Now is the time to tackle healthcare’s biggest crisis

Dr Phil McElnay
Medical Doctor and CEO, MedAll
MedAll.org
@Phil_McE
@MedAllApp

 

TLDR (Too Long, Don’t Read); The world needs to increase its training capacity by 18million healthcare professionals by 2030. It’s a workforce crisis. They have to be trained to a high standard with an increasingly tighter budget. We need to think innovatively. Teamwork and technology are going to be key in enabling us to do that.

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The eyes of the world are on medicine. Whilst healthcare is back at the top of the world’s agenda we need to call out a crisis that we’ve been facing for over a decade and harness the collective energy of the world to tackle it.

It is a crisis that has been brewing for years- long before the coronavirus pandemic, indeed even before swine flu or Ebola. It’s a crisis that we can’t solve with vaccines, masks or more drugs. It’s much more widespread, multi-faceted and systemic.

We face a workforce crisis in healthcare. 

It seems simple, but when dissected into parts you begin to realise the scale of the problem. I work with a passionate team at an organisation called MedAll. It is a problem that we’ve been working wholeheartedly to solve.

Part 1: The world desperately needs more healthcare professionals.

The World Health Organisation (WHO) estimates that we need to train 18 million additional healthcare professionals by 2030 (1). That’s as well as training the 60 million healthcare professionals we are already training and on top of everything else that healthcare faces over the next 10 years.

As you dive into the details of this monumental challenge you discover some worrying features. In the 2017 WHO regional committee for Africa estimated that this particular region will require 6.1million of those 18million healthcare professionals- proportionately greater than any other region (2). 

Don’t get it wrong: in other regions there are similar issues, and whilst they are still big issues they are not quite as big. The USA is forecast to have a deficit of 105,000 doctors and 1million nurses by 2030. Germany will need 300,000 more nurses by 2030- many with expanded roles. India requires 3.9million more healthcare workers to launch what has been referred to as “the greatest movement towards universal health care in the history of humankind.” 180,000 additional Obstetricians alone are required in China to facilitate the relaxation of its one child policy (3). However you look at it, we are careering towards a workforce cliff-edge.

We need to tackle this. We can’t be apathetic. The world needs more healthcare professionals.

Part 2: The world desperately needs to train more healthcare professionals.

To produce more healthcare professionals requires more healthcare professional education. However, the WHO regional report for Africa points to another looming problem which compounds that which already exists: there is “inadequate [healthcare worker] education and training capacity.”(2) There are 168 medical schools in the Africa region (4), for a population of 1.3billion people (5). That represents one medical school for every 7.7million people. In East Asia and South Asia there is only 1 medical school per 5million population and per 3.8 million population respectively. Compare that with Europe or the USA which has at least one medical school for 1.6million population and 1.9million population respectively (6).

Indeed the regional committee for Africa explained that 24 countries had only one medical school and 11 had none at all. Some schools are not accredited which suggests that the quality of the medical education is not assured (4).

The existing healthcare education infrastructure is stacked against us. We are in deficit of healthcare education institutions before we even begin to scale up the volume of healthcare staff we train. Worse, the regions that have the greatest need have the least institutions. 

Part 3: The world desperately needs to train more healthcare professionals to an equally high standard.

What is one of the first questions you ask when you speak to relatives as a medic? Often it’s “what do you understand about the situation already?” To be able to fill in the gaps you need to understand where those gaps are. 

The same applies to education- both at an individual level and at a macro geographical level. In 2015, thirty-four WHO Member States in the region of Africa had not yet established a workforce observatory (4). It means that there is a lack of accurate data on health workers, their number and their skills. Understanding these key facts – and the gaps that exist – is the basis for informing evidence-based workforce planning and education. Without it, organisations and healthcare systems are adopting a “spray and pray” approach to the distribution of precious training resources. 

At a more granular level the WHO highlights “grave deficiencies” in the process of determining competence to practice in healthcare disciplines- globally (7). Not every healthcare professional is trained and assessed against a high, benchmarked standard. In high income countries healthcare professionals have become accustomed to their practice being evaluated against a curriculum using “e-portfolio” software. This could solve a big part of this problem, but in many countries this sort of intervention still seems a long way off.

Indeed even after licensure “lifetime” registrations often still exist which introduces the significant risk of skill decay over time. The WHO suggests that good practice should include “the shift from a single lifetime registration to a pattern of periodic re-licensure subject to evidence of continuous professional development and/or re-assessment of competence.”(7) It makes complete sense. As a patient I would want to be treated by doctors, nurses or allied healthcare professionals who have been trained and assessed against a benchmark and are staying up to date. Again, the ability to deploy this sort of intervention has been difficult for many countries.

There is a call to take action. As well as increasing the global output of healthcare professionals by 2030, the WHO requires all Member States to have established accreditation mechanisms for health training institutions, healthcare worker registries and observatories (7). We need more professionals, but we need to make sure they are trained at a high standard.

Part 4: The world has limited resources with which to train more healthcare professionals to an equally high standard.

When dissected further you begin to understand the real challenge we face.

Not only do we have to increase the number of healthcare professionals in a system that has a less than adequate number of training institutions, but we have to implement – quite rightly – benchmarked training, assessment and continuing professional development.

 
In a world of endless resources that should be an easy thing to do. Alas, that is not the world we live in. The Taskforce on Innovative International Financing for Health Systems estimates that in those systems which were scaling up the training of their healthcare professionals it required 9% of the health system budgets(7). It’s a hugely expensive thing to do.

The Lancet Commission on Education of Health Professionals for the 21st Century estimates that just 2% of the current global healthcare budget is spent on training (8). That leaves a deficit of 7%. Not only is 2% insufficient but it potentially jeopardises the remaining 98% of the healthcare budget. 

Yet it is a mammoth feat for governments and healthcare systems to channel increasing proportions of their budget towards training when there are so many competing interests. Add to that some of the most challenging economic times the world has faced in half a century and the problem becomes acute.

Just because it’s a difficult problem to solve, doesn’t make it impossible.

It is non-negotiable that we solve this problem. Not only is there a WHO target to implement better training globally, but there is a moral and social responsibility to do so. It will improve the quality of healthcare for us, our children and our children’s children. Patients around the world deserve to be treated by highly trained healthcare professionals, who stay up to date and have been assessed and credentialed against high standards. We wouldn’t expect anything less from our airline pilots or our lorry drivers.

The solution?

If we have limited resources we need to think creatively about how we achieve scaled up training at a consistently high standard- in every setting: high, middle and low resource settings. The WHO suggests we need “transformative strategies” to scale up healthcare worker education and to strengthen the accreditation and certification of trainees (7). They include:

1. Promote Innovation

We are at a point in history where smartphones are almost ubiquitous in every country around the world. Never has so much computing power been in the hands of so many people. As a global society we have the opportunity to harness technology to distribute – at scale – healthcare education at a consistently high standard. We have the opportunity to benchmark students, trainees and qualified professionals against a consistently high standard. 

We even have the ability to assess and record competencies, skills and expertise in a traceable and assured way, on a scale that we have never been able to do before. It would mean that countries can be truly visionary with how they implement WHO guidance on forming data observatories for their healthcare professionals. For instance, in the middle of a pandemic if they need to find out how many medics can manage a ventilator in their organisation, it becomes a simple 2 second task. They can quickly see the gaps in their workforce and form evidence-based strategies on how they can upskill those needed.

1. Efficiency Gains

It is unlikely that we will see a threefold increase in the global healthcare education budget – the amount the Lancet Commission explains that we would need if we are to continue to train healthcare professionals in the current way. If that isn’t possible then we need to think how we can do things more efficiently. 

Historically these two items were mutually exclusive. It was almost impossible to introduce innovative technology whilst cutting costs and gaining efficiencies. But with technological advances we are seeing this become a possibility. With low code software, no code software and even software-built-software, the design and development of technology can be placed into the hands of entirely non-technical people.

This is exactly what we have been ploughing our energy into at MedAll. We’ve designed a tool that makes it possible for every hospital, system, organisation, training body or government to implement gold-standard e-portfolio and assessment technology. They can do it without ever needing to employ an expensive software developer. They don’t even need to talk to one. They can build, customize and deploy their own e-portfolios, e-learning, assessments and curricula without touching a line of code. Organisations can share their curricula and assessments with organisations that otherwise wouldn’t have the resources to deploy it. It means that we, as a healthcare community, can drive costs down, whilst driving standards and efficiencies up. It’s teamwork.

It’s time for action.

With the immediate crisis we face in the coronavirus pandemic, the eyes of the world have been placed on healthcare. Unless we do something, when that crisis passes we will still be hurtling towards the workforce crisis we’ve known about for a decade. 

Over the past 3 months, as the world has been increasingly prioritising healthcare we’ve been rallying some of the best minds in technology, distribution, education and healthcare to join us in solving the big problem facing the world’s healthcare workforce. We’re humbled that some impressive organisations and individuals have joined that mission alongside us.

Let’s look back in 10 years and be proud of how we- as a global medical community – used every available resource to increase the number and quality of our healthcare professionals. Our children need us to do it. And they will thank us for it.

Find out more at MedAll.org or on twitter @MedAllApp.

References:

1. World Health Organisation; Addressing the 18 million health worker shortfall, 2019, Accessed on 15th June 2020 at: https://www.who.int/hrh/news/2019/addressing-18million-hw-shortfall-6-key-messages/en/

2. World Health Organisation; What needs to be done to solve the shortage of health workers in the African Region, 2017, Accessed on 15th June 2020 at: https://www.afro.who.int/news/what-needs-be-done-solve-shortage-health-workers-african-region

3. Britnellhttps://www.nuffieldtrust.org.uk/news-item/human-solving-the-global-workforce-crisis-in-health-care

4. WHO Regional Committee for Africa Sixty-Seventh Session, The African Regional Framework for the Implementation of the Global Strategy on Human Resources for Health: Workforce 2030, 2017, Accessed on 15th June 2020 at: https://apps.who.int/iris/bitstream/handle/10665/260238/AFR-RC67-11-eng.pdf?sequence=1&isAllowed=y

5. Worldometer, Population of Africa, 2020, Accessed on 15th June 2020 at: https://www.worldometers.info/world-population/africa-population/

6. Rigby P, Gururaja RP; World medical schools: The sum also rises, Journal of the Royal Society of Medicine Open, 2017 Jun; 8(6):2054270417698631

7. World Health Organisation; Transforming and scaling up health professionals’ education and training: Guidelines, 2013, Accessed on 15th June 2020 at: https://apps.who.int/iris/bitstream/handle/10665/93635/9789241506502_eng.pdf?sequence=1

8. Frenk J, Chen L, Bhutta Z et al, Health professionals for a new century: transforming education to strengthen health systems in an interdependent world, The Lancet Commissions; 376(9756):1923-1958