1

PMAC 2014 in global contextMoving from HRH to Learning

World Health Report on HRH; AAAH (Asia-Pacific Action Alliance on HRH)

the 1st Global Forum on HRH: Kampala Declaration

the 2nd Global Forum on HRH, PMAC 2011

The 3rd Global Forum on HRH: Recife, Brazil

PMAC 2014 Transformative Learning for Health Equity

WHA ResolutionTransformative H workforceEducation

2013

WHO Global Code of Practice on International Recruitment of Health Personnel

Resolution of WHO SEA RC on H Professional Education Reform

WHO Global policy recommendations for rural retention

2010

20115C project on H Professional

Education Reform

2012Asia Pacific Network on Health Education Reform (ANHER)

2014

20062008

3

Conference programme structure • Monday 27 January 2014

– 23 side meetings• Tuesday 28 January 2014

– 5 optional field visit sites • Wednesday 29 January- Friday 31 January 2014

– 7 Keynote addresses– 5 plenary sessions – 21 parallel sessions

• Total registered participants, – 543 participants from 62 countries and Many international

partners – Approx 80 conference supporting staffs

4

Rapporteuring• Each session had three or four rapporteurs • Pre-meeting for rapporteurs• Templates for abstract and summary• Abstracts used for this session• Both abstracts and summaries will be used for the conference

proceedings• All presentations are uploaded on the web site :

www.pmaconference.mahidol.ac.th• Gratefully acknowledge the contribution of all 59 rapporteurs

Context e.g. demographic, economic changes, globalization, HR lifecycle

PS2.5, 3.2, 4.3, 4.7, PL4

Emerging conference themes

Health Equity

Cross-cutting issues PL1, PL2, PS2.6, PL3

Educational system reform

Instructional PS2.1, 2.3, 2.7, 3.1, 3.4, 3.5, 3.6, 4.5, 4.6, 4.7

Institutional PS4.1, 4.2, 4.4

Health system reformPS2.2, 2.4, 3.3, 3.7

6

I. Changing Context (1/3)

• Health workforce challenges: – “Markets drive domestic and international migration” – Increased demands for health and social care

• Demographic and epidemiologic transitions in HIC/LMIC– Socio-economic changes

• Increased expectation of population – International Labour market dynamics

• Demand for health workforce from rich countries: international migration and recruitment

• Growth of domestic private health market: internal migration

• Requires effective health workforce policy, planning and management both HIC and LMIC

7

I. Changing Context (2/3)

• Students expectations – Returns on medical education, private and specialization higher

compensation, social prestige and leisure time,• Over-specialization against generalist and family medicine,

– Market signals – The role of “hidden curriculum” – Social recognition and income

• Structural health inequity – General lack of social accountability

• By schools • By students and graduates

– Health equity, social justice not in the curriculum, • Results in

– “White (coats) follow the green ($$$)” (student debits and career choices)

8

I. Changing Context (3/3)

• Health equity embedded in UHC high in global/regional/national agenda– Yet health delivery systems, especially PHC not

equipped to provide adequate quality services– HRH: key bottleneck.

– Both number and skill mix and responsiveness

– Financing: government spending on health major challenge

9

II. Cross cutting issues (1/2)• Health equity, social justice, human rights, social accountability

not explicitly embedded in curriculum and learning platform in schools – Imbue curriculum with social values and concepts in addition to evidence

based medicines, competencies, etc. – Educators with a ‘good heart’, inspirational role model and leadership

essential“…. if I can influence their heart, I can influence their mind, then hands and feet follow”

– No easy, single solution or “silver bullet”;– Engagement and empowerment of the community vital;– Need long term vision to guide reform directions – Reforms to encompass ‘broader pool of eligible’

10

II. Cross cutting issues (2/2)

• Apply best practice, best buys options – Robust evidence, e.g. meta-analysis approach – Regular “tracking graduates” important inputs for improved

school performance • Reforms

– Stable investment in health workforce underpinned by long term political / financial commitment

– Systems approach to long term solutions for improved health equity

– Inclusive of difference cadres: MLP, CHW, social workers, managers, regulators

– Better tools to measure and evaluate process and outcome of transformative education, health workforce performance (the 3 Gaps)

11

III. Instructional reforms (1/5)• Strategic shift from tubular vision to open architect and include

both education & health systems reform• Education redesign principles:

a) competency based learning (breadth and depth)b) inter- and trans-professional learning and team buildingc) flexible and modular designs of curriculumd) experiential learning with community engagemente) level of learning: a balance between online and onsite learning for

three goals of development: information (more online than on site), formative and transformative learning (more onsite, inspirational, face2face on site learning is vital)

f) Need to integrate instructional learning: based on balance across online, on site and in-field learning sites

• Continuous leadership development: pre-service, in-serviceJulio

Frenk

12

III. Instructional reforms (2/5)

• Broader health system reforms need to be coupled with reform of the health education system to better equip health workers to address the societal shifts and local health needs and to perform within their health system environment.

• Despite some advances and successes in health professional curricula reforms, more often than not education remains outdated and stagnant– However, there are emerging initiatives e.g. MEPI/NEPI,

ANHER/AAAH, PMAC2014, others small scale evidence, – WHO Global Code of practice 2010.. – WHO global guideline 2010 (retention), 2013 (transformative scaling

up),– Need to continue to build on these momentums

13

III. Instructional reforms (3/5)

• Current ivory tower models: – Cannot meet health needs of populations

• Innovative learning – Essential for transformative health professional education and training in

the field– Involve stakeholders beyond health sector - intersectoral actions – Inter- and intra- professional collaborative practice, team building– Review competencies across different curricula to avoid “silo” and ensure

better alignment across health professionals

• Multi-stakeholder engagement– Networking and involving professional councils, associations, CSO– Community engagement: help to achieve accountable health professional

education

14

III. Instructional reforms (4/5)

• Overemphasis on hospital-based learning – Learners exposed to unrepresentative group of very ill

patients, – Not acquire key clinical, problem-solving, collaboration and

teamwork competencies as needed, – Lose internal motivation and altruistic drive, tend to focus on

career paths of highly specialized care, and not community/ rural practice

– “hidden curriculum” towards over-specialization • Need to be balanced with community based exposures

and seamless linkages

15

III. Instructional reforms (5/5)

• Great potential benefits of eLearning if managed right.

• Incorporation of on-site learning throughout learning continuum

16

IV. Institutional reforms (1/2)

• Faculty development – Ensure teaching-research-services congruence

• Building / strengthening the teaching capacity: – learning physical space, pedagogical materials, Technology platforms,

• Management – Strengthened management capacities – Mobilizing more financial resources, bursaries and fellowship,

• Create, sustain an enabling culture and environment – Values, merits, assessment and reward systems, identity, collaboration,

peer reviews, strive for excellence • Better collaboration between public and private education

institute Julio

Frenk

17

IV. Institutional reforms (2/2)

• Institutional, legal, regulatory reform – Key instruments for improving the quality, through

• Training institute and curriculum: quality assurance, accreditation and re-accreditation

• Professional quality: national license examination, relicensing processes, continuous professional development

• Licensing of public and private health facilities

• Regulation a double edge sword – Can be ineffective, constrain the needed reform and

undermine quality improvement.

18

V. Conclusion and recommendations (1/5)

• Goals for health workers in 21st Century – Health professionals are life time learners who

• Have intrinsic value of human rights, social justice, health equity, altruism, social accountability and ethical conducts,

• Are able to enquire, search, interpret and use evidence, • Are competent in clinical, public health, able to understand and

address the social determinants of health in other sectoral policies, • Able to communicate and work with other professionals, families and

communities with mutual respect, collaborate in a multi-disciplinary team

• Are responsive and accountable to health needs of the population

19

V. Conclusion and recommendations (2/5) • Cross cutting policies

– Transformative learning embedded in broader country policy commitment towards health equity, social and economic justice

– Generate convincing evidence • Added value of transformative learning on return of investment –short and

long term, – Responding and influencing international migration requires

• Better monitoring of market trends (prospective market intelligence), data from both host country and country of origin

– WHO Global Code of practice on international recruitment of health personnel » Though voluntary, foster / support improved reporting from LMIC

• Empowering health workers to be active “change agents” through leadership training

• More active public action– Global collaboration required across rich and poor nations

• Policy coherence between “health and wealth” – “health for all or job for all and economic gain from remittance”

20

V. Conclusion and recommendations (3/5)

• Cross cutting policies – Schools and health professions shall be socially accountable

for safe, quality, efficient and equitable services – Incremental small gains or “big bang” reforms depends on

political context and windows of opportunity • Legal, regulatory and institutional reforms

– Supported by evidence, regular update and feedback, institutional capacity to monitor and enforce, appropriate incentives and sanction actions in place, managed by good governance.

– Reform process needs multi-stakeholder engagement and political ownership, ensuring sustainability

21

V. Conclusion and recommendations (4/5)• Instructional reform

– Recruitments • Inclusive students from disadvantage group/communities, ensure they

return to serve their communities – Curriculum

• Health equity, social justice, social determinants of health as integral value and components of curriculum reform

• Competency based, early exposure to community, ownership of community involve in the solutions,

• Experiential learning based in the community: – A promising novel approach, improved knowledge and competencies, patient-

centered and team-based care, student and community satisfaction, support rural retention

– “Learning and practice in the community, for the community”

22

V. Conclusion and recommendations (5/5)

• Institutional– Require huge investment on infrastructure in some

countries – Effective faculty development and retention,

importance of “role models”, “inspirational teachers”

– Accreditation and quality across public and private institutions

23

A call for action by PMAC2014• We have come a long, long way, from 2006 World

Health Report – Momentum has accumulated – Global, national commitment growing though uneven, – Global/regional networks formed and functioning but need

further nurturing – Post 2015 MDG challenge:

• Positioning health workforce in the global goals in light of UHC

• A Global HRH strategy addressing health workforce in 21st century is emerging – So join us– hand in hand

24

Acknowledgements • All PMAC 2014 supporting staffs, secretariat for

their able support and dedications • Members of all session rapporteur

1 Agostinho Sousa 21 Harun Al Rasyid 41 Pedro Miranda2 Ahmad Dian Whyudiono 22 Heng-Hao Chang 42 Pennapa Kaweewongprasert3 Angkana Sommanustweechai 23 Jaratdao Reynolds 43 Pensom Jumriangrit4 Arnat Wannasri 24 Jintana Jankhotkaew 44 Prowpanga Udompap5 Aye Aye Thwin 25 Julian Fisher 45 Saipin Hathirat6 Boontuan Wattanakul 26 Kamolrat Turner 46 Simone Ross 7 Borwornsom Leerapan 27 Kanang Kantamaturapoj 47 Sirinya Phulkerd8 Chaaim Pachanee 28 Kanitsorn Samritdejkajohn 48 Srisuda Ngamkham9 Chalermpol Chamchan 29 Kari Hurt 49 Sukjai Charoensuk

10 Chanankarn Boonyotsawad 30 Laura Rose 50 Suparpit Von Boman11 Chanwit Tribuddharat 31 Lois Schaefer 51 Takahiro Hasumi 12 Chiraporn Kheedee 32 Maki Agawa 52 Thongsouy Sitanon13 Christophe Lemiere 33 Manasigan Kanchanachitra 53 Thunthita Wisaijohn14 Diana Frymus 34 Michalina 54 Trassanee Chatmethakul15 Edson Araujo 35 Monthita Urairoj 55 Viera Wardhani16 Eva Jarawan 36 Natawan Khumsaen 56 Wannapha Bamrungkhet17 Farhan Marisa 37 Nathan Satienchayakorn 57 Weranuch Wongwattanakul18 Farhan Isa 38 Orarat Wangpradit 58 Yodying Dangprapai19 Giorgio Cometto 39 Panarut Wisawatapnimit 59 Yumiko Yamashita 20 Halit Onar 40 Payao Phonsuk

Lead Rapporteur1. Akiko Maeda 3. Estelle Quain 5. Viroj Tangcharoensathien2. Jeff Johns 4. Ruediger Krech

Session Rapporteur

Rapporteur Coordinator: Walaiporn Patcharanarumol