Bottomless pit, or rich resource? – Are Cuban-trained doctors worth the cost?

The 1 292 Nelson Mandela Fidel Castro Health Collaboration Programme medical students who graduated this week join the long list of other newly qualified South African doctors caught up in government’s community service placement fiasco.

The South African Medical Association Trade Union (Samatu) has bemoaned that the Department of Health did not have funding for 644 community service and 384 interns at government health facilities for 2022. 

The Cuban cohort’s addition to the list of now unemployed medical professionals comes against the backdrop of concerns about the costs and benefits of the programme, as well as questions about the level of training and competency of SA doctors trained in Cuba.

Also Read: Free State has spent R57m on sending medical students to Cuba

The programme was first instituted in 1996 and expanded in 2011 to meet the needs of rural and under-served urban areas, resulting in about 800 students per year training in Cuba.

This according to a study on Cuban medical training for South African students, which also notes that in 2018 around 700 Cuban-trained doctors returned amidst concerns about how their training would be supervised and the subsequent costs of absorbing them into the health system.

Why not train locally?

The study also noted criticism of the logic behind training South Africans in another country, in a different language and culture. Released in June 2019, the study has further noted that as Cuban-trained graduates started to return, further concerns were raised about their competencies for practicing medicine.

In response to the perceived gaps in their training upon return, South African medical schools have provided one to three years of extended medical school training to fill skill gaps related to TB, HIV and major trauma.

Estimates in 2019 put the annual cost of training a doctor in Cuba R331,000 per person. This means government spent more than double what it would cost at a local medical school, while require a year longer for said training than had it been done locally.

The benefit of the cost of the programme has become a contentious issue, with concerns on the return of investment in the programme. This becomes doubly contentious when considering these Cuban medicine graduates still require additional training upon their return.

Independent public health practitioner Dr Shakira Choonara said like other experts, she was concerned that the costs of the programme outweighed benefits.

“It’s too expensive, and absorption of the graduates remains a challenge. Other than bilateral relations this programme is not cost effective for the health system. Government continues to ignore this,” she lamented.

Also Read: Millions for Cuban doctors in SA paid out of HIV/Aids grant – DA

Public health expert Dr Atiya Mosam said though she has had no experience with Cuban trained doctors other than from her reading, the competency concerns need further exploration.

“I will say that given the concerns raised, there needs to be a formal process of assessment by the HPCSA (Health Professions Council of SA) for these students similar to the board exam taken by foreign doctors wishing to work in SA, that pegs the Cuban trained doctors’ skill levels to that expected of a final year medical student, and only those that pass these exams be allowed to graduate into our health system,” she said.

Mosam said from her understanding, this process was not in place for Cuban-trained doctors and she viewed this as a failure of the SA health system to protect citizens from harm.

Are we getting our money’s worth?

A doctor at a Johannesburg state hospital has said that in recent years some of the junior Cuban-trained doctors’ clinical skills have come up short, suggesting a level of training far below what would be deemed acceptable in a local medical school.

The specialist suggested the doctors were possibly being passed without meeting the usually high Cuban medical training requirements, in order to get them out of the programme and make way for next cohort.

Another doctor echoed this sentiment, relaying an incident during which they ordered a recently graduated Cuban-trained doctor out of their theatre in the middle of a surgery, and ordered him to go read up on basic physiological knowledge.

Dr Glenda Davison, associate professor and head of the Biomedical Sciences Department at Cape Peninsula University of Technology in Cape Town, however, said though she was a scientist and not a medical doctor, she believed the Cuba-SA doctor training programming remains beneficial in the bigger scheme of things.

She explained that the Cuban health care system is vastly different to SA’s as it focuses on primary health care and prevention, while SA medical training emphasised curative, or reactive medicine.

Change in approach could benefit SA

Davison said the Cuban approach to health care could be very beneficial, particularly in rural communities and for people who do not have access to hospitals.

She said Cuba has been hailed for the quality of doctors and their skill in developing community programs.

The Nelson Mandela Fidel Castro Health Collaboration Programme (NMFCHCP), Davison said, was a historical agreement and aimed to allow SA medical students to acquire these skills and introduce them locally.

“South Africa has a very different approach to healthcare. In South African medical Schools the focus is more on curative medicine rather than preventative. Students are encouraged to specialise,” she explained.

“It is therefore not surprising to me that students coming from Cuba feel different and not included. Another factor to take into account is the differences in disease profiles between the two countries. South Africa has a high burden of HIV and TB compared to Cuba, and therefore medical students here would be exposed to this more often.”

She does not believe that the students coming from Cuba are incompetent at all, but have developed different skills which are more community based, saying this was perhaps an area that SA medical schools could learn from.

“These graduates are ideally placed to take preventative health care into rural areas and make a difference.  These differences should be embraced and discussed, and ways developed on how to incorporate these skills into our programs,” Davison added.

The department of health is yet to respond to these claims as well as questions on the programme cost since inception, and its measurable impact on access to health, particularly in rural areas where it is intended to assist.

It is also unclear what impact the current backlog in placing of community service doctors due to budgetary constraints would have on the placement of these new graduates.

siphom@citizen.co.za