In July 2018 some 720 South African medical students will return from Cuba where they have completed five years of their medical training. They will complete their 6th year at medical schools in South Africa and will then be posted to communities across the country.
Dr Khanyisa Makamba, the head of urology at the Port Elizabeth Provincial Hospital, was among the first of several cohorts of South African medical students to be trained in Cuba. He was in Cuba from 1998 to 2003. He then completed his training in South Africa and went on to specialise in urology here. He could practise anywhere in the world but chose to use his skills in his home province to help the vast number of public sector patients who cannot afford private medical care.
These patients will be the direct beneficiaries of National Health Insurance and the comprehensive model of health care that Health Minister Aaron Motsoaledi spoke about last week.
Makamba explains that in Cuba “medical students are trained according to a comprehensive, four pillar model. That is, not only with a curative or treatment emphasis, which is the main approach to training in South Africa, but with an equal emphasis on health promotion, disease prevention, treatment and rehabilitative medicine.”
Makamba’s group of 40 South African medical students were trained in different medical schools throughout Cuba, including La Habana University Medical School, the University of Sancti Spiritus and the Medical University of Villa Clara in Santa Clara where Makamba was trained. “The system produces a high number of comprehensive or specialist family physicians, trained to practise in diverse communities from the cities to the deep rural areas. I was raised in rural Tsolo in the Eastern Cape so I am familiar with city and rural environments,” says Makamba.
On arriving in Cuba, before starting their degree, they spent the first six months learning Spanish: “Medicine is a very difficult career per se and in a foreign language it becomes a double effort, you need to study that much harder and you need to spend more time getting yourself through,” Makamba explains. “What really helped a lot is the warmth of the Cubans, including the academics. They went out of their way to assist us and make us feel at home.”
Coming back as a Cuban-trained student he explains, they experienced the opposite treatment, and one that he impresses on all South African medical schools not to repeat with the July returnees. “There was a lot of discrimination and looking down upon us, as the attitude in several of the medical schools was that the South African medical training and health system is better than Cuba’s, which is not the case. What they offer is a more holistic approach to health care,” Makamba explains.
“From my group, several have become specialists, others are GPs, and most are in senior positions in the public health system in South Africa. It’s over 1000 of us now, which speaks to the success of the initiative, which will be even more successful when the current cohorts come back. And which is why, when the Executive Dean of Health Sciences at Nelson Mandela University, Professsor Lungile Pepeta, asked me to assist with the integration of 40 students from the current group of Cuban-trained students, in collaboration with Walter Sisulu University, it was the quickest ‘yes’ I have ever said.
“South Africa’s Cuban-trained doctors will form about one-third of all doctors in the public sector here and therefore it is very important that their integration is done correctly and with caring hands,” says Makamba. “They will not only help us to staff our hospitals and boost our primary health care sector where there is a huge need, they will also learn to deal with trauma patients and emergencies.”
Nelson Mandela University is set to open South Africa’s 10th Medical School in 2020, in Port Elizabeth, when it will offer the full MBChB, from first year to graduation.
“With National Health Insurance in the wings, we had to look at progressive health system models, such as Cuba’s,” says Pepeta who, together with his team at Nelson Mandela University, has developed a four-pillar model of medical training for the new medical school curriculum.
“While South Africa is well recognised for training world class health care practitioners and it is important to maintain our high standards, at the same time we need to introduce new population-wide approaches to health. Cuba’s health system model is working,” says Pepeta who visited Cuba with Makamba in 2017 to view the medical training facilities across the country.
“As a paediatric cardiologist and health sciences academic, I was skeptical about the four pillar approach until I visited Cuba last year and the penny dropped as to the appropriateness of comprehensive medical training for the needs of the majority of people in our country. The efficiency and professionalism of their system speaks for itself in Cuba’s health statistics: life expectancy in Cuba for the population is superb at about ±80years while ours stands at ±60 years; infant mortality is 2 per 1000; ours is soaring at 30 – 40 per 1000.”
Pepeta adds that in Cuba, 80% of medical practitioners are specialist family physicians and only 20% are specialists in other areas of medicine or are super specialists. In South Africa, it is the reverse, with many in private practice or emigrating overseas. Cuba currently has eight medical practitioners per 1000 population while most westernised countries have two to three per 1000. South Africa has 0.77 per 1000, with 50% of the 0.77 practising in the private sector.
If our health system is judged according to the World Health Organisation results then, then it paints a very different picture; one in which our results are very poor compared to Cuba.
“The death rate in that country is currently seven per 1000,” Pepeta explains. “Brazil implemented the Cuban system in the early 2000s and their death rate dropped from 9.5 per 1000 to 6 per 1000 in one year (between 2002 and 2003). They now have a better life rate than the United Kingdom and the United States at ±9 deaths per 1000. Our death rate is currently 17 per 1000, except for the 16% of our population on private medical aids, whose life expectancy is comparable to the West.
“How much is Cuba spending on health? Per capita they are spending US$500 per year, while South Africa spends US$1000 per capita per year. The US spend is ±US$3000 per capita and other first world countries are between US$1000 and 3000. In terms of the GDP, the majority of countries spend between 10 and 15% on health, with the US at 15%. South Africa spends 8% and a mere 4% of this is spent on 84% of the population that is without private medical aid. The private medical aid industry has a R160 billion turnover per year in South Africa, and this is spent on only 16% of the population.”
How did they get it right? Home-based care and local clinics are efficiently aligned to polyclinics or what we call community health centres. Every polyclinic has as a basic minimum a comprehensive or specialist family physician-nurse team, and a range of health professionals, as well as necessary equipment, including x-ray machines, certain laboratory facilities and ultrasound. Every polyclinic has a section of complementary medicine, including acupuncture, homeopathy and traditional medicine, and each patient is advised on the relative merits.
These are efficiently matched with secondary hospitals (district, regional and tertiary hospitals in South Africa) and national institutes that specialise in specific diseases, such as neurological, heart and lung diseases, oncology and urology. There are similarities between the structure of the Cuban public health system and our system, but there are also stark differences, notably in Cuba’s far superior level of efficiency, professionalism, staffing, equipment and national emphasis on the four levels of care.
To address all four levels, the entire health team plays a key role, starting at the community level where it is the role of the community health worker to visit each and every individual in their area and to ensure that every individual goes for medical check-up at least once a year, and to identify any health issues and why, for example, they have not gone to the clinic for their regular check-up.
The Cuban community health workers know each individual personally; one community health worker looks after about 50 people in their community, and they know every single person’s health status, disease status, medication, the names of the pills, and whether they are running out. They educate the patients about their health, their disease condition and the medication they are taking. They work with a team of health professionals, from doctors to physiotherapists to psychologists to dieticians to focus on all four levels of care.
A new vision of comprehensive national health care within the constraints of the national health budget has to include health promotion and disease prevention strategies that focus on maternal and child health and on the escalation of chronic Non-Communicable Diseases (NCDs), many of which can be prevented or managed.
NCDs include hypertension, other heart disease, diabetes, asthma, obesity, epilepsy and mental health issues. These are the far less publicised than communicable diseases like HIV/AIDS and TB, but they are killing the population. The myth is that these are the ‘rich man’s disease’ but evidence-based research shows that there is an epidemic increase in NCDs throughout the population in South Africa, which also has a high burden of HIV/AIDS and Communicable Diseases, and a high level of violence and related injuries.
Research by PRICELESS SA (Priority Cost Effective Lessons for System Strengthening in SA), a research unit based at the Wits University’s School of Public Health in Johannesburg, shows that South Africa can achieve a better return from the public health spend.
This includes increasingly targeting preventive health measures and addressing issues like water, sanitation and household air pollution from the use of fuels like coal for cooking, while promoting healthy lifestyles and choices of food. We must make sure that we do not bombard our population with aggressive marketing of junk foods and sugar-laden beverages, and that we help people to understand why too much salt and sugar is a health risk.
PRICELESS presented research-based recommendations to inform the 2016 regulations that addressed the salt content in ‘government issue’ bread and processed foods, including the health-related cost savings, including the number of lives that could be saved from strokes by reducing the salt content in bread alone. This was one of the key aspects of the ministerial decision to regulate salt in food in South Africa in 2016 and 2019 – a first for sub-Saharan Africa.
PRICELESS research showed that the direct costs of hospitalisation from strokes alone are ZAR 3 million annually, and that South Africa could save 6400 (4300 of them non-fatal) lives from strokes by decreasing salt in bread by 0.85 grams/slice.
“As a nation we have to start looking after the health of 85% of the population in far more comprehensive, holistic ways, and I believe that the four pillar system is the best population-wide and budget spend approach,” says Pepeta. “We should therefore embrace the medical students when they come home from Cuba and ensure they get the best possible reintegration assistance into our medical schools throughout South Africa. There is so much more we can do to improve population health, quality of life and length of life in South Africa, and these students can help us achieve it. Dr Makamba is a shining example of this, and while there is so much we need to achieve to get our health system functioning properly ahead of NHI, we need to acknowledge our students and all those contributing their expertise to public health and health sciences training in this country.”
