MEDICAL EDUCATION AND TRAINING IN THE SOUTH AFRICAN CONTEXT

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CHAPTER3 MEDICAL EDUCATION AND TRAINING IN THE SOUTH AFRICAN CONTEXT

INTRODUCTION

The evolving public higher education system in South Africa has been described by Frans van Vught, the former director of the Centre for Higher Education Policy Studies (CHEPS) and the current rector of the University of Twente, as  »probably the most ambitious and comprehensive change programme in the world today. » The changes since 1994 have been comprehensive, dramatic and rapid. They have included a changed policy framework, namely the National Plan on Higher Education (DoE 2001a), a National Qualifications Framework (NQF), a new planning approach for HEis and a proposed new funding formula (Cloete et. al. 1999:2.2).
There is evidence of a strong interventionist approach by government to regulate the size and shape of the higher education system in the pronouncements in the NPHE for merging institutions, amidst clallns that such decreed changes are aimed at improving equity, efficiency, effectiveness and quality of the higher education system (DoE 2001a:56-57). According to the Citizen, « South African universities have to manage an almost impossible set of forces – a :financial squeeze; calls for transformation and the demand for quality » (1999:12).
Medical schools are located within eight universities – three previously Afrikaans medium HAis, three English medium HAis and two HDis. The training of medical doctors is also strongly influenced by the goals and resources of the DoH (DoH n.d.: 17). The contextual realities, complexities and tensions in medical schools are in some ways similar but in most instances significantly different to those faced by other faculties and programmes in universities. The aim of this chapter is to explore these realities, complexities and tensions within the broader national and institutional policy frameworks, shifts and trends. This is therefore a fairly comprehensive and detailed expose of the history, legislation and statistical shifts and trends in medical education and training in relation to the broader institutional contexts within higher education, aimed at establishing a more in-depth and common understanding of the nature of the issues that need to be considered in managing equity in medical schools.
There is also a lack of empirical data assembled in a single study that would provide a holistic understanding of equity issues in medical schools in relation to equity issues in the broader higher education context. Baseline equity data presented in this chapter is discipline and institution-specific, and may be of use in monitoring equity in medical schools within the different universities.
Understanding the reasons for dominance of particular discourses in equity debates in medical education and training, and the relative silence on others, or the difficulty to draw the links necessary to address equity in medical schools in an integrated and holistic manner in policy, operational and functional frameworks is explored in terms of the unique dynamics and challenges in managing equity in medical schools.
This chapter begins with a discussion of the historical and legislative context of higher education, with specific reference to medical education and training within different institutional types. This includes a literature review, and the primary focus is on the period from 1994, marking the first democratic election. Comparison of the shifts and trends in students and staff profiles in universities and their medical schools, based on previous investigations is presented and in some instances statistics from 1988 are used as a baseline for comparative purposes. In most cases, comparisons are drawn between African and White profiles as they represent the extremities on the equity continuum to provide an indication of the extent of the inequities that require redress.

HISTORICAL LEGACY

Any discussion on equity needs to be finnly rooted in a general and specific historical context. In this section, a brief overview is provided of the historic shaping of higher education in South Africa, with emphasis on the establishment and :functioning of HDls and HAis and, within this overview, the particular development in terms of equity in medical education and training. The purpose of this discussion is to establish some understanding of the nature and severity of the social inequities that need to be managed in the field of medicine.
The fubric of South African society and the quality of life for its people have been shaped by and are linked to the legacy of apartheid, patriarchy and capitalism. Historically, the opportunities available to the citizens of South Africa have been directly related to their individual positioning in terms of variables such as race, class, gender, disability, geographic location, marital status and sexual orientation. These interacting variables determine to a large extent every fucet of an individual’s social existence. A result of apartheid was that the White minority was privileged in all aspects of social existence, such as access to housing, employment, water, electricity, land ownership, and of particular relevance to this study, access to education – including higher education and training to become medical doctors (Turaki 1992:3).
However, although apartheid has been a severe and primary cause of inequity for the majority of the population of South Africa, the causes of social inequities as they currently prevail cannot be reduced to apartheid (Kallaway 1984; Collins1992). Apartheid has exacerbated other causes of inequity such as patriarchy and capitalism Further, prejudice about differences such as disability, language and sexual orientation contnbutes to social inequities. While the consequences of apartheid have been rendered visible through articulation in many policies, studies and debates, the impact of patriarchy in a multicultural, apartheid society has received less attention and there is relative silence on the issue of disability (Howell 2001:12; Naidoo et.al.2001 :52-53).
Stereotypes, prejudice and discrimination based on individual and group differences are both overt and covert, but a seriously neglected factor in equity analysis is that of socio-economic class, as manifested for example, in the urban-rural divide (Piper 1981 :18-20). Material conditions, such as the availability of laboratories in schools, qualified Mathematics and Science teachers and poverty, are among the primary factors influencing access and academic success in higher education of students from rural communities (Arnott & Kubheka 1997). Other important equity issues, such as disability, access of mature learners and recognition of prior learning (RPL), are yet to be included seriously on the transformation agenda.
This study incorporates race, gender and class as integrated and intersecting variables in the investigation of equity in medical schools within universities and, by means of statistics, provides an indication of the severe impact of historical factors on current inequities in higher education.

Historical shaping of higher education

Restricted access of Blacks to higher education generally is one of the primary reasons for current inequities, particularly in the staff profiles of HEis (cf. Tables 3.19-3.24), as education was used as a repressive tool to perpetuate inferiority of Blacks in accordance with the ideology of apartheid. Prior to the promulgation of the Extension of University Education Act 45 of 1959 (S.A.1959a), Blacks on academic merit were admitted to study at the Universities of Cape Town, Witwatersrand and Natal and through correspondence at UNISA, but Black enrolment never exceeded more than 5% of the total enrolment at any of these institutions (NUSAS 1954; Beale 1994:2). For example, Africans, while constituting 67% of the population in 1955, constituted only 2.3% of the higher education population (Beale 1994:54). Kgoale (1968:29) points out that due to the low number of Black students who matriculated and because of the high fees charged by the open universities, few students enrolled at these institutions where classes were at times racially segregated, such as at Natal, while others, such as Rhodes University admitted Black students only to postgraduate courses not available at Fort Hare (Horrell 1968:121).
After the Extension of University Education Act No.45 of 1959 (S.A.1959a) and the Fort Hare Transfer Act No. 64 of 1959 (S.A. 1959b) were passed, Blacks were no longer, without ministerial consent, admitted to Wits, UCT and Natal, and such consent was very difficult to obtain (Kgoale 1982:6). For example, of 120 applications to study at these universities in 1960, only two students were granted permission (Horrell 1968:115). The increase in the enrolment of Blacks in former White universities has been slow, for example, at UCT in 1970 there was only one African student out of a total enrolment of 7 575 and only 71 African students in 1980 out of a total enrolment of 10 383 (Pavlich & Orkin 1993:1-5). Access of Blacks to higher education began to increase with the establishment of the HDis but opportunities were still inequitable.
Bunting (1994:39) describes how by 1991 there were eight technikons and 11 universities for Whites, one technikon and one university each for Indians and Coloureds, and one technikon and four universities for Africans. Statistics for the total higher education enrolments, as a proportion of the population in 1991, in the age group 18 to 22, clearly demonstrate the inequities. The student population of higher education comprised 60% Whites, 33% Indians, 11 % Coloureds and only 9% Africans. Statistics for the TBVC states were excluded, but if they were included, the figure for Africans would have dropped to about six percent.
The inferior schooling received by the majority of Black pupils was, and continues to be, a major fuctor for the low increase of African students into HEis. This is due to various reasons, such as the racially based disparate expenditure prior to 1994. While Africans constituted 66.290/o of the total population in 1960, only 2.07% of the total budget was spent on African schooling (Beale 1994:94). The severity of the inequities may be gauged from the unequal per capita expenditure, which in 1971/2 was R366 per White primary school child and R20.64 per African child, and that the percentage of under-qualified teachers in White schools was zero whereas 52% of African teachers were under-qualified (Pavlich & Orkin 1993: 1-3).
Inferior formal schooling for the majority of the population continues to affect opportunities for Blacks to enter higher education Blankley (1994:54) points out that only 27 of every 10 000 African learners who entered the school system in 1993 attained a matriculation exemption, a university pre-requisite for study for undergraduate degrees. Consideration of the fuct that only a proportion of these 27 students had the required entry grades in Mathematics and Science for admission into an MBChB programme provides some understanding of the low participation rates of African students in medical schools in 1994.
Recent statistical overviews examining the participation rates of students and staff in higher education are provided by Cloete & Bunting (2000). This study shows the decrease in student emolments from 1998, decline in the number of students obtaining a full matriculation exemption since 1994, an apparent decrease in retention rates and some understanding of the gender inequities in higher education. Of the 98 500 students who obtained a Senior Certificate with endorsement in 1997, that would make them eligible to study at university, 48 000 were male and 50 500 were female. 15 000 male and 11 500 female students passed Mathematics on the higher grade, and 12 000 female, compared to 17 000 male students, passed Physical Science on the higher grade. Although a larger number of female than male students obtained an exemption pass in the matriculation examination, fewer female than male students obtained higher grade passes in Mathematics and Science necessary for admission into MBChB programmes. It would have been useful to have this data disaggregated by race.
However, any discussion on the participation of women in higher education and in particular programmes needs to incorporate the differing patriarchal and cultural attitudes and gender stereotypes associated with educating girls. Meer (1990:90) describes the more intense patriarchal domination among Indian and Coloured communities. There appears a greater reluctance among Blacks to sending their daughters away from home to study and, where finances are limited, sons are often given preference over daughters to study (Pahliney 1991 :46).
Entry-level competencies of those applying for entry into higher education programmes are affected by a variety of other factors, such as cultural capital and the availability of role models, and are negatively influenced by factors, including the availability of facilities such as water, electricity, laboratories and qualified teachers. Arnott & Kubheka (1997) found that in 1997 only 19% of Mathematics teachers and 16% of Science teachers nationwide had one or more years of university education in the fields they were teaching. However, the attrition rate of those students deemed by HEis to have the entry-level competencies is excessively high.
According to Pretorius (2000:15), at least 100 000 students drop out of higher education each year and institutions have poor throughput rates (70% or below) and poor graduation rates (15% or below). It indicates a concern of the CHE that institutions need to become accountable to taxpayers for the R6- billion that the government spent on higher education in 1999, and that they have to answer to the parents who spend their hard-earned money on tuition fees, only to see their children fail, drop out or leave unqualified for the jobs that the economy demands.

Historical shaping of medical education and training

The extent and nature of the current inequities in medical education and training in South Africa are a direct result of the historic legacy of apartheid and prevailing traditions, assumptions and stereotypes. A few examples are cited to demonstrate the severity and pervasiveness of historic discrimination due to apartheid, as well as the resistance offered to oppressive apartheid policies and actions.
The first time that a White student could qualify as a medical doctor in South Africa was in 1920 when the University of Cape Town had sufficient facilities and qualified staff to offer a complete MBChB degree that was recognised by universities and the Royal Colleges in the United Kingdom (SAMJ 1979:864). In 1922, the late Dr. J.B. McCord and Dr. Alan B. Taylor started a private school in Durban for the training of African male doctors, but as the authorities were not prepared to recognise a qualification perceived as inferior, this initiative was abandoned (Gordon 1957:5). Although Black students had limited access to open universities, they could not train as medical doctors. For example, Black students could not be admitted to study medicine at UCT as the provincial hospitals used for clinical training were for White patients (NUSAS 1957:13). It was only in 1951 when the medical school of the University of Natal that admits primarily Black students opened, with an enrolment of 35 students, that Black students had access to medical education and training (Gordon 1957: 8). This contributes significantly to the skewed profile of medical practitioners in South Africa (c£ Table 3.27).
After the establishment of the medical school at Natal, the five scholarships offered to Black medical students that covered their fees and living expenses at the University of Witwatersrand were terminated. According to Kgoale (1982), the intention of the move to terminate the five scholarships at Wits and to increase them to 15 at Natal, was to decrease the number of Black students at mixed classes at Wits and to encourage them to study in the segregated classes at Natal, as the increase in the number of Black students at Wits was in contradiction to the government’s apartheid policy on separate higher education As a result of this decision by government and the responding resistance, students at Wits set up their own African Medical Scholarships Trust Fund and voluntarily agreed to a RI annual levy per student, aided by NUSAS (National Union of South African Students) that collected funds internationally. Between 1951 and 1954, 14 students trained through this fund. However, in 1953 Wits announced that only a limited number of Black students would be admitted to the medical faculty. No reasons were given, but this could have been due to a shortage of clinical facilities to train Black students.
In 1957, the government attempted removing the medical school from the University of Natal with the intention of placing it under the control of the University of South Africa This would have ensured the government direct control of the management of the medical school This move was criticised by the national press and vehemently objected to by heads of departments of the University of Natal and other universities, resulting in the government abandoning its plan (Gordon 1957:8). Although it was stated that White students could, under exceptional circumstances, be admitted to the Natal medical school, White students were not admitted for many decades. The faculty was established primarily for African undergraduate training and to provide facilities for research into the vast and complex illnesses and associated problems of sickness in Africa Approximately 40 students were admitted annually to the medical school at the University ofNatal (Kgoale 1982:33-37).
The nature of the racial discrimination that Black medical students endured prior to 1994 was acknowledged through publication of the Internal Reconciliation Commission (Wits 2000) report of the medical faculty of Wits University that recommended that the faculty apologise to those affected by discriminatory policies and practices. Among the submissions received from graduate Black doctors were vivid recollections of them being banned from attending a post-mortem conducted on a White corpse, but of all students being permitted to attend the conducting of a post-mortem on a Black corpse; of Black students having to find their own way to local hospitals, even though the majority of them did not own cars, as they were barred from using the shuttle run by the medical school to these hospitals as only White nurses and White medical students were permitted to use this service; and of not being allowed to borrow photographic slides overnight for study due to a perception that Black students could not be trusted with such valuable items (Sunday Independent 1999:2).
Continuing with its purpose of providing segregated and inferior higher education and professional training for Blacks, the Medical University of Southern Africa (Medunsa) was established in 1976. The intention of the government was to train medical assistants instead of medical doctors to meet the health care needs of the Black population. Strongly opposing this move, Medunsa instituted a fully-fledged MBChB programme, as well as a wide range of other health professional training programmes, primarily for the training of Black medical professionals, and continues to graduate the largest number of African medical doctors in South Africa (cf. Table 3.4). Student admissions at Medunsa are guided by an explicit affirmative action policy that allocates spaces in all programmes according to the demographic profile of the country. The medical faculty of the University of the Transkei trains the smallest number of medical doctors, but students are also predominantly African (cf. Table 3.6).
The number of African medical doctors has increased from, for example, 1972/3 when 90% of South African doctors were White and only 1.2% were African (Retief 1982:98) to 2001 where there is a minimum of 5% of doctors who are African. The 2001 race profile of doctors is based on current registrations with the HPCSA where 19 810 of the total 30 058 registered doctors did not indicate their race group. However, the attrition rate of African students in medical schools is still unacceptably high (Lehmann 2000:9). Dr. Mangaliso Mahlaba, the first Black chairperson of the Junior Doctors’ Association, in 1997 called for the more sustained support of Black students and described the pattern among Black students to a revolving door. Black students gained admission, entered and then left due to academic and :financial pressures (St Leger 1997:14), corroborating the need for more sophisticated indicators that go beyond admission and enrolment statistics to throughput and graduate statistics and qualitative data, such as student support systems, to monitor equity transformation in higher education.
Universities are pnmary sites of knowledge production and when the discussion is about equity in higher education, it is necessary to examine who is raising what issue, where and why there is such a divergence of policies, practices and views, and how these will impact on equity in terms of race, gender and class at both an institutional and faculty level This needs to extend beyond racially-based dichotomies of HDis and HAis to diverse and complex equity realities. An example in point is the University of Natal, an HAI, but with a medical faculty mission, policies and student profile more similar to those of HDis.
This discussion is intended to introduce into current discussions on transformation of higher education an understanding of the contextual differences relating to medical education and training that needs to be incorporated into equity debates.

TABLE OF CONTENTS
LIST OF TABLES
LIST OF ABBREVIATIONS AND ACRONYMS
CHAPTER 1: BACKGROUND TO STUDY, PROBLEM FORMULATION AND AIMS
1.1 Background
1.2 Need for research
1.3 Literature review
1.4 Problem statement
1.5 Aims of the study
1.6 Research design
1.7 Chapter outline
1.8 Conclusion
CHAPTER2 CONCEPTUAL FRAMEWORK
2.1 Introduction to equity and social theory
2.2 Social transformation in South Africa
2.3 Models of equity
2.4 Equity of access
2.5 Redress
2.6 Equity of outcomes
2.7 Equity-related concerns
2.8 Conclusion
CHAPTER 3 MEDICAL EDUCATION AND TRAINING IN THE SOUTH AFRICAN CONTEXT
3.1 Introduction
3.2 Historical legacy
3.3 National legislative and policy :frameworks
3.4 Trends in South African HEis and medical schools
3.5 Clarifying shifts, trends and transformation initiatives
3.6 Conclusion
CHAPTER4 RESEARCH DESIGN
4.1 Introduction
4.2 Value of combining qualitative and quantitative research methodologies
4.3 Designing the research study (Planning phase)
4.4 Organising the research study (Organisation phase)
4.5 Conducting the research (Implementation phase)
4.6 Analysis of findings
4.7 Reliability and validity
4.8 Conclusion
CHAPTERS PRESENTATION AND DISCUSSION OF FINDINGS
5.1 Introduction
5.2 National – level issues
5.3 Equity issues: institutional and faculty level
5.4 Conclusion
CHAPTER 6 SYNTHESIS OF FINDINGS, RECOMMENDATIONS AND CONCLUSION
6.1 Introduction
6.2 Overview of investigation
6.3 Summary of emerging themes
6.4 Recommendations
6.5 Further research
6.6. Limitations of study
6.7 Conclusion
BIBLIOGRAPHY
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