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BMJ No 7108 Volume 315 Personal view Saturday 6 September 1997 The future of medical education in South Africa See Editorial by Chaudhry p 560 and Education and debate p 593 When I left South Africa in 1968 academic medicine was flourishing. The best graduates wanted to pursue academic careers and there was fierce competition for posts in teaching hospitals. Although not in itself a manifestation of profound research the world's first heart transplant had revealed just how sophisticated medicine was in the country. The general medical scene was less satisfactory. Few black doctors were being trained-seven in 1966; 11 in 1967; 10 in 1968-and the distribution of doctors was grossly distorted in favour of white suburbs. This inequality of service was reflected in patterns of health and disease. At the end of 1995 I returned to join an advisory group set up by the minister of health, Dr N C Zuma, to try to restore a badly depleted and demoralised academic sector. What I found was extremely depressing. The status of academic medicine had declined seriously, the teaching hospitals had been deprived of funds, salaries for academics and those working in the public sector were quite inadequate with a resultant haemorrhage into private practice. Vast numbers of doctors had emigrated. The mix of private and public medicine had changed completely. Only 39% of health expenditure went to the public sector, 61% to the private; one third of all hospital beds were in the private sector. The new minister was determined to do something about the unequal distribution of health services and the state of academic medicine but the problems are formidable. As a first step Dr Zuma decided to shift resources to primary health care and community services, in particular to improve the availability of services for prenatal and postnatal care and for children under the age of 6 years. This put further pressure on the already depleted funding of hospitals and academic centres. Faced with the urgent need to restore morale and stop the flood of healthcare professionals from public to private medicine the advisory group made or supported several proposals. The emphasis on primary health care called for a new approach to medical education encompassed in proposals to establish comprehensive academic health service complexes for educating and training all health professionals at all levels of care including community centres and clinics. The emphasis would be on producing general physicians, surgeons, and paediatricians as well as general practitioners. Special top slicing provision would be made for highly specialised services. The government had already demonstrated its commitment to improve hospital services by funding large new hospital complexes at Cato Manor outside Durban and in Umtata in the Eastern Cape. Recently there has been a substantial increase in remuneration for doctors in full time public service aimed at encouraging people to stay even if their salaries did not match those in private practice. A further salary increase has been promised for later this year if the national coffers can stand it. There is still a problem for some newly qualified doctors who have to repay large loans taken to support themselves through medical school. At present there is no requirement to train beyond the intern year, but a new regulation of the Medical and Dental Council will make it obligatory for all doctors to spend two years after internship in approved training posts, bringing South Africa in line with most developed countries. Although it is agreed within all the medical schools that a further period of training is needed before graduates can practise independently without supervision, there has been much opposition to this requirement with accusations of conscription and renewed threats of widespread emigration. To implement the scheme appropriate training posts and supervisors will have to be found, which may not be easy with the current staff shortages. A plan to bring recently retired doctors from Britain to fill some of these posts in the short term has foundered on the rocks of bureaucracy. The previous government was aware that recruitment of good staff had become difficult. In 1991-2 the cabinet agreed that full time personnel could carry out limited private practice out of hours under controlled conditions. The scheme was not regarded as the best option; adequate remuneration would have been better. The device worked quite well at some medical schools but failed to meet the large discrepancy between academic and private income. It also failed to address the inequality that existed between centres at which private practice was easily generated and those at which it was non-existent. There were also tales of quite serious abuse of the scheme. The advisory group recommended that the scheme should be phased out provided that remuneration packages for doctors in the public sector were substantially improved. There has been strong professional opposition with entire academic departments threatening to resign and move into private hospitals. Whether this threat is real and whether the medical schools can afford to let them go and battle along with less experienced younger staff is problematic. It is possible that the government will back down. An urgent problem is how to change medical school entrance to reflect the ethnic makeup of the population. Sex imbalances have already largely disappeared-53% of all first year students in 1996 were women-but there are still marked racial disparities. Things are changing rapidly and all schools are trying to recruit black students. Several imaginative support programmes have been introduced to try to bring poorly schooled students up to standard, the most successful of which is the community college scheme run at Bloemfontein. There are eight medical schools in South Africa capable of producing about 1200 doctors a year. Three are in Gauteng, all within about 50 miles of one another. Two are in the Western Cape-Cape Town and Stellenbosch; their large and sophisticated teaching hospitals only a few miles apart. Rationalisation of resources seems inevitable but local opposition is intense. A special difficulty exists in the University of Transkei (Unitra) in Umtata. The town has fallen into a state of advanced decay and the university and medical school are struggling to survive. There is particular difficulty in recruiting staff and last year there were 66 vacancies out of an establishment of 105 teaching posts including the headships of all the main clinical departments. There has been a large allocation of funds to rebuild the hospital and the medical school though whether money alone will solve the difficulty remains to be seen. I left South Africa in December 1996 with mixed feelings about the future of academic medicine. The needs of the community are so pressing that some withholding of funds from university and urban centres is inevitable and this will undoubtedly affect them and change their character. But the quality of the teachers and the beleaguered research workers is still remarkably high and they are mostly determined to keep up standards. The other reassuring factor is the emergence of a cadre of first class administrators. Raymond Hoffenberg, former president of the Royal College of Physicians of London Home | Current issue | Past issues | Classified ads | Career Focus | Feedback Collections | About this site | About the BMJ | BMA | Medline