Health Professionals’ Education for Practice in Rural and Underserved Areas
5.2 How should universities respond?
institutional (health centre or other public facility). Medically underserved areas/
populations are areas or populations designated as having too few primary care providers, high infant mortality, high poverty and/or high elderly population. For the purposes of this chapter, ‘rural and underserved’ areas are defined as areas or sub-districts outside of metropolitan areas where there is a limitation of access to first-contact health services. ‘remote rural’ areas are understood as those with a very low population density, usually at a greater distance from human settlements than ‘rural’ areas.
challenges for health science faculties in the 21st century as the need to:
a improve quality, equity, relevance and effectiveness in healthcare delivery;
b reduce the mismatch with societal priorities;
c redefine roles of HCPs;
d provide evidence of impact on people’s health status.
In South Africa, social accountability is also a principle that the Undergraduate Committee of the Medical and Dental Professions Board of the HPCSA has adopted and will include in accreditation of medical schools in future. Universities should give priority to this principle through a reorientation towards primary care and underserved communities, including rural health.
5.2.1 Student selection
There is substantial evidence from various countries, including South Africa, that selecting students of rural origin or background is associated with their eventual practice in rural areas (De Vries and Reid, 2003; Easterbrook et al., 1999; Laven and Wilkinson, 2003; Playford et al., 2006; Rabinowitz, 1993; Stearns et al., 2000). In this respect, rural origin is especially linked to the decision to choose a rural community as one’s first practice location (Page, 2014; Sen gupta and young, 2014; Stagg, 2014). A Cochrane systematic review states: “It appears to be the single factor most strongly associated with rural practice” (grobler et al., 2009). In South Africa, students from rural areas are about 3.5 times more likely to work in such areas on graduation than their urban counterparts (De Vries and Reid, 2003).
While a bias in favour of selecting students with a rural background might be warranted, we know this process is not simple. Obligatory online application systems for admission to higher education institutions present a challenge to rural high-school students who do not have access to online facilities. Identifying the right students, and finding students who meet the criteria for admission to health science programmes, given the state of rural education in South Africa, can be a challenge. However, there are very successful models of rural recruitment in South Africa for example, in the umthombo youth Development and the wits Initiative for Rural Health Education (WIRHE) bursary programmes (Ross, 2007; Ross and Couper, 2004). Furthermore, evidence from these schemes, in kwaZulu-Natal and North West provinces, shows that working with local health districts in the selection process and supporting the application process are also critical. Once students are admitted, on-going mentorship and support, and a continuing relationship with the districts are critical (Ross, 2007; Ross et al., 2015).
5.2.2 Rural clinical placements
A ‘rural placement’ is defined as one in which students stay overnight (usually for a few weeks or more) at a location away from the main campus of their health sciences faculty (Doherty, 2011). The intention of the placement includes exposure to the complex circumstances of healthcare provision in rural, remote and often disadvantaged communities, even when students are accommodated in towns.
Doherty (2011) described five broad models for rural placements, which fall along a continuum:
a Comprehensive rural programmes: The rural programme is the only programme offered and it is compulsory for all students to attend rural placements which happen periodically throughout the curriculum, some of which are quite lengthy (six months to a year).
b Dedicated rural track offered throughout a traditional programme: These programmes allow selected students to focus on rural issues as part of the traditional, urban-based programme. Students on the track are expected to meet the same educational and clinical competencies as other students but, for a large part of the curriculum, do so through different avenues, including extended rural placements.
c Dedicated rural track offered for part of a traditional programme: This variation on the above approach involves offering a rural track for part of the curriculum. For example, students joining this track depart for an extended rural placement during one of their clinical years.
d Rural tracks offered as supplements to traditional programmes: These
programmes allow selected students to engage in activities additional to the traditional programme, including a rural placement.
e Rural placement offered within a traditional programme: Under this approach, all students experience a brief rural placement of a few weeks (typically a clerkship). The rural placement is compulsory but the rest of the programme does not have a specifically rural focus.
Worley et al. (2016) describe a typology of three broad types of longitudinal integrated clerkships (LICs) as comprehensive LICs, blended LICs, and LIC-like amalgamative clerkships. Many of these are situated in rural areas.
There is evidence from the global literature that training students in rural areas increases the likelihood of them choosing rural practice (Longombe, 2009; Smucny et al., 2005; Wang, 2002; Wilson et al., 2009) and this has also been found in the South African context (Reid et al., 2011). Furthermore, studies in Australia have demonstrated an even greater effect from combining rural origin with rural training (Walker et al., 2012). This is also one of the wHO global Policy recommendations (WHO, 2010). Australia, in particular, has positive experience of linking funding initiatives to a requirement for students to spend time in rural clinical training (Denz- Penhey et al., 2005); in its case, rural clinical schools receive extra funding when 25% of students spend at least one clinical year in a rural or regional centre.
Faculties in South Africa should explore local adaptations of various rural models, with a stipulated minimum of clinical time spent in rural areas for each curriculum.
Setting up, or expanding, a rural placement is complex. At the very least, it includes identifying collaborating teaching hospitals, clinics and communities, as well as preceptors, partnering with community-based organisations (including rural health professional associations), developing a tailor-made curriculum and integrating the programme into existing faculty curriculum commitments (Doherty, 2014). The type of model a health science faculty chooses depends on its vision and commitment,
as well as practical considerations around logistics and resources. Whatever model is chosen, it needs to be accompanied by an implementation plan that builds on the strengths of rural medical education approaches whilst overcoming the many challenges of training students in remote locations.
Recent experiences with the longitudinal model of integrated clinical learning in South Africa have been described as successful (Van Schalkwyk et al., 2014; Voss et al., 2015) despite some initial hesitation on the part of the students (Daniels-Felix et al., 2015) and their clinical supervisors (Blitz et al., 2014). The initial academic results of the students indicates that they were not disadvantaged by rural placements in terms of academic achievement compared to their urban peers, and did marginally better academically in some aspects (Van Schalkwyk et al., 2015).
However the longer-term impact of their educational experiences in rural settings in terms of teamwork, communication, leadership, patient-centredness and career choices will only be able to be evaluated after some years.
5.2.3 Community-based education
The re-engineering of PHC enables the development of a community-oriented primary care (COPC)3 approach as the basis of healthcare in the country, in line with the philosophy of PHC. universities should play a vital role in establishing COPC.
This is done by engaging with the re-engineering of PHC in a systematic manner to assist in developing the concepts, participating in implementation of and research on primary care re-engineering, and reporting on the process, outcomes and impact of this initiative. This means a formal, permanent community-oriented PHC academic platform in which service delivery, teaching and research take place.
Full involvement of undergraduate and postgraduate students is necessary to achieve this. This will not only ensure more appropriate teaching, but will also create an extensive new teaching platform for the planned expansion of medical education. This district-based academic platform in rural and urban areas will consolidate and integrate the re-engineering of PHC and create space for further expansion of the teaching platform. The beginnings of this already exist, in rural sites used by many schools, with a leading example being the Stellenbosch University’s rural clinical school (Van Schalkwyk, 2014) and in the clinical learning centres of a number of schools (e.g. University of the Witwatersrand, University of Pretoria, university of kwaZulu-Natal and the walter Sisulu university), as well as in the urban primary care sites of other schools such as the university of Pretoria COPC development in Tshwane.
As part of this process of community orientation, faculties should engage with all the elements of re-engineering of PHC, namely district clinical specialist teams, ward-based outreach teams and school health. Registrars in family medicine, paediatrics and obstetrics and gynaecology should do significant rotations in
3 Community-oriented primary care is defined as: “A continuous process by which primary health care is provided to a defined community on the basis of its assessed health needs, by the planned integration of primary care practice and public health” Abramson and kark (1983).
district-level services and participate in the training of undergraduate medical students in these services.
The purpose of this engagement is to expose students to PHC early in their programme, from the first year. In this way they will be made aware of patients’
home and community circumstances, especially with regard to the major epidemics in South Africa, such as human immunodeficiency virus/tuberculosis (HIV/TB), chronic diseases of lifestyle, maternal and child health, violence and injuries. Such early experience will foster a deep understanding of the context of care; facilitate acquisition of content knowledge and skills; help students align themselves with patient and community perspectives on illness and healthcare and make their learning more real and relevant (Dornan et al., 2006; Littlewood, 2005; yardley et al., 2010). As longitudinal involvement of students with patients, teachers and communities increases the chance of workforce impact (Maley, 2009), students should ideally engage the same communities and services over several years of their study to build up relationships with health workers, patients, families and communities over time.