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

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Presentation on theme: "Education and training of health workers: towards systems solutions July 3, 2012."— Presentation transcript:

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

2 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

3 HW make a difference 1

4 The maldistribution of HWs 1

5 Estimating the HW shortfall 1

6 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

7 Types of health workers needed 2

8 Prerequisites for successful scaling up 2

9 Aligning HHR with system needs

10 Attrition is very high in Uganda 3

11 There is an issue of quality 5,6 In Tanzania 46% of women deliver in a health facilities. Is it safe?

12 Quality gaps are system wide 7

13 Integrate education and health systems

14 New educational models

15 Towards a time table

16 Labor costs of scaling up in SSA Total health expenditures (US$b) Per capita health expenditures (US$ per person/y) Additional staff (millions) Baseline27.036.70a0a Best case scenario57.563.11.7 Projection of current trends b Worst case scenario15.817.0-0.8 a baseline number of HWs is 1.6m b 0.9m if focus on mid-level cadres; 0.4m if focus on hi-level cadres

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

18 The Zambia scale up 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.

19 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

20 The increasing burden of surgical diseases

21 The causes of mortality are changing 8

22 Global burden of surgical diseases 9 r 2 =0.996 34.8 35 14.6 15.6 average surgical rate

23 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

24 The issue of maternal mortality

25 Maternal mortality is decreasing 16 But the rate of decrease is too slow to meet the MDGs.

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

27 How do mothers die? 17

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

29 Who is responsible for anesthesia? 1.40+% of anesthesia in LMICs given by nurses 20

30 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

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

32 Tiering of the health system 22

33 Maternal mortality is stratified 7

34 Surgical activities in district hospitals 11

35 Impact of facility birthing 7

36 Plus birthing units 19,23 PersonnelNumberDeliveries/year Midwives4-5880-1100 M Assistants8-10

37 The costs are reasonable 7

38 The role of the private sector?

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

40 Unfortunately … PFP [medical] schools have a poor record for quality. This goes back to Flexner. 24 PFP schools viewed as diploma mills with different standards vs public 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

41 Indian medical schools 10 Data sources: Medical Council of India; Reserve Bank of India; Census Commissioner India % private 0-24 25-49 50-74 75-100

42 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

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

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

45 Africa’s changing face 33,34,35,36

46 Lions of growth

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

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

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

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