The findings of the SAMSS survey significantly expand the baseline knowledge of medical education in Sub-Saharan Africa. The list of medical schools generated is itself the most complete list of medical schools in the region and identifies over 60 new schools previously not listed by the World Health Organization or the Foundation for Advancement of International Medical Education and Research (FAIMER). The very number of medical schools identified demonstrates the need for current data on medical education in SSA. The findings of the SAMSS survey establish baseline training capacity indicators, identify critical barriers for capacity expansion and quality improvement, and identify innovative strategies for addressing barriers. These findings provide a building block for future evidence based medical education research, investment, and policy making.
Medical schools in SSA are expanding, both in overall number and enrolments. In the past 20 years, at least 58 new medical schools have begun training doctors. However, medical school enrolments remain relatively small with 39% of respondents reporting first year enrolment at or below 100 students. These relatively small intakes suggest an area to build on existing capacity. In fact, 73% of established respondent schools report recent enrolment increases, and 45% of respondents report plans to increase over the next five years. More than half of the schools (58%) report having mandates to expand, most often from Ministries of Education and Health. This expansion is critical for strengthening the health care workforce in the region, but it also presents significant challenges for medical schools and national health systems.
Medical schools in SSA are also offering post-graduate training opportunities with over half of respondents reporting post-graduate training programs. Increasing the number of residency posts will increase in-country training opportunities, boosting the number of specialists in the country and the pool of potential junior faculty to recruit from.
Growth has also placed a strain on medical school infrastructures. Over half of the respondents reporting plans to expand indicate that they are unlikely to reach their goal enrolment numbers. Medical schools report inadequacies in a number of key physical resource areas, including skills and research labs, journals, student residences, and computers. Expansion further taxes these scarce resources. The most significant reported barriers to improving quality and increasing graduate numbers are insufficient physical infrastructure (labs, computers, teaching resources, and libraries) and faculty shortages. Faculty shortages include both basic science and clinical faculty, and many respondents attribute shortages to salary and quality of life issues. Of note, an insufficient number of qualified applicants is not seen as a barrier at the majority of medical schools.
Schools have implemented a number of strategies to address inadequacies and barriers to expansion. Strategies generally focus on addressing insufficient physical infrastructure, increasing faculty numbers through recruitment and faculty development strategies, maximizing existing resources through the use of technology, and developing external partnerships both locally and on an international level to provide clinical teaching sites, donor support, and educational and research exchanges. A number of schools also report unique strategies such as establishing a graduate entry medical program, increasing internally generated revenues through clinical services or the operation of a fitness centre, and transferring the supervision of the medical school from the Ministry of Education to the Ministry of Health. All of these strategies will need further evaluation but the compilation and sharing of these strategies provides an important opportunity for institutions to develop and adopt successful strategies, and collaborate to develop evidence based approaches.
Schools also report a number of strategies to improve medical doctor retention in their countries. The most common strategies include increasing salaries for faculty, establishing post-graduate medical education (PGME) programs, establishing community based education, recruiting graduates as faculty, establishing career pathways, and strengthening research support for faculty. While multivariable analysis showed few significant correlations between these strategies and reduced migration of graduates out of country, schools that provided bonuses or increased salaries for their faculty appeared to have less attrition of their own teaching staff. Additionally, faculty research, which is important for faculty retention, is significantly supported by funded research time for faculty members and strengthened institutional research tools (administrative and technical support, access to journals, and research and ethics committees).
Many schools report focused recruitment of rural students and student preparatory programs--two strategies often used to improve access to medical education for rural students and improve overall rural retention of medical doctors . Sixty-nine percent of schools report compulsory service requirements for graduates in their country. While it stands to reason that compulsory service programs increase the availability of doctors in rural areas, this study provides the first continent-wide evidence that the existence of compulsory service programs increases the likelihood of future rural general practice. Schools with a moderate number of PGME programs (1-5), compared to those schools with no PGME programs and schools with many PGME programs (6-14) and French speaking schools, also demonstrate an increase likelihood of future rural general practice. These findings deserve further study to clarify the factors contributing to greater rural practice. What factors contribute to rural retention in Francophone countries and are these transferrable to other countries? Does the relationship of PGME to rural practice indicate the opportunity to pursue PGME in country decreases the likelihood of migration? Do a greater number of PGME programs relate to greater specialization and therefore decreased rural practice? These findings suggest important distinctions in strategies to address rural retention.
In the free-response section of the survey, schools were asked about their needs/requirements for increasing the quantity and the quality of their graduates. Referring to graduate quality, the highest number of respondents (35 of 94) named faculty-related challenges as the greatest need. Referring to graduate quantity, infrastructure issues were most commonly named as the greatest need (37 of 94). Needs related to the medical curriculum were primarily seen as needs related to graduate quality and challenges related to clinical training sites were primarily seen as needs to address graduate quantity. This information can help guide investment by linking the type of investment with the desired result: investment in infrastructure and clinical sites help schools train more doctors while investment in faculty and curricula help improve the quality of the doctors trained.
Despite strategies to address doctor retention in country and in rural areas, migration remains a significant issue in most countries. On average, 27% of respondents' domestic graduates were reported as likely to migrate out of their country within five years of graduation, most often to countries outside of Africa. A concerning finding of this study is the number of medical schools (40) reporting no specific school-level steps to address doctor retention and the additional nine schools explicitly stating retention is an issue which the government should address rather than the school. While doctor retention must be addressed across the spectrum of education, national, and international policies, this study clearly shows that many schools are implementing strategies to increase retention, and medical school level strategies, such as PGME, are showing promise in improving retention, particularly in rural areas.
Additional findings that deserve attention are the rise of the private (for-profit and not-for-profit) medical schools and tuition costs for medical school. The first private medical schools responding to the survey were founded in the 1990s and they represent an area of significant growth and potential for medical education in the region. However, private medical schools also present a challenge to a health care system that has historically relied on public institutions for training. Issues of quality assurance and accreditation, relationships to government organizations, and cost will need to be investigated as these private institutions continue to grow. This study suggests there are models for managing these issues. For example, four out of the five medical schools in Tanzania are under private ownership, yet all five schools report accreditation by the national level Tanzania Commission for Universities. This is in sharp contrast to other SSA countries that report inconsistent accrediting practices even among public schools. A better understanding of the Tanzanian system may help guide countries where private medical schools are just beginning to develop.
Likely related to the growth of private medical schools are the increasing levels of tuition costs seen in SSA medical schools. Although costs may be seen as modest by international standards, this may not feel so for poorer students studying medicine. Eight schools charge over US$ 5000 per year. Private medical schools are particularly dependent upon tuition fees for revenue. The increasing cost of medical school may have unintended consequences, providing access to education only for wealthy students and minimizing the likelihood that graduates will remain in country or serve in poor or peripheral areas. Trends in tuition costs and the effects of these costs should be closely monitored and accounted for in strategies to address medical education capacity expansion and doctor retention.
There were a number of limitations in the conduct of this study. A number of questions were of a subjective nature, individual surveys included some unanswered questions, and some inconsistencies were seen in country level 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. In pilot testing, it was apparent that such data was generally not available, and pilot respondents reported that more specific questions were likely to pose a significant challenge to respondents and reduce the likelihood of response. We were advised that deans or their nominees would be able to provide reasonable estimates based on their first-hand experience. The study specifically found only 18% of 67 respondents have established school tracking of graduates and an additional 13% have conducted a one-time graduate assessment study. This finding suggests improved tracking systems are needed in order to document the impact of strategies to build capacity to improve doctor retention and practice patterns.
Another limitation was unanswered questions within individual returned surveys. Some questions were understandably left blank by some respondents, as in the case of questions regarding graduates for schools that had yet to graduate students. In other cases, when questions were left unanswered, attempts were made to contact respondents to complete the questionnaires. The number of responses to each question (n) is reported for all findings. Inconsistent answers were also seen in country level questions in some countries with multiple responding schools. This was seen in both the question on compulsory service requirements and the setting of competencies or expected skill sets by the government or professional councils. The respondents' reports of compulsory service requirements are also inconsistent with other published country level reports of compulsory service programs . These inconsistencies may be a result of differing interpretations of the questions, differing requirements at school and country levels, or they may suggest communication between government bodies and medical schools needs to be evaluated and strengthened.
Finally, while a 72% overall response rate for surveyed schools 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. Response rates were lower in some countries, including the Democratic Republic of Congo, Madagascar and Sudan. In most cases, countries with a high number of identified schools had lower response rates but a high absolute number of schools responding. Furthermore, an additional 23 schools were identified after the study period closed, reducing the response rate for all identified schools in SSA to 62%. While six of these schools had only begun training medical doctors after the initiation of SAMSS, 17 were established medical schools.