Some reflections

Gail Tomblin Murphy and John Gilbert present a compelling case for strengthening healthcare systems by building interprofessional education (IPE) into workforce strategies. Why then, with faltering exceptions, has adopting that argument been so long in taking hold?

In Norway, in 1972, the government proposed a common first year for allied health, nursing, and social work students in university colleges to learn collaborative competence together. Faced with massive resistance, their education remained in silos for a further 20 years until another government made more acceptable proposals still excluding medicine, dentistry, and pharmacy in universities and implemented slowly (Bjorke & Haavie, 2006).

In the UK, the incoming Labour Government at the turn of the century called for common learning across all health and social care professions to deliver a workforce responsive to its policies to modernize the public services (Department of Health, 2000). For some interprofessional educators, those plans were music to their ears, for others ominous. Neither the professions nor the universities were consulted before policies were adopted threatening autonomy and control of curricula. Uneasy bedfellows, common learning, and IPE were reconciled with difficulty.

The UK government redoubled its commitment by pump priming four pilot programs to combine IPE with common learning (Barr, 2007; Miller, Wolf, & Mackintosh, 2006) and commissioned the Creating an Interprofessional Workforce Programme (CIPW) (Hughes, 2007) to work alongside the Centre for the Advancement of Interprofessional Education (CAIPE). CIPW succeeded in engaging human resources managers where CAIPE had failed, framing an action plan and making recommendations. Follow-up assigned to CAIPE was, however, frustrated when funding was cut short.

Reference to the WHO lead was conspicuous by its absence. Workforce and training issues had exercised the WHO since its inception in 1946, but on parallel tracks until the World Health Association asserted that inadequate and irrelevant training was impeding the healthcare available to populations. A radical approach was needed in health manpower (sic) development to be devolved to national level adopting unorthodox approaches (WHO, 1976). WHO arguments progressed over the years from recruitment and retention profession by profession to optimizing deployment of a more mobile skilled workforce educated accordingly (WHO, 2006) transforming and scaling up health professionals’ education and training (WHO, 2013) driven by the Global Health Workforce Network to optimize the performance, quality, and impact of the health workforce (WHO, 2016a).

The first of two WHO study groups on IPE had called on countries to determine their health manpower needs but gone no further (WHO, 1988). Those of us who were members of the second study group were urged by WHO officials to demonstrate how IPE would impact on the global deficit in skilled healthcare workers. Our response was circumspect, content to argue that IPE and collaborative practice could maximize the strengths and skills of health workers enabling them to function at the highest capacity. Interprofessional innovations would be necessary to manage the strain placed on health systems (WHO, 2010).

Throughout these years, the impact of the WHO remained marginal in developed countries as it became pivotal in developing countries supported by its regions. Overwhelmed by unmet healthcare needs, compounded by a critical shortfall in qualified workers, but less encumbered by conventions than developed countries, the developing countries increasingly set the interprofessional pace.

The six case studies in this issue marry IPE with the workforce from one-off projects to nationwide strategies top down and bottom up in large and small, rich and poor, and developed and developing countries.

From South Africa, we learn how the latest in a longstanding tradition of team-based practice placements projects, funded originally by the Kellogg Foundation from the United States (Lazarus et al., 1998), steers policy and practice in response to needs of a disadvantaged community. The article exemplifies how much the same model, published as one of the practice guides in another issue of this Journal, can bear fruit (Brewer & Barr, 2016).

From Lao, we discover how team-based practice learning can take root in an underendowed country with support from a more endowed country where IPE is firmly established. Suku Lee and Hide Watanabe would be the first to acknowledge how Japan learned the interprofessional art from the UK in readiness to pass it on to other countries in Asia and the Pacific. Links in the interprofessional chain are being forged as the WHO envisages (WHO, 2016b).

From Australia, we can appreciate the systematic and collaborative preparation between educational and human resource stakeholders led with persistence and determination by Roger Dunston. Traditional education and workforce approaches are being replaced by a flexible, responsive, and sustainable strategy agreed between the parties to promote universal healthcare coverage. Assuming comparable commitment, the utility and feasibility of that strategy merit critical consideration in other countries.

From Brazil and Mexico, we sample interprofessional developments in 2 of the 26 Latin American countries backed up by the Pan American Health Organization (PAHO as a WHO region) to secure human resources sufficient in number, possessing the appropriate capacities, in accordance with the needs of communities (PAHO, 2014). The authors in Brazil play down its achievements, its influence on development in neighboring countries and PAHO. They acknowledge support from the Rockefeller, Kellogg, and Ford foundations in the United States in the 1950s and 1960s in reorienting professional education towards the community, paving the way for IPE and collaborative practice as we recognize them today.

The Mexican authors explain how Interprofessional Training in Health courses at various levels focus on work in disadvantaged rural communities, as one of the 10 countries applying training models from Partners in Health. Final year medical and nursing students are trained to work in those communities as “pasantes” as well as volunteers, including many graduates and holders of professional qualifications. Findings suggest that learning together encourages interprofessional collegiality, but, also, that work remains to be done to strengthen interprofessional learning methods.

From New Zealand, we engage with Erin Fraher and Barbara Brandt as visitors from the United States seized by the portent driving its evidence-based, needs-led workforce planning strategy to educate and re-educate flexible health and social care professionals to implement new models of practice. Recognizing readily its significance worldwide, Erin and Barbara invite us to join them in making nothing less than a paradigm shift reorienting relations between practice and academe. For me, the article is poignant as I recall my own visit to New Zealand years before when its nascent workforce inquiry seemed pregnant with implications for IPE waiting to be addressed.

How convinced then can we be from these case studies, undaunted for some of us by earlier chequered experiences, that needs-based workforce-driven interprofessional learning is viable and desirable everywhere? Six examples may seem too few to inspire confidence until we remember that four of them are comprehensive and nationwide, subjected to critical review. Even so, some readers may prefer to treat the strategy as no more than a passing fad competing for time and space in overloaded curricula. Others may indeed recognize a paradigm shift demanding a redefinition of form, method, content, and purpose in interprofessional learning, balancing the needs of patients and populations.