Where Is the Stewardship? Medical Education in Iran

The World Health Organization (WHO) in World Health Report 2000 emphasized the stewardship function of the health systems. Stewardship of health human resources is described as training human resources of the health system purposefully and according to the health needs of the population. The importance of the decisions about training human resources is paramount because the impact of the decisions may appear years or even decades later and because despite physical resources, you cannot put them away when their skills are not needed any more (1).
Despite such emphasis on stewardship of health manpower by the WHO, and despite the Integration of Medical Education and Service Provision (IMESP) in Iran 15 years prior to it (2), still the calculation of student admission in health sciences in Iran does not benefit from a scientific base. The routine process of calculating the number of students in medical sciences is as follows: The head of department, based on his/her subjective estimation of potentials and infrastructure of the department, proposes a number which may be modified by the Deputy of Education (DE) of the university. The DE gathers the proposed numbers of all fields from the faculties and transfers them to the DE of the Ministry of Health and Medical Education (MHME). The deputy adjusts the final numbers and imparts them as the capacity of the university for the next year. This process repeats every year without any strategic plan for next years and decades.
The MHME uses some indices to adjust the number of admitted students among which are the ratios of physicians to the population, specialists to general physicians, physicians to hospital beds, nurses to physicians, nurses to hospital beds, nurses to the population, and dentists to the population. The first point about such ratios is that there is no standard or even census about their exact value which is appropriate. The second point is about the ratios of manpower to hospital beds. Because hospital construction is separate from the human resource planning deputies of the MHME, the DE is not aware of new hospitals under construction and their needs for manpower. Furthermore, the bed occupancy rate in different regions, different specialties, and in different years is varying (3). So these differences and their trends should also be considered in calculation of manpower for the health system. The ratios to the population also have their own issues to consider. They mostly consider the current population of the country, not the estimated future population and its growth. The structure of the population also may change during the time and should be considered. In fact, the country is going towards aging and the elders have different health needs compared to the young ones. The last but not the least point is that such ratios are not calculated for all health fields. Then, the adjustment of student admissions in these fields is a subjective matter.
We can conclude that although the primary purpose of the IMESP was to accurately estimate and easily train the needed manpower of the health system (2), it seems that after three decades the MHME is not sufficiently successful in this regard. The simple proof for this statement is the shortages of manpower in some fields and surpluses in some other fields. It seems that the DE of the MHME should take a more highlighted role in policy making and planning the training of health human resources, and by using a holistic view, conduct a strategic plan for it according to current and future health needs of the population. The IMESP had a considerable positive impacts such as repairing the shortage of physicians 3 and 4 decades earlier (4), but it has faced some problems due to subjective calculation of student admission. There are shortages in some fields such as nursing and surpluses in some others such as midwifery and the general physicians (5). In our opinion the important matter is not to integrate the medical education with service provision or not. It makes no difference that the MHME or the Ministry of Sciences and Higher Education performs the medical education task. The matter is that the MHME should take the responsibility and stewardship of the medical education in the country. In other words, the integration may accelerate the task, but it is not the sufficient condition for it.
One of the main problems that planning student admission is faced with is lack of accurate and reliable statistics. In fact, the MHME has not accurate data on the number of working manpower in various fields and the available number of them on the job market each year due to retirement, death or migration to other countries. Since the physicians have to register in the Nezam Pezeshki Organization (The Medical Association) to get their working license, the data include almost all of them. Yet the data may be over-estimating because there are some physicians that continue to study in a second field other than medicine and work with their second academic degree while the data consider them as physicians. Although there is a similar organization named Nezam Parastary (The Nursing Association) to register the nurses, but being a member of the association is not compulsory for all nurses. So, there are many nurses that work in the private sector and the MHME does not know how many they are. For the other fields there is a similar situation and the available data only is limited to the number of graduates and the workers in the public sector while some graduates should not be considered as work force for the field because some of them after being graduated study another field, work in a different job, or become housewives. On the other hand, some workers work both in public and private sectors.
Our first recommendation is to create a database in the MHME that includes the details of the graduate people in all fields of medical sciences. The database should work with the national ID code to prevent duplications. It should also include students. Registering in the database must be compulsory, and it should be updated periodically. Such a database can become an important infrastructure for many plans of the MHME. Through such systems, the exact number of active and total work force in each health-related field would be reportable. The average number of people who leave the job market annually, the number of students that will graduate the next year and years later are some potential useful reports of such a system.
Our second recommendation is creating a comprehensive planning system for admitting students of medical sciences that takes into account all the contributing factors of needed human resources. Such a planning system, in addition to the above mentioned database, requires the cooperation of various deputies of the MHME. Therefore, there is a need for a good stewardship.