A new model of health workforce training has the potential to be an innovative, cost-effective, catalytic initiative that can build national health systems, empower women and make itself obsolete in a decade.
Such an endeavour would align perfectly with the Australian government’s 2014 development strategy, which highlights performance, innovation, empowering women, value-for-money and extending Australia’s influence. Additionally, it responds to the emphasis in the government’s recent health strategy on building strong national health systems in the region, including through investments in health workforce training.
Many of the countries in the Indo-Pacific region have dramatic shortages of health workers (doctors, nurses and midwives) – below the 23 per 10,000 ratio regarded by the World Health Organization as the minimum needed to provide essential primary health care services (see note below). This means that these countries are less able to provide for the health of their people, leading to lower productivity, higher rates of preventable morbidity and mortality [pdf], higher risks of emergent infections, and less social stability. As noted in the new health strategy, “a region will only be as strong as its weakest link.”
Health worker ratios in the Indo-Pacific region
Source: WHO Global Health Workforce Statistics
As noted in an earlier post, the West African Ebola crisis highlighted the great weakness of health systems in developing countries: insufficient numbers of quality health workers where people live. Amidst low numbers of people being trained as doctors and nurses, and high numbers of trained health workers migrating to rich countries, the West African health workforce was dramatically depleted – thus opening a door for the epidemic and eroding gains in maternal and child health outcomes due to the loss or displacement of skilled health workers. Looking at the numbers in the table above, would countries in our region be able to respond to health challenges rapidly and securely without compromising their progress towards improved maternal and child health?
Over the past decades, one of the models of scholarship training preferred by the Australian government and universities (and those in many other countries including developing countries themselves) was bringing bright young students to Australia to study. Doctors, public health officers and other health workers spent time in Australian universities getting their degrees or further (non-degree) training in the form of short courses. Indeed, public health has been one of the more common degrees sought by Australia Awards recipients. (Conflict of interest declaration: I have taught a large number of Australia Awards recipients in the Masters of International Public Health program at the University of Sydney).
According to the Performance of Australian Aid 2013–14 report released earlier this year, there were around 6,000 Australia Awards awardees in Australia in that financial year and the program spent $362.5m in that time: more than $60,000 per student per year.
While my own research has noted some commendable positives of the scholarship program, value-for-money remains a key question mark hanging over the program (especially given the capture of much of the scholarship funding by Australian universities). This existing model is not sufficient given the challenges ahead. Could a different model reach more students, have greater impact, and be more cost-effective while maintaining an Australian identity?
The option of committing ourselves to building the capacity of training institutions in our region is one whose time has come. Stronger universities in Indonesia, PNG, Myanmar and elsewhere, buttressed by Australian technical and education expertise, would mean the production of a greater number of more competent health workers and would build goodwill for Australia.
The initiative could and should be modelled on that being implemented through the US government’s Medical Education Partnership Initiative (MEPI). MEPI aims to assist with increasing the number of new health care workers in Africa by 140,000 by strengthening medical education systems and building capacity of African institutions. The program brings together 13 African universities with more than 20 US collaborators. For example, the Kilimanjaro Christian Medical Centre has partnered with Duke University’s Global Health Institute and School of Medicine, and Stanford University is collaborating with the University of Zimbabwe’s Faculty of Health Sciences. The aims are to train a new generation of physicians largely by transforming the academic environment in the host country, thereby improving retention of staff and improving quality. The nuts and bolts include long and short-term staff exchanges, joint research, and educational innovation.
At the University of Nairobi, the MEPI partnership has supported more than 300 medical, nursing, dental, and pharmacy students to complete elective rotations and 180 staff members have received training in clinical teaching. Those involved in the initiative highlight not only these outcomes but the many intangible benefits: realising that their skills are comparable to that of American counterparts; fuelling optimism and confidence; and countering the isolation that many health workers feel.
MEPI is a joint effort of the Office of the US Global AIDS Coordinator, the Centers for Disease Control and Prevention, the Department of Defense and the National Institutes of Health, and benefits from funding of US$130m over five years. A similar model for nursing schools has been launched in five African countries. The governance model is well developed with two transnational coordinating centres (one in the US and one in Africa) and separate governance bodies, advisory groups, or academic consortia within each host country, which work to align priorities and agree on implementation strategies.
In my next post, I will outline how such an approach could be developed by Australia in the Indo-Pacific region.
Joel Negin is Associate Professor of International Health and Deputy Head of School at the School of Public Health at the University of Sydney. This post is the first in a two-part series about a new model of health workforce training; the second post can be found here.
Note: WHO regards a health worker-to-population density of 23 doctors, nurses and midwives per 10,000 population as the minimum needed to provide 80% coverage of basic essential services, for example, skilled birth attendance and childhood immunisation. Countries below this threshold, including several in the Indo-Pacific region, are considered to have a critical health worker shortage.
Dear Joel
I have worked for the past 28 years training doctors at the SMHS-UPNG and before that for 4 years training HEOs and Health Inspectors at the Madang College of Allied Health Sciences.
My experience is that there are very few instances when overseas training is useful to us in PNG in the health sector. And in fact many times people go for overseas training and come back with ideas and agendas which are antithetical to the needs of the PNG health service and effective training of health workers in it.
So not only a waste of money, but oftentimes we are handicapped by people with overseas training.
There are of course exceptions to the above, but recently I have noticed with the experience of the Australian awards scholarships that they are often given to people who are too old (to be be able to come back and make a difference), or to people who really only want the degree to satisfy their own ego and increase their own status in the system when they return. This particularly applies to PhD awardees. And I also see that a number of Australian institutions really help the overseas candidates cross the line, – to the extent in some cases, of theses being almost ghost written, or at least ‘supervised’ to the point of hand holding.
With regards the Cuban model: the model is good, but not good to send Pacific people to Cuba to do their programs. The latest experience where hundreds (and in the case of E Timor – a thousand) students were sent to Cuba for medical training has been a disaster. I hear that all the ‘graduates’ from the Solomon islands were unable to pass the basic registration exam on return to Honiara, and as you have noted Kiribati and other places are really struggling to now provide suitable intern (practical clinical) training for their graduates. Heaven knows what is going to happen to the E Timorese grads. When I was in E Timor 18 months ago, the first batch of 300 graduates were back – most had been posted to community health posts and had been given motor bikes to facilitate their work. However, many of them were just motoring around Dilli on the bikes.
I was also interested to hear that you say that the Burnet Institute is helping to strengthen our Dept of Public Health at the SMHS: I have not seen any evidence of this. And we really do need assistance with strengthening our faculty at SMHS – and not just in the Dept of Public Health. In fact the whole of doctor training in PNG could fall over if 4-5 of us had heart attacks in the next few months – not unlikely as mostly we are over 60.
How do we organize ourselves to get thru to dfat about the above.?? So much money being wasted at present.
Glen Mola, Professor of Reproductive Health, Obstetrics and Gynecology, SMHS
Dear Glen,
Thank you for this powerful and critically important first-hand perspective. Your account resonates with what I have heard throughout the region. There is a better model available and I do believe it would be more impactful, better value for money, and could catalyse sustainability in health education.
I will be in touch.
Joel
Thanks, Joel. I am looking forward to the next post. I am in total agreement that training is essential. I do think that examining the issue through a wider HSS lens is important, however. There are also other issues to think about in ensuring adequate numbers of health professionals. For example, when I was living in the Solomon Islands (which, I note, only just reaches the minimum 23 skilled professionals recommended), I was perplexed to learn of nurses travelling to other Pacific countries to work because they could not find work in the Solomon Islands. I never found out what was driving this, or if it was more than just a couple of stories that got blown out of proportion. But it did make me think about the barriers beyond training, such as funding for positions. So I think a holistic approach is important, to ensure various barriers to having an adequate health workforce are addressed simultaneously.
But these stories of movement of nurses within the region also raised interesting questions about the potential for a regional workforce. I wonder how many nurses, for example, would be willing to travel to other countries in the Pacific to work? It is certainly something I’ve thought of doing. There is the potential here for inservice training and workplace modelling and sharing of knowledge. I guess the problem is that all countries in the region are experiencing shortages, NZ and Australia included.
Anyway, a fascinating topic and one close to my heart, so bring on the next post and I hope the idea gets implemented.
Dear Joel,
Great topic and love the teaser…got to wait for the next blog to read about the model. So I will patiently wait 🙂 – Meanwhile, in case this is where you will take the proposal, I would like to share with you something we have also been socializing with several countries and maybe it’s also time for this initiative to be implemented.
During a meeting of the Leading Group on Innovative Financing for Development with Michelle Bachelet, we discussed an old idea that would look like the concept of Barefoot Doctor. I am currently on the other side of the Pacific where most countries have now graduated to the rank of Middle Income Country (High) but most of them have systems that are unsustainable and where the problem is not so much the qualification of the medical core (when they exist) …. but the cultural approach to the work in terms of innovation. Lots of ideas in the work and look forward to read about your proposal.
Saludos cordiales
http://www.keento.org
Would be good to see an acknowledgement of the health work force training work done by ELAM (Latin American School of Medicine in Cuba), possibly the most cost-effective model for training health workers for developing countries. Now that the US has normalized relations with Cuba perhaps USAID and others will actually bother to acknowledge Cuba’s achievements in health – at a fraction of the cost of donor countries.
Very good point. I have written on the Cuban training model in the past on this blog. It does represent a strong training model – though one that does require people to travel outside the region. Part of the challenge is now for those who return home – in terms of mechanisms for internship and residency training. For example, the Solomon Islands and Kiribati struggle to offer the next phase of medical education for those who have returned from Cuba. That is an area where Australia – perhaps in collaboration with Cuba and the US – could play a role.