(WP)HRH/ICP/HRH/002 Report series number: RS/98/GE/07(AUS)
English only
REPORT
MEETING ON GUIDELINES IN ORIENTING HEALTH PROFESSIONAL EDUCATION TO THE NEW HORIZONS IN HEALTH APPROACH
Convened by:
WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR THE WESTERN PACIFIC IN COLLABORATION WITH THE WHO REGIONAL TRAINING CENTRE, SCHOOL OF MEDICAL EDUCATION UNIVERSITY OF NEW SOUTH WALES SYDNEY, AUSTRALIA, 10-14 AUGUST 1998
Not for sale Printed and distributed by: World Health Organization Regional Office for the Western Pacific Manila, Philippines December 1998
NOTE
The views expressed in this report are those of the participants in the meeting and do not necessarily ret1ect the policy of the World Health Organization.
This report has been prepared by Ms Bronwyn Hine and Dr Jan Ritchie of the University of New South Wales in collaboration with the World Health Organization for governments of Member States in the Region and for those who participated in the Meeting of Guidelines in Orienting Health Professional Education to the New Horizons in Health Approach, which was held in Sydney, Australia from 10-14 August 1998.
CONTENTS
1.
INTRODUCTION 1.1
Objectives Participants and Secretariat ........................................................ .. Organization and outputs ............................................................ Opening ceremony .................................................................... 2 2 2
1.2 1.3 1.4 2.
PROCEEDINGS ...... ...................................................................... ... ....... .................. ACKNOWLEDGEMENTS ANNEXES : ANNEX 1 - LIST OF TEMPORARY ADVISERS, MEETING COORDINATOR AND SECRETARIAT ................................. ANNEX 2 - PROVISIONAL AGENDA ................................................. ANNEX 3 - MESSAGE OF THE REGIONAL DIRECTOR ........................ ANNEX 4 - DRAFT GUIDELINES FOR ORIENTING HEALTH PROFESSIONAL EDUCATION TO THE NEW HORIZONS IN HEALTH APPROACH ...... ..... ................. .....................
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7 11 13
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Keywords: Health persmmel- education I Education, Professional I Australia
1. INTRODUC TION
The orientation of health persom1el training to the approaches of New horizons in health is an important strategy for ensuring that future health professionals are able to effectively and efficiently operate within the changing contexts of health services resulting from the refonns being undertaken in most countries. In the two bienniums preceding 1998-1999, the WHO programme on development of human resources for health has emphasized processes such as workforce plmming m1d curriculum review, in order to strengthen the capability of countries to implement priority health progranm1es . TI1.e forty-eighth World Health Assembly recognized the need to orient health professional education and practice in line with the pri11ciples of Health For All, .in resolution WHA48 .8. In the Western Pacific Region, the policy doctunent New horizons in health sets out approaches for the achievement of Health For All.
New horizons in health calls for health service delivery which emphasizes health promotion, health protection, multisectoral action and the empowerment of individuals and communities to take more responsibility for their health. For this approach to be successful, health professionals need training which equips them with the knowledge and skills required.
An initial workshop in Orienting Human Resources to the New horizons in health approach was held at the WHO Regional Training Centre in Sydney, Australia, in August 1997 . Building on that foundation, this meeting drafted guidelines for use in the revision of health professional education throughout the Region. A further meeting to consider the implementation of these guidelines is envisaged for 1999. 1.1
Objectives The objectives of the meeting were: (1) to review progress in implementation of action plm1 since the Workshop on Orienting Human Resources to the New Horizons in Health Approach held in Sydney from 11 to 15 August 1997; (2) to develop draft guidelines that will enable health educational institutions to enhance their capacity to incorporate the New horizons in health approaches into initial m1d continuing training of the health professional workforce; and (3) to orient their research, clinical and community health activities to make an optimal contribution to changes in the mam1er of health care delivery through the principles of New horizons in health.
1.2
Participants and Secretariat
Twelve participants from eleven countries in the Region attended the Meeting in the capacity ofTemporar y Advisers. They joined Faculty of the WHO Regional Training Centre, School of Medical Education m1d Mrs Lorraine Kerse, Regional Adviser in Humm1 Resource Development, WHO/WPR O. This group brought together a wealth of experience and expertise in the area of health professional education in the Westem Pacific Region, and in health promotion, community development and management of chm1ge.
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Dr Jan Ritchie was the Meeting Convenor with Mrs Lorraine Kerse acting as Meeting Secretariat. 1.3 Organization ofthe meeting
The Temporary Advisers attending the Meeting brought with them case studies reflecting their experience of educational change and reports on the implementation of the action plans developed at the 1997 intercountry workshop. A position paper was prepared by the School of Medical Education to brief participants on relevant issues and to provide a starting point for discussion. The meeting was organized to facilitate sharing of information and experiences, with brief presentations on relevant topics followed by plenary and small group discussions and activities. The progranune is attached as Almex B. The final output of the Meeting was the development of draft guidelines in orienting health professional education to the New horizons in health approach. The guidelines are intended to support educational institutions in reviewing and strengthening their training progranunes. The draft guidelines are attached as Almex D. 1.4 Opening ceremony
The Workshop Convenor, Dr Jan Ritchie, welcomed the Temporary Advisers, and introduced Professor Arie Rotem, Director ofthe WHO Regional Training Centre. Professor Rotem welcomed the participants and introduced the faculty ofthe School of Medical Education. He spoke of the global and regional trends in health professional education, and the importance of developing practical guidelines to support institutions in reviewing their education progranunes . Mrs Lorraine Kerse, Regional Adviser in Human Resources for Health, welcomed the Temporary Advisers on behalf ofWHO and delivered an address by Dr S.T. Han, Regional Director ofWHO . This address is attached as Almex C.
2. PROCEEDINGS
The proceedings began with an overview of the Meeting progranune and objectives, and an opportunity for Temporary Advisers and resource persons to introduce themselves. Following the introduction, Dr Jan Ritchie reviewed the policy document New horizons in health (NHJH). Dr Ritchie highlighted the changes this approach involves, when compared to traditional health service delivery: • • • from disease-centred to people-centred; from reactive curative to proactive preventive; and from health sector alone to multisectoral shared .
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She described the lifespan approach which NHIH adopts and the three headings under which health care is considered: • • • preparation for life protection of life quality of life
With the context well established, a summary of the implementation of action plans developed at the 1997 intercountry workshop was presented by Ms Bronwyn Hine. She described the range of objectives and plmmed actions, and the progress reported. Issues raised in implementation included:
( 1) • • • • (2)
support for action : financial support; political supporUmandate; opportune timing; complementary progrmmnes/activities .
Barriers to action: • • competing demands on time; limited resources .
(3)
What helped to overcome barriers : • incorporating elements of action into existing activities.
During the afternoon session, Dr Jan Ritchie reviewed the concept of health promotion, m1d introduced the notion of core competencies in health promotion for health workers. The group worked to develop a list of health promoting competencies under headings in four key areas: (1) Establishing and maintaining partnerships • • • (2) communication/interpersonal skills; appropriate attitudes; and political capacity.
Acquiring a specialized knowledge base • • • • research and analysis; management; behavioural sciences; and natural history of disease.
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(3)
Platming a11d ma11aging • • • • critical decision making; appropriate use of infonnation; appropriate use of teclmology; and skills in platming through partnership .
(4)
Undertaking assessment a11d evaluation • • skills in participatory evaluation; and skills in empowering other in evaluation.
The final session of the day was a review of emerging issues with relevat1ce to the objectives of the meeting, presented by Ms Bronwyn Hine. The concept of social accountability in health professional education, the values of relevance, quality, cost-effectiveness and equity, and WHA resolution 48.8 "Reorientation of medical education a11d medical practice to health for all" were briefly addressed. On the second day, Professor Arie Rotem introduced the change process. He suggested that for change to occur there needs to be recognition of a need, realization that it is a priority, and identification of possible solutionis. He spoke of orgat1izations as systems, seeking to maintain equilibrium within an enviromnent where change is ongoing. Components within an organization include fom1al procedures and stmctures, infonnal nonns and expectations, people, and facilities and equipment. Fonnal procedures and structures are seen as being strong, regular a11d predictable, a11d therefore hard to chw1ge. He highlighted the importa11ce of analysing the forces acting to support or resist planned change, and using this infom1ation to develop strategies to reduce resistance. In small groups, the Temporary Advisers considered their own experiences of educational cha11ge, drawing on the case studies they had prepared before the meeting. In a plenary session, the group then developed an analysis of forces with potential impact on change towards the NHIH in educational institutions, under five headings: • • • • • political - international and national; socio-cultural; professional; institutional; and curriculum.
Under each of these five headings, they saw elements that could act to support or resist change. The third day of the meeting began with a review of trends in medical education, and strategies that could be used in reviewing curriculum, such as pathway a11alysis, presented by Professor Arie Rotem. Following this, the group considered graduate attribute statements in health promotion, drawing on the core competencies previously developed, with facilitation from
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Dr Jan Ritchie. Dr Peter Harris then presented an overview of core competencies and their use and value in reviewing curriculum. With the relevant issues raised, and the participants well briefed in both the content area and implementation considerations, the meeting began the development of the draft guidelines. Starting with criteria of usefulness, flexibility, relevance and feasibility, the group considered the key components and related actions in orienting health professional education to the NHIH approach. Using small groups and plenary sessions, and drawing on relevant WHO documents, three key components were defined: (1) (2) the political component; the technical component;
• • • • • (3)
institutional capacity; partnerships; curriculum; graduate attributes; research; and
the coordination component.
For each component, a rationale was written and a list of actions that could be undertaken by educational institutions was developed. The meeting noted that the list was not intended to be prescriptive, and that educational institutions should draw fonn it those actions that might be appropriate to their particular circumstances, and adapt them as necessary. The development of the draft guidelines occupied the remainder of the meeting, vvith the final draft completed in the aftemoon of day five. The meeting was officially closed by Mrs Lorraine Kerse, on behalf of Dr S.T. Han, Regional Director of the World Health Organization, Westem Pacific Regional Office on Friday, 14 August 1998.
3. ACKNOWLEDGEMENTS
Dr Jan Ritchie, Workshop Convenor, would like to offer special thanks to the Temporary Advisers who attended this meeting for their energy, effort and conunitment to the development of the draft guidelines that are presented as Almex 4 of this report. Their experience, expertise and enthusiasm were pivotal to the success of the meeting.
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ANNEX l
WORLD
HEALTH
ORGANIZATION
ORGANISATION MONDIALE DE LA SANTE
REGIONAL OFFICE FOR THE WESTERN PACIFIC BUREAU REGIONAL DU PACIFIQUE OCCIDENTAL
MEETING ON GUIDELINES IN ORIENTING HEALTH PROFESSIONAL EDUCATION TO NEW HORIZONS IN HEALTH APPROACH Sydney, Australia 10-14 August 1998
WPRJHRH/HRH(l )/98/IB/2 26 June 1998
ENGLISH ONLY INFORMATION BULLETIN NO. 2
PROVISIONAL LIST OF TEMPORARY ADVISERS, MEETING COORDINATOR AND SECRETARIAT
1.
TEMPORARY ADVISERS
Dr Barra Amevo Dean, Faculty of Medicine University of Papua New Guinea P.O. Box 5623 Boroko. N.C.D . Papua New Guinea FAX: (675) 267 187; (675) 325 0809 TEL: (675) 324 3805 E-mail:
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Dr Warne Baravilala Director Pacific Postgraduate Train-ing Centre Fiji School of Medicine Training Centre P.O.Box 11683 Suva. Fiji FPC(: (679)308122,3032 32 TEL: (679) 215273 , 308120, mobile: 920911 ; pager: 296333 E-mail: wame_b@fsm.ac.fj alternate: postgrad@fsm.ac.:fj
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Dr Peter Davis Senior Lecturer Department of Community Health School of Medicine, University of Auckland Private Bag 920 19 Auckland New Zealand Fax: +64-9-3737-503 Phone: +64-9-3737-599 ext. 6338 E-mail: pb .davis@auckland.ac.nz Dr Bridget Hsu-Hage Senior Lecturer/Program Director VicHealth Healthy Eating Healthy Living Programme Monash University Department of Medicine 246 Clayton Road Block E Level 5 Clayton 3168, Victoria Australia Fax No. (61 3) 9550 5524 Tel. No . (61 3) 9550 5521 E-mail: bridget hsu-hage@med monash.edu.au Professor Lee Hin Peng Head, Department of Community Occupational and Family Medicine Faculty of Medicine MD3 , National University of Singapore Lower Kent Ridge Road Singapore 119260 Republic of Singapore FAX: 779 1489 TEL: 874 4988 ; 874 4989 DrYoon-Seong Lee Associate Professor Department ofF orensic Medicine Seoul National University College of Medicine 288 Yongon-dong, Chongro-ku Seoul 110-799 Republic of Korea FAX: 82-2-764-8340 TEL: 82-2-740-8352 E-mail: intodark@plaza.SNU.ac.kr
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WPRIHRHIHRH(l )/98/IB/2 Page 3
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Mrs Rigieta V. Nadakuitavuki Director of Nursing Services Ministry of Health and Social Welfare Kaunikuila House Flagstaff P.O. Box 2223 Government Buildings Suva, Fiji FAX: (679) 306163 TEL: (679) 306177 I 320 Professor Ren Huimin Professor and President President's Office Xi'an Medical University 205 Zhuquedajie Xi'an, Shaanxi 710061 People's Republic of China FAX: 86-29-526-7324 TEL: 86-29-526-7354 E-mail: ren@irix.xamu.edu.cn Mrs Pelenatete Stowers Director of Nursing Department of Health Motootua Samoa TEL. : (685) 21212 Ext 347 FAX: (685) 21440 Dr Orlino 0. Tal ens Associate Dean for Academic Development and Chair of the Training Coordination Committee College of Medicine and Philippine General Hospital, University ofthe Philippines-Manila 547 Pedro Gil Street, Ermita Manila FAX/TEL: (632) 526 0371 Professor Vuong Hung Director Department of Science and Training Ministry of Health 138A Giang Vo, Badinh
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HaNoi VietNam FAX: 84-4-8430015 TEL: 84-4-846-4918
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WPR/HRH /HRH( 1)/98/IB/2 Page 4
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Ms Adeline Welin Acting Principal Tutor Vanuatu Centre for Nursing Education Department of Health Private Mail Bag 009 Port Vila Vanuatu FAX: (678) 26-204 TEL: (678) 22-512
2.
MEETING COORDINATOR
Dr Jan Ritchi WHO Regional Training Centre for Health Development School of Medical Education The University ofNew South Wales Sydney, NSW 2052 Australia FAX NO. 61-2-9385 1526 TEL. NO. 61-2 9385 2445 E-mail: J.Ritchie@unsw.edu.au
3.
SECRETARIAT
Mrs Lorraine Kerse Regional Adviser in Human Resources for Health World Health Organization Regional Office for the Western Pacific P.O . Box 2932 United Nations Avenue 1000 Manila, Philippines FAX: (632) 521 1036 TEL: (632) 528-9957 Dir.; (632) 528 8001 E-mail: kersel@who.org.ph
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ANNEX 2
WORLD
HEALTH
ORGANISATION MONDIAL DE LA SANTE
ORGANIZATION
REGIONAL OFFICE FOR THE WESTERN PACIFIC BUREAU REGIONAL DU PACIFIQUE OCCIDENTAL
MEETING ON GUIDELINES IN ORIENTING HEALTH PROFESSIONAL EDUCATION TO NEW HORIZONS IN HEALTH APPROACH Sydney, Australia 10-14 August 1998
WPR/HRH/HRH(l)/98.1 13 July 1998
ENGLISH ONLY
PROVISIONAL AGENDA
1. 2.
Opening ceremony Overview of the meeting Current and emerging issues New horizons in health approach progress on action plans from last meeting Doctors for Health, WHA Resolution 48.8 social accountability reflections on case studies Strategies for a change in orientation of health professional education why change? what needs to be changed? skills for change including communication Development of draft guidelines Evaluation Closing ceremoriy
... .J .
I
j
4.
5.
6. 7.
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ANNEX 3
MESSAGE OF DR S.T. HAN REGIONAL DIRECTOR FOR THE WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR THE WESTERN PACIFIC AT THE OPENING CEREMONY OF THE MEETING ON GUIDELINES IN ORIENTING HEALTH PROFESSIONAL EDUCATION TO THE NEW HORIZONS IN HEALTH APPROACH 10-14 AUGUST 1998 SYDNEY, AUSTRALIA
On behalf of Dr Han, the Regional Director of the World Health Organization in the Western Pacific Region, I would like to express his regrets for not being able to be present to open this "Meeting on Guidelines in Orienting Health Professional Education to New Horizons in Health Approach". He has asked me to deliver the opening address-on his behalf. I am unable to be with you at the opening of this important Meeting on Guidelines in Orienting Health Professional Education to the New horizons in health approach due to previous engagements which unfortunately I am not able to alter. Nevertheless, I am pleased to welcome you all and I am sure you will have a productive meeting. In the early 1970s there was a general realization among the authorities of academic institutions involved in the education of medical and nursing practitioners that new educational methods were required if professionals were to be kept abreast of the rapid growth in health technologies. In Centre, at the University ofNew South Wales was established as a cooperative activity of the university, the Kellog Foundation and the response, the Regional Teacher Training Centre, now the Regional Training
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Australian Agency for International Development. It eventually became a tripartite association with the Commonwealth Government of Australia, the Western Pacific Regional Office of WHO and the University ofNew South Wales. The Centre has since become an internationally recognized centre of excellence in providing training for health care practitioners. WHO has sponsored the training of many fellows at the Centre and supports a workshop each year on a selected priority health issue. This is the second in a series of three workshops at the Regional Training Centre. It is perhaps the most important of all as it will result in the publication of WHO guidelines for use in countries that are strengthening their health professional training programmes or reviewing existing training programmes. Concern continues to grow worldwide about whether the existing education of health professionals equip workers to meet the needs of the health system and of the general population. Health professionals need more appropriate training if they are to cope with the challenges of health care reforms. There has to be a fundamental shift in both the orientation of health care delivery and the setting of priorities for health care. To achieve the ultimate goal of "health for all", it has become clear that the traditional approaches of disease control, clinical diagnosis, treatment and rehabilitation, while still important, are insufficient in themselves to ensure the health of the population and a good quality of life. A much wider perspective must be taken, which strives for the attainment of positive health. The attainment of positive health is influenced by a broad and complex set of social, economic and
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environmental factors. There is a great deal of evidence to suggest that a healthy adult life is conditioned from childhood. The WHO Regional Office for the Western Pacific has already gone through a process of reappraising the Organization's role in promoting health in the Region. We have taken a hard look at where we are going with our current approaches and what needs to be changed. The regional policy document New horizons in health sets out new approaches for the achievement of health for all. It calls for health care delivery which emphasizes health promotion, health protection, multisectoral action and the empowerment of individuals and communities to take more responsibility for their own health. For this approach to be successful, health professionals need education and training which equips them with the knowledge and skills required for a holistic approach to health care. There is a widening gap between education and practice. This results from the contrast between the tradition and the academic values of educational institutions on the one hand and service requirements, consumer expectations and rapid changes in sciences and health systems on the other. The new challenges that health professionals have to meet include rapid development of biomedical technology and communication sciences, increased demands from the population and changes in the disease profile. Educational programmes must address these issues through the curriculum. The curriculum consists of a number of elements pieced together to assure quality in education and excellence in performance. The curriculum may have all the elements needed, but if it is poorly organized it will not produce the right results.
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The process of changing the education of health professionals is complex. Curriculum planners and teachers should take into account the social and personal characteristics of the community as well as health needs and priorities. Dr Gro Harlem Bruntland, WHO's new Director-General, has made it quite clear she intends to be very focused on building healthy communities and populations, combating ill health and reaching out and sustaining health. Many of these issues relate directly to the way in which health professionals are educated. This is the reason why you are all here - to produce the guidelines for best practices to prepare filture health professionals to build healthy communities and populations. I know you are all committed to developing the best possible human resources to deliver efficient and safe health services. I know you are aware that all the technology in the world will not save lives if people are not trained to use it properly. I call on you to contribute your expertise and experience to drafting these important guidelines. I look forward to reading the draft guidelines at the end of the meeting.
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DRAFT GUIDELINES
for Orienting Health Professional Education to the New Horizons in Health Approach
Developed at the WHO/WPRO Intercountry Meeting WHO Regional Training Centre School of Medical Education University of New South Wales Sydney, Australia 10-14 August 1998
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Table of Contents
Glossary ................ .. ..-... .. . .. . . ...... .. . ............ . ... .... .......... .. .. ....... .. .. ... .. .... 1 Executive Summary ....... -.. ... .. ...... ... ............ ......................... ..... .. .. .. .. . 2 Introduction ........... ............ ..... ................ .... ... ..... .. ...................... ....... 3 Background ........... ....... ... ......... .. .... ....... .... .... ........ .... .. ........ ......... ., .. .. 3 ._ ..... 4 New horizons in health ....................... .. .................... .. ...... .... .... _. _ Why change health professional Education? .............. ............. ............. 5 What needs to be changed in Education Programmes? ......................... 6 Process and Dynamics of Change . .. .. ... .. . .. .. .. ... .. ... .. .. .. . .. ... .. ... . .. ... . .. ... .. 7 Draft Guidelines ....................................................... . _ .......... _ .... _..... .. . 8 References ·································-· ········································· ·· ········-··· 12
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Glossary Health professional
this term is used in its broadest definition, and refers to all those providing health services recipients of health services :in any setting, includes patients in hospitals or clinics strong, fom1al relationship, developed with equal commitment from each partner around a common goal, the achievement of which will benefit all partners informal, cooperative relationship, developed around a common goal where the outcome may be of greater benefit to one party than to the other/s, may include one party providing support or assistance to another
Clients
Partnership
Collaboration
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EXECUTIVE SUMMARY
The WHO regional policy document Ne-w horizons in health sets out new approaches for the achievement of Health For All. It calls for health care delivery which emphasizes health promotion, health protection, multisectoral action and the empowerment of individuals and communities to take more responsibility for their own health. For this approach to be successful, health professionals need education and training which equips them with the knowledge and skills required. These guidelines where developed at the WHO/WPRO Meeting on Guidelines for Orienting Health Professional Education to the New horizons in health (NHIH) Approach, held in Sydney from August 10- 14, 1998. They are intended to support educational institutions and governments throughout the Western Pacific region in reviewing and strengthening health professional education and training (basic and continuing) in order to achieve this orientation. The key areas for action that were identified target educational curricula and the organizational environment in which education is provided and health services are delivered. The guidelines are not intended to prescribe a particular course of action, but rather to offer suggestions that countries and institutions may draw on and adapt to suit their unique circumstances and settings. Three key components of a strategy to orient health professional education to the NHIH approach are: the political component, the technical component, and the coordination component. A concerted effort in each or these areas will lead to comprehensive refom1, but action can begin incrementally, and in any area. Action within the political component seeks to secure the active support of political leaders, policy and decision-makers within the health, education and related sectors, through increasing their understanding and appreciation of the value of the NHlH approach. The technical component addresses institutional capacity in the core areas of NHIH health promotion, health protection, multisectoral action, empowennent of individuals and communities, and the need for curricula and research efforts to reflect the institutions' orientation. It targets outcome measures, in particular the attributes of graduates who have participated in education progrmes. It also emphasizes the need for institutions to develop partnerships with key stakeholders in the health sector, other sectors and in the community. The third component, the coordination component, identifies action to support collaboration between institutions involved in health professional education at both national and regional levels, to maximize opportunities for learning and reflection.
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Introduction These guidelines where developed at the WHO/WPRO Meeting on Guidelines for Orienting Health Professional Education to the New horizons in health Approach, held in Sydney from 10 to 14 August 1998. The meeting was the second in a series of three addressing this topic, with a third meeting planned for 1999. The guidelines reflect the fundamental shift that is occurring in both the orientation of health care delivery and the setting of priorities for health care. To achieve the ultimate goal of Health For All, it has become clear that the traditional approaches of disease control, clinical diagnosis, treatment and rehabilitation, while still important, are insufficient in themselves to ensure the health of the population and a good quality of life. The WHO regional policy document New horizons in health sets out new approaches for the achievement of Health For All. It calls for health care delivery which emphasizes health promotion, health protection, multisectoral action and the empowerment of individuals and communities to take more responsibility for their own health. For this approach to be successful, health professionals need education and training which equips them with the knowledge and skills required for an holistic approach to health care. These guidelines are intended to provide direction and support for countries that are reviewing and strengthening their health professional training programmes (basic and continuing) in order to achieve this orientation.
Background The initiation of the global trend towards a focus on health, rather than on disease, occurred with the Declaration of Primary Health Care, proclaimed at Alma-Ata in 1978. This document introduced the notion of attaining Health For All by tl1e year 2000, and included health education as one of the eight essential elements which member states of WHO should consider. The subsequent Global Strategy for Health For All, launched in 1981, encouraged all countries to identify goals and targets to indicate their progress in this direction. The Ottawa Charter for Health Promotion was developed in 1986 to facilitate the implementation of the Health For All strategy, and suggested five areas for action: building healthy public policy, creating supportive environments, strengthening community action, developing personal skills and reorienting health services. In 1995 the Western Pacific Region produced a policy document, New horizons in health, which set out new approaches for the achievement of Health For All. The importance offoiD1ing broad-based partnerships to work for health was emphasized in the 1997 Jakarta Declaration. Meanwhile, the Pacific Island countries documented their commitment to these principles in the Yanuca Island Declaration (1995) and the Rarotonga Agreement (1997).
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1.
New Horizons in Health
TI1e forty-eighth World Health Assembly recognized the need to orient health professional education and practice, in line with the principles of Health For All, in resolution WHA48.8. In the Western Pacific Region, the policy doclllTlent New horizons in health sets out approaches for the achievement of Health For All.
New horizons in health calls for health service delivery which emphasizes health promotion, health protection, multisectoral action and the empowerment of individuals and communities to take more responsibility for their health. Health promotion refers to measures that can be taken to encourage healthy behaviour and enhance what people can do themselves, in conjunction with their families, communities and nation, to improve and manage their own health. Health protection recognizes the fragility of human life, and its activities are based on the assumption that there are a constantly growing number of external factors that influence health. Essentially, the New horizons in health (NHIH) approach involves: 1.1
Changing directions
• from disease-centred • people-centred - health interventions are people-centred and wellness-centred not disease-focused, with the focus on positive health as part of human development; • from reactive curative • proactive preventive - a shift in emphasis from the illness itself, to the risk factors which contribute to the problem, and furtl1er to factors that will constitute good health; • from health sector alone • multisectoral shared - the health sector seeks to combine its resources and efforts towards positive health and quality of life with those of other sectors (such as schools, industry, transportation, energy, agriculture and environmental groups) to influence eA.1:emal health related factors . 1.2
Taking a lifespan approach
•
preparation for life - ensuring that infants and young children not only survive the first years oflife, but are suitably prepared to enable them to realize their health potential throughout their lives; protection of life - having progressed through childhood and adolescence, individuals are then supported in fully developing and maintaining healthy lifestyles, and are protected from illnesses caused by a potentially hazardous and degraded environment. The overall aim is to prolong productive, healthy and disability-free lives in the most cost-effective and equitable ways possible; quality of life - enabling all individuals to acquire and maintain the physical, social and mental capabilities required to lead fully creative, productive and meaningful lives.
•
•
(2)
Why change health professional education?
With a basic health infrastructure in place in all countries and areas of the Western Pacific region, there is significant concern about how to use this infrastructure more efficiently and effectively. Major health system reforms are being undertaken in many countries in the Region, as nations seek to achieve Health For All within the context of changing health profiles and economic realities. A comprehensive plan to reorient the health workforce is seen as lying at the core of any successful reform in health.
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(3)
New challenges call for new responses
The health profile of the Western Pacific Region reveals a combination of diseases, both 'those associated with poverty and those associated with affluence. While there has been a general improvement in key health indicators such as infant mortality, adult literacy and life expectancy over recent years, significant inequalities within countries remain. Emerging health issues include those associated with the "ageing" of society, and with socioeconomic development, such as rapid urbanization, changing lifestyles and environmental degradation. These health issues cannot be effectively addressed through traditional programme-based health sector responses. Health workers must be able to work effectively with non-traditional partners in health and human development, and be willing and interested in finding or creating opportunities to work together in new ways. Tomorrow's doctor (or other health worker) needs to be a care provider, decision-maker, communicator, community leader and manager. (4) Quest for relevance, quality, cost effectiveness and equity
Relevance, quality, cost-effectiveness and equity are four values implicit in the goal of Health For All. In an "ideal" health system, equal emphasis is given to each of these values. Tensions can and do arise between the four values, in particular between an emphasis on quality and cost effectiveness versus equity and relevance. The World Health Assembly resolution WHA48.8 encourages all countries to undertake activities to reform medical education and practice with a view to increasing relevance, quality, cost-effectiveness and equity in health care. Health professionals must be trained to work effectively with a health care system that adopts these values. • • • Relevance - Are the most important problems tackled first? Quality - Is health care evidence-based, technologically and culturally appropriate? Cost-effectiveness - Does the system have the greatest impact on health while making the best use of its resources? Equity -Is high quality health care available to all people in all areas?
•
(5)
Increasing accountability The health sector, including plmmers, funders, educators, researchers and health care providers, are being held increasingly accountable for what they do, and how m1d why they do it.
(6)
What needs to be changed in education programmes? (a) Orientation and emphasis
The NHIH approach to Health For All involves a significant shift in health service delivery, and thus in the knowledge and practice of health professionals. For this to occur, the orientation of health professional education (basic and continuing) must also shift, to reflect a more holistic view of health and the broadest range of health interventions. It will not be sufficient to just add extra topics, such as health promotion and management, to current basic education curricula, or to include these topics in in-service training progrmes. The whole orientation and emphasis of training needs to reflect the cornerstones of the NHIH approach- health promotion, health protection, multisectoral action and the empowerment of individuals and communities to take more responsibility for their health. Every aspect of basic and continuing education progrmes, including selection of
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students, the curriculum, student assessment, research and outcomes, must be examined for the extent to which it prepares graduates to adopt the NHIH approach. (b) Foundation skills
All health workers need a solid foundation of cognitive skills if they are to practise effectively within the changing context of health services . In particular, they need excellent communication skills, analytical, reasoning and problem solving skills . Education programmes must provide opportunities and support for students to develop and enhance these skills. 7. Process and dynamics of change
If educational institutions are to successfully reform their programmes, they need both a clear idea of what they want to change, and understanding and skills in managing change. Change is generally viewed as an episodic activity. It starts at some point, moves through a series of steps, then arrives at an outcome that is hoped to be an improvement on the starting point. When moving from the starting point to the changed state, there will be forces within an organization or system that drive the change, and forces that resist it. In today's world, change is an almost continual process, the success of which depends, to a large extent, on motivation, leadership, strategy and energy. • Initiation of change - can come from within an organization or from outside it. Organizations exist within a changing environment, and in order to "fit in" with that environment, the organization must adapt. The environment in which health services are provided has changed dramatically over the past three decades, with increased expectations from consumers, the ageing of the population, and emerging threats to health such as HIV/AIDS and pollution. Variations in funding or passage of new legislation are examples of external factors that could initiate changes in health service delivery. The release of research findings, or the introduction of new equipment, are examples of internal factors that could initiate change. The "trigger" for change will influence how easily it proceeds, and how well the outcome meets expectations. Supp01i for change- forces that drive the change can include incentives, such as increased salary or status, or improved conditions. Respected or powerful individuals who favour the change can also act as a driving force. Complementary adjustments to infrastructure within the system will add to the feasibility of the planned change. Barriers to change- resistance to change can come from many sources. Individuals within an organization may resist change out of habit, fear ofloss of security or income, fear of the unknown, or because they don't fully understand what is planned. The current structure, power relationships, resource allocation, skills and experience within the organization itself may also be barriers to change. Symptoms of resistance to change can include high staffturnover, absenteeism, wastage and errors, etc. Leadership - if change is to be successful, it must be well managed. Leadership must be provided which will drive change and enable barriers to be overcome. TI1e leader/s or change agent/s must have sufficient influence or power to be effective, and must have interest, time and energy to dedicate to supporting the change. Tactics such as education and communication, enlisting greater participation, forming partnerships, providing facilitation and support, negotiating, and even coopting or coercing may be used to overcome resistance to change.
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DRAFT GUIDELINES FOR ORIENTING HEALTH PROFESSIONAL EDUCATION TO THE NEW HORIZONS IN HEALTH APPROACH
These guidelines have been developed to support educational institutions throughout the Western Pacific region in reviewing and strengthening health professional education and training at all levels- basic, post-basic and continuing. The guidelines are not intended to prescribe a particular course of action, but rather to offer suggestions that countries and institutions may draw on and adapt to suit their unique circumstances and settings. 1. The political component
Political leaders, policy and decision-makers within the health, education and related sectors need to understand the New horizons in health (NHIH) approach and its value in the achievement of Health For All. Their active support is essential to the successful reform of health professional education and training.
1.1
Action list • Identify key decision-makers in the government, such as senior officials of Ministry ofHealth, Ministry of Education, Ministry of Finance and other relevant Ministries; Identify key stakeholders in non-government sectors, such as education institutions, regulatory & advisory bodies, professional associations, funding agencies, nongovernment organizations, consumer and advocacy groups; Establish or strengthen mechanisms for government and non-government stakeholders to meet and discuss NHIH and related matters; Demonstrate to stakeholders (through discussion and dissemination of appropriate information) the benefits of NHIH and the need to orient health professional education in this direction; Develop supportive policy statement/s at Ministry, institutional and progranune levels.
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The technical component
The technical component of these guidelines offers institutions support for action in five key areas: institutional capacity, partnerships, curriculum, graduate attributes and research. 2.1 Institutional capacity
In order to undertake the reform and provide the required support for both educators and students, institutions must first develop the necessary technical capacity in the core areas identified in NHIH (health promotion, health protection, multisectoral action, empowennent of individuals and communities) and in the management of change.
2.1.1 Action list • Identify existing organisationally structures, resources and faculty competencies which could be useful for implementing the NHIH approach; Identify relevant professionals or organizations who could help increase the technical capacity of the institution; Identify and support a focal point/leader to act as a resource for change and to organs, co-ordinate and implement the intended activities;
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Identify existing prograrmnes and curricula which either reflect the NHIH approach or have components relevant to NHIH; Assess the level of understanding and acceptance of the NHIH approach among the faculty administrators and educators; Raise the faculty ' s level of understanding and appreciation of the elements of the NHIH approach; Identify constraints to change within the institution and develop strategies to overcome them; Identify deficiencies in students' understanding and skills in the area of NHIH, including communication, analysis and problem-solving; Incorporate into the existing curriculum, teaching and learning activities to strengthen the understanding and skills of students in areas relevant to the NHIH approach.
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Partnerships
Institutions must develop working partnerships with key stakeholders in the health sector, other sectors and in the community. 2.2.1 Actionlist • Identify, inform and orient relevant organizations, institutions, authorities and community groups within and outside the health sector on the principles and benefits of the NHIH approach; Establish or strengthen links with relevant organizations, institutions, authorities, and community groups within and outside the health sector to obtain their active participation and support in in1plementing the NHIH approach.
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Curriculum
Institutions must orient basic and continuing education prograrmnes towards the NHIH approach, and emphasis foundation skills such as communication, analysis and problemsolving. 2 .3 .1 Action list • Develop a clear outline of content on health promotion and health protection in the curriculum, allocating adequate time for both theory and practice; Include student-centred learning activities in the classroom, community and other health care delivery settings; Assess students on their understanding and appreciation of NHIH as a part of their overall assessment; Evaluate education programmes regularly to ensure relevance and effectiveness; Encourage staff to undertake related research and to develop multisectoral contacts .
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2.4
Graduate attributes
Graduates of education programmes which incorporate the NHIH approach will appreciate its value, apply the relevant skills and act as advocates for health promotion, health protection, multisectoral action and empowerment of others in the attainment of Health For All. 2 .4 .1 Action list • ~
Institutions will produce graduates who: Act as role models for healthy and ethical behaviour; Establish partnerships with clients, families and communities, other professionals and organizations through effective communication, and involve non-traditional partners in addressing health issues as appropriate; Demonstrate knowledge, skills and attitudes essential to effective health promotion and health protection practice; Demonstrate competency in planning, implementing and evaluating health promotion interventions for individuals and groups; Evaluate their own performance and show a commitment to life-long professional self-development.
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2.5
Research
Research increases the understanding of the NHIH approach and its application, and underpins educational reform in this direction. 2. 5 . 1 Action list • • • • Encourage and support staff to undertake research in areas relevant to NHIH; Allocate resources for research in areas relevant to NHIH; Monitor health trends in the community; Work with the community in setting a research agenda to address local health needs and issues.
3.
The coordination component
Existing and emerging information relevant to health professional education and the NHIH approach should be disseminated. Collaboration between institutions involved in health professional education at both national and regional levels should be encouraged to maximize opportunities for learning and reflection. 3 .1 Action list • Identify in each country a responsible officer or department to coordinate activities and facilitate information exchange in implementing the reform of health professional education within the context of NHIH; Seek support from international development partners to facilitate and support reform of health professional education in the direction of the NHIH approach;
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Participate in self-evaluation at an institutional and programme level, and share experiences and outcomes nationally and regionally.
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Further reading _ Boelen C. & Heck J.E. 1995, Defining and measuring the social accountability of . medical schools, World Health Organization, Geneva. Dunphy D.C. 1991, Organizational Change by Choice, McGraw Hill, Sydney. Hine B. & Ritchie J. (eds.) 1997, Orienting Human Resources to the New Horizons in Health Approach, proceedings of the World Health Organization Intercountry Workshop, University ofNew South Wales, Sydney. Robbins S.P. 1993, Organizational Behaviour (6th Edition), Prentice Hall International, Englewood Cliff, New Jersey. World Health Organization, 1996, Doctors for health, World Health Organization, Geneva. World Health Organization - Regional Office for the Western Pacific, 1996, Health Promoting Schools, Series 5, World Health Organization, Manila. World Health Organization- Regional Office for the Western Pacific, 1995, New Horizons in Health, World Health Organization, Manila.