Healthcare education in need of a revamp – Study panel

South Africa spends R12 billion (US$880 million) on health sciences education every year but despite producing excellence “in certain areas”, the general picture is one of fragmentation, weak coordination and governance, leading to inefficient use of resources which affects quantity, quality and relevance of healthcare education and training, according to a recent Academy of Science of South Africa (ASSAf) consensus study report.

The report published in June follows the release at the end of May of a statement by the South African Committee of Medical Deans expressing concern at the crisis in the national health system and “systemic failures” in the provincial health departments, which the statement said were negatively affecting both patient care and the training of the next generation of medical professionals.

Titled Reconceptualising Health Professions Education in South Africa, the report examines the value chain in health sciences education, from student selection through to pedagogical developments. It unpacks the current bottlenecks in the system and looks at how the future health sciences education system can be financed and regulated against the backdrop of ongoing higher education crises, shortages of trained staff and the rising burden of disease.

The study was conceptualised following an ASSAf workshop on a 2010 Lancet Commission report titled Health Professionals for a New Century: Transforming education to strengthen health systems in an interdependent world.

That report found that the field of healthcare training globally had not kept pace with new infectious, environmental and behavioural risks in a period of rapid demographic transition. Education had remained static, outdated and fragmented, continuing to produce ill-equipped graduates, the report said.

Unique challenges

However, as the ASSAf report notes, South African healthcare education faces some unique challenges.

“South Africa's quadruple burden of disease, shortage of trained health personnel, particularly in under-resourced and rural areas, and the ongoing higher education crisis place unique challenges on the health sciences education sector," said Professor Jimmy Volmink, dean of the faculty of medicine and health sciences at Stellenbosch University, who led the 10-member study panel that compiled the recent ASSAf report.

According to the report, the shortage of healthcare professionals in South Africa was worsened by the closure of public nursing colleges and the rise of private training schools offering variable quality. The production of doctors has been stagnant since the 1970s but has received renewed attention with new medical schools being opened and South African students being sent to Cuba for medical training, it states.

South Africa has nine medical schools, the most recently established being the Sefako Makgatho Health Sciences University which opened in 2017.

The study makes 16 recommendations, some of which, according to an ASSAf statement, include the following:

• • There is a need to reconceptualise student selection with the aim of evaluating a broader set of criteria than those currently in use.
  
  
• • Selection and training should be orientated towards addressing inequity and meeting the needs of the most underserved, through supporting a primary care focus and increasing the supply of healthcare professionals to rural areas.
  
  
• • Public sector academic institutions need to be strengthened to scale up the production of healthcare professionals.
  
  
• • Universities should take responsibility for education and professional development from undergraduate years through to internship and community service.
  
  
• • To enable inter-professional education and collaborative practice (IPECP) to become sustainably embedded in health professional education in South Africa, a multi-stakeholder, national working group should be formed to develop and guide the implementation of a strategic plan for IPECP.
  
  
• • There is a need to take urgent action to improve governance of health sciences funding by strengthening the capacity and accelerating the momentum of the Joint Health Sciences Education Committee.
  
  
• • Improve human resource planning, resource allocation and budgeting.

Student selection

On the issue of student selection, the study notes that access to health professional education has been linked to educational issues of student retention and success, and broader societal imperatives of equity and redress. Though academic achievement appears to be the best indicator of success for both advantaged and disadvantaged students, clinical competency is not guaranteed by previous academic achievements.

“It is apparent that all the medical schools are attempting to balance the tension between selection based solely on academic merit to maintain a standard of excellence, and selection as a means of redress to achieve equity. This is fraught with difficulty, and decisions may be challenged, given the enormous competition for places,” says the report.

“The variety in selection policies may be seen as a stage in progression from widely differing traditions towards a more uniform national selection process. In the meantime, as long as the inequities of apartheid education persist, redress in terms of ‘race’ classifications is likely to persist; regional differences in ‘race’ distributions will probably be reflected in local health sciences education selection policies.”

The report recommends that universities carry out rigorous research to determine what selection criteria and student support measures best predict student success and promote the attainment of the desired graduate competencies in the South African setting; adopt evidence-based selection and admission criteria to ensure demographically and geographically representative student cohorts; and institute academic and non-academic monitoring, development, support and mentoring programmes to translate access into retention and success.

Professional councils are also called upon to introduce mandatory educational qualification, certification or professional development for health professional educators, while the Department of Health is called upon to provide an expanded, appropriately staffed clinical training platform spanning rural and urban areas across all levels of healthcare.

The report recommends that the Department of Higher Education and Training increases funding for academic development and support programmes at universities and adequately funds students to ensure that access translates to retention and success.

Scholarship programme

As a means to scale up the production of healthcare professionals, the report suggests an increase in international scholarship programmes such as the one which has existed for over two decades between South Africa and Cuba and which is now being scaled back.

While the report notes that there are “acknowledged barriers associated with training students in a different language, cultural and health system environment that requires intensive bridging programmes on their return”, it suggests that a “similar programme with English-speaking countries could address these concerns”.

As a means to address the persistent shortage of healthcare workers in the rural areas, the report argues that training students in rural areas increases the likelihood of such students choosing to work in those communities. Therefore, locating health professional schools, campuses and family medicine residency programmes outside of capitals and major cities would help retain doctors in these areas. Revising the undergraduate and postgraduate curricula to include rural health topics could also help, it suggests.

Internships

On the issue of internships, the report says it is “noteworthy” that internship in South Africa does not involve tertiary education institutions, despite it being a legal part of professional training.

The report notes that this situation is unlike the situation that pertains in most other countries and research has shown that where there is a greater involvement of tertiary education institutions, “this appears to benefit the learning and development of newly qualified doctors”.

According to the panel, in South Africa there has been little or no effort to incorporate the reforms proposed by the Lancet Commission into internship training, such as the promotion of inter-professional education, or the ‘new professionalism’ that envisages healthcare professionals as "change agents" engaged in "critical enquiry".

Furthermore, in the absence of the involvement of education institutions, “interns are generally regarded as a junior component of the medical labour force, rather than as learners, let alone innovators.”