PI: Umesh Lalloo Co-PI’s: Raziya Bobat, Sandy Pillay, Doug Wassenaar, Jack Moodley, US Partner – Columbia University: Scott Hammer, Phil LaRussa Grant Number: 5R24TW008863

Background SA: 85% population dependent state health care sector Served by 30% of doctors 46% of population lives in underserved areas 2.9% of local medical graduates choose to work in rural areas. 1 Government’s recruitment and retention strategies limited success in attracting health professionals to work in rural areas. Need to transform the current medical teaching and training platforms include these areas with the greatest need MEPI-UKZN Entree Program3 1. Bateman C, SAMJ 2011, Vol 101

Background – premise of the MLC concept Governement pledge to transform the health system Re-engineering of the PHC Approach increase medical graduate numbers three-fold International evidence that career choices are strongly influenced by where and how a student is trained Those with positive rural exposure are more likely to return to a rural setting Teaching in PHC settings allows students to understand and manage common community illness better MEPI-UKZN Entree Program4

Background Medical training at UKZN largely urban-based, in disciplinary silos KZN Ministry of Health UKZN’s medical training not geared to meet community needs Curriculum reform underway at UKZN Opportune time to align with Governement, HPC SA and MEPI objectives Decentralised clinical schools A strategy to train greater number of appropriately trained doctors More likely to remain in the underserved health sector MEPI-UKZN Entree Program5

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Theme 1: Increasing capacity MLCs will provide platform for decentralised training – potential for more undergraduate students Curriculum enrichment Medical students: Family Medicine in 4 th -6 th years initially but will expand to other clinical disciplines like O&G, Paediatrics Nursing students: 5 week Rural health attachment being developed Pharmacy students: rural attachment in the 1 st year Short courses will be hosted at MLCs NIMART, ESMOE, HIV Updates, IMCI Undergraduate students supervised by Mentors from each site MEPI HIV Diploma graduates and UKZN academic staff MEPI-UKZN Entree Program7

Theme 1: Increasing capacity Will support postgraduate training for registrars Family Medicine, Public Health Medicine Provides a platform for the District Clinical Specialist teams Local hospital, clinics and district training can occur at MLCs Family Medicine Emergency Medicine updates MEPI-UKZN Entree Program8

Theme 2: Retention Those with positive rural exposure are more likely to return to a rural setting Decentralised centres of excellence encourages the support and supervision of rural clinical staff MLCs can serve as opportunities for ongoing research by rural clinical staff MEPI-UKZN Entree Program9

Theme 3: Support locally driven research Medical students’ electives in 2,3 & 4th years at MLCs A new initiative (supported by MEPI) promoting research at an undergraduate level MEPI’s dual qualification program for the exceptional undergraduates Data collection will begin in the 4 th year at MLCs MLCs will support and provide opportunities for postgraduate research MEPI-UKZN Entree Program10

MEPI-UKZN Entree Program11 Baby boomers

Structure of MLCs Infrastructure at the major centres Lecture and meeting rooms equipped with Video- conferencing links, computer LAN with laptops and internet/intranet access Library Resource Centre with document repository- Journals, National/ International guidelines/ policies Skills laboratory Administrative site coordinators Accommodation for facilitators, students, visiting lecturers Recreational facilities 12MEPI-UKZN Entree Program

2 urban 1. Wentworth, eThekwini District 2. Northdale, uMgungundlovu District 5 rural academic centres 1. Murchison Mission, Ugu District 2. Pholela, Sisonke District 3. Bethesda Hospital, Umkhanyakude District 4. St Andrews Hospital, Harding 5. Manguzi, Umkhanyakude District

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Murchison Hospital Located in Ugu district in South Coast - 13 km from Port Shepstone Ugu identified as one of 10 most deprived health districts in SA (DHB 2007/08) Catchment population of District level of care with 260 beds. 8 satellite clinics Forms part of a complex with other district hospitals - St Andrew’s Hospital in Harding and St Apollonaris. 15MEPI-UKZN Entree Program

Murchison Hospital Rental & refurbishing of 3 Buildings on Murchison Mission completed in Sept 2012: Accommodation for 10 students + Facilitator’s house Teaching facility with LAN Proposal for purchase of land submitted by Rural Health to Atlantic Philanthropies - funding secured Procurement of the land by UKZN underway MEPI-UKZN Entree Program16

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Pholela Community Health Centre -from Jerusalem to Pholela Historical significance: birth of COPC under the direction of Sydney and Emily Kark DOH offered MEPI its full cooperation and support to establish a MLC at this site for student and staff teaching and training MLC and accommodation being set up in line with Murchison model MEPI-UKZN Entree Program18

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Bethesda Hospital 2 newly qualified family physicians have been located here Hospital management very supportive of the MEPI programme - renovating a building at their cost for the establishment of the MLC. Computers have been installed MLC expected to be complete by October MEPI-UKZN Entree Program20

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Wentworth Hospital Urban Site District Hospital Medical library as a teaching centre Video Conferencing Facility established Can accommodate 40 people Examination and skills training venue Training site for Post graduate Family Medicine Registrars Venue for CPR training for hospital staff MEPI-UKZN Entree Program22

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Northdale Urban Site District hospital in PMB Collaborative effort between the Department of Telehealth at UKZN and MEPI Video-conferencing facility and computers with LAN have been installed MEPI-UKZN Entree Program24

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The Decentralised curriculum In 2013, the 4 th year Family Medicine block was increased to 4 weeks The programme includes a 2-week rotation at one of the 3 MLCs M&E of the student programme at the MLCs has been established. MEPI-UKZN Entree Program26

Structure of Curriculum Orientation prior to clinical attachment - Skills training – IMCI, communication & procedures - HIV enrichment course - ECI Use of pedagogy suitable for decentralised sites - MOODLE, Telemedicine, Bedside tutorials, diary Evaluation - OSCE, Portfolio, written - Anonymous questionnaires MEPI-UKZN Entree Program27

Focus areas Ambulatory care in PHC facilities (HEALTH EXPERT) Multi-disciplinary team (COLLABORATOR) Patient-centeredness (COMMUNICATOR) Exposure to decentralised training in rural, peri-urban & urban sites (HEALTH ADVOCATE) MEPI-UKZN Entree Program28

Evaluation Three-phase M&E plan developed to assess short, medium and long term outcomes of the programme Currently in the first phase of the evaluation Institutional ethics approval for study “Medical students perceptions and experiences of a decentralised training programme” obtained Quantitative evaluation completed – preliminary results available Qualitative enquiry to begin post Uganda

Phase 1 evaluation perceptions and experiences of the 4 th year medical students regarding the decentralised medical training programme introduced in 2013 self-reported knowledge and skills gain perceived effectiveness of various teaching methods used in decentralised teaching challenges and benefits of decentralised teaching based on experiences differences in perceptions and experiences across the following parameters: Training sites (rural vs. urban), Successive groups/cohorts of students, and Students’ individual profile

Satisfaction with learning objectives in a Clinic vs. Hospital

Satisfaction with the training experience

Why was Moses banned from the Olympics free style swimming event?

Acknowledgements The US Government for its foresight Dr Bernard Gaede – Discipline of Rural Health, UKZN Dr Keshena Naidoo – Discipline of Family Medicine, UKZN Mr Moise Muzigaba – MEPI M&E Specialist MEPI-UKZN team The ME ME ME generation for embracing us baby-boomers MEPI-UKZN Entree Program34