Introduction

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 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 2^nd 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 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.

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:

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  What is the right balance in teaching capacity at different levels of care?
  
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  What teaching & learning activities are currently happening at each level/site?
  
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  What should the size and shape of teaching at the level/site ideally be?
  
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  What are the next steps to facilitate the establishment? Of the ideal learning site, and how could this be funded and sustained?
  
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  Does the clinical teaching platform at community, district, secondary and tertiary level need to expand, stay the same, or decrease?
  
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  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.

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 5^th 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 1^st year in the faculty in 2013 was double that of previous years, around 17% of the total number.