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Communist University - Political School Material

Issue 4, Vol 15: 3 May 2018

In this issue:

 

Viewpoint by Mluleki DlelangaIs the Mandela-Castro Project fading away

By Mluleki Dlelanga

President Nelson Mandela visits Cuba on 10 December1991 "one thing before I say anything, before we say anything, you must tell me when you coming to South Africa. We have had a visit from a variety of people and our friend Cuba , which helped us in training our people, gave us resources to get all with our struggle, trained our people as doctors and so on , you have not come to our country, when are you coming, and further said " we have come here today recognizing our great debt to the Cuban people. What other country has such a history of selfless behaviors Cuba has shown to the people of Africa. How many countries benefit from Cuban health care professionals and educators? How many of these volunteers are now in Africa. What country has ever needed help from Cuba and has not received it and how many countries threatened by imperialism or fighting for their freedom have been able to count on the support of Cuba

President Fidel Castro response "The sooner the better. I have not visited my South African homeland. I think it will be today, I will have to fly back with you"

Fidel Castro meets President Nelson Mandela on the 02 September 1998 in Johannesburg

President Nelson Mandela "It's a great moment for us to be visited by Fidel, because what he has done for us is difficult to put in words, firstly, during anti-apartheid struggle he never hesitated at all to give us maximum support, now that we are free we have a large number of Cuban doctors helping in rural areas where there are hardly any doctors at all and I've had an opportunity to thanking him on support they gave to South Africa"

President Fidel Castro" Am sure you understand. This is one of the happiest moment evenings in my life. First, I find my dear brother Mandela, better than ever in excellent health. Secondly, because I find him with the same enthusiasm he has had in his life, always. Thirdly, because of what he has just said, he will visit Cuba soon. So he is full active, very well informed about everything in the world. Very wish to take part in the forthcoming international conference. I feel privileged and honored being here"

Introduction

There are many bilateral agreements between countries were countries assist one another in capacity development programmes. One such agreement was signed by the late Fidel Castro of Cuba and the late Nelson Mandela of South Africa. This agreement is known as the South Africa-Cuba health co-operation agreement. It was aimed to address critical shortages of South African doctors.

Fidel Castro was a communist and an internationalist who believed in the negation of privatization and the negation of private property in the healthcare system, so that free quality healthcare can be accessible to all. Upon taking state power in Cuba, the Castro regime nationalized all the privately owned means of healthcare production, annihilated the conglomerate private healthcare sector and created one unified healthcare system (single tiered system) that focused on a preventative approach to healthcare. On the contrary, upon the African National Congress (ANC) taking state power in 1994, Mandela's regime kept the two-tiered system (private/public sector) in the healthcare system intact; wherein a minority that could afford healthcare was permitted to access private quality healthcare in the private sector and the majority that was working-class and poor was relegated to accessing lower quality healthcare in an under-resourced public healthcare sector. South Africa focused on a curative, doctor- centric and hospital-centric approach, though the ANC, through the RDP (1994) campaigned for a unified healthcare system and the National Health Service (NHS).2 Therefore, Cuba and South Africa's bilateral agreements date as far back as 1996. This document seeks to establish where the programme is at this stage (2018), what may be the challenges, and what needs to be done

Brief policy and historical background

During 1996, GEAR (1996) was introduced in South Africa as a macroeconomic policy framework.3 this framework led to the further expansion of the conglomerate private healthcare sector in South Africa. The gap between the rich and the poor became wider. Racialized income inequalities were heightened. Healthcare and medical training became expensive and inaccessible to the majority of the population. Comparatively, in Cuba, the policy of free healthcare for all was guided by the Cuban constitution. Cuba offered free healthcare and free medical training for all. Therefore, the bilateral agreement created a programme where South African learners from disadvantaged rural communities were sent to Cuba to become medical students at a Cuban medical school. The Cuban medical curriculum is designed to graduate a basic general doctor after six years, who will staff a family doctor's office while pursuing a residency (specialist training) in comprehensive general medicine (family medicine). Since the programme's conception in 1996, there are approximately 900 fourth-year medical students from South Africa who are studying medicine in Cuba, and who are expected to return to South Africa in their final year in 2018.

The training of South Africans in medicine by Cuba began with a bilateral agreement between former South African President Nelson Mandela and former Cuban President Fidel Castro. In 1996 the South African government entered into a bilateral agreement with the government of the Republic of Cuba to establish the Nelson Mandela-Fidel Castro Medical Collaboration programme. The first cohort trained in Cuba in 1996. Since its inception the programme has produced over 500 medical doctors who are eventually placed in health institutions in the rural areas of the country.

South Africa and Cuba celebrate over 20 years of bilateral collaboration.4 all costs of the programme are borne by the South African government including tuition, travel, accommodation and subsistence. This includes a R2 000/month stipend, stationery, food and accommodation and white coats. A recently appointed special attaché is set to take over the ‘guardian' duties for the medical students (which was formerly allocated to the South African embassy). The challenge is that medical students receive an initial five years training in medicine in Cuba, in Spanish, and then complete their final year in English at South African medical schools.

Most medical schools require the returning medical students to join a 6 or 12 month orientation programme before entering the final year. Such an orientation programme prolongs their study. For the past years, the annual output of Cuban-trained South Africans, integrated in their final year at local medical schools, came to less than 8% of the 1 000 graduates that have trained locally. Though the programme has produced over 500 medical doctors, who are eventually placed in health institutions in rural areas of the country; since its inception 590 doctors have qualified and are working in rural communities. The cooperation (Nelson Mandela-Fidel Castro Collaboration) consists of three elements: exchange in biotechnological and innovation in health, exchange of health professionals and academics, and recruitment including the undergraduate training programme. Recently, seventy (70) students have graduated at the July (2017) ceremony providing a much needed boost for healthcare in South Africa.5

The programme which trains South Africans as doctors in Cuba will expand nearly tenfold for the next 5 years, pouring 1 000 undergraduates annually into our currently under-resourced local medical campuses from 2018 onwards. The programme seeks to address the shortage of doctors in the country. South Africa needs to increase the number of doctors working in the country in order for the National Health Insurance (NHI) to succeed. The country has approximately 5 doctors per 10 000 population. South Africa would have to double its production of doctors to close the gap. There is an existing deficit of close to 12, 000 medical practitioners and specialists in South Africa. There are 2 885 South African medical students in Cuba, at various levels of study, 98 are in their final year. The students are pioneers of government's efforts to re-engineer primary healthcare.

South Africa lacks medical schools (the last one was built in 1976 when the population was 22 million). Cuba has 25 medical schools from which 11 000 doctors graduate annually, and countries from all over the world send students there. The Cubans offered to include South Africa among the 114 other countries they trained. Since Cuba has met the doctor needs of several countries, South Africa was able to take advantage of its available capacity. The argument is that providing additional training to address the "gap in skills and knowledge" in returning medical students is an important part of their successful reintegration. It is further argued that this "reintegration" strategy could be insufficient on its own and must be complemented by a range of measures designed to ameliorate the discrepancies in identity which arise from the transition from one educational model to another. There is a debate over the suitability of preventative (Cuban) medical training versus curative (South Africa) training given South Africa's current quadruple burden of disease and a shift towards Universal Health Coverage (UHC). The argument is that the assimilation of Cuban trained medical students is traditional as it involves conforming to South Africa's curative based protocols.

South African medical students in the first Cuban academic year are devoted to learning Spanish. This is one of the programme's biggest challenges: studying medicine in Spanish. Medical students are trained in Spanish. Hence, most medical students experience academic difficulties on their return to South Africa.6 Local (South African) medical tutors will spend 12 - 18 months re-orientating the Cuban-trained fifth- year students to English medical terminology, and better positioning them for the unique local patient profiles, so that they can more confidently sit for the domestic final exam (which precedes their Cuban finals). The National Department of Health (NDoH) is working with eight medical schools to increase student intake, expand the schools, and build more medical schools - one of which has now been established in Limpopo Province. The problem is said to arise from a fundamental divergence in the outcomes of the Cuban and South African medical curricula, each of which is designed with a particular healthcare system in mind. In the final examinations, approximately 50 % repeat modules in order to qualify, resulting in a prolongation of training. So far, the local failure rate of Cuban-trained students is nearly double that of those trained in South Africa, but most pass within the minimum period of time. Students who study in Cuba spend a year learning Spanish, five years doing academic medical studies, and 18 months being integrated into the South African medical health system. They also undergo a one- year internship. The students are further disadvantaged by their lack of familiarity with South African medical education practice, such as the centrality of clinical bedside work in training and the use of multiple-choice questions in examinations, objective structured clinical examinations and bedside clinical examinations in assessment, activities of which they typically have had little previous experience.

There has been no published study that explores strengths of the returning medical students. However, those who graduate finally work as interns or community service officers - and like all Cuban-trained local doctors serve 5 year post-internship in their district where they were recruited.

Cuban programme and South African challenges

Currently, South Africa lacks medical schools (the last one was built in 1976 when the population was 22 million). Cuba has 25 medical schools from which 11 000 doctors graduate annually, and countries from all over the world send students there. The Cubans offered to include South Africa among the 114 other countries they trained. Since Cuba has met the doctor needs of several countries, South Africa was able to take advantage of its available capacity. The argument is that providing additional training to address the "gap in skills and knowledge" in returning medical students is an important part of their successful reintegration. It is further argued that this "reintegration" strategy could be insufficient on its own and must be complemented by a range of measures designed to ameliorate the discrepancies in identity which arise from the transition from one educational model to another. There is a debate over the suitability of preventative (Cuban) medical training versus curative (South Africa) training given South Africa's current quadruple burden of disease and a shift towards Universal Health Coverage (UHC). The argument is that the assimilation of Cuban trained medical students is traditional as it involves conforming to South Africa's curative based protocols.

South African medical students in the first Cuban academic year are devoted to learning Spanish. This is one of the programme's biggest challenges: studying medicine in Spanish. Medical students are trained in Spanish. Hence, most medical students experience academic difficulties on their return to South Africa.6 Local (South African) medical tutors will spend 12 - 18 months re-orientating the Cuban-trained fifth- year students to English medical terminology, and better positioning them for the unique local patient profiles, so that they can more confidently sit for the domestic final exam (which precedes their Cuban finals). The National Department of Health (NDoH) is working with eight medical schools to increase student intake, expand the schools, and build more medical schools - one of which has now been established in Limpopo Province. The problem is said to arise from a fundamental divergence in the outcomes of the Cuban and South African medical curricula, each of which is designed with a particular healthcare system in mind. In the final examinations, approximately 50 % repeat modules in order to qualify, resulting in a prolongation of training. So far, the local failure rate of Cuban-trained students is nearly double that of those trained in South Africa, but most pass within the minimum period of time. Students who study in Cuba spend a year learning Spanish, five years doing academic medical studies, and 18 months being integrated into the South African medical health system. They also undergo a one- year internship. The students are further disadvantaged by their lack of familiarity with South African medical education practice, such as the centrality of clinical bedside work in training and the use of multiple-choice questions in examinations, objective structured clinical examinations and bedside clinical examinations in assessment, activities of which they typically have had little previous experience. To date there has been no published study that explores strengths of the returning medical students. However, those who graduate finally work as interns or community service officers - and like all Cuban-trained local doctors serve 5 year post-internship in their district where they were recruited.

Cuban programme and South Africa's plan for Universal Health Coverage (UHC)

South Africa suffers a serious imbalance between doctors employed in urban versus rural areas. It has been estimated that only about 35 of the 1200 medical graduates produced annually will choose a rural career in the long term. The aim of the ‘Nelson Mandela/Fidel Castro Medical Collaboration' program is to train underprivileged South African students in Cuba. The Cuban trainees are recruited from disadvantaged communities countrywide and with a significantly lower university entrance threshold. They are beneficiaries of the initiative that is aimed at returning students working in their home environments within which they are more likely to reside. This approach has its detractors. They argue that Cuba has almost no HIV/Aids patients and focuses on preventative healthcare; whereas South Africa deals with management of disease. Up to 80% of the illnesses of all patients seeking healthcare in South Africa were HIV-related. Cuba places great emphasis on community-based primary care, prevention and citizens' active participation - the same goals as South Africa's Universal Health Coverage (UHC) plan. Cuba also has one of the world's best health indices, and all its health services are government-run. An advantage of the Cuban medical program is that the curriculum is explicitly primary healthcare orientated.

South Africa's national health planning is predicated on the centrality of primary, district-based health care, yet South African curricula, despite continual discussion and incremental adjustment over many years, are still heavily weighted towards specialist, curative and urban medicine. The programme is needed for South Africa to reach its primary healthcare goals as envisaged by the National Health Insurance (NHI). South Africa should have between 800 and 1 000 new doctors who were trained in Cuba working across the country by 2018. There is a view that there is a shortage of doctors only. Therefore, to meet the goals of the NHI more doctors are needed. Yet, to implement the NHI system, South Africa needs a wide cohort of healthcare professionals i.e. doctors and nurses, pharmacists and radiographers, physiotherapists and optometrists, psychologists and audiologists, etc., (a human resource development strategy for the entire healthcare system) not just training doctors only! It is not an imposition to increase the local enrolment of healthcare science students in medicine and the allied forces not just medical students from 200 to between 500 - 1000 per annum per campus. Cohorts of South African medical students receive their initial five years medical training at a Cuban university before returning to South Africa for a six to twelve months orientation before integration into the local final year class.

Cuban-trained medical students and alienation

There is a view that returning students from Cuba "self-reported" a lack of familiarity and confidence to perform procedures with many of the practical procedures expected of locally-trained students by the end of their fifth year. It is now said to be common for Cuban-trained medical students to experience academic difficulty on their return to South Africa. Frequently, this is viewed merely as a matter of a knowledge deficit. These medical students are strongly identified as "South African" students while in Cuba, yet on their return to a South African university they find themselves labeled as "Cuban" students. In most cases, this labeling of medical students (who view themselves as South African) serves to identify Cuban-trained medical students as "foreign." This leads to alienation, guilt, low self-esteem, and unhappiness, potentially leading to depression. This establishes a self-perpetuating vicious cycle of under- performance, loss of confidence and withdrawal from learning opportunities. Yet, self-esteem is critical in medicine. The size of the programme has increased in recent years. More than 800 students will be returning to South Africa annually from 2018. A typical ratio of applicants for admission to South African medical schools and places on offer, as observed in certain medical institutions, is about 14:1. Consequently large numbers of South African students who cannot be accommodated locally, have enrolled for medical training in other countries, such as Cuba, China, Turkey, and Russia where the medical educational model is very different to that followed in South Africa. Re-integration in the South African system on its own is a process.

Recommendations

The output from the Cuban programme is too little for the size of the healthcare economy in South Africa, especially the rural economy. What should be done is to build medical schools in the rural periphery of South Africa so as to implement the human resource development strategy for the NHI. To do this a delivery vehicle may need to be developed that will focus not only on building medical schools/health science universities in the rural areas but also focus on developing the skills and the expertise that South Africa needs in foreign countries in order to address the human resource and skills shortages in the healthcare system. Due to medical training being expensive in other countries in the world such a delivery vehicle would have to be designed to be in a form of a fund: a financing mechanism, so that it funds medical education and the specific training of a cadre in the healthcare sciences that will capacitate the country's NHI program. There also needs to be a strategy for building the and construction of a health science university in the rural areas that is dedicated to producing graduates that are positioned to sustain the program of the NHI in South Africa; such a facility will serve as a dedicated facility for the integration of all medical students that have studied in foreign countries. Such a medical school in the envisioned health science university must also serve as a language school for preparing students for the foreign countries that they are to visit so as to pursue academic studies, and the foreign languages that they may have to use to pursue their medical and health science studies.

The Mandela- Castro programmes need a well-coordinated and tightly monitoring both on selection and reintegration for its sustainability as well as for the programme to achieve its intended objectives. This will need a clearly defined policy that will compel all provinces regardless of their feelings but to cooperate and participate in the programme.

Conclusion

First and foremost whether from the demand perspective or the supply perspective, as long as there is a demand of doctors in South Africa and as long as there is a huge shortage on the supply of doctors to deeply rural areas, the case for the Mandela-Castro programme remains.

The Mandela-Castro programme is beyond being a programme but a noble legacy of these two great leaders for the benefit of the poor people in our country. Therefore this is beyond the rand, cent and space. This is about well-being of the disadvantages South African population leaving in rural areas.

It is upon the current generation to first appreciate, understand and decide whether to allow this legacy to fade away. To allow the legacy of our great leaders to fade away will be destroying the ideas of our great leaders Mandela-Castro.

To allow the Mandela-Castro programme to fade away will be a betrayal to the cause of the South African working class.

To defend and sustain it will be in the interests of the disadvantage people in our country especially poor and rural people who have no access to doctors in their respectively deeply rural areas.

To sustain and defend the programme will be one step forward on building momentum and capacity for the full realization of the National health Insurance.

Young revolutionaries have no choice but to defend the legacy of Mandela-Castro, as young communists we shall defend the legacy of the two great leaders and even defend and uphold the Nelson Mandela two legacies , First of resolving conflicts through dialogue and Secondly , Mandela-Castro programme.

We dare not in our lifetime allow the Mandela-Castro programme to fade away!

We dare not in our lifetime such noble ideas got undermined and we say nothing!

Our country need more doctors to be trained in South Africa and Cuba that's the bottom line coz the YCLSA, Says So!

* Cde Mluleki Dlelanga is the National Secretary of the Young Communist League of South Africa