Transformative Education
for Health Professionals

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Skills Mix; an interview with Dr Lola Dare

Dr Lola Dare , Chief Executive Officer, CHESTRAD International 

The Centre for Health Sciences Training, Research and Development (CHESTRAD) is a global non-state, not-for-profit developmental agency. CHESTRAD works as an ethical African organization that employs evidence based approaches to advocate for the development of equitable and sustainable health systems and youth empowerment programmes that deliver services that are close to client and improve health outcomes.

Dr Julian Fisher (JF) speaks to Dr Dare about three key issues;

1. Civil Society played an active role in contributing to the development of the WHO guidelines for transforming and scaling up of health professionals’ education and training;  

2. Civil Society has an important ongoing role in supporting both the implementation of the guidelines recommendations, as well as continuing to strengthen the evidence base;

3. What are actions can civil society take / is taking going forward in terms of implementing the recommendations of the guidelines and generating evidence and advocate to address the gaps, particularly around skills mix.


JF: How has civil society contributed to the development of the WHO guidelines and their evidence base ?

LS: CHESTRAD was commissioned by WHO to conduct a survey exploring CSOs perspectives on the importance of health workforce education, and on governments’, CSOs’ and the WHO’s role in supporting the scale up of relevant health education.  Around 200 organisations (members of Global Health South, a network of southern CSOs) responded.    The views of respondents were analysed and summarized in a report that was submitted to WHO, and which informed the process of developing guidelines.

Members of Global Health South also inputted to consultation on the transformational education guidelines at the 2nd Retreat and Dialogue of GHS (Accra, 2012).


JF: What can civil society do to support the implementation of the guidelines ?

LS: A priortiy is policy dialogue and advocacy.  The above work highlighted a number of advocacy messages, detailed below.  Broadly, CSOs role in this area is to take forward key advocacy messages to their Boards, delegations, consultative fora, coalitions, networks and alliances; and to focus advocacy on country level implementation (MOE, MOH and other stakeholders).

  1. Transformational education should take place in the context of broader human resources for health (HRH) management and coordination processes.
  2. Transformational education can promote the retention and quality improvement of health professionals.
  3. Social accountability should be a critical component in the training of health professionals.
  4. Health systems and priority health needs should inform curricula design for health professional education.
  5. Governments should remain the ultimate custodians for training, and that accreditation associations for training institutions fulfil their roles accordingly and efficiently.

Service providers – especially as providers of training.  CSOs can play a role in the accreditation and regulation of CS training programmes; in linking education and services to consumer priorities; in enabling capacity to provide competence based training; and in providing service points for transformational training.  For example, our work with the Governments of Malawi and Nigeria has highlighted the important role that non-state actors play in the provision of health worker training, in particular supporting the decentralization of such training. 

Accountability.  CSOs have a fundamental role to play in ensuring effective accountability, including through their inclusion in Mutual Accountability mechanisms; in supporting social accountability - demand from government and training institutions; in ensuring Development Partner accountability – to track whether investments in training  are taking on board guideline recommendations.

Our work has highlighted the potential of a cascaded model of accountability both for the health workforce - ensuring that health workers have the right resources and working conditions to enable them to achieve the results expected of them; and of the health workforce – ensuring that health workers provide quality services that meet the needs of the communities that they serve.


JF: Have any gaps been identified, particularly around skills mix ? if so how is civil society addressing those gaps

LS: CHESTRAD and IntraHealth have supported the Ministry of Health in Malawi and Nigeria to lead a process to consult on and develop commitments on Human Resources for Health ahead of the 3rd Global Forum on Human Resources for Health, to be held in Recife, Brazil in November 2013.  The commitments that each country identified were based on a review their current frameworks for scaling up HRH, and to accelerate scale up and address gaps.  Analysing the commitments made by Malawi and Nigeria identifies some emerging themes:

  • There are insufficient numbers of health professionals, particularly in specialized cadres.
  • Accountability and coordination are important priorities.  The capacity of government to lead these efforts is key.
  • Health information systems are weak and this makes health workforce planning and management difficult. 
  • The importance of sub-national action is clear.  There is a need to strengthen the capacity of staff and systems to ensure an effective sub-national response for managing health workers effectively.  Ensuring the involvement of communities in local-level accountability mechanisms could be a valuable strategy.
  • Education and training are important to ensure the effectiveness of the existing health workforce, and as a strategy to incentivise and retain health workers.  Non-state providers of education need to be recognized and brought into the formal education system; the needs of CHW and MHW need to be better reflected in curricula (for new recruits and CPD programmes); CHW and MHW need clearer career paths.
  • Data on stock, density and distribution of health workers is not always available.  It appears though that both countries have concerns around distribution in rural areas. 


JF: what do these gaps mean for mid level providers and community health workers,  with a focus on skill mix in support of universal health coverage ?

LS: We do not know enough about the availability, distribution and density of mid- and community-level health workers. There seems to be increasing emphasis on these cadres (eg evidenced by DP focus in Nigeria) – but there has been insufficient investment in systems to manage the development and performance of these cadres. It may be that the case that the lower cost and timeframes associated with training of new MHW and CHW (compared with professional cadres) leads to greater emphasis on these cadres.  This will have to be accompanied by policies on task shifting.

CHWs and MHWs will take on an increasingly important role, with increased expectations.  It is important that they are provided with appropriate training, supervision, resources, support to enable them to meet these expectations.  It is important that they are incentivized – partly through pay and working conditions, partly through training and career development.  It is important that they are held accountable for their performance. 


JF: What are actions can civil society take / is taking going forward in terms of implementing the recommendations of the guidelines, generating evidence around skills mix and building advocacy to address the gaps, particularly around skills mix.

LS: There are four key areas;

1. Build evidence; document their experience in supporting the provision, training, accountability of CHW and MHW.  This will require support from national and international sources. Funding is very rarely available for advocacy and research activities, but mostly for service provision.

2. Continued advocacy, particulary calling for policies, resources and accountability of and for MHW and CHW.

3. Continued accountability.  We need to hold Governments, donors and health workers accountable for implementing their commitments and for performance.

4. Continued support (direct and indirect) to MHW and CHW, including through training of health workers.