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E-learning has been heralded as a revolutionary force for medical education, especially for low-resource countries still suffering from a dire lack of health care workers. However, despite over two decades of e-learning endeavors and interventions across sub-Saharan Africa and other low- and middle-income countries, e-learning for medical education has not gained momentum and continues to fall short of the anticipated revolution. Many e-learning interventions have been cul-de-sac pilots that have not been scaled up but rather terminated after the pilot phase. This is usually a result of not adopting a system-wide approach, which leads to insufficient scope of training, insufficient technological maintenance and user support, unattainably high expectations, and unrealistic financial planning. Thus, a multitude of e-learning evaluations have failed to provide scientifically sound evidence of the effectiveness of e-learning for medical education in low-resource countries. Instead, it appears that technological development has overwhelmed rather than revolutionized medical education. The question of how to push e-learning into a higher gear in low-resource countries persists. Provision of e-learning as a technology is insufficient. E-learning needs to be vigorously and sustainably integrated into the local educational setting and aligned with national strategies and other national endeavors and interventions. Adhering to a standardized framework for the implementation and evaluation of e-learning endeavors is key, especially to bridge the gap in robust evidence that should also guide e-learning implementations. The primary objective of e-learning for medical education is to strengthen the health system in order to serve the population’s health care needs and expectations. Currently, medical e-learning does not measure up to its potential or do justice to medical students in low-resource countries. Technology may help unfold the potential of e-learning, but an all-encompassing change is needed. This can only be achieved through a joint effort that follows a systematic and standardized framework, especially for implementation and evaluation.

UNSTRUCTURED E-learning has been heralded as a revolutionary force for medical education, especially for low-resource countries still suffering from a dire lack of health care workers. However, despite over two decades of e-learning endeavors and interventions across sub-Saharan Africa and other low- and middle-income countries, e-learning for medical education has not gained momentum and continues to fall short of the anticipated revolution. Many e-learning interventions have been cul-de-sac pilots that have not been scaled up but rather terminated after the pilot phase. This is usually a result of not adopting a system-wide approach, which leads to insufficient scope of training, insufficient technological maintenance and user support, unattainably high expectations, and unrealistic financial planning. Thus, a multitude of e-learning evaluations have failed to provide scientifically sound evidence of the effectiveness of e-learning for medical education in low-resource countries. Instead, it appears that technological development has overwhelmed rather than revolutionized medical education. The question of how to push e-learning into a higher gear in low-resource countries persists. Provision of e-learning as a technology is insufficient. E-learning needs to be vigorously and sustainably integrated into the local educational setting and aligned with national strategies and other national endeavors and interventions. Adhering to a standardized framework for the implementation and evaluation of e-learning endeavors is key, especially to bridge the gap in robust evidence that should also guide e-learning implementations. The primary objective of e-learning for medical education is to strengthen the health system in order to serve the population’s health care needs and expectations. Currently, medical e-learning does not measure up to its potential or do justice to medical students in low-resource countries. Technology may help unfold the potential of e-learning, but an all-encompassing change is needed. This can only be achieved through a joint effort that follows a systematic and standardized framework, especially for implementation and evaluation.

BACKGROUND E-learning in medical education can contribute to alleviating the severe shortages of health workers in many low- and middle-income countries. In the past few decades, the rapid development of technologies resulted in an abundance of new resources, including personal computers, smartphones, handheld devices, software and the Internet – at constantly decreasing costs. Consequently, educational interventions increasingly integrate e-learning to tackle the challenges of health workforce development and training. However, evaluations of e-learning interventions still lack clear methodology to assess the effectiveness and the success of e-learning for medical education, especially in those countries where they are most needed. OBJECTIVE Our specific research aim was to systematically describe currently used evaluation methods and definitions for the success of medical e-learning interventions for medical doctors and medical students in low- and middle-income countries. Our long-term objective is to contribute to generating effective and robust e-learning interventions to address critical health worker shortages in low- and middle-income countries. METHODS Seven databases were searched for e-learning interventions for medical education in low- and middle-income countries, covering publications ranging from January 2007 to June 2017. We derived search terms following a preliminary review of relevant literature and included studies published in English which implemented e-learning asynchronously for medical doctors and/or medical students in a low- or middle-income country. Three reviewers screened the references, assessed their study quality, and synthesized extracted information from the literature. RESULTS We included 52 studies representing a total of 12294 participants. Most of the e-learning evaluations were assessed summatively (83%) and within pilot studies (73%), relying mainly on quantitative evaluation methods using questionnaire (45%) and/or knowledge testing (36%). We identified a lack of evaluation standards for medical e-learning interventions, as methods varied considerably in the evaluation of their medical e-learning interventions with a high variation in study quality (general low study quality, based on study quality scales MERSQI, NOS and NOS-E), study period (ranging from 5 days up to 6 years), assessment methods (6 different main methods) and outcome measures (a total of 52 different outcomes), as well as in the interpretation of intervention success. The majority of studies relied on subjective measures and self-made evaluation frameworks, resulting in low comparability and validity of evidence. Most of the included studies reported success in their e-learning intervention. CONCLUSIONS The evaluation of e-learning interventions needs to produce meaningful and comparable results. Currently, a majority of evaluations of e-learning approaches to educate medical doctors and medical students is based on self-reported measures that lack adherence to a standard evaluation framework. While the majority of studies report success of e-learning interventions – suggesting the potential benefits of the e-learning – the overall low quality of the evidence makes it difficult to draw firm conclusions. Methods development, study design guidance, and standardization of evaluation outcomes and approaches for e-learning interventions will be important for this field of education research to prosper. Methodological strength and standardization are particularly important, because the majority of the existing studies evaluate pilot interventions. Rigorous evidence on pilot success can improve the chances of scaling and sustaining e-learning approaches for health workers.