Each year hospitals and clinics in deep rural areas welcome newly qualified doctors who have completed the bulk of their training in Cuba.
Empathetic and well-liked by their patients, these doctors are the result of a little-known programme that sends matriculants to train in a country where healthcare is focused on prevention and wellness.
Then, in their final year, they are dropped into the South African milieu of trauma and casualty and forced to catch up on the clinical skills that their South African counterparts have been honing for years.
South Africa’s medical deans have expressed concerns about the programme but Health Minister Aaron Motsoaledi disclosed this week that he is hoping to expand it to help alleviate the shortage of doctors in the country.
The programme is part of a bilateral agreement signed between South Africa and Cuba in 1996. Each year the health department provides scholarships for disadvantaged students from rural areas to study medicine at Cuban universities. There are 352 students enrolled in the programme; the annual intake was recently increased from 60 to 80.
The students do a year of Spanish language study and five years of medical training in Spanish before returning to South Africa for a period of clinical orientation. They complete the final year of the South African medical degree at one of seven local universities and write the medical exam set by the Health Professions Council of South Africa.
But medical schools have struggled to help students trained in Cuba to adjust to the South African health context and there have been allegations of mismanagement and nepotism in the programme.
In 2007 the health department commissioned an assessment of the programme but the report has not been made public. Last month representatives from South African medical schools accompanied the late deputy health minister Molefi Sefularo on a trip to Cuba to discuss ways to improve the programme.
Deans of medical schools have requested that they be formally included in the review process for the programme, including the planning, decision-making and implementation processes.
The Cuban health system is very different from South Africa’s. Gonda Perez, deputy dean of the Health Sciences Faculty at the University of Cape Town, said: ‘Cuba has eradicated many diseases that are prevalent in South Africa, like measles, TB and malaria. They do not have the levels of trauma, HIV and malnutrition that is seen daily in South African health facilities. Cuba has health statistics like those of — and sometimes better than — most developed countries. Our students trained in Cuba have to be exposed to these conditions in South African health facilities.”
In Cuba, where medical specialists are common, a general practitioner’s role is primarily to provide health education and to visit patients, identify their health problems and refer them to specialists. Students trained through the programme lack the clinical skills of their locally trained colleagues and often fail their final year clinical rotations, which they then have to repeat.
Helen Laburn, dean of the health sciences faculty at Wits University, said that only a quarter of the Cubatrained students who complete their final year at Wits do so in the minimum period. ‘Most of them take twice as long as usual — they can take three years,” she said.
Laburn said getting to grips with the difference in language, curriculum and assessment methods could be challenging for the students. And, she said, ‘their orientation back into the regular cohort of students is also very difficult because they’ve not been training with those students over the years”.
Questions have been raised about the financial feasibility of the programme. While the government does not pay fees, it contributes ‘a donation towards the Cuban government”, according to health department spokesperson Fidel Hadebe.
In addition to the donation of R200 000 per student, the government covers the students’ travelling expenses, provides them with a monthly stipend of $200 (about R1 500) and supplies them with essential supplies like textbooks, stethoscopes and lab coats.
Hadebe said the costs incurred were far lower than those of training students locally, pointing out that it would cost more than R500 000 to train a doctor at the University of Cape Town.
A health professional familiar with the programme said the process of selecting prospective students was not transparent. He said the selection panel was made up of bureaucrats who did not have the expertise to assess the students’ suitability for the medical profession, that the selection process was less rigorous than it was for students trained in South Africa, and that there had been allegations of nepotism.
Motsoaledi has admitted that ‘somewhere along the way, individuals in some provinces started doing favours when people didn’t get accepted into medical schools here by not qualifying for the stringent selection criteria”. He said the national health department was trying to rectify this to ensure that the programme met its goal of providing medical training for ‘the poorest of the poor”.
He defended the programme, saying ‘the aim is to try to improve it rather than just to say it is weak and abandon it”. He denied that it was being continued purely to maintain political relations. ‘I don’t know what the political motivation was when it started but the consideration from my side is that we don’t have enough doctors,” he said.
‘If Cuba is one of the countries that agrees to train our doctors, so be it. And we want to add many other countries [in future], even if they just give us space for five or 10 students — ”
But Laburn said universities were unlikely to support any further expansion of the programme. ‘Our view is that the money might better be spent resourcing the medical faculties to take extra students from rural areas into the first year of study. We believe it would be far more effective to train students in the current way, so they start and finish with us,” she said.