21세기 의료인력: 상호의존적인 세계에서 건강시스템 강화를 위한 교육 변화(Lancet, 2010)

Meded. 2015. 12. 3. 17:32

2015. 12. 3. 17:32

21세기 의료인력: 상호의존적인 세계에서 건강시스템 강화를 위한 교육 변화(Lancet, 2010)

Health professionals for a new century: transforming education to strengthen health systems in an interdependent world

Julio Frenk*, Lincoln Chen*, Zulfi qar A Bhutta, Jordan Cohen, Nigel Crisp, Timothy Evans, Harvey Fineberg, Patricia Garcia, Yang Ke, Patrick Kelley, Barry Kistnasamy, Afaf Meleis, David Naylor, Ariel Pablos-Mendez, Srinath Reddy, Susan Scrimshaw, Jaime Sepulveda, David Serwadda, Huda Zurayk

종합요약

Executive summary

Problem statement

100년 전 Flexner report.

100 years ago, a series of studies about the education of health professionals, led by the 1910 Flexner report, sparked groundbreaking reforms.

이로 인해서 20세기동안 수명이 두 배로 증가하는데 기여한 지식으로 무장할 수 있게 되었음.

the reforms equipped health professionals with the knowledge that contributed to the doubling of life span during the 20th century.

그러나 21세기 시작에 모든 것은 그다지 좋지 못하다.

By the beginning of the 21st century, however, all is not well.

두드러진 건강의 격차와 불평등은 국가간, 국가내에 모두 존재하고, 이는 드라마틱한 의료의 발전을 동등하게 공유하지 못한 것의 총체적 실패를 보여준다. 동시에 새로운 도전이 어렴풋하게 드러난다.

Glaring gaps and inequities in health persist both within and between countries, underscoring our collective failure to share the dramatic health advances equitably. At the same time, fresh health challenges loom.

전문직 교육은 이 도전에 따라가지 못했고, 주된 이유는 분절되고, 낙후되고, 정체된 교육과정이 제대로 준비되지 못한 졸업생을 양산했기 때문이다. 문제는 모든 곳에 있다.

Professional education has not kept pace with these challenges, largely because of fragmented, outdated, and static curricula that produce ill-equipped graduates. The problems are systemic:

mismatch of competencies to patient and population needs;
poor teamwork;
persistent gender stratification of professional status;
narrow technical focus without broader contextual understand- ing;
episodic encounters rather than continuous care;
predominant hospital orientation at the expense of primary care;
quantitative and qualitative imbalances in the professional labour market; and
weak leadership to improve health-system performance.

Major findings

전 세계적으로 2420개의 의과대학, 공중보건 관련 대학 또는 학과가 467개, 그리고 그 수도 정확히 파악되지 않을 정도의 간호교육기관이 매년 백만명의 의사, 간호사, 공중보건 전문가를 양성하고 있다. 여러 기관에서 드러나는 극도의 인력 부족은 국가 간, 국가 내 편중된 인력분포에 의해서 더 심해진다.

Worldwide, 2420 medical schools, 467 schools or departments of public health, and an indeterminate number of postsecondary nursing educational institutions train about 1 million new doctors, nurses, midwives, and public health professionals every year. Severe institutional shortages are exacerbated by maldistribution, both between and within countries.

4개 국가(중국, 인도, 브라질, 미국)는 각각 150개 이상의 의과대학이 있지만, 36개 국가에서는 의과대학이 전혀 없다. 사하라 이남 아프리카의 26개국은 의과대학이 1개 혹은 없다. 이러한 불균등을 보고 있자면 의과대학의 숫자가 인구 규모나 국가의 질병부담과 전혀 관련이 없이 존재한다는 것도 놀랍지 않다.

Four countries (China, India, Brazil, and USA) each have more than 150 medical schools, whereas 36 countries have no medical schools at all. 26 countries in sub- Saharan Africa have one or no medical schools. In view of these imbalances, that medical school numbers do not align well with either country population size or national burden of disease is not surprising.

의료전문직 교육에 들어가는 총 비용은 매년 약 $100 Billion 정도이나, 이 역시 국가간 차이가 어마어마하다. 이는 전 세계적으로 의료에 들어가는 비용의 2%도 안 되는 수준이며, 의료전문직 교육이 노동집약적이고, 고도의 능력이 필요한 산업임을 고려하면 하찮기 그지없는 수준이다. 한 명의 졸업생을 배출하는데는 의과대학에서 $113000, 간호대학에서 $46000이 필요하며, 단위 비용은 미국에서 가장 높고 중국에서 가장 낮다.

The total global expenditure for health professional education is about US$100 billion per year, again with great disparities between countries. This amount is less than 2% of health expenditures worldwide, which is pitifully modest for a labour-intensive and talent-driven industry. The average cost per graduate is $113 000 for medical students and $46 000 for nurses, with unit costs highest in North America and lowest in China.

Reforms for a second century

지난 세기의 교육 개혁은 세 개의 세대로 특징지을 수 있다.

첫 번째 세대는 20세기 초반에 시작되어 과학-기반 교육과정을 가르친 세대이다.
20세기 중반에는 두 번째 세대가 나타나서 Problem-based 교육 혁신을 도입했다.
이제 요구되는 세 번째 세대는 구체적 컨텍스트에서의 핵심 전문직 역량을 도입함으로서 의료시스템의 퍼포먼스를 향상을 목적으로 하는 시스템이어야 한다.

Three generations of educational reforms characterise progress during the past century. The fi rst generation, launched at the beginning of the 20th century, taught a science-based curriculum. Around the mid-century, the second generation introduced problem-based instructional innovations. A third generation is now needed that should be systems based to improve the performance of health systems by adapting core professional competencies to specifi c contexts, while drawing on global knowledge.

Commission은 세 번째 세대의 발전을 위한 비전을 제시하고자 한다. 모든 국가의 모든 의료전문직은, 그 지역에 책임이 있는 사람으로서, 그리고 국제적으로 상호연결된 팀의 구성원으로서, 지식을 동원(mobilize)하고 비판적 추론을 할 수 있어야 하며, 윤리적인 행실을 통해서 환자와 인구를 중심에 둔 건강시스템에 동참해야 한다. 궁극적인 목적은 양질의 포괄적인 의료서비스를 모든 사람에게 제공하는 것이며, 이것만이 국가 간, 국가 내 건강평등에 도달할 수 있게 한다.

To advance third-generation reforms, the Commission puts forward a vision: all health professionals in all countries should be educated to mobilise knowledge and to engage in critical reasoning and ethical conduct so that they are competent to participate in patient and population-centred health systems as members of locally responsive and globally connected teams. The ultimate purpose is to assure universal coverage of the high- quality comprehensive services that are essential to advance opportunity for health equity within and between countries.

이 비전을 실현시키려면 교육과 기관의 개혁이 있어야 하며, 크게 두 개의 성과가 필요하다. 하나는 전환학습(transformative learning, 이하 TfL)이며, 다른 하나는 교육의 상호의존성이다. 우리는 TfL을 세 개의 연속적 수준의 가장 높은 수준으로 보고 있으며 informative -> formative -> transformative로 옮겨가야 한다고 본다. 효과적인 교육은 이전 단계의 교육을 바탕으로 다음 단계가 이뤄질 때 가능하다.

Realisation of this vision will require a series of instructional and institutional reforms, which should be guided by two proposed outcomes: transformative learning and interdependence in education. We regard transformative learning as the highest of three successive levels, moving from informative to formative to transformative learning.

IfL은 지식과 기술의 습득에 관한 것이며, Expert를 양성하기 위한 것이다.
Informative learning is about acquiring knowledge and skills; its purpose is to produce experts.
FL은 학생들에게 '가치'를 사회화하는 것이며, Professionals를 양성하기 위한 것이다.
Formative learning is about socialising students around values; its purpose is to produce professionals.
TfL은 리더십을 개발하는 것이며, 깨어있는 change agent를 양성하기 위한 것이다.
Transformative learning is about developing leadership attributes; its purpose is to produce enlightened change agents.

Eff ective education builds each level on the previous one.

TfL은 세 개의 근원적 변화를 포함해야 한다.

Transformative learning involves three fundamental shifts:

지식의 암기에서 정보의 검색, 분석, 종합을 통한 의사결정으로,
from fact memorisation to searching, analysis, and synthesis of information for decision making;
전문직 자격증을 얻는 것에서 건강시스템 내에서의 효과적인 팀워크를 위한 핵심 역량 성취로,
from seeking professional credentials to achieving core competencies for eff ective teamwork in health systems; and
교육모델의 무비판적 수용에서 지역의 우선순위 달성을 위한 국제적 자원의 창의적 도입으로.
from non-critical adoption of educational models to creative adaptation of global resources to address local priorities.

상호의존성은, 다양한 구성요소간 상호작용을 강조하기에, 시스템 접근법의 핵심 요소라 할 수 있다. 이 성과에 도달하기 위해서 교육의 상호의존성 역시 세 가지의 근원적 변화를 필요로 한다.

Interdependence is a key element in a systems approach because it underscores the ways in which various components interact with each other. As a desirable outcome, interdependence in education also involves three fundamental shifts:

고립된 교육에서 건강시스템과 조화를 이루는 교육으로
from isolated to harmonised education and health systems;
독립적 기관에서 네트워크, 연맹, 컨소시엄을 이루는 기관으로
from stand- alone institutions to networks, alliances, and consortia; and
조직의 내부에 관한 집착에서 교육 내용/자원/혁신의 국제적 흐름의 활용으로
from inward-looking institutional preoccupations to harnessing global fl ows of educational content, teaching resources, and innovations.

TfL을 교육 개혁의 성과라고 한다면 교육의 상호의존성은 기관 개혁의 성과가 될 것이다

Transformative learning is the proposed outcome of instructional reforms; interdependence in education should result from institutional reforms.

교육의 개혁은 다음의 것을 포함 한다.

Instructional reforms should:

adopt competency-driven approaches to instructional design;
adapt these competencies to rapidly changing local conditions drawing on global resources;
promote interprofessional and transprofessional education that breaks down professional silos while enhancing collaborative and non-hierarchical relationships in eff ective teams;
exploit the power of information technology for learning;
strengthen educational resources, with special emphasis on faculty development; and
promote a new professionalism that uses competencies as objective criteria for classifi cation of health professionals and that develops a common set of values around social accountability.

기관의 개혁은 다음의 것을 포함한다.

Institutional reforms should:

establish in every country joint education and health planning mechanisms that take into account crucial dimensions, such as social origin, age distribution, and gender composition, of the health workforce;
expand academic centres to academic systems encompassing networks of hospitals and primary care units;
link together through global networks, alliances, and consortia; and
nurture a culture of critical inquiry.

이들 개혁을 추구하기 위해서는 일련의 행동이 필요할 것이다.

Pursuit of these reforms will require a series of enabling actions.

첫째, 모든 수준(지역, 국가, 세계)의 지도자들이 참여해야 한다.
First, the broad engagement of leaders at all levels—local, national, and global—will be crucial to achieve the proposed reforms and outcomes. Leadership has to come from within the academic and professional communities, but it must be backed by political leaders in government and society.
모든 영역에서의 투자를 확대하여 현존하는 자금부족이 반드시 극복되어야 한다.
Second, present funding defi ciencies must be overcome with a substantial expansion of investments in health professional education from all sources: public, private, development aid, and foundations.
사회적 책임을 다하는 인증과 같은 관리 기전이 강화되어야 한다.
Third, stewardship mechanisms, including socially accountable accreditation, should be strengthened to assure best possible results for any given level of funding.
메트릭스, 평가, 연구에 대한 지원을 통해 혁신의 지식기반 마련을 위한 공동의 학습이 강화되어야 한다.
Lastly, shared learning by supporting metrics, evaluation, and research should be strengthened to build up the knowledge base about which innovations work under which circumstances.

의료전문직은 지난 세기 동안 건강과 발전에 엄청난 기여를 했으나, 현 상태에 만족하여 20세기의 교육전략을 그것이 잘 맞지 않는 21세기에 적용하는 것은 비효과적일 뿐이다. 우리는 새로운 세기의 transformative professional education을 위하여 위 비전과 권고안을 달성하기 위한 행동으로서 전 세계적, 모든 이해관계자의 참여를 요구하는 바이다.

Health professionals have made enormous contributions to health and development over the past century, but complacency will only perpetuate the ineff ective application of 20th century educational strategies that are unfi t to tackle 21st century challenges. Therefore, we call for a global social movement of all stakeholders—educators, students and young health workers, professional bodies, universities, non-governmental organisations, inter- national agencies, donors, and foundations—that can propel action on this vision and these recommendations to promote a new century of transformative professional education.

Section 1: problem statement

Background and rationale

Complex challenges

20세기동안에는 기대수명이 놀라울 정도로 증가하여 두 배가 되었고, 이는 삶의 기준이 높아지고 지식이 향상된 것에 기반한다. 무수한 근거들이 좋은 건강의 적어도 일부는 지식-기반, 그리고 사회-주도 특성이 있음을 지지한다.

The startling doubling of life expectancy during the 20th century was attributable to improvements in living standards and to advances in knowledge.1 Abundant evidence suggests that good health is at least partly knowledge based and socially driven.2,3

많은 근거들이 의료의 보장성과 의료전문인력의 숫자가 건강 성과에 직접적 영향을 준다고 되어있다.

Much evidence suggests that coverage and numbers of health professionals have a direct eff ect on health outcomes.4

거의 틀림없이, 의료전문인력의 교육은 건강의 향상을 가져오는데 도움이 되었다. 유럽에서 germ theory가 발견된 이후, 20세기 초반에 전문직 교육의 광범위한 개혁이 있었다. 미국에서 20세기 초반에는 Flexner report, Welch-Rose report, Goldmark report와 같은 것들이 의사, 공공보건인력, 간호사의 중등과정 후 교육의 변화를 가져왔다. 이러한 노력은 과학적 성과의 토대를 만들어 의료 전문인력의 교육을 또 다른 분야로까지 확장시켰다.

Arguably, dramatic reforms in the education of health professionals helped to catalyse health gains in the past century. After the discovery of the germ theory in Europe, the beginning of the 20th century witnessed widespread reforms in professional education around the world. In the USA early in the 20th century, such reports as by Flexner,13 Welch-Rose,14 and Goldmark15 transformed postsecondary education of physicians, public health workers, and nurses, respectively (fi gure 1). These eff orts to imbed a scientifi c foundation into the education of health professionals extended into other health fi elds.16

그러나 21세기에 우리는 엄청난 건강 격차와 불평등이 국가 간, 국가 내에 존재함을 목격하고 있다.

However, in the fi rst decade of the 21st century, glaring gaps and striking inequities in health persist both between and within countries.17–20

어떤 사하라 이남 아프리카에서는 HIV/AIDS로 인해서 건강의 이득이 아니라 오히려 평균적인 기대여명이 감소하는 결과를 가져왔다. 개발도상국의 빈곤층은 지속적으로 감염, 영양실조, 모성관련건강위협 등에 노출되어 있으나, 이런 문제가 부유한 계층에서는 이미 오래 전부터 충분히 통제되어 온 위협들이다. 이렇게 뒤에 남겨진 사람들에게는 전 세계적 건강의 눈부신 발전이 건강의 진보는 동등하게 공유하지 못한 총체적 실패의 흔적일 뿐이다.

Health gains have been reversed by the collapse of average life expectancy in some countries, which in sub-Saharan Africa is attributable to theHIV/AIDS pandemic.21,22 Poor people in developing countries continue to have common infections, malnutrition, and maternity-related health risks, which have long been controlled in more affl uent populations.23 For those left behind, the spectacular advances in health worldwide are an indictment of our collective failure to ensure the equitable sharing of health progress.24

동시에, 건강 보안 역시 빠른 속도로 진행되는 인구학적 역학적 전환에 더해진 새로운 감염, 환경, 행동 위협으로부터 도전받고 있다.

At the same time, health security is being challenged by new infectious, environmental, and behavioural threats superimposed upon rapid demographic and epidemiological transitions.25–27

많은 국가에서 전문직은 더 다양한 만성적 조건의 환자를 만나게 되고, 이들은 자신의 건강을 추구하는데 보다 적극적인 사람들이다. 환자 관리는 시간과 공간을 넘어서는 조직화된 케어를 필요로 하며, 전례없는 수준의 팀워크를 요구한다. 전문직은 폭발적으로 증가하는 지식과 기술을 통합해야 할 뿐 아니라, 동시에 기능을 확장시켜야 한다. 초전문화, 예방, 여러 장소에서의 복합적 관리, 가정-기반, 지역사회-기반 관리를 아우르는 서로 다른 타입의 시설을 모두 포함한다.

In many countries, professionals are encountering more socially diverse patients with chronic conditions, who are more proactive in their health-seeking behaviour.28–31 Patient management requires coordinated care across time and space, demanding unprecedented teamwork.5–11 Professionals have to integrate the explosive growth of knowledge and technologies while grappling with expanding functions—super-specialisation, prevention, and complex care management in many sites, including diff erent types of facilities alongside home-based and community-based care (fi gure 2).7–12

분절화되고 정체되고 낡은 교육과정은 재정이 취약한 기관에서 제대로 준비되지 않은 졸업생을 양성하는 결과를 가져왔고, 그 결과로 전문직의 역량과 환자와 인구가 요구하는 우선순위 사이에 불일치가 발생하여 서서히 타오르는 재앙으로 다가오고 있다. 거의 모든 국가에서 의료전문직 교육은 기능이 마비되고, 불평등한 건강시스템을 극복하는데 실패해왔다. 이는 교육 과정의 융통성이 부족하고, 전문직은 각자의 영역에 고립되어 있고, 교육법이 정체되어 있으며, 지역적 맥락을 충분히 반영하지 못하고, 전문직이 상업화 된 것 등이 원인이다. 이러한 실패는 일차의료에서 특히 두드러지는데, 가난한 국가는 물론 부유한 국가에서도 마찬가지이다. 실패는 총체적이다. 전문직은 변화를 따라자기 못하고 있고, 단순한 기술의 관리인 역할에 머물고 있으며, 주변화된 농촌 커뮤니티를 담당하기를 꺼려하는 등과 같이 오래 된 어려움을 더 악화시키고 있다. 전문직은 효과적인 팀워크에 필요한 적절한 역량을 갖추지 못하고 있으며, 건강시스템을 변화시키기 위한 리더십도 잘 발휘하지 못하고 있다.

Consequently, a slow-burning crisis is emerging in the mismatch of professional competencies to patient and population priorities because of fragmentary, outdated, and static curricula producing ill-equipped graduates from underfi nanced institutions.5–12,18–20 In almost all countries, the education of health pro- fessionals has failed to overcome dysfunctional and inequitable health systems because of curricula rigidities, professional silos, static pedagogy (ie, the science of teaching), insuffi cient adaptation to local contexts, and commercialism in the professions. Breakdown is especially noteworthy within primary care, in both poor and rich countries. The failings are systemic—professionals are unable to keep pace, becoming mere technology managers, and exacerbating protracted diffi culties such as a reluctance to serve marginalised rural communities.32,33 Professionals are falling short on appropriate competencies for eff ective teamwork, and they are not exercising eff ective leadership to transform health systems.

부자 국가와 빈곤 국가 모두 의료인력의 부족을 겪고 있으며, skill-mix가 불균형하고, 의료인력의 분포가 부적정하다.

Poor and rich countries both have workforce shortages, skill-mix imbalances, and maldistribution of profess- ionals.7,32–35

교육 개혁을 설계하는 것이 어렵고 도입하는 것은 느리지만, 부유한 국가에서는 변화하는 건강 요구에 반응할 수 있는 전문직 역량을 개발하기 위해서 노력하고 있다. 이를 통해서 고립된 전문직을 IPE로 극복하고, IT기술을 활용하여 교육을 강화하고, 비판적 탐구를 위한 인지기술을 향상시키고, 리더십을 위한 전문직의 정체성과 가치를 강화하고자 한다. 개혁은 가난한 국가에서 특히 어려운데, 자원 부족이 주로 문제가 된다. 많은 국가에서 필수적인 서비스를 기초보건인력을 배치하여 해결하고 있는데, 전통의학과 현대의학을 막론하고 수백만명의 사람들이 자격증도 없는 서비스 제공자에 의존하고 있다.

Diffi cult to design and slow to implement, educational reforms in rich countries are attempting to develop professional competencies that are responsive to changing health needs, overcome professional silos through inter- professional education, harness information technology (IT)-empowered learning, enhance cognitive skills for critical inquiry, and strengthen professional identity and values for health leadership.36–40 Reforms are especially challenging in poor countries, which are constrained byseverely scarce resources.38,40,41 Many countries are attempting to extend essential services through the deployment of basic health workers, even as millions of people resort to providers without credentials, both traditional and modern.42

새로운 전문직의 르네상스 – 환자-중심, 팀-기반 –가 많은 논의가 있었지만, 리더십, 인센티브, 실행력이 부족했다.

A renaissance to a new professionalism—patient- centred and team-based—has been much discussed,37,43–47 but it has lacked the leadership, incentives, and power to deliver on its promise.

Fresh opportunities

역설적으로, 이처럼 명백한 격차에도 불구하고, 건강에 있어서 상호의존성은 점차 높아지고, 상호학습의 기회가 많아지고, 진보는 점점 더 공유되었다. 인간/병원균/기술/자본/정보/지식의 국제적 움직임은 건강 위험과 기회의 국제적 이동의 기저를 이루며, 국가간 경계를 넘나드는 이러한 흐름은 더 가속화되고 있다. 우리는 점차 핵심 건강자원, 특히 숙련된 의료인력에 대해서 더욱 더 상호의존적이 되고 있다.

Paradoxically, despite glaring disparities, interdependence in health is growing and the opportunities for mutual learning and shared progress have greatly expanded.1,24 Global movements of people, pathogens, technologies, fi nancing, information, and knowledge underlie the international transfer of health risks and opportunities, and fl ows across national borders are accelerating.48 We are increasingly interdependent in terms of key health resources, especially skilled workers.24

폭발적인 증가는 전체 정보의 총량 뿐 아니라, 그것에 대한 접근에 있어서도 마찬가지다. 즉, 대학과 기타 교육기관의 역할에 대해서 다시 생각해 봐야 할 때이다.

The explosive increase not only in total volume of information, but also in ease of access to it, means that the role of universities and other educational institutions needs to be rethought.49

차세대 학습자들은 무수한 양의 정보를 분별하고 필요한 지식을 추출하여 통합하는 능력이 필요하며, 이는 임상 의사결정, 인구-기반 의사결정에 필수적이다. 이러한 발전은 교육의 방법/수단/의미에 있어서 새로운 기회를 제시한다.

The next generation of learners needs the capacity to discriminate vast amounts of information and extract and synthesise knowledge that is necessary for clinical and population-based decision making. These developments point toward new opportunities for the methods, means, and meaning of education.5–12,18–20

이 전과는 전혀 다르게 건강과 국제보건에 있어서 공공의 중요성이 환경 변화를 촉진하였다. 우리는 이제 좋은 건강이란 단순히 결과가 아니라, 발전/안보/권리의 전제조건임을 알고 있다.

Like never before, the public prominence of health in general and global health in particular has generated an environment that is propitious for change. We now understand that good health is not only a result of but also a condition for development, security, and rights.

21세기의 개혁은 시의적절한데, 왜냐하면 전문직의 역량을 변화하는 맥락과 증가하는 대중의 참여, 그리고 국제적 상호의존성에 맞추어서 다시 조정해야 할 때이기 때문이다.

Reform for the 21st century is timely because of the imperative to align professional competencies to changing contexts, growing public engagement in health, and global interdependence, including the shared aspiration of equity in health.

Commission work

Integrative framework

현재와 같이 노동을 각 의료전문직 간에 구분짓는 것은 과학의 발전/기술 발전/경제 관계/정치적 이해/문화적 가치와 신념을 둘러싼 복잡한 역사적 과정이 야기한 사회적 구성이다.

The present division of labour between the various health professions is a social construction resulting from complex historical processes around scientifi c progress, technological development, economic relations, political interests, and cultural schemes of values and beliefs.

어떤 특정 시기와 사회에서 노동을 구분하는 것은 이러한 사회적 힘에 따른 것이지, 건강-관련 업무의 본질적 특성에 의한 것은 아니다.

The division of labour at any specifi c time and in any specifi c society is much more the result of these social forces than of any inherent attribute of health-related work.

이 보고서에서 ‘건강 전문직’을 전통적인 방식으로 사용하고자 한다. 우리는 보건인력으로 중등과정 후 교육을 받은, 즉 일반적으로 대학 혹은 다른 고등기관에서 교육받은 인력을 말하는 것이며, 이러한 과정을 통해서 교육적 성취를 공식적 학위를 통해 증명한 인력을 말하고자 한다.

In most of this report we continue to refer to the health professions in a conventional manner. We focus on health workers who have completed postsecondary education—typically in universities or other institutions of higher learning that are legally allowed to certify educational attainment by issuing a formal degree.

위원회는 두 개의 시스템 사이의 복잡한 관계 이해를 위한 프레임워크를 개발하였다.

the Commission developed a framework aimed at understanding of the complex interactions between two systems: education and health (fi gure 3).

인구를 건강/교육 시스템의 외부적 요인으로 보는 다른 프레임워크와 다르게, 우리는 인구를 이 두 시스템의 기반이자 동인(driver)로 보았다.

By contrast with other frameworks, in which the population is exogenous to health or education systems, ours conceives of the population as the base and the driver of these systems.

이러한 시스템적 접근에서는 건강과 교육의 상호의존성이 극도로 중요해진다.

In this system approach, the interdependence of the health and education sectors is paramount.

이 프레임워크에는 두 가지 중요한 교차점이 잇다.

하나는 노동시장으로서 의료인력 공급과 수요의 합/부합을 관장하는 것이다.
두 번째는 여러 인구집단의 약한 능력, 특히 빈곤층에게 있어서 그들의 건강과 교육 요구를 그에 대한 수요로 효과적으로 전환시키지 못하는 지점이다. 이상적인 상황에서는 인구집단의 요구와 건강시스템이 의료인력에게 요구하는 것과 교육시스템에 의한 공급이 균형을 이루어야 한다.

There are two crucial junctures inthe framework. The fi rst is the labour market, which governs the fi t or misfi t between the supply and demand of health professionals, and the second is the weak capacity of many populations, especially poor people, to translate their health and educational needs into eff ective demand for the respective services. In optimum circumstances, there is a balance between population needs, health-system demand for professionals, and supply thereof by the educational system

그러나 현실에서 의료전문직의 노동시장은 무수한 불균형으로 특징지어진다. 가장 중요한 것은 undersupply, unemployment, and underemployment이다. 이것은 양적, 질적 모두에 해당한다. 이 불균형을 회피하기 위해서는 교육시스템이 건강시스템에서 요구하는 것에 반응해야 한다.

However, in reality the labour market for health professionals is often characterised by multiple imbal- ances,50 the most important of which are undersupply, unemployment, and underemployment, which can be quantitative (less than full-time work) or qualitative (suboptimum use of skills). To avoid these imbalances, the educational system must respond to the requirements of the health system.

노동시장과의 연관성에 덧붙여서, 교육과 건강 시스템은 공유하는 하위시스템(joint subsystem)이라 할 수 있는 것을 공유한다. 즉, 보건전문직 교육 하위시스템이다. 어떤 국가에서 보건전문직 교육기관은 MOH 하위에, 어떤 국가에서는 MOE 하위에 있다.

In addition to labour market linkages, the education and health systems share what could be thought of as a joint subsystem—namely, the health professional education subsystem. Whereas in a few countries schools for health professionals are ascribed to the health ministry, in others they are under the jurisdiction of the education ministry.

교육과 건강시스템의 연결은 전달체계를 통해서 보건인력의 skill mix와 업무 이동의 관점을 결정짓는다.

The linkage between the education and the health systems should also address the delivery models that determine the skill mix of health workers and the scope for task shifting.

건강과 교육의 관련성을 명확히 한 이후, 이 프레임워크에서는 세 가지 교육의 핵심 영역을 언급하였다.

After specifi cation of the linkages between the health and educational spheres, our framework identifi es three key dimensions of education:

기관 설계institutional design (which specifi es the structure and functions of the education system),
교육 설계 instructional design (which focuses on processes), and
교육 성과 educational outcomes (which deal with the desired results; fi gure 4).

교육과 기관의 설계에 대한 측면은 이미 20세기의 여러 보고서에서 언급된 바 있다.

Aspects of both institutional and instructional design were already present in the original reports of the 20th century,13–15

원래는 건강시스템의 퍼포먼스를 이해하기 위해서 만들어진 프레임워크를 적용하여 교육시스템에 적용가능한 네 가지 기능을 생각해 볼 수 있다.

By adaptation of a framework that was originally formulated to understand health-system performance,51 we can think of four crucial functions that also apply to educational systems:

(1) 관리와 거버넌스 stewardship and governance, which encompass instruments such as norms and policies, evidence for decision making, and assessment of performance to provide strategic guidance for the various components of the educational system;
(2) 재정 fi nancing, which entails the aggregate allocation of resources to educational institutions from both public and private sources, and the specifi c modalities for determining resource fl ows to each educational organisation, with the ensuing set of incentives;
(3) 자원 생산 resource generation, most importantly faculty development; and
(4) 서비스 제공 service provision, which refers to the actual delivery of the educational service and as such refl ects instructional design.

네 가지 기능의 구조는 시스템적 수준을 정의한다. 시스템 내에 속한 개별 조직은 ownership, affiliation, internal structure 등에 따라 다양하다. 이 모든 것은 기관 설계에 중요하다.

The way that the four functions are structured defi nes the systemic level shown in fi gure 4. Within a system, individual organisations will vary according to ownership (eg, public, private non-profi t, or private for profi t), affi liation (eg, freestanding, part of a health sciencescomplex, or part of a comprehensive university), andinternal structure (eg, departmental or otherwise). Theseare all important aspects of institutional design.

마찬가지로 중요한 것은 국제적 수준이다. 관리기능은 국가적인 수준 뿐 아니라 국제적 수준의 상대방에게도 마찬가지로 행해져야 한다. 공동의 핵심 역량을 규범적으로 정의하여 모든 국가의 모든 보건전문직이 이를 갖추도록 해야 한다. ICT를 바탕으로 네트워크나 파트너십과 같은 새로운 형태의 조직을 형성하야 한다.

Equallyimportant is the global level. The stewardship functionthat should be done nationally has a global counterpart,especially with respect to normative defi nitions about common core competencies that all health professions should have in every country. An emerging development globally refers to new forms of organisation, such as networks and partnerships, which take advantage of information and communication technologies.

건강시스템과 궁극적으로는 건강 성과에 긍정적 효과를 미치기 위해서는 교육기관은 이상적인 교육 절차를 만들어내도록 설계되어야 한다. 교육 설계는 4C로 대변되는 것을 포함한다.

To have a positive eff ect on the functioning of health systems and ultimately on health outcomes of patients and populations, educational institutions have to be designed to generate an optimum instructional process. Instructional design involves what can be presented as four Cs:

(1) 입학 기준 criteria for admission, which include both achievement variables, such as previous academic performance, and adscription variables, such as social origin, race or ethnic origin, sex, and nationality;
(2) 역량 competencies, as they are defi ned in the process of designing the curriculum;
(3) 교육 체널 channels of instruction, by which we mean the set of didactic methods, teaching technologies, and communication media; and
(4) 진로 career pathways, which are the options that graduates have on completion of their professional studies, as a result of the knowledge and skills that they have attained, the process of professional socialisation to which they have been exposed as students, and their perceptions of opportunities in local or global labour markets (fi gure 4).

위원회는 보건전문직교육시스템이 달성해야 할 것으로 두 가지를 제안한다. transformative learning and interdependence in education이다. TfL은 교육 설계의 향상에 따른 결과이며, 상호의존성은 기관 개혁의 결과일 것이다.

In the case of our Commission, two outcomes were proposed for the health professional education system—transformative learning and interdependence in education. Transformative learning is the proposed outcome of improvements in instructional design; interdependence in education should result from institutional reforms (fi gure 4).

Data and methods

학부 의학교육기관은 두 개의 주요 데이터베이스(FAIMER와 Avicenna)를 활용함

Undergraduate medical educational institutions were compiled by combining two major databases: Foundation for the Advancement of International Medical Education and Research (FAIMER) and Avicenna,

비록 정밀하지는 않지만, 미시적 접근법과 거시적 접근법을 모두 활용하여 추정하였다.

Although not precise, the convergence of microapproaches and macroapproaches provides some assurance that the broad order of magnitude of our estimations is robust.

Section 2: major findings

Century of reforms

지난 세기의 역사적 발전을 보고자 개혁의 세 세대를 정의했다.

To capture historical developments in the past century, we defi ned three generations of reforms (fi gure 5).

‘세대’라는 단어는 이러한 발전이 명확히 구분되는 선형적 연속성으로 나타난다는 것을 의미하는 것이 아니라, 각 세대의 요소들이 이후의 세대에도 지속되어 복잡하고 역동적인 변화 패턴을 형성함을 말한다.

The word generation conveys the notion that this development is not a linear succession of clear-cut reforms. Instead, elements of each generation persist in the subsequent ones, in a complex and dynamic pattern of change.

Panel 1: The Flexner, Rose-Welch, and Goldmark reports

Panel 1.

The Flexner, Rose-Welch, and Goldmark reports

Three seminal US reports (Flexner, Welch-Rose, and Goldmark) had powerful effects in professional health education in North America, and arguably by extension around the world. All the reports recommended major instructional reforms to integrate modern medical sciences into the core curriculum, and institutional reforms to link education to research and the basing of professional education in comprehensive universities.

Flexner report 1910¹³

The report introduced the modern sciences as foundational for the medical curriculum into two successive phases: 2 years of basic biomedical sciences, based in universities, followed by 2 years of clinical training, based in academic medical hospitals and centres. Research was to be viewed not as an end in itself but as a link to improved patient care and clinical training. Flexner also changed the doctor's education from an apprenticeship model to an academic model, and his report created the conditions for the birth of academic medical centres, ushering in a hitherto unknown era of discovery. In 1912, Flexner extended his study of medical education to a group of key European countries.⁶³ Although the Flexner model of professional education was widely adopted outside the USA and Canada, it has often not been sufficiently adapted to address health in vastly different societal contexts.

Welch-Rose report 1915¹⁴

This report offered two competing visions of public health professional education. Rose's plan was for a national system of public health training with central national schools acting as the focus for a network of state schools, both emphasising public health practice. By contrast, Welch's plan called for institutes of hygiene, following the German model, with increased emphasis on scientific research and connections to a medical school in comprehensive universities. Welch's plan was financed by the Rockefeller Foundation to create the Johns Hopkins School of Public Health and Hygiene in 1916, and the Harvard School of Public Health in 1922. Most schools of public health in the USA followed the Welch model as independent faculties in universities. Outside the USA and Canada, both institutional models described by Rose and Welch were implemented and co-exist to this day.

Goldmark report 1923¹⁶

This report advocated for university-based schools of nursing, citing the inadequacies of existing educational facilities for training skilled nurses. The report put nursing on the same academic trajectory as medicine and public health in the USA, albeit a little later in time. Although major health burdens prevailing at the time—such as infant mortality and tuberculosis—had greatly decreased, the importance of an improved trained nursing workforce remains, including high standards of nursing educational attainment.

===

의학교육의 초기 시스템...

Early systems of medical education were reported

인도 in India around 6th century BC in a classical text called Susruta Samhita,56 and
중국 in China with lectureships in Chinese medicine at the Imperial Academy in 624 AD.57
아랍과 북미 Arab and north African civilisations had fl ourishing medical learning systems, as did the Greeks and the Mesoamerican civilisations.58,59
영국 In the UK, the Royal College of Physicians started in the 17th century.60

20세기의 교육개혁은 사회운동에서 그 뿌리를 찾을 수 있으며, 19세기의 의과학 발전과도 연관되어 있다.

Educational reforms in the 20th century share roots going back to social movements and the development of the medical sciences in the 19th century.

플로렌스 나이팅게일 In the mid-1800s, Florence Nightingale61 campaigned that good nursing care saved lives, and good nursing care depended on educated nurses.
1859년 런던, 최초의 간호 교육 프로그램 The fi rst nursing education programme began in London in 1859, as 2-year hospital-based training that soon spread quickly in the UK, the USA, Germany, and Scandinavian countries.62
근대의학과 공중보건 The roots of modern medicine and public health go back similarly to the mid-1800s, propelled by discoveries that proved the germ theory.
20세기 초반 의학과 공중보건은 과학적 진보를 따라가지 못했고 교육에 대한 확고한 기준이 없었다. By the beginning of the 20th century, the fi elds of medicine and public health had been left behind by scientifi c advances, with no rigorous standards of education and practice based on modern foundations.

서구 유럽에서 처음 발전한 이후, 20세기 초반의 1세대는 Flexner (1910), Welch-Rose (1915), Goldmark (1923),15 and Gies (1926) 보고서에 의해서 촉발되었다. 이들은 근대 보건과학을 교실로 가져왔으며, 실험실을 의학, 공중보건, 간호학, 치의학에 가져왔다.

After developments in western Europe, the fi rst generation of 20th century reforms in North America were sparked by such reports as Flexner (1910),13 Welch-Rose (1915),14 Goldmark (1923),15 and Gies (1926),16 which launched modern health sciences into classrooms and laboratories in medicine, public health, nursing, and dentistry, respectively (panel 1).

이들 개혁은 주로 연속적 의과학 교육에 뒤따르는 임상/공중보건 실습이라는 특징을 가졌고, 다른 지역에서도 비슷한 노력을 하게끔 했다. 교육과정 개혁은 기관의 변혁과 연결되었는데, 대학을 기반으로 한 대학병원이 생기고, 질이 낮은 학교가 문을 닫았으며, 연구와 교육이 시작되었다. 이러한 발전의 목표는 프로페셔널리즘이 과학적 기반, 고도의 기술과 윤리 기준을 갖추게 하는 것이었다.

These reforms, which were usually sequencing education in the biomedical sciences followed by training in clinical and public health practice, were joined by similar eff orts in other regions. Curricular reform was linked to institutional transformation— university bases, academic hospitals linked to universities, closure of low-quality proprietary schools, and the bringing together of research and education. The goals were to advance scientifi cally based professionalism with high technical and ethical standards.

the Rockefeller Foundation, the Carnegie Foundation 과 같은 미국의 독지가들은 의학과 공중보건을 의한 수 많은 학교 설립에 자금을 지원하며 이러한 교육 개혁을 촉진시켰다. Flexner 보고서가 나오고 2년이 지난 다음 플렉스너는 그 연구를 German Empire, Austria, France, England, and Scotland로 확장시켰다. 그러나 이 결과는 서유럽을 넘어서까지 전파되었다. 소위 플렉스너 모델은 새로운 의과대학 설립을 통해 실현되었으며, 가장 초기의, 동시에 가장 두드러지는 것은 Peking Union Medical College founded in China by the Rockefeller Foundation and implemented by its China Medical Board in 1917이다.

American philanthropy, led by the Rockefeller Foundation, the Carnegie Foundation for the Advancement of Teaching, and other similar organisations, promoted these educational reforms by fi nancing the establishment of dozens of new schools of medicine and public health in the USA and elsewhere.64 2 years after the publication of his original report, which focused on the USA and Canada, Flexner63 extended his study of medical education to the German Empire, Austria, France, England, and Scotland. But the infl uence went beyond nations in western Europe. The so-called Flexner model was translated into action through the establishment of new medical schools, the earliest and most prominent being the Peking Union Medical College founded in China by the Rockefeller Foundation and implemented by its China Medical Board in 1917.63,65

공공의료분야

In public health, the earlier experiences at the London School of Tropical Medicine, Tulane University,66 and the Harvard-MIT School for Health Offi cers were aff ected by the Welch-Rose report,14 which paved the way for a major growth in new schools starting with the Johns Hopkins School of Hygiene and Public Health (1916), the Harvard School of Public Health (1922), the School of Public Health of Mexico (1922), a renewed London School of Hygiene and Tropical Medicine (1924), and the University of Toronto School of Public Health (1927). The Welch- Rose model was also exported through Rockefeller’s funding of 35 new schools of public health overseas, as exemplifi ed by the School of Public Health of Mexico, which was established in 1922 as part of the Federal Department of Health.

이 대규모의 수출과 도입의 결과는 혼재되어있는데, 일부 국가에서는 매우 유용했지만, 다른 국가에서는 잘 맞지 않았다. 멕시코 사례와 아랍 국가, 남아시아의 사례.

This mass-scale export and adoption had mixed outcomes, with useful results in some countries but also severe misfi ts in others. In 1987, the pioneering Mexican school underwent major reform when it merged with the Centre for Public Health Research and the Centre for Infectious Disease Research to form the National Institute of Public Health—one of the leading institutions of its type in the developing world.67 Many other innovative examples, including several in the Arabian countries and south Asia, show the capacity of public health academic institutions to respond to diverse and rapidly changing local requirements (panel 2).

국가 정부가 점차 관여하기 시작한 것과 동시에 제2세대 개혁이 2차 세계대전과 함께 시작되었다. 의과대학이 3차병원과 academic health centres을 확장하기 시작하면서 교육-연구-진료의 세 가지 영역의 활동이 통합되었다. 1950년대에 병원-기반 academic center에서의 레지던트라는 GME의 개념이 생겼으며, 이는 도제교육과 비슷했다.

In parallel with the increasing engagement of national governments in health aff airs, a second generation of reforms began after World War 2 both in industrialised and in developing nations, many of which had just gained independence from colonialism.71 School and university development was accompanied by expansion of tertiary hospitals and academic health centres that trained health professionals, did research, and provided care, thereby integrating these three areas of activity. Pioneered in the 1950s was the idea of graduate medical education as postgraduate training, which was similar to an apprenticeship, through residency programmes in hospital-based academic centres.72

제2 세대의 주요한 교육의 돌파구는 PBL과 통합교육이었다. 1960년 캐나다 McMaster 의과대학, 그리고 미국 Case Western Reserve 의과대학 등이 선두주자. 다른 교육과정 개혁으로는 표준화환자(SP)가 있었다. 토론을 통해 환자-의사 관계를 강화하고, 더 이른 시기에 학생들을 환자에 노출시켜 교실과 임상수련의 연속체를 확장시켰다.

The major instructional breakthroughs from the second generation of reforms were problem-based learning and disciplinarily integrated curricula. In the 1960s, McMaster University in Canada pioneered student-centred learning based on small groups as an alternative to didactic lecture- style teaching.73 Simultaneously, an integrated rather than discipline-bound curriculum was experimentally de- veloped in Newcastle in the UK and Case Western Reserve in the USA.74,75 Other curricular innovations included standardised patients—ie, individuals who are trained to act as a real patient to simulate a set of symptoms or problems—to assess students on practice,76 strengthening doctor–patient relationships through facilitated group discussions,77 and broadening the continuum from classroom to clinical training through earlier student exposure to patients and an expansion of training sites from hospitals to communities.78–81

글로벌 인력 교육은 MDG에 의해서 설정된 국가적/세계적 목표 달성이 원동력이 되어 정책이 변화하면서 일어났다.세 가지 보고서를 눈여겨 볼 만 하다. Task Force on Scaling-Up and Saving Lives,20 World Health Report,19 and the Joint Learning Initiative. 이 보고서들은 모두 제대로 작동하는 건강시스템과 국제적 건강 목표 달성을 위해서 의료인력이 핵심임을 강조하고 있다. 또한 세계적으로 의료인력 부족이 발생하여 240만명의 의사 및 간호사가 57개국에서 부족할 것임을 추정하였다. 이러한 재앙은 사하라 이남 아프리카에서 가장 심각하다.

Global workforce education has witnessed a major resurgence of policy attention, partly driven by imperatives to achieve national and global health objectives as set out by the Millennium Development Goals (MDGs). Three major reports are noteworthy in terms of education and training of the workforce: Task Force on Scaling-Up and Saving Lives,20 World Health Report,19 and the Joint Learning Initiative.18 These reports all underscore the centrality of the workforce to well performing health systems to achieve national and global health goals. All the reports draw attention to the global crisis of workforce shortages estimated worldwide at 2·4 million doctors and nurses in 57 crisis countries. The crisis is most severe in the world’s poorest nations that are struggling to achieve the MDGs, particularly in sub-Saharan Africa.

이 보고서들은 교육과 수련에 투자를 상당폭 늘려야 함을 권고했다. 이 보고서들은 기초보건인력에 초점을 맞췄는데, 왜냐하면 이들이 일차의료에 중요하면서, 중등교육 후 교육에 들어가는 비용은 높기 때문이다.

These reports recommend vastly increasing investment in education and training. They concentrate on basic workers because of the importance of primary health care and the long time lag and high costs of postsecondary education.

간호교육 관련 2010년 세 개의 주요 보고서. Radical transformation, by the Carnegie Foundation; Frontline care,9 a UK Prime Minister commission;12 and the Robert Wood Johnson Foundation Initiative on the future of nursing, at the US Institute of Medicine.82

Nursing education is the focus of three major reports in 2010: Radical transformation, by the Carnegie Foundation; Frontline care,9 a UK Prime Minister commission;12 and the Robert Wood Johnson Foundation Initiative on the future of nursing, at the US Institute of Medicine.82

간호교육의 선구적 연구는 중국이나 이슬람 국가에도 영향을 주었다.

Pioneering work in nursing education is also being pursued in other regions—eg, in China and Islamic countries (panel 3).

공중보건 교육에 관한 IOM의 두 가지 주요 보고서. 이 보고서에서는 transdisciplinary and multischool 접근법을 도입할 것을 권고하고, 평생학습의 문화를 배양할 필요를 강조하고 있다.

Public health education is the subject of two major reports by the US Institute of Medicine in 2002 and 2003, both focusing on the future of public health in the 21st century.5,6 The reports recommend that the core curriculum adopt transdisciplinary and multischool approaches, and instil a culture of lifelong learning.

의학교육은 엄청난 관심을 끌었다. 보고서들.

Medical education has received great attention, as shown by a series of four selected recent reports:

Future of medical education, by the Associations of Faculties of Medicine of Canada;11
Tomorrow’s doctors, by the General Medical Council of the UK;8
Reform in educating physicians, by the Carnegie Foundation;10 and
Revisiting medical education at a time of expansion, by the Macy Foundation.7
An additional report was issued by the Association of American Medical Colleges: A snapshot of medical student education in the USA and Canada.85

모든 보고서들은 미국, 영국, 캐나다의 의료인력이 UME, PGME, CME에서 제대로 준비되지 못하고 있음을 지적했다.

All reports concur that health professionals in the USA, the UK, and Canada are not being adequately prepared in undergraduate, postgraduate, or continuing education to address challenges introduced by ageing, changing patient populations, cultural diversity, chronic diseases, care-seeking behaviour, and heightened public expectations.

이들 보고서의 초점은 지식과 사실을 넘어서는 핵심 역량에 있다. 다음의 것을 염두에 두어야 한다.

The focus of these reports is on core competencies beyond the command of knowledge and facts. Rather, the competencies to be developed include

patient-centred care,
interdisciplinary teams,
evidence-based practice,
continuous quality improvement,
use of new informatics, and
integration of public health.
Research skills are valued, as are
competencies in policy, law, management, and
leadership.

학부 교육과정에는 다음의 것이 고려되어야 하고, 사회적 책무를 지닌 프로페셔널리즘을 갖추게 해야 한다.

Undergraduate education should

prepare graduates for lifelong learning.
Curriculum reforms include outcome-based programmes
tracked by assessment,
capacity to integrate knowledge and experiences,
flexible individualisation of the learning process to include student-selected components, and
development of a culture of critical inquiry—all for equipping physicians with a renewed sense of socially responsible professionalism.

이들 주요 이니셔티브는 부유한 국가와 가난한 국가 간에, 그리고 직종간에 매우 다르다.

The perspectives of these major initiatives between rich and poor countries, and between the professions, are very diff erent.

Panel 2: Adaptation of public health education and research to local priorities

Panel 2.

Adaptation of public health education and research to local priorities

Several public health institutes have developed over recent decades in response to very diverse local contexts. We present innovations in three regions: Arabian countries, Mexico, and south Asia.

Institute of Community and Public Health, Birzeit University, occupied Palestinian territory, is one of three independent schools of public health linked to leading universities in the Arab region; the High Institute of Public Health (HIPH) at the University of Alexandria in Egypt is a large institution founded in 1956; and the Faculty of Health Sciences, American University of Beirut (AUB), Lebanon, was established as separate from AUB's medical school in 1954 and achieved accreditation of its graduate public health programme from the US Council on Education for Public Health in 2006. All were uniquely shaped by national contexts, ranging from a strong state in Egypt to civil conflict in Lebanon, to absent state structures in the occupied Palestinian territory. All have adopted different approaches to public health: application of evidence-based interventions to improve health-care delivery and environmental health in Egypt; expansion of multisectoral developmental public health practice in Lebanon; and focus on social determinants of health necessitating actions inside and outside the health sector in the occupied Palestinian territory.⁶⁸

National Institute of Public Health of Mexico (NIPH),⁶⁹ founded in 1987, responded to rapid national economic and social change, striving to balance excellence in its research and educational mission with relevance to decision making through proactive translation of knowledge into evidence for policy and practice. The Institute widely disseminated a conceptual base around the essential attributes of public health; developed educational programmes across diverse areas of concentration; implemented a wide range of innovative educational approaches, from short courses to doctoral programmes; and developed sound evidence that supported the design, implementation, and evaluation of the ongoing health reform initiative for universal coverage. The success of the NIPH underscores the crucial importance of national and international networking to withstand local difficulties by sharing of experiences to build a strong health-research system that is able to tackle a vast array of local and global health challenges.

The Public Health Foundation of India is a unique private–public partnership to energise public health by bringing together pooled resources from the Indian Government and private philanthropy to address India's priority health challenges. The Foundation is crafting partnerships with four state governments to create eight training institutes of public health in the country.⁷⁰ The BRAC University's School of Public Health, named after UNICEF's visionary leader James P Grant, was launched by the world's largest non-governmental organisation and offers an innovative 12-month curriculum for masters in public health that begins with 6 months on its Savar rural campus acquiring basic public health skills in the context of rural health action, followed by the remaining 6 months of thematic and research training. These two public health initiatives in south Asia were based on the legacy of British colonialism, which focused exclusively on medical rather than public health schools. Importantly, both these schools are developing new curricula shaped to national and global priorities, and neither is adopting wholesale the Welch-Rose model of public health education.

Panel 3.

Women and nursing in Islamic societies

Women and nursing in Islamic societies has a long and rich history. In the Middle East and north Africa, higher education in nursing started in 1955 when the first Higher Institute of Nursing in the region was established in the Faculty of Medicine of the Egyptian University of Alexandria. Endorsed by WHO, the Institute offered a bachelor of nursing degree. The Institute became an autonomous faculty affiliated to the University in 1994, offering both masters and doctoral degrees in nursing sciences. During the past 50 years, the faculty of nursing has produced more than 6000 graduates, many assuming leadership in the region.

Another pioneer is the Aga Khan University School of Nursing, which was established in Pakistan in 1980, and which began offering a bachelor of science in nursing in 1997 and the masters of science in 2001.⁸³ The school has devised a unique curriculum adapted to local contexts but based on the curriculum recommended by the American Association of Colleges of Nursing's Essentials of Master's Education in Advanced Nursing (1996).⁸⁴ Aga Khan University has also expanded the bachelors and masters nursing programmes to its campus in east Africa.⁸³ In addition to training nurses, these advanced degree programmes attract high-quality candidates in Islamic society, showing societal prestige and value for women entering the nursing profession.

Institutional design

교육기관은 매우 다양할 수 있다.

Such educational institutions might be extraordinarily diverse.

They might be independent or linked to government, part

of a university or freestanding,
fully accredited, or
even informally established.
Their facilities might range from rudimentary field training sites to highly sophisticated campuses.

한 가지 중요한 구분은 공립과 사립이다. 물론 단순한 이분법이 아니라 이 사이에도 엄청난 종류가 있다.

One major distinction is between public versus private ownership, with a wide range of patterns in between.

사립기관은 비영리이거나 영리기관일 수 있다. 역사적으로 종교나 미션스쿨은 비영리 병원을 설립하였고, 일부 의학, 간호학, 비영리 기관은 독지가에 의해서 설립되거나 자선기관 혹은 사회적 노력의 한 부분이기도 하다. 많은 국가에서 영리추구기관이 증가하고 있으며, 특히 국제적 노동시장에서 기회를 찾을 수 있는 의사와 간호사 양성을 추구할 때 그러하다. 대부분의 기관은 공립과 사립이 혼합된 패턴을 갖는다.

Private institutions might be non-profi t or for-profi t. Historically, religious and missionary movements have established many non-profi t hospitals and some medical and nursing schools. Non-profi t institutions have also been created by philanthropy, charitable organisations, and corporations as part of their social endeavours. In many countries, proprietary for-profi t schools are increasing, especially to produce doctors and nurses to exploit opportunities in the global labour market.35,86,87 Most institutions possess mixed patterns of public and private governance.

학위도 다양해서, 교육은 매우 차이가 큰데 학위는 같을 수 있다. 글로벌하게 혹은 한 국가 내에서 학위소지자의 질이나 역량에는 차이가 크다. 예컨대 중국의 경우, 전문직 진료 학위를 수여하는 프로그램은 3, 5, 7, 8년으로 다양하다. 이 졸업생은 모두 자격증을 가지고 있으며, 직업훈련만 받은 백만명에 달하는 마을 의사와 대비된다.

There is a multiplicity of degrees, and the same degree could be acquired with highly variable curricular content, duration of study, quality of education, and competency achieved. Globally, and even nationally, there is little uniformity with respect to qualifi cation and competency of degree holders. Medical doctors in China, for example, might obtain professional practice degrees with 3, 5, 7, or 8 years of postsecondary education.88 These graduates are the credentialled practitioners, compared with the nearly 1 million additional village doctors who mostly have only vocational training.89

Global perspective

의학교육기관은 매우 다양하다. 국가마다 그 양이 매우 많기도 하고 적기도 하다. 부족한 경우 그것은 국가 수입이 낮은 것과 연관되어 있다. 특히 사하라 이남 아프리카에서 그러하다. 그러나 풍족한 것은 꼭 부유한 것과는 관게가 없다. 실제로 많은 중소득 국가가 기관의 숫자를 의도적으로 늘림으로써 의료인력을 수출하고 있는데, 왜냐하면 많은 부유한 국가는 만성적으로 국가에서 필요한 수의 의료인력을 양성하지 못하는 문제에 시달리고 있기 때문이다. 의학교육기관의 숫자와 패턴이 국가의 인구규모나 GNP, 질병부담과 관련이 없는 것도 놀랍지 않다.

Not surprisingly, we recorded large global diversity in medical institutions, with abundance and scarcity across countries. Scarcity is associated with low national income, especially aff ecting sub-Saharan Africa; however, abundance is not concentrated only in wealthy countries. Indeed, several middle-income countries have increased the number of institutions to deliberately export professionals, because many wealthy countries have chronic defi cits since they underproduce below national requirements. Not surprisingly, the number and pattern of medical institutions do not match well with national population size, gross national product, or burden of disease.

약 2420개의 의과대학이 389000명의 졸업생을 매년 양성하고 있다.

We estimate about 2420 medical schools producing around 389 000 medical graduates every year for a world population of 7 billion people (table 1).

공중보건 관련 467개 기관

We also estimate 467 schools or departments of public health,

간호대학 졸업생은 541000명.

We estimate that about 541 000 nurses graduate every year,

Figure 6 shows the density of medical schools by major regions.

의학교육기관의 분포는 매우 편중되어 있다. 인도, 중국, 브라질, 미국은 각각 150개 이상의 기관을 가지고 있어 전 세계 기관의 35%를 차지한다. 31개 국가에는 전혀 없으며, 그 중 9개는 SSA에 있다. 44개 국가는 1개가 있으며, 17개는 SSA에 있다. 약 절반의 국가가 1개 혹은 그 이하의 의과대학만 가지고 있는 것이다.

Distribution of medical institutions is highly skewed between nations. India, China, Brazil, and the USA—each having more than 150 schools—make up 35% of world’s total. 31 countries have no medical school whatsoever, nine of which are in sub-Saharan Africa. 44 countries have only one medical school, 17 of which are in sub-Saharan Africa. Nearly half of countries worldwide have either one or no medical school.

의과대학의 전 세계 분포와 전 세계 인구분포, 그리고 질병부담 분포는 잘 맞지 않는다.

The global distribution of medical schools and the world distribution of population and burden of disease is not well matched (fi gure 7).

의과대학의 숫자 역시 졸업생의 숫자와 잘 맞지 않는데, 한 가지 설명은 학급 규모이다. 인도와 중국을 비교하면 인도는 300개 의과대학에서 30000명을 양성하여 학급당 110명 규모인데, 중국은 188개 의과대학에서 175000명을 양성하여 학급당 1000명에 이른다.

not match well with the number of medical graduates. One possible explanation is diff erent class sizes, which is shown by a comparison of India and China (table 2). India’s 300 medical schools are estimated to graduate about 30 000 doctors every year, suggesting an average grade size of 100 students. By contrast, China’s 188 medical schools are estimated to graduate 175 000 doctors every year, suggesting an average grade size of 1000 students.

놀랍게도, 의과대학졸업생의 수와 의사의 수 사이에 강한 상관관계가 있지 않다. 간호대 졸업생에 대해서도 마찬가지이다. 이에 대한 한 가지 설명은 노동시장이 불균형을 이루고 있는 상황에서 고용되지 못한 의사가 있기 때문이다. 도 다른 설명은 학위가 없는 사람들이 의사나 간호사 직무를 하고 있을 수 있다. rate of attrition도 한 이유가 된다. 인도 의사는 미국 내 이주 혼 의사 중 가장 많은 숫자이며, 필리핀과 캐리비안 국가의 사립학교에서 양성된 간호사들은 더 부유한 국가로 이주한다. 쿠바도 비슷. 반대로 만성적으로 의사가 부족한 미국이나 서유럽 국가, 중동 국가는 졸업생에 비해서 의료인력이 많다.

Surprisingly, there is not a strongly positive relation between the number of medical graduates and the stock of doctors, nor is there such a relation between the number of nursing graduates and the stock of nurses. A possible explanation is unemployment in graduates when labour markets are imbalanced. Another explanation is that non-degree holders might be doing some medical and nursing jobs. Diff erent rates ofattrition could provide additional insights, the most prominent of which is international migration. Indian doctors are the most numerous of all nationalities of foreign doctors emigrating to the USA.90 Many nurses in the Philippines and the Caribbean are trained in private schools especially for transfer to wealthier countries.86,91,92 Cuba has an explicit policy of medical education for sharing with other countries.93 Conversely, chronically defi cient countries, such as the USA and nations in western Europe and the Middle East, would be expected to have higher workforce stock for the size of their graduating cohorts because of the number of health professionals moving to these countries.

Financing

미시적 접근법을 통해서 한 학생당 비용을 숫자로 곱해서 산출하거나, 거시적 접근법을 통해서 3차병원 총 매출을 통해서 추정하였다. 두 방법 모두 결과는 비슷했다.

A microapproach calculates fi nancing by multiplication of the number of medical and nursing graduates by the unit costs of education. A macroapproach examines the total turnover of tertiary education and assigns a proportion to professional health education. The fact that the microapproaches and macroapproaches generated similar orders of magnitude provides assurances about the robustness of the data.

전체 의료인력 교육에 들어가는 비용은 매년 US$100 Billion 정도이다. 의과대학생 1명에 드는 비용은 $122000 정도이다.

Total yearly expenditures in health professional education is estimated at about US$100 billion formedicine, nursing, public health, and allied healthprofessions. Education of medical graduates is estimatedat $47·6 billion and nursing graduates at $27·2 billion.The fi gures for these individual professions are roughlyinfl ated, in the absence of detailed information, to$100 billion by inclusion of public health and otherrelated professions. In total, we estimated a unit cost of$122 000 per medical graduate, and a unit cost of$50 000 per nursing graduate

전문직 교육에 대한 투자는 전체 건강시스템의 퍼포먼스에 대한 중요성에 비추어 볼 때 지극히 작은 수준이다.

Investments in professional education seem to be exceedingly modest in view of its importance to health- system performance.

글로벌하게 보면 이것은 더 심한데, 교육에 들어가는 비용은 전체 글로벌 헬스케어 산업이 올리는 매출 대비 2%도 안되는 수준이다.

This alarming picture is even more apparent globally, where investments in health professional education represent less than 2% of a global health-care industry turning over an estimated $5·5 trillion yearly.

의학교육의 비용이 상승하는 것은 모든 국가에서 문제가 되고 있다. 학생과 가족뿐 아니라 빈곤층의 접근 자체를 배제시킨다. 대출에 기반하여 자금을 마련하는 것은 또 다른 문제가 되는데, 미국에서 졸업생의 평균적 대출은 $200000정도이며, 이것이 이들로 하여금 사회적으로 중요하지만 수익성은 조금 낮은 진로로부터 멀어지게 한다.

The rising cost of medical education is a growing challenge in all countries.7,99 Increased costs not only impose hardship on student families but can also exclude access by poor people. Loan-based fi nancing of medical education causes additional drawbacks. In the USA, the average debt of graduating students is now about $200 000,100 which severely burdens them with obligations that can hinder them from pursuing socially important but less lucrative careers.101

전문직 교육에 사적 영역의 투자는 증가할 수도 있다. 이러한 투자가 반가운 것은 사실이나, 거기에 따라오는 질의 문제나 사회적 목적에 대한 우려가 있다. 인도 언론은 최근 MCI로부터 인증을 기다리고 있는 새 사립대학들의 불법 지불을 보도했다. 이 보고서는 인도 정부가 인증 시스템을 개혁하게끔 만들었는데, 지난 30년간 생긴 191개의 새 의과대학 중 147개는 사립이다. 더 문제인 것은 이들은 메트로폴리탄 지역이나 부유한 지역에 위치하여 지역적 불균형을 악화시키고 있다.

Private investments in professional education might be increasing. Although this funding is welcomed, it generates concerns about quality and social purpose.35 The Indian press has reported illegal payments by new private schools seeking accreditation from the Medical Council of India, an independent body that originated during the colonial era.102,103 This report has triggered a takeover by the Indian Government to reform the accreditation system.103 Of 191 new Indian schools in the past three decades, 147 are private. These schools, moreover, are heavily concentrated in metropolitan centres and in wealthier states, exacerbating geographic imbalance.

인도의 사례는 이익의 상태가 사회적 목적보다 덜 중요할 수 있음을 보여준다. 대부분의 인도 사립의과대학은 비영리이지만, 사실상 상당한 수입원을 만들어내고 있다.

The India case also shows that profi t status might be less important than social purpose, since most new Indian private schools are listed as non-profi t but actually generate large income streams.103,104

국제적 의료인력 부족과 시장의 요구로부터 유발된 대규모의 미계획적인, 통제되지 않는 의과대학은 플렉스너가 방문하고, 비판하여 결국 문을 닫게 된, 그 시절의 저질의 proprietary school과 같은 그러한 학교를 만들어 낼 뿐이다. 플렉스너 보고서 100주년에 de-Flexnerisation process가 진행중이다.

Driven by global workforce shortages and growing market demand for health services, a large increase in unplanned and unregulated medical schools could generate the very same type of low-quality proprietary schools that Flexner visited, criticised, and successfully closed. A so-called de-Flexnerisation process is underway in which low-quality professional schools might be proliferating once again on the centennial of the Flexner report.

Accreditation

의과대학 인증은 그 기관의 교육활동을 사회적 목적과 연결시켜준다는 점에서 중요하다. 국제적으로 기존에 시행되고 있는 인증평가들에 대한 포괄적인 평가는 없지만 글로벌한 다양성이 존재함은 추측할 수 있다.

Accreditation is therefore central to the professional education institutions linking their instructional activities to their societal purpose. Although there is no systematic assessment of accreditation practices worldwide, we can assume that great global diversity exists.

WHO는 인증의 기전을 “동지중해에서 75%에서 존재하고, 동남아시아의 50% 가량에서 진행중이며, 아프리카에서 1/3 정도에서 진행중이다. 더 나아가 사립 의과대학은 공립보다 인증평가절차를 거칠 가능성이 더 낮다.

WHO has reported that accreditation mechanisms “exist in three quarters of Eastern Mediterranean countries, just under half of the countries in Southeast Asia, and only about a third of African countries. Furthermore, private medical schools are less likely than publicly funded ones to undergo accreditation procedures”.106

설문에서 확인된 바로는 많은 추가적인 아프리카 의과대학과 대부분이 인증시스템 바깥에 있다. 유럽의 부유한 국가에서도 인증평가에 대해서 지역적 차이가 큰 것에 대한 우려가 있었다. ‘EU국가 중 25개 국가는 EU기준을 충족시키고 있지만, 동유럽에는 그러한 지역 기준이 없다“

Survey work has identifi ed many additional African medical schools, and most are outside accreditation systems.108 Even in rich regions such as Europe, concerns have been expressed about the geographical variation in accreditation. “Although medical schools in the 25 countries of the European Union (EU) have to comply with EU standards, no such regional standards apply in Eastern Europe.”107

인증 강화는 국가마다 다양하다. 중국은 백만명의 마을 의사가 있으며, 인도는 백만명의 농촌의료인이 있고 이들은 인증된 학교의 졸업생이 아니다. 같은 수준은 아니지만 거의 모든 국가에 이러한 gap이 존재한다.

Enforcement of accreditation can be variable across countries. China has about 1 million village doctors, and India has about 1 million rural medical practitioners who are not graduates of accredited schools. Although not of the same scale, similar gaps in accreditation and credentials exist in almost all countries.

여기에 두 가지 주요한 과제가 있다.

첫 번째는 인증절차의 동인이 되는 궁극적인 목적과 인센티브이다.
두 번째는 글로벌 원칙과 지역적 특이성의 조화이다.

Herein arise two major challenges. The fi rst refers to the ultimate purposes and incentives driving accreditation processes; the second has to do with harmonisation of global principles versus local specifi city.

WHO는 인증에 대한 사회적 책무성을 “지역사외, 지역, 국가와 같이 의과대학이 담당해야 하는 곳의 주요 건강 문제 해결을 위한 교육, 연구, 진료의 방향을 제시하는 것”이라고 했다. 인증평가에 더 큰 사회적 책무를 가지게 하는 것은 사회적 건강 목표 – 평등, 질, 효율성 – 와 잘 맞는 인력 양성에 중요하다.

WHO has defi ned social accountability of accreditation as “directing education, research and service activities towards addressing the priority health concerns of the community, region, and/or nation they have the mandate to service”.109 The imposition of greater social accountability into accreditation could be instrumental in production of a professional workforce that is well aligned with societal health goals, including equity, quality, and effi ciency (panel 4).

그러나 모든 기관이 사회적 책무성을 위해서 세워진 것은 아니다. 비록 영리를 추구하는 의과대학은 시장에 어필하기 위해서라도 양질의 졸업생을 양성하고자 할 것이며, 이를 통해서 재정적 이득을 추구한다.

But not all institutions have been established for social accountability. Although for-profi t schools might seek to produce quality graduates since they would enhance its market appeal, they necessarily have to seek fi nancial returns.

또 다른 과제는 세계적 기준과 다양한 지역적 맥락에 대한 적용가능성을 조화시키는 것이다. 글로벌 원칙은 인증평가에 일관성/투명성/개방적 책무성을 부여하며, 지식과 실천의 지역사회가 등장하기 더 쉽게 해준다. 여러 국가 사이에 균질성을 추구하는 것은 의도치 않은 결과를 가져올 수 있는데, 의료인력이 국가간 경계를 넘어시 이주하는 것이 그것이다.

Another challenge is harmonisation of global standards with local adaptability to diverse contexts. Global principles would bring consistency, transparency, and open accountability to the accreditation process, while easing the emergence of communities of knowledge and practice. Uniformity across countries could have, however, the unintended consequences of helping with professional migration across national boundaries. Local adaptation would be necessary

글로벌-로컬 균형을 달성하는 것이 우선순위가 되어야 하며, 기관간 상호의존성이 높아질수록 필요한 것이 된다. 많은 국제기구가 기준을 정립하고 있다.

The Association of Southeast Asian Nations (ASEAN) has steadily advanced its mutual recognition processes to harmonise standardisation of professional degrees in nursing and medicine.
The International Institute of Medical Education (IIME) launched a global minimum essential requirement (GMER) initiative for adaptation by some medical schools in China to assess institutional performance on the basis of student achievements in several core domains of medical competencies.119
The World Federation for Medical Education (WFME) has collaborated with WHO to propose a global consensus development process between national stakeholders.107
Nationally, the US Institute of Medicine has recom- mended summits every 2 years for leaders to take stock, note trends, identify gaps, and develop future plans aiming to harmonise diff erent oversight bodies and to show greater transparency and accountability.120

Achievement of some global–local balance is a priority, indeed a necessity, as institutional interdependence grows. Many international bodies are setting standards for professional education either to deal with transnational threats such as pandemics or to harmonise international labour markets.115–118 The Association of Southeast Asian Nations (ASEAN) has steadily advanced its mutual recognition processes to harmonise standardisation of professional degrees in nursing and medicine. The International Institute of Medical Education (IIME) launched a global minimum essential requirement (GMER) initiative for adaptation by some medical schools in China to assess institutional performance on the basis of student achievements in several core domains of medical competencies.119 The World Federation for Medical Education (WFME) has collaborated with WHO to propose a global consensus development process between national stakeholders.107 Nationally, the US Institute of Medicine has recom- mended summits every 2 years for leaders to take stock, note trends, identify gaps, and develop future plans aiming to harmonise diff erent oversight bodies and to show greater transparency and accountability.120

Panel 4: Networking for equity

Panel 4.

Networking for equity

“Until the great mass of the people shall be filled with the sense of responsibility for each other's welfare, social justice can never be attained.”¹¹⁰ That is why networking between like-minded socially-committed individuals and groups have been key drivers for social equity through reform of professional education. Three socially driven initiatives are described here.

Social accountability and accreditation

How well do accreditation bodies—national, regional, and global—align, measure, and incentivise professional educational institutions to meet the social needs of society? This is the ambitious yet crucial agenda proposed by Boelen and Woollard,¹¹¹ who have launched a set of interactive processes to achieve a global consensus on the role of accreditation in ensuring the social accountability of medical schools. This consensus is the basis of an action plan to engage the major national and international bodies in bringing it to life. They propose a model of interdependence between health education and health systems such that the conceptualisation, production, and usability of medical school graduates reflects the priority health needs of society. They argue that accreditation systems for medical schools should measure the competency of the graduates and research production in meeting those needs. Initiatives of organisations such as International Francophone Society of Medical Education and International Organisation of Deans of Francophone Medical Schools, along with some other examples, were recognised as encouraging efforts to reform the accreditation system to bring about an era of health professionals with social sensitivity and global connectivity to meet the health-care needs of the real world.^{111 and 112} They propose a global consensus process to advance the integration of social accountability into all systems to create a future for medical education based on an adaptive commitment to explore and address the evolving health needs brought about through educational, research, and service innovations worldwide.

THEnet

Launched in 2008, THEnet is a network of collaborating medical schools experimenting with instructional and institutional innovations to attract, retain, and enhance the productivity of health professionals serving disadvantaged populations often in remote rural areas. The schools' training settings vary from remote aboriginal communities in Canada (Northern Ontario School of Medicine) to rural areas of Africa (Walter Sisulu University); and from the densely populated urban slums of Venezuela (Comprehensive Community Physician Training Programme) to the politically volatile areas of Mindanao in Philippines (Ateneo de Zamboanga University). The shared experiences are generating a systematic approach to successful staffing of previously deprived regions, and, contrary to popular perception of poor academic standards of rural or community-based institutions, students from THEnet schools have consistently scored higher than average in national examinations.¹¹³

The network:Towards Unity for Health (TUFH)

This network is an association of health professionals and academic organisations that are dedicated to creation of a global platform of equitable health care through community-based education, dynamic research, and dedicated rural service. TUFH has undertaken policy-based projects and case studies on issues of great importance, such as rural internship programmes (Brazil), promotion of healthy behaviours (Czech Republic), integrative participatory research (Kenya), family practice research in resource-poor settings (Greece), and international graduate programmes on pharmacy (Canada). In 2007, TUFH launched eEducation for health—an open-access electronic journal aimed at enhancing transnational exchange of knowledge and information.¹¹⁴

Academic systems

임상수련이 점차 확대되면서 공식적 인턴과 레지던트를 포함하게 되었고, 이것이 1세대 기관 개혁의 특징이다. 지난 50년간 2세대 개혁은 academic center의 빠른 성장을 동반했으며 이는 임상진료와 연구로부터 온 수익 덕분이었다. 발견-진료-교육의 연속체를 통합시키는 센터의 파워와 영향력도 같이 커졌다. AHC의 국제 연합은 최고의 진료를 공유하고, 국제 관계를 촉진하고 교육/진료/연구의 사명을 강화하기 위해서 설립되었다.

Gradual expansion of clinical training to include formal internships and residencies in hospitals marked the fi rst generation of institutional reforms. During the past 50 years, the second generation of reforms witnessed rapid growth of academic centres due to income from clinical services and research. The power and infl uence of these centres integrating the continuum of discovery-care-education correspondingly increased. An international association of academic health centres has been established to promote sharing of best practices, foster international relations, and enhance the missions of education, patient care, and research.121

지역사회 병원에서의 수련을 통해서 3차병원을 넘어서는 교육 옵션을 확대시키기 위해서 많은 노력이 있었으며, 가끔은 의료취약 지역사회에서의 교육까지도 포함되기도 했다. 이러한 수련지는 그 자체가 이슈였을 뿐 아니라, 연구와 진료 수입에서 오는 강력한 흐름에 비교할 때 교육에 대한 우선순위에 대한 균형과 심지어 진료 혹은 연구를 하는 교수로부터 오는 비뚤어진 롤모델링도 이슈였다.

Many eff orts have been made to expand the educational options beyond tertiary hospitals through practical training at community health centres, sometimes situated in disadvantaged communities. Not only is the training worksite an issue but the balance of education compared with the powerful streams of clinical and research income could dampen educational priorities oreven distort role-modelling of clinical and research faculty.

한 가지 위협은 3차병원이 권력과 자금에서 강해진 것 뿐 아니라, 1차나 2차 병원에 관심이 낮아진 것이다.

One danger is that tertiary academic centres would simply grow in power and funding without corresponding attention to balanced secondary and primary education.

1차의료 수련은 academic system을 포함하여 전체 건강시스템에 아주 매끄럽게 통합되어야 한다. Academic system이 맞은 도전은 로컬 커뮤니티와의 관계를 통해서 더 균형잡힌 전문직 교육 환경을 만드는 것이고, 인구-기반 예방에 적극적이어야 하며, 미래의 건강 위협에 대비하고, 건강시스템의 전체적 설꼐와 관리를 이끌어나가는 것이다.

Primary health-care training should be seamlessly integrated into the overall health system, including the academic system. The challenges for academic systems is to provide a more balanced environment for the education of professionals through engagement with local communities, to proactively address population-based prevention, anticipate future health threats, and to lead in the overall design and management of the health system.

협력은, acadmic system이 가진 강력한 도구로서, 교육의 질과 성과를 정보 공유, 학문 교류, 공동 작업, 기관간 시너지를 통해서 향상시키는 것이다.

Collaboration, a potentially powerful instrument of academic systems, describes the opportunities to enhance educational quality and productivity through sharing of information, academic exchange, pursuit of joint work, and synergies between institutions.124

많은 조직들(networks, consortia, alliances, and partnerships)이 이러한 시너지를 높고자 한다. 특히 중요한 것은 두 개의 기관이 모두 강해질 수 있는 co-equal twinning arrangement이다.

Many organisational arrangements have been used to facilitate these synergies: networks, consortia, alliances, and partnerships. Especially noteworthy is capacity building through co-equal twinning arrangements to strengthen both institutions (panel 5).

두 종류의 협력이 중요하다. 하나는 전문직 교육기관간 협력이며, 다른 하나는 교육기관가 다른 목적의 기관이 협력하는 것이다.

Two types of institutional collaborations are worthy of consideration: between professional schools and between educational and other types of institutions.

세 번째 형태의 협력은, 진정한 협력은 아닐지라도, off-shore 의과대학이다. 고소득 국가의 의과대학이 그 브랜드네임을 빌려주고, 경제적으로 성장중인 국가로부터 비용을 받는 것이다.

A third type of collaboration, although not really collaborative, is off - shore schools set up either alone or in partnership by brand-name schools in high-income countries in emerging economies, often with the aim of increasing revenues while lending out brand names.

교수들은 모든 교육기관의 궁극적인 resource이다. 그들은 교사이면서, 관리자이면서, 지식전달자이면서, 가장 중요하게는 훈련을 통해 다음 세대의 전문직을 양성하는 학생의 롤모델이다. 그러나 종종 지식의 공유나 지식의 적용보다 지식의 생성은 가장 중요한 것처럼 여겨지곤 한다.

Faculty members are the ultimate resource of all educational institutions. They are the teachers, stewards, agents of knowledge transmission, and most importantly role models for students—reproducing the profession by training the next generation of professionals. Knowledge generation is often seen as more imprtant than knowledge sharing and knowledge translation.

빈곤 국가에서 가장 큰 제약은 양질의 교사가 없는 것으로, 이들은 기초보건인력을 포함하여 다음 세대의 전문직을 양성하는데 필수적이다. 한 가지 가능한 옵션은 부유한 국가의 졸업생을 인력이 심각하게 부족한 다른 국가에 파견하는 것이다. 그러나 이러한 활동은 빈곤국가를 강화하기 위한 더 넓은 차원의 전략의 일부로서 도입되어야 한다.

In poor countries, a major constraint is the scarcity of qualifi ed teachers who are essential for training the next generation of professionals, including the training of basic health workers.19 Of the options that deserve exploration is the short-term placement of graduates from rich countries seeking opportunities to contribute in other countries that are severely defi cient in faculty.130 Such activities, however, should be part of a broader strategy for capacity strengthening in poor countries.

전문직 교육은 정보가 불충분하고 모니터링과 평가에 대한 문화가 미약하다.

Professional education as a fi eld has insuffi cient information and a weak culture of monitoring and evaluation.

예컨대, 여러 보건전문직 교육기관이 보유한 데이터는 적고 대부분 매우 소수의 국가에 집중되어 있다. 또는 협소한 국가적 목적에만 사용하고 있다.

For example, data for the number of professional health educational institutions are rare and mostly focused on a few countries, or are serving narrow national purposes such as licensing or certifi cation of doctors and nurses.

Panel 5.

Twinning for capacity development in Africa

Medical schools in all countries have benefited from twinning programmes that foster exchange, share resources, and undertake collaborative work for mutual advance. Several of sub-Saharan Africa's premier medical institutions have benefited from such twinning arrangements. Founded in 1948, Ibadan—possibly Nigeria's premier medical school—was started in collaboration with the University of London, UK. In Uganda, the prestigious Makarere health sciences schools have had many twinning programmes, including with Johns Hopkins, USA, in public health.

In Kenya, Moi University School of Medicine has pioneered a twinning arrangement with a consortium of north American universities led by Indiana. Building on customary focus of collaboration in education and research, the Moi twinning pioneer leads with care by engaging both partners directly in the delivery of services. The focus on practical application allows for the building in of appropriate education and research. Moi has also expanded the educational twinning to a triadic relation with three partners, including as partner the Kenyan Ministry of Health. Similarly, for two decades the state university of Indiana has undertaken a global health elective for its students in nearby Eldoret Kenya, who are mentored by local and visiting faculty.¹⁵The elective enables students to participate in health-care teams including clinical work, a journal, written narrative reflections, cultural acclimation, and ethical challenges.

Such models have helped to spark a new Medical Education Partnership Initiativebetween the National Institutes of Health and the US President's Emergency Plan for AIDS Relief (PEPFAR), launched in October, 2010. It will invest US$130 million over 5 years to increase the production of 140 000 health workers in Africa and transform African medical education through funding support to nearly a dozen African institutions that will, among other instruments, use twinning for capacity building.

Panel 6.

Lusophone networking and Brazilian coordination

The Community of Portugese-Speaking Countries (CPLP) has formulated a strategic plan to improve health systems in all affiliated countries for universal access to high-quality health services that includes the training of personnel and a network of projects to strengthen institutional capacity. Thus the CPLP has created a lusophone network of national institutes of health, technical health schools, schools of health governance, and centres for specialised medical training. The Brazilian Oswaldo Cruz Foundation (FIOCRUZ) is playing a key part in this network—eg, supporting the development in Mozambique of a public unit for the production of generic and essential drugs. Financing for the network's training and projects come from rich lusophone countries Portugal and Brazil, and from international agencies and private foundations.

In parallel with the network are innovations in some lusophone countries, such as the Pró-Saúde and PET-Saúde—Brazilian Programme of Reorientation of Health Professional Education. A long-standing problem in Brazil has been the mismatch between professional education and the human resource requirements of the National Unified Health System. The Ministry of Education and the Ministry of Health has therefore launched a new partnership for reform. All academic institutions are reorienting curriculum to shift training from hospitals to clinics and communities, to focus on prevention and social determinants, and to strengthen proactive, problem-based learning. More than 500 courses, 9000 fellowships, and the training in 14 health professions based in more than 80 institutions of higher education have received funding in this partnership between two key ministries.

Instructional design

11054개의 논문을 바탕으로 했음. 73%가 의학교육에 관한 것이었고, 53%가 북미 의료전문직 교육에 대한 것이었다.

Our review of publications about education identifi ed 11 054 articles in medical, nursing, and public health education. The reports about education in medicine (73%) are more abundant than are those about nursing (25%) or public health (2%). More than half of articles (53%) focus on professional education in North America, a quarter (26%) on Europe, and the remainder (21%) on other regions.

입학 기준 Criteria for admission

대부분의 국가에서 졸업생의 사회적 역량은 환자와 인구의 사회적/언어적/인종적 다양성과 일치하지 않는다. 보건의료계 학생은 사회 고위층과 다수 인종 그룹에서 주로 입학하여 불균형을 이룬다.

In most countries, the social competencies of graduates might not be aligned with the social, linguistic, and ethnic diversity of patients and populations. Health professional students are disproportionately admitted from the higher social classes and dominant ethnic groups.7,11,19

그러나 점차 환자와 인구 건강과 사회문화적, 언어적 호환성의 중요도에 대한 인식이 높아지고 있으며, 격오지의 의료가 잘 이뤄지지 않는 이유가 도시에 유리한 입학 정책 때문이라는 지적도 있다.

Yet, there is growing recognition of the importance of sociocultural and linguistic compatibility in patient care and population health, and a growing appreciation that problems such as skewed coverage of remote areas is often due to urban-biased admissions policies.33

입학에서 남녀 성별의 구성도 건강-시스템 퍼포먼스에 영향을 미친다. 성별에 따른 고정관념은 보건의료계에허 흔하다. 예컨대 간호사는 여자다, 같은 것이다. 많은 나라에서 의료인력의 여성화가 지속적으로 진행중이다. 젠더 평등이 중요한 것은 한 사회가 보유한 인간 역량을 최대로 실현하기 위해서 뿐 아니라, 환자-중심적 진료에 있어서 젠더가 중요한 측면을 가지고 있기 때문이다. 예컨대, 여성 환자는 여성 의사를 보다 선호하기도 한다. 또한 건강-시스템에 있어서 여성화가 갖는 함의가 있는데, 여성이 집안일 부담으로 인해서 근무할 시간이 더 적기 때문이다. 노동력의 분포가 성별에 따라서 달라지는 것은 노동시장 역학에 중요한 함의가 있는데, 왜냐하면 여성이 남성보다 보다 유연한 커리어 경로를 따를 가능성이 높기 때문이며, 이 말은 노동시장에 진입하거나 빠져나갈 수 있는 지점이 더 많다는 뜻이다. 여성 의사와 간호사는 가족이나 치안 문제 때문에 격오지에서 근무하는 것에 더 어려움을 느낄 수도 있다.

The gender composition in admissions has a major impact on health-system performance.133 Gender stereo- types are strong between health professionals—eg, women and nursing. In many countries, there is a continuing so-called feminisation of the medical workforce. Not only would gender equity enhance a society’s realisation of its full human potential, but gender might constitute an important aspect of patient- centredness—eg, female patients preferring female professionals in some societies. There are also health- system implications of feminisation, since women might have less time for work in view of the burden of home obligations. The distribution of the workforce by sex also has important implications for labour market dynamics, because women are more likely than men to follow fl exible career paths, with multiple points of entry into and exit from the workforce. Female physicians and nurses can fi nd it more diffi cult to be situated in remote regions because of family commitments and sometimes because of security considerations.

많은 해결책이 제시된 바 있지만 성공적인 것은 몇 없다.

Many solutions have been proposed to achieve balanced admissions, but few have been successful.

의과대학은 입학 기준을 그 국가의 사회적/언어적/인종적 프로파일과 매칭시킬 수도 있으며, 핵심 가치와 인성(의사소통, 대인관계, 협력, 전문직으로서의 흥미) 등을 포함시킬 수도 있다. Affirmative action 프로그램은 의료취약계층에서의 잠재적 지원자를 확보하기 위해 2차교육에 대한 보조와 지원을 하는 것 까지 발전될 수도 있다. 한 가지 제안은 농촌 커뮤니티에 정부 지원을 통해서 스스로 지원자를 추천하게끔 하고, 그들의 교육에 비용을 부담하게 하고, 졸업 후에 고용하는 것이다. 재정지원이 중요한데 왜냐하면 등록금이 빈곤계층의 진입장벽을 높이기 때문이며, 그 비용이 너무 커서 큰 빚을 남기기 때문이다. 또 다른 제안으로는 교육기관 자체를 취약지 지역사회에 인접하게 위치하게 하여서 학생의 모집이나 그 지역에서 전문직이 근무하는 것을 돕게끔 할 수 있다. 물론 이들 기관의 교육자원의 ‘임계질량’ 확보하는 것이 쉽지 않다는 것에도 관심을 두어야 한다. 만약 의과대학 입학생이 모두 대도시 출신이라면, 그들이 농촌에서 근무할 가능성은 매우 낮아진다. 그렇다고 하더라도, 졸업생들은 일정 기간을 사회 봉사를 위해서 농촌 지역사회에 근무하게끔 배치될 수도 있다 (멕시코에서 1936년 시도한 것이며 여러 나라에서도 도입한 바있다). 선행 경험에 따르면 궁극적으로 어떤 지역에서 진료를 하게 되는가는 다양한 요인 – 학교의 위치, 입학 기준, 교육과정기간의 노출, 적절한 인센티브 – 이 있으며, 그리고 가장 중요하게는 졸업생의 가치, 헌신, 사회적 목표가 있다.

Schools can set the criteria for admission to match the national profi le of social, linguistic, and ethnic diversity and assess key values and personal characteristics, such as communication, interpersonal and collaborative skills, and professional interests.10 Affi rmative action programmes can be developed that could extend remedial support to secondary education to enlarge the eligible pool of under-represented students. One proposal would be to have rural communities, potentially with government support, select their own candidates to recommend for admission, pay for their education, and hire them after graduation. Financing is important, because tuition costs can present barriers to entry for poor people or costs can be so high as to force students to incur large debts.7,35 Another proposal is to locate educational institutions close to underserved communities to help with the recruitment of students and the retention of professionals from those areas,33 although attention should be paid to the challenge of assuring a critical mass of educational resources in these institutions. If entering students have only urban backgrounds, the likelihood of an eventual rural work placement is very low. Even so, graduating students can be required to spend a period of social service in a rural community—a requirement that was pioneered at the medical school of the National University of Mexico in 1936, and has been adopted by many countries. Schools that have built strong social criteria into the admissions and placement processes include Escuela Latino- Americana de Medicina (ELAM) in Cuba; University of Philippines School of Health Sciences in Leyte; and Northern Ontario School of Medicine in Canada.113,134 Experience shows that the ultimate service placement of graduates is shaped by multiple factors, including school location, criteria for admissions, curricular exposure, appropriate incentives, and, most crucially, the values, commitment, and social goals of the graduating student.33,135,136

궁극적으로 입학 기준은 기관의 목적과 연관되며 그것을 보여주는 지표이기도 하다. 순수하게 경쟁에 따라 능력위주로만 선발하는 정책은 가장 똑똑한 학생을 선발할 수도 있다. 농촌/인종/사회문화적 구성의 균형을 맞추고자 하는 접근은 건강 평등을 이루고자 하는 그 기관의 목적을 보여주는 것이기도 하다. 이 두 가지의 입학 목표가 서로 공존 불가능한 것은 아니다. 실제로 많은 기관에서 이러한 여러 목적을 조화시키고 있다. 리더십은 많은 형태와 다양한 목적으로 나타날 수 있다. 사회적 혜택을 받지 못한 배경을 가진 학생들이라도 우선 기회가 주어지면 경쟁에서 더 우월함을 보일 수도 있다.

Ultimately, the criteria for admission are linked to and are indicative of institutional purpose. A purely competitive merit-based admissions policy might seek to recruit the best and brightest for professional and academic leadership. Proactive recruitment to obtain balanced rural, ethnic, and sociocultural composition might express and indicate the institutional purpose of advancing health equity.33 These admission goals are not mutually incompatible. Indeed, many institutions attempt to harmonise allied purposes into a coherent admissions policy.7 Leadership can come in many forms and for diff erent purposes. Students from disadvantaged backgrounds can often excel in competitive assessments after they have been given the opportunity.113

역량 Competencies

교육과정은 그 전문직 집단의 전통/우선순위/가치를 보여주는 역사적 유물이기도 하다. 오랜 시간에 걸쳐서 교육과정은 거의 재검토되지 않아왔으며, 아주 천천히 새로운 정보에 따라서 변화되어왔을 뿐이다. 의과대학에서 교수가 가르치고 싶어하는 것에 따라서 목표를 바꾸고 그래서 목표에 따라 교육과정이 달라지는 것이 아니라 교육과정이 목표를 좌지우지하는 일은 그다지 드문 것도 아니다.

Curricula often become closely linked to historical legacy that codifies the traditions, priorities, and values of the faculty in that profession. Over time, the curriculum is rarely re-examined but is only slowly modifi ed to accommodate new information. Not uncommonly, schools change the objectives to meet what the faculty want to teach so that the curriculum drives the objectives, rather than the wished for learning objectives driving the curriculum (fi gure 9).

역량바탕접근법은 다음과 같은 접근.

specify the health problems to be addressed,
identify the requisite competencies required of graduates for health- system performance,
tailor the curriculum to achieve competencies, and
assess achievements and shortfalls.

A competency-based approach is a disciplined approach to specify the health problems to be addressed, identify the requisite competencies required of graduates for health- system performance, tailor the curriculum to achieve competencies, and assess achievements and shortfalls.

Epstein and Hundert는 “역량은 그 전문직이 담당하고 있는 개인이나 공동체를 위하여 의사소통/지식/기술/임상추론/감정/가치/성찰을 일상적 실천에서 습관적으로, 신중하게 사용하는 것이다.”라고 했다.

Epstein and Hundert137 have stated that: “Competency is the habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and refl ection in daily practice for the benefi t of the individual and the community being served”.

역량바탕 교육과정은 전통적, 획일적 교육과정이 아니라 고도로 개별화된 학습과정을 추구한다. 이상적으로는 학생들은 여러 시기별로 역량을 성취할 수 있도록 다양한 학습활동이나 학습방법 중에서 선택을 할 기회가 있어야 한다.

Competency-based education allows for a highly individualised learning process rather than the traditional, one-size-fi ts-all curriculum.138 Ideally, students would have an opportunity to explore a range of choices in learning activities and methods that could allow them to achieve competency in variable periods.10

어떤 시간이나 과목을 보호하는 것이 아니라 구체적 역량을 달성하는 것이 교육과 평가의 특징을 정의하는 것이어야 한다. 일단 교육자들이 전문직 역량에 집중하기 시작하면, 더 많은 상상을 펼쳐서 건강시스템을 디자인할 수 있다. 역할과 보상이 더 잘 일치될 수 있다. 전통적인 전문직간 경계가 허물어질 수 있다. 자격증만 있으면 특정 지위를 얻을 수 있었던 전통적인 방식이 위협받을 것이다.

Attainment of specifi c competencies, not time or academic turf protection, must be the defi ning feature of the education and evaluation of future health professionals. Once educators focus on professional competencies, new opportunities emerge for a more imaginative design of health systems. Roles and compensation can be better aligned. Traditional boundaries between professions can be reduced. The pervasive trend towards credential creep between professions—ie, the trend whereby the credentials required for a specifi c position are increasing—can be challenged.

IPE에 있어서, 건강은 팀워크를 필요로 하고, 건강시스템의 변혁에 따라서 그 중요도가 커지고 있다.

For interprofessional education, health needs team- work, and this necessity has grown in importance because of the transformation of health systems.

TBL은 학생들로 하여금 그룹 활동을 통해 효과적이고 협력적 학습을 준비하게끔 해주는 것이다. IPE는 둘 혹은 그 이상의 전문직 교육에 있는 학생들이 모여서 서로의 역할에 대해서 함께 배우는 것으로, 공통의 교육 의제에 대해 서로 상호작용하면서 배우는 것이다. TBL이 20년 이상 비-의학 세팅에서 성공적인 결과를 가져왔지만, 보건의료전문직 교육에는 비교적 최근에 도입되었다. 비록 그 개념은 단순하지만 IPE는 도입하기 쉽지 않다. 많은 수의 학생과 낮은 학생-대-교사 비율, 비좁은 학습시설 등은 많은 교수자들로 하여금 강의-기반 교수법을 사용하게 만든다.

Team-based learning is an instructional approach aimed at preparing students for eff ective, collaborative work within a cohesive group. Interprofessional education involves students of two or more professions learning together, especially about each other’s roles, by interacting with each other on a common educational agenda. Although team- based learning has been practised successfully for more than 20 years in non-medical settings, it has only been proposed recently as an instructional tool in health professional education.140 Although simple in concept, inter- professional education is diffi cult to implement. Large number of students, low teacher-to-student ratios, and cramped facilities drive many instructors to the lecture- based didactic method.40

그러나 현실에서 팀워크는 언제나 필요했고 언제나 그 자리에 있어왔다. 그리고 과연 팀워크가 인정받아왔으며, 장려되왔으며, 우선순위였는지에 대한 의문이 있다. 중요한 것은 팀 학습과 IPE는 교실에서만 이뤄질 수 있는 것이 아니라는 점이다. 연구 결과를 보면 보조적 장치 – 공동 세미나, 공동 교과목, 공동 봉사활동, 전문직간 생활-학습 숙소 등이 있을 때 그 효과가 더 크다. 나아가서 학부에서의 IPE는 사회와 과정에 통합되어야 하며, 졸업 전과 후에 모두 학습해야 하며, 학습연속체의 한 부분으로서 학습해야 한다.

In reality, however, teamwork has always been necessary and practised, and the question has been whether it is recognised, promoted, and prioritised. Importantly, team learning and interprofessional education cannot be confi ned only to the classroom. Reports suggest greater impact with ancillary modalities including shared seminars in which cross-profession dialogue, joint course work, joint professional volunteering, and interprofessional living-learning accommodations are promoted.7,8,10,11 Furthermore, interprofessional undergraduate education should be integrated into socialisation and learning before and after graduation, as part of a continuum of learning.

마지막으로, 비전문-보건의료인을 포함하는 Transprofessional teamwork, 이 건강-시스템에 더욱 중요하다. 특히 기초보건인력과 보조보건인력, 행정가, 관리자, 정책입안자, 지역사회 리더와 팀워크가 중요하다.

Finally, it should be recognised that transprofessional teamwork that includes non-professional health workers might be of even greater importance for health-system performance, especially the teamwork of professionals with basic and ancillary health workers, administrators and managers, policy makers, and leaders of the local community.

채널 Channels

좋은 전문직 양성 프로그램은 모든 학습채널을 동원하여 최대의 가능성에 도달하고자 해야 한다.

Good professional education programmes mobilise all learning channels to their full potential:

didactic faculty lectures,
small student learning groups,
team-based education,
early patient or population exposure,
diff erent worksite training bases,
longitudinal relationship with patients and communities, and
the use of IT.

인터넷의 폭발적 성장은 힘/속도/유용성을 가져다주었다. 이제는 많은 옵션이 가능해졌다.

Explosive growth of the internet has brought power, speed, and versatility to both approaches.49 The range of options available nowadays encompass

internet-supplemented courses that might include online lectures, use of email, and linkages to online resources;
internet-dependent courses that require students to use the resources of the web;
and full online courses with little classroom or direct human interaction.

불균등한 디지털 자원의 분포를 극복하기 위한 국제적 정책은 빈곤한 사회를 도와서 이미 개발된 국가들이 겪었던 이행기를 더 빠르게 가속하거나 건너뛰도록 하는 것이다.

A global policy to overcome such unequal distribution of digital resources would go a long way towards closing gaps by empowering the poorest communities to accelerate or skip stages that developed nations transitioned through more slowly in the past.

핸드폰은 핵심 학습도구로서 포터블 장치의 활용의 변혁을 예고한다.

Mobile phones promise to transform the use of portable devices as a central learning tool.

IT 역시 지리적 장애물을 줄여줌으로써 전통적 교육의 접근성을 확장시킨다.

IT is also expanding access to formaleducation by reducing geographical barriers.

모든 기술과 마찬가지로, 건설적 변화를 유도하는 것은 하드웨어나 소프트웨어 그 자체 아니며, '휴먼웨어'라고 불리는 기술이 가져올 기관 변화이다.

As with all technologies, the drivers of constructive change are not the hardware or software by themselves, but rather the institutional transformation that the technologies enable, including what has been called humanware (ie, human beings who operate hardware and software).

실제로 IT의 활용은 TfL의 동인으로서 가장 중요한 것이다. ICT의 혁신은 OCW와 같은 open education resources movement 이다.

Indeed, the use of IT might be the most important driver in transformative learning—one of the guiding notions for this report. A particularly promising aspect of the revolution in information and communication technologies is in the open education resources movement (panel 7), with its potential to expand global access to didactic materials.147

IT가 학습자와 교사의 관계를 바꾼 것처럼, 보건의료전문직과 그들이 담당해야 할 대상(개인이든 사회든)들간의 관계도 바꾸고 있다. 전문직이 할 수 있는 가장 중요한 기여는 지식의 원료가 아니라 세밀하게 조정된 판단과 의사결정이다. 따라서 발전된 ICT는 건강전문직의 효율적 교육에만 중요한 것이 아니며, 어떤 역량이 기대되는가에 대한 변화도 가져온다. 단순하게 말하자면, 21세기 의료전문직의 교육은 사실정보를 암기하고 전달하는 것에 초점을 두기보다는 추론기술과 의사소통 능력을 강화하는데 초점을 둬야 하며, 이를 통해서 효과적인 파트너, 촉진자, 조언자, 지원자가 될 수 있을 것이다.

Just as IT has changed the relationships between learners and teachers, so too is it rapidly transforming the relationships between health professionals and the people they serve—be it individual patients or entire communities. The professionals’ most important contribution is often fi nely-tuned judgment and decision- making skills rather than knowledge gradients. Thus, advanced information technology is important not only for more effi cient education of health professionals; its existence also demands a change in expected competencies. Put simply, the education of health professionals in the 21st century must focus less on memorising and transmitting facts and more on promotion of the reasoning and communication skills that will enable the professional to be an eff ective partner, facilitator, adviser, and advocate.

커리어 Career pathways

그러나 모든 전문직은 긍정적인 것과 부정적인 것이 있다.

But all professions, medical or otherwise, have positive and negative attributes.

Freidson은 그의 고전 저술에서 '전문직'이란 단어의 두 가지 의미에 대해서 서술했다. "직업의 특정 종류" 그리고 "공언과 약속"이다. 그 약속을 지키기 위해서 프로페셔널리즘은 "신뢰의 기반을 이루는 일련의 가치, 행동, 관계"이다. 전문직 교육은 따라서 책임감 있는 프로페셔널리즘을 함양하도록 되어야 하며, 이는 지식과 기술만으로 길러지지 않고, 정체성을 함양하고 전문직의 가치/헌신/지향을 받아들임으로써 이뤄진다. 전문직 행동/정체성/가치의 기본적 특성을 발달시키는 것은 적절한 롤모델, 팀 상호작용, 코칭, 지도, 평가, 피드백을 통해서 보다 쉽게 달성할 수 있다. 이에 맞추어 '잠재 교육과정'을 정렬시키는 것도 포함되어야 하는데, 그래야 학습환경이 전문직의 레토릭과 기술된 가치와 일관될 수 있는 것이다.

In his classical work, Freidson149 explained the two meanings of the word profession as: “a special kind of occupation” and as “an avowal or promise”. To fulfi l such a promise, professionalism “signifi es a set of values, behaviors, and relationships that underpin the trust” of the public.43 Professional education, therefore, must inculcate responsible professionalism, not only through explicit knowledge and skills, but also by promotion of an identity, and adoption of the values, commitments, and disposition of the profession.10 Development of the fundamental attributes of professional behaviour, identity, and values is eased by appropriate role models, team interactions, coaching, instruction, assessment, and feedback. Included in this process is aligning the so-called hidden curriculum, so that the learning environment is made consistent with professional rhetoric and stated values.

"전문직은 상반되는 두 가지 충동을 지닌다. 한 편으로는 민주적 사회와 자유시장경제를 향한 움직임으로서, 프로페셔널리즘은 능력이 있는 자에게 자리(career)를 약속한다. 그 반대로 전문직은 독점적이다." 건강근로자들은 이러한 프로페셔널리즘의 양면을 모두 이해해야 한다. 진입에 대한 인공적 장벽을 세우고, 특권을 보호하고, 자격증을 통해서 독점적 지위를 확보하는 배제적 힘이 아니라, 21세기의 전문직은 질을 향상시키고, 팀워크를 포용하고, 윤리를 강하게 지지하고, 환잦와 인구의 이익을 중심으로 움직여야 한다.

“Professionalism was born of contradictory impulses. On the one hand, it belongs to the movement toward a democratic society and a free market economy. Professionalism promises to open careers to talent… On the other hand, professions are monopolistic…”.150 Health workers should understand the positive and negative sides of professionalism. Far from being an exclusionary force that raises artifi cial barriers to entry, protects privileges, and promotes practice monopolies through credential creep,151 a new professionalism for the 21st century should promote quality, embrace teamwork, uphold a strong service ethic, and be centred around the interests of patients and populations.

Agency란 개개인이 특정한 사회적 맥락 속에서 의도적인 행동을 수행할 능력을 말한다. 포괄적인 교육 디자인은 전문직이 되어가는 중에 있는 학생들이 지위/권위/능력을 갖춘 변화의 에이전트로서 사회 변화를 촉진할 수 있어야 한다. 졸업생들이 어떻게 이 능력을 발휘할 것인가는 개개인에게 달린 것이다. 모든 졸업생이 사회 개혁가가 되어야 할 필요는 없지만, 전문직의 사회적 agency로서의 기능을 인위적으로 막아서도 안 될 것이다.
Agency refers to the capacity of individuals to undertake purposeful action in a specifi c social context. A comprehensive instructional design should include eff orts to endow professional students as change agents with the status, authority, and ability to promote enlightened transformation in society. How the graduate exercises this capacity is an individual prerogative. Not every professional graduate needs to be a social reformer, but artifi cial barriers should not be constructed to block the social agency of professionals.

보건전문직의 또 다른 도전과제는 도시쏠림 현상으로, 많은 사람들이 격오지나 취약집단을 대상으로 근무하고자 하지 않는 것이다. 많은 혁신적 수련 프로그램은 이 불균형을 해소하고자 설계되었다. 1943년 인도의 Bhore report는 모든 의과대학이 community or social health 관련 과를 갖추도록 의무화하고 있다 등등.

One of the main challenges of the health professions is their urban bias and thus the reluctance of many of their members to work in remote rural areas among underprivileged populations.32,153 Many innovative training programmes have been designed to address this imbalance.

The 1943 Bhore report in India154 mandated that every medical school should have a department of community or social health, including compulsory coverage of three adjacent rural districts.
The Chinese barefoot doctors movement attempted to ensure access of remote rural populations to a skilled health worker.155 This exercise of social agency represents the best of socially responsible professionalism, and signifi es good citizenship, nationally and globally.

또 다른 사례는 건강과 인권이다. 건강권에 대한 UN의 첫 번째 특별 보고서는 교육과 관련한 중요성을 언급한다. "많은 건강전문직의 참여 없이 건강권을 작동시킬 가능성은 없다. 그러나 이것은 중요한 문제이다. 대부분의 건강전문직은 '건강권'이란 것에 대해서 들어 본 적도 없다. 만약 그들이 이에 대해 들어본 적이라도 있다 하더라도 무엇을 의미하는지 개념적이든 현실적이든 생각해 본 적이 없다. 건강권을 작동시키기 위해서 많은 진보가 필요하며 많은 건강전문직은 그들의 하는 일의 인권적 측면을 알아야 한다"

Another case is health and human rights. The fi rst UN Special Rapporteur on the right to health under- scored the present problem with medical education: “[T] here is no chance of operationalizing the right to health without the active engagement of many health professionals. Here, however, is a very major problem. To be blunt, most health professionals whom the Special Rapporteur meets have not even heard of the right to health. If they have heard of it, they usually have no idea what it means, either conceptually or operationally…. [I]f further progress is to be made towards the operationalization of the right to health, many more health professionals must begin to appreciate the human rights dimensions of their work.”156

Panel 7.

Information technology and open education

Advanced communication and information technology (IT) has assumed an increasingly central role in postsecondary education by revolutionising access, compilation, and flow of information and knowledge. Many innovations have been pioneered—downloading information, simulation learning, interactive teaching, distance learning, and measurement and testing.

OpenCourseWare (OCW) was first proposed by the Massachusetts Institute of Technology in 2001 and was defined as “free and open digital publication of high quality educational materials, organized as courses”.¹⁴³ OCW has enabled many universities to share online their syllabi, lectures, assignments, and examinations free for others to download, modify, and use. By 2009, OCW had more than 200 member universities, with more than 6200 courses freely online attracting more than 2 million visits per month. Members include leading universities in the USA, China, Japan, Spain, Latin America, Korea, Turkey, and Vietnam, and regional networks adapted to local languages have been built in Latin America, China, and Japan.¹⁴⁴ Johns Hopkins University Bloomberg School of Public Health started its OCW project in 2005, and is now offering 60 graduate courses online with an average of 40 000 visits per month.¹⁴⁵ Tufts University now offers more than half its medical courses online.¹⁴⁶

OCW is part of a broader movement for open-education resources that advocates “digitized materials offered freely and openly for educators, students and self-learners to use and reuse for teaching, learning and research”.¹³⁵ OCW has the potential to transform health professional education through provision of free and open access to all interested learners worldwide, including developing countries that are severely limited by educational resources. OCW can also promote content quality through sharing of materials for feedback and continuous improvement. In addition to organised movements, there are many grassroots efforts—eg, Connexions as open source textbooks and SuperCourse as an open-source library of lectures on global public health. Not surprisingly these non-for-profit movements face similar challenges—how to integrate the human face of learning with technology, adaptation to diverse contexts, intellectual property rights, reluctance over sharing, and financial sustainability.

글로벌 건강과 지역 건강

Global and local health

1910년의 플렉스너 보고서가 그 지역 내의 문제에 집중한 것은 사실이지만, 그는 그의 연구가 세계적 차원에서 갖는 함의를 이해하고 있었다. "이 연구가 미국과 캐나다에 존재하는 문제를 해결하기 위해서 수행된 것은 사실이나, 전 세계적 의과학의 발전이라는 관점에서 서술되었다" 라고 했다. 플렉스너는 핵심 유럽국가의 의학교육에 관한 1912년 보고서를 통해서 글로벌 비전을 추구하고자 했는데, 이는 기초과학과 임상과학을 연결시키는 소위 '의과대학의 플렉스너모델'이라는 형태로 전세계적으로 의과대학들이 따라하기 시작하는 계기가 되었다."

Although in his 1910 report Flexner concentrated on one region, he recognised the worldwide basis and implications of his study, noting “While the work was undertaken in the desire to improve the conditions that now exist in the United States and in Canada, it has been written from the standpoint of the advancement of medical science throughout the world”.63 Flexner proceeded to pursue this global vision through his 1912 report on medical education in key countries of Europe, sparking a cascade in many medical schools worldwide that followed a so-called Flexner model of university-based professional education linking basic and clinical sciences.63

그러나 현재의 맥락은 100년전과 크게 다르다. 다양성 수준은 전혀 다르며, 전 세계적 상호의존성의 속도, 크기, 강도는 수많은 새로운 위험을 가져오고 있으며, 많은 기회를 만들어내고 있기도 하다. 국제적 불평등의 정도를 생각해보자. 국가 수입에 있어서 가장 부유한 국가와 가장 가난한 국가는 100배의 차이가 있는데, 한 사람당 건강 관련 지출을 비교하면 1000배가 차이난다.

But context nowadays diff ers substantially from that of a century ago. The richness of diversity is not entirely new, but the pace, scale, and intensity of global interdependence have brought about many new risks and opened many new opportunities. Consider the extent of global inequality. In national income, the world’s richest and poorest countries show a 100-times diff erence, but in per head health-care expenditures the gap between the richest and poorest nations is 1000-times.

건강과 교육시스템의 엄청난 다양성이 있을 때, 이뤄야 할 것은 다른 맥락에서 만들어진 관련성이 떨어지는 모델을 도입하는 것이 아니라 지역적 효과성을 달성하기 위한 역량바탕 목표를 도입하는 것이다.

In view of the huge diversity of health and educational systems, the challenge is to adapt competency-based goals for local eff ectiveness rather than to adopt models from other contexts that might not be relevant.

높은 수준의 국제적 기준을 맞추는 것이 중요하나, 모든 기준을 도입하면 결국 부적절한 역량, 비효율적 투자, 국제 이주로 인한 졸업생 손실의 결과만 불러올 뿐이다.

Although seeking prestige and achievement of high global standards are important, the consequences of wholesale adoption are inappropriate competencies, ineffi cient investments in professional education, and the loss of graduates from the country because of international migration.

역량바탕 접근법에서, 전문직이 갖추어야 할 것은 그가 위치한 환경을 아는 것이다. 수행할 역할과 달성해야 할 역량은 해결해야 하는 문제, 가능한 자원, 사용가능한 진단/치료 기구를 반영해야 한다.

In a competence-based approach, the obligatory attributes of a professional have to indicate the context in which she or he operates. The roles to be undertaken and competencies to be attained have to refl ect the challenges to be addressed, the available resources, and the diagnostic and therapeutic instruments at the professional’s disposal.157

역설적으로, 글로벌헬스에 대한 필요를 강조하는 것에 일부는 지역적 적응의 필요 때문이다.

Paradoxically, the imperatives for global health are driven partly by the necessity for local adaptation.

많은 지역의 문제는 국제적 사건의 결과로 따라오는 것이다. 따라서 국제적 관점은 지역 문제의 원인과 해결책을 이해하는데 도움이 된다. 국제적 다양성을 이해하는 것은 상호학습을 통해서 지역에서의 적응력을 길러준다. 가장 중요한 것은, 젊은 사람들이 스스로를 글로벌 시티즌으로서, 글로벌 건강전문직으로 인식하는 것이다.

Many apparently local problems are generated or have consequences globally. Thus, a global perspective improves understanding of the causes and solutions to local problems. Understanding of global diversity improves local adaptive capacity because of mutual learning. Most importantly, young people see themselves as global health professionals and indeed as global citizens;

전문직은 지식과 관련된 글로벌 공공재를 지역의 현실에 맞게 필요한 것으로 전환시키는 human-link 를 제공한다. 이 핵심적 역할은 모든 국가가 이 근본적인 질문에 답해야 할 필요성을 강조한다. 한 국가는 어떤 종류의 건강전문직을 양성하는, 얼만큼의 수의 기관을 보유해야 하는가? 노동시장에 유입되는 전문직 학교의 졸업생이 궁극적으로 한 나라의 skill mix를 구성한다. skill mix는 한 건강시스템 내에 존재하는 건강근로자의 패턴을 보여주며, 예컨대 간호사-의사 비율과 같은 것이다. 개발도상국에서는 skill mix는 다수의 기초/보조 보건인력을 필요로 하는데, 이것이 전문직 교육에 가지는 함의가 중요하다.

Professionals off er the human link for translation of knowledge-related global public goods to the require-ments of local realities. This crucial role makes it imperative for all countries to answer a fundamental question: how many institutions producing which type of health professionals should a country aspire to have? Professional schools produce graduates who enter a labour market ultimately contributing to a particular skill mix in a country. Skill mix describes the pattern of health workers in the health system, such as the ratio of doctorsto nurses. In developing countries, the skill mix by necessity depends on many basic and ancillary health workers; this reality has important implications for professional education

가장 희소한 자원을 양성하는 많은 개발도상국의 전략은 기초/보조 보건인력의 확장을 가져왔다. 여러 근거로부터 이러한 인력들이 그 인구집단의 건강을 향상시키기 위한 노력에 큰 도움이 되며, 특히 동기부여가 된, 유능한 건강전문직이 크게 부족한 상황에서 그러하다.

Making the most of scarce resources has led many developing countries to undertake expansion of their workforce through the training of basic and ancillary health workers. Ample evidence shows that such workers can add substantially to the eff orts of improving the health of the population, especially in settings with the highest shortage of motivated and capable health professionals.42,158

MDG의 성취를 가속하기 위해서 많은 Donor들은 기초보건인력의 대량양성에 투자하고 있다. 이러한 노력에서 많은 개발도상국은 상당한 창의성과 상상력을 보여주고 있으며, 국제적으로도 교훈을 준다.

To accelerate achievement of the MDGs, many donors have invested in the massive training of basic health workers.20 In these endeavours, many developing countries have displayed great creativity and imagination, with global lessons for all (panel 8).

이러한 문제의 압박 속에서 전문직 교육은 많은 국가에서 간과되고 있다. 이러한 현상이 전문직 교육이 비용, 시간이 많이 들고 그 지역의 질병부담에 잘 조율되지 않을 수있기 때문에 이해되지 않는 바는 아니다. 프로페셔널리즘의 부정적 측면이 전문직 교육으로부터 관심을 멀어지게 하는 이유기도 하다. 가장 문제가 되는 것은 국제 이주를 통해서 빈곤국가의 역량을 떨어뜨리는 의사와 간호사들이다. 이러한 유형의 손실은 가나의 사례로부터 보여진 바 있다.

Under the pressure of these priorities, professional education has been overlooked in many countries. The neglect is to some extent understandable in view of the fact that professional education is expensive, time- consuming, and often not entirely attuned to the local disease burden. The negative aspects of professionalism have also diverted attention away from professional education. Especially troubling has been comparable credentials of doctors and nurses that has accelerated international migration with the loss of talent from poor countries. The scale of this type of loss is shown by the case of Ghana, where 61% of the 489 physicians graduating between 1985 and 1994, had migrated from the country by 1997.167

그러나 기초보건인력의 장기적 지속가능성은 전문직집단과의 적절한 균형, 그리고 강력한 협력적 고리에 크게 영향을 받는다는 것이 여러 근거로부터 보여진 바 있다. 많은 지역사회 의료인력이 실패한 이유는 전문직을 workforce mix에 성공적으로 포함시키지 못했기 때문이다. 전문직은 변함없이 리더, 플래너, 정책개발자의 역할을 한다. 도한 지역사회인력의 수련에 있어서 중요한 자원이기도 하다. "근거를 보면, 이들 지역사회근로자 프로그램은 더 큰 건강시스템 내에 통합되었을 때 가장 효과적이며, 더 잘 수련된 건강근로자에게 refer할 수 있으며, 단기재교육과 같이 이후 수련과 감독 기회를 제공받을 수도 있다"

Yet abundant evidence shows that the eff ectiveness and long-term sustainability of basic health workers depend critically on an appropriate balance and strong collaborative linkages with professional cadres.168 Many community health worker programmes have failed because they did not successfully incorporate professionals into the workforce mix.24,42,158 Professionals invariably are the leaders, planners, and policy makers of health systems. They are also an invaluable resource for the training of community workers. “(Evidence) shows that these community worker programmes are most eff ective where they are integrated into the wider health system, they can refer on to more trained health workers, and they have the opportunity for refresher or further training and supervision.”169

그러나 전문직이 지역사회 의료인력과 건설적으로 협력하기 위해서는 어떤 역량을 갖추어야 하는가? 기초근로자들을 통해서 커버리지를 확장시키는 동안, 우리는 중등교육 후 교육을 통해서만이 복잡한 추론, 불확실성에 대한 대응, 다가올 변화에 대한 준비와 대응 등 건강시스템의 퍼포먼스와 지속가능성에 필수적인 여러 기능이 가능하다고 본다. 비록 리더십은 모든 수준에서 등장할 수 있지만, 건강분야에서 가장 성공적인 리더는 중등교육 후 교육을 받은 전문직이다.

But what types of competencies should professionals acquire for constructive collaboration with community health workers? In expansion of coverage through basic workers, we should recognise that only postsecondary education can endow professionals to perform complex reasoning, deal with uncertainty, anticipate and plan impending changes, and undertake many other functions that are essential for health-system performance and sustainability. Although leadership can emerge from all levels, almost all the most successful leaders of the health sector are professionals with postsecondary education.

이러한 역량이 필요함.

Complementary requisite skills for these professionals should include key health-system functions such as planning, policy, and management. Especially useful is national leadership to manage the increasingly complex relationship with international agencies and donors. Equally important is the competency to train and supervise basic workers through collaborative and respectful relationships.

Panel 8.

Professionals in community health-worker systems

Sparked by bare foot doctors in China and the more formal Behvarz primary care health workers in Iran, there have been many efforts to develop community health workers (CHW) to strengthen the formal health sector in service delivery and health promotion. Much evidence shows the benefit of CHW-based programmes for delivery of a range of services in low-income and middle-income countries. ^42 and 159 Medical and nursing professionals have played a key part in rolling out and supporting such strategies, although such partnerships are poorly documented. In a systematic review of the experience of CHW programmes addressing the Millennium Development Goals, 326 reports were identified of which only 21 (6%) had documented supervision and monitoring by trained physicians and nurses; of the reports that documented monitoring and evaluation, 21 (30%) had medical professionals in this role. ⁴²

Some of these programmes have been implemented at large scale, such as the Lady Health Workers programme in Pakistan, reaching more than three-quarters of its rural population. Such CHW programmes have spanned a range of services and training programmes and have focused mainly on low-cost, equitable, and easily accessible health care. Generally, such programmes have served to overcome gaps and crucial shortages in human resources for health and have served as an important bridge between communities and health services.

CHW programmes in some countries with weak formal health systems—eg, Pakistan's Lady's Health Worker programme, Ethiopia's health extension programme, Mozambique's agentes polivalentes elementares programme, and Haiti's health agents/accompagnateurs—are challenged by their roles in gap filling, which require strengthening linkages and support.⁴² In other countries with strong formal systems—eg, Thailand's village health volunteers programme, Brazil's family health programme, Bangladesh's BRAC shastho shebika programme, and Uganda's village health teams—the linkages of supervision, referral, and support are fairly well developed. ⁴²

The shortage of surgeons and anaesthetists in fragile health systems can be overcome by training appropriate paraprofessionals.¹⁶⁰ There are many case of such success, but the ambitions are to greatly expand cost-effective interventions to save lives. In all contexts for primary care and surgical services, medical, surgical, and nursing-midwifery professionals have and will continue to play a crucial part in programme success.^42 and 147

Transprofessional education 는 IPE만큼 중요하다. SSA국가의 skill mix의 예시는 비-전문직 건강팀과 함께 일할 수 있는 것을 배우는 것이 얼마나 중요한지 강조한다. 따라서, 핵심 역량은 다수의 기초/보조 보건인력으로 구성된 팀과 일하는 능력이다.

Transprofessional education might be as important as interprofessional education. An examination of the skill mix in selected countries of sub-Saharan African underscores the importance of professionals learning to work with non-professionals in health teams. Thus, a key professional competency is the ability to work with teams consisting largely of basic and ancillary health workers and supportive staff .

빈곤 국가의 기초 수련과 더불어 부유한 국가의 의학교육의 확장이 최근에 있다. 수십년간의 정체기를 거쳐, 다수의 미국 의과대학은 점차 늘어나는 요구에 대응하고자 한다. 글로벌 관점을 통합하기 위한 한 가지 혁신은 교육과정의 개편이다. 문화간 민감성을 가진 전문직의 양성은 점차 다양해지는 환자군을 대하는데 중요하다.

Parallel to the expansion of basic training in poor countries is the recent movement towards expansion of medical education in rich countries. After decades of stability, the number of medical schools in the USA, for example, will grow to meet increasing demand.7 One of these innovations is the integration of global perspectives in the revitalised curriculum. Education of professionals with intercultural sensitivities is important for increasingly diverse patient populations.

글로벌헬스 과목은 다른 새로운 과목과 마찬가지로 여러 도전을 맞는다. 즉, 이미 꽉 찬 교육과정에 가용 공간과 시간을 찾아내야 한다. 글로벌 헬스에 관한 독립적 과목과 수련 세션을 갖는 것도 중요하지만, 모든 과목과 실습에 글로벌 관점을 통함시키는 것이 더욱 중요하다.

Courses in global health face the same challenge as do all other new fi elds—ie, fi nding the space and time to be added to an over-packed curriculum. Although having distinctive courses and training sessions in global health is important, the integration of a global perspective into all courses and exercises is even more important.

새로운 분야이기에 정의, 내용, 전략이 충분히 안정되지 않았다. 어떤 사람들은 respective prefession에 한 차원을 더한 것으로 보며, 다른 사람은 국제적 관점에서 수행되는 공공보건과 동등하다고 본다. 핵심 원리에 대한 컨센서스가 점차 발전하고 있는데, universalism, global perspectives in discovery and translation, inclusion of broad determinants of health, interdisciplinary approaches, and comprehensive framework 등이다.

As a young fi eld, the defi nition, content, and strategies of global health have by no means been fully settled. Some see global health as an added dimension to their respective professions. Others see it as equivalent to public health studied and practised from a worldwide perspective.170 Consensus is growing about its key tenets—universalism, global perspectives in discovery and translation, inclusion of broad determinants of health, interdisciplinary approaches, and comprehensive framework.

전문직교육에서의 국제화에 있어 다섯 가지 특징이 있다.

Five features stand out in the globalisation of professional education.

첫째는, 점차 우리가 글로벌하게 하나의 건강전문직 역량을 가지게 되어가고 있다는 인식이다.

First is the realisation that we increasingly have one global pool of health professional talent.

WHA는 최근 전문직의 국제 이주와 관련한 윤리강령을 승인하였다. 많은 부유한 국가들은 해외에서 간호사와 의사를 수입하여 만성적 인력 부족을 해결하려고 하며, 이 수는 더욱 늘어나고 있다. 약 미국, 캐나다, 서유럽의 대부분 국가에서 약 1/4의 의사는 해외 출신이다.

The World Health Assembly recently approved a code of conduct for the international migration of professionals.118 In many wealthy countries, the import of foreign doctors and nurses to meet chronic shortages is likely to persist and could even increase.171–174 About a quarter of physicians in the USA, Canada, and most countries of western Europe are trained overseas.171,173

두 번째는, 컨텍스트가 서로 매우 다름에도 일차의료에 대한 열망과 도전이 세계적으로 있다는 것이다.

Second is the universal aspiration and challenges of primary health care in very diff erent contexts.

각 국가는 자신의 개발 상태에 따라 일차의료를 다른 관점에서 보곤 했다. 부유한 국가에서는 주로 의료취약 지역사회에 전문의사, 간호인력에 대한 접근성을 확보하는 것이다. 빈곤 국가에서 일차의료는 기초 서비스를 제공하는 비-전문직 인력을 포함한다. 빈곤 국가든 부규 국가든 일차의료는 전문직교육이 엄청나게 다른 상황들에 적응할 수 있는 역량을 키워주는 연속체와 같다. 일차의료 이슈는 수요와 공급 모두가 문제이다. 일차의료전문직을 양성하는 것은 그렇게 수련받은 전문직이 직업을 가질 수 있게 건강시스템이 만들어줘야만이 효과적이다. 공급만 염두에 둔 접근으로는 유용할 수는 있어도, 강력한 일차의료 시스템을 만들지 못한다. 예를 들어 일차의료 의사들은 일본에 매우 풍부한데, 왜냐하면 보상 시스템이 병원 전문직보다 일차의료에 보다 많은 보상을 하기 때문이다. 실제로 일본의 의사들의 진로 방향을 보면 초기에 병원 전문의로부터 시작해서 보다 수익성이 좋은 일차의료 진료로 나아간다.

Primary health care has often been seen from diff erent perspectives according to the state of development of each country. In rich countries, primary care focuses on ensuring accessibility of professional doctors, nurse practitioners, and others to all people, especially those in disadvantaged communities. In poor countries, primary care often includes non-professional workers providing basic services. In both rich and poor countries, primary care constitutes a continuum, requiring adaptation of professional educational to substantially diff erent contexts. Issues of primary care include both demand and supply challenges. Training primary care professionals can only be eff ective if the health system generates an eff ective demand that attracts such trained professionals to rewarding jobs. A supply approach alone, although useful, cannot generate a strong primary care system. For example, primary care physicians are abundant in Japan because the reimbursement system rewards primary practice more than it does hospital-based specialisation. Indeed, a typical Japanese career pro-gression is initial hospital specialisation followed by more lucrative private primary care practice.176

세 번째는, 모든 건강관련 문제의 상호의존성이 커지면서 전문직 교육에 대한 함의도 높아져 가고 있는 것이다.

A third implication for professional education is underscored by our growing interdependence in all health matters.

오랫동안 오래동안 저소득, 중소득 국가의 부유한 사람들은 양질의 의료를 찾아 비용이 들더라도 부유한 국가를 찾아왔다. 최근 많은 환자들은 해외로 낮은 비용의 양질의 진료를 찾아서 나가며, 이는 의료관광이라 불린다. 치과 진료, 미용 외과, 첨단 외과 기술 등이 낮은 비용의 양질 진료가 되곤 한다. 어떤 국가의 병원들은 외국에서 오는 환자를 두고 경쟁을 한다. 환자를 보내는 국가에서는 전문직은 본국에서 어떻게 이러한 의료관광객의 지속적 관리를 제공할지를 고민해야 한다. 전문직간 서비스의 교환 경쟁은 매우 치열해질 것이며, 이는 서로 다른 국가에서 비슷한 의료기술을 제공할 때 그 비용이 매우 다른 경우에 더 극심할 것이다.

Long accepted in the most advanced medical centres in rich countries is the arrival of wealthy patients from low-income and middle- income countries seeking high quality, albeit expensive, medical care. Nowadays, many patients are travelling overseas for low-cost quality care in what has been called medical tourism. Low-cost services of particular attraction are dentistry, cosmetic surgery, and increasingly advanced medical and surgical procedures.177,178 Facilities in some servicing countries are seeking to compete for foreign patients who have long waits for treatment or high costs.177,179 In the sending countries, professionals will have to understand how to provide continuous manage- ment of such medical tourists at their home base. This trade in services will intensify competition between professionals of diff erent countries that have similar skills but operate with very diff erent cost structures.

네 번째는, 흐름은 선진국의 교육기관이 해외로 진출하여 개발도상국에 캠퍼스를 건립하기 시작한 것이다.

The fourth aspect in the globalisation of professional education is the movement abroad of schools in developed countries to establish affiliated campuses in emerging economies.

브랜드네임을 수출하는 여러 변형이 있다. 고소득국가의 일부 의과대학은 해외에 독립 branch를 두고 있다.

Many variants of this export ofbrand-name professional schools are underway Some medical schools from high-income countries now have independent branches overseas, and others have stationed faculties in diff erent countries worldwide.

마지막으로, 글로벌헬스는 전문직 교육에서 빠르게 확장되고 있다.

Finally, global health as a fi eld is expanding rapidly in professional education.

글로벌 헬스와 관련된 센터, 기관, 유닛, 프로그램 등이 전세계적으로 많이 생기고 있다.

Centres, institutes, units, and programmes in global health are being established worldwide;

the University of Cape Town in South Africa,
the Peking University Health Sciences Center in China,
and the National Institute of Public Health in Mexico are some notable examples in developing countries.
In the USA, a global health educational consortium was established in 1991, with more than 90 schools as members in the USA, Canada, Latin America, and the Caribbean.
In 2008, several major US schools established a Consortium of Universities for Global Health that now includes more than 60 universities.180

빈곤 국가나 부유한 국가의 전문직 교육 전략은 지역적 문제에 최적화하면서 지식과 자원의 transnational flow를 최대한 이용하는 것이다. 빈곤 국가는 비록 경제적으로는 제약이 있지만, 그러한 목적을 달성하기 위한 저비용 해결책을 모색하고 있으며, 전문직에 대한 자격증에 대해서 덜 제약을 받는다. 그들의 혁신은 모든 국가에게 교훈이 되곤 한다. 부유한 국가는 국제적 관점을 졸업생의 핵심 역량으로 통합시키고 있다. 외국에서 수련받은 의사의 지속적인, 진료-중 교육은 국가 내 교육의 중요한 부분이 되고 있다. 마지막으로 우리는 부유한, 빈곤한 국가의 많은 젊은 전문직이 해외에서의 진료를 할 방안을 모색하고 있음을 인식해야 한다. 단기의 방문객은 짐이 되겠지만, Global Health Corps를 통해서 적절히 조직된다면 많은 젊은 전문직이 빈곤국가가 필요로 하는 가장 중요한 자산을 제공할 수도 있다. 적극적인 학생 교환이 공감과 상호의존적이면서도 극도로 불평등한 세계가 지극히 원하는 유대감을 강화시킬 수도 있다.

The strategy for professional education in poor and rich countries is to optimise local problem solving while harnessing the benefi ts of transnational fl ows of knowledge and resources. Poor countries, although economically constrained, are compelled to search for low-cost solutions to achieve aims, and are less constrained by professional credentialling. Their innovations provide learning opportunities to all countries. Rich countries are integrating global perspectives into the core competencies of their graduates. The continuing and in-service education of foreign-trained professionals should be regarded as important as domestic education. Finally, we should recognise that many young professionals in both poor and rich countries are keen to off er their services overseas. Short-term visitors can be a burden, but, if action is properly organised in a Global Health Corps (a programme for sending young professionals for service abroad), many young professionals can join in development eff orts or provide one of the most precious assets that poor communities require—ie, professional teachers to assist in the education of both professionals and basic health workers.130 Active student exchange can strengthen the bonds of empathy and solidarity that an interdependent but highly inequitable world so greatly needs.

두 번째 100년을 위한 개혁

Section 3: reforms for a second century

건강은 사람에 대한 것이다. 전문직 교육을 이끌어나가는 핵심 목적은 건강시스템의 퍼포먼스를 강화하여 더 평등하고 효율적 방식으로 환자와 인구집단의 요구를 충족시키는 것이다. Commission은 기관과 교육의 문제가 이러한 부족/불균형/불균등분포를 악화시키고 있다고 결론내렸다. 기관은 질병부담이나 건강시스템의 요구에 따라 맞춰져 있지 않다. 양적 부족은 영리를 추구하는 의과대학을 만들어내고 있으며, 이 때문에 인증과 자격증명 절차가 전 세계적으로 불균등하게 시행되고 있다. 전문직 교육에 대한 재정 지원은 고도의 능력과 노동집약적인 산업의 특성을 고려하면 미미한 수준이다. 더 문제는, 교육 혁신을 위한 연구와 개발이 불충분하여 교육의 지식기반을 만들기에 불충분하다는 것이다. 대부분의 기관은 충분히 바깥을 내다보지 못하고 네트워킹과 연결성이 상호-강화적 힘이 있다는 것을 간과하고 있다. 이러한 문제는 일차의료에서 특히 두드러지는데, 빈곤국과 부유국을 가리지 않는다. 그러나 기회는 나타나고 있다. 교육 디자인은 제3세대 개혁에 임박해있고, 새로운 교육 도구를 통해 팀워크 역량을 강화하여 건강시스템의 퍼포먼스를 강화시킬 수 있다. 교육 개혁과 기관 개혁의 핵심에는 변화하는 지역 맥락에 적응하면서 정보/지식/자원의 transnational flow의 힘을 활용하는 것에 있다.

Health is about people; thus, the core driving purpose of professional education must be to enhance the performance of health systems for meeting the needs of patients and populations in an equitable and effi cient manner. Our Commission concluded that institutional and instructional shortcomings are leading to shortages, imbalances, and maldistribution of health professionals, both within and across countries. Institutions are not well aligned with burdens of disease or the requirements of health systems. Quantitative defi ciencies are driving the growth of for-profi t proprietary schools, thereby challenging accreditation and certifi cation processes that are unevenly practised worldwide. Financing for professional education is very feeble in a talent-driven and labour-intensive industry. To make matters worse, investment in research and development for educational innovations is insuffi cient to build a sound knowledge base for education. Most institutions are not suffi ciently outward looking to exploit the power of networking and connectivity for mutual strengthening. The breakdown is especially noteworthy for primary care, in both poor and rich countries. But opportunities are emerging. Instructional design might be at the threshold of a third generation of reforms that could enhance the performance of health systems through specifying competencies for teamwork empowered by new pedagogic instruments. Central to both institutional and instructional reform is adaptability to address changing local contexts while harnessing the power of transnational fl ows of information, knowledge, and resources.

빈곤한 국가에서 가장 큰 과제는 미해결된 과제를 해결하여, 건강 성취의 수용 불가능한 격차를 극복하는 것이다. 여기에 필수적인 요소는 모든 사람들에게 도달 할 수 있는 인력팀을 만들기 위한 지역과 국가의 리더십 전문직 교육에 수용하는 것이다. 부유한 국가에서의 과제는 건강전문직이 현재의 문제를 해결하면서 앞으로 등장할 문제를 대비하는 것이다. 그러나 해결되지 못한 과제를 넘어서, 가난한 국가는 먼저 새롭게 등장하는 위협과 싸워야 하며, 그리고 이에 더해서 부유한 국가는 건강에 대한 내부적 불평등과 싸워야 한다. 빈곤 국가와 부유한 국가가 마주한 과제는 글로벌 연속체의 일부분이며, 이 연속체의 특징은 사회적 화합을 위협하는 불평등과 공동-학습의 기회를 창조하는 다양성에 있다.

For poor countries, the most pressing challenge is to tackle an unfi nished agenda, so that the unacceptable gaps in health achievement can be overcome. A crucial factor in this endeavour will be the successful adaptation of professional education for local and national leadership in workforce teams that are capable of extending reach to all people. For rich countries, the challenge is to equip health professionals with competencies to tackle current problems while anticipating emerging problems. But beyond the unfi nished agenda, poor countries must also grapple with newly emerging threats, and in addition to emerging problems, rich countries must also struggle with persisting internal inequalities in health. Challenges facing poor and rich countries are parts of a global continuum marked both by inequality that threatens social cohesion and by diversity that creates opportunity for shared learning.

비전

Vision

극도로 상호의존적인 건강시스템에서 모든 사람과 국가는 하나로 묶여 있으며, 전문직교육의 과제는 이 상호의존성을 반영하는 것이다. 모든 국가는 자신의 전문직 인력 양성을 통해 지역의 문제를 해결해야 하면서 , 동시에 많은 건강인력은 공동의 글로벌 역량-풀을 형성한다.

All peoples and countries are tied together in an increasingly interdependent global health space, and the challenges in professional education refl ect this interdependence. Although all countries have to address local problems through building their own professionalworkforce for their health system, many health workers participate in a common global pool of talent

당연히, 공동의 전문직-글로벌-풀은 정치적 경계와 국가 내에서의 전문직 자격증으로 의해 분리되어 있다. 그러나 그 경계를 넘는 것은 이미 상당히 일어나고 있으며, 점차 늘어나서 모든 국가에서 교육 내용, 체널, 역량에 영향을 줄 것이다. 개별 전문직은 전부 나름의 특징이 있고, 그 전문직집단의 핵심 역량이라고 할 수 있는 기술을 가지고 있다. 그러나 그러한 전문성을 팀으로 모아서 효과적인 환자-중심, 인구-기반 건강 업무를 할 수 있게 만들어야 한다. 더 나아가서 서로 다른 전문직간 '직무 역량의 벽'은 매우 구멍이 많아서 직무-이동과 직무-공유를 통해서 실질적인 건강성과를 가져올 수 있게 하며, 이는 고립된 역량으로는 불가능한 것이다.

Of course, the common global pool of professionals and other health workers is divided by political borders and professional certifi cation within nation states. Yet cross-border fl ow of professional workers, patients, and health services is already substantial and will grow to aff ect educational content, channels, and competencies in all countries. Individual professions might have distinctive and complementary skills that could be considered the core of their special niche. But there is an imperative for bringing such expertise together into teams for eff ective patient-centred and population-based health work. Moreover, the walls between task competencies of diff erent professions are porous, allowing for task shifting and task sharing to produce practical health outputs that would not be possible with sealed competencies.

이 글로벌-풀 에서 중등교육 후 교육을 받은 전문직은 특히 특권층이며, 왜냐하면 그들의 수련이 시간/노력/투자를 많이 필요로 하기 때문이다. 전문직은 따라서 단순히 기술적 업무를 수행할 기능을 넘어서는 역량을 습득할 특별한 책무가 있다.

In this global pool, professionals with postsecondary education are especially privileged because their training commanded much time, eff ort, and investment Professionals, therefore, have special obligations and responsibilities to acquire competencies and to undertake functions beyond purely technical tasks

새로운 세대를 향한 우리의 비전은 TfL과 교육의 상호의존성을 실현시킬 것을 요구한다. 20세기 초의 개혁이 germ theory와 근대 의과학의 성립으로부터 진보를 이룬 것처럼, 우리 Commission역시 지식과 정보의 국제적 흐름의 힘으로부터 일어나는 구체적 컨텍스트의 역량에 대한 적응이 미래를 만들어갈 것이라 생각한다.

Our vision calls for a new era of professional education that advances transformative learning and harnesses the power of interdependence in education. Just as reforms in the early 20th century were advanced by the germ theory and the establishment of the modern medical sciences, so too our Commission believes that the future will be shaped by adaptation of competencies to specifi c contexts drawing on the power of global fl ows of information and knowledge.

우리의 목표는 국가나 전공에 무관하게 건강전문직에게 미래에 대한 공동의 글로벌 비전을 가질 것을 권한다. 이 비전에서 모든 국가의 모든 건강전문직은 지역적으로 책임감 있는, 그리고 글로벌하게 서로 연결된 팀으로서 지식을 동원하고, 비판적 추론을 하며, 윤리적으로 행동함으로써 환자-중심, 인구-중심 보건시스템에 참여할 수 있게 유능해야 한다. 궁극적인 목적은 양질의 포괄적 진료에 대한 유니버설-커버리지를 확보하는 것으로, 국가 내, 그리고 국가 간 건강 평등을 한걸음 더 나아가게 하는 것이다.

Our goal is to encourage all health professionals, irrespective of nationality and specialty, to share a common global vision for the future. In this vision, all health professionals in all countries are educated to mobilise knowledge, and to engage in critical reasoning and ethical conduct, so that they are competent to participate in patient-centred and population-centred health systems as members of locally responsive and globally connected teams. The ultimate purpose is to assure universal coverage of high-quality comprehensive services that are essential to advancing opportunity for health equity within and between countries.

이 비전을 실행하려면 일련의 교육적, 기관적 개혁이 필요하다. 우리는 이를 위한 두 개의 성과를 제안했다. 하나는 TfL이며, 다른 하나는 교육의 상호의존성이다. TfL은 다양한 교육 이론으로부터 도출된 바 있다. 비록 서로 다른 의미로 쓰이긴 했으나, 우리는 이것을 세 가지 연속적 수준의 가장 상위 개념으로 본다.

Undertaking of this vision requires a series of instructional and institutional reforms, which in our proposal are guided by the two outcomes suggested in section 1—ie, transformative learning and inter- dependence in education (fi gure 11). The notion of transformative learning derives from the work of several educational theorists, notably Freire181 and Mezirow.182 Although it has been used with diff erent meanings,183 we see it as the highest of three successive levels, moving from informative to formative to transformative learning (table 3).

Informative learning is about acquiring knowledge and skills; its purpose is to produce experts.
Formative learning is about socialising students around values; its purpose is to produce professionals.
Transformative learning is about developing leadership attributes; its purpose is to produce enlightened change agents.

Eff ective education builds each level on the previous one.

TfL은 하나의 중요한 성과로서, 세 가지 근본적 변화를 동반해야 한다.

As a valued outcome, transformative learning involves three fundamental shifts:

from fact memorisation to critical reasoning that can guide the capacity to search, analyse, assess, and synthesise information for decision making;
from seeking professional credentials to achieving core competencies for eff ective teamwork in health systems; and
from non- critical adoption of educational models to creative adaptation of global resources to address local priorities.

상호의존성은 시스템적 접근법의 핵심 요소이며, 왜냐하면 다양한 요소들이 - 그들이 서로 동등하다고 미리 가정하지 않고 - 서로 상호작용하는 방식을 강조하기 때문이다. 바람직한 성과로서, 교육의 상호의존성은 세 가지 변화를 필요로 한다.

Interdependence is a key element in a systemic approach because it underscores the ways in which various components interact with each other, without presupposing that they are equal. As a desirable outcome, interdependence in education also involves three shifts:

from isolated to harmonised education and health systems;
from stand-alone institutions to worldwide networks, alliances, and consortia; and
from self-generated and self-controlled institutional assets to harnessing global fl ows of educational content, pedagogical resources, and innovations.

Panel 9.

Proposed reforms

Instructional reforms should encompass the entire range from admission to graduation, to generate a diverse student body with a competency-based curriculum that, through the creative use of information technology (IT), prepares students for the realities of teamwork, to develop flexible career paths that are based on the spirit and duty of a new professionalism.

1: Adoption of competency-based curricula that are responsive to rapidly changing needs rather than being dominated by static coursework. Competencies should be adapted to local contexts and be determined by national stakeholders, while harnessing global knowledge and experiences. Simultaneously, the present gaps should be filled in the range of competencies that are required to deal with 21st century challenges common to all countries—eg, the response to global health security threats or the management of increasingly complex health systems.
2: Promotion of interprofessional and transprofessional education that breaks down professional silos while enhancing collaborative and non-hierarchical relationships in effective teams. Alongside specific technical skills, interprofessional education should focus on cross-cutting generic competencies, such as analytical abilities (for effective use of both evidence and ethical deliberation in decision making), leadership and management capabilities (for efficient handling of scarce resources in conditions of uncertainty), and communication skills (for mobilisation of all stakeholders, including patients and populations).
3: Exploitation of the power of IT for learning through development of evidence, capacity for data collection and analysis, simulation and testing, distance learning, collaborative connectivity, and management of the increase in knowledge. Universities and similar institutions have to make the necessary adjustments to harness the new forms of transformative learning made possible by the IT revolution, moving beyond the traditional task of transmitting information to the more challenging role of developing the competencies to access, discriminate, analyse, and use knowledge. More than ever, these institutions have the duty of teaching students how to think creatively to master large flows of information in the search for solutions.
4: Adaptation locally but harnessing of resources globally in a way that confers capacity to flexibly address local challenges while using global knowledge, experience, and shared resources, including faculty, curriculum, didactic materials, and students linked internationally through exchange programmes.
5: Strengthening of educational resources, since faculty, syllabuses, didactic materials, and infrastructure are necessary instruments to achieve competencies. Many countries have severe deficits that require mobilising resources, both financial and didactic, including open access to journals and teaching materials. Faculty development needs special attention through increased investments in education of educators, stable and rewarding career paths, and constructive assessment linked to incentives for good performance.
6: Promote a new professionalism that uses competencies as the objective criterion for the classification of health professionals, transforming present conventional silos. A set of common attitudes, values, and behaviours should be developed as the foundation for preparation of a new generation of professionals to complement their learning of specialties of expertise with their roles as accountable change agents, competent managers of resources, and promoters of evidence-based policies.

Institutional reforms should align national efforts through joint planning especially in the education and health sectors, engage all stakeholders in the reform process, extend academic learning sites into communities, develop global collaborative networks for mutual strengthening, and lead in promotion of the culture of critical inquiry and public reasoning.

7: Establishment of joint planning mechanisms in every country to engage key stakeholders, especially ministries of education and health, professional associations, and the academic community, to overcome fragmentation by assessment of national conditions, setting priorities, shaping policies, tracking change, and harmonising the supply of and demand for health professionals to meet the health needs of the population. In this planning process, special attention should be paid to sex and geography. As the proportion of women in the health workforce increases, equal opportunities need to be in place—eg, through more flexible working arrangements, career paths that accommodate temporary breaks, support to other social roles of women such as child care, and an active stance against any form of sex discrimination or subordination. With respect to geographical distribution, emphasis should be placed on recruitment of students from marginalised areas, offering financial and career incentives to providers serving these areas, and deploying the power of IT to ease professional isolation.
8: Expansion from academic centres to academic systems, extending the traditional discovery-care-education continuum in schools and hospitals into primary care settings and communities, strengthened through external collaboration as part of more responsive and dynamic professional education systems.
9: Linking together through networks, alliances, and consortia between educational institutions worldwide and across to allied actors, such as governments, civil society organisations, business, and media. In view of faculty shortages and other resource constraints, every developing country is unlikely to be able to train on its own the full complement of health professionals that is required. Therefore, regional and global consortia need to be established as a part of institutional design in the 21st century, taking advantage of information and communication technologies. The aim is to overcome the constraints of individual institutions and expand resources in knowledge, information, and solidarity for shared missions. These relations should be based on principles of non-exploitative and non-paternalistic equitable sharing of resources to generate mutual benefit and accountability.
10: Nurturing of a culture of critical inquiry as a central function of universities and other institutions of higher learning, which is crucial to mobilise scientific knowledge, ethical deliberation, and public reasoning and debate to generate enlightened social transformation.

목표 달성을 위한 행동원칙

Enabling actions

앞의 열 가지 주요 교육개혁과 기관개혁 중 6개는 교육개혁, 4개는 기관개혁

The ten major educational reforms in instruction and institution are prioritised and presented in panel 9. Six are in instruction and four are in institutional reforms.

리더십을 확보하라

Mobilise leadership

전문직교육에서 리더십은 학계와 전문직 집단에서 오는 것이 확실하긴 하나, 자원의 분배에 대한 의사결정이 필요할 때는 정부나 사회의의 다른 부분에 속한 정치지도자의 지원이 필요하다. 모든 수준의 지도자들의 포괄적 참여는 필수적이다 .

Leadership in professional education should certainly come from within the academic and professional communities, but it should also be backed by political leadership in other parts of government and society when decisions aff ecting resource allocation to health are made. This broad engagement of leaders at all levels— local, national, and global—will be crucial to energise instructional and institutional reforms.

• Philanthropic leadership clearly sparked the breakthrough reforms of the 20th century and has the opportunity to do so again. The 20th century revolution in professional education and its eff ect on health were among the most lasting contributions of foundations such as Rockefeller, Carnegie, and others. Foundations have the capacity, agility, and venture catalytic fi nancing that could spark a new wave of reforms in the second century.

• Ministerial summits hosted by the two key UN agencies responsible for leadership in this area— WHO and UNESCO—could bring together ministers of health and education to share perspectives, develop modalities for stronger intersectoral coordination, and launch country-based stakeholder consultations as a key component of joint planning mechanisms.

• National forums for professional education should be tested in interested countries as a way to bring together educational leaders from academia, professional associations, and governments to share perspectives on instructional and institutional reform.

• Academic summits could be considered to engage the support of the wider university leadership as a crucial factor for success of reform eff orts in schools and departments that are directly responsible for health professional education.

투자를 확충하라

Enhancement of investments

이 지식-유도 시스템에는 전체 매출의 2%도 안되는 비용만 투자해서 가장 유능한 인력으로 키워내기에는 부족할 뿐만 아니라 현명하지 못하다. 이러한 현실이 나머지 98%의 지출을 위협에 빠뜨리고 있다. 엄청난 재정 부족은 건강시스템 퍼포먼스에 해악을 끼치는 많은 교육적 부족부분을 설명해준다. 이러한 현실을 감안하면, 모든 국가와 기관은 전문직 교육에 들어가는 비용을 향후 5년간 두 배 가량 증가시켜야 하는데, 이것은 효과적이고 지속가능한 건강시스템의 없어서는 안 될 기여분이다. 그러나 재정을 확보하는 것 외에도 동시에 쓸데없는 낭비와 비효율을 찾아서 제거해야 하며, 질과 평등의 향상을 위해서 인센티브가 도입되어야 한다.

For a knowledge-driven system, investing less than 2% of total turnover in the development of its most skilled members is not only insuffi cient but unwise, putting the remaining 98% of expenditures at risk. Gross underfi nancing explains much of the glaring educational defi ciencies that do so much harm to health- system performance. In view of these realities, every country and agency should consider doubling its investments in professional education over the next 5 years as an indispensable contributor for eff ective and sustainable health systems. However, it is not only a matter of requesting more funding for professional education. At the same time, wastage and ineffi ciencies should be identifi ed for best possible use of current allocations, and incentives should be introduced to advance quality and equity.

• Public fi nancing is the most important source of sustainable funding in all countries, poor or rich. Such investments should be allocated to develop a skill mix that is appropriate to national contexts. Because of its importance, every eff ort should be made to increase not only the level but also the effi ciency of public fi nancing. In addition to aggregate fi nancial estimates, the set of incentives generated need to be understood by the way in which investment fl ows and subsidies are allocated to each educational institution. All too often public subsidies are insen- sitive to performance. Performance-based fi nancing through scholarships, vouchers or awards, and improved systems for quality monitoring and assurance, should be introduced and evaluated.

• Donor funding for professional education in developing countries should increase to become a signifi cant share of development assistance. After decades of almost exclusive focus on primary education by the development community, new demographic, social, and economic realities make attention to secondary and postsecondary education in low-income countries imperative. The neglect by donors has been short-sighted, since it has not taken into account the human capacity that is needed for eff ective and sustainable health systems. Such neglect is remarkable since most decision makers in bilateral and multilateral agencies (and in recipient countries) have professional degrees themselves, because otherwise they would not be credible leaders of their respective organisations. We need to end this inconsistency and translate into suffi cient investments the unavoidable fact that, especially in the most resource-constrained systems, high-quality pro- fessional leadership is crucial for progress.

• Private fi nancing should be welcomed under a clear set of ground rules to optimise health returns. Private funding is necessary because public sources cannot meet all gaps and because professional education is at least partly a private investment on the part of students and their families. Private funding in the professional education marketplace, in view of global shortages, seems to be increasing, as shown by the explosive growth of proprietary nursing and medical schools for labour export. There are genuine hazards of a de-Flexnerisation process of unregulated, unaccredited, and low-quality schools, which calls for greater transparency and oversight—both nationally and globally.

인증을 정렬하라

Alignment of accreditation

모든 국가는 인증, 면허, 건강목표가 정렬되어 나아가야 하며, 이를 위해서는 목표, 준거, 평가, 인증절차를 만든느데 관련된 이해관계자를 참여시켜야 한다. 정부/전문직 집단/학계가 반드시 참여해야 한다. 교육과 기관 준거를 모두 포함해야 한다.

All countries should progressively move to align accreditation, licensing, and certifi cation with health goals through engaging relevant stakeholders in setting objectives, criteria, assessment, and tracking of accreditation processes. The engagement of government, professional bodies, and the academic community is essential. Accreditation should be based on both instructional and institutional criteria.

• National accreditation systems should develop criteria for assessment, defi ne metrics of output, and shape the competencies of graduates to meet societal health needs.

• Global cooperation should be promoted by relevant bodies, including WHO, UNESCO, World Federation for Medical Education, International Council of Nurses, World Federation of Public Health Associations, and others, to help in setting standards that can function as global public goods, assist countries in developing the capacity for local adaptation and implementation, facilitate information exchange, and promote shared responsibilities for accreditation as required by the imperative of protecting patients and populations in the face of a globally mobile health workforce.

글로벌 학습을 강화하라

Strengthening of global learning

전문직 교육의 학습시스템은 아직 약하고 재정이 부족하다. 연구와 개발을 위한 경비는 미미하며, 대부분은 분절된 형태로, 반복적인 기관의 지출 중 일부를 전환하는 형태이다. 그러나 연구와 개발 없이 혁신은 있을 수 없으며, 아직은 극도로 낮은 수준일지라도 건강전문직교육에서 나오는 매출은 지금보다 연구와 개발에 더 많은 투자를 생성해야 한다.

Learning systems on professional education are weak and underfi nanced. Outlays for research and development in this fi eld are very meagre, mostly fi nanced in a fragmented manner by diverting resources from recurrent institutional expenditures. Yet innovation cannot fl ourish in the absence of research and development. Even at its relatively low levels, the turnover in health professional education should generate much larger investments in research and development than is the case at present.

• Metrics on professional education must be defi ned, gathered, assembled, analysed, and made widely available.

• Evaluation is central to shared learning about what has worked, what has not worked, and why—the knowledge foundation of all enterprises. Every reform eff ort, from the design phase to implementation, should be evaluated so that an evidence base on best practice can be disseminated and poor nations can be enabled to substantially advance in the adaptation of innovations.

• Research in professional education should be expanded so that the fi eld steadily builds the knowledge required for continuous improvement.

The way forward

궁극적으로, 개혁은 당면한 과제를 인정하고 그것을 해결하기 위한 방법을 찾는다는 마음가짐에서 시작해야 한다. 100년 전과의 차이는 없으며, 교육 개혁은 리더십, 관점, 업무 형태의 변화를 필요로 하며 모든 이해관계자간 좋은 관계가 전제되어야 한다.

Ultimately, reform must begin with a change in the mindset that acknowledges challenges and seeks to solve them. No diff erent than a century ago, educational reform is a long and diffi cult process that demands leadership and requires changing perspectives, work styles, and good relationships between all stakeholders.

가장 중요한 것은, 우리의 권고를 도입하는 것은 모든 이해관계자를 건강시스템 강화를 위한 조화된 노력의 한 부분으로 참여시키려는 글로벌 사회 움직을 통해서 시작될 수 있다.

Most importantly, implementation of our recommen- dations can be propelled by a global social movement engaging all stakeholders as part of a concerted eff ort to strengthen health systems.

또한 반드시 필요한 것은, 이러한 진전이 지식이 원료가 되어, Louis Menand가 적절히 필요한 바로 이 가치를 인식하는 것을 프로페셔널리즘의 핵심 역할이 되어야 한다. "지식의 추구, 생산, 전파, 보존은 문명화된 사회의 핵심 활동이다. 지식은 사회적 기억이며, 과거와 연결되어 있다. 또한 사회의 희망이면서 미래를 위한 투자이다. 인간의 적응력이란 지식을 생성하고 이것을 활용하는 능력이다. 이것이 우리가 사회적 존재로서 우리 스스로를 재생성하는 길이며, 우리가 변화하는 길이다. 바로 발은 땅에 딛고 머리는 구름 속에 두는 것이다"

Of necessity, such progress will be fuelled by knowledge, giving professionals an essential role in the realisation of the value so aptly expressed by Louis Menand: “The pursuit, production, dissemination, and pres erva- tion of knowledge are the central activities of a civilization. Knowledge is social memory, a connection to the past; and it is social hope, an investment in the future. The ability to create knowledge and put it to use is the adaptive characteristic of humans. It is how we reproduce ourselves as social beings and how we change—how we keep our feet on the ground and our heads in the clouds.”151

Lancet. 2010 Dec 4;376(9756):1923-58. doi: 10.1016/S0140-6736(10)61854-5. Epub 2010 Nov 26.

Health professionals for a new century: transforming education to strengthen health systems in aninterdependent world.

Frenk J1, Chen L, Bhutta ZA, Cohen J, Crisp N, Evans T, Fineberg H, Garcia P, Ke Y, Kelley P, Kistnasamy B, Meleis A, Naylor D, Pablos-Mendez A, Reddy S,Scrimshaw S, Sepulveda J, Serwadda D, Zurayk H.

Author information

1Harvard Schoolof Public Health, Office of the Dean, Kresge Building, Room 1005, 677 Huntington Avenue, Boston, MA 02115, USA. jfrenk@hsph.harvard.edu

Comment in

Challenges and opportunities for new medical schools in Africa. [Lancet Glob Health. 2014]
New medical schools in Africa: challenges and opportunities. CONSAMS and value of working in consortia. [Ann Glob Health. 2015]
Health professionals for the 21st century: a students' view. [Lancet. 2010]
A new epoch for health professionals' education. [Lancet. 2010]
Transforming health professionals' education. [Lancet. 2011]
Transforming health professionals' education. [Lancet. 2011]
Transforming health professionals' education. [Lancet. 2011]
Transforming health professionals' education. [Lancet. 2011]
Transforming health professionals' education. [Lancet. 2011]
Transforming health professionals' education. [Lancet. 2011]
Transforming health professionals' education. [Lancet. 2011]
Transforming health professionals' education. [Lancet. 2011]
Value of management education to enhance health systems. [Lancet Glob Health. 2014]

PMID:: 21112623; [PubMed - indexed for MEDLINE]

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