Education and training of health workers: towards systems solutions

July 3, 2012

Objectives

1. To review the Task Force Report2. To consider the changes in mortality and the

burden of surgical diseases in LMICs3. To consider the above as they relate to

improving access to high quality obstetrical services in LMICs

4. To consider the roles of the public and private sectors in system solutions

HW make a difference1

The maldistribution of HWs1

Estimating the HW shortfall1

The Task ForceLord Nigel Crisp (Co-Chair)Commissioner Bience Gawanas (Co-Chair)Hon. Stephen MallingaHon. Marjorie NgaunjeMiriam WereSrinath ReddyAlex PrekerJudith OultonAnders NordstromCathy CahillFrancisco CamposLouise HoltPeggy VidotGustavo Gonzalez-CanaliFrancis Omaswa

Types of health workers needed2

Prerequisites for successful scaling up2

Aligning HHR with system needs

Attrition is very high in Uganda3

There is an issue of quality5,6

In Tanzania 46% of women deliver in a health facilities. Is it safe?

Quality gaps are system wide7

Integrate education and health systems

New educational models

Towards a time table

Labor costs of scaling up in SSA

Total health expenditures

(US$b)

Per capita health expenditures

(US$ per person/y)

Additional staff (millions)

Baseline 27.0 36.7 0a

Best case scenario 57.5 63.1 1.7

Projection of current trends

42.0 46.5 0.6b

Worst case scenario 15.8 17.0 -0.8

a baseline number of HWs is 1.6mb 0.9m if focus on mid-level cadres; 0.4m if focus on hi-level cadres

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.

The Zambia scale up example4

Training Plan scale-up targets lead to some cadres meeting their target establishment much earlier than others

Training institutions estimate that they can meet targets of 70% increases.Modest infrastructure ($US60m) and teaching personnel investments (+400) required.

Recommendations1. Reduce attrition and improve accessibility2. Integrate pre-service and in-service education and training3. Develop common educational platforms for different types of health

worker4. Move learning to the community, using modular education and action

learning5. Increase use of information and communication technologies6. Improve education through quality assurance programs7. Build institutional capacity

i. Expand teaching capabilityii. Foster twinning and partnershipsiii. Maximize impact through regional approachesiv. Harness public-private partnerships

The increasing burden of surgical diseases

The causes of mortality are changing8

Global burden of surgical diseases9

r2=0.996

34.8

35

14.6 15.6

average surgical rate

Global burden of surgical diseases

2. Majority of surgical problems in LMICs relate to general surgery and obstetrics10,11

3. Compelling shortage of adequately trained surgical and anesthesia HRH

4. Important lessons to be learned from task shifting and TTR12

5. Task shifting can be done effectively and safely13,14,15

The issue of maternal mortality

Maternal mortality is decreasing16

But the rate of decrease is too slow to meet the MDGs.

Where are the deaths?

50% of deaths in 6 countries: India, Nigeria, Pakistan, Afghanistan, Ethiopia, DRC52% of maternal deaths in 2008 in SSA

How do mothers die?17

Shortage of obstetrical emergency coverage

Examples of countries in which there is massivedeprivation 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

Who is responsible for anesthesia?1. 40+% of anesthesia in LMICs given by nurses20

Need for nurse anesthetists

2. Need to significantly increase training of nurses who can deliver safe anesthesia in primary and district health facilities18,19,20

3. Training programs must be tailored to need4. Co-training of anesthesia and surgical

trainees may offer economies of scale and quality21

Improving access to surgical and obstetrical services

A brief systems perspective

Tiering of the health system22

Maternal mortality is stratified7

Surgical activities in district hospitals11

Impact of facility birthing7

Plus birthing units19,23

Personnel Number Deliveries/year

Midwives 4-5 880-1100M Assistants 8-10

The costs are reasonable7

The role of the private sector?

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

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

Indian medical schools10

Data sources: Medical Council of India; Reserve Bank of India; Census Commissioner India

% private

0-24

25-49

50-74

75-100

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

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.

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?

Africa’s changing face33,34,35,36

Lions of growth

References1 World Health Report 2006. Working together for health2 Scaling up, saving lives. Task Force on Scaling Up Education and Training for Health Workers3 McQuide P, Matte R, Arusha Tanzania 20064 Clinton Foundation 20085 Harvey SA et al Int J Obstet Gyn 2004;87:2036 ECSA 20087 Friberg IK et al PLoS Med 2010;7:e10002958 Murray CJL, Lopez AD Lancet 1997;349:12699 Weiser TG et al Lancet 2008;372:13910 Luboga S et al PLoS Med 2009;6:e100020011 Galukande M et al PLoS Med 2010;7:e100024312Chu K et al PLoS Med 2009;6:e100007813 Dovlo D Hum Resour Health 2004;18:714 Mullan F, Frehywot S Lancet 2007;370:215815 Pereira C et al BJOG 2007;114:153016 Hogan MC et al Lancet 2010;375:1609

References17 Kinney MV et al PLoS Med 2010;6:e100029418 Koblinsky M et al Lancet 2006;368:137719 Hodges SC et al Anesthesia 2007;62:420 Kruk ME et al PLoS Med 2010;7:e100024218 Cherian M et al Bull WHO DOI: 10.2471/BLT.09.07237119 Dubowitz G et al World J Surg 2010;34:43820 Kushner AL et al Arch Surg 2010;145:15421 Newton M, Bird P World J Surg 2010;34:44522 Lawn JE et al Lancet 2008;372:91723 Koblinsky M et al Lancet 2006;368:137724 Ludmerer KM Time to heal, OUP 199925 Supe A and Burdick WP Acad Med 2006;81:107626 Amin Z et al Acad Med 2010;85;33327 Nair M and Webster P Med Educ 2010;44:85628 Rao M et al Lancet 2011;377:59729 van Zanten M and Boulet JR Acad Med 2008;83:S3330 Kanchanachitr C et al Lancet 2011;377:76931 Mahal A and Mohanan M Med Educ 2006;40:1009

References

32 Goston LO et al PLoS Med 2011;8:100103133 Moyo D Dead Aid, 200934 Sen A Development as freedom, 199935 Sachs JD Common wealth, 200836 Lions on the move, McKinsey Global Institute, June 2010