Health professionals for a new century：transforming education to strengthen health systems in an interdependent world

The lancet commissions THE LANCET EDUCATION OF HEALTH PROFESSIONALS FOR THE 2IST CH A GLOBAL INDEPENDENT COMMISSION Health professionals for a new century: transforming education to strengthen health systems in an interdependent world Julio Frenk*, Lincoln Chen*, Zulfiqar A Bhutta, Jordan Cohen, Nigel Crisp, Timothy Evans, Harvey Fineberg, Patricia Garcia, Yang Ke, Patrick Kell Barry Kistnasamy, Afaf Meleis, David Naylor, Ariel Pablos-Mendez, Srinath Reddy, Susan Scrimshaw, Jaime Sepulveda, David Serwadda, Huda Zura Executive summary Redesign of professional health education is necessary nd timely, in view of the opportunities for mutual go, a series of studies about the education of learning and joint solutions offered by global 6736(10)61854-5 health professionals, led by the 1910 Flexner report, interdependence due to acceleration of flows of sparked groundbreaking reforms. Through integration knowledge, technologies, and financing across borders, DOt101016/50140- of modern science into the curricula at university-based and the migration of both professionals and patients. 6736(10)62008-9 schools, the reforms equipped health professionals with What is clearly needed is a thorough and authoritative Dot10 1016/50140- the knowledge that contributed to the doubling of life re-examination of health professional education, 6736(10)61968-x span during the 20th century. matching the ambitious work of a century ago " Joint first authors 4 By the beginning of the 21st century, however, all is not That is why this Commission, consisting of Harvard School of Public alL. Glaring gaps and inequities in health persist both 20 professional and academic leaders from diverse (Prof Frenk MD): China Medical within and between countries, underscoring our countries, came together to develop a shared vision and a Board, Cambridge, MA,USA collective failure to share the dramatic health advances common strategy for postsecondary education in medicine,(Chen MD)AgaKhan equitably. At the same time, fresh health challenges loom. nursing, and public health that reaches beyond the University, Karachi, Pakistan New infectious, environmen tal, and behavioural risks, at confines of national borders and the silos of individual(Prof ZA Bhutta PhD); George a time of rapid demographic and epidemiological professions. The Commission adopted a global outlook, a Center, Washington, DC, Us transitions, threaten health security of all. Health systems multiprofessional perspective, and a systems approach. ( Prof Cohen MD); Independent more complex and costly, placing additional demands on between education and health systems. It is centred on tondo UK N SChp kof: health workers people co-producers and as drivers of needs and Health,Dhaka, Bangladesh Professional education has not kept pace with these demands in both systems. By interaction through the (ProfT Evans MD): US Institute ted, outdated, and labour market, the provision of educational services licine, Washington, DC, static curricula that produce ill-equipped graduates. The generates the supply of an educated workforce to meet the PKelley MD: sch problems are systemic: mismatch of competencies to demand for professionals to work in the health system. To Health Universidad Peruana patient and population needs; poor teamwork; persistent have a positive effect on health outcomes, the professional Cayetano, Heredia, Lima, Peru gender stratification of professional status; narrow education subsystem must design new instructional and (Pro P Garcia MD): Pekin technical focus without broader contextual understand. institutional strategies g: episodic encounters rather than continuous care (ProfY Ke MD): National Health predominant hospital orientation at the expense of Major findings Laboratory Servic primary care; quantitative and qualitative imbalances in Worldwide, 2420 medical schools, 467 schools or johannesburg. the professional labour market; and weak leadership to departments of public health, and an indeterminate (KIstnasamy MD);School of Nursing, University of improve health-system performance. Laudable efforts to number of postsecondary nursing educational instit- Pennsylvania, Philadelphia, PA, address these deficiencies have mostly foundered, partly utions train about 1 million new doctors, nurses, USA(Prof A Meleis PhD) because of the so-called tribalism of the professions-ie, midwives, and public health professionals every year. unversity or oronto, toronto, the tendency of the various professions to act in isolation Severe institutional shortages are exacerbated by The Rockefeller foundation from or even in competition with each other. maldistribution, both between and within countries. New York, NY, USA ww.thelancet.com

The Lancet Commissions www.thelancet.com 5 Published Online November 29, 2010 DOI:10.1016/S0140- 6736(10)61854-5 See Online/Comment DOI:10.1016/S0140- 6736(10)62008-9 DOI:10.1016/S0140- 6736(10)61968-X *Joint first authors Harvard School of Public Health, Boston, MA, USA (Prof J Frenk MD); China Medical Board, Cambridge, MA, USA (L Chen MD); Aga Khan University, Karachi, Pakistan (Prof Z A Bhutta PhD); George Washington University Medical Center, Washington, DC, USA (Prof J Cohen MD); Independent member of House of Lords, London, UK (N Crisp KCB); James P Grant School of Public Health, Dhaka, Bangladesh (Prof T Evans MD); US Institute of Medicine, Washington, DC, USA (H Fineberg MD, P Kelley MD); School of Public Health Universidad Peruana Cayetano, Heredia, Lima, Peru (Prof P Garcia MD); Peking University Health Science Centre, Beijing, China (Prof Y Ke MD); National Health Laboratory Service, Johannesburg, South Africa (B Kistnasamy MD); School of Nursing, University of Pennsylvania, Philadelphia, PA, USA (Prof A Meleis PhD); University of Toronto, Toronto, ON, Canada (Prof D Naylor MD); The Rockefeller Foundation, New York, NY, USA Health professionals for a new century: transforming education to strengthen health systems in an interdependent world Julio Frenk*, Lincoln Chen*, Zulfiqar A Bhutta, Jordan Cohen, Nigel Crisp, Timothy Evans, Harvey Fineberg, Patricia Garcia, Yang Ke, Patrick Kelley, Barry Kistnasamy, Afaf Meleis, David Naylor, Ariel Pablos-Mendez, Srinath Reddy, Susan Scrimshaw, Jaime Sepulveda, David Serwadda, Huda Zurayk Executive summary Problem statement 100 years ago, a series of studies about the education of health professionals, led by the 1910 Flexner report, sparked groundbreaking reforms. Through integration of modern science into the curricula at university-based schools, the reforms equipped health professionals with the knowledge that contributed to the doubling of life span during the 20th century. By the beginning of the 21st century, however, all is not well. Glaring gaps and inequities in health persist both within and between countries, underscoring our collective failure to share the dramatic health advances equitably. At the same time, fresh health challenges loom. New infectious, environmental, and behavioural risks, at a time of rapid demographic and epidemiological transitions, threaten health security of all. Health systems worldwide are struggling to keep up, as they become more complex and costly, placing additional demands on health workers. Professional education has not kept pace with these challenges, largely because of fragmented, outdated, and static curricula that produce ill-equipped graduates. The problems are systemic: mismatch of competencies to patient and population needs; poor teamwork; persistent gender stratification of professional status; narrow technical focus without broader contextual understand￾ing; episodic encounters rather than continuous care; predominant hospital orientation at the expense of primary care; quantitative and qualitative imbalances in the professional labour market; and weak leadership to improve health-system performance. Laudable efforts to address these deficiencies have mostly floundered, partly because of the so-called tribalism of the professions—ie, the tendency of the various professions to act in isolation from or even in competition with each other. Redesign of professional health education is necessary and timely, in view of the opportunities for mutual learning and joint solutions offered by global interdependence due to acceleration of flows of knowledge, technologies, and financing across borders, and the migration of both professionals and patients. What is clearly needed is a thorough and authoritative re-examination of health professional education, matching the ambitious work of a century ago. That is why this Commission, consisting of 20 professional and academic leaders from diverse countries, came together to develop a shared vision and a common strategy for postsecondary education in medicine, nursing, and public health that reaches beyond the confines of national borders and the silos of individual professions. The Commission adopted a global outlook, a multiprofessional perspective, and a systems approach. This comprehensive framework considers the connections between education and health systems. It is centred on people as co-producers and as drivers of needs and demands in both systems. By interaction through the labour market, the provision of educational services generates the supply of an educated workforce to meet the demand for professionals to work in the health system. To have a positive effect on health outcomes, the professional education subsystem must design new instructional and institutional strategies. Major findings Worldwide, 2420 medical schools, 467 schools or departments of public health, and an indeterminate number of postsecondary nursing educational instit￾utions train about 1 million new doctors, nurses, midwives, and public health professionals every year. Severe institutional shortages are exacerbated by maldistribution, both between and within countries

The Lancet commissions (APablos-Mendez MD): Public Four countries(China, India, Brazil, and USA) each have agents. Effective education builds each level on the Health Foundation of India, more than 150 medical schools, whereas 36 countries previous one. As a valued outcome, transformative Deth, india have no medical schools at all. 26 countries in sub. learning involves three fundamental shifts: from fact Colleges, Troy, Ml, USA Saharan Africa have one or no medical schools. In view memorisation to searching, analysis, and synthesis of S Scrimshaw PhD); of these imbalances, that medical school numbers do not information for decision making: from seeking i8 Melinda gates align well with either country population size or national professional credentials to achieving core competencies 0 Sepulveda MD): Makarere burden of disease is not surprising. for effective teamwork in health systems; and from niversity School of Public The total global expenditure for health professional non-critical adoption of educational models to creative (Prof D Serwadda MD); and great disparities between countries. This amount is less Interdependence is a key element in a systems pulation and Health, Faculty than 2% of health expenditures worldwide, which is approach because it underscores the ways in which University of Beirut, Beirut, industry. The average cost per graduate is $113000 for desirable outcome, interdependence in education also Lebanon(Prof HZurayk PhD) medical students and $46000 for nurses, with unit costs involves three fundamental shifts: from isolated to Correspondence to: highest in North America and lowest in China. harmonised education and health systems: from stand of public health office ofthe Stewardship, accreditation, and learning systems are alone institutions to networks, alliances, and consortia; Dean, Kresge Building, Room weak and unevenly practised around the world. Our and from inward-looking institutional preoccupations to 1005, Huntington Avenue, analysis has shown the scarcity of information and arnessing global flows of educational content, teaching Boston, MA O2115, USA research about health professional education. Although resources, and innovations frenk hsph. harvardedu many educational institutions in all regions have Transformative learning is the proposed outcome of Dr Lincoln Chen, China launched innovative initiatives, little robust evidence is instructional reforms; interdependence in education available about the effectiveness of such reforms should result from institutional reforms. On the basis Cambridge, MA O2138, USA of these core notions, the Commission offers a serie Ichenecmbfoundorg Reforms for a second centur!, onal reforms characterise performance. Instructional reforms should:adopt of specific recommendations to improve systems Three generations of educati progress during the past century. The first generation, petency-driven approaches to instructional design; launched at the beginning of the 20th century, taught a adapt these competencies to rapidly changing local science-based curriculum. Around the mid-century, conditions drawing on global resources; promote the second generation introduced problem-based interprofessional and transprofessional education that instructional innovations. A third generation is now breaks down professional silos while enhancing needed that should be systems based to improve the collaborative and non-hierarchical relationships in erformance of health systems by adapting core effective teams; exploit the power of information sional competencies to specific contexts, while technology for learning: strengthen educational drawing on global knowledge resources, with specialemphasis on faculty development; To advance third-generation reforms, the Commission and promote a new professionalism that uses puts forward a vision: all health professionals in all competencies as objective criteria for classification of countries should be educated to mobilise knowledge and health professionals and that develops a common set of to engage in critical reasoning and ethical conduct so values around social accountability. Institutional that they are competent to participate in patient and reforms should: establish in every country joint population-centred health systems as members of locally education and health planning mechanisms that take responsive and globally connected teams. The ultimate into account crucial dimensions, such as social origin, purpose is to assure universal coverage of the high- age distribution, and gender composition, of the health uality comprehensive services that are essential to workforce; expand academic centres to academic advance opportunity for health equity within and systems encompassing networks of hospitals and primary care units; link together through global Realisation of this vision will require a series of networks, alliances, and consortia; and nurture a culture instructional and institutional reforms, which should be of critical inquiry guided by two proposed outcomes: transformative Pursuit of these reforms will encounter many barriers. learning and interdependence in education. We regard Our recommendations, therefore, require a series of transformative learning as the highest of three successive abling actions. First, the broad engagement of leaders at levels from informative to formative to all levels--local, national, and global--will be crucial to transformative learning. Informative learning is about achieve the proposed reforms and outcomes. Leadership acquiring knowledge and skills; its purpose is to produce has to come from within the academic and professional experts. Formative learning is about socialising students communities, but it must be backed by political leaders in around values; its purpose is to produce professionals. government society. Second, present fundin Transformative learning is about developing leadership deficiencies must be overcome with a substantial attributes; its purpose is to produce enlightened change expansion of investments in health professional education www.thelancet.com

The Lancet Commissions 6 www.thelancet.com (A Pablos-Mendez MD); Public Health Foundation of India, New Delhi, India (Prof S Reddy MD); The Sage Colleges, Troy, MI, USA (S Scrimshaw PhD); Bill & Melinda Gates Foundation, Seattle, WA, USA (J Sepulveda MD); Makarere University School of Public Health, Kampala, Uganda (Prof D Serwadda MD); and Centre for Research on Population and Health, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon (Prof H Zurayk PhD) Correspondence to: Prof Julio Frenk, Harvard School of Public Health, Office of the Dean, Kresge Building, Room 1005, 677 Huntington Avenue, Boston, MA 02115, USA jfrenk@hsph.harvard.edu or Dr Lincoln Chen, China Medical Board, Two Arrow Street, Cambridge, MA 02138, USA lchen@cmbfound.org Four countries (China, India, Brazil, and USA) each have more than 150 medical schools, whereas 36 countries have no medical schools at all. 26 countries in sub￾Saharan Africa have one or no medical schools. In view of these imbalances, that medical school numbers do not align well with either country population size or national burden of disease is not surprising. The total global expenditure for health professional education is about US$100 billion per year, again with great disparities between countries. This amount is less than 2% of health expenditures worldwide, which is pitifully modest for a labour-intensive and talent-driven industry. The average cost per graduate is $113 000 for medical students and $46 000 for nurses, with unit costs highest in North America and lowest in China. Stewardship, accreditation, and learning systems are weak and unevenly practised around the world. Our analysis has shown the scarcity of information and research about health professional education. Although many educational institutions in all regions have launched innovative initiatives, little robust evidence is available about the effectiveness of such reforms. Reforms for a second century Three generations of educational reforms characterise progress during the past century. The first generation, launched at the beginning of the 20th century, taught a science-based curriculum. Around the mid-century, the second generation introduced problem-based instructional innovations. A third generation is now needed that should be systems based to improve the performance of health systems by adapting core professional competencies to specific contexts, while drawing on global knowledge. To advance third-generation reforms, the Commission puts forward a vision: all health professionals in all countries should be educated to mobilise knowledge and to engage in critical reasoning and ethical conduct so that they are competent to participate in patient and population-centred health systems as members of locally responsive and globally connected teams. The ultimate purpose is to assure universal coverage of the high￾quality comprehensive services that are essential to advance opportunity for health equity within and between countries. Realisation of this vision will require a series of instructional and institutional reforms, which should be guided by two proposed outcomes: transformative learning and interdependence in education. We regard transformative learning as the highest of three successive levels, moving from informative to formative to transformative learning. Informative learning is about acquiring knowledge and skills; its purpose is to produce experts. Formative learning is about socialising students around values; its purpose is to produce professionals. Transformative learning is about developing leadership attributes; its purpose is to produce enlightened change agents. Effective education builds each level on the previous one. As a valued outcome, transformative learning involves three fundamental shifts: from fact memorisation to searching, analysis, and synthesis of information for decision making; from seeking professional credentials to achieving core competencies for effective teamwork in health systems; and from non-critical adoption of educational models to creative adaptation of global resources to address local priorities. Interdependence is a key element in a systems approach because it underscores the ways in which various components interact with each other. As a desirable outcome, interdependence in education also involves three fundamental shifts: from isolated to harmonised education and health systems; from stand￾alone institutions to networks, alliances, and consortia; and from inward-looking institutional preoccupations to harnessing global flows of educational content, teaching resources, and innovations. Transformative learning is the proposed outcome of instructional reforms; interdependence in education should result from institutional reforms. On the basis of these core notions, the Commission offers a series of specific recommendations to improve systems performance. Instructional reforms should: adopt competency-driven approaches to instructional design; adapt these competencies to rapidly changing local conditions drawing on global resources; promote interprofessional and transprofessional education that breaks down professional silos while enhancing collaborative and non-hierarchical relationships in effective teams; exploit the power of information technology for learning; strengthen educational resources, with special emphasis on faculty development; and promote a new professionalism that uses competencies as objective criteria for classification of health professionals and that develops a common set of values around social accountability. Institutional reforms should: establish in every country joint education and health planning mechanisms that take into account crucial dimensions, such as social origin, age distribution, and gender composition, of the health workforce; expand academic centres to academic systems encompassing networks of hospitals and primary care units; link together through global networks, alliances, and consortia; and nurture a culture of critical inquiry. Pursuit of these reforms will encounter many barriers. Our recommendations, therefore, require a series of enabling actions. First, the broad engagement of leaders at all levels—local, national, and global—will be crucial to achieve the proposed reforms and outcomes. Leadership has to come from within the academic and professional communities, but it must be backed by political leaders in government and society. Second, present funding deficiencies must be overcome with a substantial expansion of investments in health professional education

The Lancet commissions from all sources: public, private, development aid, and foundations. Third, stewardship mechanisms, including The Flexner report socially accountable accreditation, should be strengthened NURSING AN to assure best possible results for any given level of N THE UNITED STATES funding. Lastly, shared learning by supporting metrics, evaluation, and research should be strengthened to build up the knowledge base about which innovations work 量影露 under which circumstances Health professionals have made enormous contributions to health and development over the past century, but complacencywill only perpetuate theineffective application of 20th century educational strategies that are unfit to tackle 21st century challenges. Therefore, we call for a global social movement of all stakeholders--educators, Hgure Flexner, weidch-kose, and goldmark reports students and young health workers, professional bodies, complementing the importance of social determinants universities, non-governmental organisations, inter- and social movements in health. In these endeavours national agencies, donors, and foundations--that can professionals play the crucial mediating role of applying propel action on this vision and these recommendations knowledge to improve health. Much evidence suggests to promote a new century of transformative professional that coverage and numbers of health professionals have a education. The result will be more equitable and better direct effect on health outcomes. Health professionals performing health systems than at present, with are the service providers who link people to technology onsequent benefits for patients and populations information, and knowledge. They are also caregivers everywhere in our interdepend communicators and educators, team members, managers ders, and policy makers. -1z As knowledge brokers Section 1: problem statement health workers are the human faces of the health system Background and rationale Arguably, dramatic reforms in the education of health professionals helped to catalyse health gains in the past Health is all about people. Beyond the glittering surface century. After the discovery of the germ theory in Europe, of modern technology, the core space of every health the beginning of the 20th century witnessed widespread system is occupied by the unique encounter between one reforms in professional education around the world. In set of people who need services and another who have the USA early in the 20th century, such reports as by been entrusted to deliver them. This trust is earned Flexner. 3 Welch- Rose 4 and Goldmarks transformed through a special blend of technical competence and postsecondary education of physicians, public health service orientation, steered by ethical commitment and workers, and nurses, respectively(figure 1). These efforts social accountability, which forms the essence of to imbed a scientific foundation into the education of professional work, Developing such a blend requires a health professionals extended into other health fields. 6 lengthy period of education and a substantial investment However, in the first decade of the 21st century, glaring by both student and society. Through a chain of events gaps and striking inequities in health persist both fowing from effective learning to high-quality services to between and within countries. -m A large proportion of improved health, professional education at its best makes the 7 billion people who inhabit out planet are trapped in an essential contribution to the wellbeing of individuals, health conditions of a century earlier. Many face conflict families, and communities and violence. Health gains have been reversed by the Yet, the context, content, and conditions of the social collapse of average life expectancy in some countries effort to educate competent, caring, and committed health which in sub-Saharan Africa is attributable to the professionals are rapidly changing across time and space. HIV/AIDS pandemic. uz Poor people in developing The startling doubling of life expectancy during the 20th countries continue to have common infections entury was attributable to improvements in living malnutrition, and maternity-related health risks, which standards and to advances in knowledge. Abundant have long been controlled in more affluent populations evidence suggests that good health is at least partly For those left behind, the spectacular advances in health knowledge not only produces new technologies but also ensure the equitable sharing of health progress. sure to knowledge based and socially driven. 23 Scientific worldwide are an indictment of our collective failure to empowers citizens to adopt healthy lifestyles, improve At the same time, health security is being challenged care-seeking behaviour, and become proactive citizens by new infectious, environmental, and behavioural who are conscious of their rights. Additionally, knowledge threats superimposed upon rapid demographic and anslated into evidence can guide practice and policy. epidem-iological transitions. -7 Health systems are Health systems are socially driven differentiated struggling to keep up and are becoming more complex institutions with the primary intent to improve health, and costly, placing additional demands on health workers. ww.thelancet.com

The Lancet Commissions www.thelancet.com 7 from all sources: public, private, development aid, and foundations. Third, stewardship mechanisms, including socially accountable accreditation, should be strengthened to assure best possible results for any given level of funding. Lastly, shared learning by supporting metrics, evaluation, and research should be strengthened to build up the knowledge base about which innovations work under which circumstances. Health professionals have made enormous contributions to health and development over the past century, but complacency will only perpetuate the ineffective application of 20th century educational strategies that are unfit to tackle 21st century challenges. Therefore, we call for a global social movement of all stakeholders—educators, students and young health workers, professional bodies, universities, non-governmental organisations, inter￾national agencies, donors, and foundations—that can propel action on this vision and these recommendations to promote a new century of transformative professional education. The result will be more equitable and better performing health systems than at present, with consequent benefits for patients and populations everywhere in our interdependent world. Section 1: problem statement Background and rationale Complex challenges Health is all about people. Beyond the glittering surface of modern technology, the core space of every health system is occupied by the unique encounter between one set of people who need services and another who have been entrusted to deliver them. This trust is earned through a special blend of technical competence and service orientation, steered by ethical commitment and social accountability, which forms the essence of professional work. Developing such a blend requires a lengthy period of education and a substantial investment by both student and society. Through a chain of events flowing from effective learning to high-quality services to improved health, professional education at its best makes an essential contribution to the wellbeing of individuals, families, and communities. Yet, the context, content, and conditions of the social effort to educate competent, caring, and committed health professionals are rapidly changing across time and space. The startling doubling of life expectancy during the 20th century was attributable to improvements in living standards and to advances in knowledge.1 Abundant evidence suggests that good health is at least partly knowledge based and socially driven.2,3 Scientific knowledge not only produces new technologies but also empowers citizens to adopt healthy lifestyles, improve care-seeking behaviour, and become proactive citizens who are conscious of their rights. Additionally, knowledge translated into evidence can guide practice and policy. Health systems are socially driven differentiated institutions with the primary intent to improve health, complementing the importance of social determinants and social movements in health. In these endeavours, professionals play the crucial mediating role of applying knowledge to improve health. Much evidence suggests that coverage and numbers of health professionals have a direct effect on health outcomes.4 Health professionals are the service providers who link people to technology, information, and knowledge. They are also caregivers, communicators and educators, team members, managers, leaders, and policy makers.5–12 As knowledge brokers, health workers are the human faces of the health system. Arguably, dramatic reforms in the education of health professionals helped to catalyse health gains in the past century. After the discovery of the germ theory in Europe, the beginning of the 20th century witnessed widespread reforms in professional education around the world. In the USA early in the 20th century, such reports as by Flexner,13 Welch-Rose,14 and Goldmark15 transformed postsecondary education of physicians, public health workers, and nurses, respectively (figure 1). These efforts to imbed a scientific foundation into the education of health professionals extended into other health fields.16 However, in the first decade of the 21st century, glaring gaps and striking inequities in health persist both between and within countries.17–20 A large proportion of the 7 billion people who inhabit out planet are trapped in health conditions of a century earlier. Many face conflict and violence. Health gains have been reversed by the collapse of average life expectancy in some countries, which in sub-Saharan Africa is attributable to the HIV/AIDS pandemic.21,22 Poor people in developing countries continue to have common infections, malnutrition, and maternity-related health risks, which have long been controlled in more affluent populations.23 For those left behind, the spectacular advances in health worldwide are an indictment of our collective failure to ensure the equitable sharing of health progress.24 At the same time, health security is being challenged by new infectious, environmental, and behavioural threats superimposed upon rapid demographic and epidem-iological transitions.25–27 Health systems are struggling to keep up and are becoming more complex and costly, placing additional demands on health workers. Figure 1: Flexner, Welch-Rose, and Goldmark reports

The Lancet commissions challenging in poor countries, which are constrained by severely scarce resources. Many countries are attempting to extend essenti service through the deployment of basic health workers, even as millions of people resort to providers without credentials, both traditional and modern 42 In an effort to achieve health goals, many poor countries are channelling external donor funding towards implementation of disease-targeted initiatives. Consequently, in many countries, po professional education is absent from the policy agenda and is overtaken by emergency or urgent action projects and is regarded as too costly, irrelevant, or long term. igure 2: Emerging challenges to health systems A renaissance to a new professionalism--patient centred and team-based-has been much discussed. AL In many countries, professionals are encountering more but it has lacked the leadership, incentives, and power to socially diverse patients with chronic conditions, who are deliver on its promise. Some attempts to redefine the more proactive in their health-seeking behaviour. -3 future roles and responsibilities of health professionals Patient management requires coordinated care across have floundered amid the rigid so-called tribalism that time and space, demanding unprecedented teamwork. afflicts them. Advocacy for specific practitioner groups has Professionals have to integrate the explosive growth of been strong, but without an overall strategy for the broader knowledge and technologies while grappling with health professional community to work together to meet expanding functions--super-specialisation, prevention, individual and population health needs. Several and complex care management in many sites, including meaning recent efforts have attempted to address different types of facilities alongside home-based and fractures, but they have fallen short. community-based care(figure 2). -12 Consequently, a slow-burning crisis is emerging in Fresh opportunities the mismatch of professional competencies to patient Opportunities are opening for a new round of reforms to and population priorities because of fragmentary, craft professional education for the 21st century, spurred outdated, and static curricula producing ill-equipped by mutual leaming due to health interdependence, changes graduates from underfinanced institutions. -1 5-20 In in educational pedagogy, the public prominence of health almost all countries. the education of health and the growing recognition of the imperative for change fessionals has failed to overcome dysfunctional and Paradoxically, despite glaring disparities, interdependence inequitable health systems because of curricula in health is growing and the opportunities for mutual rigidities, professional silos, static pedagogy (ie, the learning and shared progress have greatly expanded. science of teaching), insufficient adaptation to local Global movements of people, pathogens, technologies contexts, and commercialism in the professions. financing, information, and knowledge underlie the Breakdown is especially noteworthy within primary international transfer of health risks and opportunities care, in both poor and rich countries. The failings are and flows across national borders are accelerating. Weare systemic--professionals are unable to keep pace, increasingly interdependent in terms of key health becoming mere technology managers, and exacerbating resources, especially skilled workers. 2 protracted difficulties such as a reluctance to serve Alongside the rapid pace of change in health, there is a marginalised rural communities. 323 Professionals are parallel revolution in education. The explosive increase falling short on appropriate competencies for effective not only in total volume of information, but also in ease teamwork, and they are not exercising effective of access to it, means that the role of universities and leadership to transform health systems. other educational institutions needs to be rethought. Poor and rich countries both have workforce shortages, Learning, of course, has always been experienced outside skill-mix imbalances, and maldistribution of profess. formal instruction through all types of interactions, but ionals 7-In neither rich nor poor countries is professional the informational content and learning potential are education generating high value for money. Difficult to today without precedent. In this rapidly evolving context, design and slow to implement, educational reforms in rich universities and educational institutions are broadenin competencies attempting to develop professional their traditional role as places where people go to obtain countries e responsive to changing health information(eg, by consulting books in libraries or needs, overcome professional silos through inter- listening to expert faculty members) to incorporate novel rofessional education, harness information technology forms of learning that transcend the confines of the (IT-empowered learning, enhance cognitive skills for class lext generation of learners needs the critical inquiry, and strengthen professional identity and capacity to discriminate vast amounts of information values for health leadership. Reforms are especially and extract and synthesise knowledge that is necessary www.thelancet.com

The Lancet Commissions 8 www.thelancet.com In many countries, professionals are encountering more socially diverse patients with chronic conditions, who are more proactive in their health-seeking behaviour.28–31 Patient management requires coordinated care across time and space, demanding unprecedented teamwork.5–11 Professionals have to integrate the explosive growth of knowledge and technologies while grappling with expanding functions—super-specialisation, prevention, and complex care management in many sites, including different types of facilities alongside home-based and community-based care (figure 2).7–12 Consequently, a slow-burning crisis is emerging in the mismatch of professional competencies to patient and population priorities because of fragmentary, outdated, and static curricula producing ill-equipped graduates from underfinanced institutions.5–12,18–20 In almost all countries, the education of health pro￾fessionals has failed to overcome dysfunctional and inequitable health systems because of curricula rigidities, professional silos, static pedagogy (ie, the science of teaching), insufficient adaptation to local contexts, and commercialism in the professions. Breakdown is especially noteworthy within primary care, in both poor and rich countries. The failings are systemic—professionals are unable to keep pace, becoming mere technology managers, and exacerbating protracted difficulties such as a reluctance to serve marginalised rural communities.32,33 Professionals are falling short on appropriate competencies for effective teamwork, and they are not exercising effective leadership to transform health systems. Poor and rich countries both have workforce shortages, skill-mix imbalances, and maldistribution of profess￾ionals.7,32–35 In neither rich nor poor countries is professional education generating high value for money. Difficult to design and slow to implement, educational reforms in rich countries are attempting to develop professional competencies that are responsive to changing health needs, overcome professional silos through inter￾professional education, harness information technology (IT)-empowered learning, enhance cognitive skills for critical inquiry, and strengthen professional identity and values for health leadership.36–40 Reforms are especially challenging in poor countries, which are constrained by severely scarce resources.38,40,41 Many countries are attempting to extend essential services through the deployment of basic health workers, even as millions of people resort to providers without credentials, both traditional and modern.42 In an effort to achieve health goals, many poor countries are channelling external donor funding towards implementation of disease-targeted initiatives. Consequently, in many countries, postsecondary professional education is absent from the policy agenda and is overtaken by emergency or urgent action projects and is regarded as too costly, irrelevant, or long term. A renaissance to a new professionalism—patient￾centred and team-based—has been much discussed,37,43–47 but it has lacked the leadership, incentives, and power to deliver on its promise. Some attempts to redefine the future roles and responsibilities of health professionals have floundered amid the rigid so-called tribalism that afflicts them. Advocacy for specific practitioner groups has been strong, but without an overall strategy for the broader health professional community to work together to meet individual and population health needs. Several well meaning recent efforts have attempted to address these fractures, but they have fallen short. Fresh opportunities Opportunities are opening for a new round of reforms to craft professional education for the 21st century, spurred by mutual learning due to health interdependence, changes in educational pedagogy, the public prominence of health, and the growing recognition of the imperative for change. Paradoxically, despite glaring disparities, interdependence in health is growing and the opportunities for mutual learning and shared progress have greatly expanded.1,24 Global movements of people, pathogens, technologies, financing, information, and knowledge underlie the international transfer of health risks and opportunities, and flows across national borders are accelerating.48 We are increasingly interdependent in terms of key health resources, especially skilled workers.24 Alongside the rapid pace of change in health, there is a parallel revolution in education. The explosive increase not only in total volume of information, but also in ease of access to it, means that the role of universities and other educational institutions needs to be rethought.49 Learning, of course, has always been experienced outside formal instruction through all types of interactions, but the informational content and learning potential are today without precedent. In this rapidly evolving context, universities and educational institutions are broadening their traditional role as places where people go to obtain information (eg, by consulting books in libraries or listening to expert faculty members) to incorporate novel forms of learning that transcend the confines of the classroom. The next generation of learners needs the capacity to discriminate vast amounts of information and extract and synthesise knowledge that is necessary Figure 2: Emerging challenges to health systems Health system Technological innovation Population demands Epidemiological and demographic transitions Professional differentiation

The Lancet commissions for clinical and population-based decision making. delimit their respective spheres of practice. The division These developments point toward new opportunities for of labour at any specific time and in any specific society is the methods, means, and meaning of education. -12B-20 much more the result of these social forces than of any Like never before, the public prominence of health in inherent attribute of health-related work. general and global health in particular has generated an In most of this report we continue to refer to the health environment that is propitious for change. Health affects professions in a conventional manner. We focus the most pressing global issues of our time: socio- health workers who have completed postsecondary economic development, national and human security, education--typically in universities or other institutions and the global movement for human rights. We now of higher learning that are legally allowed to certify understand that good health is not only a result of but educational attainment by issuing a formal degree. also a condition for development, security, and rights. At Although this definition does not include most ancillary the same time, access to high-quality health care with and community health workers and there has been financial protection for all has become one of the major substantial growth of new occupational categories or domestic political priorities worldwide. specialisations, we focus mostly on the conventional A full and authoritative examination and redesign of professions, with special emphasis on medicine, nursing. the education of health professionals is warranted to midwifery, and public health. Our analyses and match the ambition of reformers a century ago. Such a recommendations are directed at all health professions. eview would necessarily be globally inclusive and multi- However boundaries between health professions are professional, spanning borders and constituencies. delineated, all are subject to educational processes aimed Reform for the 21st century is timely because of the at developing knowledge, skills, and values to improve imperative to align professional competencies to the health of patients and populations. There is, therefore, changing contexts, growing public engagement in a fundamental linkage between professional education health, and global interdependence, including the shared on the one hand, and health conditions, on the other. For aspiration of equity in health. this reason, the Commission developed a framework aimed at understanding of the complex interactions between two systems: education and health(figure 3) The Commission on education of health professionals for By contrast with other frameworks, in which the the 21st century was launched in January, 2010. This population is exogenous to health or education systems independent initiative, led by a diverse group of ours conceives of the population as the base and the driver 20 commissioners from around the world, adopted a global of these systems. People generate needs in both education perspective seeking to advance health by recommending and health, which in turn may be translated into demand instructional and institutional innovations to nurture a for educational and health services. The provision of new generation of health professionals who would be best educational services generates the supply of an educated equipped to address present and future health challenges. workforce to meet the demand for professionals to work in Webappendix pp 1-5 lists the members of the Commission the health system. Of course, people are not only recipients See Online for webappend and its advisory bodies. We pursued research, undertook of services but actual coproducers of their own education deliberations, and promoted consultations during 1 year. and health The brevity of time constrained the scopanalyses.Our and depth of consultations, data compilation, and aim was to develop a fresh vision with practical recommendations of specific actions that might catalyse steps towards the transformation of health professional Supply of heah abour market fo Demand for health education in all countries, both rich and poor. The work of the Commission is intended to mark the centennial of the 1910 Flexner report, which has powerfully shaped medical education throughout the world. rative framework Education system Health The Commission began by defining its object of study th professional educ labour between the various health professions is a social construction resulting from complex historical processes around scientific progress, technological development, economic relations, political interests, and cultural schemes of values and beliefs. The dynamic nature of professional boundaries is underscored by the continuous ruggles between different professional groups to Figure 3: Systems framework ww.thelancet.com

The Lancet Commissions www.thelancet.com 9 for clinical and population-based decision making. These developments point toward new opportunities for the methods, means, and meaning of education.5–12,18–20 Like never before, the public prominence of health in general and global health in particular has generated an environment that is propitious for change. Health affects the most pressing global issues of our time: socio￾economic development, national and human security, and the global movement for human rights. We now understand that good health is not only a result of but also a condition for development, security, and rights. At the same time, access to high-quality health care with financial protection for all has become one of the major domestic political priorities worldwide. A full and authoritative examination and redesign of the education of health professionals is warranted to match the ambition of reformers a century ago. Such a review would necessarily be globally inclusive and multi￾professional, spanning borders and constituencies. Reform for the 21st century is timely because of the imperative to align professional competencies to changing contexts, growing public engagement in health, and global interdependence, including the shared aspiration of equity in health. Commission work The Commission on education of health professionals for the 21st century was launched in January, 2010. This independent initiative, led by a diverse group of 20 commissioners from around the world, adopted a global perspective seeking to advance health by recommending instructional and institutional innovations to nurture a new generation of health professionals who would be best equipped to address present and future health challenges. Webappendix pp 1–5 lists the members of the Commission and its advisory bodies. We pursued research, undertook deliberations, and promoted consultations during 1 year. The brevity of time constrained the scope and depth of consultations, data compilation, and analyses. Our aim was to develop a fresh vision with practical recommendations of specific actions that might catalyse steps towards the transformation of health professional education in all countries, both rich and poor. The work of the Commission is intended to mark the centennial of the 1910 Flexner report, which has powerfully shaped medical education throughout the world. Integrative framework The Commission began by defining its object of study— health professional education. The present division of labour between the various health professions is a social construction resulting from complex historical processes around scientific progress, technological development, economic relations, political interests, and cultural schemes of values and beliefs. The dynamic nature of professional boundaries is underscored by the continuous struggles between different professional groups to delimit their respective spheres of practice. The division of labour at any specific time and in any specific society is much more the result of these social forces than of any inherent attribute of health-related work. In most of this report we continue to refer to the health professions in a conventional manner. We focus on health workers who have completed postsecondary education—typically in universities or other institutions of higher learning that are legally allowed to certify educational attainment by issuing a formal degree. Although this definition does not include most ancillary and community health workers and there has been substantial growth of new occupational categories or specialisations, we focus mostly on the conventional professions, with special emphasis on medicine, nursing￾midwifery, and public health. Our analyses and recommendations are directed at all health professions. However boundaries between health professions are delineated, all are subject to educational processes aimed at developing knowledge, skills, and values to improve the health of patients and populations. There is, therefore, a fundamental linkage between professional education, on the one hand, and health conditions, on the other. For this reason, the Commission developed a framework aimed at understanding of the complex interactions between two systems: education and health (figure 3). By contrast with other frameworks, in which the population is exogenous to health or education systems, ours conceives of the population as the base and the driver of these systems. People generate needs in both education and health, which in turn may be translated into demand for educational and health services. The provision of educational services generates the supply of an educated workforce to meet the demand for professionals to work in the health system. Of course, people are not only recipients of services but actual coproducers of their own education and health. Figure 3: Systems framework Labour market for health professionals Population Demand for health workforce Supply of health workforce Provision Provision Demand Demand Needs Needs Education system Health system See Online for webappendix

The Lancet commissions In this system approach, the interdependence of the In addition to labour market linkages, the education and health and education sectors is paramount. Balance health systems share what could be thought of as a joint between the two systems is crucial for efficiency, subsystem--namely, the health professional education effectiveness, and equity. Every country has its own subsystem. Whereas in a few countries schools for health unique history and legacies of the past shape both the professionals are ascribed to the health ministry, in others present and the future. There are two crucial junctures in they are under the jurisdiction of the education ministry. the framework. The first is the labour market, which Irrespective of this administrative issue, the health governs the fit or misfit between the supply and demand professional education subsystem has its own dynamic of health professionals, and the second is the weak resulting from its location at the intersection of two major capacity of many populations, especially poor people, to societal systems. After all, health-care spaces are also translate their health and educational needs into effective educational spaces, in which the in-service education of demand for the respective services. In optimum future professionals takes place circumstances, there is a balance between population The linkage between the education and the health needs, health-system demand for professionals, and systems should also address the delivery models that upply thereof by the educational system. Educational determine the skill mix of health workers and the scope institutions determine how many of what type of for task shifting. In addition to the managerial aspects, professionals are produced. Ideally they do so in response there is a political dimension, since health professionals labour market signals generated by health institutions, do not act in isolation but are usually organised as interest and these signals should correctly respond to the needs groups. Furthermore, governments very often influence of the population. the supply of health professionals in response to political However, in reality the labour market for health situation more than tomarketrationalityorepidemiological professionals is often characterised by multiple imbal- reality. Lastly, labour markets for health professionals are ances,o the most important of which are undersupply, not only national but also global. In professionals with unemployment, and underemployment, which can be internationally recognised credentials, migration quantitative (less than full-time work) or qualitative growing occurrence. (suboptimum use of skills). To avoid these imbalances, After specification of the linkages between the health the educational system must respond to the requirements and educational spheres, our framework identifies three of the health system. However, this tenet does not imply key dimensions of education: institutional design(which a subordinate position of the education system. We see specifies the structure and functions of the education educational institutions as crucial to transform health system), instructional design(which focuses on processes ystems. Through their research and leadership and educational outcomes(which deal with the desired functions, universities and other institutions of higher results; figure 4). Aspects of both institutional and learning generate evidence about the shortcomings of instructional design were already present in the original the health system, and about potential solutions. reports of the 20th century, - which sought to answer not Through their educational function, they produce only the question of what and how to teach, but also where professionals who can implement change in the to teach-ie, the type oforganisation that should undertake organisations in which they work. the programmes of instruction. However, by contrast with the reports of a century ago, ours considers institutions Structure Process not only as individual organisations, but also as part of an Institutional design Instructional design inter-related set of organisations that implement the diverse functions of an educational system. By adaptation of a framework that was originally dship and governance formulated to understand health-system performance Channels we can think of four crucial functions that also apply to educational systems:(1) stewardship and governance, Organisational level GlobaHocal which encompass instruments such as norms and policies, evidence for decision making, and assessment of rformance to provide strategic guidance for the various components of the educational system;(2)financing, /Networks and partnerships which entails the aggregate allocation of resources to educational institutions from both public and private roposed sources,and the specific modalities for determining resource flows to each educational organisation, with the in education ensuing set of incentives; (3)resource generation, most importantly faculty development; and (4) service provision which refers to the actual delivery of the educational service igure 4: Key components of the educational system and as such reflects instructional design. www.thelancet.com

The Lancet Commissions 10 www.thelancet.com In this system approach, the interdependence of the health and education sectors is paramount. Balance between the two systems is crucial for efficiency, effectiveness, and equity. Every country has its own unique history, and legacies of the past shape both the present and the future. There are two crucial junctures in the framework. The first is the labour market, which governs the fit or misfit between the supply and demand of health professionals, and the second is the weak capacity of many populations, especially poor people, to translate their health and educational needs into effective demand for the respective services. In optimum circumstances, there is a balance between population needs, health-system demand for professionals, and supply thereof by the educational system. Educational institutions determine how many of what type of professionals are produced. Ideally they do so in response to labour market signals generated by health institutions, and these signals should correctly respond to the needs of the population. However, in reality the labour market for health professionals is often characterised by multiple imbal￾ances,50 the most important of which are undersupply, unemployment, and underemployment, which can be quantitative (less than full-time work) or qualitative (suboptimum use of skills). To avoid these imbalances, the educational system must respond to the requirements of the health system. However, this tenet does not imply a subordinate position of the education system. We see educational institutions as crucial to transform health systems. Through their research and leadership functions, universities and other institutions of higher learning generate evidence about the shortcomings of the health system, and about potential solutions. Through their educational function, they produce professionals who can implement change in the organisations in which they work. In addition to labour market linkages, the education and health systems share what could be thought of as a joint subsystem—namely, the health professional education subsystem. Whereas in a few countries schools for health professionals are ascribed to the health ministry, in others they are under the jurisdiction of the education ministry. Irrespective of this administrative issue, the health professional education subsystem has its own dynamic, resulting from its location at the intersection of two major societal systems. After all, health-care spaces are also educational spaces, in which the in-service education of future professionals takes place. The linkage between the education and the health systems should also address the delivery models that determine the skill mix of health workers and the scope for task shifting. In addition to the managerial aspects, there is a political dimension, since health professionals do not act in isolation but are usually organised as interest groups. Furthermore, governments very often influence the supply of health professionals in response to political situation more than to market rationality or epidemiological reality. Lastly, labour markets for health professionals are not only national but also global. In professionals with internationally recognised credentials, migration is a growing occurrence. After specification of the linkages between the health and educational spheres, our framework identifies three key dimensions of education: institutional design (which specifies the structure and functions of the education system), instructional design (which focuses on processes), and educational outcomes (which deal with the desired results; figure 4). Aspects of both institutional and instructional design were already present in the original reports of the 20th century,13–15 which sought to answer not only the question of what and how to teach, but also where to teach—ie, the type of organisation that should undertake the programmes of instruction. However, by contrast with the reports of a century ago, ours considers institutions not only as individual organisations, but also as part of an inter-related set of organisations that implement the diverse functions of an educational system. By adaptation of a framework that was originally formulated to understand health-system performance,51 we can think of four crucial functions that also apply to educational systems: (1) stewardship and governance, which encompass instruments such as norms and policies, evidence for decision making, and assessment of performance to provide strategic guidance for the various components of the educational system; (2) financing, which entails the aggregate allocation of resources to educational institutions from both public and private sources, and the specific modalities for determining resource flows to each educational organisation, with the ensuing set of incentives; (3) resource generation, most importantly faculty development; and (4) service provision, which refers to the actual delivery of the educational service Figure 4: Key components of the educational system and as such reflects instructional design. Institutional design • Systemic level ✓Stewardship and governance ✓Financing ✓Resource generation ✓Service provision • Organisational level ✓Ownership ✓Affiliation ✓Internal structure • Global level ✓Stewardship ✓Networks and partnerships Structure Instructional design Criteria for admission Competencies Channels Career pathways Process Context Global–local Transformative learning Proposed outcomes Interdependence in education

The Lancet commissions The way that the four functions are structured defines Data and methods the systemic level shown in figure 4. Within a system, The conceptual framework was used to guide the individual organisations will vary according to ownership Commissions research, consultations, and report (eg, public, private non-profit, or private for profit), writing. Webappendix pp 6-10 provides detailed data and affiliation (eg, freestanding, part of a health sciences methods for this work. The data consisted of a review of complex, or part of a comprehensive university), and published work, quantitative estimations, qualitative case internal structure(eg, departmental or otherwise). These studies, and commissioned papers, supplemented by are all important aspects of institutional design. Equally consultations with experts and young professionals. We important is the global level. The stewardship function searched all published articles indexed in PubMed and that should be done nationally has a global counterpart, Medline relevant to postsecondary education in medicine, especially with respect to normative definitions about nursing, and public health. Undergraduate medical common core competencies that all health professions educational institutions were compiled by combining should have in every country. An emerging development two major databases: Foundation for the Advancement of globally refers to new forms of organisation, such as International Medical Education and Research(FAIMER) networks and partnerships, which take advantage of and Avicenna, updated by recent regional and countr information and communication technologies data. We estimated public health institutional counts To have a positive effect on the functioning of health from regional association websites, but nursing. systems and ultimately on health outcomes of patients midwifery did not have comparable international data. and populations, educational institutions have to be Because of definitional ambiguity, estimation of public designed to generate an optimum instructional process. health and nursing institutions was incomplete Instructional design involves what can be presented as The numbers of graduates of medicine and nursing. four Cs:(1)criteria for admission, which include both midwifery were derived from both direct reports(eg, from achievement variables, such as previous academic the Organization for Economic Cooperation and performance, and adscription variables, such as social Development [OECDI) and estimates of yearly flows from origin, race or ethnic origin, sex, and nationality, the modelling of nursing stock reported by WHO. We did (2)competencies, as they are defined in the process of not estimate the number of public health graduates designing the curriculum; (3)channels of instruction, because of data and definitional restrictions. by which we mean the set of didactic methods, teaching Financing estimations were calculated through both technologies, and communication media; and (4)career microapproachesandmacroapproaches Microapproaches pathways, which are the options that graduates have on to estimating the financing of medical and nursing completion of their professional studies, as a result of education were based on unit costs of undergraduate the knowledge and skills that they have attained, the education multiplied by number of graduates. We process of professional socialisation to which they have compared these results with macroapproaches that been exposed as students, and their perceptions of calculated the share of tertiary educational financing pportunities in local or global labour markets devoted to medical and nursing education. Although not re 4 precise, the convergence of microapproaches and Different configurations of institutional and macroapproaches provides some assurance that the broad nstructional design will lead to varying educational order of magnitude of our estimations is robust. outcomes. Making the desired results explicit is an essential element in assessment of the performance of Section 2: major findings any system. In the case of our Commission, two The Commissions major findings are presented in four were proposed for the health professional subsections. The first describes a century of educat education system--transformative learning and reforms, grouped into three generations. The next tw interdependence in education. Transformative learning subsections present our diagnosis based on the major is the proposed outcome of improvements in categories of the conceptual framework. Analysis of instructional design; interdependence in education institutional design relies mainly on quantitative data to should result from institutional reforms(figure 4). present a global analysis of institutions, graduates, and Because they are the guiding notions of our financing, followed by key stewardship functions such recommendations, they will be discussed in the final as accreditation, academic systems, faculty development, section of this report and collaboration for shared learning. We then examine A final component of our framework, shown in instructional design, focusing on the purpose, content, figure 4, is that all aspects of the educational system are method, and outcomes of the learning process. deeply affected by both local and global contexts. Challenges are categorised according to the four Cs Although many commonalities might be shared globally, explained in the conceptual framework: criteria for there is local distinctiveness and richness. Such diversity admission, competencies, channels, and career path- rovides opportunities for shared learning across ways. In the final subsection we cut across institutions ountries at all levels of economic development and instruction by examining the challenges of local ww.thelancet.com

The Lancet Commissions www.thelancet.com 11 The way that the four functions are structured defines the systemic level shown in figure 4. Within a system, individual organisations will vary according to ownership (eg, public, private non-profit, or private for profit), affiliation (eg, freestanding, part of a health sciences complex, or part of a comprehensive university), and internal structure (eg, departmental or otherwise). These are all important aspects of institutional design. Equally important is the global level. The stewardship function that should be done nationally has a global counterpart, especially with respect to normative definitions about common core competencies that all health professions should have in every country. An emerging development globally refers to new forms of organisation, such as networks and partnerships, which take advantage of information and communication technologies. To have a positive effect on the functioning of health systems and ultimately on health outcomes of patients and populations, educational institutions have to be designed to generate an optimum instructional process. Instructional design involves what can be presented as four Cs: (1) criteria for admission, which include both achievement variables, such as previous academic performance, and adscription variables, such as social origin, race or ethnic origin, sex, and nationality; (2) competencies, as they are defined in the process of designing the curriculum; (3) channels of instruction, by which we mean the set of didactic methods, teaching technologies, and communication media; and (4) career pathways, which are the options that graduates have on completion of their professional studies, as a result of the knowledge and skills that they have attained, the process of professional socialisation to which they have been exposed as students, and their perceptions of opportunities in local or global labour markets (figure 4). Different configurations of institutional and instructional design will lead to varying educational outcomes. Making the desired results explicit is an essential element in assessment of the performance of any system. In the case of our Commission, two outcomes were proposed for the health professional education system—transformative learning and interdependence in education. Transformative learning is the proposed outcome of improvements in instructional design; interdependence in education should result from institutional reforms (figure 4). Because they are the guiding notions of our recommendations, they will be discussed in the final section of this report. A final component of our framework, shown in figure 4, is that all aspects of the educational system are deeply affected by both local and global contexts. Although many commonalities might be shared globally, there is local distinctiveness and richness. Such diversity provides opportunities for shared learning across countries at all levels of economic development. Data and methods The conceptual framework was used to guide the Commission’s research, consultations, and report writing. Webappendix pp 6–10 provides detailed data and methods for this work. The data consisted of a review of published work, quantitative estimations, qualitative case studies, and commissioned papers, supplemented by consultations with experts and young professionals. We searched all published articles indexed in PubMed and Medline relevant to postsecondary education in medicine, nursing, and public health. Undergraduate medical educational institutions were compiled by combining two major databases: Foundation for the Advancement of International Medical Education and Research (FAIMER) and Avicenna, updated by recent regional and country data. We estimated public health institutional counts from regional association websites, but nursing￾midwifery did not have comparable international data. Because of definitional ambiguity, estimation of public health and nursing institutions was incomplete. The numbers of graduates of medicine and nursing￾midwifery were derived from both direct reports (eg, from the Organization for Economic Cooperation and Development [OECD]) and estimates of yearly flows from the modelling of nursing stock reported by WHO. We did not estimate the number of public health graduates because of data and definitional restrictions. Financing estimations were calculated through both microapproaches and macroapproaches. Microapproaches to estimating the financing of medical and nursing education were based on unit costs of undergraduate education multiplied by number of graduates. We compared these results with macroapproaches that calculated the share of tertiary educational financing devoted to medical and nursing education. Although not precise, the convergence of microapproaches and macroapproaches provides some assurance that the broad order of magnitude of our estimations is robust. Section 2: major findings The Commission’s major findings are presented in four subsections. The first describes a century of educational reforms, grouped into three generations. The next two subsections present our diagnosis based on the major categories of the conceptual framework. Analysis of institutional design relies mainly on quantitative data to present a global analysis of institutions, graduates, and financing, followed by key stewardship functions such as accreditation, academic systems, faculty development, and collaboration for shared learning. We then examine instructional design, focusing on the purpose, content, method, and outcomes of the learning process. Challenges are categorised according to the four Cs explained in the conceptual framework: criteria for admission, competencies, channels, and career path￾ways. In the final subsection we cut across institutions and instruction by examining the challenges of local

The Lancet commissions daptability in an interdependent globalising world. In 1900 Science based Problem based Systems based )200o. view of the huge diversity of health and educational systems, we address the question, how can instructional and institutional design achieve effectiveness in diverse contexts while at the same time harnessing the power of Scientif Problem-based competency driven: local-global global pools and flows of knowledge and other resources institutional Health-education Academic centres Century of reforms To capture historical developments in the past century, we defined three generations of reforms (figure 5. We igure 5: Three generations of reform recognise that, as with all classification schemes, this one simplifies multidimensional realities, so our categories are broad and to some extent arbitrary. Yet, they are informed by historical analyses, and we believe that they have Panel 1: The Flexner, Rose-Welch, and Goldmark reports heuristic value. The word generation conveys the notion that this development is not a linear succession of clear-cut Three seminal US reports( Flexner, Welch-Rose, and Goldmark)had powerful effects reforms. Instead, elements of each generation persist in professional health education in North America, and arguably by extension around the world. All the reports recommended major instructional reforms to integrate the subsequent ones, in a complex and dynamic pattern of change. The first generation, launched at the beginning of modern medical sciences into the core curriculum, and institutional reforms to link the 20th century, instilled a science- based curriculum. education to research and the basing of professional education in comprehensive Around mid-century, the second generation introduced problem-basedinstructionalinnovations. A third generation is now needed that should be systems based The report introduced the modern sciences as foundational for the medical curriculum Most countries and professional institutions have mixed into two successive phases: 2 years of basic biomedical sciences, based in universities, patterns of these reforms. In some countries, most followed by 2 years of clinical training, based in academic medical hospitals and schools are entirely confined to the first generation, with centres. Research was to be viewed not as an end in itself but as a link to improved traditional and stagnant curricula and teaching methods patient care and clinical training. Flexner also changed the doctors education from an and with an inability, or even resistance, to change. I apprenticeship model to an academic model, and his report created the conditions for Many countries are incorporating second-generation the birth of academic medical centres, ushering in a hitherto unknown era of discovery. reforms, and a few are moving into the third generation In 1912, Flexner extended his study of medical education to a group of key European countries. Although the Flexner model of professional education was widely adopted generation. utside the USA and Canada, it has often not been sufficiently adapted to address Although the three generations are bounded in the 20th health in vastly different societal contexts century, we recognise that innovation in medical learning has long and deep historical roots worldwide. Early Welch-Rose report 19154 ystems of medical education were reported in India This report offered two competing visions of public health professional education round 6th century BC in a classical text called Rose s plan was for a national system of public health training with central national Susruta Samhita, and in China with lectureships in schools acting as the focus for a network of state schools, both emphasising public Chinese medicine at the Imperial Academy in 624 AD 7 alth practice. By contrast, Welch s plan called for institutes of hygiene, following the Arab and north African civilisations had flourishing German model, with increased emphasis on scientific research and connections to a medical learning systems, as did the greeks and the medical school in comprehensive universities. Welch's plan was financed by the Mesoamerican civilisations. ,9 In the UK, the Royal Rockefeller Foundation to create the Johns Hopkins School of Public Health and College of Physicians started in the 17th century. Hygiene in 1916, and the Harvard School of Public Health in 1922. Most schools of Educational reforms in the 20th century share roots ublic health in the USA followed the Welch model as independent faculties in going back to social movements and the development of universities Outside the USA and Canada, both institutional models described by Rose the medical sciences in the 19th century. In themid-1800s and Welch were implemented and co-exist to this day. Florence Nightingale l campaigned that good nursing Goldmark report 19236 care saved lives, and good nursing care depended on This report advocated for university-based schools of educated nurses. The first nursing education programme of existing educational facilities for training skilled nu report put nursing on gan in London in 1859, as 2-year hospital-based the same academic trajectory as medicine and public health in the USA, albeit a little training that soon spread quickly in the UK, the USA, later in time. Although major health burdens prevailing at the time-such as infant Germany, and Scandinavian countries. 2 The roots ortality and tuberculosis-had greatly decreased, the importance of an improved modern medicine and public health go back similarly to trained nursing workforce remains, including high standards of nursing educational the mid-1800s, propelled by discoveries that proved the germ theory. By the beginning of the 20th century, the fields of medicine and public health had been left behind www.thelancet.com

The Lancet Commissions 12 www.thelancet.com adaptability in an interdependent globalising world. In view of the huge diversity of health and educational systems, we address the question, how can instructional and institutional design achieve effectiveness in diverse contexts while at the same time harnessing the power of global pools and flows of knowledge and other resources? Century of reforms To capture historical developments in the past century, we defined three generations of reforms (figure 5). We recognise that, as with all classification schemes, this one simplifies multidimensional realities, so our categories are broad and to some extent arbitrary. Yet, they are informed by historical analyses, and we believe that they have heuristic value. The word generation conveys the notion that this development is not a linear succession of clear-cut reforms. Instead, elements of each generation persist in the subsequent ones, in a complex and dynamic pattern of change. The first generation, launched at the beginning of the 20th century, instilled a science-based curriculum. Around mid-century, the second generation introduced problem-based instructional innovations. A third generation is now needed that should be systems based. Most countries and professional institutions have mixed patterns of these reforms. In some countries, most schools are entirely confined to the first generation, with traditional and stagnant curricula and teaching methods and with an inability, or even resistance, to change.18,19 Many countries are incorporating second-generation reforms, and a few are moving into the third generation.52–55 No country seems to have all schools in the third generation. Although the three generations are bounded in the 20th century, we recognise that innovation in medical learning has long and deep historical roots worldwide. Early systems of medical education were reported in India around 6th century BC in a classical text called Susruta Samhita,56 and in China with lectureships in Chinese medicine at the Imperial Academy in 624 AD.57 Arab and north African civilisations had flourishing medical learning systems, as did the Greeks and the Mesoamerican civilisations.58,59 In the UK, the Royal College of Physicians started in the 17th century.60 Educational reforms in the 20th century share roots going back to social movements and the development of the medical sciences in the 19th century. In the mid-1800s, Florence Nightingale61 campaigned that good nursing care saved lives, and good nursing care depended on educated nurses. The first nursing education programme began in London in 1859, as 2-year hospital-based training that soon spread quickly in the UK, the USA, Germany, and Scandinavian countries.62 The roots of modern medicine and public health go back similarly to the mid-1800s, propelled by discoveries that proved the germ theory. By the beginning of the 20th century, the fields of medicine and public health had been left behind Panel 1: The Flexner, Rose-Welch, and Goldmark reports Three seminal US reports (Flexner, Welch-Rose, and Goldmark) had powerful effects in professional health education in North America, and arguably by extension around the world. All the reports recommended major instructional reforms to integrate modern medical sciences into the core curriculum, and institutional reforms to link education to research and the basing of professional education in comprehensive universities. Flexner report 191013 The report introduced the modern sciences as foundational for the medical curriculum into two successive phases: 2 years of basic biomedical sciences, based in universities, followed by 2 years of clinical training, based in academic medical hospitals and centres. Research was to be viewed not as an end in itself but as a link to improved patient care and clinical training. Flexner also changed the doctor’s education from an apprenticeship model to an academic model, and his report created the conditions for the birth of academic medical centres, ushering in a hitherto unknown era of discovery. In 1912, Flexner extended his study of medical education to a group of key European countries.63 Although the Flexner model of professional education was widely adopted outside the USA and Canada, it has often not been sufficiently adapted to address health in vastly different societal contexts. Welch-Rose report 191514 This report offered two competing visions of public health professional education. Rose’s plan was for a national system of public health training with central national schools acting as the focus for a network of state schools, both emphasising public health practice. By contrast, Welch’s plan called for institutes of hygiene, following the German model, with increased emphasis on scientific research and connections to a medical school in comprehensive universities. Welch’s plan was financed by the Rockefeller Foundation to create the Johns Hopkins School of Public Health and Hygiene in 1916, and the Harvard School of Public Health in 1922. Most schools of public health in the USA followed the Welch model as independent faculties in universities. Outside the USA and Canada, both institutional models described by Rose and Welch were implemented and co-exist to this day. Goldmark report 192316 This report advocated for university-based schools of nursing, citing the inadequacies of existing educational facilities for training skilled nurses. The report put nursing on the same academic trajectory as medicine and public health in the USA, albeit a little later in time. Although major health burdens prevailing at the time—such as infant mortality and tuberculosis—had greatly decreased, the importance of an improved trained nursing workforce remains, including high standards of nursing educational attainment. Figure 5: Three generations of reform 1900 Science based Problem based Systems based 2000+ Scientific curriculum Problem-based learning Competency driven: local–global Instructional University based Academic centres Health-education systems Institutional

The Lancet commissions by scientific advances, with no rigorous standards of examples, including several in the Arabian countries and education and practice based on modern foundations. south Asia, show the capacity of public health academic After developments in western Europe, the first institutions to respond to diverse and rapidly changing about the public generation of 20th century reforms in North America local requirements(panel 2) ndation of India see were sparked by such reports as Flexner(1910), In parallel with the increasing engagement of national w-phfLorg/ which launched modern health sciences into classrooms reforms began after World War 2 both in industrialised ro mores althseehttp://www dentistry, respectively(panel 1). These reforms, which were independence from colonialism. 7 School and university bracuniversitynet/&S/sph/ usually sequencing education in the biomedical sciences followed by training in clinical and public health practice, Panel 2: Adaptation of public health education and research to local priorities were joined by similar efforts in other regions. Curricular reform was linked to institutional transformation- Several public health institutes have developed over recent decades in response to very university bases, academic hospitals linked to universities, diverse local contexts. We present inovations in three regions: Arabian countries, closure of low.-quality proprietary schools, and the bringing Mexico, and south Asia. gether of research and education. The goals were to Institute of Community and Public Health, Birzeit University, occupied Palestinian n dvance scientifically based professionalism with high territory, is one of three independent schoolsof public health linked to leading technical and ethical standards American philanthropy, led by the Rockefeller of Alexandria in Egypt is a large institution founded in 1956; and the Faculty of Health Foundation, the Carnegie Foundation for the Advancement Sciences, American University of Beirut(AUB), Lebanon, was established as separate from and other similar organisations, promoted AUB's medical school in 1954 and achieved accreditation of its graduate public health these educational reforms by financing the establishment programme from the US Council on Education for Public Health in 2006. All were of dozens of new schools of medicine and public health uniquely shaped by national contexts, ranging from a strong state in Egypt to civil the USA and elsewhere. 2 years after the publication of conflict in Lebanon, to absent state structures in the occupied Palestinian territory. All his original report, which focused on the USA and Canada ive adopted different approaches to public health: application of evidence-based Flexner"extended his study of medical education to the interventions to improve health-care delivery and environmental health in Egypt: German Empire, Austria, France, England, and Scotland. xpansion of multisectoral developmental public health practice in Lebanon; and focus on infuence went beyond nations in social determinants of health necessitating actions inside and outside the health sector in The so-called flexner model was translated into action through the establishment of new medical schools, the e occupied Palestinian territory earliest and most prominent being the Peking Union National Institute of Public Health of Mexico(NIPH), "founded in 1987, responded to Medical College founded in China by the Rockefeller rapid national economic and social change, striving to balance excellence in its research Foundation and implemented by its China Medical Board and educational mission with relevance to decision making through proactive translation in1917635 of knowledge into evidence for policy and practice. The Institute widely disseminated a In public health, the earlier experiences at the London conceptual base around the essential attributes of public health; developed educational School of Tropical Medicine, Tulane University, and the programmes across diverse areas of concentration; implemented a wide range of Harvard-MIT School for Health Officers were affected by innovative educational approaches, from short courses to doctoral programmes; and the Welch-Rose report, "which paved the way for a major developed sound evidence that supported the design, implementation, and evaluation of growth in new schools starting with the Johns Hopkins the ongoing health reform initiative for universal coverage. The success of the NIPH School of Hygiene and Public Health(1916), the Harvard underscores the crucial importance of national and international networking to School of Public Health(1922), the School of Public thstand local difficulties by sharing of experiences to build a strong health-research Health of Mexico(1922), a renewed London School of system that is able to tackle a vast array of local and global health challenges. Hygiene and Tropical Medicine(1924), and the University The Public Health Foundation of India is a unique private-public partnership to energise of Toronto School of Public Health(1927). The Welch. public health by bringing together pooled resources from the Indian Government and Rose model was also exported through Rockefellers private philanthropy to address Indias priority health challenges. The Foundation is funding of 35 new schools of public health overseas, as crafting partnerships with four state governments to create eight training institutes of amplified by the School of Public Health of Mexico, public health in the country. The BRACUniversity's School of Public Health, named which was established in 1922 as part of the Federal after UNICEF's visionary leader James P Grant, was launched by the worlds largest This mass-scale export and adoption had mixed non-governmental organisation and offers an innovative 12-month curriculum for outcomes, with useful results in some countries but also basic public health skills in the context of rural health action, followed by the remaining evere misfits in others. In 1987, the pioneering Mexican 6 months of thematic and research training. These two public health initiatives in south school underwent major reform when it merged with the Asia were based on the legacy of British colonialism, which focused exclusively on medical Centre for Public Health Research and the Centre for rather than public health schools. Importantly, both these schools are developing new Infectious disease research to form the National institute urricula shaped to national and global priorities, and neither is adopting wholesale the of Public Health--one of the leading institutions of its Welch-Rose model of public health education type in the developing world. Many other innovative ww.thelancet.com

The Lancet Commissions www.thelancet.com 13 by scientific advances, with no rigorous standards of education and practice based on modern foundations. After developments in western Europe, the first generation of 20th century reforms in North America were sparked by such reports as Flexner (1910),13 Welch-Rose (1915),14 Goldmark (1923),15 and Gies (1926),16 which launched modern health sciences into classrooms and laboratories in medicine, public health, nursing, and dentistry, respectively (panel 1). These reforms, which were usually sequencing education in the biomedical sciences followed by training in clinical and public health practice, were joined by similar efforts in other regions. Curricular reform was linked to institutional transformation— university bases, academic hospitals linked to universities, closure of low-quality proprietary schools, and the bringing together of research and education. The goals were to advance scientifically based professionalism with high technical and ethical standards. American philanthropy, led by the Rockefeller Foundation, the Carnegie Foundation for the Advancement of Teaching, and other similar organisations, promoted these educational reforms by financing the establishment of dozens of new schools of medicine and public health in the USA and elsewhere.64 2 years after the publication of his original report, which focused on the USA and Canada, Flexner63 extended his study of medical education to the German Empire, Austria, France, England, and Scotland. But the influence went beyond nations in western Europe. The so-called Flexner model was translated into action through the establishment of new medical schools, the earliest and most prominent being the Peking Union Medical College founded in China by the Rockefeller Foundation and implemented by its China Medical Board in 1917.63,65 In public health, the earlier experiences at the London School of Tropical Medicine, Tulane University,66 and the Harvard-MIT School for Health Officers were affected by the Welch-Rose report,14 which paved the way for a major growth in new schools starting with the Johns Hopkins School of Hygiene and Public Health (1916), the Harvard School of Public Health (1922), the School of Public Health of Mexico (1922), a renewed London School of Hygiene and Tropical Medicine (1924), and the University of Toronto School of Public Health (1927). The Welch￾Rose model was also exported through Rockefeller’s funding of 35 new schools of public health overseas, as exemplified by the School of Public Health of Mexico, which was established in 1922 as part of the Federal Department of Health. This mass-scale export and adoption had mixed outcomes, with useful results in some countries but also severe misfits in others. In 1987, the pioneering Mexican school underwent major reform when it merged with the Centre for Public Health Research and the Centre for Infectious Disease Research to form the National Institute of Public Health—one of the leading institutions of its type in the developing world.67 Many other innovative examples, including several in the Arabian countries and south Asia, show the capacity of public health academic institutions to respond to diverse and rapidly changing local requirements (panel 2). In parallel with the increasing engagement of national governments in health affairs, a second generation of reforms began after World War 2 both in industrialised and in developing nations, many of which had just gained independence from colonialism.71 School and university Panel 2: Adaptation of public health education and research to local priorities Several public health institutes have developed over recent decades in response to very diverse local contexts. We present innovations in three regions: Arabian countries, Mexico, and south Asia. Institute of Community and Public Health, Birzeit University, occupied Palestinian territory, is one of three independent schools of public health linked to leading universities in the Arab region; the High Institute of Public Health (HIPH) at the University of Alexandria in Egypt is a large institution founded in 1956; and the Faculty of Health Sciences, American University of Beirut (AUB), Lebanon, was established as separate from AUB’s medical school in 1954 and achieved accreditation of its graduate public health programme from the US Council on Education for Public Health in 2006. All were uniquely shaped by national contexts, ranging from a strong state in Egypt to civil conflict in Lebanon, to absent state structures in the occupied Palestinian territory. All have adopted different approaches to public health: application of evidence-based interventions to improve health-care delivery and environmental health in Egypt; expansion of multisectoral developmental public health practice in Lebanon; and focus on social determinants of health necessitating actions inside and outside the health sector in the occupied Palestinian territory.68 National Institute of Public Health of Mexico (NIPH),69 founded in 1987, responded to rapid national economic and social change, striving to balance excellence in its research and educational mission with relevance to decision making through proactive translation of knowledge into evidence for policy and practice. The Institute widely disseminated a conceptual base around the essential attributes of public health; developed educational programmes across diverse areas of concentration; implemented a wide range of innovative educational approaches, from short courses to doctoral programmes; and developed sound evidence that supported the design, implementation, and evaluation of the ongoing health reform initiative for universal coverage. The success of the NIPH underscores the crucial importance of national and international networking to withstand local difficulties by sharing of experiences to build a strong health-research system that is able to tackle a vast array of local and global health challenges. The Public Health Foundation of India is a unique private–public partnership to energise public health by bringing together pooled resources from the Indian Government and private philanthropy to address India’s priority health challenges. The Foundation is crafting partnerships with four state governments to create eight training institutes of public health in the country.70 The BRAC University’s School of Public Health, named after UNICEF’s visionary leader James P Grant, was launched by the world’s largest non-governmental organisation and offers an innovative 12-month curriculum for masters in public health that begins with 6 months on its Savar rural campus acquiring basic public health skills in the context of rural health action, followed by the remaining 6 months of thematic and research training. These two public health initiatives in south Asia were based on the legacy of British colonialism, which focused exclusively on medical rather than public health schools. Importantly, both these schools are developing new curricula shaped to national and global priorities, and neither is adopting wholesale the Welch-Rose model of public health education. For more about the Public Health Foundation of India see http://www.phfi.org/ For more about BRAC University’s School of Public Health see http://www. bracuniversity.net/I&S/sph/

The Lancet commissions development was accompanied by expansion of tertiary Before the centennial of the Flexner report, a series of hospitals and academic health centres that trained health initiatives have once again heightened national and professionals, did research, and provided care, thereby global attention about the future of education of health integrating these three areas of activity. Pioneered in professionals. We summarise four sets of major reports the 1950s was the idea of graduate medical education that focus on education of the global health workforce, as postgraduate training, which was similar to an nursing education, public health education, and medical apprenticeship, through residency programmes in education. Recommendations in these reports are ea academ increasingly coalescing into a third generation of reforms The major instructional breakthroughs from the second that emphasise patient ar generation of reforms were problem-based learning and competency-based curriculum, interprofessional and disciplinarily integrated curricula In the 1960s, McMaster team-based education, IT-empowered learning, and University in Canada pioneered student-centred learning policy and management leadership skills. These areas based on small groups as an alternative to didactic lecture. we believe, provide a strong base for formulation of style teaching. Simultaneously, an integrated rather than reform initiatives into the 21st century discipline-bound curriculum was experimentally de- Global workforce education has witnessed a major eloped in Newcastle in the UK and Case Western resurgence of policy attention, partly driven by imperatives Reserve in the USA. 5 Other curricular innovations to achieve national and global health objectives as set out included standardised patients-ie, individuals who are by the Millennium Development Goals(MDGs). Three trained to act as a real patient to simulate a set of major reports are noteworthy in terms of education and symptoms or problemsto assess students on practice, training of the workforce: Task Force on Scaling-Up and trengthening doctor-patient relationships through Saving Lives, World Health Report, and the Joint Learning facilitated group discussions, 7 and broadening the Initiative. These reports all underscore the centrality of continuum from classroom to clinical training through the workforce to well performing health systems to achieve earlier student exposure to patients and an expansion of national and global health goals. All the reports draw training sites from hospitals to communities. - In public attention to the global crisis of workforce shortages health, disciplines expanded along with multidisciplinary estimated worldwide at 2.4 million doctors and nurses in work, and in nursing there was accelerated integration of 57 crisis countries. The crisis is most severe in the worlds schools into universities, with advanced graduate poorest nations that are struggling to achieve the MDGs programmes at the master and doctoral levels particularly in sub-Saharan Africa. The shortages also emphasise associated issues, including imbalances of skill Panel 3: Women and nursing in Islamic societies mix, negative work environment, and maldistribution of health workers. The reports cite imbalanced labour market Women and nursing in Islamic societies has a long and rich dynamics that are failing to ensure adequate rural coverage history. In the Middle East and north Africa, higher education hile generating unemployed professionals in capital nursing started in 1955 when the first Higher Institute of cities, and the international migration of professionals or more about Nursing in the region was established in the Faculty of from poor to rich countries Medicine of the Egyptian University of Alexandria. Endorsed These reports recommend vastly increasing investment WHO, the Institute offered a bachelor of nursing degree. The Institute became an autonomous faculty affiliated to the in education and training. They concentrate on basic workers because of the importance of primary health care University in 1994, offering both masters and doctoral and the long time lag and high costs of postsecondary degrees in nursing sciences. During the past 50 years, the education. Consequently, health professionals, although faculty of nursing has produced more than 6000 graduates, acknowledged, do not receive much attention.These many assuming leadership in the region. rts, however, are sparking growing interest in task nother pioneer is the Aga Khan University School of shifting and task sharing-a process of delegating practical Nursing, which was established in Pakistan in 1980, and tasks from scarce professionals to basic health workers. which began offering a bachelor of science in nursing in 1997 All reports propose increased investment, sharing of and the masters of science in 2001. " The school has devised a resources, and partnerships within and across countries unique curriculum adapted to local contexts but based on the Nursing education is the focus of three major reports in curriculum recommended by the American Association of 2010: Radical transformation, by the Carnegie Foundation olleges of Nursings Essentials of Masters Education in Frontline care. a UK Prime minister commission: 2 and the Robert Wood Johnson Foundation Initiative on the future expanded the bachelors and masters nursing programmes to of nursing, at the US Institute of Medicine. "The Carnegie its campus in east Africa In addition to training nurses, report concluded that although nursing has been effective these advanced degree programmes attract high-quality in promotion of professional identity and ethical candidates in Islamic society, showing societal prestige and comportment, the challenge remains of anticipating value for women entering the nursing profession changing demands of practice through strengthening of scientific education and integration of classroom and www.thelancet.com

The Lancet Commissions 14 www.thelancet.com development was accompanied by expansion of tertiary hospitals and academic health centres that trained health professionals, did research, and provided care, thereby integrating these three areas of activity. Pioneered in the 1950s was the idea of graduate medical education as postgraduate training, which was similar to an apprenticeship, through residency programmes in hospital-based academic centres.72 The major instructional breakthroughs from the second generation of reforms were problem-based learning and disciplinarily integrated curricula. In the 1960s, McMaster University in Canada pioneered student-centred learning based on small groups as an alternative to didactic lecture￾style teaching.73 Simultaneously, an integrated rather than discipline-bound curriculum was experimentally de￾veloped in Newcastle in the UK and Case Western Reserve in the USA.74,75 Other curricular innovations included standardised patients—ie, individuals who are trained to act as a real patient to simulate a set of symptoms or problems—to assess students on practice,76 strengthening doctor–patient relationships through facilitated group discussions,77 and broadening the continuum from classroom to clinical training through earlier student exposure to patients and an expansion of training sites from hospitals to communities.78–81 In public health, disciplines expanded along with multidisciplinary work, and in nursing there was accelerated integration of schools into universities, with advanced graduate programmes at the master and doctoral levels. Before the centennial of the Flexner report, a series of initiatives have once again heightened national and global attention about the future of education of health professionals. We summarise four sets of major reports that focus on education of the global health workforce, nursing education, public health education, and medical education. Recommendations in these reports are increasingly coalescing into a third generation of reforms that emphasise patient and population centredness, competency-based curriculum, interprofessional and team-based education, IT-empowered learning, and policy and management leadership skills. These areas, we believe, provide a strong base for formulation of reform initiatives into the 21st century. Global workforce education has witnessed a major resurgence of policy attention, partly driven by imperatives to achieve national and global health objectives as set out by the Millennium Development Goals (MDGs). Three major reports are noteworthy in terms of education and training of the workforce: Task Force on Scaling-Up and Saving Lives, 20 World Health Report, 19 and the Joint Learning Initiative. 18 These reports all underscore the centrality of the workforce to well performing health systems to achieve national and global health goals. All the reports draw attention to the global crisis of workforce shortages estimated worldwide at 2·4 million doctors and nurses in 57 crisis countries. The crisis is most severe in the world’s poorest nations that are struggling to achieve the MDGs, particularly in sub-Saharan Africa. The shortages also emphasise associated issues, including imbalances of skill mix, negative work environment, and maldistribution of health workers. The reports cite imbalanced labour market dynamics that are failing to ensure adequate rural coverage while generating unemployed professionals in capital cities, and the international migration of professionals from poor to rich countries. These reports recommend vastly increasing investment in education and training. They concentrate on basic workers because of the importance of primary health care and the long time lag and high costs of postsecondary education. Consequently, health professionals, although acknowledged, do not receive much attention. These reports, however, are sparking growing interest in task shifting and task sharing—a process of delegating practical tasks from scarce professionals to basic health workers. All reports propose increased investment, sharing of resources, and partnerships within and across countries. Nursing education is the focus of three major reports in 2010: Radical transformation, by the Carnegie Foundation; Frontline care, 9 a UK Prime Minister commission;12 and the Robert Wood Johnson Foundation Initiative on the future of nursing, at the US Institute of Medicine.82 The Carnegie report concluded that although nursing has been effective in promotion of professional identity and ethical comportment, the challenge remains of anticipating changing demands of practice through strengthening of scientific education and integration of classroom and Panel 3: Women and nursing in Islamic societies Women and nursing in Islamic societies has a long and rich history. In the Middle East and north Africa, higher education in nursing started in 1955 when the first Higher Institute of Nursing in the region was established in the Faculty of Medicine of the Egyptian University of Alexandria. Endorsed by WHO, the Institute offered a bachelor of nursing degree. The Institute became an autonomous faculty affiliated to the University in 1994, offering both masters and doctoral degrees in nursing sciences. During the past 50 years, the faculty of nursing has produced more than 6000 graduates, many assuming leadership in the region. Another pioneer is the Aga Khan University School of Nursing, which was established in Pakistan in 1980, and which began offering a bachelor of science in nursing in 1997 and the masters of science in 2001.83 The school has devised a unique curriculum adapted to local contexts but based on the curriculum recommended by the American Association of Colleges of Nursing’s Essentials of Master’s Education in Advanced Nursing (1996).84 Aga Khan University has also expanded the bachelors and masters nursing programmes to its campus in east Africa.83 In addition to training nurses, these advanced degree programmes attract high-quality candidates in Islamic society, showing societal prestige and value for women entering the nursing profession. For more about the Faculty of Nursing at the University of Alexandria see: http://www. alexnursing.edu.eg