South Africa's high-profile programme involving the training of medical students in Cuba is part of an urgent national drive to increase the number of doctors being produced by the skills-short country. The government is also pushing universities to boost the number of home-grown medical graduates.
One of the main drawcards of the Cuban system was its emphasis on primary health care and prevention in a country with a large rural population, according to national health department spokesman Fidel Hadebe.
The heads of South Africa's medical schools support the Cuba initiative. But many believe that investing the resources intended for any future international agreements in South African medical schools would better serve the country and obviate the language, cultural and curricula challenges which often surface in inter-state programmes, said Professor Khaya Mfenyana, Chair of the Committee of Medical School Deans and head of the faculty of health sciences at Walter Sisulu University in Eastern Cape province.
Driving the programme with Cuba in the past has been the incapacity of South Africa's eight medical faculties to produce not only sufficient numbers of doctors for the size of the population, but also doctors willing to work in the public sector and in rural areas, where the need is greatest.
Currently, South African medical schools produce roughly 1,200 doctors annually. Since the 1990s an increase in the burden of disease, largely as a result of the high incidence of HIV-Aids, together with the loss of qualified doctors to developed countries, has exacerbated the shortage of physicians.
World Health Organisation statistics for 2010 put South Africa's doctor-to-patient ratio at eight doctors for every 10,000 people. While this is better than neighbouring Zimbabwe, at two doctors for every 10,000, it is much worse than Spain and the United States at 38 and 27 respectively.
Some 40% of the country's doctors are serving 85% of the population who use the public health system, according to a discussion document on the ruling African National Congress' proposed national health insurance scheme.
Since the inception of the South Africa-Cuba Health Cooperation Agreement in the mid-1990s - which sees students selected from rural areas study for five years in Cuba, returning to South Africa for an 18-month period of tuition and to write their final examinations - nearly 246 doctors have been produced, specifically for the South African rural public health sector. A further 388 students are in the pipeline.
While the Cuba training programme has been hailed as a success and will continue "for as long as the two countries want it to continue", according to Hadebe, the South African government is putting pressure on medical faculties back home to increase their graduate numbers and transform their graduate demographics.
At a meeting earlier this month, Higher Education and Training Minister Dr Blade Nzimande called on representatives of all key professional bodies to agree on a strategy to build critical skills. In May last year and again last month, medical faculty deans under the umbrella body of the Committee of Medical Deans were called to a meeting with the parliamentary portfolio committee for health to discuss faculties' capacity to address the doctor shortage.
Since the Cuban arrangement was made at state level, South Africa's medical schools have increasingly geared themselves towards the training of rural doctors and have placed greater emphasis in their curricula on primary health care - a major focus of the Cuban system.
However, the shortfall in South African doctors persists.
Mfenyana told University World News that the main reason is lack of resources, particularly manpower and infrastructure. Despite constraints, universities across the board are "going out of their way" to address the doctor shortfalls and meet national needs, he said.
Professor Alan Rothberg, Acting Dean of the health sciences faculty at the University of the Witwatersrand (Wits), said his faculty acknowledged the need to train more doctors.
At the behest of government, Wits accepted an extra 37 students into the medical programme at the start of the academic year, a move which places pressure on already extended staff and infrastructure. "We've done it," Rothberg said of the increased enrolment. "But we can't easily do it every year."
Rothberg said all medical schools, Wits included, had programmes in place to attract students with potential from rural and outlying areas and had put in place academic bridging and other support programmes to assist these students in overcoming educational deficits and adjusting to university life.
Wits has also introduced, as part of a national initiative pioneered by Walter Sisulu University in the Eastern Cape, a three-year bachelor of clinical medical practice degree which effectively produces clinical associates who reduce the burden on state doctors, freeing them up for more serious medical cases, according to Rothberg.
Characterising the relationship between government and medical schools as constructive, Mfenyana said both the national health and higher education departments had invited medical faculties to propose ways in which the government could help them to increase their graduate numbers. Joint proposals are currently under discussion, he said.
The Cuban programme was "definitely" contributing towards increasing the number of rural-based doctors, but was not "without challenges", said Mfenyana. One of these was the need for South African students to learn Spanish, the language of instruction in Cuban universities, in their first year.
However, he added, communication between South African academics and their Cuban counterparts was good and curriculum and other issues were constantly subject to scrutiny and improvement.
In a recent development, Mfenyana is to represent South African medical school deans on the selection panel for students into the Cuban programme. "Now the medical schools will have more ownership over the programme and the students produced through it."
Internationalisation in the form of individual partnerships with foreign institutions is to be encouraged, he continued. "We aim to be globally connected and locally relevant. At Walter Sisulu University, we have partnerships and formal exchanges with medical institutions all over the world, which help us to improve our offerings and give our staff and students access to new ideas and systems. We learn from each other."
Rothberg agreed that exposure of students and faculty to medical systems in countries with similar challenges to those of South Africa could be extremely beneficial.
"Everyone acknowledges that medicine has changed," said Rothberg. "Today, it's not just about having clinically competent students. We acknowledge that today's graduate doesn't have to be experienced in every area, but has thinking, investigative and interpretative skills, is computer literate, and possesses an ability to see patients in the context of their community and in the context of national health needs.
"If the right country is chosen for an academic exchange or partnership, it can work."
All articles in the Special Report: The Internationalisation of Medical Education
GLOBAL: Internationalisation and medical education
ASIA: World-class medicine pursuit drives collaboration
MIDDLE EAST: Medical cities seek foreign academics
INDIA: Medical education gets international flavour
CARIBBEAN: Medical schools battle to retain US access
SOUTH AFRICA: Cuba helps to train rural doctors
AUSTRALIA: Overseas doctors fill large gaps
FRANCE: Medical reform aims to fight 'human wastage'
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