‘The beginning decades of the 21st century have been unsettling. Worldwide, many have been affected by natural disasters, terrorism, wars, the Arab Spring, drought and famine, pandemics and financial turbulence.’1 While about 1.5 billion people live in the developed world most – 5.7 billion – do not, and the disparities –economic, social and political – are huge and growing with an estimated world population of over 9 billion by the middle of this century.
A telling contrast relates to the health of populations. While close to a billion are undernourished – 19 million in the developed world! – over a billion are now overweight or obese, including many who are living in the East. It is estimated that Sub-Saharan Africa carries c. 25% of the world’s disease burden but has only 3% of the planet’s resources and only about 1% of the world’s doctors.2 There are several countries where the inhabitant to doctor ratios stand at unimaginable levels of 50,000:1 and others with ratios of 33,000:1. Both India and Pakistan ratios, although better, are still having to cope with unacceptable ratios of around 1700:1 (India has c. 0.74% doctors per 1000 people, whereas Pakistan has c.0.6% per 1000). These ratios are in stark contrast to those of many western nations that average about 400 patients per doctor, thereby ensuring life expectancies well into the 70s and 80s compared to 50s and 60s – and even 30s/40s – especially in Sub-Saharan African countries. Knowing what we know, these discrepancies –which admittedly also occur “within” rich countries- are not financially nor morally justifiable as we proceed further into the 21st century, and major re-balancing of the world order needs to take place not only in the economic/political arenas but also, and most importantly, at social –family and individual –levels, where survival and the quality of one’s life should not depend solely on where one is born or lives but on the valuing, care and compassion of human life that all who inhabit this fragile planet deserve.
Non-communicable diseases (NCDs) or chronic conditions ‘ top the global health agenda’ ‘including heart disease, cancer, stroke, diabetes and respiratory illnesses.’ Given scarce resources and stretched infrastructures in many poor countries, the leading causes of sickness and death also involve gastroenteritis, congenital abnormalities, tuberculosis, malaria, and typhoid fever. Collectively, these diseases are known as a “wicked problem” ‘for health authorities because of the overlap of so many disparate disease determinants, originating at so many levels, from individual behaviour to international trade and wealth distribution.’3 Indeed, these are, according to Dr Margaret Chan, director-general of the World Health Organization (WHO), ‘the diseases that tax health systems to the breaking point . These are the diseases that break the bank.’4
Addressing these complex and stubborn issues – key drivers of change – may no longer simply be a matter of ‘doing things better’ (evolutionary change), or more efficiently, but rather learning how ‘to do better things’ (innovation), which must include committed resolve to better the human condition within such spheres as ‘genetics, epidemiology, environment, social inequity, health literacy, behavioural risk factors and even the social networks that influence our attitudes on health and lifestyle.’ 3
Most urgently, as Professor José Martin-Moreno, professor of medicine and public health at the University of Valencia and an adviser to the World Health Organization/Europe and Terrence Sullivan, professor at the University of Toronto’s Institute of Health Policy, Management and Evaluation and chair of the board of Public Health Ontario,highlight, ‘policymakers must expand the scope of action beyond health care to confront the intersection of circumstances where individuals live and work.’
Although countries –rich or poor – differ markedly in terms of the scope, seriousness and depth of their health and social care problems, they do share a common framework for enabling changes which take shape ‘at three levels: society, community and individual.’3
- ‘Societal-level action reflects public policy and governmental interventions aimed at modifying the existing legal frameworks and the environment to make healthy individual behaviour easier.’
- The community level where ‘social settings should be exploited in order to engage people on health matters through communication, awareness, education, training and outreach.’
- At the Individual level where ‘primary care facilities are the optimal setting for personally tailored health advice, recruitment to disease-screening programs, immunizations and detection and follow-up of risk factors such as obesity.’
It is estimated that globally there is a shortage – many in remote or isolated communities5– of at least 4.1 million healthworkers. Recognising the seriousness of the challenge, the WHO / Global Health Workforce Alliance (GHWA), under the direction of Dr Mubashar Sheikh, has set a goal of training and deploying an additional 2.6 to 3.5 million additional health workers by 2016…in support of the UN Global Strategy for Women’s and Children’s Health and the Universal Coverage Goal.’ Moreover, through evidence-based, context-relevant planning ‘national health strategies will be implemented in at least 75% of Human Resources for Health (HRH) priority countries.’ 6
In her May 2012 address to the Sixty-fifth World Health Assembly in Geneva, Switzerland, Dr Margaret Chan, director-general of WHO, suggested three lines of advice on strategies and approaches that countries should follow ‘to help maintain the momentum for health in the years ahead’4:
‘First, get back to basics, like primary health care, access to essential medicines, and universal coverage. Shift to thrift. Develop a thirst for efficiency and an intolerance for waste…streamlining and integrating health programmes …channelling good aid ‘in ways that strengthen existing infrastructure and capacities.’
‘Second, as public expectations rise, costs soar, and budgets shrink, we must look to innovation as never before…Innovation does the most good when it responds to societal concerns and needs, and not just to the prospects of making a profit…’
And, thirdly, ‘Use research. Use science. Shape the research agenda and seize every opportunity opened by new findings.’
In another keynote in Oman, Dr Chan emphasised that facing ‘emerging’ and ‘enormously complex’ challenges calls ‘for nothing less than a radical change in mindset, a fundamental rethinking of the way health systems deliver services and maintain good health outcomes.’7
And, while building capacity has to be a top priority for many nations and ministries of health, so is strengthening capability, ensuring that the health and social care needs of the populations are met, now and in future years. The latter aim requires the availability of timely and accurate information from transparent and accountable national and regional health intelligence units. For example, in the UK and Australia, governments have established such units: in the UK, the Centre for Workforce Intelligence (CfWI) and in Australia, the Australian Health Workforce Institute (AHWI).
The changing patterns of disease in many nations also necessitate re-balancing hospital and community care, with increasing emphasis given to chronic conditions and treating these in primary care and community settings. These shifts will have a ‘knock-on’ effect on the education and training of health and social care professions, including task shifting and task sharing, providing considerable opportunities for innovation in skill mix and clinical roles. In terms of undergraduate and postgraduate learning, health and care curricula should, therefore, be designed to ensure that they are (1) competency and outcomes -based, (2) centred around the needs of individual learners, with a view to demonstrating ‘authentic abilities,’ (3) make the quality and safety of patient care the top priority in all training programmes, (4) provide a much better balance between curative and preventive care, and (5) nurture the self-worth, mutual respect and dignity of patients and colleagues throughout the learning experience.1 Designing more flexible –perhaps modularised – programmes along these lines, allowing trainees to ‘step in and off an education and training escalator’ to provide more immediate and dynamic care for populations with urgent needs – will necessitate strengthening medical education and in particular faculty support and educational development.
One of the steep challenges for planners at all levels may be the revitalisation of ‘patient-healthcare professional ‘relationships, and the building of a new professionalism, founded on shared understanding of and commitment to ‘new attitudes, values and behaviours,‘ that are ‘patient-centred, interprofessional and team-based’ and that, according to Dr Richard Horton, editor-in-chief of The Lancet, rise above the ‘rigid and damaging tribalism that afflicts the professions today.’1, 2
Arguably, and with a longer time-span in mind, one of the most perplexing problems facing 21st century societies as a whole ‘may be finding the right balance in terms of ‘materialism,’ technology and fundamental human values -especially recognising the centrality of the family unit, in the community and its future.’ Given these deep-rooted universal concerns , it seems that reflections and discussions along these lines – particularly by leading decision-makers – must start sooner than later. Here medical students, trainees and, in fact, all health/social care professionals have a particularly vital role to play as they -along with government ministries of health and regulators – try to sort out these issues in the coming years.
Historically, there can be little doubt that the changes societies are experiencing in the early years of the 21st century – West and East, North and South – are as profound, perhaps more so, as those from the 1890s to the 1940s which ushered in the modern era, especially within the context of economic well-being and population health. To optimise the latter, many may agree with Lord Crisp, former chief executive of the NHS and Permanent Secretary of the Department of Health (2000-2006), that ‘[u]ltimately, it is transformation in how health professionals work and, most fundamental of all, in how they think and how they understand the world that will lead to improvements in health and healthcare.’1
This is a Guest Editorial by : Dr. George R Lueddeke
George R Lueddeke BA OCT MEd PhD is the GRL Consultant in Higher and Medical Education Development and is from Southampton, Hampshire , United Kingdom
1Lueddeke GR. Transforming Medical Education for the 21st Century: Megatrends, Priorities and Change. London UK: Radcliffe Publishing Ltd; 2012.
2. Frenk J, Chen L, Bhutta ZA, Cohen J, et al. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. The Lancet.2010; 375(9721):1137-8.
3 Martin-Moreno J, Sullivan T. Three levels of action against chronic disease. Available at: http://www.theglobeandmail.com/commentary/three-levels-of-action-against-chronic-disease/article4621961/ (accessed 20 October 2012).
4Chan M. Best days for public health are ahead of us, says WHO Director General. Address to the Sixty-fifth World Health Assembly. Geneva, Switzerland: WHO; 21 May, 2012.
5Crisp N & Gawanas B. Scaling Up, Saving Lives: Summary and Recommendations (Task Force for Scaling Up Education and Training for Health Workers). Geneva, Switzerland: WHO/Global Health Workforce Alliance; May 2008.
6Global Health Workforce Alliance. Strategy for the Second Phase 2013-2016:Advancing the Health Workforce Agenda Towards Universal Access. Geneva, Switzerland: GHWA; 2012.
7Chan M. WHO Director-General addresses conference on health systems. Keynote address at the International Conference on Oman Health Vision 2050: Quality Care,Sustained Health. Muscat, Oman. Geneva, Switzerland: WHO; 30 April 2012.
Editor’s Note: This is a guest post and the views/opinions expressed in the article are solely that of the author.References and figures (if any) are not verified by the Editor for Guest Editorials .The incidents about patient experiences (if any) stated in this blog are highly fictionalised and any resemblance to any person(living or dead)and/or incident is purely co-incidental
Image Courtesy : www.flickr.com/photos/7202153@N03/2048145303/ under CCL