By: Roberta Ladenheim MD, MHPE (Argentina), Reshma G. Kini, MD (India), Daniel Nel MD, PhD (South Africa)
In October 2024, the International Competency-Based Health Professions Education Collaborative (ICBHPE) hosted a webinar on Competency-Based Education (CBE) implementation in LMICs. The meeting brought together educators and healthcare professionals from Latin America, India, and Africa to discuss the progress and challenges with CBE implementation in their contexts. The aim of the event was to facilitate international collaboration and share experiences with CBE across diverse settings. Given that 80% of the world’s population resides in LMICs, we feel that it is imperative that the implementation of CBE in these contexts receives sustained attention. For many LMICs, formal data on implementation is not available due to the recent introduction of CBE and the absence of unified national data systems. What is presented here, therefore, is not a definitive report but mainly a reflection grounded in lived experience — that of educators, administrators, and curriculum designers.
Challenges
There are a number of common challenges in LMICs impacting the implementation of a comprehensive new approach to Health Professions Education (HPE) like CBE. LMICs are characterized by significant socio-economic inequalities, with high poverty rates, income inequality, and healthcare professional shortages, particularly in rural areas. The figure below (from a Lancet Commission report) demonstrates the striking disparities in burden of disease, population and healthcare workforce between the Global North and South.1
The relentless service pressure in LMICs means it is challenging to implement something new, with limited capacity or appetite for systemic change. This is particularly true for faculty development and regulatory changes, which are critical to CBE implementation. In terms of the core components of CBE2, there has been progress by some LMICs in reaching consensus on competencies and, to some extent, on EPAs. Curricula are increasingly being aligned so that educational activities lead to the intended outcomes. However, due to limited resources and the demands of clinical service, significant challenges remain in adapting teaching approaches, incorporating programmatic assessment, and assigning appropriate value to workplace learning.
In our experience, during the early phases of CBE rollout, implementation sometimes significantly outpaced institutional readiness. Faculty development programs were introduced in parallel, yet many educators found themselves navigating unfamiliar terrain — from understanding the meaning of “competency” to applying concepts like formative assessment. The foundational ideas of continuous assessment and feedback, while central to CBE, felt unfamiliar enough that they were met with hesitation. Resistance, when it occurred, was a marker for deeper uncertainties, especially whether the proposed changes were really feasible in less resourced settings.
Across different programs, institutions, specialties, countries, and regions, the adoption of CBE has often been a deliberate choice aimed at transforming how health professionals are trained. In some contexts, however, the adoption of Competency-Based Education (CBE) has been influenced less by intrinsic educational reform and more by the need to align with international accreditation standards, such as those endorsed by the World Federation for Medical Education (WFME).This shift reflects decisions made across multiple levels — institutional, regulatory, and political — often in response to complex and evolving pressures and not necessarily as a result of top-down mandates. CBE is seen by some as a movement originating from the Global North, particularly since the overwhelming majority of scholarly works related to CBE in HPE are from HICs. Hence, for many Global South/LMIC nations, adopting CBE raises concerns about aligning with externally developed models, at odds with efforts to decolonise curricula. Even foundational CBE concepts like “competence” may also be more difficult to use in LMICs — some of us have experienced resistance to the term itself, related to complex local cultural, professional, and historical factors. Considering that the precise motivations behind CBE implementation in LMICs have not always been explicit, understanding what problems CBE was intended to solve in these contexts is an important consideration.
Progress
While these challenges persist, they have not stopped educators and institutions in LMICs from taking meaningful steps toward implementing CBE. These efforts, which we have often found to be locally-driven and isolated to individual programs or institutions, reflect a growing commitment to rethinking HPE. Though typically developed independently and without unified evaluation mechanisms, they mark important progress. Sharing such experiences more systematically could support collaborative problem-solving and inform adaptations of the model that respond to the specific realities of LMIC contexts.
One example of an accessible starting point for CBE implementation across all contexts has been the use of Entrustable Professional Activities (EPAs). In many LMIC contexts, the CBE journey has begun with the definition of EPAs, often facilitated by the online version of Prof ten Cate’s EPA course.3 This course improves access to HPE for healthcare workers in LMICs, thanks to its online format and reduced fee structure. Interestingly, the motivation for EPA adoption in our different LMIC contexts has varied: for some, it has focused on setting targets for assessing clinical competence; for others, on restructuring training to improve the learning process. Regardless of where the EPA journey begins, the close link between teaching and assessment means that more comprehensive curricular transformation toward CBE may follow over time.
Next Steps
While this blog offers a synthesized perspective from our three LMIC regions, it also serves as an invitation to continue the conversation and further develop inclusive and context-sensitive approaches to CBE in HPE. As we move forward, the focus may need to shift from adopting global models of CBE to shaping approaches that make sense in different contexts. There is value in sharing experiences across similar settings; South-South dialogue can highlight solutions that are both relevant and resource-sensitive. At the same time, it’s worth pausing to ask what trust and assessment mean in these systems—especially when shaped by hierarchy, limited resources, or cultural expectations. These reflections help us adapt with intention, rather than by default. By staying grounded in our realities and learning from one another, we can build CBE models that are not only workable, but meaningful. There is certainly also much to learn between differently resourced settings, and it is important to agree that this is not a unidirectional relationship, i.e., from HIC/Global North to LMIC/Global South. Our similarities often outweigh our differences, and we can equally learn from each other. We hope that by sharing our reflections and engaging in this ongoing dialogue, we can contribute to a more equitable and contextually relevant transformation of HPE worldwide.
About the Author:
Roberta Ladenheim, MD, MHPE, is Vice Rector of Universidad del Hospital Italiano de Buenos Aires, faculty in its MHPE program, and member of CIEPS (Center for Research in Health Professions Education). An internist, she focuses on implementing CBME and EPAs in Latin America, emphasizing contextual adaptation and faculty development.
Reshma Gopal Kini, MD is a pathologist from Father Muller Medical College, Mangaluru, India. She is a member of the Medical Education Unit of her Institution. She is the current program director of an EPA e-course designed exclusively for pathologists from India interested in implementing CBE in postgraduate pathology curriculum.
Daniel Nel, MD, PhD, is a General surgeon and senior lecturer at the University of Cape Town. He has a special interest in Health Professions Education and is a member of the ICBHPE collaborative as well as the South African WBA steering committee — tasked with rolling out WBA/EPAs nationally.
References
- Frenk J, Chen L, Bhutta ZA, Cohen J, Crisp N, Evans T, Fineberg H, Garcia P, Ke Y, Kelley P, Kistnasamy B. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. The Lancet. 2010 4;376(9756):1923-58.
- Van Melle E, Frank JR, Holmboe ES, Dagnone D, Stockley D, Sherbino J. A core components framework for evaluating implementation of competency-based medical education programs. Academic Medicine. 2019 1;94(7):1002-9.
- World Federation for Medical Education. Recognised Accreditation Agencies for Basic Medical Education [Internet]. Ferney-Voltaire: WFME; [cited 2025 May 9]. Available from: https://wfme.org/recognition/bme-recognition/accrediting-agencies-status-bme/
- Ten Cate, O. International Online EPA Course: Ins and Outs of Entrustable Professional Activities [Internet]. 2025. Available from: https://amse-med.eu/courses/international-online-course-ins-and-outs-of-entruatable-professional-activities/
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