Innovative Strategies for Transforming Internal Medicine Residency Training in Resource-Limited Settings: The Mozambique Experience

With approximately four physicians per 100,000 inhabitants, Mozambique has a critical shortage of medical doctors.1 As in other African countries, only a small proportion of the medical doctors are trained as specialists.2,3,4 This physician shortage goes back at least four decades, when most doctors left Mozambique shortly after the country’s independence (in 1975) and the Ministry of Health (MOH) hired physicians from other countries to work in public hospitals. At the time, the government merged the University of Lourenco Marques—now Eduardo Mondlane University (UEM) teaching hospital—with the Hospital Miguel Bombarda to form the Maputo Central Hospital (MCH).5 Since then, doctors at MCH have been required to provide pre-clinical and clinical instruction to medical students at UEM Faculty of Medicine (UEM-FoM). A major contributor to the shortage of physician specialists is the universal requirement for two or more years of primary care service following medical school graduation, which delays entry into postgraduate specialty training. Although this requirement has increased the availability of health care outside larger cities, it also has contributed to the lack of investment in postgraduate training, which has severely limited UEM-FoM’s faculty development and hindered its enrollment expansion. Simultaneously, the expansion of Mozambique’s health care workforce has been challenged by an internal and external “brain drain”—25% of Mozambique’s medical school graduates between 1980 and 2006 had left the country by 2010, and 62% of the remainder had moved into private practice within Mozambique.6 The MOH initiated in-country specialist training in 1984 without having a cadre of trained specialists. Therefore, UEM-FoM specialists hired for undergraduate medical education were also required to conduct postgraduate training. With the creation of the Mozambican Medical Council (MMC) in 2008, the responsibility for training specialists was transferred to the National Committee for Postgraduate Studies (NCPS).7 This body included specialists who were members of the MMC, the MOH, and the UEM-FoM faculty, and they supervised training programs in their areas of expertise. In 2010, the U.S. government launched the Medical Education Partnership Initiative (MEPI) to develop transformative models in medical education in 12 Sub-Saharan African countries, including Mozambique. The MEPI program for Mozambique is a partnership between UEM and the University of California, San Diego (UCSD), and is aimed at increasing the number and quality of postgraduate medical specialists in Mozambique, with the longer-term goal of expanding undergraduate and postgraduate medical training for the three major public universities—UEM, Universidade Lurio (Unilurio), and Universidade Zambeze (Unizambeze).