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.comThe 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