Can medically educated patients solve the global shortage of quality health professionals for UHCs by 2030?

Wednesday, 12 October 2016

WHO World Health Assembly (May 2016), WHO Regional Committee Meetings (Sep-Oct 2016) and the UN General Assembly Debate (Sep 2016) had great discussions on SDG 2030, UHC and health workforce strengthening. Kawaldip Sehmi, our CEO, has assembled critical thinking on this matter of some of the 'health gurus' who attended these meetings.

SDG 2030-the honeymoon is over: building UHCs business starts now

Last year in September, shortly after the euphoric self-congratulatory back-slapping had ended, the 193 Heads of UN Member States at the UN general Assembly and their health ministers began to reflect on the obligations that they had taken on when adopting UN resolution 70/1 Sustainable Development Goals 2030. Desperate health ministers from low and middle-income countries (LMIC) were faced with one big question:  how were they going to find the quality physicians and other health professional staff needed to honour their pledge to extend universal health coverage (UHC) to the whole of their populations by 2030 under SDG 3.8? 

This year the UN General Assembly’s Debate, 20-26 September 2016, marked the first anniversary of SDG 2030 with a much more somber and reflective mood.  The honeymoon is over and the task of educating and developing high-quality physicians and health professionals globally to staff the new UHCs has just started.

Global shortage of physicians and health professionals

LMICs are already starting from a crisis point, even before expanding their UHCs, in finding and retaining quality staff for their UHCs; they already face a disastrous ‘brain-drain’ of their quality health professionals to the health systems in high-income countries (HICs). 

Despite the WHO Global Code of Practice on the International Recruitment of Health Personnel (WHO GCP 2010)  that had asked for the establishment of a legal and institutional framework to control the international recruitment of health personnel and to prevent this ‘brain-drain’, many LMIC countries have seen the exodus of their health professional continue unabated.

The human rights of the emigre health personnel (you have the right to choose where you work and on what terms) and the attractive remuneration packages offered by health institutions in the destination countries keep on overriding the rights and expectations of the patients and citizens of source countries and their health systems.

Compensating medical education in low and middle-income countries

The discussions at all the WHO regional committees was of fairness. Émigré health professionals are propping the sustainability of UHCs in high-income countries at the expense of LMICs. The taxes and funds vital for the development of UHCs in LMICs have been subsidising the medical education of these emigres for the benefit of HICs. 

Investment in medical education in LMICs yields no returns: the moment a medical student has graduated and completed his/her residence, they leave before the country’s patients can benefit from the investment that has been sunk into their study and development!

The WHO GCP 2010 had asked HICs and LMICs to implement bilateral agreements and other international legal instruments to restore the balance in this unfair recruitment and drain on medical education investment; health systems in destination countries should compensate the source countries through a football style ‘transfer fee’ by investing in medical education in the source LMICs for each physician recruited and lost to the LMICs.

Big Idea: medical education for expert patients and ‘noctors’ to solve the shortage?

There is now a Big Idea floating about on how to solve the shortage of staff: why not invest in ‘expert patients’ programmes in LMICs; let us medically educate and train patients and carers, in-situ, to become a part and parcel of their treating health institutions and professional staff.

Chronically ill patients and their carers (experts by experience) become very knowledgeable on clinical care and other aspects of their conditions very soon. They become experts. Advocates recommend that these patients with additional medical training could become the change that they would like to see in their health systems! 

The use of ‘lay’ trained people is not without precedence. For a long time now, we have had community health workers supporting health systems in many rural and vulnerable communities in LMICs. Skilled birth attendants and Accredited Social Health Activist (ASHA) in South Asia, and schemes using medical students and rural doctors to train villagers and community leader in Thailand are good examples of where lay people have helped improve access to health services.

In many HICs  the rise in the use of ‘noctors’ , nurses who  undertake some of the work reserved for doctors, to cover a large portion of the clinical services has also helped to improve access to health services. Many simple and routine operations are being handled by ‘noctors’ and not the general practitioner.

Health professionals in LMICs have relied heavily on ‘expert patients’ in diabetes and haemoglobinopathies (thalassaemia and sickle cell) clinics to help educate new staff and rural community health workers on the clinical aspects of their disease management.  Many chronically ill patients have accessed suitable health education programmes to become nurses, and some have even gone on to become physicians themselves.

Radical rethink by medical schools on patient-accessible medical education

For change to happen, there should be a radical rethink about making medical education accessible to patients. The medical schools and curriculum authorities must explore how they can restructure some of their medical education practice and curricula to accommodate the training of ‘expert patients’.  The first step maybe to attract patients to come and advise them on their current practice and curriculum. If they like it, they may apply for admissions!

This strategy will pay-off in the long run because medically educated patients are loyal to their health systems, facilities, and fellow patient community. There will be better retention of this staff. Future universal health coverage and the human resource planning must incorporate investment in the medical education of patients to achieve the SDG goal 3.8 by 2030.

A summary of WHO meetings we attended and the documents, discussions and resolutions can be found here: WHA 69 ; WHO AFRO RC 66; WHO SEARO RC 69 ; WHO PAHO 55 DC; WHO WPRO RC 67