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The Lancet,
Volume 376, No. 9756, p1923–1958, 4 December 2010
Health professionals for a new century: transforming
education to strengthen health systems in an interdependent world
Prof Julio Frenk, MD, Dr Lincoln Chen, MD, Prof Zulfiqar A
Bhutta, PhD, Prof Jordan Cohen, MD, Nigel Crisp, KCB, Prof Timothy Evans, MD,
Harvey Fineberg, MD, Prof Patricia Garcia, MD, Prof Yang Ke, MD, Patrick
Kelley, MD, Barry Kistnasamy, MD, Prof Afaf Meleis, PhD, Prof David Naylor, MD,
Ariel Pablos-Mendez, MD, Prof Srinath Reddy, MD, Susan Scrimshaw, PhD, Jaime
Sepulveda, MD, Prof David Serwadda, MD, Prof Huda Zurayk, PhD
Executive summary
Problem statement
100 years ago, a series of studies about the education of
health professionals, led by the 1910 Flexner report, sparked groundbreaking
reforms. Through integration of modern science into the curricula at
university-based schools, the reforms equipped health professionals with the
knowledge that contributed to the doubling of life span during the 20th
century.
By the beginning of the 21st century, however, all is not
well. Glaring gaps and inequities in health persist both within and between
countries, underscoring our collective failure to share the dramatic health
advances equitably. At the same time, fresh health challenges loom. New
infectious, environmental, and behavioural risks, at a time of rapid
demographic and epidemiological transitions, threaten health security of all.
Health systems worldwide are struggling to keep up, as they become more complex
and costly, placing additional demands on health workers.
Professional education has not kept pace with these
challenges, largely because of fragmented, outdated, and static curricula that
produce ill-equipped graduates. The problems are systemic: mismatch of
competencies to patient and population needs; poor teamwork; persistent gender
stratification of professional status; narrow technical focus without broader
contextual understanding; episodic encounters rather than continuous care;
predominant hospital orientation at the expense of primary care; quantitative
and qualitative imbalances in the professional labour market; and weak
leadership to improve health-system performance. Laudable efforts to address
these deficiencies have mostly floundered, partly because of the so-called
tribalism of the professions—ie, the tendency of the various professions to act
in isolation from or even in competition with each other.
Redesign of professional health education is necessary and
timely, in view of the opportunities for mutual learning and joint solutions
offered by global interdependence due to acceleration of flows of knowledge,
technologies, and financing across borders, and the migration of both
professionals and patients. What is clearly needed is a thorough and
authoritative re-examination of health professional education, matching the
ambitious work of a century ago.
That is why this Commission, consisting of 20 professional
and academic leaders from diverse countries, came together to develop a shared
vision and a common strategy for postsecondary education in medicine, nursing,
and public health that reaches beyond the confines of national borders and the
silos of individual professions. The Commission adopted a global outlook, a
multiprofessional perspective, and a systems approach. This comprehensive
framework considers the connections between education and health systems. It is
centred on people as co-producers and as drivers of needs and demands in both
systems. By interaction through the labour market, the provision of educational
services generates the supply of an educated workforce to meet the demand for
professionals to work in the health system. To have a positive effect on health
outcomes, the professional education subsystem must design new instructional
and institutional strategies.
Major findings
Worldwide, 2420 medical schools, 467 schools or departments
of public health, and an indeterminate number of postsecondary nursing
educational institutions train about 1 million new doctors, nurses, midwives,
and public health professionals every year. Severe institutional shortages are
exacerbated by maldistribution, both between and within countries. Four
countries (China ,
India , Brazil ,
and USA ) each
have more than 150 medical schools, whereas 36 countries have no medical
schools at all. 26 countries in sub-Saharan Africa have
one or no medical schools. In view of these imbalances, that medical school
numbers do not align well with either country population size or national
burden of disease is not surprising.
The total global expenditure for health professional education
is about US$100 billion per year, again with great disparities between
countries. This amount is less than 2% of health expenditures worldwide, which
is pitifully modest for a labour-intensive and talent-driven industry. The
average cost per graduate is $113 000 for medical students and $46 000
for nurses, with unit costs highest in North America and lowest in China.
Stewardship, accreditation, and learning systems are weak and unevenly
practised around the world. Our analysis has shown the scarcity of information
and research about health professional education. Although many educational
institutions in all regions have launched innovative initiatives, little robust
evidence is available about the effectiveness of such reforms.
Reforms for a second century
Three generations of educational reforms characterise
progress during the past century. The first generation, launched at the
beginning of the 20th century, taught a science-based curriculum. Around the
mid-century, the second generation introduced problem-based instructional
innovations. A third generation is now needed that should be systems based to
improve the performance of health systems by adapting core professional
competencies to specific contexts, while drawing on global knowledge.
To advance third-generation reforms, the Commission puts
forward a vision: all health professionals in all countries should be educated
to mobilise knowledge and to engage in critical reasoning and ethical conduct
so that they are competent to participate in patient and population-centred
health systems as members of locally responsive and globally connected teams.
The ultimate purpose is to assure universal coverage of the high-quality
comprehensive services that are essential to advance opportunity for health equity
within and between countries.
Realisation of this vision will require a series of
instructional and institutional reforms, which should be guided by two proposed
outcomes: transformative learning and interdependence in education. We regard
transformative learning as the highest of three successive levels, moving from
informative to formative to transformative learning. Informative learning is
about acquiring knowledge and skills; its purpose is to produce experts.
Formative learning is about socialising students around values; its purpose is
to produce professionals. Transformative learning is about developing
leadership attributes; its purpose is to produce enlightened change agents.
Effective education builds each level on the previous one. As a valued outcome,
transformative learning involves three fundamental shifts: from fact
memorisation to searching, analysis, and synthesis of information for decision
making; from seeking professional credentials to achieving core competencies
for effective teamwork in health systems; and from non-critical adoption of
educational models to creative adaptation of global resources to address local
priorities.
Interdependence is a key element in a systems approach
because it underscores the ways in which various components interact with each
other. As a desirable outcome, interdependence in education also involves three
fundamental shifts: from isolated to harmonised education and health systems;
from stand-alone institutions to networks, alliances, and consortia; and from
inward-looking institutional preoccupations to harnessing global flows of
educational content, teaching resources, and innovations.
Transformative learning is the proposed outcome of
instructional reforms; interdependence in education should result from
institutional reforms. On the basis of these core notions, the Commission
offers a series of specific recommendations to improve systems performance.
Instructional reforms should: adopt competency-driven approaches to
instructional design; adapt these competencies to rapidly changing local
conditions drawing on global resources; promote interprofessional and
transprofessional education that breaks down professional silos while enhancing
collaborative and non-hierarchical relationships in effective teams; exploit
the power of information technology for learning; strengthen educational
resources, with special emphasis on faculty development; and promote a new
professionalism that uses competencies as objective criteria for classification
of health professionals and that develops a common set of values around social
accountability. Institutional reforms should: establish in every country joint
education and health planning mechanisms that take into account crucial
dimensions, such as social origin, age distribution, and gender composition, of
the health workforce; expand academic centres to academic systems encompassing
networks of hospitals and primary care units; link together through global
networks, alliances, and consortia; and nurture a culture of critical inquiry.
Pursuit of these reforms will encounter many barriers. Our
recommendations, therefore, require a series of enabling actions. First, the
broad engagement of leaders at all levels—local, national, and global—will be
crucial to achieve the proposed reforms and outcomes. Leadership has to come
from within the academic and professional communities, but it must be backed by
political leaders in government and society. Second, present funding
deficiencies must be overcome with a substantial expansion of investments in
health professional education from all sources: public, private, development
aid, and foundations. Third, stewardship mechanisms, including socially
accountable accreditation, should be strengthened to assure best possible
results for any given level of funding. Lastly, shared learning by supporting
metrics, evaluation, and research should be strengthened to build up the
knowledge base about which innovations work under which circumstances.
Health professionals have made enormous contributions to
health and development over the past century, but complacency will only
perpetuate the ineffective application of 20th century educational strategies
that are unfit to tackle 21st century challenges. Therefore, we call for a
global social movement of all stakeholders—educators, students and young health
workers, professional bodies, universities, non-governmental organisations,
international agencies, donors, and foundations—that can propel action on this
vision and these recommendations to promote a new century of transformative
professional education. The result will be more equitable and better performing
health systems than at present, with consequent benefits for patients and
populations everywhere in our interdependent world.
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