Article Text

Download PDFPDF

Redressing the impact of COVID-19 on medical education in Africa: the need for collective action
  1. Edmund Ndudi Ossai1,
  2. Osondu Ogbuoji2
  1. 1Department of Community Medicine, College of Health Sciences, Ebonyi State University, Abakaliki, Ebonyi, Nigeria
  2. 2Center for Policy Impact in Public Health, Duke University, Durham, North Carolina, USA
  1. Correspondence to Dr Edmund Ndudi Ossai; ossai_2{at}yahoo.co.uk

Statistics from Altmetric.com

Summary box

  • COVID-19 is having a negative impact on medical education in Africa.

  • The impact of COVID-19 on Africa is enormous as the continent is expected to experience its first recession in 25 years.

  • The budget cuts from donor countries will affect access to research funds in the continent.

  • There is the possibility of COVID-19 related brain drain which will worsen the poor human resource for health in the region with devastating effects on population health.

  • Practical mitigation efforts such as long-term planning, protecting budgets and introducing e-learning and telehealth should be prioritised.

  • African countries will not be able to provide the resources for the enormous investments needed for medical education at this period

  • There is the need to replicate successful initiatives such as Medical Education Partnership Initiative, which helped foster South-to-South and South-to-North partnerships in medical education and research in Africa.

Introduction

The ongoing COVID-19 pandemic is harming medical education in Africa. This effect will likely grow as the pandemic evolves, and in some countries, become long lasting. However, while policy-makers have focused their attention on mitigating the impact of COVID-19 on the more visible parts of the health system (eg, service delivery and health finance), little attention has been given to the less visible but essential function of medical education. Africa bears 27% of the global burden of disease, yet has only 3.5% of the global health workforce and only 1.7% of the world’s physicians.1 This situation will worsen due to the COVID-19 pandemic and the varied country responses. Currently, 24 countries in sub-Saharan Africa have only one medical school, while 11 countries have no medical school.2 Furthermore, the high total cost of medical education in the region, which ranges from US$18 870 in Uganda to US$40 383 in South Africa,3 and limited government support provided to students, place significant financial burdens on families and households.

With the onset of the COVID-19 pandemic, schools of medicine, nursing, and allied health training across Africa face challenges due to partial or total disruptions to their academic calendars. While some schools had complete shutdowns, others made adjustments, such as adopting remote learning methods. Nevertheless, these disruptions will have short-term, medium-term and long-term impacts on the number and quality of health workers trained on the continent, which will affect Africa’s ability to achieve universal health coverage by 2030.

In this paper, we discuss the impact of COVID-19 on medical education in Africa and assess policy-makers' options for mitigating these negative consequences. Current forecasts suggest that the pandemic could halt two decades of sustained economic growth in Africa, thus creating the region’s first recession in 25 years. Such a recession will have far-reaching effects on medical education. Therefore, responding to the impact of COVID-19 on medical education will require collective action for (1) early identification of the problem and (2) out-of-the-box thinking to design innovative, feasible, contextually appropriate and affordable solutions. In our discussion, we use the term medical education in an inclusive way, to describe both preservice and in-service training for all types of health workers regardless of professional affiliation. This includes physicians, nursing and allied health workers.

COVID-19 challenges

Effect of COVID-19 on students’ medical education

COVID-19 has disrupted both in-class lectures and clinical training of medical, nursing and other allied health students in Africa.4 The lack of adequate personal protective equipment (PPEs) created unsafe environments for health workers and students across the continent. For example, in Nigeria, the National Association of Resident Doctors embarked on a national strike to protest the lack of PPEs in teaching and other hospitals during the COVID-19 pandemic.5 In response to these shortages, the WHO supplied PPEs to several African countries, including Ethiopia, Gambia, Mauritania and Kenya.

Students also face challenges created by lockdowns. Between March and July 2020, education authorities in 44 out of 54 countries in Africa issued mandates to temporarily close all universities, including medical schools.6 These partial or total lockdowns have disrupted in-person didactic and clinical training. They have also resulted in cancellation or delays in academic and professional medical exams—final year medical students in Egypt requested the postponement of their examinations for fear of being infected with COVID-19. These delays have extended graduation times and caused delays in commencing postgraduate medical training. These delays will also disproportionately affect female medical students who may face cultural pressures to drop-out or students from low-income families who find it difficult to cope with the extended stay in school. Furthermore, there is evidence that lockdowns are affecting the mental health of the students. A recent global survey revealed that 83% of young people believe that the COVID-19 pandemic, school closures and restricted social connections worsened pre-existing mental health conditions.7

Some training institutions have adopted remote learning approaches such as e-learning and telemedicine, to mitigate the lockdowns' effect. However, the response has not been uniform. Only 38.5% of students in Africa’s higher institutions had access to e-learning programmes during the pandemic, with the West African subregion having the least access.8 Expanding access to these technology-based solutions will further strengthen Africa’s capacity for better medical education.9 However, the weak physical infrastructure for effective medical education in sub-Saharan Africa must be addressed.2

Effect of COVID-19 on medical educators—teaching and research faculty

Teaching and research faculty at medical training institutions in Africa also face a myriad of challenges from COVID-19. The pandemic’s economic effects will jeopardise faculty members’ reliance on the government for research funding and payment of salaries. Recent estimates from the International Monetary Fund predict that all countries in Africa will face economic contractions. At the same time, the continent as a whole will experience its first recession in 25 years. As a result, many countries have enacted emergency measures that include additional debt, budget cuts and reallocation of funds from other sectors.10

The reduction in overall research funds is worsened by the increasing reallocation of existing research funds towards COVID-19. As more donors reprogram funds away from other research areas towards COVID-19, the diversity of research topics addressed will reduce, which will exacerbate the existing shortage of faculty in basic and clinical sciences in medical schools in Africa.2 Since most medical schools in sub-Saharan Africa receive grants from the government, decreased government spending may lead to salary cuts for medical educators. Thus, with worsening service conditions, medical educators (mostly nurses and physicians) may decide to move to high-income countries to search for better career opportunities. For instance, at the peak of the pandemic response in Nigeria, 58 Nigerian-trained physicians made headlines by leaving for the UK.11 This was in response to the new UK Health and Care Visa policy that makes it easier for healthcare professionals to migrate to the UK. The USA and other Western countries including Canada and Germany have also issued similar directives. These calls may evoke a mass migration of healthcare professionals from Africa to the developed economies, thus worsening the region’s situation.

Donor budget cuts will also affect access to research funds in the continent. For example, based on the expected fall in government overseas aid spending, research institutions in the UK are preparing for significant cuts to flagship grant schemes, including the £1.5 billion Global Challenges Research Fund and the £735 million Newton Fund financed through the UK’s aid budget. The cuts are due to the expected fall in overseas aid spending due to the impact of COVID-19. Similarly, the principal research agency in South Africa, the National Research Foundation, received 10% less from the government due to the COVID-19 pandemic.12

Effect of COVID-19 on schools of medicine, nursing and allied health services

Institutions involved in medical education expect to face cash-flow challenges as a result of COVID-19. The pandemic’s adverse economic impact will affect the government, households and development partners’ ability to fund medical education in Africa.13 Government-owned universities expect decreased revenues from budget cuts to the ministries of education and health, while private universities will lose revenue from school fees. Teaching hospitals are experiencing decreased revenues due to a decrease in patients seeking care due to fears of contracting COVID-19. This trend will negatively impact medical schools in several ways. First, the constant flow of patients seeking care at teaching hospitals creates teaching opportunities for medical students. Second, teaching hospitals partly subsidise medical-school budgets, and medical instructors supplement their income by providing patient care in teaching hospitals. Third, medical schools and teaching hospitals support multiple research collaborations, with the medical school providing the research capacity to study problems observed in patients visiting the hospital. Therefore, any decrease in patient volume will negatively impact medical education and research provided through collaborations between the medical school and teaching hospitals. Medical schools also face future challenges in their pipeline. The interruptions in their academic calendar will affect their ability to graduate new health workers, while interruptions in primary and secondary schools' academic calendars will reduce new enrolments.

COVID-19 has also exposed the weak infrastructure for rapid research and updates in many of Africa’s medical schools. For example, a look at early research articles published on COVID-19 revealed a disproportionately low representation of researchers from developing countries. Authors from developing countries were involved in only 11% of early articles published on COVID-19 against 15% participation before the pandemic.14 The pace of research and development for COVID-19 is fast, and medical schools in Africa have not demonstrated the ability to keep up with the pace. These schools also have limited access to academic journals, limiting their ability to review and domesticate new evidence rapidly. Furthermore, COVID-19 travel restrictions have affected North-South research partnerships and exchange programmes. For example, the United States Bureau of Educational and Cultural Affairs suspended all exchange programmes that involved travelling to and from the United States because of the COVID-19 pandemic. Many academic institutions in high-income countries have placed restrictions on the scope of their non-COVID-19 research collaborations in Africa.

Long-term impact of on society

In the long run, African communities will suffer health consequences if these COVID-19 effects on medical education are not addressed. The prolonged closure of training institutions will create incentives for students to drop-out or practice as quacks in their communities without completing their training. Since health worker activities are poorly regulated in many African countries,15 the result will be an increase in the number of quacks providing healthcare, leading to an increase in poor-quality care and amenable deaths on the continent.16

Reallocation of funds towards COVID-19 will encourage internal brain drain (ie, switching of focus from other diseases towards COVID-19). Simultaneously, poor service conditions will cause external brain drain (ie, move to other countries in search of better opportunities). The net effect on society is a worsening of the health workforce capacity on the continent. Before COVID-19, African countries lost substantial medical education investments through the emigration of medical doctors and nurses to wealthier destination countries.3 This trend will worsen due to the pandemic if stakeholders do not adopt effective mitigating (see table 1).

Table 1

Effect of COVID-19 on medical education in Africa

Policy options and recommendations

The challenges created by COVID-19 are not insurmountable. Early implementation of common-sense solutions would enable African countries to capitalise on this opportunity to build better medical education systems. Policies that take the long-term view, include relevant stakeholders, are well coordinated and funded, are more likely to produce maximum impact. We propose that stakeholders pay attention to six potentially high-impact policy goals and action steps. These include (1) strengthening of health workforce planning processes, (2) protect and increase funding for medical education and research, (3) build infrastructure needed to support innovations in medical education and research, (4) expand e-learning and telehealth services, (5) strengthen capacity building initiatives that improve medical education and medical research, and (6) prioritise medical education and research in policy-making discussions across the continent. We describe each below and provide a summary with examples in table 2.

Table 2

Exemplar policy options and actions

  1. Strengthen health workforce planning processes: effective planning for health workforce development and retainment is a foundational requirement for building a strong health workforce. In recognition of its importance, the WHO provides technical support to help countries develop, cost, implement, monitor and update health workforce plans. In the wake of COVID-19, these processes need to be strengthened at the country level in order to reflect the new realities of COVID-19.

  2. Protect and increase funding for medical education and research: adverse economic times make it more important to prioritise continued financing of medical education.17 18 This ensures a continuous stream of health workers to address the health challenges that typically increase with economic slumps. With COVID-19 effect on the economy, and the high probability of diversion of funds away from other health components, policy-makers should actively protect and increase allocations to funding of medical education, research and student scholarship. Policy options include creating and protecting line items for medical education in health systems budgets, creating incentives to encourage private sector participation in medical education funding, and expanding access to financial aid for students and health workers in training.

  3. Build infrastructure needed to support innovations in medical education and research: innovations in medical education and research depend on the availability of a functioning physical infrastructure.19 Initiatives such as telehealth and e-learning would require policies to make broadband internet more accessible and affordable, while creation of digital libraries and clinical simulation laboratories will improve knowledge access and skills development, respectively. It has been postulated that prioritising the scale up of medical education is part of overall health system strengthening.20

  4. Expand e-learning and telehealth services: another potentially high-impact intervention is to invest in remote teaching capabilities by expanding online medical education21 and telehealth within the continent. This expansion will strengthen the health system, improve medical education quality and enhance faculty effectiveness.22 It will also prevent future interruptions to academic calendars due to unexpected shocks like COVID-19 and facilitate early return to in-class and e-learning, which will in-turn reduce drop-outs and mental health problems. It will also enable the students to exert greater control over their learning.23 Furthermore, it will create opportunities for improved patient care through telehealth. Policy options include allowing payments for telehealth to encourage service providers to expand access, supporting teaching faculty to develop e-learning modules, and allowing students access to e-learning options from multiple academic/training institutions.

  5. Strengthen capacity building initiatives that improve medical education and medical research: several important collaborative capacity building initiatives have been implemented in Africa. These range from the Human Heredity and Health in Africa Initiative, Medical Education Partnership Initiative (MEPI), Nursing Education Partners Initiative, and the African Association for Health Professions Education and Research. Together, these initiatives have spurred investments of over US$300 million to improve medical education in Africa over the past decade and have strengthened medical education capacity in Africa.24 Box 1 describes some important initiatives. Similar initiatives should be pursued to build on the success of previous ones. However, domestic funding from individual African countries and agencies like the African Development Bank should be included to encourage sustainability.25These new initiatives will create systems to encourage research funding, research network development, development of South-to-South and South-to-North partnerships for a post-COVID-19 future in sub-Saharan Africa.

  6. Prioritise medical-education and research in policy-making discussions across the continent: to ensure sustained funding and development of medical education in Africa, policy-makers must increase the visibility of medical education policies in policy-making circles on the continent. Institutions such as the United Nations Economic Cooperation for Africa, the Africa Academy of Sciences, Africa Centers for Disease Control and Prevention, and the Africa Development Bank can play pivotal roles. Examples of policies include (a) highlighting the importance of medical education in helping Africa meet its health-related sustainable development goals and Africa Agenda 2063, (b) including medical education in Africa as a top agenda in high-level policy meetings such as the Africa Leadership Meeting, African Union general assembly or regional meetings, (c) advocate for high-level policy-making institutions on the continent to issue joint statements on need for medical education capacity building in Africa, and (d) encourage convening of a special body/task force to brainstorm health workforce issues on the continent.

Box 1

Medical education collaboratives

Human Heredity and Health in Africa Initiative

A 10-year (2011–2021), US$176 million project to build health-research capacity in Africa.43 It is jointly sponsored by US National Institutes of Health (NIH), the Wellcome Trust and the African Academy of Sciences. Although not directly targeted at medical education, the research capacity built through its 51 development projects has a direct influence on the quality of medical education on the continent.

Medical Education Partnership Initiative (MEPI)

A 5-year (2010–2015), US$130 million programme to increase the number of medical graduates, the quality of medical education, and the retention of medical graduates in Africa.44 It was jointly funded by the US Presidents Emergency Plan for AIDS Relief (PEPFAR) and NIH. MEPI funded 13 grants in 12 African countries and is largely considered a success. Funded interventions included increasing medical school enrolment, curricula revision and expanded use of clinical skills laboratories, faculty recruitment and development, and expansion of e-learning. It also generated additional funding from African governments.45

Nursing Education Partnership Initiative (NEPI)

A 5 year (2012–2016), US$130 million programme to build nursing capacity in six African countries (Democratic Republic of Congo, Ethiopia, Lesotho, Malawi, South Africa and Zambia).46 47 The programme was jointly funded by PEPFAR, and the U.S. Department of Health and Human Services/Health Resources and Services Administration with support from host countries. Funded interventions included curricular reform, improving the quality of nursing education, expansion of clinical skills simulation labs, faculty development and institutional capacity building. NEPI is also considered a big success and has helped transform nurse-led HIV care in sub-Saharan Africa.

Health-Professional Education Partnership Initiative (HEPI)

A $22 million initiative funded by the NIH to build on the success of MEPI and NEPI in Africa. HEPI supports educational, research and partnership development programmes in eight African countries (Ethiopia, Kenya, Malawi, Mozambique, Tanzania, Uganda, Zambia and Zimbabwe).48

African Association for Health Professions Education and Research (AFREHealth)

A multidisciplinary network of African researchers working towards building health research capacity in Africa. The network was developed out of collaborations formed during MEPI and NEPI and is funded through a 5 year US$4 million grant from the NIH to date.49 50

These recommendations are not new but are more important in light of the impact that COVID-19 has had on the medical education system in Africa. They should therefore be strongly considered and implemented where appropriate by different African countries. However, this list does not constitute an exhaustive list of policy options but rather examples of alternatives for consideration by policy-makers.

Conclusion

The negative impact of the COVID-19 pandemic on medical education continues to grow. If left unchecked, it could worsen the health workforce situation within the continent with devastating effects on population health. Practical mitigation efforts such as long-term planning, protecting budgets and introducing e-learning and telehealth, should be prioritised and funded by African governments immediately. Moreover, due to the effect of COVID-19 on the economies of African countries, it is less likely that Africa will be able to provide the resources for the enormous investments needed for medical education. Therefore, some countries will still require external support. Hence, there is a need to replicate successful initiatives such as MEPI, which helped foster South-to-South and South-to-North partnerships in medical education and research in Africa.

References

Footnotes

  • Handling editor Seye Abimbola

  • ENO and OO contributed equally.

  • Contributors Both authors contributed equally.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement There are no data in this work.

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.