Mission and role modelling in producing a fit-for-purpose rural health workforce: perspectives from an international community of practice.

Inequities in the distribution of human resources in health around the world have long been a topic of concern and discussion. There is an absolute shortage of health care providers in many parts of the world, notably in sub-Saharan Africa and parts of the Asia–Pacific region.1 However, here and in other areas the problem is that the available health care workforce is maldistributed, both geographically and in terms of specialty.2, 3 Understanding these issues and their drivers is an important step in developing, implementing and evaluating potential solutions, but both the understanding and the solutions need to be contextualised to region and circumstance.3 Health professional educational institutions can be important engines in driving social and educational change and innovation to ensure that their products (medical, nursing and other health professional graduates) are fit for purpose in terms of meeting the needs of the populations that they serve.4 Recognition of this potential has led the World Health Organization to focus on its agenda of transformative health professional education, to consciously improve access to health services by distributing the health workforce and aligning its competencies with evolving health needs on the way to addressing the broader social determinants of health.5 Importantly, to deliver socially accountable health professional education, educational institutions must hold themselves accountable for delivering appropriate health professionals, and for working in partnership to strengthen the health system and the quality of care that it delivers. Investment in training of the health workforce and strong primary health care delivers real economic value.6 The Training for Health Equity Network (THEnet; thenetcommunity.org), which was founded in 2008, is a community of practice that now includes 13 medical and health professional schools, selected on the basis of their commitment to social accountability. Located primarily in rural and underserved areas of nine countries (low and high income), they share a commitment to producing and supporting health workforces that will meet the needs of the communities they serve (Box 1). These schools share the aims of: recruiting students from underserved and under-represented populations; providing primary care-focused curricula; delivering medical programs mainly in underserved areas and within communities; and providing postgraduate training to address local health workforce needs.7, 8 * Reproduced from Murray et al7 under a CC BY 4.0 license. † Founding school; recently withdrew from THEnet. THEnet is a collaborative learning network, where members share challenges across sectors and countries, and partner schools learn from and share with other innovative schools worldwide. Research and evaluation using a self-critical lens helps members to understand how best to improve health equity and how to maintain accountability for outcomes.7, 8 As a learning network that aims to influence health systems and share lessons between partners, THEnet considered how best to measure progress towards, and outcomes of, social accountability in its early work. Collaborative creation of THEnet's Evaluation Framework for Socially Accountable Health Professional Education was its foundational work, which involved careful attention to the use of plain language and definitions that can be used and adapted across many contexts.8, 9 This work has since been adapted and expanded to create other widely used frameworks, such as the Indicators for Social Accountability Tool, and has been incorporated into medical accreditation standards worldwide.10, 11 THEnet partner schools share a commitment to finding out where graduates work and the difference that they make. Measuring impact is important. The THEnet evidence group conducts a program of research, including the THEnet Graduate Outcome Study — a prospective cohort study of more than 6000 learners enrolled across partner schools, from which data have been received from nine schools in seven countries.12 The THEnet Evidence Group designed the study to correlate learner characteristics and practice intentions at entry to and exit from medical school, and then follow these graduates into postgraduate practice for up to 10 years, to determine the location and discipline of their actual practice. In recognition of our work in this area, THEnet has contributed to white papers for the Pan American Health Organization and a recent WHO handbook on the rationale and strategies for graduate tracking.13 These data have highlighted that, relative to other medical schools, THEnet partner schools deliberately use diverse selection processes to ensure that their learner cohort has sociodemographic characteristics that are much more similar to the population they serve.12 Data have confirmed the association between rural or low socio-economic background and intention to practise in rural and remote areas, and that this is maintained from entry to exit from medical school.14, 15 Importantly, for learners in low and middle income schools in South Africa, Sudan and the Philippines, these demographic determinants are significantly associated with lower desire to emigrate after graduation, and thus contribute to a desire to meet the health needs of their home country.15 In response to local need, THEnet members have also designed and collaborated on studies of work readiness of graduates, perceptions of social accountability among faculty and students, impact on the health system, impact on health outcomes, and social return on investment.16-21 The evidence base produced by THEnet collectively, from studies involving partnerships between two or more partner schools from different contexts, is summarised in Box 2. Larkins SL, et al (2013)8 (JCU, ELAM, Ghent U, UPM-SHS, ADZU, WSU, FU, NOSM U) THEnet's Evaluation Framework for Socially Accountable Health Professional Education was developed as a tool to assist schools in assessing progress towards social accountability. The framework considers three questions: Ross SJ, et al (2014)9 (JCU, FU, NOSM U, ADZU, UPM-SHS) Larkins S, et al (2015)12 (JCU, Ghent U, WSU, Gezira U, ADZU, NOSM U) Larkins S, et al (2018)14 (JCU, NOSM U, Ghent U, Gezira U, WSU, ADZU, FU, UPM-SHS) Johnston K, et al (2020)15 (JCU, ADZU, Gezira, WSU, UPM-SHS, PAHS, NOSM U, FU) Preston R, et al (2016)22 (FU, JCU, ADZU, UPM-SHS) Ellaway RH, et al (2018)17 (NOSM U, Ghent U, JCU, FU, UNM, Gezira U, UPM-SHS, WSU) Reeve C, et al (2017)23 (FU, JCU, ADZU, UPM-SHS) Halili S Jr, et al (2017)18 (ADZU, JCU, FU) Siega-Sur JL, et al (2017)19 (UPM-SHS, JCU, FU) Woolley T, et al (2018)20 (JCU, ADZU, UPM-SHS, FU) Woolley T, et al (2018)21 (JCU, ADZU, UPM-SHS, FU) Woolley T, et al (2019)16 (JCU, UNM, Gezira U) Woolley T, et al (2020)24 (JCU, NOSM U) Murray R, et al (2022)7 (JCU, ADZU, PAHS, UPM-SHS, NOSM U, Ghent U, UNM) Our research shows promising outcomes from THEnet partner schools in terms of: intending to practise and actually practising in rural, remote and underserved areas; practice in generalist disciplines rather than subspecialties; broadening health teams to include community-based health workers and other mid-level providers; and health professionals remaining in low and middle income countries rather than emigrating.15, 18 Longer term data from some schools suggest that practice intentions translate well into actual practice.25 By summarising and integrating evidence from our collective work and the experience of partner schools in diverse locations, we identified consistent findings that may help produce a fit-for-purpose global health workforce (Box 2). Locating health professional education institutions in remote, rural and regional areas is a key factor in terms of producing a fit-for-practice rural and remote health workforce. In addition, providing a contextualised primary care-focused curriculum to a diverse body of students who are largely from remote, rural and regional areas themselves is important. Using these approaches has become known as training health professionals “from, in, with and for” the rural and remote communities that we would like them to serve.4 However, lessons from pioneering schools suggest that these approaches are necessary but not sufficient — that the building blocks necessary for success are broader still.26 A vital common factor is a clearly expressed and widely understood mission for each school, which is linked to meeting the health needs of the population served. Also, committed and charismatic leadership that conveys each school's mission to its faculty and students is essential. Likewise, schools need diversity among the staff and the teaching body, including a wide variety of inspiring community-based and primary care practitioners or generalists, to mitigate against the hidden hospital-centric curriculum that often deters students from pursuing careers in primary care.27 In addition, exposing learners to a wide variety of inspirational rural and remote service providers provides motivation and encouragement to both mentors and mentees. Two further critical elements for producing a fit-for-purpose global health workforce are: learning in and with rural communities; and recognising the role of community members as teachers, particularly with respect to the social and cultural determinants of health. Working alongside community extension officers, Aboriginal or Torres Strait Islander health workers and practitioners, community nurses, or other mid-level health professionals is critical for these aspects of learning.28 In all of these areas, increasing skills in telehealth and digitally assisted education — accelerated by the coronavirus disease 2019 (COVID-19) pandemic — can help build a rural and remote health workforce.7 However, we believe that nothing can replace the impact of a rural longitudinal placement. THEnet's partner schools have cooperated to produce a significant collective contribution to the evidence base on approaches to education that can help build a rural and remote health workforce. They have highlighted important factors which can help ensure that we deliver on our collective social accountability mandate. However, there is still much work to do as we strive to measure and critically reflect on the impact of our activities on the health of individuals, communities and populations, and on strengthening the health system. We have started to develop and apply novel approaches to measure social return on investment — in settings within Australia, the Philippines and Canada — with a view to extending this to a broader range of schools. It is important to measure the economic and social impact of school activities and outcomes for communities. Current work is also focused on measuring the impact of a learning health system and is looking at how we can build a chain of association from health professional education activities to accessibility of health services (and other markers of quality of care) through to improved health outcomes. Despite marked differences in the settings where THEnet's partner schools operate, similarities in approach provide lessons that may support more equitable distribution of the health and medical workforce into the future. We acknowledge all members of THEnet's Evidence Group and their valuable contributions to research synthesised in this article. Open access publishing facilitated by James Cook University, as part of the Wiley - James Cook University agreement via the Council of Australian University Librarians. No relevant disclosures. Commissioned; externally peer reviewed.