can be done effectively and safely13,14,15

24. The issue of maternal mortality

25. Maternal mortality is decreasing16 But the rate of decrease is too slow to meet the MDGs.

26. Where are the deaths? 50% of deaths in 6 countries: India, Nigeria, Pakistan, Afghanistan, Ethiopia, DRC 52% of maternal deaths in 2008 in SSA

27. How do mothers die?17

28. Shortage of obstetrical emergency coverage Examples of countries in which there is massive deprivation in coverage for obstetrical emergencies. A clear rural-urban divide is evident. The shortfall relates to poor HRH coverage, poor quality of care and poor facilities.18 In Uganda, only 6% of anesthesiologists felt they could provide safe anesthesia for CS.19

29. Who is responsible for anesthesia? • 40+% of anesthesia in LMICs given by nurses20

30. Need for nurse anesthetists Need to significantly increase training of nurses who can deliver safe anesthesia in primary and district health facilities18,19,20 Training programs must be tailored to need Co-training of anesthesia and surgical trainees may offer economies of scale and quality21

31. Improving access to surgical and obstetrical services A brief systems perspective

32. Tiering of the health system22

33. Maternal mortality is stratified7

34. Surgical activities in district hospitals11

35. Impact of facility birthing7

36. Plus birthing units19,23

37. The costs are reasonable7

38. The role of the private sector?

39. Potential of the private sector • Builds on the reputation/accomplishments of the NFP private sector • Adds significant intellectual and capital capacity • Provides agility and ability to anticipate market forces • Driven by success • Not bound by tradition • Double and triple bottom line increasingly understood

40. Unfortunately … • PFP [medical] schools have a poor record for quality. This goes back to Flexner.24 • PFP schools viewed as diploma mills with different standards vs public schools25 • Outdated curricula with few/poor teachers26,27,28 • Graduates may not do as well on qualifying exams29 • PFP schools may not meet local needs30

41. Indian medical schools10 Data sources: Medical Council of India; Reserve Bank of India; Census Commissioner India

42. Private networks • Drive the accountability agenda • focus on accreditation and governance • Participate actively in global initiatives • Education of health professionals for the 21st century11 • Joint action and learning initiative32 • Develop consortium approaches • Confidence Partnerships

43. Summary • The huge demand for growth in health professional education means that the PFP sector has an important role to play. • The PFP sector has a variable reputation in health professional education. • But it has an exceptional opportunity to drive innovation in medical and health sciences education.

44. Private sector provisos • Is the PFP investment characterized by patient money? • How to ensure compatibility with the principles of universal coverage? • How to enhance the strength of the public sector? • How to ensure continued viability and development of the primary care sector? • How to think beyond the SCHOOL and the HOSPITAL?

45. Africa’s changing face33,34,35,36

46. Lions of growth

47. References 1 World Health Report 2006. Working together for health 2 Scaling up, saving lives. Task Force on Scaling Up Education and Training for Health Workers 3McQuide P, Matte R, Arusha Tanzania 2006 4 Clinton Foundation 2008 5 Harvey SA et al Int J ObstetGyn 2004;87:203 6 ECSA 2008 7Friberg IK et al PLoS Med 2010;7:e1000295 8 Murray CJL, Lopez AD Lancet 1997;349:1269 9 Weiser TG et al Lancet 2008;372:139 10Luboga S et al PLoS Med 2009;6:e1000200 11Galukande M et al PLoS Med 2010;7:e1000243 12Chu K et al PLoS Med 2009;6:e1000078 13Dovlo D Hum Resour Health 2004;18:7 14Mullan F, Frehywot S Lancet 2007;370:2158 15 Pereira C et al BJOG 2007;114:1530 16 Hogan MC et al Lancet 2010;375:1609

48. References 17 Kinney MV et al PLoS Med 2010;6:e1000294 18Koblinsky M et al Lancet 2006;368:1377 19 Hodges SC et al Anesthesia 2007;62:4 20 Kruk ME et al PLoS Med 2010;7:e1000242 18Cherian M et al Bull WHO DOI: 10.2471/BLT.09.072371 19Dubowitz G et al World J Surg 2010;34:438 20 Kushner AL et al Arch Surg 2010;145:154 21 Newton M, Bird P World J Surg 2010;34:445 22 Lawn JE et al Lancet 2008;372:917 23 Koblinsky M et al Lancet 2006;368:1377 24Ludmerer KM Time to heal, OUP 1999 25Supe A and Burdick WP Acad Med 2006;81:1076 26 Amin Z et al Acad Med 2010;85;333 27 Nair M and Webster P Med Educ 2010;44:856 28Rao M et al Lancet 2011;377:597 29 van Zanten M and Boulet JR Acad Med 2008;83:S33 30Kanchanachitr C et al Lancet 2011;377:769 31Mahal A and Mohanan M Med Educ 2006;40:1009

49. References 32Goston LO et al PLoS Med 2011;8:1001031 33Moyo D Dead Aid, 2009 34Sen A Development as freedom, 1999 35 Sachs JD Common wealth, 2008 36 Lions on the move, McKinsey Global Institute, June 2010