International Journal of Africa Nursing Sciences 18 (2023) 100535

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International Journal of Africa Nursing Sciences

journal homepage: www.elsevier.com/locate/ijans

Transforming nursing education to support health workforce and nursing

education development in Angola: An integrative review
Mário Fresta a, *, Inês Fronteira b, Judith Luacute c, Paulo Ferrinho b
a
CEDUMED, Universidade Agostinho Neto, recinto do Hospital Américo Boavida, Av. Hoji ya Henda, Luanda, Angola
b
Global Health and Tropical Medicine, Instituto de Higiene e Medicina Tropical, Universidade Nova de Lisboa. Rua da Junqueira 100, 1349-008 Lisboa, Portugal
c
Nursing Management of the Angolan Minister of Health, Angola

A R T I C L E I N F O A B S T R A C T

Keywords: The Angolan State has been looking for a way to strengthen the health sector with a balanced workforce for
Nursing education which nursing is a cornerstone. This study reviews the evolution of nursing education in Angola, in order to
Nursing students better understand the contribution of the educational sector to nursing workforce development.
Health workforce planning
Methods: Integrative review of unpublished and published documents and literature on nursing education in
Angola
Human resources for health
Angola. The literature is qualitatively analyzed and discussed using the policy triangle framework proposed by
Walt and Gilson.
Results and discussion: The transformation of the nursing workforce in Angola has gone through four phases: (i)
colonial, (ii) post-independence expansion of coverage with basic nursing skills, (iii) professional and academic
differentiation of the profession with strategic guidance of the national health workforce plan of 1997–2007, and
(iv) a recent expansion of tertiary education training driven by the private for-profit sector.
The challenges for nurse education in Angola are similar to those faced by other sub-Saharan African countries.
These challenges need to be understood and addressed within a broad health labor market framework, in order to
ensure cultural relevance, responsiveness of the cadres trained to the population’s and users’ needs, fitness to
employment opportunities in both public and private sectors and balanced distribution of future graduates be­
tween urban and rural and different levels of care.

1. Introduction initially in the context of the development of a health workforce strategy

The Angolan State has been looking for ways to strengthen the health
sector with the necessary human resources in quantity, quality and
distribution throughout the country and by levels of care, recognizing
that without a balanced workforce, health gains are not possible. (WHO,
2016) Nurses are a touchstone of such workforce. (WHO, 2020) The
government’s responses have been framed in a National Health Policy
(República de Angola, 2010), a National Health Development Plan
(República de Angola, 2012), successive Human Resources Develop­
ment Plans (República de Angola, 1999; República de Angola, 2014) and
a National Staff Training Strategy (Estratégia Nacional de Formação de
Quadros – ENFQ) (República de Angola, 2012) and its corresponding
National Staff Training Plan (Plano Nacional de Formação de Quadros –
PNFQ) (República de Angola, 2012);
This study reviews the historical development of nursing education
in Angola, from colonial times to 2021. Conducted by the authors,
for Angola in 2013, the review findings have been updated to current
times, in order to understand the past and assist with the future trans­
formation of nursing education in Angola.
2. Materials and methods
An integrative literature review was carried out to answer to the
question “What has been the evolution of nursing education in terms of
context, processes, content and actors in Angola since colonial times
until the present time?”. This review method allows to summarize
empirical and theoretical literature, using different methodological ap­
proaches, to better understand a problem or phenomenon and poten­
tially influence policy making. (Roth, 2022; Whittemore and Knafl,
2005; De Souza et al., 2010) To develop the integrative review we
adopted the method proposed by Whittemore and Knafl (Whittemore
and Knafl, 2005).

* Corresponding author.
E-mail address: mariofresta@gmail.com (M. Fresta).

https://doi.org/10.1016/j.ijans.2023.100535
Received 27 November 2020; Received in revised form 27 December 2022; Accepted 22 January 2023
Available online 27 January 2023
2214-1391/© 2023 Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
M. Fresta et al. International Journal of Africa Nursing Sciences 18 (2023) 100535

The literature search included reviews, opinions, perspectives, let­ República de Angola, 1999; República de Angola, 2014; República de
ters to the editor, quantitative, mixed methods and qualitative studies. Angola, 2012; República de Angola, 2012; República de Angola, 2002;
Unpublished literature (official documents and student theses) were República de Angola, 2002; Fresta et al., 2007; República de Angola,
included aiming to reduce publication bias and to provide a balanced 2007; República de Angola, 2007; Tyrrel, 2007; Projecto 9.ACP.MTR.04,
view of the available evidence, by increasing the comprehensiveness of 2011; República de Angola, 2012; República de Angola, 2012; Ferrinho
the review. (Paez, 2017) No language or time restrictions for inclusion of et al., 2013; República de Angola, xxxx) Personal contacts of the re­
studies were defined. searchers with experts allowed the identification of 12 more documents
The search algorithms and the data bases searched for literature are (Fig. 1). (de Carvalho, 2012; Langa, 2013; Hernández et al., 2013;
identified in Table 1. The search focused solely on Angola. Alfonso, 2013; González, 2013; Medina and Vázquez, 2013; Leyva and
The abstracts of the retrieved documents were assessed in order to Jorge, 2013; Torres and Jorge, 2013; Torriente et al., 2013; García and
judge if: (i)they contributed to the objective of understanding the Batista, 2013; Simões et al., 2016; República de Angola, xxxx) All doc­
context, the processes, the content and the key actors in the develop­ uments retained for analysis were either in Portuguese, English or
ment of nursing education in Angola; (ii) they addressed issues related to Spanish. All documents retrieved electronically were done or recon­
nursing education, nursing students, health workforce planning, or firmed on the 13th of January 2022.
human resources for health in Angola. In case no abstract was available, To extract and analyze the data, we adopted the analytical frame­
the criteria were applied either to the executive summary or the intro­ work for health policy making - context, processes, content and key
duction of the documents. When eligibility criteria were met, documents actors – as proposed by Walt and Gilson (Walt and Gilson, 1994).
were selected for full-text analysis. In this phase, the eligibility criteria According to these authors, health policy making can be understood
were again applied and 9 documents met the criteria to be retained for looking at four intertwined factors that can be schematically represented
analysis (Fávero et al., 1996; Tiago, 2011; Mandriz, 2011; Marchi-Alves as a triangle which vertex are the context, the processes and the context
et al., 2013; Hernández and Smith, 2017; Torres García et al., 2018; and in the center of the triangle are the key actors (individuals, groups
Corrales, 2018; García and Mukendi, 2018; Tavares et al., 2018). and organizations). The policy triangle is useful to systematically think
The references of these 9 documents were searched manually and the about the educational and workforce policies under consideration.
documents selected subjected to the assessment described above (iden­
tifying another 14 documents (Oguisso, USP.1993;; Serrano, 2012; Costa 3. Results
Mendes et al., 2013; Novais and Díaz Cruz, 2014; Tomás, 2014; Suárez-
Lezcano et al., 2015; de Azevedo, 2016; Santos Smith and Bravo Despite its enormous natural resources, Angola is a relatively fragile
Hernández, 2017; Chicumba, 2019; Clarence-Smith and Thornton, state. (Arko-Cobbah and Olivier, 2016) The country has been trying to
2021; Filho and Aleaga, 2021; Mendes et al., 2021; Mendes et al., 2021; cope with four transitions simultaneously from: colonial territory to
Ventura et al., 2021). Additionally, 17 relevant official policy docu­ independent state; war to peace; single-party rule to multiparty de­
ments were identified during and related to the 2013 workforce plan­ mocracy; a command-based to a free-market economy (Munslow, 1999).
ning process. (República de Angola, 2010; República de Angola, 2012; Oil and diamonds have been the pillars of the country’s economy. As
the second largest oil producer in sub-Saharan Africa (SSA), Angola is a
Table 1 ’resource cursed’ country ailing from a ’paradox of abundance (Barros,
Draft of search algorithms per database used as literature sources. 2012; Hammond, 2011) aggravated by a 13-year liberation war, fol­
lowed, after independence in 1975, by a civil war until 2002, with
Electronic databases Search algorithm Documents Search
used as literature retrieved date negative impacts on the education and health sectors and their work­
sources forces. The collapse of oil prices since 2008 initiated a persistent severe
Medline – PubMed htt ((“nurses”) AND 4 13/01/
economic crisis.
ps://pubmed.ncbi. (“education” OR 2022 The challenges of developing an adequate nursing workforce need to
nlm.nih.gov/ “teaching/methods” OR be understood and addressed in this context and within a broad health
“educational status” OR labor market framework (Sousa et al., 2013), in order to ensure cultural
“teaching”) AND
relevance, responsiveness of the cadres trained to the population’s and
(“Angola”))
((“nursing”) AND 13 13/01/ users’ needs, fitness to employment opportunities in both public and
(“education” OR 2022 private sectors and balanced distribution of future graduates between
“teaching/methods” OR urban, rural and underserved areas and different levels of care. The
“educational status” OR country’s demographics and the growing number of young people who
“education” OR
“teaching”) AND
finished primary and secondary education (with significant learning
(“Angola”)) fragilities) completes the pressures for the development, first of mid-
Scopus https://www. ((“nurses”) AND 7 13/01/ level technical training and, later, for the reinforcement of university
scopus.com/home.uri (“education” OR 2022 education.
“teaching/methods” OR
With about 33 million inhabitants (2020), there are 0.408 nurses per
“educational status” OR
“teaching”) AND 1000 inhabitants (2018) (https://data.worldbank.org/indicator/SH.ME
(“Angola”)) D.NUMW.P3?locations=AO), making it a country with a severe shortage
((“nursing”) AND 11 13/01/ of nurses. Hence, the acknowledgment by the National Staff Training
(“education” OR 2022 Strategy (ENFQ) that the stock of practicing nurses should double until
”teaching/methods“ OR
”educational status” OR
2020 (República de Angola, 2012), despite the acknowledgement that
“teaching”) AND nurses are still the largest professional group within the Angolan health
(“Angola”)) workforce. Even so, paradoxically, in January 2019, the Nursing Council
Latin American and “nursing education” AND 7 13/01/ (Ordem dos Enfermeiros de Angola – ORDENFA) reported the existence of
Caribbean Health 2022
“Angola”
more than 10 000 nurses unemployed. In addition to the issue of un­
Sciences Literature ((“nursing” OR “nurses”) 0 13/01/
(Lilacs) https://lilacs. AND (“education” OR 2022 employment, ORDENFA identified key bottlenecks associated with the
bvsalud.org/en/ ”teaching/methods“ OR inadequacy of the career system and the proliferation of poor-quality
”educational status” OR nursing schools. Other issues related to the practice of nursing
“teaching”) AND included non-payment for a standard package of extra working hours,
(“Angola”))
discrimination and professional disrespect and lack of promotion

2
M. Fresta et al.
Fig. 1. Flow diagram of literature review. Adapted from: Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020
statement: an updated guideline for reporting systematic reviews. BMJ 2021;372:n71. https://doi.org/10.1136/bmj.n71. (Page et al., 2020) For more information,
visit: https://www.prisma-statement.org/.
opportunities, of food security for shift workers in the health care units
and of assistance with housing and transportation for those working in
remote areas. (https://allafrica.com/stories/201901170562.html).
These have been major causes of the frequent strikes among Angolan
nurses.
As reflected in Table 2, the transformation of the nursing workforce
education in Angola has gone through four phases: (i) colonial, (ii) post-
independence expansion of coverage with basic nursing skills, (iii) mid-
level differentiation of the profession with strategic guidance from the
national health workforce plan of 1997–2007, and (iv) a recent expan­
sion of mid-level and tertiary education and training driven by the pri­
vate for-profit sector.
4. Colonial period
4.1. General education
Portuguese colonial policy did not encourage education for the
“indigenous” Angolan population. Until 1961, when a reviewed edu­
cation program was decreed by the colonial government, most educa­
tion was in the hands of religious institutions—the Roman Catholic
Church focusing on settlers from Portugal and a small number of Afri­
cans and Protestants active among the “indigenous” population. There
was only one secondary school in Luanda, created in 1919. Tertiary
education was established in 1962. The literacy rate was then extremely
low (Tiago, 2011; Serrano, 2012; Chicumba, 2019; Clarence-Smith and
Thornton, 2021; Filho and Aleaga, 2021).
4.2. Nursing education
An 1844 decree, followed by another in 1845, laid the legal basis for
the creation of an institute for the preparation of “health practitioners”
in Luanda, with competences in nursing and in “small medicine”. The
first Nursing Assistants, Attendants and Practitioners Training School at
Hospital Maria Pia (now Maria Pia - Josina Machel Hospital) in Luanda,
3
International Journal of Africa Nursing Sciences 18 (2023) 100535
dates from 1883. There is reference in the literature to another Nursing
Assistant Course since the 1940s. But nursing education in Angola was
only formalized with the setting up of the Technical School of Health
and Assistance Services in Luanda and in Huambo (then named Nova
Lisboa), respectively in 1967 and 1969. In 1970, the Portuguese Gov­
ernment created, in the Cota Municipality of Malanje, the Rural Health
Assistance Agents Training School (Tiago, 2011).
Christian churches also played then a relevant role in the training of
health professionals through schools and health facilities associated
with their missionary activity. (Serrano, 2012) This contribution has not
yet been studied in a systematic way.
At the time of independence, in 1975, there were two categories of
nursing professionals, namely general nurses (enfermeiros gerais) with
two years training (after nine years of primary and secondary school
education) and nursing assistants (auxiliares de enfermagem) with one
year of training (after six years of school education) (Judith Luacute,
personal communication, August 2021).
5. After independence
5.1. General education
Immediately after independence, the Government’s policy of “pri­
mary education for all” tripled primary school enrollment between 1976
and 1979, which then declined significantly from the 1980 s onwards, as
almost three decades of civil war took a toll on Angola’s educational
system, destroying four-fifths of all schools in the country. Even so,
enrollment in secondary schools and in the Agostinho Neto University
expanded continuously after 1975, as these institutions suffered less
than primary schools from political insecurity and war. During this time,
recruitment into the armed forces of the MPLA and UNITA had a greater
impact than Angola’s school system on the spread of literacy, the
increased use of the Portuguese language, the acquisition of technical
skills and the training of nurses (Tiago, 2011; Clarence-Smith and
Thornton, 2021).
M. Fresta et al. International Journal of Africa Nursing Sciences 18 (2023) 100535

Table 2
Phases of evolution of nursing workforce education in Angola according to the policy triangle.
Time frame Context (overlapping Key actors Processes Focus/content – four phases
(overlapping transitions)
periods)

Before 1975 Colonial territory; Colonial government; Emergence of first centers to train health Service-based training centers.
Independence war. Missionaries. auxiliaries and nursing assistants.
1975–1991 Independence from National Government – Ministries of Health First reform of the education system – Universal literacy plan.
Portugal; one party (MINSA), Education (MED) and of National ideological orientation (1977). Rapid expansion of auxiliary
Marxist-Leninist Defense; key international partners (WHO, Nation-wide network of technical Schools of nursing staff as undifferentiated
regimen; Soviet Union and Cuba and other socialist Public Health to train auxiliaries; emergence providers of health care to ensure
civil war. countries). of first mid-level nurses training centers. universal coverage.
Since 1992 Transition from one- to National government: MINSA, MED; private Regionalization and rapid expansion of mid- Differentiation of mid-level
(ongoing) multi-party system. sector investment in mid-level training; level nurses training centers; emergence of nursing professionals and
diversification of international partners first public sector tertiary training institution emergence of university-trained
(Brazil, Cuba, Portugal, Sweden). for nurses. nurses (mostly abroad).
Since 2001 Collapse of oil prices National government: MINSA, MED, Second reform of the education system – Laissez-faire expansion of tertiary
(ongoing) and liberalization of Ministry of Higher Education, Science and National Plan of Action for Education for All - education training of nurses.
the economy. Technology (MESCT); private sector alignment with the liberalization of the
investment in higher education; economy (2004).Third reform of the
international partners (Cuba, Members education system – performance oriented -
states of the Lusophone Community of (2016)
Countries, South Africa). .
Regionalization and rapid expansion of
tertiary education training institutions for
nurses.

Although higher education in Angola dates back to 1962, during the
colonial period, the only university in the country, renamed Uni­
versidade Agostinho Neto (UAN) in 1985, in honor of the first president
of the country, remained the single higher education institution in the
country until 1999 when private universities were established. By then,
UAN had established campuses in 7 of Angola’s 18 provinces. The period
from 2002 to 2010 was marked by significant changes in Angolan higher
education governance structures and mechanisms: 2003, establishment
of the national directorate of higher education in the structure of the
Ministry of Education (MED); 2005, appointment of a deputy minister of
education in higher education; 2006, guidelines for the reform and
improvement of higher education; 2007:, establishment of the state
secretariat for higher education; 2009, resizing of UAN and the estab­
lishment of new public higher education institutions organized into
seven academic regions; 2010, Establishment of the Ministry of Higher
Education and Science and Technology (MESCT) and of the Institute for
Quality Assurance and Accreditation of Higher Education. By the end of
2010, there were already 23 higher education institutions in Angola,
seven of which were public and 16 private. Despite the establishment of
accreditation procedures for the opening of private universities this have
not been adhered to, resulting in inadequate facilities, lack of resources
and study materials, libraries, laboratories and appropriate courses, and
widespread sub-standard level of quality in the tertiary education sector.
There were also too few staff to service the number of universities, with
the result that many of them teach (illegally) at more than one univer­
sity. It is only since 2020 that the MESCT initiated several processes for
harmonization of the syllabus of the higher education programs (Filho
and Aleaga, 2021; Simões et al., 2016; de Carvalho, 2012; Langa, 2013).
5.2. Nursing education
Immediately after independence, in 1975, Law No. 9/75 of
December 10, extinguished the General and Nursing Assistant Programs
and institutionalized the Basic Nursing Technician course. During 1976,
twenty-two Technical Schools of Public Health were created in all 18
provinces, with the objective of massifying the training of nursing as­
sistants. During 1979 the training of promoters of occupational and rural
health was also intensified throughout the national territory. The Min­
istry of Health (Ministério da Saúde - MINSA) also begun with the
specialization of nursing assistants in areas such as pedagogy and di­
dactics, maternal and child care, pediatrics and child care, public health,
medical and surgical health care, anesthesiology and physical
rehabilitation (Tiago, 2011).
The transformation of the training system continued into the 1980s
(República de Angola, 2002; Fresta et al., 2007) with a reform that
established several Midlevel Institutes of Health (Institutos Médios de
Saúde – IMS). (Fresta et al., 2007) The first mid-level technical nursing
course was created in 1982 at Bié’s IMS (Tiago, 2011).
With the adoption of the first HRH Development Plan (Plano Nacional
de Desenvolvimento de Recursos Humanos – PNDRH, 1997–2007)
(República de Angola, 1999), the transformation of technical and pro­
fessional education in health underwent a new impulse. This impulse
was sustained in 2007 by the adoption of “Angola 2025” – a long term
sustainable development strategy for the country (Chicumba, 2019), by
the approval of a national health policy 2010–2025 (WHO, 2016), the
adoption of a strategic plan for the health sector 2012–2025 (República
de Angola, 2012), the 2012 strategy for the educational sector (ENFQ)
(República de Angola, 2012), the national plan for the education sector
2012–2020 (PNFQ) (República de Angola, 2012), the 2013–2025 HRH
development plan (República de Angola, 2014) and the 2014 HRH na­
tional policy (Ferrinho et al., 2013).
5.3. Regionalization and expansion of training of mid-level nurses
With the adoption of the first HRH Development Plan (República de
Angola, 1999), basic nursing training was interrupted and schools of­
fering basic training were converted into Provincial Recycling Centers to
promote basic nurses into mid-level nurses with one-year courses. The
regionalization of training was proposed, leading to the progressive
transformation of IMS into Health Professional Technical Schools
(Escolas Técnicas Profissionais de Saúde – ETPS) with regional scope. The
ETPS would also concentrate on promotion of courses for assistant
technicians and specialization for midlevel nurses already in the system
(Tiago, 2011; Ferrinho et al., 2013).
In fact, the process of reorganizing the national training network for
health professionals through its rationalization and requalification - as
provided for in the 1997–2007 HRH strategic framework (República de
Angola, 1999) - experienced significant deviations. (República de
Angola, 2007) In 2006, the only operational ETPS were the ones at
Lubango (the first to be created and a “model” for future ones) and
Luanda. (Tomás, 2014) In 2011, instead of the 5 ETPS planned, there
were 10 ETPS and 11 IMS (Projecto 9.ACP.MTR.04, 2011) in the public
sector. In Luanda alone, there were 21 private institutions for the
training of midlevel nurses, but only 7 met the conditions necessary to

4
M. Fresta et al.
be accredited. (República de Angola, 2012) In 2013, 6 other private
institutions would be accredited (António Alves da Costa, personal
communication, June 2013).
The emergence of private sector involvement is explained by the
growing demography-driven demand for nurse training (mid and uni­
versity level) and the inability of the public sector to satisfy this demand:
the 2010 estimates of the national strategy for the training of the
Angolan workforce (ENFQ) were that the demand for nursing training
(mid and university level) until 2020 would be 25,000 to 30,000 but the
capacity of the education system would be able to satisfy only 7,500 to
10,000,1 (República de Angola, 2012). The national plan for workforce
training (PNFQ) specifies that about 8,000 of these would be mid-level
trainee nurses and paramedics, but the national capacity would meet
the demand only for 6,000 trainees (República de Angola, 2012).
An assessment of 10 midlevel institutions in 2011 revealed that they
all lacked suitable libraries. Access to laboratories and practical rooms,
computer equipment, equipment to support classes and the internet was
low. Teacher training was considered deficient. The number of students
per class was variable, but low capacity forced most institutions to run
several classes per day in the same room. The possibility for distance
learning existed only in Lubango (Huíla). (Projecto 9.ACP.MTR.04,
2011) The findings of this evaluation were similar to those of the 2002
Malange Meeting, which highlighted the lack of criteria for selecting
internship placements for midlevel students (República de Angola,
2002).
5.4. The emergence of university training of nurses
In Angola nurse training became associated with university training
only from the late 1980s onwards.
In 1985 MINSA created the Center for Higher Education in Nursing
(Centro de Ensino Superior de Enfermagem – CESE) with the support of the
World Health Organization (WHO). (Tiago, 2011; Oguisso, 1993) The
growth of university training for nurses was greatly supported by the
University of São Paulo (USP). (Fávero et al., 1996; Mandriz, 2011;
Mendes et al., 2021; Ventura et al., 2021) During 1990 CESE was con­
verted into the Higher Institute of Nursing (Instituto Superior de Enfer­
magem – ISE), and integrated into UAN in 2002 as the Higher Institute
for Health Sciences (Instituto Superior de Ciências de Saúde – ISCISA).
(Tiago, 2011) ISE suspended its activities between 1992 and 1998 after
the looting of its facilities with the restart of the civil war. (Mandriz,
2011) In 2011, the higher education degree in nursing was already
offered in 10 provinces (even if without the required standardization/
accreditation). (Fávero et al., 1996; Mendes et al., 2021; República de
Angola, 2012) In 2012, 10 % of the nursing stock (excluding auxiliaries
and midwives) already had university level education. It is among these
university-trained nurses that the tendency to emigrate was most
marked. (República de Angola, 2012) The national plan for workforce
training (PFQ) identified the need to train 18,750 nurses at university
level, but acknowledged that the national education system had the
capacity to train only 4,450 between 2010 and 2020 (República de
Angola, 2012).
The cost of training a university level nurse was estimated at 4,900
USD per year compared with 3,900 USD per year for a mid-level nurse
(Tyrrel, 2007).
5.5. International cooperation
Since Alma-Ata (1978), WHO supported assistant nurses training all
1 Since the 2004 National Plan of Action for Education for All, primary
The national training strategy estimates were based on population estimates
of 2012 that predicted a 2020 population of 24,460,000. This was a gross un­
derestimation, as the “Angola Population and Housing Census of 2014” –
https://ghdx.healthdata.org/record/angola-population-and-housing-census-
2014 – estimated the 2014 population already at 25,789,024.
5
International Journal of Africa Nursing Sciences 18 (2023) 100535
over the country (curriculum development, consultancy and bibliog­
raphy). During the 1980s, WHO also supported rebuilding the building
where ISE was installed and provided a French teacher to support
training (Tiago, 2011; Oguisso, USP.1993).
By the late eighties, the World Bank, the Portuguese Cooperation and
the Fundação Calouste Gulbenkian supported the conversion of IMS into
ETPS with the initial aim of capacitating them to provide to provide a
bachelor’s degree (Tiago, 2011; Tomás, 2014).
The Swedish International Development Agency (SIDA) supported a
curriculum reform in the IMS (from 1984 until the nineties), for medium
level nursing specialization in midwifery and health units’ managers,
and the CESE conversion process into ISE (1988–1998). It also funded
the training of Angolan nurses at the Colleges of Nursing in the São Paulo
and in the Ribeirão Preto campuses, University of São Paulo (USP)
(Fávero et al., 1996; Tiago, 2011; Mendes et al., 2021).
The first thirty-two nurses with higher education received their
training, between 1988 and 1999, at the Colleges of Nursing in São
Paulo and in Ribeirão Preto campuses. These students reinforced the
faculty of ISE, but they were also important to ensure the management
and teaching in the IMS and to introduce university trained nursing
professionals into the health sector. In 1991, MINSA signed the first
“umbrella” agreement with USP and later, in 2005, ISCISA formalized
this agreement. In 2000, UAN signed the first academic agreement with
the University of South Africa (UNISA), allowing the Angolan nurses to
enroll in their Nursing Masters (the first blended learning course
developed by UNISA, in South Africa). From 2007, USP began to receive
students for supervised curricular internships and in 2011 signed a new
agreement with ISCISA to advise on the organization and installation of
the master’s course in nursing in Angola. (Marchi-Alves et al., 2013;
Mendes et al., 2021; Fávero et al., 1996; Tiago, 2011) The national plan
for health workforce training identified the need to train 400 nurses at
master level and 100 at PhD level until 2020 (República de Angola,
2012).
ISCISA became an important center to train university level nurses
for the other African Lusophone countries, where university trained
nurses lagged behind. Acknowledging that, the International Council of
Nurses, in 2005, supported a workshop in Luanda, on the process of
integration of higher education institutions of nursing in Portuguese-
speaking countries and the licensing of such nurses in those countries
(Tiago, 2011; Fávero et al., 1996; Mendes et al., 2021).
Eventually, these international collaborations extended to mid-level
training institutions in Luanda, Huíla and Bengo that, in 2011, reported
relationships with the Joaquim Venâncio Polytechnical School of Health
of Brazil and the Lisbon Higher School of Health Technology (de Aze­
vedo, 2016; Projecto 9.ACP.MTR.04, 2011).
Cuba has a long-standing relationship with Angola that pre-dates
independence. Its involvement has been important to sustain the
expansion of higher education nursing training, by providing teachers to
staff the emerging training institutions, with significant investment in
quality improvement, pedagogic processes and research capacity
(Novais and Díaz Cruz, 2014; Suárez-Lezcano et al., 2015; Santos Smith
and Bravo Hernández, 2017; Hernández and Smith, 2017; Torres García
et al., 2018; Corrales, 2018; García and Mukendi, 2018; Hernández
et al., 2013; Alfonso, 2013; González, 2013; Medina and Vázquez, 2013;
Leyva and Jorge, 2013; Torres and Jorge, 2013; Torriente et al., 2013;
García and Batista, 2013).
6. Current situation
6.1. General education
and secondary school education expanded rapidly increasing the de­
mand for mid-level and higher education training.
M. Fresta et al.
6.2. Nursing education
In Angola, pre-service training of health professionals is a co-
responsibility of three Ministries: Education (MED), Higher Education,
Science and Technology (MESCT) and Health (MINSA), although with
the commitment of others, such as National Defense. (Ferrinho et al.,
2013) MED licenses secondary education institutions, approves their
teaching programs and recognizes diplomas or degrees obtained outside
Angola. It also finances and manages public mid-level health worker
training institutions. It is MINSA that methodologically monitors these
training institutions and their teaching programs. (Ferrinho et al., 2013)
The MESCT licenses universities and polytechnical institutes, approves
their teaching programs and recognizes diplomas or degrees obtained
outside Angola (Ferrinho et al., 2013).
The coordination of postgraduate training of physicians, registered
nurses and mid-level technicians is a direct responsibility of MINSA
(Ferrinho et al., 2013), which also regulates the awarding of sector
professional scholarships. (República de Angola, xxxx) The involvement
of the professional councils in professional post-graduation processes
has been growing in recent years.
In the current situation, registered nurses are trained at 41 higher
education institutions (8 public and 33 private) and staff nurses at 89
mid-level institutions, both in the public (n = 18) and private (n = 71)
sectors (Mário Fresta, personal communication, January 2022; the
numbers presented refer to 2019). Assistant nurses (auxiliaries de
enfermagem), who in 2013 still represented the large majority of nursing
team members, received six-years of primary school education followed
by two-years on the job nursing auxiliary training and their technical
activities do not differ from those of staff nurses: training for this cate­
gory has been extinct. (Ferrinho et al., 2013) University trained regis­
tered nurses, addressed also as “doctors”, after completing a 4-year
undergraduate tertiary program in nursing, are active in teaching,
research, service management, care delivery and health surveillance.
They are a valuable asset, whenever adequately placed in the health
system and health units; in spite of this, when registered nurses first
became available in 2006, their role and potential was not well under­
stood in the labor market, many were ostracized and felt frustrated
hence, some decided to undergo medical training and eventually left
nursing (Judith Luacute, personal communication, August 2021). (Fer­
rinho et al., 2013) Technical professional nurses (staff nurses) have 12
years of education (eight of primary and secondary school education
followed by a four-year mid-level program, focused in professional
nursing during its final two years) and can work in basic service man­
agement and health care, including where there are no registered nurses
(Ferrinho et al., 2013).
6.3. Remaining challenges
Despite the developments observed, higher education in general, and
for nurses in particular, still faces great challenges. (Marchi-Alves et al.,
2013; Torres García et al., 2018; Novais and Díaz Cruz, 2014; Santos
Smith and Bravo Hernández, 2017; Filho and Aleaga, 2021; de Carvalho,
2012; Mendes et al., 2021; Mendes et al., 2021; Ventura et al., 2021;
Hernández et al., 2013; Alfonso, 2013; González, 2013; Medina and
Vázquez, 2013; Leyva and Jorge, 2013; Torres and Jorge, 2013; Tor­
riente et al., 2013; García and Batista, 2013; Simões et al., 2016) Above
all, the training of nurses in Angola is hampered by the lack of clarity
regarding the professional definition of nursing and the profile of nurses
that the country needs. Others believe that the exit profile is clear
enough, but there is a lack of curricular standardization between the
various schools, as well as a lack of dialogue between trainers, on one
side, and employers and clients on the other side (Judith Luacute, per­
sonal communication, August 2021). This is being addressed by the
current effort to harmonize curricular across higher education in­
stitutions (Mário Fresta, personal communication, January 2022).
There is also a consensus that nursing is not valued enough as a
6
International Journal of Africa Nursing Sciences 18 (2023) 100535
differentiated profession. It is still, often, seen as an intermediate step in
the journey to reach a medical degree or as a profession to stopgap for
skills missing in the health system. There are also serious problems in the
internship and socialization conditions of nursing students (most of
them still lack a registered nurse as role model or to mentor them),
which result in some discomfort regarding the level of skills with which
they enter the health system. There must be openness for the registered
nurse to demonstrate hers/his real competences, skills and performance
so that the institutions realize that this is the missing piece in human
resources and in the health system (Judith Luacute, personal commu­
nication, August 2021).
Both mid and university level nursing students complain about the
available academic support systems (i.e. access to canteens, student
hostels, learning aids, study rooms, clinical cases, laboratories, leisure
and sports’ facilities, and library support). (Ferrinho et al., 2020) This
dissatisfaction with support systems is similar to findings from nursing
students from Guiné-Bissau and São Tomé e Príncipe (Fronteira et al.,
2014) and to findings from medical and para-medical students in Angola
and other Lusophone countries (de Azevedo, 2016; Ferrinho et al., 2020;
Sousa et al., 2007; Ferrinho et al., 2010; Ferrinho et al., 2010; Ferrinho
et al., 2011; Fronteira et al., 2011; Delgado et al., 2017).
Master and doctoral programs in nursing are still fairly recent and
remain rare in most SSA countries, including Angola (no data available)
and are a strategic priority for the country. (República de Angola, 2012;
República de Angola, 2012) Specialization of mid-level and registered
nurses is specified in the existing legislation and the Nursing Council is
currently operationalizing the mechanisms for the formal training of
nurse specialists with the creation of specialist colleges (for emergency
and trauma, intensive care, maternal health and public health) (Tavares
et al., 2018; República de Angola, xxxx; República de Angola, 2012;
República de Angola, 2012).
6.4. Recommendations regarding future developments
Future developments in the Angolan nursing workforce development
must take consideration of four key aspects: African realism; incomplete
transitions; strategic coherence; and labor market dynamics.
6.5. African realism
A recent literature review highlights that the majority of countries
within SSA are experiencing common challenges related to six major
nursing themes, namely: curriculum reforms, professional regulation,
transformative teaching strategies, collaborations and partnerships, ca­
pacity building and infrastructure and resources (Bvumbwe and Mtshali,
2018). Some of these themes, also identified as challenges for Angola,
are rooted in the history of the development of nursing education in SSA
in general and African Lusophone countries in particular (Oguisso,
USP.1993;; Costa Mendes et al., 2013; Filho and Aleaga, 2021; Mendes
et al., 2021; Simões et al., 2016; Mandriz, 2011; Marchi-Alves et al.,
2013; de Carvalho, 2012; Langa, 2013).
This historical roots of professional education in Africa are being
confronted: students, including nursing undergraduates, and teachers
alike, question the current models of education and demand due
attention to African cultural specificities and people’s needs. They
contest curricula which, so they claim, are still guided by colonial
worldviews. Curricula need to recognize “African realism” and include
African “lived experiences” and prepare health care professionals,
including nurses, to understand and deal with African traditional
indigenous healing practices (Ngunyulu et al., 2020). Western academic
models have neglected oral culture replacing it with a reading culture
that does not always provide relevant skills and information necessary
for health workers to deal with rural communities and more tradition­
ally minded communities. This neglect ignores the fact that most nursing
students do still have a rural background or strong bonds to families they
consider to have a significant rural background. (Ferrinho et al., 2020)
M. Fresta et al.
This background and bond will surely make them receptive to curricular
changes that further strengthen that bond. One of the approaches to
achieve this is the development of community-based learning programs.
(Tavares et al., 2018; Mtshali and Gwele, 2016; Mthembu et al., 2014)
Training programs in Angola, apart from universal and local
epidemiology-based approaches, should prepare students to live and
behave in rural, poor and isolated context, as well as to establish/work
in private health practice, always focusing on Primary Health Care as
stated in reference national and international strategic documents (de
Azevedo, 2016).
6.6. Incomplete transitions
In February 2021 Angola obtained from the United Nations (UN) the
postponement, until 2024, of its graduation from Low Income Country
(LIC) to Middle Income Country (MIC). This extension of the transition
period by three years was decided by the UN General Assembly, through
a resolution adopted by consensus of the member states, to allow the
country’s economic recovery. The UN took into account the fact that
Angola, an oil dependent country, remains “highly vulnerable” to the
fluctuation of its price (https://www.angop.ao/en/noticias/politi
ca/angola-obteve-da-onu-adiamento-da-graduacao-para-pais-de-rendi
mento-medio/). Angola needs to complete its transition from a state-
controlled economy to a more market-oriented economy, less depen­
dent on oil revenues.
The economic situation is complicated by other incomplete transi­
tions: a simmering low-intensity independence guerrilla in the enclave
of Cabinda; autonomist/separatist groups contesting the legitimacy of
the Angolan nation-state in the eastern diamond-producing provinces of
Lunda Norte and Lunda Sul (the Lundas), where inhabitants feel that
their civic and cultural rights are not respected, and feel little to no
benefit from the resource extraction taking place in their respective
provinces; an incomplete transition to a multiparty democracy that has
not resulted in democratic alternance in the parties governing the
country with persistent blurring of the lines between the executive,
parliament and the judiciary, as well as between party, government and
the military (Stiftung, 2020).
These movements condition the resources available for develop­
ment, hindering the dynamics of the labor market and curtailing the
extension of the educational sector in general and of nursing education
in particular.
6.7. Strategic coherence
The hallmark of successful strategies is that they are “strategically
coherent” to the extent that they complement and reinforce one another.
Nursing education straddles several fields of activity: education itself,
science and technology, health, international relations and partnerships,
defence, economy and labor market dynamics, inter alia. The govern­
ment of Angola has made significant progresses aligning education and
training strategies, with health policy and health workforce planning.
Still it is difficult to grasp the myriad of plans, programs and policy
projects – initiated by government, civil society organizations, the pri­
vate sector and national and international partners - that have impact in
nursing education and training. It is understandable that in a plural
society diversity of opinion will prevail; but in a resource constrained
country like Angola, all the efforts should be made to ensure gains in
efficiency and quality through strategic coherence. The lack of regular
evaluation of strategies and plans precludes timeous correction of the
paths for development.
6.8. Labor market dynamics
The challenges for nurse education in Angola are similar to those
faced by many other SSA. These challenges are controlled by labor
market dynamics. (Sousa et al., 2013) Hence, in order to ensure cultural
7
International Journal of Africa Nursing Sciences 18 (2023) 100535
relevance, responsiveness of the cadres trained to the population’s and
users’ needs, fitness to employment opportunities in both public and
private sectors and balanced distribution of future graduates between
urban, rural and underserved areas and different levels of care, these
labor market dynamics need to be understood.
A recent development in nurse training is the involvement of the for-
profit private education sector (Bvumbwe and Mtshali, 2018; Reynolds
et al., 2013; Reynolds et al., 2013; Vasuthevan et al., 2013), as observed
in Angola, a trend that it is not well documented. This trend is not
without consequences as there are some important differences in the
expectations of nurses trained privately or within the public system:
those trained privately have more aspirations to work in the private
sector in an urban context than those trained in a public institution.
(Ferrinho et al., 2020; Hernández et al., 2013; Alfonso, 2013) The
relevance of the nature of the training institution to the choices students
make regarding their positioning in the labor market has been high­
lighted from other studies in Angola (Fronteira et al., 2021) HYPERLINK
"SPS:refid::bib83" .
The growth of private training and the inability of the public health
care system to absorb the growing numbers of nurses graduating is likely
to reinforce the growing trend to engage in private and/or dual practice.
(Russo et al., 2018; Tankwanchi et al., 2019; Temane et al., 2014; Nzi­
makwe, 1996; Oladapo, 2020; Christmals and Armstrong, 2019) It is
also likely to reinforce the nurse staffing disadvantage of rural areas in
relation to urban areas, particularly when strategic planning is insuffi­
cient and the private training develops “spontaneously” as a simple
profitable business initiative, disconnected of strategic considerations.
The degree of nurses’ engagement with and ownership of private
practices has varied significantly in SSA. It has a well-established
tradition in countries like South Africa, Nigeria and Ghana, but it is a
recent development in most other countries (Temane et al., 2014; Nzi­
makwe, 1996; Oladapo, 2020; Christmals and Armstrong, 2019). In
Guiné-Bissau and São Tomé and Príncipe over half of nursing students,
mid-level and higher level, from public and private institutions, wanted
a future practice exclusively in the public sector (Fronteira et al., 2014).
This is similar to findings from Angola. (Ferrinho et al., 2020) This
probably relates to the paradox that the major employment market is in
the public sector which does not have the capacity to absorb all the
nurses produced by the educational system, which are then tempted by a
small, but growing private market, still unable to absorb the growing
demand from newly graduated nurse, contributing to a growing pool of
unemployed nurses (Asamani et al., 2020).
While medical education has received a lot of attention from aca­
demics, much less attention has been paid to nursing education, despite
the fact that nurses are the backbone of healthcare provision in Africa.
This review, despite its limitations, mainly related to the lack of a
database of the relevant grey literature, contributes to narrow this
knowledge gap and to provide insights that may help to ensure the
development of the nursing profession according to their rightful place
in the workforce, as independent professionals that have much to offer
to quality healthcare in Angola and Africa.
Declaration of Competing Interest
The authors declare that they have no known competing financial
interests or personal relationships that could have appeared to influence
the work reported in this paper.
Acknowledgements
Rosa Ferrinho for assistance with literature search. Nkanga
Guimarães and Helga Freitas for comments on earlier drafts of the paper.
Fundação para a Ciência e Tecnologia for funds to GHTM UID/04413/
2020.
M. Fresta et al.
Authors’ contributions
MF and PF wrote the paper; PF conducted the review, conducted first
data analysis; MF and IF collaborated in the planning and imple­
mentation of the review. All authors read, reviewed all versions of the
paper and approved the final manuscript.
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