the sub-saharan african medical school study
TRANSCRIPT
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 Sub-Saharan african Medical School STudy 3
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
4 The Sub-Saharan african Medical School STudy
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.
The Sub-Saharan african Medical School STudy 5
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
6 The Sub-Saharan african Medical School STudy
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
The Sub-Saharan african Medical School STudy 7
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
8 The Sub-Saharan african Medical School STudy
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
The Sub-Saharan african Medical School STudy 9
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)
10 The Sub-Saharan african Medical School STudy
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
The Sub-Saharan african Medical School STudy 11
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.
12 The Sub-Saharan african Medical School STudy
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
The Sub-Saharan african Medical School STudy 13
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.
14 The Sub-Saharan african Medical School STudy
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.
The Sub-Saharan african Medical School STudy 15
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.
16 The Sub-Saharan african Medical School STudy
The Sub-Saharan african Medical School STudy 17
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
18 The Sub-Saharan african Medical School STudy
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 Sub-Saharan african Medical School STudy 19
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
20 The Sub-Saharan african Medical School STudy
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.
The Sub-Saharan african Medical School STudy 21
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 (**).
22 The Sub-Saharan african Medical School STudy
CounTRy SChooL nAME ownERShIP FounDIng DATE
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
Private Not for Profit
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
The Sub-Saharan african Medical School STudy 23
CounTRy SChooL nAME ownERShIP FounDIng DATE
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
Private Not for Profit
*
*
1963
2000
*
*
Namibia University of Namibia ** **
Niger Faculté des Sciences de la Santé, Université Abdou Moumouni Public 1974
24 The Sub-Saharan african Medical School STudy
CounTRy SChooL nAME ownERShIP FounDIng DATE
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
Private Not for Profit
*
*
*
*
*
*
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
Private Not 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
Private Not for Profit
Private Not for Profit
2000
2002
Table 3: Medical SchoolS in Sub-Saharan africa conTinued
The Sub-Saharan african Medical School STudy 25
CounTRy SChooL nAME ownERShIP FounDIng DATE
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
Private Not For Profit
Unknown
Unknown
Unknown
Public
Unknown
Public
Unknown
Unknown
Public
Private Not For Profit
Unknown
Public
Public
Unknown
Unknown
Private Not For Profit
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
26 The Sub-Saharan african Medical School STudy
CounTRy SChooL nAME ownERShIP FounDIng DATE
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
Private Not for Profit
Private not for Profit
Public
Private Not for Profit
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)
Table 3: Medical SchoolS in Sub-Saharan africa conTinued
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
The Sub-Saharan african Medical School STudy 27
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.
28 The Sub-Saharan african Medical School STudy
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
The Sub-Saharan african Medical School STudy 29
“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
30 The Sub-Saharan african Medical School STudy
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.
The Sub-Saharan african Medical School STudy 31
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
32 The Sub-Saharan african Medical School STudy
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
The Sub-Saharan african Medical School STudy 33
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
34 The Sub-Saharan african Medical School STudy
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.
The Sub-Saharan african Medical School STudy 35
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.
36 The Sub-Saharan african Medical School STudy
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
The Sub-Saharan african Medical School STudy 37
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
38 The Sub-Saharan african Medical School STudy
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).
The Sub-Saharan african Medical School STudy 39
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).
40 The Sub-Saharan african Medical School STudy
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
The Sub-Saharan african Medical School STudy 41
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.
42 The Sub-Saharan african Medical School STudy
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
The Sub-Saharan african Medical School STudy 43
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
44 The Sub-Saharan african Medical School STudy
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.
The Sub-Saharan african Medical School STudy 45
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
46 The Sub-Saharan african Medical School STudy
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.
The Sub-Saharan african Medical School STudy 47
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.
48 The Sub-Saharan african Medical School STudy
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
The Sub-Saharan african Medical School STudy 49
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
50 The Sub-Saharan african Medical School STudy
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
The Sub-Saharan african Medical School STudy 51
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
52 The Sub-Saharan african Medical School STudy
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
The Sub-Saharan african Medical School STudy 53
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
54 The Sub-Saharan african Medical School STudy
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 Sub-Saharan african Medical School STudy 55
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.
56 The Sub-Saharan african Medical School STudy
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
The Sub-Saharan african Medical School STudy 57
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,
58 The Sub-Saharan african Medical School STudy
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 Sub-Saharan african Medical School STudy 59
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.
60 The Sub-Saharan african Medical School STudy
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.
The Sub-Saharan african Medical School STudy 61
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.
62 The Sub-Saharan african Medical School STudy
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.
The Sub-Saharan african Medical School STudy 63
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,
64 The Sub-Saharan african Medical School STudy
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).
The Sub-Saharan african Medical School STudy 65
» 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
66 The Sub-Saharan african Medical School STudy
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.
The Sub-Saharan african Medical School STudy 67
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
68 The Sub-Saharan african Medical School STudy
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
The Sub-Saharan african Medical School STudy 69
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).
70 The Sub-Saharan african Medical School STudy
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.
The Sub-Saharan african Medical School STudy 71
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.
72 The Sub-Saharan african Medical School STudy
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.
The Sub-Saharan african Medical School STudy 73
figure 13: nuMber of Medical School graduaTeS (2008)
figure 12: nuMber of Medical School firST year enrollMenTS (2008)
74 The Sub-Saharan african Medical School STudy
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.
The Sub-Saharan african Medical School STudy 75
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
76 The Sub-Saharan african Medical School STudy
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.
The Sub-Saharan african Medical School STudy 77
figure 19: nuMber of yearS reQuired To graduaTe
figure 20: uSe of learning aPProacheS
78 The Sub-Saharan african Medical School STudy
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
The Sub-Saharan african Medical School STudy 79
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
80 The Sub-Saharan african Medical School STudy
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
The Sub-Saharan african Medical School STudy 81
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
82 The Sub-Saharan african Medical School STudy
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
The Sub-Saharan african Medical School STudy 83
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
84 The Sub-Saharan african Medical School STudy
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
The Sub-Saharan african Medical School STudy 85
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
86 The Sub-Saharan african Medical School STudy
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
The Sub-Saharan african Medical School STudy 87
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.
88 The Sub-Saharan african Medical School STudy
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.
The Sub-Saharan african Medical School STudy 89
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.
90 The Sub-Saharan african Medical School STudy
figure 37: adeQuacy of Technology reSourceS
* n varies due to non-response by some schools on some questions.
figure 38: adeQuacy of clinical Teaching SiTeS
* n varies due to non-response by some schools on some questions.
The Sub-Saharan african Medical School STudy 91
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.
92 The Sub-Saharan african Medical School STudy
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.
The Sub-Saharan african Medical School STudy 93
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
94 The Sub-Saharan african Medical School STudy
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
The Sub-Saharan african Medical School STudy 95
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
96 The Sub-Saharan african Medical School STudy
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.
The Sub-Saharan african Medical School STudy 97
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
98 The Sub-Saharan african Medical School STudy
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 Sub-Saharan african Medical School STudy 99
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
100 The Sub-Saharan african Medical School STudy
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.
The Sub-Saharan african Medical School STudy 101
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)
102 The Sub-Saharan african Medical School STudy
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
ouTCoME VARIABLE STATISTICALLy SIgnIFICAnT PREDICToRS (DIRECTIon oF ASSoCIATIon)
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
The Sub-Saharan african Medical School STudy 103
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.
ouTCoME VARIABLE STATISTICALLy SIgnIFICAnT PREDICToRS (DIRECTIon oF ASSoCIATIon)
% 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
104 The Sub-Saharan african Medical School STudy
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.
The Sub-Saharan african Medical School STudy 105
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
106 The Sub-Saharan african Medical School STudy
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
The Sub-Saharan african Medical School STudy 107
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.
108 The Sub-Saharan african Medical School STudy
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
The Sub-Saharan african Medical School STudy 109
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.
110 The Sub-Saharan african Medical School STudy
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.
The Sub-Saharan african Medical School STudy 111
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
112 The Sub-Saharan african Medical School STudy
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
The Sub-Saharan african Medical School STudy 113
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.
114 The Sub-Saharan african Medical School STudy
1 WHO 2006 Working together for health; the World Health Report 2006 Geneva Switzerland
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