Scaling up the Health Workforce
4.3 Key findings from the global literature
4.3.1 International experience with building institutional capacity and increasing production
According to the WHO Taskforce for Scaling Up Education and Training for Health workforce 2006 (Crisp, 2008) there is an estimated shortage of around 4.3 million healthcare workers globally affecting the majority of countries including developing countries although some developing countries (e.g. India, China and the Philippines) over-produce HCPs to create a surplus that will move abroad and support the local economy through remittances (Henderson and Tulloch, 2008).
The WHO Taskforce proposed an approach to address the acute shortages in skilled HCPs that focuses on three areas:
a Production of ten-year national scale up plans to rapidly increase community and mid-level workers who will be trained, paid and supervised parallel to scaling up HCP cadres.
b Curricula that are focused on health needs of the country and are
community and team-based drawing on the resources of the public and the private sectors and the skills of international partners and that use innovative means to increase training capacity such as ICT and regional approaches.
c Development partners and international organisations providing comprehen- sive and sustained support (Crisp, 2008).
This approach argues for increased production linked to political leadership, collaboration between the public and the private sector, effective workforce planning, sensible policies around foreign recruitment and attention to retention and distribution. The health workforce also needs to be deployed in a system with competent and trained managers who use reliable information sources to monitor HrH needs and deployment (Crisp, 2008).
4.3.1.1 Increasing the number of academic institutions
A number of countries have scaled up production by establishing more academic institutions. The approaches used include establishing new government-funded institutions, encouraging the private sector to establish new institutions or a combination of both. Brazil has followed a combination of all these options and has increased access to tertiary education to 30% of the population, with a third of students studying through the private sector (Redden, 2015). Since the 1990s there has been increasing deregulation in the higher education market, allowing entry of private-sector providers and, as a result, in South America and Asia the majority of medical schools are now privately owned.
Private-sector models range from non-profit models, often linked to faith-based institutions, to purely for-profit models. In high-income countries the role of the private sector varies, with the uSA having a long tradition of both private (for-profit and not-for-profit) and public academic institutions. Other developed countries with this combination include Austria, Australia, Belgium, France, germany, Ireland, Italy, Japan and Spain (World Directory of Medical Schools, 2015). Based on the World Directory of Medical Schools at least 93 countries (50%) have privately owned medical schools.
The most comprehensive data from Africa comes from the Sub-Saharan Medical School Survey (SSMSS) from 2009 (SAMSS, 2014) which shows that both the total number of medical schools and the overall number of students enrolled have increased dramatically since 1990 (Fig. 4.7). This survey identified 149 medical schools in 40 countries with 44 privately owned. In the 20 years since 1990, 58 new medical schools were established all with doctor-training programmes. A number also train medical specialists and other HCPs with 46% being privately owned.
The increase has been accelerating since 2000, with 33 new schools established, of which 14 are privately owned. The private ownership models included: seven medical schools owned by faith-based organisations (private non-profit), ten owned by NgOs (private non-profit) and seven for-profit.
Source: SAMSS, 2014
Figure 4.7: New medical schools by decade of being established and ownership Based on the survey, the number of students enrolled in first-year medical studies remains relatively small, with 39% of respondents reporting first-year enrolment at or below 100 students. However, 45% were planning to increase intakes within the next five years and 58% reported having mandates for expansion, usually from ministries of education and health (Chen et al., 2012).
In countries where universities have historically been state-run, the entry or possible entry of private institutions, often triggers debates and concerns about the quality of graduates, cost of tuition fees and fears that such institutions would recruit scarce academic faculty from public medical schools. In India, where 194 out of the 356 medical schools are privately owned and where 72% of the new intake slots created since 2000 have been in the private sector (Davey et al., 2014), serious concerns have been raised about staffing norms, availability of infrastructure, tuition fees and quality of students produced (Chen et al., 2012).
The quality of graduates produced is directly linked to the quality of regulatory oversight, including accreditation and quality assurance measures (SAMSS, 2009).
The better these are, the better the quality of the graduate, irrespective of whether the institution is in the public or the private sector. South korea, which has responded to the need to increase production by following a predominantly private-sector approach (31 out of 40 medical schools are private-sector based) (kim and kee, 2010) has a well-regulated system with no apparent difference in the quality of graduates. The curriculum is standardised across schools, and online learning resources are shared through the Consortium of e-Learning in Medical Education.
Quality assurance is ensured by the korean Institute of Medical Education and Evaluation (kIMEE) which evaluates (1) the school’s administrative system, (2) educational objectives and the curriculum, (3) student support, (4) faculty, (5) educational facilities, and (6) postgraduate education (kim and kee, 2010).
1910- 1919
1920- 1929
1930- 1939
1940- 1949
1950- 1959
1960- 1969
1970- 1979
1980- 1989
1990- 1999
2000- 2009 35
30 25 20 15 10 5 0
Public
Private, Non-Prot, Faith-Based
Private, Non-Prot, Other Private, for Prot
To prevent poaching, India has introduced restrictions that prevent private medical schools from employing public-sector academics prior to them retiring (Davey et al., 2014).
4.3.1.2 Increasing productivity of existing institutions
globally, academic institutions are required to increase production in a reality of stagnant or decreasing funding (Cota et al., 2011; Eley et al., 2008; Moodie et al., 2002). This can only be achieved through improving productivity, which implies increasing output (graduates) while curtailing costs.
A review of USA colleges with productivity rates 60% higher than average, found that they shared a number of organisational characteristics including: i) well-func- tioning operational management systems, ii) policies that encouraged ongoing improvement in efficiency; and, iii) management and academic staff who com- bined good academic practice with good management (Cota et al., 2011).
Internationally, strategies to boost productivity include:
a Creating a policy environment that requires academic institutions to track productivity indicators. Mckinsey argues that the best indicator of how effectively an academic institution uses its resources is the cost per degree, calculated by dividing total annual costs by the number of degrees
awarded. This indicator tracks two important indicators of academic institution productivity: cost efficiency and completion rates.
b Improving student completion rates.
c Using information technology to reduce cost (Worthington and Lee, 2005).
This includes library services, learning materials, online registration, distance education and online multi-campus teaching.
d Centralising study material development.
e Revamping the academic calendar to increase teaching time usually with increased salaries.
f Improving efficiency in support services through greater use of technology allowing an improvement in the ratio of students to support staff.
g Using academic staff to teach across disciplines and faculties.
h Differentiation between academic institutions based on teaching and research.
4.3.1.3 International scholarship programmes
Increasingly countries are supplementing local production capacity through large, government-operated scholarship programmes (British Council, 2014; David and Rosen, 2003). South Africa has actively pursued this option by sending students to Cuba (kritz, 2013).
4.3.1.4 Deregulate the market for international competitors
Cross-border trade liberalisation of higher education has been a highly contested political issue across all international, regional and bilateral trade liberalisation negotiations, with proponents arguing for the economic growth benefits of open markets and opponents expressing fears about the local impact of competition from abroad. globalisation of higher education services negotiations tend to focus on two major issues – market access, a subject often rigorously opposed by local academic entities who fear the disruptive potential of foreign competitors, and mutual recognition of professional qualifications, often less rigorously opposed (Barrett, 2015). Depending where countries fall in this political spectrum influences their willingness to embrace increased access to education by allowing international entrants to their market.