From Competence to System-Readiness: Aligning Medical Education With Health System Realities in Low- and Middle-Income Countries.

Medical education in low- and middle-income countries (LMICs) often results in clinically competent doctors who are not well equipped to function effectively in fragile, resource-limited health systems. Competency-based medical education (CBME) provides structured learning outcomes, observable competencies, and accountability; however, it was developed mainly in high-income countries with stable health systems and ample resources and thus has limited relevance in the LMIC context. The challenges faced by medical graduates in LMICs include managing scarce resources, leading a multidisciplinary team, conducting quality improvement initiatives, and addressing population-level health priorities, which are capacities we define as system-readiness. Health Care System-Based Medical Education (HCSBME) adds value to CBME by embedding learners in an operational health system setting, such as hospitals, primary care, rural clinics, and community programs, and fosters the development of leadership, teamwork, cost-awareness, and system-level thinking. Integration of CBME and HCSBME enables the medical education system to train physicians who are clinically competent and system-ready. Evidence from Rwanda, Thailand, Ghana, and Ethiopia shows that system-embedded curricula improve workforce distribution, retention, and preparedness for responding to health system needs. This integration thus fills the existing gaps in LMIC medical training and aligns the preparation of physicians with the needs of patients and health systems to improve workforce and health system resilience.