Effectively addressing the health needs of South Africa's population: the role of health professions education in the 21st century.
Abstract: The causes of the poor health status of the South African population are probably multifactorial, but to be socially accountable we must ensure that the education and training of health professionals continue to be aligned with the population's health needs.

The authors of a seminal report published in the Lancet in 2010 provide guidelines for the future training of health professionals. Since November 2010, this report, together with other guiding publications, informed a series of strategic initiatives undertaken by the Undergraduate Education and Training subcommittee of the Medical and Dental Professions Board of the Health Professions Council of South Africa (HPCSA). These initiatives seek to ensure alignment of the training of health professionals in South Africa (SA) with the health needs of the population and with international educational norms and standards. These initiatives are described and the role of the HPCSA in guiding the education and training of SA's health professionals is explored.

S Afr Med J 2013;103(1):21-22. DOI:10.7196/SAMJ.6463
Subject: Medical personnel (Training)
Author: van Heerden, B.
Pub Date: 01/01/2013
Publication: Name: South African Medical Journal Publisher: South African Medical Association Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2013 South African Medical Association ISSN: 0256-9574
Issue: Date: Jan, 2013 Source Volume: 103 Source Issue: 1
Product: Product Code: 8010000 Medical Personnel NAICS Code: 62 Health Care and Social Assistance
Accession Number: 312828764
Full Text: The Medical and Dental Professions Board (MDB) of the Health Professions Council of South Africa (HPCSA) is the custodian of undergraduate training of clinical associates, dentists and medical doctors in South Africa (SA).

The Undergraduate Education and Training (UET) subcommittee of the MDB is mandated to monitor adherence to established training standards, mainly through an accreditation process that commenced in 2001. Since then, the training programmes have been accredited at least twice at all faculties offering these academic programmes. The outcomes of these accreditations suggest that that the standards are rigorous, that the programmatic offerings are generally of a high quality, and that the institutions deliver well-trained professionals.

This begs the following questions: why are we not seeing an improvement in the health outcomes of the country's population, why is there no movement towards health equity, and why are rural areas still desperately under-served?

Is the training of health professionals inadequate, or are politicians to blame for the state of the nation's health?

Training health professionals for the 21st century

While the answers to the above questions are multifaceted, it would be arrogant for us to believe that the training institutions are not at least partly accountable. In a seminal commissioned report that appeared in the Lancet in December 2010, Julio Frenk and collaborators provide some answers to the questions above. (1)

They argue that the changes in health professions education that followed the publication of the Flexner report in 1910 (2) and resulted in the global inclusion of basic and pre-clinical sciences in curricula, contributed to the doubling of the human lifespan in the 20th century. They allege, however, that health professions education has not kept pace with changing global health needs, and that current curricula are static and outdated and deliver graduates that are, inter alia, ill equipped to act as leaders and agents of change or to work in teams.

Transformative learning and interdependence in education

The key recommendations of the report relate to the objectives of transformative learning and interdependence in education.

Since Flexner's report, training institutions have mainly focused on the first two levels of learning: informative and formative. Informative learning refers to the learning of facts and skills and produces a technical expert. Formative learning exposes the student to the elements required to become a professional, i.e. ethical norms, professional behaviour, etc. The third level (transformative learning) facilitates the development of change agents that will help ensure that the population's health needs are met, that inequities are minimised, and that health system deficiencies are addressed in co-operation with the relevant stakeholders. The key driver of our educational endeavours should be the health needs of the population and the needs of the health system. These inform the competencies that our graduates require, and should in turn inform the outcomes, content and design of our curricula.

Interdependence refers to the need for close collaboration between members of the various healthcare professions (and even other professions). It furthermore refers to harmonisation of the education and health systems in training of health professionals and addressing the population's healthcare needs, the dismantling of professional silos, and the need to be globally connected but locally focused.

Although the Lancet report has been received with some minor misgivings, (3) it has generally been lauded and embraced by leading global education and primary healthcare-orientated organisations.

Response by the Medical and Dental Professions Board

The 5-year term of the current MDB commenced in November 2010. The UET subcommittee decided to embrace the report of the Lancet commission at its first strategic planning meeting in February 2011, resolving that it would serve as a guide for future training of clinical associates, dentists and medical doctors in SA and would therefore inform future accreditation policy and processes.

To obtain national consensus, a second strategic planning workshop was held on 22 June 2011. Deans, or their representatives, from all relevant SA institutions responsible for the training of all three professions were invited to attend. The Lancet report was studied and representatives decided on the five key elements that should inform training of these professionals in future. These are:

* Competency-driven instructional design

* Ability of graduates to work optimally in inter- and transprofessional teams

* Ability of graduates from various professions to share tasks where needed and appropriate

* Willingness of training institutions to utilise and share open educational resources

* Willingness to engage with other stakeholders in the health and education systems to optimise collaboration (e.g. in joint planning of training and service delivery).

Delegates agreed that these elements are acceptable and achievable in the SA context, and that they could be operationalised. Potential challenges to successful implementation were identified. It was agreed that in future these elements should be specifically evaluated during accreditation visits (HPCSA, unpublished data).

The Lancet report articulates the view that 'we cannot carry out 21st century health reforms with outdated or inadequate competencies ...' and 'That is why we call for a new round of more agile and rapid adaption of core competencies based on transnational, multi-professional, and long-term perspectives to serve the needs of individuals and populations.'

A core competency framework for physicians was developed in the 1990s by the Royal College of Physicians and Surgeons of Canada. This framework was subsequently refined, the most recent version being called CanMEDS 2005.5 This framework identifies seven meta-competencies (or 'roles'). The central role, integrating elements of the other roles, is called the 'medical expert' and the other six roles are 'collaborator', 'communicator', 'health advocate', 'manager', 'professional' and 'scholar'. Each of these roles comprises a set of key and enabling competencies.

At another national UET workshop, held on 23 June 2011, the CanMEDS framework was adapted to make the key and enabling competencies of the roles applicable to undergraduate education and training of health professionals in the SA and African context and to be sufficiently generic to guide the training of all health professionals. It was decided that the adapted CanMEDS framework will in future inform all the UET subcommittee's accreditation processes.

Social accountability

Social accountability of academic institutions undertaking training of health professionals was defined by the World Health Organization in 1995 as 'The social obligation to direct education, research and service activities towards addressing the priority health concerns of the community, region, or nation they have a mandate to serve.' This concept underpins the recommendations of the Lancet commission and also what the UET subcommittee of the MDB strives for.

Another national workshop of the subcommittee, held on 12 and 13 July 2012, therefore dealt exclusively with the subject of social accountability. The workshop was held in co-operation with the Collaboration for Health Equity through Education and Research (CHEER) and again involved representatives from all relevant SA education and training institutions.

The aim of this workshop was to refine a social accountability evaluation framework that was originally developed by the Training for Health Equity Network ('THENet') (4) and subsequently adapted by CHEER. The product is a user-friendly evaluation tool suitable for the SA context. The workshop also identified key challenges, as well as significant opportunities, facing SA institutions in their endeavour to become progressively more socially accountable. At least two training institutions volunteered to participate in a CHEER-driven peer review process to obtain a baseline measure of their social accountability score as part of a research project.

The way forward

The UET subcommittee is now planning a workshop in July 2013 to align its accreditation self-evaluation questionnaire and process with the outcomes of these three workshops. It also aims to make accreditation a more inclusive, non-punitive and guiding process in future.

We are excited about the road the MDB has embarked upon and confident that it will assist in enhancing health equity in the country and addressing the key health needs of the population.

To achieve this we will have to train health professionals in socially accountable institutions and support those willing to collaborate with other stakeholders, including other training institutions, the community, government and NGOs, to address society's needs. Introducing effective transformative learning principles and practices into curricula should enable institutions to train health professionals to operate in welltrained healthcare teams that will be able to act as agents of change for social good and moreover will be equipped with the core competencies required to adequately address the health needs of SA's people, not only in the urban areas but in the deep rural areas as well.

The vision

Involvement in public healthcare in SA often leads to a feeling of pessimism, because it seems that we are currently unable to achieve health equity, as a result of which large sections of the population's healthcare needs are not adequately met. The condition of the public healthcare sector has been a cause of grave concern for many years.

However, there are initiatives, such as the plan to re-engineer primary healthcare and the National Health Insurance project, that promote cautious optimism.

We believe that the HPCSA can play a significant role in addressing the country's health problems by guiding the education and training of health professionals in line with the principles proposed by the Lancet commission's report, and those that underpin social accountability.

Acknowledgements. The author wishes to acknowledge the invaluable contribution and support of the other members of the UET subcommittee, namely Professors Vanessa Burch, U M E Chikte and T S Gugushe, Dr L L Ledwaba, and Professors K Mfenyana, P D Moipolai, T S Pillay, K S Satyapal and W L van der Merwe, and the committee co-ordinator, Ms Y Meintjes.

(1.) Frenk, J, Chen L, Bhutta ZA, et al. Health professionals for a new century: Transforming education to strengthen health systems in an interdependent world. Lancet 2010;376:1923-1958. [http://dx.doi.org/ 10.1016%2FS0140-6736%2810%2961854-5]

(2.) Flexner A. Medical Education in the United States and Canada (The Flexner Report). A report to the Carnegie Foundation for the Advancement of Teaching by Abraham Flexner. Bulletin Number Four. 1910. Reproduced in 1972. http://www.carnegiefoundation.org/publications/medical-educationunited-states-and-canada-bulletin-number-four-flexner-report-0 (accessed 6 August 2012).

(3.) Gordon D, Karle H. The state of medical and health care education: A review and commentary on the Lancet Commission report. World Medical and Health Policy 2012;4:1-18. [http://dx.doi. org/10.1515%2F1948-4682.1219]

(4.) Training for Health Equity Network. THENet's Social Accountability Evaluation Framework. Version 1. Monograph 1. 1st ed. THENet, 2011. http://www.thenetcommunity.org/files/articles/The%20 Monograph.pdf (accessed 22 November 2012).

Professor Ben van Heerden, MB ChB, MSc, MMed (Int), a physician and nuclear medicine physician, is currently Director of the Centre for Health Professions Education of the Faculty of Medicine and Health Sciences at Stellenbosch University. He is also Chairperson of the Undergraduate Education and Training subcommittee of the Medical and Dental Professions Board.

Corresponding author: B van Heerden (bbvh@sun.ac.za)
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