The pre-service or initial education of a health worker prior to deployment into the healthcare system is critically important. It ensures that all workers begin their careers with a foundation built on competence and are prepared to be lifelong learners and potential leaders. There has been long-standing global attention to developing and strengthening pre-service education (PSE) pathways for health workers in low-resource settings as a means to address an ongoing, severe shortage of human resources for health (HRH). Unfortunately, many efforts have failed to achieve the sustainable results intended [1], [2]. Minimal educational and infrastructure resources, poorly constructed systems for ensuring educational quality, and other daunting influencing factors have combined to impede improvements in community and health systems outcomes through PSE. The pervasive lack of documented results despite a steady stream of well-intended innovations suggests a need for a new approach to designing and strengthening PSE systems. The conceptual model depicted in Fig. 1 [3] provides a visual link between desired pre-service outcomes, the inputs needed to achieve them (for example, students, teachers, clinical practice sites), and the influencing factors affecting the education, deployment, and assimilation of graduates into the healthcare system. The authors hope that this commentary will result in readers making the wisest investment possible in a complex system that is influenced by a host of factors, sometimes beyond educators’ control. We aim to convince readers that future efforts to improve PSE must begin with careful consideration of the performance outcomes that graduates need in order to improve outcomes in their community and the larger health systems to which they will dedicate their careers. Conceptual model: the health impacts of pre-service education. This figure was adapted from Johnson et al. [3]. It is slightly different from the original. Optimal health and health system outcomes cannot be achieved without a fully capable health workforce prepared to provide the range of services needed to achieve them. While we must trust that this assumption is valid, we can also measure the performance outcomes of students and, to some extent, the impact that they have on their community. During the planning or at the outset of projects aimed at improving PSE, leaders are advised to closely examine health workforce requirements at both the national and community levels. They should consider government packages of health services outlining service expectations at varying levels of the health system, job descriptions for the cadres being educated, and regulatory documents outlining professional scopes of practice. Task analysis, a method of surveying graduates about the frequency and importance of tasks they perform in their work, can provide valuable evidence guiding PSE inputs [4]-[6]. Stakeholders should ask whether essential resources and materials required for graduate performance are in place before adding competencies to a curriculum. Stakeholders might consider whether communities are ready to accept the services that graduates are prepared to offer and should consider whether the health system authorizes the graduates to perform those services. Educating students to provide care that they are unable to deliver is a completely wasted effort. Education and development experts must understand these outcomes and prepare for them with a measurable set of indicators as a first step in any project aimed at improving PSE systems. With measurable outcomes, direct linkage of results with pre-service education is feasible. For example, the community outcome of greater utilization of local health centers for healthy timing and spacing of pregnancy links with PSE clinical experience in the community, emphasis on counseling skills, and development of community relationships with the health facility and the educational institution. Given that the purpose of PSE is to graduate competent new service providers who can be absorbed into the health system with relative ease, both sides of the model must be examined and considered in implementing any plan. Student selection criteria should be evaluated and possibly revised in relationship to the outcomes desired. The traditional criterion of academic grades or scores on admission exams, though predictive of academic success, limits the pool of students. With limited resources for HRH, it is important to select students who will not only matriculate and graduate, but will also remain in the profession and contribute to the health workforce. There are numerous examples of targeted recruitment that positively affect student selection and subsequent retention [7]-[11]. Some programs have found it imperative to include a cultural lens in student selection. For example, in Afghanistan, candidates for education as community midwives are selected by their communities. In a culture where a woman is required to obtain permission from her father or husband, at a minimum, to work or go to school, community support of the student is imperative [8]. Although some countries assign students to cadres without considering the students’ interest in the profession, this is likely to be a detriment to successful education and deployment. Fowler and Norrie [12] note that absence of expressed interest in the profession is a predictive factor for attrition. Enlisting community and professional stakeholders in efforts to identify qualified candidates may lead to recruitment of qualified students who would otherwise be overlooked. Students who enter with the encouragement or sponsorship of professionals in their chosen field may have the advantage of being vetted by their future colleagues. Targeting recruitment to specific geographic or population groups may increase the likelihood that graduates will return to their communities, particularly if recruitment is paired with support such as graduate internships or other bridge programs, academic mentoring, and peer tutoring [10], [11], [13], [14]. Although including investment in teacher preparation in improvements to PSE is intuitive, it does not always happen [2]. Effective teaching in competency-based education requires competent teachers [15]. Preparation of teachers and maintenance of teacher competency should be outcome-focused and integrated with the educational program, including preceptors and clinical sites. Preceptors should be a formal part of the faculty and have student assessment responsibilities and authority. When educational integration is extended to clinical sites, classroom tutors become part of the facility, reducing artificial academic–clinical barriers and connecting teachers and preceptors to the larger educational system. Teachers who are closely connected to clinical settings are aware of the parameters of facilities and are more able to develop lesson plans that leverage resources and mitigate challenges. The outcome focus of graduating competent providers should be grounded in reality, and all teaching staff (teachers and preceptors) must work with students to solve problems and provide the best care using available resources. Retention of teachers and preceptors is improved when they are respected in the community. This is a reason for targeting faculty recruitment to areas where they are needed and more likely to share the language and culture of the community members. It is important that professional leaders demonstrate both academic and clinical competence. Overwhelming workloads in both classroom and clinical settings are disincentives for teachers and preceptors to be effective educators, much less take on additional professional work. Teacher/preceptor incentives must include manageable workloads, time for professional activities, and recognition of the need for ongoing preparation. Teachers may have great difficulty maintaining their own clinical competency, given their educational responsibilities. Providing teachers with opportunities for clinical practice should be encouraged but may be a challenge to implement with current teacher shortages. There is good evidence from the in-service training literature [16] that learners’ practice in simulated settings increases their engagement in their education and enhances their skill competency before they see patients. An appropriately equipped and organized simulation lab facilitates practicing in a situation that reflects the clinical setting as closely as possible. Use of standardized patients, cases, role plays, and simulations should replicate what is likely to be seen in the community. An effective learning environment requires a sufficient number of teaching and learning tools for the student cohort, physical space for classrooms, and an area where students can study, whether it is a library or computer lab or a combination. Modern education practices require a computer lab. In areas of unavailable or irregular connectivity, there are offline resources such as the eGranary Digital Library from the WiderNet Project that work to reduce digital divide barriers [17]. Providing education models and resources to clinical facilities strengthens the PSE program and offers additional opportunities for staff to practice. Brief, on-site continuing education programs benefit the facility as well as the students. The curriculum should reflect national health needs balanced with international competencies. International competencies for practice [18]-[21] can be appropriately integrated with the work that graduates must be able to do to affect outcomes in their country. Assignments should be consistent with local practices and culture; learning materials should be reflective of national health needs rather than classic texts. An example would be placing greater emphasis on kangaroo care for pre-term and low birth weight newborns and less emphasis on use of neonatal exchange transfusion. Support from regulators of educational programs such as relevant ministries and professional councils is needed for policy-level buy-in. Administrators and practitioners at sites associated with the school should understand the content and flow of the curriculum as well as the role of teachers. Clinical sites must reflect a balance that considers the needs of the learner, the needs of individuals seeking care, and the needs of the facility and providers. For an education program to be outcome-focused, the clinical sites must have the resources they need for education as well as the resources to achieve the desired outcomes. Educational institutions have to be part of a resource stream; health professional students require a significant amount of relevant, high-quality clinical practice to become competent providers. Competent providers working at a clinical practice site increase opportunities for engagement with the community that receives the services and therefore improve community health outcomes. High-quality clinical sites should be assessed by standard criteria for quality, maintain quality improvement systems, and place a high value on demonstration of professional behavior and ethics. The parts of the PSE conceptual model are inextricably linked, and successful investment in PSE requires consideration of the whole model. Nongovernmental organizations that invest in PSE have different scopes of interest and implementation budgets. However, at a minimum, those interested in investing in, establishing, or improving education systems should go through the exercise of figuring out where their efforts fit with each part of the model. Factors on both sides of the model inevitably influence any investment in PSE. Consideration may need to be given to advocacy for alternative investments. For example, instead of a new curriculum, more critical needs might include stronger clinical sites, better-prepared teachers, and preceptors who can assess student learning. Implementers have an obligation to ensure that an intervention does not do damage to other parts of the model. Investment in PSE is a long-term commitment—and it is a crucial investment in preparing leaders for the future. The authors have no conflicts of interest.