Functions, challenges and opportunities of health professions education units in Africa: a qualitative study across Eastern, Southern and Western regions

Abstract

Background

Teaching in Health Professions Education (HPE) is complex, with educators balancing teaching, clinical, and scholarly responsibilities. Medical, nursing, and other health professional schools have created units to move HPE forward. However, little is known about how these units have evolved over the past 15 years. This study explored the landscape of HPE units in Eastern, Southern, and Western Africa, their evolution, functions, challenges, and opportunities for continued growth.

Methods

This exploratory qualitative study used purposive sampling to recruit HPE professionals from educational institutions across ESWA. Recruitment methods included self-identification on a survey, snowball sampling, and direct outreach by the research team which included HPE professionals from ESWA. This team co-developed a semi-structured interview guide and conducted interviews via Zoom. This project used a content analysis approach to understand the functions, challenges and opportunities of these units. Transcripts were coded in Dedoose and exported by code for review, discussion, and categorization.

Results

We conducted 22 interviews from 21 institutions in 9 countries. Most units are approximately 20 years old. Units sit in various locations within institutions, for example at a faculty-level, within the Dean’s office, or as a stand-alone department. There is also heterogeneity in funding sources and staff size. The most common activities are Faculty development; Research in health professions education; Curriculum development, review, renewal, and implementation; and Teaching and training. Noted challenges HPE units face are human resource issues due to lack of adequately trained faculty and the inability to hire them; tension between clinical and educator identities; and institutional incentives that are not aligned to quality teaching. Despite these challenges, units are experiencing major successes such as reshaping perspectives on thinking and learning within their institutions, influencing curricula, and creating graduate programs in HPE.

Conclusions

The charge of HPE units in ESWA remains much the same as it was in prior studies with similar functions, challenges and opportunities. This study adds important context around these activities, helping to understand opportunities for growth, such as establishing and entrenching an HPE professional identity and promoting collaborations as ways to strengthen and accelerate HPE units in ESWA.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12909-025-08403-0.

Background

Teaching in health professions education (HPE) is inherently complex within the field of higher education [1]. These challenges are further amplified in Low-and Middle- income countries, where educators often balance substantial clinical workloads with academic duties. This can generate tension between teaching and patient care, often exacerbated by other academic responsibilities such as scholarly productivity, thereby limiting opportunities for professional growth through training and development [2, 3]. This issue heightens the need for institutions to take responsibility for supporting and sustaining quality education and has led to the establishment of structures within these institutions that are dedicated to this work. Today many faculties or schools of health sciences or medicine have such structures, often described as units, centers, or departments of health professions education, health sciences education and scholarship, medical education, or other similar titles [4]. This nomenclature differs based on the institutional structure and the envisaged mission for the entity. In this paper, we refer to all these entities as HPE units.

Studies dedicated to exploring the role and function of HPE units suggest much variability in terms of their structures, staffing, aspects of curriculum development, faculty development to strengthen teaching and learning, and educational scholarship [5–7]. Much of this early work focused on units in North America, Australia, Europe with less work emerging from Africa, Asia and South America. The mid-2010’s were a time of significant HPE innovation in Africa [8–10] as many new medical schools were established and identified the need for a place to harness this new growing field [11, 12].

In response, a group of HPE researchers set out to explore the history and status of four medical education departments in Uganda, South Africa, Zambia and Zimbabwe supported by the Medical Education Partnership Initiative. They highlighted the role of each department in strengthening medical education within their respective institutions [11]. Subsequent work sought to build on this study, through the identification of 28 HPE units in similar regions across the African continent, many of which had been established in the previous decade [12]. Humphrey-Murto and colleagues explored the longitudinal development of HPE units with a specific focus on scholarship, foregrounding people (capacity), institutional structures and funding as key factors [6]. Their work highlighted how the field has matured with an increasing focus on scholarship as part of the work of an HPE unit. However, little is known about how HPE units have evolved in terms of structure, capacity, and funding since the initial mapping of the field. As a group of educational researchers working in Eastern, Southern and Western Africa (ESWA) with a shared interest in global health education, we were keen to discern the extent to which the growth of the field might be mirrored in units in the region, while at the same time also expanding the reach and scope of previous work. Specifically, the goal of this study was to explore the current status of HPE units dedicated to supporting HPE development and scholarship in ESWA.

Methodology

Research team composition

This project used a shared leadership approach to ensure it was aligned with the priorities of HPE researchers from ESWA and to promote contributions in research from this region. The leadership team (SBW, ADP, SVS, EKM) worked as a group to conceptualize the project, develop data collection tools and strategies, and advise on the framing of the study. The data collection team consisted of nine faculty/emerging HPE researchers from seven countries throughout ESWA. This team provided feedback on the interview guide, assisted with recruitment, and conducted interviews. Three members of this team (AH, FN and VSS) conducted data analysis and served as authors and presenters on project dissemination products. Amri et al.’s scoping review on key components of decolonizing global health includes their principle of establishing agency and self-determination of the global south, done by enabling knowledge production from these countries and expanding research in favor of more equitable global health partnerships [13]. Our leadership approach aligns with this principle. By engaging local faculty throughout the study, the project benefited from their country- and region-specific knowledge and networks while offering professional development opportunities through training and scholarship opportunities.

Study design

This exploratory qualitative study sought to understand the functions, challenges and opportunities of health professions education units through interviews with participants at various institutions in Eastern, Southern, and Western Africa. An exploratory method was chosen given the lack of prior research on HPE units in this region.

Study setting

We used the World Directory of Medical Schools to compile a list of medical schools in the region. To this list we added institutions known to have HPE units if they were not initially included. Our final sample of schools totaled 200 health professional schools (e.g., medical schools, nursing schools) throughout the ESWA region. Our goal was to complete 30 interviews, distributed evenly across the ESWA region. We kept track of the distribution of interviews throughout various countries in ESWA and strengthened recruitment efforts in countries that did not have a participant.

Study participants

Study participants included members of HPE units within identified schools that could speak to the establishment, facilitators, challenges, activities and future goals of their unit. Usually, this was the head of the unit, but participation was not limited to only unit leads. Initial outreach was to the indicated head of the unit. If they indicated or if contact was not possible, the team member attempted to contact another member of the unit.

Sampling technique

Potential interview participants were identified in three ways. The first was through self-identification on a survey sent to all 200 identified schools. The 33-item survey included quantitative questions about the size, staffing, funding, and activities of the unit and asked if the respondent would be willing to participate in an interview to elaborate on the topics covered in the survey. The second was through snowball sampling, with survey respondents giving suggestions for future participants. The third method was through direct outreach by the research team. The list of 200 schools was broken into smaller geographic areas and then assigned to team members. Team members contacted the individuals leading the HPE units in their region and invited them to complete an interview. An attempt to reach all 200 schools was made with these methods. The research team sent one round of follow-up emails a few weeks after the first attempt to get more survey responses. Email and WhatsApp was utilized for direct outreach. We tracked country representation in the sample in an attempt to ensure geographic coverage and thus generalizability to ESWA.

Data collection tool

We modified Kiguili-Malwadde and colleagues’ interview guide [11] for this project. The initial interview guide was revised based on the aims and scope of the current project and sent to the data collection team for their review and input based on their content and context expertise. The final semi-structured interview guide consisted of 25 questions.

Data collection procedure

Participants were provided a project information sheet and verbal consent was obtained from the interviewees. Interviews were conducted, recorded and transcribed via Zoom for ease of interviewer logistics and so that interviews could be recorded and transcribed using Zoom’s internal mechanism. Interview participants received the equivalent of $15 USD for their time and effort. Data collection was done from May 20 to October 2, 2024. Each interview lasted approximately one hour.

Data analysis

A content analysis of the interview data was conducted. SBW prepared the data by removing interviewee names, correcting obvious transcription errors, and uploading transcripts to Dedoose (9.2.22) for analysis. Thereafter, SBW reviewed the first 15 of 22 interviews and categorized responses into major groups using rapid summary methods, similar to the RADaR method [14]. These preliminary results were presented to the research team and experts in the field to enhance confirmability during a workshop at the AFREhealth conference on August 7, 2024. This initial, inductive analysis and discussion became the basis for the codebook, which was further refined with input from the leadership and the nine data collection team members. The topic areas within the codebook are included in additional files. For the main analysis, SBW coded all interviews in Dedoose and exported the excerpts by topic area of the codebook for further analysis. AH, FN, SBW, and VSS summarized the excerpts and created condensed groups within each topic area. All excerpts were summarized and grouped, independently, by SBW and another member of the team, AH, FN or VSS, then discussed to ensure agreement was reached. Given the differing perspectives brought by the multidisciplinary team, these discussions aided the reflexivity process and allowed us to challenge our assumptions and biases [15]. The process for these discussions included the independent grouping and then review of the partner’s grouping. Any divergence was discussed until the pair agreed on the appropriate grouping. There were no instances of failing to come to consensus through this process. The grouped excerpts were presented to the leadership and author team for categorization and abstraction. Within this process, the final set of larger domains was decided to organize the areas of similarity or overlap in discussion from respondents. The team reviewed and considered the data independently and then the team came together for a series of meetings to discuss them within the larger context of the project with relation to the research aims as well as the generated themes relevant to strengthening and supporting HPE in ESWA. Lastly, for the table, institutions’ activities were categorized by SBW and double-checked by GXN or ZZH based on the summarized descriptions of what was said by interviewees.

Results

Fifty-two individuals responded to the initial survey (response rate 26%), six of whom self-identified to participate in the interview. The team completed 22 interviews with representatives from 21 institutions in nine countries in ESWA. The experiences, structures, activities, challenges and priorities of the units were heterogeneous. The data are organized under three domains (a) Establishment (b) Operations and (c) Activities and Priorities.

Establishment

Most HPE units were established between 1980 and 2023, with a large concentration in the 2010s. Establishment of these units was driven by both internal and external factors. Internally, the implementation of a new educational strategy and insights from curriculum review identifying a need for enhancing faculty development. Externally, growing demand for health professions educators and a focus on improving patient safety underscored the need for improved training and therefore more effective teaching.

“The interest in health professions education came about as a result of our adoption of an innovative teaching and learning methodology which is the problem-based learning. So, when we adopted that curriculum at that time… they felt that there was a need to also have a health profession’s education unit …. and the purpose of that unit was to coordinate all teaching and learning activities.” - Participant 8.

“A teacher for nursing school … does not have a pedagogical expertise [as well as] the physician or undergraduate medicine or post-graduate program. He’s a content expert rather than the pedagogical expertise, so that by itself had an impact on the quality of education. … so the other, maybe the need for equal quality of education across the globe.” - Participant 15.

“They understood at the time, because the case was made to them [leadership] that health sciences education is based on the principles of higher education. But there are significantly different practices which we want our staff to be able to do and know about…. that the [existing unit] couldn’t take further unless they had a health science education person there. So the question really was, should they just have a health science education person in that unit? Or could we become our own unit? And because we’re a big faculty. I think that they allowed the formation of our own unit.” - Participant 16.

Champions were instrumental in establishing the unit, both for the initial ideation as well as logistical and political support throughout. These key contributors included government officials, senior leadership, and faculty trained in HPE. In some cases, institutions had assistance from an international partner university in establishing their unit and providing guidance and financial support.

“Strong support of the top management…and of course, the university.” - Participant 14.

“During initial phase of establishment, leadership takes the major role.” - Participant 19.

“Collaboration with universities in Europe and North America was necessary especially those universities which were implementing problem based and community-based curricula.” - Participant 11.

Operations

Structural location

Most of our interviewee’s units are located in ESWA schools of medicine, though there are some exceptions (i.e., schools of nursing). These HPE units are located at various levels within an institution’s structure – faculty, department, school/college, or university/directorate. Where the unit is located significantly influences leadership, staffing, and funding. While we have been using the term “unit” to represent a stand-alone entity, some operate within a larger department, while others are fully-fledged departments or centers. These variations in structure shape the different opportunities and challenges. It was also clear that the positioning of these units was critical to their longevity, specifically, those that were not recognized as on par with an academic department were often vulnerable to institutional shifts.

“We actually formed [a] department. Unfortunately, later…there was some formal restructuring, and [they] wanted us to downsize, reduce on the numbers of departments, especially those which didn’t have students… [the] department was made into a unit.” - Participant 17.

“It was established a number of years ago, and actually very quickly became a department which I think is an unusual space versus other universities where it kind of starts as a unit or a center, or something like that. But I think interestingly, at [our university], it was formalized as a department quite early on which I think is incredibly beneficial to the system.” - Participant 12.

Staffing and identity

Most units had a staff complement of 3–6, though staff size ranged from 1 to 38. Units were staffed by a mix of full-time and part-time faculty and staff, with many clinical faculty “seconded” or adjuncts to the unit. Unit staff included administrators, advisors, scientific officers, clinical communication facilitators, clinical instructors, clinical skills unit staff, curriculum review officers, heads of department/unit, learning designers, lecturers, PhD candidates/post-doc fellows, professors, and program leaders.

While many leaders and faculty had formal HPE training, this was not universal. Staffing challenges are common among HPE units including insufficient faculty and staff, difficulty recruiting those with expertise, limited funding or institutional approval to hire, trained faculty retiring or leaving. Additionally, faculty interested in HPE faced barriers such as competing demands from clinical duties and a perceived lack of career advancement opportunities professionally.

“Most doctors that graduate are looking to become surgeons, to be obstetricians, gynecologists, people tend to forget about teaching, you know. Nobody sees teaching as a full profession” - Participant 2.

“The crop that were trained initially, senior staff, some of them have retired…So that is also beginning to be a major problem…for instance, the set of members of the team now, they are brand new, because majority have either retired or left.” - Participant 14.

“If I’m a pathologist and I’ve done health profession, education, do I belong to the health profession education, or do I belong to pathology?…Many leaders will be hesitant because you have few staffs…The head of department in Public Health says, ‘no, you can’t take my staff’, and yet there’s need in the other department. So, there’s that challenge of who goes where? Who do you move to the health professions? Yeah. So there’s a challenge with aligning, staffing human resource with the health professions, education.” - Participant 9.

“[The founding head of department] had to move out of the department…he had to move to [a different] school because of sometimes the challenges of ‘What is your future? How do I grow my career?’” - Participant 8.

Funding models

Most HPE units face significant funding challenges. Funding for the operation of these units comes from both internal and external sources, and usually units have a mix of the two. Internal sources include internal grants or awards or being part of the institution’s budget. External sources include research, project and clinical training grants as well as from philanthropic, government and non-governmental organizations. Funding also is generated by the unit itself through tuition from students or consultation fees on service activities. In several cases, units had been established with seed funding but sustaining operations depends on their ability to develop independent and ongoing revenue streams.

“A very valuable asset is that the division is recognized…, and the faculty does take ownership. So, we get an allocation every year from the faculty management budget…. we [also] generate funding through postgraduate students, and that is then fed back to the faculty management…we don’t have to generate our own funding. It’s allocated annually through the faculty budget. But … we probably also contribute to the budget income because of the postgraduate students that we deliver.” - Participant 5.

“We do get financial support from the school, in terms of our other activities, particularly that have to do with the affiliation and the curriculum development. We do this on some kind of business approach which they have the clients pay for those services. For instance, we conduct exam examinations for colleges as external examiners and they pay the affiliation fee and so on.” - Participant 13.

“For the moment, to get us started, we’ve got internal funding to run the workshops, to run the post graduate, I mean the boot camps, etc., and all of that. And then also, once we start running short courses that will definitely be our third stream of income that can come in together with post graduate students, together with grants, etc. So, you can see we’ve got seed funding to start off with, and we are now focusing on how we can actually strengthen that to track external grants.” - Participant 1.

“If people are looking to expand, it’s hard to find grants where people are funding development of workshops and teaching, rather than funding outputs with regard to research conferences and publications. And so those niche grants are the ones that we’re particularly going for, which is funding of faculty development.” - Participant 16.

Activities and priorities

HPE units engage in a wide range of activities with diverse target audiences. Activities include Faculty development; Research in health professions education; Curriculum development, review, renewal and implementation; Teaching and training; Scholarship in teaching and learning; Service (community engagement, institutional service, service to the field, working with other universities on HPE matters); Quality assurance at the institution and affiliated schools; Assessment; Consult/provide support on education matters; Postgraduate diplomas, Masters and Doctorate degrees in HPE; Student support; Evaluation; Accreditation; Manage the clinical skills/simulation laboratory; Use and promotion of digital learning; and Mentor faculty. Activity frequency is presented in Table 1.

Table 1.

Activities of HPE units (n = 20)

	Percent of units engaging in the activity
Faculty development	95%
Research in health professions education	75%
Teaching and training	75%
Curriculum development, review, renewal and implementation	75%
Scholarship in teaching and learning	60%
Quality assurance at the institution and affiliated schools	60%
Service (community engagement, institutional service, service to the field, working with other universities on HPE matters)	55%
Assessment	50%
Consult/provide support on education matters	35%
Student support	35%
Postgraduate diplomas, Masters and Doctorate degrees in HPE	35%
Accreditation	25%
Evaluation	25%
Manage the clinical skills/simulation laboratory	20%
Use and promotion of digital learning	20%
Mentor faculty	10%

Note: One institution did not provide a response to the question about unit activities that allowed for categorization. The responses from the same institution were combined

Some units serve only their own faculty or school, while others serve everyone in the institution. Similarly, many units intentionally collaborate across departments, faculties and schools within their institution as well as with other institutions nationally and internationally. Collaboration with the library and institutional technology was also common.

“We bring students of health sciences together. We actually teach these courses together with students in allied health sciences, nursing, optometry, medical lab, science, so that we build a lot of teamwork… [and] interprofessional activity in our curriculum, content, delivery.” - Participant 2.

“There’s a course that all medical, all health professions, and nursing students take in their 1 st year. So that course, we developed it together with another unit… So that’s how we do it. We develop courses together, and we do capacity building together.” Participant 17.

“We’ve done like assessment kind of benchmarking…Also the universities close to us who are talking about setting up medical schools…So we, we have collaborated with them about the requirements of their programs in relation to kind of our program. …. We’ve given workshops, for example, on mostly things like assessment practices and developing blended learning those kinds of things…Then we have research collaborations …We’ve got a couple of students that we have both joint supervision of in terms of their research projects …. And then internationally… we do have collaborations beyond our own environments. Although I have to say that it’s kind of hard work. because there’s so much going on within our own environment that that the collaborations are definitely seen as an extra.” - Participant 16.

One participant spoke of the non-traditional forms of support they provide to students, highlighting the range of efforts that units may engage in for their learners.

“Our department also hosts what we call the student support office…. we found the socioeconomic factors, they can derail our students sometimes. So just making sure that our students are taken care of, we … raise funds [and] support them where we can, with at least toiletries and food, so that they can continue to flourish.” - Participant 22.

Participants spoke of the many achievements and successes within their HPE units. Overarching categories of achievements include growing capacity in HPE, promoting education focus, establishment of degree programs, and acknowledgement as a field.

“The educational leadership fellowship has shifted the ecosystem, like quantum leap, because in two years we’ve trained 70 teachers. You now have a language around education and to thinking about things in a curriculum and educational way, not just in the disciplinary context.” - Participant 12.

“[We have] been a unique change agent in introducing quality problem solving education programs in the region. All the degree programs in the college of health sciences are developed and implemented along a problem-based learning/community-based learning approaches.” - Participant 11.

“The introduction of the master’s in HPE. That’s a big success, because the introduction of any program takes up a lot of time and a long effort.” - Participant 21.

“People are beginning to see the value of what we do. Teaching methods are beginning to change. Students, classes are beginning to become more interactive.” - Participant 2.

“It’s losing the fear. It’s feeling like there is a place to go. It’s establishing that there are always things we could be doing better, but also in developing that teaching and learning community. Success for me is when people don’t use their title as they come through the door…it’s not about your seniority, and it’s not about what your training is. It’s about what you’re prepared to give as a teacher.” - Participant 16.

Some participants described how it was often difficult to prioritize quality teaching, a key value of the unit, when institutional incentives often favored research. This misalignment led to faculty having to make decisions about directing their energies into research activities rather than teaching in order to meet institutional expectations.

“A university is a teaching institution. But our processes of assessment, of evaluation of teachers are… definitely skewed towards research. So people, it’s just human nature that if you’re spending this many hours in teaching and not research, and then at the end of the year you learn ‘Oh, I if I don’t have a paper, this is what happens’ then you maybe do it another year, but after that you’re not doing that again. After that you are going to do that which gives you certain results, even though those results come at huge consequences for student learning and student learning outcomes. … as long as the university, in its measurement of what academic staff ought to be doing, values research above all else, at the expense of all else, hence, it’s going to be a very bumpy road.” - Participant 22.

“There was great resistance from lecturers, most of whom had come from traditional universities and most of whom did not know about innovative curricula. There was also resistance from students who were sensing negativity from their lecturers. Innovative curricula are relatively more expensive than traditional curricula to implement. Medical education department was resented by the lecturers and the students because they were seen as the agents of change.” - Participant 11.

“I think strong leadership is really essential if you want a faculty or a department even to prioritize what we think is important in teaching and learning, and to establish the faculty culture.” - Participant 16.

In the absence of financial, structural, and staffing resources, HPE units manage to engage in the work and activities they prioritize. Strategies mentioned included the alignment of faculty career needs with activities to incentivize participation.

“Postgraduate supervision is a valuable commodity for an academic who wishes to further their academic career… supervision plus you’re doing the publication. So, you might not directly be reimbursed or rewarded. But it is part of the journey; and it’s been part of your development. Similarly, with staff members who support us with lecturing or assessment, I mean for years before I was in the division, I was involved in training and faculty development initiatives, and so on which for me, obviously is valuable on my CV as well. It helped me to grow in health professions education as a field, even though I wasn’t full time working in health professions education.” - Participant 5.

Another strategy included dedicated time and focus on writing to support scholarship.

“We also have a wonderful history of writing retreats… and discovered the power of bringing people together… It’s something we’ve tried to maintain. It’s become very expensive, so. … [another] thing is that on a Friday morning we meet from 8 until 9:30, and we have what we call writing time. We set many goals …and we write and so I’d like to believe that through all of these different initiatives people have realized that this is part and parcel of them being better at the work that they do, because there’s a reason for the research. It’s not research for research sake.” - Participant 6.

Participants spoke about important activities that could move their units toward their ultimate goals.

“Units need to be very intentional about the kind of constructs that are not necessarily in health professions education but are part of running good groups and organizations. So good leadership, good organizational design, organizational culture, good systems and processes…, I think that units where the leadership and systems and organizational culture works, you can see that the whole thing hangs together, and they have more outputs and they are more effective in the academic educational endeavors.” - Participant 12.

Finally, participants mentioned having goals around the creation and acceptance of HPE as a field and how having an identity as a field is important.

“Our master’s graduates have come through are all now working in senior management levels, which is fantastic. We’d like those people particularly to move up to PhDs so that they have a fixed career in health professions education, as opposed to being the clinicians that they were. So developing that identity as a health profession’s educator, rather than their primary identity being, ‘I’m a doctor. I’m a nurse. I’m a pharmacist.’” - Participant 16.

“What the ideal situation would look like is if all the sub-competencies within the HPE competency framework and the expectations of the development of an interprofessional identity. Once we can tick all those boxes if we put our curriculum next to it, and we can tick all the boxes, I think that to me is the ideal of what our education component of the unit should look like.” - Participant 7.

Discussion

HPE units are increasingly recognized as essential components of health professional training institutions [4, 16, 17]. They play a leading role in improving the quality, relevance, efficiency and scholarship of health professions education. However, as indicated earlier, there is a paucity of information on this topic in Africa despite the growth in the number of HPE units on the continent. This study sought to extend the work that has been done, specifically Kiguli-Malwadde and colleagues [11], and explore what has changed for HPE units over the past 10 years.

In terms of operations, staffing structures across HPE units were found to vary, with most employing faculty and staff in multiple different roles and from many different departments—a reflection of the inherently multidisciplinary nature of HPE, which draws members from diverse professional backgrounds. HPE qualifications are often pursued as secondary diplomas or degrees, so there are few professionals that are primarily educators. The core activities undertaken by these units align closely with the functions outlined by the International Association for Health Professions Education [18] and have remained fairly stable over the past two decades with similar activities reported by van Schalkwyk and colleagues [19], Kiguli-Malwadde and colleagues [11], and Al-Wardy [20] in 2020, 2015, and 2008, respectively.

Numerous achievements attributed to these units were reported, all contributing to the overarching goals of enhancing the quality of HPE and providing support to both faculty and students. Most importantly, the establishment of diploma, master’s and PhD programs in HPE is an achievement that has the potential to drive the ongoing advancement of HPE in the region, ultimately fostering a critical mass of educators that will contribute to HPE research and scholarship.

As noted by Kiguli-Malwadde in 2015, however, HPE units in this study continue to face significant challenges related to funding [11]. While many receive support from both internal institutional sources and external donors and funding agencies, investment in health professions education across the region was described as limited which aligns with prior findings that funding in HPE is low, globally [21]. Low funding inevitably impacts what units are able to do. Based on our results, we see there is often an interplay between an HPE unit’s funding, structure, staffing, and activities, and these relationships will impact the success of the unit (Fig. 1). This interplay reflects the influence of institutional logics on HPE units, where organizational structures and resource flows shape the scope of education activities [4]. For example, at some institutions becoming a stand-alone department can lead to access to renewed, consistent funding. However, for a unit to achieve movement in institutional hierarchies, it depends on their ability to generate income, and units with low staffing levels may have a harder time applying for grants or completing projects that could generate funds. Furthermore, a unit having their faculty and staff effort covered by budgeted institutional dollars can provide security from which to plan activities. HPE units without dedicated institutional funding will need to focus on securing funding as a key activity. This choice may limit the amount of time available for other activities, including ones that over the long term could result in more staff or funding in the future. Overall, this interplay of funding, structure, staffing, and activities can explain differences in how HPE units operate.

Fig. 1.

The interplay of funding, structure, staffing and activities within HPE Unit

A unique perspective emerging from this study, absent from prior literature, was that among HPE unit leadership, an HPE identity is important for themselves, their colleagues, and the units. Beyond a professional identity within the healthcare sector, such as doctors, nurses, etc., individuals working in HPE can begin to see themselves also as educators and having an HPE identity. Having dual or multiple professional identities is foundational. Research on the development of professional identity in medicine has shown that it is not defined by a single community, but rather by a landscape of distinct identities that emerge from the various activities and roles within medicine [22]. As mentioned by several interviewees, the HPE identity can come from many facets, including faculty participation in HPE unit activities, building a community of teaching and learning, and an establishment within institutions of a career pathway in HPE. Having an HPE unit makes it more likely that those situations and activities to occur, which further builds on the importance of individuals having an HPE identity in relation to the unit [23].

Our study found that having a strong HPE identity in the unit is an important facilitator in retaining individuals in the field of HPE and as a career. One of the main challenges since the inception of HPE units is staffing, as observed by Burdick as early as 2007 [24] and was noted again by Kiguli-Malwadde as a critical need in maintaining unit functions [11]. While some of our Interviewee’s units had a large staff, most did not. In addition, the engagement of staff from multiple departments and disciplines didn’t mean that the number of engaged individuals was sufficient. Such challenges were restated by this study’s interviewees with descriptions of career development opportunities being limited in HPE, individuals going into other fields of healthcare, and a growing number of retirements within the field of HPE, all of which underscores the broader, endemic shortage of faculty within institutions to do the work of HPE, move research in the field forward, and mentor the next generation of HPE faculty. Building the HPE workforce requires a multifaceted approach; however, at the core, a robust group of trained HPE faculty and professionals are needed. One step toward this goal is increasing the number of individuals who identify as an HPE professional and view HPE work as central to their research and practice [25]. HPE is multidisciplinary and should remain so as much of the strength comes from interprofessional collaboration and perspectives, however building an identity among this larger group of professionals will only strengthen commitment and dedication to HPE work. As discussed above, Fig. 1 highlights the relationship of funding, structure, staffing, and activities within an HPE Unit. However, the HPE identity also serves as a mediating factor in these relationships and can impact the overall success of the unit. For example, units that have lacking or reduced funding for staff, may still be able to produce a wide array of HPE activities, if the staff and faculty at the institution overall have a strong HPE identity in their career and work activities and are invested in the unit outcomes. Similarly, the structure and funding of an HPE unit may be re-organized or improved if an HPE identity is seen as an asset in academic careers, and more faculty want to work on HPE activities.

This study also found that partnerships of an HPE unit, within their institution as well as with other institutions nationally and internationally, are crucial to the development of the unit. In some cases, the establishment of new HPE units was made possible through support from existing units, often located internationally. As noted by Kiguli-Malwadde et al. [11], one of the challenges of unit establishment was the issue of medical education and health professions education lacking credibility or understanding. Strategic collaborations can aid in overcoming this barrier by offering legitimacy, guidance, and constructive feedback. For other units, partnerships were essential to expanding activities beyond teaching—such as working on HPE research. Because building and maintaining these collaborations often requires additional effort, strong leadership support is essential to ensure the sustainability and success of these partnerships, echoing broader calls for organizational innovation and leadership in medical education [26].

Limitations

This study is limited by the number of institutions who participated, considering the substantial number of HPE institutions in Africa who are not included. This limitation was the result of the exclusion criteria to Anglophone African medical schools, which resulted in more interviews from the East and Southern African region and therefore is not representative of all HPE units in Eastern, Southern and Western Africa. This also limited generalizability to Francophone and Lusophone countries. Additionally, our sampling strategy has a high potential for selections bias, most notably through the self-identification on the survey. The survey response rate of 26% is very low, as such, the individuals who responded and indicated interest in participating in the interview are likely, as a group, different from the population of HPE professionals in general. Similarly, our direct outreach has the same issue of self-selection bias as we had very few participants overall, from the general population. In total, twenty-two interviews were completed. Additionally, the results presented are only those from institutions with HPE units. The narratives for those with no HPE unit or are working on creating one, could provide meaningful knowledge on establishment challenges. We recommend a wider study including such institutions to investigate where HPE work is being done, the progression to getting a unit, and how the institutions are paying attention to HPE aspects despite lacking a formalized unit. Researcher involvement could be seen as a limitation that could lead to bias due to involvement in all steps and prior expertise in HPE. To address this, the team consisted of members from multiple fields and included multiple rounds of analysis and discussion to ensure no one viewpoint was presented without vetting from others. Additional areas of further research include the collaboration and mentorship between HPE units, advocacy for policy support at universities and universities, investment in research and data to demonstrate the impact of HPE, and the utilization of artificial intelligence and digital tools to enhance the work of HPE units. Finally, the categorization of institutions’ activities (Table 1) was based on generally accepted definitions known to the coding team. However, we understand that this categorization does not imply full homogeneity in terms of the activities themselves as different terms may have different meanings in different institutions, regions, and countries.

Conclusions

Health Professions Education units in Eastern, Southern and Western Africa have expanded from the few researched in the preliminary stages of work in this field. The foundational principles that motivated the establishment of HPE units in 2015 remain relevant today, and the core functions of the HPE units are also similar to what was stated in prior research. This paper contributes additional perspectives to a growing discourse on research into and next opportunities for HPE units. To strengthen HPE units in ESWA, we recommend the following: (1) establishing institutional policies that formally recognize HPE as a distinct academic career path to entrench HPE professional identity in faculty; (2) securing core institutional funding to ensure HPE unit stability beyond project-based grants; and (3) fostering regional HPE networks to support mentorship, collaborative research, and shared resource development.

Abbreviations

ESWA

Eastern, Southern, and Western Africa

HPE

Health professions education

USD

United States’ dollars

Authors’ contributions

The leadership team for this project consisted of two individuals from the United States, ADP and SBW, and two individuals from ESWA, SVS and EKM. ADP is an academic researcher, internal medicine clinician, medical educator, and director of a global health master’s program. EKM is a radiologist and academic researcher who specializes in HPE curriculum development, evaluation, and research. SVS is a researcher focusing on HPE, transformative learning theory, and postgraduate studies. SBW is an evaluation and research methodologist with expertise in qualitative methods. ADP, SVS, and EKM conceptualized and led the study and were involved in all stages of the project. SBW conducted a qualitative methods workshop to ensure all interviewers were adequately trained on interview methods and the purpose of the project and did quality assurance on the first interviews completed by the team. SBW led the data collection and drafted the manuscript. FN contributed to conducting interviews, analyzing data, drafting and reviewing manuscript. VSS contributed to data collection and review of the manuscript. AH contributed to conducting interviews, analyzing data, drafting, and reviewing the manuscript. GXN assisted in interview transcription, activity coding, and revision of the manuscript. ZZH served as a second coder on unit activities and contributed to manuscript preparation and editing. All authors have read, edited, and approved the final manuscript.

Funding

This project was funded by a philanthropic gift to the Robert J. Havey, MD Institute for Global Health at Northwestern University Feinberg School of Medicine.

Data availability

The interview data generated and analyzed during the current study are not publicly available due to privacy considerations but are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

This project was reviewed and approved by the Northwestern University Institutional Review Board (#STU00220296) and Mulago Hospital Research Ethic Committee (MHREC-2024-153). The project was deemed exempt. Informed Consent was obtained from all the participants. This project adhered to the Declaration of Helsinki.

Consent for publication

Participants gave their consent for publication of their deidentified, coded data.

Competing interests

The authors declare no competing interests.