Strengthening public universities in low- and middle-income countries to improve global health equity

Abstract

Public universities in LMICs are pivotal for creating innovative solutions, accelerating national development and producing the health workforce in sufficient quality and quantity. The dwindling resources and performance of public universities in LMICs cannot be repaired by private universities alone due to the smaller scale of their contribution to the workforce. Equitable partnerships with high income country institutions for research, capacity building, mentorship and training can foster brain circulation and access to resources while promoting the discovery and delivery of precision health products, technologies and suitable solutions for equitable global health outcomes. LMIC policymakers should prioritize and support the knowledge ecosystem as a vehicle for accelerating equitable, inclusive, and sustainable national development and becoming healthier and more prosperous countries.

Universities advance knowledge, create innovative solutions to societal problems and accelerate national development. They are the main producers of skilled workforce including medical personnel. For example, University of Ibadan, which has the first medical school in Nigeria, pioneered the education of health-workers and has produced over 10,000 medical doctors and dentists, and helped established other public medical schools accounting for most of the 130,000 medical doctors registered in Nigeria according to the Medical and Dental Council of Nigeria [1]. However, only 58,000 doctors renewed their annual practicing license in 2023, due to brain-drain [1].

Brain drain and academic transition

Brain drain is the substantial emigration of highly skilled or professional individuals from one country, region, or sector to another [2]. In the last 5 years the exodus of locally trained medical doctors has been reported to be over 16,000 [3]. Thus Nigeria, with a population of over 227 million, has 1 medical doctor to 4000 people, far below the WHO’s recommendation of 1:500 [3]. Many African (e.g. Zambia, Malawi, Ethiopia), Arab (e.g. Yemen) and Asian countries (e.g. Papua New Guinea) have doctor-to-population ratio of < 2/10,000 [4]. The projected health workforce shortage in the WHO African Region by 2030 is 5.85 million [5]. These shortages are due to a combination of chronic underinvestment, low retention, and intense brain drain with nearly 46% of health workers reporting intentions to migrate, driven by poor working conditions and limited career opportunities [5]. This massive brain-drain, coupled with the loss of ~$2 billion annually in Nigeria to medical tourism, is occurring when the public universities in Nigeria and other low- and middle-income countries (LMIC) which are supposed to replenish the workforce are facing daunting challenges [6,7].

One of these challenges is an “academia transition”, with the insidious substitution of high-quality public universities by private universities whose rankings are rising compared to the public universities. University ranking is heavily weighted on research environment, quality, and productivity. While private universities are autonomous and able to provide basic research infrastructure and enabling environment to support the strive for excellence, public universities in LMICs, are often shackled by government bureaucracy (which impedes staff recruitment, promotion, and development); and inadequate power, water, information technology, laboratory and library facilities.

These challenges have also contributed to internal brain-drain within countries from public to private universities. However, existing track-record, personnel and expertise for residency training and faculty development, while deteriorating, primarily still reside in the public university system. As such, the declining resources within the public universities provide a catalyst for most early career medical professionals to depart LMICs, thereby exacerbating public health crisis and global health disparities.

In LMICs, not only are governments not providing adequate funds for research and development, but access to research funds provided from international funders is often cumbersome due to bureaucratic bottlenecks. Moreover, persistent budget cuts and hiring reductions have contributed to higher student-to-faculty ratios, and thereby a lower quality educational experience. These challenges resulted in 22.2% increase in the number of Nigerian students in US universities from 14,438 in the previous year to 17,640 in the 2022/23 academic year [8]. Between 2010 and 2020, foreign education expenses amounted to $28.65 billion capital outflow from Nigeria [7]. This loss of funds, staff and students from Nigeria and other LMICs, will further worsen the disparity in health-worker to population ratio.

Private universities are attempting but unable to bridge the gap as they are unable to produce at scale to meet the demands of emerging economies workforce. For example, though there are no available universally acceptable metrics/data for comparing the quality of graduates, while the private Covenant University in Nigeria graduated only 57 PhDs in 2023, the public University of Ibadan produced 724 doctoral graduates during the same time. Similarly, the public National Autonomous University of Mexico has 350,000 students, a number far above what private universities could individually muster due to the higher cost of tuition compared to public universities [9]. It is therefore crucial for public universities to be supported to create a conducive environment to improve the contributions of public universities to the knowledge ecosystem (Fig. 1).

Fig. 1.

Entrepreneurial knowledge ecosystem to accelerate development through discovery and innovation.

legend: Entrepreneurial knowledge ecosystem to accelerate development through discovery and innovation. This diagram is adapted and redesigned from the open-source work by CTA and CIAT, Staiger, S. (2015). Available at: https://alliancebioversityciat.org/stories/cta-ciat-partner-pan-african-bean-alliance-knowledge-management. (Accessed: 27 October 2025).

Components of the knowledge ecosystem/value chain include:

• Sun, Soil and Water: Build capacity by providing vibrant structure, infrastructure, training, mentorship, leadership and enabling environment and resources
• Knowledge creation: Find out what is required, and what is available. Develop what is required from what is available to generate relevant products e.g. patents, publications, technologies and services and other innovative products and solutions for societal development, which are the fruits of the knowledge tree,
• Knowledge transfer(impartation): Make knowledge/findings available and accessible through teaching, training, and mentorship.
• Knowledge use: Disseminate (share) and apply knowledge through entrepreneurship, Evaluate and monitor the impact of knowledge used through relevant metrics.

Global health equity and partnerships

If public universities in LMICs continue to decline, the inequity gap within the country will increase and the developmental gap between HICs and LMICs will widen further, with worsening of the grossly inadequate doctor-to-population ratio and brain-drain. The inequity within LMICs due to lack of access to quality education in public universities could lead to loss of relevant workforce. Partnership with HIC institutions driven by global health equity is required to promote brain circulation, bridge the developmental gap and enable LMIC health systems to respond adequately to the global burden of diseases which is borne mostly by LMICs amidst scarce resources with worsening health outcomes.

“Global health equity” refers to mutually beneficial power-balanced partnerships leading to equitable health globally [10]. Equitable professional partnerships with HIC institutions will foster equitable processes in research, training, capacity building and creation of new interventions, products and services to reduce the burden of diseases. Despite the current political climate, HICs should continue to support these collaborations to ensure the most efficient way of improving global health because most diseases transcend geographical borders. Moreover, some LMICs may be better positioned due to their distinctive burden of diseases and genetic architecture to contribute unique expertise/experience and the quantum of research data and samples needed in the quickest possible way for cross-learnings, novel translatable discoveries and solutions which are applicable globally.

LMIC institutions should establish equitable strategic partnerships with top-ranking HIC institutions with track-record of leadership in research. This will serve as institutional/corporate mentorship to engender a culture of grantsmanship and facilitate access to international research grants and better utilization of local grants. To achieve this, linkages with HIC institutions can be sought by LMICs through participation in the global mentorship, fellowship, grant, research, exchange programs, conferences and other collaborative activities offered by the HICs. This can grow to become funded institutional and programmatic partnerships.

Transformative humanistic mentorship by HICs should be driven by trust, respect, altruism, magnanimity, meaningful relationships and problem-sharing with due responsibilities for both mentors and mentees to help create willingness in mentees to be trained as individuals ready to take on an independent path [11]. Such independent thinking researchers must be deeply empathetic towards their national context, problems and disease-burden priorities [11–14]. For example, LMIC researchers in conflict-heavy zones (e.g. the war in Ethiopia) could investigate healthcare system effect, effect on routine vaccinations and emergency responses, maternal and reproductive health, post-traumatic stress disorder, chronic diseases, nutrition and resurgent infectious disease threats [15].

To truly shift power and end epistemic exclusion [16], LMIC collaborators must take ownership and identify context-specific research, capacity building, mentorship and training needs [11–14]. For equitable partnerships to occur, Global South institutions must play an active role, take responsibility and be accountable. Equitable partnership in research will imply sharing lead investigator, speaker and author responsibilities with meaningful roles for LMIC researchers to frame relevant questions, co-lead analysis and provide context and interpretation for the research findings [10]. Equitable knowledge ecosystems (Fig. 1, Table 1) will deliver precision health products, appropriate solutions and targeted technologies which will be effective in LMIC settings and globally [10]. To achieve this, stakeholders in LMICs need to develop a clear theory of change to support the knowledge ecosystem for generating contextual evidence through relevant research for societal impact [17].

Table 1.

How to strengthen public universities in low- and middle-income countries (LMIC) to improve global health equity.

Recommended Actions (What and How)	Responsible entities (Who)
1 LMIC policymakers should prioritize the knowledge ecosystem to boost their human capital and share in the global knowledge economy (brain economy). They should incentivize research for knowledge production, a critical pillar of the knowledge ecosystem, which also includes knowledge impartation through teaching, knowledge dissemination and knowledge application (and entrepreneurship). This can be done by providing sufficient funds for student and academic staff research grants for developing innovative entrepreneurial knowledge products e.g. the Student Venture Capital Grant funded by the Federal Ministry of Education, Nigeria [19] as well as moonshot research infrastructural and capacity-building projects. Also, grants can be provided to cover journal subscription, publication costs, and conference participation.	LMIC policymakers
2 LMIC public universities should foster entrepreneurial training, and innovation incubation hubs, and stimulate the creation of start-up companies in partnership with policymakers, the private sector and the public to harness novel initiatives such as biotechnology to boost their contributions to job creation and sustainable economic development and improved health outcomes. For example, the Federal Government of Nigeria, in partnership with the United Nations Development Programme and the Tertiary Education Trust Fund (TETFund) of the Federal Ministry of Education established University Innovation Pods [20].	LMIC policy makers, University Administrators
3 Establish LMIC strategic bilateral and multilateral partnerships and exchange programs with top-ranking high income country institutions with track-record of leadership in research. This will serve as institutional mentorship to engender a culture of grantsmanship and facilitate access to international research grants.  3 To achieve this, linkages with HIC institutions can be sought by LMICs through participation in the global mentorship, fellowship, grant, research, exchange programs, conferences and other collaborative activities offered by the HICs. This can grow to become funded institutional and programmatic partnerships.	University Administrators and staff
4 Convert LMIC brain-drain to brain-gain by harnessing the power of the alumni and the diaspora through collaboration, strategic partnerships, mentorship, diasporan investments/remittances, and creation of adjunct and/or visiting faculty positions. This will attract the best staff and students from across the globe.	LMIC policy makers
5 Include research mentorship and grantsmanship in LMIC undergraduate and postgraduate curricula. Implement orientation and mentorship program and incentive-aligned annual productivity appraisal initiatives for academic and support staff of universities to guide them in developing their career plan. Provide institutional pilot grants.	University Administrators and Academic staff
6 Implement personnel remuneration at international rates to attract and retain the best staff, researchers and scholars from across the globe and reduce brain-drain.	LMIC policy makers, University Administrators
7 Support university autonomy for efficient and effective decision-making for appropriate and prompt application of resources and resolutions of challenges [9].	LMIC policy makers, University Administrators
8 LMIC governments should invest a high percentage of their GDP in university research development and infrastructure including uninterrupted electricity, water, information technology and internet facilities and library facilities [9]. With about two-thirds of the ranking criteria dependent on research, it is crucial to incentivize research by providing the right environment and sufficient funds for the facilities, infrastructure, resources, and equipment needed. This will reduce helicopter science, decolonize research, and reduce inequalities while accelerating the achievement of the SDGs by 2030 [9]. The research agenda should be driven by the contextual priorities of the individual countries based on developmental and policy needs and disease burden.	LMIC policy makers, University Administrators
9 International development partners [such as Foreign, Commonwealth & Development Office (FCDO), European Union, United Nations, WHO, World Bank] should support medical schools and Universities in LMIC. This is because there are no disease borders per se, and weak medical schools and universities in LMICs ultimately impact global health [21].	International development partners
10 Incentivize and enable LMIC researchers to obtain grants from major international funders of research. Facilitate better access to awarded research grant funds by eliminating bureaucratic barriers. This will empower them to lead discovery, epidemiological and implementation science research in all areas of health and science. An example is H3Africa https://h3africa.org/.	LMIC policy makers, University Administrators
11 Stakeholders should support a quadruple helix approach involving academia, policymakers, industry, and civil society/public to ensure sustainability. This will foster academic productivity and societal impact to promote global health equity.	Academic and Research institutions, policymakers, industry, and civil society/public

^*These recommendations are based on the lived experience, literature familiarity, and interactive dialogue of the authors, both of whom are longstanding university administrators with expertise in conducting research, developing trainees, and delivering care in LMICs.

Supporting the knowledge ecosystem

With the dwindling of international funding for global health from HICs in the Global North, local policymakers and university administrators in LMICs should provide a conducive environment through adequate funding and provision of infrastructure (Table 1). Local policymakers and university administrators should identify and track relevant quality metrics and indices to stimulate improvement of the knowledge ecosystem and production of high-quality health-workers in adequate numbers. (More details are provided in Table 1 which are based on the lived experience, literature familiarity, and interactive dialogue of the authors, both of whom are longstanding university administrators with expertise in conducting research, developing trainees, and delivering care in LMICs).

LMIC policymakers should prioritize the knowledge ecosystem to boost their human capital and share in the global knowledge economy. They should incentivize knowledge production (patents, publications, innovative products, technologies and services), a critical pillar of the knowledge ecosystem. They should support other components of the ecosystem including knowledge impartation through teaching, knowledge dissemination and knowledge application (Fig. 1). The knowledge value chain demonstrates the critical importance of providing vibrant infrastructure and enabling environment to power academic productivity, creativity, innovations and solutions for societal development, which are the fruits of the knowledge tree.

To fund these activities, LMIC governments should invest a high percentage of their GDP and tax revenue in universities to support research, development and infrastructure including uninterrupted electricity, water, information technology and internet facilities and library resources. LMIC researchers should collect data, develop quality metrics and an economic case including the return on investment as an advocacy tool for LMIC stakeholders. Public universities could be further supported by philanthropic organizations, the private sector, foundations, trust funds, patients [17] and other donors. With about two-thirds of the ranking criteria dependent on research, it is crucial to incentivize research by providing the right environment and sufficient funds for the facilities, infrastructure, resources, and equipment needed [9]. This will reduce helicopter science, decrease scenarios where the LMIC partners are treated as “glorified data collectors” [12], decolonize research [13,14,16], and reduce inequalities while accelerating the achievement of the SDGs by 2030 [9].

Local investments by LMIC governments in universities and dedicated health research councils/funds can be supported by international funders and development partners [such as Foreign, Commonwealth & Development Office, European Union, United Nations, WHO, World Bank, etc.]. This is because there are no disease borders per se, and weak medical schools and universities in LMICs ultimately impact global health.

Furthermore, policymakers can be supported by the alumni of universities to convert brain-drain to brain-gain through brain circulation. LMIC institutions can harness the resources of the alumni and the diaspora through collaboration, strategic partnerships, mentorship, staff and student exchange programs, diasporan investments/remittances, and creation of adjunct and/or visiting faculty positions. This will attract and retain the best staff, researchers and scholars from across the globe and reduce brain-drain especially if LMIC institutions implement personnel remuneration at international rates/purchasing power.

Moreover, LMIC policymakers should support university autonomy for efficient and effective decision-making for appropriate and prompt application of resources and resolutions of challenges. In Africa and HICs including the Americas, funding reliance on state budgets, can give governments direct leverage over institutional operations, whereby authorities could use financial restrictions and delayed subventions to punish non-compliant institutions or critical faculty [18]. Also, government sometimes handpick vice-chancellors, rectors, and council heads, subverting merit-based leadership as occurred in Uganda and military dictatorships; while civil servants with little academic background sometimes make core tertiary decisions, creating friction over institutional mandates [18].

Above all, all stakeholders should support a quadruple helix approach involving academia, policymakers, industry/private sector, and civil society/public to ensure sustainability.

In conclusion, strengthening public universities will foster academic productivity and accelerate the production of a critical mass of highly skilled workforce which will accelerate economic growth, improve living conditions, stem brain-drain, reverse medical tourism and promote global health equity.