Reforming the education of physicians, nurses, and midwives

Dr Margaret Chan
Director-General of the World Health Organization

Opening remarks at the WHO/PEPFAR consultation on transformative scale up of medical, nursing and midwifery education
Geneva, Switzerland

14 December 2010

Honourable ministers, distinguished deans and educators, representatives of professional associations, colleagues in public health, ladies and gentlemen,

Welcome to Geneva, and welcome to a consultation with a transformative ambition.

You have come from many countries and represent a broad diversity of disciplines, universities, institutions and agencies. Transformative change in the education of health professionals depends on broad-based action spanning the health, education, finance, and labour sectors.

You have an important, and a packed, agenda, so I will make just two main points.

First, this is a vital initiative that is long overdue. WHO is eager to support the development of policy guidance and a platform for sharing experiences and best practices. The need to reform the education of physicians, nurses, and midwives touches every country.

The commitment to improve health, especially for poor and vulnerable groups, has never been greater. The Millennium Development Goals recognized the power of better health to reduce poverty and drive overall socioeconomic development.

The international health community learned a number of things during the first decade of this century. Powerful interventions and the money to purchase them will not improve health outcomes in the absence of robust, and equitable, systems for delivery.

Health systems cannot deliver quality health services in the absence of sufficient numbers of appropriately trained, motivated, and remunerated health care staff. Using health as a poverty-reduction strategy will not work as long as facilities and staff remain concentrated in urban settings, catering to better-off groups.

Nowadays, nearly every time I see a brilliant, innovative solution to a long-standing health problem, I see the initial optimism and enthusiasm fade when it faces the harsh reality. How can we do more when staff numbers are already insufficient to meet the most basic health care needs?

In 2006, the World Health Report drew attention to a critical worldwide shortage of more than 4 million doctors, nurses, and other health care staff. As that report noted, the physician-to-population ratio is lowest in sub-Saharan Africa, where the disease burden is greatest.

The reasons for this shortfall are numerous, from demographic aging and the growing demand for chronic care, to the globalization of the labour market and the tendency of doctors to leave the countries that invested in their training. Professional education also plays a role.

In recent weeks, we have received guidance from the report of a high-level Commission on Education of Health Professionals in the 21st century, and from the Sub-Saharan African Medical School Study, both published in the Lancet.

These publications give us guidance, but they also focus badly needed attention on the need for transformative reform. They identify some international challenges, and some specific challenges in Africa.

As stated, we cannot fight this century’s unique health battles when health personnel, those truly on the frontline, have been educated and trained for a 20th century job.

Discussions during this consultation will benefit greatly from the presence today of Commissioners, officials from African nations and their medical schools, and the Lancet’s editor, Richard Horton.

The Commission pinpoints specific institutional and instructional shortcoming that are leading to shortages, imbalances, and maldistribution of health professionals, both within and across countries. It sets out ten key areas for reform.

Let me repeat just one statistic cited by the Commission. Between 1985 and 1994, Ghana produced 489 physicians. By 1997, 61% of these physicians had migrated from the country.

Ladies and gentlemen,

In October of this year, the US President’s Emergency Plan for AIDS Relief, or PEPFAR, in collaboration with the US National Institutes of Health and the Health Resources and Services Administration, launched a five-year initiative aimed at strengthening medical education in sub-Saharan Africa. Improving research capacity in Africa is an equally important objective.

I warmly welcome the emphasis being given to medical education in Africa, which includes financial support and a partnering of African schools with US institutions. Long experience, also in Africa, shows that such twinning arrangements are mutually beneficial.

The capacity of Africa to produce more health care staff, and retain them, faces many challenges. Faculty are in short supply and tend to be overloaded with work, limiting their capacity to undertake research. Many infrastructures, including laboratories, need to be upgraded.

Weak systems of secondary education feed into the problem of enrolling adequate numbers of students. Tuition can be a barrier. Lack of computers and bandwidth limits the ability of African schools and students to leap ahead with advances in information and communication technologies.

Many students need to go to North America or Europe for specialized post-graduate training. And many never return.

This brings me to my second point.

As the study of African medical schools tells us, African nations are not starting from scratch. Many countries have a clear idea of what is needed, particularly in terms of matching school curricula with a nation’s priority health needs, especially in underserved communities.

We have much to learn from the innovations already under way.

The Commission on Education of Health Professionals anticipates resistance to some of its proposed reforms, citing, among other factors, so-called “rigid professional tribalism”.

In contrast, trends in medical education in Africa show that some of these reforms are already under way. This reinforces the wisdom, and relevance, of the Commission’s recommendations.

School curricula show some impressive innovations. Several schools are using community-based education, problem-based learning, and multidisciplinary team-based learning. I am sure this is music to the Commissioners’ ears.

Some schools design curricula to directly engage students in community work and give them hands-on experience with needs and expectations in underserved communities.

Creative ways are being used to retain faculty staff. Several schools have found innovative ways to rapidly increase enrolment and the number of successful graduates.

Incentives are being found to adjust the rural-urban imbalance in staff distribution. Some schools have made strong efforts, over several decades, to build research capacity.

Competencies are being trained to match priority domestic health needs. This is the first reform called for by the Commission.

As one African health minister observed: “Wealthy countries take our best football players, and our best medical graduates.” They do so, of course, because these professionals are good, talented, and internationally valued.

I do not mean to gloss over or underplay the obstacles and needs. The number of medical graduates being produced in Africa remains inadequate, and the quality of education is uneven.

The point I wish to make is this. The education of health professionals in Africa is moving in the right direction. This makes support, such as that being provided by PEPFAR, all the more opportune.

Ladies and gentlemen,

I have a final comment.

I appreciate, in particular, the emphasis being given to equity and social purpose in recent discussions of educational reform.

As the Commission noted, today’s medical students need, and often want, some grounding in the social values and expectations that surround the care they will be providing.

A good physician, nurse or midwife has compassion, and a passion to heal. These qualities are likely to be the strongest, and the best, motivation to continue learning, to continue sharpening clinical skills.

These qualities need to be nurtured.

I wish you a most productive meeting.

Thank you.