the sub-saharan african medical school study

The Sub-Saharan african Medical School STudy i

The Sub-Saharan African Medical School StudyData, ObservatiOn, anD OppOrtunity

University of Cocody, Cote d’Ivoire Jimma University, Ethiopia

The Catholic University of Mozambique

University of Ibadan, Nigeria

University of Gezira, Sudan

Hubert Kairuki Memorial University, Tanzania

University of Malawi University of Mali

Walter Sisulu University, South Africa

Makerere University, Uganda

Cover art is from a mural at the Catholic University of Mozambique.

The Sub-Saharan african Medical School STudy 1

The Sub-Saharan African Medical School StudyData, ObservatiOn, anD OppOrtunity

2 The Sub-Saharan african Medical School STudy

authOrs

The Secretariat: Fitzhugh Mullan, Seble Frehywot, Candice Chen, Ryan Greysen, Travis Wassermann, Heather Ross, Huda

Ayas, Selam Bedada Chale, Soeurette Cyprien, Jordan Cohen, Tenagne Haile-Mariam, Ellen Hamburger, Laura Jolley,

Gilbert Kombe, Andre-Jacques Neusy

The Advisory Committee: Francis Omaswa, Diaa ElDin ElGaili Abubakr, Magda Awases, Charles Boelen, Mohenou Jean-

Marie Isidore Diomande, Delanyo Dovlo, Josefo Ferro, Abraham Haileamlak, Jehu Iputo, Marian Jacobs, Abdel Karim

Koumaré, Mwapatsa Mipando, Gottleib Lobe Monekosso, Emiola Oluwabunmi Olapade-Olaopa, Paschalis Rugarabamu,

Nelson Sewankambo

The Partnering Institution: Eric Buch, Patiswa Zola Njongwe


The authors of the Sub-Saharan Medical School Study would like express our sincere appreciation to the ten medical

schools who hosted study site visits, their administrators, and their students. Without these institutions and people, this

study would not have been possible. Thank you to everyone for your hospitality, patience, and honesty.

» College of Medicine, University of Ibadan

» College of Medicine, University of Malawi

» Hubert Kairuki Memorial University

» Jimma University School of Medicine

» Makerere University School of Medicine

» The Catholic University of Mozambique Faculty of Medicine

» Walter Sisulu University School of Medicine

» University of Cocody School of Medicine

» University of Gezira Faculty of Medicine

» University of Mali Faculty of Medicine

saMss site visit institutiOns


acknOwleDgeMents

The authors of the Sub-Saharan Medical School Study would like to thank the following people for helping to make

this study and report possible: Mushtaq Ahmed; Brownell Anderson; Bruce Andinda; Hortenzia Beciu; Markley Boyer;

Robin Broadhead; Kathy Cahill; Jim Campbell; Lincoln Chen; Jan de Maeseneer; John Donnelly; Gilles Dussault;

Loveness Dzikiti; Ali Habour; Laura Hambleton; Dan Hunt; Art Kaufman; Patrick Kelley; Barry Kistnasamy; Joseph C.

Kolars; Wuleta Lemma; John Mellors; Keto Mshigini; John Norcini; Angus O’Shea; Steve Reid; M. Roy Schwartz; Brenda

Sekabembe; Gulzar Shah; Michael Sinclair; Esamai Songa; Salif Sow; William Stones; Wim Van Damme; J.P. de Van

Neikerk; Anvarali Velji; Waratch Wakunga

FunDing

The Sub-Saharan African Medical School Study was funded by the Bill & Melinda Gates Foundation. The SAMSS team is

deeply grateful to the Bill & Melinda Gates Foundation for its foresight in investing in the education of Africa’s next genera-

tion of doctors and leaders.

in MeMOriaM

Gilbert Kombe, one of the authors of this Study, passed on November 6th, 2009. His contributions as a clinician, professor,

leader, mentor, friend, husband, and father will be missed.


Acronyms 8

Executive Summary 10

Introduction and Background 10

Sub-Saharan African Medical School Study 10

SAMSS Research Plan 10

SAMSS Findings 12

SAMSS Recommendations 15

Chapter 1: Introduction and Background 17

The SAMSS Team 18

Medical Schools in Sub-Saharan Africa 21

Key Informant Interviews 26

Methods

Results

Chapter 2: Literature Review and Synthesis 28

Introduction 28

Methods 28

Findings 30

Innovation

Capacity

Retention

Conclusion

Limitations 41

Chapter 3: Site Visit Report 42

Introduction 42

Selection of Site Visited Schools

Methods 42

Pre-Visit Data Collection

Site-Visit Data Collection

Results 44

General Findings

Challenges

Innovations

Limitations 62

Chapter 4: Survey Report 63

Introduction 63

Methods 63

Study Design

Survey Instrument

Study Population and Sample

Survey Implementation and Protocol

Analysis

Core Characteristics of the Medical Schools

Core Characteristics—Summary

Undergraduate Students

Undergraduate Students—Summary

Post Graduate Students

Post Graduate Students—Summary

Teaching Staff

Teaching Staff—Summary

Resources and Facilities

Resources and Facilities—Summary

Relationships with External Organizations

Relationships with External Organizations—Summary

Barriers and Innovations

Barriers and Innovations—Summary

Multivariable Analyses

Multivariable Analyses—Summary

Limitations 106

Chapter 5: Discussion 108

Chapter 6: Recommendations 111

References 114

table OF cOntents


tables anD Figures

Tables

Table 1: SAMSS Secretariat Members

Table 2: SAMSS Advisory Committee Members

Table 3: Medical Schools in Sub-Saharan Africa

Table 4: Online Resources Used in the Literature Review

Table 5: Site Visited Schools

Table 6: Greatest Needs for Increasing the Quality and

Number of Graduates

Table 7: Focus of Innovations Reported by Survey

Respondents

Table 8: Strategies Implemented to Improve Medical

Doctor Retention in a Country

Table 9: Components of Medical School Resource Indices

for Correlative Analyses

Table 10: Significant Correlations Seen in Analysis of

Resources

Table 11: Significant Correlations Seen in Analysis of

Barriers

Table 12: Significant Associations Seen in Correlative

Analyses

Figures

Figure 1: SAMSS Organizational Chart

Figure 2: Key Literature Review Findings

Figure 3: Journals with 10 or More Publications

Regarding Medical Education

Figure 4: Countries Described in Published Works

Figure 5: Location of Primary Institutional Affiliation of

First Author of Published Works

Figure 6: Survey Plan

Figure 7: Survey Responses by Region and Language of

Instruction

Figure 8: Date of Establishment of Schools by Ownership

Figure 9: Other Categories of Health Workers Trained at

Responding Medical Schools

Figure 10: Medical School Tuition and Sources of Medical

School Income

Figure 11: Annual Expenditures for Medical Schools

Figure 12: Number of First Year Enrollments

Figure 13: Number of Medical School Graduates (2008)

Figure 14: Percent Change in First year Enrollment over

Past Five Years

Figure 15: Planned increase in Enrollment over Next Five

Years

Figure 16: Likelihood of Reaching Goal Enrollment

within Five Years

Figure 17: Mandates to Increase Enrolment

Figure 18: Focused Recruitment and Reserved Positions

Figure 19: Number of Years Required to Graduate

Figure 20: Use of Learning Approaches

Figure 21: Student Research Project Requirements for

Graduation

Figure 22: Mean Location of Medical School Graduates

Five Years After Graduation

Figure 23: Percentage of Graduates Reported to have

Emigrated Outside of Africa

Figure 24: Graduate Tracking by Medical Schools

Figure 25: Compulsory Service Requirements by Country

Figure 26: Post-Graduate Training Offered In SSA

Medical Schools

Figure 27: Number of Teaching Staff


Figure 28: Percent of Available Faculty Positions Vacant

Figure 29: Percent of Faculty Positions Filled by Women

or Foreign-born Personnel

Figure 30: Primary Sources of Teaching Staff Salaries

Figure 31: Percent of Faculty who Supplement Income

Through Private Practice

Figure 32: Net Percentage Change in Faculty over the Past

Five Years

Figure 33: Reasons for Staff Loss

Figure 34: Percent of Faculty Involved in Grant Supported

Research

Figure 35: Measures to Support Research

Figure 36: Adequacy of Student and Teaching Resources

Figure 37: Adequacy of Technology Resources

Figure 38: Adequacy of Clinical Teaching Sites

Figure 39: Participation of External Organizations in

Setting Medical School Priorities

Figure 40: Set Competencies for Medical Doctors by

Country Governments or Professional Councils

Figure 41: Measurement Tools for Competencies, Tasks,

or Skill Lists

Figure 42: School Participation in Setting Country

Strategies or Policies

Figure 43: Medical School International Collaborations

Figure 44: Barriers to Improving the Quality of Graduates

Figure 45: Barriers to Increasing the Number of

Graduates

Figure 46: Barriers to Increasing the Number of Medical

Doctors in a Country

Appendixes

Appendix 1: Letter of Introduction to Medical Schools

Appendix 2: Survey of Medical Schools

Appendix 3: Letter to Deans

Appendix 4: Informed Consent Form

Appendix 5: Letters of Support for SAMSS

Appendix 6: Site Visit Reports

Appendix 7: Innovations Implemented to Address

Barriers to Increasing Number and Quality of Doctors

Trained

Appendix 8: Key Informants


acrOnyMs

AAMC Association of American Medical

Colleges

ACHEST African Centre for Global Health and

Social Transformation

AFRO WHO African Region

AIDS Acquired Immune Deficiency Syndrome

CBE Community Based Education

Ch.B Bachelor of Surgery

CIDMEF Conférence Internationale des Doyens et

des Facultés de Médecine d’Expression

Française (French)

CINAHL Cumulative Index to Nursing and Allied

Health Literature

COBES Community Based Education and

Service

COM College of Medicine

DDS Doctor of Dental Surgery

DRC Democratic Republic of Congo

DSc Doctor of Science

ERIC Educational Research Information

Clearinghouse

FAIMER Foundation for Advancement of

International Medical Education and

Research

FCS Fellow of the College of Surgeons

FMUG Faculty of Medicine of the University of

Gezira (Sudan)

FRCP Fellow of the Royal College of Physicians

FRCS Fellow of the Royal College of Surgeons

FWACP Fellow of the West African College of

Physicians

FWACS Fellow of the West African College of

Surgeons

GHWA Global Health Workforce Alliance

GWU George Washington University (USA)

HIV Human Immunodeficiency Virus

HKMU Hubert Kairuki Medical University

(Tanzania)

HMPP Health Management Planning and Policy

HRH Human Resources for Health

IIME Institute for International Medical

Education

IT/ICT Information Technology/Information

Communications Technology

JLI Joint Learning Initiative

KCMC Kilimanjaro Christian Medical Centre

(Tanzania)

MA Master of Arts

MB Medicinae Baccalaureus (Bachelor of

Medicine)

MBBS Bachelor of Medicine and Bachelor of

Surgery

MBChB Bachelor of Medicine, Bachelor of

Surgery

MD Medical Doctor

MDG Millennium Development Goal


Mdent Master in Dentistry

MMed Master in Medicine

MOE Ministry of Education

MOH Ministry of Health

MPH Masters in Public Health

MSc Master of Science

MWACP Member, West African College of

Physicians

NEPAD New Partnership for Africa’s

Development

NGO Non Governmental Organization

NORAD Norwegian Agency for Development

Cooperation

NPC Non-Physician Clinician

Ob/GYN Obstetrics and Gynecology

OSCE Observed-Structured Clinical Exam

PBL Problem Based Learning

PGME Post Graduate Medical Education

PHC Primary Health Care

PhD Doctor of Philosophy

PPP Purchase Power Parity

QARA Quality Assurance and Relevance Agency

(Ethiopia)

QECH Queen Elizabeth Central Hospital

(Malawi)

RN Registered Nurse

RSC Research Support Centre

SADC Southern African Development

Community

SAHCD Southern Africa Human Capacity

Development

SAMSS Sub-Saharan African Medical School

Study

SD Standard Deviation

SMSB Sudan Medical Specializations Board

SSA Sub-Saharan Africa

SWAp Sector Wide Approach

TUFH The Network Towards Unity For Health

UK United Kingdom

UNESCO United Nations Educational Scientific

and Cultural Organization

UNITRA University of Transkei (see Walter Sisulu

University)

UP University of Pretoria (South Africa)

USA United States of America

USAID United States Agency for International

Development

USD United States Dollar

WebCT Web-based Course Tools

WFME World Federation of Medical Education

WHO World Health Organization

WSU Walter Sisulu University (South Africa)

(See UNITRA)


Introduction and Background

Africa suffers 24% of the world’s total burden of disease but

has only 3% of the world’s health workforce1. Many types of

health workers are required to maintain a working health

system, but no health system will function well without an

adequate core of doctors to serve as clinicians, managers,

teachers, and policymakers. This realization has garnered

global attention in recent years. Sub-Saharan Africa (SSA)

has an estimated 145,000 physicians2 to serve a population

of 821 million3. As a whole, SSA has a physician to popu-

lation ratio of 18/100,000, as compared to other countries,

such as India (60/100,000)2, Brazil (170/100,000) 2 and the

United States (270/100,000). 2 Africa’s poorest countries

face even greater physician workforce shortages.1,3

The very low physician to population ratios in Sub-Saharan

African countries are a result of a number of factors includ-

ing small numbers of medical schools with modest out-

puts of students. There are 168 medical schools in the 48

countries of Sub-Saharan Africa. These schools are esti-

mated to graduate 10,000 physicians per year. The chal-

lenges of medical workforce development are compounded

by the subsequent emigration of many graduates to North

American, European and Persian Gulf countries. Any con-

tinental effort intended to stabilize and improve health sys-

tem functioning in Sub-Saharan Africa must consider the

options for increasing the productivity of medical educa-

tion in the region and improving the retention of the grad-

uates of all schools.

In order to make significant gains in the size of the physi-

cian workforce in the countries of SSA, attention must be

focused on the role and the results of medical education

as an essential element of broader health workforce strat-

egy. Interest has been building in strategic investment in

African medical education, but little is known about the sta-

tus of this education or the trends within it on a continental

level. This lack of pan-African data and perspective has been

a problem for organizations intent on following evidence-

informed policies to address physician workforce shortages.

Sub-Saharan African Medical School Study

The Sub-Saharan African Medical School Study (SAMSS)

is an examination of the state of medical education in

Sub-Saharan Africa including all countries, all identi-

fied and recognized schools, and all languages of instruc-

tion. The study was undertaken to help provide a platform

of understanding regarding the status, trends and present

and future capacity building efforts for educators, policy

makers, and international organizations. While the results

of the Study provide valuable and actionable information

about Sub-Saharan African medical education, the study

is “landscaping” in nature. It provides detailed insight into

certain schools and general information about others. The

Findings and Recommendations of the Study address gen-

eral themes and promising innovations. It is intended that

they will increase practical knowledge about medical edu-

cation in SSA in order to better inform educators, national

policy makers and potential funders about the challenges

and opportunities in the field. These stakeholders can lever-

age the information from this study to increase the capac-

ity of African medical schools and encourage the retention

of doctors, which in turn would improve the health of their

countries’ populations.

SAMSS Research Plan

The work of SAMSS began with a comprehensive litera-

ture review and a series of key informant interviews to

gain a complete, overall picture of medical education in

executive suMMary


SSA. Primary data was gathered using two techniques;

site visits of selected schools and a survey of all identified

schools. Site visits were made to ten medical schools gath-

ering onsite and largely qualitative information about each

school in its national context. The selected schools repre-

sent a mix of geography, language of instruction, age of

school, ownership type, and curriculum types, chosen as a

group to reflect the continental variability of these institu-

tions. The participating schools are:

» College of Medicine, University of Ibadan (Nigeria)

» College of Medicine, University of Malawi

» Hubert Kairuki Memorial University (Tanzania)

» Jimma University School of Medicine (Ethiopia)

» Makerere University School of Medicine (Uganda)

» The Catholic University of Mozambique Faculty

of Medicine

» Walter Sisulu University School of

Medicine (South Africa)

» University of Cocody School of Medicine

(Cote d’Ivoire)

» University of Gezira Faculty of Medicine

(Sudan)

» University of Mali Faculty of Medicine

Site visit teams included two members of the

Secretariat and two members of the Advisory

Committee. Site visits followed a semi-struc-

tured interview protocol, and included meet-

ings with the medical school administrative

leadership, faculty members, students, and

clinical instructors, as well as public offi-

cials at the ministries of health and education

and the national medical council or equiva-

lent. Capacity development, innovation, and

retention were constant themes in all visits.

The site visits took place between May, 2009 and February,

2010. Each site visit concluded with the visitors delineat-

ing a series of findings concerning the school, its challenges

and successes.

The second data gathering instrument was a descriptive

survey including quantitative and qualitative questions

sent to all identified SSA medical schools. The requested

information included institutional characteristics, funding,

students, faculty, curriculum, school infrastructure, and

barriers to scaling up the numbers and quality of medi-

cal doctors trained. Questionnaires also provided space for

qualitative inputs from respondents. A response rate of 72%

(105 responses to 148 surveys) was achieved. The survey

study was coordinated and the questionnaires reviewed by

a research team at the University of Pretoria in conjunction

with the Secretariat at GWU.


Following the final site visit and the close of the survey

study, the Secretariat grouped, organized and prioritized

all of the site visit findings and performed a descriptive

analysis of the survey results. After extensive consulta-

tion with the advisory committee, 14 issues were endorsed

as the final SAMSS Findings. These are divided into three

groups: general findings, challenges, and innovations.

SAMSS Findings

General FindinGs

1) Many countries are prioritizing the scale up of

medical education as part of overall health sector

strengthening.

There is a high level of interest in expanding and

improving medical education in Sub-Saharan Africa. In

many cases, expansion is being advanced by national,

regional and local governments – drafting long term

plans, making major financial commitments, and focus-

ing on the retention and distribution of medical gradu-

ates. This has resulted in substantial positive energy in

many medical schools. In countries where governments

have national plans for the scale up of human resources

for health, medical education and physician capacity

are benefitting.

2) Physician “brain drain” is a special problem for medical

education.

The emigration (external brain drain) of faculty mem-

bers and specialized doctors poses a particular prob-

lem for the stability and growth of medical education.

Internal brain drain, or loss of physicians and medi-

cal school faculty to non-governmental organizations

(NGOs), is an additional challenge to medical education

and public health care systems. Medical schools have

difficulty competing with NGO salaries and benefits.

3) accreditation and quality measurement are important

developments for standardizing medical education

and physician capabilities.

Many countries have instituted accreditation policies

for medical schools and some have developed certification

exPanSion of Survey reSPonding Medical SchoolS in Sub-Saharan africa

eSTiMaTed locaTion of docTorS 5 yearS afTer graduaTion


standards for doctors. While these are not uniform, they

represent significant benchmarks for medical education

and important efforts to standardize the quality of medi-

cal training and physician practice. There are also some

efforts to create regional standards which would provide

economies of scale in testing and the ability to share eval-

uation resources.

ChallenGes

4) The status of the country’s health system affects medi-

cal education and physician retention.

In some countries there is a mismatch between the

number of medical students trained and the number of

doctors the government can employ, creating a failure of

absorption and contributing to physician emigration. In

many countries a private sector is developing which may

increase physician absorption, but the preponderance of

jobs for medical graduates remains in the public sector.

Therefore, positions available, reasonable compensa-

tion, good management, opportunities for advancement

and further training, and personal security all are criti-

cal to the retention of medical graduates. Further, lack

of infrastructure (clinical supplies, IT, basic utilities) can

discourage physicians from practicing in rural areas.

5) coordination among ministries of education and min-

istries of health improves medical schools’ ability to

increase health workforce capacity.

Ministries of education fund medical schools, effectively

determining the number of doctors available for prac-

tice. Ministries of health hire medical graduates and

are responsible for national staffing of health care sys-

tems. Coordination between the ministries of education

and health for the purposes of planning, budgeting, and

managing educational outcomes is essential and often

not as effective as it might be.

6) Shortages of medical school faculty are endemic and

problematic.

Despite innovations at many schools to improve fac-

ulty recruitment and retention through financial and

nonfinancial incentives (such as salary top ups, research

support, housing, educational support for families),

substantial and long term faculty scarcities remains a

major barrier to medical school expansion. Areas that

are particularly problematic are the basic sciences,

where few scientists are trained, and specialty physi-

cians, whose numbers are few and for whom emigration

is a constant threat. Some schools rely heavily on expa-

triate faculty from Europe or North America but this is

seen by all as a temporary solution.

7) Problems with infrastructure for medical education are

ubiquitous and limiting.

Medical schools are demanding institutions. They

require basic services such as an adequate physi-

cal plant and a dependable source of power as well as

laboratories, classrooms, hostels, teaching aids, books,

libraries, journals, computers, connectivity, and clini-

cal teaching sites. Some schools have been innovative

in developing their own income generating activities in

order to support education activities. However, infra-

structure continues to pose a major educational chal-

lenge in many settings and warrants strategic attention

and investment.


8) variability in secondary school quality creates

challenges in medical school admissions.

The variability of secondary education in many set-

tings presents a problem for medical educators, partic-

ularly in increasing the number of students from rural

and underserved areas. Some schools have implemented

pre-university preparatory programs to ready students

for the medical school curriculum. However, prepara-

tory programs are an additional cost burden for medical

schools and students.

innovations

9) educational planning that focuses on national health

needs is improving the ability of medical graduates to

meet those needs.

At government and individual school levels, increas-

ing emphasis is being placed on educational curricu-

lums focusing on priority health needs of the country.

Context-focused approaches to medical education are

improving the ability of graduates to address national

health problems. Many countries now require national

service from physicians after graduation, effectively pro-

viding physicians to rural and underserved communi-

ties in return for the educational and vocational benefit

of a medical education.

10) international partnerships are an important asset for

many medical schools.

Many medical schools have developed partnerships with

medical schools, universities, and funding organizations

in other countries. These partnerships support teaching,

service and research activities, through visiting faculty,

program development, and research collaborations.

11) impressive curricular innovations are occurring in

many schools.

There are significant areas of curricular and teaching

innovation taking place at many schools designed to

meet local and regional health care needs. Innovations

often involve critical thinking skills and community-

based education (CBE), both of which reflect innova-

tions taking place globally in medical education. These

innovations address regional needs by teaching prob-

lem-solving skills for work in any setting and by tak-

ing learning to communities where health needs are

greatest. Other advances include the teaching of family

medicine and public health and plans for the use of tele-

health and distance learning when bandwidth problems

can be solved.

12) beyond the creation of new knowledge, research is an

important instrument for medical school faculty devel-

opment, retention, and infrastructure strengthening.

While research remains limited at most medical schools

due to limited funds and lack of experienced faculty,

schools that have succeeded in establishing funded

research enterprises, benefit from a significant posi-

tive effect on faculty development and retention. Some

schools have also demonstrated that research revenues

can be used to further strengthen the school’s educa-

tional infrastructure.

13) Private medical schools hold promise for adding to

physician capacity development.


Secular and faith-based, not-for-profit medical schools

are open and graduating physicians and contributing to

national workforce development. Private schools have

special challenges including reliance on tuition, optimiz-

ing government and international linkages, sustainabil-

ity and growth over time.

14) Post-graduate medical education is an important

element of a national health system development

strategy.

The presence of post-graduate training programs is an

important aspect of a country’s medical education sys-

tem and prospects for physician retention. The principle

reason cited by ambitious medical graduates for emi-

grating is the pursuit of post-graduate training. Local

residency programs focused on priority national health

needs are both a mechanism for developing national

capacity and a way of retaining medical graduates.

SAMSS Recommendations

Strong health systems are central to the attainment of

health equity, and lack of human resources is a key obsta-

cle to the attainment of strong health systems. Physicians

are a core component of the human resource pool, and

Sub-Saharan Africa needs more physicians while ensur-

ing the quality and relevance of medical school graduates.

It also needs strong medical schools in Africa which are

accredited to assure quality, well-resourced, and relevant to

national health needs. Therefore the SAMSS team proposes

the following set of recommendations to medical schools,

professional associations, governments, regional bodies,

international partners, and donors:

1. launch campaigns to develop Medical School faculty

capacity including recruitment, Training,

and retention

2. ramp up investment in Medical education

infrastructure

3. institute Structures to Promote inter-Ministerial

collaboration for Medical education

4. fund research and research Training at Medical Schools

5. Promote community oriented education based on

Principles of Primary health care

6. establish national and regional Post-graduate

Medical education Programs to Promote excellence

and retention

7. establish national or regional bodies responsible

for accreditation and Quality assurance of

Medical education

8. increase donor investment in Medical education

aligned with national health needs

9. recognize and review the growing role of Private

institutions in Medical education

10. revitalize the association of Medical Schools in africa

Africa suffers 24% of the world’s total burden of disease but has only 3% of the world’s

health workforce.


Health in Africa matters, both because it is an intrinsic

good and because it is necessary for the improvement of

global health and development. This realization has gar-

nered global attention in recent years. Africa suffers almost

25% of the world’s total burden of disease but has only 3%

of the world’s health workforce1. Within that health work-

force, Sub-Saharan Africa has only an estimated 145,000

physicians–fewer than the United Kingdom–to serve a

population of over 800,000,000 people, about equal to that

of all of Europe3. Though a health workforce has many

components, no health system can be complete without an

adequate supply of doctors who serve as clinicians, man-

agers, leaders, teachers, and policymakers. Sub-Saharan

Africa’s total of 18 physicians per 100,000 population falls

far short of other countries, such as India (60/100,000)2

Brazil (170/100,000)2 and the United States (270/100,000);2

Africa’s poorest countries face even greater physician work-

force shortages1,3.

Recently, much discussion has highlighted the role of

“brain drain” in limiting Africa’s supply of physicians.

However, although emigration is significant, less than

15% of doctors trained in Sub-Saharan Africa emigrate to

the United States, United Kingdom, Canada, or Australia

(some of the biggest recipient countries)4, meaning that

the vast majority stay and practice in Africa. Therefore, in

order to make significant gains in the supply of physicians,

attention must focus on the role and the results of medical

education as a critical element of a broader health work-

force strategy. Interest has been building in strategic invest-

ment in African medical education, but little is known

about the status of medical education or the trends within

medical education on a continental level. This lack of pan-

African data has been a major barrier to organizations hop-

ing to develop evidence-informed policies to address physi-

cian workforce shortages.

The Sub-Saharan African Medical School Study (SAMSS) is

the first comprehensive study on the state of medical educa-

tion in Sub-Saharan Africa (SSA). SAMSS analyzes the cur-

rent state of medical education in the region and describes

the emerging innovations and trends that will shape the

future of medical education in Africa. SAMSS has used

several benchmarking methods, including key informant

interviews, representative case studies, and a data gathering

survey of Sub-Saharan African medical schools to gain new

insight into the education and retention of medical profes-

sionals on the African continent.

The purpose of this study is to increase the practical knowl-

edge about medical education in SSA in order to better

inform educators, national policy makers, and potential

funders about the challenges and opportunities in the field.

These stakeholders can leverage the information from this

study to increase the capacity of African medical schools

and encourage the retention of doctors, which in turn

would improve the health of their countries’ populations.

SAMSS began with a comprehensive literature synthesis

and a series of key informant interviews to gain a com-

plete picture of the recent past of medical education in

SSA. SAMSS then gathered detailed insight into the cur-

rent practices and future plans of the ten medical schools

selected as case studies. This in-depth information was sup-

plemented by the more general information collected from

other medical schools through the SAMSS survey. The col-

lective insights from these methods provide an evidence

base to guide policymakers and potential investors who

wish to strengthen medical education in SSA. This report

will conclude with a set of ten specific, actionable recom-

mendations. Additionally, the report will note areas merit-

ing further study.

chapter 1: intrODuctiOn anD backgrOunD


The SAMSS Team

SAMSS is a multinational, multi-institutional collaboration of medical educators, medical education researchers, and poli-

cymakers. The individuals involved in SAMSS were either members of the Secretariat, the Advisory Committee, or the

Partnering Institution. All participants met near the beginning of the project to discuss expectations and directions, col-

laborated with close communication through the project, and met near the end of the project to discuss uses and dissemi-

nation of the findings.

GW

U A

dministrative Support

Partnering InstitutionUniversity of Pretoria

South Africa

Co-chair of Advisory Committee

Francis Omaswa

GWU Co-PISeble Frehywot

Advisory CommitteeMembers

10 from visitedmedical schools

5 general field experts

GWU AssistantResearch Professor

GWU FacultySite Visiting Team

Selected Medical SchoolsIn Africa

Consultants

GWU PI & Co-chair of Advisory Committee

Fitzhugh Mullan

GWU AdministratorSoeurette Cyprien

GWU ResearchAssociates

figure 1: organizaTion charT for The SaMSS TeaM


The Secretariat was based at the George Washington University in Washington, DC. Fitzhugh Mullan, MD and Seble

Frehywot, MD, MSHA led the GWU team as Co-Principal Investigators on the Study. The Secretariat’s responsibilities

included managing the key informant interview process, making logistical arrangements for meetings and site visits, con-

tributing to the development and analysis of the SAMSS survey, gathering and analyzing qualitative data in the site vis-

its, and synthesizing site visit reports as well as the final report. The Secretariat works in consultation with the Advisory

Committee. The Secretariat is comprised primarily of George Washington University School of Medicine faculty and

Department of Health Policy faculty and staff.

Fitzhugh Mullan, MD Principal Investigator and Co-Chair of the SAMSS Advisory Committee; Murdock Head Professor of

Medicine and Health Policy, George Washington University

Seble Frehywot, MD, MHSA Co-Principal Investigator; Assistant Research Professor of Health Policy and Global Health, George

Washington University

Huda Ayas, EdD Executive Director, International Medicine Program, George Washington University

Candice Chen, MD, MPH Assistant Professor of Pediatrics, Department of Health Policy, George Washington University

Selamawit Bedada Chale Presidential Administrative Fellow, Master of Public Health Candidate, George Washington University

Jordan J. Cohen, MD Professor of Medicine and Public Health, George Washington University, President Emeritus, Assn. of

American Medical Colleges

Soeurette Cyprien Research Associate, Department of Health Policy, George Washington University

S. Ryan Greysen, MD, MA Robert Wood Johnson Clinical Fellow, Yale University School of Medicine

Tenagne W. Haile-Mariam, MD Assistant Professor of Emergency Medicine, Medical Faculty Associates, George Washington

University

Ellie K. Hamburger. MD Associate Professor of Pediatrics, George Washington University

Laura J. Jolley, MPH Research Associate, Department of Health Policy, George Washington University

Gilbert Kombe, MD, MPH Senior HIV/AIDS & Health Systems Technical Advisor, Abt Associates, Inc. (deceased)

Andre-Jacques Neusy, MD, DTM&H Executive Director and co-founder of THEnet (Teaching for Health Equity Network)

Heather R. Ross, MPH Research Associate, Department of Health Policy, George Washington University

Travis Wassermann, MPH Senior Research Assistant, Department of Health Policy, George Washington University

Michael E. Whitcomb, MD Vice President for Medical Education Emeritus, American Association of Medical Colleges

Table 1: SaMSS SecreTariaT


Table 2: The SaMSS adviSory coMMiTTee

Magdalena Awases PhD,MA, HMPP, RN Regional Advisor for Human Resources for Health (HRH) Development, AFRO

Charles Boelen MD, MPH, MSc Former WHO HRH Chief and AFRO Representative

Mohenou Isidore Jean-Marie Diomande MD Dean of the School of Medicine, University of Cocody, Cote d’Ivoire and President of CIDMEF

Dela Dovlo MB Ch.B, MPH, MWACP Former Director, HRH, Ministry of Health, Accra, Ghana

Diaa Eldin El Gali Abu Bakr MD Director, Education Development and Research Centre, Professor of Psychiatry, Head of Dept. of

Mental Health, Faculty Of Medicine, University of Gezira

Josefo João Ferro MD Dean of the Faculty of Medicine, Catholic University of Mozambique

Abraham Haileamlak MD Associate Professor of Pediatrics and Child Health, Faculty of Medical Sciences, Jimma University,

Ethiopia, Editor in Chief, EJHS

Jehu Iputo MBChB, PhD Vice Dean, Faculty of Health Sciences, Walter Sisulu University, South Africa

Marian Jacobs MBChB Dean of the Faculty of Health Sciences, University of Cape Town, South Africa

Abdel Karim Koumaré MD, MPH Professor of Anatomy and Surgery, Faculty of Medicine, University of Mali

Mwapatsa Mipando MSc, PhD Head of Physiology and Dean of Students, College of Medicine, University of Malawi

Emiola Oluwabunmi Olapade-Olaopa MD,.

FRCS, FWACS

Senior Lecturer, Department of Surgery, College of Medicine, University of Ibadan, Nigeria

Francis Omaswa MBChB, MMed, FRCS, FCS Former Director, Global Health Workforce Alliance, and present Executive Direct or of ACHEST

(Co-Chair)

Paschalis Rugarabamu DDS, Mdent Deputy Vice Chancellor for Academic Affairs, Hubert Kairuki Memorial University, Tanzania

Nelson K. Sewankambo MBChB, M.Sc,

M.Med,

Professor of Medicine and Principal of Makerere University College of Health Sciences, Uganda

The African Advisory Committee consisted of represen-

tatives of the ten African medical schools that were site

visited as well as five policy leaders and African medi-

cal educators serving as at-large members. Dr. Francis

Omaswa of Uganda and Dr. Fitzhugh Mullan served as

co-chairs. Several criteria were used to select the Advisory

Committee members. First, each of the ten selected site

visit schools was invited to nominate a faculty member to

the Committee. Five other individuals with knowledge of

medical education in Africa were then invited to join the

committee as ‘at large’ members. The committee brought a

wealth of information to the process, as the school faculty

members have a deep knowledge of their own institutions

and the ‘at large’ committee members have a broad under-

standing of medical education generally.

The Committee provided orientation, advice, and direc-

tion to the GWU research team; served as participant site

visitors with their GWU colleagues on all case studies; co-

authored site visit and final reports; reviewed the survey

instruments; co-developed final recommendations; and

provided learning, leadership, and networking opportuni-

ties for this group of African medical educators in an effort

to facilitate their future participation in continental medi-

cal educational policy development and implementation.

The Advisory Committee and Secretariat met in Kampala,

Uganda, in February 2009. This meeting served several pur-

poses, including team building, explaining the study and

the committee members’ roles in it; reviewing of the survey

instrument and interview protocols; and logistical planning.


CounTRy SChooL nAME ownERShIP FounDIng DATE

Angola Faculdade de Medicina, Agostinho Neto

Universidade Jean Piaget de Angola

Universidade Jose Eduardo dos Santos

Universidade Mandume Ya Ndemofayo

Universidade Lueji

Faculdade de Medicina Universidade Katyavala Bwila

Universidade Onze de Novembro

Public

*

**

**

**

**

**

1963

*

**

**

**

**

**

Benin Faculté de Médecine, Université de Parakou

Faculté des Sciences de la Santé de Cotonou

Public

Public

2001

1968

Botswana University of Botswana School of Medicine Public 2009

Burkina Faso Institut Supérieur des Sciences de la Santé

Ecole Supérieure des Sciences de la Santé, Université d’Ouagadougou

Public

*

2005

*

Burundi Faculty of Medicine, University of Burundi Public 1968

Cameroon Faculté de Médecine et des Sciences Biomédicales, Université de Yaoundé

Faculté de Médecine et des Sciences Pharmaceutiques de Douala

Université des Montagnes

Université de Buea

Public

Public

Private Not for Profit

*

1969

2006

2000

*

Central African

Republic

Faculté de Sciences de la Santé de l'Université de Bangui Public 1976

Chad University of N'djamena * *

Comoros Ecole de Médecine et de Santé Publique * *

Republic of Congo Université Marien Ngouabi de Brazzaville Public 1975

Côte d'Ivoire UFR Sciences Médicales d’Abidjan

UFR Sciences Médicales de Bouake

Public

Public

1962

1997

Table 3: Medical SchoolS in Sub-Saharan africa

Medical Schools in Sub-Saharan Africa

Note: A school is considered a medical school if it was actively training undergraduate medical doctors as of the summer

of 2010. Ownership and Founding Date (the date a school first started training medical doctors) are listed for all medical

schools that responded to the SAMSS survey. The schools that the SAMSS team attempted to survey but did not receive a

response from (either because the school did not successfully receive the survey or because it did not complete a received

survey) are marked with one asterisk (*). Schools that began to admit medical students or were identified after the close of

the survey period (December, 2009) are marked with two asterisks (**).



Democratic Republic of

Congo

Faculté de Médecine, Université Catholique de Bukavu

Goma University

Université Adventiste de Lukanga

Université Catholique de Bandundu

Université Catholique de Graben

Université Chrétienne Internationale

Université Chrétienne Kinshasa

Université Evangélique en Afrique de Bukavu

Université de Kinshasa

Université de Kisangani

Université Kongo

Université Mbujimayi

Université Notre Dame du Kasayi

Université Protestante au Congo

Université Protestante de Kimpese

Université Simon Kimbangu

Université Simon Kimbangu de Bukavu

Université Technologique Bel Campus

Université de Lubumbashi


Public

**

**

**

**

**

**

*

*

*

*

**

**

**

**

**

**

*

1990

1994

**

**

**

**

**

**

*

*

*

*

**

**

**

**

**

**

*

Djibouti Ecole de Médecine de Djibouti ** **

Equatorial Guinea Universidad Nacional de Guinea Ecuatorial ** **

Eritrea Orotta School of Medicine Public 2004

Ethiopia Adama University

Arbaminch School of Medicine

Defense Health College, Medical School

Faculty of Medicine, Addis Ababa University

Faculty of Medicine, Bahir Dar University

Haramaya University Medical Faculty

Hawassa University College of Health Sciences

Hayat Medical School

Mekelle University College of Medicine and Health Sciences

School of Medicine, Gondar College of Medicine and Health Sciences

School of Medicine, Jimma University

St. Paul’s Millennium Medical School

*

Public

Public

Public

Public

Public

Public

*

Public

Public

Public

Public

*

2009

No Response

1963

2007

2007

2003

*

No Response

No Response

1983

2008

Table 3: Medical SchoolS in Sub-Saharan africa conTinued



Gabon Faculté de Médecine et des Sciences de la Santé Public 1972

Gambia University of the Gambia Medical School * *

Ghana School of Medical Sciences, Kwame Nkrumah Univ of Science and Tech

School of Medical Sciences, University of Cape Coast

University for Development Studies

University of Ghana Medical School

Public

*

**

Public

1975

*

**

1964

Guinea Faculté de Médecine Pharmacie et Odontostomatologie, Université de Conakry

Faculté des Sciences Médicales, Université Kofi Annan de Guinée

Université la Source

Public

Private for Profit

Private for Profit

1967

2006

2007

Guinea-Bissau Raul Diaz Arguelles Public 2005

Kenya Moi University School of Medicine

University of Nairobi

Kenyatta University

Public

*

**

1990

*

**

Liberia A.M. Dogliotti College of Medicine Public 1968

Madagascar Université d’Antananarivo

Université de Mahajanga

*

*

*

*

Malawi College of Medicine, University of Malawi Public 1991

Mali Faculté des Sciences de la Santé, Université Kankou Moussa

Faculty of Medicine, Pharmacy and Odontostomatologie

Private for Profit

Public

2009

1969

Mauritania Université de Nouakchott ** **

Mauritius Department of Medicine, Faculty of Science, University of Mauritius

Sir Seewoosagur Ramgoolam Medical College

Public

*

1997

*

Mozambique Faculty of Medicine, Eduardo Mondlane University

Universidade Católica de Moçambique

Universidade Lúrio

Universidade Zambeze

Public


*

*

1963

2000

*

*

Namibia University of Namibia ** **

Niger Faculté des Sciences de la Santé, Université Abdou Moumouni Public 1974



Nigeria Abia State University

Ahmadu Bello University

College of Health Science, Ebonyi State University

College of Health Sciences, Benue State University

College of Health Sciences, Delta State University

College of Health Sciences, Igbinedion University

College of Health Sciences, Ladoke Akintola University of Technology

College of Health Sciences, Nnamdi Azikiwe University, Nnewi Campus

College of Health Sciences, Obafemi Awolowo University

College of Health Sciences, Osun State University

College of Health Sciences, University of Abuja

College of Health Sciences, University of Ilorin

College of Health Sciences, University of Port Harcourt

College of Medical Sciences, University of Maiduguri

College of Medicine, Ambrose Alli University Ekpoma

College of Medicine, University of Ibadan

College of Medicine, University of Nigeria, Enugu Campus

Danfodiyo University

Faculty of Medicine, Bayero University Kano

Lagos State University College of Medicine

Madonna University College of Medicine

University of Benin

University of Calabar

University of Jos

University of Lagos

*

*

Public

Public

Public

Private for Profit

Public

Public

Public

Public

Public

Public

Public

Public

Public

Public

Public

*

Public

Public


*

*

*

*

*

*

1992

2005

2001

1999

1991

1987

1972

2007

2004

1977

1979

1978

1991

1948

1967

*

1986

1999

1999

*

*

*

*

Rwanda Faculty of Medicine, National University of Rwanda Public 1963

Senegal Brighton International University School of Medicine

Faculté de Médecine, Pharmacie et d’Odontologie, Université Cheikh Anta Diop

Institut Privé de Formation et de Recherches Médicales de Dakar

Saint Christopher Iba Mar Diop

Private for Profit

Public

Private for Profit


2006

1918

2009

2000

Seychelles University of Seychelles, American Institute of Medicine - -

Sierra Leone College of Medicine and Allied Health, University of Sierra Leone Public 1988

Somalia Amoud Medical School

Benadir University



2000

2002




South Africa Faculty of Health Sciences, Stellenbosch University

Faculty of Health Sciences, University of Cape Town

Nelson R. Mandela School of Medicine

School of Medicine, Faculty of Health Sciences, University of the Free State

University of Limpopo, Medunsa Campus

University of Pretoria

Walter Sisulu University

Wits Medical School, University of the Witwatersrand

Public

Public

Public

Public

Public

Public

Public

Public

1956

1919

No Response

1971

1978

1943

1985

1919

Sudan Ahfad Medical School for Women

Al Neelain University

El-Razi Medical and Health College

Faculty of Medicine, University of West Kordofan

Faculty of Medicine and Health Sciences, Sinnar University

Faculty of Medicine and Health Sciences, University of Elimam Elmahadi

Faculty of Medicine and Health Sciences, University of Kassala

Faculty of Medicine, Gadarif

Faculty of Medicine, International University of Africa

Faculty of Medicine, The National Ribat University

Faculty of Medicine, University of Aali Anail

Faculty of Medicine, University of Bahr Gazal

Faculty of Medicine, University of Bakt Ruda

Faculty of Medicine, University of Dongola

Faculty of Medicine, University of Elfashir

Faculty of Medicine, University of Gezira

Faculty of Medicine, University of Juba

Faculty of Medicine, University of Khartoum

Faculty of Medicine, University of Kordofan

Faculty of Medicine, University of Medical Sciences and Technology

Faculty of Medicine, University of Omdurman Islamic

Faculty of Medicine, University of Red Sea

Faculty of Medicine, University of Shendi

Faculty of Medicine, University of Technology

Khartoum College for Medical Sciences

National College for Medical and Technical Studies

Private Not For Profit

Public

Unknown

Unknown

Public

Public

Public

Public

Public


Unknown

Unknown

Unknown

Public

Unknown

Public

Unknown

Unknown

Public


Unknown

Public

Public

Unknown

Unknown


1990

2009

Unknown

Unknown

1997

2008

1991

1998

1998

2000

Unknown

Unknown

Unknown

1997

Unknown

1978

Unknown

Unknown

1991

1996

Unknown

1998

1990

Unknown

Unknown

2005



Sudan

(continued)

Nile Valley University - Faculty of Medicine & Health Science

Sudan International University

University Alzaeim Al Azhari

Public

*

Public

2006

*

No Response

Tanzania Hubert Kairuki Memorial University

International Medical and Technological University

Kilmanjaro Christian Medical College

School of Medicine, Muhimbili University of Health and Allied Sciences

Weill Bugando University College of Health Sciences



Private not for Profit

Public


1997

1997

1998

1968

2003

Togo Faculté Mixte de Médecine et de Pharmacie (FMMP), Université de Lome Public 1970

Uganda Gulu University Faculty of Medicine

Mbarara University Medical School

School of Medicine, Kampala International University

School of Medicine, Makerere University College of Health Sciences

Public

Public

Private for Profit

Public

2004

1989

2006

1923

Zambia School of Medicine, University of Zambia Public 1966

Zimbabwe College of Health Sciences, University of Zimbabwe

National University of Science and Technology, Faculty of Medicine

Public

*

1963

*

* Did not return the SAMSS Survey or did not successfully receive the SAMSS Survey

** Identified or began admitting medical students after the close of the SAMSS Survey (Dec 2009)


A Partnering Institution was chosen to contribute to

the development and implementation of the SAMSS sur-

vey. The University of Pretoria, South Africa, led by Dr.

Eric Buch from the School of Health Systems and Public

Health partnered with the Secretariat and the Advisory

Committee to develop, distribute, and analyze a survey of

medical schools in SSA (see Table 3 above for a listing of

medical schools in SSA). The University of Pretoria team

had principal responsibility for disseminating, collecting,

and analyzing the SAMSS survey, providing a counter-

point to the work of the George Washington University’s

Secretariat. The Partnering Institution was selected

through a competitive bidding process. The team from the

University of Pretoria was selected due to its excellent plan

to ensure thorough follow up and achieve a high response

rate for the SAMSS survey, as well as its demonstrated

capabilities in data analysis.

Key Informant Interviews

Methods

Key informant interviews were undertaken with 50 indi-

viduals identified as knowledgeable about Sub-Saharan

African medical education as a whole or about specific top-

ics, regions, or countries. Efforts were made to identify a

range of experts in the field. A semi-structured question-

naire was used to elicit information about the topics of the


study as well as about the relationship between medical

education and health policy. The goals of these interviews

were to identify candidate medical schools for participa-

tion as site visit case studies, to look for potential members

of the SAMSS Advisory Committee, and to develop better

information about the actual number of medical schools in

SSA. Efforts were made to identify a variety of schools with

innovative programs which focused on national disease

priorities and the retention of graduates. The interviews

were not intended to produce an independent database.

Rather their purpose was to assist the research team in

establishing a baseline understanding of the history, orga-

nization, institutions, and themes in Sub-Saharan African

medical education. Additionally, these interviews provided

a platform for the team to talk with many deans and other

educational leaders, many of whom were subsequently

invited to join the SAMSS Advisory Committee.

A complete list of the SAMSS Key Informants may be

found in Appendix 8.

results

The interviews, indeed, helped identify candidate schools

for site visits, provided a basis for selection of Advisory

Committee members, and brought to light many medical

schools previously unlisted in international databases. They

also assisted the research team in gaining a more complete

picture of the history and current state of medical educa-

tion in SSA.Physicians are a core

component of Human Resources for Health. Thirty-six countries in Sub-Saharan

Africa are experiencing critical shortages of health workers.


chapter 2: literature review anD synthesis

Introduction

To better understand the history and current state of

research, practice, and policy in medical education in

Sub-Saharan Africa, the SAMSS Secretariat performed an

extensive literature search. The review focused on identify-

ing documents about medical education, education policy,

health policy as it relates to medical education, and articles

about innovations, accreditations, and regulations perti-

nent to medical education. An annotated bibliography and

a sample of key articles found during this process served as

orientation material for the Advisory Committee and for

site visit teams.

The resources located through this search, it is hoped, will

further increase the utilization of these sources of infor-

mation. The extensive literature review found several gaps

in the current body of writing about SSA medical educa-

tion. For instance, while there are excellent descriptions of

priorities for workforce planning and management within

the literature about capacity, there are few accounts docu-

menting successes, failures, and challenges. There is little

information in the general literature about how individ-

ual schools dealt with funding for faculty and the school’s

infrastructure. Literature about micro- and macro-level

funding was especially scant from the newer and private

medical schools on the continent.

Our key findings (Figure 2) emphasize the rapid develop-

ment of this literature, particularly in new or “non-tradi-

tional” resources. Major strengths and weaknesses are also

noted, but recommendations for changes in the literature

are presented along with other recommendations meant to

inform the SAMSS project itself and to avoid fragmentation

of effort within the research team.

While this search was thorough in its execution and we

have tried to present as much as possible here that is perti-

nent to the SAMSS project, we realize that many valuable

publications and electronic resources are not represented

here. Therefore, we have also created a full bibliography,

which receives ongoing updates of current literature. This

continually growing collection is available on the SAMSS

website: http://samss.org/literature/default.aspx?literature

Methods

Online searches were performed in early 2009 of five

large “traditional” medical databases (Medline, CINAHL,

ERIC, Global Health, EMBASE), along with three large

figure 2 – Key liTeraTure review findingS

The body of literature on medical education in Sub-Saharan Africa is growing rapidly

Many journals in this literature are written in the English language, and many are based in the UK and the US

A North-South gap in publishing quantity persists but is narrowing due to recent expansion of grey literature

The grey literature is growing even more rapidly than the traditionally-indexed literature

Literature disproportionately represents countries with older medical schools: South Africa, Nigeria, and Uganda

There are many detailed descriptions and assessments of PBL, CBE, HRH capacity planning, sources of “brain drain” and retention strategies

There is a small but growing body of literature analyzing use of technology, macro-financing for medical education, HRH scale-up execution and out-

comes including post-graduate training and primary care

Medical education as a field of inquiry and practice specific to SSA region is underdeveloped


“non-traditional” databases (African Indicus Medicus,

African Journals Online, and Biomed). These featured

many African journals not indexed by traditional data-

bases (Table 4). Keyword terms used included “medical

education, medical schools, and medical students” for all

searches. “Africa” was added as a limiting search term for

traditional databases. For Medline only, terms for MeSH

headings “schools, teaching” and “health manpower” were

added, based on Medline’s categorization scheme. These

search terms returned a total of 3,749 citations, which

were reviewed for relevancy, and 642 of these citations

were retained for further analysis. Full citation informa-

tion, abstracts, and full text were retrieved when available

for as many of these as possible. The characteristics of each

Table 4: online reSourceS uSed in liTeraTure review

nAME oF RESouRCE AnD PAREnT oRgAnIzATIonS oR CoLLABoRAToRS

wEB ADDRESS (uRL) TyPES oF InFoRMATIon AVAILABLE

African Journals online

Independent, private non-profit organization based in South

Africa

www.ajol.org 378 African Journals

>49, 000 Abstracts

>38, 000 Full-text articles

Bioline

University of Toronto (Canada) and Reference Center on

Environmental Information (Brazil)

http://www.bioline.org.br 19 African Journals

Abstracts and full-text for all articles

African Indicus Medicus

WHO Regional Office for Africa, and Assoc Health Info

Libraries in Africa

http://indexmedicus.afro.who.int 139 African Journals

Abstracts available for most, links to full-

text for some

The network Towards unity For health (TuFh) www.the-networktufh.org Education for Health (journal), books, posi-

tion papers, curricula, newsletters

hRh global Resource Center www.hrhresourcecenter.org Journal articles and reports, evaluations,

curricula, multimedia

The Capacity Project uSAID www.capacityproject.org Reports by governmental organizations and

NGOs

who Africa health workforce observatory http://www.afro.who.int/hrh-obser-

vatory/index.html

Reports, country-level fact sheets, interactive

maps, technical notes

global health workforce Alliance http://www.who.int/

workforcealliance/about/en

Reports and publications, taskforce and

working group recommendations

Equinet http://www.equinetafrica.org Reports by governmental organizations and

NGOs

Medecins Sans Frontiers (Doctors without Borders) www.msf.org Articles, reports, multi-media, position

papers

Physicians for human Rights www.physiciansforhumanrights.org Reports, position papers, speeches, testi-

mony, multi-media


publication, such as primary institutional affiliation of

first author, name and nationality of journal publishing

each article, and country or region described by the arti-

cle, were noted.

Although the reviewers categorized all articles, this report

will include information from only three categories felt to

be of highest relevance to SAMSS: innovations in physi-

cian training, building capacity for increased physician

training, and retention of physicians once trained. Finally,

to supplement the searches of peer-reviewed literature

with “grey literature” sources, several internet sites were

reviewed for committee reports, consensus statements, and

similar documents pertinent to the SAMSS project which

produced additional reports and related documents (Table

4). This review presents the major findings from review of

these 453 sources about medical education in Sub-Saharan

Africa from the grey and peer-reviewed literature.

Findings

innovation

Medical education in SSA has experienced remarkable

growth both in scale and innovation over the last cen-

tury – particularly considering the vast diversity of lan-

guages, cultures, and customs, as well as limitations

in available resources. While it is true that some insti-

tutions’ curricula have evolved very little from “tradi-

tional” mid-century Western curricula, the literature

also reveals institutions and educators who have worked

for decades at the forefront of innovation in step with

global trends in medical education.

Community-Based Education and Service-oriented

Learning: Community-Based Education (CBE) became the

foundational approach for several medical schools start-

ing in the late 1960s and implementation at other institu-

tions continued over the following decades.5,6,7,8,9,10,11 By the

1970s-80s, several established schools had adapted ele-

ments of CBE such as: “family attachment” in which stu-

dents followed a patient as part of a family for two to three

years;12 visits to rural homes and health centers where stu-

dents engage in patient counseling, community and home

needs assessments, and consultations with local school

teachers;13 and small-group discussions of community and

public health topics.14 Over the past two decades, interest in

community-based education has increased, as has experi-

ence with teaching and assessment methodologies. Authors

commenting on one school’s 20-year experience noted that

the preparation which would be needed for students and

faculty alike was underestimated initially but modifica-

tions, including a steady but gradual increase in use of CBE

and structured evaluation techniques15 has led to high satis-

faction, lower student attrition rates, and greater perceived

A dormitory room at the Faculty of Medicine, Pharmacy, and Denstistry, University of Mali.


A class at Universite de Cocody, Abidjan, Cote d’Ivoire

ability to function in rural communities.19 Other difficul-

ties encountered include unreliable public services and

utilities, language barriers at some rural sites, and chal-

lenges in maintaining high educational standards with

community physicians who supervise learners.16,17,18 Some

authors have described the challenges and rewards of

partnering with communities. These partnerships include

service-based educational programs to increase tuber-

culosis control19 or vaccination rates.20 When carefully

implemented, communities and students both report high

levels of participation and satisfaction with CBE and ser-

vice-oriented learning. In Malawi, students experience

“learning by living” with families in poor, rural areas.21

Community members in Nigeria found students to be

good role models and inquired about even greater involve-

ment.18,22 While the educational superiority of such pro-

grams as compared to traditional curricula is difficult to

demonstrate, at least one study comparing senior students

and recent graduates from CBE curricula with those from

traditional curricula showed greater sensitivity to com-

munity health needs by the former as opposed to individ-

ual health needs by the latter.18

Problem-Based Learning: Often incorporated with CBE

and rural or service-based learning,16,18,19,23 Problem-Based

Learning (PBL) strategies have become increasingly inte-

grated into SSA curricula in the past two decades. Most

articles describe PBL activities that closely reflect those

commonly employed in Western curricula: Small groups

of learners are led by faculty facilitators with clinical cases

prompting students to identify and explore basic science

and clinical learning.25 Likewise, many of the challenges

described are familiar to medical educators using PBL in

any country: Faculty must adapt their teaching skills to

accommodate active learning.24 For instance, clinical rea-

soning is more challenging than lecturing on content,25 but

some challenges such as high startup costs, lack of ade-

quate library facilities and learning materials, and student

poverty affect SSA more than other areas.26,27 These chal-

lenges notwithstanding, evidence is mounting that cur-

ricula using PBL can lead to improved outcomes such as

giving students greater sophistication in learning strate-

gies,28 increased understanding and application of basic

sciences,29 lower overall attrition rates and higher rates of

on-time graduation,35,30 as well as improvement in social

skills, such as cooperation, communication, confidence,

tolerance, and patience.31 The choice to implement PBL

in African curricula is often a complex balancing act. On

one hand, faculty do not need to have expertise in the con-

tent they facilitate,32 which creates greater flexibility and

encourages greater role-modeling and mentorship.41,33 On

the other hand, mastery of facilitation techniques can be

challenging to faculty more familiar with traditional peda-

gogy, and thus increases the need for faculty support, par-

ticularly in the early phases of implementation.34,35 Beyond

its use in undergraduate education, successful use of PBL to

facilitate continuing education in SSA has also been men-

tioned by several authors.36,37


Assessment and Evaluation: One difficult paradox facing

medical educators in SSA is that scarce resources cannot

be wasted on ineffective techniques, yet research to assess

educational effectiveness is often difficult to support. Some

authors have described analytic and prospective models

for selecting assessment methods best suited to a particu-

lar institution38 or a “causal model” for curricular innova-

tion such as community-based learning39 and others have

used validated tools to assess quality of education in vari-

ous settings.40,41 Most studies illustrate lessons learned

through soliciting feedback and measuring outcomes after

implementation of innovations such as service-based or

problem-based learning.42,43,44 Direct feedback from faculty

and students are among the more important methods for

evaluating curricular innovation. The process itself can be

very empowering for learners45 and, over time, can fortify

the ability of interactive curricula such as PBL to reconcile

differences in performance among different racial/ethnic

groups,38 as well as alleviate challenges in teaching to stu-

dent populations with highly diverse cultural and linguistic

backgrounds.53 Beyond curricular improvement through

feedback, another impetus for research of assessment meth-

ods is the global trend towards increased evaluation of clin-

ical skills. To date, reports of Observed-Structured Clinical

Exams (OSCEs) in SSA are very rare and reported pass

rates are rather low.46,47 Some schools have implemented

early clinical-skills training with high student and faculty

approval,48 described structured clinical summaries49 or

structured assessments of communication skills,50 while

others have attempted to shape consensus among educa-

tors and practitioners about what procedures and skills

should be considered essential for new physicians.51 Finally,

several authors have described truly unique approaches,

such as student reward systems for high performance on

histology exams,52 use of student drawings to convey for-

mal feedback44 and integration of difficult material into a

game-based format.53 Similarly, in light of challenges faced

by admissions committees to select qualified applicants

based on limitations of standardized tests,54 one study

explored “creative thinking” in educationally-disadvan-

taged applicants, which proved to be a reliable predictor of

academic performance.55 While these approaches may be

unconventional, their initial results are promising.

Technology: Modern information and communica-

tion technologies have revolutionized medical education

in many countries and promise to bring greater access

to high-quality educational products to schools in Sub-

Saharan Africa as well.56 Educators have described the inte-

gration of Web-based Course Tools (WebCT) into a new

problem-based curriculum with great success: Students

and faculty used the interface to communicate more fre-

quently. Students were able to access resource materials

previously only available to them at the library, and the

faculty was able to conduct online quizzes.57 Other edu-

cators have reported use of WebCT as superior to other

distance-learning technologies such as interactive tele-

vision58 and have developed online “spiral curricula,” in

which students build and reinforce competency in new

subject areas by revisiting prior course materials online.59

While WebCT represents the cutting edge of educational

technology, it does require startup and maintenance costs,

which are prohibitive for many SSA schools. Accordingly,

some educators have employed more affordable technolo-

gies such as “Video-projected Structured Clinical Exam”60

and video-conferencing for teaching, clinical consulta-

tion,61,62 and continuing medical education.63,64 Beyond

the obvious cost barriers, another considerable problem

is the so called “digital divide” or gap in computer liter-

acy between students in resource-poor countries and the

West. While generalizations are difficult to make, several

authors have uncovered discouraging basic deficiencies in


computer use.65,66,67,68 On the other hand, some authors have

shown that students are able to adapt quickly to internet-

based innovations regardless of whether they were highly

computer-savvy or barely computer-literate when they

entered medical training.69,70 Some authors have argued

that the paradigm shift of PBL requires adaptation beyond

students and faculty to include libraries and information

specialists to help build “knowledge-management infra-

structure” to support access to evidence-based medi-

cine and critical analysis of the wide array of information

available via the internet.36

CapaCity

Capacity is a core issue around which the broader move-

ment of human resources for health (HRH) has gath-

ered. Building consensus within this movement and

coordinating priorities for scaling up now look beyond

physical facilities and focus on the creation of a more

ideal mix of healthcare professionals according to spe-

cialty mix, physicians vs. non-physicians, and diversity

of provider demographics.

general workforce Planning and Scaling up: As noted

by many collaborative groups, including the Global Health

Workforce Alliance and Joint Learning Initiative on HRH,

global inequities in workforce have never been greater and

no continent is more severely affected than Africa.71,72,73

Accordingly, there is broad consensus in grey literature

reports that the foremost priority for addressing the work-

force is to scale up the sheer number of workers.81,74,75,76,

Other consensus priorities include increased funding

through government budgets.86,87, NGOs in the donor com-

munity,78,79 increased collaboration with other nations

(both North-South and South-South)85,90 and the creation

of strategic planning and management organizations for

HRH to coordinate needs and utilization patterns across

different regions.83,84,85,86 Many of these consensus issues

are mirrored in the peer-reviewed literature. Country-

specific concern about physician shortages can be seen

from the Era of Independence80,81 to the present,82,83,84 with

more recent commentaries and briefs casting the issue

in broader continental or global terms.85,86,87 While rais-

ing capital to start educational programs is difficult, sev-

eral authors point out that sustaining adequate funding is

often an even greater challenge, especially once the 10-year

mark is reached.88,89 Speaking to the need for increased col-

laboration, several senior educators have recently cham-

pioned a collective social mission for academic medical

centers in SSA over traditional country-focused missions

to improve “global health,” and the health of Africans spe-

cifically.90,91,92,93 Finally, correlations between health worker

density and health outcomes94 form the empirical basis

for increased strategic planning to coordinate needs and

resources for scaling up HRH,82,83,95 particularly for HIV

care.95,96 One important issue in the peer-reviewed litera-

ture not readily appreciated in grey literature reports is the

lack of accreditation or certification for training programs

in SSA. To date, information regarding such regulatory

A student at the University of Gezira, Sudan


bodies is available for only a dozen countries (accreditation

is mandatory in seven of these); information about others is

lacking.97,98 Basic information about the number and char-

acteristics of medical schools across the SSA region is also

lacking in the literature available to this point.5,99

Infrastructure: Descriptive accounts of new medical

schools flourished in the Independence Era of the 1960’s-

70 and trailed off during the 1980’s and early 1990’s. 100,101,102,103,104,105,106,107 These articles emphasize the impor-

tance of the creation of new schools in advancing the health

and developmental aspirations of the newly independent

nations. Although a new phase of investment in infrastruc-

ture has spawned many new medical schools more recently,

that is not reflected in the literature. One notable exception

is the new school in Malawi, which opened in 1991 with

unusual support from German, British, and Australian

governments at various stages of its development from 1986

to 1995. This unique North-South collaboration included

funding for physical infrastructure and staffing, expertise

from senior visiting faculty and administrators (including a

founding Dean from Australia), and conditional post-grad-

uate training abroad for new graduates, who would return

to replace these foreign start-up faculty.108,109 The abrupt

withdrawal of support from these governments, however,

has come to serve as a cautionary tale about reliance on

external support.99 At the level of national infrastructure

for medical education, several authors describe the recent

history and number of schools and their relationships to

national or regional accrediting agencies in Nigeria,93,110,111

Zimbabwe,112 Malawi,113 and the Sudan.114 Common chal-

lenges cited by these authors include inadequate funding

and pedagogical training for teachers in the face of rapidly

expanding student bodies.

Post-graduate Training: Much of the recent literature

describing training infrastructure has tended to focus

upon post-graduate specialty training, mostly in surgi-

cal fields. These programs are of critical importance, not

only for supplying specialists for the population, but also

to reinforce and advance teaching cadres in SSA medi-

cal schools. In Ghana, a regional training program for

Obstetrics/Gynecology was created with expertise from

British, American, and West African specialty boards

and initial funding by the Carnegie Foundation.115,116,117

Other articles describe large training centers for sur-

gery in Tanzania,118 Kenya,119 and Zambia.120 The articles

detail clinical case loads and some information on num-

ber and demographics of graduates, but offer few specif-

ics about sources of financial support or teaching expertise.

Four articles provide similar details at the national level

for surgery in South Africa,121 Uganda,122 and Nigeria121,123

and emergency medicine in Rwanda,124 South Africa,125

Madagascar,126 and Francophone SSA.127 As summarized

by Ogediz et al in describing the surgical workforce crisis

in SSA, access to surgical management of malignancies,

trauma, obstetric complications, and congenital defects is

even less than for primary care.128 Several articles describe

training infrastructure and capacity across Sub-Saharan

Africa in surgery129 and in non-surgical specialties includ-

ing neurology130, anesthesia,131,132,133 and radiology.134 While

not as procedure oriented as the surgical fields, similar bar-

riers to training and retention of specialists in these fields

exist due to their need for technologically advanced imag-

ing and anesthetic and monitoring devices. Several authors

describe psychiatry or mental health training for under-

graduates, but not as a post-graduate specialty135,136,137,138

outside of South Africa. Similarly, articles describing post-

graduate training in pediatrics or internal medicine (and

subspecialties) are notably missing.


Primary Care: One perennial question arising from dis-

cussions of infrastructure is how to attain the right mix

of providers to address both primary and specialty care

needs. Following the recommendations of the Alma Ata

report,139 many SSA nations have endorsed the Primary

Health Care (PHC) approach, yet building an academic

core for primary care or family practice has been challeng-

ing. In South Africa, primary care is part of most under-

graduate curricula with several institutions offering post-

graduate training140 leading to specialty certification by

the Medical Council of South Africa,141 with the support of

an Academy of Family Practice and Primary Care.142 For

their part, students recognize the importance of primary

care and value family medicine training in the commu-

nity,143 but express reservations about the implementation

of the PHC model at the national level in South Africa.144,145

Moreover, students in many countries have mixed feelings

about primary care versus specialization and may some-

times favor the latter.146,147 Nigeria endorsed the PHC model

in 1987, but, as yet, few schools teach primary care in com-

munity settings.18 Schools utilizing the Community-Based

Education and Service (COBES) model have reported high

student and community satisfaction.18,148,149 At the same

time, students may also express negative views of primary

care if faculty commitment is perceived as weak, or if cur-

ricula are seen as unfocused and unmatched to realities in

communities.150

non-Physician Clinicians: In recent decades, the topic of

provider mix has expanded to include discussions of non-

physician clinicians (NPCs) in the context of broader HRH

development for the SSA region.151 Currently, NPCs may be

widely under utilized, with only 25 of 47 countries deploy-

ing them in significant numbers, yet the number of NPCs

have equaled or surpassed that for physicians in at least

nine countries. While broad consensus exists on increasing

the number of NPCs, 83,85,86 little information is available

about ideal ratios or functions.152 Indeed, the JLI observed

that 1:3 ratios of physicians-to-NPCs seen in the US may be

unrealistic for SSA, but ratios of 1:6 or greater might be just

as unmanageable due to inadequate leadership and supervi-

sion.82 Nonetheless, there are obvious advantages to scaling

up the number of NPCs alongside physicians. Beyond the

reduced costs and duration of training, NPCs may be more

easily trained in the community with focus on local needs,

they are less dependent on technology, and are generally

less likely to emigrate.153 Moreover, NPC roles are increas-

ingly expanding beyond primary care to augment the care

in specialty shortage areas such as trauma or obstetric care

mentioned above.154,155,156,157 As the role of these providers

becomes more defined, particularly for basic care in crisis

areas such as HIV/AIDS, more research on effective use in

task shifting 90,158 and descriptions of team-training models

at health science schools will be increasingly important.

Diversity: Finally, many medical educators in SSA have

championed the cause of diversity in the medical profes-

sion that strives to more closely resemble their patient pop-

ulation in terms of gender, race, socioeconomic class, and

rural vs. urban backgrounds. South Africa159 and Sudan160

have led the region in recruiting women into the profession

with definitive success, yet issues of balancing professional

requirements with traditional family roles (including preg-

nancy and motherhood), as well as issues of sexual harass-

ment and discrimination are still problematic.161 With

respect to recruitment of traditionally disadvantaged stu-

dents from poor and/or rural settings, several schools have

increased the role of non-academic criteria for admission to

allow increased enrollment.162,163,164,165,166,167 Of equal impor-

tance, social and academic support must be provided for

these students after admission in order for them to achieve

successful advancement and graduation.


retention

Undoubtedly, the greatest threat to adequate retention of

physicians in SSA is emigration of these trained personnel

to nations with more developed health care systems (the so-

called “brain drain”). 96,168,169 In addition to the problem of

international migration, Africa faces serious internal rea-

sons for physician attrition and difficulties in attaining ade-

quate distribution of the workforce to rural areas. Finally,

scaling up the physician workforce in SSA is further com-

plicated by difficulties in recruiting and retaining talented

individuals within academic medicine.

Medical Migration: At least one in eight physicians trained

in the SSA region is lost to more developed nations; 4,170

however, future shortages are predicted to be even greater

with notable variations by country.171,172 Indeed, by some

estimates, six of the 47 SSA countries have lost over 60% of

their physician workforce to migration and only ten have

lost less than 20%.173 By sheer numbers, medical migration

is mostly an Anglophone phenomenon with four princi-

pal recipient nations (US, UK, Canada, Australia) draw-

ing the greatest numbers from three SSA countries (South

Africa, Nigeria, Ghana), although the effects of losing

even a few physicians can be devastating to smaller coun-

tries with total workforces averaging less than 1,000. 4,174

Financially, estimates for lost investment by SSA countries

range from $180,000 to $500,000 (US) for each physician

that leaves.175,176,177

The underlying causes of the brain drain are complex, but

have been broadly classified as “push” and “pull” factors.178

To the extent that these can work to either encourage or

discourage retention, they can also be seen as “gradients.”

They include income, job satisfaction, career development

opportunities, civil and social stability, personal health

risk, and retirement security.179,180 These factors influence

physicians’ and students’ everyday decisions. reported rates

for intended emigration reaching as high as 86% in some

countries179,189 and an attendant “culture of migration”

where emigration is normalized and may even be viewed

as the ultimate marker of career success185, 181. While there

are few policy responses to address these trends currently

in place, many have described moral obligations to do so

to halt the “robbing” and “looting” of human resources in

poor countries.182,183,184,185 The rights of individual physi-

cians to seek better lives for themselves and their fami-

lies is well recognized. 192,186 Voluntary codes or provisions

of labor agreements could establish principles to at least

discourage or limit recruitment by governments and for-

profit recruitment agencies.187,188 Further, blanket strate-

gies to curb all aspects of brain drain may be counterpro-

ductive and could slow the development of guidelines for

ethical recruitment such as limited visas for training and

reimbursing monetary investments made by poor countries

in education.189 Accordingly, specific options for the major

recipient countries – US, 90 UK,190 Canada198,191– have been

proposed, as have policy options for African countries.88

Finally, how medical education enables brain drain is

debated and tracking of graduates from individual schools

is often difficult,192 the general thought is that schools,

which teach Northern standards of medical practice, tend

to have high rates of migration among graduates. This idea

is supported by student attitudes,193,194,195,196,197,198,199 as well as

some post-graduation empirical evidence.200,201,202

Internal drain and rural distribution: Certainly, a mas-

sive internal burden facing physicians in SSA is the HIV/

AIDS crisis, which strains the existing workforce in two

ways: increased need for care as prevalence increases, and

decreased manpower as healthcare workers are themselves

infected.90,179,189,191,203 Indeed, infection rates in healthcare


workers may be even higher than in the general population,

leading the JLI to label HIV “the straw that broke the cam-

el’s back.”82 Some medical school analyses have reported

more graduates are deceased than living overseas.204

Trainees have reported feelings of hopelessness, leading

to burnout in settings where demand for care is high and

eager providers are paralyzed by a lack of basic supplies,

utilities, and medications. 205,206 In response to this cri-

sis, international collaborators have introduced a Pediatric

AIDS Corps,207,208 and others have proposed expanding

this concept to an HIV Peace Corps for Health, sponsored

the US government209 or similar, multi-national collabo-

rations.85 Pre-service (undergraduate) physician train-

ing and post-graduate courses on HIV care have also been

proposed to help build the skills base of physicians dealing

with populations heavily-burdened with HIV/AIDS.210,211,212

Ultimately, greater direct financial and social support for

physicians caring for such populations may be needed to

retain them, particularly as the setting for such care is often

in rural areas.90,189,213,214 In addition to increasing salaries,

physicians have cited improving living and working condi-

tions, bettering career development, and expanding educa-

tional opportunities for their children as important goals

to retain doctors in rural settings.215,216 Supportive changes

in medical education are also critical. Students often report

having initial high motivation to serve the poor and help

advance the PHC model for care, but many reverse their

opinions before the end of their studies and pursue their

careers in urban areas. 207,215,217,218 This shift may, in part, be

explained by inadequate commitment from teachers and

mentors to rural needs and further complicated by prob-

lems of curricular sequencing of rural experiences.219

Building Academic Medicine: Resource management and

development for medical education in SSA is challeng-

ing,220,221 but recruitment of teaching staff is also a constant

concern. Traditional non-financial rewards which attract

individuals to academic life, such as research and teach-

ing opportunities are underdeveloped. This leaves faculty

without adequate resources to conduct original investiga-

tions or even to provide quality instruction to students.108

Efforts to develop the teaching skills of faculty have been

described by only a few authors, typically in the context

of training for roles as PBL facilitators.44,45,222 While these

authors report high satisfaction from participating fac-

ulty, there is still a great need for broader training in edu-

cational methods beyond PBL and greater recognition of

teaching service in promotion and tenure decisions. One

study documents rewards given to professors expressly for

teaching in seven of eight South African medical schools;

however, standards for selection and significance of the

rewards varied greatly.223 Efforts to build research infra-

structure as a means to increase recruitment and reten-

tion of academic faculty are more frequently described in

the literature and often involve international collabora-

tion.224,225,226 Several Northern universities have partnered

with schools in SSA to increase training specifically for

HIV research and care,227,228,229,230 while others have made

efforts to improve teaching and research in fields such as

surgery.231 In Uganda, a regional center for HIV care and

research was established, which has trained more than

1,500 professionals from 27 countries with initial finan-

cial assistance from a major pharmaceutical company.240

For another in Lesotho, human resources for primary

care and HIV treatment and research were developed with

grants from the Kellogg Foundation, USAID, and the US

State Department.239 While these examples are encourag-

ing, collaborators from developed nations must always be

careful to avoid encouraging “post-colonial syndrome,”

in which the research interests and goals of the Northern

partner dominate over those of the Southern partner.232


figure 3 – JournalS wiTh Ten or More PublicaTionS on Medical educaTion in SSa (n=395 arTicleS)

*Country of origin for journal listed in parentheses if not in journal title

**Articles from these 14 journals represent 62% of all 642 articles identified for this review

Accordingly, guidelines for ethical “twinning” of foreign partners with African institutions have been advocated by several

organizations.235,236,233

SUMMARY

Several important themes, strengths, weaknesses, and unanswered questions emerge from this broad consideration of the

current body of literature on medical education in Sub-Saharan Africa. Thematically speaking, the peer-reviewed literature

presented here is predominantly written in the English language and printed in journals from English-speaking countries

(Figure 3).


figure 4 – counTrieS deScribed in PublicaTionS on Medical educaTion in SSa

* n is 667 because some articles describe more than one country

** Countries described in <5 articles: Mozambique (4 articles), Zamiba (3), Congo, Madagascar, Mauritania, Senegal (2 each),

Lesotho, Mauritius, Namibia, Rwanda, Sierra Leone (1 each)

*** Central Africa, Southern Africa, and Francophone Africa also described in 2 articles each.

In terms of countries described in these articles, South

Africa is disproportionally represented with 39% of the total

literature even though the country is home to only 6% of all

SSA medical schools. The second most-frequently described

country, Nigeria, has a more proportionate share of the lit-

erature (18% corresponding to 23% of SSA schools), as does

the third-most frequently described country, Uganda, with

5% of the literature and 3% of SSA schools (Figure 4).


figure 5 - rePorTed locaTion of PriMary affiliaTion of firST auThor (n=642 arTicleS)

In terms of authorship, American and British first-authors

represent a large portion of the literature and, when com-

bined with South African first-authors, comprise over 50%

of the literature (Figure 5).

Another important trend is the recent rise of a parallel

body of “grey” literature. Discussions about medical educa-

tion in SSA can be found in peer-reviewed African journals

but not indexed for traditional databases such as PubMed

or have been published independently in print or online by

organizations, committees, or other groups such as WHO

or the Global Healthcare Worker Alliance (Table 4). This

study analyzes those portions of the “grey” literature avail-

able via the internet or found in print through this study

group (SAMSS). While the traditional literature is growing

rapidly, this “grey literature” is likely expanding even faster,

albeit with less global reach due to lack of Internet access.

Presently, it is unclear whether this “grey” literature will

help to narrow the “North-South gap” or merely increase

the information written about medical education in SSA in

a fragmented way.

Through this review, SAMSS has identified several impor-

tant strengths and weaknesses of the “grey” literature.

Curricular innovations such as PBL and CBE are richly

described, yet how well these programs work in an African

setting has not been explored thoroughly. For instance, do

graduates of these programs go on to provide care where

they are needed most? Again, innovations in the assessment

and use of technology are documented, but more is needed

here to describe challenges and solutions to implementation.

Within the literature about medical school capacity, there

are excellent descriptions of workforce planning and

*Not reported = information unavailable in abstract, full article unavailable online

** One article each: Egypt, Iran, Israel, Italy, Madagascar, Mauritania, Portugal, Philippines, Poland, Senegal, Switzerland,

Saudi Arabia, Trinidad & Tobago


management, but more accounts of attempts at imple-

menting these ideas, with their successes, failures, and

challenges, are needed. Another key area lacking in the

capacity literature is information about macro and micro-

financing for medical education: How can funding at the

country-level be improved and what innovations have

individual schools found to deal with their needs for a

physical plant, personnel, and other critical infrastruc-

ture? Much more information is needed especially from

newer medical schools. Inevitably, approaches among

schools will be very different. Much more information

about post-graduate training in “primary care” special-

ties such as pediatrics and internal medicine as well as

their sub-specialties is needed. Finally, much more atten-

tion to the role of research as a means for capacity build-

ing is needed as research activity has been essential to the

success of older schools such as Makerere University, the

University of Cape Town, and the University of Ibadan.

Research will likely play an important role in the growth

and sustainability of new schools across the continent.

Similarly, the phenomena of “brain drain” and internal

drain are very well described as are many solutions, but

there is very little connection to medical education refer-

enced in the literature. Again, the question of outcomes is of

paramount concern: Is there anything medical schools can

do to encourage the retention of their graduates within their

country? Given the known correlation between HRH and

health indices, do health outcomes actually improve when

physicians and other healthcare workers are retained in

greater numbers? Finally, much more information is needed

overall about building the field of academic medicine in

Sub-Saharan Africa: What are emerging strategies for fac-

ulty development, how is research capacity being developed,

how is excellence in educational activities such as curricular

reform, teaching, and mentoring being recognized?

ConClusion

Medical education in Sub-Saharan Africa has experienced

dramatic changes over the last 50 years, and the literature

describing this transformation has also grown significantly

in size and sophistication. This expansion in the litera-

ture has occurred within traditionally-indexed databases

of peer-reviewed journals, but has also moved toward an

alternate, “grey literature” of new databases and online

resources. Despite this recent expansion, there are still far

more questions to be studied and solutions to be reported

in order to advance the cause of quality higher medical

education and better training of physicians for the Sub-

Saharan region. It is hoped that this review will aid current

and future efforts to build on the existing literature and

improve the utility of this body of knowledge to medical

educators and policy makers across the region.

Limitations

The literature review for this report was limited by sev-

eral factors. The first is that the literature found concern-

ing medical education in Africa was overwhelmingly in

English. Articles written in French were less numerous and

those in Portuguese and Arabic rare. Even though attempts

were made to identify more non-English articles with the

assistance of SAMSS Advisory Committee members, the

results were limited. The preponderance of Anglophone

Advisory Committee members and staff also limited the

study’s access to non-English sources of information.


Introduction

Since visiting all Sub-Saharan African medical schools was

not possible, the SAMSS study design included site visits

to ten schools, a number judged sufficient to allow a repre-

sentative sample of all schools. Although site visit school

selection could not be a formally scientific process, the goal

of the process was to identify a varied sample of schools

appropriate for a benchmarking study. Factors considered

in the selection of the schools included language groups,

geographical region, ownership, educational format (tra-

ditional, community oriented, problem-based), and date

of founding. Final selection was also influenced by school

receptivity, school communications capabilities, and secu-

rity issues. The ten selected schools are noted in Table 5.

seleCtion oF site visited sChools

In all, 146 medical schools were identified in SSA during the

SAMSS study period (an additional 22 either opened or were

identified after the close of the survey period). Key informant

interviews helped to identify the number of medical schools

in Sub-Saharan Africa and to choose the medical schools to

study further using site visits. Also important in the choice

of schools were consultations with Advisory Committee

members and a review of relevant literature. The chosen

schools use innovative educational initiatives and are insti-

tutionally diverse. Schools selected represented east, west,

southern, and central Africa. Instruction was in French,

Portuguese, English and Arabic. They included public and

private schools; new and old schools; and schools using a

variety of curricula.

Methods

The site visits gathered on-site and largely qualitative infor-

mation about each of the schools in its national context.

Each site visited medical school nominated one member to

the Advisory Committee. This Advisory Committee mem-

ber served as the host and coordinator of that school’s site

chapter 3: site visit repOrt

Table 5: The SelecTed Ten SiTe viSiT SchoolS

Owner‐ship

Educational Model

ivate

Africa

later

1990 earlier

iona

l y‐Orien

ted

Date of Founding

South Africa Walter Sisulu School of Medicine X X X X X

Linguistic Group

GeographicRegion

uese

Africa

ern

East

Africa

Sorn

uthe

Africa

CountryMedical School Name (English Translation)

Abbreviated Name N

ew/Pr

Central

Western

1991

or

1960

‐

1959

or

Public

Private

Trad

it

Commun

it

Arabic

English

Fren

ch

Portug

Côte d'IvoireUniversité de Cocody ‐ Abidjan, Unité de Formation et de Recherche(Cocody University ‐ Abidjan, Medical Sciences Teaching and Researc

Sciences Médicaleh Unit)

s ‐ Cocody Côted'Ivoire

X X X X X

Ethiopia Jimma University School of MedicineJimma‐Ethiopia

X X X X X

Malawi College of Medicine, University of Malawi COM‐Malawi X X X X X

MaliUniversité du Mali, Faculté de Médecine, de Pharmacie et d'Odonto‐(University of Mali, Faculty of Medicine, Pharmacy, and Dentistry)

Stomatologie FMPOS‐Mali X X X X X

MozambiqueUniversidade Católica de Moçambique, Faculdade de Medicina (The Catholic University of Mozambique Faculty of Medicine)

CMatholicozam

‐bique

X X X X X

Nigeria College of Medicine, University of Ibadan, NigeriaIbadan‐Nigeria

X X X X X

South Africa Walter Sisulu University School of MedicineUniversityWSU‐South Af iAfrica

X X X X X

Sudan جامعة الجزيرة آلية الطب (Faculty of Medicine, University of Gezira)

‐Gezira XSudan X X X X

Tanzania The Hubert Kairuki Memorial UniversityHKMU‐Tanzania

X X X X X

Uganda Makerere University College of Health SciencesMakerere‐Uganda

X X X X X


visit. Before the visit, the host medical school Advisory

Committee member arranged appointments for the site

visit team with relevant related institutions: Ministries of

Education and Health of the national and/or state govern-

ment; the Human Resources for Health technical working

group; professional medical association (if relevant); medi-

cal regulatory bodies (if present); and other institutions

that the host Advisory Committee member deemed rele-

vant. Prior to each site visit, the advisory committee mem-

ber from the hosting school filled out the SAMSS survey

(described in Chapter 4). Each advisory committee mem-

ber from a site visit school also prepared a brief about the

school’s founding, history, vision, and mission. In addition,

members of the Secretariat prepared briefing materials

which included relevant legislation, regulation, and accred-

itation practices in the country, as well as a selection of rel-

evant literature identified in the literature review process.

All pre-visit data collected was provided to the site visit

team to orient team members before their visits began.

Each site visit team consisted of at least two members of

the Secretariat and at least two members of the Advisory

Committee, including at least one representative from a

different site-visit school. A site visit lasted five or more

days, allowing ample time for information gathering at the

medical school and at partnering institutions, such as clin-

ics or teaching hospitals, and where needed, additional days

for the team to travel to the country’s capitol to speak with

government representatives.

During each visit, multiple interviews were conducted by the

site visit team based on a set protocol and interview guide

developed by the GWU Secretariat in collaboration with the

Advisory Committee. Interviewees included each school’s

executive dean, academic dean, key department chairs, fac-

ulty members, student groups, and clinical site educators.

They were asked about their school’s mission, the social

context of the school, curricular content, attitudes of par-

ticipants toward emigration and retention, innovation in

educational programs, programs serving rural or under-

served areas, admissions policies, and relationships with

other health science institutions or educational programs.

The teams were particularly interested in the schools’ capac-

ity building plans and prospects. Questions asked included:

Did the school’s curriculum and programs support country-

relevant aims; Did the school have the potential to expand its

enrollment or programming; Were there innovations in the

curriculum dealing with public health or leadership-related

learning; and What were the available post-graduate medi-

cal education opportunities? Additionally, during site vis-

its, teams followed up on any issues from the survey that the

host institution had highlighted.

Prior to leaving the visited county, teams drafted site visit

reports based upon a standard template. Essential to each

report were the site visit “Findings”—noteworthy observa-

tions of either a promising or problematic nature that were

proposed and debated by the team members. Observations

deemed significant by the team and agreed on unanimously

were reported as the formal site visit findings.Complete site

visit reports are available in Appendix 6.

In each site visit, the following types of information were

collected:

pre-visit data ColleCtion

In preparation for each site visit a survey questionnaire was

sent to the school and returned to the study team. This sur-

vey collected baseline scholastic demographics on the insti-

tution. It covered largely quantitative topics including data

about faculty, students, educational programs, graduate


medical education, alumni, and academic outcomes. It also

inquired about school infrastructure including finances,

physical facilities, computers and information technology.

Additionally, each school was asked to provide material (or

references to material) pertaining to the founding, history,

mission, legislation/regulation, accreditation and current

status of the institution.

site-visit data ColleCtion

During the site visit, multiple interviews were conducted by

the site visit team based upon developed interview proto-

cols. These interviews covered topics including the school’s

mission; the social context of the school; curricular con-

tent; attitudes toward emigration and retention; innova-

tive educational programs or systems; programs focusing

on health for rural and underserved areas; admissions poli-

cies; and relationships with other health science education

programs. The team asked about prospects for capacity

building including questions relating to in-country support

for domestic focus, expansion potential, public health and

leadership curriculum; and post-graduate medical educa-

tion opportunities.

The individual schools’ site visit findings were discussed by

the entire Secretariat and Advisory Committee to produce

the overall Site Visit Findings below.

Results

General FindinGs

1) Many countries are prioritizing the scale up of med-

ical education as part of overall health sector

strengthening.

There is a high level of interest in expanding and

improving medical education in Sub-Saharan Africa. In

many cases, expansion is being advanced by national,

regional and local governments – drafting long term

plans, making major financial commitments, and focus-

ing on the retention and distribution of medical gradu-

ates. This has resulted in substantial positive energy in

many medical schools. In countries where governments

have national plans for the scale up of human resources

for health, medical education and physician capacity

are benefitting.

A number of national governments are investing heavily in

human resources for health, and are producing health sec-

tor strategic plans that include health care workforce scale

up. Medical education is recognized as a critical compo-

nent of the health care workforce and an integral piece of

health sector human resource plans.

Ethiopia is one example where the government is invest-

ing heavily in new facilities and equipment, developing a

First year students at the University of Malawi experience “shock therapy” living and working in a village.


scale-up plan for health workforce based on a “flood and

retain” strategy, and reorganizing its health delivery sys-

tem to maximize its health workforce. Estimates for the

current number of physicians in practice in the country

vary, but the total workforce is about 2,000 for a popu-

lation of 85 million, or about three health workers per

100,000 persons in the population, far less than the mini-

mum recommended by WHO. To address this shortage,

the Ethiopian government has adopted a strategy of rapid

expansion of medical education or a “flood strategy.” This

strategy begins with a huge increase in the number of medi-

cal schools in the country (from three to 12; 11 of them pub-

lic). Moreover, all medical schools have a mandate from the

Ministry of Education (MOE) to expand their class sizes.

Jimma University’s first year class, for instance, rose from

200 students in 2008 to 250 in 2009. By 2012, the class is

expected to include 350 students. The government is sup-

porting this expansion through significant investments in

physical infrastructure. Jimma University is in the midst of a

massive expansion and upgrade of campus facilities, includ-

ing the construction of a new modern teaching hospital.

In order to increase physician service and retention, the

government has also worked with medical schools to

withhold graduation credentials, pending each student’s

completion of a period of compulsory service within the

country. It appears the national government plan has been

developed through a well-coordinated, collaborative effort

including ministries, universities, and professional societ-

ies with a “shared vision” for health care.

Tanzania provides another example of government invest-

ment in medical education expansion. The government

has begun a program of cost sharing, which provides stu-

dent loans and grants and has resulted in an increase in

the number of medical schools in the country, particularly

private schools, and expansion of class sizes. Hubert

Kairuki Memorial University (HKMU) has seen an expan-

sion in student admissions which were initially planned to

increase from 25 to 50 students annually over five years, but

instead grew rapidly to 80 students.

The Tanzanian government has also implemented a civil

servant insurance scheme, which is increasing the number

of patients seeking services at hospitals and has the poten-

tial for supporting the expansion of the private health care

market and providing positions for graduating physicians.

With this scale-up, two areas that will need additional

attention are medical school faculty shortages and the

unintended consequences of student debt. Rapid expan-

sions in student numbers will likely further strain fac-

ulty and facilities, which may threaten faculty retention,

the quality of education, and ultimately the competency of

students. Students report that debt is an incentive to forgo

rural service to seek higher paying urban, non-governmen-

tal organization (NGO), or international positions.

2) Physician “brain drain” is a special problem for medical

education.

The emigration (external brain drain) of faculty mem-

bers and specialized doctors poses a particular prob-

lem for the stability and growth of medical education.

Internal brain drain, or loss of physicians and medi-

cal school faculty to non-governmental organizations

(NGOs), is an additional challenge to medical education

and public health care systems. Medical schools have

difficulty competing with NGO salaries and benefits.

Physician “brain drain” is a societal challenge, requir-

ing concrete action by all at the local, national, and


international levels. Current students in all visited schools

indicated strong interest in pursuing opportunities abroad.

The University of Ibadan (Nigeria) estimates as many as

70% of their graduates leave the country for training and

practice opportunities in Europe and North America.

However, many students report they would like to stay in

their countries, provided that the country is stable, practice

opportunities are increased, and medical working condi-

tions are improved.

Of those physicians who remain in the countries where

they were trained, many stay in urban areas, causing an

urban-rural mal-distribution, which negatively impacts

access to heath care in rural, remote, and underserved

areas. In most of the countries visited, there are no insti-

tutional and/or ministry led initiatives to improve distri-

bution of medical school graduates, either geographically

or by specialty choice. Also, there are currently no mecha-

nisms to track the location and career development of med-

ical school graduates.

Physician brain drain is a particular problem for institu-

tions of medical education. Severe faculty shortages pro-

mote further faculty loss and are a significant barrier to

capacity scale up. Shortages “stretch” existing faculty,

placing increasing teaching and clinical demands on fac-

ulty, limiting research and career development activities,

and promoting migration to either international or national

private, urban, or NGO opportunities. The Ministries of

Health in several countries have initiated or proposed

efforts to combat brain drain; however, all of these efforts

are relatively new and none have yet borne fruit.

To complement the scale-up in education of medical doc-

tors, many countries are implementing physician reten-

tion strategies, including requiring compulsory service. In

Mozambique, for example all medical school graduates are

required to work for the government in assigned positions

in peripheral areas for two to four years following gradu-

ation. In Ethiopia, required service is typically four years;

however, in designated remote regions, service is required

for only two years, and doctors receive additional incen-

tives such as a higher salary, a laptop computer, and text-

books. Technically in Ethiopia, graduates can “pay out” of

these service requirements. However, the pay out amount

of $32,000 (US) is generally higher than any young doc-

tor can afford. Following completion of their compulsory

service, physicians can move to different regions, go on to

post-graduate training, move to non-governmental posi-

tions, or leave the country.

It is unclear what the effect of compulsory service will be

on long-term retention of doctors. Some students report

the lack of choice in placement location breeds a “distrust”

of the government. The MOH Director of the Human

Resource Development Directorate in Ethiopia reports that

when the compulsory service policies were implemented,

there was an outcry by graduates whose credentials were

withheld, as there had been no prior explanation of the new

policies. The MOH convened a meeting of these gradu-

ates to explain the government’s health mission and vision

At HKMU in Tanzania, students may check out a year’s textbooks from the ‘book bank’ for US $60.


for Ethiopia’s health care system during a 21-day train-

ing period. Following the session, the Minister reports that

99% of graduates self-selected rural areas for compulsory

service. The MOH has maintained close relationships with

these young doctors in an attempt to address issues which

would promote migration.

In Uganda, the MOH has proposed a number of incen-

tives to address physician retention. Makerere University

is addressing the rural-urban mal-distribution by sending

students to rural areas to work. Some students are report-

ing that they are inspired to return to practice in these

regions after graduation. Public service jobs in the country

have improved salaries and benefits particularly for those

doctors serving in hard-to-reach areas. Leadership and

management skills during professional training are empha-

sized. These “real-world” skills are often insufficient for

young physicians who may be working in areas experienc-

ing conflict or in other complex situations. The focus has

been on improving the work environment for public service

jobs, making them conducive to effective practice with ade-

quate medical supplies and reliable utilities. Finally, oppor-

tunities for career development and continuing education

are being made available to Ugandan physicians.

In South Africa, Walter Sisulu University is recruiting

students from rural areas, as evidence indicates that doc-

tors who originate in rural areas are more likely to work

there. The university has seen some success with these

recruiting mechanisms.

Over the next few years, it is hoped that each of these initia-

tives will be thoroughly evaluated and shown to improve the

distribution of medical personnel to all areas of need, includ-

ing to institutions of medical learning.

3) accreditation and quality measurement are important

developments for standardizing medical education

and physician capabilities.

Many countries have instituted accreditation policies

for medical schools and some have developed certifica-

tion standards for doctors. While these are not uniform,

they represent significant benchmarks for medical edu-

cation and important efforts to standardize the qual-

ity of medical training and physician practice. There

are also some efforts to create regional standards which

would provide economies of scale in testing and the abil-

ity to share evaluation resources.

Accreditation and quality assurance measures are vital for

the future of medical education and for providing qual-

ity health care. Many of the schools visited describe defi-

ciencies in their accreditation systems. In Ethiopia, for

instance, there is no official accrediting body for medi-

cal schools, and accreditation is granted only when an

institution is initially founded. The “Quality Assurance

and Relevance Agency (QARA)” under the Ministry of

Education accredits higher learning institutions (colleges

and universities). However specific accreditation for medi-

cal schools is not in place. Almost all medical schools in the

country are parts of larger universities.

In Mozambique, a newly formed Medical Council plans to

develop accreditation standards for medical schools and

external examinations for medical students. In Tanzania,

the Tanzanian Commission for Universities visits teach-

ing institutions once before granting initial accreditation

and then every four years. However, all visits are currently

on hold pending approval of charter applications newly

required of all universities.


Many schools report seeking innovative ways to accredit

institutions or to evaluate graduates. The Malawi Medical

Council accredits teaching institutions in Malawi. The

Council uses the guidelines of the Southern African

Development Community (SADC) for accreditation and

quality assurance purposes. Walter Sisulu University

(South Africa) has a system in place for conducting struc-

tured periodic evaluations of students. As in many schools,

these include evaluation by both WSU faculty and external

examiners. In Sudan, all graduates of the country’s medi-

cal schools are required to pass a standardized, computer-

administered exam before obtaining a license to practice.

In most of the site-visited countries, the level of rigor-

ous accreditation standards developed by the Ministry of

Higher Education, which is responsible for oversight of

medical schools, is minimal. Governments should encour-

age the adoption of regional, continental, and international

standards. To facilitate this, governments should finance

exchanges of examiners and specialist teachers. Although

evaluation and accreditation of academic institutions are

recognized as important functions, no concrete initiatives

have been taken to develop norms, procedures, or incen-

tives to enhance the quality of medical education.

ChallenGes

4) The status of the country’s health system affects medi-

cal education and physician retention.

In some countries there is a mismatch between the

number of medical students trained and the number of

doctors the government can employ, creating a failure of

absorption and contributing to physician emigration. In

many countries a private sector is developing which may

increase physician absorption, but the preponderance of

jobs for medical graduates remains in the public sector.

Therefore, positions available, reasonable compensa-

tion, good management, opportunities for advancement

and further training, and personal security all are criti-

cal to the retention of medical graduates. Further, lack

of infrastructure (clinical supplies, IT, basic utilities) can

discourage physicians from practicing in rural areas.

Ideally, governmental investments in medical educa-

tion and medical practice opportunities (public and pri-

vate) should be balanced and at a level that will address the

country’s major health challenges. These training and prac-

tice policies should be driven by a national assessment of

needs and the strategic use of public investments in educa-

tion and service. Lack of this conjoint planning will result

in inadequate career opportunities for medical graduates

and wasteful mismatches in the health sector.

Non-absorption of medical graduates remains a chal-

lenge in some countries. For example in Mali, the annual

number of medical graduates from the University of

Bamako Faculty of Medicine is significantly greater than

can be accommodated with available post-graduate, spe-

cialty training opportunities, or employment through the

Ministry of Health, the community health centers, and

the private sector. The result is an unknown number of

qualified but unemployed doctors. In Nigeria, the num-

ber of internships available is insufficient to allow all cur-

rent medical school graduates to satisfy the requirements

for registration with the Medical and Dental Council of

Nigeria. As new schools are established, this mismatch

is growing. Hence, some graduates remain unemployed

and others choose to emigrate in search of post-graduate

training and employment opportunities. Employment in

Nigeria’s large and essential network of secondary hospitals

is considered by the country’s doctors to be difficult due to


massive shortages of clinical supplies, support personnel,

and basic hospital equipment. Primary care work is funded

at the district level where pay and support are so poor that

medical doctors generally shun such placements entirely.

In Uganda, health care systems problems adversely affect

Makerere University’s graduates’ motivation to join the

local work force. Decentralization of health care delivery, as

well as involvement of multiple poorly led and coordinated

regulatory and oversight entities has led to a system that is

inadequately responsive and unwelcoming to newly gradu-

ated doctors. In Sudan, absorption problems for graduates

suggest a mismatch between investments in the educational

and the health service systems. There is evidence that the

number of annual graduates of Sudan’s medical schools

greatly exceeds the government’s capacity to hire new

medical officers, despite considerable need. While many

Sudanese graduates eventually migrate to the Persian Gulf

region and elsewhere, there is a reasonable question about

the long-term sustainability and cost-benefit rationale of

the country’s high level of production of medical doctors.

5) coordination among ministries of education and min-

istries of health improves medical schools’ ability to

increase health workforce capacity.

Ministries of education fund medical schools, effectively

determining the number of doctors available for prac-

tice. Ministries of health hire medical graduates and

are responsible for national staffing of health care sys-

tems. Coordination between the ministries of education

and health for the purposes of planning, budgeting, and

managing educational outcomes is essential and often

not as effective as it might be.

Better planning and coordination between ministries of

health and ministries of education are needed. In most

countries, the ministry of education provides the funds for

medical education including student tuition and a bud-

get for the salaries of medical faculty members. Ministries

of health are the principal employer of medical schools’

graduates. Despite these intrinsic relationships, however,

in many countries, joint planning, budgeting and evalu-

ation does not take place. Improved and close coordina-

tion between the policies and budgets of the two ministries

would promote better use of the funds available for physi-

cian training and employment.

The Faculty of Medicine of the University of Gezira (Sudan)

enjoys extraordinarily close working relationships with

the Federal and State Ministries of Health and Education.

This enables the effective integration of university teach-

ing programs with the service delivery activities of the

Ministry of Health – to the benefit of both. At Gezira,

there is an uncommon decentralization of authority

from the federal government to the state government and

from the vice chancellor of the university to the Faculty

of Medicine. This decentralization positively impacts the

teaching, service, and research programs of the Faculty of

Medicine and enables creativity and partnerships at all lev-

els to the considerable benefit of the academic enterprise.

Decentralization is the result of decisions made at the fed-

eral level by the Ministry of Health and Ministry of Higher

Education, as well as an impressive level of trust at the uni-

versity itself.

In Tanzania, there is a positive environment where the

government, at the highest level, has placed priority on

the health sector and on developing human resources for

health. The government, through the Ministries of Health

and Education, provides support for students enrolled


in a private medical school, the Hubert Kairuki Medical

University. This collaborative relationship also allows

HKMU to use two municipal hospitals in Dar es Salaam

and three referral hospitals (Mirembe in Dodoma, Bugando

in Mwanza, and KCMC in Kilimanjaro) for sites of clinical

learning for students of this private medical school.

At Walter Sisulu University (South Africa), there is a gen-

uine and pervasive involvement of the community in

the operations of the school and an exceptionally strong

involvement from local authorities, which is uniquely

located in a rural setting. This support includes having

community members on medical school admissions pan-

els, as well as strong clinical and financial support from

the District Health Department. The mission and con-

tribution of the School of Medicine is clearly valued as

reflected in substantial and ongoing financial support from

the Provincial Department of Health. Moreover, national

policy and funding from the Departments of Health and

Education have a profound impact on the ability of WSU to

fulfill its mission. South Africa is undergoing an effort to

coordinate better between these two departments with an

eye toward aligning the health education platform with the

health services needs of the country. Funding mechanisms

are currently under review at all levels.

At the College of Medicine of the University of Malawi,

managing the teaching/service interface has been com-

plex. The Ministry of Health and Population (MOH) owns

the teaching hospital used by the college, which means that

the heads of the clinical departments are also senior staff

for the college. To make sure the Queen Elizabeth Central

Hospital (QECH) provides the right environment for the

teaching of under- and post-graduate students, the col-

lege has become intimately involved in managing the hos-

pital. A “joint management” committee has been set up

with equal representation from the College of Medicine

and QECH. The college, the Medical and Nursing Councils

and the MOH have established a second committee, the

“Tripartite Committee” with involvement from each.

While by no means perfect, the Tripartite Committee is

helping to coordinate issues related to QECH’s training and

service delivery.

In several schools visited, coordination between ministries

of health and education in conjunction with university col-

leges of medicine is minimal, contributing to problems,

such as inappropriate curriculum and the graduation of

medical doctors who cannot find employment in the coun-

try. Intra-ministerial coordination and the implementa-

tion of conjoint strategic plans on the part of the ministries

would promote educational relevance and would maximize

the use of scarce educational resources.

6) Shortages of medical school faculty are endemic and

problematic.

Despite innovations at many schools to improve faculty

recruitment and retention through financial and non-

financial incentives (such as salary top ups, research

support, housing, educational support for families),

substantial and long term faculty scarcities remains a

major barrier to medical school expansion. Areas that

are particularly problematic are the basic sciences,

where few scientists are trained, and specialty physi-

cians, whose numbers are few and for whom emigration

is a constant threat. Some schools rely heavily on expa-

triate faculty from Europe or North America but this is

seen by all as a temporary solution.

Almost all of the site-visited schools suffer from some

degree of faculty shortage. Shortages are more common


and more severe in basic science faculties than in clinical

science faculties. Limited salaries and career options, heavy

teaching workloads, limited space, growing student enroll-

ment, lack of equipment, and lack of technical and support

staff are the prime barriers to training and maintaining

adequate numbers of faculty.

At Catholic University (Mozambique), the academic and

structural problems present ongoing challenges to the new

school. The initial faculty in 2002 was entirely composed of

doctors from Europe and elsewhere in Africa. The continu-

ing heavy reliance on expatriate faculty stands out as a sig-

nificant challenge to the new school.

At the University of Jimma (Ethiopia), severe faculty short-

ages continue to promote further faculty loss and are a

significant barrier to capacity scale up. Faculty shortages

“stretch” current existing faculty and promote migration

to other countries or local relocation to private, urban, and

NGO opportunities. Salary is a significant barrier to faculty

recruitment and retention. Within the university system,

the clinical teaching staff is paid on the salary scale set by

the Ministry of Education, as are all university professors.

The base salary of a university professor is lower than that

of a public sector physician set by the Ministry of Health

(MOH), making recruitment of physician teaching staff

even more difficult.

At Makerere University (Uganda), recruitment and reten-

tion of faculty is challenging given the workload demand,

low levels of reimbursement of faculty, and limited oppor-

tunities for promotion. At HKMU (Tanzania), there was

a rapid expansion of annual student admissions from a

planned 25 to 80 students, without a concomitant increase

in faculty and infrastructure. As a result, the small teach-

ing staff is overstretched with, as one professor stated, “no

time to breathe.” At the Faculty of Medicine, University of

Gezira (FMUG) (Sudan), shortages of basic science faculty

challenges delivery of courses in that portion of the cur-

riculum. At FMUG and elsewhere in Sudan, it is reported

that there are not enough basic scientists being trained, and

that clinicians often have to teach basic science to medi-

cal students – a suboptimal solution. The WSU School of

Medicine (South Africa) faces serious challenges in fac-

ulty retention, recruitment, and scaling up capacity. Many

of the school’s founding faculty came from Uganda and

Nigeria, and there continues to be a conspicuous lack of

South Africans on the academic staff.

Schools have tried to put in place certain retention strat-

egies to build the needed critical mass of faculty. At

Makerere University, the strategic plan for 2010 and beyond

is addressing some of these issues. At HKMU, staff reten-

tion strategies include increasing salaries to be competi-

tive with the public sector and offering incentives such as

housing and communications allowances, telephone air

time, motor vehicle fuel, and participation in seminars. At

Catholic University, the situation has improved, and today

20 out of 32 full time faculty members and 41 out of 51 part

time faculty members are Mozambicans. Some of this is

a result of eager and capable students from Mozambique

willing to cope with the academic and tuition challenges of

private education.

Despite this progress, recruitment and retention is difficult

and most of the specialist faculty remains foreign nationals

working on contract for specified time periods.

At the time of the founding of the Faculty of Medicine of

the University of Gezira, it was the second medical school

in the country outside of Khartoum – the dominant cen-

ter of medicine and medical education in Sudan. Faculty


recruitment and retention were seen as a challenge. From

early in the history of the FMUG, therefore, there has been

a strong reliance on recruitment of the school’s own gradu-

ates for faculty positions. At the present time 40% of the

formal faculty are FMUG graduates, a figure that has been

typical over the years.

At Walter Sisulu University, the severe shortage of clini-

cal faculty is overcome in large part through the school’s

partnership with the clinicians at Nelson Mandela Hospital

and Mthatha General Hospital, who are employed by the

District of Health and are mandated to teach WSU students

by their contracts. These clinician-educators comprise over

75% of the teaching faculty on the school’s main campus.

The strong relationship with the provincial Department

of Health has allowed WSU to maximize this capacity.

However, these clinicians remain stretched in their clinical

responsibilities and their departments experience the same

difficulties with recruitment and retention that the School

has with its faculty. WSU has recently added post-graduate

medical education programs and has plans for an aggressive

faculty recruitment strategy targeting its own graduates.

7) Problems with infrastructure for medical education are

ubiquitous and limiting.

Medical schools are demanding institutions. They

require basic services such as an adequate physi-

cal plant and a dependable source of power as well as

laboratories, classrooms, hostels, teaching aids, books,

libraries, journals, computers, connectivity, and clini-

cal teaching sites. Some schools have been innova-

tive in developing their own income generating activi-

ties in order to support education activities. However,

infrastructure continues to pose a major educational

challenge in many settings and warrants strategic atten-

tion and investment.

Lack of or deficiency in physical and portable infrastructure

is endemic in many schools. At the Catholic University of

Mozambique, structural problems including a lack of com-

puters, limitations in internet connectivity, and the absence

of hostels for students present ongoing challenges. At the

University of Ibadan College Hospital, many informants

expressed concern to the site-visit team that almost daily

power outages result in the need for departments to have

their own generators to maintain clinical and didactic func-

tions. At Jimma University (Ethiopia), basic utilities such as

power and water, and advanced utilities such as telecommu-

nications are unreliable at the national level and negatively

impact capacity and jeopardize innovation at the local level.

At HKMU (Tanzania), current teaching, research, and ser-

vice activities are outgrowing the existing physical infra-

structure. Investment is needed to expand facilities to meet

current needs and to allow for further growth and expan-

sion. HKMU has made plans for, and has an additional

campus designated for this expansion. The new campus is,

unfortunately, at a distance from the current “landlocked”

campus. At WSU (South Africa), some school facilities are

shared with other faculties in the University, sometimes

causing compromises in programming. Lack of housing for

faculty near the main campus has been a barrier to recruit-

ment, and inadequate housing for students near sites of clini-

cal training at the main teaching hospitals and community

sites is a hindrance to optimal education.

An example of strategic investment in infrastructure

is found at the College of Medicine of the University of

Malawi. Assisted by funds from the governments of Sweden

and Norway and from the Global Fund, the school has been

able to construct or enhance facilities, including lecture


halls, libraries, hostels, computer facilities, offices, and rec-

reational areas. These improvements have been built to

accommodate larger class sizes, a growing faculty, and to

make room for the demands of what will certainly become

a regionally and internationally important academic center.

For example, the new library will have conference facili-

ties to host international academic meetings. The College

is investing in IT facilities that will increase its appeal and

efficiency for education and administration. Curricular

materials, such as lecture notes and faculty resource mate-

rials, will be accessible using the school’s IT system.

8) variability in secondary school quality creates chal-

lenges in medical school admissions.

The variability of secondary education in many settings

presents a problem for medical educators, particularly in

increasing the number of students from rural and under-

served areas. Some schools have implemented pre-univer-

sity preparatory programs to ready students for the medical

school curriculum. However, preparatory programs are an

additional cost burden for medical schools and students.

A sound secondary education system is an important pre-

requisite for ensuring that medical school applicants pos-

ses the knowledge base and learning skills necessary to be

successful as medical students. Administrators of many of

the site visited schools reported weak secondary school sys-

tems in their countries, which in turn affects the quality

of the schools’ applicant pool. Some medical schools have

devised pre-medical school programs or revised the medi-

cal school curriculum to address inadequacies in academic

preparation of their students. These efforts appear to have

improved the applicant pool and/or have increased gradua-

tion rates of admitted students.

At Catholic University (Mozambique), weakness in second-

ary school education necessitates a medical school prepara-

tory year which is required of most applicants to the school.

About half of the students accepted to this preparatory

program perform well enough to be admitted to the medi-

cal school the following year. Likewise, the Pre-University

Program at HKMU (Tanzania) has increased access to

medical education. Through such programs, students are

better prepared for the level of technical learning required

during medical education.

At the College of Medicine in Malawi, there are difficulties

in recruitment of students from rural areas. The initiation

of a pre-med program has produced a local solution for a

local problem to recruit the needed number of students to

the medical college. Attending this program is expensive

(about $2,000 US per year), and currently, reliable and sus-

tainable sources of funding that can be used to offer schol-

arships to the pre-medical program are scarce. Moreover,

there is also no detailed “means” testing for determin-

ing and assisting candidates from poor and vulnerable

groups to identify students who qualify for pre-med, but

who require support in order to pay the required fees. Lack

of funds is a deterrent for qualifying applicants from low-

income families, especially for those who are among the 60

students accepted per year, but who did not score among

the top 10% on the entrance examinations.

Walter Sisulu University (South Africa) promotes access

to and success in medical school for previously under-rep-

resented South African students. WSU has developed an

innovative admissions policy and first term educational

strategy. Recognizing continuing inequities in access to rig-

orous secondary education, WSU does not base admissions

purely on qualifying examination scores. It has established

quotas by race to reflect the demographics of South Africa


and interviews applicants using a scoring system that

includes motivation and demonstration of commitment to

service. In addition, the school’s first term curriculum pro-

vides language instruction (in Xhosa for English speak-

ers and in English for students whose primary language is

Xhosa), computer fluency, and traditional didactic teaching

in basic science with a focus on study skills. A peer mentor-

ing program is in place to help incoming students adjust to

campus life.

innovations

9) educational planning that focuses on national health

needs is improving the ability of medical graduates to

meet those needs.

At government and individual school levels, increas-

ing emphasis is being placed on educational curricu-

lums focusing on priority health needs of the country.

Context-focused approaches to medical education are

improving the ability of graduates to address national

health problems. Many countries now require national

service from physicians after graduation, effectively pro-

viding physicians to rural and underserved communi-

ties in return for the educational and vocational benefit

of a medical education.

Many schools are emphasizing “community oriented,”

“relevant,” or “nationally focused” medical education.

Although some initiatives are undertaken by the schools

alone, many are set in the context of government priorities

and national service programs.

At the Catholic University of Mozambique, rotations

are designed to give students rural exposure prior to

their graduation. The school is also incorporating more

management training for students in recognition of the fact

that many of its graduates will be serving in administrative

tasks as regional health officers or hospital chief medical

officers a short time after graduation.

At the College of Medicine (COM) in Malawi, the cur-

riculum was designed to immerse students in local health

issues. The COM has introduced a fully integrated cur-

riculum. During their first two years, students study

basic sciences and how they relate to clinical problems.

Approximately 25% of the Bachelor of Medicine and

Bachelor of Surgery (equivalent of MD) courses are dedi-

cated to community health, in order to produce doctors

“rooted in the cultural milieu of Malawi.” Students in their

first year get “shock therapy;” a week’s immersion liv-

ing with a family in a village, which is part of a “learning

by living” philosophy. The COM curriculum also focuses

on the 20 most common diseases and health conditions in

Malawi and the sub-region.

Walter Sisulu University’s Faculty of Health Sciences

(South Africa) aims to fill a specific niche. The curriculum

focuses on rural health, where real needs exist in South

Africa. Thus, much of the curriculum is delivered in the

community at District hospitals, Community Health cen-

ters, clinics, and patients’ homes. Problem-Based Learning

(PBL) and Community-based Education and Service

(COBES) are introduced in the first year and continue

through the final year. WSU is one of the few schools in

South Africa to offer small group PBL tutorials during the

clinical years of training. As they advance through the aca-

demic years, students spend increasing amounts of their

time in the community and their entire final year is con-

ducted at a district community hospital. With a six-year

curriculum to be introduced in 2010, students will spend


the fifth year in district hospitals, and return to tertiary

hospitals in their sixth and final year.

Jimma University (Ethiopia) has established innovative

approaches across all disciplines based upon the founda-

tional concept of Community-Based Education (CBE).

CBE is best understood as a pervasive institutional culture

rather than simply an innovative pedagogical overlay. CBE

has three components. The first, the Community Based

Training Program, is discipline based. Medical students

shuttle daily to rural and urban sites 30-40 km from the

university, moving through a progression of tasks includ-

ing tool development, data collection, community diag-

nosis, analysis, and development of a solution proposal for

local problems. The second, the Team Training Program,

requires medical, dental, pharmacy, nursing and health

officer students to travel to village health centers as a team

for two months during the final year of their studies. They

provide public health and clinical services. Last, at the

end of internship each pupil prepares a Student Research

Project. This report is based on the data the student has

collected from the community on a subject of personal

interest. This project is defended during a comprehensive

examination done at the end of internship.

At Gezira University (Sudan), community based issues

comprise 25% of all studies. One quarter of the commu-

nity courses are conducted at field sites. Students are posted

at clinical training sites starting from their first year. At

the University of Ibadan (Nigeria), the Family Medicine

residency program and the soon-to-be established depart-

ment of Family Medicine are part of a growing presence

of Family Medicine in Nigeria and represent a new and

practical approach to health services delivery. At Makerere

University (Uganda), curricular change has recently been

instituted to better address national needs. In its search

for a medical education that is relevant and responsive,

Makerere University has implemented a globally rec-

ognized approach, which meets the healthcare needs of

Uganda. HKMU (Tanzania) has developed private-public

partnerships in order to train students within district hos-

pitals, providing the benefit of exposing them to real life

working conditions in the country and increasing opportu-

nities for practical experience.

10) international partnerships are an important asset for

many medical schools.

Many medical schools have developed partnerships with

medical schools, universities, and funding organizations

in other countries. These partnerships support teaching,

service and research activities, through visiting faculty,

program development, and research collaborations.†

All of the schools visited by the SAMSS team have developed

collaborations both within the country and internationally.

The University of Bamako (Mali) has benefited from the

support of the World Health Organization, and from

cooperation with the French government, which devel-

ops community health programs for graduates and pub-

lic health training for students. Bilateral agencies con-

tribute to research programs (European Union, Belgium,

etc.), as do foreign universities (University of Maryland,

Tulane University, Liverpool School of Tropical Medicine,

University of Aix, the University of Angers, the University

of Paris VI, University of Abidjan, University of Dakar,

University of Cotonou). The University also has received

research and training grants from the National Institutes of

Health in Bethesda, Maryland.

† However, the research agenda is often set by the outside part-ners rather than by the African schools.


HKMU (Tanzania) conducts research with University

of Utah and Duke University in the USA and Darwin

University in Australia. A collaborating team from Yale

University and the University of Connecticut is also par-

ticipating in genetic and HIV/AIDS research. Recently the

Egyptian embassy in Tanzania was approached in an effort

to recruit academic staff from Egypt.

At Makerere University (Uganda), there are multiple for-

eign academic and non-profit linkages, many with a long

history on the campus. More than 30 of these international

and local collaborations provide extensive research capa-

bility. Some partners such as Johns Hopkins University,

Baylor College of Medicine, Walter Reed Hospital, and Yale

University have a large visible presence on campus and

provide some teaching at the post-graduate level. Some of

the University’s non-profit partners have supported medi-

cal students in their work at community sites by provid-

ing funds for transportation or housing. They also support

“sandwich” programs, whereby students who complete

their undergraduate medical education travel to the donor

institution for further training before returning to Uganda

to practice.

The Catholic University of Mozambique has excellent part-

nerships with the Catholic Church, as well as a good cooper-

ation with the government of Mozambique. The school has

also benefitted from the establishment of an extraordinary

network of donor organizations and individuals in Europe

and North America, and the steady presence of significant

numbers of committed expatriate physicians who have pro-

vided much of the teaching staff for the school to date.

The College of Medicine (COM) at Malawi exemplifies a

“South to South” collaboration with its involvement in joint

training programs through the Southern Africa Human

Capacity Development (SAHCD) Coalition. The college’s

Masters in Medicine and the Masters in Public Health

training programs provide opportunities for regional col-

laboration. For instance, students in these programs are

sent to other countries in the (SADC) region, but they tend

to return to work in Malawi, according to an agreement

with SADC. External examiners from neighboring coun-

tries or the sub-region assist with accreditation and qual-

ity assurance processes. The COM has affiliations with

other regional international agencies such as the Southern

African Center for Research Excellence. In time, these rela-

tionships and exchanges will help build a critical mass of

practitioners able to function with ease in the entire SADC

region. Additionally, the COM has had extensive linkages

with various donor programs - NORAD, WHO, MOH and

its donors via SWAp funds. Various independent inter-

national research projects in Blantyre and elsewhere in

Malawi (Johns Hopkins University, Malaria Alert, etc.) are

“affiliates” of the COM and also have been direct and indi-

rect sources of training and staff development and reten-

tion support. These research projects provide not only

teaching opportunities and some infrastructure and con-

sumables support for the teaching hospital, but also are

sources of income supplementation for faculty. They may be

playing a very significant role in faculty retention.

11) impressive curricular innovations are occurring in

many schools.

There are significant areas of curricular and teaching

innovation taking place at many schools designed to

meet local and regional health care needs. Innovations

often involve critical thinking skills and community-

based education (CBE), both of which reflect inno-

vations taking place globally in medical education.

These innovations address regional needs by teaching


problem-solving skills for work in any setting and by

taking learning to communities where health needs are

greatest. Other advances include the teaching of family

medicine and public health and plans for the use of tele-

health and distance learning when bandwidth problems

can be solved.

Community engagement and community oriented teaching

are common themes and features at many medical schools.

Community exposure is common in the pre-clinical years,

and Community Based Education (CBE) is central to the

curriculum of many schools. Both structured community

exposure and CBE provide students with experience work-

ing with rural and poor populations and increase the prep-

aration of graduates to deal with national health problems.

Schools also reflect the importance of community engagement

through outreach and social responsibility activities.

At the College of Medicine in Malawi, the curriculum is

designed to immerse students in local health issues. The

COM has introduced a fully integrated curriculum. During

their first two years students study basic sciences and how

they relate to clinical problems. Approximately 25% of the

Bachelor of Medicine and Bachelor of Surgery (MBBS)

courses are dedicated to community health, in order to

produce doctors “rooted in the cultural milieu of Malawi.”

The COM also focuses on the 20 most common diseases

and health conditions in Malawi and the sub-region. One

hurdle in teaching the new curriculum is that there are

insufficient numbers of both computers and core books.

Many university programs support the COM. For instance,

25% of the undergraduate curriculum is provided by the

Community Health Department. In addition, students live

and learn in rural villages. With this dual exposure to a

community-based medical curriculum and rural experien-

tial learning, COM graduates are better prepared to meet

the health challenges in Malawi and find the sense of social

responsibility that is at the core of physician retention.

At Jimma (Ethiopia), CBE provides both clinical and public

health service to rural communities and increases graduate

preparedness. However, its effect on retention is unclear.

The creation of the College of Health Sciences at Makerere

University (Uganda) represents part of a campus-wide

effort to change the nature of health science education. The

current University strategic plan includes moving all fac-

ulties and programs to a learner-centered approach, with

a component of community-based service learning. The

community-based education curriculum is designed for

maximal exposure to the health care needs and system of

care in the rural underserved communities of Uganda. The

design of the curriculum provides students with goal-ori-

ented community-based learning through substantial and

repeated exposure to patients in underserved rural com-

munities as part of an interdisciplinary team. This team-

oriented approach to health care will likely prepare them

for their roles in teams throughout the healthcare delivery

system in Uganda.

At Gezira University (Sudan), the curriculum is influenced

by community-based healthcare, providing a potent organiz-

ing principal for medical students, faculty, and graduates. This

community orientation and a deep sense of social respon-

sibility are present in all aspects of the work of the school.

As a result, students and faculty feel a binding sense of pur-

pose and an extraordinary level of community engagement.

At Walter Sisulu University (South Africa), there is a well-

established tradition of learner-centered, self directed

education. Since its successful implementation in 1992,

WSU has employed a problem-based learning curriculum,


starting with basic sciences in the first three years and car-

rying on through the clinical years. Faculty attrition and

larger student numbers since that time have detracted from

the school’s ability to optimally deliver the demanding sys-

tem of PBL. Despite this strain, the faculty remains com-

mitted to this educational strategy, believing that it pro-

vides students with the best possible training for challenges

ahead. Students and recent graduates of WSU express con-

fidence in their skills, which they attribute to the problem-

based learning approach. They say this approach guides

them to think critically, to develop life-long learning skills,

and, in some cases, to overcome cultural and personal

obstacles they have faced having grown up in disadvan-

taged, rural settings. Students at WSU have substantial

community-based education and service learning oppor-

tunities, from first through their final years. They remark

that this exposure to rural communities motivates them

and shapes their understanding of the real-life challenges

and health care needs of the population in the surround-

ing region.

12) beyond the creation of new knowledge, research is an

important instrument for medical school faculty devel-

opment, retention, and infrastructure strengthening.

While research remains limited at most medical schools

due to limited funds and lack of experienced faculty,

schools that have succeeded in establishing funded

research enterprises, benefit from a significant posi-

tive effect on faculty development and retention. Some

schools have also demonstrated that research revenues

can be used to further strengthen the school’s educa-

tional infrastructure.

Medical schools recognize that research is critical for the

recruitment and retention of staff, as well as providing

opportunities to generate new knowledge and more fund-

ing. In most medical schools, research is seen as essential

for career advancement, both to meet appointment and

promotion requirements and to meet the professional ful-

fillment of faculty. Schools with strong research portfolios,

which in SSA are primarily the older, established schools,

report that successful research promotes staff recruitment

and retention and attracts an increasing number of exter-

nal partners. These schools have invested and continue

to invest in research activities internally and externally.

These investments allow further resource development

and training for young faculty. The University of Ibadan

(Nigeria) is an example of a well established research insti-

tute in Africa. In order to continue to support and pro-

mote research, the University has implemented innovations

such as hiring clinical consultants to provide patient care.

This allows faculty to focus on training and research and

researchers to top up salaries from research grants.

However, the success of established research programs

creates a conundrum for younger, smaller schools. These

schools often have younger faculty who lack the train-

ing, experience, and mentorship necessary to success-

fully bid for competitive research grants. An inability to

break through this research barrier limits the schools’ abil-

ity to build current and future research capacity. Further,

severe staff shortages at many schools increase the teaching

requirements on individual staff, limiting time available to

pursue research activities and training. Additional chal-

lenges include insufficient laboratory space and equipment.

Staff at these schools report that poor research capacity is

a barrier for faculty recruitment. Potential applicants rec-

ognize the lack of research support at these schools, which

can be linked to career advancement, and will often choose

other positions if available.


The University of Bamako in Mali is an example of a school

which has thoughtfully built its research capacity over the

past 30 years. In 1976, the University established a research

center with a strong emphasis on faculty development

and research support. Initially, faculty members were sent

abroad for graduate training. When they returned, they

were guaranteed employment, career building opportuni-

ties, and grant writing assistance. Initiation of the center

required significant up-front investments to train research

faculty; however, as faculty have been successful, funds to

support additional development and training have been

built into new research proposals. As research capacity

has grown, many graduate training programs have also

been established at the University. Research faculty teaches

within the medical school; this benefits both the research

faculty and the school. The University of Bamako stands

as a model for thoughtful long term research and teaching

capacity building.

The University of Malawi is another school that has thought-

fully developed its research capacity. The College of Medicine

established a Research Support Center (RSC) that pro-

vides assistance to faculty in grant writing, research design,

and grant administration. The Center also coordinates all

research efforts and monies at the College. The RSC col-

lects an indirect cost of 10% from all research grants. These

funds are used to further develop research capacity at the

College, to support the Center activities, develop new labs,

and augment research faculty salary. This support struc-

ture represents an important infrastructure investment in

research. The application of an indirect cost is an innovation

in African medical schools, which allows current research

grants to support future research capacity expansion.

While some SSA schools have well established research pro-

grams, many challenges persist, particularly for schools in

the early stages of developing their research programs. The

University of Bamako and the University of Malawi have

developed successful research programs that can be used

as models for other schools. Younger, smaller schools pres-

ent an opportunity for thoughtful development of research

programs, which in turn will ultimately strengthen overall

school infrastructure. This will be useful to increase faculty

recruitment and retention and to generate medical school

income that can be used to further build capacity. External

organizations should partner with established research

programs. They should seek out opportunities to partner

with developing schools to establish programs that clearly

focus on long term research capacity development, includ-

ing faculty training and infrastructure enhancement.

13) Private medical schools hold promise for adding to

physician capacity development.

Secular and faith-based, not-for-profit medical schools

are open and graduating physicians and contributing to

national workforce development. Private schools have

special challenges including reliance on tuition, optimiz-

ing government and international linkages, sustainabil-

ity and growth over time.

Private medical schools have proliferated in Sub-Saharan

Africa over the past 20 years. The founding of these private

schools is likely related to international policies support-

ing government decentralization in developing countries.

These same expanding economies have tended to promote

growth in the private sector both in health care and in edu-

cation. Coincidentally during this same time period, coun-

tries and international organizations have been focusing on

the development of human resources for healthcare.


Private schools face special challenges. Their revenue

streams are largely based on tuition. With the significant

budgetary demands of medical education and pressure

from external bodies to expand schools, administrators

in many private medical schools recognize that they must

diversify their funding sources. However, as young insti-

tutions representing a new model in Africa – the private

medical school - they struggle to develop partnerships and

define their roles with governments and donors. Private

schools often compete with public schools for government

and donor funds, faculty, and staff, but are often at a disad-

vantage due to the newness of programs, a young staff, and

limited incomes. Often, they must rely upon their larger,

better-established counterparts for support and part-time

teaching faculty. This use of part-time faculty is usually not

optimal to create stable educational programs.

Private schools also pose a new and special challenge for

governments. Regulation of medical schools is generally

loose in most countries. However, with public institutions,

governments often maintain close relationships and strong

informal controls on the school’s mission and planning.

Since most private medical schools do not have these

informal controls, they challenge planners to formal-

ize the accreditation processes to ensure the education of

high quality physicians. For-profit private medical schools

raise more concerns: How do these schools balance the

need to earn money, the educational mission, and the

needs of the country?

Despite the challenges, private medical schools represent an

area of innovation in SSA medical education. The private

model itself is a 20-year-old departure from the standard

government sponsorship of African medical education.

These schools have shown a lot of innovation developing

status and funding patterns often not seen in older and

public schools. Two of the ten schools visited were private

institutions.

The Hubert Kairuki Memorial University (HKMU) is a pri-

vate not-for-profit Tanzanian medical school founded in

1997. The school’s dynamic leaders well recognize the spe-

cial challenges of establishing and maintaining a private

school. HKMU is known for producing high quality, suc-

cessful graduates and has remained committed to its mis-

sion to provide high quality education and service to the

public, despite budgetary constraints. The University has

recently reduced its total first year enrollment in order to

maintain quality by matching the intake with the avail-

able human and infrastructural resources. HKMU offers a

pre-university program to assist disadvantaged students to

enter medical school. HKMU has also sought to diversify

its income through public and private partnerships. The

Tanzanian government supports HKMU through schol-

arships and grants which assist students in paying tuition

costs. HKMU partners with public district hospitals to

The University of Bamako, Mali relies on numerus clausus. About 1,800 students are enrolled in this first year class. Few will move on to their second year.


provide students with clinical teaching sites and to expose

students to working conditions found throughout the

country. Leadership has worked aggressively to develop

the school’s first international research partnerships.

Developing research capacity features prominently in the

University’s long term planning.

The Catholic University of Mozambique is a faith-based

not-for-profit medical school founded in 1995. The

University is a model of a successful collaboration among

a private educational institution, the government of

Mozambique, the Catholic Church, and a number of inter-

national donor organizations. The University is housed in

a building owned by the Catholic Bishops of Mozambique

and renovated with funds from the Bishops, German and

Italian religious organizations, and the Ipswich Hospital

(UK). The government supports the University through the

provision of clinical sites and student scholarships. Non-

governmental organizations, embassies and private donors

also donate to scholarships and fund expatriate faculty sal-

aries. The University has relied heavily on expatriate staff,

but is now developing a local staff, primarily cultivated

from school graduates.

More private medical schools in Sub-Saharan Africa mean

more opportunities for medical education. To sustain these

schools and create more will require continued commitments

from the schools, governments, and external organizations.

Governments then need to establish standards for medi-

cal doctors and ensure rigorous accreditation and licens-

ing to maintain quality and to produce graduates who will

address the needs of the country. As education is standard-

ized, schools will be challenged to maintain innovations.

14) Post-graduate medical education is an important

element of a national health system development

strategy.

The presence of post-graduate training programs is an

important aspect of a country’s medical education system

and prospects for physician retention. The principle rea-

son cited by ambitious medical graduates for emigrating is

the pursuit of post-graduate training. Local residency pro-

grams focused on priority national health needs are both a

mechanism for developing national capacity and a way of

retaining medical graduates

Makerere University (Uganda) and the University of

Ibadan (Nigeria) have well-developed systems for post-

graduate medical education (PGME). Other schools offer

some basic PGME in such fields as Medicine, Surgery,

and Obstetrics and Gynecology, while a few do not have

any post-graduate programs. PGME is being used by

many schools as a capacity building and retention tool.

By increasing the number of programs and the number

of positions available in PGME, schools have been able to

retain more graduates, as well as hire some of the newly

trained graduates as lecturers and assistant professors.

Some schools implement “sandwich PGME programs,”

where residents train at the host school for a period, fol-

lowed by time at another partnering regional or interna-

tional program then finish up their training at home. These

sandwich programs, especially the South-to-South collab-

orations, are intended to mitigate the tendency of doctors

who go north for training and stay in the North when their

training is complete.

In Mali, one of the main reasons for South-to-North migra-

tion is the paucity of PGME training available in the country.


The University of Bamako offers specialty-training programs

in Internal medicine, Surgery, Obstetrics and Gynecology,

Pediatrics, Psychiatry, Dermatology, Ophthalmology, and

Cardiology. Each specialty only has ten places available to

enroll students. The University has proposed to the MOH

to start seven new specialty training programs. The school

hires its own top graduates as lecturers.

At the University of Gezira (Sudan), post-graduate education

is growing with a stated goal of building the critical mass of

faculty needed to effectively teach each medical and surgical

field. The University has also recently started to offer masters

and PhD programs in the basic sciences. The rapid scale up of

post-graduate training positions in Sudan and the presence of

the Sudan Medical Specializations Board (SMSB) to monitor

the system are promising developments. However, the size of

the expansion and the presence of 27 specialties within the

SMSB raise questions about the role of specialty practice in the

country in the future.

Limitations

Of the ten schools selected for site visits, two (in Mali and

Cote d’Ivoire) were French speaking (one less than popula-

tion parity would warrant) while six were Anglophone, one

Lusophone, and one Arabic- speaking. The Francophone

shortfall occurred despite multiple attempts to establish con-

tacts with schools in the Democratic Republic of the Congo,

Senegal, and Cameroon.


By far the oldest school visited, the University of Ibadan, Nigeria, was founded in 1948.

chapter 4: survey repOrt

Introduction

This survey of Sub-Saharan African medical schools pro-

vides a quantitative evidence base important for under-

standing the current status, trends, capacity building

needs, and retention opportunities for African medical

schools. This information can be used by policy makers to

formulate a strategic plan to strengthen and scale up train-

ing capacity for medical staff in Africa, as called for by

African Union Heads of State in their endorsement of the

Africa Health Strategy: 2007-2015,234 and serve as a guide

for developing national and international policies for tak-

ing workforce scale up plans forward.

The University of Pretoria, South Africa, School of Health

Systems and Public Health was selected by a competitive

bidding process to contribute to the implementation of the

SAMSS survey. The University of Pretoria partnered with

the Secretariat and the Advisory Committee to develop

the survey, and was given principal responsibility for dis-

seminating, collecting, and analyzing the survey, provid-

ing a counterpoint to the work of the George Washington

University’s Secretariat.

Methods

study desiGn

This is a descriptive survey of Sub-Saharan African medi-

cal schools. Respondents are the Deans of African Medical

Schools or key informants identified by them. The informa-

tion therefore comes not from an outsider perspective, but

from the people who know medical education in Africa best.

survey instruMent

The survey instrument was developed based upon pre-

vious studies of medical and health professional

schools,235,236,237,238,239 key informant interviews, and

input from the SAMSS Advisory Committee. The sur-

vey instrument was pilot tested with the SAMSS Advisory

Committee. The Advisory Committee members nominated

by the ten site visited schools completed the survey for their

school prior to an initial Advisory Committee meeting in

Kampala, Uganda in 2009. The members then provided

feedback on the overall survey and individual questions for

appropriateness of content, wording, and answer choices.

The survey included quantitative and qualitative ques-

tions focused on basic demographic, capacity, retention,

innovation, and issues related to health systems. Questions

covered topics such as institutional characteristics, fund-

ing, a student profile, postgraduate training, teaching staff,


curriculum, and adequacy of various resources, including

information and technology resources, teaching rooms,

student facilities, and clinical teaching sites. The survey

also requested information about external relationships

and barriers to scaling up the numbers and quality of

medical doctors trained. The last section of the question-

naire included free response questions on issues such as

barriers to scale-up and innovations implemented at the

medical school.

study population and saMple

All medical schools in Sub-Saharan Africa identified by

the survey team before January, 2010, including private

schools,‡ are included in the survey. Creating an exhaustive

list of medical schools was essential to success of the Study.

Toward this end, a list of Sub-Saharan African medical

schools was compiled, combining publicly available global

directories of medical schools,240,241,242 contact lists of a

meeting hosted by the World Health Organization (WHO)

in Addis Ababa in 2002 and the Conference Internationale

des Doyens et des Facultes de Medicine d’Expression

Francaise (CIDMEF), and the database of the Global

Health Workforce Alliance (GHWA) “Scaling Up Task

Force.” University websites were searched, national medical

professional registration bodies and Ministries of Health

were contacted, and international telephone directory

enquiries were used. SAMSS Advisory committee members

and other experts knowledgeable about medical schools

in Africa reviewed the compiled list for accuracy and to

fill gaps. In addition, one survey question was designed

to elicit the total number of medical schools in a country.

This number was then checked against the study’s work-

ing list of medical schools (Table 3). The process of actively ‡ At the close of the survey period, SAMSS had uncovered 146 medical schools in SSA. Since that time, 21additional schools have been founded or brought to the attention of the SAMSS team.

identifying schools and gathering their contact information

continued through the entire data collection phase.

survey iMpleMentation and protoCol

Recognizing the challenges of implementing a survey study

with busy deans of medical schools, the following steps

were applied, with some flexibility, in order to maximize

the response rate (Figure 6):

» deans or deans’ offices were contacted through a brief

introductoy e-mail and/or telephone call, requesting

an appointment to speak to the dean. a letter of intro-

duction to the SaMSS survey and overall study were

included in this contact (appendix 3).

» during telephone follow up with the dean, the study

was introduced, including potential benefits to african

medical schools. verbal support for participation was

obtained and the dean was asked to identify a coordi-

nating respondent to take responsibility for complet-

ing the questionnaire. in many instances, the dean

personally chose to be the respondent. during the call,

or afterwards by phone or e-mail, contact details of

the coordinating respondent were obtained.

» once personal contact had laid the foundation, the

survey (appendix 2), a letter to deans (appendix 3),

an informed consent form (appendix 4) and letters of

support for SaMSS from who, ghwa, and the gates

foundation (appendix 5), were e-mailed to the coordi-

nating respondent. written support was also provided by

the new Partnership for africa’s development (nePad)

(appendix 5).


» follow up by e-mail and/or telephone was conducted

periodically to encourage responses and answer any

questions or concerns. in all communication, the SaMSS

team sought to create a sense of partnership with the

medical schools, working with them as part of a team

exploring medical education, rather than as objects of

research. The SaMSS team sought to be open, transpar-

ent and responsive. at various points, SaMSS advisory

committee members assisted in connecting researchers

with deans and encouraging completion of surveys.

» The original information and questionnaires in english

were translated into french and Portuguese and sent in

the language of choice of respondents.

» out of respect for the valuable time and effort that

completion of the questionnaire took, respondents

were offered a small honorarium. it was also recog-

nized that this might improve the response rate and

quality of the information received.

analysis

Data were entered, cleaned and analysed using STATA.

Open ended questions were coded into categories and

also analysed using STATA. Analysis was largely descrip-

tive. Stepwise multivariable analysis was also performed

on a number of outcome and independent variables.

Simple linear regressions were used when all variables were

Introduction Letterand letters of support

(NEPAD, Gates, WHO/AFRO,CIDMEF, etc.)

UP high level personal contactwith Deans introducesStudy, requests school

contact person

UP staff contact1. Confirms contact person

2. Sends survey3. Confirms receipt and

answers questions

UP staff contactfollows up, encourages

responses, answersquestions

List of Medical Schools

Ministry of HealthMinistry of Education

Medical SchoolLeadership

Deans

Response

SchoolContact

Response

Follow upNon response

Response

Follow upNon response Response

Advisory CommitteeMembers assist with

developing list of medicalschools, contact information

Advisory CommitteeMembers call or e-mail school

contacts to proactivelyencourage responses

Advisory CommitteeMembers contact Deans

to encourage surveyresponse

UP staff contactfollow up responses;

honorariums sent to schoolcontact person

Follow upNon response

UP staff contactfollow up responses;

honorariums sent to schoolcontact person

figure 6: Survey Plan


continuous or binary, analysis of covariance (ANCOVA)

was used when independent variables included categorical

variables, and ordinal logistic regressions were used when

examining ordinal outcome variables. In all multivariable

analyses, statistically insignificant independent variables

were serially eliminated from the model until all

remaining variables were statistically significant at a 95%

confidence level. Each eliminated variable was individu-

ally added back into the model once at that point to test for

statistical significance again. Correlations of pairs of ordi-

nal variables were performed with Pearson’s Chi Squared

test. This analysis is further described in the Multivariable

Analysis section.

The study protocol, survey and supporting information

received ethical approval from the Committee for Research

on Human Subjects of the Faculty of Health Sciences of

the University of Pretoria (Approval number: 20/2009).

All respondents were fully informed about the objectives

and content of the study (Appendices 2,4,5). The intent

and potential risks and benefits were articulated, and it

was indicated that there would be no risks to schools or

personnel due to non-participation. In the event that sup-

port for and scale up of resources to medical schools fol-

low on the report, as envisaged, there will be clear benefits.

Participation was voluntary.

Students at Makerere University present research.


Aggregate findings of the study were to be shared with

the Deans and widely disseminated, including to African

Ministers of Health and of Education. Sensitivity to

the identification of each school was observed by mak-

ing only basic profile information publicly available. All

other responses are reported in the broader aggregation of

schools. Any release of information about schools beyond

their basic profile is only to be done with the school’s

additional express permission. Each school has been

coded and the questionnaires and coding index is only

available to the researchers.

Core CharaCteristiCs oF the

MediCal sChools

Surveys were distributed to 146 medical schools in 40 of 48

Sub-Saharan African countries. An additional 22 medi-

cal schools were identified after the close of the survey

period for a total of 169 medical schools at the time of pub-

lication (Table 3).§,¶ One hundred and five out of the 146

schools identified during the survey period returned sur-

veys, a response rate of 72%. (Figure 7) Of the 105 survey

respondents, 84 (80%) reported English as a language of

instruction, including ten reporting English and Arabic

as languages of instruction, eight reporting English and § Algeria, Egypt, Libya, Morocco, Saharawi and Tunisia were excluded from the study.¶ Medical schools were not identified in Cape Verde, Lesotho, Sao Tome and Principe, or Swaziland.

figure 7: Survey reSPonSeS by region and language of inSTrucTion

* Regions follow UN conventions with the exception of Sudan, which UN groups with North Africa


French, two reporting English and Afrikaans, one report-

ing English and Portuguese, and one reporting English

and Igbo. Twenty-seven (26%) of the responding schools

reported French as a language of instruction, including the

eight that listed English and French. Three schools (3%)

listed Portuguese as a language of instruction, includ-

ing one school listing English and Portuguese. For the

purposes of the figures presented in this work, the cat-

egory “English” included schools using only English as

a language of instruction as well as the schools that also

give instruction in Arabic, Afrikaans, or Igbo, since no

responding schools taught only in those languages. The

school teaching in English and Portuguese was included

in the “Portuguese” category since it was in a Lusophone

country. “French” includes only schools whose single lan-

guage of instruction was French, and “English & French”

includes schools using both languages.

Medical education began in four respondent schools before

1925 with steady growth in numbers beginning in the

1960’s. Twenty-two survey respondents had not yet gradu-

ated their first students at the time of the SAMSS study.

Eighty-three were public schools. Twenty-two were pri-

vate, six were faith-based not-for-profit, nine were non-

faith-based not-for profits, and seven were private for-profit

schools (Figure 8).

figure 8: daTe of eSTabliShMenT of SchoolS by ownerShiP


figure 9: oTher caTegorieS of healTh worKerS Trained aT reSPonding Medical SchoolS

* Other includes Radiography, Occupational Therapy, Speech & Language Therapy, Health Education, Nutrition, Anesthesia,

Cataract Surgery, Sports & Exercise Science.

Ninety-eight percent of respondents were affiliated with

a university. Ninety percent of schools had mission state-

ments in which recurring themes included striving to

produce professionally competent medical doctors (and

other health officers) with adequate knowledge and skills

in health promotion, disease prevention, and curative and

rehabilitative health care for the prevailing health prob-

lems of their countries. Many statements also mentioned

working towards conducting research relevant to develop-

ing countries.

Eighty-one percent of respondents reported undergoing a

periodic accreditation or formal evaluation conducted by

an external body or organization - generally national uni-

versity commissions/boards or medical councils. Seventy-

nine percent did self-assessments, i.e. undertook an estab-

lished process within their medical school or university to

assess their curriculum, activities, and programs in terms

of content, quality, and output; 38% did so at least once

every two years.

Many schools trained other categories of health workers,

the most common being nurses and public health practitio-

ners (Figure 9).


Due to the complexity of financing and budgetary organi-

zation within medical schools, the survey did not gather

absolute data on income and expenditures, but rather pro-

portions as determined by respondents. The largest source

of income for public schools was Ministries of Education,

while the largest source of income for private schools was

generally student tuition and fees (Figure 10). Most expen-

diture was incurred on professional personnel (Figure 11).

Tuition fees varied widely; nine percent of respondents

offered free tuition and 39% charged $1,000 (US) or less,

while nine percent charged more than $5,000 (US) per

annum (Figure 10).

Core CharaCteristiCs—suMMary

The exhaustive process of creating a database of schools

for the survey produced the most complete and up to date

listing of Sub-Saharan African medical schools currently

available. This list, in and of itself, will be of use to many

stakeholders.

The 72% response rate from the 146 schools identified

before the close of this survey (January, 2010) indicates this

study provided a credible picture of medical education in

Sub-Saharan Africa. Non-responders were scattered, but

the Democratic Republic of Congo, Nigeria, and Sudan

figure 10: Medical School TuiTion and SourceS of Medical School’S incoMe

* Other includes other internal income generation through investments or business, capital from the medical schools’ owners

and bank loans.


figure 11: annual exPendiTureS by Medical SchoolS

* One school reported 100% expenditures in goods and services and faculty paid through the university, not as part of medical

school budget.

accounted for 59% of non-responders. These countries were

host to large numbers of medical schools. An additional 22

schools opened or were identified after the close of the sur-

vey, including twelve located in the Democratic Republic

of Congo. The language distribution of the medical schools

generally mirrored the population distribution of Sub-

Saharan Africa, (approximately 58% Anglophone, 30%

Francophone, 5% Lusophone, and 7% Arabic).

The emergence of medical schools with the end of the

colonial era is striking – while only seven respondents

were established prior to 1960, another 35 were estab-

lished before 1990, all public schools. The next two decades

saw the emergence of the first private schools –40% of

the 55 newest schools including the first for-profit school.

Although there was a steady growth of public schools, there

was also a pattern of emerging private schools, likely driven

by increasing decentralization of governments and market

opportunities. This trend has important implications for

financing, administration, tuition, access for disadvantaged

students, and capacity of medical education in Africa.

Private institutions require further detailed study and must

be taken into account in any policy developments.

It was positive to see that the schools were rooted in wider

universities, many coincident with training in a range of

other health disciplines and with mission statements that

focus around the needs of their country or the continent.

It was also positive that most schools underwent a peri-

odic accreditation or formal evaluation conducted largely

by national university commissions / boards or medical

councils, although it was worrying that 19% of schools were

still not subject to such external review. Similarly, the lack

of self assessments of their curriculum, activities and pro-

grams in 20% of schools needs attention.


Consistent with most respondents’ status as public institu-

tions, the primary funders of medical schools were federal

Ministries of Education. However, many schools reported

at least some level of funding from regional and local gov-

ernments, donors, student tuition and fees, research grants

and faculty medical practice. All of these funding sources

are important. Trends in funding levels are a reflection of

changing government and health care systems, and have

implications for capacity development and expansion. For

example, funding from regional and local governments

may reflect an increasing decentralization of government

in countries, and faculty practice may reflect a growing

privatization of health care services or a mechanism for

expanding income and retention of staff. In both cases,

further study is needed to elucidate cause and effect, and

opportunities and implications for medical education and

the health care system.

The apparent affordability of medical education when com-

pared with international costs was also in line with the

largely public nature of the medical schools and the financial

support they receive from government. While many schools

charged no or low tuition fees (48% charge $1,000 US or less

per annum), the number of private and public schools charg-

ing tuition fees of $2,000 (US) or higher may have had sig-

nificant consequences in terms of access to medical schools,

particularly for rural and poor students. The range of tuition

costs also raises the question of what the true unit cost of

training a medical doctor in Sub-Saharan Africa is. If a rea-

sonable figure or range were known, it would form the basis

for adequately funding institutions and fair charging, partic-

ularly for private institutions.

Medical school expenditures were largely spent on profes-

sional personnel. This was consistent with the expenditures

of most professional institutions. Yet the most commonly

reported need for improving quality and increasing the

number of graduates among respondents was improv-

ing salaries and numbers of teaching staff (See page 94).

But there were many other unmet needs also requiring

expenditure, such as physical infrastructure and teach-

ing resources (See page 94), suggesting that there may be

limited ability to shift spending among competing needs.

These findings demonstrated the fine balance institutions

have to maintain in distributing their limited financial

resources, and suggested that medical schools will likely

be seeking increasing funding from both government and

other sources in the future to address their challenges.

underGraduate students

The number of applicants and first year students enrolled

varied widely among survey respondents. As expected,

schools generally received significantly more applications

than the number of students they were able to enroll.

Nearly half of respondents to the relevant questions (40

out of 81) received more than 500 applications with 28

receiving over 1,000 applications, but 32% received fewer

than 200 applications. Thirty-nine percent of respondents

enrolled 100 or fewer students in their first year classes.

Five schools enrolled more than 500 students in their first

year class (Figure 12).

Although a few (11%) schools graduated more than 200 stu-

dents in a year, most (57%) graduated 100 or fewer (Figure

13). A high proportion (mean=81%, SD=21.0) of those

enrolled graduate - 56% of schools graduated 90% or more

of their enrollment. The main reason for not completing the

course was academic failure. Only five schools reported poli-

cies to reduce the class size after 1st or 2nd year. Transfers

to other schools, ill health, and financial reasons were also

mentioned as affecting small numbers of students.


figure 13: nuMber of Medical School graduaTeS (2008)

figure 12: nuMber of Medical School firST year enrollMenTS (2008)


Seventy-two percent of respondents had increased their first year enrollments in the past five years. Nineteen percent had

more than doubled their enrollment; however, nine percent had decreased enrollments (Figure 14).

figure 15: Planned PercenT increaSe in enrollMenT over The nexT 5 yearS

figure 14: PercenT change in firST year enrollMenTS over The PaST five yearS

* Limited to schools enrolling students prior to 2000 as changes in first year enrollment for new schools is likely to largely reflect

planned scale up to target enrollment.


figure 16: liKelihood of reaching goal enrollMenT wiThin 5 yearS

Forty-five percent of respondent schools planned to increase the number of students in their first year class within the next

five years. Fifteen schools planned to more than double their enrollment (Figure 15). However, only 36% of respondents

indicate they are likely to reach their goal, 56% indicate they are likely to increase enrollment, but not reach their goal,

and nine percent indicate they are unlikely to increase numbers at all (Figure 16). Fifty-eight percent of respondents had

received mandates to increase enrollment, generally from ministries of education or health (Figure 17).

figure 17: MandaTeS To increaSe enrollMenT


Many schools reported focused recruitment to increase

class diversity and reserved spaces to encourage applica-

tions and enrollment from specific groups. Thirty-seven

percent of respondents specifically recruited female stu-

dents and 40% recruit rural students. Twenty-eight percent

reserve positions for women and 24% do so for rural stu-

dents. Respondents also reported recruitment and reserved

positions for educationally disadvantaged students, mature

entrants, disabled students, and other disadvantaged

groups (Figure 18).

Thirty-eight percent of respondents (38 of 101) offered

student preparatory programs - defined as any program

offered prior to medical school entry to specifically prepare

students for the medical school curriculum and to improve

performance during the medical school years. Forty-five

percent of these schools required all students to participate

in the preparatory program.

Thirty-four percent of respondents (35 of 103) had formal

agreements to train students from other countries. Most

East African countries had an agreement with at least

one medical school, while in Central Africa only schools

in Cameroon and the DRC had such agreements, and in

West Africa only schools in Niger, Mauritania, Mali and

Liberia have such agreements. Four respondents reported

agreements to train students from advanced industrial-

ized countries.

Curriculum: Schools generally required five to seven

years for students to graduate (Figure 19). Figure 20 shows

that community based and multi-disciplinary team based

learning and to a slightly lesser extent problem based

learning, were extensively or frequently used in the cur-

riculum, particularly in clinical rotations. Twenty-six per-

cent of respondents also reported students were required

to undertake a research project in the preclinical years

in order to graduate, and 81% report a required research

project be completed during the clinical years. Eighty-one

percent of respondents (n=100) required a research report

or thesis to graduate (Figure 21).

figure 18: focuSed recruiTMenT and reServed PoSiTionS

*Other includes educationally disadvantaged, peripheral areas, top candidates, mature entrants, and disabled students.


figure 19: nuMber of yearS reQuired To graduaTe

figure 20: uSe of learning aPProacheS


Graduates from 35% of schools (36 of 103) were required

to complete national licensing examinations beyond their

university examinations to be able to practice in the coun-

try, while graduates from 82% of schools (86 of 105) were

required to complete an internship and 16% of schools

(17 of 105) reported postgraduate training was required.

There was some inconsistency between schools in the same

countries reporting different internship and post-graduate

training requirements.

underGraduate students—suMMary

An increase in the overall number of medical graduates

in Sub-Saharan Africa is essential to reaching health tar-

gets and improving health care in Africa. African medi-

cal schools are responding. Most schools (73%) reported

an increase in their first year enrollments over the past five

years. Thirty new schools had opened the decade prior to

the survey’s collection and 45% of schools reported plans

to increase their enrollments over the following five years –

most of these schools had mandates to do so. However, with

appropriate support, the schools could go further. Only

36% felt they would reach their “5 years time” enrollment

targets, presumably due to the barriers articulated in page

94. Considering the speed at which it can be done, the mar-

ginal and opportunity costs of expanding intakes at exist-

ing medical schools, and schools’ wish to do so, this is a

prime area for support. Given the long lead time to gradua-

tion of six or more years in the majority of schools, invest-

ments made now to scale up physician production will

begin to yield benefits later in the same decade.

African medical schools show many promising areas: the

focused recruitment of women and rural students, the

collaboration of medical schools with neighboring coun-

tries to expand regional workforce, and the implementa-

tion of community based, problem based, and team based

learning. Approximately 40% of schools reported focused

figure 21: STudenT reSearch ProJecT reQuireMenTS for graduaTion


recruitment of either women or rural students. However,

given continental commitments to advance women’s educa-

tion and to recruit from rural communities, and given the

expectation that rural students are more likely to be disad-

vantaged19 and also more likely to remain in their coun-

tries82, this is an area that should be expanded.

At the writing of this report, four countries in Sub-Saharan

Africa did not have medical schools and most countries had

less capacity for training physicians than they needed. The

existing base of formal agreements to train students from

other countries provides information on how these mod-

els work and can best be expanded. As medical education in

Africa scales up, it is imperative that countries that are not

able to grow their own training capacity are not left behind.

Finally, the rather extensive implementation of community

based, problem based, and team based learning in African

medical schools was an indication that schools were

responsive to innovative approaches that also take into

account the health needs of the communities they serve

and the developing health care systems of their countries. It

is an area that can be further supported and expanded.

post Graduate students

Physician migration was seen to be a significant problem

for Sub-Saharan African countries. On average, almost

27% of a school’s domestic graduates were reported as likely

to migrate out of their country within five years of gradu-

ation, mostly to countries outside of Africa (Figure 22).

Twenty-five percent of those schools reporting migration

out of Africa (17 of 68) lost 30% or more within five years.

Five schools—four Francophone schools and one Sudanese

school—reported no emigration (Figure 23).

figure 22: Mean locaTion of Medical School graduaTeS (%) five yearS afTer graduaTion


Respondents indicated that on average 26% of a school’s graduates were in public general practice (either rural or urban)

and 19% were in private general practice 5 years after graduation. These statistics were based on 18% of schools tracking

where their graduates are working, 13% performing a one time study of their graduates, and 69% using estimates based on

their experience (Figure 24). On average, 24% of a school’s graduates moved into specialization.

figure 24: graduaTe TracKing by Medical SchoolS

figure 23: PercenTage of graduaTeS rePorTed To have eMigraTed ouTSide of africa


Compulsory or community service, undertaken in most

instances in both urban and rural areas, was required of

graduates from 69% of respondent schools (n=103), and in

21 of the 35 countries from which responses were received

(Figure 25). The community service was largely paid and

was for a year in 59% of schools, two years in 27%, and

more than 2 years in 14% (n=56). Forty-two percent of

schools with community service (29 of 68) reported that

some groups are exempt from it. Reasons for exemptions

included age over 30 years, illness or disability, and post-

graduate training in high need disciplines. Of note, in eight

countries with more than one school responding to the sur-

vey, respondents provided inconsistent answers regarding

the compulsory or community service requirement in their

country. In another eight countries with multiple schools

responding to the survey, answers were consistent and in 20

countries there was only one school responding.

figure 25: coMPulSory Service reQuireMenTS by counTry


About two thirds of schools offered postgraduate spe-

cialist training in the core specialist disciplines – inter-

nal medicine, surgery, obstetrics and gynecology, and

pediatrics. Other major specialties were taught in about a

third of schools (Figure 26). Fifty-five percent of respond-

ing schools (55 of 100) said that additional examinations

beyond the university were required for a graduate to prac-

tice as a specialist in their country, representing 19 of 35

countries with at least one responding school.

post Graduate students—suMMary

Physician migration remains a significant problem for the

scale up of health workforce and medical school capacity

in Sub-Saharan Africa. Medical schools reported on aver-

age 23% of their graduates migrate out of Africa within

five years after graduation. While there are many factors

driving migration beyond the control of medical schools,

strategies must be implemented within medical schools to

recruit and admit students who are more likely to remain

in the country, train students to be prepared and commit-

ted to working in the country and in rural and underserved

areas, seek innovative solutions to the issues or retention

figure 26: PoST-graduaTe Training offered in Sub-Saharan african Medical SchoolS


and migration, and work with the government and other

external organizations to improve graduate retention.

It was promising to see that many schools were undertak-

ing post-graduate training programs. Increasing the num-

ber of local residency posts will increase in-country train-

ing opportunities and in turn effectively boost the number

of specialists in the country, better physician retention, and

help recruit junior faculty to teach. Lack of faculty was one

of the most consistently mentioned barriers of respondents

for increasing both the number and quality of undergrad-

uate medical education programs. Many countries were

also addressing retention issues through compulsory ser-

vice requirements. The majority of countries represented had

some required compulsory service following graduation from

medical school. Both post-graduate training and compulsory

service are areas for further research and investment.

Finally, an area that needs attention is the tracking of phy-

sicians following medical school graduation. Only 18% of

schools reported a tracking system, with an additional 13%

reporting having completed a one time study to determine

where their graduates have gone. Physician tracking is

complicated. However, this is an area for medical schools to

work with governments to establish tracking systems that

will allow both parties to determine the extent of any prob-

lem and the success of any interventions.

teaChinG staFF

Teaching staff is critical for the functioning of medi-

cal schools and for future expansion. The total number of

teaching staff at medical schools, including all individu-

als with teaching responsibilities - full, part time, or vol-

unteer - varied widely. Twenty-five percent of respondents

reported fewer than 50 teaching staff (Figure 27). Of con-

cern was that on average 29% of faculty positions were

unfilled among the 99 responding schools. Forty-six per-

cent reported greater than 30% of their available posts were

unfilled (Figure 28).

figure 27: nuMber of Teaching STaff


Seventy-two percent of respondents reported women comprised less than 30% of their teaching staff. Staff were largely from

the country of the school, with only nine percent reporting more than 30% foreigners on their teaching staff (Figure 29).

figure 28: PercenT of available faculTy PoSiTionS vacanT

figure 29: PercenT of faculTy PoSiTionS filled by woMen or foreign-born PerSonnel


Staff were paid through a variety of arrangements, primar-

ily from the medical school with additional support from

the teaching hospital (Figure 30). One school reported staff

were paid 100% through private practice and two schools

reported staff were paid 100% by an outside organization.

In addition, 63% of respondents (50 of 79) reported more

than 30% of their staff supplemented their income through

private practice (Figure 31). Only 14% reported none of

their staff supplemented income through private practice.

figure 31: PercenT of faculTy who SuPPleMenT incoMe Through PrivaTe PracTice

figure 30: PriMary SourceS of Teaching STaff Salary

* Other includes the University and the Government


Figure 32 shows that, although 23% of respondents had a net loss in staff compared to five years ago and one school reported

no net change, 76% reported a net gain. Reasons given for staff leaving revealed a mixed picture. The greatest loss was a result

of emigration from the country of origin (mean of 29%) followed by retirement due to age (19%), movement to non-govern-

mental organizations (15%), private practice (12%) and to other governmental or ministerial positions (12%) (Figure 33).

figure 32: neT PercenT change in faculTy over The PaST five yearS

* Excludes schools starting 2004 and later as change in faculty numbers over five years likely reflects natural growth of a new

school. In addition three schools reported net loss and one school reported net gain of faculty without reporting absolute numbers.

figure 33: reaSonS for STaff loSS

* Other includes staff loss due to movement to other institutions, death, security reasons


Research: Respondents reported that an average of 13% of staff was involved in grant supported research. Seventy-five per-

cent of respondents reported less than 20% of their staff were involved in grant supported research; 17% reported no staff

were involved in grant-supported research (Figure 34). Schools reported using many measures to support research (Figure

35). Unique innovations included starting a master’s in clinical epidemiology program and appointing research champions.

figure 35: Medical School MeaSureS To SuPPorT reSearch

figure 34: PercenT of faculTy involved in granT SuPPorTed reSearch

*Strengthened institutional research tools include administrative and techni-

cal support, access to journals, research and ethics committees etc.


teaChinG staFF—suMMary

Teaching staff are critically important to medical schools

to meet current needs and for capacity scale up. Schools

need a critical mass of teaching staff to cover the range of

disciplines that must be taught. In general, medical schools

reported low absolute numbers of teaching staff, with

approximately half of schools reporting fewer than 100 fac-

ulty members. Faculty sufficiency should take into account

faculty teaching duties, required supervision of graduate

students, clinical responsibilities, outreach responsibilities,

and research activities, as well as overall student taught.

This study was not able to determine accurate faculty-to-

student ratios due to a number of limitations, including the

inability to determine total student enrollment numbers,

faculty time spent in responsibilities outside of teaching,

and full versus part time staff. However, the high number

of schools that report high proportions of faculty vacan-

cies suggested medical schools often have insufficient fac-

ulty. Faculty shortages raise concerns about the pressure

on teaching staff who must also carry out clinical duties

and research activities. It is certainly a key factor impeding

increasing medical school output and improving quality in

all areas, including education, services, and research.

The high proportion of faculty vacancies points to

two critical issues: faculty recruitment and retention.

Incentives are needed to both recruit staff to fill cur-

rent vacancies and to retain current and new staff. Two

areas that show promise for addressing faculty recruit-

ment and retention are supplementing income through

private practice, and research. The majority of schools

reported faculty members did just that, thereby allowing

a salary top up for clinical staff. However, private prac-

tice places an additional workload burden on staff and

does little to help basic science staff. Research is linked

to career advancement, and research opportunities can

promote faculty recruitment and retention. The major-

ity of schools reported implementing measures to sup-

port faculty research including offering training pro-

grams, strengthening institutional research tools, direct

funding for research time and equipment, and opportuni-

ties to attend external training programs. However, grant

supported research remained limited; few faculty mem-

bers are involved in this type of income-generating work.

Research remains an area for future development.

Medical schools reported the greatest staff losses due to

emigration, retirement, and movement to non-governmen-

tal organizations, private practice, and other governmen-

tal and ministerial positions. This faculty loss highlighted

the importance of recruitment and showed how the hiring

practices of external organizations impacted the infrastruc-

ture and capacity of medical schools. In other words, inter-

national governments and organizations, as well as national

governments, need to re-examine the effects of their hir-

ing policies. On the positive side, the majority of schools did

report a net gain in faculty over the last five years.

Infrastructure improvements at the College of Medicine, University of Malawi, have included new classrooms and lecture halls.


resourCes and FaCilities

Schools were asked to score the adequacy of the quantity

and quality of various resources on a Likert scale: 0 for does

not exist, 1 for severely inadequate, 2 for somewhat inad-

equate, 3 for adequate, and 4 for good. An average of the

scores of all the schools was determined for each resource.

A summary of these averages is presented in Figures 36-38.

Overall, schools faced many resource challenges. With

the exception of the size of the library, there was no sin-

gle resource for which more than a quarter of schools

described either quality or quantity of the resource

as “good.” Basic facilities, such as library buildings,

classrooms and clinical teaching sites tended to score bet-

ter than more advanced facilities such as laboratories, con-

ferencing technology, and journals. Greatest areas of need

included journals, research labs, skills labs, student resi-

dences, conference calls, and telemedicine technologies.

Fifty-two percent of respondents (52 of 101) reported using

the internet to augment their teaching, eight percent used

video distance lecturing, and 22% used online curricula.

Of the 49% of respondents who did not use the internet for

teaching, the most often cited reasons were lack of infra-

structure and funds (90%), lack of IT connections (69%),

and lack of trained persons to support instruments (57%).

figure 36: adeQuacy of STudenT and Teaching reSourceS

* n varies due to non-response by some schools on some questions.


figure 37: adeQuacy of Technology reSourceS


figure 38: adeQuacy of clinical Teaching SiTeS



resourCes and FaCilities—suMMary

African medical schools clearly function under significant

resource constraints. The majority of schools reported less

than adequate resources across all assessed areas and many

schools reported functioning with severely inadequate

resources or in the absence of particular resources. Basic

facilities such as library buildings, book collections, class-

rooms, and clinical teaching sites tended to be available

and to be of better quality than more advanced resources

such as laboratories, journals, and technology. Inadequate

teaching and skills labs limit the quality of the educational

experience and inadequate research labs severely limit the

ability of faculty to pursue research activities and grants.

As medical schools look to expand and the complexity of

medical education continues to grow, the adequacy of both

basic and advanced resources will be further stretched.

Technology offers an opportunity to enhance teaching,

clinical, and research activities. More than 50% of schools

reported using the internet to augment teaching activi-

ties. However, the majority of schools reported technol-

ogy resources such as computers for students and faculty

and internet connections were less than adequate. More

advanced resources such as telemedicine often did not

exist. Schools that did not use the internet report lack of

internet infrastructure, funds, IT connections, and IT sup-

port as limiting factors. The inadequacy of basic technology

resources and identified limitations suggest technology is

an area for greater external investment and support.

An additional resource that needs attention is student resi-

dences. The majority of schools reported student residences

are less than adequate in both quantity and quality. Fifteen

percent of schools (15 of 101) reported student residences do

not exist. Recruitment of rural and disadvantaged students

is likely to affect the ultimate retention of physicians in the

country. The availability of student residence will be critical

to support recruitment of rural and disadvantaged students.

A limitation of the resource adequacy findings was the sub-

jective nature of responses. There are no set measures or stan-

dards for adequacy of resources in medical schools making it

difficult for schools to aim for a standard or compare them-

selves to others. The development of standards and measures

in these areas would contribute significantly to efforts to

improve the quality and capacity of medical schools.

relationships with external orGanizations

Medical schools have developed relationships with many

external organizations. A number of organizations partici-

pate in setting medical school priorities to different degrees

(Figure 39). Ministries of Education, Ministries of Health

and Professional Councils were generally the most signifi-

cant drivers of medical school priorities.

Students at Walter Sisulu University are exposed to com-munity needs from the start of their education.


Sixty-three percent of respondents reported the govern-

ment or professional councils set competencies for medi-

cal doctors in their country. Twenty-one percent of respon-

dents reported the existence of a list of expected tasks and

skills for graduating doctors and 16% reported neither

(Figure 40). Responses were from 35 different countries.

Of concern, of the 15 countries from which more than one

schools responded, schools in 11 countries reported differ-

ing answers for this question. Schools in 21 countries consis-

tently reported either competencies or tasks/skills list set by

the government or professional councils. Fifty-nine percent

of respondents reported measurement tools for all the com-

petencies or tasks/skills, 15% reported tools for some, and

26% reported no measurement tools but feel faculty have a

general idea of competencies, but do not measure it. None

felt they had no measurement (Figure 41).

figure 40: SeT coMPeTencieS for Medical docTorS by counTry governMenT or ProfeSSional councilS

figure 39: ParTiciPaTion of exTernal organizaTionS in SeTTing Medical School PrioriTieS

* Seven schools reported “other” external organizations participate in setting medical school

priorities. Others included donors, the Ministry of Defense, and national policies.


figure 41: MeaSureMenT ToolS for coMPeTencieS or TaSKS/SKillS liSTS

Many schools also reported they participated in setting their country’s health strategies and policies, although to differ-

ing degrees (Figure 42). School officials most often sat on official councils or committees (42% of respondents) or informally

advised government policies (37%).

figure 42: School ParTiciPaTion in SeTTing counTry STraTegieS or PolicieS


relationships with external

orGanizations—suMMary

Medical schools maintain a number of different relation-

ships with external organizations. These relationships are

bilateral, with governments and professional organizations

contributing to setting school priorities and schools par-

ticipating in setting country strategies and policies. This

bilateral relationship is important to ensure medical school

policies reflect national health care needs. Country health

and human resource policies should take into account

production needs and evidence-based research provided by

medical schools.

Not surprisingly, the most significant external drivers of

school priorities were federal Ministries of Education and

Ministries of Health, consistent with the primary funding

source of many schools. It was promising that the major-

ity of schools (83%) in 31 out of 35 countries reported

their government or professional councils set competen-

cies or tasks/skills lists for medical doctors in their coun-

try. However, only 59% of these schools had a measurement

Schools collaborated widely with other universities and institutions within and beyond their country. Collaborations var-

ied from limited student exchanges to staff training, faculty exchanges, accreditation, research collaboration, contributions

to community based activities, and policy formulation at national level. Collaborations with institutions outside the con-

tinent were mainly in research, curriculum review, internship programs, distance learning programs, student and faculty

exchanges, staff training, and capacity building of the faculty. Collaborations were most frequently with European, North

American, and other African institutions (Figure 43).

figure 43: Medical SchoolS’ inTernaTional collaboraTionS


tool for all competencies or tasks and skills. It is concerning

that schools in 11 countries provided inconsistent answers,

often with at least one school reporting no competencies

or tasks/skills list, while other schools in the same country

reported the existence of these standards. Schools report-

ing no set competencies or tasks/skills were not consistently

public or private schools, or younger schools. It is unclear

if this inconsistency was due to a misunderstanding in

answering the question or poor dissemination of compe-

tency and tasks/skills lists by country governments or pro-

fessional councils. This is an area that needs further study

but suggests schools may benefit from both standardized

competencies and measurement tools.

Medical schools also collaborated with an array of exter-

nal universities and institutions. Collaborations included

student and faculty exchanges, faculty training, research,

curriculum development, and distance learning initiatives.

These relationships are clearly of value and can continue to

be developed to improve the educational quality and capac-

ity of medical schools. An area for future research is how

to improve and measure these collaborations to maximize

efficacy and provide evidence for success.

Barriers and innovations

Barriers to increasing the number and quality of medical

doctors trained: Schools were asked to score the impor-

tance of eight identified barriers to improving the quality

and increasing the numbers of graduates trained by their

institution on a Likert scale of 0 to 4 (0=Not a Barrier to

5=Severe Barrier). Figure 44 summarizes the perceived

barriers to increasing quality of graduates. Amongst the

options offered by the survey were insufficient labora-

tory space and resources, and insufficient basic science or

clinical teachers. Insufficient pools of qualified applicants

was not seen as a barrier of significant concern for most

schools. The most commonly noted barrier for increas-

ing the number of graduates (Figure 45) was poor salaries

for teaching staff. Insufficient basic scientists and teaching

resources were also prominent, as well as insufficient posts

for basic science and clinical teaching staff.

figure 44: barrierS To iMProving The QualiTy of graduaTeS


Respondents were given the opportunity to provide open-

ended responses to questions asking them to identify the

three greatest needs for improving the quality and increas-

ing the number of their graduates, in order of importance.

Responses were coded by main theme, such as those refer-

ring to faculty-related issues or to curricular issues. Within

each main theme, responses were further coded accord-

ing to sub-categories (Table 6). In order to increase both

the quantity and the quality of graduates, issues related to

infrastructure and equipment were most frequently raised,

followed by faculty-related issues and issues related to clini-

cal training sites. However, faculty-related issues were the

most commonly cited as the single greatest need in order

to increase the quality of graduates (35 of 94 responses) fol-

lowed by infrastructure related issues (28 of 94 responses).

Responses regarding increasing quantity saw the oppo-

site trend, with 37 of 94 respondents identifying the single

greatest need as infrastructure-related and 30 of 94 identi-

fying the greatest need as faculty-related.

Schools were asked about innovations developed and

implemented by the medical schools to address barriers to

increasing the number of medical doctors trained in their

countries. The responses included construction of addi-

tional facilities, faculty recruitment and development,

seeking donor support, developing institutional linkages,

including linkages with community hospitals and clin-

ics to expand clinical teaching sites, curriculum develop-

ment, community-based education, use of technology for

teaching, and strategies to reduce student failure. Unique

responses included: establishing a graduate entry medi-

cal program, introducing a book bank available to all stu-

dents, embarking on a serious drive to improve internally

generated revenue (examples include operating a Clinical

Diagnostic Center and a Fitness Center), and transferring

supervision of the medical school from the Ministry of

Education to the Ministry of Health. The focuses of these

innovations can be seen in Table 7. The full list of the inno-

vations mentioned is included in Appendix 7.

figure 45: barrierS To increaSing The nuMber of graduaTeS

* Teaching resources include classrooms, laboratory space, library and computers.


Total Answers

Greatest Need

Second Greatest Need

Third Greatest Need

Total Answers

Greatest Need

Second Greatest Need

Third Greatest Need

281 94 94 93 277 94 94 89

Total 91 28 38 25 96 37 38 21General or multiple types 40 17 17 6 52 25 20 7Labs 14 7 4 3 10 3 5 2Computers/ICT 18 1 7 10 6 0 3 3Teaching Aids/Resources 8 2 4 2 12 4 7 1Libraries 4 1 2 1 4 0 1 3Other 7 0 4 3 12 5 2 5

Total 84 35 25 24 77 30 27 20General or quantity 32 12 10 10 50 24 19 7Salary/Quality of life issues 23 6 6 11 12 1 3 8Basic Science Faculty 10 4 4 2 5 0 2 3Training/Pedagogy 7 5 2 0 1 0 0 1Faculty Quality 6 4 1 1 3 1 1 1Clinical Faculty 3 2 1 0 2 2 0 0Other 3 2 1 0 4 2 2 0

Total 25 3 15 7 33 9 15 9General 12 2 6 4 14 3 8 3Academic Hospital 13 1 9 3 16 6 7 3Clinics 0 0 0 0 3 0 0 3

Total 21 10 2 9 22 6 4 12General 14 9 0 5 17 5 3 9Student Aid/Grants 3 0 0 3 4 1 1 2Governmental Support 4 1 2 1 1 0 0 1

Total 21 7 3 11 5 3 0 2General/Aligned with needs 12 5 2 5 4 3 0 1Community‐Based/ Problem‐Based 5 1 1 3 0 0 0 0PGME 2 1 0 1 1 0 0 1Other 2 0 0 2 0 0 0 0

Total 39 11 11 17 44 9 10 25Secondary Education/ Admissions policies 7 3 1 3 11 2 5 4Research 10 3 3 4 2 0 0 2Linkages/Cooperation 3 0 1 2 6 0 0 6Administrative Reform Inside School 5 2 2 1 3 0 1 2Understanding from Gov't 0 0 0 0 8 5 0 3Student Living Conditions 3 0 0 3 4 1 1 2Other 11 3 4 4 10 1 3 6Other

Increase Quality of Graduates Increase Quantity of Graduates

Infrastructure and

Eq

uipm

ent Issue

sFaculty‐Re

lated

Issues

Clinical

Training

Sites

Budg

etary

Issues

Curricular

Issues

Total number of responses

Table 6: greaTeST needS for increaSing The QualiTy and nuMber of graduaTeS


ISSuE ADDRESSED InnoVATIonS nAMED

Faculty 50

Infrastructure 34

Curriculum 27

Clinical Sites 26

Student 23

Collaboration 14

Funding 12

Other 32

Table 7: focuS of innovaTionS rePorTed by Survey reSPondenTS (uP To Three Per School)

Barriers to increasing the number of medical doctors in

the country: Respondents were asked to score eight identi-

fied barriers to increasing the overall number of medical doc-

tors in their country (Figure 46). The poor salaries received

by medical doctors was the most common barrier identified.

Insufficient paid medical doctor positions and practicing doc-

tors migrating out of the country or leaving the country for

post-graduate training are also important barriers.

figure 46: barrierS To increaSing The nuMber of Medical docTorS in The counTry


The survey asked whether medical doctor retention is a

problem in the school’s country and what strategies have

been implemented by the medical school to improve doc-

tor retention. Out of 100 respondents who answered the

question, 80 indicated that retention is a problem; four

indicated retention is a minimal problem and 16 indi-

cated retention is not a problem in their country. Among

the respondents who reported that doctor retention is a

problem, issues of pay and poor working conditions were

frequently reported explanations. In implementing strate-

gies to improve doctor retention, of the 100 responses, 27

schools indicated that they had taken no steps to address

doctor retention, an additional nine explicitly stated that

retention was an issue which the government should

address rather than the school, and a further 13 responded

by listing strategies undertaken at the national level.

Thirty-seven of those 49 schools without school-level strat-

egies for retention said that doctor retention is a prob-

lem. Among the 51 schools reporting strategies to improve

retention, a wide variety of strategies were reported. The

most frequently cited strategies involved increasing faculty

salaries, instituting or strengthening post-graduate medi-

cal education programs, instituting community-based

education, and recruiting the university’s graduates as

junior faculty (Table 8).

Barriers and innovations—suMMary

Exploring the barriers medical schools face to improving

quality and increasing the number of graduates from their

institutions highlights the range of challenges SSA medi-

cal schools face. Out of eight options suggested for improv-

ing the quality and quantity of graduates, only the avail-

ability of qualified students was not seen as a barrier for the

majority of schools. Barriers range from insufficient physi-

cal infrastructure (laboratory and classroom space, teach-

ing resources, and teaching hospitals) to faculty shortages

(both basic science and clinical teaching staff).

While recognizing the breadth of needs seen at the many

schools in SSA, certain needs do stand out as being both

common and severely limiting. Consistent with reports

of inadequate research and teaching labs, insufficient

laboratory space and resources are rated as significant or

severe by over half of the 105 respondents to the survey.

Faculty shortages and the factors affecting faculty recruit-

ment and retention, such as salaries, are also consistently

rated as significant to severe. These findings are in line with

the high proportion of unfilled faculty positions reported

and reports from a majority of schools that medical doc-

tor migration is a problem in their country. Only 16 schools

reported that migration is not a problem, and the most

often cited reason for migration was that doctors can earn

better pay in other countries. Funding is a significant con-

cern of medical schools. Respondents report poor salaries

and insufficiently funded basic science and clinical teach-

ing posts as severe barriers; both are limited by funding

and relate closely to faculty shortages. The survey’s findings

suggest faculty shortages, insufficient infrastructure, and

related funding needs are a priority for medical schools.

STRATEgIES IMPLEMEnTED To IMPRoVE DoCToR RETEnTIon In ThE CounTRy

no. oF SChooLS

Raising salaries for faculty at the University 20

Launching or strengthening PGME programs 13

Launching or strengthening CBE programs 9

Recruiting graduates as faculty/providing a career path 6

Providing research support inside the medical school 4

Lobbying the government to make changes 3

Other 5

Table 8: STraTegieS iMPleMenTed To iMProve Medical docTor reTenTion in counTry

*Some schools provided more than one answer


Significantly, when respondents were asked the greatest

barrier to scaling up the quantity of graduates, the most

frequent type of answer was an answer related to infra-

structure, and when asking about quality, faculty-related

issues were most common. This seems to indicate that

deans viewed investments in faculty foremost as invest-

ments in graduate quality while they viewed investments in

infrastructure primarily as investments in graduate quan-

tity. Similarly, curricular reform and research were viewed

primarily as investments in graduate quality while expan-

sion of clinical sites is seen foremost as an investment in

quantity. These findings emphasize the importance of com-

plementary types of investment in medical education in

order to produce both the quantity and the quality of grad-

uates needed to address Africa’s burden of disease.

Schools have implemented a variety of strategies aimed

at improving doctor retention and addressing barriers to

increasing the number of medical doctors trained in their

country. The most often cited school level strategies for

improving doctor retention are raising salaries for fac-

ulty at the university, launching or strengthening post-

graduate programs and community based education,

and recruiting graduates as faculty while strengthening

career paths. Medical schools have addressed barriers to

the scale up of training through the construction of addi-

tional classrooms and laboratories, the use of regional and

district hospitals as teaching sites, development of rural

and community-based educational approaches, train-

ing more basic science and clinical instructors and seek-

ing donor funding to supplement university budgets. A

number of respondents described their innovative use of

linkages for exchange, support and collaboration. Other

innovations aim to reduce student attrition, such as

allowing students to take courses or exams in a way that

avoids forcing students to repeat an entire year after fail-

ing a single course. These activities require further sup-

port and evaluation. Successful strategies should be high-

lighted and serve as models for other institutions seeking

to address similar barriers.

Medicinal plants are cultivated in the gardens of the Catholic University of Mozambique.


MultivariaBle analyses

Multivariable analyses are useful for the illustration of

trends and relationships observed in data. The following sec-

tion of this report presents a series of correlative analyses

intended to draw out key messages garnered from the survey.

Facilities: Respondents were asked to rate the adequacy

of the quantity and quality of twenty individual resources

on a 0-4 Likert scale (Figures 36-38). Those responses

were aggregated into six “resource index scores”, as indi-

cated in Table 9. These scores were used as dependent vari-

ables for a series of regressions. Each was tested against a

series of independent variables: the age of the school, the

school’s ownership (public or private), use of each of the

four main languages as modes of instruction (English,

French, Portuguese, and Arabic), tuition charged per year,

size of the entering medical school class, percent of faculty

involved in research (quartile), national gross domestic

product (GDP) per capita (log scale), and population of the

country. All independent variables were tested together in

an analysis of covariance (ANCOVA) regression, the vari-

able with the least statistically significant predictive rela-

tionship was dropped, and the process was repeated until

all remaining independent variables had statistically sig-

nificant relationships to the outcome variable of interest. At

that point, each previously eliminated variable was added

back into the regression once to see if it had been mistak-

enly omitted.

In these analyses, some consistent trends were seen (Table

10). In five of the six analyses, countries with a higher per-

capita GDP (PPP) reported better resource scores; this

trend held true in every index except the Clinical Sites

Score. In four of the six analyses, newer schools reported

poorer resources than older schools; this trend was seen

in the Library, Clinical Sites, Laboratory, and Advanced

ICT scores. In the Library Score, the Laboratory Score,

and the Internet Score, public schools reported lower

resource scores than private schools. Some linguistic vari-

ation was also seen; schools using English as a language of

instruction tended to report better Library Scores, schools

Table 9: coMPonenTS of Medical School reSource indiceS for correlaTive analySeS

MEDICAL SChooL RESouRCE InDICES

CoMPonEnTS

Building Score Library building (size & quality), Classrooms (quantity & quality), Student Residences (quantity & quality)

Library Score Library building (size & quality), Book Collection (quantity & quality), Journals (quantity & quality), E-Journals

(quantity & quality)

Clinical Sites Score Academic Hospital(s) (quantity & quality), District/Community Hospitals (quantity & quality), Health Centers/Clinics

(quantity & quality)

Laboratory Score Teaching Labs (quantity & quality), Research Labs (quantity & quality), Skills Laboratory (quantity & quality)

Internet Score Computers for Students (quantity & quality), Internet for Students (quantity & quality), Computers for Faculty (quan-

tity & quality), Internet for Faculty (quantity & quality)

Advanced ICT Score Conference Call Technology (quantity & quality), Video Conference Technology (quantity & quality),

Telemedicine/Teleradiology Links (quantity & quality)


using Arabic as a language of instruction tended to report

better Overall Clinical Sites Scores, and schools using

French as a language of instruction tended to report lower

Building Scores.

Although the percent of faculty involved in research was

not a significant predictor of any of the resource scores,

it was almost statistically significant as a predictor of

the Overall Laboratory Score (p=0.10). Looked at more

closely, if only the Research Laboratories component of the

Overall Laboratory Score is considered, correlations with

GDP, public/private status, age of school, and percent of

faculty involved in research are all significant predictors.

This indicates that there is clearly a relationship between

the quality of research facilities and the amount of faculty

involved in research.

Scaling up: Further questions were asked about the bar-

riers that medical schools face regarding attempts to

increase the quantity and quality of graduates (Figures

44-45). Barrier-related questions were combined into

four Barrier Scores: an Infrastructure-related Barrier

Score, a Faculty-related Barrier Score, a Clinical Sites

Barrier Score, and a Secondary Education Barrier

Score. Variables tested included a school’s age, lan-

guages of instruction, ownership, country GDP, and

size. Fewer associations were seen in the Barrier Scores.

Infrastructure-related barriers were seen to be signifi-

cantly lower in countries with higher GDP, secondary

education was seen to be a more significant barrier for

Lusophone schools, and no other significant relationships

were seen (Table 11).

ouTCoME VARIABLE STATISTICALLy SIgnIFICAnT PREDICToRS (DIRECTIon oF ASSoCIATIon)

Building Score French as a Language of Instruction (-)***

GDP Per Capita (+)**

Library Score Age of Medical School (+)***

Public Ownership of Medical School (-)***

English as a Language of Instruction (+)***

GDP Per Capita (+)**

Clinical Sites Score Arabic as a Language of Instruction (+)*

Age of Medical School (+)*

Laboratory Score GDP Per Capita (+)***

Age of Medical School (+)**

Public Ownership of Medical School (-)*

Internet Score GDP Per Capita (+)***

Public Ownership of Medical School (-)*

Advanced ICT Score Age of Medical School (+)***

Tuition at Medical School (+)***

GDP Per Capita (+)***

Table 10: SignificanT correlaTionS Seen in analySiS of reSourceS

*p<0.05, **p<0.01, ***p<0.001


Infrastructure-Related

Barrier Score

GDP Per Capita (-)**

Secondary Education Barrier

Score

Portuguese as a Language of Instruction

(+)***

Table 11: SignificanT correlaTionS Seen in analySiS of barrierS

*p<0.05, **p<0.01, ***p<0.001


other outcomes of interest: Other educational outcomes

of interest were also tested, with observed correlations

summarized in Table 12.

The percentage of graduates who remained in their coun-

tries and preferred rural general practice five years after

graduation was tested as a dependent variable. Independent

variables included GDP per capita, age of school, pub-

lic or private ownership, language of instruction, percent

of national population living in rural areas, community-

based education (CBE) in clinical years, CBE in preclini-

cal years, the existence of a preparatory program for medi-

cal students, PGME programs, specific Family Medicine

PGME programs, targeted recruitment program for rural

students, any other targeted recruitment program, and

the existence of compulsory service requirements. Schools

reporting compulsory service programs within their coun-

tries reported a higher estimated percentage of gradu-

ates preferring rural practice five years after graduation.

Schools which use French as a language of instruction also

estimated a higher percent of graduates in rural general

practice. Schools with a moderate number of post-graduate

medical education (PGME) programs (1-5) reported more

rural general practitioners than schools with zero PGME

programs or schools with many (6-14) programs. No other

factors were statistically significant.

As faculty shortages were a commonly reported problem,

percentage of faculty vacancies was another outcome of

interest. It was observed that schools in countries with

higher per capita GDPs were likely to have a lower per-

cent of unfilled faculty positions. It was also observed that

public schools were likely to have a higher percent unfilled

faculty positions that private schools. Independent vari-

ables that were found not to be statistically significant

predictors included the age of the school, language of

instruction, the percent of faculty who support their

income through private practice, and the percent of fac-

ulty involved in research.


% of Graduates Preferring Practice as General

Practitioners 5 Years out

Existence of a compulsory service programs (+)* Moderate number of PGME programs (+)*

French as a Language of Instruction (+)*

% of Teaching Staff Positions Vacant GDP Per Capita (-)** Public Ownership of Medical School (+)*

% of Faculty Involved in Research Strengthened Institutional Research Tools (+)*** Provision of Funded Research Time (+)*

English as a Language of Instruction (+)* Arabic as a Language of Instruction (-)*

Use of TBL, PBL, CBE Preclinical years: TBL-PBL (+)*** Preclinical years: CBE-PBL (+)***

Preclinical years: TBL-CBE (+)*** Clinical years: TBL-PBL (+)***

Clinical years: TBL-CBE (+)***

Total Number of Medical Schools in a Country Population of Country (+)*** Total Land Mass of Country (+)***

Table 12: SignificanT aSSociaTionS Seen in correlaTive analySeS

*p<0.05, **p<0.01, ***p<0.001


Research was an area where much innovation and develop-

ment is occurring. Therefore percent of faculty involved in

grant-supported or other funded or commissioned research

activities was an outcome variable of interest. This variable

was divided into quartiles and an ordinal logistic regres-

sion was used to determine statistical significance. It was

seen that a school’s reported use of strengthened insti-

tutional research tools and provision of funded research

time were associated with more faculty involvement in

grant-funded research (research tools include administra-

tive and technical support, access to journals, ethics com-

mittees, research committees, etc.). English as a language

of instruction made faculty research involvement more

likely and Arabic as a language of instruction made faculty

involvement less likely. Variables that did not significantly

impact the percentage of faculty involved in grant-sup-

ported research included internal research training pro-

grams for faculty, funding for external research training

programs for faculty, funding support for research equip-

ment and supplies, research collaboration with other insti-

tutions, student research requirements, age of the school,

public/private status, and national GDP per capita.

Relationships between team-based education (TBE), com-

munity-based education (CBE), and problem-based learn-

ing (PBL) were also examined. It was seen that if a school

employs a higher degree of any one of these in the clinical

years, it is more likely to have any of the others in the clini-

cal years. A similar relationship was seen in the preclini-

cal years. All six of these pairs of relationships (TBL-CBE,

CBE-PBL, and TBL-PBL in the clinical and preclinical

years) were statistically significant by Pearson’s chi squared

test at a 99.9% confidence level except for CBE-PBL in the

clinical years (p=.055).

Another regression examined the predictors of the quan-

tity of total medical schools and of private medical schools

existing in a country. This analysis included all schools

listed in Table 3, not just the schools returning surveys.

Examining all schools, it was found that a country’s popu-

lation and its land mass were the strongest predictors of its

total complement of medical schools. For about every 7.5

million additional population, a country would be expected

to add a school, and for about every quarter million square

kilometers of area, it would add an additional school.

Variables that were not significant predictors of the number

of medical schools in a country included GDP per capita,

predominant language, proportion of population living in

rural areas, official development assistance per capita, and

the number of physicians per capita.

Students at the University of Gezira, Sudan, learn with a registered midwife.


MultivariaBle analyses—suMMary

The correlations seen in this work provide quantitative

demonstrations of various trends and relationships in med-

ical education in SSA. The correlations relating to resources

and barriers call attention to trends that can guide donor

investment. Not surprisingly, medical schools in poorer

African countries report poorer resources and more

unfilled faculty positions than do medical schools in less

poor African countries, indicating that investments may be

most needed in the poorest countries. The correlations also

tended to showed that newer medical schools tend to report

poorer resources than older schools; indicating that while

many new schools are being established to increase the

capacity of the medical educational enterprise in Africa,

they may be particularly vulnerable in their first years.

Additional support during the first few years of a medical

school’s existence may be a much needed asset for young

schools working to establish themselves. Somewhat surpris-

ingly, public schools reported more severe resource con-

straints and more unfilled faculty positions than equivalent

private schools. This finding emphasizes the importance

of adequate governmental investment for public schools. It

may also represent a bias in reporting between public and

private schools. Private schools in general are a newer and

less established entity in SSA, as such private schools may

be less willing to report inadequate resources or faculty

shortages. The difference in unfilled faculty positions may

also be an administrative difference, public schools may be

more likely to create and report positions they are unsure

whether they will be able to fill while private schools are

less likely to create positions they cannot fill.

Many of the other correlations seen also provide an evi-

dentiary basis valuable for policymaking. While it stands

to reason that compulsory service programs increase the

availability of doctors in rural areas, this survey provides

the first continent-wide evidence that the existence of com-

pulsory service programs continue to have an impact five

years after graduation. It also seems that the schools that

have done the best job of placing graduates in rural areas

are those with a moderate number of PGME programs--

those that do not focus excessively on specialty education

while providing their graduates of the opportunity to spe-

cialize locally. The finding that graduates of Francophone

schools seem more likely to prefer rural general practice

deserves further study to identify the factors that contrib-

ute to greater rural general practice.

Research was a particular area of interest in the SAMSS

project since it was seen that participation in research

activities can strengthen the quality of medical education

and encourage faculty retention. The SAMSS survey asked

schools whether they provided any of five separate types of

research support to their faculty (Figure 35). In multivari-

able regressions, only two of those five types of research

support had a statistically significant relationship with

A lecture hall at the University of Ibadan, Nigeria


the percentage of faculty who were involved in research:

strengthened institutional research tools and funded time

for faculty research. Therefore, priority areas for invest-

ment to increase faculty research might be providing

funded time and creating institutional support structures

such as research committees, ethics committees, and other

mechanisms for technical and administrative support. It

would seem that Anglophone schools have had more suc-

cess in faculty pursuing grant-funded research. This find-

ing deserves further study as to the factors contributing to

the success of Anglophone schools and the barriers faced

by non-English speaking schools. Opportunities for col-

laborations and research funding for non-English speakers

deserves further attention.

The findings concerning the number of medical schools

in a country were also interesting. It is somewhat sur-

prising that higher GDP does not appear associated with

a higher number of medical schools; this result could be

changed if the total number of medical graduates was con-

sidered rather than simply the number of schools, but this

analysis was not possible lacking survey responses from

every medical school. The only factors that were seen to

be important were population and land size, with both

tending to increase the number of medical schools as they

increased. Likewise, the number of private medical schools

in a country did not increase with GDP (while not statisti-

cally significant the relationship observed actually showed

a greater likelihood of private schools in poorer countries);

rather, the quantity of private schools was seen to be great-

est when a country was large in area and population but

had few public medical schools. Each public medical school

built eliminated the need for slightly more than one private

medical school. This seems to indicate that private medical

schools have been founded to fill gaps when public medical

education has not been sufficient to meet a country’s need.

The successes and failures of a medical school are greatly

influenced by the environment it faces and the decisions it

makes. Analyses such as those presented here that describe

the different challenges faced by medical schools in dif-

ferent circumstances help to build an evidentiary basis for

decisions about where and how to target resources.

Limitations

There were a number of limitations in the conduct of this

survey, including the subjective nature of a number of the

questions, unanswered questions in surveys of some indi-

vidual schools, and inconsistently answered questions from

schools within the same countries. Questions such as the

proportion of income from various sources, reasons for

staff loss, and graduates’ emigration and practice choices

were often best estimates by respondents rather than data-

based answers. These questions were purposely less pre-

cise in phrasing than may have been optimal. The decision

to remain imprecise was made based on pre-testing and

expert feedback suggesting that more detailed questions

would decrease the likelihood of receiving answers at all

due to the limited data available about these issues. Surveys

were targeted to deans or high level school officials in the

hope of maximizing the accuracy of educated estimates

for these questions. One question that proved particularly

problematic concerned the location and practice choices of

graduates. Respondents were asked whether their answer

to this question, was based on a graduate tracking system,

a one time study, or a best estimate. The low number of

respondents reporting tracking systems or studies indicates

an area of need for future evaluations.

Another limitation was unanswered questions within

returned surveys. Some questions were understandably left

blank by some school leaders, as in the case of questions


about graduates from schools that had yet to graduate stu-

dents. When questions were left unanswered without an

explanation, attempts were made to contact respondents

to complete the questionnaires. The number of responses

to each question (n) is reported for each relevant finding.

In some cases, inconsistent answers pertaining to national

requirements were found among multiple responses from

schools in the same country. For example, eight countries

with multiple schools responding gave inconsistent answers

regarding whether a compulsory service requirement exists

in their country. While this inconsistency may be a result

of a misunderstanding of the question, it would seem more

likely to be a reflection of poor communication between

national level agencies and individual medical schools.

More investigation is necessary to examine this finding.

Finally, while a 72% overall response rate is a strong

response rate for a survey study of this kind, the findings

reflect only a portion of the existing medical schools in

sub-Saharan Africa. In addition, response rates were lower

in some countries, including the Democratic Republic of

the Congo, Sudan, and Nigeria, than in others. In most

cases, countries with high numbers of identified schools

had lower response rates, although a higher absolute num-

ber of schools responding. The reported response rate

from the Democratic Republic of the Congo was further

complicated by the late identification of 12 private medi-

cal schools, which are not reflected in the 72% as these

schools were identified after the close of the survey period.

Seventeen total schools were not included in the reported

number, either due to late identification or to the schools’

first opening after the start of the survey period.


SAMSS found a remarkable growth in medical education in

Sub-Saharan Africa over the last two decades, antedating

the more recent attention by international organizations to

health workforce shortfalls. The decision of many countries

to invest in building new medical schools and expand cur-

rent ones, the intense interest of young people in the study

of medicine, and the emergence of private medical educa-

tion are all evidence of this movement. Moreover, the cur-

rent, global attention being paid to health workforce scale-

up makes this a propitious time for medical education in

SSA. These factors promise great opportunity but do not

obviate the many barriers that have limited the develop-

ment of medical education in the past. SAMSS found ample

evidence of these obstacles. Addressing chronic problems

directly is an important point of departure in seeking to

capitalize on the current positive environment.

The essence of a medical school is the faculty available to

students to learn both didactic and clinical material. While

scarcity in human and material resources is no surprise to

anyone familiar with medical education in Africa, SAMSS

documented the consistency and magnitude of these prob-

lems, establishing a baseline from which to begin scale up.

Basic sciences and clinical medical faculty are in short

supply everywhere, severely limiting quality educational

scale-up. Additionally, it is well-established that many fac-

ulty members supplement their salaries with private prac-

tice, further reducing their hours of academic availabil-

ity. Recruitment, training, and retention of preclinical and

clinical faculty for medical schools must be a priority in

medical education capacity development. National authori-

ties and international partners must work together with

medical colleges to prioritize faculty development focused

on the preparation and recruitment of basic and clinical

science faculty. This could be accomplished by establishing

dedicated funding, raising endowments for teaching, and

when necessary, using expatriate faculty strategically.

Severe deficiencies are often present in laboratories, librar-

ies, classrooms, lecture halls, and hostels. The deficit in

information technology was apparent everywhere. Dated

computers were few in number and labored with inade-

quate bandwidth, denying students the possibility of leap-

frogging older learning technologies to avail themselves of

the exploding world of Web-based learning. Nonetheless,

enormous possibilities exist here, and these possibili-

ties will be more accessible with the anticipated growth

in regional bandwidth. In addition to the strategic use of

national education budgets, international donors might

establish medical school infrastructure investment funds

to devote money to building and improving the physical

plants and computer capabilities of new and expanding

medical colleges. As research portfolios grow at medical

schools, a percentage of research money might be dedicated

to developing teaching labs and the learning environment.

Inadequate coordination between ministries of education

and ministries of health is commonplace and problematic.

Developing inter-ministerial councils for medical educa-

tion and practice (or similar coordinating mechanisms)

would offer a low cost strategy to improve the training and

deployment of the medical workforce. These councils could

also initiate tracking systems to measure the locations and

types of practice of medical school graduates.

Most African doctors seeking advanced training have

traveled to Europe and North America. Many have not

returned. Developing and expanding national programs of

post graduate medical education will be essential to build-

ing sustainable, quality physician cadres in every country

and increasing the ranks of medical school faculties. PGME

chapter 5: DiscussiOn


expansion should include increased post graduate specialty

training posts, graduate programs in medical basic science

fields, regional centers of excellence for highly specialized

training (South-South), and strategic North-South spe-

cialty training collaborations.

SAMSS documented a number of areas in which promising

developments suggest new pathways to overcoming tradi-

tional obstacles. These are important because they provide

evidence of what some schools and counties have done to

strengthen the functionality of their medical schools and,

therefore, what others might do.

SAMSS found evidence that in addition to generating new

knowledge, research promoted faculty development and

retention. This suggests that research investments in medi-

cal schools will help grow faculty in addition to generating

new science. Given national needs, research agendas might

include investments in population science and health ser-

vice delivery as well as biomedical and clinical sciences.

Research should help to build the scientific as well as teach-

ing capacity of the school.

Community based education and a focus on commu-

nity oriented primary care is present in the curricula of

many medical schools. Master’s degrees in public health

and post graduate education in family medicine are pres-

ent at a growing number of institutions and these dis-

ciplines seem to be enjoying increased student interest.

Social accountability, population health, and the reten-

tion of graduates in country are topical issues with deans

and medical educators. Since health system strengthen-

ing is essential to improve population health, these trends

are promising. Improved systems of primary care deliv-

ery led by doctors will be crucial to the strengthening

of health systems. Support for these trends by national

governments and international donors can help legitima-

tize and fund this movement.

Several Sub-Saharan African countries have recently estab-

lished active regulatory frameworks for medical schools

and medical graduates which should provide models for

countries planning to improve their regimen of qual-

ity assurance in medical education. Despite the recogni-

tion of these functions as important, many countries still

have only have in place a one-time registration for gradu-

ate doctors. Concrete initiatives need to be considered by

more governments and supported by international donors

to develop norms, procedures, and incentives to implement

accreditation and certification programs for the purpose of

quality assurance and improvement.

The sudden presence of private medical education in many

countries is controversial. Some believe that this is both

overdue and the way of the future. Others think that pri-

vate schools are an omen of unfortunate commercial trends

in education, questioning the affordability, stability, and

Laboratory at Walter Sisulu University, South Africa. Research may aid in the retention of faculty.


the quality of these institutions. However, private schools

are indisputably a mechanism for medical education capac-

ity expansion in SSA. Private schools further challenge gov-

ernments to establish standards for medical graduates, to

ensure rigorous accreditation and licensing processes, and

to develop policies that incentivize students to train for

national needs.

Despite the growing interest and support for medical edu-

cation, a professional organization to support and general-

ize this movement is currently inactive. The Association of

Medical Schools in Africa (AMSA) was established in 1963

and re-constituted in the 1990s. It remains a member of the

World Federation of Medical Education. The opportunity

exists for the African academic medical community revive

AMSA, possibly with external financial support. The level

of interest in medical education today as well as the pres-

ence of the World Wide Web as a tool for communication

presents an exceptional opportunity for the reestablish-

ment of an organization of African medical schools. Such

an organization would be in a position to coordinate and

disseminate information about African medical education

including best practices, data on existing programs, accred-

itation and certification initiatives, and updates on current

and developing medical schools.

This is, indeed, a moment of opportunity for the interna-

tional donor community. Medical school leaders as well

as political leaders in many countries are persuaded of the

importance of building their medical workforces. To make

the most of this momentum, donor investments should be

aligned with population health needs and the health sys-

tems of the respective countries. Funding strategies should

engage the spectrum of issues but those that are most press-

ing are faculty development and school infrastructure.

Lack of available computers and internet bandwidth is ubiquitous and limiting.


Strong health systems are central to the attainment of

health equity and lack of human resources is a key obsta-

cle to the attainment of strong health systems. Physicians

are a core component of the human resource pool, and

Sub-Saharan Africa needs more physicians while ensuring

the quality and relevance of medical school graduates and

it also needs strong medical schools in Africa which are

accredited to assure quality, well-resourced and relevant to

national health need. Recommendations were developed

with the help of the Advisory Committee during every

step of the process. The Advisory Committee met in Dar

es Salaam, Tanzania, in April 2010 to review the site visit

and survey reports and findings as well as to finalize con-

tent, form and phrasing of the SAMSS recommendations as

listed in this report.

The SAMSS team proposes the following set of recommenda-

tions to medical schools, professional associations, govern-

ments, regional bodies, international partners, and donors:

1) launch campaigns to develop Medical School

faculty capacity including recruitment, Training, and

retention

Recommendation: Medical teachers (Basic Sciences and

Clinical Sciences faculty) are in short supply everywhere,

severely limiting quality educational scale-up potential.

Recruitment, training, and retention of preclinical and

clinical faculty for medical schools must be a priority strat-

egy in medical education capacity development. It is rec-

ommended that national authorities and international

partners working together with medical colleges under-

take faculty development campaigns that would involve

increased focus on preparation and recruitment of basic

and clinical sciences faculty, by establishing dedicated

funding, the raising of endowments for teaching, and if

necessary, structured use of expatriate faculty.

2) ramp up investment in Medical education infrastructure

Recommendation: To address the severe deficiencies often

present in laboratories, libraries, IT, classrooms, lecture

halls, and hostels, national and international funds need be

brought to bear systematically. National education budgets

should focus on these needs. International donors, singly or

in coalitions, should establish a medical school infrastruc-

ture investment fund that devotes money to building and

improving the physical plants and resources of new and

expanding medical colleges. Also, a percentage of research

money that comes from international funds should be

dedicated to developing teaching labs and the learning

environment.

3) institute Structures to Promote inter-Ministerial

collaboration for Medical education

Recommendation: Given the frequent lack of coordina-

tion between ministries of education (that provide fund-

ing for medical education) and ministries of health (that

serve as the principal employers of medical graduates), it is

recommended that inter-ministerial councils on medical

education be established in every country for the purpose

of strategic planning and joint budgeting. These councils

should also initiate tracking systems that will measure the

locations and types of practice of medical school graduates.

In countries that have autonomous regulatory bodies, it is

advised that a tripartite council can be created including

the ministry of health, the ministry of education and the

regulatory body.

chapter 6: recOMMenDatiOns


4) fund research and research Training at Medical

Schools

Recommendation: Because research promotes faculty

development and retention in addition to generating new

knowledge, it is recommended that national science invest-

ments and international donors focus research funding on

medical schools in an effort to develop both human and

scientific capacity. Research agendas should include invest-

ments in population sciences and health service delivery as

well as biomedical and clinical sciences. Research should

not function in a silo but should help to build the scientific

as well as teaching capacity of the school.

5) Promote community oriented education based on

Principles of Primary health care

Recommendation: Since health system strengthening is

essential to improve population health, medical colleges

should educate medical doctors prepared for that task.

More robust systems of primary care delivery led by medi-

cal doctors will be crucial to the strengthening of health

systems. It is recommended that all medical colleges plan,

articulate, and implement community based educational

strategies that include programs in family medicine toward

the end of preparing primary care practitioners and lead-

ers for the future. National governments and international

donors should devote resources to this initiative. Also,

since national service as a requirement for medical gradu-

ates creates an opportunity to supplement services in needy

areas of countries, it is recommended that all countries that

do not currently have a national service requirement adopt

one linked to receipt of diploma or licensure. In addition

to service rendered, this will give all graduates an opportu-

nity to work in parts of the country where they would not

otherwise practice and provide medical care and enhanced

population health to communities with limited health care.

6) establish national and regional Post-graduate Medical

education Programs to Promote excellence and

retention

Recommendation: Historically most medical doctors

seeking advanced training traveled to Europe and North

America. Many never returned. Developing and expanding

national PGME as well as graduate programs with appro-

priate certification authorities will be essential to building

a sustainable, quality physician community in every coun-

try. Good PGME will also serve as an important avenue

to build the needed critical mass of faculty. All African

nations should develop and implement a forward plan for

national postgraduate medical education and graduate pro-

grams for medical basic sciences fields. The plans should

be built on the principles of adequate PGME at a national

level, regional centers of excellence for highly specialized

training (South-South), and strategic north-south PGME

training collaborations.

7) establish national or regional bodies responsible

for accreditation and Quality assurance of Medical

education

Recommendation: In many countries, oversight of medical

schools and the graduates of those schools is neither stan-

dardized nor regularized. Although medical school accred-

itation and external certification of the schools’ graduates

are recognized as important functions, systematic pro-

grams to accomplish these important validation tasks are

often not in place. Concrete initiatives should be taken

by national governments and supported by international

donors to develop norms, procedures, and incentives to


implement accreditation and certification programs for the

purpose of quality assurance and improvement.

8) increase donor investment in Medical education

aligned with national health needs

Recommendation: There is enormous receptivity in the

African medical school community and significant politi-

cal support as well for the rapid scale up of medical educa-

tion toward the end of health systems strengthening and

improving national and continental health. This pres-

ents a huge opportunity to make a difference for public

and private donor organizations. To make the most of this

momentum, donor investments need to be aligned with

population health needs and the health system of the coun-

try. They should engage issues of school infrastructure, fac-

ulty development, and student needs, as well as national

policies and support from the ministries of education,

health, and finance. Governments should clearly articulate

their expansion plans for medical education so that donors

can make their commitments align with those plans.

Decisions on funding should be guided by local needs

assessments and judgments of the level of support provided

by the school and the national government.

9) recognize and review the growing role of Private

institutions in Medical education

Recommendation: The contributions of private medical

schools to medical education and the sustainability of these

schools need to be studied in detail. Where appropriate

these schools should be supported or facilitated within the

context of national health policies. This would include pri-

vate not-for-profit, for-profit, and faith-based schools.

10) revitalize the association of Medical Schools in africa

Recommendation: Since organizations of medical edu-

cators benefit member institutions and faculty in carry-

ing out their missions, it is recommended that an African

Organization of Medical Colleges be established to focus,

coordinate, and disseminate information about African

medical education including best practices, data on exist-

ing programs, and anticipated benefit of current and

developing medical schools. The Organization should

include representation from Anglophone, Lusophone,

Francophone, and Arabic speaking schools. To be most

effective, it should be an autonomous, not-for-profit, mem-

bership organization which establishes its own terms of

agreement with international organizations such as AFRO,

UNESCO, and WFME.


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