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.comThe 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