"Challenges in World Health and Medical Education"
Opening Address, World Federation of Medical Educators
Hans Karle, Stefan Lindgren, Ladies and Gentlemen,
It is a great pleasure for me to be able to address you here today. Since 1984, the World Federation of Medical Educators and WHO have had close and fruitful collaboration towards the reorientation of medical education. Cornerstones in this process were the two World Conferences in Medical Education leading to the Edinburgh declaration on medical education of 1988, which was adopted by the World Health Assembly in 1989, and the World Summit recommendations on medical education, which are reflected in a 1995 Health Assembly Resolution.
Let me begin by a little mind game. Imagine that this is the year of 1963 and your task is to design a medical education which would prepare your students for the coming forty years of medical practice.
Would you have included discussions about HIV/AIDS; about brain imaging methods; about the use of the internet for telemedicine and for learning; about genomics and biotechnology; about the ethics of artificial reproductive technologies or about caring for the ageing in their homes ? Obviously not.
Medical education is about transmitting large amounts of technical and increasingly complicated knowledge to young minds. But mastering the reality of today does not prepare students for the challenges of tomorrow. Medical education is also - and today more than ever - about teaching how to manage change.
So, what are the challenges meeting new doctors today, and how are they likely to change in the years to come ? That, of course, varies greatly depending on where they would live and practise. But here is a brief global overview.
The century we just left behind has been a remarkable one for human development. Fifty years ago, the majority of the world's population died before the age of 50. Today average life expectancy in developing countries is 64 years and is projected to reach 71 years by 2020.
But as we pride ourselves on the trends in the traditional macro-indicators of health status – life expectancy and infant and child mortality – poverty has been eating away at many of the health gains. At the outset of a new millennium, I believe it can be said as harshly as this: We risk going down in history as the generation that allowed the hard-won health achievements of the past century to be lost.
Never have so many had such broad and advanced access to health care. But never have so many been denied access to even basic health. The developing world carries 90 per cent of the disease burden, yet poorer countries benefit from only 10 per cent of the resources that go to health.
One fifth of humanity does not have access to modern health services. Half of us lack regular access to essential drugs.
We need a broad global focus on poverty, and the multi-dimensional deprivation which is part and parcel of it.
The Human Development Index shows that even in affluent industrial countries, between 7 and 17 per cent of the population is poor. That adds up to more than 100 million people.
In the United Kingdom, a child born today in the highest social class can expect to live 5 years longer than a child born among the poorest. On the other side of the Atlantic the figures are even more striking. According to one study of differences in life expectancy within the United States, an affluent, white woman can expect to live 41 years longer than a poor black man.
Many rich countries are in danger of creating a permanently poor underclass. Many are chronically ill, too sick for productive work and unable to give their children the start in life which could help them escape the predicament of their parents.
This is not only shameful. It is very costly. The main burden on the health care systems of rich nations in the next century will be from lung and heart diseases, cancer, diabetes, mental disorders and accidents. A disproportionate number of those suffering will come from the 7 to 17 per cent who live in poverty.
In developing countries, there is a double burden of disease. An onslaught of the health problems of industrialized society, such as heart diseases, cancers, mental health disorders, accidents and violence, now tax health systems already reeling under the burden of infectious diseases and maternal and infant conditions that pry on the poor.
With globalization comes the reality of global diseases. Profound changes in lifestyles, in communication and movement of goods and people affect the way diseases and health risks are spread and contained.
The separation between domestic and international health problems is losing its usefulness as people and goods travel across continents. When a physician in Denmark or New Zealand sees a patient with high fever, he will have to include malaria and dengue among the possible causes. If the patient has a severe chest infection, it could be TB.
It is not only infectious diseases that spread with globalization. Changes in lifestyle and diet prompt an increase in heart disease, diabetes and cancer. More than anything, tobacco is sweeping the globe as it is criss-crossed by market forces. Only weeks after the old socialist economies in Europe and Asia opened up to western goods and capital, camels and cowboys began to appear on buildings and billboards.
The structure and policies of national health systems are trailing behind these developments, both in developing and in industrialized countries. Many developing countries still have a health system mainly geared towards treatment of basic infectious diseases, despite the fact that chronic conditions are becoming a dominant part of their total disease burden. Many industrialized countries on their count, have continued a treatment focused-regime which is placing untenable financial burdens on public and private financing mechanisms.
In a major move towards a preventive way of looking at health issues, the theme of the latest World Health Report is "Risks to Health". By looking at risks, in addition to the traditional focus on the burden of disease, we can give a more complete picture of health service needs, not only at present, but in the future.
We found that the risks associated with underdevelopment are still exacting a high toll. They include unsafe water, poor sanitation and hygiene, unsafe sex (particularly related to HIV/AIDS), iron and other nutrient deficiency, and indoor smoke from solid fuels.
Other enemies of health are more associated with unhealthy consumption patterns. They include high blood pressure and blood cholesterol, tobacco use, excessive alcohol consumption, obesity, inadequate fruit and vegetable intake and physical inactivity. These risks, and the diseases they cause, are dominant in all middle- and high-income countries.
Throughout the world, unhealthy consumption patterns are replacing healthier ways of eating. Sedentary life has replaced regular activity. These changes are now starting to affect the health of all - young and old, rich and poor.
The reality of such risks presents new challenges for the medical profession. The line separating clinical medicine and public health has become increasingly blurred. The responsibilities of medical practitioners are now going far beyond the consultation room or operating theatre.
Patients are now consumers of health care. They are better informed than ever before and have high demands while being conscious about costs. Striking the right balance between controlling health costs and ensuring that adequate resources are available for health is a delicate political and economic exercise. Economic realism, linked to science-based knowledge and the basic principle of the right to health care for all, must be the foundation for any health systems development in this new century.
The success of health policies, of improvements in health care, and of efforts to promote health and control disease depends on the people who provide it. This applies whatever the nature and type of health system, and the resources available. When all is said and done by the political leadership, the fact remains that it is mainly medical practitioners and other health professionals who will determine how health systems address illnesses that cause poverty, undermine well-being, or promote inequities. How can the best health professionals be retained and sustained ? How can others be helped to perform to their full potential ?
These are questions we must face as we develop curricula for the next generation of health professionals.
They challenge the current content of many curricula. Many were designed in developing countries to deal with maternal and child health. Very little attention was given to prevention; or to skills required to provide leadership in health teams; or to provide the optimal mixture of epidemiological, economic and ethical analyses when decisions are made about individual and community intervention choices.
Many of you are from medical schools that have been experimenting with new ways of instilling students with a problem-solving ability, regardless of the problem. From McMaster University, a powerful network of problem-oriented and increasingly, community-based schools, have developed on every continent, with support from WHO and several foundations.
These schools are joined by others in countries that have undergone profound political change. One example is South Africa. At least three medical schools in the country are responding to increased public demand for equitable access to prevention and care by radically transforming the content and focus of medical education. That includes the way students are selected and mentored.
In Latin America, more than 20 medical schools are promoting changes towards better quality of education and health care using different academic models, breaking with the “biomedical and hospital-centred model”. This change was inspired by the Flexner Report, a report which influenced medical education for decades.
The transformation aims to lead to a stronger unity between education and service provision in defined communities. They recognize that the days of medical schools being isolated from the people they serve has come to an end. Rather, their role is increasingly being defined in terms of how good they are at solving public health problems and providing quality care.
WHO is addressing the need for evidence-based national policies and strategies to scale up the health workforce to meet these challenges.
A comprehensive review of all potential sources of information on the health workforce has been carried out through partnership with ministries, research centres, libraries, schools of public health and national bureaux of statistics, as part of a process of building capacity in WHO’s Member States on the management of human resources for health. Our knowledge of the health workforce has never been better: we are working with countries to improve their data collection and analysis. This will enable them to make better predictions of requirements in human resources, and to develop more effective policies for recruitment, retention and deployment.
Education of health professionals is critical to meeting global and national health challenges. Unfortunately, in many countries there has been long-term neglect of essential components of the health workforce. That is why critical choices have now to be made about education - the number of people to be trained, and what and how they will learn. Appropriate choices now will result in increased efficiency later in health services and, consequently, in the ability of these services to contribute to health policy objectives. Education is an investment for the future.
Throughout the world there are more than 1800 medical schools. Each society, even some of the poorest, invests important efforts in training the required human resources for its health system.
Medical doctors are a crucial and, in many countries, a scarce resource, and we need to look closely at how well education prepares and supports them in their practice. We have to encourage them to work in the places they are most needed, using appropriate knowledge and skills in the most effective way, and ensure that there is a strong health system in which they can practise.
We must, however, acknowledge and understand that doctors are only one piece of the puzzle, albeit an important one. Medical education must stretch to include an overall strategy for all needed professional groups and work to create a seamless whole in the future work environment.
WHO has a long history in promoting the relevance of medical education to people’s priority health needs, and we have encouraged academic institutions to be active partners with us. In the African region, for example, we currently have five WHO Collaborating Centres in health professionals’ education, two of which are for medical education.
In addition to these five centres, we have almost 1200 others distributed across the world: all are also involved in aspects of research and training of future medical doctors. While they may each address specific disease, risk or health policy issues, as a group they represent a powerful network of influence for improving health globally.
Together with these Collaborating Centres, we are assessing and changing the curricula for education and training in medicine and developing innovative approaches to educating doctors, such as community-based learning and problem-solving. WHO is participating in evaluations of these changes, and comparing outcomes with those of more traditional approaches so that we can collect and disseminate evidence on best practices in medical education and monitor processes of educational reform.
During the last two or three decades medical education has not been able to adjust quickly enough to changes in health care delivery systems and to people’s needs and expectations. In many countries, education has not kept pace with changing demography and health conditions, which should, ideally, influence curriculum development and educational delivery models. In addition to providing traditional public health skills in the prevention and control of diseases, the training of health professionals must reflect the growing concerns with the influence of lifestyles and the environment on health.
WHO has been developing, with many countries, mechanisms to improve coordination between producers and users of health professionals through alliances and networking between institutions, health professional associations and health departments. These close linkages are helping to ensure the relevance of training to the requirements of health programmes at national and community levels.
WHO works as a catalyst in promoting alliances such as the new ‘Network: Towards Unity for Health’. This alliance of medical educational institutions promotes sustainable partnerships between policy makers, health professionals, academic institutions and communities. WHO continues to support consultative meetings and regional initiatives to develop appropriate policies, strategies and guidelines for undergraduate, postgraduate, in-service and continuing medical education. Strengthening partnerships between medical education and the health services, including community-oriented medical education, has been an important area of work in the WHO’s Eastern Mediterranean Region. Coordination between medical education and health services has been established by the formation of joint councils or committees in Bahrain, Egypt and United Arab Emirates.
All regions are concerned with the accreditation of educational institutions – an area, which is relevant to your conference. WHO is committed to supporting national agencies to develop appropriate and robust accreditation mechanisms. At the WHO Regional Consultation meeting on Accreditation Guidelines for Educational Institutions in Public Health in India in September 2002, a framework for accreditation was developed, to enable countries to formulate national standards. The accreditation should cover such diverse matters as curriculum models and instructional methods; staffing policy of the public health institutions; educational resources for the students and for the delivery and assessment of the curriculum; field practice; methods for assessment of students, and a mechanism for programme evaluation. WHO sees assessment of educational institutions as a way to improve their integration with the health system. We are facilitating institution-to-institution linkages to address academic quality improvement and the formulation of standards, tools and guidelines to support academic quality improvement and institutional self-assessment efforts.
The performance of the health workforce is of course critical in shaping the overall performance of the health system and health care is a knowledge-intensive process. One of the most exciting areas in which WHO is currently engaged is in exploring the links between education and practice – between the education of the health workforce and the quality of the health system. In April, WHO will host an informal meeting of experts to take this work further.
We believe that there are several components which need further attention. First, the issue of pre-service education for health professionals, which I have already discussed. Then the issue of how to keep practising professionals updated with the rapidly changing knowledge and competencies they need. Evidence shows us that some educational methods are more effective at persuading practitioners to change their practice, and we are working with Member States to strengthen their use of effective methods at all levels of medical education. We now want to link this to outcomes – to health system performance – and are engaging partner institutions to help us in this new and exciting field of work for WHO.
We are working with countries to improve data collection and analysis, so that they can make better predictions of requirements in human resources, and develop more effective policies. Countries must take as one of their priorities the development of capacity for data collection, analysis and policy formulation. WHO has a supporting role to play. Ministries of health need skilled policy-makers and health systems professionals to analyse health workforce problems and devise innovative solutions, and to engage the private sector and external partners in their national strategy to strengthen education and continuous professional development. Tools for the education and management of the health workforce and technical support from WHO have already improved the quality and standards of training. And, through the WHO fellowship programme, health workforce capacity in most countries has been strengthened. For example, in the African region, almost 4000 (3892) fellowships were awarded to 46 countries from 1990 to 2002. Placement of fellows in Africa has significantly increased as part of efforts to fight the brain drain, reduce education costs and train professionals in an environment close to their daily work. Currently, 90% of fellows in the region are also trained in Africa.
The World Federation for Medical Educators and WHO work as partners in making medical education relevant to the health needs of populations. Based on that support, countries have the responsibility to make it happen.
Ladies and gentlemen,
We live in a rapidly changing world. As educators, you need to inspire the future health professionals to embark upon a lifelong learning and applying quest. That will be their assurance of being able to provide their future patients with the best quality care they need 40 years from now.