Dainius Pūras – UN Special Rapporteur on the right to health
Many of the problems in global health stem from power imbalances in the health workforce, and these can be traced back to medical education systems. There is an urgent need to overhaul medical education if we are serious about achieving universal health coverage, and realizing people’s right to health entitlements. This is the main message in my report presented to the United Nations General Assembly today.
In the report, I recommend that all health workforce education is reframed around human rights imperatives, and I give practical recommendations as to how this could happen. We should ensure that health-care workers have rights-based competencies and skills not only to stop violations of human rights in the care of patients but also to promote and protect their own rights, for example, rights to a decent wage and equal rights to participate in the health system. We must also acknowledge that people enter health education with their own biases; a rights-based health education helps health-care workers recognise and address their inherent discriminatory behaviours and attitudes.
The traditional model of medical education creates power asymmetries within the health workforce with disparities between physicians who have specialised in certain aspects of medicine, and the rest of the health-care workforce. Not only does this result in vast salary differences, but it limits the opportunity for all health workers to participate in decision making and health system accountability. These power imbalances enable systems of corruption to emerge as I have reported previously (see A/72/137), and also results in bullying and attrition from the workforce.
Health-care workers who have been trained to employ human rights-based approaches to health can help overcome these imbalances and reshape health systems to become more participatory, equitable, inclusive, non-discriminatory and responsive. To gain that understanding, however, it is not enough to have a single lecture or course on human rights in patient care. The culture change needed in health care requires human rights being ingrained in curricula, and training delivered in a rights-based environment, and in settings as close as possible to the environments in which people live. Some of my recommendations to achieve this include selection of students without discrimination, from marginalised groups and rural or remote areas, and to reflect the needs of the country.
Power being in the hands of medical specialists also provides them with influence over what is taught at medical school. So although there is a global shortage of primary health care workers, including medical doctors, medical schools continue to promote and reward specialisation, at huge expense and loss to primary health care. Specialists work mainly in secondary or tertiary hospitals and private facilities, in urban areas. This helps create the global problem that people in rural or poor urban areas who are those most in need of quality primary health care are least able to access it. It simply will not be possible to achieve the Sustainable Development Goal of health for all, and universal health coverage by 2030, while this imbalance in workforce education remains. To place an emphasis on primary health care, I recommend that all health education facilities have their curricula aligned with national health sector strategies and health workforce plans and provide incentives to attract to and retain people in primary health care.
Traditional medical education emphasises biomedical constructs of ill health. Medical students are inculcated with an overreliance to see ill health as disease that can be cured by the health sector, even though the social, political, and environmental determinants play by far the larger part in creating ill health. Medical care is estimated to account for only 10–20 per cent of the modifiable contributors to healthy outcomes for a population. But there is resistance within traditional medical education to training a workforce to focus less on medical and surgical care and more on the determinants of health, or more broadly, to train fewer physicians and more mid-level workers. It is nearly 10 years since The Lancet commission on the education of health professionals for the 21st century identified problems including a mismatch of competencies to individual and population needs and predominant hospital orientation at the expense of primary care, but little has changed despite the urgent need to do so.
I acknowledge in the report that physicians have a large and important role in health care and their clinical leadership over diagnostic and therapeutic decisions is vitally important. However, there are many decisions made within health-care services, including policy, planning, diagnostic and treatment issues, and health promotion, which can be effectively led by nurses and non-medical workers. It can not only be cost effective, but a better reflection of society through the inclusion of more and different voices.
If health education was human rights-based, health workers would develop a practical understanding that all people have human rights entitlements to health, and the determinants of health. The change needed to bring about health for all must start with health-care workers being equipped to see challenges to health as human rights issues, and themselves as change agents and human rights advocates.
 Hood, C. M., K. P. Gennuso, G. R. Swain and B. B. Catlin, “County health rankings: relationships between determinant factors and health outcomes ”, American Journal of Preventive Medicine, vol. 50, No. 2 (2016), pp. 129–135.
 Julio Frenk, et al “Health professionals for a new century: transforming education to strengthen health systems in an interdependent world”, The Lancet, vol. 376, No. 9756 (2010), pp. 1923–1958.
This report was presented to the 3rd Committee of the UN General Assembly, which is available to watch live here: http://webtv.un.org/live-now/watch/third-committee-36th-meeting-general-assembly-74th-session/5708145961001
Fact sheet on Medical Education_Factsheet_FINAL