Health Professionals for a New Century: Transforming Education to Strengthen Health Systems in an Interdependent World The Harvard community has made this article openly available. Please share how this access benefits you. Your story matters Citation Frenk, Julio, Lincoln Chen, Zulfiqar A. Bhutta, Jordan Cohen, Nigel Crisp, Timothy Evans, Harvey Fineberg, et al. 2010. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. The Lancet 376(9756): 1923-1958. Published Version doi:10.1016/S0140-6736(10)61854-5 Citable link http://nrs.harvard.edu/urn-3:HUL.InstRepos:4626403 Terms of Use This article was downloaded from Harvard University’s DASH repository, and is made available under the terms and conditions applicable to Other Posted Material, as set forth at http:// nrs.harvard.edu/urn-3:HUL.InstRepos:dash.current.terms-of- use#LAA The Lancet Commissions Health professionals for a new century: transforming education to strengthen health systems in an interdependent world Julio Frenk*, Lincoln Chen*, Zulfiqar A Bhutta, Jordan Cohen, Nigel Crisp, Timothy Evans, Harvey Fineberg, Patricia Garcia, Yang Ke, Patrick Kelley, Barry Kistnasamy, Afaf Meleis, David Naylor, Ariel Pablos-Mendez, Srinath Reddy, Susan Scrimshaw, Jaime Sepulveda, David Serwadda, Huda Zurayk Executive summary Redesign of professional health education is necessary Published Online Problem statement and timely, in view of the opportunities for mutual November 29, 2010 100 years ago, a series of studies about the education of learning and joint solutions offered by global DOI:10.1016/S0140- 6736(10)61854-5 health professionals, led by the 1910 Flexner report, interdependence due to acceleration of flows of See Online/Comment sparked groundbreaking reforms. Through integration knowledge, technologies, and financing across borders, DOI:10.1016/S0140- of modern science into the curricula at university-based and the migration of both professionals and patients. 6736(10)62008-9 schools, the reforms equipped health professionals with What is clearly needed is a thorough and authoritative DOI:10.1016/S0140- the knowledge that contributed to the doubling of life re-examination of health professional education, 6736(10)61968-X span during the 20th century. matching the ambitious work of a century ago. *Joint first authors By the beginning of the 21st century, however, all is not That is why this Commission, consisting of Harvard School of Public Health, Boston, MA, USA well. Glaring gaps and inequities in health persist both 20 professional and academic leaders from diverse (Prof J Frenk MD); China Medical within and between countries, underscoring our countries, came together to develop a shared vision and a Board, Cambridge, MA, USA collective failure to share the dramatic health advances common strategy for postsecondary education in medicine, (L Chen MD); Aga Khan equitably. At the same time, fresh health challenges loom. nursing, and public health that reaches beyond the University, Karachi, Pakistan (Prof Z A Bhutta PhD); George New infectious, environmental, and behavioural risks, at confines of national borders and the silos of individual Washington University Medical a time of rapid demographic and epidemiological professions. The Commission adopted a global outlook, a Center, Washington, DC, USA transitions, threaten health security of all. Health systems multiprofessional perspective, and a systems approach. (Prof J Cohen MD); Independent worldwide are struggling to keep up, as they become This comprehensive framework considers the connections member of House of Lords, London, UK (N Crisp KCB); more complex and costly, placing additional demands on between education and health systems. It is centred on James P Grant School of Public health workers. people as co-producers and as drivers of needs and Health, Dhaka, Bangladesh Professional education has not kept pace with these demands in both systems. By interaction through the (Prof T Evans MD); US Institute challenges, largely because of fragmented, outdated, and labour market, the provision of educational services of Medicine, Washington, DC, USA (H Fineberg MD, static curricula that produce ill-equipped graduates. The generates the supply of an educated workforce to meet the P Kelley MD); School of Public problems are systemic: mismatch of competencies to demand for professionals to work in the health system. To Health Universidad Peruana patient and population needs; poor teamwork; persistent have a positive effect on health outcomes, the professional Cayetano, Heredia, Lima, Peru gender stratification of professional status; narrow education subsystem must design new instructional and (Prof P Garcia MD); Peking University Health Science technical focus without broader contextual understand- institutional strategies. Centre, Beijing, China ing; episodic encounters rather than continuous care; (Prof Y Ke MD); National Health predominant hospital orientation at the expense of Major findings Laboratory Service, primary care; quantitative and qualitative imbalances in Worldwide, 2420 medical schools, 467 schools or Johannesburg, South Africa (B Kistnasamy MD); School of the professional labour market; and weak leadership to departments of public health, and an indeterminate Nursing, University of improve health-system performance. Laudable efforts to number of postsecondary nursing educational instit- Pennsylvania, Philadelphia, PA, address these deficiencies have mostly floundered, partly utions train about 1 million new doctors, nurses, USA (Prof A Meleis PhD); because of the so-called tribalism of the professions—ie, midwives, and public health professionals every year. University of Toronto, Toronto, ON, Canada (Prof D Naylor MD); the tendency of the various professions to act in isolation Severe institutional shortages are exacerbated by The Rockefeller Foundation, from or even in competition with each other. maldistribution, both between and within countries. New York, NY, USA www.thelancet.com 5 The Lancet Commissions (A Pablos-Mendez MD); Public Four countries (China, India, Brazil, and USA) each have agents. Effective education builds each level on the Health Foundation of India, more than 150 medical schools, whereas 36 countries previous one. As a valued outcome, transformative New Delhi, India (Prof S Reddy MD); The Sage have no medical schools at all. 26 countries in sub- learning involves three fundamental shifts: from fact Colleges, Troy, MI, USA Saharan Africa have one or no medical schools. In view memorisation to searching, analysis, and synthesis of (S Scrimshaw PhD); of these imbalances, that medical school numbers do not information for decision making; from seeking Bill & Melinda Gates align well with either country population size or national professional credentials to achieving core competencies Foundation, Seattle, WA, USA (J Sepulveda MD); Makarere burden of disease is not surprising. for effective teamwork in health systems; and from University School of Public The total global expenditure for health professional non-critical adoption of educational models to creative Health, Kampala, Uganda education is about US$100 billion per year, again with adaptation of global resources to address local priorities. (Prof D Serwadda MD); and great disparities between countries. This amount is less Interdependence is a key element in a systems Centre for Research on Population and Health, Faculty than 2% of health expenditures worldwide, which is approach because it underscores the ways in which of Health Sciences, American pitifully modest for a labour-intensive and talent-driven various components interact with each other. As a University of Beirut, Beirut, industry. The average cost per graduate is $113 000 for desirable outcome, interdependence in education also Lebanon (Prof H Zurayk PhD) medical students and $46 000 for nurses, with unit costs involves three fundamental shifts: from isolated to Correspondence to: highest in North America and lowest in China. harmonised education and health systems; from stand- Prof Julio Frenk, Harvard School of Public Health, Office of the Stewardship, accreditation, and learning systems are alone institutions to networks, alliances, and consortia; Dean, Kresge Building, Room weak and unevenly practised around the world. Our and from inward-looking institutional preoccupations to 1005, 677 Huntington Avenue, analysis has shown the scarcity of information and harnessing global flows of educational content, teaching Boston, MA 02115, USA research about health professional education. Although resources, and innovations. [email protected] many educational institutions in all regions have Transformative learning is the proposed outcome of or Dr Lincoln Chen, China Medical launched innovative initiatives, little robust evidence is instructional reforms; interdependence in education Board, Two Arrow Street, available about the effectiveness of such reforms. should result from institutional reforms. On the basis Cambridge, MA 02138, USA of these core notions, the Commission offers a series [email protected] Reforms for a second century of specific recommendations to improve systems Three generations of educational reforms characterise performance. Instructional reforms should: adopt progress during the past century. The first generation, competency-driven approaches to instructional design; launched at the beginning of the 20th century, taught a adapt these competencies to rapidly changing