Transforming Healthcare: Evaluating a Decade of Postgraduate Training at the Liberia College of Physicians and Surgeons

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Bakker, Douglas Weru Alice, Benetta Collins Andrews, Philderald Pratt, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6629290/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Background Postgraduate training in Liberia was commenced in 2013 under the Liberia College of Physicians and Surgeons (LCPS). Since its inception, 125 medical doctors have specialized to membership level in seven disciplines: Internal medicine, Pediatrics, Surgery, Obstetrics & Gynecology, Family Medicine, Ophthalmology and Psychiatry. This study evaluates the outcomes of the postgraduate training in Liberia after a decade and examines whether graduates’ competencies align with their current work roles. Methods An online questionnaire was distributed to all graduates, collecting data on demographics, work history, motivation, self-assessed competencies, and training experiences including examinations, research and feedback. Descriptive analysis was used to calculate response frequency distributions. Results Ninety graduates (72.0%) responded to the questionnaire. All respondents worked in Liberia, with 56.3% in Montserrado County. Most (94.4%) were primarily employed in the public sector, whereas 21.1% held additional roles in the private sector or academia. After membership level, 30.0% pursued additional education, including 18.9% fellowship training. Overall, graduates expressed strong confidence in competencies gained during the postgraduate training, particularly medical knowledge, professionalism and teaching, with over 95% of graduates considering themselves competent in these areas. In contrast, only 44.3% felt competent in research. Nearly all graduates (95.4%) reported that the training supported their career growth and would recommend it to colleagues. Suggestions for improvements included increasing faculty numbers and diversity, enhancing training resources, and expanding research opportunities. Conclusions The LCPS has contributed significantly to developing a competent specialist health workforce in Liberia. Specialist graduates had a high retention rate and were primarily employed in clinical roles in the public sector. Challenges remain, such as too few specialists and limited healthcare coverage in rural areas. To train well-equipped specialists, it is crucial to strengthen faculty, institutional capacity and training resources, and to build research capacity. Sustained investment and continued collaborations between the government and partners are needed to implement strategies to maintain retention and improve equitable distribution of specialists and to support their career growth. These efforts will ensure the program’s impact to meet Liberia’s evolving healthcare demands effectively. Medical education postgraduate training specialization health workforce human resources evaluation Liberia West-Africa Figures Figure 1 Figure 2 Figure 3 Figure 4 Background The workforce is a cornerstone of any health system and is playing a vital role in improving health service coverage ( 1 ). In 2016, the World Health Organization introduced the “Workforce 2030” a global strategy on human resources for health ( 2 ). The strategy emphasizes achieving effective health worker coverage through adequate availability, acceptability, accessibility, quality, and service utilization. To enhance coverage, it is essential to optimize the health workforce, prepare for future needs, build institutional capacity, and strengthen data on human resources for health ( 2 ). Health workforce in Liberia Liberia is a low-income country in West-Africa with persistent critical health worker shortages. The civil war between 1989 and 2003 severely affected the health system, the education of health workers collapsed, many practicing health care workers left the country, reducing the number of employees in the public health sector from 3,526 to 1,396 ( 3 ). A human resource census in 2009 totaled 67 doctors and 23 surgeons for a population of 3.9 million at the time ( 4 ), making the country heavily reliant on external aid and non-governmental organizations ( 3 ). Nearly 70% of the health workforce consisted of unskilled or non-clinical staff, highlighting a significant need to expand and strengthen the workforce, particularly by increasing the number of doctors, physician assistants and certified midwives ( 4 ). While Liberia was still in the phase of rebuilding the health system and workforce after the civil war, it was faced with the West-African Ebola Virus disease outbreak in 2014–2016, claiming the lives of 8% of all healthcare workers ( 5 ). In addition, an unknown number of healthcare workers left their work, either out of fear of contracting Ebola or pressured by relatives or communities, further disrupting healthcare services ( 6 , 7 ). Post-Ebola, Liberia continued to have one of the lowest densities of healthcare workers globally with 0.04 physicians per 1,000 people ( 8 ), far from the WHO estimate for adequate coverage at a minimum 2.5 per 1,000 population. The Liberia Health Workforce Plan 2015–2021, developed by the Government of Liberia, outlined strategies and priorities to (re)build the health workforce ( 9 ). Priority areas of intervention included building a fit-for-purpose workforce by increasing the number of health workers, improving education quality, and diversifying skills. The strategy targeted five key cadres: community health workers, health managers, registered midwives, registered nurses, and physicians (both general and specialist). For physicians, the aim was to raise annual medical education enrollment from about 40 to 125 while specialists training targeted an increase from 18 to 24 annual enrollments by 2021 ( 9 ). Despite limited specialty training programs in Liberia, there was a strong emphasis on developing national capacity to produce specialists essential for strengthening the medical and clinical education systems. Establishment of the Liberia College of Physicians and Surgeons (LCPS) In 2012 the LCPS was established by an Act of Legislation to train and qualify specialists in Liberia ( 10 ). Through international partnerships and donors, funding for the program was secured and the core faculties were strengthened by international consultants. Initially, four faculties were developed to start postgraduate medical residency training in the disciplines of General surgery, Internal medicine, Obstetrics and Gynecology, and Pediatrics. The training structure and curricula were modelled after regional programs of the West-African College of Physicians (WACP) and the West-African College of Surgeons (WACS). The programs are nationally accredited by the LCPS and regionally by the WACP and WACS. Postgraduate training began in September 2013 but was suspended for 10 months during the Ebola outbreak. The first Liberian-trained specialists in Surgery, Internal Medicine, Obstetrics and Gynecology and Pediatrics were inducted in 2017. In the following years, additional faculties were established, including Family Medicine (2017), Ophthalmology (2019), Psychiatry (2019), and Community Medicine (2023). Current workforce in Liberia There are no unified figures for the actual number of medical doctors in Liberia. The WHO National Health Workforce Accounts reported 954 medical doctors in 2022, of whom 84 general practitioners and 114 specialists ( 11 ), whereas according to the Liberia Medical and Dental Council (LMDC), the number of specialists had increased from 15 to 120 Liberian specialist between 2012 and 2019, as well as 248 non-Liberian specialists ( 10 ). Most healthcare services are delivered by non-specialist providers, even though a survey among medical school graduates showed that less than half of them assessed themselves as fully competent ( 12 ). Between 2013 and 2023, 125 Liberian-trained specialists across seven specialties were inducted by the LCPS at membership level. In 2018, 48 out of the 67 (71.6%) surgical specialists, including obstetricians and gynecologists and ophthalmologists, worked in Montserrado County, the capital region ( 13 ). Aim of this study The retention, employment locations, roles, and relevance of the knowledge and skills acquired by specialists trained under the LCPS postgraduate training program remain unclear. This study aims to evaluate the impact of a decade of postgraduate training by assessing program outcomes and alumni competencies, with the goal of improving the program and guiding continuous professional development efforts. Methods Study design In this cross-sectional, survey-based study, all graduates of the LCPS membership program were requested to participate in an online survey to examine the effectiveness and appropriateness of postgraduate training in Liberia. Setting Liberia is a low-income West African country with 5.3 million inhabitants. It is divided into 15 counties, with Montserrado County including the capital Monrovia being the most populous (1.9 million) ( 14 ). The A.M. Dogliotti School of Medicine under the University of Liberia, the only medical school in the country, enrolled about 40 students annually in 2015 ( 9 ). In 2021, its curriculum was updated to a seven-year integrated, competency-based program and new faculty were trained in basic sciences and teaching methods ( 12 ). After graduation, a one-year internship in general surgery, internal medicine, obstetrics and gynecology, and pediatrics and a year of rural service are required before applying for postgraduate residency training under the LCPS. Residency programs, primarily based at John F. Kennedy Medical Center in Monrovia, include three years of training with rotations at various departments and at additional nationally and regionally accredited hospitals, leading to LCPS membership after a final examination ( 15 ). A two-year fellowship program is also available for some specializations. Study population and tools This study included all medical doctors who completed their postgraduate training under the LCPS from inception in 2013 to September 2023. Residents who were still in training at the time of the study, who had dropped out during training, or Liberian specialists who specialized abroad were not eligible for inclusion. An online questionnaire (Supplementary material) retrieved demographic information, educational background, current and previous work situation, and a self-evaluation of medical competencies gained during the postgraduate training. The 15 question self-assessment was framed to evaluate seven core competencies the LCPS wanted the postgraduate trainees to acquire during training ( 15 ). These competencies included patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, systems-based practice, and teaching. Participants were asked to evaluate each competence on a 5-point Likert scale (strongly disagree, disagree, neutral, agree, strongly agree). In addition, questions were asked about several aspects of the training, such as feedback, examination and research during the postgraduate training, and a reflection on their motivation before and after the training. Data collection Data collection took place between September and December 2023. The questionnaire was disseminated to all 125 graduates of LCPS postgraduate training through the online platform Nettskjema ( 16 ). All graduates were contacted by phone call, email, WhatsApp or text message, or a combination. Each person was contacted at least three times and in different ways before concluding as a non-responder. To optimize the response rate, two presentations were held at the main teaching hospital in Liberia (John F. Kennedy Medical Centre) and at the annual scientific meeting of the LCPS to explain the purpose of the study. In addition, several larger hospitals across Liberia were visited to distribute information about the study. Data analysis and ethical considerations Data was exported from Nettskjema to Microsoft Excel (Microsoft Corporation, USA) for processing and descriptive statistics. Personal identifiers were removed prior to analysis. Where applicable, answers to open questions were transformed into categorical variables. Analysis was performed for the complete data set and stratified by specialization. The study was approved by the Atlantic Center for Research & Evaluation Institutional Review Board (ACRE IRB) in Liberia on 28 August 2023 (Reference number 23-08-383). Results Response rate The response rate to the questionnaire was 72.0% (90 of 125) varying between 53.3% for Family Medicine and 100.0% for Psychiatry. For all specialists' tracks, the response rate was more than 50%, and for all but Family Medicine and Obstetrics & Gynecology it was above 70% (Fig. 1 ). For the majority of the 34 non-responders the reason not to participate is unknown, whereas two were not able to complete the questionnaire due to internet problems, and one indicated not to have time to participate. Demographics Sixty percent of the respondents was male and 40.0% female, compared to 64.0 and 36.0% of all graduates, respectively (Table 1 ). The median age at graduation was 37.5 years. Most respondents (92.2%) were Liberian nationals. Twenty-seven (30.0%) had pursued an additional education after completing the membership level of postgraduate training. The most common additional training was postgraduate training at fellowship level (17 of 90), or a master’s degree (7 of 90), most often within public health. The majority (76.6%) finalized their training within three years. Two thirds of those who took 4–5 years were in the first cohort that started in 2013, whose training was affected by the Ebola outbreak. Table 1 Demographics, employment and education status of respondents. Graduates (n = 125) Respondents (n = 90) Gender Female Male 45 (36.0%) 80 (64.0%) 36 (40.0%) 54 (60.0%) Median years between medical school and residency training (IQR) - 2 ( 2 – 4 ) Median age at end of residency program (IQR) - 37.5 (34–42) years Nationality Liberian Other - - 83 (92.2%) 7 (7.8%) Current function Clinical Specialist Consultant Fellow Clinical/Admin Medical director Administrative MOH/CHO # Administrative Other Leave Other 94 (75.2%) - - - 8 (6.4%) - 11 (8.8%) - - 12 (9.6%) 7 (5.6%) 5 (4.0%) 70 (77.8%) 51 (56.7%) 17 (18.9%) 2 (2.2%) 13 (14.4%) 13 (14.4%) 6 (6.7%) 3 (3.3%) 3 (3.3%) 1 (1.1%) - 1 (1.1%) Position Full-time Part-time - - 89 (98.9%) 1 (1.1%) Sector Public Private Other 102 (81.6%) 9 (7.2%) 14 (11.2%) * 85 (94.4%) 3 (3.3%) 2 (2.2%) Additional work Yes Private practice Teaching Other No - - - - - 19 (21.1%) 10 (11.1%) 6 (6.7%) 3 (3.3%) 71 (78.9%) Median months working in current job (IQR) - 24 (11–52) Duration of residency training Within 3 years More than 3 years - - 69 (76.7%) 21 (23.3%) Additional education Master’s degree Fellowship Other None - - - - 7 (7.8%) 17 (18.9%) 3 (3.3%) 63 (70%) Co-authored publications None 1–2 3–5 > 5 - - - - 37 (41.1%) 32 (35.6%) 12 (13.3%) 9 (10.0%) # MOH = Ministry of Health, CHO = County Health Office, * includes 7 on leave (study/absence) * Excluding ophthalmology (n = 3) and psychiatry (n = 3) Work location and history Most of the graduates (94.4%) worked in the governmental sector, whereas 3.3% worked in the private sector and 2.2% in other sectors (Table 1 ). Even though only one person specified to work in a part-time position, 21.1% percent of the respondents indicated to have a second job next to their first employment. These second employments were mostly in the private sector or in teaching. Most respondents indicated their additional work taking place in evening hours or weekends. Respondents originated from all but one county in Liberia (Fig. 2 A). According to the LCPS, 12 graduates were currently abroad (9.6%). All counties have at least one specialist who graduated from the program, apart from Gbarpolu (Fig. 2 C). Our study found that after residency training, 54.4% percent of the respondents worked in Montserrado County, while in 8 counties there was only one or no respondent (Fig. 2 B). This was similar to the distribution among all graduates, where 51.2% worked in Montserrado. The median time respondents worked in their current job was 24 months (IQR 11–52). Forty-three respondents (47.8%) also provided information about their previous work history. Out of these 43, eleven (25.6%) remained in the same county. Out of the 23 people who worked in Montserrado prior to their current job, only 8 remained in Montserrado, whereas 15 are currently working in other counties. Specialists in Obstetrics & Gynecology were most spread with graduates working in 9 different counties, and 47.9% working outside Montserrado County. Evaluation of competence Overall, the graduates were confident with the competencies gained during the postgraduate training (Supplementary Table 1). The highest rated competencies were medical knowledge, teaching, professionalism and system-based practice with over 96% of graduates assessing themselves as competent, whereas 44.3% felt competent to perform research, and 74.4% indicated that the curriculum adequately covered all clinical subjects that they need in their work (Fig. 3 ). Although 50.6% of the respondents agreed with the statement that they had opportunities to engage in research activities, 58.9% of the respondents had (co-)authored research publications at the time of study. Almost all graduates (95.5%) reported that the training has provided them with opportunities for career growth and would recommend it to junior colleagues. There were only slight differences between the various specializations. Graduates in psychiatry rated their competence highest with an average score of 88.3%. With still an average score of 81.4% of the maximum, this was lowest for pediatrics. Motivational factors The main motivational factors to enroll in postgraduate training were interest in patient care, personal interest in the subject, and a desire to become an expert in the field. Motivational factors that reduced most during postgraduate training were financial benefits (44.8–18.4%) and desire to become expert in the field (83.9–58.6%) (Fig. 4 ). External factors, such as financial benefits, career development, and improving job prospects reduced more than patient-related factors or clinical aspects. Suggestions Thirty-eight graduates offered open-ended replies and expressed both strengths and challenges with the training program, as well as suggestions for improvement of the program. Several graduates praised the program for enhancing their medical knowledge and skills, enabling them to deliver high-quality patient care. They also emphasized the importance of postgraduate training in improving health systems and contributing to the national healthcare workforce. Common criticisms included the lack of adequate mentorship due to overburdened faculty, insufficient training resources such as laboratory and imaging facilities, and poor infrastructure, including inadequate resident housing and minimal salary progression after specialization. The shortage of faculty, particularly for hands-on training was frequently cited. Additionally, many respondents expressed concerns about the lack of research opportunities and external rotations to other institutions. Suggestions for improvement of the training program included increasing faculty numbers, especially in subspecialties, improving research and publishing training, providing better investigative tools, and enhancing collaboration with external organizations and faculty during rotations. Addressing salary disparities and career progression post-graduation were also highlighted as key areas for improvement. Discussion Key findings This study examines ten years of postgraduate training in Liberia, highlighting a high domestic retention rate among graduates, most of whom contribute to clinical service delivery in the public sector. The competencies gained through the postgraduate training were perceived relevant and well-aligned with their current work responsibilities. Impact of postgraduate training in Liberia on the health system Before the establishment of postgraduate training in Liberia, the country suffered from a severe shortage of specialist and the country relied exclusively on regional and international support to train its doctors, leading to issues with affordability, accessibility, and retention ( 10 ). Many trained abroad did not return, exacerbating the scarcity of specialists within the country ( 17 , 18 ). The establishment of postgraduate training in Liberia addressed these challenges by building local capacity to produce specialists tailored to the nation’s specific health system needs. The local training of 125 specialists represents a significant milestone, directly contributing to improving access to specialized healthcare services and reducing the dependency on foreign-trained professionals. Results from this study clearly demonstrate that the graduates assess their competencies to be relevant and adequate for the functions required of them. The graduated specialists have strengthened the public health facilities and likely enhanced clinical service delivery. Postgraduate training is a mostly hands-on, in-service training of health workers, and thus the quality and level of service delivery in the system where people are trained directly influences the quality of the training. Therefore, training programs can boost service delivery and vice versa. Looking ahead, greater emphasis should be placed on strengthening academic competencies, particularly research and methodology training. These were identified by graduates as their least developed skills but are crucial for practicing context adapted evidence-based medicine and building academic capacity. Regional collaboration with WACP and WACS enhances opportunities for graduates to register with regional colleges and pursue additional fellowship education ( 19 , 20 ). Both Dahn et al. ( 21 ) and Sanoe et al. ( 22 ) emphasize the importance of building academic and institutional capacity and infrastructure to successfully educate health workers. Specialists have an essential role in the strengthening of the health system, as well as to ensure sustainability and self-reliance of the training program. From its inception in 2013, the program has been designed to support national capacity building. Initially, the postgraduate training program was heavily dependent on external resources, both in terms of funding as well as faculty for teaching and service gaps. Several partnerships with international institutions were formed ( 20 , 22 , 23 ). The faculty employed under the Health Workforce Program funded by the World Bank during the initial five years of postgraduate training has played an important role in advancing the faculty pipeline and has developed a foundation for further mentorship and education of the next generation of specialists in Liberia. Most of the international faculty deployed under the program were from the West-African region, which not only ensured alignment of the training with the accreditation requirements and curricula of the regional bodies of WACP and WACS but also strengthened the quality of training and collaboration between faculty in the region. Despite these efforts, currently there is still an important role for collaboration until the number of fully Liberian-trained specialists and Liberian faculty has increased further. In the 2022 Faculty Sustainability Plan, the LCPS specified a pathway towards sustainability of the program, which included a minimum of five additional academic years of core visiting and sub-specialist faculty needs, as well as the need for a progressive increase of the government budget allocation towards the LCPS training program ( 24 ). Retention and distribution A significant challenge in healthcare systems in low-income countries is attracting and retaining health workers in the country after training, and to distribute them according to the needs ( 25 ). The migration of well-trained health workers to other countries resulting in “brain drain” is a major issue in some West-African countries, with especially Nigeria and Ghana being among the largest “supplier countries” ( 18 ). Among the specialists in Liberia, there was mostly temporary migration for education purposes. A study among the surgical specialists trained under the Colleges of Surgeons of East, Central and Southern Africa (COSECSA) also found high retention rates with 85% of graduates remaining in the country where they were trained, and 88% in the region ( 26 ). At the level of medical specialists, Liberia may be experiencing a “brain gain” benefitting from the contribution of international specialists, primarily from West and East Africa, as well as the return of Liberian professionals trained abroad who are reintegrating into the national health system. However, the data presented in this paper do not account for internal migration, wherein specialists transition from the public sector to the private health sector. This shift poses a significant challenge to equitable access to healthcare services. In recent years, there has been a rapid increase in private health facilities in Liberia, particularly in urban areas ( 27 ). In addition, we observed that more than half of the respondents in this study worked in Montserrado county, where approximately one third of the Liberian population lives. At the same time, in rural areas the health care system still heavily relies on non-specialist medical doctors and non-physicians to provide care ( 13 ). The unequal distribution of specialists over the counties will hamper the goal of achieving universal health coverage ( 28 ). Decisions to relocate to, stay in, or move from a rural area are influenced by several factors, such as personal reasons, financial aspects, working and living conditions, family and community, including job and education opportunities for family members, and mandatory services or placement ( 29 , 30 ). The concentration of the main training institutions, such as the medical school and the main teaching hospital, in Monrovia, contributes to this urban-rural divide. Joharifard et al. described a significant change in surgical procedures in a rural hospital in Liberia after the arrival of a surgeon as compared to before with more varied and subspecialist procedures, such as oncologic and neonatal surgeries ( 31 ). Where specialists work in rural regions, this does not only increase access to quality services for patients. In addition, building the capacity of (rural) training centers has the potential to transform regional or district hospitals into more attractive training sites for e.g. interns/medical doctors, and nursing students ( 22 ). Training health workers locally has the added advantage of higher retention rate, in addition to a better preparing for the health system and context where they will work ( 29 , 32 ). Implications for the future: Health workforce strategies Despite the progress in addressing the health worker crisis in Liberia over the last decade, an important gap remains between the current specialist health workforce and the need for health services. With the expected population growth and current production rate of specialists, this gap is expected to increase further. Several strategies have demonstrated to effectively address health labor market challenges. These can broadly be divided into three main categories: strategies focusing on the production of health workers (education), addressing the inflows and outflows of qualified health workers (such as migration, retention, and recruitment of unemployed health professionals), and policies aiming to address maldistribution of the workforce and inefficiencies. The latter includes strategies to improve the productivity and performance of the existing health workforce, resolve skills-mix disparities, and promote the redistribution and retention of health workers in underserved regions ( 2 , 33 ). To mitigate the clustering of specialists in certain regions in Liberia, it is crucial to tackle structural causes. Efforts should focus on recruiting students from rural areas, establishing educational institutions nearby, and integrating rural exposure into training. Financial and non-financial incentives, along with supportive policies, are necessary to retain specialists in underserved regions, advancing equitable universal health coverage and ensuring access to specialized care nationwide ( 34 ). Liberia’s public sector retains most specialists post-training, offering the government an opportunity to influence workforce distribution. However, producing sufficient specialists remains a challenge, with only 15 graduates annually and the additional burden of fulfilling roles in service delivery, administration and governance, academia, and education. Mandatory rural service, expanding rural workers' scope, and creating specialized workforce categories, as recommended by WHO ( 29 ), can help address these gaps. Policies must balance strengthening primary care systems—essential for cost-effective, equitable health coverage—with increasing access to specialist care. Specialist training should align with broader health system goals, balancing the workforce mix to enhance efficiency and sustainability ( 35 ). Even though task-sharing has been an integrated part of the Liberian health system since the 1960’s through its physician assistant training program ( 36 ), and the more recently implemented task-sharing program for experienced midwives to perform emergency obstetric and neonatal care ( 37 ), conflicting views among medical doctors and stakeholders challenge the expansion of task-sharing into different areas ( 38 ). Establishing structures for financial advancement and continuous professional development are essential to maintain a skilled, productive and motivated workforce ( 34 ). The narratives of specialists working in rural areas emphasized the lack of resources and diagnostic tools to work with, resulting in frustration and demotivation. These challenges ultimately push professionals to return back to urban areas or to transition to private or dual practice. Addressing health worker factors (e.g., knowledge, skills, motivation), work factors (e.g., clinical guidelines), and the health facility environment (e.g., caseload, supervision, availability of equipment and supplies) not only supports retention but also ensures the sustained high-quality performance of health workers ( 39 ). Strengths and limitations This study provides a comprehensive overview of the impact of the first ten years postgraduate training in Liberia. The response rate among the graduates contributes to the legitimacy of the study, although we cannot account for 28% of graduates. Graduates working in rural areas might have challenges in participating in an online questionnaire, which could have underestimated the graduates working outside Montserrado County. The relatively small number of graduates per specialty limits the possibility of subgroup analysis. In addition, graduates performed a self-evaluation of the competences they gained during the postgraduate training, which provides a subjective view. Their answers were not validated with their actual job tasks and the services they delivered. Lastly, this study focused on graduates from the LCPS training in Liberia, and results are therefore not representative of the entire specialist workforce. Conclusion and Recommendations The LCPS has made significant strides in building the country’s specialist health workforce over the past decade, but challenges remain. Addressing faculty shortages, building institutional and academic capacity, improving training resources, and promoting research are critical to ensuring that the program produces well-rounded specialists. Furthermore, tackling geographic disparities in the distribution of specialists, enhancing career progression pathways, and fostering external collaborations will strengthen the LCPS program and improve healthcare outcomes in Liberia. Continuous investment in postgraduate training and professional development is essential to meet the evolving healthcare needs of Liberia and build a resilient and skilled specialist health workforce. Abbreviations ACRE IRB Atlantic Center for Research & Evaluation Institutional Review Board LCPS Liberia College of Physicians and Surgeons LMDC Liberia Medical and Dental Council WACP West-African College of Physicians WACS West-African College of Surgeons Declarations Ethics approval and consent to participate: The study was approved by the Atlantic Center for Research & Evaluation Institutional Review Board (ACRE IRB) in Liberia on 28 August 2023 (Reference number 23-08-383). Informed consent was obtained from all participants. Consent for publication: Not applicable. Availability of data and materials: The datasets generated and analysed during the current study are available from the corresponding author on reasonable request. Competing interests: BCA, PP and JM are working for the LCPS, the authority responsible for postgraduate training in Liberia. Funding: This study had no dedicated funding. It was conducted under a PhD grant from the Norwegian University of Science and Technology. Author’s contributions Conception, design, and data collection were conducted by JMB, DWA, BCA, AvD and HAB. The manuscript was prepared by JMB and DWA. All authors were involved in interpretation of the results and revision of the work. All authors have approved the final submitted version. Acknowledgements: Not applicable. References World Health Organization (WHO). Everybody’s business. Strengthening health systems to improve health outcomes. WHO’s framework for action. [Internet]. Geneva; 2007 [cited 2020 May 21]. 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Available from: https://link.springer.com/article/ 10.1007/s00268-021-06379-8 Liberia Institute of Statistics & Geo-Information Services. 2022 Liberia Population and Housing Census [Internet]. Monrovia; 2023 [cited 2024 Aug 14]. Available from: https://www.lisgis.gov.lr/document/LiberiaCensus2022Report.pdf Liberia College of Physicians and Surgeons. Resident Policies and Procedures Handbook (Revised 2019). 2019;1–27. Nettskjema [Internet]. [cited 2024 Dec 4]. Available from: https://nettskjema.no/ Jenkins R, Kydd R, Mullen P, Thomson K, Sculley J, Kuper S, et al. International Migration of Doctors, and Its Impact on Availability of Psychiatrists in Low and Middle Income Countries. PLoS One [Internet]. 2010 Feb 4 [cited 2024 Dec 27];5(2):e9049. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC2816209/ Ebeye T, Lee HE. Down the brain drain: a rapid review exploring physician emigration from West Africa. Glob Heal Res Policy [Internet]. 2023 Dec 1 [cited 2024 Oct 10];8(1):23. Available from: /pmc/articles/PMC10294534/ Rickard J. Systematic review of postgraduate surgical education in low- and middle-income countries. World J Surg [Internet]. 2016 Jun 1 [cited 2022 Oct 14];40(6):1324–35. Available from: https://link.springer.com/article/10.1007/s 00268-016-3445-x Ghebrehiwet S, Ogundare T, Owusu M, Harris BL, Ojediran B, Touma M, et al. Building a postgraduate psychiatry training program in Liberia through cross-country collaborations: initiation stages, challenges, and opportunities. Front Public Heal [Internet]. 2023 [cited 2024 Sep 17];11. Available from: /pmc/articles/PMC10505824/ Dahn B, Kerr L, Nuthulaganti T, Massaquoi M, Subah M, Yaman A, et al. Liberia’s first health workforce program strategy: Reflections and lessons learned. Ann Glob Heal [Internet]. 2021 Oct 8 [cited 2022 Jan 12];87(1). Available from: http://www.annalsofglobalhealth.org/articles/ 10.5334/aogh.3242/ Sanoe I, Beyan-Davies K, Anyango S, Ekwen G, Pierre J, Farley J, et al. The role of family medicine training in addressing workforce challenges in rural liberia – early implementation experience. Ann Glob Heal. 2021;87(1). Beddoe AM, Reis M, Benson A, Rehwaldt L, Mullbah J, Johnson J, et al. Community-Institutional Partnerships to Strengthen Maternal Health Care: Case Study of the First Obstetrics and Gynecology Specialty Training Program in Liberia. Front Public Heal [Internet]. Feb [cited 2024 Jun 20];9:779035. Available from: /pmc/articles/PMC8858838/ Liberia College of Physicians and Surgeons. The Liberia College of Physicians and Surgeons 5 Year Faculty Sustainability Plan for the Post-Graduate Medical Residency Training Program in Internal Medicine, Pediatrics, General Surgery, and Obstetrics and Gynecology. Monrovia; 2022. World Health Organization. WHO guideline on health workforce development, attraction, recruitment and retention in rural and remote areas [Internet]. 2021 [cited 2024 Dec 24]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK570760/ Hutch A, Bekele A, O’Flynn E, Ndonga A, Tierney S, Fualal J, et al. The Brain Drain Myth: Retention of Specialist Surgical Graduates in East, Central and Southern Africa, 1974–2013. World J Surg [Internet]. 2017 Dec 1 [cited 2024 Aug 22];41(12):3046–53. Available from: https://onlinelibrary.wiley.com/doi/full/ 10.1007/s00268-017-4307-x World Health Organization. Service Availability and Readiness Assessment (SARA) and Quality of Care 2018 Final Report [Internet]. Geneva; 2018 [cited 2025 Apr 18]. Available from: https://www.who.int/data/data-collection-tools/service-availability-and-readiness-assessment-(sara ) Adde HA, van Duinen AJ, Andrews BC, Bakker J, Goyah KS, Salvesen Ø, et al. Mapping population access to essential surgical care in Liberia using equipment, personnel, and bellwether capability standards. Br J Surg [Internet]. 2023 Jan 10 [cited 2023 May 10];110(2):169–76. Available from: https://academic.oup.com/bjs/article/110/2/169/6873880 World Health Organization. WHO guideline on health workforce development, attraction, recruitment and retention in rural and remote areas. Geneva; 2021. Lehmann U, Dieleman M, Martineau T. Staffing remote rural areas in middle- and low-income countries: A literature review of attraction and retention. BMC Health Serv Res [Internet]. 2008 Dec 23 [cited 2020 Mar 30];8(1):19. Available from: https://bmchealthservres.biomedcentral.com/articles/ 10.1186/1472-6963-8-19 Joharifard S, Price N, Ipanaqué JGY, Clarke RH, Nyemah E, Wallace AF, et al. The Impact of Implementing a Comprehensive Surgical Program on the Surgical Cohort at a Remote Referral Hospital in Southeastern Liberia. World J Surg 2019 443 [Internet]. 2019 Nov 13 [cited 2021 Oct 15];44(3):680–8. Available from: https://link.springer.com/article/ 10.1007/s00268-019-05277-4 Russell D, Mathew S, Fitts M, Liddle Z, Murakami-Gold L, Campbell N, et al. Interventions for health workforce retention in rural and remote areas: a systematic review. Hum Resour Health [Internet]. 2021 Dec 1 [cited 2024 Dec 24];19(1):1–24. Available from: https://human-resources-health.biomedcentral.com/articles/ 10.1186/s12960-021-00643-7 Witter S, Hamza MM, Alazemi N, Alluhidan M, Alghaith T, Herbst CH. Human resources for health interventions in high- and middle-income countries: findings of an evidence review. Hum Resour Heal 2020 181 [Internet]. 2020 Jun 8 [cited 2021 Oct 16];18(1):1–17. Available from: https://human-resources-health.biomedcentral.com/articles/ 10.1186/s12960-020-00484-w Dormon F, Balen J, Schmidtke KA, Vlaev I. Healthworkers’ motivation in low- and middle-income countries: A systematic review of the literature. Med Res Arch [Internet]. 2017 [cited 2024 Dec 27];5(8). Available from: https://esmed.org/MRA/mra/article/view/1423/1150 Sriram V, Bennett S. Strengthening medical specialisation policy in low-income and middle-income countries. BMJ Glob Heal [Internet]. 2020 Feb 11 [cited 2021 Oct 16];5(2):2053. Available from: /pmc/articles/PMC7042575/ Liberia National Physician Assistants Association [Internet]. [cited 2025 Jan 10]. Available from: https://www.liberiapas.org/ Dolo O, Clack A, Gibson H, Lewis N, Southall DP. Training of midwives in advanced obstetrics in Liberia. Bull World Health Organ [Internet]. 2016 May 1 [cited 2025 Jan 2];94(5):383. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC4850529/ Werz MJ, van Duinen AJ, Hampaye TC, van den Broek A, Bolkan HA. Exploring barriers and enabling factors for surgical task sharing with physician assistants in Liberia: a qualitative pre-implementation study. BMJ Open [Internet]. 2024 Jul 1 [cited 2024 Oct 10];14(7):e081363. Available from: https://bmjopen.bmj.com/content/14/7/e081363 Rowe AK, de Savigny D, Lanata CF, Victora CG. How can we achieve and maintain high-quality performance of health workers in low-resource settings? Lancet [Internet]. 2005 [cited 2020 Feb 19];366(9490):1026–35. Available from: https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(05)67028-6.pdf Additional Declarations Competing interest reported. BCA, PP and JM have a leadership role in the LCPS, the authority responsible for postgraduate training in Liberia. Supplementary Files Supplementarymaterials.docx Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 01 Sep, 2025 Reviews received at journal 30 Aug, 2025 Reviews received at journal 25 Aug, 2025 Reviewers agreed at journal 25 Aug, 2025 Reviewers agreed at journal 14 Aug, 2025 Reviewers invited by journal 11 Aug, 2025 Editor assigned by journal 11 May, 2025 Submission checks completed at journal 11 May, 2025 First submitted to journal 09 May, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6629290","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":500615023,"identity":"b2bf0fd8-35c7-4096-8796-e7cea0bf52ca","order_by":0,"name":"Juul M. Bakker","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA1UlEQVRIiWNgGAWjYBACxgYGxgNAOoGBhw1IVRCnhQFJyxkGCaJsQmhhbCNCC/OMHIMDjDkMefw9xxIfV867U2cukcD24AM+h4G1bGMoljjbdtjw7LZnEpYzEtgNZxChJbHhPHubZOO2wxIGNxLYpHmI0TL/PHv7z8Y5pGjZcLbtGGNjAzFaep4VHEjcJlFseOZYsmTDscOSG848bJPE5xfD9uSNDz5us8mTO5Nm+LGh5jC/wfHkYxL4QsywgQEUKSixAYpePEAer+woGAWjYBSMAhAAAKb+UOql4VXMAAAAAElFTkSuQmCC","orcid":"","institution":"Norwegian University of Science and Technology (NTNU)","correspondingAuthor":true,"prefix":"","firstName":"Juul","middleName":"M.","lastName":"Bakker","suffix":""},{"id":500615024,"identity":"bc3d48f4-0ed4-4e53-a794-349167facc15","order_by":1,"name":"Douglas Weru Alice","email":"","orcid":"","institution":"Norwegian University of Science and Technology (NTNU)","correspondingAuthor":false,"prefix":"","firstName":"Douglas","middleName":"Weru","lastName":"Alice","suffix":""},{"id":500615026,"identity":"f578182a-776d-47fb-830b-284b582a14ac","order_by":2,"name":"Benetta Collins Andrews","email":"","orcid":"","institution":"Liberia College of Physicians and Surgeons (LCPS)","correspondingAuthor":false,"prefix":"","firstName":"Benetta","middleName":"Collins","lastName":"Andrews","suffix":""},{"id":500615027,"identity":"6885df82-e206-431b-92f8-55361c1c55e8","order_by":3,"name":"Philderald Pratt","email":"","orcid":"","institution":"Liberia College of Physicians and Surgeons (LCPS)","correspondingAuthor":false,"prefix":"","firstName":"Philderald","middleName":"","lastName":"Pratt","suffix":""},{"id":500615028,"identity":"ae416d96-830c-4576-8756-ef0f60f7a702","order_by":4,"name":"John Mulbah","email":"","orcid":"","institution":"Liberia College of Physicians and Surgeons (LCPS)","correspondingAuthor":false,"prefix":"","firstName":"John","middleName":"","lastName":"Mulbah","suffix":""},{"id":500615029,"identity":"8992664f-a3ff-4337-9766-1db6e2ad8b08","order_by":5,"name":"Alex J. van Duinen","email":"","orcid":"","institution":"Norwegian University of Science and Technology (NTNU)","correspondingAuthor":false,"prefix":"","firstName":"Alex","middleName":"J. van","lastName":"Duinen","suffix":""},{"id":500615030,"identity":"35b7da18-3f9f-476b-9b89-67d272e35042","order_by":6,"name":"Hakon A. Bolkan","email":"","orcid":"","institution":"Norwegian University of Science and Technology (NTNU)","correspondingAuthor":false,"prefix":"","firstName":"Hakon","middleName":"A.","lastName":"Bolkan","suffix":""}],"badges":[],"createdAt":"2025-05-09 13:53:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6629290/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6629290/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":89543915,"identity":"88dc58cd-239e-4d96-9591-ea1118a92988","added_by":"auto","created_at":"2025-08-21 06:55:14","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":39813,"visible":true,"origin":"","legend":"\u003cp\u003eTotal number of graduates and respondents by specialization.\u003c/p\u003e","description":"","filename":"Figure1PNG.png","url":"https://assets-eu.researchsquare.com/files/rs-6629290/v1/2ca20bc421a8134b323a871c.png"},{"id":89542435,"identity":"43e52463-7fc8-446e-b33f-6542ad79f33e","added_by":"auto","created_at":"2025-08-21 06:47:14","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":250080,"visible":true,"origin":"","legend":"\u003cp\u003eCounty of origin of respondents (2A, n=83), work location of respondents (2B, n=87), and work location of all graduates (n=113)\u003c/p\u003e","description":"","filename":"Figure2white.png","url":"https://assets-eu.researchsquare.com/files/rs-6629290/v1/8604302e00336bad11b93ba0.png"},{"id":89544589,"identity":"4fbc9cb1-4968-4d67-b791-06150f1cc97e","added_by":"auto","created_at":"2025-08-21 07:03:14","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":70128,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eOverview of responses by competencies and by specialization\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Figure3PNG.png","url":"https://assets-eu.researchsquare.com/files/rs-6629290/v1/839870a5c2d42a716f7dc5cf.png"},{"id":89544588,"identity":"5be87ad6-630e-46d9-aa6b-a3442975e953","added_by":"auto","created_at":"2025-08-21 07:03:14","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":53022,"visible":true,"origin":"","legend":"\u003cp\u003eMotivational factors before and after postgraduate training\u003c/p\u003e","description":"","filename":"Figure4PNG.png","url":"https://assets-eu.researchsquare.com/files/rs-6629290/v1/d919fd070494e25e10735c1c.png"},{"id":89545486,"identity":"2682d4ae-1c7e-4fd8-b7cb-7c96e5d6335a","added_by":"auto","created_at":"2025-08-21 07:11:15","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1141262,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6629290/v1/79df0695-f9f5-43d7-896f-bb3614d34ccb.pdf"},{"id":89542431,"identity":"11f8709a-ace9-4b98-8906-df4cc3d76dc9","added_by":"auto","created_at":"2025-08-21 06:47:14","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":30663,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementarymaterials.docx","url":"https://assets-eu.researchsquare.com/files/rs-6629290/v1/62a6f4650baddc22f141534b.docx"}],"financialInterests":"Competing interest reported. BCA, PP and JM have a leadership role in the LCPS, the authority responsible for postgraduate training in Liberia.","formattedTitle":"Transforming Healthcare: Evaluating a Decade of Postgraduate Training at the Liberia College of Physicians and Surgeons","fulltext":[{"header":"Background","content":"\u003cp\u003eThe workforce is a cornerstone of any health system and is playing a vital role in improving health service coverage (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). In 2016, the World Health Organization introduced the \u0026ldquo;Workforce 2030\u0026rdquo; a global strategy on human resources for health (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). The strategy emphasizes achieving effective health worker coverage through adequate availability, acceptability, accessibility, quality, and service utilization. To enhance coverage, it is essential to optimize the health workforce, prepare for future needs, build institutional capacity, and strengthen data on human resources for health (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eHealth workforce in Liberia\u003c/p\u003e\u003cp\u003eLiberia is a low-income country in West-Africa with persistent critical health worker shortages. The civil war between 1989 and 2003 severely affected the health system, the education of health workers collapsed, many practicing health care workers left the country, reducing the number of employees in the public health sector from 3,526 to 1,396 (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). A human resource census in 2009 totaled 67 doctors and 23 surgeons for a population of 3.9\u0026nbsp;million at the time (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e), making the country heavily reliant on external aid and non-governmental organizations (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Nearly 70% of the health workforce consisted of unskilled or non-clinical staff, highlighting a significant need to expand and strengthen the workforce, particularly by increasing the number of doctors, physician assistants and certified midwives (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eWhile Liberia was still in the phase of rebuilding the health system and workforce after the civil war, it was faced with the West-African Ebola Virus disease outbreak in 2014\u0026ndash;2016, claiming the lives of 8% of all healthcare workers (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). In addition, an unknown number of healthcare workers left their work, either out of fear of contracting Ebola or pressured by relatives or communities, further disrupting healthcare services (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e\u003cp\u003ePost-Ebola, Liberia continued to have one of the lowest densities of healthcare workers globally with 0.04 physicians per 1,000 people (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e), far from the WHO estimate for adequate coverage at a minimum 2.5 per 1,000 population. The Liberia Health Workforce Plan 2015\u0026ndash;2021, developed by the Government of Liberia, outlined strategies and priorities to (re)build the health workforce (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Priority areas of intervention included building a fit-for-purpose workforce by increasing the number of health workers, improving education quality, and diversifying skills. The strategy targeted five key cadres: community health workers, health managers, registered midwives, registered nurses, and physicians (both general and specialist). For physicians, the aim was to raise annual medical education enrollment from about 40 to 125 while specialists training targeted an increase from 18 to 24 annual enrollments by 2021 (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Despite limited specialty training programs in Liberia, there was a strong emphasis on developing national capacity to produce specialists essential for strengthening the medical and clinical education systems.\u003c/p\u003e\u003cp\u003eEstablishment of the Liberia College of Physicians and Surgeons (LCPS)\u003c/p\u003e\u003cp\u003eIn 2012 the LCPS was established by an Act of Legislation to train and qualify specialists in Liberia (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Through international partnerships and donors, funding for the program was secured and the core faculties were strengthened by international consultants. Initially, four faculties were developed to start postgraduate medical residency training in the disciplines of General surgery, Internal medicine, Obstetrics and Gynecology, and Pediatrics. The training structure and curricula were modelled after regional programs of the West-African College of Physicians (WACP) and the West-African College of Surgeons (WACS). The programs are nationally accredited by the LCPS and regionally by the WACP and WACS. Postgraduate training began in September 2013 but was suspended for 10 months during the Ebola outbreak. The first Liberian-trained specialists in Surgery, Internal Medicine, Obstetrics and Gynecology and Pediatrics were inducted in 2017. In the following years, additional faculties were established, including Family Medicine (2017), Ophthalmology (2019), Psychiatry (2019), and Community Medicine (2023).\u003c/p\u003e\u003cp\u003eCurrent workforce in Liberia\u003c/p\u003e\u003cp\u003eThere are no unified figures for the actual number of medical doctors in Liberia. The WHO National Health Workforce Accounts reported 954 medical doctors in 2022, of whom 84 general practitioners and 114 specialists (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e), whereas according to the Liberia Medical and Dental Council (LMDC), the number of specialists had increased from 15 to 120 Liberian specialist between 2012 and 2019, as well as 248 non-Liberian specialists (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Most healthcare services are delivered by non-specialist providers, even though a survey among medical school graduates showed that less than half of them assessed themselves as fully competent (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Between 2013 and 2023, 125 Liberian-trained specialists across seven specialties were inducted by the LCPS at membership level. In 2018, 48 out of the 67 (71.6%) surgical specialists, including obstetricians and gynecologists and ophthalmologists, worked in Montserrado County, the capital region (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAim of this study\u003c/p\u003e\u003cp\u003eThe retention, employment locations, roles, and relevance of the knowledge and skills acquired by specialists trained under the LCPS postgraduate training program remain unclear. This study aims to evaluate the impact of a decade of postgraduate training by assessing program outcomes and alumni competencies, with the goal of improving the program and guiding continuous professional development efforts.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eStudy design\u003c/p\u003e\u003cp\u003eIn this cross-sectional, survey-based study, all graduates of the LCPS membership program were requested to participate in an online survey to examine the effectiveness and appropriateness of postgraduate training in Liberia.\u003c/p\u003e\u003cp\u003eSetting\u003c/p\u003e\u003cp\u003eLiberia is a low-income West African country with 5.3\u0026nbsp;million inhabitants. It is divided into 15 counties, with Montserrado County including the capital Monrovia being the most populous (1.9\u0026nbsp;million) (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). The A.M. Dogliotti School of Medicine under the University of Liberia, the only medical school in the country, enrolled about 40 students annually in 2015 (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). In 2021, its curriculum was updated to a seven-year integrated, competency-based program and new faculty were trained in basic sciences and teaching methods (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). After graduation, a one-year internship in general surgery, internal medicine, obstetrics and gynecology, and pediatrics and a year of rural service are required before applying for postgraduate residency training under the LCPS. Residency programs, primarily based at John F. Kennedy Medical Center in Monrovia, include three years of training with rotations at various departments and at additional nationally and regionally accredited hospitals, leading to LCPS membership after a final examination (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). A two-year fellowship program is also available for some specializations.\u003c/p\u003e\u003cp\u003eStudy population and tools\u003c/p\u003e\u003cp\u003eThis study included all medical doctors who completed their postgraduate training under the LCPS from inception in 2013 to September 2023. Residents who were still in training at the time of the study, who had dropped out during training, or Liberian specialists who specialized abroad were not eligible for inclusion. An online questionnaire (Supplementary material) retrieved demographic information, educational background, current and previous work situation, and a self-evaluation of medical competencies gained during the postgraduate training. The 15 question self-assessment was framed to evaluate seven core competencies the LCPS wanted the postgraduate trainees to acquire during training (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). These competencies included patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, systems-based practice, and teaching. Participants were asked to evaluate each competence on a 5-point Likert scale (strongly disagree, disagree, neutral, agree, strongly agree). In addition, questions were asked about several aspects of the training, such as feedback, examination and research during the postgraduate training, and a reflection on their motivation before and after the training.\u003c/p\u003e\u003cp\u003eData collection\u003c/p\u003e\u003cp\u003eData collection took place between September and December 2023. The questionnaire was disseminated to all 125 graduates of LCPS postgraduate training through the online platform Nettskjema (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). All graduates were contacted by phone call, email, WhatsApp or text message, or a combination. Each person was contacted at least three times and in different ways before concluding as a non-responder. To optimize the response rate, two presentations were held at the main teaching hospital in Liberia (John F. Kennedy Medical Centre) and at the annual scientific meeting of the LCPS to explain the purpose of the study. In addition, several larger hospitals across Liberia were visited to distribute information about the study.\u003c/p\u003e\u003cp\u003eData analysis and ethical considerations\u003c/p\u003e\u003cp\u003eData was exported from Nettskjema to Microsoft Excel (Microsoft Corporation, USA) for processing and descriptive statistics. Personal identifiers were removed prior to analysis. Where applicable, answers to open questions were transformed into categorical variables. Analysis was performed for the complete data set and stratified by specialization. The study was approved by the Atlantic Center for Research \u0026amp; Evaluation Institutional Review Board (ACRE IRB) in Liberia on 28 August 2023 (Reference number 23-08-383).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eResponse rate\u003c/p\u003e\u003cp\u003eThe response rate to the questionnaire was 72.0% (90 of 125) varying between 53.3% for Family Medicine and 100.0% for Psychiatry. For all specialists' tracks, the response rate was more than 50%, and for all but Family Medicine and Obstetrics \u0026amp; Gynecology it was above 70% (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). For the majority of the 34 non-responders the reason not to participate is unknown, whereas two were not able to complete the questionnaire due to internet problems, and one indicated not to have time to participate.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eDemographics\u003c/p\u003e\u003cp\u003eSixty percent of the respondents was male and 40.0% female, compared to 64.0 and 36.0% of all graduates, respectively (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The median age at graduation was 37.5 years. Most respondents (92.2%) were Liberian nationals. Twenty-seven (30.0%) had pursued an additional education after completing the membership level of postgraduate training. The most common additional training was postgraduate training at fellowship level (17 of 90), or a master\u0026rsquo;s degree (7 of 90), most often within public health. The majority (76.6%) finalized their training within three years. Two thirds of those who took 4\u0026ndash;5 years were in the first cohort that started in 2013, whose training was affected by the Ebola outbreak.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDemographics, employment and education status of respondents.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eGraduates (n\u0026thinsp;=\u0026thinsp;125)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eRespondents (n\u0026thinsp;=\u0026thinsp;90)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGender\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e45 (36.0%)\u003c/p\u003e\u003cp\u003e80 (64.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e36 (40.0%)\u003c/p\u003e\u003cp\u003e54 (60.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMedian years between medical school and residency training (IQR)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2 (\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMedian age at end of residency program (IQR)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e37.5 (34\u0026ndash;42) years\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNationality\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eLiberian\u003c/p\u003e\u003cp\u003eOther\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e83 (92.2%)\u003c/p\u003e\u003cp\u003e7 (7.8%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eCurrent function\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eClinical\u003c/p\u003e\u003cp\u003e\u003cem\u003eSpecialist\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eConsultant\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eFellow\u003c/em\u003e\u003c/p\u003e\u003cp\u003eClinical/Admin\u003c/p\u003e\u003cp\u003e\u003cem\u003eMedical director\u003c/em\u003e\u003c/p\u003e\u003cp\u003eAdministrative\u003c/p\u003e\u003cp\u003e\u003cem\u003eMOH/CHO\u003c/em\u003e\u003csup\u003e\u003cem\u003e#\u003c/em\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eAdministrative\u003c/em\u003e\u003c/p\u003e\u003cp\u003eOther\u003c/p\u003e\u003cp\u003e\u003cem\u003eLeave\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eOther\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e94 (75.2%)\u003c/p\u003e\u003cp\u003e-\u003c/p\u003e\u003cp\u003e-\u003c/p\u003e\u003cp\u003e-\u003c/p\u003e\u003cp\u003e8 (6.4%)\u003c/p\u003e\u003cp\u003e-\u003c/p\u003e\u003cp\u003e11 (8.8%)\u003c/p\u003e\u003cp\u003e-\u003c/p\u003e\u003cp\u003e-\u003c/p\u003e\u003cp\u003e12 (9.6%)\u003c/p\u003e\u003cp\u003e7 (5.6%)\u003c/p\u003e\u003cp\u003e5 (4.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e70 (77.8%)\u003c/p\u003e\u003cp\u003e51 (56.7%)\u003c/p\u003e\u003cp\u003e17 (18.9%)\u003c/p\u003e\u003cp\u003e2 (2.2%)\u003c/p\u003e\u003cp\u003e13 (14.4%)\u003c/p\u003e\u003cp\u003e13 (14.4%)\u003c/p\u003e\u003cp\u003e6 (6.7%)\u003c/p\u003e\u003cp\u003e3 (3.3%)\u003c/p\u003e\u003cp\u003e3 (3.3%)\u003c/p\u003e\u003cp\u003e1 (1.1%)\u003c/p\u003e\u003cp\u003e-\u003c/p\u003e\u003cp\u003e1 (1.1%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003ePosition\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFull-time\u003c/p\u003e\u003cp\u003ePart-time\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e89 (98.9%)\u003c/p\u003e\u003cp\u003e1 (1.1%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eSector\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePublic\u003c/p\u003e\u003cp\u003ePrivate\u003c/p\u003e\u003cp\u003eOther\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e102 (81.6%)\u003c/p\u003e\u003cp\u003e9 (7.2%)\u003c/p\u003e\u003cp\u003e14 (11.2%)\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e85 (94.4%)\u003c/p\u003e\u003cp\u003e3 (3.3%)\u003c/p\u003e\u003cp\u003e2 (2.2%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eAdditional work\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003cp\u003e\u003cem\u003ePrivate practice\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eTeaching\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eOther\u003c/em\u003e\u003c/p\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003cp\u003e-\u003c/p\u003e\u003cp\u003e-\u003c/p\u003e\u003cp\u003e-\u003c/p\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e19 (21.1%)\u003c/p\u003e\u003cp\u003e10 (11.1%)\u003c/p\u003e\u003cp\u003e6 (6.7%)\u003c/p\u003e\u003cp\u003e3 (3.3%)\u003c/p\u003e\u003cp\u003e71 (78.9%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eMedian months working in current job (IQR)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e24 (11\u0026ndash;52)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDuration of residency training\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eWithin 3 years\u003c/p\u003e\u003cp\u003eMore than 3 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e69 (76.7%)\u003c/p\u003e\u003cp\u003e21 (23.3%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAdditional education\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eMaster\u0026rsquo;s degree\u003c/p\u003e\u003cp\u003eFellowship\u003c/p\u003e\u003cp\u003eOther\u003c/p\u003e\u003cp\u003eNone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003cp\u003e-\u003c/p\u003e\u003cp\u003e-\u003c/p\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e7 (7.8%)\u003c/p\u003e\u003cp\u003e17 (18.9%)\u003c/p\u003e\u003cp\u003e3 (3.3%)\u003c/p\u003e\u003cp\u003e63 (70%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eCo-authored publications\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNone\u003c/p\u003e\u003cp\u003e1\u0026ndash;2\u003c/p\u003e\u003cp\u003e3\u0026ndash;5\u003c/p\u003e\u003cp\u003e\u0026gt;\u0026thinsp;5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003cp\u003e-\u003c/p\u003e\u003cp\u003e-\u003c/p\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e37 (41.1%)\u003c/p\u003e\u003cp\u003e32 (35.6%)\u003c/p\u003e\u003cp\u003e12 (13.3%)\u003c/p\u003e\u003cp\u003e9 (10.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003csup\u003e\u003cem\u003e#\u003c/em\u003e\u003c/sup\u003e \u003cem\u003eMOH\u0026thinsp;=\u0026thinsp;Ministry of Health, CHO\u0026thinsp;=\u0026thinsp;County Health Office, * includes 7 on leave (study/absence)\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003cem\u003e* Excluding ophthalmology (n\u0026thinsp;=\u0026thinsp;3) and psychiatry (n\u0026thinsp;=\u0026thinsp;3)\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eWork location and history\u003c/p\u003e\u003cp\u003eMost of the graduates (94.4%) worked in the governmental sector, whereas 3.3% worked in the private sector and 2.2% in other sectors (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Even though only one person specified to work in a part-time position, 21.1% percent of the respondents indicated to have a second job next to their first employment. These second employments were mostly in the private sector or in teaching. Most respondents indicated their additional work taking place in evening hours or weekends.\u003c/p\u003e\u003cp\u003eRespondents originated from all but one county in Liberia (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eA). According to the LCPS, 12 graduates were currently abroad (9.6%). All counties have at least one specialist who graduated from the program, apart from Gbarpolu (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eC). Our study found that after residency training, 54.4% percent of the respondents worked in Montserrado County, while in 8 counties there was only one or no respondent (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eB). This was similar to the distribution among all graduates, where 51.2% worked in Montserrado. The median time respondents worked in their current job was 24 months (IQR 11\u0026ndash;52). Forty-three respondents (47.8%) also provided information about their previous work history. Out of these 43, eleven (25.6%) remained in the same county. Out of the 23 people who worked in Montserrado prior to their current job, only 8 remained in Montserrado, whereas 15 are currently working in other counties. Specialists in Obstetrics \u0026amp; Gynecology were most spread with graduates working in 9 different counties, and 47.9% working outside Montserrado County.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eEvaluation of competence\u003c/p\u003e\u003cp\u003eOverall, the graduates were confident with the competencies gained during the postgraduate training (Supplementary Table\u0026nbsp;1). The highest rated competencies were medical knowledge, teaching, professionalism and system-based practice with over 96% of graduates assessing themselves as competent, whereas 44.3% felt competent to perform research, and 74.4% indicated that the curriculum adequately covered all clinical subjects that they need in their work (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Although 50.6% of the respondents agreed with the statement that they had opportunities to engage in research activities, 58.9% of the respondents had (co-)authored research publications at the time of study. Almost all graduates (95.5%) reported that the training has provided them with opportunities for career growth and would recommend it to junior colleagues. There were only slight differences between the various specializations. Graduates in psychiatry rated their competence highest with an average score of 88.3%. With still an average score of 81.4% of the maximum, this was lowest for pediatrics.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eMotivational factors\u003c/p\u003e\u003cp\u003eThe main motivational factors to enroll in postgraduate training were interest in patient care, personal interest in the subject, and a desire to become an expert in the field. Motivational factors that reduced most during postgraduate training were financial benefits (44.8\u0026ndash;18.4%) and desire to become expert in the field (83.9\u0026ndash;58.6%) (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). External factors, such as financial benefits, career development, and improving job prospects reduced more than patient-related factors or clinical aspects.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eSuggestions\u003c/p\u003e\u003cp\u003eThirty-eight graduates offered open-ended replies and expressed both strengths and challenges with the training program, as well as suggestions for improvement of the program. Several graduates praised the program for enhancing their medical knowledge and skills, enabling them to deliver high-quality patient care. They also emphasized the importance of postgraduate training in improving health systems and contributing to the national healthcare workforce. Common criticisms included the lack of adequate mentorship due to overburdened faculty, insufficient training resources such as laboratory and imaging facilities, and poor infrastructure, including inadequate resident housing and minimal salary progression after specialization. The shortage of faculty, particularly for hands-on training was frequently cited. Additionally, many respondents expressed concerns about the lack of research opportunities and external rotations to other institutions. Suggestions for improvement of the training program included increasing faculty numbers, especially in subspecialties, improving research and publishing training, providing better investigative tools, and enhancing collaboration with external organizations and faculty during rotations. Addressing salary disparities and career progression post-graduation were also highlighted as key areas for improvement.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eKey findings\u003c/p\u003e\u003cp\u003eThis study examines ten years of postgraduate training in Liberia, highlighting a high domestic retention rate among graduates, most of whom contribute to clinical service delivery in the public sector. The competencies gained through the postgraduate training were perceived relevant and well-aligned with their current work responsibilities.\u003c/p\u003e\u003cp\u003eImpact of postgraduate training in Liberia on the health system\u003c/p\u003e\u003cp\u003eBefore the establishment of postgraduate training in Liberia, the country suffered from a severe shortage of specialist and the country relied exclusively on regional and international support to train its doctors, leading to issues with affordability, accessibility, and retention (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Many trained abroad did not return, exacerbating the scarcity of specialists within the country (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). The establishment of postgraduate training in Liberia addressed these challenges by building local capacity to produce specialists tailored to the nation\u0026rsquo;s specific health system needs. The local training of 125 specialists represents a significant milestone, directly contributing to improving access to specialized healthcare services and reducing the dependency on foreign-trained professionals. Results from this study clearly demonstrate that the graduates assess their competencies to be relevant and adequate for the functions required of them. The graduated specialists have strengthened the public health facilities and likely enhanced clinical service delivery. Postgraduate training is a mostly hands-on, in-service training of health workers, and thus the quality and level of service delivery in the system where people are trained directly influences the quality of the training. Therefore, training programs can boost service delivery and vice versa. Looking ahead, greater emphasis should be placed on strengthening academic competencies, particularly research and methodology training. These were identified by graduates as their least developed skills but are crucial for practicing context adapted evidence-based medicine and building academic capacity. Regional collaboration with WACP and WACS enhances opportunities for graduates to register with regional colleges and pursue additional fellowship education (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eBoth Dahn et al. (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e) and Sanoe et al. (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e) emphasize the importance of building academic and institutional capacity and infrastructure to successfully educate health workers. Specialists have an essential role in the strengthening of the health system, as well as to ensure sustainability and self-reliance of the training program. From its inception in 2013, the program has been designed to support national capacity building. Initially, the postgraduate training program was heavily dependent on external resources, both in terms of funding as well as faculty for teaching and service gaps. Several partnerships with international institutions were formed (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). The faculty employed under the Health Workforce Program funded by the World Bank during the initial five years of postgraduate training has played an important role in advancing the faculty pipeline and has developed a foundation for further mentorship and education of the next generation of specialists in Liberia. Most of the international faculty deployed under the program were from the West-African region, which not only ensured alignment of the training with the accreditation requirements and curricula of the regional bodies of WACP and WACS but also strengthened the quality of training and collaboration between faculty in the region. Despite these efforts, currently there is still an important role for collaboration until the number of fully Liberian-trained specialists and Liberian faculty has increased further. In the 2022 Faculty Sustainability Plan, the LCPS specified a pathway towards sustainability of the program, which included a minimum of five additional academic years of core visiting and sub-specialist faculty needs, as well as the need for a progressive increase of the government budget allocation towards the LCPS training program (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eRetention and distribution\u003c/p\u003e\u003cp\u003eA significant challenge in healthcare systems in low-income countries is attracting and retaining health workers in the country after training, and to distribute them according to the needs (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). The migration of well-trained health workers to other countries resulting in \u0026ldquo;brain drain\u0026rdquo; is a major issue in some West-African countries, with especially Nigeria and Ghana being among the largest \u0026ldquo;supplier countries\u0026rdquo; (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Among the specialists in Liberia, there was mostly temporary migration for education purposes. A study among the surgical specialists trained under the Colleges of Surgeons of East, Central and Southern Africa (COSECSA) also found high retention rates with 85% of graduates remaining in the country where they were trained, and 88% in the region (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAt the level of medical specialists, Liberia may be experiencing a \u0026ldquo;brain gain\u0026rdquo; benefitting from the contribution of international specialists, primarily from West and East Africa, as well as the return of Liberian professionals trained abroad who are reintegrating into the national health system. However, the data presented in this paper do not account for internal migration, wherein specialists transition from the public sector to the private health sector. This shift poses a significant challenge to equitable access to healthcare services. In recent years, there has been a rapid increase in private health facilities in Liberia, particularly in urban areas (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn addition, we observed that more than half of the respondents in this study worked in Montserrado county, where approximately one third of the Liberian population lives. At the same time, in rural areas the health care system still heavily relies on non-specialist medical doctors and non-physicians to provide care (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). The unequal distribution of specialists over the counties will hamper the goal of achieving universal health coverage (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). Decisions to relocate to, stay in, or move from a rural area are influenced by several factors, such as personal reasons, financial aspects, working and living conditions, family and community, including job and education opportunities for family members, and mandatory services or placement (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). The concentration of the main training institutions, such as the medical school and the main teaching hospital, in Monrovia, contributes to this urban-rural divide. Joharifard et al. described a significant change in surgical procedures in a rural hospital in Liberia after the arrival of a surgeon as compared to before with more varied and subspecialist procedures, such as oncologic and neonatal surgeries (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). Where specialists work in rural regions, this does not only increase access to quality services for patients. In addition, building the capacity of (rural) training centers has the potential to transform regional or district hospitals into more attractive training sites for e.g. interns/medical doctors, and nursing students (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Training health workers locally has the added advantage of higher retention rate, in addition to a better preparing for the health system and context where they will work (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eImplications for the future: Health workforce strategies\u003c/p\u003e\u003cp\u003eDespite the progress in addressing the health worker crisis in Liberia over the last decade, an important gap remains between the current specialist health workforce and the need for health services. With the expected population growth and current production rate of specialists, this gap is expected to increase further. Several strategies have demonstrated to effectively address health labor market challenges. These can broadly be divided into three main categories: strategies focusing on the production of health workers (education), addressing the inflows and outflows of qualified health workers (such as migration, retention, and recruitment of unemployed health professionals), and policies aiming to address maldistribution of the workforce and inefficiencies. The latter includes strategies to improve the productivity and performance of the existing health workforce, resolve skills-mix disparities, and promote the redistribution and retention of health workers in underserved regions (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eTo mitigate the clustering of specialists in certain regions in Liberia, it is crucial to tackle structural causes. Efforts should focus on recruiting students from rural areas, establishing educational institutions nearby, and integrating rural exposure into training. Financial and non-financial incentives, along with supportive policies, are necessary to retain specialists in underserved regions, advancing equitable universal health coverage and ensuring access to specialized care nationwide (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). Liberia\u0026rsquo;s public sector retains most specialists post-training, offering the government an opportunity to influence workforce distribution. However, producing sufficient specialists remains a challenge, with only 15 graduates annually and the additional burden of fulfilling roles in service delivery, administration and governance, academia, and education. Mandatory rural service, expanding rural workers' scope, and creating specialized workforce categories, as recommended by WHO (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e), can help address these gaps. Policies must balance strengthening primary care systems\u0026mdash;essential for cost-effective, equitable health coverage\u0026mdash;with increasing access to specialist care. Specialist training should align with broader health system goals, balancing the workforce mix to enhance efficiency and sustainability (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). Even though task-sharing has been an integrated part of the Liberian health system since the 1960\u0026rsquo;s through its physician assistant training program (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e), and the more recently implemented task-sharing program for experienced midwives to perform emergency obstetric and neonatal care (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e), conflicting views among medical doctors and stakeholders challenge the expansion of task-sharing into different areas (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eEstablishing structures for financial advancement and continuous professional development are essential to maintain a skilled, productive and motivated workforce (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). The narratives of specialists working in rural areas emphasized the lack of resources and diagnostic tools to work with, resulting in frustration and demotivation. These challenges ultimately push professionals to return back to urban areas or to transition to private or dual practice. Addressing health worker factors (e.g., knowledge, skills, motivation), work factors (e.g., clinical guidelines), and the health facility environment (e.g., caseload, supervision, availability of equipment and supplies) not only supports retention but also ensures the sustained high-quality performance of health workers (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eStrengths and limitations\u003c/p\u003e\u003cp\u003eThis study provides a comprehensive overview of the impact of the first ten years postgraduate training in Liberia. The response rate among the graduates contributes to the legitimacy of the study, although we cannot account for 28% of graduates. Graduates working in rural areas might have challenges in participating in an online questionnaire, which could have underestimated the graduates working outside Montserrado County. The relatively small number of graduates per specialty limits the possibility of subgroup analysis. In addition, graduates performed a self-evaluation of the competences they gained during the postgraduate training, which provides a subjective view. Their answers were not validated with their actual job tasks and the services they delivered. Lastly, this study focused on graduates from the LCPS training in Liberia, and results are therefore not representative of the entire specialist workforce.\u003c/p\u003e"},{"header":"Conclusion and Recommendations","content":"\u003cp\u003eThe LCPS has made significant strides in building the country\u0026rsquo;s specialist health workforce over the past decade, but challenges remain. Addressing faculty shortages, building institutional and academic capacity, improving training resources, and promoting research are critical to ensuring that the program produces well-rounded specialists. Furthermore, tackling geographic disparities in the distribution of specialists, enhancing career progression pathways, and fostering external collaborations will strengthen the LCPS program and improve healthcare outcomes in Liberia. Continuous investment in postgraduate training and professional development is essential to meet the evolving healthcare needs of Liberia and build a resilient and skilled specialist health workforce.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eACRE IRB\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Atlantic Center for Research \u0026amp; Evaluation Institutional Review Board\u003c/p\u003e\n\u003cp\u003eLCPS\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Liberia College of Physicians and Surgeons\u003c/p\u003e\n\u003cp\u003eLMDC\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Liberia Medical and Dental Council\u003c/p\u003e\n\u003cp\u003eWACP\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;West-African College of Physicians\u003c/p\u003e\n\u003cp\u003eWACS \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; West-African College of Surgeons\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u0026nbsp;\u003c/strong\u003eThe study was approved by the Atlantic Center for Research \u0026amp; Evaluation Institutional Review Board (ACRE IRB) in Liberia on 28 August 2023 (Reference number 23-08-383). Informed consent was obtained from all participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u0026nbsp;\u003c/strong\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u0026nbsp;\u003c/strong\u003eThe datasets generated and analysed during the current study are available from the corresponding author on reasonable request.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBCA, PP and JM are working for the LCPS, the authority responsible for postgraduate training in Liberia.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eThis study had no dedicated funding. It was conducted under a PhD grant from the Norwegian University of Science and Technology.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor’s contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConception, design, and data collection were conducted by JMB, DWA, BCA, AvD and HAB. The manuscript was prepared by JMB and DWA. All authors were involved in interpretation of the results and revision of the work. All authors have approved the final submitted version.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u0026nbsp;\u003c/strong\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization (WHO). Everybody\u0026rsquo;s business. Strengthening health systems to improve health outcomes. WHO\u0026rsquo;s framework for action. [Internet]. Geneva; 2007 [cited 2020 May 21]. 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Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(05)67028-6.pdf\u003c/span\u003e\u003cspan address=\"https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(05)67028-6.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"human-resources-for-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"hrhe","sideBox":"Learn more about [Human Resources for Health](http://human-resources-health.biomedcentral.com)","snPcode":"12960","submissionUrl":"https://submission.nature.com/new-submission/12960/3","title":"Human Resources for Health","twitterHandle":"@HRH_Journal","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Medical education, postgraduate training, specialization, health workforce, human resources, evaluation, Liberia, West-Africa","lastPublishedDoi":"10.21203/rs.3.rs-6629290/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6629290/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003ePostgraduate training in Liberia was commenced in 2013 under the Liberia College of Physicians and Surgeons (LCPS). Since its inception, 125 medical doctors have specialized to membership level in seven disciplines: Internal medicine, Pediatrics, Surgery, Obstetrics \u0026amp; Gynecology, Family Medicine, Ophthalmology and Psychiatry. This study evaluates the outcomes of the postgraduate training in Liberia after a decade and examines whether graduates\u0026rsquo; competencies align with their current work roles.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eAn online questionnaire was distributed to all graduates, collecting data on demographics, work history, motivation, self-assessed competencies, and training experiences including examinations, research and feedback. Descriptive analysis was used to calculate response frequency distributions.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eNinety graduates (72.0%) responded to the questionnaire. All respondents worked in Liberia, with 56.3% in Montserrado County. Most (94.4%) were primarily employed in the public sector, whereas 21.1% held additional roles in the private sector or academia. After membership level, 30.0% pursued additional education, including 18.9% fellowship training. Overall, graduates expressed strong confidence in competencies gained during the postgraduate training, particularly medical knowledge, professionalism and teaching, with over 95% of graduates considering themselves competent in these areas. In contrast, only 44.3% felt competent in research. Nearly all graduates (95.4%) reported that the training supported their career growth and would recommend it to colleagues. Suggestions for improvements included increasing faculty numbers and diversity, enhancing training resources, and expanding research opportunities.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eThe LCPS has contributed significantly to developing a competent specialist health workforce in Liberia. Specialist graduates had a high retention rate and were primarily employed in clinical roles in the public sector. Challenges remain, such as too few specialists and limited healthcare coverage in rural areas. To train well-equipped specialists, it is crucial to strengthen faculty, institutional capacity and training resources, and to build research capacity. Sustained investment and continued collaborations between the government and partners are needed to implement strategies to maintain retention and improve equitable distribution of specialists and to support their career growth. These efforts will ensure the program\u0026rsquo;s impact to meet Liberia\u0026rsquo;s evolving healthcare demands effectively.\u003c/p\u003e","manuscriptTitle":"Transforming Healthcare: Evaluating a Decade of Postgraduate Training at the Liberia College of Physicians and Surgeons","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-21 06:47:09","doi":"10.21203/rs.3.rs-6629290/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-09-01T06:13:18+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-30T17:42:13+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-26T02:08:42+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"194782016999357660956593538256671708876","date":"2025-08-25T12:20:21+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"45848930324020540536276927578479289115","date":"2025-08-14T14:55:02+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-12T03:56:59+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-05-12T00:52:14+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-12T00:48:49+00:00","index":"","fulltext":""},{"type":"submitted","content":"Human Resources for Health","date":"2025-05-09T13:42:08+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"human-resources-for-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"hrhe","sideBox":"Learn more about [Human Resources for Health](http://human-resources-health.biomedcentral.com)","snPcode":"12960","submissionUrl":"https://submission.nature.com/new-submission/12960/3","title":"Human Resources for Health","twitterHandle":"@HRH_Journal","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"acd97f37-d070-484c-91fe-8ddec9c32dc5","owner":[],"postedDate":"August 21st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-06T08:56:16+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-21 06:47:09","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6629290","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6629290","identity":"rs-6629290","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}