KWAZULU-NATAL PROVINCIAL DEPARTMENT OF HEALTH and UNIVERSITY OF KWAZULU-NATAL COLLEGE OF HEALTH SCIENCES

Executive Summary:

In KZN a Primary Health Care (PHC) approach should be followed.  A Primary Health Care Curriculum (PHCC) should be implemented and enforced to facilitate training of Health Care Professionals (HCP) in the community.  The CBTPHCM needs to address clinical training, the increase of training capacity, transformation of academic staff, transformation of the student body, the control and formalization of internship training, introduction of specialized training for mid-level career specific HCP, optimizing the training of Registrars/Specialists and the assurance that Continued Professional Development (CPD) is supported and provided in the PHC context.

Important concepts in the CBTPHCM are summarized under the specific headings as follow:

1. Primary Health Care Curriculum:

• Re-engineering of PHC is needed to ensure implementation in service delivery, training and planning for health services.
• CBTPHCM should include the service and training in primary health facilities such as clinics, community health centres, district hospitals and regional hospitals.
• UKZN is committed to promoting and training in primary health care principles and develop and sustain graduate competencies for all HCPs.
• All curricula at UKZN will be refined to ensure they agree with the basic principles of the CBTPHCM.

2. Research in Primary Health Care:

• Curricula in the CHS include research capacity development to ensure evidence-based, context-specific clinical practice and service delivery in tandem with relevant research.
• The CBTPHCM should be evaluated over time, to allow for changes and modifications if necessary.
• UKZN staff will do research in Health Sciences education pertaining to the CBTPHCM.

3. Decentralized Clinical Teaching Platforms for Training of all Health Science Professionals:

• KZN-DoH and UKZN will collaborate to increase the capacity of Clinical Teaching Platforms (CTP).
• Decentralized CTPs should include training opportunities associated with health services delivered in clinics, community health centers, district hospitals and regional hospitals.
• The pedagogic principles of PHC should apply and will need to feed back to the PHCC.
• The increases in the number of students training in Cuba add to the need for an expanded CTP for efficient clinical training within the next 4-5 years.
• In terms of sustainability the HR requirement for a CTP is a minimum of three specialists per discipline.
• Planning of HR should indicate the potential for rural development in specific districts and indicate the benefits for the community at large.
• The numbers of HCPs will need to be determined according to HPCSA, SANC and SAPC recommended staff:student ratios to optimize clinical training at decentralized CTPs.
• The PMB complex is a CTP with an enormous growth potential.  The currently limitation is housing capacity, which necessitates that additional housing for students be sourced immediately.
• Human resources and physical facilities are important for placing of students in decentralized CTPs.
• Ngwelezane/Lower Umfolozi has been identified as potential decentralized CTP.
• The development of a CTP in the Ngwelezane/Lower Umfolozi Hospital complex need to be planned to identify the clinics, community centres and hospitals that will be part of the CTP and to optimize the clinical disciplines and ensure that teaching facilities and accommodation are provided.
• Student placement will be planned between the UKZN and KZN-DoH task team in line with the basic principles of the CBTPHCM.
• The KZN-DoH and UKZN will need to investigate the development of additional decentralized CTPs in a phased approach.
• The placement of medical students in PMB can be increased significantly provided the limitations in resources and physical facilities – especially housing can be addressed.
• The placement of students from the other Health Sciences programmes in CTPs needs to be planned in collaboration with the KZN-DoH and the relevant Deans.
• The expected outcomes from planning of decentralized training sites are the following:

1. 1. A CTP plan that will identify all the relevant clinics and hospitals that will form part of the CTP.
   2. A staffing plan that will indicate the needs to train the agreed number of students of all HCPs.
   3. A teaching plan that will indicate the specific disciplines that will be taught as well as the level at which students should be taught in all the relevant CTPs.
   4. An infrastructure plan that will indicate the immediate needs as well as long term needs for teaching facilities and accommodation to facilitate the agreed numbers of students at the different sites.
   5. A financial model that will indicate the specific costing needed for the development of the decentralized CTPs.

4. Increased student numbers in the Community  Based Training in a Primary Health Care Model:

• Increased student numbers in the Cuban programme for 2014 should be absorbed by UKZN in 2015.
• UKZN agreed to a stepwise increased intake provided the resources that would have been allocated for the training of students in Cuba or a Cuban based model will be allocated to UKZN.
• The intake of students will be phased in to allow for the placement of clinical training for students that are currently trained in Cuba.
• Planning for the placement of the Cuban trained students when they return to South African should be included in all decentralize CTP planning.
• Specific immediate needs for the increase in student numbers have been identified.

5. Student Transformation:

• Current intake of students into all HCP programmes (except MBChB) is at 15% from Q1 and Q2 schools before the normal intake is undertaken.
• In the MBChB programme a total of 28% of first year entry students are admitted from Q1 and Q2 before the normal intake of students.
• Admission of additional students in the HCP programmes should be discussed and defined by a task team to make provision for intake from Q1 and Q2 schools as well as from specific, ideally rural/decentralized, regions/districts in the province.2. Mid-Level Workers and Specialized Nursing:

• In line with the NHI goals and the needs for implementation of the CBTPHCM the role of mid-level workers in the CBTPHCM will need to be defined and planned.
• The DoH has identified that there is a serious need to improve care for maternal and child health with one option being specialized training of HCPs in maternal and neonatal health.
• The SNPH will look into the option to introduce a coursework Masters programme for qualified nurses to become ‘Surgical Nurses’ and or specialized nurses in various disciplines.
• The development of a Masters programme is seen as a potentially quicker route to facilitate the training of specialized nurses for the needs in SA.

6. Registrar Training and Scholarships in KZN:

• It is proposed that a Scholarship/Grant Model be introduced for Registrar training in KZN.
• Registrars should be awarded a Scholarship/Grant in which the same principle rules that apply to undergraduate (UG) bursaries will apply.
• This will ensure that Registrars that take up scholarships will remain in KZN for service as Consultants.
• Details of the proposal and matters for clarification have been listed.4. Internship training in KZN:

• Current internship training does not always add value to the newly qualified HCPs.
• The training of interns will need to be formalized to ensure that both the needs and expectations of the KZN-DoH and UKZN are addressed.
• At the end of the internship training period the newly qualified HCP should comply with basic competencies that are defined by the HPCSA, DoH and UKZN.
• The definition of specific CPD during the term of community service for all newly qualified HCP need to be investigated and formalized.

7. Recommendations:

• Specific task teams need to be appointed to facilitate the implementation of the CBTPHCM.

8. Conclusion:

• It is important that this strategic document is implemented to ensure success of training and service delivery.
• The continued collaboration of UKZN and KZN-DoH will be key to determine the success of this approach to change the landscape of health care in KZN.

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Community Based Training in a Primary Health Care Model (CBTPHCM)

1. Preamble:

The province of KZN has the second highest population in South Africa at 19.83% (10.267 million) of the total population, after Gauteng which has a population of 23.71% (12.272 million).  It is understandable that the demand for the equitable access to relevant health care to the whole population of the province is a huge and demanding task even more so if one considers that the province contains vast rural areas away from large urban development.

Most Universities in South Africa that are involved in training of Health Care Professionals (HCP) do train for the country as a whole and unfortunately in many instances HCPs that are trained in SA actually leave the country to follow a career elsewhere in the world.  This actually contributes to the increased under-provision of HCPs in KZN.  The KZN-DoH is embarking on a staff audit which will clarify the real needs for provision of HCPs, but routinely collected data already indicates shortages in all categories of HCP except for Staff-Nurses and Assistant- Nurses.

There is general agreement that the training of HCP should align with the primary drivers for health in the province and with the NHI.  In the Province of KZN it has been agreed that a Primary Health Care (PHC) approach should be followed to ensure optimal health service delivery to all communities and all members of the population.  The Primary Health Care Curriculum (PHCC) is proposed to address service delivery and training of HCPs in the context of the re-engineering of PHC.  This requires that the PHCC will need to be implemented by the tertiary training institutions and at all sites for clinical training, necessitating the increase of training capacity, transformation of academic staff, transformation of the student body, the control and formalization of internship training, introduction of specialized training for mid-level career specific HCP, optimizing the training of Registrars/Specialists and the assurance that Continued Professional Development (CPD) is supported and provided in the PHC context.

The broad guidelines for the planning and implementation of a Community Based Training in a Primary Health Care Model (CBTPHCM) in KZN as a collaborative initiative between the KZN-DoH and UKZN are outlined in this document.  These guidelines are based on the resolutions of the Human Resources Commission of the recent Strategic Planning workshop held by the Department of Health, and on discussions between the College of Health Sciences at UKZN and representatives of the KZN Department of Health.  These discussions focused on the needs for alignment with the NHI, the implementation of a PHC approach, the need for increased numbers of HCPs, the substitution of training of HCP analogue to the Cuban programme for training of medical doctors and the Mozambican programme for training of ‘Surgical Nurses, the training of Registrars, the continued training need for interns and CPD.  It is proposed that several task teams are appointed to plan and implement the finer details of all the different components of the CBTPHHCM.

2. Primary Health Care Curriculum:

2.1  Re-engineering of Primary Health Care:

An integral part of the NHI strategy is re-engineering of PHC which serves as a suitable context for ensuring that the concepts and general understanding of the goals and specific outcomes of PHC are drivers for all role players in Health in KZN.  In order to ensure that PHC is implemented in the service delivery to the community and the training of HCPs is in line with the approach of the KZN-DoH and the NHI, this re-engineering should be a primary goal to ensure PHC is implemented in service delivery, training and planning for Health services.  CBTPHCM should include the service and training in primary health facilities such as clinics, community health centres, district hospitals and regional hospitals.

The UKZN is committed to promoting and training in primary health care principles.  The CHS has also embarked on a programme to develop and sustain a set of graduate competencies for all HCPs.  These competencies will prepare UKZN qualified HCP to cope with their workload as professionals, fulfil their role in the community and to become leaders in the community.

Curricula in the School of Health Sciences (SHS) and the School of Nursing and Public Health (SNPH) are supporting the basic principles of primary health care.  These curricula will be refined to ensure that all aspects defined and agreed to in mutual consultations will be included and are dealt with appropriately.  The SHS and SNPH will also ensure that clinical placement and training of students is in line with agreed basic principles of the CBTPHCM.  The DoH will in turn review the service delivery platform in facilities to make adequate provision for operationalising the reviewed training platform.

All three the Schools involved in the training of medical doctors are committed to develop the MBChB curriculum to address primary health care and to develop components that will enable students to be comprehensively conversant in the undergraduate programme in aspects of primary health care.  The School of Clinical Medicine (SCM) has already started with a process to refine the curriculum for clinical training.  The curriculum of six blocks throughout the clinical years has been revised and the old traditional modules of Internal Medicine, Surgery, Obstetrics and Gynaecology, Paediatrics, Psychiatry and Family Medicine have been replaced by the following newly defined integrated modules:

• Integrated Medicine
• Child Health
• Mental Health
• Integrated Surgical Practice
• Integrated Obstetrics and Gynaecology
• Integrated Primary CareThe general approach for a primary health care curriculum will be to present a basic clinical medicine curriculum with a strong PHC focus that will fulfil the training needs for MBChB while simultaneously providing students with the opportunity to specialize by way of selectives in which they can choose to do further primary health care, surgical care, family medicine and or any other specialization that has been developed and is presented with the aim of enhancing the training of medical doctors in SA and KZN.  The three schools will work together to develop these specialization fields and students will have to decide their relevant specialization field at an earlier stage of their studies (end of 3^rd year).  Within the College these specialization fields will be developed such that students can actually complete these selectives during their study time.  It is envisaged that the assessment of the students will include a formalized assessment of the selectives modules in their specific field of specialization.

The development of the Dentistry curriculum (BDS) is currently in process and the basic principles of CBTPHCM are applied in the planning of the curriculum and this will be further developed once clinical placement and training of BDS students commences.  It is envisaged that the clinical training of the BDS programme will take place in the community with a primary health care emphasis.  Current planning for the first intake of BDS students is for 2015, provided the approval of the BDS curriculum is concluded in time.

2.2  Research in Primary Health Care:

As the UKZN is a research-led university it is important to note that all curricula in the CHS will include research capacity development from undergraduate level to ensure evidence-based, context-specific clinical practice and service delivery in tandem with advancing the research ethos and drive in the College.  It has been proven that research activity is important for continued sustainability and relevance of training programmes.  In this regard research should be encouraged in the various disciplines as well as in teaching and learning (educational research).

Communities are rich sources of information that can influence the approach to health care and health practices.  When utilizing this information as basis for research the HCP can assist in optimizing health in the community.  In the PHCC students, HCPs and academics will learn from the practices in the community and these will drive community based research to improve the general understanding and implementation of CBTPHCM.  Evidence based research will direct the PHC research which will influence and support efficient planning of health care in the province.  The priority setting process of the KZN-DoH involve primarily “hands on”, district based health workers who will be capacitated to undertake the research they identified on their own in the community.  This will help to institutionalize research at the coal face, and this principle will apply to staff and students.  The research questions that students and staff identify at clinics and district hospitals may be very different from the questions they identify at higher levels of care, and will help to improve service delivery at the PHC level.  The research priorities from the DoH process will be widely available for staff and students to take up the questions, but students should be encouraged to also identify research questions for themselves.  In addition, the scaling up of student training and implementation of the CBTPHCM are themselves interesting areas for research.  The CBTPHCM should be evaluated over time, to allow for changes and modifications if necessary, whilst UKZN staff can use the provided opportunities to do research in Health Sciences education.

3. Decentralized Clinical Teaching Platforms for Training of all Health Science Professionals:

UKZN and the KZN-DoH are in a partnership in providing a clinical training platform (CTP) for training of Health Science Professionals (HSP).  Within the immediate Durban region there are some constraints in the provision of sufficient placements for students to ensure efficient clinical training.  The facilities at hospitals as well as the resources (including HR) may constrain the optimal utilization of the CTP.  With the increase in student enrolment, as already agreed in the enrollment plan of UKZN as well as the plan to increase student numbers even further to make provision for an intake of students that would have been send to Cuba, the CHS has to work in collaboration with the DoH to increase the capacity of the CTP.  The development of decentralized clinical training platforms that can accommodate between 50 to 150 or even more Health Sciences students is a mechanism for the clinical training of the increased student numbers.

In defining the CBTPHCM it is important to ensure that the concept of decentralized CTP in relation to CBTPHCM is unambiguous.  The decentralized CTP includes the training opportunities associated with health services delivered in clinics, district hospitals and regional hospitals.  Community based training using the clinics as a base will ensure the basic principles of health care is addressed in both training and service delivery as students should be exposed to all PHC principles in this context.  The pedagogic principles of PHC should apply and will need to feed back to the PHCC.  The successful training of PHC doctors in Cuba and the principles of the NHI in South Africa indicate that the training of a PHCC needs to start at clinic level.  The resource plans of the KZN-DoH and UKZN in terms of HR, governance, logistics and physical facilities will need to address the needs for training in the decentralized CTP.

In the SCM the increase in the number of students that were trained in medicine in Cuba add to the need for an expanded clinical training platform.  Cuban trained students currently join the MBChB programme for an additional 18 months of clinical training, which increases the requirement for clinical training placements.  It is furthermore also important to keep the recent increases in the numbers of Cuban trained students in mind as this will result in additional needs and tension on the placement of medical students for clinical training within the next 4-5 years.

The SCM has indicated that the ratio of human resources for the placement of students in a clinical discipline will be one specialist consultant, supervising three registrars and the combination of consultant and registrars supervising the clinical training of twelve students.  In terms of sustainability there is however general agreement that a minimum of three specialists need to be available per discipline in the decentralized CTP.  This will ensure sustainability if one specialist leave the service of the DoH and will allow time for replacement to ensure continued sustainability.  Three specialists per discipline will result in an increased number of registrars per CTP as well as an increased potential for student placement for training.

In general the number of placements in terms of the ratio will result in the clinical training at a CTP as follow:

• A CTP that can house all six discipline blocks will result in the total clinical training staff and students to consist of six specialist consultants, eighteen registrars and 72 MBChB students. With three specialists per discipline for sustainability, these numbers should actually triple, but it may be more realistic to double the total numbers as three is the optimal which will not be reached and maintained easily.

In decentralized CTP it is important to acknowledge that consultants have diverse roles which may include their clinical duties, administration, management, outreach activities and support and supervision of staff.  It is therefore important to ensure that the staffing plan of the KZN-DoH provide for the minimum number of consultants to assure sustainability of the decentralized CTP.  KZN-DoH and UKZN should plan the redeployment and future placement of human resources.  UKZN is committed to transformation of the staffing body to be representative of the demographics.  The CHS is in the process of implementing a staffing plan that will ensure the transformation of staff.

The planning of HR should indicate the potential for rural development in specific districts and indicate the benefits for the community at large.  An association of rural development with the training potential and academic input in that region will ensure sustainability.  It is further envisaged that the economies of scale when placing sufficient training staff in a CTP will have a positive impact on the economy, cultural and social activities in the community.  Apart from the planning of KZN-DoH and UKZN to increase staffing capacity and infrastructure development in the CTPs, the increased numbers of staff and students at rural facilities will passively have a positive impact on rural development.  This impact can be increased by consciously planning for this with other Departments such as Transport, Education, Sports and Recreation, Arts and Culture, etc.

In the whole scheme of clinical training, the number of other HCP (including mid-level workers and specialized nurses) will need to be determined according to HPCSA, SANC and SAPC-recommended staff:student ratios to optimize clinical training at decentralized CTPs.

3.1  PMB-complex as decentralized CTP:

The PMB complex involved currently in training of students includes Greys, Edendale, Northdale and Townhill Hospitals.  The placement of medical students in PMB to rotate through these hospitals occurred in the past and although medical students were not placed for clinical training in PMB during 2013, students will be placed in PMB again in 2014.  The current placement potential and proposal for the expansion of the clinical teaching platform is summarized as follow:

1. Ideally, students in the 5^th year of the MBChB programme will be placed from 2014 for the full year of clinical training in PMB.
2. In terms of the training capacity in the different disciplines in PMB, it is possible to place the complete fifth year group in PMB, but precluded by the limited housing capacity necessitating that additional housing for students be sourced.  In terms of available accommodation, the students that will be placed in PMB in 2014 will be housed in Denison Residence on the Golf Road Campus.  This residence can house 132 students.
3. Previous planning for placements of students has indicated that the PMB complex can accommodate the placement of 100 MBChB students in each of the clinical years, i.e. 300 students across the clinical years of training but this placement is currently hampered by the limited accommodation of students.  Placing of additional students will be contingent on the building or sourcing of sufficient student accommodation.
4. The SCM will work with the various discipline leaders to develop the clinical training capacity in PMB even further to accommodate more than the mentioned numbers.  Ideally this engagement should indicate the number of medical students who can be placed on the entire PMB clinical training platform and the duration of this placement.
5. The teaching platform should include further expansion of placement in Northdale, Edendale and Townhill Hospitals as well as more peripheral district hospitals that are part of the referral network.
6. The SHS and SNPH should identify the number of students in Health Science Professions other than Medicine that can be placed in PMB.
7. As both human resources and physical facilities are important for this planning, the CHS, KZN-DoH and the Hospital Managers need to evaluate existing facilities and plan for the expansion of facilities to provide both teaching venues and accommodation.
8. The planning should also include the expansion of the teaching platform to additional district hospitals and clinics in uMgungundlovu.

3.2  Ngwelezane/Lower Umfolozi as decentralized CTP:

There have been several discussions on additional decentralized CTPs.  In the definition of the CTP the UKZN, KZN-DoH, Hospital-, Community Health Centre – and Clinic Managers will have to assess suitability of the different clinics, centres and hospitals and discuss possible placement of students in terms of the clinical training potential within the PHCC.  UKZN in conjunction with KZN-DoH will determine which disciplines can be accommodated at the decentralized CTP.  The UKZN and KZN-DoH planning team will provide an overview of short term developments needed to facilitate clinical teaching of all HCP students.

The development of a CTP in the Ngwelezane/Lower Umfolozi Hospital complex has been discussed before and the complex of clinics and district hospitals in the Ngwelezane, uThukela and Umkhanyakude areas has been identified as favourable.  A number of the district hospitals in Umkhanyakude are already being used as placements for final year medical students and Bethesda Hospital is currently being set up as a decentralized family medicine training site.  Planning needs to be done to identify the clinics, community centres and hospitals that will be part of the CTP and to optimize the clinical disciplines and ensure that teaching facilities and accommodation are provided.  The KZN-DoH, SCM, SHS and SNPH will determine the optimal numbers of students in all HCP disciplines that can be accommodated here.  Student placement will be planned between the UKZN and KZN-DoH task team in line with the basic principles of the CBTPHCM.

3.3  Other decentralized CTPs:

The KZN-DoH and UKZN will need to investigate the development of additional decentralized CTPs in a phased approach.  The Newcastle/Madadeni area has been identified as a potential CTP.  As with the other decentralized CTP the KZN-DoH and UKZN will need to identify the clinics, community health centres and district hospitals that should be included in the CTP and plan the HR and logistics to ensure the sustainability of the CTP.

As there is a specific need for development of a CTP in the southern part of KZN the development of a CTP at Murchison was discussed before.  The CTP can include Port Shepstone as a regional hospital.  The MEPI programme of UKZN is developing facilities in collaboration with the discipline of Rural Medicine.  The CHS will obtain all relevant information on the site and if suitable and feasible plan the development of this site as a CTP in collaboration with MEPI and the KZN-DoH keeping in mind that the site should be able to accommodate and support the training of an optimal number of students.

3.4  Expected increase in clinical placement:

With the increase in placements at Northdale, Edendale and Townhill Hospitals as part of the CTP in PMB, it is expected that there can be a permanent clinical placement of well over 300 medical students in PMB.  With the placement of students in other CTPs the total clinical teaching placement for medical students can increase to more than 500.  The placement of students from the other Health Sciences programmes needs to be planned in collaboration with the KZN-DoH and the relevant Deans.

3.5  Expected outcomes from planning of decentralized training sites:

1. A CTP plan that will identify all the relevant clinics and hospitals that will form part of the CTP.
2. A staffing plan that will indicate the staffing needs to train the agreed number of students in all HSP discipline.
3. A teaching plan that will indicate the specific disciplines that will be taught as well as the level at which students should be taught in all the relevant CTPs.
4. An infrastructure plan that will indicate the immediate needs as well as long term needs for teaching facilities and accommodation to facilitate the agreed numbers of students at the different sites.
5. A financial model that will indicate the specific costing needed for the development of the decentralized CTPs.

4. Increased student numbers in the Community  Based Training in a Primary Health Care Model:

The recommendation of the Human Resource Commission at the 2013 KZN-DoH Strategic Planning workshop of 8 and 9 October proposed that the increase in student numbers in the Cuban programme for 2014 should be absorbed by UKZN in 2015.  UKZN agreed to a stepwise increased intake provided the resources that would have been allocated for the training of these students in Cuba or in a model based on the Cuban model will be allocated to UKZN.  The intake of students will be phased in to allow for the placement of clinical training for students that are currently trained in Cuba.   It is very important that planning for the placement of the Cuban trained students when they return to South African should be included in all decentralize CTP planning.

As the increase in student numbers will have an impact on HR and physical facilities, some of the immediate needs to be addressed by UKZN and KZN-DoH are the following:

1. Ensure that staff planning for lecturing, supervision and clinical training is done to fulfil the requirements for the increased student numbers.
2. Provide additional accommodation for students in the first three years of training as well as in years 4-6 when they will be placed in decentralized clinical training sites.
3. Plan and increase the basic training facilities for training of medical students in year 1-3.
4. Plan for the increase in student numbers over all HCP programmes to ensure the needs of the province can be addressed.
5. Identify and develop additional clinical training sites to accommodate the increased numbers of students both from UKZN and the Cuban trained students.

The increase in student numbers in all HCP disciplines and more specifically in medicine as identified, needs to be planned carefully to ensure the following:

1. Resources are available and distributed where the training needs are identified.
2. Those students who have completed the basic scientific based training can be absorbed in the CTP.
3. Students can be absorbed into the KZN health care facilities for internship training once the university based training has been completed.

5.   Student Transformation:

The CHS has already changed the intake of students to ensure that more students are taken from Quintile 1 and 2 schools.  In-line with the UKZN drive to increase the intake from Q1 and Q2 schools, a total of 15% of all first year entry students into all HCP (except MBChB) programmes are admitted from Q1 and Q2 schools before the normal intake is undertaken.  In the MBChB programme a total of 28% of first year entry students are admitted from Q1 and Q2 before the normal intake of students.  In the admissions from Q1 and Q2 schools the racial quotas of selection do not apply.

It is important to facilitate the transformation of the student body and to select students who will actually return to rural settings to provide health care in rural areas where there is a huge need for HCPs and leadership to enhance the health of these communities.  It is therefore proposed that the admission of additional students in the HCP programmes should be discussed and defined by a task team to make provision for intake from Q1 and Q2 schools as well as from specific, ideally rural/decentralized, regions/districts in the province.  As the applications for placement in all HCP programmes surpass the available places and the real intake can be increased by ten times with students who fulfil the minimum requirements, it is believed that the inclusion of geographical entrance criteria will not necessitate lowering of the academic entrance criteria and hence UKZN minimum entrance criteria for all disciplines will apply.

6. Mid-Level Workers and Specialized Nursing:

 In line with the NHI goals and the needs for implementation of the CBTPHCM there is a need to develop specific training that will address human resource shortages in specific disciplines and fulfil the community needs for PHC and the role of mid-level workers in the CBTPHCM will needs to be defined and planned.

In order to comply with the Millennium Development Goals (MDGS) for Health the DoH has identified that there is a serious need to improve the maternal and child health with one option being specialized training of HCPs in maternal and neonatal health.  In this regard a delegation from the KZN-DoH undertook a study tour to Mozambique to investigate and familiarize themselves with the specific model of ‘Surgical Nurses’ undertaking caesarians with relative high success.  Discussions between the CHS and the KZN-DoH during the Human Resources Commission of the recent Strategic Planning workshop of the KZN-DoH identified that there is a need for a specific specialized nurse to perform caesarian sections and care for mothers and babies to reduce mortalities.  It was also identified that there may be more specialized nurses needed such as Psychiatric Nurses, Paediatric Nurses, Geriatric Nurses, Neonatal Nurses, etc.

It was recommended that the SNPH will look into the option to introduce a coursework Masters programme for qualified nurses to become ‘Surgical Nurses’ and or specialized nurses in various disciplines.  Whilst this will provide the necessary training for specialized disciplines the Masters component will also stimulate research in the specific area and ensure the sustainability of the programme.  In the development of these specialization fields for the Nursing profession, the various needs of the population as identified by KZN-DoH will be addressed.  In the development of this programme the SNPH will need to collaborate with the DoH and the South African Nursing Council (SANC).  The development of a Masters programme is seen as a potentially quicker route to facilitate the training of specialized nurses, rather than accrediting a whole new cadre of health workers with the SANC.  Specialized nurses such as anaesthetic nurses – which are analogue to the proposed programme – are well known to the SANC and have worked successfully in the health care system in KZN.

7. Registrar Training and Scholarships in KZN:

7.1  Registrar training in KZN:

Registrars are postgraduate students, registered as such at a university, that undergo specialist training in one of the specialized fields of medicine or dentistry.  The required entry qualification is the MBChB or BDS degree or an equivalent of this. The minimum duration of training is 4 years for each of the disciplines as stipulated by the HPCSA.  The duration of training is currently being discussed as, in particular, the surgical disciplines include increasingly complicated techniques that may require a longer period of exposure as is already the case in many other countries.  During the 4 year of training, the students receive an academic education including research.  The number of training posts is controlled by the HPCSA which provides trainee identification numbers (N-numbers for UKZN).  The number of N-numbers per discipline depends on training capacity which is determined by the number of specialist consultants in that discipline.

At the end of the 4-year period, the student sits a final national examination which is organized by the College of Medicine of South Africa.  This examination tests practical skills and students that pass have shown mastery in the professional skills to practice in their respective disciplines.  They receive a specialist qualification and become a fellow of the specialist society in that discipline.  In addition, the student needs to hand in a dissertation that reports on a research project carried out during the 4 years of training.  This leads to the MMed or MDS qualification, awarded by the university at which the student is registered.

7.2 Funding and selection:

Funding of the registrar training programme is a joint effort between UKZN and the DoH.  Whilst both institutions provide the staff for training, the KZN-DoH provides the training platform and the University provides learning tools like libraries, internet access, research supervision and research-related capacity development as well as academic forums for discussions.  Personal funding for the students is provided by the DoH in the form of a salary.  This means that they are appointed as full-time DoH employees.  In return, the registrars contribute, through their in-service training to the service delivery in the provincial DoH.

The process of selection of students into the training programme went through two phases. Initially, the Professor and Head of Department, who had a joint appointment between the University and the provincial DoH, had the authority to select suitable students from the pool of applicants.  He/she did this with or without the assistance of senior members of his/her department’s faculty.  This undemocratic process was changed several years ago to a system in which a committee of senior managers of the provincial DoH together with representatives of the academic staff of the University made the selections. The DoH input was deemed relevant since registrars are DoH employees.

7.3  Throughput Challenges:

Most registrars complete their training in the set minimum period of 4 years.  Problems arise when that is not the case.  Then a poorly performing student/employee is blocking the post for a new trainee.  Not only because of the funding but also because he/she occupies one of the HPCSA approved training posts in the discipline concerned.

7.4  Proposal for a Scholarship/Grant Model:

Provided the funding that is channeled to KZN-DoH for the training of registrars permits, it is proposed that Registrars should be awarded a Scholarship/Grant in which the same principle rules that apply to undergraduate (UG) bursaries will apply.  This will ensure that Registrars that take up scholarships will remain in KZN for service as Consultants.

The Scholarship/Grant Model consists of the following:

1. Registrars in KZN will be registered students at UKZN but are no longer appointed as employees of the provincial DOH.
2. UKZN selects the students as for any other postgraduate students according to pre-determined selection criteria formulated jointly by UKZN and the KZN DoH with due consideration to equity and transformation.
3. The student then applies for a scholarship from the province if he/she so wishes.
   1. This scholarship will be provided on an annual basis for a maximum of four years and will be the equivalent of the salary earned by current employed registrars.
   2. Registrars need to commit themselves to public service of two years after completion of the qualification.
   3. During this public service the qualified registrar can be placed at any hospital in UKZN in agreement with a joint committee of UKZN and KZN-DoH and may be requested to rotate through different hospitals to facilitate placement at rural hospitals.
   4. Scholarships will only be renewed if there is a positive progress report received from UKZN.  The provision of the scholarship should be described in a MOA
   5. The MOA should include the rules for scholarship, the requirement for fulfilling the scholarship and will need to be legally approved by the UKZN and KZN-DoH.
   6. The proposed system does not change the financial obligations of the KZN-DOH or UKZN towards the student and the student’s income does not change either.  There may be a tax benefit for the DoH.
   7. The advantage of the proposal is that the training post becomes available for another applicant if the student’s progress and performance are inadequate.
   8. To guarantee transparency and the possibility to appeal, UKZN needs to develop a system for annual assessment of registrar performance in each discipline.

If the funding that is provided for the training of registrars have limitations that will not allow the implementation of the above mentioned scholarship proposal, then the KZN-DoH and UKZN will collaborate to define a very specific Job Profile for registrars that will address all the teaching, training, service delivery, supervision and academic needs of the specific training position.

7.5  Matters to be clarified for the Scholarship/Grant Model:

1. Medical insurance and professional indemnity for students – will this be included from UKZN?
2. Responsibility in hospitals where training takes place should be within DoH.
3. UKZN and KZN-DoH should engage in writing an overall MOA.
4. Define the specific criteria for the scholarship/grant and how this will be handled by both UKZN and KZN-DoH.
5. Clarify the legal aspects wrt rosters, employment, amounts, etc.
6. Look into the provision of a bursary and employment of registrars in ‘sessional appointments’ with KZN-DoH.  This will address the service needs in KZN-DoH whilst ensuring optimal placement for training.  An agreement will need to ensure accountability for sessional work as well as progress of students (Progression rules and sessional responsibility will need to be defined.  Sessional appointments will have to optimize training needs and service needs for training).
7. Investigate the utilization of commuted overtime as an ‘incentive’ for KZN-DoH JME staff to fulfill the supervisor role for registrars in decentralized or remote hospitals.  All staff to be required to do ‘outreach’ overtime, whilst planning of placement will be done in collaboration of UKZN and KZN-DoH.

8. Internship training in KZN:

Interns are junior HCPs that have just qualified from university and need to undergo continued clinical training under supervision to prepare them to function independently as HCP.  The minimum duration of training as an intern may vary and it is important to implement a basic core competency plan for the training of interns.  In many instances the current internship training does not add value to the newly qualified HCPs.  The training of interns will need to be formalized to ensure that both the needs and expectations of the KZN-DoH and UKZN are addressed.

At the end of the internship training period the newly qualified HCP should comply with basic competencies that are defined by the HPCSA, DoH and UKZN.

The definition of specific CPD during the term of community service for all newly qualified HCP needs to be investigated and formalized.

9. Recommendations:

9.1    Primary Health Care Curriculum

The UKZN and KZN-DoH ensure that all curricula are inline and addressing PHC.

(Re-engineering of PHC, Developing and improving of PHCC, ensuring that research is PHC orientated).

Task team:           Profs Slotow, Hift, Ncama, Essack, Daniels, Sturm, Dr Mazizi, Mr Zungu, Dr Lutge, Ms Snyman.

9.2  Decentralized Clinical Teaching Sites for Training of all Health Science Professionals

UKZN and the KZN-DoH form a task team that is responsible for planning, development and implementation.

(Immediate expansion of CTP in PMB, development of CTP at Ngwelezane/Umkhanyakude, development of other CTPs)

Core Task Team: Profs Slotow, Hift, Ncama, Essack, Daniels, Sturm, Botha, Dr Mazizi, Mr Zungu, Dr Lutge, Ms Snyman, Dr B Gaede.

Sub task teams will be formed where applicable.

9.3  Increased student numbers in the Community  Based Training in a Primary Health Care Model

UKZN and KZN-DoH need to plan the increase in student numbers and resources needed.

(Increase in numbers at UKZN, accommodation of Cuban trained students in CTPs)

Core Task Team:  Profs Slotow, Hift, Ncama, Essack, Daniels, Sturm, Botha, Dr Mazizi, Mr Zungu, Mr Govender, Ms Snyman, Mrs Mthembu.

9.4  Student Transformation

UKZN and KZN-DoH to plan and implement selection criteria for admission of students.

Core Task Team:  Profs Slotow, Hift, Ncama, Essack, Daniels, Sturm, Botha, Dr Mazizi, Mr Zungu, Mrs Mthembu.

9.5  Mid Level Workers and Specialized Nursing

UKZN will look into the option to introduce a coursework Masters programme for qualified nurses to become ‘Surgical Nurses’ and or specialized nurses in various disciplines.

Core Task Team: Profs Slotow, Hift, Ncama, Essack, Daniels, Sturm, Dr Mazizi, Mr Zungu.

9.6  Registrar Training and Scholarships in KZN

a. Provided that funding that is channeled to KZN-DoH for the training of registrars permits, the scholarship model should be further refined and implemented.

b.  If the funding that is provided for the training of registrars has limitations that will not allow the implementation of the proposal, then the KZN-DoH and UKZN will collaborate to define a very specific Job Profile for registrars that will address all the teaching, training, service delivery, supervision and academic needs of the specific training position.

Core Task Team:  Profs Slotow, Hift, Ncama, Essack, Daniels, Sturm, Botha, Dr Mazizi, Mr Zungu, Dr Simelane, Mrs Mthembu.

9.7    Internship training in KZN

UKZN and KZN-DoH will formalize internship training to ensure that both the needs and expectations of the KZN-DoH and UKZN are addressed in line with basic competencies that is defined by the HPCSA, DoH and UKZN.

Core Task Team: Profs Slotow, Hift, Ncama, Essack, Daniels, Sturm, Dr Mazizi, Mr Zungu.

Conclusion:

This document present a summary of activities that will advance the teaching and service delivery of Health Services in KZN towards fulfilling the healthcare needs of the province whilst ensuring that training and service delivery is optimized and maintained at a high standard.  It is based on the resolutions of the HR Commission at the Department’s recent Strategic Planning workshop, and discussions between the College of Health Sciences at UKZN and representatives of the KZN Department of Health. The proposed activities are aimed at creating economies of scale and creating platforms that will address and ensure the long term sustainability and efficiency of health care training and service delivery in KZN.  It is important that this strategic document is implemented to ensure success of training and service delivery.  The continued collaboration of UKZN and KZN-DoH will be key to determine the success of this approach to change the landscape of health care in KZN.

Document compiled by:

Prof SJ Botha – DPS, CHS, UKZN

Prof WA Sturm – Consultant, KZN-DoH

Document discussed and edited by a work group after attending a meeting between UKZN, CHS and KZN-DoH which was held in the DVC Boardroom, Desmond Clarence Building, Howard College Campus, UKZN on Friday 25 October 2013 at 08:00, which was attended by:

1. Prof SJ Botha
2. Prof AW Sturm
3. Prof R Slotow
4. Dr B Gaede
5. Ms E Snyman
6. Dr E Lutge