A mapping of health education institutions and programs in the WHO African Region [version 1; peer review: awaiting peer review]

Background: Information on health education institutions is required for planning, implementing and monitoring human resources for health strategies.  Details on the number, type and distribution of medical and health science programs offered by African higher education institutions remains scattered. Methods: We merged and updated datasets of health professional and post-graduate programs to develop a mapping of health education institutions covering the World Health Organization African Region as of 2021. Results: Nine hundred and nine (909) institutions were identified in the 47 countries.  Together they offered 1,157 health professional programs (235 medicine, 718 nursing, 77 public health and 146 pharmacy) and 1,674 post-graduate programs (42 certificates, 1,152 Master’s and 480 PhDs). Regionally, East Africa had the most countries with multiple academic health science centres institutions offering medical degrees and at least one other health professional program. Among countries, South Africa had the most institutions and postgraduate programs with 182 and 596, respectfully.  A further five countries had between 53-105 institutions, 12 countries had between 10 and 37 institutions, and 28 countries had between one and eight institutions. One country had no institution. Countries with the largest populations and gross domestic products had significantly more Open Peer Review Reviewer Status AWAITING PEER REVIEW Any reports and responses or comments on the article can be found at the end of the article. AAS Open Research Page 1 of 11 AAS Open Research 2021, 4:55 Last updated: 14 DEC 2021


Introduction
The shortage of health personnel in the World Health Organization African Region (WHO AFR 1 ) is well documented [1][2][3][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  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 WHO African Region
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 .

Methods
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.

Health professional programs
The first team mapped three HPPs (medicine, nursing and public health) in all WHO AFR countries except Algeria. Specifically, first-degree medicine programs (e.g. MD, MBBS, doctorat de medicine and diplôme d'État de docteur en medicine), nursing programs (in which a diploma or bachelor's degree was earned) and public health programs (in which an MPH, MHSc or M.Med in Community Medicine or equivalent were earned) were mapped. Different campuses of the same institution were counted as separate institutions.
The initial sources of data for the three types of HPPs were the Sub-Saharan African Medical Schools Study 8 , the Health Training Institutions WHO AFRO Data 2005.xls 13 for nursing, and the Council on Health Research for Development (COHRED) database of African public health schools 14 . The initial findings were complemented with information from The Guide to Higher Education 13 , university web-sites and Wikipedia. In the latter two cases, searchers were conducted using the specific names of universities already identified and the terms "medical", "nursing" or "public health" and "schools" or "program" (mes) and "Africa". All data was entered into a MS Excel spreadsheet. The findings were analysed using SPPS and presented at two conferences 15,16 and on a website 17 (see Figure 1).

Post-graduate programs
The second team mapped four groupings of PGPs in SSA countries: 1) medical sciences; 2) biomedical sciences; 3) public health; and 4) 'other' health-related disciplines. "Medical sciences" consisted of second degrees, fellowships and diplomas in clinical fields including dentistry, medicine, nursing and pharmacy. "Biomedical sciences" consisted of life science programs directly relevant or applied to medicine. "Public health" included programs examining populations health and health promotion, for example epidemiology, biostatistics and nutrition. "Other" included all other health-related programs, for example health economics and hospital management.
Information was gathered online from March to August 2017 using: institutional registries; websites of HEIs in SSA; websites of the Ministries of Education and Health (to identify universities and schools of health training); websites of national accreditation bodies for health diplomas; and online registries such as the World Directory of Medical Schools 18 and information available from the Agence Universitaire de la Francophonie (AUF) 19 and the Foundation for Advancement of International Medical Education and Research (FAIMER) 20 . Google searches used the names of countries or institutions and the keywords "Health Education in sub-Saharan Africa", "Health Education Institutions in sub-Saharan Africa", "Health Education in sub-Saharan Africa", and "Opportunities for Higher Education in sub-Saharan Africa". The findings were posted on the web-site of the Liverpool School of Tropical Medicine 21 and included in a written report 22 . 9 The most recent figure for each country was taken between the years 2010 and 2017. 10  Updating and merging into a common data set The HPP data set was updated and expanded, as practicable. The World Directory of Medical Schools 23 (MDOMS) was accessed to update medical schools. Since only schools that have applied for certification from the Educational Commission for Foreign Medical Graduates (ECFMG) in the United States (US) were included in MDOMS, we included some unlisted medical programs, 24 in particular some non-anglophone programmes identified from other sources. Similarly, the HPP dataset had nursing programs not included in the South African Nursing Council (SANC) lists of accredited nursing education institutions available online 25 and some institutional names and/or locations (town or city) had changed. South African programs not recognized by the SANC were deleted and institutions names and cities were updated. Pharmacy programs were added using information from the International Pharmaceutical Federation 26 and national online sources, such as the Ghana Pharmacy Council web-site of accredited programs 27 . In addition, Algerian institutions with medicine and pharmacy programs were added (not nursing nor public health programs, however) and PGPs were added for only one Algerian institution 28 . The HPP and PGP data sets were merged manually to create a common data set with the number of institutions that had health education programs in medicine, nursing, public health, pharmacy and/or the number of PGPs each HEI offered in the health sciences -see Centre for Capacity Research 14 .

Analyses
We produced two MSExcel tables: one of HEIs with binary "yes" or "no" columns for medicine, nursing, public health  24 We are grateful to William Burdick for bringing this to our attention. 25  28 It wasn't practicable to be more comprehensive with programs in Algeria due to limited resources. and pharmacy programs 14 ; and another listing all 47 WHO AFR countries and the total number of each HPPs, PGPs, HEIs, academic health science centres (AHSCs) and selected indicators from 12 . AHSCs, institutions with a medical school and at least one other health professional program and a teaching hospital, were highlighted because they have the tripartite mission of providing education, conducting research and performing service, important for sustaining advancement in the health sciences 15,16 .
HPP, PGP and other country indicators were analyzed using SPSS27, including frequencies, crosstabs and analysis of variance (ANOVA). For the ANOVA analyses countries were grouped into strata of institutions per country (quartiles for HEIs and terciles for AHSCs) to compare means (SD) of population, GDP, GDP per capita (current), GINI Index, current health expenditure, life expectancy at birth, physicians -per 1,000 people (2010-17), and publications by field of science (total and medical sciences) across strata 29 12 .

Institutional and program findings
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, Table 1 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.

Sub-Region
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). 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).

Discussion
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][24][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.