Transforming and Scaling up Health Professional Education ... · interventions to achieve the...

Draft report on assessment of preferences and values

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Transforming and Scaling up Health Professional Education and Training

Assessment of values and preferences of relevant stakeholders


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Contents

1. Background ................................................................................................................................................................ 5

2. Study objective .......................................................................................................................................................... 6

3. Study design and methodology .......................................................................................................................... 6

3.1 Rationale of values and preferences approach ......................................................................................... 6

3.2 Research methods ................................................................................................................................................ 8

3.3 Research instrument ............................................................................................................................................ 9

3.4 Target audience and sampling ....................................................................................................................... 11

3.5 Data collection and analysis ............................................................................................................................ 11

4. Results ........................................................................................................................................................................ 13

4.1. Outcomes of interest: quantity, quality and relevance of health professionals ................... 14

4.2. Values and preferences for the interventions of interest ............................................................. 24

4.2.1 Education and training institutions ....................................................................................................... 24

4.2.2. Regulatory frameworks .............................................................................................................................. 40

4.2.3. Financing ........................................................................................................................................................... 49

4.3 Other interventions ....................................................................................................................................... 66

5. Conclusions .................................................................................................................................................................... 68


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Figures

Figure 1. Guideline development process

Figure 2. Scale range applied for the study

Figure 3. Sample of the questionnaire used in the study

Figure 4. Histogram on values for quantity of health professionals

Figure 5. Histogram on values for quality of health professionals

Figure 6. Histogram on values for relevance of health professionals

Figure 7. Histogram on acceptability and feasibility of policy-makers’ participation in school governance

Figure 8. Histogram on acceptability and feasibility of “Active recruitment, supported by regulatory mechanisms, to enrol students from underserved, underrepresented, or rural populations”

Figure 9. Histogram on acceptability and feasibility of “Continuous development programmes” to support faculties/current health workers to effectively teach in both undergraduate and postgraduate programmes

Figure 10. Histogram on acceptability and feasibility of “Inter-professional and trans-professional learning” to adapt a curricular to population needs for both undergraduate and postgraduate programmes

Figure 11a. Histogram on acceptability and feasibility of “Streamlined educational pathways and ladder programmes” to make effective enforcement of regulations for both undergraduate and postgraduate programmes

Figure 11b. Histogram on acceptability and feasibility of “Accreditation/periodical re-accreditation of all educational institutions, both public and private” to make effective enforcement of regulations for both undergraduate and postgraduate programmes

Figure 11c. Histogram on acceptability and feasibility of “Certification/licensure and revision of national standards, both public and private” to make effective enforcement of regulations for both undergraduate and postgraduate programmes

Figure 12a. Histogram on Acceptability and feasibility of an intervention to “Increase the allocation of resources targeted to health professional education/training” to design financial plans for transforming and scaling up education and training

Figure 12b. Histogram on acceptability and feasibility of an intervention “Aligning international assistance to domestic investment” to design financial plans for ransforming and scaling up education and training

Figure 12c. Histogram on acceptability and feasibility of an intervention “Introducing results-based financing” to design financial plans for transforming and scaling up education and training

Figure 12d. Histogram on acceptability and feasibility of an intervention “Providing financial assistance to students” to design financial plans for transforming and scaling up education and training

Figure 12e. Histogram on acceptability and feasibility of an intervention “Providing direct financial assistance to students” to design financial plans for transforming and scaling up education and training


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Tables

Table 1. Respondents’ profile

Table 2. Relative values for quantity of health professionals (N, %)

Table 3. Relative values for quality of health professionals, (N, %)

Table 4. Relative values for relevance of health professionals, (N, %)

Table 5. Acceptability and feasibility of policy-makers’ participation in school governance

Table 6. Acceptability and feasibility of “Active recruitment, supported by regulatory mechanisms, to enrol students from underserved, underrepresented, or rural populations”

Table 7. Acceptability and feasibility of “Continuous development programmes” to support faculties/current health workers to effectively teach in both undergraduate and postgraduate programmes

Table 8. Acceptability and feasibility of “Inter-professional and trans-professional learning” to adapt a curricular to population needs for both undergraduate and postgraduate programmes

Table 9a. Acceptability and feasibility of “Streamlined educational pathways and ladder programmes” to make effective enforcement of regulations for both undergraduate and postgraduate programmes

Table 9b. Acceptability and feasibility of “Accreditation/periodical re-accreditation of all educational institutions, both public and private” to make effective enforcement of regulations for both undergraduate and postgraduate programmes

Table 9c. Acceptability and feasibility of “Certification/licensure and revision of national standards, both public and private” to make effective enforcement of regulations for both undergraduate and postgraduate programmes

Table 9a. Accessibility and feasibility of an intervention to “Increase the allocation of resources targeted to health professional education/training” to design financial plans for transforming and scaling up education and training

Table 10b. Acceptability and feasibility of an intervention “Aligning international assistance to domestic investment” to design financial plans for transforming and scaling up education and training

Table 10c. Acceptability and feasibility of an intervention “Introducing results-based financing” to design financial plans for transforming and scaling up education and training

Table 10d. Acceptability and feasibility of an intervention “Providing financial assistance to students” to design financial plans for transforming and scaling up education and training

Table 10e. Acceptability and feasibility of an intervention “Providing direct financial assistance to students” to design financial plans for transforming and scaling up education and training


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1. Background

There is a global health workforce crisis: severe shortages of health professionals combined with skill mix imbalances and unequal geographical distribution have left millions of people without access to appropriate health services. Recent estimates indicate that an additional 2.4 million doctors, nurses and midwives are needed worldwide to respond to global health care needs. The number of new doctors, nurses and midwives receiving and completing appropriate and adequate education falls well short of that needed to close this gap, especially in sub-Saharan Africa where the health needs are greatest. New public health issues alongside demographic and epidemiological transitions are challenging population health, while all around the world health systems are struggling to adapt to all of these rapid changes.

Often the education of health professionals has been isolated from health service delivery needs and not adapted to match the rapidly changing population health requirements resulting from these rapid changes. The resulting problems are systemic and embedded: a mismatch of health professional competencies to the individual and population health needs; little understanding, or experience, of working in a team; favouring a more specialist focus over a broader contextual understanding; episodic encounters with patients rather than continuous care; preferential focus on hospital care at the expense of primary health care; imbalances in the professional skill mix; and inadequate professional leadership required in order to help improve health system performance.

To improve population health, fundamental reforms are required in both undergraduate and postgraduate education and with regards to training systems and institutions, in order to increase the number of adequately trained health professionals and to ensure that they are equitably distributed among all geographical areas and health services, from primary to tertiary levels, to provide high quality care.

This radical transformation of health professional education puts population health needs and expectations at the centre of health systems and uses population health outcomes as a crucial measurement to assess the success of the educational process. Isolated improvements in individual educational institutions or narrowly defined health sector reforms will not be enough. While the expansion of health professional schools may serve to increase the quantity of professional health workers, expansion alone will not meet the equally important objectives of improving the quality and relevance of the health workforce, or meeting the labour market needs and absorption capacity. The efforts of national education and health ministries will only be effective alongside simultaneous engagement of educational institutions, private sector providers, professional associations, civil society and communities.

For a major transformation of health professional education the following issues must be addressed: governance, education and training, regulation, financing, planning, implementation, and monitoring and evaluation in order to achieve the outcome of improving the quality, quantity and relevance of the professional health care workforce.

A transformative scale up of health professional education and training is defined as the expansion and reform of health professional education and training to increase the quantity, quality and relevance of health professionals to best meet population health needs and expectations in an equitable and efficient manner, while strengthening country health systems and improving population health outcomes. These three outcomes have been defined as follows:

Quantity refers to the number of health professionals and the adequacy of that number to address the health needs of a specific population.

Quality refers to the qualifications of health professionals and the adequacy of these qualifications to address the health needs of a specific population.

Relevance refers to the relevance of health professionals’ education to meet the current and future health needs of specific populations, including skill mix, availability and equitable distribution of health professionals to the local context.


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2. Study objective

The purpose of the study is to better understand the feasibility and acceptability of various recommended interventions, according to the views expressed by a range of stakeholders at the country level, including those who would be affected by such reforms and those who would be expected to implement the guidelines. It also seeks to expand the participation of stakeholders, by providing their opinions in order to increase the acceptability of the guidelines and to strengthen their evidence base. This will: reflect the diversity of specific contexts for the global recommendations; respond to present and future needs of education; assess the acceptability and feasibility of the guidelines and so facilitate and broaden their implementation. In particular, the study has endeavoured:

to assess the values and preferences of a widely representative group of stakeholders, potential users and beneficiaries of the guidelines; and

to ensure that the guidelines are realistic and applicable at the country level.

The following research questions were identified:

1. What are the relative values given to the possible outcomes such as quantity, quality and relevance of health professionals’ education to meet the current and future health needs of specific populations?

2. What is the degree of acceptability and feasibility by the main stakeholders of the proposed interventions?

3. What is the experience/expertise of the interviewed stakeholders with individual interventions?

3. Study design and methodology

3.1 Rationale of values and preferences approach

A WHO guideline is defined as any document containing recommendations about health interventions, whether they are clinical, public health or policy. At the request of its Member States and partners, WHO is developing policy guidelines to transform and scale up health professional education to assist countries, development partners and other stakeholders in efforts to expand the health workforce and improve the alignment between the education of health workers and population health needs.

The WHO Initiative on transforming and scaling up health professional education aims to support and advance the performance of country health systems so as to meet the needs of individuals and populations in an equitable and efficient manner. The guidelines will recommend interventions to achieve the transformative scaling up of health professional education to eventually increase the quantity, quality and relevance of health professionals in order to strengthen their impact on population health outcomes.

WHO guidelines are developed based on internationally accepted best practices, including the GRADE methodology1. The process encompasses the formal assessment of the quality of evidence, the values and preferences of key stakeholders, the benefits and limitations surrounding the recommendation, and the consideration of resource use and costs.

1 GRADE (Grades of Recommendation, Assessment, Development and Evaluation) is a systematic method of assessing

the quality of studies included in a systematic review and developing recommendations or guidelines based upon the evidence. This approach provides an explicit method for arriving at recommendations classified according to the quality of supporting evidence.


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In 2009, a broad consultation on the need for a transformative scaling up of health professional education was initiated and continued with a series of Technical Reference Group meetings in 2010. The reference groups include representatives from all key stakeholder groups, such as doctors, nurses, midwives, service users, policy-makers, implementers and development partners. In early 2011, a core guidelines development group was convened to make a decision on the proposed interventions, to develop the guideline questions and to assess the evidence supporting the recommendations following the GRADE methodology, and to develop draft recommendations.

In more specific terms, the process for the development of WHO guidelines entails nine steps, illustrated in Figure 1 below.

Figure 1. Guideline development process

With specific reference to the strength of a recommendation, it usually reflects to which degree the desirable effects of a recommendation, across the range of service users for whom the recommendations are intended, outweigh undesirable effects. The strength of the recommendation is determined by: the quality of the supporting evidence; values and preferences; trade-offs between benefits and harms; and costs and resources use.

In the context of developing policy recommendations, value and preference are defined as follows:

Value is the relative importance or worth of the consequences of a decision, including ethical considerations. It usually relates to the outcomes that are achievable through application of a given intervention. In this case, we have three possible outcomes (quantity, quality and relevance of health professionals) achievable individually or in combination through implementation of a recommendation. The assessment that should be conducted is the value given to one outcome compared with the others.


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Preference is the relative individual desirability of a range of interventions (15, 17). The assessment of the preferences of those who will be affected by the implementation is particularly useful for controversial interventions.

Donabedian's three-part quality model (structure, process and outcome) provides a useful heuristic for sorting out the various referents about which individuals may develop preferences. Individuals may establish preferences about structural aspects of health system/care for decision-making (professional and organizational resources) (16). Preferences for treatment options, such as surgical rather than medical interventions, represent the individual's appraisal about process aspects of health care (things done to and for the patient as part of treatment). A third referent for preference is outcomes of health actions (desired states resulting from the care process).

Assessment of values and preferences becomes relevant in understanding the feasibility and acceptability of the proposed recommendations. The feasibility and acceptability affect the implementation of the recommendations.

When developing guidelines, WHO assesses the values and preferences within the core guidelines development group. Although this panel is diverse and representative of the key stakeholders, it is still far from representing the reality on the ground, in terms of geographical diversity, the settings in which they work and their professional background. Values and preferences for specific outcomes of interest and interventions can vary across constituencies, jurisdictions and countries, and as such they are worth assessing in a more inclusive fashion when developing global health policy reform with a broad multisectoral reach.

This study was conducted to assess values and preferences, on the policy guidelines developed by WHO, for informing decision makers about transforming and scaling up health professional education in collaboration with a broad range of stakeholders.

3.2 Research methods

To achieve the objective of this study, a mixed method approach was used that incorporated both qualitative and quantitative data. When different approaches are used to focus on the same phenomenon and they provide the same result, you have "corroboration": i.e. superior evidence for the result. Other important reasons for adopting mixed approaches are: to complement one set of results with another; to expand a set of results; or to discover something that would have been missed if only a quantitative or a qualitative approach had been used. Furthermore, there are two ways of applying these approaches: (1) applying each method sequentially, one after the other; or (2) applying the two methods in parallel. For this study a parallel approach was adopted. We applied both qualitative and quantitative research approaches at the same time, in parallel. For example, a researcher might conduct a survey using a questionnaire composed of both multiple closed-ended or quantitative type items and open-ended or qualitative type items.

Quantitative research refers to the systematic empirical investigation of social phenomena via statistical, mathematical or computational techniques. It is inclined to be deductive. In other words, it tests theory. The objective of quantitative research is to develop and employ any mathematical models, theories and/or hypotheses pertaining to the phenomena. The process of measurement is central to quantitative research because it provides the fundamental connection between empirical observation and mathematical expression of quantitative relationships. Quantitative methods can be used to confirm which of such hypotheses are true, and afford stronger justification for using economic analysis and more verifiable results. In addition, quantitative designs of research tend to produce results that can be generalized.

For this study a “survey style” of research was applied. The rationale for this approach was to describe phenomena such as relationships among variables. For example, the concern is about the views of the main stakeholders regarding the recommendations of the new policy, i.e. the guidelines.

http://en.wikipedia.org/wiki/Observation


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Qualitative research has become more recognizable and applicable in health economics, and such studies have been used in health research in the last decade. Qualitative analysis aims to understand particular circumstances and/or phenomena and to describe the meaning placed on those circumstances and/or phenomena from the perspective of an individual or group. Qualitative research develops theory inductively, in that the experiences of the study population are the basis of the theory. Thus, qualitative approaches allow for the collection of evidence for existing theories, or to formulate new theories, or to derive hypotheses based on this evidence. Louviere et al. (17). stated that if qualitative methods are used in conjunction with quantitative methods, especially to develop the quantitative instruments in order to gain a greater understanding of their results, as per Coast, then it is particularly beneficial for further analysis (14, 17).

It is important to note that applying this qualitative approach allows us to gain a deeper understanding of our target population’s values and preferences for the attributes (outcomes) and levels (interventions) that would be used in this study. However, it is not intended to provide a precise measurement or strategic recommendations.

3.3 Research instrument

The research instrument was designed to derive the preferences and values on the following issues: (1) the importance of all three outcomes (quantity, quality and relevance of health professionals) and (2) the acceptability and feasibility of interventions derived from PICO questions within the following five broad areas to achieve the outcome of improving the quality, quantity and relevance of the professional health care workforce. The acceptability2 and feasibility3 of each of those interventions may vary by country and may depend on various factors including social values and current capacities. These areas include:

governance

education and training

regulation

financing

planning, implementation, monitoring and evaluation.

It should be highlighted that a “glossary of intervention terms” was developed (see Annex) to enable better understanding of specific intervention terminologies and their interpretation included in this study. It also reduces the systematic bias that a respondent might show if the respondent misinterprets or misunderstands the nature of the interventions.

The respondents were asked to choose the response that most closely represents their viewpoint concerning the main areas of interventions for the above mentioned five areas, and to score this on a scale ranging from the most negative (1) to the most positive (9). This is a particularly important technique for the construction of attitude scales.

In order to measure the importance of all three outcomes, and the acceptability and feasibility of each of the interventions, a range scale was applied; this is presented in Figure 2 below.

2 The perception among implementation stakeholders that a given service, practice or innovation is agreeable, palatable or satisfactory. Acceptability should be assessed based on the stakeholder's knowledge of or direct experience with various dimensions of the intervention to be implemented, such as its content, complexity or comfort. We refer here particularly to social acceptability, which addresses the acceptability of the intervention in the context of the culture of the society in which the users operate. 3 Whether or not something can be accomplished given specific conditions and criteria. Common variables suggestive of feasibility include: economic cost and resources available in the area or community necessary to implement the programme; organizational rules that may interfere in the implementation and carrying out of a given agenda, such as laws, ethics and so forth; and receptivity of parallel, cooperative or divergent agencies in the community necessary to sustain ongoing productivity of the new programme.


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Figure 2. Scale range applied for the study

Not important Important Critical

1 2 3 4 5 6 7 8 9

Not acceptable at all

Acceptable Highly

Acceptable 1 2 3 4 5 6 7 8 9

Not feasible at all

Feasible Highly

feasible 1 2 3 4 5 6 7 8 9

Additionally, beside each score that a respondent identified, open-ended questions were asked such as “Please explain your answer”. This allowed the respondents to express their ideas and opinions and state their preferences and values on the selected interventions; this new information can supplement existing information about a topic. The answers to the open-ended questions can enable deeper analysis and thus improve the recommendations for policy decision-makers about the transformative scaling up of health professional education (Figure 3).

Figure 3. Sample of the questionnaire used in the study

Intervention Acceptability (Social)

Rate (1-9)

Feasibility (resources incl. time, staff, etc.)

Rate (1-9)

Please explain your

answer

To incorporate into core curricula such topics that would be needed to address population health needs (e.g. epidemiology, burden of disease, preventive services, screening/counseling/family planning)

To incorporate into core curricula such topics that would be needed for effective health services delivery (e.g. decision-making, initiation of change, leadership/management, working in teams, lifelong learning)

To regularly evaluate curricula in order to update/innovate it to the needs of populations, health systems and health service delivery

To launch inter-professional and trans-professional learning,

Other (specify): ____________________________________

The questionnaire consisted of the following four sections:

Section 1. Profile of respondent

Section 2. General assessment of values and preferences for the outcomes of interest

Section 3. Values and preferences for the interventions of interest

Section 4: Closing questions.

The questionnaire was tested/piloted to find out whether the developed questions were valid and reliable for the study. Moreover, the piloting of research instruments helped to eliminate misunderstandings and ambiguities and to identify the less important items in the research instrument. The clarity of questions, their appropriateness, relevance and comprehension were checked through the pilot study. The piloting of the questionnaire could have been achieved with about 5-7 respondents but a total of 14 persons participated. These consisted of nurses,


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midwives and 3 individuals at the regional level in WHO. The respondents included in the pilot were asked to assess the questionnaire on the basis of its content, format, expressions and the importance of the questions. The feedback from the pilot study was used to modify the questionnaire. The pilot sample results were omitted from the main study.

3.4 Target audience and sampling

To be included in the broad group who assessed values and preferences, respondents needed to be affected by the implementation of the policy guidelines. The target audience included the following groups:

a selected number (according to the sample size) of representatives of the stakeholders involved in the development and implementation of the guidelines as per the outcome framework (national policy-makers; education and training institutions and associations; professional associations and regulatory bodies; health services administrators; communities and civil society; development partners and agencies);

institutions and organizations affected by the implementation of the guidelines.

This study was administered globally in all WHO regions and in collaboration with the WHO Regional Offices:

WHO African Region

WHO Region of the Americas

WHO South-East Asia Region

WHO European Region

WHO Eastern Mediterranean Region

WHO Western Pacific Region.

Purposive sampling of the main stakeholders, identified above, was applied to this study. Purposive sample sizes are often determined on the basis of theoretical saturation (the point in data collection when new data no longer bring additional insights to the research questions). Purposive sampling is therefore most successful when data review and analysis are done in conjunction with data collection.

3.5 Data collection and analysis

The developed questionnaire was administered to the target audience selected for this study via the internet, applying the WHO datacol (web-based) format. Datacol is laid out in a similar fashion to Survey Monkey. The targeted audience members were given the log in and password to complete the questionnaire.

Each completed questionnaire was given a unique code. The filled datacol was transferred first into Excel, and then into SPSS to carry out statistical analysis. Before data analysis took place, the database was cleaned and checked for reliability. The results are presented in absolute numbers and the percentage is given for each selected intervention ranked by respondents from 1 to 9. While analyzing data we presented a cumulative percentage of those responses ranked from 5-9, i.e. interventions rated as important, acceptable and feasible to implement (see above sub-section on “research instruments”). However, items scoring less than 5 in the tables are also recorded. The mean and standard deviation (SD) are estimated and presented in a histogram illustrating the distribution of responses and normal distribution curve. The normal distribution curve shows the mean of a large number of random variables drawn from the same distribution; the mean is distributed approximately normally, irrespective of the form of the original distribution (central limit theorem). Moreover, all the results are presented by the region, level of responsibility and current position of the respondents, to enable a better analysis of the results.


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Qualitative data (the respondents’ comments and replies) were analyzed using content analysis and are presented in this report through narratives. NVivo-8 software was applied to analyze qualitative data, which helped to identify the common words and sentences; based on this generated data the most common ideas and propositions across all resonances are presented in this report.


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4. Results

A total of 136 people participated at this survey, from all WHO regions; however, there were more respondents from Europe, Africa and South and East Asia (35%, 34% and 13% respectively). Respondents were largely 41-60 years old and the majority were female (54%) (Table 1). In this survey, more respondents with a national level of responsibility (46%) participated; about 28% and 20% had regional or district responsibility. The majority of respondents had a PhD or Master’s degree (44% and 41%). About 52% of the respondents held a position in an education and/or training institution, such as associate dean of rural medical education, director of educational evaluation, vice rector, training and development officer etc.; about 21% were health professionals, 13% were policy-makers at different levels, and 10% were members of a professional association or regulatory body (Table 1).

Table 10. Respondents’ profile

Total (N) %

Region

Europe 47 35

Africa 46 34

South and South East Asia 18 13

North America 9 7

Eastern Mediterranean 7 5

Western Pacific 7 5

Latin America 2 2

Level of responsibility `

National 62 46

Regional 38 28

District 27 20

Mixture of responsibilities 9 7

Current position

Education and/or training institution 71 52

Health professional 28 21

Policy-maker 18 13

Professional association or regulatory body 14 10

Development partner or agency 2 1

Other 2 1

Missing 1 1

Highest education

PhD or equivalent 60 44

Master's degree e.g. MSc/MA 56 41

Bachelor's degree e.g. BSc 17 13

College fellowship or equivalent 2 1

Age group

26-30 15 11

31-35 14 10

36-40 8 6

41-45 13 9.6

46-50 20 15


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51-55 22 16

56-60 29 21

61-65 8 6

70+ 1 1

Missing 6 4

Gender

Female 73 54

Male 57 42

4.1. Outcomes of interest: quantity, quality and relevance of health professionals

In this section preferences and values for each of the three main dimensions of health professionals (quantity, quality and relevance) are presented based on the respondents’ scoring (quantitative data) and their comprehensive comments (qualitative data).

Quantity. 130 responses were received; 6 missing respondents were excluded from the data analysis The great majority of the respondents (90%) ranked “quantity” of health professionals from 5-9,emphasizing the importance of this outcome. About 27% of respondents scored this outcome as extremely important (9). The mean score for this outcome is 6.9, again underlining its importance, which was recognized by respondents from all regions. A slightly smaller percentage in Europe of respondents who have responsibilities at the national level (93%) believe that the number of health professionals, and the adequacy of that number, are reasonably important for improving the population health, as do 89% of respondents at regional and district levels. All policy-makers (100%) who participated in this survey highlighted this outcome as important, while slightly fewer (97%) health professionals thought the same. For more details please see Table 2 and the Figure 4 below.

Figure 4. Histogram on values for quantity of health professionals


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Table 11. Relative values for quantity of health professionals (N, %)

Not important 2 3 4 Important 6 7 8 Critical Total

N % N % N % N % N % N % N % N % N % N %

Overall 2 2% 4 3% 3 2% 4 3% 19 15% 11 8% 33 25% 19 15% 35 27% 130 100% Region

Africa 2 5% 2 5% 7 16% 9 21% 23 53% 43 100% Europe 2 4% 4 9% 2 4% 3 7% 8 18% 6 13% 12 27% 4 9% 4 9% 45 100% Latin America 2 100% 2 100% North America 1 13% 3 38% 2 25% 2 25% 8 100% South and South East Asia 1 6% 1 6% 3 17% 1 6% 6 33% 2 11% 4 22% 18 100% Eastern Mediterranean 1 14% 1 14% 3 43% 1 14% 1 14% 7 100% Western Pacific 2 29% 1 14% 2 29% 1 14% 1 14% 7 100% Total 2 2% 4 3% 3 2% 4 3% 19 15% 11 8% 33 25% 19 15% 35 27% 130 100%

Level of responsibility

National 3 5% 1 2% 12 20% 4 7% 17 28% 8 13% 15 25% 60 100% Regional 1 3% 1 3% 2 5% 2 5% 2 5% 8 22% 9 24% 12 32% 37 100% District 1 4% 1 4% 1 4% 4 15% 5 19% 6 22% 2 7% 7 26% 27 100% National, District 1 50% 1 50% 2 100% National, Regional 1 25% 2 50% 1 25% 4 100% Total 2 2% 4 3% 3 2% 4 3% 19 15% 11 8% 33 25% 19 15% 35 27% 130 100% Current position

Education and/or training institution 2 3% 3 5% 3 5% 3 5% 5 8% 7 11% 12 18% 11 17% 20 30% 66 100% Health professional 1 3% 5 17% 1 3% 8 28% 4 14% 10 34% 29 100% Policy-maker 7 39% 1 6% 7 39% 1 6% 2 11% 18 100% Professional association/regulatory body 1 8% 2 15% 2 15% 5 38% 1 8% 2 15% 13 100% Development partner or agency 1 50% 1 50% 2 100% Other 1 50% 1 50% 2 100% Total 2 2% 4 3% 3 2% 4 3% 19 15% 11 8% 33 25% 19 15% 35 27% 130 100%


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Most of the respondents commented in their responses that uneven distribution of health professionals across urban and rural areas remains a major issue for the health care system in many developing and some developed countries. Such imbalance precludes universal access to and availability of health services. Typically, a lack of specialized health care practitioners, such as cardiologists, anaesthesiologists and emergency physicians, in rural areas compels the rural population to seek medical assistance in urban hospitals:

“…hundreds of health professionals graduate each year in public and private institutions, in [this] country and abroad. While health professionals working in primary health care and public health are sufficient in the system, a shortage of specialist doctors is identified in almost all regional and district hospitals…” (developing country in the European region).

“…We have sufficient [numbers] but they are poorly deployed and distributed…” (developed country in the European region).

Adequate access to medical care in remote areas requires thoughtful distribution of human resources across the country and incentives for professionals to move and work there. Comprehensive management of human resources should be in place to ensure that adequate numbers of professionals are available in the right place and at the right time.

“…all public health facilities have inadequate staffing and in some instances key staff like medical doctors [are] totally lacking…, …many health professionals are of [an] age to be retired…” (African region).

“..South Africa's health-care workers suffer under the burden of staff shortages, which ultimately leads to poor quality patient care...”

“…I believe that we should not increase the number of health workers in Russia. Need to use them differently. It is necessary to transfer some functions of doctors to nurses. Need to more efficiently organize their activities…” “…We need to further rationalize services. Physicians cannot continue to work independently, and must be prepared to delegate to appropriately train allied professionals. At the same time the role of the family physician as ‘gate keeper’ and coordinator needs to be re-enforced…” (North American region).

Considering the number of people in need of health care at all levels of health provision in the East, Central and South Africa (ECSA) region, which has a population of about 200 million people, quantity is currently critical. It is important to pay attention to quality while increasing numbers. However, this balance may be difficult to achieve and numbers are therefore still important, even if quality is compromised:

“…Numbers are very important — too few nurses place a massive burden on the remaining nurses, and [this] also reduces quality of care. But on the other hand, targeting quantity without attending to quality is problematic. A bad nurse is not better than no nurse at all…” (African region).

In the developed countries in the European region, “improving numbers is very important but not critical”; however, demand for more medical staff, particularly physical therapists and qualified primary care nurses, will increase in the future because of demographic change in an ageing society:

“…With variety of health systems in vogue, a quantitative approach could be one of the best options as of today, i.e. to involve health professionals from non-allopathic fields at primary health care level. …” (South and South East Asia region).


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“…Quantity cannot really be separated from appropriate levels of expertise and distribution...” (developed country in Europe).

“…The World Bank analysis showed that we have actually high number of doctors and 'low productivity' of doctors. Lack of nurses…” (developed country in Europe).

“…While there are areas of practice where there are job freezes etc. the quantity of health professionals is not so relevant as the way in which they are deployed and the quality of leadership to enhance practice…” (developed country in the European region).

“…Safe staffing levels are crucial to patient care. There is a need for a comprehensive workforce planning system and strategies with oversight at national level to ensure safe staffing levels. A purely localised approach may not take account of national workforce trends and appropriate staffing levels. It is vital that continued professional development (CPD) is safeguarded against cuts to ensure that nursing staff continue to update their skills and are equipped to tackle the challenges of the future. CPD is critically important to developing and maintaining a workforce which is fit for purpose and able to meet changes in health care service delivery and demands…” (North American region)

Quality. 128 responses were received; 8 missing respondents were excluded from the data analysis. About 94% of all respondents ranked the “quality” of health professionals from 5-9, emphasizing it as an important outcome; 34% of all respondents ranked it as extremely important (9). Across WHO regions, the importance of “quality” was widely acknowledged, particularly in the Latin American and Eastern Mediterranean regions (100%) and slightly less in Asia-Pacific countries (94%). The mean score for this outcome was 7.2, underlining its importance. 95% of respondents at national level believe that the qualifications of health professionals and the adequacy of these qualifications is rather important for addressing the health needs of a population; the figures are 97% at regional and 89% at district level. All policy-makers (100%) who participated in this survey emphasized that this outcome is as important as “quantity”; the other stakeholders also rated it as quite important: over 90% scored it from 5 to 9. For more details please see Table 3 and Figure 5.

Figure 5. Histogram on values for quality of health professionals


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Table 12. Relative values for quality of health professionals, (N, %)

Not important 2 3 4 Important 6 7 8 Critical Total N % N % N % N % N % N % N % N % N % N %

Overall 1 2% 1 2% 7 17% 1 2% 8 19% 6 14% 18 43% 42 100%

Region Africa 1 2% 1 2% 7 17% 1 2% 8 19% 6 14% 18 43% 42 100% Europe 2 5% 1 2% 9 20% 4 9% 11 25% 5 11% 12 27% 44 100% Latin America 1 50% 1 50% 2 100% North America 1 13% 2 25% 4 50% 1 13% 8 100% South and South East Asia 1 6% 1 6% 1 6% 3 17% 4 22% 8 44% 18 100% Eastern Mediterranean 1 14% 3 43% 3 43% 7 100% Western Pacific 1 14% 1 14% 2 29% 2 29% 1 14% 7 100% Total 1 1% 5 4% 2 2% 20 16% 7 5% 29 23% 21 16% 43 34% 128 100%


National - 1 2% 1 2% 1 2% 7 12% 2 3% 14 24% 11 19% 22 37% 59 100%

Regional - 1 3% 7 19% 3 8% 6 17% 7 19% 12 33% 36 100%

District - 2 7% 1 4% 5 19% 2 7% 8 30% 2 7% 7 26% 27 100%

National, District - 1 25% 1 25% 2 50% 4 100%

National, Regional - 1 3% 7 19% 3 8% 6 17% 7 19% 12 33% 36 100%

Total - 1 1% 5 4% 2 2% 20 16% 7 5% 29 23% 21 16% 43 34% 128 100%

Current position

Education and/or training institution 4 6% 1 2% 12 18% 5 8% 14 21% 10 15% 20 30% 66 100%

Health professional 1 4% 1 4% 6 21% 2 7% 5 18% 3 11% 10 36% 28 100%

Policy-maker 1 6% 7 41% 3 18% 6 35% 17 100%

Professional association/regulatory body 1 8% 1 8% 3 23% 5 38% 3 23% 13 100%

Development partner or agency 0% 2 100% 2 100%

Other 2 100% 2 100%

Total 1 1% 5 4% 2 2% 20 16% 7 5% 29 23% 21 16% 43 34% 128 100%


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Improving the quality of health professionals is a necessary process: it demonstrably improves patients’ outcomes and enhances clinical effectiveness. The quality of health professionals should be a priority on the health sector agenda in every country:

“….entry of huge number of private schools is functioning in[a] different field, so quality assurance in health human resources development has become very important in developed countries…” (South and South-East Asian region).

“…Although the quality is good at basic level, there is a tendency to neglect postgraduate levels including specialists for advanced care. This affects the quality as the specialists are now of retiring age or opt for cities and other greener pastures…” (South African region).

Continuous education is important for health professionals; however, the additional dimension of testing effectiveness performance is equally important:

“…Existing regulations require that Armenian doctors and nurses take continuous education courses every five years. As of 2006, this standard had been met by 56.7% of the medical doctors and 32.5% of the nurses. Estimates for 2010 show an improvement for these indicators, with the percentage of doctors and nurses receiving such training within the previous five years being 66% and 50%, respectively. When assessing the training of medical personnel, it is important to assess the effectiveness of training as well as the numbers of staff trained. Indicators that might be used to assess the effectiveness of health-care services include testing and adherence to clinical guidelines” (developed country in the European region).

It is necessary to improve the theoretical underpinning of health professional training in order to improve quality of health care. Moreover, health professionals should be trained in critical thinking and innovation, particularly to deal with staff shortages and insufficient resources:

“…in the future more physical therapists need to have a MSc/MA degree to help improve the position of this profession in the health care system. Furthermore improving the quality of health professionals could be essential to improve the quality of work of each physical therapist…” (developed country in the European region).

There are significant differences in the quality of nursing education globally. In some countries there are very high quality programmes. In others programmes vary from high to fairly poor quality with minimal oversight or control. This has become a particular problem in some regions with rapidly increasing numbers of private schools. Poor quality education not only leaves the nurse at a serious disadvantage with little opportunity for professional advancement or higher education or mobility, it also presents a risk to the public if nurses are not equipped to provide safe and competent care:

“….there are few formalized post qualification career pathways for nurses. It is essential that there is also national oversight of nursing education and the commissioning of nursing education to protect national standards and ensure that the future workforce is fit for purpose” (developed country in the European region).

It was also suggested that health professionals could use sophisticated technology:

“to provide for continuing medical education in line with new technological developments in health care provision and to provide for specialities that currently are not developed by the country’s medical education training institutions…” (African region).


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Relevance. 127 responses were received; 9 missing respondents that were not included in the data analysis. 95% of all respondents ranked the “relevance” of health professionals from 5-9, emphasizing the importance of this outcome, including 34% who ranked it as extremely important (9). The mean score was 7.34, underlining the importance of this outcome. Across all the WHO regions the “relevance” outcome was recognized as highly important. All respondents (100%) who are responsible at the regional level believe that relevance of health professionals’ education, including skill mix, availability and equitable distribution of health professionals appropriate to the local context, is an important outcome for addressing the needs of a population; the corresponding figures are 95% and 93% for those at national and district levels. All health professional and development partners (100%) who participated in this survey stated that this outcome is equally important; other stakeholders also ranked it as quite important, ranging from 92-94%. For more details please see Table 3 and Figure 6.

Figure 6. Histogram on values for relevance of health professionals


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Table 13. Relative values for relevance of health professionals, (N, %)

Not important 2 3 4 Important 6 7 8 Critical Total N % N % N % N % N % N % N % N % N % N % Overall 2 2% 4 3% 17 13% 11 9% 28 22% 22 17% 43 34% 127 100% Region Africa - 5 12% 4 10% 3 7% 11 27% 18 44% 41 100% Europe 2 5% 2 5% 9 20% 2 5% 13 30% 5 11% 11 25% 44 100% Latin America 1 50% 1 50% 2 100% North America 1 13% 1 13% 1 13% 2 25% 1 13% 2 25% 8 100% South and South East Asia 1 6% 1 6% 1 6% 6 33% 3 17% 6 33% 18 100% Eastern Mediterranean 2 29% 2 29% 3 43% 7 100% Western Pacific 1 14% 2 29% 2 29% 2 29% 7 100% Total 2 2% 4 3% 17 13% 11 9% 28 22% 22 17% 43 34% 127 100%

Level of responsibility National 1 2% 2 3% 7 12% 5 8% 11 19% 8 14% 25 42% 59 100% Regional 4 11% 1 3% 9 26% 10 29% 11 31% 35 100% District 1 4% 1 4% 4 15% 5 19% 5 19% 4 15% 7 26% 27 100% National, District 1 50% 1 50% 2 100% National, Regional 1 25% 1 25% 2 50% 4 100% Total 2 2% 4 3% 17 13% 11 9% 28 22% 22 17% 43 34% 127 100%

Current position Education and/or training institution 2 3% 2 3% 9 14% 6 9% 16 25% 10 15% 20 31% 65 100% Health professional 6 21% 3 11% 3 11% 8 29% 8 29% 28 100% Policy-maker 1 6% 1 6% 5 29% 1 6% 9 53% 17 100% Professional association/regulatory body 1 8% 1 8% 1 8% 4 31% 1 8% 5 38% 13 100% Development partner or agency 2 100% 2 100% Other 1 50% 1 50% 2 100% Total 2 2% 4 3% 17 13% 11 9% 28 22% 22 17% 43 34% 127 100%


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The comments provided by respondents relating to relevance show that this outcome is recognized as an important social determinant. In particular, specific skills of health workers are needed to address outbreaks of some infectious diseases, the increase of noncommunicable diseases, increasing rates of maternal deaths, etc.

“…need for focusing on the social, demographic and economic changes of the modern society with all existing challenges arising from governmental planning on health system reforms, patients (citizens) rights for better health care services…” (developing countries from Europe).

“… After the quantity and quality of health professionals are met, then relevance would be easier to address…” (African region).

“…traditionally the main stream of the health system was for a doctor to be more efficient; but the focus has been shifted to the patient and multidisciplinary teams…” (South and South East Asia region).

“…The nature of health care is changing with increased emphasis on caring in community settings such as for older people and long-term conditions. It is vital that health professional education is able to adapt to the changing nature of care…” (developed country in European region).

Relevance must also be improved in the light of the current urgent need for quality health services. It is crucial that health professionals are trained to address national health priorities first, but without neglecting international trends. Rural health care is suffering; therefore every training programme for health professionals should include a rural health component. This will not only orientate the health professionals to rural areas, but may have a positive impact if and when those health professionals see the plight of rural communities and opt to work there after graduation:

“…Health professional training did not follow relevance previously, thus the curricular activities are simply dependent on the government’s need, not other non-governmental stakeholders…” (developing country in the African region).

“...There is room to enhance the roles of some professionals within a multidisciplinary setting. For example modern medicines are complex and a pharmacist has extensive scientific knowledge but is one cadre that may be somewhat underutilised in the context of my country… I think it is important to establish health professionals as health mentors in communities to encourage people to take increased responsibility over their own health, particularly where noncommunicable diseases are concerned. I don’t believe that a god-like atmosphere around doctors or any other professionals is helpful or positive for communities. In Ireland we have too much reliance on the hierarchal structure of medicine and this can be very damaging. In turn I do feel that the relevance of allied health professionals and the role of nurses is undervalued and underutilized…” (developed country in the European region).

“…It is always important to improve relevance — in our country those with the highest health needs access the services least so the target needs to be to these population groups. However, it should be highlighted that all population groups irrespective of their group should have access to health care…” (developed country in the Western Pacific region).

Nursing education is primarily relevant, but there needs to be a greater focus on making it relevant in the local context: the specific disease burdens being faced (e.g. HIV, malaria,


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tuberculosis, NCDs) and the delivery of primary health care. The percentage of specialized nurses is low and this has a negative impact on nursing care:

“...the number of nurses per 100 000 population is low in Armenia compared to the concentration in developed European countries (ER-27) and in the Commonwealth of Independent States (CIS) [see Table]. On the other hand, the ratio of physicians per 100 000 population is close to the average for the ER-27 and well below that of Georgia and Azerbaijan. With the exception of Georgia, the nurse to physician ratio in Armenia is lower than in the other countries, reflecting the fact that during the optimization phase of the national health reforms, the relative reduction of the number of nurses was more significant than among physicians…” (developing country in the European region).

“…In Germany health care is dominated by medicine. This guides health care budgets towards diagnosis and therapy of acute conditions. There is a lack of professional and high standard support/treatment for older people, chronically ill people. Quality of life could be much improved by non-medical interventions…” (developed county in the European region).

This needs to be linked with the national development plan and other relevant ministries, for example with the Ministry of Education, in order to have enough eligible students completing advanced level qualifications and being able to enrol for medical training, and with the planning department of the Ministry of Finance to support identify critical areas for focus medical training, e.g. safe motherhood programmes etc.

“…Relevance is very important, but who defines and dictates relevance and on what grounds? The health services are very narrowly focused and doctor driven and as a result are mainly curatives. Who decides that that is relevant? Although health care is supposed to be more socially focused and more primitive and preventive it is still focused on curative and medical management…” (African region).

Comparing these three outcomes. Respondents expressed the view that these three outcomes are quite important to meet population health needs and expectations in an equitable and efficient manner, while strengthening country health systems and improving population health outcomes. However, slightly higher weight was given to “relevance” and “quality” outcomes (95% and 94%) than to “quantity”: 90% across all regions. Overall, respondents across all the regions and at all levels (national, regional and district) reflected the same pattern.


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4.2. Values and preferences for the interventions of interest

To improve population health, fundamental reforms are required in both undergraduate and postgraduate education and training systems and institutions to increase the numbers of adequately trained health professionals and to ensure that they are equitably distributed among all geographical areas and health services, from primary to tertiary levels, to provide high quality care. Major transformation of health professional education must address the following issues: governance, education and training, regulation, financing, planning, implementation, and monitoring and evaluation in order to improve the quality, quantity and relevance of the professional health care workforce.

4.2.1 Education and training institutions

4.2.1.1. Involving policy-makers in school governance

126 responses were received; 10 missing respondents were not included into the analysis. The respondents were asked to assess the acceptability and feasibility of active participation by policy-makers within the framework of this study in the governance structures of health professional schools based on revised PICO questions. This stakeholder was evaluated on a 9-point scale with 1 being “not acceptable at all” or “not feasible at all”, 5 being either “acceptable” or “feasible” and 9 being “highly acceptable” or “highly feasible”. Table 5 below presents the preferences and values that were given by the respondents scoring each of these stakeholders from 1 to 9. A histogram is also presented below (Figure 7).

About 84% of all respondents expressed the view that active participation by policy-makers in the governance structures of health professional schools affecting the quantity, quality and relevance of health professionals is acceptable, but only 78% think it is feasible to involve policy-makers. The mean score for acceptability is 6.3 and for feasibility 5.51. Respondents with responsibility at the national level ranked this intervention as more acceptable (90%) but a bit more difficult to implement (83% scored as feasible) than those at the regional and district levels (80% and 71% respectively).

Figure 7. Histogram on acceptability and feasibility of policy-makers’ participation in school governance


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Table 14. Acceptability and feasibility of policy-makers’ participation in school governance

A&F Not acceptable at all

2 3 4 Acceptable 6 7 8 Highly acceptable

Total

N % N % N % N % N % N % N % N % N % N %

Acceptability 3 2% 2 2% 8 6% 7 6% 26 21% 17 13% 19 15% 20 16% 24 19% 126 100%

Feasibility 5 4% 5 4% 10 8% 8 6% 44 35% 15 12% 16 13% 12 10% 11 9% 126 100%

Level of responsibility National Acceptability 2 3% 2 3% 2 3% 10 17% 11 19% 11 19% 9 16% 11 19% 58 100%

Feasibility 4 7% 2 3% 4 7% 21 36% 8 14% 7 12% 7 12% 5 9% 58 100%

Regional

Acceptability 2 6% 2 6% 3 9% 11 31% 3 9% 4 11% 5 14% 5 14% 35 100%

Feasibility 2 6% 3 9% 5 14% 15 43% 5 14% 2 6% 1 3% 2 6% 35 100% District Acceptability 1 4% 3 11% 2 7% 4 15% 2 7% 2 7% 6 22% 7 26% 27 100% Feasibility 1 4% 1 4% 3 11% 2 7% 6 22% 1 4% 6 22% 3 11% 4 15% 27 100% National, District Acceptability 1 50% 1 50% 2 100% Feasibility 1 50% 1 50% 2 100% National, Regional Acceptability 1 25% 1 25% 1 25% 1 25% 4 100% Feasibility 1 25% 1 25% 1 25% 1 25% 4 100%

Total Acceptability 3 2% 2 2% 8 6% 7 6% 26 21% 17 13% 19 15% 20 16% 24 19% 126 100%

Feasibility 5 4% 5 4% 10 8% 8 6% 44 35% 15 12% 16 13% 12 10% 11 9% 126 100%

Current position Education and/or training institution

Acceptability 3 5% 1 2% 5 8% 3 5% 15 23% 7 11% 9 14% 11 17% 10 16% 64 100%

Feasibility 3 5% 3 5% 4 6% 6 9% 23 36% 7 11% 8 13% 6 9% 4 6% 64 100%

Health professional Acceptability 1 4% 3 11% 4 14% 4 14% 4 14% 4 14% 4 14% 4 14% 28 100% Feasibility 1 4% 1 4% 4 14% 2 7% 8 29% 3 11% 4 14% 2 7% 3 11% 28 100% Policy-maker Acceptability 4 24% 4 24% 2 12% 2 12% 5 29% 17 100% Feasibility 1 6% 1 6% 8 47% 2 12% 2 12% 1 6% 2 12% 17 100% Professional association/regulatory body


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Acceptability 3 23% 2 15% 4 31% 1 8% 3 23% 13 100% Feasibility 2 15% 4 31% 3 23% 1 8% 1 8% 2 15% 13 100% Development partner or agency

Acceptability 1 50% 1 50% 2 100% Feasibility 2 100% 2 100%

Other Acceptability 1 50% 1 50% 2 100% Feasibility 1 50% 1 50% 2 100% Total Acceptability 3 2% 2 2% 8 6% 7 6% 26 21% 17 13% 19 15% 20 16% 24 19% 126 100%

Feasibility 5 4% 5 4% 10 8% 8 6% 44 35% 15 12% 16 13% 12 10% 11 9% 126 100%

Region Africa Acceptability 2 5% 1 3% 2 5% 8 20% 6 15% 6 15% 9 23% 6 15% 40 100% Feasibility 2 5% 1 3% 5 13% 2 5% 15 38% 4 10% 6 15% 3 8% 2 5% 40 100%

Europe Acceptability 5 11% 2 5% 11 25% 6 14% 6 14% 6 14% 8 18% 44 100% Feasibility 1 2% 3 7% 3 7% 2 5% 17 39% 6 14% 4 9% 5 11% 3 7% 44 100% Latin America Acceptability 1 50% 1 50% 2 100% Feasibility 2 100% 2 100% North America Acceptability 1 13% 1 13% 1 13% 2 25% 1 13% 1 13% 1 13% 8 100% Feasibility 1 13% 1 13% 3 38% 1 13% 1 13% 1 13% 8 100% South and South East Asia Acceptability 1 6% 2 11% 3 17% 1 6% 3 17% 1 6% 7 39% 18 100%

Feasibility 1 6% 1 6% 1 6% 3 17% 5 28% 2 11% 2 11% 3 17% 18 100% Eastern Mediterranean Acceptability 1 14% 1 14% 1 14% 3 43% 1 14% 7 100% Feasibility 1 14% 1 14% 2 29% 2 29% 1 14% 7 100% Western Pacific Acceptability 1 14% 3 43% 1 14% 1 14% 1 14% 7 100% Feasibility 3 43% 2 29% 1 14% 1 14% 7 100% TOTAL Acceptability 3 2% 2 2% 8 6% 7 6% 26 21% 17 13% 19 15% 20 16% 24 19% 126 100%

Feasibility 5 4% 5 4% 10 8% 8 6% 44 35% 15 12% 16 13% 12 10% 11 9% 126 100%


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These are some of the opinions put forward by the respondents.

“…Academics should be the ones to carry out education. Policy-makers’ participation is acceptable on advisory boards...”

“…Based on current health needs and provision gaps it make sense to ensure that graduates are able to fill gaps in certain areas, e.g. health promotion…”

“…I am not sure that all institutions of learning would accept policy-makers, who can often be obstructive and employ delaying tactics. In terms of feasibility many of the policy-makers have more important issues to deal with in the day-to-day rendering of a health care service…”

“…If this involves government policy-makers, there must be respect for academic freedom. It is possible that such involvement could serve to entrench government policy rather than support best evidence…”

“…Many (if not most) of the stakeholders in the governance structures of the medical schools are also policy-makers…”

“…May be challenging to be involved in active participation — but at the national level can set policy direction…”

“…More involvement by the Ministry of Health and Ministry of Education. Policy-makers should be more proactive in the labour market…”

“…Most schools are required by their regulatory authority to include senior policy-makers in the board and on some committees; these members are only advisory, meet sporadically and have little active participation…”

“…Our current government situation has bred distrust in the academic medical fields, and getting policy-makers involved in education would impede any good progress…”

“…Policy-makers need to guide the schools but also to know what are the current practical aspects of concern and to adapt policies accordingly…”

“…The priorities of policy-makers are different from those of educators, and the academic freedoms of educators must be protected…”

“… there should be a balanced view on this. While policy-makers need to know what is going on within education, too much interference (active participation) in governance may not necessarily be feasible…”

“...are relevant but there are always political agendas which get in the way of getting the job done. Every new minister of health has a new direction and we keep changing direction and talking but never get the job done…”

“…While it is relatively easy to engage with policy-makers, it may not be acceptable where political affiliations are different to those of the educationalists…”

“…These issues are well understood at policy level but policy-makers don’t have the necessary guidance and leadership…”


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4.2.1.2. Involving students in transforming and scaling up health professional education and training for both undergraduate and postgraduate programmes

Under this section the respondents were asked to rate their preference and values on what strategies/interventions should be undertaken to involve students in transforming and scaling up health professional education and training for both undergraduate and postgraduate programmes, in order to improve the quantity, quality and relevance of health professionals. They were also asked to assess whether it was feasible to implement those strategies. One intervention identified was active recruitment, supported by regulatory mechanisms, to enrol students from underserved, underrepresented or rural populations. Table 6 below presents the respondents’ scores from 1 to 9. A histogram is also presented below (Figure 8).

About 82% of all respondents expressed the view that active recruitment, supported by regulatory mechanisms, to enrol students from underserved, underrepresented, or rural populations is acceptable, but only 68% think that it is feasible. The mean score for acceptability is 6.4, and for feasibility 5.55. Respondents at regional and district levels ranked this intervention as more acceptable, almost equally (89% and 88% respectively) than those at national level (77%).

Figure 8. Histogram on acceptability and feasibility of “Active recruitment, supported by regulatory mechanisms, to enrol students from underserved, underrepresented, or rural populations”


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Table 15. Acceptability and feasibility of “Active recruitment, supported by regulatory mechanisms, to enrol students from underserved, underrepresented, or rural populations”



Total

N % N % N % N % N % N % N % N % N % N %

Acceptability 6 5% 4 3% 7 6% 5 4% 21 17% 13 11% 17 14% 17 14% 32 26% 122 100%

Feasibility 5 4% 5 4% 10 8% 8 6% 44 35% 15 12% 16 13% 12 10% 11 9% 122 100%

Level of responsibility National Acceptability 6 11% 1 2% 3 5% 3 5% 9 16% 5 9% 8 14% 7 12% 15 26% 57 100%

Feasibility 8 14% 3 5% 5 9% 4 7% 11 19% 5 9% 10 18% 5 9% 6 11% 57 100%

Regional

Acceptability 3 9% 1 3% 8 23% 5 14% 5 14% 6 17% 7 20% 35 100% Feasibility 1 3% 5 14% 6 17% 5 14% 4 11% 4 11% 6 17% 4 11% 35 100% District Acceptability 2 8% 1 4% 4 17% 3 13% 3 13% 3 13% 8 33% 24 100% Feasibility 1 4% 1 4% 3 13% 5 21% 1 4% 6 25% 4 17% 3 13% 24 100% National, District Acceptability 1 50% 1 50% 2 100% Feasibility 1 50% 1 50% 2 100%

National, Regional Acceptability 1 25% 1 25% 1 25% 1 25% 4 100% Feasibility 1 25% 1 25% 2 50% 4 100% Total Acceptability 6 5% 4 3% 7 6% 5 4% 21 17% 13 11% 17 14% 17 14% 32 26% 122 100% Feasibility 8 7% 6 5% 12 10% 13 11% 21 17% 11 9% 23 19% 15 12% 13 11% 122 100% Current position Education and/or training institution

Acceptability 1 2% 1 2% 4 6% 3 5% 8 13% 7 11% 9 15% 12 19% 17 27% 62 100%

Feasibility 2 3% 4 6% 6 10% 10 16% 7 11% 4 6% 14 23% 7 11% 8 13% 62 100%

Health professional Acceptability 2 8% 3 12% 3 12% 1 4% 6 23% 2 8% 1 4% 3 12% 5 19% 26 100%

Feasibility 2 8% 1 4% 4 15% 1 4% 7 27% 1 4% 4 15% 4 15% 2 8% 26 100%

Policy-maker Acceptability 1 6% 1 6% 4 24% 2 12% 4 24% 1 6% 4 24% 17 100%

Feasibility 1 6% 2 12% 2 12% 3 18% 3 18% 2 12% 3 18% 1 6% 17 100%

Professional


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association/regulatory body Acceptability 2 15% 3 23% 2 15% 2 15% 1 8% 3 23% 13 100%

Feasibility 2 15% 1 8% 3 23% 2 15% 2 15% 1 8% 2 15% 13 100%

Development partner or agency

Acceptability 1 50% 1 50% 2 100%

Feasibility 1 50% 1 50% 2 100%

Other Acceptability 2 100% 2 100%

Feasibility 1 50% 1 50% 2 100%


Feasibility 8 7% 6 5% 12 10% 13 11% 21 17% 11 9% 23 19% 15 12% 13 11% 122 100%

Region Africa Acceptability 1 3% 2 5% 1 3% 3 8% 3 8% 8 21% 7 18% 14 36% 39 100% Feasibility 1 3% 1 3% 5 13% 3 8% 7 18% 2 5% 10 26% 4 10% 6 15% 39 100% Europe Acceptability 6 14% 2 5% 1 2% 2 5% 11 26% 6 14% 2 5% 4 10% 8 19% 42 100% Feasibility 7 17% 3 7% 3 7% 6 14% 9 21% 4 10% 5 12% 3 7% 2 5% 42 100% Latin America Acceptability 2 100% 2 100% Feasibility 1 50% 1 50% 2 100% North America Acceptability 1 14% 2 29% 1 14% 3 43% 7 100% Feasibility 2 29% 2 29% 1 14% 1 14% 1 14% 7 100% South and South East Asia

Acceptability 1 6% 3 17% 4 22% 1 6% 2 11% 2 11% 5 28% 18 100% Feasibility 2 11% 2 11% 2 11% 4 22% 2 11% 4 22% 2 11% 18 100% Eastern Mediterranean Acceptability 2 29% 2 29% 2 29% 1 14% 7 100% Feasibility 1 14% 1 14% 1 14% 2 29% 1 14% 1 14% 7 100% Western Pacific Acceptability 1 14% 1 14% 1 14% 1 14% 1 14% 1 14% 1 14% 7 100% Feasibility 1 14% 1 14% 1 14% 2 29% 1 14% 1 14% 7 100% Total Acceptability 6 5% 4 3% 7 6% 5 4% 21 17% 13 11% 17 14% 17 14% 32 26% 122 100% Feasibility 8 7% 6 5% 12 10% 13 11% 21 17% 11 9% 23 19% 15 12% 13 11% 122 100%


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These are some of the opinions put forward by the respondents.

Guidelines are needed from policy-makers based on the country, regional or district situation. The examples below show this variation according to country needs. In some countries, students from underserved and underrepresented areas need to be actively recruited otherwise they are "forgotten" in the service training and delivery of health in the country.

“….admissions are based on local needs plus national admissions…”

“…Although the will exists, finding recruits with the required entry qualifications is more difficult…”

“…Feasibility depends on support mechanisms being in place — particularly social…”

“…This is becoming more acceptable. There is some reluctance because the challenge is that students from those backgrounds often did not have access to good schools and thus need additional academic support…”

Some respondents pointed to the need for support structures to improve chances of success, e.g. intervention programmes should be in place for students from these populations. Active recruitment without support tends to result in failure.

“In professional schools, we try to let everybody take part in the student community without consideration of where he/ she comes from or who he she is. But it seems to be tough to get in contact with underserved young people because of a lower level of education and use of information sources. It is no problem to get in contact with rural younger people because of a decent transport system and infrastructure.”

“…Need to better understand what is meant by ‘supported by regulatory mechanisms’. Active recruitment is fine but what regulatory mechanisms are in place is also crucial to implement this intervention.”

“…Pull the student to participate in health awareness programmes…”

“…recruitment is only based on qualification but there is also space to consider both place/underserved and qualification…”

In other countries, respondents do not perceive a need for active recruitment. The number of applicants always exceeds the number of places available.

“…Even if it is feasible, health professional schools are still highly attractive, and in small countries the majority of areas are covered. So I believe there is no need to initiate active recruitment for health professionals…”

“…I think this would be less accepted as it might be viewed as profiling and discriminating for interested students with good qualifications…”

“There are difficulties with this due to the academic standards and the rigor of programmes for these individuals. Some require exceptional extra help. Concerns arise with ability to meet licensure standards.”

“…to address the skewed distribution, this would be the way to go but challenging to implement…”

“Regulatory mechanisms for promoting this gives the impression of promoting inequalities among potential students from the urban areas...”


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4.2.1.3. Continuous development programmes to support faculties/current health workers to teach effectively in both undergraduate and postgraduate programmes

Under this section the respondents were asked about the feasibility and acceptability of an intervention that supports faculties and current health workers to teach effectively in both undergraduate and postgraduate programmes, in order to enhance the quantity, quality and relevance of health professionals. In particular, this intervention was labelled: “Introduction of continuous development programmes (CDP) for faculty/teaching staff”, which update both teaching and clinical competencies according to the evolving needs of a population/community (e.g. curriculum development and instructional design). Table 7 below presents the respondents’ scores from 1 to 9. A histogram is also presented below (Figure 9).

A fairly high percentage of respondents expressed the view that the introduction of CDP for faculty/teaching staff is both acceptable and feasible to implement, scoring 92% and 90% respectively. The mean score for acceptability is 7.58, and for feasibility 6.67. Respondents at the district and national levels ranked this intervention as more acceptable, almost equally (91% and 89% respectively) than at regional level (74%).

Figure 9. Histogram on acceptability and feasibility of “Continuous development programmes” to support faculties/current health workers to effectively teach in both undergraduate and postgraduate programmes


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Table 16. Acceptability and feasibility of “Continuous development programmes” to support faculties/current health workers to effectively teach in both undergraduate and postgraduate programmes



Total

N % N % N % N % N % N % N % N % N % N %

Acceptability 2 2% 2 2% 5 4% 7 6% 10 8% 19 16% 21 18% 54 45% 120 100%

Feasibility 2 2% 2 2% 8 7% 5 4% 17 14% 13 11% 26 22% 18 15% 29 24% 120 100%

Level of responsibility National Acceptability 2 4% 4 7% 4 7% 8 14% 9 16% 29 52% 56 100%

Feasibility 2 4% 3 5% 1 2% 9 16% 3 5% 12 21% 9 16% 17 30% 56 100%

Regional

Acceptability 2 6% 3 9% 2 6% 4 11% 7 20% 7 20% 10 29% 35 100%

Feasibility 1 3% 4 11% 4 11% 4 11% 7 20% 8 23% 4 11% 3 9% 35 100%

District Acceptability 2 9% 1 4% 1 4% 4 17% 4 17% 11 48% 23 100%

Feasibility 1 4% 1 4% 4 17% 3 13% 5 22% 2 9% 7 30% 23 100%

National, District Acceptability 1 50% 1 50% 2 100%

Feasibility 2 100% 2 100%

National, Regional Acceptability 1 25% 3 75% 4 100%

Feasibility 1 25% 1 25% 2 50% 4 100%

Total Acceptability 2 2% 2 2% 5 4% 7 6% 10 8% 19 16% 21 18% 54 45% 120 100%

Feasibility 2 2% 2 2% 8 7% 5 4% 17 14% 13 11% 26 22% 18 15% 29 24% 120 100%


Acceptability 1 2% 3 5% 2 3% 6 10% 8 13% 10 16% 31 51% 61 100%

Feasibility 4 7% 5 8% 5 8% 7 11% 13 21% 7 11% 20 33% 61 100%

Health professional Acceptability 1 4% 1 4% 2 8% 2 8% 8 32% 4 16% 7 28% 25 100%

Feasibility 1 4% 2 8% 3 12% 4 16% 3 12% 5 20% 4 16% 3 12% 25 100%

Policy-maker Acceptability 3 18% 2 12% 1 6% 3 18% 8 47% 17 100%

Feasibility 4 24% 1 6% 5 29% 3 18% 4 24% 17 100%

Professional association/regulatory body


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Acceptability 1 8% 2 15% 1 8% 3 23% 6 46% 13 100%

Feasibility 1 8% 1 8% 1 8% 1 8% 3 23% 4 31% 2 15% 13 100%


Acceptability 0 1 50% 0% 1 50% 2 100%

Feasibility 0 2 100% 2 100%

Other Acceptability 0 0% 1 50% 1 50% 2 100%

Feasibility 0 1 50% 1 50% 2 100%


Feasibility 2 2% 2 2% 8 7% 5 4% 17 14% 13 11% 26 22% 18 15% 29 24% 120 100%

Region Africa Acceptability 1 3% 1 3% 1 3% 1 3% 9 23% 5 13% 21 54% 39 100% Feasibility 1 3% 2 5% 3 8% 1 3% 5 13% 12 31% 3 8% 12 31% 39 100%

Europe Acceptability 1 2% 2 5% 4 10% 3 7% 9 22% 6 15% 16 39% 41 100% Feasibility 1 2% 4 10% 2 5% 10 24% 3 7% 8 20% 7 17% 6 15% 41 100% Latin America Acceptability 1 50% 1 50% 2 100% Feasibility 1 50% 1 50% 2 100% North America Acceptability 1 14% 2 29% 4 57% 7 100% Feasibility 1 14% 1 14% 1 14% 1 14% 1 14% 2 29% 7 100% South and South East Asia

Acceptability 1 6% 1 6% 3 17% 1 6% 4 22% 8 44% 18 100% Feasibility 1 6% 2 11% 2 11% 3 17% 3 17% 7 39% 18 100%

Eastern Mediterranean

Acceptability 1 14% 1 14% 1 14% 1 14% 3 43% 7 100% Feasibility 1 14% 1 14% 1 14% 2 29% 2 29% 7 100% Western Pacific Acceptability 1 17% 1 17% 2 33% 2 33% 6 100% Feasibility 1 14% 1 14% 1 14% 2 29% 2 29% 7 100% Total Acceptability 2 2% 2 2% 5 4% 7 6% 10 8% 19 16% 21 18% 54 45% 120 100% Feasibility 1 14% 1 14% 1 14% 2 29% 2 29% 7 100%


35

Continuous development programmes are essential for improving knowledge and competence at all levels of under- and postgraduate medical and allied health sciences education and training based on research needs. They should be designed in broad consultation with national councils, committees and boards of specialties in order to meet the health sector’s needs and to monitor the provision of health care services. The following quotations demonstrate a range of opinions, perceived challenges and suggested solutions.

“…A high percentage of old professors and the limited number of them in many schools will be barriers to implementing this intervention…”

“It is very acceptable to offer these programmes — the problem is getting people to attend. Unless there is some university policy requiring upgrade it won't happen.”

“It will force teaching staff to attend to self development, however, self development is not the only responsibility and could overburden the staff members.”

“…Crucial to maintain staff interest, quality and skills…”

“Especially if this was integrated into research programmes, this strategy would have a very good chance of being successful.”

“It is very important for us to have a teaching staff with updated knowledge in accordance with the European strategy and health policy ‘Health for all in the 21 century’".

“…Staff development is central to retention and good work performance…”

CPD is crucial for keeping up to date with advances in one’s field.

“CPD should include teaching updates in cases where professionals are in teaching positions.”

The availability of CPD is usually determined by the budget; this is usually controlled and not shared. Faculty development is self-driven and not system-driven, with a focus on attaining higher degrees rather than attaining teaching development skills, and often for self-promotion purposes.

“…Great concept, but again difficult with other institutional values and economic issues pushing practices…”

“…it can be accepted but can be hindered by limited resources…”

“Preceptors feel driven to produce in terms of numbers of patients seen, and often don't find the time to attend such programmes.”

“This is very important and well accepted, but there should be budget and equitable opportunities for all, including funding for such programmes.”


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4.2.1.4. Inter-professional and trans-professional learning to adapt a curriculum to population needs for both undergraduate and postgraduate programmes

Under this section the respondents were asked about their preferences and values concerning a proposed intervention to adapt a curriculum to population needs for both undergraduate and postgraduate programmes, in order to enhance the quantity, quality and relevance of health professionals. In particular, respondents were asked to assess whether it is acceptable and feasible to launch inter-professional and trans-professional learning. Table 8 below presents the respondents’ scores from 1 to 9. A histogram is also presented below (Figure 10).

About 90% of all respondents expressed the view that the introduction of inter-professional and trans-professional learning was acceptable but would be complicated to implement; only 77% think that it would be feasible. The mean score for acceptability is 6.69, and for feasibility 6.12. Respondents at the district level ranked this intervention as more acceptable (91%) than those at the national and regional levels (81% and 91% respectively).

Figure 10. Histogram on acceptability and feasibility of “Inter-professional and trans-professional learning” to adapt a curricular to population needs for both undergraduate and postgraduate programmes


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Table 17. Acceptability and feasibility of “Inter-professional and trans-professional learning” to adapt a curricular to population needs for both undergraduate and postgraduate programmes



Total

N % N % N % N % N % N % N % N % N % N %

Acceptability 2 2% 5 4% 5 4% 7 6% 23 20% 6 5% 11 9% 20 17% 37 32% 116 100%

Feasibility 2 2% 4 3% 11 9% 10 9% 25 22% 13 11% 10 9% 15 13% 26 22% 116 100%


Feasibility 2 4% 2 4% 4 7% 4 7% 8 14% 7 13% 3 5% 11 20% 15 27% 56 100%

Regional

Acceptability 2 6% 2 6% 3 9% 8 25% 3 9% 3 9% 6 19% 5 16% 32 100%

Feasibility 5 16% 5 16% 9 28% 5 16% 3 9% 2 6% 3 9% 32 100%

District Acceptability 1 5% 1 5% 3 14% 1 5% 3 14% 6 27% 7 32% 22 100%

Feasibility 2 4% 2 4% 4 7% 4 7% 8 14% 7 13% 3 5% 11 20% 15 27% 56 100% National, District Acceptability 1 50% 1 50% 2 100%

Feasibility 1 50% 1 50% 2 100%

National, Regional Acceptability 1 25% 2 50% 1 25% 4 100%

Feasibility 3 75% 1 25% 4 100%


Feasibility 2 2% 4 3% 11 9% 10 9% 25 22% 13 11% 10 9% 15 13% 26 22% 116 100%


Acceptability 2 3% 1 2% 5 9% 10 17% 4 7% 5 9% 9 16% 22 38% 58 100%

Feasibility 1 2% 7 12% 3 5% 14 24% 7 12% 6 10% 6 10% 14 24% 58 100%

Health professional Acceptability 3 13% 3 13% 5 21% 3 13% 7 29% 3 13% 24 100%

Feasibility 2 8% 3 13% 2 8% 5 21% 2 8% 2 8% 5 21% 3 13% 24 100%

Policy-maker Acceptability 1 6% 1 6% 2 12% 5 29% 1 6% 1 6% 2 12% 4 24% 17 100%

Feasibility 1 6% 1 6% 1 6% 2 12% 3 18% 2 12% 0 0% 3 18% 4 24% 17 100%

Professional association/regulatory


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body Acceptability 1 8% 1 8% 2 15% 2 15% 7 54% 13 100%

Feasibility 1 8% 1 8% 2 15% 2 15% 2 15% 1 8% 4 31% 13 100%



Feasibility 1 50% 1 50% 2 100%




Feasibility 2 2% 4 3% 11 9% 10 9% 25 22% 13 11% 10 9% 15 13% 26 22% 116 100%

Region Africa

Acceptability 2 6% 4 11% 11 31% 1 3% 3 8% 4 11% 11 31% 36 100% Feasibility 2 6% 3 8% 3 8% 9 25% 5 14% 3 8% 2 6% 9 25% 36 100% Europe Acceptability 2 5% 1 2% 3 7% 2 5% 7 17% 3 7% 1 2% 6 15% 16 39% 41 100% Feasibility 2 5% 2 5% 4 10% 3 7% 10 24% 2 5% 5 12% 5 12% 8 20% 41 100% Latin America Acceptability 1 50% 1 50% 2 100%

Feasibility 1 50% 1 50% 2 100% North America Acceptability 1 14% 1 14% 2 29% 3 43% 7 100% Feasibility 1 14% 1 14% 2 29% 1 14% 2 29% 7 100% South and South East Asia Acceptability 1 6% 1 6% 1 6% 2 11% 1 6% 2 11% 5 28% 5 28% 18 100% Feasibility 1 6% 2 11% 2 11% 1 6% 1 6% 5 28% 6 33% 18 100% Eastern Mediterranean Acceptability 1 14% 1 14% 1 14% 3 43% 1 14% 7 100% Feasibility 1 14% 1 14% 1 14% 3 43% 1 14% 7 100% Western Pacific Acceptability 1 20% 1 20% 2 40% 1 20% 5 100% Feasibility 1 20% 1 20% 3 60% 5 100% Total Acceptability 2 2% 5 4% 5 4% 7 6% 23 20% 6 5% 11 9% 20 17% 37 32% 116 100% Feasibility 2 2% 4 3% 11 9% 10 9% 25 22% 13 11% 10 9% 15 13% 26 22% 116 100%


39

Below are some of the opinions expressed by respondents to explain their scores. It is an important issue; it could increase the motivation for excellence. In fact, inter-professional learning is desired, but its feasibility in terms of coordinating timetables makes it difficult to achieve. Trans-professional learning was less highly ranked by the respondents. They thought it would be time consuming, often not well accepted by students, and without strong evidence that it makes a big difference. The following quotations provide a range of opinions, challenges and suggested solutions.

“Although there is much dialogue re this there has not been much success to date.”

“…can be a significant challenge as there may be limitations in overlap among their educational needs.”

“Feasibility may be a problem as programmes are not of the same duration. Therefore this should be introduced at appropriate levels for different health professionals.”

“…many countries are poor in this and also many of them narrow minded this is very important as my concern…”

“…Need to have inter/trans-professional practice visible before [it] could be teachable…”

“… a cultural shift in learning systems is required. Health professionals do have their own courses and have some inter-professional opportunities but can be increased. A BSc (Health Science) has been introduced for an inter-professional student body...”

“…Resistance from medical and senior professionals…”

“…the evidence suggests that this is not a productive pathway and can be highly counter-productive…”

“Sharing common modules and training periods among health professionals could provide a better understanding between them and more effective work-teams. The acceptability wouldn’t be so good at the beginning.”

“There is disparity in numbers of students from different disciplines; this tends to make this type of educational experience difficult to manage…”

“…This already occurs here; however, co-ordination and scheduling among departments remains a significant challenge.”

“This is being trialed in two projects sponsored by the Ministry of Health; it takes time to establish and costs may be high once the project is underway and funding ceases; the success or otherwise of the projects will be reviewed.”


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4.2.2. Regulatory frameworks

Under this section the respondents were asked to state their preference and values concerning what strategies/interventions should be undertaken to make effective enforcement of regulations for both undergraduate and postgraduate programmes in order to enhance the quantity, quality and relevance of health professionals. Respondents were also asked to assess whether it would be feasible to implement. The following interventions were identified:

the introduction of streamlined educational pathways and ladder programmes, for the advancement of practising health professionals, including restructuring the delivery of curricula;

the accreditation/periodical re-accreditation of all educational institutions and their associated clinical practice placement sites, both public and private;

the introduction of certification/licensure and revision of national standards (including periodic re-licensure/re-certification), both public and private.

Tables 9a, 9b and 9c below present the respondents’ scores from 1 to 9. A histogram for each intervention is presented below (Figure 11a, 11b, 11c).

4.2.2.1 To introduce streamlined educational pathways and ladder programmes, for the advancement of practising health professionals, including restructuring the delivery of curricula

About 92% of all respondents expressed the view that the introduction of streamlined educational pathways and ladder programmes is acceptable, but would be complicated to implement; only 78% thought that it was feasible. The mean score for acceptability is 6.92, and for feasibility 5.86. Respondents at the national and district levels ranked this intervention equally (95%) and as more acceptable than those at the regional level (84%).

Figure 11a. Histogram on acceptability and feasibility of “Streamlined educational pathways and ladder programmes” to make effective enforcement of regulations for both undergraduate and postgraduate programmes


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Table 9a. Acceptability and feasibility of “Streamlined educational pathways and ladder programmes” to make effective enforcement of regulations for both undergraduate and postgraduate programmes



Total

N % N % N % N % N % N % N % N % N % N %

Acceptability 2 2 3 3 2 2 2 2 24 21 8 7 15 13 24 21 32 29 112 100

Feasibility 1 1 6 5 7 6 11 10 27 24 18 16 17 15 9 8 16 14 112 100

Level of responsibility National Acceptability 2 4% 1 2% 9 16% 3 5% 8 15% 15 27% 17 31% 55 100%

Feasibility 1 2% 4 7% 3 5% 15 27% 9 16% 8 15% 8 15% 7 13% 55 100%

Regional

Acceptability 3 10% 1 3% 1 3% 10 32% 4 13% 4 13% 3 10% 5 16% 31 100%

Feasibility 3 10% 3 10% 6 19% 4 13% 5 16% 6 19% 1 3% 3 10% 31 100%

District Acceptability 1 5% 3 15% 1 5% 2 10% 5 25% 8 40% 20 100%

Feasibility 3 15% 2 10% 5 25% 3 15% 2 10% 5 25% 20 100%

National, District


Feasibility 1 50% 1 50% 2 100%

National Regional

Acceptability 2 50% 1 25% 1 25% 4 100%

Feasibility 2 50% 1 25% 1 25% 4 100%


Feasibility 1 1% 6 5% 7 6% 11 10% 27 24% 18 16% 17 15% 9 8% 16 14% 112 100%


Acceptability 1 2% 1 2% 1 2% 2 4% 10 19% 3 6% 7 13% 12 22% 17 31% 54 100%

Feasibility 3 6% 2 4% 7 13% 13 24% 7 13% 6 11% 5 9% 11 20% 54 100%

Health professional Acceptability 1 4% 1 4% 6 25% 2 8% 3 13% 5 21% 6 25% 24 100%

Feasibility 2 8% 2 8% 2 8% 7 29% 1 4% 4 17% 3 13% 3 13% 24 100%


Feasibility 2 12% 2 12% 3 18% 5 29% 3 18% 1 6% 1 6% 17 100%



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Acceptability 1 8% 1 8% 1 8% 3 23% 3 23% 4 31% 13 100%

Feasibility 1 8% 1 8% 3 23% 3 23% 4 31% 1 8% 13 100%


Acceptability 1 50% 1 50% 0 0% 2 100%

Feasibility 1 50% 1 50% 0 0% 2 100%

Other Acceptability 1 50% 1 50% 2 100%

Feasibility 1 50% 1 50% 2 100%


Feasibility 1 1% 6 5% 7 6% 11 10% 27 24% 18 16% 17 15% 9 8% 16 14% 112 100%

Region Africa Acceptability 1 3% 1 3% 1 3% 5 15% 3 9% 6 18% 8 24% 9 26% 34 100% Feasibility 2 6% 3 9% 3 9% 7 21% 5 15% 6 18% 2 6% 6 18% 34 100% Europe Acceptability 1 3% 1 3% 1 3% 11 28% 2 5% 6 15% 7 18% 11 28% 40 100% Feasibility 1 3% 2 5% 1 3% 5 13% 14 35% 5 13% 6 15% 3 8% 3 8% 40 100% Latin America Acceptability 1 50% 1 50% 2 100% Feasibility 1 50% 1 50% 2 100% North America Acceptability 1 17% 1 17% 1 17% 1 17% 2 33% 6 100% Feasibility 1 17% 1 17% 1 17% 2 33% 1 17% 6 100% South and South East Asia

Acceptability 1 6% 5 28% 2 11% 2 11% 8 44% 18 100% Feasibility 3 17% 4 22% 3 17% 2 11% 1 6% 5 28% 18 100% Eastern Mediterranean Acceptability 1 14% 1 14% 3 43% 2 29% 7 100% Feasibility 1 14% 1 14% 2 29% 2 29% 1 14% 7 100% Western Pacific Acceptability 1 20% 1 20% 3 60% 5 100% Feasibility 1 20% 1 20% 1 20% 1 20% 1 20% 5 100% Total Acceptability 2 2% 3 3% 2 2% 2 2% 24 21% 8 7% 15 13% 24 21% 32 29% 112 100% Feasibility 1 1% 6 5% 7 6% 11 10% 27 24% 18 16% 17 15% 9 8% 16 14% 112 100%


43

This issue is viewed as important, but difficult to introduce. The issues of assessment and guarantee of meeting qualification standards will require much work. Political will and engagement by the parties are necessary. The following quotations from respondents provide a range of opinions, challenges and suggested solutions.

“…Enforcement could be challenging…”

“….Good idea but it is very hard to do and assumes that knowledge and experience are the only factors that influence [a] successful health practitioner.”

“…It would be well accepted by the lower level of qualification professions (i.e. nursing assistants). The feasibility would depend on acceptability among different groups of health professionals. This intervention needs an agreement or consensus among all health professions.”

“…possible but funds limitation can prevent it being successfully implemented...”

“…There are a lot of different possibilities to improve the knowledge of health practitioners in a structured way, e.g. Bachelor’s degree and MSc, PhD.”

“…there is good progress regarding introducing higher diploma for medical education and other paths reflecting the intentions of the health professionals…”

“…There is potential interest from regulators but the idea is not completely accepted by educational institutions…”

4.2.2.2. To accredit/periodically re-accredit all educational institutions and their associated clinical practice placement sites, both public and private

About 91% of all respondents expressed the view that accreditation and periodic re-accreditation of all educational institutions and their associated clinical practice placement sites is acceptable, but could be difficult to implement. 84% of respondents thought it was feasible. The mean score for acceptability is 7.13, and for feasibility 6.49. Respondents at the district and national levels ranked this intervention as more acceptable (95% and 91% respectively) than those at the regional level (84%).

Figure 11b. Histogram on acceptability and feasibility of “Accreditation/periodical re-accreditation of all educational institutions, both public and private” to make effective enforcement of regulations for both undergraduate and postgraduate programmes


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Table 9b. Acceptability and feasibility of “Accreditation/periodical re-accreditation of all educational institutions, both public and private” to make effective enforcement of regulations for both undergraduate and postgraduate programmes



Total

N % N % N % N % N % N % N % N % N % N %

Acceptability 2 2 2 2 5 5 2 2 15 14 5 5 17 15 29 26 34 31 111 100

Feasibility 3 3 2 2 8 7 5 4 24 21 6 5 18 16 20 18 26 23 112 100


Feasibility 1 2% 3 5% 5 9% 13 24% 1 2% 9 16% 11 20% 12 22% 55 100%

Regional

Acceptability 2 6% 2 6% 5 16% 1 3% 6 19% 8 26% 6 19% 31 100%

Feasibility 1 3% 2 6% 3 10% 7 23% 4 13% 4 13% 4 13% 6 19% 31 100%

District Acceptability 1 5% 3 16% 4 21% 4 21% 7 37% 19 100%

Feasibility 1 5% 2 10% 4 20% 1 5% 3 15% 3 15% 6 30% 20 100%


Feasibility 1 50% 1 50% 2 100%


Feasibility 2 50% 1 25% 1 25% 4 100%


Feasibility 3 3% 2 2% 8 7% 5 4% 24 21% 6 5% 18 16% 20 18% 26 23% 112 100%


Acceptability 1 2% 1 2% 3 6% 1 2% 6 11% 1 2% 8 15% 14 26% 18 34% 53 100%

Feasibility 2 4% 1 2% 3 6% 1 2% 9 17% 2 4% 12 22% 10 19% 14 26% 54 100%

Health professional Acceptability 1 4% 2 8% 1 4% 2 8% 1 4% 6 25% 5 21% 6 25% 24 100%

Feasibility 1 4% 3 13% 9 38% 1 4% 2 8% 5 21% 3 13% 24 100%


Feasibility 1 6% 3 18% 3 18% 2 12% 3 18% 2 12% 3 18% 17 100%



45

Acceptability 1 8% 0% 1 8% 1 8% 1 8% 3 23% 6 46% 13 100%

Feasibility 1 8% 0% 2 15% 1 8% 1 8% 3 23% 5 38% 13 100%


Acceptability 0% 1 50% 1 50% 2 100%

Feasibility 1 50% 1 50% 2 100%


Feasibility 1 50% 1 50% 2 100%


Feasibility 3 3% 2 2% 8 7% 5 4% 24 21% 6 5% 18 16% 20 18% 26 23% 112 100%

Region Africa Acceptability 1 3% 1 3% 3 9% 8 24% 12 35% 9 26% 34 100% Feasibility 1 3% 3 9% 2 6% 4 12% 3 9% 7 21% 8 24% 6 18% 34 100% Europe Acceptability 1 3% 1 3% 3 8% 1 3% 7 18% 3 8% 5 13% 7 18% 12 30% 40 100% Feasibility 1 3% 1 3% 1 3% 3 8% 12 30% 1 3% 6 15% 5 13% 10 25% 40 100% Latin America Acceptability 1 50% 1 50% 2 100% Feasibility 1 50% 1 50% 2 100% North America Acceptability 1 50% 2 100% 1 50% 2 100% 6 300% Feasibility 1 17% 2 33% 1 17% 2 33% 6 100% South and South East Asia

Acceptability 1 6% 3 18% 2 12% 2 12% 3 18% 6 35% 17 100% Feasibility 1 6% 1 6% 1 6% 2 11% 2 11% 3 17% 3 17% 5 28% 18 100% Eastern Mediterranean Acceptability 1 14% 1 14% 2 29% 3 43% 7 100% Feasibility 1 14% 3 43% 1 14% 1 14% 1 14% 7 100% Western Pacific Acceptability 1 20% 3 60% 1 20% 5 100% Feasibility 1 20% 3 60% 1 20% 5 100% Total Acceptability 2 2% 2 2% 5 5% 2 2% 15 14% 5 5% 17 15% 29 26% 34 31% 111 100% Feasibility 3 3% 2 2% 8 7% 5 4% 24 21% 6 5% 18 16% 20 18% 26 23% 112 100%


46

Below are some opinions expressed by respondents to explain their scores. Periodic accreditation and re-accreditation of all educational institutions and their associated clinical practice placement sites is seen as a key issue to ensuring ongoing quality and relevance.

“…Highly important to assess the quality of clinical practice placements sites. But could be challenging if demand driven.

“…much effort is needed to organize and build a clear strategy to achieve this task.”

“…Need to very careful about how things are measured so as to not be punitive.”

“…Processes cumbersome and licensing authorities take ages to licence…”

“…Specified periods for reaccreditation are needed. However, this should not be too soon or too late…”

“…This system exists at the moment. However, the professional body responsible for re-accreditation seems to be reluctant to take steps against non-compliant organizations, probably because they could not afford to close down any delinquent organizations.”

“…To determine which would be the competent authorities for those accreditations and to establish the criteria and the developmental process would take some time, so it would be feasible in the medium term.”

4.2.2.3. To introduce certification/licensure and revision of national standards (including periodic re-licensure/re-certification), both public and private

A smaller percentage of respondents expressed the view that the introduction of certification and licensure and revision of national standards is acceptable (84% of respondents) but it is rather complicated to implement: 77% thought it was feasible. The mean score for acceptability is 6.68, and for feasibility 6.23. Respondents at the regional and national levels ranked this intervention as more acceptable (87% and 84% respectively) than those at the district level (80%).

Figure 11c. Histogram on acceptability and feasibility of “Certification/licensure and revision of national standards, both public and private” to make effective enforcement of regulations for both undergraduate and postgraduate programmes


47

Table 9c. Acceptability and feasibility of “Certification/licensure and revision of national standards, both public and private” to make effective enforcement of regulations for both undergraduate and postgraduate programmes



Total

N % N % N % N % N % N % N % N % N % N %

Acceptability 4 4 3 3 6 5 5 4 16 14 10 9 18 16 16 14 34 30 112 100

Feasibility 2 2 4 4 9 8 11 10 23 21 10 9 8 7 19 17 26 23 112 100


Feasibility 1 2% 2 4% 4 7% 3 5% 13 24% 4 7% 4 7% 9 16% 15 27% 55 1

Regional

Acceptability 1 3% 1 3% 2 6% 6 19% 4 13% 7 23% 5 16% 5 16% 31 100%

Feasibility 2 6% 3 10% 3 10% 6 19% 6 19% 1 3% 6 19% 4 13% 31 100%

District Acceptability 1 5% 1 5% 1 5% 1 5% 1 5% 4 20% 3 15% 8 40% 20 100%

Feasibility 1 5% 2 10% 4 20% 3 15% 0 0% 2 10% 3 15% 5 25% 20 100%


Feasibility 1 50% 1 50% 2 100%

National, Regional Acceptability 1 25% 1 25% 1 25% 1 25% 4 100%

Feasibility 1 25% 1 25% 1 25% 1 25% 4 100%


Feasibility 2 2% 4 4% 9 8% 11 10% 23 21% 10 9% 8 7% 19 17% 26 23% 112 100%


Acceptability 1 2% 1 2% 3 6% 3 6% 4 7% 5 9% 12 22% 9 17% 16 30% 54 100%

Feasibility 1 2% 4 7% 7 13% 8 15% 6 11% 4 7% 10 19% 14 26% 54 100%


Feasibility 1 4% 2 8% 4 17% 1 4% 6 25% 2 8% 4 17% 4 17% 24 100%

Policy-maker Acceptability 2 12% 4 24% 4 24% 0 0% 2 12% 5 29% 17 100%

Feasibility 1 6% 2 12% 4 24% 3 18% 2 12% 1 6% 4 24% 17 100%



48

Acceptability 2 15% 1 8% 3 23% 2 15% 5 38% 13 100%

Feasibility 1 8% 1 8% 3 23% 1 8% 3 23% 4 31% 13 100%


Acceptability 2 100% 2 100%

Feasibility 1 50% 1 50% 2 100%


Feasibility 1 50% 1 50% 2 100%


Feasibility 2 2% 4 4% 9 8% 11 10% 23 21% 10 9% 8 7% 19 17% 26 23% 112 100%

Region Africa Acceptability 2 5% 2 5% 3 8% 3 8% 7 18% 2 5% 5 13% 4 10% 12 30% 40 100% Feasibility 1 3% 3 9% 1 3% 8 24% 3 9% 5 15% 7 21% 6 18% 34 100% Europe Acceptability 2 5% 2 5% 3 8% 3 8% 7 18% 2 5% 5 13% 4 10% 12 30% 40 100%

Feasibility 2 5% 1 3% 1 3% 9 23% 10 25% 1 3% 1 3% 4 10% 11 28% 40 100%

Latin America Acceptability 2 5% 2 5% 3 8% 3 8% 7 18% 2 5% 5 13% 4 10% 12 30% 40 100%

Feasibility 1 50% 1 50% 2 100%

North America Acceptability 1 17% 2 33% 1 17% 2 33% 6 100%

Feasibility 1 17% 2 33% 1 17% 2 33% 6 100%

South and South East Asia

Acceptability 1 6% 1 6% 1 6% 3 17% 3 17% 1 6% 8 44% 18 100%

Feasibility 1 6% 2 11% 1 6% 2 11% 3 17% 5 28% 4 22% 18 100%

Eastern Mediterranean Acceptability 1 14% 1 14% 1 14% 1 14% 3 43% 7 100%

Feasibility 1 14% 2 29% 1 14% 1 14% 2 29% 7 100%

Western Pacific Acceptability 1 20% 1 20% 1 20% 1 20% 1 20% 5 100%

Feasibility 1 20% 1 20% 1 20% 2 40% 5 100%


Feasibility 2 2% 4 4% 9 8% 11 10% 23 21% 10 9% 8 7% 19 17% 26 23% 112 100%


49

Below are some opinions expressed by respondents to explain their scores.

This issue is important for public safety. A lot of work is needed to build the tools for assessment. Mechanisms and legislation are also needed to support the process. The following quotations provide a range of opinions, challenges and suggested solutions.

“…a dynamic and continuous practice of the MOH together with academies and associations.”

“…Lack of time, manpower and commitment to carry it out.”

“…possible but financial problem.”

“…The competence of health professional’s regulation is currently shared by the Ministry and professional bodies, but the role of these last ones is going to be reviewed in a new law. The relevance of establishing a certificate or licence will be heavily discussed. Right now it would be neither acceptable nor feasible.”

“….The regulatory council needs to strengthen its administrative capacity to be able to do this.”

“…There is a lot of reaction to competence re-certification policies.”

“…will be difficult to monitor.”

4.2.3. Financing

Under this section the respondents were asked to state their preferences and values on what strategies/interventions should be undertaken to design financial plans for transforming and scaling up education and training in order to enhance the quantity, quality and relevance of health professionals. Respondents were also asked to assess whether it would be feasible to implement. The following interventions were identified:

increasing the allocation of resources (local/international/private) targeted to health professional education/training, including cost-effectiveness assessments and strategic management;

aligning international assistance to domestic investment and priorities for health professional education;

introducing results-based financing for health professional schools;

providing financial assistance to students by subsidizing education in return for compulsory service in underserved/ rural areas;

providing direct financial assistance to students (e.g. loans, grants, fellowships).

Tables 10a, 10b, 10c, 10d and 10e below present the respondents’ scores from 5 to 9. Histograms are also presented below (Figure 12a, 12b, 12c, 12 d, 12e).


50

4.2.3.1. To increase the allocation of resources (local/international/private) targeted to health professional education/training, including cost-effectiveness assessments and strategic management

About 85% of all respondents expressed the view that increasing resource allocation for health professional education/training, including cost-effectiveness assessments and strategic management, is acceptable; however, it is difficult to implement: only 69% of respondents believe that it is feasible. The mean score for acceptability is 7.11, and for feasibility 5.51. Respondents at all levels ranked this intervention as acceptable, more or less equally: national and regional levels 84%, and district level 85%.

Below are some opinions expressed by respondents to explain their scores.

Allocation of resources targeted to effective and strategic management is necessary to maintain national health systems and if it is well explained to people it would be both acceptable and feasible. The following quotations suggest a range of opinions, challenges and solutions.

“…Competition for the same pie of national resources. But this is an investment in health care delivery, not isolated education…”

“…corruption and poor management practices result in losses of funds for the health system.”

“...governments need advice on how this could work effectively. Should be determined by local priorities…”

“…Great idea if the resources were available but with the economic difficulties it is unlikely to be feasible… The current economic situation offers a great challenge for increase in the allocation of financial resources.”

“…Wellstructured financial resources are needed to guarantee a better quality of education in the health professionals' schools…”

“…Would need to be sustainable…”

Figure 12a. Histogram on acceptability and feasibility of an intervention to “Increase the allocation of resources targeted to health professional education/training” to design financial plans for transforming and scaling up education and training


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Table 18a. Acceptability and feasibility of an intervention to “Increase the allocation of resources targeted to health professional education/training” to design financial plans for transforming and scaling up education and training



Total

N % N % N % N % N % N % N % N % N % N % Acceptability 1 1 3 3 7 6 6 5 13 12 7 6 10 9 18 16 47 42 112 100 Feasibility 2 2 7 6 13 12 13 12 29 26 9 8 15 13 10 9 14 13 112 100 Level of responsibility National Acceptability 2 4% 5 9% 2 4% 7 13% 1 2% 4 7% 11 20% 23 42% 55 100%

Feasibility 1 2% 2 4% 8 15% 6 11% 14 25% 4 7% 8 15% 4 7% 8 15% 55 100%

Regional

Acceptability 1 3% 1 3% 3 10% 4 13% 3 10% 5 16% 2 6% 12 39% 31 100%

Feasibility 1 3% 3 10% 3 10% 4 13% 9 29% 3 10% 2 6% 4 13% 2 6% 31 100%


Feasibility 2 10% 1 5% 3 15% 5 25% 2 10% 4 20% 3 15% 20 100%


Feasibility 1 50% 1 50% 2 100%


Feasibility 1 25% 1 25% 1 25% 1 25% 4 100%


Feasibility 2 2% 7 6% 13 12% 13 12% 29 26% 9 8% 15 13% 10 9% 14 13% 112 100%


Acceptability 2 4% 2 4% 2 4% 5 9% 4 7% 7 13% 6 11% 26 48% 54 100%

Feasibility 6 11% 5 9% 5 9% 11 20% 6 11% 6 11% 7 13% 8 15% 54 100%


Feasibility 2 8% 1 4% 3 13% 2 8% 6 25% 1 4% 8 33% 1 4% 24 100%

Policy-maker Acceptability 1 6% 1 6% 6 35% 2 12% 2 12% 5 29% 17 100%

Feasibility 3 18% 3 18% 6 35% 1 6% 1 6% 1 6% 2 12% 17 100%



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body Acceptability 2 15% 0 0% 0 0% 0 0% 1 8% 4 31% 6 46% 13 100%

Feasibility 1 8% 2 15% 4 31% 1 8% 1 8% 4 31% 13 100%



Feasibility 1 50% 1 50% 2 100%


Feasibility 1 50% 1 50% 2 100%


Feasibility 2 2% 7 6% 13 12% 13 12% 29 26% 9 8% 15 13% 10 9% 14 13% 112 100%

Region Africa Acceptability 1 3% 1 3% 1 3% 2 6% 2 6% 2 6% 6 18% 19 56% 34 100% Feasibility 1 3% 2 6% 1 3% 3 9% 13 38% 2 6% 5 15% 3 9% 4 12% 34 100% Europe Acceptability 1 3% 5 13% 2 5% 6 15% 3 8% 3 8% 6 15% 14 35% 40 100%

Feasibility 3 8% 8 20% 6 15% 10 25% 3 8% 3 8% 3 8% 4 10% 40 100%

Latin America Acceptability 1 50% 1 50% 2 100%

Feasibility 1 50% 1 50% 2 100%

North America Acceptability 1 17% 2 33% 3 50% 6 100%

Feasibility 1 17% 1 17% 1 17% 1 17% 1 17% 1 17% 6 100%


Acceptability 2 11% 3 17% 1 6% 2 11% 4 22% 6 33% 18 100%

Feasibility 1 6% 1 6% 1 6% 1 6% 4 22% 1 6% 4 22% 3 17% 2 11% 18 100%


Feasibility 2 29% 2 29% 2 29% 1 14% 7 100%

Western Pacific Acceptability 2 40% 1 20% 2 40% 5 100%

Feasibility 1 20% 1 20% 1 20% 1 20% 1 20% 5 100%


Feasibility 2 2% 7 6% 13 12% 13 12% 29 26% 9 8% 15 13% 10 9% 14 13% 112 100%


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4.2.3.2 Aligning international assistance to domestic investment and priorities for health professional education

About 82% of all respondents expressed the view that aligning international assistance to domestic investment and prioritizing health professional education is acceptable; however, it might be difficult to implement: only 70% of respondents believed that it was feasible. The mean score for acceptability is 6.47, and for feasibility 5.41. Respondents at all levels ranked this intervention as acceptable, more or less equally: national 82%, regional 81% and district 80%. Figure 12b. Histogram on acceptability and feasibility of an intervention “Aligning international assistance to domestic investment” to design financial plans for transforming and scaling up education and training

Below are some opinions expressed by respondents to explain their scores. The following extracts suggest a range of opinions, challenges and solutions.

“It is an important issue. There is a global recession so where will the money come from? There are always problems with international money. To be sustainable, programmes have to be realistically funded by national resources. A little extra money is always helpful but international money should not be the prime source.”

“…Certainly to prioritize for health professional education, but not necessarily for domestic investment as this may be determined by political decision-makers.”

“….determined by local priorities.”

“…governments would have trouble getting around this.”

“…international assistance is difficult to attain for these more long term goals that do not have such evident deliverables.”

“…international priorities can blind government to local needs in their bid to obtain available funding.”

“…Many universities have twinning relationships with international authorities and they are working well.”

“…Systems can be open to abuse and misappropriation of funds.”

“….To encourage domestic advancement if needing more assistance.”


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Table 10b. Acceptability and feasibility of an intervention “Aligning international assistance to domestic investment” to design financial plans for transforming and scaling up education and training



Total

N % N % N % N % N % N % N % N % N % N %

Acceptability 7 6 3 3 6 5 4 4 20 18 7 6 14 13 21 19 30 27 112 100

Feasibility 8 7 8 7 12 11 6 5 24 21 15 13 13 12 13 12 13 12 112 100


Feasibility 5 9% 4 7% 7 13% 3 5% 13 24% 6 11% 5 9% 6 11% 6 11% 55 100%

Regional

Acceptability 2 6% 1 3% 1 3% 2 6% 6 19% 2 6% 6 19% 6 19% 5 16% 31 100%

Feasibility 1 3% 4 13% 3 10% 2 6% 5 16% 8 26% 4 13% 2 6% 2 6% 31 100%

District Acceptability 1 5% 1 5% 2 10% 4 20% 1 5% 4 20% 7 35% 20 100%

Feasibility 2 10% 1 5% 1 5% 5 25% 1 5% 4 20% 3 15% 3 15% 20 100%




Feasibility 1 25% 2 50% 4 100%


Feasibility 8 7% 8 7% 12 11% 6 5% 24 21% 15 13% 13 12% 13 12% 13 12% 112 100%


Acceptability 2 4% 2 4% 1 2% 3 6% 8 15% 5 9% 7 13% 8 15% 18 33% 54 100%

Feasibility 2 4% 6 11% 5 9% 3 6% 9 17% 6 11% 7 13% 6 11% 10 19% 54 100%


Feasibility 2 8% 1 4% 4 17% 2 8% 4 17% 2 8% 4 17% 4 17% 1 4% 24 100%

Policy-maker Acceptability 1 6% 1 6% 4 24% 1 6% 2 12% 4 24% 4 24% 17 100%

Feasibility 2 12% 1 6% 1 6% 1 6% 6 35% 2 12% 2 12% 1 6% 1 6% 17 100%



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body Acceptability 2 15% 1 8% 2 15% 2 15% 4 31% 2 15% 13 100%

Feasibility 2 15% 1 8% 0% 4 31% 3 23% 0% 2 15% 1 8% 13 100%



Feasibility 1 50% 1 50% 2 100%


Feasibility 1 1 1 50% 1 50% 2 100%


Feasibility 8 7% 8 7% 12 11% 6 5% 24 21% 15 13% 13 12% 13 12% 13 12% 112 100%

Region Africa Acceptability 1 3% 1 3% 1 3% 3 9% 4 12% 5 15% 8 24% 11 32% 34 100% Feasibility 2 6% 4 12% 2 6% 5 15% 6 18% 4 12% 5 15% 6 18% 34 100% Europe Acceptability 5 13% 1 3% 3 8% 2 5% 8 20% 1 3% 6 15% 4 10% 10 25% 40 100%

Feasibility 7 18% 2 5% 6 15% 1 3% 12 30% 2 5% 5 13% 4 10% 1 3% 40 100%

Latin America Acceptability 1 50% 1 50% 0 0% 2 100%

Feasibility 1 50% 1 50% 0 0% 2 100%


Feasibility 1 17% 1 17% 1 17% 1 17% 1 17% 1 17% 6 100%


Acceptability 1 6% 3 17% 1 6% 1 6% 5 28% 7 39% 18 100%

Feasibility 2 11% 2 11% 3 17% 2 11% 2 11% 2 11% 5 28% 18 100%


Feasibility 1 14% 2 29% 3 43% 1 14% 7 100%

Western Pacific Acceptability 1 20% 1 20% 1 20% 2 40% 5 100%

Feasibility 1 20% 1 20% 1 20% 1 20% 1 20% 5 100%


Feasibility 8 7% 8 7% 12 11% 6 5% 24 21% 15 13% 13 12% 13 12% 13 12% 112 100%


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4.2.3.3. To introduce results-based financing for health professional schools

A smaller percentage of respondents expressed the view that the introduction of results-based financing for health professional schools is acceptable (69%); however, it might be difficult to implement: only 65% of respondents believed that it is feasible. The mean score for acceptability is 5.27, and for feasibility 5.73. Respondents at the national level ranked this intervention as more acceptable (70%) than those at regional and district levels, whose numbers were equal (65%).

Figure 12c. Histogram on acceptability and feasibility of an intervention “Introducing results-based financing” to design financial plans for transforming and scaling up education and training

Below are some opinions expressed by respondents to explain their scores. The following quotations suggest a range of opinions, challenges and solutions.

“…although it could be a good idea I don't see we are prepared for that…”

“…Culture of accountability is not prevalent…”

“…Done in state supported schools, but difficult to gain acceptance in the institution and obtain expected results in output…”

“…Concept difficult to monitor. What are the results of a school? Number of graduates vs. number of teachers?”

“...If you expect schools to train disadvantaged students who are contextually and linguistically challenged [you] are going to fail. So this would be inappropriate if incredible student resources are not available…”

“…Less acceptable due to many political interests. Might cause unsatisfactory feelings for others, thus it is not feasible…”

“…Results are too difficult to define and take too long to achieve for this to be feasible. The only exception I see relates to the next question, where I think that it would be reasonable to fund places in schools and students with a requirement that the graduates work in underserved areas…”

“…Reward for outcomes - as long as these are outcomes based on health care needs….”

“…The worst performing schools might need more resources than the best performing…”


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“…there would be lots of disagreements as to what results are good results…”

“…This could be viewed as perverse incentives…”

“…This would increase both quantity and quality…”

“…Waiting for results only might be too late: some health professionals' courses take four to six years before being financed. Let there be more financial support for credible newcomers into the courses…”


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Table 10c. Acceptability and feasibility of an intervention “Introducing results-based financing” to design financial plans for transforming and scaling up education and training

Not acceptable at all


Total

N % N % N % N % N % N % N % N % N % N %

Acceptability 6 5 8 7 11 10 10 9 19 17 12 11 13 12 8 7 25 22 112 100%

Feasibility 8 7 8 7 15 13 8 7 22 20 15 13 14 13 7 6 15 13 112 100%


Feasibility 4 7% 6 11% 7 13% 3 5% 9 16% 8 15% 7 13% 2 4% 9 16% 55 100%

Regional

Acceptability 2 6% 2 6% 4 13% 3 10% 6 19% 2 6% 4 13% 2 6% 6 19% 31 100%

Feasibility 2 6% 1 3% 3 10% 4 13% 7 23% 4 13% 6 19% 2 6% 2 6% 31 100%


Feasibility 2 10% 4 20% 1 5% 6 30% 2 10% 1 5% 2 10% 2 10% 20 100%


Feasibility 1 50% 1 50% 2 100%


Feasibility 1 25% 1 25% 1 25% 1 25% 4 100%


Feasibility 8 7% 8 7% 15 13% 8 7% 22 20% 15 13% 14 13% 7 6% 15 13% 112 100%


Acceptability 2 4% 4 7% 3 6% 5 9% 10 19% 8 15% 8 15% 3 6% 11 20% 54 100%

Feasibility 3 6% 4 7% 5 9% 5 9% 9 17% 8 15% 9 17% 3 6% 8 15% 54 100%

Health professional

Acceptability 3 13% 5 21% 4 17% 2 8% 3 13% 2 8% 5 21% 24 100%

Feasibility 1 4% 2 8% 6 25% 1 4% 4 17% 5 21% 1 4% 2 8% 2 8% 24 100%

Policy-maker Acceptability 2 12% 1 6% 1 6% 1 6% 5 29% 0% 1 6% 2 12% 4 24% 17 100%

Feasibility 2 12% 1 6% 3 18% 2 12% 3 18% 1 6% 2 12% 1 6% 2 12% 17 100%



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body Acceptability 2 15% 2 15% 2 15% 1 8% 1 8% 2 15% 3 23% 13 100%

Feasibility 2 15% 1 8% 4 31% 1 8% 1 8% 1 8% 3 23% 13 100%





Feasibility 1 50% 1 50% 2 100%


Feasibility 8 7% 8 7% 15 13% 8 7% 22 20% 15 13% 14 13% 7 6% 15 13% 112 100%

Region Africa Acceptability 2 6% 2 6% 3 9% 5 15% 5 15% 6 18% 11 32% 34 100% Feasibility 2 6% 6 18% 1 3% 7 21% 4 12% 6 18% 2 6% 6 18% 34 100% Europe Acceptability 3 8% 5 13% 5 13% 2 5% 7 18% 4 10% 4 10% 4 10% 6 15% 40 100%

Feasibility 6 15% 4 10% 5 13% 2 5% 9 23% 4 10% 4 10% 3 8% 3 8% 40 100%

Latin America


Feasibility 1 50% 1 50% 2 100%

North America Acceptability 1 17% 1 17% 1 17% 2 33% 1 17% 6 100%

Feasibility 3 50% 2 33% 1 17% 6 100%


Acceptability 2 11% 1 6% 4 22% 1 6% 2 11% 2 11% 6 33% 18 100%

Feasibility 1 6% 1 6% 2 11% 1 6% 2 11% 2 11% 4 22% 1 6% 4 22% 18 100%

Eastern Mediterranean Acceptability 1 14% 2 29% 1 14% 1 14% 1 14% 1 14% 7 100%

Feasibility 1 14% 1 14% 2 29% 2 29% 1 14% 7 100%


Feasibility 1 20% 1 20% 3 60% 5 100%


Feasibility 8 7% 8 7% 15 13% 8 7% 22 20% 15 13% 14 13% 7 6% 15 13% 112 100%


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4.2.3.4 To provide financial assistance to students by subsidizing education in return for compulsory service in underserved/ rural areas

About 83% of all respondents expressed the view that provision of financial assistance in return for compulsory service in underserved/rural areas is acceptable; however, it might be difficult to implement: only 74% of respondents believed that it was feasible. The mean score for acceptability is 6.47, and for feasibility 5.41. About 87% of respondents at regional level ranked this intervention as acceptable, 84% at national level and 80% at district level.

Figure 12d. Histogram on acceptability and feasibility of an intervention “Providing financial assistance to students” to design financial plans for transforming and scaling up education and training

Below are some opinions expressed by respondents to explain their scores, and . suggest a range of opinions, challenges and solutions.

“…It is very important, but should be monitored appropriately”.

“…Another good idea that is being implemented in South Africa at present.”

“…If the graduate will be appropriately skilled by the time of graduation and supported once they are in underserved/rural areas.”

“…In all the opinion studies that were done in Romania, young graduates are not willing to work in rural areas for any financial reason.”

“…Should be a national programme to which all students with need and potential can apply. Some funds may be targeted for rural students…”

“…Some of these exist: good for other countries…”

“…This would require considerable political will that does not appear to be present…”

“…will encourage loyalty to service provider…”


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Table 10d. Acceptability and feasibility of an intervention “Providing financial assistance to students” to design financial plans for transforming and scaling up education and training



Total

N % N % N % N % N % N % N % N % N % N %

Acceptability 6 5 1 1 7 6 5 4 13 12 9 8 23 21 15 13 33 29 112 100

Feasibility 6 5 3 3 12 11 8 7 21 19 14 13 16 14 13 12 19 17 112 100


Feasibility 3 5% 1 2% 8 15% 5 9% 9 16% 6 11% 7 13% 8 15% 8 15% 55 100%

Regional

Acceptability 2 6% 2 6% 6 19% 1 3% 9 29% 4 13% 7 23% 31 100%

Feasibility 1 3% 2 6% 3 10% 6 19% 6 19% 7 23% 2 6% 4 13% 31 100%


Feasibility 2 10% 2 10% 5 25% 2 10% 2 10% 1 5% 6 30% 20 100%

National, District Acceptability 1 50% 0 0% 1 50% 2 100%

Feasibility 1 50% 1 50% 2 100%


Feasibility 1 25% 1 25% 1 25% 1 25% 4 100%


Feasibility 6 5% 3 3% 12 11% 8 7% 21 19% 14 13% 16 14% 13 12% 19 17% 112 100%


Acceptability 2 4% 1 2% 3 6% 3 6% 7 13% 3 6% 12 22% 6 11% 17 31% 54 100%

Feasibility 2 4% 2 4% 6 11% 4 7% 10 19% 5 9% 9 17% 6 11% 10 19% 54 100%


Feasibility 3 13% 1 4% 1 4% 1 4% 3 13% 5 21% 3 13% 1 4% 6 25% 24 100%

Policy-maker Acceptability 1 2 2 6 35% 2 12% 4 24% 17 100%

Feasibility 2 12% 3 18% 2 12% 3 18% 2 12% 3 18% 2 12% 17 100%



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Acceptability 1 8% 2 15% 0% 2 15% 1 8% 1 8% 4 31% 2 15% 13 100%

Feasibility 1 8% 3 23% 0% 2 15% 1 8% 2 15% 3 23% 1 8% 13 100%







Feasibility 6 5% 3 3% 12 11% 8 7% 21 19% 14 13% 16 14% 13 12% 19 17% 112 100%

Region Africa Acceptability 1 3% 1 3% 1 3% 1 3% 2 6% 8 24% 4 12% 16 47% 34 100% Feasibility 1 3% 4 12% 6 18% 5 15% 2 6% 5 15% 11 32% 34 100% Europe Acceptability 5 13% 1 3% 3 8% 3 8% 6 15% 5 13% 6 15% 5 13% 6 15% 40 100%

Feasibility 5 13% 1 3% 5 13% 6 15% 10 25% 4 10% 6 15% 3 8% 40 100%


Feasibility 1 50% 1 50% 2 100%


Feasibility 2 33% 1 17% 2 33% 1 17% 6 100%


Acceptability 4 22% 4 22% 3 17% 7 39% 18 100%

Feasibility 2 11% 1 6% 3 17% 1 6% 2 11% 3 17% 6 33% 18 100%

Eastern Mediterranean Acceptability 1 14% 2 29% 2 29% 2 29% 7 100%

Feasibility 1 14% 2 29% 2 29% 1 14% 1 14% 7 100%

Western Pacific Acceptability 1 20% 1 20% 1 20% 1 20% 1 20% 5 100%

Feasibility 1 20% 1 20% 1 20% 2 40% 5 100%


Feasibility 6 5% 3 3% 12 11% 8 7% 21 19% 14 13% 16 14% 13 12% 19 17% 112 100%


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4.2.3.5 To provide direct financial assistance to students (e.g. loans, grants, fellowships)

About 83% of all respondents expressed the view that the provision of direct financial assistance to students, such as loans, grants and fellowships, is acceptable; however, it might be difficult to implement: only 80% of respondents believed that it was feasible. The mean score for acceptability is 7.32, and for feasibility 6.47. About 94% of respondents at regional level ranked this intervention as acceptable, 89% at the national level and 85% at district level.

Figure 12e. Histogram on acceptability and feasibility of an intervention “Providing direct financial assistance to students” to design financial plans for transforming and scaling up education and training

Below are some opinions expressed by respondents to explain their scores, and suggesting a range of opinions, challenges and solutions.

“…But high turnout of graduates might not address the skewed distribution of the health work force…”

“…Each student receives from the government a certain amount of grant for their education fees…”

“…It would be important to explore direct funding to health professional schools rather than grants which sometimes end up being abused…”

“…many students did benefit from such programmes, but the process need to be more transparent and more students need to be engaged…”

“…some assistance may be beneficial but health professionals in Canada are essentially guaranteed work upon completion, and are generally well paid. Guaranteed loans may be beneficial for health professionals…”

“…The loans are welcomed, but afterwards it is difficult to repay them, creating a debt right in the start of professional life…”

“…With WHO utilization of its fellowship programme…”


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Table 10e. Acceptability and feasibility of an intervention “Providing direct financial assistance to students” to design financial plans for transforming and scaling up education and training



Total

N % N % N % N % N % N % N % N % N % N %

Acceptability 2 2 7 6 2 2 11 10 10 9 10 9 26 23 44 39 112 100%

Feasibility 3 3 1 1 12 11 6 5 17 15 13 12 12 11 19 17 29 26 112 100


National Acceptability 2 4% 3 5% 1 2% 1 2% 4 7% 5 9% 15 27% 24 44% 55 100%

Feasibility 3 5% 8 15% 2 4% 4 7% 7 13% 6 11% 11 20% 14 25% 55 100%

Regional

Acceptability 0 2 6% 6 19% 4 13% 4 13% 5 16% 10 32% 31 100%

Feasibility 1 3% 3 10% 3 10% 7 23% 3 10% 4 13% 3 10% 7 23% 31 100%

District Acceptability 0 2 10% 1 5% 3 15% 2 10% 5 25% 7 35% 20 100%

Feasibility 1 5% 1 5% 5 25% 1 5% 2 10% 4 20% 6 30% 20 100%

National, District Acceptability 0 1 50% 1 50% 2 100%

Feasibility 1 50% 1 50% 2 100%

National, Regional Acceptability 0 1 25% 1 25% 2 50% 4 100%

Feasibility 1 25% 1 25% 1 25% 1 25% 4 100%


Feasibility 3 3% 1 1% 12 11% 6 5% 17 15% 13 12% 12 11% 19 17% 29 26% 112 100%

Current position

Education and/or training institution

Acceptability 2 4% 5 9% 5 9% 6 11% 12 22% 24 44% 54 100%

Feasibility 1 2% 5 9% 2 4% 9 17% 4 7% 7 13% 9 17% 17 31% 54 100%


Feasibility 1 4% 4 17% 1 4% 3 13% 3 13% 3 13% 4 17% 5 21% 24 100%

Policy-maker Acceptability 1 6% 1 6% 1 6% 2 12% 1 6% 3 18% 3 18% 5 29% 17 100%

Feasibility 2 12% 1 6% 2 12% 1 6% 4 24% 4 24% 3 18% 17 100%

Professional


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association/regulatory body Acceptability 2 2% 1 8% 1 8% 5 38% 6 46% 13 100%

Feasibility 2 15% 1 8% 1 8% 2 15% 2 15% 1 8% 4 31% 13 100%


Acceptability 2 100% 2 100%

Feasibility 1 50% 1 50% 2 100%




Feasibility 3 3% 1 1% 12 11% 6 5% 17 15% 13 12% 12 11% 19 17% 29 26% 112 100%

Region Africa Acceptability 2 6% 1 3% 1 3% 3 9% 2 6% 9 26% 16 47% 34 100% Feasibility 1 3% 1 3% 7 21% 3 9% 3 9% 7 21% 12 35% 34 100% Europe Acceptability 2 5% 2 5% 1 3% 5 13% 5 13% 4 10% 7 18% 14 35% 40 100%

Feasibility 2 5% 6 15% 4 10% 6 15% 5 13% 4 10% 5 13% 8 20% 40 100%


Feasibility 1 50% 1 50% 2 100%

North America Acceptability 1 17% 2 33% 3 50% 6 100%

Feasibility 2 33% 2 33% 2 33% 6 100%


Acceptability 1 6% 3 17% 2 11% 4 22% 2 11% 6 33% 18 100%

Feasibility 1 6% 1 6% 2 11% 1 6% 2 11% 1 6% 4 22% 2 11% 4 22% 18 100%

Eastern Mediterranean Acceptability 1 14% 4 57% 2 29% 7 100%

Feasibility 1 14% 3 43% 2 29% 1 14% 7 100%


Feasibility 1 20% 1 20% 1 20% 1 20% 1 20% 5 100%


Feasibility 3 3% 1 1% 12 11% 6 5% 17 15% 13 12% 12 11% 19 17% 29 26% 112 100%


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4.3 Other interventions

The respondents were also asked to comment on other interventions that were not included in this survey but were important for improving the transforming and scaling up of health professional education. Some of their comments are presented below.

Miscellaneous approaches

“A hybrid intervention might need to evolve that addresses skewed distribution of health workforce in some settings with high turnover of graduates of health sciences focusing on retention strategies for underserved, hard to reach, hard to stay and hard to serve settings.”

“Team training programme that establishes integration between the whole health care provider teams should be established and encouraged. Jimma University will be benchmarking for such team approach learning for the country, as well as the whole region of Africa.”

“In Europe there is a discussion going on about the modernization of the Professionals Qualifications Directive (2005/36/CE). This Directive specifies the minimum training requirements for some professions, including health professionals. A new proposal for Directive is in the European Parliament for discussion. To have European impact, any scale-up of health professional education should take place within this process.”

“Opportunities for the promotion of teachers/ faculty are important. Criteria should not be similar to those in other university faculties (or departments) which have no clinical component.”

“All private educational institutions in this country are for-profit institutions and thus quality in education is just a marketing tool or slogan but not a responsibility. The involvement of political patronage and private education makes for a very challenging environment for the production of quality health professionals.”

“…improvement is well noticed regarding resources, yet the work needs to be more transparent and based on evidence…”

“Improve recognition of outputs from educators of health professionals so that they do not leave for other jobs…”

Investments

“The Ministry of Education should better coordinate with the Ministry of Health for planning in a more appropriate way the HRH.”

“To invest in local education leadership and health management is important for health system for effective provision of health care services…”

“Investment in HRH is the key to improvement of health professional education. Introduction of mandatory accreditation (as it is the case for licensing) is a must for the needed transformation.”

“….the less financing is provided to the schools the more commercialization we see from universities and colleges. I think there should be a greater government regulation on schools to reduce commercialization…”

Health system approach

“…Health systems strengthening needs to be taken into consideration…”

“Rather than going for different kinds/types/areas of public health programmes for the public, consider improving the health of the individual in their own culture. Increasing immunity


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alone answers many problems in the society. Consider systems like naturopathy and yoga; also the preventive measures given in the ancient medicines such as Ayurveda and Siddha in improving peoples’ innate immunity as the primordial prevention.”

Country context

“What is required is context specific and context dependent. ... It is clear that the social and cultural context of medical education and clinical practice means that neither education nor communication, in style and approach, is generalizable beyond certain limits. And those limits might be greater than the dominant rhetoric implies. Education systems are not culturally neutral. They are the product of the cultural ebb and flow of modern life . In the debate about globalization in education, two distinct lines of thought are apparent. Wong describes this very clearly: Two theoretical perspectives on globalization in education highlight the debate between global discourses of homogenization and local discourses of culture and context. Proponents of the neo-institutionalist perspective view the global standards initiative as consistent with the theory that all education systems are converging into a universal model. By contrast, the culturalist perspective focuses on the enduring ability of different cultures and ways of knowing to reinterpret, transform and hybridize education practices to best suit local context. That there are differences in educational [and assessment] culture has been shown in medical education, even between western countries. So differences are not simply between west and east — it might be that these are even more pronounced. Wong makes a number of concluding points in relation to her research. Even similar curriculum organizations can be underpinned by different views of scholarship leading to different practices in academic and clinical activities and different approaches to supervision.”

“There are different approaches to team and individual work in different cultures. There are different relationships between seniors and trainees: ranging from familial to collegial. The relationship between teacher and student can take many different forms: respectful of knowledge, hierarchical, personal, motivational. She concludes that, unlike a single universal definition of medical education, a socio-cultural conceptualization of medical education recognizes that many different models of effective teaching may exist in the world. This is a very practical problem, especially given the lack of evidence base in relation to teaching and learning approaches. Communication, and so education, is a culturally mediated and culturally understood phenomenon. Singh and Sood quote Jerome Bruner: ‘Culture shapes mind, it provides us with the tool kit by which we construct not only our worlds but our very conceptions of ourselves and our powers.’ You cannot understand mental activity unless you take into account the cultural setting and its resources; the very things that give mind its shape and scope. Learning, remembering, talking and imaging: all of them are made possible by participating in a culture. Mennin himself points out that: What is clear from these authors is that culture, health professions education, and assessment must be viewed as a continuously evolving socio-political and economic environment. It is easy to lose this perspective in the rush to import and implement new educational tools, methods and techniques from Europe and North America and in the challenges of seeking recognition from and parity with them. This context is fundamental to the practical and ethical issues of global health and international action. Some of the key issues in relation to communication will be focused on the increasing number of short-term international visits that are made. Most of these are from west to east, or north to south. A number of these will be as part of funded projects, or in relation to NGO work, while an increasing proportion involve students who are taking intercalated degrees in international health or are undertaking electives periods abroad. In these cases both communication and wider issues of the balance of benefit and effect are important.”


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5. Conclusions

Outcomes of interest: quantity, quality and relevance of health professionals

Comparing these three outcomes, respondents expressed the view that they are all quite important for the aim of best meeting population health needs and expectations in an equitable and efficient manner, while strengthening country health systems and improving population health outcomes. However, slightly more importance was attributed to the “relevance” and “quality” outcomes (95% and 94%) than to “quantity” (90%) across all regions. Overall, respondents across all regions and at all levels (national, regional and district) reflected the same pattern.

Education and training institutions

Involving policy-makers in school governance

About 84% of all respondents expressed the view that active participation by policy-makers in the governance structures of health professional schools affecting the quantity, quality and relevance of health professionals is acceptable, but only 78% think that it is feasible to involve policy-makers. The mean score for acceptability is 6.3, and for feasibility 5.51. Respondents at the national level ranked this intervention as more acceptable (90%) but a bit more difficult to implement (83% scored it as feasible) than at the regional and district levels (80% and 71% respectively).

Involving students in transforming and scaling up health professional education and training in both undergraduate and postgraduate programmes

About 82% of all respondents expressed the view that active recruitment, supported by regulatory mechanisms, to enrol students from underserved, underrepresented or rural populations is acceptable, but only 68% believe that this is feasible. The mean score for acceptability is 6.4, and for feasibility 5.55. Respondents at the regional and district levels, almost equally (89% and 88% respectively) ranked this intervention as more acceptable, than those at national level (77%).

Continuous development programmes to support faculties/current health workers to teach effectively in both undergraduate and postgraduate programmes

A rather high percentage of respondents expressed the view that the introduction of continuous development programmes for faculty/teaching staff is both acceptable and feasible to implement, 92% and 90% respectively. The mean score for acceptability is 7.58, and for feasibility 6.67. Respondents at the district and national levels ranked this intervention as more acceptable, almost equally (91% and 89% respectively) than those at regional level (74%).

Inter-professional and trans-professional learning to adapt curricula to population needs for both undergraduate and postgraduate programmes

About 90% of all respondents expressed the view that the introduction of inter-professional and trans-professional learning is acceptable, but complicated to implement: only 77% of respondents believe that it was feasible. The mean score for acceptability is 6.69, and for feasibility 6.12. Respondents at the district level ranked this intervention as more acceptable (91%) than those at the national and regional levels (81% and 91%).

Regulatory framework


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Introduction of streamlined educational pathways and ladder programmes

About 92% of all respondents expressed the view that the introduction of streamlined educational pathways and ladder programmes is acceptable, but complicated to implement; only 78% believe that it is feasible. The mean score for acceptability is 6.92, and for feasibility 5.86. Respondents at the national and district levels, equally, ranked this intervention as more acceptable (95%) than those at the regional level (84%).

Accreditation and periodical re-accreditation of all educational institutions and their associated clinical practice placement sites

About 91% of all respondents expressed the view that accreditation and periodic re-accreditation of all educational institutions and their associated clinical practice placement sites is acceptable, but could be difficult to implement: 84% of respondents believe that it is feasible. The mean score for acceptability is 7.13, and for feasibility 6.49. Respondents at the district and national levels ranked this intervention as more acceptable (95% and 91% respectively) than those at the regional level (84%).

Introduction of certification and licensure and revision of national standards

A rather small percentage of respondents expressed the view that the introduction of certification and licensure and revision of national standards is acceptable (84% of respondents) but it is rather complicated to implement: 77% believe it could be feasible. The mean score for acceptability is 6.68, and for feasibility 6.23. Respondents at regional and national levels ranked this intervention as more acceptable (87% and 84% respectively) than those at the district level (80%).

Financing

Increase of allocation of resources (local/international/private) targeted to health professional education/training, including cost-effectiveness assessments and strategic management

About 85% of all respondents expressed the view that increasing resource allocation for health professional education/training, including cost-effectiveness assessments and strategic management, is acceptable; however, it is difficult to implement: only 69% of respondents believe that it is feasible. The mean score for acceptability is 7.11, and for feasibility 5.51. Respondents at all levels ranked this intervention as acceptable, more or less equally: national and regional levels 84%, and district level 85%.

Aligning of international assistance to domestic investment and priorities for health professional education

About 82% of all respondents expressed the view that aligning international assistance to domestic investment and prioritizing health professional education is acceptable; however, it might be difficult to implement: only 70% of respondents believed it is feasible. The mean score for acceptability is 6.47, and for feasibility 5.41. Respondents at all levels ranked this intervention as acceptable, more or less equally: national 82%, regional 81% and district 80%.

Introduction of results-based financing for health professional schools

A rather small percentage of respondents expressed the view that the introduction of results-based financing for health professional schools is acceptable (69%); however, it might be difficult to implement: only 65% of respondents believe that it is feasible. The mean score for acceptability is 5.27, and for feasibility 5.73. Respondents at national level ranked this intervention as more acceptable (70%) than those at regional and district levels (both 65%).


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Provision of financial assistance to students by subsidizing education in return for compulsory service in underserved/ rural areas

About 83% of all respondents expressed the view that the provision of financial assistance in return for compulsory service in underserved/rural areas is acceptable; however, it might be difficult to implement: only 74% of respondents believe that it is feasible. The mean score for acceptability is 6.47, and for feasibility 5.41. About 87% of all respondents at regional level ranked this intervention as acceptable, 84% at national level and 80% at district level.

Provision of direct financial assistance to students (e.g. loans, grants, fellowships)

About 83% of all respondents expressed the view that the provision of direct financial assistance to students, such as loans, grants and fellowships, is acceptable; however, it might be difficult to implement: only 80% of respondents believe that it is feasible. The mean score for acceptability is 7.32, and for feasibility 6.47. About 94% of all respondents at regional level ranked this intervention as acceptable, 89% at national level and 85% at district level.


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References

1. Transformative scale up of health professional education: an effort to increase the numbers of health professionals and to strengthen their impact on population health. Geneva, World Health Organization, 2011 (WHO/HSS/HRH/HEP2011.01).

2. Gupta N et al. Human resources for maternal, newborn and child health: from measurement and planning to performance for improved health outcomes. Human Resources for Health, 2011, 9:16.

3. Van der Weijden et al. How to integrate individual patient values and preferences in clinical practice guidelines? A research protocol. Implementation Science, 2010, 5:10 http://www.implementationscience.com/content/5/1/10.

4. Grol R et al. Attributes of clinical guidelines that influence use of guidelines in general practice: observational study. British Medical Journal, 1998, 317:858-61.

5. Grol R. Has guideline development gone astray? Yes. British Medical Journal, 2010, 340:c306.

6. Haines A et al. Bridging the implementation gap between knowledge and action for health. Bulletin of the World Health Organization, 2004, 82:10.

7. Crawford M et al. Systematic review of involving patients in the planning and development of health care. British Medical Journal, 2002, 325:30.

8. Giacomini M. Values in Canadian health policy analysis: what are we talking about? Canadian Health Services Research Foundation, 2001. http://www.chrsf.ca

9. Beverley C et al. Eliciting users’ views of the processes of health care: a scoping exercise. The School of Health and Related Research and Consumer Health Psychology, University of Sheffield, NCCSDO, 2001.

10. Ismail M. Quantitative research methodology. Pusat Pengajian Ilmu Pendidikan. Kolokium Pelajar Pengajian Siswazah PPIP 2005. Input Session IV, 16 December 2005 (Jumaat)

11. Hunter L. Collaborative research in sociology: trends and contributing factors. American Sociologist, 2008, 39:290–306.

12. Beverley C et al. Eliciting users’ views of the processes of health care: a scoping exercise. The School of Health and Related Research and Consumer Health Psychology, University of Sheffield, NCCSDO, 2001.

13. Booske B, Sainfort F, Hundt A. Eliciting consumer preferences for health plans – health plan choice. Health Services Research, 1999.

14. Coast J. The appropriate use of qualitative methods in Health Economics. Health Economics, 1999, 8:345-353.

15. Ryan M et al. Eliciting public preferences for healthcare: a systematic review of techniques. Health Technology Assessment, 2001, 5 (5).

16. Mooney G. What else do we want from our health services? Social Science and Medicine, 1994, 39 (2).

17. Louviere J, Hensher D, Swait J. Stated choice methods: analysis and application. Cambridge, Cambridge University Press, 2000.

http://www.implementationscience.com/content/5/1/10

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Annex 1. Glossary of intervention terms

Acceptability The perception among implementation stakeholders that a given service, practice, or innovation is agreeable, palatable or satisfactory. Acceptability should be assessed based on the stakeholder's knowledge of or direct experience with various dimensions of the intervention to be implemented, such as its content, complexity or comfort. We refer here particularly to social acceptability, which addresses the acceptability of the intervention in the context of the culture of the society in which the users operate.

Accreditation A particular form of quality assurance which leads to the formal approval of an institution or programme that has been found by a legitimate body to meet predetermined and agreed upon standards, eventually resulting in an accredited status granted to that provider or programme by responsible authorities. Accreditation can be awarded by an external quality assurance agency, such as in the United States, or both can be separated, as in the Dutch-Flemish accreditation system. For instance, in the Australian system, accreditation can be given by the institution itself, which is then “self-accrediting”.

Active participation

Defines a high level of engagement in planning and proactive contribution with regard to governance and policy formation.

Active recruitment

The process of generating a pool of potential applicants (students) rather than merely tapping one, or of the undertaking to favourably influence a potential student’s decision to enter a programme of health professional education.

Adjunct faculty Faculty hired on a part-time or temporary basis (i.e. any instructor teaching courses whose compensation in salary and/or fringe benefits is not equal to the compensation received by full-time contractual faculty).

Certification The process whereby a profession or occupation voluntarily establishes competency standards for itself. Certification plays a helpful role in protecting the public, especially in cases where the state legislature has not opted to regulate the profession or occupation through licensure. However, there are broad variations in this voluntary process.

Competencies A combination of the essential knowledge, abilities, skills and values necessary for the practice of health promotion.

Compulsory service

A country's law or policy that governs the mandatory deployment of health workers in remote or rural areas for a certain period of time, with the aim of ensuring the availability of services in these areas. It can be either imposed by the government (for positions that are under government employment) or linked to various other policies.

Continuing professional development (CPD)

Training which is beyond clinical update and includes wide-ranging competencies such as: research and scientific writing; multidisciplinary context of patient care; professionalism and ethical practice; communication, leadership, management and behavioural skills; team building; information technology; auditing; and appropriate attitudinal change to ensure improved patient service and research outcomes and attainment of the highest degree of satisfaction by stakeholders. CPD includes education methods beyond the didactic, embodies concepts of self-directed learning and personal development, and considers organizational and systemic factors.

Core competencies

The minimum set of competencies that constitute a common baseline for all health promotion roles (i.e. what all health promotion practitioners are expected to be capable of doing to work efficiently, effectively, and appropriately in the field).

Core curriculum A curriculum, or course of study, which is deemed central and usually made


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mandatory for all students of a school or school system. Direct admission An admissions system which builds on previous learning experience and

provides a way for individuals from relevant undergraduate, postgraduate or other educational programmes to transition into higher levels of health professional studies.

Feasibility Whether or not something can be accomplished given specific conditions and criteria. Common variables affecting feasibility include: the economic cost and the resources available in the area or community to implement the programme; organizational rules that may hamper the implementation and carrying out of a given agenda, such as laws, ethics etc.; and the receptivity of parallel, cooperative, or divergent agencies in the community necessary to sustain the on-going productivity of the new programme.

Financial assistance

Including all forms of monetary aid for students, e.g. any grant, loan, tuition assistance, scholarships, fellowships, tax credits, savings subsidies, or other arrangement by which an entity provides, or otherwise makes available, monetary support to a student for undergraduate or postgraduate training.

Governance

The system, composed of structures and processes, through which faculty, administrators, and other campus constituents make collective institutional decisions. The concept of governance includes not only control of decisions about the operations of educational institutions, but also control over the decisions made regarding their objectives. Such structures might include, for example, advisory boards, governing boards, councils, boards of governors, boards of trustees, senates, or committees dealing with various matters within an institution.

Infrastructure Broadly defined as the underlying foundation or basic framework of a system or organization. We refer here specifically to material infrastructure, which includes laboratories, offices, lecture and instrument room spaces that faculty, students and staff need for various learning activities.

In-kind assistance Refers to contributions or assistance provided to a student in a form other than money (e.g. goods, services or other non-monetary benefits). May include accommodation, food, clothing, and other basic necessities.

In-service training

Training received while fully employed in the health sector. The aim is to equip health workers or the trainers of health workers with the skills to deliver specific interventions.

Inter-professional education

Faculty and students from two or more health professions engaged in learning with, from and about each other, in all components of curricula, including the practical ones, in order to enable effective collaboration and improve health outcomes.

Joint appointment A formalized agreement between two institutions where one individual holds a position in both institutions and carries out defined responsibilities.

Ladder programme

A system of employee salary progression that provides for advancement through a set of graded steps or levels. Progression on the ladder occurs in relation to achievement.

Licensure The process whereby a government authority, in accordance with state statute, determines the competency of individuals seeking to perform certain services. Through licensure, state governments grant individuals the authority to engage in an area of practice, generally to the exclusion of others, based on demonstrated education, experience and examination. As a general rule, state governments possess the authority to discipline licensees who fail to comply with statutes and regulations and to take action against unlicensed individuals who practice within the scope of a licensed profession or occupation.

Pooled funding scheme

A scheme by which funding is provided by multiple investors contributing assets and holding them as a group. A common example of a pooled fund is a unit trust.


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Regulatory bodies A national organization, external to an institution, charged with the responsibility of setting and maintaining educational and practice standards for a profession, and controlling entry into the profession (i.e. accreditation).

Preference The relative desirability of a range of interventions. Research capacity The collective capability of an education faculty to conduct independent

research or to contribute to interdisciplinary research. Results-based financing

A cash payment or non-monetary transfer made to a national or sub-national government, manager, provider, payer or consumer of health services after predefined results have been attained and verified. Payment is conditional on measurable actions being undertaken.

Retention (of students)

A programme outcome involving the maintenance of a student’s satisfactory progress toward his or her pedagogical objective until it is attained.

Return of service commitment

An arrangement whereby a health worker in training or a fully trained health worker enters into a contract to work for a number of years in an underserved area in exchange for a financial or in-kind incentive.

Rural population A population of an area that is not urban in nature, where ‘urban’ delineates the contours of a contiguous territory inhabited at urban density levels without regard to administrative boundaries. Recognizing the absence of a universal or standardized definition of “rural” that is meaningful in an international context, the diversity of definitions commonly utilized in the literature may also be accepted, based on factors including distance from nearest urban centre, population density, common nature of employment, government structures, degree of isolation and distance from nearest “major hospital” or high-level health care institution.

Scope of practice The activities that an individual health professional performs in the delivery of patient care. Scope of practice reflects the types of patients for whom the health professional can care as well as what procedures/activities the health professional can perform, and influences the ability of the health professional to seek reimbursement for services provided. Determining scope of practice includes advanced practice education in a role and specialty, legal implications and scope of practice statements as published by national professional specialty and advanced practice organizations.

Streamlined educational pathway

A means of connecting education, training and support services to prepare students for the next level of education and training. Each step on a streamlined pathway is designed explicitly to prepare students to progress to the next level of education (e.g. through multiple entry points and innovative programme delivery mechanisms such as flexible scheduling). A streamlined nursing education programme might, for example, ensure that registered nurses who wish to advance their nursing expertise and career by enrolling in a higher degree in nursing can do so without having to repeat the same courses and content they have already mastered; associated regulations would thus prohibit institutions from requiring a student, who already holds a nursing licence or relevant lower-level degree, to complete coursework whose content they have already covered in a previous course of study.

Targeted admission policy

A policy that provides a number of reserved places in limited-entry undergraduate or postgraduate programmes for applicants from groups that are underrepresented and/or disadvantaged in terms of gaining access to a university education and for whom participation in the programme will assist in achieving equal educational opportunity.

Trans-professional education

Health professionals learning with, from and about non-professional health workers, especially basic and ancillary health workers, administrators and managers, policy-makers and leaders of the local community. The intention is to break down professional silos while enhancing collaborative and non-hierarchical relationships in effective teams.

Twinning The establishment of a formal link between a specific department/institution in


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a developed country and a corresponding department/institution in the developing world.

Underrepresented population

A racial or ethnic population that is underrepresented in health care professions relative to their numbers in the general population.

Underserved population

Interpreted in the broadest sense, a relatively poorer population inhabiting an area with limited access to qualified health care providers and health services of adequate quality. May include, for example, populations occupying the following types of settings: remote rural areas; small or remote islands; urban slum areas; areas that are in conflict or post-conflict; refugee camps; and areas inhabited by minority or indigenous groups.

Value The relative importance or worth of the consequences (outcomes) of an intervention.

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