BackgroundIn the face of severe faculty shortages in resource-constrained countries, medical schools look to e-learning for improved access to medical education. This paper summarizes the literature on e-learning in low- and middle-income countries (LMIC), and presents the spectrum of tools and strategies used.MethodsResearchers reviewed literature using terms related to e-learning and pre-service education of health professionals in LMIC. Search terms were connected using the Boolean Operators “AND” and “OR” to capture all relevant article suggestions. Using standard decision criteria, reviewers narrowed the article suggestions to a final 124 relevant articles.ResultsOf the relevant articles found, most referred to e-learning in Brazil (14 articles), India (14), Egypt (10) and South Africa (10). While e-learning has been used by a variety of health workers in LMICs, the majority (58%) reported on physician training, while 24% focused on nursing, pharmacy and dentistry training. Although reasons for investing in e-learning varied, expanded access to education was at the core of e-learning implementation which included providing supplementary tools to support faculty in their teaching, expanding the pool of faculty by connecting to partner and/or community teaching sites, and sharing of digital resources for use by students. E-learning in medical education takes many forms. Blended learning approaches were the most common methodology presented (49 articles) of which computer-assisted learning (CAL) comprised the majority (45 articles). Other approaches included simulations and the use of multimedia software (20 articles), web-based learning (14 articles), and eTutor/eMentor programs (3 articles). Of the 69 articles that evaluated the effectiveness of e-learning tools, 35 studies compared outcomes between e-learning and other approaches, while 34 studies qualitatively analyzed student and faculty attitudes toward e-learning modalities.ConclusionsE-learning in medical education is a means to an end, rather than the end in itself. Utilizing e-learning can result in greater educational opportunities for students while simultaneously enhancing faculty effectiveness and efficiency. However, this potential of e-learning assumes a certain level of institutional readiness in human and infrastructural resources that is not always present in LMICs. Institutional readiness for e-learning adoption ensures the alignment of new tools to the educational and economic context.

The adoption of Course Management Systems (CMSs) for web-based instruction continues to increase in today's higher education. A CMS is a software program or integrated platform that contains a series of web-based tools to support a number of activities and course management procedures (Severson, 2004). Examples of Course Management Systems are Blackboard, WebCT, eCollege, Moodle, Desire2Learn, Angel, etc. An argument for the adoption of elearning environments using CMSs is the flexibility of such environments when reaching out to potential learners in remote areas where brick and mortar institutions are non-existent. It is also believed that e-learning environments can have potential added learning benefits and can improve students' and educators' self-regulation skills, in particular their metacognitive skills. In spite of this potential to improve learning by means of using a CMS for the delivery of elearning, the features and functionalities that have been built into these systems are often underutilized. As a consequence, the created learning environments in CMSs do not adequately scaffold learners to improve their self-regulation skills. In order to support the improvement of both the learners' subject matter knowledge and learning strategy application, the e-learning environments within CMSs should be designed to address learners' diversity in terms of learning styles, prior knowledge, culture, and selfregulation skills. Self-regulative learners are learners who can demonstrate 'personal initiative, perseverance and adaptive skill in pursuing learning ' (Zimmerman, 2002). Self-regulation requires adequate monitoring strategies and metacognitive skills'.The created e-learning environments should encourage the application of learners' metacognitive skills by prompting learners to plan, attend to relevant content, and monitor and evaluate their learning. This position paper sets out to inform policy makers, educators, researchers, and others of the importance of a metacognitive elearning approach when designing instruction using Course Management Systems. Such a metacognitive approach will improve the utilization of CMSs to support learners on their path to self-regulation. We argue that a powerful CMS incorporates features and functionalities that can provide extensive scaffolding to learners and support them in becoming self-regulated learners. Finally, we believe that extensive training and support is essential if educators are expected to develop and implement CMSs as powerful learning tools. The educational technology revolutionSince the late 1990s, the utilization of CMSs for web-based instruction has steadily increased in higher education. The implementation of CMSs in universities followed on the revolution of educational technology that promised better quality, learner-centred education and claimed that it would deliver more independent and active students (Swinney, 2004). E-learning delivered electronic learning materials to distant learners and it was considered to be the new vehicle that would lea...

How should eLearning be implemented in resource-constrained settings? The introduction of eLearning at four African medical schools and one school of pharmacy, all part of the Medical Education Partnership Initiative (MEPI) eLearning Technical Working Group, highlighted the need for five factors essential for successful and sustainable implementation: institutional support; faculty engagement; student engagement; technical expertise; and infrastructure and support systems. All five MEPI schools reported strengthening technical expertise, infrastructure, and support systems; four schools indicated that they were also successful in developing student engagement; and three reported making good progress in building institutional support. Faculty engagement was the one core component that all five schools needed to enhance.

The Medical Education Partnership Initiative (MEPI) supports medical education capacity development, retention, and research in Sub-Saharan African institutions. Today, MEPI comprises more than 40 medical schools in Africa and 20 in the United States. Since 2011, the MEPI Coordinating Center, working with the MEPI schools and the U.S. government, has laid the groundwork and served as a catalyst for the creation and development of MEPI "communities of practice" (CoPs). These CoPs encompass seven components, some of which are virtual while others are tangible. They include technical working groups, principal investigator site visit exchanges, an annual symposium, a MEPI journal supplement, the MEPI Web site, newsletters, and webinars. Despite certain challenges and the question of sustainability, the presence within the MEPI network of an organization focused on promoting group consciousness and facilitating collaborative projects is an asset that is likely to continue to pay dividends for the foreseeable future.