Abstract
Why take a year Out of Programme (OOP) in South Africa (SA)? Rural hospitals and primary care facilities in SA and other developing countries have a significant need for doctors and allied health care professionals. This is due to numerous well-described push factors, such as limited academic opportunities and equipment shortages and pull factors such as private sector salaries and an urban lifestyle. This has lead to chronic challenges for recruitment and retention of South African medical graduates. Working in rural SA as a UK trainee offers multifaceted and varied medicine along with the challenges and rewards of rural living. Trainees in General Practice, as well as those in other speciality training, are likely to benefit from a variety of enhanced skills and competencies (Box 1). For a more detailed guidance on the practicalities of organizing an OOP, please see Ladbrook, 2010.
The London Deanery recognizes the increasing demand for trainees wanting ‘Time Out of Programme’ to gain experience in international healthcare systems. In 2008, as a response to the Crisp Report, a pilot scheme on the St Mary's GP Training Programme (organized through the London GP Deanery) offered a year working in rural SA, which was accredited, unlike many OOP placements, for 6 months of GP Training. This grew into a fully supported and quality assured programme in approved hospitals in SA through a partnership with the not-for-profit organization Africa Health Placements (AHP) (Box 2). Accreditation for training is subject to General Medical Council (GMC) and local Deanery approval and not all posts are accredited at the time of writing.
Programme development
In February 2008, Dr Neera Dholakia filled the first 12 month post in KwaZulu Natal. She was supported by an educational supervisor in the UK, a clinical supervisor in the South African placement hospital and by the AHP team. Following a successful pilot, the programme has continued with eight further trainees taking up this opportunity. The programme has further diversified into other hospitals and now offers managed, quality assured, Out Of Programme Experience (OOPE) posts, with a number of hospitals in KwaZulu Natal and the Eastern Cape participating.
Case study: Dr Neera Dholakia, GP Trainee
I worked in Manguzi Hospital in northern KwaZulu Natal which has 280 beds, a number of satellite clinics, covers all specialities and has approximately 12 doctors. This scheme afforded me the opportunity for a challenge in a new environment with a guaranteed job on my return.
Scenes from South Africa Photographs provided by Africa Health Placements www.ahp.org.za
Challenges of living and working in rural South Africa:
Electricity and water shortages - overcome with barbeques for cooking and mineral water
Contact with home - inadequate internet and telephone communication
Remoteness - planning in advance if you need to go to a city
Little beasties - mosquitoes, cockroaches, scorpions, snakes
Conclusions
Through the London GP Deanery-AHP partnership, a streamlined process of preparation, induction, local support, quality assurance and reflection for OOPs in SA has been developed and continues to evolve. An alumni programme also exists. The London GP Deanery plans to build in sustainability by offering a continuing resource of GP trainees for OOP hospital posts in rural Southern Africa. The posts will be evaluated for suitability for ST4 placements, in line with the Tooke Report for extension of GP Training. It is planned that the programme will be extended to Zambia and Rajasthan from 2011.
Enhanced skills and curricular competencies
Use of interpreters, non-verbal communication and patient-held records in the consultation Zulu language and culture lessons including role of isangoma (witchdoctors) and alternative healers Approach to health with human immunodeficiency virus (HIV) testing and safe sex promotion, good nutrition and ways to grow food
Experience of all specialities (medicine, surgery, paediatrics, obstetrics, outpatients, emergency, HIV, TB and satellite clinics) and allied health care, e.g. physiotherapy, dietetics and audiology Time management of a wide caseload with complex acute and advanced presentations
Video conferencing/telemedicine of dermatology clinics Consideration of whom to refer with limited transport
Minor surgery a regular feature
Working with colleagues and in teams in a small community
Stock and budget control meetings, planning for resource shortages Setting up a new service, e.g. mental health using current guidelines
SA doctors offered training to UK doctors in: HIV, tuberculosis, tropical medicine, surgical skills, e.g. minor operations and caesarean sections UK doctors offered training to SA doctors in: cognitive behavioural therapy, palliative care, chronic disease management
Africa Health Placements
AHP is a not-for-profit non-governmental organization that supports doctors working in Southern Africa by:
Facilitating registration and work permit applications for SA, Swaziland and Lesotho Matching the doctor's needs to available opportunities Orientation and induction support including cultural information, access to language courses and logistical arrangements Clinical and management training (e.g. 2 week anaesthetics course) and distance learning [e.g. HIV management course, through the Foundation for Professional Development (FPD)] Ongoing support throughout the stay through access to courses and a continual point of contact for assistance with local issues
Email:
For guidance on working abroad, please refer to guidance from the British Medical Association (BMA) (www.bma.org.uk/international/working_abroad/broadeningyourhorizons.jsp) and the Royal College of General Practitioners (RCGP) Junior International Committee (www.rcgp.org.uk/international_home/junior_international_committee.aspx)
Footnotes
Acknowledgements
Dr Neera Dholakia, was a trainee at the time of writing and is now a salaried and freelance GP. This article is based on a poster presentation prepared by Neera for the 2009 RCGP Conference, which can be viewed on the AHP website (
). Photographs provided by Africa Health Placements www.ahp.org.za.
The authors would like to thank the dedicated staff at the London Deanery and AHP, as well as the GP trainees who participated in the programme.