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### Overlooked Aspects of Medical Education in Africa’s Rankings



At 3am, I find myself gazing at the trembling vocal cords of a premature infant. Carefully, I insert a small tube through the cords and exhale as the phone rings. While the nurse attends to the call, I administer medication through the tube to aid the baby’s fledgling lungs in expanding, utilizing a bag to assist in regulating the baby’s breathing and ensuring the medication reaches the lung peripheries.

“Emergency C-section, they’ll be waiting for you in the theater,” the nurse informs me with a sympathetic look as we finish the procedure.

Inside the modest hospital theater, I methodically inspect the anaesthetic equipment and scrub my hands thoroughly. Speaking softly to the patient in the local language (isiZulu), I proceed to insert the spinal needle.

This marks the third C-section of the night. I exchange a nod with the surgeon, reflecting on our shared journey from medical school, now three years into our professional careers. Despite his adept hands skillfully making the incision, his eyes betray a youthful vigor not immediately apparent.

As we transport the mother and newborn to the recovery room, my phone buzzes once more. A patient in the surgical ward requires reinsertion of a chest drain. En route, I touch base with the neonatal nurse regarding the premature baby’s condition. The night silently transitions into daybreak, devoid of witnesses.

Deliberate Training

In retrospect, when recounting to my international medical peers the typical experiences of a junior doctor during a shift in my hometown in South Africa, they often express shock or disbelief at the level of responsibility and breadth of practice involved.

Yet, throughout that night, I never perceived my duties as daunting or inconceivable. My training had instilled in me a contextual understanding of the tasks at hand, enabling me to execute them with utmost care, much like my colleagues across the nation and beyond.

Only upon entering the realm of international health education did I realize the deliberate nature of the training I had received, tailored towards healthcare provision in underserved communities. Despite the systemic challenges, this training stands as a remarkable achievement and a tribute to the commitment of numerous medical educators based in Africa.

Unacknowledged Contributions

Presently, the African continent grapples with a myriad of health challenges, witnessing a surge in non-communicable diseases alongside communicable diseases and injuries.

However, it harbors the lowest healthcare worker density globally, with only 29% of the required medical doctors according to the World Health Organization (WHO).

This deficit necessitates imparting advanced competencies to generalist clinicians, often necessitating a level of proficiency seldom demanded by medical schools in affluent settings.

Nevertheless, existing literature on African medical training predominantly highlights its deficiencies. These encompass valid concerns regarding staying abreast of evolving care practices and evidence-based approaches, deficiencies in human resources and infrastructure, bridging cultural competency gaps, inter-facility disparities, and more.

These issues persist as patient safety concerns and contribute to the burden of morbidity and mortality in the region.

Amidst these challenges, the distinctive strengths and competencies of African medical graduates and institutions merit equal acknowledgment.

Advantages of African-Centric Training

Developing medical education that is responsive to extensive community needs is a formidable task, not undertaken lightly. By 2023, there were 444 medical schools in Africa – many established in direct response to healthcare workforce shortages.

The curricula of these institutions undergo continual refinement to better cater to the evolving needs of the populace, incorporating Competency-Based Medical Education (CBME) and Problem-Based Learning (PBL) methodologies.

A significant emphasis in many curricula is placed on social responsiveness, prioritizing the healthcare requirements of marginalized community segments and equipping graduates to deliver competent care.

This emphasis on primary care cultivates a profound understanding of prevalent regional conditions such as malaria, tuberculosis, and HIV, diverging from the research-centric approach adopted by many medical schools that prioritize cutting-edge research and sophisticated treatment modalities.

Several programs integrate cultural competency training and medical terminology courses in local languages. Given the linguistic diversity in many contexts, this component assumes critical importance in enhancing patient communication and experience.

Moreover, these programs aim to nurture societal accountability – a dedication to addressing pertinent healthcare challenges.

Indigenous research is gaining prominence, empowering local stakeholders to shape research agendas aligned with their contexts. This research often exhibits a strong sense of social responsibility. Notably, Rwanda’s Human Resources for Health Program exemplifies this ethos.

The surge in African-led research hubs signifies the emergence of a cohort of clinician-scientists committed to addressing clinical practice challenges. Innovations in education and health technology are also on the ascent.

For instance, Tunisia developed a high-tech simulator to train healthcare professionals in technical clinical procedures during the Covid-19 pandemic.

Furthermore, the experiential breadth and depth of African-trained graduates contribute significantly to the continent’s adept medical workforce. Training in such environments not only refines practical skills but also cultivates clinical acumen and judgment by necessitating effective practice in low-resource settings, where reliance on diagnostic investigations like CT scans and MRIs may be limited.

The divergence in practical competencies between graduates from Africa and their counterparts in high-income countries is frequently underscored in assessments of medical elective and exchange programs.

These structured initiatives afford medical students and practitioners the opportunity to engage in diverse healthcare settings, often emphasizing hands-on experience. Scholarly accounts extol the benefits of African-based electives in enhancing the clinical proficiencies of trainees from high-income nations across various disciplines.

Equity Concerns

Despite the robust medical education in Africa described above, the continent produces a cadre of capable, adaptable, and dedicated healthcare professionals. While these professionals often operate in challenging environments, their skill sets and the educational framework that nurtured them should not be underestimated.

Regrettably, the lack of recognition accorded to African medical education in academic discourse is mirrored in university rankings. Out of the 444 medical schools in Africa, only one institution secured a position in the top 100 in both global and regional rankings. This disparity can be attributed to the scoring criteria in these rankings, which predominantly mirror the priorities of high-income nations.

These metrics prioritize research output over responsiveness to local healthcare needs. To address this imbalance, Times Higher Education introduced a ranking for Sub-Saharan African universities, incorporating metrics like societal impact and ethical leadership.

While this segregated approach demonstrates the feasibility of integrating such metrics, a rationale for their exclusion from global rankings remains elusive.

It is imperative to deliberate on the inclusion of contextual metrics in international medical school rankings or reassess the global relevance of existing ranking methodologies.

In the interim, recognition of health educators throughout Africa is warranted on global platforms and initiatives.

Their unwavering commitment plays a pivotal role in ensuring that graduating healthcare professionals are not only clinically proficient but also attuned to the socio-cultural landscapes they serve.

Amy Paterson, a South African medical practitioner, currently pursues a DPhil at the Pandemic Sciences Institute, University of Oxford, United Kingdom. This article was originally featured in the and has been republished with permission. The blog, hosted by the London School of Economics and Political Science (LSE), provides a platform for academics, educators, and students to share insights and experiences related to teaching and learning in the UK and worldwide.