Health Professionals for a New Century: Transforming Education to Strengthen Health Systems in an Interdependent World
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Healt H professionals for a new century HEALTH PROFESSIONALS FOR A NEW Transforming education to strengthen health systems in CENTURY an interdependent world The Commission The The Commission on education of health Professionals for the 21st Century was launched in January 2010 with the aim of landscaping the field, identifying gaps and opportunities, and offering recommendations for reform a century after the landmark Flexner Report of 1910. This independent initiative was led by co‑chairs Julio Frenk and Lincoln Chen working with a diverse group of 20 Commissioners from around the world: Zulfiqar A Bhutta, Jordan Cohen, nigel Crisp, Timothy evans, harvey Fineberg, Patricia Garcia, Richard Horton, Ke Yang, Patrick Kelley, Barry Kistnasamy, Afaf Meleis, David naylor, Ariel Pablos‑mendez, srinath Reddy, susan Scrimshaw, Jaime sepulveda, David serwadda, and huda Zurayk. sponsored by the Bill and melinda Gates Foundation, the Rockefeller Foundation, and the China medical Board, the co‑chairs supervised the research and management teams operating out of the China medical Board and the harvard school of Public health. HEALTH PROFESSIONALS FOR A NEW Transforming education to strengthen health systems in CENTURY an interdependent world HEALTH PROFESSIONALS FOR A NEW Transforming education to strengthen health systems in CENTURY an interdependent world This Commission report (Frenk J, Chen L, et al. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. Published online at www.thelancet.com (DOI:10.1016/S0140- 6736(10)61854-5) on Nov 29, and in The Lancet Dec 4, 2010, vol 376; pp 1923–58) was published initially in The Lancet in November 2010. It is being reproduced in expanded book form by the Commission in full recognition of the copyrights of The Lancet. Distributed by Harvard University Press, Cambridge MA ISBN 978-0-674-06148-4 Editing, design, and production by Communications Development Incorporated, Washington, DC, and Peter Grundy Art & Design, London, UK. Contents Page number vii Foreword ix The Commissioners xi Research Team xii Scientific Advisory Committee and Youth Commissioners 1 Executive summary 5 Section 1: New contexts, new challenges 15 Section 2: Major findings 51 Section 3: Reforms for a second century 61 References 69 Annex 1: About the Commission 78 Annex 2: Data, methods, and definitions of regions 86 Annex 3: Commissioned papers 87 Annex 4: Three comments v Page number Figures 6 1: Flexner, Welch-Rose, and Goldmark reports 7 2: Emerging challenges to health systems 10 3: Systems framework 12 4: Key components of the educational system 16 5: Three generations of reform 25 6: Density of medical schools by region 25 7: World maps resized by population (A), burden of disease (B), density of medical schools (C), and density of workforce (D) 29 8: New medical schools (public and private) in India (A) and Brazil (B) 38 9: Competency-based education 40 10: Models of interprofessional and transprofessional education 53 11: Vision for a new era of professional education 57 12: Recommendations for reforms and enabling actions 81 A2.1: GDP per capita and cost per graduate-physicians (n=7) 81 A2.2: GDP per capita and physician wages (n=32) Panels 17 1: The Flexner, Rose-Welch, and Goldmark reports 19 2: Adaptation of public health education and research to local priorities 21 3: Women and nursing in Islamic societies 31 4: Networking for equity 34 5: Twinning for capacity development in Africa 35 6: Lusophone networking and Brazilian coordination 42 7: Information technology and open education 46 8: Professionals in community health-worker systems 54 9: Proposed reforms Tables 24 1: Institutions, graduates, and workforce by region (2008) 26 2: Financing of medical and nursing graduates by region (2008) 53 3: Levels of learning 80 A2.1: Select medical education cost studies across countries (physicians) vi Foreword One hundred years ago a series of seminal documents, starting with the Flexner Report of 1910, sparked an enormous burst of energy to harness the power of science to transform higher education in health. Professional education, however, has not been able to keep pace with the challenges of the 21st century. As we close a year of centennial celebrations of the Flexner Report, a new generation of reforms is needed to meet the demands of health systems in an interdependent world. The Commission on the Education of Health Professionals for the 21st Century—a global, independent initiative—consists of 20 leaders from diverse disciplinary backgrounds, institutional affiliations, and regions of the world, who worked together to articulate a fresh vision and to recommend renewed actions. Our Report, “Health Professionals for a New Century: Transforming Education for Health Systems in an Interdependent World,” was originally published in full in a regular issue of The Lancet (vol. 376, pp. 1923–58, 4 December 2010). Building on a rich legacy of educational reforms during the past century, our findings and recommendations adopted a global and multi-professional perspective using a systems approach to analyze education and health, with a focus on institutional and instructional reforms. The idea for the Commission emerged from a series of conversations that the two of us had with Harvey Fineberg, from the Institute of Medicine, and Jaime Sepulveda and Kathy Cahill from the Bill & Melinda Gates Foundation. That impetus sparked a lively set of Commissioner interactions and external consultations. In addition to the rich participation of the Commissioners, we also secured valuable input from several advisory groups. We would also like to thank the President of the Global Health Program at the Gates Foundation, Tachi Yamada, and from the Rockefeller Foundation, Judith Rodin and Ariel Pablos-Méndez. Without them and our other sponsors, the China Medical Board and The Lancet, this ambitious undertaking would not have been possible. This Commission’s journey, although constrained by time and budget, has been extraordinarily rich. Our reward is the quality of the vii collective interactions for achieving our aspiration, not necessarily for wholesale adoption of our report’s recommendations, but most importantly for sparking dialogue and debate over a new century of reforms matched to our times. We invite all stakeholders to join us in a much needed rethinking of reforms to revitalize health professional education to improve health systems in our interdependent world. Julio Frenk, MD, MPH, PhD Lincoln C. Chen, MD, MPH Commission Co-Chair Commission Co-Chair viii The Commissioners Julio Frenk, Co-Chair Dean, Harvard School of Public Health, Boston, USA Lincoln Chen, Co-Chair President, China Medical Board, Cambridge, USA Zulfiqar. A Bhutta Professor of Pediatrics, Aga Khan University Medical Center, Karachi, Pakistan Jordan J. Cohen Professor of Medicine and Public Health, George Washington University Medical Center, Washington DC, USA Lord Nigel Crisp House of Lords, United Kingdom Tim G. Evans Dean, James P. Grant School of Public Health, Dhaka, Bangladesh Harvey Fineberg President, US Institute of Medicine, Washington DC, USA ix Patricia Garcia Ariel Pablos-Mendez Professor of Public Health, Universidad Managing Director, The Rockefeller Peruana Cayetano Heredia, Lima, Peru Foundation, New York, USA Srinath Reddy Richard Horton President, Public Health Foundation of Editor-in-Chief, The Lancet India, New Delhi, India Ke Yang Executive Vice-President, Peking University Health Science Center, Beijing, Susan Scrimshaw China President, The Sage Colleges, Troy, USA Patrick Kelley Director, Boards on Global Health and African Science Academy Development, Jaime Sepulveda US Institute of Medicine, Washington DC, Senior Fellow, Bill & Melinda Gates USA Foundation, Seattle, USA David Serwadda Barry Kistnasamy Professor of Disease Control and National Health Laboratory Service, Environmental Health, Makerere School South Africa of Public Health, Kampala, Uganda Huda Zurayk Afaf. I Meleis Professor and Director, Center for Dean of Nursing, Professor of Nursing Research on Population and Health, and Sociology, University of Faculty of Health Sciences, American Pennsylvania, Philadelphia, USA University of Beirut, Beirut, Lebanon David Naylor President, University of Toronto, Toronto, Canada x Research Team Catherine M. Michaud Research Coordinator, Senior Research Scientist, Harvard School of Public Health and China Medical Board Ananda S. Bandyopadhyay Public Health Epidemiologist Division of Infectious Disease and Epidemiology, State Department of Health, Providence, RI Chenhui Liu Research Fellow, Harvard School of Public Health and China Medical Board Ruvandhi Nathavitharana New York University, Internal Medicine Residency Program, New York, NY Stanislava Nikolova Research Associate, Office of the Dean, Harvard School of Public Health Sonali Vaid USAID Healthcare Improvement Project, University Research Co., LLC Leana S. Wen Research Fellow, Resident Physician, Brigham & Women’s Hospital, Boston, MA xi Scientifi c Advisory Committee and Youth Commissioners Scientifi c Advisory Committee Fitzhugh Mullan Murdock Head Professor of Srinath Reddy, Co-Chair President, Public Health Medicine and Health Policy, The George Washington Foundation of India University Kathy Cahill, Co-Chair President, Cahill, Davila and Francis Omaswa Executive Director, African Associates Center for Global Health and Social Transformation Paulo Buss President Oswaldo Cruz Foundation/ (ACHEST), Uganda