Merry et al.

BMC Medical Education (2023) 23:498 BMC Medical Education

[Link]

RESEARCH Open Access

Continuing professional development

(CPD) system development, implementation,
evaluation and sustainability for healthcare
professionals in low‑ and lower‑middle‑income
countries: a rapid scoping review
Lisa Merry1,2*, Sonia Angela Castiglione3, Geneviève Rouleau4,5, Dimitri Létourneau1, Caroline Larue1,
Marie‑France Deschênes1, Dolly Maria Gonsalves6 and Lubana Ahmed6

Abstract
Background Policymakers and program developers in low-and lower-middle-income countries (LLMICs) are increas‑
ingly seeking evidence-based information and guidance on how to successfully develop and implement continu‑
ing professional development (CPD) systems. We conducted a rapid scoping review to map and synthesize what is
known regarding the development, implementation, evaluation and sustainability of CPD systems for healthcare
professionals in LLMICs.
Methods We searched MEDLINE, CINAHL and Web of Science. Reference lists were screened and a cited reference
search of included articles was conducted. Supplementary information on the CPD systems identified in the articles
was also identified via an online targeted grey literature search. English, French and Spanish literature published from
2011 to 2021 were considered. Data were extracted and combined and summarized according to country/region and
healthcare profession via tables and narrative text.
Results We included 15 articles and 23 grey literature sources. Africa was the region most represented followed
by South and Southeast Asia and the Middle East. The literature most often referred to CPD systems for nurses and
midwives; CPD systems for physicians were frequently referred to as well. Findings show that leadership and buy-in
from key stakeholders, including government bodies and healthcare professional organizations, and a framework are
essential for the development, implementation and sustainability of a CPD system in a LLMIC. The guiding framework
should incorporate a regulatory perspective, as well as a conceptual lens (that informs CPD objectives and methods),
and should consider contextual factors (support for CPD, healthcare context and population health needs). In terms
of important steps to undertake, these include: a needs assessment; drafting of a policy, which details the regula‑
tions (laws/norms), the CPD requirements and an approach for monitoring, including an accreditation mechanism; a
financing plan; identification and production of appropriate CPD materials and activities; a communication strategy;
and an evaluation process.

*Correspondence:
Lisa Merry
[Link]@[Link]
Full list of author information is available at the end of the article

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Merry et al. BMC Medical Education (2023) 23:498 Page 2 of 22

Conclusion Leadership, a framework and a clearly delineated plan that is responsive to the needs and context of the
setting, are essential for the development, implementation and sustainability of a CPD system for healthcare profes‑
sionals in a LLMIC.
Keywords Continuing professional development (CPD), Low- and lower-middle income countries, Rapid scoping
review, Bangladesh, CPD system development and implementation

Introduction in high-income countries, especially in Europe [6–11].

Around the world, continuing professional development While this body of literature can offer insights and rec-
(CPD) is increasingly expected and required of health- ommendations for CPD system development, implemen-
care professionals in order to maintain their credentials tation and sustainability, it may be of limited relevance
and right to practice. CPD refers to the ongoing educa- for a LLMIC, where the social, cultural, political and eco-
tion and competency development by healthcare pro- nomic conditions are significantly different from the con-
fessionals beyond their initial training; the purpose is to texts of many high-income (mostly Western) countries.
update and advance their knowledge, skills and profes- It is only recently that reviews, and protocols for
sional proficiency [1]. Although findings have not been reviews, that include or focus specifically on CPD sys-
consistent, a number of benefits and positive impacts tems in LMICs, have begun to emerge [12–20]. Mag-
have been associated with CPD, particularly in high- wenya et al. (2022) provide a global overview of CPD
income countries [2]. At the individual level, in addition systems in different countries, including guiding frame-
to acquiring new knowledge and skills (e.g., on illnesses, works and their characteristics, however, the countries
best practices and broader determinants that influence examined in the review are mostly high-income coun-
health and care), and improving their clinical perfor- tries [17]. The reviews conducted by Azad et al. (2020)
mance (e.g., increased use of guidelines, incorporation of and Chan et al. (2021) are restricted to CPD for nurses
best practices), healthcare professionals may gain further and pharmacists respectively; the former does not dis-
confidence in their role, develop more positive attitudes cuss CPD system development or implementation pro-
(e.g., towards certain patient groups, their colleagues/ cesses, while the latter is focused on only two countries
institution) and broaden their networks; the latter may (Pakistan and Jordan) [14, 19]. Guillaume et al. (2022)
translate to reduced isolation/greater sense of belonging evaluate evidence on digital platforms used for CPD in
and increased sharing of resources and information [2]. LMICs [15] while Hill et al. (2021) aim to describe best
CPD may also lead to personal growth, career advance- practices and approaches, as well as facilitators and bar-
ment, including new roles and responsibilities, and schol- riers when involving international collaborators from
arly achievements (e.g., publications), and hence, more high income countries to establish and deliver CPD in
commitment to the profession. At the organizational LMICs [18]. Three other reviews map the continuing
level (hospitals, educational institutions), CPD may result medical education systems (for physicians); in China,
in new protocols and policies or curricula and peda- Indonesia and India [12]; in 33 countries in South-East
gogical approaches for training of healthcare profession- Asia and Eastern Mediterranean regions, most of which
als [2]. In sum, CPD enables the healthcare workforce are LMICs [13]; and in South-East Asian countries [20],
to evolve and better respond to patients’ needs and the respectively. Although the results across these reviews
ever-changing practice environment. Ultimately this may are quite extensive and informative for guiding health-
lead to better care and health outcomes [2, 3]. care professional CPD system development and imple-
In many low- and lower-middle-income countries mentation in LLMICs, the authors call for more inquiry,
(LLMICs), CPD is not mandated and uptake and par- including additional details on the steps involved in
ticipation by healthcare professionals are limited due to these processes. To our knowledge, no recent review has
access barriers [1, 4, 5]. Established CPD systems are fre- closely looked at the development, implementation and
quently lacking in LLMICs due to funding, infrastructure sustainability of CPD systems for healthcare profession-
and resource challenges [1]. Policymakers and program als (broadly defined) in LLMICs.
developers in these countries are increasingly seeking
evidence-based information and guidance on how best
Context
to navigate these challenges and to successfully plan,
Bangladesh’s healthcare system faces multiple challenges
develop and implement CPD systems. There are several
in providing quality healthcare, most notably, a severe
reviews that have been conducted over the last 15 to
nursing shortage; it is one of the only countries where
20 years that have examined and compared CPD systems
there are more doctors than nurses [21, 22]. Negative

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Merry et al. BMC Medical Education (2023) 23:498 Page 3 of 22

societal perceptions of the profession due to cultural, • What are the characteristics of CPD systems (laws/
social, gender and religious factors, as well as little norms, monitoring methods and accreditation struc-
opportunity for career progression, have resulted in few tures)?
being drawn to pursue a career in nursing [21]. Regulat- • What process and outcome indicators were used to
ing training quality, especially in the private sector, has evaluate and sustain CPD systems?
also been challenging due to the rapidity in which nurs-
ing programs have emerged across the country. Despite
some attempts made towards advancing the profession, Methods
the nursing workforce remains inadequate in terms of We used a scoping review methodology [25]. The Joanna
numbers and skill level to meet population needs [21, 23, Briggs Institute (JBI) guidance document for the conduct
24]. In an effort to elevate its professional status, and to of scoping reviews [26] informed the process. Due to
increase the number of qualified and competent practic- constraints imposed by the project timeline, rapid review
ing nurses, the Bangladeshi government has committed methods were adopted; this consisted of restricting the
to a series of actions to improve nurse training and devel- number of databases and grey literature searched, apply-
opment, including establishing a CPD system. This ini- ing more stringent inclusion criteria, involving only one
tiative is supported by the “Empowering women through reviewer for some of the screening steps, not contact-
professionalization of the nursing sector in Bangladesh ing authors for clarifications or missing information, and
(ProNurse)” project implemented by Cowater Interna- limiting the stakeholder consultation to the Bangladeshi
tional in collaboration with the University of Montreal partners [27]. We did not register a review protocol. The
(Canada). PRISMA extension for scoping reviews was used to guide
As part of the ProNurse project and to support the the reporting of this review (see Additional file 1).
planning and decision-making regarding the CPD system
in Bangladesh, it was requested that a review of the litera- Database literature search strategy
ture be conducted. The purpose was to identify strategies The search strategy was developed in consultation with
and lessons learnt from the experiences of other LLMICs a medical librarian and with input from the research
that have embarked on planning, developing, implement- team. One team member (SC) searched three databases
ing and/or evaluating a CPD system for healthcare pro- MEDLINE, CINAHL and Web of Science on December
fessionals. This endeavor, which is reported in this paper, 13 and 17, 2021. Keywords (including truncations) and
involved nurse researchers at the University of Montreal subject headings were used and combined with Boolean
and the ProNurse National Nursing Specialist (DG) in terms to capture four concepts: Continuing professional
Bangladesh. A technical working group comprised of development (Continuing education and professional
key stakeholders in Bangladesh, namely, the Ministry of development), healthcare professionals, low to middle
Health and Family Welfare (MoHFW), the Directorate income countries, and program development and imple-
General of Nursing and Midwifery (DGNM), and the mentation. Searches were limited to English, French and
Bangladesh Nursing and Midwifery Council (BNMC), Spanish articles published during the period of 2011 to
were also involved. Our objective was to conduct a rapid 2021(see Additional file 2).
scoping review to map and synthesize what is known
regarding the development, implementation, evaluation Eligibility criteria
and sustainability of healthcare professional CPD sys- Our eligibility criteria were initially broad in order to
tems in LLMICs. cast a wide net. The criteria were later refined through
the selection process where only the most relevant arti-
Research questions cles which aligned with the research questions would be
How are CPD systems for healthcare professionals devel- included (see Additional file 3).
oped, implemented, evaluated and sustained in LLMICs?
Specifically: Population and location
We included articles where a CPD system/broad CPD
• What approaches or frameworks informed CPD sys- program for licensed and/or regulated healthcare pro-
tem development and implementation? viders in LLMICs were described or discussed. The list
• Who and what processes or steps were involved in of included healthcare providers was derived from the
CPD system development and implementation? Canadian Institute for Health Information (CIHI) [28].
• What facilitating and hindering factors influenced LLMICs were defined according to the Organisation for
CPD system development, implementation and sus- Economic Co-operation and Development (OECD) 2021
tainability? list of countries [29]; articles that addressed ‘low-resource

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Merry et al. BMC Medical Education (2023) 23:498 Page 4 of 22

settings’, even if the countries were not specified, were or sustainability of a CPD system/broad CPD program
also considered for inclusion. Articles that focused on that could be used to inform recommendations to Bang-
upper-middle income countries were excluded since the ladesh stakeholders for the development and implemen-
economic, social and political contexts in many of these tation of their nursing CPD system; those with a narrow
countries are vastly different from Bangladesh. or very broad focus were assigned low priority. The short
list was then reviewed by GR, DL, LM, and CL, and arti-
CPD system cles selected as priority by at least three reviewers, were
A CPD system/broad CPD program was defined as retained for a full-text review. The full-text reviews were
the infrastructure to support ongoing learning activi- conducted by SC, who confirmed the final selection of
ties, which are provided and made available for health- articles for data extraction.
care professionals to maintain and develop a variety of The reference lists were screened and a cited reference
knowledge and skills to meet the needs of patients and search was conducted by SC for all included articles. In
for the protection of the public [30]. We included articles order to provide updated or complementary information
that described the development, implementation and/or on the CPD systems/broad CPD programs described in
evaluation of a CPD system/broad CPD program, and/ the included articles, SC also conducted a targeted grey
or described a needs assessment to inform the develop- literature search using Google. Search terms included
ment or implementation of a CPD system/broad CPD “Continuous professional development” or “CPD” and
program. Articles that described a CPD framework and/ were combined with the country name to identify online
or its development were also eligible for inclusion. We information, documents and other relevant materials
excluded articles that described/evaluated a single or produced by governments associations and professional
specific educational CPD activity or focused on learning organizational bodies. Lastly, the Bangladeshi partners
activities/systems directed at students or trainees. Arti- were consulted and they provided additional literature
cles that described: the assessment/evaluation of knowl- for consideration. Articles and grey literature sources
edge, attitudes and practices related to a specific practice identified through these searches and consultation were
or clinical issue; the development or validation of a tool included for extraction if they met the inclusion criteria
to measure CPD activities; or a global health partnership as described above.
without mention of CPD system development or imple-
mentation, were also excluded. There were no restric- Data extraction process and data items
tions regarding the research design or type of article. Article data were extracted by CL (n = 3), GR (n = 1), LM
(n = 3), DL (n = 3), and SC (n = 5) and then verified by
Selection of information sources SC and LM. A data extraction form was generated using
All records from the database searches were down- Excel, and data items were defined a priori in discussion
loaded into Endnote; duplicates were removed by hand. with all reviewers. Data extracted included: country;
A screening form, developed by SC with input from the healthcare professional(s); the CPD definition applied;
team, was then used to determine eligibility. The screen- the stakeholders involved in CPD development, imple-
ing process was iterative and involved multiple steps; mentation and/or evaluation; the political process; the
titles and abstracts were screened first, and then full CPD framework used; the needs assessment; the CPD
text articles. After deduplication, the first 200 titles and system characteristics; the timeline for implementation;
abstracts were screened by two reviewers (SC & LM) the implementation process; implementation barriers
and discrepancies discussed. The eligibility criteria were and facilitators identified or anticipated; evaluation pro-
subsequently clarified and refined based on these discus- cess and/or outcomes; sustainability concerns/issues/
sions; ongoing team meetings were held throughout the strategies; the accreditation process; policies, rules, reg-
screening and selection process to ensure consistency in ulations and/or laws relating to CPD; recommendations
the application of the inclusion/exclusion criteria. The for CPD system development, implementation and/or
remaining titles/abstracts were screened by one reviewer evaluation; and any other information deemed relevant
(SC). Another reviewer (DL) verified 10% of excluded to the research questions. Articles were subjectively
citations to confirm the initial screening process. appraised for their level of transparency and complete-
Records flagged for inclusion were independently ness, and rigor in their methods and reporting.
assessed by LM, GR, and DL and a selection of these Data were also extracted for the grey literature. A sep-
were prioritized for a full text review. To be considered arate Excel form with fewer items was created and one
for a full text review there had to be a clear indication reviewer (SC) was responsible for this process. The fol-
that the article would have some information regard- lowing information was extracted: the source (website,
ing the development, implementation, evaluation and/ organization); the author, document title, date and type

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Merry et al. BMC Medical Education (2023) 23:498 Page 5 of 22

of document; location where document was published or (drafted by LM). Team members (CL, GR, DAL, MFD,
disseminated; web link; country; health professional(s); SC) reviewed the text and tables and these were further
and information deemed pertinent to CPD system devel- refined based on their input. A synthesis of the findings,
opment, implementation and/or evaluation. The grey lit- using PowerPoint (figures, tables, bullet points), was
erature was subjectively appraised based on its currency, presented to the technical working group in June 2022.
relevance, authority, accuracy and purpose [31]. The group discussed and reviewed the results in relation
to their own needs and the local context and additional
Synthesis of results revisions were made based on their feedback.
The data extracted from the articles and grey literature
sources were summarized into two tables respectively. Results
The data extracted were then combined and synthesized The PRISMA flow diagram is depicted in Fig. 1. The data-
by country and health profession into one data matrix base searches yielded 1323 records. We removed 308
table in Excel. The matrix table was used to generate a duplicates and 891 records that clearly did not meet the
narrative synthesis and several summary tables, organ- inclusion criteria. The reviewers screened the remaining
ized according to the respective research questions 124 records and prioritized 17 of these to be considered

Fig. 1 PRISMA Flow Diagram

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Merry et al. BMC Medical Education (2023) 23:498 Page 6 of 22

for full-text review. Three articles were removed during of factors influencing CPD system needs, implementa-
the full text review, and 14 articles were included in the tion, and effectiveness [63]. A couple of sources (n = 2)
review. No additional articles were included following described strategies and/or recommendations for
a scan of reference lists and a cited reference search of improving healthcare CPD implementation [64, 65];
included articles. An additional 23 grey literature sources one source described an international structure for CPD
and 1 article suggested by the Bangladeshi partners were activities and accreditation [66], and another described
identified and included. an organization whose mandate is to provide support and
resources (via an online platform) for CPD in LLMICs
Characteristics of included articles and grey literature [67](see Additional file 4). Africa was the region most
sources represented (n = 19), followed by South-Asia/South-
Nine articles were published within the last five years, east Asia (n = 4) and the Middle East (n = 2); the coun-
the other six were older publications. Eleven articles tries/regions were not stated in two sources, and in one,
described the development and implementation of a CPD systems from several countries of different regions
CPD system [23, 32–39], two of these also reported were discussed. Seventeen of the sources focused on or
on the evaluation of the CPD system [40, 41]; one arti- made some reference to CPD for nurses/midwives, while
cle described strategies to strengthen a CPD system five referred to CPD for physicians, and two discussed
[42]; another article provided an overview of different CPD for pharmacists, and CPD for dentists and physi-
approaches for implementing a CPD system in a low otherapists were each mentioned in one source; many
resource setting [5]; and two described CPD systems of the sources referred to CPD for a mix of healthcare
already in place, one of which was done with the inten- professionals.
tion of providing recommendations for improving the Overall, the grey literature sources reported current
CPD system [43, 44]. Six regions were represented, information evidenced by the date on the document or
including West Asia/Middle East (n = 3); South Asia update date found on the website, which were all within
(n = 3); West Africa (n = 2); South Africa (n = 2); East the parameter dates set for the review. All sources were
Africa (n = 3); and Latin America/Caribbean (n = 1); one deemed relevant as they provided complementary or
paper referred to low-resource countries without specify- updated information on the CPD systems reported in
ing any location. Eight articles described CPD for nurses/ the articles. Accuracy of the information presented was
midwives, while CPD for physicians and pharmacists/ good based on its consistency with what was reported
assistants were the focus in six and three articles respec- in the articles and also across the grey literature; many
tively, and physiotherapists and dentists were each the had supporting references as well, and thus provided fur-
focus in one article. ther assurance that information reported was valid. All
Overall, the articles were structured and clear, only sources were created, sponsored or authored by known
one was quite difficult to read and understand [39]. The and recognized organizations and institutions including
texts were sufficient to grasp the CPD system and/or its national and international organizations, government
development/implementation and to have some level ministries and professional healthcare bodies. All sources
of confidence that the information reported was based provided factual information, rather than opinion (see
on rigorous methods and processes. However, all of the Additional file 4).
articles lacked details on one or more aspects related to
the development, implementation and/or outcomes and CPD definition and CPD system frameworks
evaluation of the CPD system (see Additional file 4). Across the literature, CPD incorporated different terms
The grey literature varied in type, including web including most frequently, continuing education and
pages (n = 7), presentations (n = 3), guidelines/direc- continuing medical education. The wording of the defini-
tives (n = 2), reports (n = 4), a database (n = 1) and other tions of CPD differed somewhat between the articles and
types of documents (n = 6). Three of the sources were sources, however there were common elements across
published within the last five years, five were older and definitions. Generally, CPD was defined as a process by
fifteen had no specific date of publication. The majority which professionals maintain or acquire skills, knowl-
(n = 14) described one or more aspects of a CPD system edge, or competencies. CPD is viewed as a career-long
(roles and responsibilities of those involved in the sys- responsibility and the objective is to ensure that profes-
tem, tools, guidelines, procedures, policies, and/or CPD sionals are up-to date and that their practice is safe, legal
resources and activities) [45–58]; one source had more and evidence-based. It can be achieved via participation
emphasis on regulations related to CPD [59], while three in a diversity of activities (e.g., seminars, scientific or
others focused on the political process and stakeholder academic work, conferences, online training modules,
involvement [60–62], and another provided an overview on-the job training) and the outcomes include personal

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Merry et al. BMC Medical Education (2023) 23:498 Page 7 of 22

development (self-esteem, professional advancement), CPD system development and implementation

strengthening of the profession/maintenance of profes- Table 1 provides an overview of CPD system develop-
sional standards, and improvement in the quality of care ment and characteristics by country/region. In almost
and patient/public health [23, 32–35, 37–39, 42–45, 50, all countries, key stakeholders involved in CPD sys-
55, 56, 58, 59]. tem development included the Ministry of health (or
The frameworks/approaches used for guiding the equivalent) and the healthcare professional represent-
development and implementation of CPD systems that ing bodies. Also common was the involvement of local
were described in the literature can be broadly grouped educational institutions (universities) and hospitals and
into three categories: 1) regulatory/legislative; 2) contex- other medical services. In some countries, other gov-
tual; and 3) competency/professional development. Reg- ernmental departments, for example the Directorate
ulatory/legislative frameworks emphasize the rules and of nursing or the Ministry of labor, and/or local non-
procedures to be followed as well as the laws that govern governmental organizations were also implicated; in
CPD [32, 36, 44, 45, 56, 65]. Rules and procedures pertain Ethiopia and Malawi, CPD providers were involved as
to the healthcare professionals, the profession and to the well. In a handful of countries, advisory and financial
organizations or other institutions that may be involved support were provided from international partners, for
in delivering the CPD activities. For example, for health- example universities in the US or from international
care professionals this may include the amount of CPD agencies, donors and/or organizations, including pro-
activities expected to be completed within a given time- fessional bodies, such as the International Council of
frame, for the profession it could refer to the monitor- Nurses (ICN). The African Health Professions Regula-
ing procedures, whereas for the organizations this may tory Collaborative (ARC) provided technical assistance
include the standards for accreditation. Laws refer to the and guidance in a number of African countries. Infor-
CPD requirements in order to maintain licensing for a mation technology and CPD content expertise, espe-
given profession. cially from the World Continuing Education Alliance
A contextual approach stresses the importance to (WCEA), were provided in several countries/regions,
consider environment and system factors, includ- including Haiti, Malawi, Lesotho, Swaziland, Liberia,
ing population health needs, the healthcare structure, Bangladesh and Pakistan.
the availability, distribution and competency level of None of the articles or sources provided detailed
the healthcare workforce, and the resources (financial, accounts of the exact steps taken for developing (or
human, and infrastructure) and motivation at various updating) and implementing the CPD system and often
levels (professional, system, and government) to sup- the timeline and the order of steps were not clear. In
port the implementation and sustainability of a CPD sys- some instances, it was only one aspect or one step of the
tem [33, 34, 38, 41, 44, 45, 65]. Competency/professional CPD system development and implementation process
development frameworks focus on learning and profes- that was described. Generally, it took anywhere from a
sional development principles and theories, including few years to almost a decade to develop and implement
the competencies to be developed (standards), the level the CPD system; some countries took longer since they
and learning needs and learning styles of the profession- initiated the process then stopped and only reinitiated
als, the methods that can be used to develop the compe- again at a later time [32, 35, 37–39, 41, 42, 62]. For some
tencies, and the indicators that can be used to assess for countries (Haiti, Lesotho, Bangladesh), they were still in
competency attainment [33, 34, 38, 45, 65]. This approach the process of planning/developing and/or implementing
also incorporates the values, ethics and scope of practice their CPD systems. It seems that fragmented or longer
of the profession. timelines may in part be due to a lack of leadership and/
The purpose of a regulatory and legislative approach or motivation to implement a CPD system.
is to provide structure and quality-assurance of the CPD For the most part, it appears that the CPD system
system whereas both contextual and competency focused development and implementation process was driven
approaches aim to ensure the CPD system is feasible, by the government’s interest to improve the quality of
appropriate and adapted to the local context. The three healthcare. Certain countries, including Armenia (for
categories of frameworks/approaches are overlapping physicians), Jordan (for all healthcare professionals),
and the defining components of each are not mutually Ghana (for nurses and midwives), Rwanda (for physi-
exclusively. Most articles/sources (and countries) did not otherapists) and Malawi (for nurses and midwives)
overtly report using a specific framework and generally adopted laws to enforce and regulate CPD while other
described drawing from and using various aspects from countries, including Swaziland (for nurses and mid-
each of these approaches to guide CPD system develop- wives), Lesotho (for nurses and midwives) and Nepal (for
ment and implementation. physicians) established professional norms and standards

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 Table 1 Summary of CPD system development and characteristics by country/region
Country, Region Healthcare Stakeholders Needs Assessment Policy, Rules, CPD System (Y = yes; N = no; ? = unclear; n.s. = not stated)
Professionals involved Regulations and/
or Laws Established Mandatory Credits/ points Frequency Monitoring Accreditation
system system

Armenia, West Asia/ Physicians Physicians, Needs assessment Law requires health‑ Y Y 220 credits 5 yrs Y Y
Middle East Nurses, was not described care professionals to 140 credits
Dentists, There was a need recertify to continue (nurses)
Pharmacists, to improve quality clinical practice
Merry et al. BMC Medical Education

Pharmacist assistants, care and retention of

EACCME, and the healthcare workers
Armenian Ministry of
Health
Jordan, West Asia/ Physicians and other MOH, private A study assessed Mandatory participa‑ Y Y n.s 5 yrs ? n.s
Middle East healthcare workers sector, Royal factors that influence tion for relicensure
Medical Services and CPD offerings, needs, required by law
(2023) 23:498

university hospitals. practices, experi‑ implemented in April

Representatives from ences and effective‑ 2018
HCP groups were also ness. A structured
consulted self-report question‑
naire was used
Georgia, West Asia/ Physicians The president, No needs assessment The President made a ? N n.s n.s Y? ?
Middle East Minister of Labor, described. It was law, then the Ministry
Health, and Social stated that there was of Labor, Health, and
Affairs, Tbilisi Medical a particular need for Social Affairs made
Academy, the Profes‑ improving maternal, CPD mandatory, then
sional Development pediatric, and perina‑ cancelled it
Council, and the tal care
Ministry of Science
and Education
Nepal, South Asia Physicians IT designers and Interviews con‑ Nepal Medical Y? N n.s n.s n.s n.s
developers, local ducted with local Council mandates
people, a group physicians working in CPD. However, there
of physicians who remote areas. Barriers is lack of regulatory
advocate improving to CPD informed the requirement for CPD.
rural health, an topic (emergency This could change
international CPD medicine) and the in the near future.
content provider, CPD infrastructure In 2015, the medical
medical administra‑ (considerations council was working
tors at hospitals and for remote access, on "mandatory CPD
clinics, the Secretary asynchronous and and re-licensing
of Health, Director of with low/unstable requirements" but
the Medical Council, internet, easy-to-use) has yet to come into
Emergency Medicine and fees (free), and force

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Review, donors content should be
(Microsoft, Dtaplicity, updatable when
Google, Salesforce, internet is available
Github, Amazon), and
NGOs (Timmy Global
Health, Global Emer‑
gency Care, Handup
Congo)
Page 8 of 22
 Table 1 (continued)
Country, Region Healthcare Stakeholders Needs Assessment Policy, Rules, CPD System (Y = yes; N = no; ? = unclear; n.s. = not stated)
Professionals involved Regulations and/
or Laws Established Mandatory Credits/ points Frequency Monitoring Accreditation
system system

Pakistan, South Pharmacists Pharmacists and An exploration of CPD is not com‑ Y? N n.s n.s n.s n.s
Asia participants in the stakeholder’s views, pulsory
study selected from perceptions and
regulatory authorities, practices regarding
Merry et al. BMC Medical Education

academia and com‑ CPD in Pakistan was

munity pharmacy done using qualita‑
settings tive inductive meth‑
ods (semi-structured
interview)
Pakistan, South Nurses and midwives Pakistani Nursing Not described CPD is not com‑ Y? n.s n.s n.s n.s n.s
Asia Council, the ICN, and pulsory
(2023) 23:498

the WCEA
Bangladesh, South Nurses Partnership between Development team CPD is not com‑ N N n.s n.s n.s n.s
Asia American higher worked with local pulsory
education and the hospitals to define
AK Khan Health‑ nursing staff and
care Trust (a NGO) hospital and nurs‑
nursing faculty from ing administration
Bangladesh, United educational needs.
States, and India, local 2015 assessment of
hospital and nursing CPD showed limited
administrators, and implementation of
the WCEA CPD and in-service
training, poorly
coordinated and not
mandatory
Ghana, West Africa Nurses, midwives, Nursing assistants, Not described CPD requirements Y Y Nursing Assistants: 1 yr Y Y
and nursing assis‑ nurses and midwives, are in compliance 10pts
tants and employer/ with Part Three of Staff nurses/
nurse managers and Health professions midwives—nursing/
educators regulatory bodies Act midwife officers:
2013 (Act 857), Nurs‑ 15pts
ing and midwifery Senior nursing/
council midwife officer,
health tutor, assistant
lecturer or above:
20pts

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Page 9 of 22
 Table 1 (continued)
Country, Region Healthcare Stakeholders Needs Assessment Policy, Rules, CPD System (Y = yes; N = no; ? = unclear; n.s. = not stated)
Professionals involved Regulations and/
or Laws Established Mandatory Credits/ points Frequency Monitoring Accreditation
system system

Ghana, West Africa Pharmacists Pharmacists and Stakeholder’s views Attainment of CPD Y Y n.s 1 yr n.s n.s
participants in the were explored, credits is compulsory
study selected from including percep‑
regulatory authorities, tions and practices
Merry et al. BMC Medical Education

academia, and com‑ regarding CPD.

munity pharmacy Qualitative inductive
settings methods were used
(semi-structured
interview)
Liberia, West Africa Nurses and midwives The Liberian Board of Not described. Need The regulatory board Y N 20 h 2 yrs Y Y
Nurses and Midwives, based on the fact for Nursing and of
(2023) 23:498

and the WCEA that maternal mortal‑ Midwifery offer CPD

ity ratio remains very but it’s not manda‑
high and quality tory
maternal care is
lower in rural areas
than urban areas.
There is also a lack
of coordination of
CPD for healthcare
professionals and an
absence of quality
control over the
training for practicing
Swaziland Nurses and midwives National Health Policy A structured Each nurse registered Y Y 10 h 1 yr Y Y?
(Eswatini), South of Swaziland, the questionnaire was with the Swaziland
Africa Swaziland Nursing administered to Nursing Council
Council, ARC, the nurses and midwives is expected to
Swaziland Post and to identify barriers of undertake CPD prior
Tele-communications engagement, prior‑ to renewing their
Cooperation, and the ity topics for CPD license
WCEA and the preferred
learning methods.
A group discussion
of the findings and
a literature review
were then used to
develop an original
CPD framework to
operate within the

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context of Swaziland
Page 10 of 22
 Table 1 (continued)
Country, Region Healthcare Stakeholders Needs Assessment Policy, Rules, CPD System (Y = yes; N = no; ? = unclear; n.s. = not stated)
Professionals involved Regulations and/
or Laws Established Mandatory Credits/ points Frequency Monitoring Accreditation
system system

Lesotho, South Nurses and midwives MOHSW and its The MOHSW con‑ MOHSW requires In process Y? Min 12 pts 1 yr Y Y
Africa nursing directorate, ducted a health sec‑ professional regula‑
the Lesotho Nursing tor human resources tory bodies to ensure
Council, ARC, the needs assessment compliance in the
Merry et al. BMC Medical Education

Lesotho Nursing in 2004 implementation of

Association, NHTC, the continuing edu‑
CHAL, local NGOs, cation requirements
and the WCEA by their members
Rwanda, East Africa Physiotherapists USA universities, Input was gathered Law requiring CPD Y Y 60 CPD points 2 yrs Y Y?
an American NGO, from stakeholders for licensure enacted
Rwandan clinicians (focus groups) and a in 2013
(2023) 23:498

from rural & urban steering committee

regions, physio- comprised of physio
therapist faculty, and leaders finalized
leaders of the Asso‑ topics for the CPD
ciation of Rwandan courses
physiotherapists

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Page 11 of 22
 Table 1 (continued)
Country, Region Healthcare Stakeholders Needs Assessment Policy, Rules, CPD System (Y = yes; N = no; ? = unclear; n.s. = not stated)
Professionals involved Regulations and/
or Laws Established Mandatory Credits/ points Frequency Monitoring Accreditation
system system

Malawi, East Africa Nurses and midwives A registrar from the An initial assessment The Nurses and Y Y 35 points 1 yr Y Y In process
NMCM, the Chief was not described. Midwives Act of
Nursing Officer from After one year of the 1995 requires that all
the MOH, the Presi‑ initial CPD program nurses and midwives
Merry et al. BMC Medical Education

dent of the NONM, a phase, monitor‑ show evidence of

representative from a ing and evaluation attending in-service
nurse training institu‑ visits by the NMCM education prior to
tion, CPD providers, to health facilities licence renewal
ARC, a partnership revealed that nurses, The NMCM is
between the CDC, midwives, and CPD mandated by Nurses
Emory University, the facilitators, did not and Midwives Act
(2023) 23:498

Commonwealth Sec‑ fully understand the No 16 (1995) to

retariat, and the East, concept of CPD, and regulate nursing and
Central and Southern nurse managers were midwifery training,
Africa Health Com‑ not supporting staff education and
munity and the WCEA to fulfill CPD require‑ practice
ments. Additional CPD requirements
challenges included are dependent on
inaccessibility of CPD the type of profes‑
resources in rural sional and exemp‑
posts, and knowl‑ tions are stipulated
edge deficits on the
CPD documentation
process
The review also
revealed: a need for
role clarification for
various stakeholders
in the implementa‑
tion of CPD; that
there were negative
attitudes toward
CPD by some nurs‑
ing and midwifery
practitioners and that
CPD activities were
not "mainstreamed"
by institutions and
there was a need
to incorporate new

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trends
Page 12 of 22
 Table 1 (continued)
Country, Region Healthcare Stakeholders Needs Assessment Policy, Rules, CPD System (Y = yes; N = no; ? = unclear; n.s. = not stated)
Professionals involved Regulations and/
or Laws Established Mandatory Credits/ points Frequency Monitoring Accreditation
system system

Ethiopia, East Africa All health workers The Food, Medicine Not described Information on laws n.s N 30 credits 1 yr Y Y
and Healthcare and norms are not
Administration and stated
Control Regula‑
Merry et al. BMC Medical Education

tion, the Federal

Democratic Republic
of Ethiopia MOH,
CPD providers and
accreditors, Health‑
care Professionals,
Employers, Develop‑
(2023) 23:498

mental Partners and a

CPD Committee com‑
prised of: the MOH,
the Regional Health
Bureau, accredited
professional associa‑
tions, training institu‑
tions and partner
members
Haiti, Caribbean Nurses Nurses, Haitian A needs assessment Laws and norms N n.s n.s n.s n.s n.s
MOH, Zanmi Lasante was not described. not discussed, but
(ZL)-Partners in In response to the Ministry is involved in
Health (PIH) (a NGO provision of new overseeing CPD
of providers in Haiti), advanced care ser‑
HUM, head nurses, vices (i.e., Intensive
local nursing schools Care Unit) at the
and local professors, HUM, there was a
and the WCEA need for nurses to
quickly acquire spe‑
cialized knowledge
and skills to meet the
complex needs of
high-acuity patients
in critical care units.
Development of
course content will
also be based on the
literature and the
perspectives of local

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stakeholders

Abbreviations: ARC​African health professions regional collaborative for nurses and midwives, CDC Centers for disease control, CHAL Christian health association of Lesotho, CPD Continuing professional development,
EACCME European accreditation council for continuing medical education, HCP Healthcare professionals, HUM Hôpital Universitaire de Mirebalais, ICN International council of nurses, IT Information technology, MOH
Ministry of health, MOHSH Lesotho ministry of health and social welfare, NGO Non-governmental organization, NHTC National health training college, NMCM Nurses and midwives council of Malawi, NONM National
organization of nurses in Malawi, WCEA The world continuing education alliance
Page 13 of 22
Merry et al. BMC Medical Education (2023) 23:498 Page 14 of 22

to promote CPD compliance. In Georgia (for physicians), activities, including eligibility criteria and the procedures
a law was implemented but was then rescinded. for obtaining accreditation.
Impetus for developing and implementing a CPD sys- The process of CPD development and implementa-
tem also seems to have come from the healthcare pro- tion was iterative and gradual in many cases. For exam-
fessionals, either due to the organic evolution of the ple, Nepalese physicians were asked to provide feedback
profession over time, or because there was determination pre- and post-development of a CPD mobile application
to actively advance the profession. The latter was most through three design cycles. Similarly, in Liberia the CPD
evident in African countries (Lesotho, Malawi and Swazi- platform and mobile application for nurses and midwives
land), where local nursing teams led initiatives, including were pilot tested before being fully launched. In Leso-
seeking funding and collaboration from ARC to establish tho, the CPD system for nurses and midwives was pilot
their CPD systems. tested and received feedback both from regional peers
Needs assessments (see Table 1) were a common ini- and technical experts at two ARC learning sessions held
tial step for assessing healthcare professionals’ attitudes during the project period. The implementation was also
towards CPD, their current involvement in CPD activi- done in a staged process across districts, and CPD was
ties, their interest and willingness to participate (or con- initially voluntary and then became mandatory over
tinue to participate), and preferences/needs for CPD time. In Rwanda, CPD courses for physiotherapists were
(priority topics and format), as well as barriers to par- initially delivered by US academics and clinical experts
ticipation. Assessment of key stakeholders’ (healthcare and Rwandan co-instructors, and then the latter progres-
institutions, healthcare professional associations, uni- sively took over. In Haiti, the intention was to implement
versities) perceptions and priorities for CPD, was also a specific CPD program (a series of modules) for nurses
often part of this process. Input from healthcare profes- that could then be scaled-up and/or used as a model for
sionals and stakeholders was gathered either from a self- the development of other programs.
report questionnaire or directly via interviews or focus
groups. Reviewing existing policy documents (locally and Barriers, facilitators and CPD system sustainability
internationally) and consulting the scientific literature A number of barriers and facilitators to CPD develop-
was also sometimes done in conjunction with a needs ment and implementation on the delivery and user-ends,
assessment. at both the individual and system levels, were observed
Other steps in CPD system development and imple- across countries (see Table 2). At the system level, key
mentation noted across the literature [5, 37, 38, 42, 45, barriers include a lack of funding, structures and quali-
52, 62, 64] were: developing a framework; outlining the fied human resources to coordinate and manage the CPD
specific CPD requirements (e.g., number of hours or system, which are exacerbated when there is no support
credits to complete, timeframe for completing CPD from the government or healthcare professional bodies
activities, activities considered eligible) and drafting a [32, 37, 38, 41, 42, 63]. At the individual level, participa-
policy; planning the financing (applying for grants); spec- tion and adherence to CPD are affected by limited tech-
ifying the roles and responsibilities of each stakeholder nical skills, competing demands (e.g., family obligations),
in the CPD system; determining who and how CPD will and when there is a disinterest in, or negative views of
be monitored and mobilizing key stakeholders accord- CPD, among healthcare providers [37, 40, 42, 44, 63].
ingly; defining the outcomes and process for evaluating Workplace (e.g., scheduling, low salaries) and environ-
the CPD system; creating a system and the materials mental factors (e.g., limited electricity, difficult transport)
(guidelines, forms, etc.) for recording and logging CPD further contribute to adherence issues [32, 35, 37, 38,
(which may or may not be directly linked to licensing 40, 41, 44, 63]. To address these challenges, leadership,
renewal and may be done through an online or paper- financial investment, and the mobilization of material
based system); identifying and/or designing and offering and human resources, including the training of person-
CPD activities and materials (online or in-person) and if nel, all at the local level, are required [37, 38, 42, 62].
needed, providing training to CPD providers; developing Making CPD mandatory, offering a diversity of options
and implementing training for healthcare professionals for CPD, that are easily accessible and available at low-
(e.g., how to use an application) and for those monitor- cost, and ensuring work environments are supportive,
ing CPD activities (e.g., verification procedures); mount- are suggested strategies to promote CPD uptake [32, 33,
ing and launching a communication strategy (websites, 35, 40, 41, 44, 62, 63]. Active promotion and market-
brochures, radio, site visits, texts) to raise awareness ing, and providing incentives, may also alter healthcare
and foster involvement and compliance in the CPD sys- providers’ attitudes and further lead to participation in
tem for all those concerned; and planning and putting in CPD activities [37, 44, 63]. Overall, sustainability of a
place an accreditation structure for CPD providers and CPD system requires buy-in and support from a diversity

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Merry et al. BMC Medical Education (2023) 23:498 Page 15 of 22

Table 2 Barriers and facilitators to CPD system development and ­implementationa

Barriers Facilitators

System System
• Lack of government funding to support the system/dependence on • Leadership
grants or donor support • Key stakeholders actively support and are involved in the development
• No buy-in from stakeholders and implementation process from the onset
• Lack of human resources, time, skills and/or capacity to develop and • Having ongoing marketing and sensitization including promotion of CPD
implement and maintain the CPD system, including CPD activities and benefits
resources • CPD is compulsory
• Poor coordination and structure, including technological capacity, within • Funding
the system • The system builds from existing structures and policies
• Confusion and misunderstandings among stakeholders regarding their • The system is structured, efficient and properly resourced, including moni‑

○ CPD monitoring linked to the licensing registry/database;

roles and responsibilities toring and accreditation processes

○ core courses are offered;

• Absence of quality control

○ human resources are available and trained to maintain websites,

• Translated CPD materials not available in local language
• CPD materials available are not adapted to local context

○ guidelines exist for each process;

Individual forms, databases and to conduct monitoring and accreditation;

○ CPD facilitators or coordinators are available and trained support and

• Low motivation and interest in CPD and/or a lack of understanding of
the concept from professionals

○ roles of stakeholders are clearly delineated;

• A lack of technical skills oversee CPD process at the ground level;

○ ongoing technical support is provided

• Insufficient time to participate in CPD activities (workload, family obliga‑
tions, especially for women)
• Difficulties tracking hours/credits completed and/or completing the • Outcomes for CPD system evaluation are determined and defined a priori
documentation process for CPD recognition • The system is harmonized within a larger CPD system (i.e., recognition of
Environment (hospital, community) CPD activities already accredited by other associations or organizations
• Unsupportive employers and administrators (no time allotted for CPD) internationally)
• Cost of CPD activities (low salaries) • There is capacity to develop and offer suitable CPD activities
• Incompatible scheduling or inadequate availability of CPD activities and • A diversity of CPD activities are available and recognized for credits/
resources hours (e-learning and in-person; local and international level; from differ‑
• Difficult access to CPD activities (transport, road conditions and lodging, ent organizations and institutions; theoretical, practical, or professional in
particularly for those in non-urban areas) content)
• Limited internet connection or electricity and technical issues (e.g., old • CPD activities are easily accessible, low cost/free, and offered at conveni‑
operating systems) ent times (e.g., online repository where content can be downloaded; trans‑
port support provided or activities offered onsite or in multiple locations;
targeted, prescribed CPD activities/programs are offered)
• CPD activities are straightforward to complete
• CPD activities are tailored to learning needs and are relevant and up to
date according to practice and population health needs
Individual
• Positive attitudes toward CPD
Environment (hospital, community)
• Employers and administration are supportive (protected time, culture and
environment that values CPD)
• Incentives to complete CPD are provided (promotion, salary increases)
a
Summary based on experiences and recommendations found across the literature; CPD Continuing professional development

of stakeholders, consistent funding and resources, and Haiti (nurses), Ethiopia (all healthcare professionals) and
the establishment of robust regulation, monitoring and Bangladesh (nurses). In Lesotho (nurses and midwives) it
accreditation structures [37, 38, 41, 42, 45, 62, 63]. The was in the process of becoming mandatory (see Table 1).
system should also be dynamic wherein modifications
and improvements can be introduced over time. CPD monitoring
Different systems are used for quantifying and moni-
CPD system characteristics toring CPD, either hours or credits/points; require-
Laws and/or norms and standards ments usually differ by profession, with the number
CPD is mandatory and required for re-licensing in Arme- of hours or credits being highest for physicians (see
nia (physicians), Jordan (physicians), Ghana (nurses, Table 1). For nursing, Armenia requires 140 cred-
midwives, pharmacists), Rwanda (physiotherapists), Swa- its/5 years; Ghana, 10 points/year; Malawi, 35 points/
ziland (nurses and midwives) and Malawi (nurses and year; Liberia, 20 h/2 years; Swaziland 10 h/year; and
midwives), and it’s not (or yet) compulsory in Georgia Lesotho 12 points/year. CPD formats and content avail-
(physicians), Nepal (physicians), Pakistan (nurses, mid- able and considered eligible for CPD credit, vary. For-
wives and pharmacists), Liberia (nurses and midwives), mats include in-person or distance-learning courses,

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Merry et al. BMC Medical Education (2023) 23:498 Page 16 of 22

e-learning materials, seminars, online platform/mobile CPD accreditation

applications (e.g., WCEA), self-directed learning activi- Regarding accreditation and approval of CPD activities
ties, tailored programs, workshops, conferences, aca- and resources, in Armenia, it’s the centralized center that
demic events, formal education, in-service trainings, is responsible for this task (as mentioned already, they
receiving coaching or mentoring, research-related also accept activities accredited by the EACCME and
activities (e.g., publishing) and other types of activi- AMA), whereas in other countries it’s either the profes-
ties (e.g., participating in policy development). Con- sional regulatory body (e.g., Lesotho, Rwanda, Malawi,
tent comprises theoretical knowledge, practical, clinical Liberia) or the Ministry of health (e.g., Georgia, Ethio-
training, and/or professional development (e.g., com- pia) who oversees this process; in Ethiopia, however, the
munication, ethics). In several countries, CPD activi- ministry delegates the responsibility to a committee com-
ties have to be accredited or approved by the ministry prised of government and healthcare officials. In some
of health and/or professional representing bodies to be countries CPD providers can also be accredited (e.g.,
accepted for CPD recognition; Armenia also accepts Lesotho, Liberia, Rwanda, Malawi, Ethiopia). In Rwanda
activities accredited by the European Accreditation the professional association is directly involved in the
Council for CME (EACCME) and the American Medi- development of CPD courses.
cal Association (AMA). Some countries (e.g., Armenia, Some of the criteria used to accredit/approve activi-
Ghana, Rwanda) stipulate that to fulfill requirements ties, resources and CPD providers include: relevance to
there must be certain types of CPD activities completed current or future practice; recency of the content; scien-
(e.g., practical skills, and theoretical knowledge) while tific soundness (i.e., evidence-based); has a measurable
in other countries there is compulsory content (e.g., outcome (e.g., diploma); potential for bias or conflict of
HIV/AIDS in Lesotho) or modules or courses (e.g., interest; qualifications of those who developed and/or
Malawi) that must be followed. Lesotho also has some who are delivering the CPD activities; learning objec-
restrictions on the percentage of CPD activities that tives; teaching and learning methods; accessibility and
can be self-directed learning or in-service training. affordability; time needed to complete the activity; ade-
The process for monitoring differs across countries quacy and appropriateness of the resources to deliver the
as well. Armenia put in place a dedicated, centralized training; and learning assessment procedures (to deter-
center for monitoring which also maintains a registry mine whether learning objectives have been met). The
of all healthcare workers. In Swaziland, Lesotho, Ghana amount of credits or points allotted for different activities
and Malawi, for nurses and midwives, and in Rwanda for may vary. Activities within or outside of the country may
physiotherapists, professionals are required to maintain be eligible for accreditation (e.g., Lesotho, Armenia). To
a logbook and have their CPD activities verified by their obtain accreditation, an application usually must be sub-
employer or the CPD coordinator at their institution and mitted to the administering body and renewal is required
this information is then forwarded to the professional to maintain the status; in Lesotho renewal is required
regulatory body. In contrast, in Ethiopia, the ministry of after two years. In Ethiopia, quality assurance checks of
health (a designated case team) is responsible for over- CPD providers are done by the CPD committee. A sum-
seeing the monitoring. Information and documentation mary of CPD accreditation criteria is provided in Table 3.
that must be recorded and submitted may include: the
description of the CPD activity (type, content, location CPD system evaluation
and provider), date of completion, the number of hours, The evaluation of the CPD system was not explicitly
the learning objectives and outcomes, and/or a cer- described in most resources or articles. Across countries,
tificate as proof of completion of an activity. The period evaluation tended to be the responsibility of the gov-
for monitoring is most often done annually (Ethiopia, ernment and/or of the professional representing body;
Malawi, Lesotho, Ghana), in Rwanda and Liberia it’s done outcomes considered, frequency of evaluations, and
every other year, and in Jordan and Armenia, it’s con- methods of evaluation varied. For CPD systems using the
ducted every five years. Armenia and Lesotho mentioned WCEA platform (e.g., Liberia, Pakistan, Malawi), an eval-
disciplinary action for non-compliance (in Armenia a uation component is embedded within the system and
test must be passed if less than 70% of credits are not provides data on the number of users, the frequency of
obtained; in Lesotho the license may be suspended, or use, and which courses were accessed and completed. In
the individual may be required to pass an exam or prac- Liberia, in addition to the WCEA system, progress learn-
tice under supervision). In Malawi, Ghana and Lesotho, ing of nurses was also evaluated through a mobile service
nurses and midwives may be exempt for CPD, for exam- managed by the Ministry of health and through visits
ple, if a clinician is retired or not actively practicing the from reproductive health supervisors; quality of care was
profession. assessed every three years.

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Merry et al. BMC Medical Education (2023) 23:498 Page 17 of 22

Table 3 CPD accreditation criteria and indicators for ­evaluationa

CPD accreditation criteria Indicators for CPD system evaluation

• Relevant • Number of professionals participating in CPD activities and meeting

• Recent requirements
• Evidence-based • Frequency, type and quantity of CPD activities and resources accessed
• Accessible and affordable • Who and where were CPD activities offered
• Non-biased/no conflict of interest • Satisfaction with CPD activities and resources
• CPD developers and/or providers are qualified • Challenges experienced while accessing CPD activities and resources
• Objectives and teaching and learning methods are suitable and adapted to • Knowledge, skills and competency levels of professionals
the learners • Attitudes towards CPD
• Has a measurable outcome • Monitoring process (challenges experienced, number of professionals
• Time required to complete the activity is reasonable verified)
• Resources are adequate for delivery of the training • Quality assurance (CPD providers)
• Learning assessments are appropriate • Retention of healthcare professionals
• Quality of healthcare
• Patient/population health outcomes
a
Summary based on data extracted from the articles and grey literature sources
CPD Continuing professional development

In Nepal, improvements of the CPD mobile application and recommendations for improvement. Surveys were
for physicians were informed by data generated through also distributed to nurses who were responsible for veri-
the integrated user-tracking and feedback system. There fying logbooks; data collected included number of log-
were also plans to assess the impact of the application on books verified, attitudes toward CPD, challenges and
clinical practices, professional development, and views experiences with the verification process, and recom-
on CPD by administering a questionnaire one year post- mendations for improvement. In Lesotho, statistics (e.g.,
implementation. For the CPD program developed for number of individuals attaining required points, number
nurses in Bangladesh, participants’ understanding and of logbooks submitted and accurately verified) were also
application of knowledge and skills were assessed directly generated on an annual basis. In Rwanda, the evaluation
through quizzes, clinical laboratories and debriefing ses- of the series of CPD courses developed for physiothera-
sions and indirectly through feedback collected from pists was done concurrently with implementation. It
their nursing directors; data on nurses’ perceptions of involved site visits, pre-and post- knowledge and feed-
the program were also collected. A recommendation was back surveys with participants, instructors’ reports and
also made to gather data on health outcomes in order to debriefing with stakeholders. Lastly, in Haiti, evalua-
assess impacts over the long term. tion of the CPD program (series of modules) for nurses
In Malawi, a taskforce was created to evaluate the is planned and the elements to be assessed include:
CPD system through site visits to healthcare facilities. retained knowledge, perceived autonomy, job satisfaction
They gathered data from the nurses (e.g., CPD points and intention to stay, and turnover rates within the pro-
completed) and from those monitoring and facilitating fession. Methods will involve self-evaluations, structured
CPD (e.g., understanding of CPD and role) and also on observations and pre-post tests. A summary of indicators
the quality and dissemination of the CPD materials. In for CPD system evaluation is reported in Table 3.
Ethiopia, the case team, put in place by the Ministry of
health, is responsible for overseeing the evaluation of the Discussion
CPD system (all healthcare professionals), which includes Our objective was to conduct a rapid scoping review to
ensuring that the CPD provider list is up to date, qual- map and synthesize what is known regarding the devel-
ity assurance (CPD providers and content) is adhered to, opment, implementation, evaluation and sustainability of
and that overall, CPD is implemented across the various healthcare professional CPD systems in LLMICs in order
professions. They also provide general support to the to inform stakeholders’ planning and decision-making
CPD committee who is responsible for regulation. for the development and implementation of a CPD sys-
In Lesotho and Swaziland, evaluations are conducted tem for nurses in Bangladesh. In summary, a framework,
every other year via a random distribution of a survey leadership and buy-in from key stakeholders, access to
to 5–10% of nurses and midwives in each district; some resources and a clearly delineated plan that is responsive
of the data gathered included: level of satisfaction, atti- to the needs and context of the setting, are essential for
tudes toward CPD, barriers in accessing activities, type of the development, implementation and sustainability of a
activities completed, compliance with CPD requirements CPD system for healthcare professionals in a LLMIC.

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Merry et al. BMC Medical Education (2023) 23:498 Page 18 of 22

The review does not point to any particular framework by providing expertise, knowledge, skills and funding,
that should be adopted when developing and implement- but a Western bias, and sustainability over the long-
ing a CPD system in a LLMIC but rather it suggests that term are significant issues. The results emphasize that
it should incorporate a regulatory perspective, as well capacity-building at the local level, including the train-
as a conceptual/theoretical lens, and should consider ing and development of local CPD providers, is vital for
contextual factors. As remarked by others, regulation, ensuring sustainability; this notion is supported by oth-
standards and/or a legal framework, can provide CPD ers as well [12, 13]. In addition, Hill et al. (2021) under-
legitimacy, while a conceptual approach (to inform the score the importance of collaborations being genuine,
CPD goals and guide the methods and activities), that founded on principles of cultural humility, trust and
aligns with the local/profession’s culture, attitudes and equity, and reflexivity, with commitment for the long-
values, optimizes effectiveness of the system [1, 13, 17, term [18]. Two international actors, the ARC initiative
19, 68]. Magwenya et al. (2022) further specify that the and the WCEA, were identified in the review as key col-
use of validated theories (e.g., adult learning, behavioural laborators and resources that may be accessed for CPD
change, reflective practice, problem-based learning, qual- system development and implementation support in
ity improvement) can lead to more efficacious CPD activ- LLMICs. The ARC has played a meaningful role in pro-
ities [17]. It has also been previously emphasized that viding technical assistance and tools to a dozen of Afri-
successful CPD system implementation and sustainabil- can countries to improve and advance their nursing and
ity can only be achieved if the local environment is taken midwifery CPD systems. They have created a number of
into account, in particular population health needs and resources, including a toolkit [69] which includes a step-
the existence of support for a CPD system [1, 3, 14, 19]. by-step guide for developing and implementing a CPD
It is clear from the literature that leadership and buy- system; a survey questionnaire that may be used for con-
in from stakeholders, including government ministries ducting a needs assessment; example of how to approach
and healthcare professional bodies and associations, are evaluation; a list of criteria for accrediting CPD provid-
crucial for the establishment of a sustainable CPD sys- ers; and a list of web links for accessing additional mate-
tem. As shown in the review, a number of challenges rials, activities and tools. They have also developed an
exist in LLMICs that render the CPD system develop- online library of continuing education content [70]. The
ment and implementation much more complex, namely WCEA has also partnered with a number of countries
limited financing, technological barriers, a lack of human and international stakeholders; they offer e-health and
resources and structures to maintain a CPD system, m-health solutions in order to address capacity and rel-
negative attitudes, and a dearth of CPD materials and evance issues related to CPD delivery [71]. More recently,
activities that are relevant to the context and available an initiative funded by the Japan International Coopera-
in the local language. As highlighted by others, and also tion Agency (JICA), provides additional opportunities
in this review, government level engagement can ensure for knowledge and resource sharing between countries
resources, including financing, are mobilized, and can of the Asia Pacific Action Alliance on Human Resources
provide support for setting standards; they may also pay for Health, through their ongoing workshops on CPD
a role in enforcement [1, 10, 13, 17]. Vakani et al. (2022) system development and implementation for nurses [72].
observed, however, that government involvement and The workshops are forums that offer concrete solutions
effectiveness are often related to political stability within and tools for participating LLMICs seeking to establish
a country, and thus the larger context must be consid- or improve their CPD systems.
ered as well [13]. As for healthcare professional bodies, Regarding the plan for developing and implementing a
it has been shown that they are often well-positioned to CPD system, no paper or study was identified that pro-
identify strategies to help navigate some of the imple- vided an explicit overview of the steps to follow. How-
mentation challenges, and that championing from the ever, taken together the review indicates that the process
profession can enhance relevancy and promote positive should include: establishment of leadership; a needs
attitudes and uptake of CPD [1, 13, 14, 18, 19]. In the assessment; development of a framework; drafting of
context of nursing, particularly in Bangladesh, the impli- a policy (based on the framework), which details CPD
cation of nurse leaders may also be empowering [19] and requirements and a monitoring and regulation strat-
strengthen societal perceptions of the profession, which egy, including an accreditation mechanism; a financing
in turn may further aid in securing support and resources plan; identification and production of appropriate CPD
for a CPD system. materials and activities; a communication strategy; and
The review reveals that partnerships with high-income an evaluation process. The process is often iterative and
countries or international organizations, are common. steps may vary depending on the context. These findings
Involvement of international partners can have benefits are coherent with recommendations from the WHO, the

Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Merry et al. BMC Medical Education (2023) 23:498 Page 19 of 22

United States Agency for International Development data with official country documents or sources. There
(USAID), the ARC toolkit, as well as recent reviews, was no evaluative component to our process, therefore
which all highlight one or more of these as key elements conclusions regarding the best approaches for develop-
to CPD system development and implementation in a ing, implementing and evaluating a CPD system cannot
LLMIC [1, 3, 12–14, 17, 73]; they also iterate the impor- be drawn. However, we included data from a range of dif-
tance of having a strategy, i.e., an outline of steps to be ferent countries and regions, our process was rigorous,
followed, towards developing and implementing a CPD and the summary tables and the action plan provide a
system. In terms of the financing plan, what emerged broad, comprehensible overview of the various consid-
as crucial, is ensuring that funding is not short term erations and steps involved when developing, implement-
(i.e., not dependent on grants or international aid). The ing and evaluating a CPD system in a LLMIC, and thus
recent review by Magwenya et al. (2022) also recommend can be useful resources for others undertaking such an
including a code of ethics, as well as clear guidelines con- endeavour in the future.
cerning the involvement of the pharmaceutical industry
to avoid commercial influence [17]. They also advocate
for low-cost activities so that healthcare providers do not Conclusion
bear an unreasonable burden in order to participate in CPD can strengthen networks, improve motivation and
CPD, which is consistent with the findings in this review. be empowering for healthcare professionals in LLMICs,
With regards to monitoring approaches, and the content especially for those working in more isolated and rural
and delivery methods of CPD, there is no consensus, but regions [3]. The positive effects of CPD in turn can
rather it is proposed that these should be determined translate to retention and higher quality care [19]. To
according to local needs and setting to ensure effective- effectively develop, implement and sustain a CPD sys-
ness [1, 3, 12–14, 17, 73]; making CPD mandatory, how- tem in a LLMIC, leadership, especially from the health-
ever, does appear to be an effective strategy for ensuring care professionals, a framework, funding, CPD materials
CPD uptake. For accreditation, clear standards need to and activities that are accessible and responsive to local
be put in place [12, 13, 17], while for CPD system evalu- needs, and the establishment of robust regulation, moni-
ation, a number of indicators can be applied; Magwenya toring and accreditation structures and an evaluation
et al. (2022), however, emphasize that healthcare pro- mechanism, are essential.
vider behavioural changes and patient outcomes are key
items to measure over the long term. To further inform Supplementary Information
this process, future research that provides a longitudinal The online version contains supplementary material available at [Link]
org/​10.​1186/​s12909-​023-​04427-6.
view of CPD system implementation in LLMICs, includ-
ing ongoing evaluation to assess for sustainability, is Additional file 1. Preferred Reporting Items for Systematic reviews and
warranted. Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Checklist.
Lastly, the findings of the review served as the basis for Additional file 2. Search Strategy for Medline.
the development of an action plan for the nursing CPD Additional file 3. Refinement of Inclusion and Exclusion Criteria.
system development and implementation in Bangla- Additional file 4. Characteristics of Included Articles and Grey literature.
desh (see Additional file 5). This action plan is currently Additional file 5. Bangladesh TWG-CPD action plan and timeline, July
being implemented and includes a timeline and a num- 2022.
ber of detailed steps according to the needs and context
in Bangladesh. The DGNM and the BNMC will play an Acknowledgements
important leadership role. This action plan adds to the The ProNurse project is led by Cowater International, a global develop‑
repertoire of existing resources, and can be used as a ment consulting company, headquartered in Ottawa, Canada ([Link]
cowat​er.​com/​en/​cowat​er-​inter​natio​nal-​and-​partn​ers-​to-​advan​ce-​womens-​
template for other LLMICs planning, developing and empow​erment-​in-​bangl​adesh-​throu​gh-​the-​profe​ssion​aliza​tion-​of-​the-​nursi​
implementing a CPD system. ng-​sector/).
We would like to thank Assia Mourid, the librarian for allied health sciences
at the University of Montreal for her assistance in developing the database
Strengths and limitations search strategies.
We would also like to thank the technical working group for their feedback on
Due to the rapid nature of the review and the prioritiza-
the results of the review and acknowledge their contribution in developing
tion process used to select articles and sources, not all the CPD system action plan for Bangladesh which is reported in Additional
relevant literature may have been included. Details were file 5. The technical group members are: Afroza Banu (DGNM-Nursing);
Abdul Latif (DGNM-Nursing); Sherin Sultana (Dhaka Nursing College); Shipra
not always clear or were piecemeal across the articles and
Karmaker (NICVD hospital); Shariful Islam (NIANER); Dipali Mallick (NIANER);
sources, and so it’s possible that there are some inaccura- Shamsun Nahar (Ahmed Nursing college); Pronita Raha (DGNM-Midwifery);
cies in the data extracted and reported. We also did not Rabeya Basri (DGNM-Midwifery); Nilufar Yesmin (BNMC); Rashida Akhter
(BNMC); Salma Afroz Lily (ProNurse); and Dolly Gonsalves (ProNurse).
conduct a widespread check to verify consistency of the

Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Merry et al. BMC Medical Education (2023) 23:498 Page 20 of 22

Authors’ contributions 7. Garattini L, Gritti S, De Compadri P, Casadei G. Continuing medical educa‑

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