Health services reform in Poland: issues in recent developments

After ten years of debate and discussion, the political situation within Poland finally allows the possibility to implement basic reforms in the health care system. Parallel development of the political and technical aspects of the reform has now lead to a final proposal for fundamental reforms in health system responsibility, financing and management. This article describes the current conceptual developments and the political and social context for these final reform proposals at the time of their submission to the government. The primary changes suggested are aimed at increasing the awareness of local, regional and national administrations, health care professionals and the general public that health care has a cost, and that resources must be used carefully if they are to cover health needs. In addition, 'health care' as a term must be extended to include factors and activities besides direct medical services. Such factors as air and water quality, diet, smoking and alcohol consumptions are examples of matters which will also be included in the focus of health system planners. A key element of the organisational reforms is decentralisation of responsibility for health care planning and administration within the framework of nationally set standards and priorities. Based on local decisions, the current basic organisation unit of health care delivery, the ZOZ or integrated health care units, will be redefined and either decomposed into their component services or receive newly defined responsibilities more adapted to the local realities of available manpower and medical facilities. In addition, the development of a private health care sector complementing and even competing with the public services sector will be actively encouraged.     

住院医师培养国家与医院筹资能力分析

住院医师培养是医学教育过程的重要组成部分,而筹资是实施该教育过程的基本保障。根据对国家宏观卫生经济的分析和全国10个省、直辖市、自治区52所医院的数据,详细论述了住院医师培养的国家和医院筹资能力,并对国家筹资的10年计划进行了估算。结果表明,住院医师培养每人每年需2.00万元人民币,国家筹资目前极少,建议国家承担人均每月1000.00元,作为其生活补助;国家10年筹资计划总额为104.52亿元,占全国财政支出的4.24/万;建议医院每年专项用于住院医师培养的经费平均应在20.00万元。     

Undergraduate medical education in the U.S. and Israel: contrasts and common challenges

In 2014, the Israeli Council for Higher Education (CHE) commissioned an international panel of outstanding educators to prepare an ad hoc report reviewing the four established medical schools in Israel. The report described the strengths, weaknesses and challenges facing medical education in Israel with a focus on three specific areas: workforce planning, the structure of the curriculum and the financing of medical education.There are interesting parallels between the challenges facing medical education in the U.S. and in Israel: a lack of clarity regarding the optimal size for the workforce and the optimal method for enhancing the number of primary care physicians; an absence of methodologies for evaluating innovations in medical education and a lack of transparency in funds flow. However, there are also important differences, one of the most important being an absence in Israel of students’ hands-on responsibility for their patients until year six of their undergraduate medical education.The presence of a small number of medical schools with common funding and geographic proximity, in a relative sense, provides the Israeli medical schools with a unique opportunity to evaluate innovations in medical education and to set a high bar for inter-school collaboration and cooperation.     

The hospital medical director: his role and professional qualification in Modena (Italy) health care system

The development of health care system in Italy, from 1968, have changed the hospital medical director function and have put him in conflict with the desired physicians involvement in health care management. In Modena the health care system organisation, the self government and the responsibility decentralisation, promoted the achievement of an organisation model tempering every competence because the success of everyone's task depends on the other one's. Therefore, Italian laws are suitable of getting more efficiency and effectiveness in health care system without new rules, if the clinical governance becomes a way to involve the physicians in management and not an instrument to leave out managers and hospital medical directors.     

Reforming higher specialist training in the United Kingdom--a step along the continuum of medical education

OBJECTIVES: The requirement to align the arrangements for postgraduate training in the United Kingdom with those elsewhere in the European Community provided the opportunity to review and reform our arrangements for higher specialist training. This paper describes the case for change--the strengths and deficiencies of the traditional pattern of postgraduate medical training, demographic influences in the medical workforce and the need for a more structural or planned approach to training. CONCLUSIONS: Over the past 5 years substantial progress has been made: the introduction of new regulatory arrangements and a new higher specialist training grade; the development of a managed and flexible system for delivering training to standards set by the Royal Colleges and which can accommodate the needs of those pursuing academic and research medicine; and the opportunity for trainees' progress to be measured against published curricula. The significant programme of change has been underpinned by careful workforce planning and the publication of comprehensive guidance. Significant reform of higher specialist training has been achieved. This paper also makes the case for a more strategic approach to planning and developing medical education across the continuum, from entry to medical school until retirement, which can guide medical education and improve patient care into the next millennium.     

The distribution of health planning and management responsibilities between centre and periphery: historical patterns and reform trends in four Caribbean territories

The degree to which health planning and management functions are decentralised has been one of the key questions in developing countries from when they first gained independence. This paper's aim is to examine the question of the historical distribution of responsibilities within the health sector of four territories, Trinidad and Tobago, the Bahamas, Martinique, and Suriname, in order to identify the roles of the different levels, changes over time and recent reform trends, and to seek to explain the reasons for changes. These territories were selected deliberately, on the grounds of their different colonial backgrounds. Common features included identification over several decades of management structures and skills as key problems; proposals for regionalisation and greater hospital autonomy as desirable solutions; and in three of the four territories, recent implementation of major structural reforms. Important influences on the timing and nature of decentralisation reforms included political and economic factors, the attitudes of the public service unions and the medical profession, and external funders who were particularly important in financing reforms and supporting the development of detailed implementation plans. The bureaucratic inheritance of the two English-speaking countries provided major barriers to structural change, which they have addressed through reforms involving the creation of agencies with delegated authority.     

Both service and training demand attention in obstetrics and gynaecology

New proposals for workforce planning, training and ways of working in the NHS are under consideration. Aspects of service, training and workforce in obstetrics and gynaecology that call out for change include training in the senior house officer grade, especially for GPs and non-EC doctors, and the work of consultants. Proposals for change present a golden opportunity for the specialty to lead in new systems of both service and training, which are closely linked.     

Restructuring the health workforces of the NIS countries: report of an unprecedented multinational conference

Health professionals, educators, and policy-makers in the US and the Newly Independent States met in Tashkent, Uzbekistan, and shared concerns on health workforce planning, access to care, and training. The International Conference on the Health Care Workforce for the 21st Century recognized the scope and interdependence of workforce strategies that must be employed to achieve health reform objectives in the new political system. Specific issues addressed in the conference include health workforce planning; interdisciplinary and multidisciplinary education; primary care, family medicine, and general practice; the supply of physicians; medical education; supply and role of nurses; assessing the competency of practitioners; continuing education and training; the role of professional organizations; accreditation; and international collaboration. Conclusions of the deliberations provide insight into present conditions, prospects for change and how future development assistance can most usefully be targeted.     

Health system's response for physician workforce shortages and the upcoming crisis in Ethiopia: a grounded theory research

Background

A rapid transition from severe physician workforce shortage to massive production to ensure the physician workforce demand puts the Ethiopian health care system in a variety of challenges. Therefore, this study discovered how the health system response for physician workforce shortage using the so-called flooding strategy was viewed by different stakeholders.

Methods

The study adopted the grounded theory research approach to explore the causes, contexts, and consequences (at the present, in the short and long term) of massive medical student admission to the medical schools on patient care, medical education workforce, and medical students. Forty-three purposively selected individuals were involved in a semi-structured interview from different settings: academics, government health care system, and non-governmental organizations (NGOs). Data coding, classification, and categorization were assisted using ATLAs.ti qualitative data analysis scientific software.

Results

In relation to the health system response, eight main categories were emerged: (1) reasons for rapid medical education expansion; (2) preparation for medical education expansion; (3) the consequences of rapid medical education expansion; (4) massive production/flooding as human resources for health (HRH) development strategy; (5) cooperation on HRH development; (6) HRH strategies and planning; (7) capacity of system for HRH development; and (8) institutional continuity for HRH development.The demand for physician workforce and gaining political acceptance were cited as main reasons which motivated the government to scale up the medical education rapidly. However, the rapid expansion was beyond the capacity of medical schools’ human resources, patient flow, and size of teaching hospitals. As a result, there were potential adverse consequences in clinical service delivery, and teaching learning process at the present: “the number should consider the available resources such as number of classrooms, patient flows, medical teachers, library…”. In the future, it was anticipated to end in surplus in physician workforce, unemployment, inefficiency, and pressure on the system: “…flooding may seem a good strategy superficially but it is a dangerous strategy. It may put the country into crisis, even if good physicians are being produced; they may not get a place where to go…”.

Conclusion

Massive physician workforce production which is not closely aligned with the training capacity of the medical schools and the absorption of graduates in to the health system will end up in unanticipated adverse consequences.

     

Building partnerships for healthy environments: research,leadership and education

As populations across the globe face an increasing health burden from rising rates of obesity, diabetes and other lifestyle‐related diseases, health professionals are collaborating with urban planners to influence city design that supports healthy ways of living. This paper details the establishment and operation of an innovative, interdisciplinary collaboration that brings together urban planning and health. Situated in a built environment faculty at one of Australia's most prestigious universities, the Healthy Built Environments Program (HBEP) partners planning academics, a health non‐government organisation, local councils and private planning consultants in a state government health department funded consortium. The HBEP focuses on three strategic areas: research, workforce development and education, and leadership and advocacy. Interdisciplinary research includes a comprehensive literature review that establishes Australian‐based evidence to support the development, prioritisation and implementation of healthy built environment policies and practices. Another ongoing study examines the design features, social interventions and locational qualities that positively benefit human health. Formal courses, workshops, public lectures and e‐learning develop professional capacity, as well as skills in interdisciplinary practice to support productive collaborations between health professionals and planners. The third area involves working with government and non‐government agencies, and the private sector and the community, to advocate closer links between health and the built environment. Our paper presents an overview of the HBEP's major achievements. We conclude with a critical review of the challenges, revealing lessons in bringing health and planning closer together to create health‐supportive cities for the 21st century.     

Medical and dental staffing prospects in the NHS in England and Wales 1993

This article provides a brief update on current national policies affecting medical education and training, and information on the present medical and dental workforce. Although of general interest, senior medical students and doctors in the training grades may find it particularly helpful when considering choices of future career. As there may be marked local variations in career prospects for any one specialty, further information and advice is available from Regional Postgraduate Medical and Dental Deans, specialty advisors (through Royal College and specialty associations) and clinical tutors. The information in this article relates to the present situation only and a review of previous articles in this series may be useful to observe certain trends.     

Health workforce development: a needs assessment study in French speaking African countries

In 2006, WHO alerted the world to a global health workforce crisis, demonstrated through critical shortages of health workers, primarily in Sub-Saharan Africa (WHO in World Health Report, 2006). The objective of our study was to assess, in a participative way, the educational needs for public health and health workforce development among potential trainees and training institutions in nine French-speaking African countries. A needs assessment was conducted in the target countries according to four approaches: (1) Review at national level of health challenges. (2) Semi-directed interviews with heads of relevant training institutions. (3) Focus group discussions with key-informants. (4) A questionnaire-based study targeting health professionals identified as potential trainees. A needs assessment showed important public health challenges in the field of health workforce development among the target countries (e.g. unequal HRH distribution in the country, ageing of HRH, lack of adequate training). It also showed a demand for education and training institutions that are able to offer a training programme in health workforce development, and identified training objectives and core competencies useful to potential employers and future trainees (e.g. leadership, planning/evaluation, management, research skill). In combining various approaches our study was able to show a general demand for health managers who are able to plan, develop and manage a nation’s health workforce. It also identified specific competencies that should be developed through an education and training program in public health with a focus on health workforce development.     

The future of health care in the United States

The U.S. government is involved in health care in various ways that include (1) providing services to veterans, (2) paying for care received by Medicare and Medicaid beneficiaries, (3) assuring quality through regulatory activity, (4) financing the discovery of medical breakthroughs, and (5) training members of the health workforce and assuring that the nation has an adequate supply of them. With the aging of the population, the role of the government in these endeavors will increase. This essay considers ways in which the health care of tomorrow will be affected by the intermingling of factors such as demography, epidemiology, economics, technology, globalization, and individual health behavior.     

Organisation of workplace learning: a case study of paediatric residents’ and consultants’ beliefs and practices

Several studies have examined how doctors learn in the workplace, but research is needed linking workplace learning with the organisation of doctors’ daily work. This study examined residents’ and consultants’ attitudes and beliefs regarding workplace learning and contextual and organisational factors influencing the organisation and planning of medical specialist training. An explorative case study in three paediatric departments in Denmark including 9 days of field observations and focus group interviews with 9 consultants responsible for medical education and 16 residents. The study aimed to identify factors in work organisation facilitating and hindering residents’ learning. Data were coded through an iterative process guided by thematic analysis. Findings illustrate three main themes: (1) Learning beliefs about patient care and apprenticeship learning as inseparable in medical practice. Beliefs about training and patient care expressed in terms of training versus production caused a potential conflict. (2) Learning context. Continuity over time in tasks and care for patients is important, but continuity is challenged by the organisation of daily work routines. (3) Organisational culture and regulations were found to be encouraging as well inhibiting to a successful organisation of the work in regards to learning. Our findings stress the importance of consultants’ and residents’ beliefs about workplace learning as these agents handle the potential conflict between patient care and training of health professionals. The structuring of daily work tasks is a key factor in workplace learning as is an understanding of underlying relations and organisational culture in the clinical departments.     

Central Asian republics: a case study for medical education reform

Social, political, and economic changes in the former Soviet Union precipitated both the collapse of a once-centralized medical education system in the region and the development of individual models in its place. In the context of rapid globalization and international concerns about health, this development of "nation-based" models for the structure, content, language, and duration of instruction generated concerns about regional accreditation; workforce planning; student qualifications; residency training; continuing education; and infrastructure, such as access to literature, an adequate clinical training base, and links to certification and licensure. The World Health Organization acknowledges that the development of human resources for health is a complex and key element in reforming health systems. In Central Asia, international donor agencies facilitated the development of a regional council of rectors and a partnership consortium of medical academies as reform vehicles. International medical education organizations provide counsel and share their organizations' models, greatly facilitating the reform progress. The groups work to address both the political and regulatory environment and the professional and academic environment that affect the quality of medical schools. The council of rectors is establishing credibility as a regional nongovernmental organization that can advise governments about workforce planning, budgeting, admissions policies, accreditation, and licensure. The group sponsors faculty development workshops, bringing together regional educators around educational and institutional issues of mutual concern. Partnership academies collaborate to develop institutional and individual professional capacity, focusing on standardized evaluation, structure and content of the curriculum, pedagogy, and leadership development.     

Demonstrating a new approach to planning and monitoring rural medical training distribution to meet population need in North West Queensland

Background

Improving the health of rural populations requires developing a medical workforce with the right skills and a willingness to work in rural areas. A novel strategy for achieving this aim is to align medical training distribution with community need. This research describes an approach for planning and monitoring the distribution of general practice (GP) training posts to meet health needs across a dispersed geographic catchment.

Methods

An assessment of the location of GP registrars in a large catchment of rural North West Queensland (across 11 sub-regions) in 2017 was made using national workforce supply, rurality and other indicators. These included (1): Index of Access –spatial accessibility (2); 10-year District of Workforce Shortage (DWS) (3); MMM (Modified Monash Model) rurality (4); SEIFA (Socio-Economic Indicator For Areas) (5); Indigenous population and (6) Population size. Distribution was determined relative to GP workforce supply measures and population health needs in each health sub-region of the catchment. An expert panel verified the approach and reliability of findings and discussed the results to inform planning.

Results

378 registrars and 582 supervisors were well-distributed in two sub-regions; in contrast the distribution was below expected levels in three others. Almost a quarter of registrars (24%) were located in the poorest access areas (Index of Access) compared with 15% of the population located in these areas. Relative to the population size, registrars were proportionally over-represented in the most rural towns, those consistently rated as DWS or those with the poorest SEIFA value and highest Indigenous proportion.

Conclusions

Current regional distribution was good, but individual town-level data further enabled the training provider to discuss the nuance of where and why more registrars (or supervisors) may be needed. The approach described enables distributed workforce planning and monitoring applicable in a range of contexts, with increased sensitivity for registrar distribution planning where most needed, supporting useful discussions about the potential causes and solutions. This evidence-based approach also enables training organisations to engage with local communities, health services and government to address the sustainable development of the long-term GP workforce in these towns.

     

Continuing-education needs of the currently employed public health education workforce

OBJECTIVES: This study examined the continuing-education needs of the currently employed public health education workforce. METHODS: A national consensus panel of leading health educators from public health agencies, academic institutions, and professional organizations was convened to examine the forces creating the context for the work of public health educators and the competencies they need to practice effectively. RESULTS: Advocacy; business management and finance; communication; community health planning and development, coalition building, and leadership; computing and technology; cultural competency; evaluation; and strategic planning were identified as areas of critical competence. CONCLUSIONS: Continuing education must strengthen a broad range of critical competencies and skills if we are to ensure the further development and effectiveness of the public health education workforce.     

A workforce survey of health promotion education and training needs in the state of Victoria

OBJECTIVE: This study investigates the education and training needs of health professionals and factors affecting participation in education and training. METHODS: A survey of health promotion professionals, health professionals, GPs and CEOs of community health centres, conducted across different settings and locations. Information was obtained on: involvement in health promotion activities, most useful content and format of past training, current preferences for education and training and barriers and incentives to education and training. RESULTS: Health promotion professionals were involved in the widest variety of health promotion activities, including more evaluation, research and planning than GPs and other health professionals who were involved in more client-focussed activities. Professionals' preference for training content reflected the type of activities in which they were most frequently involved. Practical courses, of short duration, delivered by experienced peers or health promotion experts were preferred over university and TAFE courses. Professionals in rural and provincial locations require both greater access to information on training and conveniently located training. More organisational support, funding and time release would encourage the training of professionals in government departments, community health centres and public hospitals. CONCLUSIONS: To be most effective, training must be tailored to suit the specific needs of different professionals involved in health promotion and take into consideration how factors, such as financial incentives and time release, influence participation across different settings and locations. IMPLICATIONS: Further development of the health promotion workforce will require recognition of its professional diversity and a more responsive and organised approach to education and training programs.     

Rural origin and rural medical exposure: their impact on the rural and remote medical workforce in Australia

Australia, like many countries, finds it difficult to recruit enough medical practitioners to live and work in rural and remote communities. Over the last decade the Australian Commonwealth Government has invested in a national strategy to train its medical workforce to encourage recruits to rural and remote general practice. This strategy is based on overseas experience that rural origin students, and those experiencing early and repeated rural exposure during training, are more likely to practise in a rural location. The importance of rural origin as a predictor of rural practice is well documented in the literature. More recent studies have tended to focus on rural exposure during both undergraduate and early postgraduate years, and on developing rural curricula in a multifaceted approach to medical training. All 11 medical schools in Australia have modified their selection criteria to encourage students from rural and remote locations, and have, to a varying degree, encouraged rural exposure in parallel with developing uniquely rural content in their curricula. Many of these initiatives are quite recent and have not yet been thoroughly evaluated against their success in addressing shortages in the rural and remote medical workforce. The aim of the review is to explore how the relationship between rural origin and rural exposure during undergraduate and postgraduate training and choice of practice location has underpinned initiatives in medical education in Australia in the years 1990-2003.     

Linking public health education and practice: the Australian experience

The public health workforce in Australia is highly skilled, multifunctional, and drawn from a variety of backgrounds, including clinical practice and non-health areas. A wide range of activities is needed to meet the educational and training requirements of this workforce, including on the job inservice training, context specific continuing education programs and short courses, distance and self-directed learning packages, and postgraduate University level courses. The core components of public health today include: a social and political commitment to health, a shared responsibility between government and the public, and a multidisciplinary field of action. The challenge for those providing education and training for the public health workforce is to ensure graduates have the broad range of knowledge and skills needed in this climate. A system-wide approach to learning, where knowledge and skill development is related to the practices and settings of service and program delivery, will ensure strong links between education and practice.