Pre-service education and training
Pre-service education is the first opportunity for providers to receive training that will influence technical quality. Most of the literature on education relates to program accreditation and licensing of professionals, discussed within the quality management infrastructure module (forthcoming). However, the WHO Global Strategy on Human Resources for Health provides a few suggestions for strengthening health education and training. It recommends that institutions and policies should be designed to be nimble enough to respond to local human resource needs. The strategy also suggests collaboration with Ministries of Education to ensure that primary and secondary school institutions prioritizes science education in order to prepare students who choose to go into health professional education and training. Additionally, education programs and institutions should ensure that they are promoting equal opportunities for all individuals.5 While the WHO strategy specifically discusses ensuring opportunities for women, equality of access to education should be promoted across all social strata and demographics including but not limited to caste, religion, race, and ethnicity.
In 2010, the Lancet Commission on the Education of Health Professionals for the 21st Century was established to explore an ideal vision for medical education given rapidly improving technology as well as worldwide demographic and epidemiological transitions. The Commission unsurprisingly found that medical education institutions are maldistributed across the world, with 36 countries having no medical schools at all.7 Across countries, a fairly stagnant medical curriculum has resulted in mismatched provider competencies and patient needs. The vision of the Commission is that “all health professionals in all countries should be educated to mobilize knowledge and to engage in critical reasoning and ethical conduct so that they are competent to participate in patient and population-centered health systems as members of locally responsible and globally connected teams.”7 Achieving this vision requires instructional and institutional reforms.
The Lancet Commission focused their reviews and recommendations on medicine, nursing-midwifery, and public health education though they recognized the importance of competencies for broader cadres such as community health workers. Through the development of a framework and a robust review of historical medical education, the Commission suggested 10 categories for reforms:
- Competency-based curricula – curricula should be designed based on competencies that are related to local needs
- Interprofessional education – providers should train and learn together to improve collaboration and reduce hierarchical relationships. Because team-based care organization is an aspiration for high-quality primary health care, this type of training can help prepare providers for in-service collaboration. Interprofessional education is discussed in greater detail in the team-based care organization module.
- Use of information technology (IT) – as IT becomes more pervasive, even within low and middle-income countries, educational institutions should take advantage of the learning opportunities it offers while also preparing providers to use IT in-service to improve quality of care.
- Harness global resources but adapt locally – students should be able to take advantage of global learning resources while also learning how this knowledge relates to and can be adapted to local needs.
- Strengthen educational resources – countries should invest in the professional advancement of medical educators. As with in-service medical providers, educators should stable career paths, frequent evaluation, and incentives for good performance.
- Use competencies as criteria for classification of professionals – in order to reduce silos within medicine, all providers should receive education related to attitudes, values, and behaviors with additional specialized competencies.
- Joint planning mechanisms – educational planning should be a joint process, particularly between the Ministries of Health and Education. These planning mechanisms should ensure that opportunities are created for marginalized populations.
- Expand academic centers to academic systems – medical education should extend beyond the education institution and teaching hospitals to communities and primary health care facilities.
- Link networks, alliances, and consortia between educational institutions – using regional and global consortia and information technologies, countries should aim to share knowledge, tools, and resources, particularly to enhance medical education in countries where there is a shortage of medical educators.
- Encourage inquiry – institutions should work to encourage a culture of curiosity and inquiry.
It should also be noted most curricula lack a focus on comprehensive primary care service delivery, despite the substantial workforce need. Training opportunities are often limited to hospitals, and many medical schools lack a department of family medicine or general practice, resulting in a training environment ill-suited to learning about the practical application of skills in outpatient medicine and primary care. In support of high quality primary health care specifically, institutions providing health professional education should prioritize primary care-related competencies in their curricula and integrate core principles of primary care throughout training.8 Students benefit from early exposure in their education to comprehensive primary care settings and the accompanying competencies. Similarly, other health professionals expected to work as part of a primary health care team should have exposure to training in the core principles of primary care service delivery as a regular part of their undergraduate curriculum.7
The value and rigor of primary care should be a core component of strong medical professional training, with leading students encouraged to contribute to further academic study in the field. In addition, students should be exposed to the importance of post-doctoral training in primary care, emphasizing the value of discipline-specific training to ensure sufficient workforce competency, as with other medical specialties.
The most effective primary health care systems include a formally-recognized medical discipline such as family medicine or general practice exclusively committed to the delivery of comprehensive primary care in addition to an accredited post-graduate training program focused on the development of competency in the provision of primary care. These programs should be rigorous in content and educational approach while being delivered primarily in the performance context in which graduates will be expected to practice, with at least some substantial training in outpatient facilities. The World Organization of Family Physicians (WONCA) has adapted the World Federation of Medical Education (WFME) post-graduate program guidelines, with curricula centered on the core principles of primary care but tailored to address the specific local clinical needs on the region.9 These guidelines may be used to help develop post-doctoral program curricula and accreditation criteria in settings where primary care specialty training does not yet exist.
Graduates of such programs should be prepared to care for patients of all genders and ages, stratify illness severity, diagnose and manage a wide range of common local illnesses impacting a variety of organ systems, provide continuous and ongoing care to individuals and families, support community-based public health surveillance and prevention efforts, coordinate care across and refer patients to different levels of the health care system, take action to promote optimized access to grassroots care for the vulnerable, and adapt care plans to consider a patient’s unique pattern of multi-morbidity and personal health goals and desires. Ideally, national systems for credentialing are put in place to measure and ensure the presence of these competencies in graduates before they are licensed to practice in the field. For those already practicing in primary care settings but without such competency, opportunities should be provided to complete similar in-service “up-training” close to their existing practice location in order to improve their skill sets and provide them with equivalent competency and certification.
Particularly when scopes of practices are expanded, it is important to make sure that health workers are licensed to deliver these tasks to ensure patient safety. There is strong evidence that the quality of care provided by mid-level practitioners is comparable to doctors for vertically-oriented outcomes in maternal health as well as communicable and non-communicable diseases.10 Less is known about their impact on overall outcomes in routine delivery of comprehensive primary care services. Nonetheless, the existing evidence provides strong support for consideration of shifting responsibilities in targeted clinical areas to mid-level providers in many primary care settings. It is important, however, to ensure that these providers are supported by necessary inputs, training, and supervision to carry out the tasks that are delegated to them.
There is growing evidence that community-based programs may be a cost-effective strategy to improving coverage of certain health services.11 These services are generally delivered by providers with limited training. Here, this cadre of providers is referred to as “community health workers” (CHWs) – they may be referred to differently across contexts. The benefit of community-based approaches depends on full integration into the health system. CHWs must be appropriately educated, remunerated, supervised, and integrated into multidisciplinary teams.12 Globally, there is often little regulation and standardization of CHW training within and between countries, partially due to wide differences in CHWs’ expected tasks and skills across settings.12 As a result, the length of pre-service training for CHWs varies significantly, from a few days to more than 6 months.13 A report from Practitioner Expertise to Optimize Community Health Systems suggests frequent and ongoing in-service training in addition to pre-service training and use of practice-based learning strategies. Determining the appropriate pre-service and in-service training depends on a number of considerations including: 1) priorities of the national healthcare system; 2) priorities of local stakeholders; 3) local and national epidemiology and needs; 4) balancing of responsibilities between CHWs and other providers in the region; and 5) the make-up and competencies of the health workforce.
Additional resources on CHWs from the WHO can be found here.
Finally, as information technology becomes more advanced and widespread, peer-to-peer learning and collaboration communities have become quite common. A few of these communities include:
- The Joint Learning Network for Universal Health Coverage – this network of global health policymakers collaborate using collective knowledge, practice, and research to create knowledge management products that will advance the agenda of Universal Health Coverage.
- The Global Health Delivery Project – This is an initiative designed by Brigham and Women’s Hospital and Harvard University in the United States that includes case studies, courses, and online communities.
- The Quality of Care Network – The network has convened a number of countries to share how they have made improvements in maternal, newborn, and child health. They have created a space for country stakeholders to share their experience with improvement and learn from one another.
Continuing Professional Development
Medical education and training should also be ongoing throughout a provider’s career, and continuing professional development (CPD) is an important opportunity to keep providers’ technical skills refreshed and updated. CPD typically includes certification or re-certification, and there is a dearth of evidence on the best way to administer CPD in LMIC, particularly related to primary health care. In order to promote uptake of new skills and promote group learning, CPD may be best delivered in primary care facilities, though this is often not the reality.14 Global partnerships and private sector corporations support or provide a significant amount of CPD in LMIC, although these are often specifically focused on vertical programs. For instance, PEPFAR conducted more than 3.7 million continuing education encounters between 2003 and 2008, and the Global Fund conducted 14 million between 2002 and 2012.15 These partnerships can be quite complex and require effective communication and buy-in from local stakeholders as well as close consideration of local context. An expert consultation with individuals involved in these global continuing medical education partnerships surfaced the following suggestions:
- Programs can address the knowledge-to-practice gaps if high and low-income countries come together to address education needs.
- Programs can work more efficiently if resource-rich countries and resource-poor countries share resources and goals for training.
- A needs assessment is an important first step for partnerships to develop educational content that is context-specific.
- Continuing medical education programs benefit from local leaders who are well versed in the local environment.15