Background

Paediatric training and the practise of paediatrics is built on the bedrock of ensuring best possible health outcomes for all children, optimising opportunity for those without full health and contributing to a voice, in advocacy, for children. In the world’s high-income countries (HICs), child health outcomes are comparatively good, and the paediatric workforce well trained to manage the health issues of children. Paediatric training and continuing professional development is generally under the authority of paediatric societies or colleges. Such organisations are well funded and supported, have long traditions of curriculum and resource development with supervisors trained in postgraduate training and supervision. They have a history of matching training needs to the health needs of their children. Some attempt at supporting advocacy and a voice for children is made, and a sense that paediatricians do all they can for the underprivileged is instilled during training. Such approaches are right and proper, but do they miss something fundamental?

Deficits

The global context of child health is somewhat different from that in the HICs. Mortality is far greater in the low-income and middle-income countries (LMICs), and morbidity is also much higher, not just from communicable disease but increasingly from non-communicable disease. Newborn deaths make up half of childhood deaths. Much has been made of the fall in under-5 mortality rates during the Millennium Development Goal (MDG) era, implying that we are on a steady trajectory to eliminating under-5 deaths. However, rates of improvement have slowed, indeed in some countries there has been a decline in survival rates. We know that under-5 mortality is around 6 million, which is too many, let alone the enormous morbidity which is not counted or measured.1 There are many excellent publications such as the recent paper by Liu et al, 2 which analyses data and provides statistics to the global community on child survival. Continued measurement of these problems is important, but it is not the solution. Papers on child survival make a call for increased resources to combat high mortality, but seldom with a commentary on how best such resource is used to ensure falls in mortality and morbidity.

Much of the health workforce for children are either nurses or community health workers, often with limited access to doctors or paediatricians. There are few paediatricians in areas of great need in the LMICs, and those working in child health are overloaded with clinical pressures, resource constraints and relative isolation. The estimated density of paediatricians practising in countries in Africa range from 0.03 to 0.8 per 1 00 000 population, and even this is considered an overestimate, compared with the European figures (11–86 paediatricians per 1 00 000 population in the UK and Germany).3

Health workforce

It can be seen that the health workforce in the LMICs is of a different nature to that in the HICs. The health workforce is stretched, access to higher-level support not readily available, limited numbers of child health experts and little capacity for paediatricians to contribute to higher-order tasks such as child health policy development, health system strengthening, advocacy, training and support of other health cadres and of doctors and paediatric trainees.4 Yet these are the settings in which the world’s children suffer the most. Workforce distribution around child health is highly skewed. In general, countries with the worst child health outcomes have the lowest number of trained child health professionals and the lowest rates of spending on education and training for their health workforce.5 There is good evidence that a well-trained workforce is needed to implement health interventions, without which there are major bottlenecks.6 Alongside poor infrastructure, inadequate drugs and supply systems and weak information systems, severe shortages of health workers are one of the main health-system constraints in achieving the health-related MDGs.7 Poor quality of care is a critical barrier to children’s utilisation of health services and to health outcomes in many LMICs. Provision of high-quality services for children requires a competent and motivated health workforce.8

Training to strengthen the health workforce

Of the 2600 medical schools worldwide,9 the majority are in HICs where health outcomes for children are generally high. Postgraduate training in paediatrics is highly structured in the HICs, whereas many LMICs have less structure in which to place postgraduate training. Many paediatricians in the LMICs have extremely high levels of child health competence, but lack of a systematic training programme embedded within local health needs, alongside competing pressing clinical pressures and medical workforce shortages curtails opportunity for comprehensive training. Hence, in the world’s areas with the highest prevalence of child health problems there is less opportunity in training than in those parts of the world with better health outcomes for children. This inverse training law is not in the interests of child health when viewed through a global lens.

When the HICs undertake training in paediatrics, it is to develop the health workforce that meets the needs locally. Training is about workforce, a workforce fit to meet the health needs of their populations. Have our training organisations in either the LMICs or the HICs developed a suite of measures of health for the world’s children? The political system at the United Nations (UN) has, in the MDGs initially, followed more recently by the Sustainable Development Goals (SDGs).10 The High-Level UN-led Commission on Health Employment and Economic Growth11 reported recently that investing in the health workforce is needed to make progress towards the SDGs, including gains in health, global security and inclusive economic growth. Recognising the need globally for an additional 40–45 million health workers by 2030, the Commission has made 10 recommendations on the health workforce, most of these call for an investment in worker training, in collaboration globally and in processes to strengthen the health workforce.11 Among these recommendations are two critical elements:

• Scale-up transformative, high-quality education and lifelong learning so that all health workers have skills that match the health needs of populations and can work to their full potential. Harness the power of cost-effective information and communication technologies to enhance health education, people-centred health services and health information systems.

• Promote intersectoral collaboration at national, regional and international levels; engage civil society, unions and other health workers' organisations and the private sector; and align international cooperation to support investments in the health workforce, as part of national health and education strategies and plans.

A scale-up of education and lifelong learning for the child health workforce, alongside information and communication technologies is a huge task for the LMICs. It could be asked, can the HICs, with their relative abundance of educational resource, not be better placed, through appropriate partnership, to support the LMICs in helping to build and strengthen educational and training capacity locally, in the areas of greatest child health need? Indeed another of the Commission’s recommendations, above, requests collaboration at all levels to better support national health and education strategies and plans. Should not the global paediatric training groups be taking some leadership on this recommendation? Indeed they should. An example of how this can be done is the work by Wilmshurst et al in Cape Town, where support and training of paediatric leaders in Africa is provided, including follow-up. Evidence to date suggests this approach is highly effective.3

Workforce in child health is a key priority of WHO and the UN. The overall goal in the WHO Global Strategy Workforce 203012 is to ‘improve health, social and economic development outcomes by ensuring universal availability, accessibility, acceptability, coverage and quality of the health workforce through adequate investments to strengthen health systems, and the implementation of effective policies at national, regional and global level’. Some of the suggested 2020 global milestones in this report include:

• All countries have inclusive institutional mechanisms in place to coordinate an intersectoral health workforce agenda.

• All countries have established accreditation mechanisms for health training institutions.

• All countries are making progress on health workforce registries to track health workforce stock, education, distribution, flows, demand, capacity and remuneration.

• All bilateral and multilateral agencies are strengthening health workforce assessment and information exchange.

Furthermore, this report states:

Health systems can only function with health workers; improving health service coverage and realising the right to the enjoyment of the highest attainable standard of health is dependent on their availability, accessibility, acceptability and quality. Mere availability of health workers is not sufficient: only when they are equitably distributed and accessible by the population, when they possess the required competency, and are motivated and empowered to deliver quality care that is appropriate and acceptable to the sociocultural expectations of the population, and when they are adequately supported by the health system, can theoretical coverage translate into effective service coverage.

Therefore, workforce needs both numbers and quality—competence, motivation and empowerment. Might countries struggling under the weight of multiple health priorities and major resource constraints be assisted through global efforts in the generation of quality of their workforce? Health priorities of the post-2015 agenda for sustainable development—such as ending AIDS, tuberculosis and malaria; achieving drastic reductions in maternal mortality; expanding access to essential surgical services; ending preventable deaths of newborns and children under 5 years; reducing premature mortality from non-communicable diseases; promoting mental health; addressing chronic diseases and guaranteeing universal healthcare (UHC)—will remain aspirational unless accompanied by strategies involving transformational efforts on health workforce capability.4 WHO calls for transforming efforts to support the global workforce.

In the WHO’s ‘Towards a new global strategy for women’s, children’s and adolescent’s health’,13 training is a key to workforce development, and collaboration is a way to achieve such scale-up. Sustainable Development Goal 3c calls for a substantial increase in health financing and in the recruitment, development, training and retention of the health workforce in middle-income countries. A disparity exists, however, between population needs and market-based demands, as those countries where basic health needs are the greatest have the fewest economic resources to create employment positions in the public health sector. The proposed sustainable development goals, which are implicit in the ‘Every Woman Every Child’ strategy, will not be achieved without unprecedented international governance and solidarity, together with innovative national approaches to maximise the efficiency of available resources.13 So WHO is calling for training to better support workforce development; collaboration is a key.

In addition to quality training to improve child health outcomes, healthcare system improvements are needed. In some of the interventional disciplines, fly-in fly-out health workers can add some value through short-term operational initiatives. In the case of child health, such approaches are, in general, of less value. So how can the global child health community add value where it is needed? A more fundamental strengthening of local child health leadership, leadership training, educational supports where requested, registrar exchange programmes and other cooperative links, provided they reflect true partnership might be good beginnings. At the heart of a child healthcare system is human leadership. Currently, there is recognition of a disconnect between professional training programmes and how they prepare graduates to work within and influence operation of the healthcare system. The influential Lancet Commissions5 report on Health Professionals for the 21st Century identified the need for greater strategic planning and interaction between education of the health workforce and the healthcare delivery systems if there is to be effective impact on health outcomes. Interconnection between health needs and training needs is required. Development of child health leaders and leadership is required to better support the local health system. This sort of education is not just on diseases and their management, it reaches to leadership development, health systems understanding and strengthening. Such leadership development can be very difficult to source in those countries in most need of such leadership.

Given the aspirations of the UN towards the SDGs and the need to substantially improve the training and retention of the health workforce in many countries, the global paediatric academic community should come together to better support these global aspirations. A number of paediatric academic and training institutions have extensive involvement in and commitment to global child health. The Royal College of Paediatrics and Child Health has a number of programmes in the LMICs, and is actively supporting the development of paediatric training programmes at the postgraduate level in a number of countries. Within the USA, there are a number of activities, both under the auspices of the American Academy of Pediatrics and the American Board of Pediatrics, as well as through many individual academic institutions, to support global child health at an institutional and national paediatric society level. The International Pediatric Academic Leaders Association supports cross-fertilisation of ideas and educational imperatives through the International Pediatric Association. The Global Pediatric Education Consortium has developed a global paediatric curriculum. These activities, worthy as they all are, tend not to focus on the WHO workforce requirements or the UN SDGs, or collaborate globally and strategically with the aim of improving child health through a well-trained and equipped workforce. None is linked to the aims of the UN General Assembly.

A suggested approach from the global paediatric academic community

It is therefore proposed that consideration be given to developing a more cohesive and integrated approach to the education and training of the global paediatric workforce, with a particular commitment to paediatricians and the role of paediatricians as leaders in advancing the child and adolescent health agenda. Although paediatricians and paediatric medical and surgical specialists represent only a fraction of the child health workforce, they are often in a position to provide leadership in child health and influence child health policy and delivery at the local, regional and country level. Consideration also needs to be given to linking paediatric workforce development to initiatives related to other child health professionals. In consideration of the focus on reducing stillbirths and neonatal deaths, we need particularly to consider links between paediatricians, obstetricians and midwives, in addition to links with nursing and primary child healthcare workers. Such healthcare professionals need to be supported in having an extended role in LMICs to ensure improved child health outcomes.

It might then be argued that the fundamental matter most paediatric training programmes miss is the global dilemma around child health. This is of relevance to all, given the new world order of migration and cultural diversity within so many of our populations. Rather than focus solely on the needs of children locally, some consideration should be given to the global crises that affects the world’s children, and some responses to the great need of children worldwide be given. This after all is a moral dilemma that should touch all of us in child health. It is hoped that a global collaboration among the world’s paediatric training providers to better support the global child health workforce might provide one pathway forward, and would ensure consistency of intent, clarity of focus and synergy in action.