Problems and progress in public health education
Alena Petrakova a, Ritu Sadana b
The poor-world, rich-world divide is well known, as is the divide between dominant and marginalized groups within countries. While across-country inequities were known previously, the past decade has seen the unearthing of within-country inequities in almost every corner of the world and across the entire social gradient.1,2
Although the Millennium Development Goals have raised new hopes for a world free of poverty, poor health and other deprivations, these goals do not address within-country inequities. Among others, a recent report published by the Task Force on Maternal Health and Child Health under the UN Millennium Project has called for a new vision and strategies to address the health problems that people in low- and middle- income countries face. A key component is how existing knowledge can be made available to the world’s poor and marginalized.3 This message is not new, but remains to be acted on.
Further development of public health, as a profession and as a discipline, is critical to enable people to act. Public health, as defined nearly a century ago by CEA Winslow, is “the science and art of preventing disease, prolonging life and promoting health and efficiency through organized community effort”.4 The Alma Ata Conference of 1978 reaffirmed the critical role of public health in attaining health for all, with particular emphasis placed on the centrality of equity, community participation and intersectoral collaboration.
The institutions that are dedicated to promoting both the science and art of public health include the schools, institutes or faculties of public health. These institutions have been in existence for nearly a century. However, in recent times there has been increasing debate about their relevance and direction.5,6 Are the existing models of public health schools adequately preparing graduates? Are they able to make a significant contribution towards improving the health of the population, and particularly of the poor and other marginalized groups? If not, why are they failing? Is there a mismatch between the ideal and the reality of the situation? Is the world producing enough quality graduates to lead public health programmes and relevant research?
As WHO noted in 2006, the world is facing a major shortage of health workers, including those who are trained to address population health.7 Is it not scandalous that 57 countries are in crisis, with 36 of these countries concentrated in the African region? Although information is known about the distribution of clinicians (e.g. physicians, nurses, midwives, dentists), little is known about workers addressing population health, including public and environmental health workers, community health workers or health managers.
WHO recently estimated that there are probably 400 schools of public health around the world. This, of course, does not include departments of community medicine or similar programmes attached to medical schools. How are these schools distributed? The United States of America (USA) alone has some 40 accredited schools plus many more programmes. Compare that with large regions of the world, such as Africa or South-East Asia. With a population five times as large as the USA, South Asia is estimated to have 12 schools.8 Africa has about 50 schools.7
Beyond the numbers, what resources (faculty, infrastructure, students, field sites, etc.) do schools draw on? Schools can use training, research and practice to convert resources into professionals who could meet and perhaps exceed the expectations of future employers.
The challenge is to scale up the production of public health professionals with appropriate skills and competencies. What is at stake? Some schools emphasize getting the right balance between teaching and research; others, particularly in low- and middle-income countries, focus on aligning training to develop competencies that enable individuals to manoeuvre within a specific country’s health system. Clearly, quality as well as quantity matters. The quality of training and impact on students is a function of many factors: faculty, curriculum, pedagogical methods, teaching aids, facilities and students, who bring their experiences and expectations.
Almost all schools of public health in low-income countries are perennially deficient in quality faculty. There are many reasons for this: inadequate supply, lack of appropriate training, absence of financial and motivational incentives, and migration. Will the promise of distance learning materialize to strengthen public health capacity?
In many countries, the skills and competencies of public health graduates are not well matched to the task of addressing the population’s health needs, particularly in the area of health policy, health management and leadership. What approaches exist to increase collaboration across policy-makers, public health managers, communities, researchers, educators and public health practitioners, to make curriculum relevant? How can curriculum reinforce public health approaches, such as intersectoral, interdisciplinary and community-oriented, as well as benefit from coordinated international collaboration?
Most public health schools set up in low-income countries follow their counterparts in high-income countries; that is, they are essentially classroom-based. Yet there is a movement to integrate community experiences, such as the Rockefeller Foundation-sponsored Schools of Public Health Without Walls taking place in Ghana, Kenya, Uganda, Viet Nam and Zimbabwe. These efforts and others either remain relatively small-scale or their success is not well documented. Will information and communications technologies allow greater numbers of professionals to train within their own country and perhaps on the job?
Who becomes a public health student? Is diversity in terms of personal and professional backgrounds being adequately achieved in order to fulfil the art and the science of public health?
Knowledge generation and evidence building needs to be driven by values that make explicit the goals of public health and its application to serve disproportionately the disadvantaged and marginalized. Was Wright4 on the mark with his assessment that schools in the USA have systematically ignored the art (application) in favour of the science based on discovery and the medical model of diagnosis and treatment? In low- and middle-income countries, is the opposite true? Has this imbalance resulted in the mismatch of the progress of public health’s art and science? Or is the narrative more complex?
All debates underscore the need to integrate training and research with practice, if schools of public health are to attract diverse students and faculty, teach relevant and timely content, and enable graduates to work in specific contexts whether within an institution, sector, country or region. However, successes seem few and far between.6
This round table discussion asks deans and directors of schools of public health (or other educational institutions providing public health education and training) from around the world to address these issues:
- Evans TG, Whitehead M, Diderichsen F, Bhuiya A, Wirth ME, editors. Challenging inequities in health. New York: Oxford University Press; 2001.
- Leon D, Walt G, editors. Poverty inequity and health. Oxford: Oxford University Press; 2001.
- Freedman LP, Waldman RJ, de Pinho H, Wirth ME, Chowdhury AMR, Rosenfield A. Who’s got the power: transforming health systems for women and children. Task Force on Child Health and Maternal Health. New York: UN Millennium Project; 2005.
- Wright K, editor. Demonstrating excellence in academic public health practice. Washington DC: Association of Schools of Public Health; 1999.
- R Sadana, AMR Chowdhury, A Petrakova. Strengthening public health education and training to improve global health. Bull World Health Organ 2007; 85: 163.
- Bloom B. The future of public health. Boston: Harvard School of Public Health; 2003.
- The world health report 2006 – working together for health. Geneva: WHO; 2006.
- Lal S. Background paper. In: Training in public health in India – prospects and challenges. New Delhi; 2004 (unpublished conference).
- Human Resources for Health, World Health Organization, 20 avenue Appia, 1211 Geneva 27, Switzerland.
- Ethics, Equity, Trade and Human Rights, World Health Organization, Geneva, Switzerland.