The 21st Century Global Healthcare Workforce

Preparing the 21st century global healthcare workforce
Sheri D Pruitt, JoAnne E Epping-Jordan
To meet the growing global demands of caring for the increasing numbers of patients with chronic
conditions, we need to develop a new approach to training
Chronic conditions currently accountfor more than
half of the globaldisease burden and are a primary
challenge for 21st century healthcare systems.1 This is a
dramatic shiftfrom the health concerns ofthe 20th
century, when acute infectious diseaseswere the
primary focus in every country.While the world is
experiencing a rapid transition from acute diseases to
chronic health problems,training of the healthcare
workforce, however, relies on early 20th century mod-
els thatemphasise diagnosis and treatmentof acute
diseases. Educational leaders, health professional bod-
ies, and the World Health Organization recognise such
models as inadequate for health workers caring for a
growing population of patients with health problems
that persist across decadesor lifetimes.2–5 Training
should be restructured to include a new setof core
competencies(knowledge,skills, abilities, personal
qualities,experience,or other characteristics)—new
“tricks” thatprepare 21stcentury health workers to
manage today’s most prevalent health problems.
The workforce is not prepared
The global crisis in the healthcare workforce has
attracted much attention in recent years.6–10 There is a
global imbalance of human resources for health and, in
particular, a shortage of healthcare workers in
developing countries.11
Clearly,the scarcity of healthcare workers is cause
for concern.Unchecked migration ofthe workforce
from rural to urban areas and from poor to wealthy
countries has dire consequences for the health of those
living in abandoned communities.The sole focus on
the quantity of healthcareworkers, however,has
obscured a second butequally troubling issue:the
quality of the training and preparation of the
workforce.There is an obvious mismatch between the
most prevalent health problems (that is, chronic condi-
tions) and the preparation ofthe workforce to deal
with them. Acute medical problems will always require
the attention ofhealthcare providers,but a training
model focused exclusively on treating acute symptoms
becomes more inadequate by the year.
Caring for patients with chronic conditions is
different from caring for patients with episodic
illnesses. Effective care for patients with ongoing health
problems requires treatment that is continuous across
settings and across types of providers; care for chronic
conditions needs to be coordinated over time. Health-
care workers need to collaborate with each other and
with patients to develop treatmentplans,goals,and
implementation strategies thatcentre on the needs,
values,and preferences of patients and their families.
Self managementskills and behavioursto prevent
complications need to be supported by a workforce
that understands the fundamental differences between
episodic illness that is identified and cured and chronic
conditions that require management across years. The
reality, however,is that patients consult multiple
providers who lack coordination among themselves
and across settings,resulting in care thatis, at best,
expensive,confusing,and conflicting and,at worst,
harmful to patients.3
In addition to diagnosis and treatment of acute ill-
ness and injury, today’s healthcare workers need a core
set of competencies that will yield better outcomes for
patients with chronic conditions.A workforce for the
21st century must emphasise management over cure
and long term over episodic care.
A different set of competencies
A recent review by WHO listed five core competencies
for delivering effective health care for patients with
chronic conditions (box 1).12 Determination of the
competencies included a review ofthe literature on
educational reform for healthcare providers and
health care for chronic conditions.In addition,WHO
examined published standards and discipline-specific
competenciesof various professionalorganisations.
Throughout the process, the emphasis was on
the identification of workforce competenciesthat
addressed the needsof patientsand their families.
WHO identified and described common competencies
across various professionalgroups (including family
physicians,nurses,pharmacists,dentists,and allied
health workers)in a draft document.International
professionalcouncils, educationalleaders,patients’
advocacy groups,and experts in the care ofpatients
with chronic conditions reviewed the draft and made
suggestions resulting in a finallist of core competen-
cies thatapply to everyone caring for patients with
chronic conditions.
Patient centred care—Understanding the experience
of illness from the patient’s perspective captures the
essence ofpatientcentred care.This type of care is
responsive to and respectful of the needs, values, differ-
ences, and preferences of the patient. It includes addi-
tional components: coordinating continuous and
timely care; relieving pain and emotional suffering; lis-
tening and communicating;providing education and
information;sharing decision making and manage-
ment; preventing disease, disabilities, and impairments;
and promoting wellness and healthy behaviour.
Partnering—Partnering is the ability to join with
patients, other providers, and communities for effective
Box 1: The five basic competencies
• Patient centred care
• Partnering
• Quality improvement
• Information and communication technology
• Public health perspective
Learning in practice
Behavioural Science
Integration, Kaiser
Permanente,
Sacramento, CA,
USA
Sheri D Pruitt
director
Health Care,
Department of
Chronic Diseases
and Health
Promotion, World
Health
Organization,
Geneva, Switzerland
JoAnne E
Epping-Jordan
coordinator
Correspondence to:
J E Epping-Jordan
[e-mail]
BMJ 2005;330:637–9
637BMJ VOLUME 330 19 MARCH 2005 bmj.com

care of patients with chronic conditions. The workforce
needs skills that allow them to share power and involve
patientsin all aspectsof decision making in their
health care. They need the ability to work in teams and
collaborate with other providers:those who care for
the patient across time, in different settings,from
different disciplines,and for different diseasesthat
might coexistin the same patient.This competency
necessitates strong communication skills, including the
ability to negotiate,share decisions,collectively solve
problems,establish goals,implementaction,identify
strengths and weaknesses,clarify roles and responsi-
bilities, and evaluate progress. Partnering with commu-
nities willhelp to redistribute responsibility between
the healthcare system and the neighbourhoods and
villages in which patients spend mostof their time.
Referral pathways between the healthcare setting and
outside organisations can be developed when every-
one works together.
Quality improvement—Quality improvement requires
the healthcare workforce to be clear about the
outcomes they are working towards, know what
changes would lead to improvements,and know how
to evaluatetheir efforts.13 In addition, a quality
improvementapproach requires workers to translate
into practice evidence from their own efforts at
improvement and those of others. Improved safety for
patients and increased efficiency of service delivery is
embedded in this competency.
Information and communicationtechnology—The
workforce needs the skills to use available technologies
to support care of patients. Information systems (from
paper and pencilrecords to sophisticated electronic
databases) are essential for organising and monitoring
patients’ responses to treatments and outcomes. Com-
munication systems(from fixed line telephones to
mobile devices to the internet) allow the exchange of
information on patients with other providers, who may
be in other settings or distant locations.
Public health perspective—Thinking from a public
health perspective moves the workforce from caring for
one patient at a time to planning care for populations of
patients.Related to this is the concept of systems
thinking—the understanding that health care is a series
of systems that are embedded in other, broader systems.
Patientsand providersare influenced by healthcare
organisations that are in turn influenced by even larger
national healthcare policies. Finally, a public health per-
spective includescare acrossthe disease continuum,
from clinical prevention to palliative care.
Importance for developing countries
These competencies are vitally important in develop-
ing countries,where increasingly health workers care
for patients with chronic conditions.For example,in
sub-Saharan Africa,86% of the disease burden is
attributable to chronic conditions.14 While HIV, AIDS,
and tuberculosis account for most chronic conditions,
other chronic problems are on the rise. About a quar-
ter of the healthcare budget in South Africa is spent on
cardiovasculardiseases.15 In fact, among South
Africans over age 45,the prevalence of cardiovascular
disease surpasses that of HIV and AIDS.16
Experts agree that urgent mobilisation of human
resources is criticalto combat HIV and AIDS and to
meet the millennium developmentgoals that were
endorsed by 189 countries in 2000.17 These goals out-
line their commitment to reduce poverty and hunger
and address ill health, sex inequality, lack of education,
and environmental degradation—all by 2015. The need
for additional healthcare workers to meetthe goals
provides an opportunity to prepare a new cohortof
health professionals to care for chronic health
problems including cardiovascular diseases, tuberculo-
sis, and HIV and AIDS. Will this opportunity be met by
training a new workforce in the skills necessary to care
for patients with chronic conditions or will the chance
slip away and resultin our teaching “new dogs” the
same “old tricks”? This new workforce will increasingly
confront a double burden of chronic HIV and AIDS
and chronic non-communicable conditions. Innovative
and integrated approaches for care will be necessary as
will a new set of competencies that transcend specific
illnesses and apply to all healthcare workers, regardless
of discipline.
Moving to implementation
The competencies outlined in the WHO publication
are supported by several influential health professional
bodies,including the World MedicalAssociation,the
How willcountries such as Malawicope with HIV and AIDS and other chronic conditions?
Life expectancy has dropped to just 39 years
WHO/PIERRE VIROT
Urgent mobilisation of human resources is criticalto meet the millennium development goals
WHO/PIERRE VIROT
Learning in practice
638 BMJ VOLUME 330 19 MARCH 2005 bmj.com

International Council of Nurses, and the International
PharmaceuticalFederation (collectively representing
the World Health Professionals Alliance) and the
European Respiratory Society.Importantly,the publi-
cation also has the support of the International
Alliance of Patients’Organisations.The competencies
must now be translated into reality by reform in health
training institutions and centres of higher education.
To prepare healthcare workers to manage chronic
conditions some experts have proposed new teaching
methods,2 18 19 while others have experimented with
innovative training models.2 20 On the basis of these
proposalsand experiences,we recommend thatall
healthcare workers, regardless of discipline, be system-
atically exposed to training opportunities as partof
their curriculum (box 2).
Are these recommendations unrealistic or outof
touch with the needs of developing countries? Perhaps
not, considering the current training efforts in Eritrea,
Sudan, Swaziland,and Uganda, where healthcare
workers are learning to deliver chronic care for people
with HIV and AIDS. In addition to basic biomedical
training,the workforce is learning to negotiate care
plans with patients, to support patients in self manage-
ment, to use information systems, and to work as mem-
bers of healthcare teams.
The urgent need for mobilisation of human
resources to combat HIV and AIDS and to meet the
millennium development goals creates an opportunity
to advance the quality ofhealthcare training.A new
workforce can be prepared to deliver21st century
health care for 21st century health problems—new
“dogs” can learn new “tricks.”
Contributors:SDP and JEE-J developed and wrote the article,
and JEE-J is guarantor. SDP is a scientist-practitioner in the inte-
gration of behavioural science into health care. She has a long-
standing interest in methods for improving healthcare workers’
skills for chronic conditions. JEE-J is also a behavioural scientist
and, at WHO, she has coordinated efforts to help reorganise
health care so that it is more effective and efficient for the man-
agement of chronic conditions. This paper is based in part on a
recent WHO publication on core competencies for delivering
effective health care for patients with chronic conditions, and on
subsequentdiscussions between the authors on how to begin
translation ofthese competencies into training methods that
could help meet the millennium development goals.
Funding: None.
Competing interest: None declared.
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(Accepted 11 February 2005)
Box 2: What healthcare workers should do as
part of training
• Learn how to move from reactive care to proactive,
planned, and preventive care, using several of the new
competencies outlined above
• Learn how to negotiate individualised care plans
with patients, taking into account their needs, values,
and preferences
• Learn how to support patients’ efforts at self
management
• Learn how to organise and implement group
medical visits for patients who share common health
problems
• Care for a defined group of patients over time
• Work as a member of a healthcare team
• Work in a community based setting
• Design and participate in quality improvement
projects
• Develop information systems (for example, patient
registries) and use available technology and
communication systems to exchange information on
patients
• Learn to think beyond caring for one patient at a
time to a “population” perspective
• Develop a broad perspective of care of patients
across the continuum from clinical prevention to
palliative care
Summary points
Traditional models of acute care are inadequate
for training a workforce to manage today’s most
prevalent health problems: chronic conditions
WHO has led an effort to identify a new set of
core competencies that will yield better outcomes
for patients with chronic conditions
These competencies apply to everyone who cares
for patients with chronic conditions
Several influential health professional bodies and
patients’ associations support these competencies
The competencies must now be translated into
reality by initiating reform in training institutions
and centres of higher education
Learning in practice
639BMJ VOLUME 330 19 MARCH 2005 bmj.com