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POLICY FORUM Maximizing the Impact of Training Initiatives for Health Professionals in Low-Income Countries: Frameworks, Challenges, and Best Practices Corrado Cancedda1,2,3*, Paul E. Farmer1,2,3, Vanessa Kerry2,4,5, Tej Nuthulaganti6,7, Kirstin W. Scott7, Eric Goosby8, Agnes Binagwaho2,9,10 1 Brigham and Women's Hospital, Boston, Massachusetts, United States of America, 2 Harvard Medical School, Boston, Massachusetts, United States of America, 3 Partners In Health, Boston, Massachusetts, United States of America, 4 Seed Global Health, Boston, Massachusetts, United States of America, 5 Massachusetts General Hospital, Boston, Massachusetts, United States of America, 6 Clinton Health Access Initiative, Boston, Massachusetts, United States of America, 7 Harvard University, Cambridge, Massachusetts, United States of America, 8 University of California San Francisco, San Francisco, California, United States of America, 9 Ministry of Health of Rwanda, Kigali, Rwanda, 10 Geisel School of Medicine—Dartmouth, Hanover, New Hampshire, United States of America * firstname.lastname@example.org Summary Points • Historically, the impact of many health professional training initiatives in low-income countries has been limited by narrow focus on a small set of diseases, inefficient utiliza- tion of donor funding, inadequate scale up, insufficient emphasis on the acquisition of practical skills, poor alignment with local priorities, and lack of coordination. • Fortunately, several innovative training initiatives have emerged over the past five years in sub-Saharan Africa. This articles focuses on four initiatives funded by the United States government: the Medical Education Training Partnership Initiative (MEPI), the Nursing Training Partnership Initiative (NEPI), the Rwanda Human Resources for Health Program (HRH Program), and the Global Health Service Partnership (GHSP). • The best practices adopted by these initiatives are: alignment to local priorities, country ownership, competency-based training, institutional capacity building, and the estab- lishment of long-lasting partnerships with international stakeholders, • Based on these best practices, we outline a framework for health professional training ini- tiatives that can help better address thehealth workforce shortage in low-income countries. Introduction The Global Shortage of Health Professionals The immense suffering taking place in West Africa due to the Ebola epidemic is a tragic and powerful example of an “acute on chronic” problem facing many low-income countries: the health workforce shortage . PLOS Medicine | DOI:10.1371/journal.pmed.1001840 June 16, 2015 1 / 11 OPENACCESS Citation: Cancedda C, Farmer PE, Kerry V, Nuthulaganti T, Scott KW, Goosby E, et al. (2015) Maximizing the Impact of Training Initiatives for Health Professionals in Low-Income Countries: Frameworks, Challenges, and Best Practices. PLoS Med 12(6): e1001840. doi:10.1371/journal. pmed.1001840 Published: June 16, 2015 Copyright: © 2015 Cancedda et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Funding: No funding was received for this work. Competing Interests: CC is Co-Principal Investigator for Rwanda HRH Program at Brigham and Women's Hospital/Harvard Medical School. VK is CEO of Seed Global Health, which is discussed in this article. TN is CHAI Program Director of Rwanda’s HRH Program. EG is former US Global AIDS Coordinator that oversees PEPFAR program. AB is a member of the Editorial Board of PLOSMedicine. Abbreviations: CDC, Centers for Disease Control; GHSP, Global Health Service Partnership; HRH, Rwanda Human Resources for Health; MEPI, Medical Education Training Partnership Initiative; NEPI, Nursing Training Partnership Initiative; NGO, non-governmental organization; PEPFAR, US Insufficient training capacity and the “brain drain” of health professionals from Africa are principal drivers of the current situation [1–3]. Health professional schools in low-income countries face notable limitations in physical space, equipment, curricula, training materials, faculty, administrative staff, and funding [4–7]. These limitations stifle efforts to expand the number and the diversity of training programs and to improve the quality of training. Simulta- neously, practicing health professionals are often overwhelmed by the grinding work of deliver- ing health services in under-supplied and over-crowded hospitals and clinics, inadequately compensated for their work, and demoralized by a lack of continuing professional development opportunities [1,3,8]. The health workforce shortage has negatively affected the response to the global HIV/AIDS epidemic, to the emerging threat of non-communicable diseases in sub-Saharan Africa, and most recently, to the Ebola epidemic in West Africa. To improve health outcomes globally, it is critical to increase the number and to diversify and strengthen the competencies of health pro- fessionals in low-income countries [1–4,9]. Past and Current Efforts to Address This Shortage The number of health professional training initiatives in low-income countries has significantly increased over the past ten years [4,7,10,11]. A diverse range of internal (e.g., local governments and academic institutions) as well as external stakeholders have been involved in developing and implementing these initiatives [4,7,12]. External stakeholders have included both develop- ment partners (which contribute funding) and training partners (which contribute expertise and assist with training implementation) (Table 1). Especially in earlier years, the framework adopted by many of these training initiatives has led to less-than-ideal outcomes (Fig 1) [2,4,5,7,8,10,11]. First, many of these initiatives have been primarily driven by the priorities of individual de- velopment and training partners and have often focused on a narrow set of diseases. Addition- ally, integration into national strategic plans (when they exist) or alignment with local priorities has often been marginal [2,4,5,10]. As a result, the same initiatives have rarely been brought to scale and have not addressed the health workforce shortage comprehensively [4,5,7,13,14]. Second, donor funding generally has come with many spending restrictions, which have prevented governments from utilizing the funds effectively, if at all [15,16]. In the past, many development partners have selected and directly funded training partners with limited input from local governments and local academic institutions . These training partners often have spent a substantial proportion of funds on overhead rather than direct training costs [15,16]. Lastly, spending restrictions have often prevented training partners from investing in critical infrastructure and equipment within health professional schools and teaching hospitals that are necessary to create a strong teaching environment [13,14]. Third, many health professional training initiatives have prioritized mostly classroom teach- ing. Such ad hoc, short-term lectures and seminars have not been shown to effectively diversify the skills and strengthen the competencies of local health professionals [4,7,8,13,14]. Until re- cently, the competencies that allow different cadres of health professionals to work together as a team have been rarely addressed by curricula and training materials . Furthermore, many initiatives have focused on training clinicians as opposed to other health professionals (e.g., health managers, community health workers, public health professionals, or researchers) [4,5]. The duration of these initiatives has been determined more by the arbitrary availability of fund- ing and training expertise than by the time required for building local institutional capacity [4,7,8,13,14]. PLOS Medicine | DOI:10.1371/journal.pmed.1001840 June 16, 2015 2 / 11 President’s Emergency Plan for AIDS Relief; USAID, US Agency for International Development. Provenance: Not commissioned; externally peer reviewed Lastly, governments and academic institutions in low-income countries face the over- whelming challenge of coordinating multiple health professional training initiatives, aligning them to national priorities, and integrating them with initiatives already being implemented in the country [2,4,5,13,14]. The challenge is further aggravated by the weak governance struc- tures and lack of communication in many low-income countries among key policymaking enti- ties, such as local ministries of health or health regulatory bodies and professional societies. As a result of these limitations, low-income countries have been on the receiving end of a disorderly patchwork of small-scale, insufficient quality, short-term, and unsustainable health professional training initiatives that have focused only on a few diseases, created unnecessary gaps or overlaps in resources, and failed to help meet long-term national health workforce needs [2,4,5,7,8,14]. Table 1. Current landscape: Examples of healthcare workforce development and training partners. Examples of Development Partners Bilateral Development Agencies United States Agency for International Development Norwegian Agency for Development Cooperation Swedish International Development Cooperation Agency United Kingdom Department For International Development National Research Institutes and Centers National Institute of Health US Center for Disease Control and Prevention Multilateral Donors Regional Development Banks The World Bank Group Global Health Initiatives United States President’s Emergency Plan for AIDS Relief Global Fund to Fight AIDS, Tuberculosis, and Malaria Private Philanthropy Bill & Melinda Gates Foundation ELMA Foundation Rockefeller Foundation Wellcome Trust Examples of Training Partners Academic Institutions Academic Medical Centers Medical Schools Nursing Schools Schools of Management Schools of Public Health Non-Governmental Organizations Clinton Health Access Initiative IntraHealth JHPIEGO (formerly Johns Hopkins Program for International Education in Gynecology and Obstetrics) Management Sciences for Health Partners In Health Seed Global Health Volunteer Services Oversees doi:10.1371/journal.pmed.1001840.t001 PLOS Medicine | DOI:10.1371/journal.pmed.1001840 June 16, 2015 3 / 11 New Models for Increasing Health Workforce Capacity A number of innovative programs exist to address health workforce shortages globally, includ- ing the Cuban medical training model to address shortages in Pacific Island Countries; the MEDUNAM program between Finland, Namibia, and Mozambique; and Danish International Development Assistance (DANIDA) support of country-led national HRH plans in various countries [17,18]. We focus here on four health professional training initiatives funded entirely or partially by the US government (through the US President’s Emergency Plan for AIDS Relief [PEPFAR]) that have emerged over the past five years to address these shortages in sub-Saha- ran Africa. These US-based initiatives are the Medical Education Training Partnership Initia- tive (MEPI), the Nursing Training Partnership Initiative (NEPI), the Rwanda Human Resources for Health Program (HRH Program), and the Global Health Service Partnership (GHSP) (Table 2)[15,19–21]. Though they vary in both scale and scope, we believe their char- acteristics are useful to summarize in the context of this new framework for addressing health workforce shortages globally. Fig 1. Current framework and practices for training initiatives aimed at increasing health professionals in low-income countries. doi:10.1371/journal.pmed.1001840.g001 PLOS Medicine | DOI:10.1371/journal.pmed.1001840 June 16, 2015 4 / 11 Proposed New Framework and Best Practices for Training Initiatives in Low-Income Countries As contributing authors, we have played a critical role in the development and implementation of these training initiatives. In this article we outline a new framework that is informed by the following best practices, which we determined to be shared to a certain degree by all four train- ing initiatives (Fig 2): • Alignment to local priorities, joint planning, and coordination • Funding flexibility and host country ownership • Competency-based training and pedagogic innovation • Institutional capacity building • Sustainability strategy • Establishment of long-lasting partnerships and communities of practice Adoption of such a framework and best practices could inform future training and develop- ment partners as they seek to help local governments and academic institutions build a diverse, large, and competent health workforce in low-income countries. Table 2. Characteristics of new health professional training initiatives. Name Host Country or Countries Budget1 Duration Type (and Number) of Academic Institutions Supported in Host Countries Main Health Professional Cadres Targeted2 Medical Education Partnership Initiative (MEPI) Botswana, Ethiopia, Ghana, Kenya, Malawi, Mozambique, Nigeria, South Africa, Tanzania, Uganda, Zambia, Zimbabwe US$130 million 5 years Medical school (13), academic medical center (3), other academic institution (6) Physicians (new graduates, specialists), nurses, other (pharmacy, dentistry, etc.), educators, researchers Nursing Education Partnership Initiative (NEPI) Democratic Republic of Congo, Ethiopia, Lesotho, Malawi, Zambia US$33 million 5 years Nursing schools (19) Nurses and midwives, educators, researchers Human Resources for Health Program (HRH) Rwanda US$170 million 8 years Medical school (1), nursing school (5), dentistry school (1), scademic medical center (3), school of public health (1) Physicians [new graduates (557) specialists (401)], nurses and midwives (2871), oral health professionals (302), managers and implementers (140) Global Health Service Partnership (GHSP) Malawi, Tanzania, Uganda US$26.5 million3 Indeterminate Medical school (2), nursing School (4), academic medical center (5), other academic institution (2) Physicians (new graduates, specialists), nurses, midwives 1Funding for each program provided partially or in full by the US President’s Emergency Plan for AIDS Relief (PEPAR) Program; For more information for each training initiative, please visit: MEPI: http://www.pepfar.gov/partnerships/initiatives/mepi/index.htm; NEPI: http://www.pepfar.gov/partnerships/ initiatives/nepi/; HRH: http://www.hrhconsortium.moh.gov.rw; GHSP: http://www.peacecorps.gov/volunteer/globalhealth/ 2Projected number of trainees in parentheses 3For ﬁ rst six years doi:10.1371/journal.pmed.1001840.t002 PLOS Medicine | DOI:10.1371/journal.pmed.1001840 June 16, 2015 5 / 11 Alignment to Local Priorities, Joint Planning, and Coordination Health professional training initiatives should be guided primarily by the national strategic plans of low-income countries rather than by the priorities of individual development and training partners [2,4,5,13–15]. When strategic plans do not exist, local and international stakeholders should engage in extensive negotiations and joint planning before initiating im- plementation. Governance bodies, ideally embedded within local governments or academic in- stitutions, should be established to harmonize individual contributions in funding and training expertise. Lastly, the scale of training initiatives needs to be commensurate to the needs of low- income countries in order to bridge at least some of the gaps between both the number and the type of available and needed health professionals. Such an approach is consistent with the guid- ing principles espoused by the Paris Declaration on Aid Effectiveness, including harmonization and ownership . Fig 2. Proposed new framework and practices for training initiatives aimed at health professionals in low-income countries. doi:10.1371/journal.pmed.1001840.g002 PLOS Medicine | DOI:10.1371/journal.pmed.1001840 June 16, 2015 6 / 11 For example, MEPI and NEPI have established two transnational coordinating centers (one at George Washington University and one at the African Centre for Global Health and Social Transformation) and separate governance bodies, advisory groups, or academic consortia within each host country, at which Ministries of Health, Ministries of Education, academic in- stitutions (US and local), and health professional associations align priorities and agree on im- plementation strategies [23–25]. Similarly, the HRH Program in Rwanda established a steering committee and four technical working groups—consisting of representatives from the Ministry of Health, Ministry of Education, and US Agency for International Development (USAID)—to facilitate joint planning between the local health and education sectors. After the start-up phase, when seconded staff from Clinton Health Access Initiative provided strategic planning and management support, the HRH Program is now managed entirely by Ministry of Health staff. Moreover, the 25 participating US academic institutions have organized into a consor- tium to promote greater coordination and collaboration . Lastly, the GHSP leadership has collaborated directly with the Ministry of Health, Ministry of Education, and medical and nurs- ing councils of Tanzania, Malawi, and Uganda (and their partner academic institutions) to align training targets and national health workforce needs and to select an adequate number of training sites . Funding Flexibility and Country Ownership Funds from development partners should come with fewer spending restrictions [13–16,26]. Also, they should allow low-income countries to adopt a “diagonal” approach to development and strengthen institutions and systems [13,26–28]. For example, many sub-Saharan African countries participating in MEPI, as well as Rwanda (as the host-country for the HRH Pro- gram), have utilized funds for infrastructure and equipment within health professional schools and teaching hospitals [15,25,29]. Moreover, all academic institutions participating in the HRH Program have agreed to charge overhead costs at less than 10% , while Seed Global Health (as partner non-governmental organization [NGO]) charges no overhead costs for its implementation of GHSP. Whenever possible (and always with proper systems in place to ensure accountability), low- income countries should also have more direct control of funds. Through MEPI and the HRH Program, local governments and/or academic institutions have been the primary recipients of funds and have been able to select the training partners whom they view as the best fit to ad- dress local priorities [15,16]. Definitive evidence that funding flexibility and allocation to local governments results in a more effective utilization of funds will be generated over the next few years as the initiatives described in this article undergo serial evaluations and audits. Competency-Based Training and Pedagogic Innovation Training initiatives should prioritize the acquisition of competencies through sustained men- torship and supervision rather than the acquisition of knowledge through ad hoc, short-term lectures and seminars [4–7,30]. The competencies and skills that allow different cadres of health professionals to work together as a team and address both biomedical and psychosocial determinants of health are especially important and have begun to be prioritized only recently, such as in programs recently launched in Ethiopia and South Africa [4,9,31–33]. Given this commitment to sustained mentorship and supervision, MEPI, the HRH Pro- gram, and GHSP have all established “teaching” hospitals, health centers, and communities where trainees can witness firsthand how high-quality health care is delivered and good gover- nance pursued across all levels of the health system [15,24,34]. To increase retention after grad- uation, the curricula and training materials developed through MEPI in 12 sub-Saharan PLOS Medicine | DOI:10.1371/journal.pmed.1001840 June 16, 2015 7 / 11 African countries are specifically designed to prepare trainees for practice in remote and under-resourced health facilities [34,35]. Similarly, the GHSP has prioritized the acquisition of competencies and skills by physicians and nurses in rural areas . Uniquely among the other initiatives described in this article, the HRH Program has also prioritized training of hospital administrators and implementation experts tasked with managing Rwanda’s health facilities and strengthening the health system . The potential of information technology is being harnessed not only to overcome the shortage of faculty but also to drive pedagogical innovation through e-learning and reverse classroom approaches [9,23,29,36]. Institutional Capacity Building Development and training partners should be tasked with building institutional capacity within academic institutions and the public health sector of low-income countries and avoid the estab- lishment of parallel systems [4,5,14]. MEPI, NEPI, the HRH Program, and GHSP are strengthening the teaching and mentoring skills of local faculty through a variety of approaches [4,7,13,14,21,26]. For example, in Kenya, MEPI has recruited and trained clinicians in rural areas to serve as adjunct faculty for trainees during their community-based rotations . NEPI offers scholarships to candidates pursuing a master’s or doctorate degree in nursing and midwifery education . The HRH Program and GHSP are twinning local faculty and trainees with US faculty based in the country to devel- op both curricula and training materials, as well as to drive pedagogical innovation [15,21]. Building research and evaluation capacity to answer research questions that are locally relevant may also help improve faculty retention. Thus, MEPI, NEPI, and the HRH Program seek to strengthen research and evaluation skills among local faculty, with a particular focus on imple- mentation science [15,23,38]. Sustainability Strategy The engagement of development and training partners in low-income countries should neither end abruptly nor last indefinitely [13–15,26]. Funding and training expertise should gradually decrease over time until (and only when) both become no longer necessary. Conversely, local governments should assume responsibility for sustaining and further expanding these initia- tives and have a long-term plan for hiring and adequately compensating the newly trained health professionals [4,7]. For example, in the HRH Program, faculty deployment by US academic institutions and funding from the US Centers for Disease Control (CDC) and the Global Fund will continue but gradually decrease from over 100% to 0% over the course of eight years, the time estimated for the training targets identified by the public health sector to be met . Similarly, US facul- ty deployed through the GHSP are expected to serve as “force multipliers” by training local cli- nicians to serve as faculty and as “force multipliers” themselves, thus exponentially increasing the pool of experienced and committed educators over the years. Promoting Long-Lasting Partnerships and Communities of Practice Academic institutions in low-income countries are seldom able to systematically collaborate on research and training initiatives with one another and with foreign academic institutions from high-income countries. Simultaneously, foreign academic institutions from high-income coun- tries have resources and expertise that can benefit low-income countries while facing a growing demand from their own faculty and trainees to practice overseas [4,7,39,40]. By twinning local faculty with US faculty, the HRH Program and GHSP seek to foster aca- demic collaborations that ideally will continue even after both initiatives have formally ended. PLOS Medicine | DOI:10.1371/journal.pmed.1001840 June 16, 2015 8 / 11 Similarly, MEPI and NEPI have established communities of practice and advisory groups that allow faculty and academic institutions from many sub-Saharan African countries to collabo- rate among themselves and with their counterparts in the US through regular site visits, annual symposia, webinars, and joint academic writing . Challenges to the New Framework There are many challenges associated with implementing ambitious and innovative health pro- fessional training initiatives such as the four described in this article. Primarily, we have found that establishing consensus among multiple stakeholders has been one of the most difficult and time-intensive steps, requiring extensive negotiations and leadership on all sides, as well as a shared commitment to the ultimate vision. Additionally, the stakeholders initially lacked the resources, knowledge, or processes re- quired to effectively initiate and sustain implementation. For instance, new policies developed for building research capacity (e.g., ethical approval and authorship protocol), training (e.g., ac- creditation and intellectual property for newly developed curricula), and health service delivery (e.g., credentialing, licensing, and malpractice coverage for foreign clinicians) have stretched significantly the bureaucracies of both the sub-Saharan and US academic institutions involved. Despite a concerted effort to build local administrative capacity, a large influx of US educators, researchers, and clinicians in the host countries has added a considerable amount of work on an already scarce and overstretched local staff. Reconciling differences in culture and practice between local and US staff has required extensive orientation trainings and ongoing reassess- ment of interpersonal and inter-institutional relationships. Lastly, monitoring and evaluation for the four initiatives is ongoing but at an early stage. Because of the scale and complexity of each initiative, implementation took precedence over monitoring and evaluation. Only recently has newly generated knowledge begun to inform implementation and further consolidate the new framework and best practices outlined in this article. Evidence to date, albeit in its infancy, has been encouraging that programs with this approach represent a “paradigm shift” for global health education . Conclusion A sizeable, diverse, and competent needs-based health workforce is essential to strengthen health systems in low-income countries, which suffer from a severe shortage of health professionals. The harsh consequences of this shortage in West Africa, for example, demonstrates the urgency to fund and develop innovative partnerships to bolster smart training initiatives moving forward. In this article, we outline a new framework for health professional training initiatives informed by the best practices adopted by four innovative US-led health professional training initiatives, which prioritize country ownership, funding flexibility, the acquisition of competencies, institu- tional capacity building, and long-term sustainability. Though there are notable challenges that exist in operationalizing these best practices, we believe that greater investments into future pro- grams that adopt this framework holds great promise to meaningfully address the workforce shortage that has plagued the poorest countries in the world for too long. Author Contributions Wrote the first draft of the manuscript: CC TN. Contributed to the writing of the manuscript: CC PEF VK TN KWS EG AB. 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