It is well known that South Africa doesn’t have enough doctors. What is less well known is that it is not producing enough medical sub-specialists in fields such as fertility and cardiology, among others.
Candice Bailey spoke to Miemie Struwig, Paul Dalmeyer and Theunis Kruger to unpack why this is the case and what can be done about it.
1. What’s the problem?
South Africa is not training enough medical sub-specialists. Medical sub-speciality takes place in a particular field after a general specialisation and can take another two to three years of training.
This means that a practising specialist has to leave their practice and monthly income to work for the state as a trainee until they are fully qualified in their sub-speciality.
While lawyers and accountants are mainly trained in the private sector after they complete their basic degrees, medical training is only done in the public sector. This includes medical sub-speciality training.
The second problem is that the Health Professions Council of South Africa decides which academic units should be allocated sub-specialist posts to train each year. The limited number of sub-specialists being trained does not meet the country’s current requirements. This is acute in several sub-specialist disciplines.
2. You have a solution. What is it?
Although the onus for training sub-specialists rests on the public sector, it does not have the capacity and the resources to train them. One way out of this problem would be to open up the process to a public-private partnership. This would remove the government as the sole financier of this expensive training. The outcome would be that more sub-specialists could be trained each year.
But to go down this route requires a paradigm shift on a number of fronts. This includes:
Changing the way institutions are chosen and allocated medical sub-specialists training status which includes the private sector.
The current council should become more inclusive, involving the present public training institutions and sub-speciality represented bodies. For example, the Southern African Society of Reproductive Medicine and Gynaecological Endoscopy, as well the South African Menopause Society – both subgroups of the South African Society of Obstetricians and Gynaecologist – understand the needs in their particular fields. Because they are closest to their members they should be allowed to play a more active role in deciding on the allocation of training numbers.
Sub-specialist societies can also play an integral role in accrediting distant learning sites along with the academic institutions.
3. How do you know this approach would be viable?
We created a business model as part of an academic research project, which will be published later this year, to test whether the trial model could be implemented in a wider context in South Africa. The two key components of the model dealt with training and finance.
On the training front, the model allowed the trainee sub-specialist to chose their area of specialisation in the area in which they were practising. This enabled them to continue earning while doing their sub-specialist training.
The hurdles that needed to be overcome to get this to work included:
The development of a curriculum. Here academic institutions developed the curriculum for reproductive medicine as a sub-speciality. It was accepted by the Colleges of Medicine South Africa, and registered by the council.
Academic capacity. This continues to be a challenge but distance learning alleviates the problem.
Acquiring appropriate funding. Funding required lateral thinking and involved seed funding from the private sector.
Accepting and accrediting a decentralised training facility. The Southern African Society of Reproductive Medicine and Gynaecological Endoscopy accredited the decentralised training facilities. This meant trainee sub-specialists could be enrolled on a four-year program, working in their home practice environment for three weeks in a month, attached to an accredited unit, and the last week in an academic institution.
Registering the fellowship with the Health Professions Council of South Africa.
By the end of the trial period, three sub-specialists completed the program as decentralised trainees. The trainees were self-funded but also received funding raised from the private sector.
4. What other developing countries do this? And how successful are they?
Sub-specialist education is not the primary focus of the state medical education. It is understandable that with the shortage of doctors, the state’s focus is on training general practitioners and general specialists. It is in this space that a public-private partnership model can fill an enormous gap. It can help the state produce sub-specialists while relieving the financial burden.
This educational model is practised successfully by certain states in the US, EU and India, wherever there is a lack of capacity. Contrary to expectations, outcomes of the trainees in the private sector is superior to those in the state due to exposure to a more balanced disease profile.
Sub-specialist education is important for another reason too in a developing country like South Africa. It sets the standard of medical education from undergraduate education to the highest level of education in a specific sub-speciality.
5. Is there a way of implementing your solution?
We are in discussions with the Department of Health. We are very optimistic that the suggested private public partnership can be achieved.