New Educational initiatives to address rural health human resource needs in South Africa

1
New Educational initiatives to address rural
health human resourceneeds in South Africa

• Ian Couper
• Professor of Rural Health
• University of the Witwatersrand (Wits)
• couperid_at_medicine.wits.ac.za

2
Outline

• Background
• Context
• Medical education
• Pipeline of rural health education in South
  Africa
• The Integrated Primary Care rotation
• The training of Clinical Associates

3
Background Social Context

• South Africa
• Southern tip of Africa
• 46 million people
• Still riding the wave of hope post 1994
• Major economic growth
• Major unemployment
• Crime problematic
• AIDS more problematic

4
The statistics
HIV Prevalence trends among antenatal clinic
attendees in South Africa 1990-2005
5
Background Health context

• Public health system based on WHO model district
  health system
• Referrals PHC clinics health centres (nurse
  based) district hospitals (GP based) regional
  hospitals (general specialities) tertiary
  hospitals academic centres
• 20 of health care expenditure in public health
  system relied on by 80 of population.
• Shortage of doctors everywhere worse in rural
  areas.

6
DISTRIBUTION OF POPULATION AND HEALTH WORKERS IN
PROVINCES
Sources 1. HEALTH SYSTEMS TRUST (2004) South
African Health Review 2003/04 Durban Health
Systems Trust 2. HCJ van Rensburg (2004) Health
and Health Care in South Africa. Pretoria Van
Schaik.
7
Background Medical education

• 8 medical schools
• All 8 have active FM department
• 3 have rural health units
• About 1200 doctors per year
• Combination of 5 and 6 year programmes
• Exception Wits hybrid 4 year GEMP
• Most use integrated, problem-based curricula
• Affirmative action to reflect demographics of
  society
• Where are we in the pipeline of rural medical
  education?

8
The Pipeline Concept

• Significant evidence exists that a sequential set
  of training experiences focused on preparation
  for rural generalist practice can be successful
  in the training of rural family physicians
• This set of experiences can be thought of as a
  pipeline

9
Why Bother With The Pipeline Metaphor

• It fits well
• It is easily understood by rural people who
  utilize irrigation systems
• It is easily conceptualized by politicians who
  fund medical education

But in rural South Africa other forms of
irrigation are more often used!
10
(No Transcript)
11
Selection of students

• Major problem
• Lack of adequate schooling
• Obstacles in admission process
• Poverty
• Recent research by the Rural Doctors Association
  of Southern Africa (RuDASA)

12
Proportion of rural origin medical students in SA
medical schools
13
Bonded scholarships

• The Friends of Mosvold Scholarship Scheme, rural
  KwaZuluNatal province
• Wits Initiative for Rural Health Education
  (WIRHE)
• Friends of Tintswalo, rural Limpopo province
• Bophirima District Department of Health, rural
  North West province

14
Undergraduate training

• Rural blocks of varying lengths (maximum is 7
  weeks at Medunsa)
• One regional, community based medical school
  (Walter Sisulu university)
• Stellenbosch Regional hospital-based exposure
• KwaZuluNatal Selective in rural health (2nd, 3rd
  or 4th year out of 5)
• Wits Some rural exposure for all, more exposure
  for some
• 1-day visits in GEMP 1 and 2
• 2 weeks rural community orientated primary care
  in GEMP 3
• Integrated Primary Care rotation for 6 weeks in
  GEMP 4
• Electives (60 students in 2006!)

15
Internship and beyond

• New 2 year internship with compulsory family
  medicine rotation academic complexes to include
  rural district hospitals
• Challenge of supervision
• Compulsory community service service rather
  than training
• Challenge of supervision
• Need to incorporate training

16
Postgraduate training

• Family medicine
• Previously only part-time training
• About to commence formal specialist training
• focus on rural areas
• Rural training
• No specific programme
• Need for skills training traditionally addressed
  through diplomas (e.g. child health,
  anaesthetics, public health)
• To be incorporated into FM training

17
The way forward

• The pump is primed but there is not much water
  yet

18
(No Transcript)
19
Integrated Primary Care Block at Wits University

• A new rotation
• (GEMP 4)

20
GEMP 3 and 4

• Clinical years
• Series of 7 rotations per year
• Themes throughout
• Special activities to integrate medical school
  days
• Final integrated exam at end of each year

21
GEMP 3

• 6 week blocks in medicine. surgery, obstetrics,
  and paediatrics
• Acute and Perioperative care Integrated 6 week
  block of emergency medicine, trauma, forensics
  and anaesthetics
• Mixed blocks (2 weeks per component)
• Urology, ophthalmology, public health (done in
  Bushbuckridge)
• Psychiatry, ENT, family medicine (GP placement)
• Research project

22
GEMP 4

• 6 week blocks in medicine. surgery, gynaecology,
  psychiatry, and paediatrics
• Mixed block of medical specialities and
  orthopaedics
• 6 week Integrated Primary Care (IPC) block

23
Purpose of the IPC block

• For students to experience and to practise
  integrated primary care medicine that is
  responsive to patients, their families and
  communities

24
Key features of the block

• Interdisciplinary
• Medicine, Paeds, OG, Psych, Public health, Fam
  Med, Surgery
• Integrated
• Community-based with district hospital experience
• Structured around the primary care consultation
• Focus on patients with undifferentiated problems
• Task orientated
• Student directed

25
Sites

• Placement in one site for 5½ weeks
• (Excludes orientation, evaluation assessment)
• Students choose peri-urban (Gauteng province) or
  rural (North West province)
• Sites are health centres/clinics linked to
  district hospitals

26
Activities

• About 30 different activities
• Main focus the undifferentiated patient
• Key competence managing common presenting
  problems
• Guide book
• Logbook

27
Activities

• Examples
• Health facility audit
• Quality improvement project
• Anaesthetic case study (local or regional block)
• Home visit report
• Support group attendance
• Counselling sessions (5)
• Accompanying a referred patient

28
Assessment

• Year mark (50)
• Logbook, Written tasks, Participation
  professionalism, Clinical assessment
• End of block mark (50)
• Observe consultation (on site)
• Exam
• Prepared by team according to agreed upon
  blueprint, with integration provided by rural
  health unit
• OSCE
• Examiners from different disciplines
• Written papers
• Short answer management problems
• Computer loops (OSPE)
• (Students not passing the block repeat it
  immediately)

29
Supervision

• Doctor/PHC nurse to provide constant supervision
• On site supervision by local preceptors
  hospital/health centre staff (Partnership NB)
• Local preceptors under guidance of district
  specialist (e.g. district family physician)
• Weekly contact with senior staff from faculty, by
  teleconference (presentation of cases, reflection
  on activities, problem solving)
• Overall responsibility IPC management team

30
CLINICAL ASSOCIATE PROGRAMME

• A new initiative to train midlevel medical
  workers to supplement the rural medical workforce.

31
History

• MINMEC DECISION 2003
• Draft National Human Resource Plan
• 2003 Visits USA, Tanzania
• 2004 Consultations and National Workshop
• 2005 Scope of Practice, Curriculum outline,
  National Implementation Plan
• 2006 Preparation for implementation

32
3 Member Clinical Team

• District Facilities

Hospital Clinical Associate Emergency Injuries Pro
cedures
Clinic PHC nurse First contact Prevention Chronic
Family Physician
33
Scope of Practice

• District Hospital
• Assist doctor
• Procedures
• Emergency unit
• Theatre
• Wards

34
Scope of Practice

• Procedural skills
• Investigations
• Therapeutic
• Consultation skills
• Emergency care
• Counseling
• Teamwork
• Communication

35
National Programme

• CA part of team of district health clinicians
• National Training Programme through medical
  schools
• Training in district hospitals
• District training complexes
• Undergraduate (meds and other)
• Interns
• Family medicine registrars
• PHC Nurse clinicians
• Clinical Associate
• Service learning community development

36
FaMEC

• Clinical Associate as part of district clinical
  team
• Develop Scope of Practice, Curriculum
• Model on national approach to family medicine
  training
• Outcomes, curriculum, training resources,
  district training complexes
• Core task team

37
Academic Tasks

• Scope of Practice
• Curriculum
• Registration of qualification
• Registration of programmes
• Course development
• Resource development
• Training the Trainers
• Support programme implementation
• Review / Quality Assurance

38
Planned curriculum

• 3 years
• Training in district hospitals under family
  physicians
• Linked to university faculties of health sciences
  (medical schools)
• Apprenticeship model
• 2 years of system-base blocks, then 1 year of
  integrated blocks, with skills learning and
  clinical practice concurrently

39
Outline curriculum

• Years 1 and 2
• (Repeated spiral approach)
• Foundation Skills
• Human Biology
• Cardiovascular System
• Respiratory System
• Gastro-Intestinal System
• Genito-Urinary Tract System
• Central Nervous System, Eyes, and Ear Nose and
  Throat
• Musculoskeletal System
• Endocrine System, Skin, and Reticulo-Endothelial
  System

40
Outline curriculum

• Year 3
• Core
• Womens Health
• Child Health
• Accident and Emergency
• Infectious Diseases
• Anaesthetics
• Dispensing
• Mental Health
• Health Care System
• Electives (Choice of 2)
• Medico-legal and Clinical Forensic Medicine
• Termination of Pregnancy and Family Planning
• Orthopaedics
• Health Management and Quality Improvement
• Trauma and Emergency
• Air Evacuation and Combat
• Tropical Health

41
Conclusion

• Expand the range of professionals to deliver
  clinical care
• Large scale intervention
• Opportunity for a coordinated relevant national
  programme
• Innovative new educational initiative

42
Thank you!