Rapporto frenk

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Rapporto frenk

  1. 1. The Lancet CommissionsHealth professionals for a new century: transformingeducation to strengthen health systems in aninterdependent worldJulio 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 ZuraykExecutive summary Redesign of professional health education is necessary Lancet 2010; 376: 1923–58Problem statement and timely, in view of the opportunities for mutual Published Online100 years ago, a series of studies about the education of learning and joint solutions offered by global November 29, 2010 DOI:10.1016/S0140-health professionals, led by the 1910 Flexner report, interdependence due to acceleration of flows of 6736(10)61854-5sparked groundbreaking reforms. Through integration knowledge, technologies, and financing across borders, See Comment pages 1875of modern science into the curricula at university-based and the migration of both professionals and patients. and 1877schools, the reforms equipped health professionals with What is clearly needed is a thorough and authoritative *Joint first authorsthe knowledge that contributed to the doubling of life re-examination of health professional education, Harvard School of Publicspan during the 20th century. matching the ambitious work of a century ago. Health, Boston, MA, USA By the beginning of the 21st century, however, all is not That is why this Commission, consisting of (Prof J Frenk MD); China Medicalwell. Glaring gaps and inequities in health persist both 20 professional and academic leaders from diverse Board, Cambridge, MA, USA (L Chen MD); Aga Khanwithin and between countries, underscoring our countries, came together to develop a shared vision and a University, Karachi, Pakistancollective failure to share the dramatic health advances common strategy for postsecondary education in medicine, (Prof Z A Bhutta PhD); Georgeequitably. At the same time, fresh health challenges loom. nursing, and public health that reaches beyond the Washington University MedicalNew infectious, environmental, and behavioural risks, at confines of national borders and the silos of individual Center, Washington, DC, USA (Prof J Cohen MD); Independenta time of rapid demographic and epidemiological professions. The Commission adopted a global outlook, a member of House of Lords,transitions, threaten health security of all. Health systems multiprofessional perspective, and a systems approach. London, UK (N Crisp KCB);worldwide are struggling to keep up, as they become This comprehensive framework considers the connections James P Grant School of Publicmore complex and costly, placing additional demands on between education and health systems. It is centred on Health, Dhaka, Bangladesh (Prof T Evans MD); US Institutehealth workers. people as co-producers and as drivers of needs and of Medicine, Washington, DC, Professional education has not kept pace with these demands in both systems. By interaction through the USA (H Fineberg MD,challenges, largely because of fragmented, outdated, and labour market, the provision of educational services P Kelley MD); School of Publicstatic curricula that produce ill-equipped graduates. The generates the supply of an educated workforce to meet the Health Universidad Peruana Cayetano, Heredia, Lima, Peruproblems are systemic: mismatch of competencies to demand for professionals to work in the health system. To (Prof P Garcia MD); Pekingpatient and population needs; poor teamwork; persistent have a positive effect on health outcomes, the professional University Health Sciencegender stratification of professional status; narrow education subsystem must design new instructional and Centre, Beijing, China (Prof Y Ke MD); National Healthtechnical focus without broader contextual understand- institutional strategies. Laboratory Service,ing; episodic encounters rather than continuous care; Johannesburg, South Africapredominant hospital orientation at the expense of Major findings (B Kistnasamy MD); School ofprimary care; quantitative and qualitative imbalances in Worldwide, 2420 medical schools, 467 schools or Nursing, University of Pennsylvania, Philadelphia, PA,the professional labour market; and weak leadership to departments of public health, and an indeterminate USA (Prof A Meleis PhD);improve health-system performance. Laudable efforts to number of postsecondary nursing educational instit- University of Toronto, Toronto,address these deficiencies have mostly floundered, partly utions train about 1 million new doctors, nurses, ON, Canada (Prof D Naylor MD);because of the so-called tribalism of the professions—ie, midwives, and public health professionals every year. The Rockefeller Foundation, New York, NY, USAthe tendency of the various professions to act in isolation Severe institutional shortages are exacerbated by (A Pablos-Mendez MD); Publicfrom or even in competition with each other. maldistribution, both between and within countries.www.thelancet.com Vol 376 December 4, 2010 1923
  2. 2. The Lancet Commissions Health Foundation of India, Four countries (China, India, Brazil, and USA) each have agents. Effective education builds each level on the New Delhi, India more than 150 medical schools, whereas 36 countries previous one. As a valued outcome, transformative (Prof S Reddy MD); The Sage Colleges, Troy, MI, USA have no medical schools at all. 26 countries in sub- learning involves three fundamental shifts: from fact (S Scrimshaw PhD); Saharan Africa have one or no medical schools. In view memorisation to searching, analysis, and synthesis of Bill & Melinda Gates of these imbalances, that medical school numbers do not information for decision making; from seeking Foundation, Seattle, WA, USA align well with either country population size or national professional credentials to achieving core competencies (J Sepulveda MD); Makarere University School of Public burden of disease is not surprising. for effective teamwork in health systems; and from Health, Kampala, Uganda The total global expenditure for health professional non-critical adoption of educational models to creative (Prof D Serwadda MD); and education is about US$100 billion per year, again with adaptation of global resources to address local priorities. Centre for Research on great disparities between countries. This amount is less Interdependence is a key element in a systemsPopulation and Health, Faculty of Health Sciences, American than 2% of health expenditures worldwide, which is approach because it underscores the ways in which University of Beirut, Beirut, pitifully modest for a labour-intensive and talent-driven various components interact with each other. As a Lebanon (Prof H Zurayk PhD) industry. The average cost per graduate is $113 000 for desirable outcome, interdependence in education also Correspondence to: medical students and $46 000 for nurses, with unit costs involves three fundamental shifts: from isolated to Prof Julio Frenk, Harvard School highest in North America and lowest in China. harmonised education and health systems; from stand- of Public Health, Office of the Dean, Kresge Building, Room Stewardship, accreditation, and learning systems are alone institutions to networks, alliances, and consortia; 1005, 677 Huntington Avenue, weak and unevenly practised around the world. Our and from inward-looking institutional preoccupations to Boston, MA 02115, USA analysis has shown the scarcity of information and harnessing global flows of educational content, teaching jfrenk@hsph.harvard.edu research about health professional education. Although resources, and innovations. or many educational institutions in all regions have Transformative learning is the proposed outcome of Dr Lincoln Chen, China Medical Board, Two Arrow Street, launched innovative initiatives, little robust evidence is instructional reforms; interdependence in education Cambridge, MA 02138, USA available about the effectiveness of such reforms. should result from institutional reforms. On the basis lchen@cmbfound.org of these core notions, the Commission offers a series 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 local science-based curriculum. Around the mid-century, conditions drawing on global resources; promote the second generation introduced problem-based interprofessional and transprofessional education that instructional innovations. A third generation is now breaks down professional silos while enhancing needed that should be systems based to improve the collaborative and non-hierarchical relationships in performance of health systems by adapting core effective teams; exploit the power of information professional competencies to specific contexts, while technology for learning; strengthen educational drawing on global knowledge. resources, with special emphasis on faculty development; To advance third-generation reforms, the Commission and promote a new professionalism that uses puts forward a vision: all health professionals in all competencies as objective criteria for classification of countries should be educated to mobilise knowledge and health professionals and that develops a common set of to engage in critical reasoning and ethical conduct so values around social accountability. Institutional that they are competent to participate in patient and reforms should: establish in every country joint population-centred health systems as members of locally education and health planning mechanisms that take responsive and globally connected teams. The ultimate into account crucial dimensions, such as social origin, purpose is to assure universal coverage of the high- age distribution, and gender composition, of the health quality comprehensive services that are essential to workforce; expand academic centres to academic advance opportunity for health equity within and systems encompassing networks of hospitals and between countries. primary care units; link together through global Realisation of this vision will require a series of networks, alliances, and consortia; and nurture a culture instructional and institutional reforms, which should be of critical inquiry. guided by two proposed outcomes: transformative Pursuit of these reforms will encounter many barriers. learning and interdependence in education. We regard Our recommendations, therefore, require a series of transformative learning as the highest of three successive enabling actions. First, the broad engagement of leaders at levels, moving from informative to formative to all levels—local, national, and global—will be crucial to transformative learning. Informative learning is about achieve the proposed reforms and outcomes. Leadership acquiring knowledge and skills; its purpose is to produce has to come from within the academic and professional experts. Formative learning is about socialising students communities, but it must be backed by political leaders in around values; its purpose is to produce professionals. government and society. Second, present funding Transformative learning is about developing leadership deficiencies must be overcome with a substantial attributes; its purpose is to produce enlightened change expansion of investments in health professional education1924 www.thelancet.com Vol 376 December 4, 2010
  3. 3. The Lancet Commissionsfrom all sources: public, private, development aid, andfoundations. Third, stewardship mechanisms, includingsocially accountable accreditation, should be strengthenedto assure best possible results for any given level offunding. Lastly, shared learning by supporting metrics,evaluation, and research should be strengthened to buildup the knowledge base about which innovations workunder which circumstances. Health professionals have made enormous contributionsto health and development over the past century, butcomplacency will only perpetuate the ineffective applicationof 20th century educational strategies that are unfit totackle 21st century challenges. Therefore, we call for a Figure 1: Flexner, Welch-Rose, and Goldmark reportsglobal social movement of all stakeholders—educators,students and young health workers, professional bodies, complementing the importance of social determinantsuniversities, non-governmental organisations, inter- and social movements in health. In these endeavours,national agencies, donors, and foundations—that can professionals play the crucial mediating role of applyingpropel action on this vision and these recommendations knowledge to improve health. Much evidence suggeststo promote a new century of transformative professional that coverage and numbers of health professionals have aeducation. The result will be more equitable and better direct effect on health outcomes.4 Health professionalsperforming health systems than at present, with are the service providers who link people to technology,consequent benefits for patients and populations information, and knowledge. They are also caregivers,everywhere in our interdependent world. communicators and educators, team members, managers, leaders, and policy makers.5–12 As knowledge brokers,Section 1: problem statement health workers are the human faces of the health system.Background and rationale Arguably, dramatic reforms in the education of healthComplex challenges professionals helped to catalyse health gains in the pastHealth is all about people. Beyond the glittering surface century. After the discovery of the germ theory in Europe,of modern technology, the core space of every health the beginning of the 20th century witnessed widespreadsystem is occupied by the unique encounter between one reforms in professional education around the world. Inset of people who need services and another who have the USA early in the 20th century, such reports as bybeen entrusted to deliver them. This trust is earned Flexner,13 Welch-Rose,14 and Goldmark15 transformedthrough a special blend of technical competence and postsecondary education of physicians, public healthservice orientation, steered by ethical commitment and workers, and nurses, respectively (figure 1). These effortssocial accountability, which forms the essence of to imbed a scientific foundation into the education ofprofessional work. Developing such a blend requires a health professionals extended into other health fields.16lengthy period of education and a substantial investment However, in the first decade of the 21st century, glaringby both student and society. Through a chain of events gaps and striking inequities in health persist bothflowing from effective learning to high-quality services to between and within countries.17–20 A large proportion ofimproved health, professional education at its best makes the 7 billion people who inhabit out planet are trapped inan essential contribution to the wellbeing of individuals, health conditions of a century earlier. Many face conflictfamilies, and communities. and violence. Health gains have been reversed by the Yet, the context, content, and conditions of the social collapse of average life expectancy in some countries,effort to educate competent, caring, and committed health which in sub-Saharan Africa is attributable to theprofessionals are rapidly changing across time and space. HIV/AIDS pandemic.21,22 Poor people in developingThe startling doubling of life expectancy during the 20th countries continue to have common infections,century was attributable to improvements in living malnutrition, and maternity-related health risks, whichstandards and to advances in knowledge.1 Abundant have long been controlled in more affluent populations.23evidence suggests that good health is at least partly For those left behind, the spectacular advances in healthknowledge based and socially driven.2,3 Scientific worldwide are an indictment of our collective failure toknowledge not only produces new technologies but also ensure the equitable sharing of health progress.24empowers citizens to adopt healthy lifestyles, improve At the same time, health security is being challengedcare-seeking behaviour, and become proactive citizens by new infectious, environmental, and behaviouralwho are conscious of their rights. Additionally, knowledge threats superimposed upon rapid demographic andtranslated into evidence can guide practice and policy. epidemiological transitions.25–27 Health systems areHealth systems are socially driven differentiated struggling to keep up and are becoming more complexinstitutions with the primary intent to improve health, and costly, placing additional demands on health workers.www.thelancet.com Vol 376 December 4, 2010 1925
  4. 4. The Lancet Commissions challenging in poor countries, which are constrained by Epidemiological and severely scarce resources.38,40,41 Many countries are demographic transitions attempting to extend essential services through the deployment of basic health workers, even as millions of people resort to providers without credentials, both Technological Health Professional traditional and modern.42 In an effort to achieve health innovation system differentiation goals, many poor countries are channelling external donor funding towards implementation of disease-targeted initiatives. Consequently, in many countries, postsecondary Population professional education is absent from the policy agenda demands and is overtaken by emergency or urgent action projects and is regarded as too costly, irrelevant, or long term. Figure 2: Emerging challenges to health systems A renaissance to a new professionalism—patient- centred and team-based—has been much discussed,37,43–47 In many countries, professionals are encountering more but it has lacked the leadership, incentives, and power to socially diverse patients with chronic conditions, who are deliver on its promise. Some attempts to redefine the more proactive in their health-seeking behaviour.28–31 future roles and responsibilities of health professionals Patient management requires coordinated care across have floundered amid the rigid so-called tribalism that time and space, demanding unprecedented teamwork.5–11 afflicts them. Advocacy for specific practitioner groups has Professionals have to integrate the explosive growth of been strong, but without an overall strategy for the broader knowledge and technologies while grappling with health professional community to work together to meet expanding functions—super-specialisation, prevention, individual and population health needs. Several well and complex care management in many sites, including meaning recent efforts have attempted to address these different types of facilities alongside home-based and fractures, but they have fallen short. community-based care (figure 2).7–12 Consequently, a slow-burning crisis is emerging in Fresh opportunities the mismatch of professional competencies to patient Opportunities are opening for a new round of reforms to and population priorities because of fragmentary, craft professional education for the 21st century, spurred outdated, and static curricula producing ill-equipped by mutual learning due to health interdependence, changes graduates from underfinanced institutions.5–12,18–20 In in educational pedagogy, the public prominence of health, almost all countries, the education of health pro- and the growing recognition of the imperative for change. fessionals has failed to overcome dysfunctional and Paradoxically, despite glaring disparities, interdependence inequitable health systems because of curricula in health is growing and the opportunities for mutual rigidities, professional silos, static pedagogy (ie, the learning and shared progress have greatly expanded.1,24 science of teaching), insufficient adaptation to local Global movements of people, pathogens, technologies, contexts, and commercialism in the professions. financing, information, and knowledge underlie the Breakdown is especially noteworthy within primary international transfer of health risks and opportunities, care, in both poor and rich countries. The failings are and flows across national borders are accelerating.48 We are systemic—professionals are unable to keep pace, increasingly interdependent in terms of key health becoming mere technology managers, and exacerbating resources, especially skilled workers.24 protracted difficulties such as a reluctance to serve Alongside the rapid pace of change in health, there is a marginalised rural communities.32,33 Professionals are parallel revolution in education. The explosive increase falling short on appropriate competencies for effective not only in total volume of information, but also in ease teamwork, and they are not exercising effective of access to it, means that the role of universities and leadership to transform health systems. other educational institutions needs to be rethought.49 Poor and rich countries both have workforce shortages, Learning, of course, has always been experienced outside skill-mix imbalances, and maldistribution of profess- formal instruction through all types of interactions, but ionals.7,32–35 In neither rich nor poor countries is professional the informational content and learning potential are education generating high value for money. Difficult to today without precedent. In this rapidly evolving context, design and slow to implement, educational reforms in rich universities and educational institutions are broadening countries are attempting to develop professional their traditional role as places where people go to obtain competencies that are responsive to changing health information (eg, by consulting books in libraries or needs, overcome professional silos through inter- listening to expert faculty members) to incorporate novel professional education, harness information technology forms of learning that transcend the confines of the (IT)-empowered learning, enhance cognitive skills for classroom. The next generation of learners needs the critical inquiry, and strengthen professional identity and capacity to discriminate vast amounts of information values for health leadership.36–40 Reforms are especially and extract and synthesise knowledge that is necessary1926 www.thelancet.com Vol 376 December 4, 2010
  5. 5. The Lancet Commissionsfor clinical and population-based decision making. delimit their respective spheres of practice. The divisionThese developments point toward new opportunities for of labour at any specific time and in any specific society isthe methods, means, and meaning of education.5–12,18–20 much more the result of these social forces than of any Like never before, the public prominence of health in inherent attribute of health-related work.general and global health in particular has generated an In most of this report we continue to refer to the healthenvironment that is propitious for change. Health affects professions in a conventional manner. We focus onthe most pressing global issues of our time: socio- health workers who have completed postsecondaryeconomic development, national and human security, education—typically in universities or other institutionsand the global movement for human rights. We now of higher learning that are legally allowed to certifyunderstand that good health is not only a result of but educational attainment by issuing a formal degree.also a condition for development, security, and rights. At Although this definition does not include most ancillarythe same time, access to high-quality health care with and community health workers and there has beenfinancial protection for all has become one of the major substantial growth of new occupational categories ordomestic political priorities worldwide. specialisations, we focus mostly on the conventional A full and authoritative examination and redesign of professions, with special emphasis on medicine, nursing-the education of health professionals is warranted to midwifery, and public health. Our analyses andmatch the ambition of reformers a century ago. Such a recommendations are directed at all health professions.review would necessarily be globally inclusive and multi- However boundaries between health professions areprofessional, spanning borders and constituencies. delineated, all are subject to educational processes aimedReform for the 21st century is timely because of the at developing knowledge, skills, and values to improveimperative to align professional competencies to the health of patients and populations. There is, therefore,changing contexts, growing public engagement in a fundamental linkage between professional education,health, and global interdependence, including the shared on the one hand, and health conditions, on the other. Foraspiration of equity in health. this reason, the Commission developed a framework aimed at understanding of the complex interactionsCommission work between two systems: education and health (figure 3).The Commission on education of health professionals for By contrast with other frameworks, in which thethe 21st century was launched in January, 2010. This population is exogenous to health or education systems,independent initiative, led by a diverse group of ours conceives of the population as the base and the driver20 commissioners from around the world, adopted a global of these systems. People generate needs in both educationperspective seeking to advance health by recommending and health, which in turn may be translated into demandinstructional and institutional innovations to nurture a for educational and health services. The provision ofnew generation of health professionals who would be best educational services generates the supply of an educatedequipped to address present and future health challenges. workforce to meet the demand for professionals to work inWebappendix pp 1–5 lists the members of the Commission the health system. Of course, people are not only recipients See Online for webappendixand its advisory bodies. We pursued research, undertook of services but actual coproducers of their own educationdeliberations, and promoted consultations during 1 year. and health.The brevity of time constrained the scope and depth ofconsultations, data compilation, and analyses. Ouraim was to develop a fresh vision with practicalrecommendations of specific actions that might catalysesteps towards the transformation of health professional Supply of health Labour market for Demand for health workforce health professionals workforceeducation in all countries, both rich and poor. The work ofthe Commission is intended to mark the centennial of the1910 Flexner report, which has powerfully shaped medical Provision Provisioneducation throughout the world.Integrative framework Education system Health systemThe Commission began by defining its object of study— Demand Demandhealth professional education. The present division oflabour between the various health professions is a socialconstruction resulting from complex historical processes Needs Needsaround scientific progress, technological development, Populationeconomic relations, political interests, and culturalschemes of values and beliefs. The dynamic nature ofprofessional boundaries is underscored by the continuousstruggles between different professional groups to Figure 3: Systems frameworkwww.thelancet.com Vol 376 December 4, 2010 1927
  6. 6. The Lancet Commissions In this system approach, the interdependence of the In addition to labour market linkages, the education and health and education sectors is paramount. Balance health systems share what could be thought of as a joint between the two systems is crucial for efficiency, subsystem—namely, the health professional education effectiveness, and equity. Every country has its own subsystem. Whereas in a few countries schools for health unique history, and legacies of the past shape both the professionals are ascribed to the health ministry, in others present and the future. There are two crucial junctures in they are under the jurisdiction of the education ministry. the framework. The first is the labour market, which Irrespective of this administrative issue, the health governs the fit or misfit between the supply and demand professional education subsystem has its own dynamic, of health professionals, and the second is the weak resulting from its location at the intersection of two major capacity of many populations, especially poor people, to societal systems. After all, health-care spaces are also translate their health and educational needs into effective educational spaces, in which the in-service education of demand for the respective services. In optimum future professionals takes place. circumstances, there is a balance between population The linkage between the education and the health needs, health-system demand for professionals, and systems should also address the delivery models that supply thereof by the educational system. Educational determine the skill mix of health workers and the scope institutions determine how many of what type of for task shifting. In addition to the managerial aspects, professionals are produced. Ideally they do so in response there is a political dimension, since health professionals to labour market signals generated by health institutions, do not act in isolation but are usually organised as interest and these signals should correctly respond to the needs groups. Furthermore, governments very often influence of the population. the supply of health professionals in response to political However, in reality the labour market for health situation more than to market rationality or epidemiological professionals is often characterised by multiple imbal- reality. Lastly, labour markets for health professionals are ances,50 the most important of which are undersupply, not only national but also global. In professionals with unemployment, and underemployment, which can be internationally recognised credentials, migration is a quantitative (less than full-time work) or qualitative growing occurrence. (suboptimum use of skills). To avoid these imbalances, After specification of the linkages between the health the educational system must respond to the requirements and educational spheres, our framework identifies three of the health system. However, this tenet does not imply key dimensions of education: institutional design (which a subordinate position of the education system. We see specifies the structure and functions of the education educational institutions as crucial to transform health system), instructional design (which focuses on processes), systems. Through their research and leadership and educational outcomes (which deal with the desired functions, universities and other institutions of higher results; figure 4). Aspects of both institutional and learning generate evidence about the shortcomings of instructional design were already present in the original the health system, and about potential solutions. reports of the 20th century,13–15 which sought to answer not Through their educational function, they produce only the question of what and how to teach, but also where professionals who can implement change in the to teach—ie, the type of organisation that should undertake organisations in which they work. the programmes of instruction. However, by contrast with the reports of a century ago, ours considers institutions Structure Process not only as individual organisations, but also as part of an inter-related set of organisations that implement the Institutional design Instructional design diverse functions of an educational system. • Systemic level Criteria for admission By adaptation of a framework that was originally Stewardship and governance Competencies formulated to understand health-system performance,51 Financing Channels Resource generation Career pathways we can think of four crucial functions that also apply to Service provision Context educational systems: (1) stewardship and governance, • Organisational level Global–local which encompass instruments such as norms and policies, Ownership evidence for decision making, and assessment of Affiliation Internal structure performance to provide strategic guidance for the various • Global level components of the educational system; (2) financing, Stewardship which entails the aggregate allocation of resources to Networks and partnerships educational institutions from both public and private Proposed outcomes sources, and the specific modalities for determining resource flows to each educational organisation, with the Interdependence Transformative in education learning ensuing set of incentives; (3) resource generation, most importantly faculty development; and (4) service provision, which refers to the actual delivery of the educational serviceFigure 4: Key components of the educational system and as such reflects instructional design.1928 www.thelancet.com Vol 376 December 4, 2010
  7. 7. The Lancet Commissions The way that the four functions are structured defines Data and methodsthe systemic level shown in figure 4. Within a system, The conceptual framework was used to guide theindividual organisations will vary according to ownership Commission’s research, consultations, and report(eg, public, private non-profit, or private for profit), writing. Webappendix pp 6–10 provides detailed data andaffiliation (eg, freestanding, part of a health sciences methods for this work. The data consisted of a review ofcomplex, or part of a comprehensive university), and published work, quantitative estimations, qualitative caseinternal structure (eg, departmental or otherwise). These studies, and commissioned papers, supplemented byare all important aspects of institutional design. Equally consultations with experts and young professionals. Weimportant is the global level. The stewardship function searched all published articles indexed in PubMed andthat should be done nationally has a global counterpart, Medline relevant to postsecondary education in medicine,especially with respect to normative definitions about nursing, and public health. Undergraduate medicalcommon core competencies that all health professions educational institutions were compiled by combiningshould have in every country. An emerging development two major databases: Foundation for the Advancement ofglobally refers to new forms of organisation, such as International Medical Education and Research (FAIMER)networks and partnerships, which take advantage of and Avicenna, updated by recent regional and countryinformation and communication technologies. data. We estimated public health institutional counts To have a positive effect on the functioning of health from regional association websites, but nursing-systems and ultimately on health outcomes of patients midwifery did not have comparable international data.and populations, educational institutions have to be Because of definitional ambiguity, estimation of publicdesigned to generate an optimum instructional process. health and nursing institutions was incomplete.Instructional design involves what can be presented as The numbers of graduates of medicine and nursing-four Cs: (1) criteria for admission, which include both midwifery were derived from both direct reports (eg, fromachievement variables, such as previous academic the Organization for Economic Cooperation andperformance, and adscription variables, such as social Development [OECD]) and estimates of yearly flows fromorigin, race or ethnic origin, sex, and nationality; the modelling of nursing stock reported by WHO. We did(2) competencies, as they are defined in the process of not estimate the number of public health graduatesdesigning the curriculum; (3) channels of instruction, because of data and definitional restrictions.by which we mean the set of didactic methods, teaching Financing estimations were calculated through bothtechnologies, and communication media; and (4) career microapproaches and macroapproaches. Microapproachespathways, which are the options that graduates have on to estimating the financing of medical and nursingcompletion of their professional studies, as a result of education were based on unit costs of undergraduatethe knowledge and skills that they have attained, the education multiplied by number of graduates. Weprocess of professional socialisation to which they have compared these results with macroapproaches thatbeen exposed as students, and their perceptions of calculated the share of tertiary educational financingopportunities in local or global labour markets devoted to medical and nursing education. Although not(figure 4). precise, the convergence of microapproaches and Different configurations of institutional and macroapproaches provides some assurance that the broadinstructional design will lead to varying educational order of magnitude of our estimations is robust.outcomes. Making the desired results explicit is anessential element in assessment of the performance of Section 2: major findingsany system. In the case of our Commission, two The Commission’s major findings are presented in fouroutcomes were proposed for the health professional subsections. The first describes a century of educationaleducation system—transformative learning and reforms, grouped into three generations. The next twointerdependence in education. Transformative learning subsections present our diagnosis based on the majoris the proposed outcome of improvements in categories of the conceptual framework. Analysis ofinstructional design; interdependence in education institutional design relies mainly on quantitative data toshould result from institutional reforms (figure 4). present a global analysis of institutions, graduates, andBecause they are the guiding notions of our financing, followed by key stewardship functions suchrecommendations, they will be discussed in the final as accreditation, academic systems, faculty development,section of this report. and collaboration for shared learning. We then examine A final component of our framework, shown in instructional design, focusing on the purpose, content,figure 4, is that all aspects of the educational system are method, and outcomes of the learning process.deeply affected by both local and global contexts. Challenges are categorised according to the four CsAlthough many commonalities might be shared globally, explained in the conceptual framework: criteria forthere is local distinctiveness and richness. Such diversity admission, competencies, channels, and career path-provides opportunities for shared learning across ways. In the final subsection we cut across institutionscountries at all levels of economic development. and instruction by examining the challenges of localwww.thelancet.com Vol 376 December 4, 2010 1929
  8. 8. The Lancet Commissions adaptability in an interdependent globalising world. In 1900 Science based Problem based Systems based 2000+ view of the huge diversity of health and educational systems, we address the question, how can instructional and institutional design achieve effectiveness in diverse contexts while at the same time harnessing the power of Scientific Problem-based Competency driven: global pools and flows of knowledge and other Instructional curriculum learning local–global resources? Institutional University based Academic centres Health-education Century of reforms systems To capture historical developments in the past century, we defined three generations of reforms (figure 5). We recognise that, as with all classification schemes, this oneFigure 5: Three generations of reform simplifies multidimensional realities, so our categories are broad and to some extent arbitrary. Yet, they are informed by historical analyses, and we believe that they have Panel 1: The Flexner, Rose-Welch, and Goldmark reports heuristic value. The word generation conveys the notion that this development is not a linear succession of clear-cut Three seminal US reports (Flexner, Welch-Rose, and Goldmark) had powerful effects in reforms. Instead, elements of each generation persist in professional health education in North America, and arguably by extension around the subsequent ones, in a complex and dynamic pattern of the world. All the reports recommended major instructional reforms to integrate change. The first generation, launched at the beginning of modern medical sciences into the core curriculum, and institutional reforms to link the 20th century, instilled a science-based curriculum. education to research and the basing of professional education in comprehensive Around mid-century, the second generation introduced universities. problem-based instructional innovations. A third generation Flexner report 191013 is now needed that should be systems based. The report introduced the modern sciences as foundational for the medical curriculum Most countries and professional institutions have mixed into two successive phases: 2 years of basic biomedical sciences, based in universities, patterns of these reforms. In some countries, most followed by 2 years of clinical training, based in academic medical hospitals and schools are entirely confined to the first generation, with centres. Research was to be viewed not as an end in itself but as a link to improved traditional and stagnant curricula and teaching methods patient care and clinical training. Flexner also changed the doctor’s education from an and with an inability, or even resistance, to change.18,19 apprenticeship model to an academic model, and his report created the conditions for Many countries are incorporating second-generation the birth of academic medical centres, ushering in a hitherto unknown era of discovery. reforms, and a few are moving into the third generation.52–55 In 1912, Flexner extended his study of medical education to a group of key European No country seems to have all schools in the third countries.63 Although the Flexner model of professional education was widely adopted generation. outside the USA and Canada, it has often not been sufficiently adapted to address Although the three generations are bounded in the 20th health in vastly different societal contexts. century, we recognise that innovation in medical learning has long and deep historical roots worldwide. Early Welch-Rose report 191514 systems of medical education were reported in India This report offered two competing visions of public health professional education. around 6th century BC in a classical text called Rose’s plan was for a national system of public health training with central national Susruta Samhita,56 and in China with lectureships in schools acting as the focus for a network of state schools, both emphasising public Chinese medicine at the Imperial Academy in 624 AD.57 health practice. By contrast, Welch’s plan called for institutes of hygiene, following the Arab and north African civilisations had flourishing German model, with increased emphasis on scientific research and connections to a medical learning systems, as did the Greeks and the medical school in comprehensive universities. Welch’s plan was financed by the Mesoamerican civilisations.58,59 In the UK, the Royal Rockefeller Foundation to create the Johns Hopkins School of Public Health and College of Physicians started in the 17th century.60 Hygiene in 1916, and the Harvard School of Public Health in 1922. Most schools of Educational reforms in the 20th century share roots public health in the USA followed the Welch model as independent faculties in going back to social movements and the development of universities. Outside the USA and Canada, both institutional models described by Rose the medical sciences in the 19th century. In the mid-1800s, and Welch were implemented and co-exist to this day. Florence Nightingale61 campaigned that good nursing Goldmark report 192316 care saved lives, and good nursing care depended on This report advocated for university-based schools of nursing, citing the inadequacies educated nurses. The first nursing education programme of existing educational facilities for training skilled nurses. The report put nursing on began in London in 1859, as 2-year hospital-based the same academic trajectory as medicine and public health in the USA, albeit a little training that soon spread quickly in the UK, the USA, later in time. Although major health burdens prevailing at the time—such as infant Germany, and Scandinavian countries.62 The roots of mortality and tuberculosis—had greatly decreased, the importance of an improved modern medicine and public health go back similarly to trained nursing workforce remains, including high standards of nursing educational the mid-1800s, propelled by discoveries that proved the attainment. germ theory. By the beginning of the 20th century, the fields of medicine and public health had been left behind1930 www.thelancet.com Vol 376 December 4, 2010
  9. 9. The Lancet Commissionsby scientific advances, with no rigorous standards of examples, including several in the Arabian countries andeducation and practice based on modern foundations. south Asia, show the capacity of public health academic After developments in western Europe, the first institutions to respond to diverse and rapidly changing For more on the Public Healthgeneration of 20th century reforms in North America local requirements (panel 2). Foundation of India see http://were sparked by such reports as Flexner (1910),13 In parallel with the increasing engagement of national www.phfi.org/Welch-Rose (1915),14 Goldmark (1923),15 and Gies (1926),16 governments in health affairs, a second generation of For the BRAC University’swhich launched modern health sciences into classrooms reforms began after World War 2 both in industrialised School of Public Health seeand laboratories in medicine, public health, nursing, and and in developing nations, many of which had just gained http://www.bracuniversity.net/dentistry, respectively (panel 1). These reforms, which were independence from colonialism.71 School and university I&S/sph/usually sequencing education in the biomedical sciencesfollowed by training in clinical and public health practice, Panel 2: Adaptation of public health education and research to local prioritieswere joined by similar efforts in other regions. Curricularreform was linked to institutional transformation— Several public health institutes have developed over recent decades in response to veryuniversity bases, academic hospitals linked to universities, diverse local contexts. We present innovations in three regions: Arabian countries,closure of low-quality proprietary schools, and the bringing Mexico, and south Asia.together of research and education. The goals were to Institute of Community and Public Health, Birzeit University, occupied Palestinianadvance scientifically based professionalism with high territory, is one of three independent schools of public health linked to leadingtechnical and ethical standards. universities in the Arab region; the High Institute of Public Health (HIPH) at the University American philanthropy, led by the Rockefeller of Alexandria in Egypt is a large institution founded in 1956; and the Faculty of HealthFoundation, the Carnegie Foundation for the Advancement Sciences, American University of Beirut (AUB), Lebanon, was established as separate fromof Teaching, and other similar organisations, promoted AUB’s medical school in 1954 and achieved accreditation of its graduate public healththese educational reforms by financing the establishment programme from the US Council on Education for Public Health in 2006. All wereof dozens of new schools of medicine and public health in uniquely shaped by national contexts, ranging from a strong state in Egypt to civilthe USA and elsewhere.64 2 years after the publication of conflict in Lebanon, to absent state structures in the occupied Palestinian territory. Allhis original report, which focused on the USA and Canada, have adopted different approaches to public health: application of evidence-basedFlexner63 extended his study of medical education to the interventions to improve health-care delivery and environmental health in Egypt;German Empire, Austria, France, England, and Scotland. expansion of multisectoral developmental public health practice in Lebanon; and focus onBut the influence went beyond nations in western Europe. social determinants of health necessitating actions inside and outside the health sector inThe so-called Flexner model was translated into action the occupied Palestinian territory.68through the establishment of new medical schools, theearliest and most prominent being the Peking Union National Institute of Public Health of Mexico (NIPH),69 founded in 1987, responded toMedical College founded in China by the Rockefeller rapid national economic and social change, striving to balance excellence in its researchFoundation and implemented by its China Medical Board and educational mission with relevance to decision making through proactive translationin 1917.63,65 of knowledge into evidence for policy and practice. The Institute widely disseminated a In public health, the earlier experiences at the London conceptual base around the essential attributes of public health; developed educationalSchool of Tropical Medicine, Tulane University,66 and the programmes across diverse areas of concentration; implemented a wide range ofHarvard-MIT School for Health Officers were affected by innovative educational approaches, from short courses to doctoral programmes; andthe Welch-Rose report,14 which paved the way for a major developed sound evidence that supported the design, implementation, and evaluation ofgrowth in new schools starting with the Johns Hopkins the ongoing health reform initiative for universal coverage. The success of the NIPHSchool of Hygiene and Public Health (1916), the Harvard underscores the crucial importance of national and international networking toSchool of Public Health (1922), the School of Public withstand local difficulties by sharing of experiences to build a strong health-researchHealth of Mexico (1922), a renewed London School of system that is able to tackle a vast array of local and global health challenges.Hygiene and Tropical Medicine (1924), and the University The Public Health Foundation of India is a unique private–public partnership to energiseof Toronto School of Public Health (1927). The Welch- public health by bringing together pooled resources from the Indian Government andRose model was also exported through Rockefeller’s private philanthropy to address India’s priority health challenges. The Foundation isfunding of 35 new schools of public health overseas, as crafting partnerships with four state governments to create eight training institutes ofexemplified by the School of Public Health of Mexico, public health in the country.70 The BRAC University’s School of Public Health, namedwhich was established in 1922 as part of the Federal after UNICEF’s visionary leader James P Grant, was launched by the world’s largestDepartment of Health. non-governmental organisation and offers an innovative 12-month curriculum for This mass-scale export and adoption had mixed masters in public health that begins with 6 months on its Savar rural campus acquiringoutcomes, with useful results in some countries but also basic public health skills in the context of rural health action, followed by the remainingsevere misfits in others. In 1987, the pioneering Mexican 6 months of thematic and research training. These two public health initiatives in southschool underwent major reform when it merged with the Asia were based on the legacy of British colonialism, which focused exclusively on medicalCentre for Public Health Research and the Centre for rather than public health schools. Importantly, both these schools are developing newInfectious Disease Research to form the National Institute curricula shaped to national and global priorities, and neither is adopting wholesale theof Public Health—one of the leading institutions of its Welch-Rose model of public health education.type in the developing world.67 Many other innovativewww.thelancet.com Vol 376 December 4, 2010 1931
  10. 10. The Lancet Commissions development was accompanied by expansion of tertiary Before the centennial of the Flexner report, a series of hospitals and academic health centres that trained health initiatives have once again heightened national and professionals, did research, and provided care, thereby global attention about the future of education of health integrating these three areas of activity. Pioneered in professionals. We summarise four sets of major reports the 1950s was the idea of graduate medical education that focus on education of the global health workforce, as postgraduate training, which was similar to an nursing education, public health education, and medical apprenticeship, through residency programmes in education. Recommendations in these reports are hospital-based academic centres.72 increasingly coalescing into a third generation of reforms The major instructional breakthroughs from the second that emphasise patient and population centredness, generation of reforms were problem-based learning and competency-based curriculum, interprofessional and disciplinarily integrated curricula. In the 1960s, McMaster team-based education, IT-empowered learning, and University in Canada pioneered student-centred learning policy and management leadership skills. These areas, based on small groups as an alternative to didactic lecture- we believe, provide a strong base for formulation of style teaching.73 Simultaneously, an integrated rather than reform initiatives into the 21st century. discipline-bound curriculum was experimentally de- Global workforce education has witnessed a major veloped in Newcastle in the UK and Case Western resurgence of policy attention, partly driven by imperatives Reserve in the USA.74,75 Other curricular innovations to achieve national and global health objectives as set out included standardised patients—ie, individuals who are by the Millennium Development Goals (MDGs). Three trained to act as a real patient to simulate a set of major reports are noteworthy in terms of education and symptoms or problems—to assess students on practice,76 training of the workforce: Task Force on Scaling-Up and strengthening doctor–patient relationships through Saving Lives,20 World Health Report,19 and the Joint Learning facilitated group discussions,77 and broadening the Initiative.18 These reports all underscore the centrality of continuum from classroom to clinical training through the workforce to well performing health systems to achieve earlier student exposure to patients and an expansion of national and global health goals. All the reports draw training sites from hospitals to communities.78–81 In public attention to the global crisis of workforce shortages health, disciplines expanded along with multidisciplinary estimated worldwide at 2·4 million doctors and nurses in work, and in nursing there was accelerated integration of 57 crisis countries. The crisis is most severe in the world’s schools into universities, with advanced graduate poorest nations that are struggling to achieve the MDGs, programmes at the master and doctoral levels. particularly in sub-Saharan Africa. The shortages also emphasise associated issues, including imbalances of skill Panel 3: Women and nursing in Islamic societies mix, negative work environment, and maldistribution of health workers. The reports cite imbalanced labour market Women and nursing in Islamic societies has a long and rich dynamics that are failing to ensure adequate rural coverage history. In the Middle East and north Africa, higher education while generating unemployed professionals in capital in nursing started in 1955 when the first Higher Institute of cities, and the international migration of professionals For the Faculty of Nursing at Nursing in the region was established in the Faculty of from poor to rich countries. the University of Alexandria Medicine of the Egyptian University of Alexandria. Endorsed see: http://www.alexnursing. These reports recommend vastly increasing investment edu.eg by WHO, the Institute offered a bachelor of nursing degree. in education and training. They concentrate on basic The Institute became an autonomous faculty affiliated to the workers because of the importance of primary health care University in 1994, offering both masters and doctoral and the long time lag and high costs of postsecondary degrees in nursing sciences. During the past 50 years, the education. Consequently, health professionals, although faculty of nursing has produced more than 6000 graduates, acknowledged, do not receive much attention. These many assuming leadership in the region. reports, however, are sparking growing interest in task Another pioneer is the Aga Khan University School of shifting and task sharing—a process of delegating practical Nursing, which was established in Pakistan in 1980, and tasks from scarce professionals to basic health workers. which began offering a bachelor of science in nursing in 1997 All reports propose increased investment, sharing of and the masters of science in 2001.83 The school has devised a resources, and partnerships within and across countries. unique curriculum adapted to local contexts but based on the Nursing education is the focus of three major reports in curriculum recommended by the American Association of 2010: Radical transformation, by the Carnegie Foundation; Colleges of Nursing’s Essentials of Master’s Education in Frontline care,9 a UK Prime Minister commission;12 and Advanced Nursing (1996).84 Aga Khan University has also the Robert Wood Johnson Foundation Initiative on the future expanded the bachelors and masters nursing programmes to of nursing, at the US Institute of Medicine.82 The Carnegie its campus in east Africa.83 In addition to training nurses, report concluded that although nursing has been effective these advanced degree programmes attract high-quality in promotion of professional identity and ethical candidates in Islamic society, showing societal prestige and comportment, the challenge remains of anticipating value for women entering the nursing profession. changing demands of practice through strengthening of scientific education and integration of classroom and1932 www.thelancet.com Vol 376 December 4, 2010
  11. 11. The Lancet Commissionsclinical teaching. The UK Commission identifies the competencies of different professions. At the same time,requisite core competencies, skills, and support systems they underscore the opportunities for mutual learningfor nursing. For the National Health Service it recommends across diverse countries.24 Taken together, they form a basemainstreaming nursing into national service planning, of convergence around a third generation of reforms thatdevelopment, and delivery. Pioneering work in nursing promise to address gaps and opportunities in aeducation is also being pursued in other regions—eg, in globalising world.China and Islamic countries (panel 3). Public health education is the subject of two major Institutional designreports by the US Institute of Medicine in 2002 and 2003, In this subsection, we focus on institutions ofboth focusing on the future of public health in the 21st postsecondary education that offer professional degreescentury.5,6 The reports recommend that the core in medicine, public health, or nursing. Such educationalcurriculum adopt transdisciplinary and multischool institutions might be extraordinarily diverse. They mightapproaches, and instil a culture of lifelong learning. They be independent or linked to government, part of aalso urge that public health skills and concepts be better university or freestanding, fully accredited, or evenintegrated into medicine, nursing, and other allied health informally established. Their facilities might range fromfields, become more engaged with local communities rudimentary field training sites to highly sophisticatedand policy makers, and be disseminated to other campuses. And each country, of course, has its ownpractitioners, researchers, educators, and leaders. unique legacy because institution building is a long-term,Importantly, the reports argue in favour of expanding path-dependent development process.federal funding for public health development. One major distinction is between public versus private Medical education has received great attention, as shown ownership, with a wide range of patterns in between.by a series of four selected recent reports: Future of medical Although some are autonomous, many publicly ownededucation, by the Associations of Faculties of Medicine of institutions are also publicly operated, usually under theCanada;11 Tomorrow’s doctors, by the General Medical oversight of the ministry of education or the ministry ofCouncil of the UK;8 Reform in educating physicians, by the health. In decentralised countries, state or provincialCarnegie Foundation;10 and Revisiting medical education at governments might be especially engaged. The oversighta time of expansion, by the Macy Foundation.7 An additional between these ministries and departments often fallsreport was issued by the Association of American Medical predominantly to one or the other, and coordinationColleges: A snapshot of medical student education in the USA might not be strong because of preoccupation ofand Canada.85 All reports concur that health professionals competing priorities.in the USA, the UK, and Canada are not being adequately Private institutions might be non-profit or for-profit.prepared in undergraduate, postgraduate, or continuing Historically, religious and missionary movements haveeducation to address challenges introduced by ageing, established many non-profit hospitals and some medicalchanging patient populations, cultural diversity, chronic and nursing schools. Non-profit institutions have alsodiseases, care-seeking behaviour, and heightened public been created by philanthropy, charitable organisations,expectations. and corporations as part of their social endeavours. In The focus of these reports is on core competencies many countries, proprietary for-profit schools arebeyond the command of knowledge and facts. Rather, the increasing, especially to produce doctors and nurses tocompetencies to be developed include patient-centred exploit opportunities in the global labour market.35,86,87care, interdisciplinary teams, evidence-based practice, Most institutions possess mixed patterns of public andcontinuous quality improvement, use of new informatics, private governance. Private institutions often dependand integration of public health. Research skills are valued, heavily on public subsidies for research, scholarships,as are competencies in policy, law, management, and and services, whereas publicly owned and operatedleadership. Undergraduate education should prepare institutions often have distinguished private individualsgraduates for lifelong learning. Curriculum reforms serving in leadership and governance roles.include outcome-based programmes tracked by In our study, all such institutions have degree-grantingassessment, capacity to integrate knowledge and authority. There is a multiplicity of degrees, and the sameexperiences, flexible individualisation of the learning degree could be acquired with highly variable curricularprocess to include student-selected components, and content, duration of study, quality of education, anddevelopment of a culture of critical inquiry—all for competency achieved. Globally, and even nationally, thereequipping physicians with a renewed sense of socially is little uniformity with respect to qualification andresponsible professionalism. competency of degree holders. Medical doctors in China, The perspectives of these major initiatives between rich for example, might obtain professional practice degreesand poor countries, and between the professions, are very with 3, 5, 7, or 8 years of postsecondary education.88 Thesedifferent. These differences reflect the huge diversity of graduates are the credentialled practitioners, comparedconditions between countries at various stages of with the nearly 1 million additional village doctors whoeducational and health development and the core mostly have only vocational training.89 In public health,www.thelancet.com Vol 376 December 4, 2010 1933
  12. 12. The Lancet Commissions bachelor degree holders constitute a large proportion of is associated with low national income, especially professionals worldwide. Many postgraduate degree affecting sub-Saharan Africa; however, abundance is holders have attended independent public health schools, not concentrated only in wealthy countries. Indeed, but many attended medical school departments or several middle-income countries have increased the subunits. Postgraduate public health degree holders number of institutions to deliberately export come from multiple professions—clinical medicine, professionals, because many wealthy countries have nursing, dentistry, pharmacy—or other fields such as chronic deficits since they underproduce below national social sciences, law, humanities, biology, and social requirements. Not surprisingly, the number and pattern policy. Nursing produces postsecondary graduates with a of medical institutions do not match well with national bachelor of science in a nursing degree. An increasing population size, gross national product, or burden number of nurses are continuing on to masters or of disease. doctoral training.9 However, substantial numbers, We estimate about 2420 medical schools producing perhaps even the bulk of nurses, have vocational or on- around 389 000 medical graduates every year for a world the-job training. population of 7 billion people (table 1). Noteworthy are Our study undertook a quantitative assessment of the large number of medical schools in India, China, educational institutions in medicine, nursing, and western Europe, and Latin America and the Caribbean, public health. To our knowledge, this is the first-ever by contrast with the scarcity of schools in central Asia, mapping of health professional education around the central and eastern Europe, and sub-Saharan Africa. We world. After showing the patterns of institutions, also estimate 467 schools or departments of public health, graduates, and financing, we discuss frontier challenges which is 20% of the number of medical schools. Our as key drivers for institutional improvement— count of public health schools is hampered by variability accreditation, academic centres, collaboration, faculty in definition. We aggregated degree-granting public development, and learning. health institutions with medical school departments or subunits offering varying degree titles such as community Global perspective medicine, preventive medicine, or public health. We Because of restricted data availability, our global estimate that about 541 000 nurses graduate every year, perspective focuses on medical education, but when which is nearly double the number of medical graduates. data are available we cite comparable information about Counts of nursing schools are not straightforward nursing, public health, dentistry, pharmacy, and because of few data and ambiguous definitions. Although community health workers. Not surprisingly, we nursing has many postgraduate programmes, there are recorded large global diversity in medical institutions, also many certificate programmes in vocational schools. with abundance and scarcity across countries. Scarcity Many are traditional or informal practitioners with Population Estimated number of schools Estimated graduates per year Workforce (thousands) (millions) (thousands) Medical Public health Doctors Nurses/midwives Doctors Nurses/midwives Asia China 1371 188 72 175 29 1861 1259 India 1230 300 4 30 36 646 1372 Other 1075 241 33 18 55 494 1300 Central 82 51 2 6 15 235 603 High-income Asia-Pacific 227 168 26 10 56 409 1543 Europe Central 122 64 19 8 28 281 670 Eastern 212 100 15 22 48 840 1798 Western 435 282 52 42 119 1350 3379 Americas North America 361 173 65 19 74 793 2997 Latin America/Caribbean 602 513 82 35 33 827 1099 Africa North Africa/Middle East 450 206 46 17 22 540 925 Sub-Saharan Africa 868 134 51 6 26 125 739 World 7036 2420 467 389 541 8401 17 684 Webappendix pp 6–11 shows data sources and regional distribution. Table 1: Institutions, graduates, and workforce by region (2008)1934 www.thelancet.com Vol 376 December 4, 2010
  13. 13. The Lancet Commissionson-the-job training without formal degrees. The cutoff Figure 6 shows the density of medical schools by majorbetween pre-secondary and postsecondary schooling is regions. The most abundant regions are western Europe,difficult to navigate. north Africa and the Middle East, and Latin America and Number of medical schools per 10 million population ≤2·0 2·1–6·0 >6·0Figure 6: Density of medical schools by regionData sources are shown in webappendix pp 6–11. A Population B Burden of disease DALYs (all causes) Population (in millions) per 100 000 <100 <15 000 100–1000 15 000–30 000 >1000 >30 000 C Number of medical schools D Workforce Number of medical schools Doctors/nurses/midwives (in thousands) per 10 million population per 10 million population >6 >60 2·1–6 30–60 ≤2 <30Figure 7: World maps resized by population (A), burden of disease (B), density of medical schools (C), and density of workforce (D)Data sources are shown in webappendix pp 6–11. DALY=disability-adjusted life-years.www.thelancet.com Vol 376 December 4, 2010 1935

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