PRIMARY HEALTH CARE DIRECTORATESELF-REVIEW REPORT 1995-2014 FOR

DEPARTMENTAL ACADEMIC REVIEW

INTRODUCTION

The Primary Health Care Directorate (PHCD) is an inter-disciplinary unit with a mission to promote the Primary Health Care (PHC) approach as the “lead theme” in the Faculty of Health Sciences, in order to equip our graduates to provide equitable and holistic care at all levels of the South African health care system.

The adoption of PHC as the foundation of national health policy and practice under the newly-elected democratic government in 1994 was recognized by the Faculty as the stimulus for change, in order to ensure that our graduates are equipped to meet the changing demands of the health system.

A policy on the PHC approach was adopted by a Special Faculty Assembly in August 1994, which committed the Faculty to the following set of principles with respect to teaching, research, and clinical service, and in its engagement with communities:

1. Displaying bio-psychosocial and cultural sensitivity towards the patient.2. Practising health promotion at individual and community levels.3. Promoting evidence-based health care. 4. Promoting equity and human rights in health care.5. Treating patients at the appropriate level of care.6. Promoting multi-professional health care. 7. Promoting broad intersectoral collaboration. 8. Encouraging communities to assert their rights and interests.9. Monitoring and evaluating the effectiveness, efficiency and equity of health services.

What is Primary Health Care?

"Primary Health Care is essential health care based on practical, scientifically sound and socially acceptable methods and technology, made universally accessible to individuals and families in the community through their full participation and at a cost that the community and the country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination" ( Alma Ata Declaration on Primary Health Care, WHO-UNICEF, 1978).

PHC is therefore understood as an approach to health care that promotes the attainment by all people of a level of health that will permit them to live socially and economically productive lives. Health care using the PHC approach is essential, scientifically sound (evidence-based), ethical, accessible, equitable, affordable, and accountable to the community.

PHC is therefore not only primary medical or curative care, nor is it a package of low-cost medical interventions for the poor and marginalized. On the contrary, it calls for the integration of health services with the process of community development, a process

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that requires political commitment, intersectoral collaboration, and multidisciplinary teamwork for success.

THE HISTORY OF THE PHC DIRECTORATE (1995 – 2014)

A Chair and a Department of Primary Health Care were established in 1995 under the late Prof Dumo Baqwa who passed away suddenly in 2001. In 2003 the Department was renamed the PHC Directorate, a cross-disciplinary unit placed under the Dean's office with the mission of promoting the PHC Lead Theme in the Faculty of Health Sciences.

It was Prof Baqwa’s vision as an academic physician, anti-apartheid activist and public health advocate that drove its initial development by embracing his commitment to humane, holistic health care for all through transforming the health system and educating a new generation of socially aware health professionals. During his directorship, the PHCD was comprised of academic educators from the disciplines of Public Health (Alperstein, Arendse, Weir, Olckers) and Family Medicine (Schweitzer, Bresick). The unit was situated in the Old Main Building, Groote Schuur Hospital next to the Department of Medicine and from here Prof Baqwa successfully collaborated with Professors Padayachee, Jacobs, Hirsch, Khan, Benatar, Seggie and Reynolds to formulate policies for transformation.

A particular strength of this initiative was driving multi-disciplinary reform of the medical and allied health science curricula for PHC to be integrated throughout the existing health service and into community and rural settings. In this initiative Baqwa was part of a small team including Hartman, Watson, Cooper and Duncan that began to re-design the curriculum and teaching platform. This process required the recruitment of new academic staff, including Vivian and Keikelame, to participate in the design team process that intended to develop community based education, health promotion, and medical anthropology.

During this time Family Medicine continued its teaching of 6th year medical students in district and secondary hospitals and clinics, and the joint PHCD/Public Health teaching programme for 4th year medical students doing research and health promotion was successfully developed and coordinated by Alperstein. The 4th year programme maintained community teaching sites under the direction of site facilitators such as Arendse in Atlantis/Mamre and Olckers in Woodstock.

Under Baqwa’s leadership, health service partnerships in communities were firmly established through working in a multi-disciplinary context with other university units. Of note was his active hosting of workshops to develop a community based teaching platform and this brought in organizations such as the Progressive Primary Health Care Network, SACLA, and the Health Care Trust - an NGO in Browns Farm, Zibonele, Town 2. In 2002 Baqwa led a Community Partnership Workshop where partnerships and resource needs were deliberated; a committee was formed which included stakeholders from all sites; and Keikelame was appointed as a Site Development Coordinator.

In addition, the Centre for Higher Education Development (CHED) became part of the community partnership vision assisting the PHCD with the development of the Site Facilitator job descriptions; multi-disciplinary teaching was extended to Woodstock and SACLA; and good relationships were established with Utrecht and Stanford Universities which fostered additional exchange programmes for medical students.

Prof Baqwa was the warden of Forest Hills Residence and an active supporter of the Health Sciences Student Council and Rural Support Network. After his death Prof Baqwa’s legacy was memorialized in both Faculty and University memorial services and subsequently in the naming of the Jeffery Dumo Baqwa Memorial Lecture as well as the re-naming of Barnard Fuller Building, Conference Room 1 & 2 to the Dumo Baqwa Room.

Following Prof Baqwa’s death, the PHCD was absorbed for some years into the Department of Public Health under the auspices of Family Medicine. In 2003 Prof Jimmy Volmink took up the Glaxo Wellcome Chair of Primary Health Care and the Directorate

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was placed under the Dean’s Office. Prof Volmink’s strength lay in research and he created a more independent unit, re-establishing it once again in Groote Schuur Hospital. The PHCD continued to drive curriculum reform and made a significant contribution to teaching. Throughout the history of the PHCD the unit has in this respect worked closely with the disciplines of Public Health and Family Medicine, and in particular with London, Hoffman, Swartz, Hellenberg, Bock, Namane, Coetzee, and other staff members from H&RS.

Given Prof Volmink’s international reputation as an outstanding academic researcher the PHCD began to develop an innovative research and publications profile, encouraged members to complete their postgraduate degrees, invited doctoral and post-doctoral students to study in the unit, and established yearly reviews and strategic planning meetings. Research and teaching intended to interrogate the PHC principles, drive transformation from tertiary care into communities, transform curricula to be PHC and patient sensitive and to extend the teaching platform. Functionally this was done in recruiting Petro and later Molteno to establish community based teaching sites. The PHCD team was led by James Irlam as acting director when Prof Volmink left in December 2005.

In 2010, Prof Steve Reid took up the post of Glaxo-Wellcome Chair of Primary Health Care and Director and has been engaged in developing this role to support UCT medical and health science graduates to become more relevant and appropriately skilled in Africa. This has included a revision of the clinical years of the medical curriculum, an extension of the clinical teaching platform from tertiary hospitals to primary and community sites, including the development of the Vredenburg platform. He has also acted as consultant to the Western Cape Department of Health (DoH) District Health Services Division on primary health care, community engagement and human resources for health.

The strategic goals of the PHCD were revised in 2010 to include the following:

OBJECTIVE 1: To integrate a primary health care approach into the FHS undergraduate and postgraduate curriculaeOBJECTIVE 2: To extend and develop the FHS clinical teaching platform in rural and primary care sitesOBJECTIVE 3: To deepen community engagement within the health service and the FHS

curriculaeOBJECTIVE 4: To enhance the recruitment and support of students of rural origin in the

FHS

In 2011, an additional objective was added:OBJECTIVE 5: To increase inter-disciplinary research in health sciences

Accordingly, Prof Reid initiated the Clinical Teaching Platform Committee to advise the Dean on all matters pertaining to the development, management and monitoring of the clinical teaching platform for the Faculty; made a number of proposals to Faculty and the Provincial Government of the Western Cape (PGWC), including a business plan for the creation of a George complex; continued as national chair of The Collaboration for Health Equity through Education and Research (CHEER); initiated the MBChB Clinical Curriculum Revision Task Team (CRTT) aimed at revising the MBChB curriculum clinical years 4-6; and initiated the Rural Students Recruitment Project to increase the output of skilled rural graduates to benefit rural communities.

SERVICE LEARNING AND TEACHING

Community Based Education (CBE)

UCTs Faculty of Health Sciences adopted primary health care as its Lead Theme and this new strategic direction led to the Faculty embarking upon a set of community-based educational, research and health service strengthening initiatives in the Western Cape, based on a PHC approach. At the heart of the PHC philosophy is a commitment to

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advancing the health of both individuals and communities, which is driven by respect for human rights. But it is recognized that, unless health interventions are developed and implemented with due regard to the best available evidence, this new enthusiasm will lead to scarce resources being squandered on actions that are inappropriate, ineffective or even harmful.

The Vanguard Student Learning Centre (SLC) attached to the Vanguard Community Health Centre (CHC) in Bonteheuwel/Langa was opened on the 2nd September 2005 as a result of a unique funding partnership with the Rangoonwala and Liberty Life Foundations, facilitated by UCT and driven by Prof Volmink. The partnership was initiated so that partners would have an opportunity to guide resources towards community health-related activities that directly impact the health status of economically disadvantaged communities in South Africa and so that the PHCD would gain an additional forum in which evidence-based decision-making could be developed and implemented, for maximum community benefit.

Since its creation in January 2003, the Directorate has worked closely with the PGWC, Cape Town Unicity Health authorities and civil society groups in the Western Cape to identify communities for designation as PHC focus areas. These communities are selected on the basis of need (major health problems and poor services) and potential for the adaptation or development of suitable facilities for teaching and learning. The sub districts of Langa, Bonteheuwel, Khayelitsha, Hanover Park, Mitchell’s Plain and Retreat, as well as the rural district of Vredenburg, were selected in 2005 and new sites since then have been proposed for integration into the teaching platform. However this progress was been delayed by the processes leading to the Multi-Lateral Agreement, which was eventually signed in 2012.

Successful PHC planning, implementation and monitoring require reliable information on the baseline health status of the local population and the current state of the existing health care delivery system. A comprehensive situation analysis of the communities of Bonteheuwel and Langa (served by the Vanguard Drive CHC) was thus completed by Naidoo & Irlam in 2005 which provided information on the health status and health needs of the population; the health research efforts that were underway; the gaps in available information on health status and/or health needs; and key socio-economic determinants of health. The findings were discussed with community representatives and local health authorities with a view to prioritizing the development of appropriate interventions to address health and social problems in the area. As part of the prioritization process an audit was also conducted of deaths in Langa and Bonteheuwel.

The Vanguard SLC was the first custom-built CBE site in Cape Town at which education and research could take place, and has since been followed by the Vredenburg site. They have provided multi-disciplinary, supervised, learning opportunities for all medical and health and rehabilitation sciences students. These placements have allowed our students to understand the social context of health and disease, to learn to work cooperatively with communities and health services, to learn clinical skills and to conduct community-based research projects. The aim has been to expose our students to a learning environment that is safe and conducive for learning and to ensure that the experience of CBE is so positive that they would want to return to community practice in an underserved area in the future. Given the ongoing shortage of adequate public sector facilities, the establishment of additional purpose-built educational centers, in George for example, remain on the Directorate’s agenda.

A university-wide Community Based Education Workshop was hosted by the PHCD in June 2006 in collaboration with Prof Martin Hall, Deputy Vice Chancellor, and Prof Marian Jacobs, Dean of the Faculty of Health Sciences aimed at interrogating CBE with respect to its significance, optimal effectiveness, sustainability and opportunities for cooperation across the university. Issues explored were: Learning modes across UCT; the significance and benefits of CBE for the community at large; the fundamental purposes of pursuing CBE; implementation of CBE through multi-disciplinary collaboration, curricula design and partnerships; principles that inform CBE; trends, contexts and challenges; the enhancement of student learning; and the factors inhibiting and enabling CBE. The substantial value of CBE to students and the community was underlined and it was

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agreed that the core business of the University should be enriched by community engagement. Prof Hall called for the three ‘strands’ of CBE - scholarly social responsiveness, community service and volunteerism - to combine into an over-arching compact structure and recognized that CBE needed to be woven into the fabric of what the University does. He concluded that for CBE to work it had to be fully institutionalized and mandated within the structures of the University.

A situational analysis of the Saldanha Bay Sub-District was initiated by Prof Reid and Frank Molteno and conducted in 2010 with the aim of establishing a rural teaching Centre in the Sub-District to respond to needs in underserved communities; engage with the social context of health and disease; increase the knowledge and understanding of health, disease, disability; and, expose students to challenges in under-resourced areas. It provided an understanding of the specific context and challenges within which a targeted rural student teaching site and placement programme would be located, in partnership with Vredenburg Provincial Hospital and the Provincial DoH.

The narrative leading to the establishment of the rural academic programme based in Vredenburg started within the Faculty around 2003 and culminated in the implementation of the Vredenburg site in 2011 through the efforts of Prof Gonda Perez, Prof Derek Hellenberg, and Mr Frank Molteno, PHCD Community Based Education Manager. The Vredenburg house accommodates up to 18 students close to the hospital and is fitted with video conferencing and ADSL connections for distance learning. A joint staff Senior Family Physician oversees and coordinates the training of students on the platform. The multi-professional programme continues to meet all teaching objectives successfully, with a major part played by the Department of Health and Rehabilitation Sciences, and academic activities have been integrated into the service platform, adding value to the delivery of health services in the area.

The site has offered abundant research opportunities; student projects have contributed to quality improvement initiatives and health promotion activities at a community level; HPCSA accreditation as a postgraduate training site for Family Medicine has attracted doctors to the Vredenburg Provincial Hospital, thereby helping to address staff shortages; the academic platform has encouraged staff training thus improving staff recruitment and retention; and, above all, Vredenburg presents an opportunity for students to experience a District Hospital serving a rural population as part of a district package of care. The Vredenburg site is important as a precedent for further development of the teaching platform outside of Cape Town.

Clinical Teaching Platform

As chair of the Clinical Teaching Platform Committee, Prof Reid has been responsible for assisting the Faculty with interrogating the needs and development of the clinical teaching platform, together with Frank Molteno.

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The above diagram illustrates the current platform (at the top of the diagram) and the planned expansion (at the bottom of the diagram). The implementation of this has been delayed by the Multi-Lateral Agreement (MLA) process with the Provincial Government Department of Health.

The following key questions were raised in 2013 and continue to be grappled with: What is the right balance in teaching capacity at different levels of care? What teaching & learning activities are currently happening at each level/site? What should the size and shape of teaching at the level/site ideally be? What are the next steps to facilitate the establishment? Of the ideal learning site,

and how could this be funded and sustained? Does the clinical teaching platform at community, district, secondary and tertiary

level need to expand, stay the same, or decrease? If it does need to change, in which departments and by how much?

A number of iterations of a business plan have been put forward for the development of a campus in the George “complex” in the Eden district which includes Mossel Bay, Knysna, Oudtshoorn and Beaufort-West district hospitals. These include the placement of final year medical students in a longitudinal integrated curriculum for the whole year in the complex, which requires changes to the MBChB curriculum in order for the experience to be equivalent to that offered in Cape Town. The components of the plan are illustrated in the diagram below.

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Rural Health

The available evidence indicates that the current curriculum does not adequate equip students for rural practice. The international literature shows that students regard rural placements more highly than urban ones in terms of educational benefit due to the number of patients they see; the wider range of experiences; continuity of care; and the scope provided by rural practice. Rural medicine is more multi-disciplinary, community based and more likely to involve participants in a wide range of community organizations. Rural-origin students are helped to connect with their own values and communities, and attitudes are shown to change irrespective of origin.

A portion of a Faculty R1.2m Atlantic Philanthropies 3-year grant dispersed to the PHCD in 2009 was utilized to encourage the recruitment of health sciences students from rural and underserved areas, support them to develop leadership skills, better prepare medical students for rural practice, and contribute overall to health equity. The PHCD appointed a Rural Recruitment Officer who assisted with raising the profile of rural health amongst the students and Faculty; expose an increasing number of students to rural situations via the subsidy provided for 5th year rural electives; raise awareness amongst rural learners about health careers and processes to be followed to become health professionals in future; and expose students to leadership through workshops and practice whilst leading their student societies. As a result of the Recruitment Officer’s work in rural high schools around the country, the number of rural origin students who registered for 1st year in the faculty in 2013 was double that of previous years, around 17% of the total number.TEACHING

The key principles of the PHC Approach are integrated into various courses that make up the MBChB and Health and Rehabilitation Sciences curriculum. Plenaries and lectures, tutorials and seminars, case studies, service learning, and community surveys are used as methods of teaching and learning. In addition textbooks, readings, lecture notes, exercises, worksheets and survey forms are used as learning resources. Students are assessed by means of examinations, assignments, portfolios, research projects, oral presentations, and reflective journals. An annual multi-disciplinary portfolio-based exam is used to assess student understanding of how the PHC principles apply to their clinical learning.

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Dr Lauraine Vivian and Ms Sarah Crawford-Browne are responsible for the PHC sub-theme of culture, psyche and illness (CPI). Students are taught a bio-psychosocial and cultural approach to patient care in the context of major South African health challenges and health system inequities. Problem-based learning facilitates reflection on patients’ cultures and rights, on students’ own cultural backgrounds, and on medical culture, in order to inform a critical analysis of patient histories in their correct context. PHC ward rounds in the 4th Year General Medicine rotation at GF Jooste/Lentegeur Hospital are facilitated by Dr Vivian, Ms Crawford-Browne and Prof Reid who join the consulting physician and lead students in tutorials to explore their insights into the bio-psychosocial history and cultural context of selected patients on the round.

The key PHC principles of equity and patient rights also feature prominently in teaching on the District Health System, on PHC and equity in health, and on advocating for the rights of patients. A four-week free choice or guided PHC Elective in the 5th year coordinated by Mr James Irlam, allows students to reflect on the validity and applicability of all PHC principles in a variety of clinical settings. Students are assessed via a written clinical report which encompasses their learning objectives, description of the placement site, a reflection on their clinical or research-based work, and reflections on the principles of PHC. The Faculty has incentivized rural electives from 2009-2013 by assisting students with their elective expenses to any rural site within South Africa and feedback from students who have done rural electives has been unanimously positive. Students have reflected that they have grown as health professionals; developed a range of knowledge and skills within a multi-disciplinary team; gained a compassionate insight into the needs and challenges faced by rural medicine; have strengthened their patient- and service-centred foci; and have been inspired to contemplate working in rural areas once they qualify.

Dr Gaunt, Dr le Roux and Prof Reid provide rural health seminars to 4th year students on the challenges and rewards of working at the rural coalface. The seminars unpack poverty and inequality; child health indicators; access to health services; multi-disciplinary teamwork; generalist versus specialist skills; community medicine; disease prevention; and retention and recruitment of rural health workers.

The 2nd year MBChB Special Study Module (SSM) blocks have provided opportunities for students to conduct small research projects, literature reviews or researched digital stories within the auspices of the PHC, health promotion and CPI streams as well as the developing theme of arts & healthcare. Prof Reid has teamed up with Dr Patrice Repar from the University of New Mexico, Arts-in-Medicine Programme since 2011 on collaborative Music & Medicine and Arts & Healthcare SSMs.

Sarah Crawford-Browne has introduced digital storytelling as a flexible tool that can promote learning as an assignment, during lectures or as a research tool. Digital storytelling allows students to engage with concepts creatively and integrate theory with experience. Sharing the stories with peers and family facilitates further discussion, reflection and learning. Lecturers see the value of the tool for developing writing skills, critical thinking and conceptualization and Ms Crawford-Browne has facilitated 2 training courses and 4 seminars for UCT colleagues. Sarah has also contributed to the 1st year Transitions programme.

The PHC Approach is also integrated into the 2nd year Health and Rehabilitation Sciences curriculum within the Communication Sciences, Physiotherapy and Occupational Therapy divisions through a special course entitled PHC and Disability. Topics include integration of the PHC approach into the AHS curriculum; health promotion; behaviour change theories and approaches; and planning a health promotion project. Teaching on integrated health systems in years 2 and 3 address alternative medicine perspectives; ethical issues; belief systems; bio-psychosocial and cultural issues; and relevant PHC principles.

PHC is taught in the following postgraduate courses: Masters in Medicine (research); Masters in Public Health (evidence-based health care, public health & society); Masters in Family Medicine (health & culture, community oriented primary care); MPhil in Maternal

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& Child Health (epidemiology, research ethics); MSc Occupational Therapy (evidence based health care, health promotion); MSc in Genetic Counselling; MPhil Social Justice, Law and Poverty; and the MEd ICTs in Education. Postgraduate diploma teaching includes the Diploma in Family Medicine (evidence based health care); Diploma Clinical Educators Course; Diploma  Community Eye Health - Vision 2020 (health promotion); Opthalmic Nursing (health promotion); and Nephrology Nursing in Primary Care Settings (health promotion).

MMed Research Methods for Registrars Workshops are conducted twice a year with the purpose of strengthening research capacity of Registrars within all departments. The two-day Saturday workshops include: Research hypotheses; selection and sampling; quality control of measurement; systematic reviews; ethical issues; case-control, cross-sectional and cohort studies; collecting and organizing data; data management; hypothesis testing; and library literature reviews.

James Irlam teaches basic epidemiology and evidence-based practice to undergraduates and postgraduates by means of a variety of methods. These include lectures and critical appraisal exercises, evidence-based journal clubs, and role-plays in primary care consultations followed by self-reflection on evidence-based learning needs. He has also become the proponent of climate change & health within the Directorate, lecturing to 4th year students and developing an advocacy and research profile on the subject.

Students are taught the theory and practice of health promotion by Johannah Keikelame and her team of site & NGO facilitators including Tsuki Xapa, Christolene Beauzac, Mercia Arendse, Mandy Botsis and Claudia Naidu in partner communities and NGOs through years 2 to 4 of the medical curriculum. Health promotion learning equips students to deal effectively with the diverse health needs of individuals and communities, and there is ample opportunity in the 4th year Public Health block to apply health promotion theory. Student groups undertake a variety of community-based health promotion projects at various off-campus sites where they learn about the importance of community participation and partnerships, health rights and health promotion ethics, and effective teamwork.

A postgraduate certificate course in Community Eye Health for Vision 2020 aims to introduce health promotion as an important strategy for promoting eye health. The module covers definitions of health promotion and milestones; Ottawa Charter strategies and actions; health promotion approaches; behavior change theories; ethics; health rights; community participation; and empowerment of individuals and communities at all levels of care including models for planning health promotion programmes, tools for analysing health problems, and advocacy for eye health promotion.

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RESEARCH & PUBLICATIONS

The PHCD has shown a steady increase in research output in its DOHET Publication Count submissions for accredited peer-reviewed journal articles and book chapters since 2006. It submitted 5 journal articles in 2006; 4 in 2007; 1 in 2008; 3 in 2009; 6 in 2010; 4 in 2011; 10 in 2012; and 11 in 2013. 1 book chapter was submitted in 2012 and one in 2013.

As at April 2014, 2 accredited journal articles have been published; 1 is in press; 5 have been accepted for publication; and 8 are under review. Additionally, 2 book chapters have been published; 2 have been accepted for publication; and 1 monograph is under review.

2006 2007 2008 2009 2010 2011 2012 2013 20140

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4

6

8

10

12

14

16

18

54

1

3

6

4

1011

17

Number of accredited journal articles by year

Year

Prof Reid and Dr Vivian are NRF C-rated researchers recognized by their peers as leading international scholars in their field for the quality and impact of their research outputs.

Among PHCD staff members, 2 PhDs have been completed and 4 are currently in progress.

Staff member University & Discipline TitleDr Lauraine Vivian

UCT Dept of Psychiatry(2008)

“Psychiatric disorders in Xhosa-speaking men following circumcision”

Prof SteveReid

UKZN Faculty of Education (2011)

“Education for rural medical practice”

Ms Sarah Crawford-Browne

UCT Dept of Psychology(in progress - on sabbatical)

“Meaning constructions about violence and psychological adjustment amongst women residing in a high violence community”

Mrs Johannah Keikelame

SU Dept of Psychology(in progress - on sabbatical)

“Perspectives on epilepsy on the part of patients and carers in a South African urban township”

Mrs ClaudiaNaidu

UCT Dept of Medicine(in progress)

“An evaluation of the development of social accountability of medical graduates at UCT”

Ms Christolene Beauzac

UWC School of Public Health (in progress)

“Regulating the Body: Health promotion and diabetes in the Western Cape, South Africa”

Research themes have varied widely depending on the research orientation of staff members as well as their teaching fields, fitting fundamentally or generally into the PHC

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Lead Themes that have underlined the mission and foci of the Directorate. Themes have broadly covered the following topics:

Health Systems Evidence based health care; meta-ethnography of qualitative literature. Faith-based organizations; health care partnerships between African traditional

healers and biomedical personnel in South Africa. Rural health; rural-based medical education and principles of practice; evaluating the

rural health placements of the Rural Support Network. Human Resources for Health: compulsory community service, increasing access to

health workers in remote and rural areas through improved retention. The implementation of community-oriented primary care; continuity of care; PGWC

community based services support; intermediate care policy for the Western Cape DoH; access to the service platform; patient-centered experiences; an evaluation of the utilization of the Discovery Health ID; evaluation of community based services for the development of revised provincial frameworks.

Perspectives on key principles of generalist medical practice in public service; responding to health needs of the population and striking a balance between generalists and specialists.

Understanding of Family Medicine in Africa; the African family physician and development of family medicine in Africa.

Health Sciences Education Medical Education: Medical students’ experiences of professional lapses and patient

rights abuses in the Health Sciences Faculty; social accountability outcomes of medical education; impact of undergraduate students on service delivery in the District Health service; global consensus on social accountability; health sciences undergraduate education transformation at UCT; communities’ views, attitudes and recommendations on community-based education of undergraduate health sciences students; admission processes at South African medical schools; the home visit teaching tool for medical education; development of agency during UCT medical student electives.

Contribution of curricula to prepare health professionals for working in rural/under-served areas; career plans of final-year medical students; educational factors that influence the urban-rural distribution of health professionals in South Africa; evaluation of medical students’ community placements in South Africa; qualitative exploration of the career aspirations of rural origin health science students; internship training preparation of medical graduates for community; career and practice intentions of health science students; developing student graduateness and employability

Collaboration for health equity through education and research; human rights. Culture, psyche and illness; writing culture into undergraduate medical education

Health Promotion and Chronic Diseases: Primary prevention of rheumatic fever and rheumatic heart disease. Health behavior theories; health promotion. ARV treatment for HIV-infected children; HIV/AIDS and stigma; ARV outcomes at

primary health care facilities; male circumcision and HIV prevention; management of patients with TB; TB & HIV/AIDS medication adherence.

Causes, perceptions, general practitioners’ perceptions of management of epilepsy; health literacy factors affecting epilepsy; epilepsy metaphors and stigma; traditional healers’ views on epilepsy and collaboration.

Mental health problems in disadvantaged communities. Resilience in young people/adolescents.

Inter-disciplinary Studies Violence prevention and safety in SA; the use of concept mapping in engaging

women to identify the factors that influence violence; breaking the cycle of violence; theory and practice of community action towards a safer environment.

Child deaths in the Red Cross Children’s Hospital PICU; quality of care in PICUs; understanding of genetic inheritance among Xhosa-speaking caretakers of children

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with hemophilia; improving child health and nutrition in SA; pathways to care of the critical ill child; factors affecting the psychological states and outcomes of children in the Red Cross Hospital PICU.

Creativity and Health: arts and medicine; hospice and palliative care; systematic patient narratives to improve the pathway to hospital care; stretching the limits of cognitively disable performers through dance/movement therapy; transgenerational trauma and repetition in the body; creativity and innovation in the rural context.

Climate change and occupational health; social justice agenda for health; advocacy for healthier national energy policies.

SOCIAL RESPONSIVENESS

The PHCD convened a workshop on the Social Accountability of Medical and Health Sciences Education in 2010 chaired by an invited expert - Charles Boelen – an international consultant in Health Systems & Personnel and former Coordinator of the WHO Programme of Human Resources for Health. The aim of the workshop was to develop and define indicators of social accountability for medical and health sciences education that are feasible in our context. The expected outcomes of the workshop were a set of feasible indicators that could be used by health science faculties in South Africa for monitoring and evaluation of institutions, faculties and programmes in our context. The workshop looked at the development of global social accountability, reflected upon UCT’s social responsiveness journey, examined the University of Stellenbosch’s Hope Initiative, and explored the indicators for measuring social responsiveness via the CPU (conceptualization, production, usability) Model.

Prof Reid gave input to the health sector chapter of the National Planning Commission in 2011, and is a member of the ministerial National Health Insurance (NHI) Task Team tasked with reviewing the pilot sites and business plans for the NHI. The Western Cape Eden District is receiving some extra attention. He is part of a UWC team that developed a policy for Intermediate Care in the Western Cape which was accepted by the PGWC DoH. The policy provides a framework for the delivery of facility-based services for step-down care, palliative care, chronic care and short-term rehabilitation in the province, collectively referred to as Intermediate Care. The idea is that there should be an intermediate care facility within each sub-district in the province and the project has begun to review the Community-Based Services (CBS) in Eden which involves a review of what community health workers (home-based carers, TB Dots supporters, farm workers) actually do, that will advocate options for a more comprehensive and population-based approach in line with the PHC re-engineering ideas. Prof Reid also chairs the faculty’s Admissions Policy Committee which is under intense pressure every year with more than 5000 applications for a few hundred places. An important objective of the committee is to examine how the profile of the student body can change through appropriate policy changes.

James Irlam is a member of the provincial Health Climate Change Committee; the provincial Climate Change Adaptation Working Group; the national Long Term Adaptation Scenarios Health Sector Expert Group; and the review team on the National Climate Change and Health Adaptation Plan. He presented at the People’s Health Movement Workshop on Climate Change and Health at the National Health Assembly and People’s Health Assembly. He co-convened a provincial workshop on Energy and Health, which culminated in an oral and written submission to the Department of Energy on the public health implications of the Integrated Energy Plan (IEP) and the Integrated Resource Plan 2010. He co-hosted and presented at a workshop on the Health Effects of Climate Change at the annual conference of the Public Health Association of South Africa (PHASA) and published the summary findings of the three provincial Energy and Health workshops in the PHASA newsletter. He addressed meetings of the Centre for Environmental Rights (CER) and the One Million Climate Jobs (OMCJ) campaign about this work. He served as the UCT representative on the CHEER collaboration from 2009 to 2013 and was a member of CHEER Peer Review teams at Wits, Pretoria, and UWC during that time.

Sarah Crawford-Browne is a consultant for the Worcester Hope and Reconciliation Project’s support of survivors and victim-offender dialogue and supported the project in 2013 with conceptualizing a victim-offender dialogue between Stefaans Coetzee and

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survivors of the 1996 Shoprite bomb. She has strategized responses to violent or traumatic situations in Sudan, Congo-Brazzaville, and two local situations. Ms Crawford-Browne contributed to Victim Empowerment Policy, the CSIR’s safer city / safer province project and led the Action for a Safer South Africa’s Victim Support Strategy. Through five rounds of consultations, she contributed as an expert panelist to the Center for the Study of Violence and Reconciliation’s development of an “African Torture Rehabilitation Model” (CSVR publication) in 2013. She has facilitated training in trauma intervention at The Trauma Centre for Survivors of Violence and Torture, and Community Action for a Safer Environment (CASE-Hanover Park), and facilitated staff supervision for CASE (2010-2011) and Catholic Welfare and Development-Trauma Programme (2009-2013), and assessed and guided local projects for financial support by Het Maagdenhuis (Dutch donor organization – 2008 – 2013). She made contributions to publications for lay audiences of the Restitution Foundation and of CASE. In 2011 she gave feedback to a Hanover Park community meeting that was strategizing a ceasefire, on her PhD research regarding the factors that women perceive as influencing violence in Hanover Park, and has contributed to discussions regarding gangsterism, e.g. that facilitated by SaVI in 2013. Ms Crawford-Browne has contributed to UCT’s Safety and Violence Initiative through planning sessions and starting the website.

Johannah Keikelame has partnered with Epilepsy South Africa, St John Ambulance and the Langa Health Committee to use findings from her PhD project to help address problems related to epilepsy. She organized a workshop for 12 traditional healers who were trained by the Epilepsy South Africa Western Cape branch staff and findings from observations were shared with board members of Epilepsy South Africa Western Cape, as well as Vanguard CHC staff, to promote awareness about health literacy factors affecting epilepsy.

The Collaboration for Health Equity through Education and Research (CHEER), chaired by Prof Reid, has been successful in pursuing the theme of social accountability in health sciences education to the next level, including through international collaborations and a successful peer review at the University of Limpopo. The collaboration amongst the 9 partner faculties around the country remains strong and Claudia Naidu’s doctoral thesis will contribute to a longitudinal view of the development of social accountability in medical students and graduates as they progress through the system.

The Rural Students’ Recruitment and Support Project received the attention of the Deanery and the Western Cape DoH offered 13 bursaries for medical students from rural areas of the Western Cape. It builds on the work done by Mandla Masiza and Sipho January and collaborations made with students through the Rural Students Network. The project aims to increase the output of skilled rural graduates which will benefit rural communities by targeting and recruiting the top matric learners from the poorest rural areas to become health professionals; promoting the faculty; supporting learners through mentoring programmes; and assisting them, once in university, to surmount obstacles and graduate successfully.

STAFF & EQUITY PROFILES

The current equity profile of 20 staff members includes 2 white males, 5 white females, 2 African females, 8 coloured females and 2 Indian females. Aside from the Director who took up his post in 2010 as well as 4 out of the 5 incumbent Honorary Lecturers, all PASS and academic staff recruitment processes in the past 8 years have brought in staff members from designated groups, in keeping with the UCT employment equity targets and mission. The Directorate has strived to build a diverse, high quality staff profile as well as an academic staff profile which promotes equal opportunity, encourages development and adds value to the teaching experience of a diverse student population.

5 honorary lecturers have been employed since 2008 and contributed to the objectives of teaching students the key principles of PHC. Dr Feng Chao Lin imparted his knowledge on complementary healing and taught students key PHC principles in community sites including appropriate referral between the domains of biomedical and complementary practice; an understanding of culture and bio-psychosocial factors; health promotion; and evidence-based practice. Acupuncture has been shown by WHO to be the most

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affordable and effective form of primary treatment in poor countries. He lectured to 2nd

and 3rd year MBChB and physiotherapy students on Chinese medicine and practices, and convened Acupuncture & Medicine SSMs for the duration of his honorary lectureship.

Dr Peter Bock was a strong advocate of the PHC approach coordinating the 4th year Public Health programme and contributing substantially to the MBChB semester 3-5 Design Team by lecturing, providing resource materials, designing assessments, sharing his problem-based learning methods skills, and assisting in the teaching of PHC principles in the 4th-year General Medicine block at GF Jooste hospital.

Dr Ben Gaunt, the Clinical Manager of Zithulele Hospital - a remote district hospital in the Eastern Cape - and Dr Karl le Roux, the Principal Medical Officer have together been powerful role-models for students with respect to delivering primary care services, leadership and teaching, and their understanding of the PHC approach. They have addressed staff and students on rural health and presented the 4th year MBChB rural health block seminars, highlighting the challenges and rewards of working at the rural coalface, thereby promoting the agenda of PHC in the faculty.

Dr Rob Baum is an experienced academic in the field of dance and movement therapy and has brought in a trans-disciplinary approach to medical teaching. She has contributed to the Directorate publications output in the areas of dance movement therapy, transgenerational trauma and health, and the transformation of the body through art praxis.

MAJOR HIGHLIGHTS since 2010

Curriculum Revision

The Faculty-led Clinical MBChB Curriculum Revision Task Team (CRTT) co-chaired by Prof Reid and Prof Burch met for their final meeting in October 2013 to review what has been achieved since the inception of the Task Team in August 2010, evaluate if the major objectives have been served and to bring clarity to the way forward with respect to salient issues that remain a work-in-progress and will be taken up by the MBChB Programme Committee.

A pilot project for longitudinal patient follow up, which arose out of the curriculum revision process, was administered in 2012. The aim was to identify potential obstacles, strengths and logistical implications of patient follow-up involving home visits by 4th year MBChB students. The project examined the impact of the home visit on the patient/family; the impact on the student's time and participation in the clinical rotation; the logistical implications from the co-ordinator's perspective; the safety and resource implications for student support; the feasibility of the longitudinal study across different clinical disciplines; and the optimal form of assessment amongst three methods (portfolio case report, forum posting and journal report) and the protocol was approved by the HREC.

Initial revisions to the 4th year curriculum will take effect in 2014 including the introduction of primary care Paediatrics; incorporating additional on-site student clinical work; inclusion of alternative off-campus sites; home visits; and integrating PHC themes and learning outcomes across the curriculum. Revisions to the 6th year curriculum will continue to be interrogated with the aim of exploring the implementation of a longitudinal 6th year programme in George or other community-based off-campus sites on the expanded teaching platform, and exploring workable models.

Task Teams will continue to examine graduate attributes in relation to templates that were designed to identify and integrate PHC threads across the major themes of human rights; inter-professional teamwork; communications & cultural competence; evidence based practice; life-long learning; bio-psychosocial approach; ethics; gender & sexuality (LGBTI); SHAWCO Health Proposal; and oral health. The curriculum mapping process, which was half-way through, will also be completed.

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The CPI curriculum moved through a review process that consolidated learning outcomes, and a spiral of teaching within MBChB regarding gender based violence was mapped, to initiate review.

Medicine and the Arts

A new postgraduate Medicine and the Arts course which commenced in 2014 was designed by Prof Reid in collaboration with Dr Susan Levine, Department of Social Anthropology. The course contributes to new inter-disciplinary research initiatives underway at UCT, and provides an unparalleled opportunity for students from the Health Sciences and Humanities to engage with the production of knowledge of and about the body, from multiple perspectives. The course also provides an intellectual platform for students to explore new possibilities, already activated on the global stage, about the ways in which the arts can constructively engage with medical pedagogy and practice, and to engage in key debates relating to medicine, the arts and medical anthropology.

Inter-disciplinary Research

James Irlam brought together a workshop in 2012 on Inter-disciplinary & Trans-disciplinary (IDTD) Research in the Faculty to facilitate the Directorate’s role as a cross-cutting unit within the Dean’s office whose purpose was to play a role in developing IDTD research and practice as well as promote collaborative research within the university and beyond, within the context of the Faculty Strategic Plan for Research 2013-2020 and the university-wide IDTD Task Team Review.

Strategic questions that arose from the workshop included: Should the goals of IDTD cascade down from the Faculty Strategic plan; should one grow seeds which could be strengthened and become the basis for major research initiatives; should space be made for creating the conditions for new ideas and new questions which are the hallmark of IDTD research; should one work with the converted or try and grow the pool of researchers; should one promote IDTD as an approach or rather through particular issues or signature themes?

Ideas for promoting IDTD included: Encouraging participation via journal clubs and working groups; defining one’s own work; sharing and disseminating work with colleagues; encouraging IDTD publishing; taking on supervision beyond one’s own discipline; creating opportunities to provoke discussions; examine institutional values which hinder IDTD; and promote critical pedagogy as a way of thinking beyond disciplines. The Faculty could encourage IDTD by: Creating an annual IDTD research award; encouraging course conveners to participate in IDTD graduate programmes; developing short courses to teach IDTD postgraduate skills; coach students about the difficulties of IDTD; draw up list of successful grant proposals on Vula to identify what collaborative research is underway at UCT; train supervisors on how to supervise and examine IDTD theses; train staff and students on methodology; change existing protocols so that IDTD is encouraged; create spaces to think and talk about research approaches; incentivize IDTD through funding; lobby NRF to fund IDTD; host a seminar series; make it more visible within the Faculty; and include IDTD in performance appraisal systems.

The statistics from around the world show that the output of those universities that have deliberately created an enabling environment for inter-disciplinary research, has increased exponentially, as compared to those who continue ploughing the same furrows within their disciplinary boundaries. Although a lot of the work done at the PHCD is inter-disciplinary, this is not the case for most departments, and one of our core functions is to initiate and stimulate this kind of thinking within the Faculty.

Strategic Research A Strategic Planning Workshop was held in January 2012 to review the Directorate’s progress against its 2010 Operational Plan, review its progress against the key outcomes

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of it Research Strategy workshop held in 2011, and review its mission and objectives in relation to UCT’s six strategic goals as well as the Faculty’s Strategic Plan 2010-2015.

The PHCD’s over-arching research objectives are to: Enhance research collaboration Develop trans-disciplinary research collaboration within the university Promote the Faculty’s research strategy

The PHCD’s primary goals are to: Integrate a primary health care approach into the FHS curricula Extend and develop the FHS clinical teaching platform in rural and primary care

sites Deepen community engagement within the health service and the FHS curricula Enhance the recruitment and support of students of rural origin in the FHS

The PHCD’s operational goals are to: Pay more attention to post-graduate teaching and develop a post-graduate teaching plan Interact more with clinical departments Re-orientate more health professionals to the PHC Approach Encourage students to publish research and present to different stakeholders Seek external funding from agencies Write new grant proposals with respect to rural elective funding and research projects

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Collaboration for Health Equity through Education and Research (CHEER)

Following a meeting with the DG Health and the submission of a Concept Note for the Committee of Medical Deans on the conditional funding of medical student training, the CHEER collaboration, of which Prof Reid is the national Chairperson, were asked in August 2013 by the DDG: Primary Health Care to develop proposals for the re-orientation of medical education in South Africa. Prof Reid, Dr Couper and Dr Hugo forwarded a proposal to the National Health Council on “Orientating doctors towards primary care and rural medicine: Transforming the training of medical students in South Africa” in order to produce more doctors who were willing to commit themselves to working in primary care and in rural health care. The key proposal suggested offering direct funding to faculties that are willing and able to transform their approaches to medical education in order to address this need, through the strategies of changing the selection and admissions processes; shifting academic orientation from a limited focus on tertiary care to a broader focus, with an emphasis on primary health care at community level; and developing specific training for and in rural contexts, and other underserved areas. Faculty development will be required in order to achieve these goals and the approaches will also need to be extended across the health professions, which would facilitate inter-professional training and team-work. In the long term, faculties could be measured on their ability to produce graduates that meet the specific human resource needs of the country.

Sabbatical Research

Dr Lauraine Vivian returned from her 2012 one-year sabbatical in the Gender Unit, Department of General Practice at the Faculty of Health Sciences, University of Copenhagen where she worked on a monograph titled ‘Ukoluka – Going for Circumcision’ which was a write-up on the ethnographic research that she did for her doctoral thesis on a descriptive study of psychiatric disorder in amaXhosa men following circumcision. She was mentored by Prof Margrethe Silberschmidt, an anthropologist who specializes in gender, masculinity and the customs of African autochthons in Kenya and Tanzania. She also completed two academic articles and involved herself in teaching and research at the University of Copenhagen, contributing to the life of the department and immersing herself in learning what ‘being a good citizen’ meant in Denmark. She was able to engage in debate bringing a South African perspective to medical education in Denmark and the rest of Africa as the department is engaged in active research and intervention programmes to develop health systems in Africa. The University of Copenhagen place a strong emphasis on promotion for staff involved in undergraduate medical education as the graduation of good medical doctors is crucial for the Danish health system. She sustained 3 major research projects during her sabbatical: Medical Education, Operation BraveHeart, and Masculinity and Mental Health and was given an NRF C rating and funding for the last. Dr Vivian presented a case study on how undergraduate medical students at UCT understand sexual reproduction, culture and health care at the Sexual Reproduction and Technology Conference in Copenhagen stimulating much debate on issues of equity between the developed and developing world, and the availability and suitability of sexual reproductive technology in a South African health setting.

Sarah Crawford-Browne is currently on sabbatical leave of six months to write up PhD research. At the four month mark she has drafted three chapters of her thesis. She will contribute to a SAAHE workshop on the value of critical theory in medical education, and to the WUN resilience project.

World Universities Network (WUN) Resilience in Young People

The theme of “Resilience in Young People in Different Cultural Contexts” was conceived at a Washington DC meeting in 2013, and a small group headed by Prof Reid put together a RDF proposal to WUN which was successful, backed by pledges from a number of WUN universities. This allowed a group of 15 to meet for two days in Cape Town just prior to the larger conference on Climate Change and Public Health, in order to develop the initial ideas into feasible research projects. Two research projects were conceptualized - one focusing on resilience in young people and the promotion of

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positive adaptation, resilience and well-being in migrant youth; the other focusing on the resilience of professionals (such as teachers and health workers) who promote the health of young people and how they adjust positively to occupational adversity over time.

REFLECTION

The PHCD has been in existence for 10 years and needs to be reviewed in the light of changes in its composition and functions since its inception, as well as the changing context of the Faculty of Health Sciences, the University of Cape Town, the province and the country. The extent to which the original goals of the PHCD have been achieved, needs to be assessed, and the goals themselves reviewed.

Through the leadership of 3 directors and an acting director over the period of 10 years, many changes have taken place. Primary Health Care is not a cognate discipline in itself, but requires a complex interdisciplinary and intersectoral approach, so the PHCD has to work through other departments in order to achieve its goals. As the mission of the PHCD suggests, most of these are achieved through education and social responsiveness, although academic research in the field is now also increasingly being produced.

The structure of the PHCD as a cross-faculty unit under the Dean’s office is both an advantage and a disadvantage. The advantages include the ability of the unit to interact at an equal level but not competitively with the whole range of departments in the faculty, and to take responsibility for cross-cutting issues that are not otherwise taken up and implemented. The disadvantages include the inability of the Directorate to run postgraduate programmes or register PhD students independently, which means that the unit cannot develop its own funding streams but must rely on faculty funds.

The relationship of the PHCD with the Department of Public Health and Family Medicine is a close one, starting from the situation of being part of the Department prior to 2003. The division of responsibility for the MBChB 4th year block into public health and health promotion course codes, creates a conceptual separation of the discipline of Public Health from the PHC approach that is somewhat contrived. From an undergraduate teaching perspective, this separation can cause confusion. However the insertion of the PHC approach into the teaching of other disciplines such as internal medicine or paediatrics is clearer.

FUTURE DIRECTIONS

This review must answer the strategic question of the optimal organizational place of the PHC Directorate within the Faculty. The proposed Department of Health Sciences Education presents an opportunity for new thinking regarding the teaching of PHC. As another cross-cutting entity within the faculty, the DHSE could strengthen currently fractured undergraduate teaching through supporting the development of the so-called “transversal skills and attributes”. Alternatively the DHSE could incorporate the PHC Directorate which could create a viable structure but potentially weaken the PHC theme through a dilutional effect in a larger Department. The teaching and learning of the PHC approach can and should be strengthened, and the application of solid educational theory and principles in a new DHSE could achieve this. Working from a starting point of social accountability, we need to challenge students to think critically, creatively and with agency about initiatives that will facilitate health for all once they are qualified.

At a provincial level, the signing of the MLA with the Western Cape Province Department of Health in 2012 has significant implications for the clinical teaching platform. The successful implementation of teaching at Vredenburg has set a positive precedent in a rural environment, but at a cost that cannot be replicated in every district hospital. The expansion of the clinical teaching platform to George is the next big step, and different teaching models will need to be developed.

At a national level, the PHC re-engineering strategy and the imminent white paper on the National Health Insurance will change the landscape of health services in years to come,

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in the context of the National Development Plan. We need to be preparing our students and graduates for the NHI and using this as a lever for the PHC approach.

Globally, primary health care is still the way to go, as articulated by the World Health Organization, so the need for a focus on the PHC approach in the teaching, research and service of the Faculty of Health Sciences and UCT will continue for the foreseeable future.

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