CBE and the Missing 'E': Making Competency-Based Education an Equitable Framework for Global Health Professions Education.

It is generally assumed that competency-based health professions education (CBHPE) is a positive and ongoing educational reform. However, the assumption that CBHPE naturally leads to more equitable outcomes has not been thoroughly examined. This 'Eye Opener' identifies global challenges in implementing equitable CBHPE, with particular attention to majority-world (low- and middle-income) contexts. These tensions include: 1) variable approaches to adoption that limit transferability, 2) uneven infrastructure for implementation and innovation, 3) export of predeveloped conceptual frameworks that may not be locally fit for purpose or implemented alongside collaborative knowledge exchange, and 4) pressures for fidelity in implementation that impede flexibility and compromise effectiveness in local contexts. In each area of tension, the authors outline challenges to equity and suggest potential ways forward. From their analysis, the authors propose that equity must be deliberately embedded in CBHPE at multiple levels, and the proposed solutions include addressing equity on three levels - the micro level of individual learner access and assessment; the meso level of curricula, faculty development, and program learning culture; and the macro level of national accreditation standards and education policies. Examples of opportunities at each level and for each of the five core components of CBHPE are also provided. The authors argue for a shift in perspective-from "outside-in," in which Western nations export CBHPE to the majority world, to "outside-in, inside-out and all around," in which CBHPE frameworks are co-created to leverage contributions from both Western and majority-world education systems. They believe that more thoughtful adaptation and embracing Global South ways of knowing, doing, and being, rather than simple replication, alongside the continuous application of a social justice lens, are needed to ensure that CBHPE serves all communities and contributes to equitable, high-quality learning and healthcare without discrimination.