Within larger efforts to modernize primary health care systems in Southeast Asia, innovations in health workforce training are a key opportunity to expand and improve equitable access to cancer care. Leveraging the available opportunities first requires mapping out all the key players, exploring how the parts of the system could better work together, and then identifying the training and oversight needed to implement the changes while maintaining quality delivery of services. Existing policy dialogues within and among countries have identified the need for more health care workers per capita, different geographical distributions of health care workers, and workers better equipped to provide high-quality care. Beyond technical skills required for health professionals to safely and effectively provide services, educational best practices incorporate skill sets around management, teamwork, and task shifting to optimize different compositions of multidisciplinary teams in different contexts.

The World Health Organization (WHO) South-East Asia Region identified strengthening the health workforce as a top priority in 2014, passed the Regional Committee Resolution Strengthening Health Workforce Education and Training, and formally began the Decade for Strengthening Human Resources for Health in the South-East Asia Region (2015–2024)(Dhillon et al., 2023). WHO South-East Asia Region countries have reported working toward improving accreditation, regulation, the leveraging of technological advances, professional development for health workers and relevant faculty, curriculum updates, and collaboration among different health professions (Zapata et al., 2021).

In 2019, noncommunicable diseases accounted for approximately 40 million deaths globally—mostly in low- and middle-income countries—with that number expected to surpass 100 million deaths per year by 2025 (WHO, 2023). By 2030, the estimate is that 13.7% of the population within the WHO South-East Asia region will be aged 60 or older; by 2050, that proportion will reach 20.3% (WHO, n.d.). As populations age, the prevalence of chronic diseases increases, and the demand for long-term care for chronic health issues grows; there is an important role for the primary health care system to play in providing a coordinated, affordable, person-centered approach to managing ongoing care (WHO, n.d., 2016a; WHO Regional Office for South-East Asia, 2019).

The usefulness of international best practices depends on their being disseminated, appropriately tailored, and effectively implemented in each context. Every health care system is unique, necessitating a careful tailoring of international best practices to each country context. Multistakeholder assessment and collaboration will strengthen considerations of the complexities of the respective country’s particular situation (WHO, 2016a). Thorough guidelines detailing a range of policy considerations for improving health workforce education and training are available from international organizations, such as the WHO, but they require substantial investment of time and resources of each country to identify the best fit for its context and operationalization through policymaking, resource support, and accountability.

Thailand is often considered an exemplar of universal health coverage due to its strong investment and measurable progress over several decades. Thailand’s universal service coverage index has reached 82%, and more than 98% of people in Thailand are covered by one of the three existing financial risk protection plans (Dhillon et al., 2023; Suriyawongpaisal et al., 2019; WHO Regional Office for South-East Asia, 2021). The Thai Ministry of Public Health manages the Village Health Volunteers (VHVs) program, whose success has been recognized globally (Dhillon et al., 2023). Thailand has effectively integrated its more than one million VHVs into health promotion activities central to its primary health care strategy (Dhillon et al., 2023; WHO Regional Office for South-East Asia, 2021).

Cancer has been Thailand’s leading cause of death since 2000 (Insamran and Sangrajrang, 2020). Although Thailand has made steady progress toward achieving universal health coverage, there are still gaps in the range of services covered, including cancer care (Hofmarcher et al., 2021). This means that while the proportion of the population in Thailand that has access to the package of basic essential services is high, there is not necessarily a high proportion of the population that can access all relevant specialized services needed for cancer care.

Thailand has established the Thai Foundation of National Health Professional Education Reform and passed “[t]ransformative health professional education in response to population needs under Thai context” (Dhillon et al., 2023). Beginning in 2006, Thailand has invested in a variety of health workforce training programs to improve the ability of primary care providers to meet the demand for services and specifically to address noncommunicable diseases through integrated care (Suriyawongpaisal et al., 2019). Preliminary research has shown a positive association between some of the existing training programs that focused on training primary care team members on multiple competencies coupled with how to apply those competencies in their specific context and health-related quality of life of patients with multiple chronic conditions (Suriyawongpaisal et al., 2019). Further research is needed to strengthen the evidence base across programs and could be used to inform resource allocation (Suriyawongpaisal et al., 2019).

Because the health care workforce is inextricably linked to health services, improving health care workforce education and training is a key step to operationalizing innovations and expanding access to primary health care. Updated approaches to education and training are needed to improve how multidisciplinary teams within the primary health care system function, particularly considering aging populations and the rise of noncommunicable diseases that are increasing demand for coordinated care over longer periods of time (WHO, n.d., 2016a; WHO Regional Office for South-East Asia, 2019).

Investing in primary health care systems is crucial for improving health equity in Southeast Asia. The World Health Organization (WHO) projects that up to 60 million lives could be saved globally by 2030 by expanding primary health care in low- and middle-income countries (WHO, 2021). International efforts to encourage investing in primary health care include the Declaration of Alma Alta in 1978 and the Declaration of Astana in 2018, as well as myriad regional and country-level commitments (WHO Regional Office for South-East Asia, 2021). Despite global, regional, and national commitments to improving primary health care, approximately half of people worldwide do not have access to the full range of essential health services, and even fewer have access to affordable care (Singh, 2021). Primary care is often the first and sometimes the only accessible option for specialized treatment, including cancer care. This is especially true in remote rural areas.

Within larger efforts to modernize primary health care systems in Southeast Asia, innovations in health workforce training are a key opportunity to expand and improve equitable access to cancer care. The WHO defines the primary health care workforce as both paid and unpaid workers; volunteers; and caregivers providing treatment or other care, working on health promotion or disease prevention, or otherwise involved in public health efforts (WHO, 2018). The critical roles of unpaid caregivers and volunteer community health workers are not always considered in planning and coordinating; even so, their contributions are vital. Recognizing the many actors within the primary health care system provides opportunities for innovation, including through task shifting (WHO, 2018). Leveraging the available opportunities first requires mapping out all the key players, exploring how the parts of the system could better work together, and then identifying the training and oversight needed to implement the changes while maintaining quality delivery of services. 

The WHO highlights investment in the health care workforce as an important factor in making progress towards achieving health objectives such as the Sustainable Development Goals (SDGs) (WHO, 2016a). Existing policy dialogues within and among countries have identified the need for more health care workers per capita, different geographical distributions of health care workers, and workers better equipped to provide high-quality care. Education and training, as well as resource investment and multisectoral planning, play a role in addressing all these concerns. Challenges of aligning evolving population health needs with the complexity of health care system management as well as emerging opportunities for technological advances have generated international recommendations for new training priorities. Beyond technical skills required for health professionals to safely and effectively provide services, educational best practices incorporate skill sets around management, teamwork, and task shifting to optimize different compositions of multidisciplinary teams in different contexts. Lessons learned from the COVID-19 pandemic, including utilizing technology to support remote training, have been shown to offer benefits beyond crisis response. Being able to standardize remote training and support requires both educational institutions to have the skill sets necessary for developing and facilitating high-quality virtual trainings and for individual learners to have the technological skills and connectivity capacity to participate in remote learning.

Political will to invest in reforming training and educational systems and commitment to meaningful collaboration across ministries are the foundations of ensuring significant alignment between training and updates to the health system. Southeast Asia is a region in which efforts are already underway. The World Health Organization (WHO) South-East Asia Region identified strengthening the health workforce as a top priority in 2014, passed the Regional Committee Resolution Strengthening Health Workforce Education and Training, and formally began the Decade for Strengthening Human Resources for Health in the South-East Asia Region (2015–2024)(Dhillon et al., 2023).

Although resource-intensive, comprehensively updating education and training curriculum for the health care workforce to include a variety of skill sets is a necessary step in implementing innovations to how primary health care systems expand equitable access. In Building the Primary Health Care Workforce of the 21st Century, the WHO recommends curriculum that includes competencies related to information and communication technology and providing remote support, innovation and adaptability, systems thinking, multidisciplinary teams, and cultural sensitivity to modernize primary health care workforce training (WHO, 2018).

The phrase “transformative health professional education” refers to changing the education system itself as well as changing curriculum to better educate health professionals to address the population’s needs (Zapata et al., 2021). Rather than focusing on expanding the number of participants who can receive existing education and training (thereby increasing the number of health professionals), investing in transformative education aims to improve the quality of education for health care workers to better address population needs (Dhillon et al., 2023). Within its efforts to date to implement this approach, WHO South-East Asia Region countries have reported working toward improving accreditation, regulation, the leveraging of technological advances, professional development for health workers and relevant faculty, curriculum updates, and collaboration among different health professions (Zapata et al., 2021). The approach of transformative health professional education is that merely updating curriculum is not enough; considering all of these components together is necessary for meaningful change.

Competency-based education is centered on training learners to develop specific skills. Whereas traditional educational models may focus on didactic lecture-based approaches in which teachers present knowledge for students to memorize and repeat on assessments, competency-based models design educational content around skills that the learners should be able to demonstrate. By building skills that will be used in their work, learners have the opportunity to practice and develop confidence, including by improving problem-solving skills. National-level planning can identify competencies and skills for each health profession or role within the health system. While the specific competencies identified may vary from country to country, each cohort of health professionals within a country should come away from a competency-based system with the same set of skills. This universality in skill sets is an important part of expanding equitable access to services within a country. Assessments requiring learners to demonstrate the skills they have acquired are a useful measure in determining preparedness to apply new skills with patients, particularly if learners work in remote areas far from specialist supervision.

Simulations provide real-world practice; learners have the space to practice and receive immediate feedback without the risks of applying new skills on actual patients without supervision.  This method of hands-on learning provides space for learners to potentially make mistakes as part of the learning process in a safe environment so that they are more prepared for using their new skills with patients. This is particularly helpful for workers who may have less direct supervision for applying these new skills in their places of work.

Simulations range from high tech and resource intensive (high fidelity), such as working with realistic and reactive medical “manikins” in specialized labs, to low tech and inexpensive (low fidelity), such as assigning group work with only simple pen-and-paper materials required. For example, a simulation to work on planning, communication, and collaboration could include tasking a group with practicing better engagement of youth at the health center by exchanging ideas on how to make it a more youth-friendly space.

In 2019, noncommunicable diseases accounted for approximately 40 million deaths globally—mostly in low- and middle-income countries—with that number expected to surpass 100 million deaths per year by 2025 (WHO, 2023). By 2030, the estimate is that 13.7% of the population within the WHO South-East Asia region will be aged 60 or older; by 2050, that proportion will reach 20.3% (WHO, n.d.). As populations age, the prevalence of chronic diseases increases, and the demand for long-term care for chronic health issues grows; the primary health care system has an important role to play in providing a coordinated, affordable, person-centered approach to managing ongoing care (WHO, n.d., 2016a; WHO Regional Office for South-East Asia, 2019). Through the 2016 Colombo Declaration: Strengthening Health Systems to Accelerate Delivery of Noncommunicable Diseases Services at the Primary Health Care Level, the WHO Regional Committee for South-East Asia highlighted the role of noncommunicable disease training for the primary health care–level workforce among several key recommendations (WHO Regional Office for South-East Asia, 2016).

Traditionally, specialists can be used to deliver a range of services within their areas of expertise. When the various tasks are broken down, it is clear that a specialist is not needed for all of the tasks. Within cancer prevention, screening, treatment, and supportive care, a spectrum of technical expertise is needed for the many tasks involved. Some tasks, while important to the overall goal, may not require a high level of preservice education but can be covered in a targeted training; other tasks could be accomplished by a generalist with proper training and oversight on the task. For example, health care workers such as nurses with relevant generalist skills but without cancer specializations can receive tailored training to play a role in cancer education, screening, treatment, care, and research (Challinor et al., 2016). This approach both expands services available in locations without specialists and uses the time of specialists more efficiently on tasks requiring their expertise. For quality and accountability purposes, these trainings and the subsequent changes in responsibilities should be formalized. For the safety of health care workers taking on new tasks, training should include how they should protect themselves, such as when they are handling chemotherapy drugs; education should align with service delivery standards, such as what personal protective equipment (PPE) will be available (Challinor et al., 2016).

Education and training have a role to play in efforts to address insufficient distribution of health care workers across all regions of a country, particularly in rural areas. Globally, many countries experience shortages in primary health care professionals while higher proportions of specialists are working in hospitals (WHO, 2018). In addition to considering economic incentives to realign the supply with the need for primary health care workers in rural areas, the WHO recommends updating workforce education to center the population’s needs, from changing admissions priorities at educational institutions to updating curriculum content to develop primary health care as a specialty (WHO, 2018). Additionally, educational approaches should include planned continuing training throughout a worker’s career span (WHO, 2016a).

Decentralizing education, increasing training in rural areas, ensuring affordable tuition and fees, and providing scholarships linked to returning to serve in rural locations are more sustainable solutions to address shortages of trained health professionals in rural areas, compared to short-term solutions such as mandatory postings in rural areas (WHO, 2016b, 2018). Depending on the country context, workers in other sectors with fewer economic opportunities may be given training to reskill and play appropriate roles within the health system (WHO, 2016a). For example, workers who have a hard time finding employment in their original field could be recruited to receive short trainings to allow them to be hired for specific, lower-skilled tasks, which may be more realistic and appealing than encouraging workers to begin a long educational pathway to become a higher-skilled health professional (WHO, 2016a).

Along with the initial resource investment, remote learning requires both instructional expertise and technological infrastructure. Participating in available remote learning opportunities inherently requires the devices, connectivity, and skills to use them. Investing in technological systems provides the foundation to operationalize innovations as opportunities arise, such as having infrastructure in place to utilize telemedicine or remote support (Peiris et al., 2021).

If both the technological capacity and the educational design are in place, rural sites can utilize opportunities for remote components of preservice and in-service training, which can reduce barriers to participating in training as well as save costs in the long term (WHO and UNICEF, 2020). Traveling to an urban center for training can be resource intensive in terms of both time and money, so reducing the in-person time would be cost-effective. It may be logistically challenging for participants to leave their responsibilities at home for an extended period of time, such as family caretaking duties or other sources of income generation, to attend a training. In some contexts, this may disproportionately discourage certain participants more than others from attending a longer in-person training in a distant location, based on factors such as gender or age.

In addition to the potential to increase participation and decrease costs, e-learning also provides opportunities for more student-centered learning and digital tools such as gamification and virtuality reality simulations (WHO, 2016b). Although designing and rolling out these educational tools require resources and technological expertise, the potential for improved outcomes may be worth the investment. As artificial intelligence (AI) improves, there will likely be even more opportunities for digital educational approaches that tailor content to each student’s specific learning needs. Engaging materials, such as photos, videos, and interactive aspects of the lesson, are important for effective e-learning content. Adult learning theories that are used to design in-person training can also be applied to e-learning curricula.

As with the need for accreditation of formal in-person education, remote education should similarly be regulated and accredited to ensure quality information and instructional methods (WHO, 2019).  Strong knowledge management systems will help document professional and demographic information about the learners as well as track how learners are performing. In addition to requiring pretests and posttests of learner knowledge, following up with learners at a later stage to assess their implementation performance and behavior change will help evaluate the efficacy of the training program and identify where improvements may be needed.

Best practices indicate that remote trainings should be seen as complementary to in-person trainings and not a complete replacement; educational specialists should be involved in determining what is appropriate for remote learning and what should still be taught in person (WHO, 2019). The “flipped classroom” approach provides learners opportunities to absorb initial information through e-learning before in-person sessions with instructors who use the time to help learners practice and apply what they have learned.

The potential of technological advances to increase access to care requires a workforce trained to effectively leverage new technologies as they become available; ongoing opportunities for continued education to improve relevant skills, as well as relevant coaching and support, will be necessary as technology advances over time (WHO, 2018). Each country should set educational standards and assessments to ensure trainings on new technology are effective and that professionals are able to competently use their new skills (WHO, 2016a). Technological advances can also support monitoring of individuals’ respective education and training over time (WHO, 2016a).

Appropriate training, supervision, and support of health care workers can provide opportunities for effective task shifting, a pivotal strategy to address gaps in access to cancer care and a way to maximize efficiency of health care teams. While task shifting may seem controversial to some, especially among traditionally trained health care workers who may feel territorial, it has the potential to reduce the load for health professionals who shoulder the biggest burdens, as well as to expand access to relevant services. Within the context of cancer control, the ability of a variety of health care workers to effectively screen for certain types of cancer reduces the burden on the higher-skilled team members who can focus on more specialized tasks or have more time to spend with patients (Barış et al., 2021). Additionally, task shifting allows access to the provision of care in locations where there are no higher-skilled team members physically present rather than relying on faraway hospitals or specialized centers (Tangcharoensathien, 2021). The importance of training, supervision, and support of private sector health workers in addition to public sector health workers cannot be overlooked, both to expand benefits to patients and as a means of accountability and regulation (Peiris et al., 2021). Similarly, both public and private institutions providing education and training for health professionals must be held accountable to the same national standards, including accreditation requirements (WHO, 2016a).

Task shifting has been shown to increase access to services and decrease patient wait times (WHO, 2016b). This requires strategically coordinating the different roles to function as part of the same cohesive system—such as appropriately training, supervising, and compensating community health volunteers (WHO, 2018). In addition to making the system more efficient, training community health volunteers and health service providers who are often the first point of entry into the health care system for patients can improve trust in the system (WHO Regional Office for South-East Asia, 2021). Strategically integrating community health volunteers within the primary health care system and recognizing the important role they play will provide opportunities to maximize their potential impact (WHO, 2016a, 2016b).

National governments should work with relevant agencies and associations to develop models of how task shifting and collaboration within multidisciplinary teams can most effectively occur, as well as how best to regulate these new approaches; as this process is rolled out, national regulatory authorities may benefit from international knowledge sharing (WHO, 2016a). Although a tailored approach to each health system is necessary, sharing success stories and lessons learned as different countries train their respective workforces for task shifting can be a cost-effective starting point.

In addition to clinical training that allows for task shifting, relevant management training for primary health care professionals will strengthen the capacity of their teams (Peiris et al., 2021). Trainings that cover skills for working on multidisciplinary teams will improve collaboration among different types of professionals working within the primary health care system (WHO, 2016a). While these skills may not have been traditionally included in education and training for all health professionals, they should not be overlooked in developing teams in which task shifting can be effectively implemented.

Planning for substantial educational and training reforms will be most effective when all relevant stakeholders across sectors are involved and when the health workforce is regarded as a whole—rather than considering the needs of each occupation individually (WHO, 2016a). Relatedly, accountability mechanisms should be included at all relevant levels of the system (WHO, 2016a). Where these regulation and accountability measures should be situated within the health system will vary by context. The WHO recommends each country encourage collaboration among both health and education ministries (as well as with finance, labor, and other ministries as needed) to invest in designing high-quality curricula that consider needs of historically underserved or vulnerable groups, embed social responsibility and social determinants of health into educational approaches, cultivate capable trainers, and formalize educational standards and regulations with national government oversight (WHO, 2016a). In addition to government agencies, professional associations are key partners in understanding workforce needs, while community advocacy groups can represent the patient’s voice. Each of these stakeholders should be included in relevant aspects of the educational design process.

Rigorous institutional accreditation, overseen by a specialized regulatory body, plays an important role in enhancing the availability of quality and continuing education for the health care workforce; requirements for continuing education and relicensing, when relevant, encourage health care workers to keep their skills up to date (WHO, 2018). Key aspects of quality assurance include considering graduation from only accredited sources as a professional registration requirement and strictly regulating education and in-service training to adhere to educational standards (WHO, 2018). For regulation to be an effective accountability and quality control mechanism, regulatory agencies must have both sufficient capacity and safeguards in place against potential conflicts of interest (WHO, 2016a).

Formal national commitments and transparent monitoring are other important accountability measures. Countries can formalize updates to health care workforce education and training (including accountability mechanisms) by including them in their national strategies and plans (WHO, 2016a). Unfunded mandates will likely be harder to operationalize than political commitments with resource allocations tied to them. Another role for high-level collaboration is in data collection. Collaboration among stakeholders will improve a country’s ability to collect information needed to project population health needs and track the health care labor market to inform educational and training priorities (WHO, 2016a). Consistent and thorough data collection will support future evidence-based policymaking and budget advocacy.

Responding to the COVID-19 pandemic necessitated swift changes to the status quo, and many of the lessons learned can be applied beyond times of crisis. Although the pandemic provided important learnings related to infectious disease response, it also highlighted gaps in health care systems related to maintaining health services for noncommunicable diseases. As previously discussed, remote health care professional education and in-service training enabled by technology is a prime example of a practice with lasting benefits (Zapata et al., 2021). Before the pandemic, remote learning may have been deemed inappropriate or unnecessary; it was only through necessity that these practices became more widely accepted.

Localizing services to reach patients in rural areas such as performing local laboratory tests, holding virtual tumor board meetings, and having medications mailed to patients are other opportunities that do not need to end as the world moves beyond COVID-19 pandemic restrictions (Jazieh et al., 2020). Even though these changes were initially implemented to reduce the spread of COVID-19, their benefits to patients are far greater. They address some of the barriers to accessing services and have the potential to save costs to the health system. Each of these opportunities requires adequate training, support, and regulation—whether local health care workers are directly taking on new responsibilities through task shifting or are simply assisting patients to connect to remote support from specialists.

At a global level, the pandemic highlighted the importance of developing trust between health systems and populations. This was demonstrated both at the macro level as trust in health institutions and health messaging was eroded and at the level of health care workers and patients. Building trust requires listening to patients, valuing their priorities, addressing their concerns, and demonstrating caring about their needs. Health care workforce education and trainings can improve health care worker skills through simulations to practice building rapport and creating comfortable environments for patients. Training community health workers who are already living in patients’ communities improves their ability to foster trust in the system (WHO Regional Office for South-East Asia, 2021). Community advocacy groups can advise on key issues to incorporate into the design of educational tools to ensure the trainings reflect patient needs.

International best practices are only as useful as they can be disseminated, appropriately tailored, and effectively implemented in each context. Every health system is unique, necessitating a careful tailoring of international best practices to each country context. Multistakeholder assessment and collaboration will strengthen considerations of the complexities of the respective country’s particular situation (WHO, 2016a). Thorough guidelines detailing a range of policy considerations for improving health care workforce education and training are available from international organizations, such as the WHO, but they require substantial investment of time and resources from each country to identify the best fit for its context and operationalization through policymaking, resource support, and accountability.

In Building the Primary Health Care Workforce of the 21st Century, the WHO recommends each country conduct an assessment of the current state of the health care workforce and a strategic alignment of training (initial, in-service, and ongoing) with the health needs of the country’s population (WHO, 2018). In Transforming and Scaling Up Health Professionals’ Education and Training: World Health Organization Guidelines 2013, the WHO provides specific guidelines for policymakers in each country to increase the size and improve the quality of the health care workforce (WHO, 2013). The WHO provides recommendations in the realms of education and training institutions, accreditation and regulation, financing and sustainability, monitoring and evaluation, and governance and planning, while emphasizing that each government must take ultimate responsibility for identifying what should be prioritized in its respective context (WHO, 2013).

Institutional capacity to design and facilitate updated trainings may vary widely across and within countries; building this capacity may be the first step in updating health care workforce training and education (WHO, 2016a). Similarly, given the role of professional associations in health care workforce training, country contexts without strong professional associations may need to build this capacity as part of its investment in improving health care workforce trainings (WHO, 2016a). The people involved in the process and where in the health system updates are focused depend in part on how decentralized the health care workforce administration is in a particular country and how responsibilities are divided between national and subnational levels (WHO, 2016a). Even if subnational levels of government have the authority to make certain decisions, a coordinated approach—or at least a commitment to knowledge sharing—will likely benefit all involved.

When appropriate, piloting updates to education and training in one geographic area of a country can build evidence to encourage scaling up in the future (WHO, 2016a). This may be a cost-effective strategy if the efficacy of a new approach is not clear. A pilot approach could also be helpful politically, whether or not it is shown to be successful. If it is successful, it will support proponents of scaling up by providing evidence. If it is unsuccessful, it allows for pivoting as needed, rather than entrenchment in an ineffective strategy.

Translating research into practice requires an investment of resources (WHO, 2013). If new research findings or recommendations are not actively disseminated to the appropriate audiences and integrated into relevant standards of practice, they risk never being operationalized. Similarly, practical applications of research often require training. If existing educational standards do not include the new recommendations, formalizing the updates may be needed to protect training institutions. Trainings and any regulations for practitioners must be considered together so that they are updated in alignment. 

Although international professional organizations for different types of health care workers provide guidelines for training and continuing education, continuing education is not always available as recommended in lower-resourced settings (WHO, 2018). Some countries do not currently have adequate training available and accessible for their health care workforce, while others may have trainings that do not align with population needs and priorities (WHO, 2016a). In addition to a lack of availability of opportunities for continuing education, some countries do not require recertification for health care professionals to continue practicing throughout their careers (WHO, 2018). Without the requirements to do so, many professionals may not attend in-service trainings, particularly if they are relatively costly.

In relevant contexts, improving primary and secondary education—particularly in science—can enhance students’ capacities to advance in their education and become health care workers (WHO, 2016a, 2018). Without the foundation of strong primary and secondary education, it will be difficult to succeed in higher education. Some countries may also benefit from efforts to increase secondary education graduation rates, which would expand the pool of students in higher education (WHO, 2016b). As previously mentioned, in some countries it may be necessary to first strengthen the capacity of professionals designing health care workforce education and training (WHO, 2016a). Investing in capacity building for professionals who will be engaged in reforming the system will improve the outcome of the changes. 

Many technological innovations rely on electricity and internet connectivity, which may not be readily available or may be extremely costly in some remote areas (WHO, 2016b). This influences both remote training, that is, can students in rural areas participate in the remote training, and the content of trainings focused on technological skills. Agencies and institutions designing trainings must consider resources and constraints to ensure that the training aligns with technology that will be used in practice; it is more relevant to train health care workers in resource-limited settings based on the actual context in which they work rather than best practices that are not locally available (Suriyawongpaisal et al., 2019; WHO, 2016a). In contexts without sufficient investment in updated technology, advocates could point to the potential for modern technology to expand equitable access to care, especially in rural areas, as well as the potential for cost savings, such as through remote trainings, when relevant. Concerns about data protection and confidentiality may also arise in response to using digital technology; these considerations must be addressed first through each country’s laws and then incorporated into aligned trainings (WHO, 2016b).

Some countries, such as those with small total populations, low population density, or other geographic factors (such as island nations), may face particular challenges in health care workforce education and training (WHO, 2016a). These health care systems may especially benefit from: investing in remote trainings and virtual support; international collaboration on training, accrediting, and regulating; and regional and global knowledge sharing to help countries avoid duplication of efforts and learn from one another’s experiences (WHO, 2016a).

Universal Health Coverage. Thailand is often considered an exemplar of universal health care coverage due to its strong investment and measurable progress over several decades. Beginning in 2002, Thailand has invested heavily in pursuing universal health coverage (Tangcharoensathien et al., 2018). Thailand’s universal health coverage policy covers essential health services for all Thai citizens throughout the life cycle; Thailand’s universal service coverage index has reached 82% (Dhillon et al., 2023; WHO Regional Office for South-East Asia, 2021). The high level of coverage achieved is one reason Thailand is seen as an exemplar in the Southeast Asia region and beyond. Furthermore, more than 98% of people in Thailand are covered by one of the three existing financial risk protection plans (Suriyawongpaisal et al., 2019). In addition to working toward its earlier commitments, Thailand has continued to push for improvements to its health system. In 2019, Thailand launched the Primary Health System Act to improve primary health care efficiency, equity, and quality (Dhillon et al., 2023). Despite the significant progress made in primary health care, 75% of Ministry of Public Health nurses and nearly 69% of Ministry of Public Health doctors in Thailand work at the tertiary level (highly specialized care) (Dhillon et al., 2023). While this pattern is not unique to Thailand, it suggests that further progress at the primary care level may expand equitable access. Health care workforce training is a key approach to supporting this shift.

Village Health Volunteers. Community health workers play an invaluable, if sometimes underappreciated, role in many health systems. In Thailand, community health care workers are called Village Health Volunteers (VHVs). The Thai Ministry of Public Health manages the VHV program, whose success has been recognized globally (Dhillon et al., 2023). Thailand has effectively integrated its more than one million VHVs into health promotion activities central to its primary health care strategy (Dhillon et al., 2023; WHO Regional Office for South-East Asia, 2021). Communities select individuals to serve as VHVs, aiming for one VHV per 10 households (Dhillon et al., 2023). While its current integration of VHVs into the health system has already made Thailand a model in this area, there may be additional contributions for VHVs to make in expanding equitable access to care. Starting from such a solid foundation may provide even greater return on investing in additional trainings for VHVs if the system is in place to maximize their extended capacity.

Accreditation. Thailand applies international standards of accreditation for its educational institutions. Thai medical schools are accredited by the Institute for Medical Education Accreditation (IMEAc), under the Consortium of Thai Medical Schools (COTMES); the Medical Council of Thailand, under the Ministry of Public Health; and the Office of Higher Education Commission, under the Ministry of Education (IMEAc, n.d.). Accreditation guidance is provided by the South East Asia Regional Association for Medical Education (SEARAME), which is under the World Federation of Medical Education (WFME)—originally established under the WHO and World Medical Association (Ha & Siddiqui, 2022; SEARAME, n.d.). As of March 2024, IMEAc has listed twenty-five medical schools as fully accredited, while seven newly founded medical schools are in various stages of accreditation ranging from provisionally accredited with conditions to accredited with reevaluation required every year (IMEAc, 2024).

In 2018, IMEAc was recognized by the WFME (IMEAc, n.d.; Zapata et al., 2021). Recognition by the WFME entails a rigorous assessment process to determine whether the accrediting agency meets international best practices (WFME, n.d.). To maintain high quality, IMEAc continues to review and revise its standards based on updates to the WFME Global Standards for Basic Medical Education; feedback from stakeholders such as the National Congress for Medical Education, the Health Professional Education Reform committee, and medical institutions; and relevant evolving needs and contextual factors in Thailand (IMEAc, 2021). Building in mechanisms for ongoing updates to its standards according to relevant recommendations and advancements in international standards allows IMEAc to uphold its commitment to stringent accreditation of Thai medical schools in line with global best practices.

Cancer Care. Cancer has been Thailand’s leading cause of death since 2000 (Insamran and Sangrajrang, 2020). Although Thailand has made steady progress toward achieving universal health care coverage, there are still gaps in the range of services covered, including cancer care (Hofmarcher et al., 2021). This means that while the proportion of the population in Thailand that has access to the package of basic essential services is high, there is not necessarily a high proportion of the population that can access all relevant specialized services needed for cancer care. On the other hand, while approximately half of cancer patients in middle-income countries experience catastrophic out-of-pocket health spending (more than 30% of annual household income), the level is much lower—approximately 25%—in Thailand (Hofmarcher et al., 2021). This level of financial protection again makes Thailand exemplary. At the same time, the level of catastrophic health spending for cancer patients in Thailand is much higher than for Thailand’s general population, by at less than 5%; there is still room for improvement (Dhillon et al., 2023). 

In addition to its participation in regional commitments, Thailand has made formal country-level commitments to update its health care professional education and training. Thailand has established the Thai Foundation of National Health Professional Education Reform and its National Health Assembly passed the resolution “Transformative health professional education in response to population needs under Thai context” (Dhillon et al., 2023). With increased access to care in Thailand stemming from its prioritization of universal health care coverage but still with a relatively low number of doctors per capita, Thailand developed its own training programs for health care workers to address gaps through task shifting (Suriyawongpaisal et al., 2019).

Beginning in 2006, Thailand has invested, through domestic funding and inclusion in national policies, in a variety of health care workforce training programs to improve the ability of primary care providers to meet the demand for services and specifically to address noncommunicable diseases through integrated care (Suriyawongpaisal et al., 2019). The scope of each training program varies—including but not limited to multisectoral collaboration, management, teamwork, and integrated service delivery—but all include engaging community health care workers and considering local funding (Suriyawongpaisal et al., 2019). 

A cross-sectional study using patient and provider surveys in three regions across Thailand found the training programs that had a positive association with health-related quality of life of patients with multiple chronic conditions were those that focused on training primary care team members on multiple competencies paired with applying those competencies in their specific context (Suriyawongpaisal et al., 2019). These findings align with research in other countries suggesting the importance of contextualized systems-based trainings (Suriyawongpaisal et al., 2019). Further research is needed to strengthen the evidence base across programs, including replicating research in other areas of the country, recruiting a larger sample size, and conducting longitudinal studies and/or ongoing monitoring of programs (Suriyawongpaisal et al., 2019). Building a strong evidence base could inform resource allocation, such as scaling up successful interventions or reforming interventions that are not shown to be as effective  (Suriyawongpaisal et al., 2019). 

Thailand’s progress in expanding access to care is a model for the region and beyond. With political commitment, domestic investment, and locally designed training programs for health care workers, Thailand is well situated to leverage health care workforce training to further increase equitable access to care.

Opportunities to further apply international best practices for health care workforce training include continuing to invest in international best practices, such as simulations, and to rigorously evaluate current efforts to assess impact on equitable access to care and any association with health outcomes. Identifying what is and is not working and transparently sharing the data with relevant stakeholders and policymakers will pave the way for scaling up successful interventions. In addition to increasing simulations, both high fidelity and low fidelity, other hands-on learning opportunities such as job shadowing and internships could support empowering different actors within the system to build their skills.

Challenges for improving health care workforce training include securing investment while balancing competing priorities and barriers seen in other countries in the region, specifically the proportion of doctors and nurses per capita, which is still below the 2016 WHO recommendation (Zapata et al., 2021). Another challenge is advocating for more investment to expand access to cancer care specifically, including expensive treatments that may be difficult to administer given the other health issues competing for resources. Some health issues may be more or less politicized, including when there is a global agenda and funding available to focus on certain diseases. A potential challenge will be the optics of investing in expanding equitable access to cancer care, as it may alter statistics in which Thailand looks extremely strong. For example, Thailand currently has a high index of universal service coverage and a high level of financial risk protection coverage; however, there are still many gaps in specialized services covered—including cancer care (Dhillon et al., 2023; Hofmarcher et al., 2021; Suriyawongpaisal et al., 2019; WHO Regional Office for South-East Asia, 2021). Including more cancer services and adding expensive cancer drugs to the list of essential medicines may influence Thailand’s statistics, as doing so would set the bar higher.

Given the inextricable link between the health care workforce and health care services, improving health care workforce education and training is a key step to operationalizing innovations and expanding access to primary health care. Updated approaches to education and training are needed to improve how multidisciplinary teams within the primary health care system function, particularly considering aging populations and the rise of noncommunicable diseases that are increasing demand for coordinated care over longer periods of time (WHO, n.d., 2016a; WHO Regional Office for South-East Asia, 2019). In addition to increasing equitable access to cancer care, these updates are expected to support improving outcomes across a variety of health issues. As the WHO emphasizes, achieving health objectives such as the SDGs will require serious investment in the health care workforce (WHO, 2016a).

While contextualizing international best practices to each unique health care system is necessary, certain approaches—such as competency-based education, simulations, and remote learning opportunities—should be useful in any context. Collecting data will allow countries to continue to refine and update their training approaches as needed as well as incorporate evidence to guide resource allocation and support advocacy to scale up new approaches as relevant.

Improving health care workforce training to expand equitable access to cancer care requires a high-level multisectoral effort to consider the health care system as a whole to ensure alignment between updated training and how the system operates, including standards, available technologies, responsibilities of different players, accreditation, and accountability mechanisms. Meaningful improvements to health care workforce training must bring together relevant stakeholders to examine educational design; expand educational opportunities (including volunteers, private sector workers, and participants from rural areas); and provide accountability through accreditation and regulation, available technological infrastructure, funding, and the generating of political will. To forge effective partnerships across sectors, roles and responsibilities should be formalized for each partner to promote accountability and clarity (WHO, 2013). Rather than siloed efforts to update trainings for each health care profession, considering the health care workforce as a whole may reveal opportunities for task shifting and otherwise empower different actors to take on new responsibilities that will expand access to care (WHO, 2018).

The overall goal of the WHO’s Global Strategy on Human Resources for Health: Workforce 2030 is stated as “to improve health, social and economic development outcomes by ensuring universal availability, accessibility, acceptability, coverage and quality of the health workforce through adequate investments to strengthen health systems, and the implementation of effective policies at national, regional, and global levels,” emphasizing the interconnectedness of all these factors related to the health care workforce to improve health—and other—outcomes (WHO, 2016a). Just as the improvement of health care workforce training requires inputs from and coordination among a variety of actors, a health care system must have the support in place to leverage the benefits of a better-trained health care workforce to achieve more equitable access to care.

Key Informant

Claire Raether, Senior Training and Education Specialist, ICAP at Columbia University

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