Introduction

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 affordable and effective form of primary treatment in poor countries. He lectured to 2^nd 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 4^th 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 4^th-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 4^th 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 4^th 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 6^th year curriculum will continue to be interrogated with the aim of exploring the implementation of a longitudinal 6^th 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.
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 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:

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  Enhance research collaboration
  
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  Develop trans-disciplinary research collaboration within the university
  
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  Promote the Faculty’s research strategy
  

The PHCD’s primary goals are to:

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  Integrate a primary health care approach into the FHS curricula
  
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  Extend and develop the FHS clinical teaching platform in rural and primary care sites
  
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  Deepen community engagement within the health service and the FHS curricula
  
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  Enhance the recruitment and support of students of rural origin in the FHS
  

The PHCD’s operational goals are to:

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

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 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 4^th 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, 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.