Dartmouth College Dartmouth Digital Commons Dartmouth Scholarship Faculty Work 6-16-2015 Maximizing the Impact of Training Initiatives for Health Professionals in Low-Income Countries: Frameworks, Challenges, and Best Practices Corrado Cancedda Harvard University Paul E. Farmer Harvard University Vanessa Kerry Harvard University Tej Nuthulaganti Harvard University Kirstin W. Scott Harvard University FSeeollow next this page and for additional additional works authors at: https:/ /digitalcommons.dartmouth.edu/facoa Part of the Health Services Administration Commons, Health Services Research Commons, and the International Public Health Commons Dartmouth Digital Commons Citation Cancedda, Corrado; Farmer, Paul E.; Kerry, Vanessa; Nuthulaganti, Tej; Scott, Kirstin W.; Goosby, Eric; and Binagwaho, Agnes, "Maximizing the Impact of Training Initiatives for Health Professionals in Low-Income Countries: Frameworks, Challenges, and Best Practices" (2015). Dartmouth Scholarship. 1653. https://digitalcommons.dartmouth.edu/facoa/1653 This Article is brought to you for free and open access by the Faculty Work at Dartmouth Digital Commons. It has been accepted for inclusion in Dartmouth Scholarship by an authorized administrator of Dartmouth Digital Commons. For more information, please contact [email protected]. Authors Corrado Cancedda, Paul E. Farmer, Vanessa Kerry, Tej Nuthulaganti, Kirstin W. Scott, Eric Goosby, and Agnes Binagwaho This article is available at Dartmouth Digital Commons: https://digitalcommons.dartmouth.edu/facoa/1653 POLICY FORUM Maximizing the Impact of Training Initiatives for Health Professionals in Low-Income Countries: Frameworks, Challenges, and Best Practices Corrado Cancedda1,2,3*, Paul E. Farmer1,2,3, Vanessa Kerry2,4,5, Tej Nuthulaganti6,7, Kirstin W. Scott7, Eric Goosby8, Agnes Binagwaho2,9,10 1 Brigham and Women's Hospital, Boston, Massachusetts, United States of America, 2 Harvard Medical School, Boston, Massachusetts, United States of America, 3 Partners In Health, Boston, Massachusetts, United States of America, 4 Seed Global Health, Boston, Massachusetts, United States of America, 5 Massachusetts General Hospital, Boston, Massachusetts, United States of America, 6 Clinton Health Access Initiative, Boston, Massachusetts, United States of America, 7 Harvard University, Cambridge, Massachusetts, United States of America, 8 University of California San Francisco, San Francisco, California, United States of America, 9 Ministry of Health of Rwanda, Kigali, Rwanda, 10 Geisel School of Medicine—Dartmouth, Hanover, New Hampshire, United States of America * [email protected] OPEN ACCESS Citation: Cancedda C, Farmer PE, Kerry V, Summary Points Nuthulaganti T, Scott KW, Goosby E, et al. (2015) Maximizing the Impact of Training Initiatives for • Historically, the impact of many health professional training initiatives in low-income Health Professionals in Low-Income Countries: countries has been limited by narrow focus on a small set of diseases, inefficient utiliza- Frameworks, Challenges, and Best Practices. PLoS tion of donor funding, inadequate scale up, insufficient emphasis on the acquisition of Med 12(6): e1001840. doi:10.1371/journal. pmed.1001840 practical skills, poor alignment with local priorities, and lack of coordination. • Published: June 16, 2015 Fortunately, several innovative training initiatives have emerged over the past five years in sub-Saharan Africa. This articles focuses on four initiatives funded by the United Copyright: © 2015 Cancedda et al. This is an open States government: the Medical Education Training Partnership Initiative (MEPI), the access article distributed under the terms of the Creative Commons Attribution License, which permits Nursing Training Partnership Initiative (NEPI), the Rwanda Human Resources for unrestricted use, distribution, and reproduction in any Health Program (HRH Program), and the Global Health Service Partnership (GHSP). medium, provided the original author and source are • The best practices adopted by these initiatives are: alignment to local priorities, country credited. ownership, competency-based training, institutional capacity building, and the estab- Funding: No funding was received for this work. lishment of long-lasting partnerships with international stakeholders, Competing Interests: CC is Co-Principal • Based on these best practices, we outline a framework for health professional training ini- Investigator for Rwanda HRH Program at Brigham tiatives that can help better address the health workforce shortage in low-income countries. and Women's Hospital/Harvard Medical School. VK is CEO of Seed Global Health, which is discussed in this article. TN is CHAI Program Director of Rwanda’s HRH Program. EG is former US Global AIDS Coordinator that oversees PEPFAR program. AB is a member of the Editorial Board of PLOS Medicine. Introduction Abbreviations: CDC, Centers for Disease Control; GHSP, Global Health Service Partnership; HRH, The Global Shortage of Health Professionals Rwanda Human Resources for Health; MEPI, Medical Education Training Partnership Initiative; The immense suffering taking place in West Africa due to the Ebola epidemic is a tragic and NEPI, Nursing Training Partnership Initiative; NGO, powerful example of an “acute on chronic” problem facing many low-income countries: the non-governmental organization; PEPFAR, US health workforce shortage [1]. PLOS Medicine | DOI:10.1371/journal.pmed.1001840 June 16, 2015 1/11 President’s Emergency Plan for AIDS Relief; USAID, Insufficient training capacity and the “brain drain” of health professionals from Africa are US Agency for International Development. principal drivers of the current situation [1–3]. Health professional schools in low-income Provenance: Not commissioned; externally countries face notable limitations in physical space, equipment, curricula, training materials, peer reviewed faculty, administrative staff, and funding [4–7]. These limitations stifle efforts to expand the number and the diversity of training programs and to improve the quality of training. Simulta- neously, practicing health professionals are often overwhelmed by the grinding work of deliver- ing health services in under-supplied and over-crowded hospitals and clinics, inadequately compensated for their work, and demoralized by a lack of continuing professional development opportunities [1,3,8]. The health workforce shortage has negatively affected the response to the global HIV/AIDS epidemic, to the emerging threat of non-communicable diseases in sub-Saharan Africa, and most recently, to the Ebola epidemic in West Africa. To improve health outcomes globally, it is critical to increase the number and to diversify and strengthen the competencies of health pro- fessionals in low-income countries [1–4,9]. Past and Current Efforts to Address This Shortage The number of health professional training initiatives in low-income countries has significantly increased over the past ten years [4,7,10,11]. A diverse range of internal (e.g., local governments and academic institutions) as well as external stakeholders have been involved in developing and implementing these initiatives [4,7,12]. External stakeholders have included both develop- ment partners (which contribute funding) and training partners (which contribute expertise and assist with training implementation) (Table 1). Especially in earlier years, the framework adopted by many of these training initiatives has led to less-than-ideal outcomes (Fig 1) [2,4,5,7,8,10,11]. First, many of these initiatives have been primarily driven by the priorities of individual de- velopment and training partners and have often focused on a narrow set of diseases. Addition- ally, integration into national strategic plans (when they exist) or alignment with local priorities has often been marginal [2,4,5,10]. As a result, the same initiatives have rarely been brought to scale and have not addressed the health workforce shortage comprehensively [4,5,7,13,14]. Second, donor funding generally has come with many spending restrictions, which have prevented governments from utilizing the funds effectively, if at all [15,16]. In the past, many development partners have selected and directly funded training partners with limited input from local governments and local academic institutions [13]. These training partners often have spent a substantial proportion of funds on overhead rather than direct training costs [15,16]. Lastly, spending restrictions have often prevented training partners from investing in critical infrastructure and equipment within health professional schools and teaching hospitals that are necessary to create a strong teaching environment [13,14]. Third, many health professional training initiatives have prioritized mostly classroom teach- ing. Such ad hoc, short-term lectures and seminars have not been shown to effectively diversify the skills and strengthen the competencies of local health professionals [4,7,8,13,14]. Until re- cently, the competencies that allow different cadres of health professionals to work together as a team have been rarely addressed by curricula and training materials [9]. Furthermore, many initiatives have focused on training clinicians as opposed to other health professionals (e.g., health managers, community health workers, public health professionals, or researchers) [4,5]. The duration of these initiatives has been determined more by the arbitrary availability of fund- ing and training expertise than by the