Medical education, reflections and perspectives from South Africa: a review

Abstract

Medical Education (ME) in South Africa has a century long legacy which continues to make a significant impact globally through its graduates. The aim of this paper is to showcase the evolving landscape of ME in South Africa, whiles addressing the legacy of socio-economic and educational disparities influenced by its colonial and Apartheid history. The paper focuses on the effectiveness of recent reforms to create a more equitable and inclusive healthcare education system that can meet the diverse needs of the population and prepare healthcare professionals for challenges in varied and resource-constrained environments. This reflection therefore contributes to setting the scene for the formulation of strategic objects for the future.Key areas explored include widening access and participation through student admission and selection processes designed to promote inclusivity and equity; the development of student and academic support programmes to meet the needs of a diverse student population; the implementation of integrated, outcomes-based curricula; and the decentralisation of clinical training to underserved and rural areas. These measures aim to align medical training with a primary healthcare approach and to foster socially accountable and contextually responsive practitioners equipped to address local health challenges. Indeed, transformative learning experiences are shaping a resilient, agile and competent healthcare workforce.However, this paper additionally identifies persistent challenges, including disparities in resource allocation, gaps in leadership and governance, accreditation and the tension between addressing historical inequities and ensuring robust academic standards. Moreover, the public healthcare system, which serves as the primary training ground for medical students, struggles to balance a quadruple burden of disease and infrastructural deficiencies with education needs.Opportunities for growth are noted in the increasing emphasis on research and scholarship in ME, supported by the creation of a dedicated journal and five departments for medical and health professions education out of the ten medical schools in the country, formalising faculty development and postgraduate qualifications. This highlights the need for expansion of similar approaches in the other medical schools to address the gaps in research and the dearth of skilled clinician-educators.Despite these strides, within the complexity of ongoing challenges, a focus on sustaining and strengthening robust quality assurance, a focus on primary healthcare, and expanding training of students and clinician-educators remains central.

Keywords: Africa; Curriculum transformation; Diversity; Equity; Faculty development; Inclusivity; Low-and-middle income countries; Medical education; Scholarship; South Africa.

Fig. 1

Geographical locations of medical schools in South Africa. There are ten medical schools in SA: two in the Western Cape, at Stellenbosch University (SU, established in 1955) and the University of Cape Town (UCT, 1912); two in the Eastern Cape, at Nelson Mandela Metropolitan University (NMMU, 2021) and Walter Sisulu University (WSU, 1976); one in Kwa Zulu Natal, at the University of Kwa Zulu Natal (UKZN, 1950); one in the Free State, at the University of the Free State (UFS, 1969); three in Gauteng, at Sefako Makgatho Health Sciences University (SMU, 2014), the University of Pretoria (UP, 1943) and the University of the Witwatersrand (WITS, 1919); and one in Limpopo, at the University of Limpopo (UL, 2005). Three provinces do not have medical schools. (Taken from https://www.gfmer.ch/Medical_search/Countries/SouthAfrica.htm; accessed 9 May 2023)

Fig. 2

The structure, timing and regulation of ME in SA. Students can enter medical training directly after graduating from high school or with a previous degree. In general, undergraduate medical degrees span six (6) years of training (exceptions: a 5-year programme at UFS and WITS graduate entry medical programme of 4 years), followed by an additional mandatory three (3) years of public health system training: two (2) years of clinical internship and one (1) year of community service. Only once these compulsory nine (9) years of training are completed are graduates certified to practice independently as medical practitioners. Further formal postgraduate specialist and sub-specialist training is available (but not compulsory) and is beyond the scope of this article. Throughout undergraduate training, trainees are referred to as “medical students”, whereas, upon graduation and entry into public clinical training and service they are called “interns”, followed by “medical practitioners”. During postgraduate training, doctors are referred to as “registrars” until they complete their specialist qualification and then are called “consultants”. NQF: National Qualifications Framework; DBE: Department of Basic Education; DHET: Department of Higher Education and Training; HPCSA: Health Professions Council of South Africa; DoH: Department of Health; CMSA: Colleges of Medicine of South Africa

Fig. 3

Afri-MEDs competency framework [54]