Opinion Pieces

Health Education in Europe – Response to the report of the Lancet Global Commission

A Lancet Commission recently presented a report on the education of health professionals in the future. Of the 20 members of the Commission only one is from Europe. This may reflect the limited contributions of Europe in previous reforms of professional training. Further development of education is now necessary in view of new challenges to health. The significance of interdisciplinary collaboration and global health training are emphasised in the report. The new generation of reforms should be competency-driven and adaptive to local challenges but in a global perspective. Europe should not take a back seat in this essential process.

Recently, the Lancet Commission on Education of Health Professionals presented a report on its work at the website [1]. This is a landmark report on a central issue for health – development of human resources. Recently, Global Health Europe presented a paper on the role of knowledge production, including education, for global health. Obviously, education is one of the key requirements to improve health. The Lancet commission includes 19 key global leaders in health, representing different perspectives and different regions. Remarkably, only one of these leaders is from Europe. I will return to this poor representation of our continent and consider what it might imply.

The report recognises that the development of education of health professionals during the previous century was essential for the remarkable improvement in health that we have experienced during the last hundred years. Three generations of educational reforms have contributed to the development of individual professional knowledge. The first generation of reforms was heralded by the report by Flexner [2]. It was characterised by the introduction of the concept of a science-based curriculum. Even though the Flexner report focused on education in the United States and Canada, it had profound influences on education of health professionals in Europe as well. Reform of education during this phase of development was typically led by academic leaders.

The second generation of reforms was in the pedagogies and organisation of instruction. The concept of problem-based learning as a new technique for instruction was introduced first at the McMaster University in Canada [3]. The medical school at Maastrich was a pioneer in Europe. The problem-based learning reform was influenced by new attitudes to knowledge acquirement in society. Nevertheless, the reform was developed primarily within the academic community.

Today it is obvious, according to the Commission, that a third generation of reforms is necessary. New challenges to health are developing, and the human resources for health no longer have adequate competencies to handle these challenges. The Commission argues that the new generation of reforms should be competency-driven and adaptive to local challenges but in a global perspective. An important competence to acquire is that of leadership and governance of the health system. It is obvious that necessary competencies must be defined within the health system at large, and it is uncertain whether the academic community alone can develop the necessary reforms.

The Commission considers three levels of learning in health. The first level is informative. Here, formal knowledge is transferred largely uni-directionally to the students, traditionally through lectures to a large group of students. This traditional form of education is most current in medical schools in Europe and typical of the early Flexnerian époque. The second level of learning is formative. Here, the student is socialising to the role of physician, nurse, public health practitioner, dentist, pharmacist and so forth. Contacts with the professional situation, discussions on ethical values are typical components of the formative level of learning for health professionals. Obviously, this includes more contacts with the society outside of the educational institutions than the informative level of learning.

We are now entering the transformative level of learning, which includes competencies to lead and change the health system, interactions with other health professionals in teams and knowledge about the governance of the health system and its components. At this stage it is essential that societal interactions are established already during the basic education of health professionals. This may be reflected also in new forms for governance of education of health professionals.

Whether academia can guide the development of education of health professionals through this new stage is unclear. It is also unclear whether different health professionals will accept the interactions with other professional groups. The significance of a global health perspective at the transformative level of learning is emphasised by the Commission. A balance between a local and a global perspective is underscored, where the local perspective must be considered in establishing necessary competencies to be developed during the education, while the global perspective is necessary in view of the effects of globalisation. Health professionals are also the links for translation of knowledge-related global public goods to the requirements of local realities.

Thus, the significance of global health in the third generation of educational reforms is paramount in the Commission report. The Commission points at the recent collapse of previous health gains, particularly in Sub-Saharan Africa and the fact that health security both in so-called developed and in the developing countries is challenged by new infectious, environmental and life style threats of global character. As not only the health threats but also the health professionals become increasingly mobile, these challenges must be included in the curricula for the education of health professionals.

However, presences of educational institutions vary considerably over the world. The lowest numbers are found in areas where health professionals might be most needed, such as in Sub-Saharan Africa. It may be necessary to consider new levels of professional training as well as task shifting between traditional categories of health professionals in these areas. The Commission also highlights that rich countries cover up for their own failures in education through recruitments from countries where resources are already scarce. This should be compensated for by support of education of health professionals in the developing countries. The need of competencies necessary for the challenges of globalisation should be advanced through curricular inclusion of not only global health as a knowledge area but also through cross-cultural and cross-national experiential exposures. This could be achieved through improved collaboration between educational institutions in the developed world with those in the developing world.

The Commission voices the ambition to encourage all health professionals to share a common global vision for the future, so that all of them are competent to participate in a patient- and population-centred health system as members of a locally responsive and globally connected team. To enable this, it is essential to mobilize leadership, both in professional education and in developing health systems.

This may be a strain for the financial systems in many countries. Therefore, philanthropy should be mobilised as it was a hundred years ago in the first phase of educational reform. At the same time public financing should be improved. Rich countries need to recognise the value of human resources for health presently recruited from poor countries and support educational development there. Leadership both within the political and in the academic system should be mustered to support the development of education of health professionals throughout the world in accordance to the Commission’s proposals.

The report by the Lancet Commission is a milestone in the development of education of health professionals and should be discussed widely in Europe as well. I hope that the scarcity of European members in the commission does not reflect that our continent is the archetype for a region where education of health professionals is “fragmented, outdated, and [has] static curricula that produce ill-equipped graduates”. Europe has not been a leader in earlier phases of reform of education of health professionals and it could be argued that many institutions still rest in the Flexnerian era.

There is no doubt that during the early 20th century, the influences of Flexner to develop a science-based curriculum meant an improved quality of the education of health professionals. Today this is reflected in accreditation of education of health professionals in many countries. This is a quality control method that is essential to retain and develop. However, in my view there is also no doubt that today, the academic environment, particularly in Europe, is not responsive enough to the requirements of society for competencies necessary to improve health in the future. Therefore, a competency-based new curriculum developed through the interaction with society is essential.

Among the most essential competencies to be introduced in a new curriculum are those in global health. These competencies need to be reinforced by political sciences, economy, behavioural sciences and other fields. Global responsibilities for the development towards a new reform in education of health professionals would include not only the academic systems but also political systems at the highest level. Responsibilities for education of health professionals in areas where health challenges are largest must be assumed also in Europe. The report from the Lancet Commission provides an excellent starting-point for this development. However, Europe also needs to consider the report by the Lancet commission seriously on the professional as well as the political level. A global health perspective should not be restricted to dedicated global health educations, as covered by the European Academic Global Health Alliance, but integrated in all education for all health professionals. To implement this, the academic community in Europe may be cast too rigidly in old forms. Political leadership by the European Union is important to enact necessary reforms.


1. Frenk J, 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.
Health professionals for a new century: transforming education to strengthen health systems in an interdependent world.
Lancet. 2010 Dec 4;376(9756):1923-58. Epub 2010 Nov 26.

2. Flexner A. Medical education in the United States and Canada: a report to the Carnegie Foundation for the Advancement of Teaching, 1910. As cited in Frenk et al (ref 1).

3. Neufeld VR, Woodward CA, MacLeod SM
The McMaster M.D. program: a case study of renewal in medical education. Acad Med. 1989 Aug;64(8):423-32.