•
WORLD HEALTH ORGANIZATION
REGIONAL OFFICE FOR THE WESTERN PACIFIC BUREAU RtGIONAL DU PACIFIQUE OCCIDENTAL
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ORGANISATION MONDIALE , DE LA SANTE
REGIONAL COMMITTEE Thirty-second session Seoul 22-28 September 1981
WPR/RC32/l2 24 July 1981
ORIGINAL:
ENGLISH
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Provisional agenda item 17
REVIEW OF THE FELLOWSHIP PROGRAMME
The following report 1S presented to the Regional Commi ttee in pursuance of resolution WPR/RC30.R17, which requests the Regional Director "to continue evaluation of the fellowship programme, particularly of the utilization of former fellows on return to their home countries". After review and discussion by the Regional Committee, the report will provide a subs tantive input to the discussions at the sixty-ninth session of the WHO Executive Board in January 1982, at which the subject of Health manpower development: use of fellowships will be discussed.
WPR/RC32/12 page 2
1.
INTRODUCTION
The WHO programme of fellowships and related educational act1.V1. ties enables health workers to undertake courses of study which are not available in their home countries. Fellowships are an important resource used by countries to meet the manpower demands of evolving national health delivery systems, and the programme 1S thus a major component of WHO collaborative activity. The key issue in reviewing whether it has contributed to manpower plan aimed at meeting fellowships are only one of the of speci fic programmes, another training capability, the answers often be affected by changes 1.n turn will dictate how fully the knowledge and attitudes. the fellowship programme is to determine the implementation of an overall health the needs of the health system. Since approaches used to achieve the objectives being the development of national heal th are not easy to obtain. Their impact will the health system of the country, which in heal th workers utilize their new skills,
....
_
It will be realized that such an evaluation should be done at country level and will be most effective when the programme can be measured against health manpower plans and programmes.
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2.
PRESENT SITUATION
Most, if not all, countries or areas are faced with at least one of two main categories of manpower constraint, which the fellowship programme proposes to alleviate: (1) There is a shortage of the health personnel required to implement and develop health programmes, which may be due to: (a) the inadequacy of existing training facilities, including an insufficient number of qualified teachers; unavailability of training programmes 1.n some fields, because of the scarcity of national resources and the limited needs in term of numbers of such personnel required.
(b)
(2)
Even when qualified manpower have been trained locally, they may feel the need for an international exchange of knowledge and techniques related to health matters. This need is particularly acute with regard to recent developments in such fields as appropriate technology for health, primary health care, control of communicab Ie diseases, heal th information systems, and management processes.
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WPR/RC32/l2 page 3
3.
OBJECTIVES
As a strategy for achieving health for all by the year 2000, the objectives have been established to alleviate, at least following partially, the constraints brought about by the aforementioned situation; (1)
to train national health staff outside their countries of origin in order to support health programmes of priority to the countries of origin; to strengthen national training institutions through the training abroad of health teachers, both in their technical areas and in teaching methodology; to provide opportunities for exchanging views between experienced health workers of different countries;
( 2)
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(3)
4•
APPROACHE S
To achieve the objectives, one or more of the following approaches are being used; (1)
Provision of basic training in medical, nursing or allied health fields, when such training is not available locally. Provision of training for health workers at the post-basic or post-graduate level through formal (academic) training. As far as possible, care is taken to select the training programme most relevant to the country's needs and not necessarily a programme leading to a higher degree. If required, a few ad hoc training programmes may also be developed directly by WHO to accommodate fellows. Provision of training through attachment to service institutions stressing the acquisition of skills rather than formal studies • Provision of teacher training, either as a full-time study or as part of other types of training programme. course of
(2)
(3)
..... (4)
(5)
Promotion of training in the most appropriate environment, preferably within the Western Pacific Region or 1.n a similar environment. Making available in the Region fellows from other regions. facilities for the training of
(6)
(7)
Organization of short study tours in one or more countries for exper ienced heal th workers to allow the exchange of ideas and technical cooperation, particularly in innovative fields.
WPR/RC32/l2 page 4
5. MAJOR ACTIVITIES 1S
The following May 1981.
a summary of activities during the period May 1979 to
Eight-hundred and seventy-six awards were made, to which may be added 612 participants in short group educational activities organized direcny by the Regional Office. Twenty-six countries or areas of the Region made use of the fellowship programme. The number of awards ranged from 148 fellows from China to one fellow from French Polynesia. One area which did not request fellowships sent participants to group educational activities organized by WHO. Fellowships were awarded in priority to programme areas such as health services development, including primary health care (34.5%), family health (16%), and prevention and control of communicable diseases (15%). Fifty-six per cent. of the fellows studies in the Western Pacific Region. Sixteen per cen t. 0 f the than the WHO regular budget. fellows undertook at least part of their
~
were supported
from sources
other
6.
REVIEW OF FELLOWSHIP UTILIZATION
A study was conducted in early 1981, 1n which the WHO Programme Coordinators were asked to follow up all fellows who had been awarded fellowships of twelve weeks or more in 1978. There were 172 such fellows. The WHO Programme Coordinators used a questionnaire as the follow up tool and were able to provide information on 78% of the study sample. The detailed results of the survey are given in the attached Annex. The durations of the fellowships were fairly equally spaced between short-term (3 to 6 months) 32%, medium-term (6 to 12 months) 31%, and long-term (12 months or longer) 37%. The study also confirmed Regional Office policy of placing fellows in the Region whenever possible, and showed that 69% of the fellows undertook studies 1n countries of the Western Pacific Region. Most health professions were represented among the fellows, 30% of whom were medical graduates. The fields of study of the fellows were quite varied. However, the WHO programme area of heal th services development accounted for the major portion of the fellowships, namely 43%. Othet programme areas included family health (11%), communicable disease prevention and control (5%), noncommunicable disease prevention and control (8%), prophylactic, diagnostic and therapeutic substances (5%), promotion of environmental health (14%), health information (4%) and other categories of training (10%).
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...
WPR/RC32/l2 page 5
Of the fellows on whom information was collected, only 2% were apparently lost to their countries. 83% returned to their countries of origin and were sti11 there in 1981. Of the remaining 17%, a total of 9% were still studying outside their countries of or1g1n and 6% did not respond to the question. Of the fe110ws still in their countries of origin, 87% were employees of the ministry of health or of other government departments. Ten per cent. were working in universities and 3% in other types of agency in the private sector. The study has also shown that 80% of the fellows return to a service delivery position while 14.5% return to teaching responsibilities. Another 3.5% are involved primarily in research. Two per cent. did not answer the questionnaire. Finally, 92% of the fellows indicated that the training they received was either essential or, at least, partially useful to their present responsibilities. Seven per cent. found the training only marginally use ful or not useful at all. However, relevance as determined by a fellow is highly subjective, since, because of the fellowship, he often benefits through promotion or increased status. Ultimately, relevance must be measured against cledrly stated objectives and national health manpower and service delivery priorities.
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7.
FELLOWSHIP FUNDING
A separate review of fellowship funding for the year 1979 has been undertaken. In 1979, US$2 928 500 was earmarked for fellowships, representing 20% of the total regional budget. The health manpower development regular budget amounted to US$3 324 200, corresponding to 23% of the total budget, wi th US$l 983 900 going to fellowships. Fellowships in health manpower development represented 60% of the health manpower development budget and 68% of the total fellowship budget. I t is important to note that the health manpower development budget provides for long- and short-term staff, meetings and seminars, supplies and equipment in addition to fellowships. Fellowships budgeted under other progrannnes amounted to US$944 600, representing 8% of the budget for those programmes and 32% of the total fellowship budget. Overall implementation of fellowship funding was 80%.
8.
MEASURES TAKEN TO IMPROVE THE EFFICIENCY AND EFFECTIVENESS OF THE PROGRAMME
Constant modifications are being made to enhance efficiency and effectiveness, and improvements have been introduced by the Regional Office with respect to both the technical and the administrative management of the fellowship progranune.
WPR/RC32/l2 page 6
The improvements include the (1)
followjng~
Special attention is being given to relating specific country programmes and projects.
fellowships
to
(2)
Fellowships are being awarded for the training of supervisors and persons 1.n charge of fellowship programmes in r('!ceiving countries. The purpose is to familiarize them with various fellowship management methods and also with the environment of the students, 1.n order to adjust their training programmes accordingly. Procedures have been improved to facilitate language testing and training. In order to provide more time to arrange the most suitable training programme, a more active follow up and strict enforcement of Regional Office rules concerning the submission of late applications are being applied. Better mOl~itoring of the management of fellowships assured through the development of a review list, updated and communicated to the WHO country offices. has been regularly
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(3)
(4)
( 5)
(6)
Greater flexibility has been introduced l.n adjusting stipend rates for short-term fellowships. Provisions have been made for appropriate increases in stipends, to cover short stays in countries, which involve additional living expenses. Stipend rates are also being revised more frequently than in the past to meet the rapidly increasing cost of living. Provisions for been improved. medical insurance coverage 0
(7)
f
the
fellows
have
( 8)
A meeting of nationa1 fell owsh ip 0 fficers is planned 1.n the biennium 1982-1983 to create a better understanding between countries, define more precisely the common problems, and introduce more efficient management practices.
I t should be noted in parenthesis that fellowship applications should contain clear descriptions of training objectives. The objectives developed by the sending country should speci fy the skills and knowledge that the training experience should provide, and should be clearly consistent with the overall objectives and strategies of the national health manpower and service delivery plans.
In addition, fields of study for proposed fellowships should normally be indicated when details of the programme for the next biennium are submitted to WHO. This procedure enables all parties concerned to ascertain the relevance and relationship of the proposed studies to the other programme components. I t also facilitates budgetary estimates and avoids many of the difficulties that ar1.se when this procedure 1.S not followed.
WPR/RC32/12 page 7/8
9.
SUMMARY
The fellowship programme now has clearly defined objectives and approaches. Most countries are making full and enthusiastic use of fellowship provisions. When their fellowship progrannnes are linked with national health plans and health manpower practices, the progrannne can fully realize its potential as an effective part of the strategy for health for all by the year 2000. In addi tion , timely processing of fellowships at country and WHO levels will avoid delays and cancellations. A clear statement of the training objectives would help identify the most suitable place of study.
WPR/RC32/l2 page 9
ANNEX 1
REVIEW OF UTILIZATION OF FELLOWS
1.
Introduction
One of the key issues in the fellowship programme is to ascertain whether the national staff trained abroad are utilized in support of the priority health programmes of their countries. Almost from the inception of the WHO fellowship programme, a procedure has been in force for evaluating the extent to which the knowledge and skills acquired by a former fellow during his period of study are utilized on his return home. This procedure takes into account the follow-up reports sent by fellows to the Regional Office one to two years after the completion of studies. The report includes a statement by the government concerning the employment of the fellow and his contribution to the health serVl.ces. Such attempts to evaluate fellowships have, in the past, been hampered by the fact that a substantial proportion of fellows do not submit reports. Governments have been asked to see that they are prepared regularly, but this request seems to have had little effect. In 1977, a sample of 73 fellowships which had terminated in 1976 was examined. In only two cases (3%) had reports been received. Neither of them was endorsed by the government. Even in these two cases, it was not possible to assess the fellows' usefulness to the national health services. In 1980/81, recognizing the very severe constraints which limit the effectiveness of the regular evaluation procedure, it was decided to carry out a simple review of the utilization of a well-identified sample of former fellows. 2. Objectives of the review
The objectives of the review were to determine the extent to which former fellows were utilized on return to their home countries and to answer more specifically the following questions~ (1) (2) What proportion of fellows, if any, did not return? What proportion returned to work in government or government-related agencies, and what functions did they perform? Had they been promoted to posts of increased responsibility? Was the training responsibilities? received perceived as relevant to their
(3) (4)
( 5)
Were the fellows involved 1n further collaboration with WHO or more generally in activities related to technical cooperation between countries? Had they received further training?
(6)
WPR/RC32/l2 Annex 1 page 10
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3. 3.1
Me thodo logy Selection of sample The sample selected for the study was defined as follows;
"Fellows who had been awarded a fellowship of 12 weeks or more in 1978". This criterion for selection was based on the belief that 12 weeks was the minimum duration of a fellowship which would be likely to have an impact on the career of a fellow. Most fellows who started in 1978 would have had time to return home and to contribute through their newly acquired skills and knowledge to national health development activities. On the other hand, they would be more eas'ily traceable than fellows who had completed their studies earlier. 3.2 Method of follow-up
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Since it had never proved satisfactory to rely on correspondence with ex-fellows, it was felt that the most efficient method of collecting data would be through the> WHO Programme Coordinators. Depending on the local situations, they would consult government offices and/or the ex-fellows themselves if necessary and feasible. Individual three areas; ques tionnaires were therefore devised to include data in
background of the fellow pr10r to award of the fellowship the fellowship itself the post-fellowship period The first two areas served to provide profiles of the fellows which could be related to the post-fellowship period. The completed individual questionnaires were analysed in the Regional Office. 4. Resul ts sent out; 134 were
One hundred and seventy-two questionnaires were returned. This represented a response rate of 78%. 4.1 Background of fellow (prior to fellowship)
Age: 90% (121) were between 25 and 54; 6% (8) were under 25, and 4% (5) were over 55. Most of the fellowships were therefore awarded to staff who were mature but young enough to remain in active service for several years. Sex; 72% (97) were male and 28% (37) female.
WPR/RC32/12 Annex 1 page 11
Qualifications: functions of the
The
following
table
sets
out
the
qualifications
or
fellows~
Function/Qualification Medical graduates Nurses Environmental health personnel Scientists/engineers
Number 41
Percen ta Sf'
30.5% 18%
24
12 10
9%
7.5% 6%
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School leavers Den tis ts Laboratory technicians Pharmacists Statisticians Social workers/ medical assistants Health educators Architects X-ray technicians
8 7
5% 5% 4% 4%
7 5 5
3
2% 2% 2% 1.5% 3%
3 3 2
4.2
Vnspeci fied
4
It will be seen that most health-related disciplines are represented. Fellowship period
Duration Less than s~x months From s~x months to less than one year One year or more Place of study ~42)
=
32% (43) 31% (42)
37% (49)
69% (92) studied 1.0 countries of the Western Pacific Region and 31% in other regions, the majority in the Americas and Europe.
WPR/RC32/l2 Annex 1 page 12
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Field of study Fields of study are listed according to the current WHO progranune classification structure. Fellowships awarded under the health manpower development progranune have been reclassified according to the actual field of study; Health services development Family heal th Communicable disease prevention and control Nonconununicable disease prevention and control Prophylactic, diagnostic and therapeutic substances Promotion of environmental health Health information Others
43% (58) 11% (15) 5% (7) ~.
8% (ll) 5% (6) 14% (19) 4% (5) 10% (13)
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42.5% (57) undertook academic tra~n~ng (whether or not leading to a formal qualification) and 21% (28) undertook practical tra1n1ng or an observation tour. The types of study were not specified by 36.5% (49) of the fellows. 9% (12) of the fellows failed his final examination. have not yet completed their studies. One
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4.3
Utilization of the fellows on return to their home countries
Of the 134 respondents, 83% (111) returned to their 'countries of 11% OS) either returned and left origin and are still there in 1981. again or never returned. 6% (8) did not answer the question. Al though 15 of the fellows are not at present in their countries, it should be noted that 12 of them are still studying abroad, and therefore only 2% (3) of those for whom information was given are apparently lost to their countries. The statistics that follow are based on the III who returned to their countries and are still there.
WPR/RC32/12 Annex 1 page 13
Type of employment 86% (96) are employed by a government agency, 79 by the Ministry of Health, either at the central level (38) or at the peripheral level (41), and 17 by other government agencies. 10% (11) work in universitites and 3% U) work either in the private sector or in other agencies. One did not answer this question. Field of activity Information was requested on the primary and, secondary functions of the ex-fellows at present. where applicable, the
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As far as their main functions are concerned, 80% (89) are carrying out a service activity, 14.5% (16) have a main teaching responsibility, and 3.5% (4) are engaged in research. Two did not answer this question. 38% (42) also have a secondary function, related to teaching, research or service. Impact of fellowship on career development For 50% (55), the posts they are currently occupying represent a promotion, i.e. increased responsibility, compared with their pos1t10ns prior to the fellowship. No promotion was involved for 48% (53). Three did not answer the question. Relevance of training to the present post 92% (102) stated that the training received was either essential or at least reasonably useful for their present responsibilities. 7% (8) found it only marginally useful or not useful at all. There was one who did not answer the question. Continuing involvement in collaborative activities with WHO Information was sought as to whether the ex-fellows were involved in activities related to technical cooperation between their countries and WHO. 19% (21) stated that, meetings organized by WHO. since returning home, they had participated 1n which 1n turn could be
1.11
22.5% (25) had been actively involved in WHO collaborative activities their own countries.
Involvement in TCDC activities other than through WHO 4% (4) through WHO. said they had been involved in TCDC activities other than
Further training received after return home 15% (17) declared that they returning to their home countries. had received further training after