.. 1 1 , 23 January 1987
ORIGINAL:
E~GLISH
REPORT
• • • j ;
I
~C~ICAL DISCUSSIONS ON CHANGES I~ {6UCATION FOR NATIONAL HEALTH MANPOWER FOR THE 'IWENTY-FIRSl' CENTURY
held in conjunction with the thirty-seventh session of the ~HO Regional Committee for the Western Pacific Manila, Philippines 19 September 1986
r
I 1 t Not for Sale Printed and Distributed by the Regional Office for the ~estern Pacific of the World Health Organization Manila, Philippines January 1987
NOTE
The views e~press~d in this report are those of the participants in the Technical D~scuss~ons on the Changes in Education for National Health Man~o~er for the Twenty-first Century and do not necessarily reflect the pol~c~es of the Organization.
This report has been prepared by the Regional Office for the Western Pacific of the World Health Organization for the governments of the Member States in the Region and for the participants in the Technical Discussions on the Changes in Education for National Health Manpower for the Twenty-first Century, which was held in Manila, Philippines, on 19 September 1986, in conjunction with the thirty-seventh session of the WHO Regional Committee for the Western Pacific.
CONlEt\l'S
1.
INTRODUCT ION
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2.
SECRETARIAT'S PRESENTATION GENERAL DISCUSSION COt-lCLUSIONS At-lNEX 1 ANNEX 2 -
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3. 4.
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AGENDA
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CHANGES IN EDUCATION FOR NATIONAL HEALTH MANPOWER FOR THE TWENTY-FIRST CENIURY (~PR/RC37/Technical Discussions/2) MEETINGS ON HEALTH MANPOWER IN THE WESTERN PACIFIC REGION ••••••••••••••••
9
ANNEX 3 -
25
1.
INTRODUCTION
By its resolution WPR/RC3b/R21, the WHO Regiona: Comm~ttee ~or the Western Pacific decided that the subject of the Techn1ca1 D1scuss10ns to be held in conjunction with its thirty-seventh session would be "Changes 1n ' " Th e education for national health manpower for the twenty- f 1rst cen t ury. discussions were held on 19 September 1986 from 2.30 p.m. to 5.30 p.m. The Agenda for the meeting is shown in Annex 1. The Moderator, Dr Khalid (Malaysia), opening the meeting, said that the importance of health manpower development in the context of health programme development could not be over-emphasized, particularly in the light of the adoption of the global strategy of health for all through primary health care. The concern about health manpower development was not only with the number and types of health personnel required but also with its effectiveness and competence to deliver the services expected of health personnel. In consonance with the new primary health care strategies, the Technical Discussions would focus on one aspect of health manpower development, namely, the educational processes and, specifically, the changes needed to make health personnel more effective and more relevant to the health-for-all goal based on primary health care. The Moderator referred to the meetings and conferences held or planned to be held which were relevant to the subject of the Technical Discussions (Annex 3). Those activities indicated that the issues of health manpower education and training were of extreme importance and concern to many of the Member States. What was required was a more concerted and coordinated effort at all levels and a greater commitment to the necessary changes. The Agenda of the Technical Discussions is attached as Annex 1. The panel of resource persons comprised Dr Luis A. Branda (Faculty of Health Sciences, McMaster University, Canada), Dr Masahisa Nishizono (School of Medicine, Fukuoka University, Japan), Dr Alberto Romualdez, Jr. (College of Medicine, University of the Philippines, Philippines), and Dr Wen-Pin Chang and Dr Hyung Jong Park of the WHO Regional Office for the Western Pacific. 2. SECRETARIAT'S PRESENTATION
Dr Luis A. Branda, Consultant in Health Manpower Development, WHO Regional Office, presented the Technical Discussions paper, "Changes in education for national heal th manpower for the twenty-firs t century." (See Annex 2). The Moderator observed that the presenter had indicated the changes nhat were needed in the education of health personnel in order to deliver effective primary health care, to meet the requirements of the health system and to be relevant to local needs. Dr Branda had used the training of physicians as an example because of the experience accumulated by innovative, community-oriented, medical programmes. He had presented certain innovative changes that were needed if they were to satisfy the requireme~ts pertaining to health personnel for the strategy of health for all based on primary health care.
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3.
GENERAL DISCUSSION
.The Moderator suggested that the general discussion should be D1Scuss10ns paper: 0:gan1z~d around the following questions listed on page I of the Technical
what should be the attributes and skills of the health care personnel needed? what changes should be introduced in teaching/learning programmes to educate and train the necessary personnel? What should be the role of teaching programmes in preparing students to.deal with advances in biotechnology, and to assess the appropr1ateness of their application to primary health care? What was required to overcome the obstacles in the way of change in health care systems and teaching programmes? What should be the role of governments, universities and WHO in health manpower development? The various questions and comments of the participants, and the replies and comments of members of the resource panel are summarized hereunder. The process of selection of students based on their desired characteristics and attributes in relation to primary health care was discussed at length. Questions were raised concerning the characteristics and attributes of students to be selected for a career in the health professions. It was observed that, even if an agreement was reached, there was little information on the effectiveness of methods of measuring those characteristics and attributes. There were, however, methods that could be used to measure some of the attributes, e.g. critical reasoning. The assessment of the applicant's ability to do critical reasoning was considered very iOlportant, particularly in relation to problem solving. The value of interviews in selecting applicants for the health professions was emphasized, particularly with regard to assessment of personal characteristics. The difficulties in convincing the faculty and the university authorities that there were attributes other than academic qualifications which should be assessed in selecting applicants for medical schools were discussed. It was observed that academic qualifications should be considered a non-negotiable minimum, other criteria being applicable over and above this minimum. The low level of academic preparation of applicants in a number of countries was mentioned as a limiting factor in the selection process. However, taking into account what was available, the question was how the most suitable applicants were to be selected.
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The question was raised whether it was the possession of skills or the potential which should be sought among applicants. It was agreed that it was the ability or potential of the applicants to develop the desired attitudes, skills and attributes that should be evaluated in the selection process. There was a consensus that all health professionals should be expected to possess a common core of skills and, on top of the common core, additional experience acquired during the training programme. Training programmes should also provide learning opportunities to the students to. enable them to change their own role to make it relevant to the changes 1n health care delivery. It was agreed that motivation, integrity, concern for people, and readiness to serve the community - and not necessarily themselves - were very important attributes to be expected of all health professionals. The difficulties in measuring such attributes were recognized. However, to some extent, motivation could be assessed by ascertaining whether the applicant's previous activities indicated a broad interest in health care and social problems. An additional difficulty in determining motivation lay in assessing whether the applicant had been motivated to be a student or to become a health care practitioner. Certain studies pointed to the contrast between the idealism of students on entry to medical school and the materialistic attitude of students in their final year. Another aspect of motivation to be considered was the place of assignment and the lack of interest among graduates from some health professional schools in practising in rural areas. Several participants observed that students lacked good role models among the faculty or among practising professionals. There was also a lack of role models as regards work outside the urban areas. In order to develop a commitment to a specific area, region or community, some medical programmes had instituted a regional admissions programme. In such cases the school of medicine's admissions committee was no longer the body that selected applicants. Once the applicants had satisfied the minimum requirements with regard to academic qualifications, members of the local community continued with the rest of the selection process on behalf of the university. It was noted that the problem of planning for health manpower development had not been dealt with appropriately in the Technical Discussions paper. The matter under discussion concerned changes in education for national health manpower development. In dealing with this area it was essential to keep in mind the existing situation in certain countries which lacked health personnel or where the health personnel lacked the appropriate qualifications. Another issue discussed was the present role of the medical doctor as general practitioner. Was the general practitioner a thing of the past? In some countries there were training programmes for health personnel with qualifications intermediate between those of physician and nurse. It was observed that it was going to be increasingly difficult to find university educated doctors who were willing to work in depressed areas. The question was whether the role of the doctor was not more that of an organizer or health administrator and whether other less educated health professionals might not be more suitable for field work. It was pointed out that the
- 4 lack of interest of doctors in working in rural areas might be related to suc~ questions as motivation, the reward system and the way they were tra1ned rather than to being overtrained for the job. It was observed that the training of doctors should include assessing the needs of the community. They should thus be capable of changing their roles whe~ changes were ~eeded in the community. Community involvement was thus requ1red of the med1cal students and not just exposure to the community. There was a need for a change in attitudes and the realization that doctors must be prepared to play other roles than the traditional ones. The role of the physician was also affected by the role of other health workers. That influence was more evident when the physician was a member of a health care team. The need for doctors to develop organizational, managerial and group skills was emphasized. Skills should be developed to enable them to perform effectively as a member of a team of health care workers comprising individuals with a wide range of interests, educational backgrounds and experiences. It was pointed out that all health personnel should be trained for to know how to accept it and who to go to for help to achieve it. However, much remained to be done to convince the authorities in both the universities and the government of the need for change in medical and health professional planning and education. Governments, universities and professional organizations should work together to achieve change and to define the role of each member of the health work force. change~
Participants concurred with the final points made in the Technical Discussions paper, including the need for effective links between the ministries and universities, which required more than an affirmation of good will. It was agreed that governments could playa major leadership role by establishing a dialogue with universities to persuade them to introduce changes in medical education aimed at the training of a health work force to ensure the effective delivery of primary health care. Dr Park, Regional Adviser in Health Manpower Development, observed that, in deciding on the type of doctor to be trained, it was important to examine other issues presented in the Technical Discussions paper, including the selection of students. A decision on the role of the physician called for knowledge of the community it was proposed to serve. The type of health delivery system to be developed also had to be defined. Without such knowledge it was very difficult to decide on the type of doctor to be trained. Another question was whether medical education alone could solve the problem of placement of doctors in rural areas. To be dependent on a few well-rootivated doctors who volunteered for work in rural areas was quite unsatisfactory. In considering the problem of placement of doctors, other factors (e.g. social, economic and cultural) should be taken into consideration, in addition to the role of medical education. The Regional Director, Dr Nakajima, referred to the changes in community needs, which forced changes in the delivery of health services and development of health manpower. A distinction should be made between community needs and community wants and demands. In order to be able to
- 5/6 serve the community, it was necessary to define it. Communities varied not only from place to place, but also according to who provided their leadership. In some cases the community functioned without a formally identified leader, and that had to be recognized in planning health care delivery. It was also necessary to clarify what type of health professional a physician was, particularly now that there was a danger of the doctor becoming just a technician. Another issue concerned the resources available for the development of health manpower. Health manpower development was expensive and its cost effectiveness very low In view of the lengthy training required and the large number of people involved. The budget cycle of organizations, including that of governments and WHO, was shorter than the period required to educate a physician. That also presented additional difficulties in the planning of health manpower development.
4.
CONCLUSIONS
The Moderator observed that all participants seemed to agree, directly or by implication, that there was a need for changes in medical education. The direction, type and extent of such changes would vary from country to country. ~HO had also stated through its various forums and resolutions that there was a role for the Organization to fulfil in that process. In order to help the Regional Director plan an effective programme to bring about such changes in medical education, more information would be required from Member States. It was agreed therefore to transmit the following suggestions to the Regional Director: (1) Member States of the Region should be requested to provide the WhO Secretariat with an indication of the steps their countries had taken or were considering taking, to orient - within the context of the Technical Discussions session - the training of health personnel towards primary health care. (2) The WHO Secretarial should be responsible for collecting additional information to the same end. (3) The WHO Secretariat should be responsible for the appointment of an expert task force to analyse all the information collected and to prepare a report with recommendations for future action. The report should be submitted to the Regional Director prior to the next Regional Committee session.
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ANNEX 1
TECHNICAL
DISCUSSIO~S
19 September 1986
AGENDA 14.30 14.30-14.40 14.40-15.00
Opening of the meeting Moderator's opening remarks (Dr Khalid) Secretariat's report (Dr Luis A. Branda) General discussion Coffee break General discussion (continuation) Conclusions and Moderator's closing remarks Closure of the meeting
15.00-15.45 15.45-16.00 16.00-17.15 17.15-17.30
17 .30
- 9 ANNEX 2
WORLD HEALTH ORGANIZATION
ORGANISATION MONDIALE DE LA SANTE
REGIONAL OFFICE FOR THE WESTERN PACIFIC BUREAU RilGIONAL DU PACifiQUE OCCIDENTAL
REGIO/'ljAL COMMITTEE Thirty-seventh session Manila 15-19 September 1986
\\- PR/R C37 /Technical Discussions/2 18 August 1986 ORIGINAL: ENGLISH
CHANGES IN EDUCATION FOR NATIONAL HEALTH MANPOWER FOR THE TWENTY-FIRST CENTURY Technical Discussions
The planning, production and utilization of health personnel must be carried out in a way which serves the national health-for-aU strategies. To achieve this, several issues need to be raised and questions addressed: What should be the attributes and skills of the personnel needed? What changes should be introduced in teaching-learning programmes to educate and train the personnel needed? - Are the programme objectives explicit, compatible with and relevant to primary health care? - Are the teaching methods appropriate for the students to achieve these objectives? - Are the students provided with opportunities for community involvement? - Are the methods used to select students appropriate for assessing the potential of applicants to develop the attributes and skills required for primary health care? - Are follow-up studies of graduates and research on career choices being conducted to assess factors affecting health manpower development? - Are programmes in place to help faculty to improve teaching skills and become proficient in new approaches to education? - Are systems in place to reward the contribution of the faculty to teaching? What is the role of teaching programmes in preparing students to deal with advances in biotechnology, and to assess the appropriateness of their application to prirnary health care? What is required to overcome the obstacles in the way of change in health care systems and teaching programmes? \\-hat is the role of governments, universities and WHO in health manpower development?
Annex 2
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WPR/RC37/Technical Discussions/2 page 2
I.
INTRODUCTION
KEY ISSUES If\; HEALTH MANPOWER DEVELOPMENT ARISING FROM THE HEAL TH-FOR-ALL GOAL
The Declaration of Alma-Ata (1978) asserts that the key to attaining the target of health for alJ by the year 2000 is primary health care, and that "All governments should formulate national policies, strategies and plans of action to launch and sustain primary health care as part of a comprehensive national health system and in coordination with other sectors".! This reorientation of health systems towards primary health care calls for a reorientation of health manpower development. The planning, production and utilization of health care personnel must be carried out in a way which serves the national strategies of health for aU. Some of the recommendations resulting from the International Conference on Primary Health Care, held in Alma-Ata in 1978, indicate the need for a redefinition of the "technical role, supportive skills, and attitudes required for each category of health worker according to the functions that need to be carried out to ensure effective primary health care".2 The Conference further recommends that governments "undertake or support reorientation and training for all levels of existing personnel and revised programmes for the training of new community health personnel; that health workers, specially physicians and nurses, should be socially and technically trained and motivated to serve the community; that all training should include field activities; that physicians and other professional health workers should be urged to work in under served areas early in their career; and that due attention should be paid to continuing education ••• ") The regional health-for-all strategy recommends that special attention be given to "strengthening training programmes and institutions in terms of faculty development, reviewing curricula to improve their relevance and to emphasize promotive and preventive health care".4
1World Health Organization. Alma-Ata 197&: primary health care. 1978, reprinted 1981 ("Health for All" series, f\;o. 1), page 5. 2Ibid, page 26. 3lbid, page 27. 4World Health Organization. 2000. Manila, 1982, page 36.
Geneva,
Regional strategy for health for all by the year
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Annex 2 WPR/RC37 /Technical Discussions/2 page 3
In the same context, the Conference on "Towards future health and medical manpower: New strategies in education for the XXIst century", held in Tokyo in 1985, recommended that governments should "support selectively universities and other training institutions for health personnel so as to encourage the reorientation of their training programmes towards the requirements of a primary health care-oriented health system;" and "encourage aU training i~stitutions for. he,:,-lth ~ersonnel, .i~ p~rticular medic~l schools to be involved, in dose coordmatlon wlth the mlnIstnes concerned, m commu~ity health services so as to enhance the relevance of their training and research activities and to enable them to contribute to health development". The Conference also recommended that training institutions should "urge all training institutions for health personnel to ensure that graduates possess a set of skills and attributes enabling them to work effectively in a primary health care-oriented system; select students more appropriately on the basis of criteria reflecting their future role in a primary health care-oriented system; use and evaluate a teaching/learning process which will enable students to integrate the available knowledge in health sciences for solving health problems effectively; give students ample opportunities to be involved in a range of learning settinfis reflecting their future practice, including both the hospital and the community." The Declaration of Tokyo on Health and Medical Manpower for the Twenty-first Century, adopted at the same Conference, urges training institutions to be responsive to the changes in the health systems, and to be receptive to the introduction of changes in curriculum content and process. 2
II.
WHAT KIND OF HEALTH PERSONNEL IS NEEDED? AND WHAT CHANGES ARE REQUIRED IN EDUCA TIONAL/TRAINlNG PROGRAtvIMES?
The Seventh General Programme of Work provides that, by 1989, "most countries or areas wlU have strengthened the capacity of educational institutions to ensure that sufficient health manpower is produced, of the right type and in the right quantity, to meet the requirements of the health system", and that
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Annex 2 WPR/RC37/Technical Discussions/2 page If
"all countries or areas will have restructured their training progranlllles, where necessary, in order to increase their relevance to local needs, using a task- and cornmunity-oriented approach". I The Declaration of Tokyo also addresses the skills and attributes which it is considered essential health personnel should possess in order to meet the requirements of health systems based on primary health care. This paper wiU develop some arguments in this context and describe the kind of educational opportunity that should be offered to the student in training. Although examples have been drawn from the medical curricula of two universities - McMaster University in Canada and the University of Newcastle in Australia - there are other medical curricula which use educational approaches that are relevant to the issues discussed in this paper. The reorientation of health manpower planning, production and utilization applies to aU health personnel. The new approaches to medical education discussed in this paper can be used to illustrate some of the changes required in training in the health fields. Some of the not-so-new undergraduate medical programmes such as the two mentioned above have accumulated considerable experience, testifying to their success in offering educational opportunities to their students to enable them to d~velop attributes and skills relevant to the practice of primary health care. In many instances, governmental health care agencies and universities are jointly involved in the planning and implementation of educational activities. An increase in the interaction between universities and governments has resulted in better clarification and definition of common goals directed to the improvement of health care. Better knowledge by government officials of the educational approaches that universities can apply wiJi lead to the more effective use of resources in the community. The following list shows areas of relevance to prinlary health care to which medical curricula should give special attention so that students can develop the appropriate skills: Critical appraisal of the need for and costs and benefits of health care interventions Organization and management Group dynamics Leadership Interpersonal communication Teaching: individuals and groups Learning methods (e.g. probleOl-based learning, self-directed learning, criticaJ appraisal) Problem solving
I Document WPR/RC37/5 (J 986), pages 52 and 53.
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Annex 2 WPR/RC37/Technkal Discussions/2 page 5
Economks of health care Bioethks Integration in individual health care, from all perspectives. The attributes and skills considered essential for the training of health personnel are of course, interrelated. However, in this paper, they are presented separately in ord~r to discuss the learning opportunities relevant to each attribute/skill.
1. ATTRIB UTE/S KIL L: ability to identify and to be responsive to community needs OPPORTUNITY TO LEARN: critical appraisal of the need for and costs and benefits of health care interventions
Of the various approaches that can be used to appraise the need for and costs and benefits of health care interventions, the Measurement Iterative Loop, described by Tugwell and coworkers, is the one used in innovative medical curricula. THE MEASUREMENT ITERA TIVE LOOP (after Tugwell et al.) I
/ 7
BURDEN OF ILLNESS Determine health status "'in, health indicato"
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REASSESSMENT Reassessment of magnitude of burden of iUness
ETIOLOGY OR CAUSATION Identify and assess possible causes of burden of iHness
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MONITORING OF PROGRAlvi~IE Ongoing monitoring using markers selected to indicate success
r.
3 CO~ilviU NITY
EFFECTlVEN ESS Assess benefit/harm ratio of potentially feasible interventions and estimate reduction of burden of iHness if programmes successful
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SYNTHESIS &. IMPLEMENTATION Integration of feasibility, impact and efficiency to make recommendations
EFFICIENCY Determine relationship between costs and effects across programmes
.J
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Annex 2 WPR/RC37/Technical Discussions/2 page 6
2. ATTRIBUTE/SKILL: ability to work effectively in complex organizations, multidisciplinary teams and community groups OPPORTUNITY TO LEARN: organiza tional and managerial skills, group dynamics, leadership skills
Although the need has been identified, there are no well-known examples of innovative medical programmes that have introduced a formal approach to the teaching of organizational and managerial skills in their curricula. On being in charge: a gUide for middle-level management in primary health care, published by the World Health Organization, provides a good introductIOn to organizational and mclf1agerial approaches for health personnel involved in primary health care'! The guide addresses such questions as: what a health team is, how to set up a team using principles of interpersonal relations, how to establish relations with communities, and how to use organizational principles to manage a health team. After working through this guide, the student should also be able to identify principles of management applicable to a variety of situations, and become familiar with some of the criteria that management uses to evaluate a health team's performance. In medical programmes such as the ones at the University of Newcastle and McMaster University, working in small groups is a central part of the student's learning activities. Through his work in these tutorials, the student becomes familiar with group dynamics and also learns how to act effectively in a group composed of individuals with different backgroundS. However, this alone may not provide sufficient experience in working as a member of a team of health workers, who will have a very wide range of interests, educational backgrounds and experiences. Additional opportunities are provided by assigning students to community placements and by arrangements made with regional social services, public health offices and nursing and other health care agencies. Some additional objectives of these experiences are: _ to learn first-hand how the health care system looks through the eyes of the uninformed and, therefore, disadvantaged consumer; _ to become familiar with the health service provided not only by physicians but by other health workers in the community; _ to see first-hand the cultural influences bearing upon health, and health utilization; _ to hear directly about the needs of the community and its understanding of primary. health care.
I McMahon, R., et al. On being in charge: a guide for middle-level management in primary health care. Geneva, World Health Organization, 1980.
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Annex 2 WPR/RC37/Technical Discussions/2 page 7
It is recognized that the achievement of the objectives described will be only the beginning of an effective involvement of medical students ~s member~ of a health care team. Additional activities, which build on the experience acqUired t~rough community involvement, must be developed and continued through further education.
3. ATTRIB UTE/SKILL: ability to communicate and negotiate with community leaders and consumers regarding their involvement in health programmes OPPORTUNITY TO LEARt>I: communication skills, teaching skills
Many educational programmes train health personnel in communication skills (including interviewing skills). In innovative medical curricula, this is done by assigning groups of students to preceptors, who supervise them in the learning and practice of communication skiJIs. Several of the preceptors are from the health personnel in the community. Another group outside the university which plays an important role in the education of students consists of phySicians not formally affiliated to the university. The involvement of these physicians with medical students from some innovative medical schools is considered very important for the student's education and training in dealing with and working in the community. In these programmes, students elect to work on a regular basis in private clinics which have agreed to accept students. In a country where a significant proportion of community health care is delivered by physicians not formally affiliated to the university, their involvement in the education of medical students is critical. Close liaison needs to be developed between the unIversity and these phYSicians to ensure that the clinicians in the community are in tune with the philosophy and methods of the teaching programme. Universities must be prepared to promote and support the participation of physicians not affiliated to their teaching programmes in various educational activities geared to familiarizing them with the standards and values that the university considers appropriate to the teaching of health workers to ensure the effective achievement of the heaith-for-all goal.
4. ATTRIBUTE/SKILL: ability to promote healthy life-styles on an individual/community basis OPPORTUf>.;ITY TO LEARN: teaching skiHs, leadership skills
The involvement of students in community activities as part of their formal training and - in the case of some innovative programmes - as part of their electives period, provides an opportunity not only for service but also for community education. Among others, this experience will allow the student to develop skills to determine from patients what their knowledge base is, to assess which aspects of the patient's
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Annex 2
WPR/RC37/Technical Discussions/2 page 8
Ufe are healthy and therefore should be reinforced, which aspects are unhealthy and need to be corrected, and to develop appropriate strategies to assist the patient with compJiance and other behavioural changes. , A,s described previously, these activities are not planned exclusively by the unJverslty, but may be organized and offered with the cooperation of government and community agencies. Additional teaching skills are acquired by the student's participation in the tutorial system, where he also assumes responsibility for the education of peers.
II
5. ATTRIB UTE/SKIL L: ability to keep abreast of the latest developments in the health sciences OPPORTUl\.ITY TO LEARN: learning skills (e.g. problembased learning, self-directed learning, critical appraisal skills)
The problem-based learning approach used at innovative medical schools does appear to result in an increase in the abilities of students and graduates to cope with the rapid development in biomedical knowledge. By emphasizing learning skills instead of memorization of specific knowledge, the student must identify and seek out the relevant information to manage the problem at hand. In problem-based learning, the student is given a situation (health care problem) which becomes the stimulus for learning. In problem-based learning, no prior formal exposure to information is necessarily provided by the programme. This differentiates problem-based learning from problem-centred learning where the problem is commonly used to integrate previously acquired knowledge which has been offered to the student through formal educational activities. Problem-based learning is more lifelike but more difficult to implement; problem-centred learning is less lifelike but easier to implement. Both can be applied to intradisciplinary or interdisciplinary problems.
In problem-based learning, given a health care problem, the following steps wilJ be followed: I. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. Clarification and definition of the problem Analysis of the problem Development of hypothesis(ses)/plausible explanations Identification and characterization of the knowledge needed Identification of what is already known Identification of appropriate learning resources Collection of new information/knowledge Synthesis of old and new information, and understanding of it by application to the problem, i.e. how much of the problem can now be explained? Repetition of all or some of the previous steps, as necessary Identification of what was not learnt Summary of what was learnt, and, if possible, Testing the understanding of the knowledge by its application to another problem
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Annex 2
WPR/RC37/Technical Discussicns/2 page 9
An integral component of problem-based learning is self-directed, illdependent learning. Independent student learning does not imply that the faculty relinquishes its responsibilities to provide an appropriate structure to facilitate and guide the learning process. The student must, however, learn how to work and to manage resources effectively. Problem-based learning is a familiar way of assuring continuing learning. The new problems and situations encountered oblige one to identify the knowledge that must be acquired to solve the problem at hand.
6. ATTRIBUTE/SKILL: ability to critically assess the appropriateness of technologies OPPORTUNITY TO LEARN: critical appraisal of data/evidence skil1s
The learning of the students in some innovative programmes includes critical reasoning and critical assessment of evidence. The development of these skiUs is crucial in self-directed learning and essential for the rigorous analysis and interpretation of information, clinical observation and appraisal of the design, and interpretation of scientific experiments and clinical trials. They include the skiHs intrinsic to epidemiology and biostatistics.
7. ATTRIBUTE/SKILL: abiJity to make clinical and managerial decisions OPPORTUNITY TO LEARN: problem-solving skiJJs, managerial skills
Although in traditional programmes health personnel are trained to solve problems, this aspect is usuaUy only emphasized during the clinical years. In some innovative programmes, from the beginning of their education, the students have opportunities to solve and manage problems, thus developing problem-solving skil1s very early. In the initial stages, however, the emphasis is on problem-based learning, problem solving being graduaUy stressed as the student progresses through the programme.
8. ATTRIBUTE/SKILL: abiJity to balance individual expectations, cost to society, ethical considerations OPPORTUNITY TO LEARN: problem-solving skills, economics of health care, bioethics
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Annex 2
WPR/RC37/Technical Discussions/2 page 10
Each of the health care problems used in the problem-based learning approach in some innovative programmes provides an opportunity to study issues concerning the economics of health care. These issues include the financing of health care and the different alternatives facing the health policy makers in relation to regulatory strategies. In addition to the opportunity to discuss issues of medical ethics at the individual or micro level which have to do with life-and-death questions, the health care problems provide the basis for discussing the less commonly examined social or macro-level ethical questions. These relate to the social obligation to provide health care, the inequalities in the distribution of health care that may be acceptable, and the question of how governments establish restrictions for providers and patients on the distribution of health care. A close examination of these macro-level ethical issues helps the health sciences student to understand how the health system arrives at decisions on the type of health service to be provided in a given community, and who is to control its distribution and delivery.
9. ATTRIBUTE/SKILL: ability to deliver individual care that takes into consideration the total needs of the patient OPPORTUNITY TO LEARN: the abili ty to integrate knowledge from all perspectives in individual care
Although most medical curricula identify issues in the behavioural and social sciences as important, the tendency is for students and faculty to be more comfortable dealing with biological science issues at the expense of the non-biological sciences. A major strength of both problem-based and problem-centred learning is their integrative ability, which forces the student to examine the patient's problems from al1 perspectives: biological, behavioural and social.
1II.
SOME KEY EDUCATIONAL ISSUES 11\ HEALTH MANPOWER DEVELOPMENT
I. The technological advances in the biomedical field, e.g. new communication channels, computer technology, have social, cultural, administrative and economic implications for future health personnel. These need to be known and quantified. Educational programmes should provide exposure and a certain degree of knowledge/proficiency but should not induce dependency. The basic skills needed for the effective practice of health care should remain independent of the sophistication of technological developments in the biomedical field.
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Annex 2 WPR/RC37/Technical Discussions/2 page 11
2. Obstacles in the way of change require an understanding by both the health care system and the training/education institution of the dynamics of resistance to change. 3. The need for the revision of curricula for health personnel should be more widely acknowledged, with emphasis om (a) a definition of explicit goals/objectives which are in consonance with the health care policies of the country, including those related to preventive medicine, and are relevant to primary health care and health for aU; this requires the participation of the health care system in defining the overall goals, the methods of implementation being decided by the educational/training institution concerned; teaching methods which emphasize the skills to be learnt and attitudes to be encouraged, taking into account what is known about the facilitation of learning and the disadvantages (for the student') of traditional teaching methods.
(b)
WHAT FACILITATES LEARl\iING? - Stimuli for activation of prior knowledge - A situation that provides retrieval cues - Opportunity for immediate challenge by the learner (discussion, writing summaries, etc.)
SOME DISADVANTAGES OF TRADITIONAL TEACHING METHODS (FOR THE STUDENT!) Little immediate obvious relevance Little opportunity or chaUenge to integrate Imperfect model for continuing education Demonstrated difficulty in student'S application of knowledge Inappropriate knowledge organization
Although perhaps worded in different ways, every medical school has set out the same general objectives for its programme: (a) to h~lp students become effective managers of health problems, by enablmg them to understand the principles essential to the solution of sucl1 problems; and to foster attitudes leading to behaviour as responsible professionals in their relations with patients, coUeagues and society.
(b)
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However, the traditional programmes have not provided many educational opportunities that appear to be relevant to these objectives. The new approaches to health sciences education, i.e. student-centred learning and problem-based learning, provide a system that facilitates the development of attitudes and skills compatible with and relevant to primary health care. The changes pioneered by McMaster University have now gained wide acceptance. Schools in many developed and developing countries have already established or are in the process of establishing educational programmes with the same educational philosophy. 4. Educational/training programmes should offer students the opportunity to be involved in a wide range of learning settings outside the teaching institution, particularly those relevant to primary health care. This outside involvement should provide opportunities for better understanding of the preventive aspects of health care, including health promotion, health maintenance and disease prevention. Community involvement, particularly in industrial settings, should permit the student to be exposed to environmental effects (including the work environment) on the health of the individual and the community. 5. The selection of students to be admitted to health educational programmes should be based on an assessment of the ability of candidates to develop the desired attitudes/attributes/skills. Selection procedures should include, in addition to a measure of the applicant's academic ability, an assessment of the following: educational profile: broad background sciences/social sciences /humani ties; education in the biological
personal attributes: past activities showing a broad interest in health care and social problems; suitable attitudes and personality traits; problem exploration skills: experiences showing the ability or potential to problem solve. 6. Educational institutions should develop foHow-up studies on their graduates to assess to what extent career choices and postgraduate performances affect the development of primary health care and health manpower development. An understanding of the factors involved in career choices may influence both health care systems and teaching institutions. 7. Faculty development programmes should be established by universities to assist faculty in developing teaching skills and promote an understanding of new developments in medical education. These programmes should also include explicit recognition of faculty contributions to teaching to help them in their career progress. Universities and governments should also work together to establish an appropriate career structure and incentives for health professionals who plan to make a long-term commitment to primary health care.
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Annex 2 WPR/RC37/Technical Discussions/2 page 13
IV.
CONSIDERATIONS FOR FUTURE ACTION
The Thirty-seventh World Health Assembly in 1984 adopted resolution WHA37.31, which addresses the role of universities in the strategies for health for all. It urges Member States: "to support universities in orienting the education and training of workers in health and related fields towards the attainment of health for all; and invites universities: "to provide the kind of education and training for students and postgraduates in the health and related disciplines that will prepare them technically and attune them socially to meet the health needs of the people they are to serve". In his report to the Health Assembly, the Chairman of the Technical Discussions identified obstacles faced by universities in realiZing their potential to achieve the health-for-all goal. Some of the obstacles have to do with the resistance to introducing changes in their teaching programmes to make them more student-centred and less teacher-centred. The report also mentions problems in the relationship between universities and government health services, the majority stemming from difficulties in effective communication between institutions. These problems must be addressed, and the report recommends: that UNIVERSITIES restructure their teaching programmes to respond to the primary health care needs of the communities and the achievement of the health-for-all goal; that GOVERNMENTS involve universities in assessing the health manpower planning and training requirements to meet the primary health care needs of the communities their graduates will serve; that WHO facilitate the interaction between government and universities and provide all parties concerned with information on the strategies for health for aU. I Among the targets for the regional medium-term programme for the Western Pacific Region are the strengthening of educational institutions and the reorientation of training programmes towards a student-centred and community-oriented approach. The main thrusts are identified as the strengthening of collaborative activities at country level with emphasis on the development of national health manpower policies and plans in the context of a holistic framework, including all aspects of the health manpower development process, and the strengthening of linkages between training institutions and health services.
I The role of universities in the strategies for health for all: report by the Chairman, Thirty-seventh World Health Assembly Technical Discussions, Geneva, 1984 (WHO document A37/Technical Discussions/3).
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The spirit behind the final thought of this paper can be found in one of the recommendations to governments made to the Thirty-seventh World Health A_seJTlbly by the Chairman of the Technical Discussions: "Universities and ministries should work together to design means and methods of continued education, reorientation and attitude change for aU those regardless of sector - who are likely to contribute to health for all".! Effective links between governments and universities require more than an affirmation of good will. They call for a relationship in which each of the parties concerned is prepared to relinquish some of the independence of action that results from working alone. Some successful arrangements have been made between governments and universities for the provision of health services, for example, the involvement of universities in the planning of health services and the placement of health professionals outside the university hospitals. These could be used as models for collaboration between governments and universities in the planning and education of health professionals.
IThe role of uniVerSIties in the strategies for health for all: report by the Chairman, Thirty-seventh World Health Assembly Technical Discussions, Geneva, 1984 (WHO document A37/Technical Discussions/3), page 12.
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BIBLIOGRAPHY
World Health Organization. Alma-Ata 1978: primary health care. Geneva, 1978, reprinted 1981 ("Health for AU" Series, No. D. Branda, L.A. A case study - McMaster University School of Medicine. Conference on Changing Community Needs and Future Medical Education. Kyoto and Kurashiki, Japan, 1986.
Daniels, N. Just health care. Cambridge, Cambridge University Press, 1985. Interregional Meeting on Health Manpower Development. Washington D.C., 1984. McMahon, R., et al. On being in charge: a guide for middle-level management in primary health care. Geneva, World Health Organization, 1980. McMaster Undergraduate Medical Programme - Vademecum. McMaster University, Faculty of Health Sciences. Hamilton, Ontario, Canada, 1983. Mejia, A. World trends in health manpower development. Manpower Development. Seoul, 198.5. Workshop on Health
New policies for health education and information in support of health for aU by the year 2000. Technical presentation to the thirty-third session of the Regional Committee. Manila, 1982 (WHO document WPR/RC33/Technical Presentation/t)o Primary health care in undergraduate medical education. Report on a WHO meeting. Exeter, 1983. World Health Organization. Regional strategy for health for aU by the year 2000. Manila, 1982. Saunders, N.A. Strategies and tactics for change in medical education. Conference on Changing Community Needs and Future Medical Education. Kyoto and Kurashiki, Japan, 1986. World Health Organization. The role of universities in the strategies for health for all. Geneva, 1984. The University of Newcastle - Faculty of Medicine. The University of Newcastle, Newcastle, New South Wales, Australia. 1986. Tugwell, P., et al. The measurement iterative loop: a framework for the critical appraisal of r.eed, benefits and costs of health interventions. Journal of Chronic Diseases, 38 (4): 339-3.51 (1985).
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ANNEX 3
ME~TINGS
ON HEALTH MANPOW~R IN THE WEST~RN PACIFIC REGION HELD DURING 1985 - 1986
International Conference International Conference on "Towards future health and medical manpower~ New strategies in education for the XXist century", 9-15 Apr il 1985, Tokyo, Japan. National Conferences/Meetings NEW ZEALAND National Conference on "The role of the doctor in New Zealand ~ Implications for medical education", 7-11 October 1985, Palmerston North, New Zealand. Conference Workshop on "Health manpower for the twenty-first century'. The role of universities for the goal of Health for All by the Year 2000", 20-27 February 1986, Manila, Ph ilippines. Conference on "Changing community needs and future medical education", 24-28 June 1986, Kyoto and Kurasiki, Japan. Workshop on "Medical Education". 10-11 July 1986, Canberra, Aus tral ia. International Conference on medical education "Tomorrow's Today", 12-17 July 1986, Khota BIlaru, Ke1antan, Malaysia.
PHILIPPINBS
JAPAN
AUSTRALIA
MALAYSIA
Physician~
KOREA
Workshop on "Production and utilization of health manpower", 21-23 August 1986, Seoul. Korea.
Regional Meeting Intercountry Workshop on "Management of change in tra1n1ng institutions", 9-21 February 1986, WHO Regional Teacher training Centre, Sydney, Australia. MEETINGS National Meeting CHINA "Medical Education in China for the XXlst Century", 17-27 November 1986 PLANNED~
Regional Meeting Intercountry Workshop on "Implementation of innovations in medical education", 8-20 February 1987, WHO Regional Teacher Training Centre, Sydney, Australia.