Healthcare users have a right to receive effective, currently relevant healthcare aligned to the Sustainable Development Goals (SDGs) and delivered by competent nurses and midwives (Baloyi & Mtshali, 2018) . Regularly new evidence-based practice is emerging in an attempt to meet changing healthcare needs. Africa's healthcare needs lie amidst both a context of a rapidly changing health/disease landscape and the simultaneous ever-changing advancement of science and technology, which require nurses and midwives to continually update their knowledge and skills to reduce health inequities (Baloyi & Mtshali, 2018; WHA66.23, 2013) . The skills shortage compounds the demands on the nurse and midwife in sub-Saharan Africa, with 3.5 percent of the global health workforce responsible for 27 percent of the global disease burden (GNCBP, 2018) . The delivery of healthcare in Africa, which requires a skill-mix, is not confined alone to the above changes, but overarched by cultural sensitivity. This sensitivity is attributed to the shrinkage of the global village as its populations connect with increased frequency in real-time or through virtual worlds, and increases the demands of the nurse and midwife, for continuing professional education
The term Continuing Professional Development (CPD) has been subject to much debate. It is used interchangeably with such terms as continuous professional education, in-service education, continuing education, lifelong learning, professional development (Ross, Barr & Stevens, 2013) , workforce advancement (Msibi, Mkhonta, Nkwanyana, Mamba, & Khumalo, 2014) , on the job training and staff development. How professionals maintain and develop their knowledge for their professional life defines continuous professional education (Filipe, Silva, Stulting, & Golnik, 2014; SAQA, 2015) , while CPD includes the informal manner of gaining knowledge and experience (Gallagher, 2007) . Education provided "on the job" to build staff capacity, and efficiency has traditionally and previously been defined as in-service education. This article will utilise the term "continuing professional development"(CPD) as a form of scaling up transformative education and training. CPD is defined as "the means by which members of the profession maintain, improve and broaden their knowledge, expertise, and competence, and develop the personal and professional qualities required throughout their professional lives" (Nursing & Midwifery Board of Australia, 2016:4) . Giri et al. (2012:1) further add that "CPD is a systematic and ongoing process of education… to ensure continuing competence extended knowledge and skills to new responsibilities or changing roles..." Ingwu et al., (2019) emphasised that CPD continues throughout the professional's life, which occurs outside of undergraduate and postgraduate training and excludes short courses, but keeps the nurse/midwife up-to-date in recent developments and practices in the profession.
For nurses and midwives to have the capacity to practice safely and competently while meeting the level of competence required by both the profession and the healthcare users, they need to engage in mandatory CPD (Ingwu et al., 2019; Ross et al., 2013) . Through such engagement, quality person and people-centered care make Universal Health Coverage (UHC) possible, particularly in Africa, where access to good quality healthcare services remains a considerable challenge and hinders the attainment of the SDGs (Hasumi, & Jacobsen, 2014) . The World Health Organization (WHO) recognized the "strengthening of nursing and midwifery to support UHC as a key imperative for improving the health of populations" (WHO, 2016:3). Theme-3 of the four thematic areas of the global strategic direction for strengthening nursing and midwifery 2016-2020 states: "Working together to maximize the capacities and potentials of nurses and midwives through intra-and interprofessional collaborative partnerships, education, and continuing professional development" (WHO, 2016:21) . Different modes of delivery exist for CPD. Face-to-face contact continues to be a well-used mode. However, mHealth is an emerging platform that increases access, particularly to nurses and midwives in rural areas (Botha & Booi, 2016) . Emerging platforms and organisations offer mHealth learning opportunities in lower-middle-income countries (LMICs) for nurses and midwives. Additional recognition of nurses and midwives' need to access resources is provided by the World Continuing Education Alliance (WCEA) (WCEA, nd), who assist LMICs, and this has resulted in the promotion, development, implementation, and regulation of CPD frameworks.
Despite the numerous changes in the CPD landscape of the WHO Afro-region member states, a composite picture is not available for future project planners, researchers, and policy developers. The objective of this article is to provide the status of CPD evident in the WHO Afro-region member states.
One of the global foci of critical decision-makers is the attainment of the Sustainable Development Goals (SDGs) and Universal Health Coverage (UHC). However, there is evidence of underperformance of the Global Health Indicators, particularly in the WHO Afro-region, with slower progress to the 43 health-related SDG indicators, across a wide range of health domains (Lozano et al., 2017; WHO, 2019) . SDG-4 highlights the importance of promoting life-long learning. Yet, quality, effective healthcare delivery, and access to information about best practice remains a challenge to nurses and midwives in the WHO Afro-region (Bvumbwe & Mtshali, 2018a; Leuning, Haufiku, & Gordon, 2016) . Current evidence-based information is essential to strengthening nurses' and midwives' relevant contributions towards attaining the Global Health Indicators. The WHO (2019) Statistical Report indicates that the WHO Afro-region member states show the highest global statistics, amongst others for maternal, under-5, and neonatal mortality rates, malaria, and road traffic injuries. Also, the WHO (2019) Statistical Report highlights a reversal of progress for five of the indicators, three of which are highest in the Afro-region.
At global and national levels driving changes in health care, is strategic for policymakers and programme developers, which inter-alia requires an overall perspective of the progress, current and possible future challenges of CPD, to direct program developments. A map of the CPD landscape for the WHO Afro-region member states throws light on the target countries to ensure equity in the investment of a relevant, and responsive nursing and midwifery workforce, which is a critical building block for a competent health care system (Bvumbwe & Mtshali, 2018b) . The development of nurses and midwives can add value to the realisation of global health goals and attaining UHC (WHO, 2017) . "2020, Year of the Nurse and Midwife", continues through the COVID-19 pandemic; hence, this article echoes the need for the visibility of CPD in the Afroregion.
In the process of shining a light on CPD in the WHO Afro-region states, recent literature from the past five years (1 January 2015 to 31 December 2019) was searched. The following databases were consulted: Academic Search Complete, Education Source, Health Source (Nursing and Academic Edition), Cumulative Index of Nursing and Allied, Health Literature (CINAHL), and Scopus and a direct search through Google Scholar for literature on the subject. References of relevant or applicable literature were scanned to identify further relevant citations. The five years were selected to identify the most current evidence of the implementation of mandatory CPD. Mandatory CPD was selected as it is endorsed by the relevant regulatory bodies, in recognition of the upskilling of nurses and midwives towards meeting country-specific healthcare needs and, ultimately, Global Health Indicators. The literature search resulted in the adoption of an organised approach to ensure as close as possible a representation of the CPD status of the WHO Afro-region member states. Inclusion criteria were set, and key-words were used to search the literature. The key wrds were:nurse, nurse practitioner, midwife, healthcare provider, healthcare practitioner, continuous professional education, in-service education, in-service training, continuing education, lifelong learning, professional development, workforce advancement, on the job training, staff development, continuing professional learning, mandatory and the 46 WHO Afro-region member states. Eight articles within the selected period addressed mandatory CPD in the WHO Afro-region member states (Gross et al., 2015; Hosey, Kalula, & Voss, 2016; Ingwu et al., 2019; Kelley et al., 2017; Leuning et al., 2016; Michel-Schuldt et al., 2018; Mosol, Obwoge, Kei & Ndwiga, 2017; Viljoen, Coetzee & Heyns, 2017) . Only articles in English were included. Additional information about mandatory CPD was gathered from the websites of the professional regulatory bodies.
Publications without evidence of a link to mandatory CPD, were evident for targeted, sometimes single once-off programmes addressing such areas as palliative care ( 
The results of the extraction of information from the literature and the professional bodies' websites revealed strengths, weaknesses, opportunities, and threats to the CPD status. The predominance of information was from the 21 Anglophone countries ( Table 1 ). The conclusion of "No evidence" (NE) was recorded in Table 1 , based on no evidence of information in the literature or on the web-sites of the professional bodies.
The strengths are evident in the beginnings of mandatory CPD, targeting Global Health Indicators, nurse and midwife regulated, and annual licensure renewal for the Afro-region (Table 1 ).
In some WHO Afro-region member states, nurses and midwives are required to attend formalised programmes (Table 1) , delivered face-to-face or online, and 16 (34.7%) states have instituted CPD points as a mandatory measure to ensure the public has access to up-to-date skilled, relevant practitioners (Feldacker et al., 2017a; Ross et al., 2013) (Table 2) .
Some WHO Afro-region states dictated the CPD requirements governing licensure through the disease-specific modules such as HIV (Feldacker et al., 2017b; Kelley et al., 2017 & Gross et al., 2018 , which allowed for the targeting of Global Health Indicators specific to that country. Also, apart from Rwanda and Namibia, who are regulated by Health Professions Councils (HPCNA, 2011; HPCR, 2013) , the regulation of CPD by countries with evidence of regulatory bodies is through a Nursing and Midwifery body (Table 1 ). Nursing actions regulated by nurses benefit the relevant country, as through CPD, nursing activities can be aligned to healthcare needs. A Rwandan study evaluated the influence of CPD on nurses and midwives' performance (Kasine et al., 2018) . The study identified the translation of an accredited CPD course (Helping Babies Breathe) into practice by practicing midwives (n=10) (Kasine et al., 2018) . The HBB© was implemented in an attempt to improve the practice outcomes of neonatal asphyxia, the leading cause of neonatal mortality (Kasine et al., 2018) . The participants recognised the benefits of CPD for the profession, families, the newborn, and the healthcare system with such outcomes as increased practice confidence, improved sense of autonomy, and motivation towards life-long learning (Kasine et al., 2018) .
A further strength of the countries with the requirement of CPD renewal to maintain licensure is that it is predominantly an annual requirement (Table 1) Progress is evident in South Africa, although for various reasons including ICT support, it has not yet rolled out its annual 15 CPD point program for licensure (SANC, 2018) . South Africa, however, has a CPD framework and a formal accreditation system in place and meets bi-annually with the stakeholders (Feldacker et al., 2017b) . Notwithstanding, a private hospital group in South Africa has run a program requiring an annual 22 hours attendance of CPD training (Viljoen et al., 2017) .
The weaknesses lay in the skill-base shortages, dependence on sponsors, inequity of CPD distribution across the 46 member states and failure to measure impact (Table 1 ).
In the Afro-region, attempts to meet the Global Health Indicators are complicated by low healthcare provider-patient ratios (8.7 nurses per 10 000 population) (WHO, 2020a), which is concerning given the lack of evidence for CPD for the five Lusophone ( Table 2 ). The dependency on sponsor has been highlighted as a shortfall (Hosey et al., 2016) . The groups of countries with the least evidence of published information about mandatory CPD activity were the Lusophone countries with no evidence, followed closely by the Francophone countries except for Rwanda. Despite the Anglophone countries showing the greatest evidence of CPD, there was no evidence of publications focussed on mandatory CPD or professional regulatory body information from 18.6 percent of these countries, namely Algeria, Eritrea, Ethipoia, Gambia, Mauritius and Sierra Leone (Table 1) .
Although the influence of CPD on nurses and midwives' performance has been measured (Kasine et al., 2018) , it is infrequent. It appears there is no evidence of the measured impact of CPD on country health outcomes or the increased relevance of the nursing and midwifery workforce, following the attendance of CPD. It holds importance to measure the impact to inform future CPD programme development.
Opportunities for CPD programmes have resulted in international academic partnerships with evidence for further engagement. The capitalisation on such opportunities can allow for the emergency preparedness and response capacity of nurses and midwives through the COVID-19 pandemic to the realisation of not only health related SDGs, but SDG 4, 5, 8 and 9.
The majority of CPD activity was evident in the Anglophone countries (n=17; 80.9%), with lesser to no evidence in the Francophone (n=1; 5%) and Lusophone countries (0%) of CPD frameworks in place (Table 1) . Mozambique, a Lusophone country recived technical assistance from African Health Profession Regulatory Collaborative (ARC), but the institution of CPD did not move past the initial process (Hosey et al., 2016) . This evidences an opportunity for global and national policy dialogue over the next three to five years, to focus on the Francophone and Lusophone and the seemingly neglected Anglophone countries to build the capacity of their nurses and midwives. CPD has been conceptualised for many years in Africa. However, it is only in recent years (2008 to 2020), that inquiry has ensued about its progression to implementation as a mandatory activity for nurses and midwives' licensure (Table 1, Table 2 ). The opportunity to capitalise the gains for health are shown in the Afro-region's progress towards CPD, given that inception was in 2008 (Table 1) , with Kenya (Mosol et al., 2017) as the forerunner, followed in 2010 by Namibia and Nigeria (Ingwu et al., 2019; Leuning et al., 2016 ). An opportunity exists to unlock and drive the investment in nurses and midwives, the crux of the healthcare workforce, as the Afro-region targets meeting the SDGs and UHC (WHO, 2019). Through the COVID-19 pandemic, the global value of nurses as an adaptable, flexible, resilient, highly significant healthcare workforce (Chersich et al., 2020) has been highlighted and evidenced the opportunities for their continued strengthening.
Despite the lesser evidence of mandatory CPD among the Afro-region member states (n=16, 34.7%) ( Table 1, Table 2 ), organisations such as The ARC and the Office of Global Initiatives (Dohrn et al., 2016) have been involved in improving the relevance of the workforce in some WHO Afro-region member states (Cato et al., 2019; Kelley et al., 2017) . Through partnerships, ARC has recognised the opportunity and actively promoted regulatory reform in 17 countries across East, Central, and Southern Africa (Kelley et al., 2017) . From July 2013, ARC has made available a toolkit to facilitate the development of a National CPD framework (Mccarthy & Illiffe, 2013) . ARC has worked to develop a web-based CPD library for nurses and midwives in the East, Central, and Southern Africa (ECSA) region (Hosey et al., 2016) . The concept of the CPD library recognises the difficulty for nurses and midwives to attend conferences, especially in resourcerestricted countries (Hosey et al., 2016) . The evaluation of ARC's involvement showed many positive consequences for the development of CPD, which ranged from the establishment of a council for nurses in Mozambique to assisting in the development of structures to support CPD licensure renewal in Lesotho (Kelley et al., 2017) , and the availability from July 2013 of a toolkit published by ARC to facilitate the development of a National CPD framework (Mccarthy & Illiffe, 2013) . In addition, although not mandatory, in recognition of the "2020 Year of the Nurse and Midwife", WCEA has provided a free CPD platform as an e-learning solution to 18 (39.1%) WHO Afro-regions.
Online modules offer a variety of opportunities. The opportunities are: a chance to meet the difficulties nurses and midwives experience in accessing CPD, meeting mandatory CPD requirements for licensure renewal, reducing training related absenteeism, providing a less fragmented approach to learning, encouraging self-directed learning and addressing the sustainability of CPD (Feldacker et al., 2017a; Nsemo, John, Etifit, Mgbekem, & Oyira, 2013) . Mobile platforms also have the potential to meet the needs of educators who have felt side-lined (Nsemo et al., 2013) .
Despite the opportunities, policymakers and CPD programme developers need to be mindful of the threats to implementing CPD in the Afro-region. The threats are evident in the health context of the Afro-region, the shortage of nurses and the lesser participation in CPD programs.
The WHO Afro-region member states have shown the highest increase by 10.3 years in life expectancy to 61.2 years, during the period 2000 to 2016 (Worldmeter, 2020) , but the gaps in evidence of CPD are concerning. Concern lies in Africa's life expectancy being lower than the global life expectancy of 72.0 years (WHO, 2020b), and the under-five mortality rate, which is an essential measure of global health and an indication of a country's health status (Van Malderen et al., 2019) . The following Afro-region states have shown a higher under-five mortality rate in 2017 compared to 1990: Benin, Cameroon, Chad, Equatorial Guinea, Lesotho and Mauritania (Roser, Ruitchie & Dadonaitre, 2019) , of which only Lesotho has a mandatory CPD programme in place (Kelley et al., 2018) . Under-five mortality is amenable to healthcare and prevention (Van Malderen et al., 2019) , which can be targeted through CPD.
Nurses and midwives as the backbone of healthcare delivery in Africa, are expected to address the lower life expectancy's incumbent burden of disease; yet their ratio to patients is the lowest of all WHO regions (Dohrn et al., 2016) . To further complicate the attainment of UHC and the SDGs, only 21.7 percent (n=10) of WHO Afro-region member states' nurses and midwives are expected to complete mandatory CPD (Table 1, Table 2 ). Despite the debates surrounding mandatory CPD, disparity for nurses and midwives to access CPD programmes in WHO Afro-region member states is evident in the uneven distribution of CPD promotion and support.
Threats to CPD, lie not only in the healthcare demands but also in the CPD program implementation. South Africa, as with other countries, has shown that low attendance of CPD programmes was attributed to ineffective communication about the program, lack of awareness of the importance of CPD programs to professional development, time and fimancial constraints, a negative attitude, the use of a top-down approach, and responsibilities at home (Viljoen, et al., 2017) . At a system level, challenges identified for the implementation of CPD programmes were lack of funding, and inconsistencies in CPD requirements (Feldacker et al., 2017b) . The attendance of CPD programs in Namibia poses challenges, as nurses are assigned to the rural areas (Leuning et al., 2016) .
Similar health challenges face other African countries (WHO, 2019), which offers an opportunity for a unified approach involving partnerships, and inter-professional collaboration to maximise the preparation of their nurses and midwives to realise the global health agendas. However, the Afroregion has progressed at different paces to develop and implement national CPD frameworks and advance their CPD programs (Table 1, Table 2 ) (Feldacker et al., 2017b; Kelley et al., 2017) . In addition, there is a lack of consistency across the member states offering CPD for the allocation of CPD hours, and these vary from a point per hour in Eswatini to an award structure based on a hierarchy of activities in such countries as Ghana, Lesotho, Malawi, Namibia, Rwanda, and Tanzania (Table 1) .
Strengths, weaknesses, opportunities, and threats to the WHO Afro-region member states' CPD status have been highlighted. CPD is a topical subject amongst nursing professionals, and debate exists around the significance of the concept of mandatory CPD, as it questions the willingness and motivation of the professional to upskilling for quality service improvement (Feldacker et al., 2017b) . Located within debates surrounding mandatory CPD, lies the disparity for nurses and midwives to access CPD programmes in WHO Afro-region member states, evident in the uneven distribution of CPD promotion, support and partnerships (Table 1,Table 2 ). Counter to the debates is the assurance in some countries of increasing the relevance of nurses and midwives for their healthcare needs through the delineation of compulsory modules or domains of required CPD points (Feldacker et al., 2017b; Gross et al., 2018) .
Amongst these debates, obtaining the information for all the WHO Afro-region member states was restricted by a paucity of both published literature, conference proceedings, and information from the professional bodies' web-sites for the Francophone and Lusophone and some of the Anglophone countries. CPD activity is concentrated in the Anglophone countries with evidence of a large number of neglected countries (Table 1) . This deficit lies amidst the current ethos of continuous professional improvement (Cato et al., 2019; Feldacker et al., 2017b; Ingwu et al., 2019; Kelley et al., 2018) .
Hope for further change in mandatory CPD requirements, comes through the comparison of the current CPD status in the WHO Afro-region member states with that described just a few years ago by various authors (Feldacker et al., 2017b; Viljoen et al., 2017) . The comparison shows the increased CPD activity in the WHO Afro-region member states, which is expected to increase further in celebration of "2020 Year of the Nurse and Midwife". Nigeria shows such an example, wherein this celebration, the Nursing and Midwifery Council of Nigeria (NMCN) has joined the WCEA to provide its nurses and midwives with free assistance through a mobile application for the acquisition of the mandatory CPD points (NMCN, 2019). (Gross et al., 2015; Kelley et al., 2017; Mosol, et al., 2017) 
The illumination of the CPD status in the Afro-region offers a point of reference for international dialogue, policy makers and programme developers, as they embark on change. A revised CPD landscape is necessary to strengthen the relevance and response capacity of nurses and midwives, as key contributors towards the Global Health Indicators. The contribution of nurses and midwives towards achieving the SDGs and UHC is acknowledged in the World Health Assembly's designation of 2020 as the "Year of the Nurse and Midwife" (WHO, 2020c). Regardless of who is delivering such programs, where they are being delivered or the mode of delivery, CPD needs to be available, accessible, and affordable to all nurses and midwives. CPD programs are an investment that impacts nurses, healthcare user outcomes (Kasine et al., 2018) , and countryspecific health targets.
 Further studies to measure the impact of CPD programmes on nurses and midwives' knowledge and competencies as well their relevance in meeting the healthcare needs of the Afro-region populations they serve.  Further in-depth studies at country specific-levels with specific CPD policy driven outcomes.  CPD programme development for the WHO Afro-region member states with no CPD activity.
The literature search was limited to articles in English and from select databases.
The information contained in this paper is reflective of information extracted from the professional bodies' web-sites, and the published and grey literature about the subject matter available at the time of the paper's submission. It might not be fully reflective of each WHO Afro-region member state's current CPD landscape.