There is no national plan for the education and training of clinical researchers in South Africa, despite its importance not only for the promotion of health in the South African public but also as a necessary catalyst of economic activity in one of the major missions of the government, the ‘farmer to pharma’
programme of developing the potential of indigenous remedies for worldwide application, and becoming a major globally important centre of clinical trials activity.
The justifiably high priority given to primary health care in the national public health system has been allowed, inexplicably, to result in the weakening of academic hospitals and tertiary facilities in the public sector. This means small complements of professionals in specialist clinics, high service workloads, and poorly equipped facilities for diagnosis and treatment. At the same time, the withdrawal of any kind of support for research (as opposed to service) by provincial health administrations, the refusal of the National health laboratory Service (NhlS) to discount fees for research projects, and the under-funding of the MRc in respect of its resulting ‘sole mandate’ for research support in the clinical area, have amounted to a massive disinvestment by the state in clinical research activity.
The above situation has been addressed in part by the recent decision to provide significant funds to health science faculties via the Department of Education (DoE) for clinical training at both undergraduate and postgraduate
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levels (I. A. Bunting, DoE, Personal communication, 2008). In the 2007/08 to 2009/10 national budgets, the National Treasury allocated funds for the first time to the DoE for the clinical training of health sciences professionals. The amounts involved were: 2007/08: R8 million to fund a review of clinical training in the health sciences; 2008/09: R200 million to support clinical training in universities; and 2009/10: R300 million to support clinical training in universities.
In March 2007, the Director-General of the then Department of Education established a committee to undertake the review referred to above. This review committee had as chair the Deputy Director-General: Higher Education, and as members officials from the Departments of Education, Finance and Health, and representatives from the Health Sciences Professional Council and from Higher Education. The review committee was set four broad tasks:
(1) to examine the current financial arrangements which hold between provincial health departments and higher education institutions;
(2) to investigate the clinical training needs of higher education institutions;
(3) to examine the current student-carrying capacity of health sciences faculties, and consider ways in which this capacity could be increased;
(4) to determine how the 2008/09 and 2009/10 allocations for clinical training should be distributed between universities.
The uses to which these allocations could be put included the appointment of additional clinical training staff and other staff to support the delivery of clinical training services, support of partnership agreements with public and/
or private providers of clinical training services, meeting operating costs of clinical training service delivery, and improving the infrastructure needed for clinical training, including equipment, building refurbishment, and the construction of new clinical training facilities. Allocations were provided when detailed spending plans had been submitted and approved. Progress reports were required.
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The mechanism distribution of the clinical training funds (R500 million in 2008/09 and 2009/10) proposed by the official working group was based on a simple formula. All programmes which had clinical training requirements were included, mainly undergraduate degree programmes in medicine, dentistry,physiotherapy, occupational therapy, pharmacy, speech pathology, audiology, dietetics, dental therapy, as well as master’s-level specialist training programmes in medicine, surgery and dentistry. These degree programmes were assigned, for each year of study, a weighting which represented the proportion of the curriculum for that year devoted to clinical training. These weightings were applied to the 2006 head count student enrolment in the programmes which qualify for clinical training funding. (These head count enrolment totals had to be supported by a certificate from each institution’s external auditors). The weighted totals of undergraduate and postgraduate clinical training students were aggregated into a total for each institution, and ultimately a weighted national total. The allocation each institution received was then determined as:
(institutional weighted total/national weighted total)*funds available.
It is evident that this highly significant intervention in clinical training, approved and funded in 2008, interfaces directly with the subject of clinical research training, and presents a model which could produce massive improvements in the quality and quantity of South African clinical research as advocated in this report. There is already a possibility that the funding of research/research training in the case of MMed candidates could be funded under the scheme as it is currently set up.
DEGREE STRUCTURES PROmOTING RESEARCH TRAINING AND DEVELOPmENT
intercalated BSc degrees in medical sciences are available in most South African medical schools, and in the past have served to induct promising individuals into the research in this area. They have, however, been seen by most faculties as minor programmes for the gratification of the personal interest
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of a small number of gifted students, and as rather costly, and certainly not as deliberately planned pathways to develop a new generation of research- active clinicians (but see international example below).
The BScMed honours programmes offered in various special directions by most health science faculties are generally open to medically qualified students, but the take-up has been very low in recent years, associated with the extensions of compulsory community service, high student indebtedness, and the lack of adequate bursaries at the level concerned.
The Master of Medicine (MMed) degree is offered by the eight South African universities with programmes leading to the MB ChB degree and related postgraduate programmes. It is one of the pathways to registration as a specialist in South Africa, but serves mainly as a professional qualification – its relatively minor research component generally does not result in the initiation or production of high-quality research, nor is there frequently significant continuation of research activity after registration. In fact, several universities for many years tacitly registered students for the MMed degree only to allow them to complete their College examinations and default on completing the master’s degree (registered by the Department of Education as ‘drop outs’). The Health Professions Council of South Africa (HPCSA), the authority that sets the standards of training and requirements for registration of doctors, is proposing to make the completion of a research component a condition for registration of specialists in South Africa. This initiative offers an opportunity to turn the research component of the MMed degree into programmes to develop properly equipped clinical researchers, for example by combining them with honours work offered by the same institution and faculty.
There is little incentive for clinicians to train in doctoral programmes, resulting in a very small number of the clinical professoriate having doctoral degrees.
No equivalent of the MD/PhD programme which is so active in the US has yet been developed in South Africa into analogous MB ChB/PhD programmes (see below), where purist interpretations of both the standardised undergraduate curriculum and the ‘very senior’ PhD degree have conspired to make the pursuit of doctoral degrees specially ambitious and rare. Financial support packages at this level are also not readily available.
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While the above situation in respect of formal postgraduate studies in clinical research provides many reasons for declining numbers of clinical researchers and declining outputs, it is likely that the problem begins much earlier, in the approach to the undergraduate phase of development.