BACKGROUND
 

The Prince Mahidol Award Conference (PMAC) is an annual international conference focusing on policy-related health issues of global significance. The conference is hosted by the Prince Mahidol Award Foundation, the Thai Ministry of Public Health, Mahidol University and other global partners. It is an international policy forum that Global Health Institutes, both public and private, can co-own and use for advocacy and for seeking international perspectives on important global health issues. The Conference in 2014 will be co-hosted by the Prince Mahidol Award Conference, the World Health Organization (WHO), the World Bank, U.S. Agency for International Development (USAID), Japan International Cooperation Agency (JICA), the Rockefeller Foundation and China Medical Board with the support from other key related partners. The Conference will be held in Bangkok, Thailand, from 27 -31 January 2014.

The 1910 Flexner report led to the integration of modern science into medical curricula at university-based medical schools. The reforms equipped medical professionals with scientific knowledge which contributed to the doubling of life span during the 20th century.

At the beginning of the 21st century, however, there are several changes affecting worldwide health care services. Inequities in terms of access to healthcare and quality underscore failure to share health gains across rich-poor, urban-rural population, domestically and internationally. Emerging and re-emerging infectious diseases across national borders, environmental degradation and behavioural risks, various socio-economic factors and social determinants which contribute to ill-health, increased ageing population and demands for long-term care, all have major ramifications on the appropriate profiles and skills of health professional and the way they are trained and deployed. Healthcare cost, driven by ageing population, technology advancement and increased demands by population becomes increasingly unaffordable and unsustainable.Universal health coverage has been recommended by the World Health Organization to be the most important strategy for achieving health equity; and this will present new demands and opportunities for the health professionals.

Advancement in biomedical knowledge as well as information technology (IT) are also progressing at an unprecedented pace, and will be much faster in the near future. These will very much affect healthcare systems worldwide.

Today, health professional education has not been well adapted to address these challenges; largely, because of outdated, static and fragmented, content oriented curricula, which produce graduates with insufficient knowledge, skills and competencies necessary to understand determinants of ill health and become more responsive to the changing population and communities’ health needs. The problems also aggravated by various factors; poor teamwork and inadequate collaboration within and across health professionals, narrow contextual understanding, episodic encounters with patient illnesses rather than continuous health care, emphasizing treatment rather than disease prevention and health promotion, lack of understanding in social determinants of health and imbalance between health workforces and health needs in both qualitative and quantitative aspects. There is also inadequate collaboration and communication between health professional training institutes and health delivery systems in terms of competencies of various health professionals and effective deployment after graduation.

There is also increasing global consensus that the education of health professionals is failing to keep pace with the scientific, social and economic changes transforming the healthcare environment. Fresh visions, revitalized energy, new actors and others have joined to tackle these problems. Starting with the Joint Learning Initiative in 2004, the WHO World Health Report 2006 sparked a series of global initiatives including the advent of the Global Health Workforce Alliance (GHWA), the Asia Pacific Alliance on HRH (AAAH), USAID CapacityPlus Project, PEPFAR’s MEPI-NEPI, and others. The Second Global Forum on HRH was conducted by PMAC 2011 fostering the global momentum on human resources for health, and Brazil plans to host the Third Global Forum on HRH in November 2013. Complementing this broad perspective, the PMAC 2014 will focus on health professional and leadership education with its distinctive aspects including enhancing local-global linkages in competencies, team work, the revolution in IT-based learning, and new organizational forms like networking.

The Commission on Education of Health Professionals for the 21st Century chaired by Lincoln Chen and Julio Frenk released the Commission report on “Education of Health Professionals for the 21st Century: A Global Independent Commission” on December 4th, 2010. There has been a strong movement in health education reform in many regions; Africa, Asia, and the Americas.

 Since 2011, a network of 5 countries, including Bangladesh, China, India, Thailand and Vietnam, was formed and volunteered to conduct in-depth analyses of health professional training (medical doctors, nurses and public health) in these five countries which contribute to evidence-based reform. Assessment covers national level, institutional (faculty) level and outcome through quantitative surveys of the last year students who are about to graduate and among the professional in the service sector to assess their rural attitudes, clinical and nursing competencies and job preference or transition. Success and good practices will be identified for scaling up and deficiencies for improvement. Appropriate practical health professionals education intervention in line with the nation’s socio-economic, cultural and health system context will be developed, implemented and evaluated; as part of the evidence-based reform.

Similar activities such as the MEPI and NEPI in Africa are exciting. Gathering and sharing these information and experience among global, regional and national health leaders would provide further momentum for the global HRH education reform. It is thus quite timely to convene the Prince Mahidol Award Conference 2014. The theme for PMAC 2014 will be “Transformative Learning for Health Equity” .

CONCEPTUAL FRAMEWORK

1.  Health Professional Education Reform: Instructional Dimensions

Ensuring skills and competency of teachers and faculties

•  Fostering leadership and cultivating transformative learning to teachers and faculties, and learners, students.

• Competency driven design of curriculum, teaching and learning modalities and outcomes of different models
• Technology supporting effective learning, including revolutions in IT-based learning, on-site and distant learning experiences

 Ensuring skills and competency of graduates

• Innovative methods for transferring, practicing and measuring skill development and mastery
• Nurturing a culture of critical inquiry
• Adequate responses to emerging health needs of population and structure of health systems
• Community-based and field-based education, policy, implementations and outcome of different modalities
•  Inter-professional education which promote the practice of team work in health and its outcomes after graduation?
• Outcome measurement: the assessment of clinical/nursing and public health competencies among graduates based on different instructional modalities

Ensuring quality and responsiveness of health professionals

• Pre-service: Quality assurance of health professional education such as accreditation of curriculum and training institutions, requirement of national license examination
• In-service: Continue professional education: policy, implementation, effectiveness and outcome, learning and lessons drawn; requirement of continuing professional education (CPE) as conditions for re-licensing.
• What are the effective models of CPE, what are the discourses between mandatory versus voluntary CPE and requirement of mandatory re-licensing of different professionals?
• Student assessment and evaluation methods and outcome
• Debates on health professionalism versus ethics, role of health professionals in the society and their social responsibilities

Ensuring number and quality of health professional after graduation

• Workforce development and in-service training: e.g. short courses, long courses, distant courses, refresher courses, application of e-learning in the workplace
• Discourse on the balance between pre- and post-service training and education, demand for and supply of general doctors versus specialists and sub-specialty, in the context of national health systems and health needs and demand for health care by the population
• What are the opportunities in reorienting CPE in line with demographic and epidemiological transition in order to improve skill and competency of in-service health workforce in response to these changes?

2.  Health Professional Education Reform: Institutional Dimensions

 Developing and sustaining faculty and teaching staffs capacity: recruitment, remuneration, incentives, retention strategies and sustainability

• Facilitating health professional education reform to strengthen health systems

• Policies and processes to strengthen capacity of health training institutions
• New models of training institutions for primary care
• Public and private ownership of training institutes, public and private sources of financing health professional education and its outcome in terms of  access to education, contributions to health systems of countries, attitude and responsiveness to health systems
• Stewardship, accreditation and certification of health education programs
• Health professional education in favour of equity and offer opportunities to the socially disadvantaged group and mechanisms to ensure contributions to their ethnic groups, rural areas
• Linkage between tertiary education and secondary education
• Perspectives of stakeholders in health professional education reforms: students, graduates, teachers or educators, and users and system managers
• Expand academic centres to academic systems encompassing networks of hospitals and primary care units
• Link together through global networks, alliances, and consortia

3. Advancing Health Equity Through Health Workforce Education, Training and Deployment

To achieve health equity, government needs to move closer to and finally reach universal health coverage by ensuring equitable access to healthcare by all socio-economic groups: rich-poor, urban-rural and vulnerable populations, with adequate financial risk protection. All these pose a huge challenge on financing and service provision, for which adequate number and proper mix of health workforce cadres, commitment play a vital role.

A number of questions or issues may be raised, such as:

• Universal health coverage has major ramification on health professional education and training, what cadres (diploma, bachelor, and post graduates, as well as other paramedics), how many to be trained? Can the government and private sector employ all these graduates and ensure they properly contribute to health needs of the population?
• What are the relative contributions of different cadres of health professionals (in a broad sense) in enhancing health equity?
• What skill-mix, cadre-mix, types of training (pre-services, in-service and post-services) are required to improve access to health services and achieving UHC?
• What are the models, and good practice of inter-professional and trans-professional team works in practice? Lessons from different country settings
• Evolution of education programmes and plans towards UHC: different country experiences
• Contributions of different tracks of student recruitment into health professional education e.g. National entrance examination, special quota for rural, ethnic minorities on rural retention and home town services
• At clinical and public health practice context, how health professional recognize and understanding the contributions of social determinants to (ill) health of population, how health professional education support such skills and attitudes?
• What are effective models of strengthening capacity of health workforce to
  • facilitate intersectoral actions in order to address social determinants contributing to ill health?
  • facilitate community participation and social mobilization?
  • effectively communicate with public and strengthen health literacy?
• Trends in the application of technology and ICT in health service delivery
• Contributions of health of the population such as burden of diseases, risk factors, poverty and ill health, health systems configuration to the design and reform of health professional education curriculum. What are the effective interface between health professional training institutes, health systems and the national health authority (MOH)?

4. Changing Context and Impact on Labour Market and Health Professional Training

At country level, the social determinants of health, demographic and epidemiological transition (increased NCD in almost all countries and double burden of communicable and non-communicable diseases in low income countries) have impact on demand for health professionals. Government needs to plan for number and cadres mix requirement for the country health needs; and understand the labour market dynamics to achieve better results in the distribution, retention and performance of the health professionals.

At global level, the trends in economic and health systems in one country have major ramification on health workforce in another country. In the light of rights to employment, migration and settlement, free international migration of health workforce will have major impact to health systems and patients in the source countries. Demands of elderly and chronic patient care coupled with high purchasing power in rich countries trigger exodus of trained health workforce from poorer countries. Many countries also face acute mal-distribution of health workers within their borders, due to unattractive employment conditions in remote and rural areas, which create barriers to recruitment and retention of health workers, and inequities in the availability of health services for the population.

In low income countries where Global Health Initiatives (GHI) plays a significant financing role in health sector in general or in diseases specific, migration of health workforce to accommodate these GHI programmes may have either positive or negative impact on retention of health workforce in areas where health needs are urgent but not funded by GHI. Understanding these issues would help mitigate impact.

Economy which changes from export-led growth to stimulating domestic consumption of services will have major impact on demand for health workforce. In the economic boom, the increased demand for private health care triggers domestic migration of trained health workforce from public to private; and vice versa, in a economic bust situation; reverse migration was observed. Public sector reform, downsizing government and opening up for increased private sector role have major impact on the choice of employment, including migration of health workforce. Employment conditions matter, such as the emergence of flexible career pathway and alternative careers, changing demographic profile of the health workforce, availability of part-time and full-time work, and multi-task generation have major impacts on the performance of and employment options accessible to the health workforce. Therefore, understanding these economic factors and labour market context and determinants are important contributions to effective strategies and solutions to protect public interests and to prepare the health professionals for a productive and fulfilling career.

The above mentioned 4 key areas and issues under each area were used as a guideline in the design of organized sessions for the conference.