The changing profile of medical education in South Africa

Healthcare provision still has problems hanging over from the apartheid era

Medical education in South Africa is undergoing dramatic changes in response to a variety of influences (see box 1), chief among which is the end of apartheid and the subsequent transition to democratic rule following the 1994 elections. In the apartheid era, South Africa's eight medical schools admitted students according to ethnicity and language. Three admitted only black students, three admitted only white students with a preference for Afrikaans as the language of instruction, and two admitted whites and used English as the language of instruction (see box 2). The university of Cape Town (UCT) and the university of the Witwatersrand (Wits) had taken advantage of legal loopholes in the apartheid era to admit a handful of black students each year as a way of asserting their status as liberal institutions. Conversely, the Afrikaans medium universities had readily embraced the legislation to exclude black students on ideological grounds.

Historically, white medical schools came under growing social and political pressure to open up to black students consistent with the country's demographic profile, following the 1994 political changes. White medical schools responded positively, some more swiftly than others, so that in 1998 black students represented 55.4% of the total enrolment at UCT, compared with only 16.3% at Stellenbosch.¹ Medical schools suddenly found themselves in virtual "cut throat" competition for qualified black students, who are a scarce commodity, much as they are in America.² Medical faculties are not the only ones looking for good black candidates. As medicine has begun to lose some of its gloss in the South African context, medical schools have found themselves in head-to-head competition with other faculties. There is some evidence at UCT that commerce and business disciplines have begun to siphon away the sort of student-black or white-who has traditionally gone into medicine.

The reason why black applicants are so hard to come by is one of the troubling ironies of postapartheid South Africa. The overall output of matriculated high school graduates has been in steady decline since democratic rule began in 1994. Only 13% of all candidates sitting the final high school examinations countrywide in 1999 achieved the required minimum performance scores for admission to university. Only 5% obtained the necessary grades in mathematics for entry into disciplines such as the natural sciences, health sciences, and engineering, according to the unpublished data released by the authoritative Centre for Higher Education Transformation (CHET) based in Pretoria. The pass rate varied widely, from better than 80% in previously white schools to near zero in some previously black schools. This is reflected in the proportion of youths aged 20-24 enrolled in higher education, estimated at 12% for indigenous Africans and 47% for white South Africans. This dilemma, of course, represents an apartheid legacy that has yet to be overcome.

How has medicine lost some of its gloss? To begin with, medical study in South Africa has become too long. In addition to the six year undergraduate degree and a one year internship, there is now a mandatory two years of community service in which the graduate is assigned to a rural, peri-urban, or other non-academic hospital, often in a remote location and away from family or spouse. Therefore, whereas community service per se has the general support of the profession and the students, there are deep anxieties about the often insensitive manner in which it is implemented. This adds up to a total of nine years before a graduate can register as a qualified practitioner or enter specialty training. Other disincentives include the funding and other systemic problems within the public and private healthcare sectors that have dulled the prospects of professional satisfaction in practice or a good income.

South Africa is engaged in a debate about the appropriateness of the medical curriculum inherited from Britain in the early 20th century, which is still largely in place in most medical schools. Specifically, both government and civil society are putting to the academic establishment the question posed by Lord Rosenheim in 1972: whether "in this chaotic and changing world, our efforts to train doctors are producing the right men and women for the job."³ Medical schools are accused of producing elitist doctors best suited to practice in British Columbia and Perth or the South African leafy suburbs rather than in the less privileged communities of South Africa. In response, medical schools are re-examining their programmes in terms of what is taught, where it is taught and how it is taught. A methodological paradigm shift in teaching is occurring in the form of integrated, non-departmental preclinical teaching, student centred learning, and clinical exposure at ambulatory sites. These innovations are similar to those occurring in both America and the UK.^4,5

The spectrum of disease and treatment options in publicly funded tertiary academic hospitals has shifted in recent years "as a result of a decrease in financial resources, an increase in the levels of violent injury, and the HIV/AIDS pandemic."⁶ The funding constraints derive from the otherwise understandable redistribution of state funding resources from the previously over-resourced tertiary hospitals, to the historically under-resourced primary health sites. However, the redistribution has been too drastic, leaving the teaching hospitals in dire straits. In the process, the private sector has come to surpass academic hospitals in terms of technological advances and professional expertise, having lured the latter away from the academy. Consequently, medical schools such as UCT and Wits are now looking at the option of a parallel, private sector teaching platform.⁶ This would involve formal partnerships with the previously loathed private medicine-clearly a watershed for academic medicine. Despite problems in the past, we are slowly venturing into a brave new world for South African health care.

Dan J Ncayiyana, deputy vice-chancellor, University of Cape Town, Rondebosch 770
Email: aesdjn@bremner.uct.ac.za


studentBMJ 2000;08:303-346 September ISSN 0966-6494

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