Innovation and Implementation Reports
A Strategy for Developing Future Academic Leaders for South Africa in a Resource-Constrained Environment Umesh G. Lalloo, MD, Raziya A. Bobat, MD, Sandy Pillay, MBChB, and Douglas Wassenaar, PhD
Abstract A key challenge in addressing the shortage of health care workers in resource-constrained environments is ensuring that there is optimal academic capacity for their training. South Africa’s University of KwaZulu-Natal has placed academic and research capacity building at the heart of its program with the Medical Education Partnership Initiative in a program called ENhancing Training and REsearch capacity and Expertise (ENTREE). The program aims to increase
T
he Medical Education Partnership Initiative (MEPI) seeks to address the challenge of providing an optimal number of health care workers in SubSaharan Africa where it is estimated there will be a shortage of approximately 150,000 personnel by 2020.1 This is based on the projected health care needs of the region, largely driven by HIV and TB, and the next wave of noncommunicable diseases such as diabetes mellitus, hypertension, obesity, ischemic heart disease, and chronic obstructive pulmonary disease. A recent series on health in South Africa, 15 years after its first democratic election in 1994, indicates that the country is faced with a quadruple burden of disease.2–5 South Africa has eight medical schools, with a total intake capacity of approximately 2,000 new students annually for a training duration of six years. This is inadequate for South Africa’s needs. Existing health care workforce shortages have severely Please see the end of this article for information about the authors. Correspondence should be addressed to Professor Lalloo, University of KwaZulu-Natal, Nelson R. Mandela School of Medicine, Department of Pulmonology and Critical Care, 719 Umbilo Rd., Durban 4001, South Africa; telephone: (+27) 31-260-4537; e-mail: [email protected]. Acad Med. 2014;89:S55–S59. doi: 10.1097/ACM.0000000000000354
the quantity, quality, and retention of health care graduates. It is premised on the basis that research capacity development will lead to an increase in teachers who will be essential to improving the quality and quantity of health care workers needed to meet South Africa’s health challenges. This is being achieved through four components of the program: (1) infusion of the undergraduate program with research modules; (2) attraction of academically
talented students in the middle of their undergraduate program into a parallel track that has research capacity as its major thrust; (3) attraction of qualified health care personnel into a supported PhD program; and (4) providing strong research ethics training and mentorship. A significant proportion of the program is being executed in rural training sites, to increase the probability that trainees will return to the sites as mentors.
constrained the rollout of antiretroviral treatment for HIV. Rural areas are inhabited by 46% of the total population, but only 12% of doctors and 19% of nurses work there. Further disparities exist within the public sector, as health care practitioners continue to migrate to the private sector and to other countries.6,7 The factors surrounding these shortages include finances, job satisfaction, career opportunities, security, postgraduate education, family, work relationships, and workload.8–11
premise that health care professionals who are well trained and experienced in medical research are more likely to follow an academic research career and to be retained within local academic institutions.13
The ENTREE Program at University of KwaZulu-Natal
KwaZulu-Natal has a population of about 10.3 million and is the most populous of the nine provinces of South Africa, with a population of 51.8 million.12 KwaZuluNatal is also the epicenter of the HIV epidemic and has a TB incidence rate of about 1,000/100,000.4 The University of KwaZulu-Natal (UKZN) Nelson Mandela School of Medicine currently enrolls a maximum of 210 students annually and has limited capacity for training allied health care professionals such as nurses and pharmacists. The new UKZN MEPI program is called ENTREE (ENhancing Training and REsearch capacity and Expertise). The program aims to increase the quantity, quality, and retention of health care graduates by increasing research capacity. This is based on the
Academic Medicine, Vol. 89, No. 8 / August Supplement 2014
The ENTREE program targets UKZN’s medical, nursing, and pharmacy students in its College of Health Sciences, using existing programs and resources within the college and school and in collaboration with Columbia University College of Physicians and Surgeons in New York. The ENTREE strategy is summarized in Figure 1 and shows the projects that are focused on academic and research capacity development. The program’s main objectives include: (1) To increase the competence of medical, nursing, and pharmacy students in the management of HIV and AIDS by enhancing undergraduate training through infusing the curriculum with a continuum-of-care approach to HIV and AIDS and improved clinical preceptorship; and scaling up of an innovative parallel training track for selected undergraduate medical students in HIV toward a diploma/ master’s degree program, from which students will be identified for postgraduate development programs and academic research career paths.
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the four posters were judged as exceptional by the panel of referees, which consisted of senior academics from the College of Health Sciences of UKZN. These three groups submitted abstracts and presented posters to the Public Health Association of South Africa conference in Cape Town in September 2013.
Enhance quality of clinical and research capacity Undergraduate students: Medical Pharmacy Nursing
Enrichment of curriculum in clinical HIV and Public Health 1. Didatic 2. Preceptorship
Dual qualification
Faculty and HCWs
Providing an enabling research environment
Attracting outstanding students to an MPH program
Recruit ±10 PHD candidates per year
Diploma in HIV, Research methods and mentorship
Figure 1 The University of KwaZulu-Natal Medical Education Partnership Initiative ENhancing Training and REsearch capacity and Expertise (ENTREE) program. The program aims to increase the quantity, quality, and retention of health care graduates by increasing research capacity.
(2) I ncrease the competence of junior doctors through the development of a program that will create a cadre of master trainers to support and enhance the internship experience, create a supportive learning environment, and attract medical trainees to return to these centers. (3) D evelop and support a program to enhance skills in research methodology, research ethics, and research implementation, with particular emphasis on HIV and related complications so that a cadre of academics and researchers can be established. (4) D evelop a program to promote retention of academic and research staff by providing a research career pathway and research support. The major thrust of the MEPI program is to increase the quality and quantity of health care workers. In this report we describe how UKZN’s ENTREE program is designed to increase research capacity, which is fundamental to increasing capacity for the production of competent health care workers. Four Key Components
Incorporating research into undergraduate programs This component offers third-year undergraduate medical students, in a six-year program, an exposure to research methods. The students are divided into groups to conduct community-based
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research projects and prepare scientific research posters for presentation at a Poster Day meeting. During the week, eight lectures on research methods are presented. This includes a session from one of the senior members of the university research ethics committee so that students are better prepared to develop their community-based research protocol. By the end of this week, the protocols for each group are expected to be completed and submitted for research ethics approval. The group presenting the best-assessed poster receives a cash gift voucher. Research electives in rural areas are supported by the development of academic learning centers called MEPI Learning Centres (MLCs), developed through the ENTREE program. These comprise physical academic resources such as video and teleconferencing facilities and a small-group (15–20 students) lecture theatre and skills laboratory, situated within designated rural areas and urban centers away from the medical school, where undergraduate students rotate through a MEPIsupported expanded rural and family medicine rotation, supported by trained academic leaders/supporters. Two cohorts of medical students have experienced these ENTREE research modules to date, resulting in poster presentations by four groups of students. These were facilitated by the ENTREE program’s audiovisual and videoconference facilities to communicate with the MLCs and medical school. The group assessed to be the best poster received $100. Three of
It was envisaged that 10 students would be selected on the basis of outstanding academic performance and potential during the third year of their six-year undergraduate medical (MB ChB) program to participate in a parallel track program as part of the master’s in public health program. Selection is planned to favor black African students of which at least 60% will be female. Incentives built into this parallel track include academic fee remission, research electives at ENTREE’s U.S. partner institution, Columbia University College of Physicians and Surgeons, and development of a master’s-level research protocol under expert supervision. It is also envisaged that these students would graduate with a medical degree (MB ChB) and simultaneously or soon thereafter complete the requirements for the equivalent of a master’s degree. The dual qualification was approved when the UKZN ENTREE project was conceived. However, UKZN has withdrawn approval for students simultaneously registering for more than one degree to comply with the South African National Department of Higher Education and Training regulations, which no longer permits such dual registration. Therefore, a new proposal has been made whereby the students selected for the dual track will undertake and accumulate credits for course work toward the additional master’s degree. The curriculum will be reorganized such that these students will complete their basic medical degree six months earlier than they would have under the former program and spend the remaining six months completing their master’s degree and related dissertation. Attracting health care personnel to a PhD program This program for UKZN faculty and the South African Department of Health staff is aligned with the mission of UKZN to achieve academic excellence and produce
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Innovation and Implementation Reports
innovative research. The program is also aligned with the Ministry of Health’s National Health PhD Scholars Program, which was launched in March 2013 to ensure that the country has an adequate number of competent researchers and academics. The program provides the candidates with the following support: • Scholarships of $5,000 to the candidates as a bursary upon them receiving research ethics (IRB) approval • Participation in an epidemiology and biostatistics module developed by ENTREE • Grant and manuscript writing workshops • Participation in scientific writing workshops
Table 1 Spectrum of PhD Research Topics Within the University of KwaZulu-Natal Medical Education Partnership Initiative Project Discipline
Topic
Pediatric HIV TB and HIV
Early vs. delayed ART in HIV-infected children with malnutrition Role of HIV-1 nef sequence in TB/HIV co-infection
Rheumatology
Arthritis associated with HIV
Nephrology
HIV-associated renal disease and renal replacement options
Pulmonology
TB-associated COPD
Cardiology
Factors affecting short-term outcomes of patients presenting with significant congenital heart disease to a tertiary center
Gerontology
HIV and aging
Obstetrics–gynecology
Genital tract TB in HIV-infected pregnant women Effect of sexually transmitted infections and genital tract inflammation in HIV acquisition in women
Emergency medicine
Snakebites in KwaZulu-Natal
TB
TB GeneXpert for point of care in KwaZulu-Natal
Microbiology
Early bacteriocidal effect of meropenem-clavulonic acid in patients with TB
Psychiatry
The metabolic syndrome and severe mental illness in KwaZulu-Natal
Health systems
Health systems policy changes in the context of HIV for the health care workforce Implementation of an integrated chronic disease management model at primary health care Health systems performance in relation to perinatal care in district hospitals Dynamics and structural determinants of child mortality in rural KwaZulu-Natal
Medical education
Barriers to completion among post-graduate students in public health Aligning occupational therapy education with public health expectations
Biostatistics
Estimating the effect of treatment in randomized controlled trials: application of instrumental variables
Bioethics
Using the ethical framework to assess the quality of IRB responses to researchers conducting clinical trials in developing countries
• Support for data management • Quarterly meetings where the candidates’ progress, achievements, and challenges are discussed • UKZN’s MEPI partner, Columbia University College of Physicians and Surgeons, will provide a mentorship role with scientific and technical input from experts in the various fields of research. This will be done through e-mail, video conferencing, and periodic visits to UKZN by Columbia University College of Physicians and Surgeons academic staff. Eleven candidates were accepted into this program in 2011. Five of the 2011 candidates are conducting data analysis, while the rest are completing their PhD study protocol. The demand for the program increased, and 15 candidates were accepted into the program in 2012. The candidates are all on track with their goals, and one has published two manuscripts in peer-reviewed journals. There were 17 applicants for this component of our program in 2013, and 16 were accepted. The candidates signed contracts to ensure that they are accountable to the funder and commit to faculty and student development by providing two years of service after obtaining their PhDs. Two biostatistics modules were conducted in 2012 and 2013 through collaboration between the Department of Public Health Medicine of UKZN and the University of Washington. Table 1 shows some of the research topics undertaken by the MEPI ENTREE PhD program students. It reflects the broad spectrum of research areas that
are proposed or under way. It is therefore anticipated that the project will promote academic capacity in a large number of disciplines to support an increase in the quantity and quality of health care workers. The ENTREE team has set up costeffective collaborations to bolster supervision capacity for the PhD students with specialized existing research and training entities. These include the Centre for AIDS Program of Research in South Africa, the HIV Pathogenesis Program, the Enhancing Care Initiative, the KwaZulu-Natal Research Institute for TB and HIV, the UKZN South African Research Ethics Training Initiative (SARETI), and our U.S. collaborator, Columbia University College of Physicians and Surgeons.
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Providing strong research ethics training and mentorship The research ethics capacity program component of MEPI aims to build institutional capacity in research ethics to supplement the research components of the MEPI program. The activities include the following: • South African Research Ethics online module—Training and Resources in Research Ethics Evaluation (TRREE) Web site (see http://elearning.trree.org) • MEPI Biomedical Research Ethics Committee Fellowships • Capacity development for research ethics intern • SARETI Modules (http://sareti.ukzn. ac.za/Homepage.aspx)
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• National Institutes of Health (NIH) Grants Management Workshop—This workshop is conducted by UKZN local expert faculty who have experience with NIH grants and grants management. ENTREE has funded the development of a certificategenerating online research ethics module based specifically on current South African health law, regulations, ethics guidance, and Good Clinical Practice documents. The module is open access, free of charge, and hosted on the international TRREE platform at http://elearning.trree.org/. More than 120 certificates have been generated to date, and a dissemination strategy is aiming to increase this. Two research ethics fellows were recruited in 2012 and completed their fellowships in January 2013, and two selected in 2013 are currently completing their fellowships. Forty-six ENTREEsponsored students registered for and completed advanced master’s-level SARETI modules in research ethics. Nine UKZN PhD students have completed or are currently completing a mentored fellowship in research ethics. Several have taken leading research ethics advisory and review roles in their base settings. Research ethics publications are also in progress. More than 50 UKZN health researchers and UKZN research office and grants administrators have attended our NIH grants management workshops. One research psychologist has been trained in project management and advanced research ethics. Discussion
The ENTREE program addresses the key objectives of the MEPI program to increase the number and quality of health care workers and to promote locally relevant research. In this context it should contribute significantly to local academic and research capacity building through several components of the ENTREE program. Two cohorts of undergraduate medical students have received intensive mentorship in research methodology, and several have undertaken community-based research projects and presented their results. The ENTREE PhD mentorship program has registered the largest number of PhD candidates of any single program in a health sciences faculty of an academic institution in KwaZulu-
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Natal. The research ethics capacity development project is unique on the African continent and has provided mentorship to a wide spectrum of health care workers and developed a certificategenerating online South African research ethics module that is freely available internationally. We believe that if we can create an enabling environment for research and academic enrichment with optimal mentorship, this will enhance the possibility of medical faculty and trainees remaining in academia. The current status quo is such that most doctors undergo training in their chosen fields and then leave the academic sector for private practice, emigrate to developed countries, or move into the public health sectors where there is no “academic pressure” to “publish or perish.”14 Many institutions such as UKZN have made it imperative for academics to have a PhD to qualify for promotion without creating an environment that is optimal for doctoral studies. ENTREE has responded to this dilemma by providing substantive support for budding academics to obtain PhD qualifications. Senior and junior academics will be frustrated unless such support is provided. Thus, succession planning is critical for sustaining and expanding the training of competent, research-minded health care workers. If we fail to do this, academic and service standards will suffer, and the vicious spiral of a declining workforce with deteriorating academic standards will be perpetuated.15 ENTREE is unique among the MEPI projects in that it has addressed a critical void in academic research capacity development—namely, research ethics. We plan to open our research ethics activities described above to applicants from other African MEPI sites to maximize benefits and returns on the UKZN MEPI investment. In conclusion, ENTREE has several components in its programs that directly address academic and research capacity development, with the aim of producing and retaining the next generation of medical academics to address the critical shortage of health care workers. We have identified several challenges. Our program is sufficiently flexible to rapidly adapt to address new challenges. The momentum created by ENTREE should
be self-sustaining, as the programs are by design embedded within the institution. Acknowledgments: The authors acknowledge support from many collaborators and partners who have assisted in making the University of KwaZulu-Natal Medical Education Partnership Initiative ENTREE program viable. Funding/Support: This publication was made possible by grant number 5R24TW008863 from the Office of the U.S. Global AIDS Coordinator (OGAC) and the National Institutes of Health (NIH OAR and NIH OWAR). Other disclosures: None reported. Ethical approval: Reported as not applicable. Disclaimers: The contents of this paper are solely the responsibility of the authors and do not necessarily represent the official views of the OGAC or NIH. Professor Lalloo is senior professor and head, Department of Pulmonology and Critical Care, University of KwaZulu-Natal, Durban, South Africa. Professor Bobat is associate professor and head, Pediatric Infectious Diseases, Department of Pediatrics and Child Health, University of KwaZuluNatal, Durban, South Africa. Dr. Pillay is honorary lecturer, Department of Pulmonology and Critical Care, and director, HIV Graduate Program, University of KwaZulu-Natal, Durban, South Africa. Professor Wassenaar is professor and director, South African Research Ethics Training Initiative, School of Applied Human Sciences, and chair, Biomedical Research Ethics Committee, University of KwaZulu-Natal, Durban, South Africa.
References 1 World Health Organization. Strategy of WHO Human Resources for Health—2010–2015. www.who.int/hrh/strategy/en/index.html. Accessed April 15, 2014. 2 Coovadia H, Jewkes R, Barron P, Sanders D, McIntyre D. The health and health system of South Africa: Historical roots of current public health challenges. Lancet. 2009;374:817–834. 3 Chopra M, Daviaud E, Pattinson R, Fonn S, Lawn JE. Saving the lives of South Africa’s mothers, babies, and children: Can the health system deliver? Lancet. 2009;374:835–846. 4 Abdool Karim SS, Churchyard GJ, Karim QA, Lawn SD. HIV infection and tuberculosis in South Africa: An urgent need to escalate the public health response. Lancet. 2009;374:921–933. 5 Mayosi BM, Flisher AJ, Lalloo UG, Sitas F, Tollman SM, Bradshaw D. The burden of non-communicable diseases in South Africa. Lancet. 2009;374:934–947. 6 Wilson NW, Couper ID, De Vries E, Reid S, Fish T, Marais BJ. A critical review of interventions to redress the inequitable distribution of healthcare professionals to rural and remote areas. Rural Remote Health. 2009;9:1060. 7 Ijsselmuiden C, Marais DL, Becerra-Posada F, Ghannem H. Africa’s neglected area of human resources for health research—the
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Innovation and Implementation Reports way forward. S Afr Med J. 2012;102: 228–233. 8 Essack SY. Models for increasing the health workforce. S Afr Med J. 2012;102(11 pt 1): 830–832. 9 de Vries E, Reid S. Do South African medical students of rural origin return to rural practice? S Afr Med J. 2003;93:789–793. 10 Reid SJ. Rural health and transformation in South Africa. S Afr Med J. 2006;96:676–677.
11 Chopra M, Lawn JE, Sanders D, et al; Lancet South Africa team. Achieving the health Millennium Development Goals for South Africa: Challenges and priorities. Lancet. 2009;374:1023–1031. 12 Census fact sheet—statistics South Africa. http://www.statssa.gov.za/Census2011/ Products/Census_2011_Fact_sheet.pdf. Accessed April 15, 2014. 13 Russell SH, Hancock MP, McCullough J. The pipeline. Benefits of undergraduate
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research experiences. Science. 2007;316: 548–549. 14 Gevers W. Clinical research in South Africa: A core asset under pressure. Lancet. 2009;374:760–762. 15 Bhargava A, Docquier F. HIV pandemic, medical brain drain and economic development in Sub-Saharan Africa. World Bank Econ Rev. 2008;22:345–366.
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A Strategy for Developing Future Academic Leaders for South Africa in a Resource-Constrained Environment Umesh G. Lalloo, MD, Raziya A. Bobat, MD, Sandy Pillay, MBChB, and Douglas Wassenaar, PhD
Abstract A key challenge in addressing the shortage of health care workers in resource-constrained environments is ensuring that there is optimal academic capacity for their training. South Africa’s University of KwaZulu-Natal has placed academic and research capacity building at the heart of its program with the Medical Education Partnership Initiative in a program called ENhancing Training and REsearch capacity and Expertise (ENTREE). The program aims to increase
T
he Medical Education Partnership Initiative (MEPI) seeks to address the challenge of providing an optimal number of health care workers in SubSaharan Africa where it is estimated there will be a shortage of approximately 150,000 personnel by 2020.1 This is based on the projected health care needs of the region, largely driven by HIV and TB, and the next wave of noncommunicable diseases such as diabetes mellitus, hypertension, obesity, ischemic heart disease, and chronic obstructive pulmonary disease. A recent series on health in South Africa, 15 years after its first democratic election in 1994, indicates that the country is faced with a quadruple burden of disease.2–5 South Africa has eight medical schools, with a total intake capacity of approximately 2,000 new students annually for a training duration of six years. This is inadequate for South Africa’s needs. Existing health care workforce shortages have severely Please see the end of this article for information about the authors. Correspondence should be addressed to Professor Lalloo, University of KwaZulu-Natal, Nelson R. Mandela School of Medicine, Department of Pulmonology and Critical Care, 719 Umbilo Rd., Durban 4001, South Africa; telephone: (+27) 31-260-4537; e-mail: [email protected]. Acad Med. 2014;89:S55–S59. doi: 10.1097/ACM.0000000000000354
the quantity, quality, and retention of health care graduates. It is premised on the basis that research capacity development will lead to an increase in teachers who will be essential to improving the quality and quantity of health care workers needed to meet South Africa’s health challenges. This is being achieved through four components of the program: (1) infusion of the undergraduate program with research modules; (2) attraction of academically
talented students in the middle of their undergraduate program into a parallel track that has research capacity as its major thrust; (3) attraction of qualified health care personnel into a supported PhD program; and (4) providing strong research ethics training and mentorship. A significant proportion of the program is being executed in rural training sites, to increase the probability that trainees will return to the sites as mentors.
constrained the rollout of antiretroviral treatment for HIV. Rural areas are inhabited by 46% of the total population, but only 12% of doctors and 19% of nurses work there. Further disparities exist within the public sector, as health care practitioners continue to migrate to the private sector and to other countries.6,7 The factors surrounding these shortages include finances, job satisfaction, career opportunities, security, postgraduate education, family, work relationships, and workload.8–11
premise that health care professionals who are well trained and experienced in medical research are more likely to follow an academic research career and to be retained within local academic institutions.13
The ENTREE Program at University of KwaZulu-Natal
KwaZulu-Natal has a population of about 10.3 million and is the most populous of the nine provinces of South Africa, with a population of 51.8 million.12 KwaZuluNatal is also the epicenter of the HIV epidemic and has a TB incidence rate of about 1,000/100,000.4 The University of KwaZulu-Natal (UKZN) Nelson Mandela School of Medicine currently enrolls a maximum of 210 students annually and has limited capacity for training allied health care professionals such as nurses and pharmacists. The new UKZN MEPI program is called ENTREE (ENhancing Training and REsearch capacity and Expertise). The program aims to increase the quantity, quality, and retention of health care graduates by increasing research capacity. This is based on the
Academic Medicine, Vol. 89, No. 8 / August Supplement 2014
The ENTREE program targets UKZN’s medical, nursing, and pharmacy students in its College of Health Sciences, using existing programs and resources within the college and school and in collaboration with Columbia University College of Physicians and Surgeons in New York. The ENTREE strategy is summarized in Figure 1 and shows the projects that are focused on academic and research capacity development. The program’s main objectives include: (1) To increase the competence of medical, nursing, and pharmacy students in the management of HIV and AIDS by enhancing undergraduate training through infusing the curriculum with a continuum-of-care approach to HIV and AIDS and improved clinical preceptorship; and scaling up of an innovative parallel training track for selected undergraduate medical students in HIV toward a diploma/ master’s degree program, from which students will be identified for postgraduate development programs and academic research career paths.
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the four posters were judged as exceptional by the panel of referees, which consisted of senior academics from the College of Health Sciences of UKZN. These three groups submitted abstracts and presented posters to the Public Health Association of South Africa conference in Cape Town in September 2013.
Enhance quality of clinical and research capacity Undergraduate students: Medical Pharmacy Nursing
Enrichment of curriculum in clinical HIV and Public Health 1. Didatic 2. Preceptorship
Dual qualification
Faculty and HCWs
Providing an enabling research environment
Attracting outstanding students to an MPH program
Recruit ±10 PHD candidates per year
Diploma in HIV, Research methods and mentorship
Figure 1 The University of KwaZulu-Natal Medical Education Partnership Initiative ENhancing Training and REsearch capacity and Expertise (ENTREE) program. The program aims to increase the quantity, quality, and retention of health care graduates by increasing research capacity.
(2) I ncrease the competence of junior doctors through the development of a program that will create a cadre of master trainers to support and enhance the internship experience, create a supportive learning environment, and attract medical trainees to return to these centers. (3) D evelop and support a program to enhance skills in research methodology, research ethics, and research implementation, with particular emphasis on HIV and related complications so that a cadre of academics and researchers can be established. (4) D evelop a program to promote retention of academic and research staff by providing a research career pathway and research support. The major thrust of the MEPI program is to increase the quality and quantity of health care workers. In this report we describe how UKZN’s ENTREE program is designed to increase research capacity, which is fundamental to increasing capacity for the production of competent health care workers. Four Key Components
Incorporating research into undergraduate programs This component offers third-year undergraduate medical students, in a six-year program, an exposure to research methods. The students are divided into groups to conduct community-based
S56
research projects and prepare scientific research posters for presentation at a Poster Day meeting. During the week, eight lectures on research methods are presented. This includes a session from one of the senior members of the university research ethics committee so that students are better prepared to develop their community-based research protocol. By the end of this week, the protocols for each group are expected to be completed and submitted for research ethics approval. The group presenting the best-assessed poster receives a cash gift voucher. Research electives in rural areas are supported by the development of academic learning centers called MEPI Learning Centres (MLCs), developed through the ENTREE program. These comprise physical academic resources such as video and teleconferencing facilities and a small-group (15–20 students) lecture theatre and skills laboratory, situated within designated rural areas and urban centers away from the medical school, where undergraduate students rotate through a MEPIsupported expanded rural and family medicine rotation, supported by trained academic leaders/supporters. Two cohorts of medical students have experienced these ENTREE research modules to date, resulting in poster presentations by four groups of students. These were facilitated by the ENTREE program’s audiovisual and videoconference facilities to communicate with the MLCs and medical school. The group assessed to be the best poster received $100. Three of
It was envisaged that 10 students would be selected on the basis of outstanding academic performance and potential during the third year of their six-year undergraduate medical (MB ChB) program to participate in a parallel track program as part of the master’s in public health program. Selection is planned to favor black African students of which at least 60% will be female. Incentives built into this parallel track include academic fee remission, research electives at ENTREE’s U.S. partner institution, Columbia University College of Physicians and Surgeons, and development of a master’s-level research protocol under expert supervision. It is also envisaged that these students would graduate with a medical degree (MB ChB) and simultaneously or soon thereafter complete the requirements for the equivalent of a master’s degree. The dual qualification was approved when the UKZN ENTREE project was conceived. However, UKZN has withdrawn approval for students simultaneously registering for more than one degree to comply with the South African National Department of Higher Education and Training regulations, which no longer permits such dual registration. Therefore, a new proposal has been made whereby the students selected for the dual track will undertake and accumulate credits for course work toward the additional master’s degree. The curriculum will be reorganized such that these students will complete their basic medical degree six months earlier than they would have under the former program and spend the remaining six months completing their master’s degree and related dissertation. Attracting health care personnel to a PhD program This program for UKZN faculty and the South African Department of Health staff is aligned with the mission of UKZN to achieve academic excellence and produce
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Innovation and Implementation Reports
innovative research. The program is also aligned with the Ministry of Health’s National Health PhD Scholars Program, which was launched in March 2013 to ensure that the country has an adequate number of competent researchers and academics. The program provides the candidates with the following support: • Scholarships of $5,000 to the candidates as a bursary upon them receiving research ethics (IRB) approval • Participation in an epidemiology and biostatistics module developed by ENTREE • Grant and manuscript writing workshops • Participation in scientific writing workshops
Table 1 Spectrum of PhD Research Topics Within the University of KwaZulu-Natal Medical Education Partnership Initiative Project Discipline
Topic
Pediatric HIV TB and HIV
Early vs. delayed ART in HIV-infected children with malnutrition Role of HIV-1 nef sequence in TB/HIV co-infection
Rheumatology
Arthritis associated with HIV
Nephrology
HIV-associated renal disease and renal replacement options
Pulmonology
TB-associated COPD
Cardiology
Factors affecting short-term outcomes of patients presenting with significant congenital heart disease to a tertiary center
Gerontology
HIV and aging
Obstetrics–gynecology
Genital tract TB in HIV-infected pregnant women Effect of sexually transmitted infections and genital tract inflammation in HIV acquisition in women
Emergency medicine
Snakebites in KwaZulu-Natal
TB
TB GeneXpert for point of care in KwaZulu-Natal
Microbiology
Early bacteriocidal effect of meropenem-clavulonic acid in patients with TB
Psychiatry
The metabolic syndrome and severe mental illness in KwaZulu-Natal
Health systems
Health systems policy changes in the context of HIV for the health care workforce Implementation of an integrated chronic disease management model at primary health care Health systems performance in relation to perinatal care in district hospitals Dynamics and structural determinants of child mortality in rural KwaZulu-Natal
Medical education
Barriers to completion among post-graduate students in public health Aligning occupational therapy education with public health expectations
Biostatistics
Estimating the effect of treatment in randomized controlled trials: application of instrumental variables
Bioethics
Using the ethical framework to assess the quality of IRB responses to researchers conducting clinical trials in developing countries
• Support for data management • Quarterly meetings where the candidates’ progress, achievements, and challenges are discussed • UKZN’s MEPI partner, Columbia University College of Physicians and Surgeons, will provide a mentorship role with scientific and technical input from experts in the various fields of research. This will be done through e-mail, video conferencing, and periodic visits to UKZN by Columbia University College of Physicians and Surgeons academic staff. Eleven candidates were accepted into this program in 2011. Five of the 2011 candidates are conducting data analysis, while the rest are completing their PhD study protocol. The demand for the program increased, and 15 candidates were accepted into the program in 2012. The candidates are all on track with their goals, and one has published two manuscripts in peer-reviewed journals. There were 17 applicants for this component of our program in 2013, and 16 were accepted. The candidates signed contracts to ensure that they are accountable to the funder and commit to faculty and student development by providing two years of service after obtaining their PhDs. Two biostatistics modules were conducted in 2012 and 2013 through collaboration between the Department of Public Health Medicine of UKZN and the University of Washington. Table 1 shows some of the research topics undertaken by the MEPI ENTREE PhD program students. It reflects the broad spectrum of research areas that
are proposed or under way. It is therefore anticipated that the project will promote academic capacity in a large number of disciplines to support an increase in the quantity and quality of health care workers. The ENTREE team has set up costeffective collaborations to bolster supervision capacity for the PhD students with specialized existing research and training entities. These include the Centre for AIDS Program of Research in South Africa, the HIV Pathogenesis Program, the Enhancing Care Initiative, the KwaZulu-Natal Research Institute for TB and HIV, the UKZN South African Research Ethics Training Initiative (SARETI), and our U.S. collaborator, Columbia University College of Physicians and Surgeons.
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Providing strong research ethics training and mentorship The research ethics capacity program component of MEPI aims to build institutional capacity in research ethics to supplement the research components of the MEPI program. The activities include the following: • South African Research Ethics online module—Training and Resources in Research Ethics Evaluation (TRREE) Web site (see http://elearning.trree.org) • MEPI Biomedical Research Ethics Committee Fellowships • Capacity development for research ethics intern • SARETI Modules (http://sareti.ukzn. ac.za/Homepage.aspx)
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• National Institutes of Health (NIH) Grants Management Workshop—This workshop is conducted by UKZN local expert faculty who have experience with NIH grants and grants management. ENTREE has funded the development of a certificategenerating online research ethics module based specifically on current South African health law, regulations, ethics guidance, and Good Clinical Practice documents. The module is open access, free of charge, and hosted on the international TRREE platform at http://elearning.trree.org/. More than 120 certificates have been generated to date, and a dissemination strategy is aiming to increase this. Two research ethics fellows were recruited in 2012 and completed their fellowships in January 2013, and two selected in 2013 are currently completing their fellowships. Forty-six ENTREEsponsored students registered for and completed advanced master’s-level SARETI modules in research ethics. Nine UKZN PhD students have completed or are currently completing a mentored fellowship in research ethics. Several have taken leading research ethics advisory and review roles in their base settings. Research ethics publications are also in progress. More than 50 UKZN health researchers and UKZN research office and grants administrators have attended our NIH grants management workshops. One research psychologist has been trained in project management and advanced research ethics. Discussion
The ENTREE program addresses the key objectives of the MEPI program to increase the number and quality of health care workers and to promote locally relevant research. In this context it should contribute significantly to local academic and research capacity building through several components of the ENTREE program. Two cohorts of undergraduate medical students have received intensive mentorship in research methodology, and several have undertaken community-based research projects and presented their results. The ENTREE PhD mentorship program has registered the largest number of PhD candidates of any single program in a health sciences faculty of an academic institution in KwaZulu-
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Natal. The research ethics capacity development project is unique on the African continent and has provided mentorship to a wide spectrum of health care workers and developed a certificategenerating online South African research ethics module that is freely available internationally. We believe that if we can create an enabling environment for research and academic enrichment with optimal mentorship, this will enhance the possibility of medical faculty and trainees remaining in academia. The current status quo is such that most doctors undergo training in their chosen fields and then leave the academic sector for private practice, emigrate to developed countries, or move into the public health sectors where there is no “academic pressure” to “publish or perish.”14 Many institutions such as UKZN have made it imperative for academics to have a PhD to qualify for promotion without creating an environment that is optimal for doctoral studies. ENTREE has responded to this dilemma by providing substantive support for budding academics to obtain PhD qualifications. Senior and junior academics will be frustrated unless such support is provided. Thus, succession planning is critical for sustaining and expanding the training of competent, research-minded health care workers. If we fail to do this, academic and service standards will suffer, and the vicious spiral of a declining workforce with deteriorating academic standards will be perpetuated.15 ENTREE is unique among the MEPI projects in that it has addressed a critical void in academic research capacity development—namely, research ethics. We plan to open our research ethics activities described above to applicants from other African MEPI sites to maximize benefits and returns on the UKZN MEPI investment. In conclusion, ENTREE has several components in its programs that directly address academic and research capacity development, with the aim of producing and retaining the next generation of medical academics to address the critical shortage of health care workers. We have identified several challenges. Our program is sufficiently flexible to rapidly adapt to address new challenges. The momentum created by ENTREE should
be self-sustaining, as the programs are by design embedded within the institution. Acknowledgments: The authors acknowledge support from many collaborators and partners who have assisted in making the University of KwaZulu-Natal Medical Education Partnership Initiative ENTREE program viable. Funding/Support: This publication was made possible by grant number 5R24TW008863 from the Office of the U.S. Global AIDS Coordinator (OGAC) and the National Institutes of Health (NIH OAR and NIH OWAR). Other disclosures: None reported. Ethical approval: Reported as not applicable. Disclaimers: The contents of this paper are solely the responsibility of the authors and do not necessarily represent the official views of the OGAC or NIH. Professor Lalloo is senior professor and head, Department of Pulmonology and Critical Care, University of KwaZulu-Natal, Durban, South Africa. Professor Bobat is associate professor and head, Pediatric Infectious Diseases, Department of Pediatrics and Child Health, University of KwaZuluNatal, Durban, South Africa. Dr. Pillay is honorary lecturer, Department of Pulmonology and Critical Care, and director, HIV Graduate Program, University of KwaZulu-Natal, Durban, South Africa. Professor Wassenaar is professor and director, South African Research Ethics Training Initiative, School of Applied Human Sciences, and chair, Biomedical Research Ethics Committee, University of KwaZulu-Natal, Durban, South Africa.
References 1 World Health Organization. Strategy of WHO Human Resources for Health—2010–2015. www.who.int/hrh/strategy/en/index.html. Accessed April 15, 2014. 2 Coovadia H, Jewkes R, Barron P, Sanders D, McIntyre D. The health and health system of South Africa: Historical roots of current public health challenges. Lancet. 2009;374:817–834. 3 Chopra M, Daviaud E, Pattinson R, Fonn S, Lawn JE. Saving the lives of South Africa’s mothers, babies, and children: Can the health system deliver? Lancet. 2009;374:835–846. 4 Abdool Karim SS, Churchyard GJ, Karim QA, Lawn SD. HIV infection and tuberculosis in South Africa: An urgent need to escalate the public health response. Lancet. 2009;374:921–933. 5 Mayosi BM, Flisher AJ, Lalloo UG, Sitas F, Tollman SM, Bradshaw D. The burden of non-communicable diseases in South Africa. Lancet. 2009;374:934–947. 6 Wilson NW, Couper ID, De Vries E, Reid S, Fish T, Marais BJ. A critical review of interventions to redress the inequitable distribution of healthcare professionals to rural and remote areas. Rural Remote Health. 2009;9:1060. 7 Ijsselmuiden C, Marais DL, Becerra-Posada F, Ghannem H. Africa’s neglected area of human resources for health research—the
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Innovation and Implementation Reports way forward. S Afr Med J. 2012;102: 228–233. 8 Essack SY. Models for increasing the health workforce. S Afr Med J. 2012;102(11 pt 1): 830–832. 9 de Vries E, Reid S. Do South African medical students of rural origin return to rural practice? S Afr Med J. 2003;93:789–793. 10 Reid SJ. Rural health and transformation in South Africa. S Afr Med J. 2006;96:676–677.
11 Chopra M, Lawn JE, Sanders D, et al; Lancet South Africa team. Achieving the health Millennium Development Goals for South Africa: Challenges and priorities. Lancet. 2009;374:1023–1031. 12 Census fact sheet—statistics South Africa. http://www.statssa.gov.za/Census2011/ Products/Census_2011_Fact_sheet.pdf. Accessed April 15, 2014. 13 Russell SH, Hancock MP, McCullough J. The pipeline. Benefits of undergraduate
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research experiences. Science. 2007;316: 548–549. 14 Gevers W. Clinical research in South Africa: A core asset under pressure. Lancet. 2009;374:760–762. 15 Bhargava A, Docquier F. HIV pandemic, medical brain drain and economic development in Sub-Saharan Africa. World Bank Econ Rev. 2008;22:345–366.
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