• Peter Johnson, Linda Fogarty, Judith Fullerton, Julia Bluestone, and Mary Drake.
• Jhpiego, 1615 Thames Street, Baltimore, MD 21231-3492, USA. peter.johnson@jhpiego.org.
• Hum Resour Health. 2013 Aug 28; 11: 42.

BackgroundWith decreasing global resources, a pervasive critical shortage of skilled health workers, and a growing disease burden in many countries, the need to maximize the effectiveness and efficiency of pre-service education in low-and middle-income countries has never been greater.MethodsWe performed an integrative review of the literature to analyse factors contributing to quality pre-service education and created a conceptual model that shows the links between essential elements of quality pre-service education and desired outcomes.ResultsThe literature contains a rich discussion of factors that contribute to quality pre-service education, including the following: (1) targeted recruitment of qualified students from rural and low-resource settings appears to be a particularly effective strategy for retaining students in vulnerable communities after graduation; (2) evidence supports a competency-based curriculum, but there is no clear evidence supporting specific curricular models such as problem-based learning; (3) the health workforce must be well prepared to address national health priorities; (4) the role of the preceptor and preceptors' skills in clinical teaching, identifying student learning needs, assessing student learning, and prioritizing and time management are particularly important; (5) modern, Internet-enabled medical libraries, skills and simulation laboratories, and computer laboratories to support computer-aided instruction are elements of infrastructure meriting strong consideration; and (6) all students must receive sufficient clinical practice opportunities in high-quality clinical learning environments in order to graduate with the competencies required for effective practice. Few studies make a link between PSE and impact on the health system. Nevertheless, it is logical that the production of a trained and competent staff through high-quality pre-service education and continuing professional development activities is the foundation required to achieve the desired health outcomes. Professional regulation, deployment practices, workplace environment upon graduation and other service delivery contextual factors were analysed as influencing factors that affect educational outcomes and health impact.ConclusionsOur model for pre-service education reflects the investments that must be made by countries into programmes capable of leading to graduates who are competent for the health occupations and professions at the time of their entry into the workforce.

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