Presentation on theme: "Education and training of health workers: towards systems solutions July 3, 2012."— Presentation transcript:
Education and training of health workers: towards systems solutions July 3, 2012
Objectives 1.To review the Task Force Report 2.To consider the changes in mortality and the burden of surgical diseases in LMICs 3.To consider the above as they relate to improving access to high quality obstetrical services in LMICs 4.To consider the roles of the public and private sectors in system solutions
HW make a difference 1
The maldistribution of HWs 1
Estimating the HW shortfall 1
The Task Force Lord Nigel Crisp (Co-Chair) Commissioner Bience Gawanas (Co-Chair) Hon. Stephen Mallinga Hon. Marjorie Ngaunje Miriam Were Srinath Reddy Alex Preker Judith Oulton Anders Nordstrom Cathy Cahill Francisco Campos Louise Holt Peggy Vidot Gustavo Gonzalez-Canali Francis Omaswa
Types of health workers needed 2
Prerequisites for successful scaling up 2
Aligning HHR with system needs
Attrition is very high in Uganda 3
There is an issue of quality 5,6 In Tanzania 46% of women deliver in a health facilities. Is it safe?
Quality gaps are system wide 7
Integrate education and health systems
New educational models
Towards a time table
Labor costs of scaling up in SSA Total health expenditures (US$b) Per capita health expenditures (US$ per person/y) Additional staff (millions) Baseline a0a Best case scenario Projection of current trends b Worst case scenario a baseline number of HWs is 1.6m b 0.9m if focus on mid-level cadres; 0.4m if focus on hi-level cadres
But … Costs for education and training scale up are not included. These costs alone are estimated at $US26.4b! How can you do both within a sharply circumscribed and inadequately funded system? Consider the use of ICTs, measures to decrease attrition and outward migration, modular education, COBES, career paths, changing skill mix.
The Zambia scale up example 4 Training Plan scale-up targets lead to some cadres meeting their target establishment much earlier than others Training institutions estimate that they can meet targets of 70% increases. Modest infrastructure ($US60m) and teaching personnel investments (+400) required.
Recommendations 1.Reduce attrition and improve accessibility 2.Integrate pre-service and in-service education and training 3.Develop common educational platforms for different types of health worker 4.Move learning to the community, using modular education and action learning 5.Increase use of information and communication technologies 6.Improve education through quality assurance programs 7.Build institutional capacity i.Expand teaching capability ii.Foster twinning and partnerships iii.Maximize impact through regional approaches iv.Harness public-private partnerships
The increasing burden of surgical diseases
The causes of mortality are changing 8
Global burden of surgical diseases 9 r 2 = average surgical rate
Global burden of surgical diseases 2.Majority of surgical problems in LMICs relate to general surgery and obstetrics 10,11 3.Compelling shortage of adequately trained surgical and anesthesia HRH 4.Important lessons to be learned from task shifting and TTR 12 5.Task shifting can be done effectively and safely 13,14,15
The issue of maternal mortality
Maternal mortality is decreasing 16 But the rate of decrease is too slow to meet the MDGs.
Where are the deaths? 50% of deaths in 6 countries: India, Nigeria, Pakistan, Afghanistan, Ethiopia, DRC 52% of maternal deaths in 2008 in SSA
How do mothers die? 17
Shortage of obstetrical emergency coverage Examples of countries in which there is massive deprivation in coverage for obstetrical emergencies. A clear rural-urban divide is evident. The shortfall relates to poor HRH coverage, poor quality of care and poor facilities. 18 In Uganda, only 6% of anesthesiologists felt they could provide safe anesthesia for CS. 19
Who is responsible for anesthesia? 1.40+% of anesthesia in LMICs given by nurses 20
Need for nurse anesthetists 2.Need to significantly increase training of nurses who can deliver safe anesthesia in primary and district health facilities 18,19,20 3.Training programs must be tailored to need 4.Co-training of anesthesia and surgical trainees may offer economies of scale and quality 21
Improving access to surgical and obstetrical services A brief systems perspective
Tiering of the health system 22
Maternal mortality is stratified 7
Surgical activities in district hospitals 11
Impact of facility birthing 7
Plus birthing units 19,23 PersonnelNumberDeliveries/year Midwives M Assistants8-10
The costs are reasonable 7
The role of the private sector?
Potential of the private sector Builds on the reputation/accomplishments of the NFP private sector Adds significant intellectual and capital capacity Provides agility and ability to anticipate market forces Driven by success Not bound by tradition Double and triple bottom line increasingly understood
Unfortunately … PFP [medical] schools have a poor record for quality. This goes back to Flexner. 24 PFP schools viewed as diploma mills with different standards vs public schools 25 Outdated curricula with few/poor teachers 26,27,28 Graduates may not do as well on qualifying exams 29 PFP schools may not meet local needs 30
Indian medical schools 10 Data sources: Medical Council of India; Reserve Bank of India; Census Commissioner India % private
Private networks Drive the accountability agenda focus on accreditation and governance Participate actively in global initiatives Education of health professionals for the 21 st century 11 Joint action and learning initiative 32 Develop consortium approaches Confidence Partnerships
Summary The huge demand for growth in health professional education means that the PFP sector has an important role to play. The PFP sector has a variable reputation in health professional education. But it has an exceptional opportunity to drive innovation in medical and health sciences education.
Private sector provisos Is the PFP investment characterized by patient money? How to ensure compatibility with the principles of universal coverage? How to enhance the strength of the public sector? How to ensure continued viability and development of the primary care sector? How to think beyond the SCHOOL and the HOSPITAL?
Africa’s changing face 33,34,35,36
Lions of growth
References 1 World Health Report Working together for health 2 Scaling up, saving lives. Task Force on Scaling Up Education and Training for Health Workers 3 McQuide P, Matte R, Arusha Tanzania Clinton Foundation Harvey SA et al Int J Obstet Gyn 2004;87:203 6 ECSA Friberg IK et al PLoS Med 2010;7:e Murray CJL, Lopez AD Lancet 1997;349: Weiser TG et al Lancet 2008;372: Luboga S et al PLoS Med 2009;6:e Galukande M et al PLoS Med 2010;7:e Chu K et al PLoS Med 2009;6:e Dovlo D Hum Resour Health 2004;18:7 14 Mullan F, Frehywot S Lancet 2007;370: Pereira C et al BJOG 2007;114: Hogan MC et al Lancet 2010;375:1609
References 17 Kinney MV et al PLoS Med 2010;6:e Koblinsky M et al Lancet 2006;368: Hodges SC et al Anesthesia 2007;62:4 20 Kruk ME et al PLoS Med 2010;7:e Cherian M et al Bull WHO DOI: /BLT Dubowitz G et al World J Surg 2010;34: Kushner AL et al Arch Surg 2010;145: Newton M, Bird P World J Surg 2010;34: Lawn JE et al Lancet 2008;372: Koblinsky M et al Lancet 2006;368: Ludmerer KM Time to heal, OUP Supe A and Burdick WP Acad Med 2006;81: Amin Z et al Acad Med 2010;85; Nair M and Webster P Med Educ 2010;44: Rao M et al Lancet 2011;377: van Zanten M and Boulet JR Acad Med 2008;83:S33 30 Kanchanachitr C et al Lancet 2011;377: Mahal A and Mohanan M Med Educ 2006;40:1009
References 32 Goston LO et al PLoS Med 2011;8: Moyo D Dead Aid, Sen A Development as freedom, Sachs JD Common wealth, Lions on the move, McKinsey Global Institute, June 2010