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Introduction¹

The U.S. Government Accountability Office (GAO), the World Health Organization (WHO), and the World Bank all agree that “an adequate, well-trained, and diverse health [care] workforce is essential for providing access to quality health [care] services” (GAO, 2015). However, according to the World Bank, “despite more than a decade of concerted global action to address the health workforce crisis, collective efforts are falling short in scaling up the supply of health workers” (Evans et al., 2016). The resulting health workforce shortage affects people’s access to quality health care around the globe. The WHO independent expert group to the High-Level Commission on Health Employment and Economic Growth led by Richard Horton predicted that “the resultant negative externalities of untreated sickness and disability will have direct adverse economic consequences” (Horton et al., 2016). Such adversities include personal financial deficits caused by lost days of work, a need to draw upon already restricted budgets to care for loved ones, and loss of future income as children are kept from school to support family members who cannot work. In addition to affecting family finances, untreated sickness and disability also affect employers’ bottom line as they try to function with a compromised or absent workforce.

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¹ The planning committee’s role was limited to planning the workshop, and the Proceedings of a Workshop has been prepared by the workshop rapporteurs as a factual summary of what occurred at the workshop. Statements, recommendations, and opinions expressed are those of individual presenters and participants, and are not necessarily endorsed or verified by the National Academies of Sciences, Engineering, and Medicine, and they should not be construed as reflecting any group consensus.

The WHO states that chronic underinvestment in health workforce education and training creates a mismatch between strategies to educate the right number and mix of health professionals and meeting the needs of the population particularly within remote and underserved communities (WHO, 2016). Even in high-income countries with well-functioning health systems, such as the United States and Britain, there can be an oversupply of health workers and health professionals coexisting with a shortage owing to imbalances in the distribution of health workers (Evans et al., 2016; WHO, 2016). According to the GAO (2015), a “more coordinated effort could help to ensure an adequate supply and distribution of the health care workforce.” Incentives are important levers policy makers and others have to influence recruitment, motivation, and retention of health professionals. The International Council of Nurses and others have noted that “incentives can be positive or negative, financial or nonfinancial, tangible or intangible” (ICN et al., 2008).

Matching population health needs with the right number, mix, distribution, and skill set of health workers while considering how supply and demand drive decisions within education and health was the topic of a National Academies of Sciences, Engineering, and Medicine workshop held October 6–7, 2016, in Washington, DC. The workshop, titled Future Financing of Health Professional Education,² was hosted by the Global Forum on Innovation in Health Professional Education (see full list of Forum members). It was open to the public and was also a webcast.³

As written into the statement of task found in Box 1-1, this workshop sought to explore resources for financing health professional education in high-, middle-, and low-income countries, and to examine innovative methods for financially supporting investments in health professional education within and across professions. Through presentations and small-group discussions, participants of the workshop had an opportunity to apply broad concepts—set up by economists and health workforce experts—to personal situations within their own profession. The workshop began with a welcome from Susan Scrimshaw; she, along with Malcolm Cox, form

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² The term financial economics more accurately captures the discussions that took place at the workshop, which is why the title of this Proceedings of a Workshop differs from the title of the workshop. Financial economics is defined as a “branch of economics focused on the elements of time, risk, opportunity cost, and other variables related to financial decisions. This field of study concentrates on how financial moves are made under uncertain conditions” (BusinessDictionary, n.d.).

³ Videos of the workshop can be found on the Global Forum on Innovation in Health Professional Education workshop website, http://nationalacademies.org/hmd/Activities/Global/InnovationHealthProfEducation/2016-OCT-6.aspx (accessed March 9, 2017).

the leadership of the Global Forum on Innovation in Health Professional Education.

Scrimshaw described how this workshop is a reflection of the increasingly complex topics Forum members have elected to undertake for their activities. These topics include the role of health professionals and educators in addressing the social determinants of health, interprofessional work and learning, assessment within and among the health professions, and defining professionalism in and with society. Previous activities such as the ones listed in Appendix D frequently set the stage for exploring other important topics, such as accreditation, which was looked at in an April 2016 workshop, and this workshop topic on financing health professional education.

With those brief remarks, Scrimshaw handed the microphone to Erin Fraher, University of North Carolina at Chapel Hill, who underscored the importance of this workshop, which is taking place at a time of great change and uncertainty in health care.

ORIENTATION TO THE WORKSHOP

Erin Fraher, University of North Carolina at Chapel Hill

My job this morning is to tell you, why now? What is the sense of urgency? Why are we here? These were the words of Erin Fraher, who continued to say incredibly rapid health system changes are occurring that are putting new demands on the health workforce. She then described the multiple ways the system is changing.

Factors Influencing Health Professional Education Financing

Traditional roles for many of the health professions are shifting,⁴ and the importance of preparing a workforce for population health has taken hold. Recently, the Josiah Macy Jr. Foundation issued conference-driven recommendations on preparing registered nurses for enhanced roles in primary care (Josiah Macy Jr. Foundation, 2016). There are occupational therapists and physical therapists who are increasingly working in people’s homes in an attempt to prevent readmissions to the hospital. Social workers are taking on incredible roles in health care that they perhaps have always done, but maybe are becoming more in the forefront now that other health professions are recognizing the importance of addressing the social determinants of health.

In building on the work of social services, Fraher asked what new roles might an upstream social focus in health create within the health workforce? The health workforce is increasingly changing as more roles look at spanning boundaries that bridge community and health care settings. These new areas include community health workers, health coaches, and others who are working with communities. This transformation has caused role changes and placed new demands on the health care workforce.

At the same time, new payment models and new care delivery models, such as accountable care organizations, have created a new way of interacting as a team that includes new players with a social or community-engaged focus.

The major issue for Fraher as a workforce researcher is the shift in care from acute to community settings and what that might mean for the workforce. For example, how does the nurse who has done all of his or her clinical placements and work in acute care settings get retrained in order to work in ambulatory care? While such change offers tremendous opportunities for nurses in community-based settings, how do health systems and

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⁴ Throughout the workshop, speakers referred to health professions and health professionals. While professions has a broader context than professionals, it was left to the individual preference of the speaker as to which term he or she used.

payers of education respond to the challenge of retraining or retooling the current workforce to be relevant for meeting the changing needs of patients and populations?

The future of education is not just about preparing students who are in the pipeline. If health care is to be transformed to better align with health systems, the global health workforce already in practice will need to be retrained because they are the people who are going to transform health care, said Fraher.

A difficulty is how health professionals and educators will meet this challenge at a time of constrained resources. Some are looking for new sources of money and new ways of financing health and educational activities, but increasingly, payers of health professional education are asking, “What am I getting for that money? What is the return on investment for dollars spent on education?” Fraher further commented that the discussion goes beyond the roughly $12 billion spent each year on graduate medical education (GME) (Dower, 2012). The discussion also includes nursing, physical therapy, occupational therapy, and all the health professions. The key question, said Fraher, is what is the return? How is education creating a workforce that is responsive to the needs of the health care system and the population?

These are the challenges facing health professional education that framed the workshop and that underscore the absolute timeliness of this workshop. Fraher stated that education will need to keep pace with changes in health care, demographics, and technology; training will have to shift from acute to community; interprofessional practice models will need to be the focus; and all of these changes will need to occur with little to no extra money.

Workshop Goal and Objectives

The goal of this workshop is to help Forum members and workshop participants think about how to face these challenges. Fraher then outlined the learning outcomes envisioned for the conference. One is to increase participants’ understanding of the evidence that is currently available. Another is to test traditionally held assumptions through structured dialogue realizing that at times, assumptions can create tensions. Fraher hopes the discussions will bring those tensions to the forefront so they can be openly addressed in hopes of better understanding the varied perspectives. The final outcome and learning objective is to explore financial levers or incentives that can be used to address the challenges identified by workshop participants and speakers.

Organization of the Proceedings of a Workshop

These learning objectives described by Fraher are embedded in an agenda that is found in Appendix A of this Proceedings of a Workshop and is reflected in the following chapters. Chapter 2 begins with the framing of health professional education financing from a global perspective, provided by Edson Araujo. As a Brazilian and an employee of the World Bank, Araujo offers an economic lens to describe the needs of the population and what the health professional education system is producing. Existing in between these forces is the market, which hopefully sends the right market signals but has been known to fail, resulting in mismatches. This chapter lays out a discussion about those mismatches and some of the challenges they create for health professional education financing systems. It also contains a discussion about the design of an ideal health professions education financing system and the guiding principles that could be the foundation for such a system. Some of these attributes could include being responsive to society, flexibility, and a focus on lifelong learning.

Within this chapter is a conversation about the actors involved in health professional education financing. Answering this involved a stakeholder analysis where the workshop participants explored the following questions: Who is involved? What kind of influence do they have? What kind of levers can they pull? What do they want to do? How can they be incentivized?

Chapter 3 then compares (1) proposed notions discussed by the workshop participants with (2) health professional education financing examples drawn from South Africa, the United Kingdom, and the United States. It also looks at tensions in health professional education through the pedagogy of debates. These debate propositions explore whether public spending on health professional education should be significantly increased, and whether it is acceptable to demand a social return on investment from health professional schools. Embedded in this chapter are ideas drawn from the four breakout groups that delve more deeply into different aspects of the mismatches and other relevant issues, such as levers and drivers for financing health professional education.

Chapter 4 offers an opportunity to reflect on the discussions taking place throughout the workshop and those specifically related to building a model for financing health professional education. In this regard, Charles Ok Pannenborg, formerly with the World Bank, highlighted numerous windows through which health professional education could be viewed from a financial perspective. Malcolm Cox gave his personal reflections on building a model such as the one described throughout this proceedings. His remarks led into Erin Fraher’s presentation; she took her original model on financing health professional education and reworked it based on comments

she heard throughout the workshop. Her additions and edits to the model (including a new title that uses the term financial economics), the guiding principles, and the list of actors are found in Chapter 4.

REFERENCES

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