May, 2011 - SUPPORT Summary of a systematic review | print this article |

Do changes in the pre-licensure education of health workers impact on the supply of health workers?

In many countries there is a shortage of health workers. The high financial and resource investments needed to train health workers make it important to find ways to increase the number of students entering health professional training and reduce the number of pre-graduation drop-outs. Minority academic advisory programmes that include academic, personal, financial and vocational advising, skills building, mentorships, supplementary training, and annual evaluations are some of the ways to achieve this amongst minority students.


Key messages


  • There is little evidence of the effects of interventions to increase the capacity of health professional training institutions, reduce student drop out rates or increase the number of students recruited from other countries
  • Two studies conducted in the United States of America (USA) provide low-quality evidence that Minority Academic Advising Programs (MAAP) may increase the number of minority students enrolled in health sciences; may slightly increase retention through to graduation; and may decrease differences in retention levels through to graduation between minority and non-minority students in the health sciences
  • There is a lack of evidence of the effects of other types of changes in the pre-licensure education of health workers on health worker supply


There is a considerable shortage of health workers globally and this shortfall is greatest in sub-Saharan Africa. Health worker education is costly in terms of the financial, temporal and other resources required, but vital in terms of providing universal good-quality health care services and attaining health-related objectives such as the millennium development goals. Strategies to increase the number of students in relevant courses and promote their retention to graduation are therefore essential.

About the systematic review underlying this summary

Review Objectives
/ What the review authors searched for What the review authors found

Interventions that could:
- Increase the capacity of schools
- Reduce the loss of students (and increase the likelihood that students will graduate)
- Increase school recruitment of students from other countries

2 controlled before-and-after studies of minority academic advising [advisory?] programmes. These programmes consisted of academic, personal, financial and vocational advice, skills building, mentorships, supplementary training and annual evaluations.


Health professional students prior to licensure

2 studies among black and general health professional students


No restrictions

2 studies from the USA


Increased numbers of health workers ultimately available for recruitment into the health workforce
Improved population-to-health professional ratios


2 studies of the numbers of health workers ultimately available for recruitment into the health workforce

Date of most recent search: October 2007/February 2008

Limitations: This is a good quality systematic review with only minor limitations

Pariyo GW, Kiwanuka SN, Rutebemberwa E, Okui O, Ssengooba F. Effects of changes in the pre-licensure education of health workers on health-worker supply. Cochrane Database of Systematic Reviews 2009, Issue 2. Art. No.: CD007018. DOI:10.1002/14651858.CD007018.pub2. See in Cochrane Library

Summary of findings

Two controlled before-and-after studies conducted among students at health professional training institutions in the USA were identified. A Minority Academic Advising Program (MAAP) was implemented in two institutions, and changes in the levels of black student enrolment and retention to graduation rates were measured.

Minority academic advising programmes may:

  • Increase the number of black health sciences students enrolled
  • Slightly increase retention to graduation
  • Decrease the difference in retention levels to graduation be-tween blacks and those in other population groups in the USA
  • There is a lack of evidence of the effects of other pre-licensure measures to increase health worker supply in low- and middle-income countries

Patient or population: Students (black, general) in health professional training institutions
Settings:  Health professional training institutions, USA
Intervention: Minority Academic Advising Program (MAAP) academic, personal, financial and vocational advice; skills building; mentorships; supplementary training; and annual evaluations
Comparison: Pre-MAAP (non-MAAP, non-black to account for secular changes)

Outcomes Impact No of Participants
Quality of the evidence

Increased numbers of health workers ultimately available for recruitment into the health workforce

Hesser 1993:

45% (Male: 48%, Female: 43%) relative increase in the total number of black allied health sciences students enrolled. Re-tention to graduation of black students increased from 72% to 83% (p=0.051)
Relative difference in retention to graduation between blacks and non-blacks reduced from 14% to 2.5% (p<0.0002)

Hesser 1996:
Percentage of minority students retained to graduation in-creased by 5.2% (p>0.05). Fraction of black students in-creased by 11%.

MAAP: 129
Pre-MAAP: 89
Non-black comparison group: 1884

MAAP: 76
Pre-MAAP: 38
Non-MAAP comparison group: 608


p: p-value GRADE: GRADE Working Group grades of evidence (see above and last page)

Relevance of the review for low-income countries

Findings Interpretation*


  • All included studies were conducted in high-income countries. No relevant evidence from low- or middle-income countries was identified



  • The challenges faced in health care worker education in high- and low-income countries are qualitatively and quantitatively different (e.g. the availability of funds, laws regarding equity and awareness of these, job prospects including remuneration, and curricula)
  • Appropriate interventions could be expected to have a comparatively higher impact in low-income countries where alternatives and opportunities are generally more limited than in high-income countries. However, there is no evidence regarding the effects of such interventions.





  • The included studies focus on equity between racial groups in a high-income country





  • Similar interventions (such as the promotion of minorities, marginalised populations or other sub-groups within the society) are likely to have positive effects on equity, irrespective of the context
  • Interventions focusing solely on increasing absolute numbers of health workers will probably not have a notable effect on equity irrespective of the context





  • The review did not provide information on absolute costs and cost-effectiveness



  • Direct costs of interventions, however small, will be difficult to meet or justify in low-income countries where education in general, and the health sector in particular, are cash-strapped
  • Increasing the overall quantity and quality of health workers incurs substantial costs (such as investments in facilities, teaching staff, and materials. Low-income countries may not be able to afford the burden of additional education and training expenses.
  • Health worker education could be conducted as a business if high numbers of health workers are trained to a standard that enables them to work abroad and their home countries are able to rely on remittancies (for example, the Philippines)



The currently available evidence is very limited and restricted to one high-income country


  • All changes in the pre-licensure education of health workers that are intended to improve the supply of health workers in low- and middle-income countries should be rigorously monitored and evaluated since evidence of their effects is lacking
*Judgements made by the authors of this summary, not necessarily those of the review authors, based on the findings of the review and consultation with researchers and policymakers in low and middle-income countries. For additional details about how these judgements were made see:

Additional information

Related literature

Grobler LA, Marais BJ, Mabunda S, Marindi P, Reuter H, Volmink J. Interventions for increasing the proportion of health professionals practising in rural and other underserved areas. Cochrane Database Syst Rev. 2009;1:CD005314.

Kessel RA. The A.M.A and the supply of physicians. Law and Contemporary Problems 1970;35:267–83.

World Health Organization. World Health Report. World Health Organization 2006.

Wilson NW, Couper I, de Vries E, Reid S, Fish T, Marais BJ. A critical review of interventions to redress the inequitable distribution of medical professionals to rural and remote areas. Rural Remote Health 2009;9:1060.

Wyss K. An approach to classifying human resources constraints to attaining health-related Millenium Development Goals. Human Resources for Health 2004;2:1–11.


This summary was prepared by

Peter Steinmann, Swiss Tropical and Public Health Institute, Switzerland


Conflict of interest

None declared. For details, see: Conflicts of Interest



This summary has been peer reviewed by: Ben Marais, South Africa and George Pariyo, Switzerland.


This summary should be cited as

Steinmann P. Do changes in the pre-licensure education of health workers have an effect on health worker supply? A SUPPORT Summary of a systematic review. October 2010.