AHSCs              academic health science centres

AUF                  Agence Universitaire de la Francophonie

COHRED          Council on Health Research for Development

ECFMG            Educational Commission for Foreign Medical Graduates

GDPs                gross domestic products

HEIs                 health education institutions

HRH                 human resources for health

WDOMS          World Directory of Medical Schools

PGPs                post graduate programs

SANC              South African Nursing Council

SSA                 sub-Saharan Africa

UK                  United Kingdom

USA                United States of America

The shortage of health personnel in the World Health Organization African Region (WHO AFR ¹ ) is well documented ^{1– 4} . Equally well documented is the relatively low research output of the African continent relative to other regions ^{5, 6} . IJsselmuiden et al. ⁷ mapped advanced public health programs in Africa and Mullan et al. ⁸ mapped sub-Saharan African medical programs over a decade ago. Klopper and Uys ⁹ produced a book on nursing education in Africa, but it included mainly Anglophone countries and is not available widely in African libraries ² . These three sources took important steps towards mapping health education institutions (HEIs) ³ but most have lagged behind advances. For example, Ethiopia increased the number of medical schools from five to 23 between 2003 and 2009 ¹⁰ , yet the Mullan et al. ⁸ mapping listed only 12.

Objective Four of the WHO’s Global strategy on human resources for health ¹¹ addresses the need to strengthen human resources for health (HRH) ⁴ data to improve “monitoring and accountability of national and regional strategies ….” The first milestone for this objective is, “[B]y 2020, all countries will have made progress to establish registries to track health workforce stock, education, distribution, flows, demand, capacity and remuneration” (Ibid. p.33]. An accessible, up-to-date mapping of health education throughout WHO AFR would help to reach one part of this milestone. It would assist institutions offering and considering offering programs, African students and planners in ministries of health and education, as well as granting agencies, institutions, and individuals interested in supporting HRH development throughout the region.

This paper presents a first joint mapping of institutions offering health education programs in WHO AFR and discusses issues concerning their distribution. It concludes by proposing a format that would allow the data set to be updated on an ongoing basis and accessed freely by all stakeholders.

The authors chose to map WHO AFR for a number of reasons. First, this paper builds on two data sets that both stated they mapped “sub-Saharan Africa (SSA)” though included countries differed. Two, SSA is not a formal region of the world ⁵ . Three, WHO AFR is the main UN agency for health in Africa. Of course, mapping health programs in all members of the African Union would have been preferable but the resources of the team were limited. .

WHO AFR consists of 47 members of the African Union ⁶ . The top 10 (21%) most populous countries account for 66% of the region’s population, led by Nigeria with 18.4% and Ethiopia with 10.3%. WHO AFR works in three official languages, listing 22 countries as English-speaking, 21 as French-speaking and four as Portuguese-speaking. The AU has five sub-regions: North, Southern, East, West and Central. ⁷ .

The economies of the countries range in size from approximately US$400 billion for Nigeria to US$400 million for São Tomé and Príncipe. Average per capita income ranges from US$16,434 (30,557 Int’l$ ⁸ ) in Seychelles to US$272 (744 Int’l$) for Burundi. South Africa is the most economically unequal member with a GINI Index of 63, Algeria the most equal with a GINI Index of 27.6. The Anglophone countries represent 67.5% of the GDP of WHO AFR, Francophone 25.7% and Lusophone 6.7%.

Current average health expenditure per capita ranges from 1,207 Int’l$ in Mauritius to 30 Int’l$ in the Central African Republic. Regarding human resources for health, Liberia has the fewest nurses per 1,000 people with 0.10 and South Africa the most at 3.52, Malawi the fewest physicians per 1,000 people with 0.02 and Mauritius the most with 2.02 and Sierra Leona has the fewest specialist surgical workforce per 100,000 with 0.13 and Seychelles the most with 48.57 ^{9 12} . Centre for Capacity Research ¹² includes a complete listing of the 47 countries of the region with key geographic, demographic, economic, health, human resources for health and research indicators, extracted from World Bank ¹⁰ and UNESCO sources ^{11, 12} .

A team from the University of the Western Cape in South Africa and the University of Toronto in Canada developed the first data set of health professional programs (HPPs) in 2011. The second data set, of health post graduate programs (PGPs), was developed by a team from the Liverpool School of Tropical Medicine in the United Kingdom (UK) and the Institute Pasteur in France in 2017.

In total, 909 institutions together offered 1,176 health professional programs (235 medicine, 718 nursing, 77 public health and 146 pharmacy) as of July 2021 ³⁰ , and 1,641 post-graduate clinical and research programs (42 certificates, 1,149 Master’s and 480 PhDs) were offered at 183 of the 909 HEIs. South Africa, Nigeria, Kenya, Ethiopia and Ghana housed 482, or 52.7%, of the institutions (see Table 1). Of the PGPs, Medical Science programs were the most numerous with 851 (51.9%), followed by Biomedicine with 286 (17.4%), Public Health (including nutrition and environmental health) with 271 (16.5%), Nursing with 62 (3.8%), Dentistry with 47 (2.9) and Pharmacy with 45 (2.7%). São Tomé and Príncipe was the only country without any health education program perhaps as it is the only WHO AFR country with a GDP below US$1 billion, at US$422.3 million.

Anglophone countries had the most institutions overall and on a per capita basis [718 (79%)], although they account for 60.5% of WHO AFR’s population. Francophone countries had 164 institutions (18%) and Lusophone had 27 institutions (3%) but represent 33.6% and 5.9% of WHO AFR’s population, respectively. Anglophone country HEIs had more PGPs than did Francophone, 1,353 (81%) to 320 (18%), respectively. Ten countries had 114 of the 154 (74%) of the 154 AHSCs (see Table 1).

The ownership of 710 (78.1%) institutions was identifiable: 448 (63.1%) were publicly owned; 254, (35.9%,) were privately owned; and seven (1.0%) had joint public/private ownership. The date institutions were founded, or the year programs began, was found for 404 (44.4%) of cases. Of these, 152 (37.6%) were founded in 2000 or later. Just over half, 51.5%, of the private institutions were founded since 2000 compared to approximately one-third, 31.9%, of the public institutions.

Although the data are substantially skewed (SD > mean for many categories), there were statistically significant differences in indicators across a number of HEI strata (see Table 2). Countries with fewer institutions had a statistically significant lower population, GDP, total science publications and medical science publications (Tukey post-hoc test). A similar pattern was observed across terciles for AHSCs (0, 1, and >1 AHSC per country) ³¹ (see Figure 2).

Although the number of HEIs/country was associated with higher country populations, HEIs in WHO AFR were not equally distributed: over half of the institutions (54.1%) were located in five countries that together have only 41.8% of the WHO AFR population. These five countries (South Africa, Nigeria, Kenya, Ethiopia and Ghana) accounted for 54.5% of the region’s GDP (current US$) in 2018, consistent with our finding that GDP was also associated with number of HEIs and AHSCs. The uneven distribution of PGPs in WHO AFR was more marked, with only three countries (South Africa, Nigeria and Kenya) housing 58.3% of the PGPs. Such a concentration of medicine and health science PGPs is consistent with the findings of Adams, King ¹⁷ regarding scientific hubs in Africa. Algeria has a large number of AHSCs and likely has a large number of PGPs too, as the one university we collected data for had 28 PGPs. However, North Africa is not well represented in WHO AFR with only two members. Egypt, the research hub country in the sub-region ¹⁷ , is a member of the WHO Eastern Mediterranean (WHO EMR) not WHO AFR.

The relatively low number of Francophone and Lusophone HEIs in the mapping is consistent with these groups of countries having lower GDPs per capita than Anglophone countries. As institutions in the non-Anglophone countries may have larger student bodies, information on the number of graduates per HEI per year would be useful. Bilingual Cameroon had the most AHSCs and PGPs of non-English countries (although it is officially bilingual in terms of UN languages). It is identified as having “significant relative productivity” in West Africa by Adams et al. ¹⁸ .

East Africa has the greatest diversity in terms of countries with multiple AHSCs (four countries with 7 or more AHSCs) and three countries with 53 or more PGPs, likely an important strength for the sub-region. Although Ethiopia, Kenya and Tanzania have the most HEIs and PGPs in the region, one of the best known AHSCs in the region, Makerere University, is in a fourth country (Uganda) and a relatively young and innovative institution, the University of Global Health Equity (UGHE), is in a fifth country (Rwanda). This subregion has long been the favourite of international university partners and donors reflected in its disproportionally high number of international partnerships ¹⁹ .

Although such variation may demonstrate untenable inequities in human resources for health, concentration alone may not be problematic. Trainees from other African countries often attend and HEIs often support the development of HPPs and PGPs elsewhere. For example, the development of the post-graduate Ophthalmology program at the University of Nairobi in 1978 through a partnership with Ludwig Maximilian University of Munich started training non-Kenyans a few years after it was established. By 2013 167 students had graduated, 57 of them were from 16 other WHO AFR countries ²⁰ . The Nairobi program helped developed other PGPs in East Africa ^{21, 22} . The importance of international partnerships for African institutions for research output and research capacity strengthening is often identified by researchers ^{20, 23– 25} . At the same time, it has been argued that the growth in HEIs in WHO AFR in the first two decades of this century coincides with the growth in research on the continent, with increasing “autonomous research output” and research self reliance [ 18, p. 550]

As noted, our work suffers limitations: not including the nursing, public health or most PGPs of Algerian HEIs nor PGPs of Lusophone countries; lack of universal information about accreditation; and missing details on some institutions (e.g. date founded). Recently established institutions or programmes are also likely missing. Although our common data set is likely the most comprehensive of its kind currently, several challenges remain: a) to establish a managed, open-source, on-line, Wiki-like database that institutions can access to update their information and new institutions can add their details b) to develop a visually attractive, user-friendly web-site so trainees, researchers, administrators and other interested parties can access information they desire easily; and c) to ensure that all programs and institutions listed are registered in their country. We look forward to collaboration to develop this potentially useful resource.