April 2017

Members of a collaborative Cuba-UK-South Africa project exploring the value of Cuban-training for South African medical students met this year to discuss how the programme can promote Universal Health Coverage (UHC).

The ‘South Africa-Cuba doctors programme’, which offers bursaries to South Africans from disadvantaged backgrounds to study medicine in Cuba as part of a deal struck by Fidel Castro and Nelson Mandela two decades ago, was the subject of a Department for International Development funded policy research project, which included researchers from London School of Hygiene and Tropical Medicine (LSHTM), Imperial College London, Public Health England and the Human Sciences Research Council (HSRC), South Africa.

The large number of Cuban-trained South African would-be doctors returning to work in South Africa (600-900 medical students return each year) are a major resource with the potential to re-engineer South Africa’s primary healthcare system to focus on preventive care and promote UHC. The researchers noted this was especially advantageous as they found few South African-trained doctors wish to make a career in family medicine (general practice). Therefore, improving the quality and quantity of family physicians (GPs) is critical for South Africa to achieve UHC. Returning trained doctors from the programme plug some of this gap as they go on to work as doctors in the public sector; they are also more likely to work in underserved areas that they come from long-term.

A major recommendation of the project was for improved support and re-integration of the doctors trained in Cuba upon their return to South Africa. Returning students must undergo up to three years of additional training to ensure they have experience of diseases such as HIV/AIDS, TB and malaria, which no longer exist in Cuba. As a result, some of them effectively return to train as 3rd year medical students, despite their six years of training in Cuba.

The research also found that students experience personal, academic and structural challenges when they return to study in South African medical schools. Duration and content of orientation programmes differed between the schools; language difficulties made studying difficult (Cuban-trained students spend their first year on premedical bridging training and become proficient in Spanish) and cultural adjustment after six years away was needed. Findings also indicated returning students had to adapt to more hospital and ‘rescue’ medicine emphases; and experienced difficulties with an unfamiliar exam system.

Further recommendations included: more systematic collection of data on both Cuban- and South African- trained cohorts to enable monitoring of careers pathways and relevance to South Africa’s needs; investment of new resources based in rural and urban underserved areas for medical training in South Africa; and for future research to focus on the political economy of medical education to understand the challenges, agents for change and examples of success that can be expanded.

The end-of-project meeting, which took place in April 2017, was attended by representatives from Imperial College, LSHTM, Public Health England, the Royal College of General Practitioners, Tropical Health & Education Trust (UK), HSRC, Medical Executive Committee for Health (South Africa), Cuban-trained doctors returned to South Africa from the University of Cape Town and Cuban representatives from the Ministry of Health, the Pan American Health Organization. Read the meeting agenda, full meeting report, a longer blog (at project end) by Shah Ebrahim, view key presentation slides; and watch video interviews with Dr SM Dhlomo, the Member of the Executive Council for Health in KwaZulu-Natal, South Africa and a medical student from the South Africa-Cuba doctors programme. 

NICE International co-hosts Cuba medical education workshop in Pretoria 

June 2015

At the end of June 2015, NICE International participated as a co-organiser with London School of Hygiene and Tropical Medicine (LSHTM), Public Health England (PHE) and the Human Sciences Research Council (HSRC) of South Africa in a two-day conference in Pretoria, about the value of Cuban medical training to the South African setting, as part of the DFID funded project.

With support from HSRC and LSHTM, NICE International will be carrying out a health technology assessment of alternative training models with a view to drawing lessons for primary care transformation models in Sub Saharan Africa, but also in countries like the UK, which are facing a crisis with regard to human resources for primary care.

Read more about the event in Shah Ebrahim’s blog, and read more about the project in the concept note submitted to Ministry officials in Cuba and Republic of South Africa, and the case study prepared for UN High Level Commission on Health Employment and Economic Growth.

Panel discussion event at the house of Lords

March 2015

On the 4 March 2015, NICE International, Public Health England and the London School of Hygiene and Tropical Medicine held a panel discussion event at the House of Lords.

The discussion looked at the ‘Potential Lessons for Primary Care Emerging from the Cuban Model of Medical Education’. The event was hosted by the All Party Parliamentary Group on Global Health and Chaired by Lord Crisp. Speakers included representatives from the Pan American Health Organisation, the Faculty of Public Health, the World Health Organisation and the Embassy of the Republic of Cuba.

The event highlighted the Cuban approach to medical education and looked at research being undertaken to test how effective this approach is. The event also looked at how transferable the Cuban model could be into other contexts. Contrasting views of the successes of the Cuban model were shown in two video presentations shown at the event. The presentations stimulated audience discussion around the future development of primary care and medical education in the UK.

The discussions will be used to inform the ongoing project exploring the applicability of the Cuban model to other settings.

Read more in Professor Shah Ebrahim’s blog post about the event.

Scoping visit to Havana

October 2014

A team from NICE International (Kalipso Chalkidou), LSHTM (Shah Ebrahim) and Public Health England (Neil Squires) (formerly DFID), visited Havana to scope out the joint project on the Cuban model of medical education for Africa. The project is being run by NICE, PAHO, LSHTM and the Cuban MoH.

The team also participated in the 2nd International Conference on Medical Education for the 21st Century organised by the Cuban Ministry of Public Health. The Conference was attended by over 400 people from several countries including Angola and Latin America. Over three days, the conference explored the direction of travel in modern medical education in light of countries’ commitments to Universal Healthcare Coverage and of emerging challenges of chronic diseases and increasing financial pressures on limited budgets.

Dr Neil Squires gave a plenary address during which he highlighted the importance of publicising the lessons of the Cuban medical education model, supported by evidence of its effectiveness and cost-effectiveness, and using these lessons to influence the ongoing consultation by WHO on a longer term global healthcare workforce strategy.

During a whole day side event organised by the Ministry, the UK team had the opportunity to connect with major stakeholders in Cuba including the Rector of the Latin American University, senior professors including the vice president of the University of Havana’s Medical University, the secretary of the Cuban university accreditation board, the CEO of THEnet, the Director of the Cuban School of Public Health, members of the Board of and the CEO of MEDICC, senior MINSAP officials including Dr Ileana Morales, the President of the Conference, and PAHO, including the Director of the country office. The discussion explored the research proposal which recently gained approval from DFID, its policy implications and practical ways for taking the work forward incl. major partners in Cuba and in Arica.

In addition, the UK team had working meetings with PAHO and visited the British Ambassador in Cuba who has been supporting the DFID funded work since its launch.

NICE/LSHTM/PHE will work with their Cuban counterparts and African researchers to modify the research protocol, assign research tasks and organise additional field visits to Cuba and Africa over the next 12 months, with a view to using it research findings to influence the ongoing consultation on the WHO’s Human Resources for Health Strategy, due to report in 2016, but also with the aim of further publicising the attributes of the primary care-focused Cuban model and its potential relevance for the UK setting.

NICE International visited Cuba to scope out partnerships on policy and research

November 2013

This is the second visit, following summer 2013, when we visited supported by the Rockefeller Foundation, to take part in a Lancet organised event on learning lessons from the history and evolution of Latin American and Caribbean healthcare systems.

With support from the PAHO country office, the NICE chairman, Professor David Haslam, the director of NICE International Kalipso Chalkidou, and Professor Shah Ebrahim of LSHTM and an honorary NHS consultant with NICE, spent 3 days meeting senior academic colleagues, including professors and deans of the National School of Public Health, the Cuban Medical University of Havana, the Cuban International Cooperation Centre, managing the Cuban Medical Missions overseas, as well as officials from the MoH, including the Vice Minister and Centro Nacional Coordinador de Ensayos Clínicos (CENCEC), the clinical trials regulatory authority of Cuba. INFOMED, the medical electronic portal of Cuba, and Escuela Latinoamericana de Medicina(ELAM), the Latin American Medical University training overseas students from LAC, Asia and Africa, where also part of the visit. Finally, they had the chance to meet the British Ambassador in Havana.

NICE International, with its academic partners in the UK, will be looking to engage in a collaborative research project with the Cuban academics to assess the primary care and prevention focused model of medical education of Cuba in the context of Sub Saharan Africa.

Cuba maintains medical missions in over 60 countries around the world, working in emergency situations or in remote rural areas and is in parallel, training – mostly for free – thousands of doctors in Cuba or Cuban Universities overseas.

Another aspect of our partnership could focus on methods for developing and implementing clinical guidelines and HTA with an emphasis on quality and efficiency, taking a whole system (as opposed to a technology focused) approach. Options for partnering up with LSHTM and with the Public Health Foundation of India, were also discussed.

NICE International visits Cuba to take part in the Lancet meeting on universal health coverage

July 2013

Kalipso Chalkidou, Director of NICE International visited Cuba to take part in the Lancet meeting on universal health coverage (UHC) in the Latin American countries (LAC), with support from the Rockefeller Foundation. Cuba has a primary care focused healthcare system, which ranks highly globally in terms of access, quality and health outcomes and efficiency.

During the short visit, Kalipso met colleagues from:

• government
• the regulators
• universities
• non-government organisations
• Pan American Health Organization (PAHO), including the Director of PAHO, Dr Carissa Etienne.

There is a joint commitment for PAHO, NICE and Rockefeller, working together on priority setting for UHC and on sharing the knowledge and experiences (good and bad) of the LAC region with other countries transitioning towards UHC. We will work together with other partners such as the Department for international development (DFID) and the World Bank, to set out specific actions we can carry out together, in accordance to the strategic priorities of PAHO and the countries in the region and with an emphasis on catalysing South-South partnerships with countries in LAC but also sub-Saharan Africa.

The visit offered the opportunity to meet the Minister of Health of Cuba and his vice ministers, including the vice minister responsible for international cooperation with whom, along with the PAHO lead and the Director for International cooperation, Kalipso discussed opportunities for partnerships and sharing our system’s experience, and for working on a tripartite basis in countries where Cuba supports human resources and medical education and NICE offers technical assistance for strengthening priority setting processes and technology evaluation.

Finally, Kalipso visited the Cuba neuroscience centre, which concentrates on developing high value low cost diagnostic, screening and management technologies for high priority diseases and conditions, to serve the needs of the Cuban population. The Centre also exports technologies and healthcare solutions (e.g. screening policies for hearing impairment and learning difficulties in young children) around the world.

There was broad agreement as to the potential for partnership up with the Cuban Ministry of Health and sharing experiences with countries in the region and beyond. NICE International will work with PAHO, Rockefeller and also with the Ministry of Health of Cuba and the UK’s DFID to scope out potential joint projects especially on capacity building for UHC in sub-Saharan African countries.

Cuba’s reputation for producing dedicated health workers who are prepared to work in difficult or remote health contexts is well known and was profiled by Jose Luis de Fabio, Director of the Pan American Health Organisation in Cuba. Since the 1970s Cuba has been a major producer of health workers with a commitment to international solidarity in health and provides doctors to countries facing severe shortages of health workers. The selection process for entry to Cuban medical education focuses on social skills and competencies as much as academic ability which has helped overcome the mal-distribution of health workers, common in most countries, which leave major  gaps in service provision for poor and marginalised populations.

But perhaps the Cuban experience is not all it seems.  Jimmy Volmink, Dean of the Medical School of Stellenbosch University in South Africa laid out the advantages and disadvantages of a long-standing scheme that trains African students in Cuba with the aim of providing doctors for rural areas. Volmink highlighted the culture shock that awaits rural black African students in Cuba, the language problems, the lack of internet to enable easy communication with relatives back home, and problems of re-integration with South African trained students when they return home for ‘top-up’ courses on malaria,   HIV/AIDS, neonatal infections – preventable diseases that are not common in Cuba.  One returning student said: “if you buy a cat, don’t expect it to bark!”  The culture shock and the process of adaptation experienced by these students may be essential components that makes the Cuban approach so powerful.  Incubating Cuban approaches within Africa – a potentially more logical and less disruptive plan – but without the experience in Cuba may not work so well.

These optimistic and pessimistic views of the transferability and utility of Cuban medical education arise because of different contexts and ways of implementing the Cuban approach – which is very flexible and is modifiable depending on the resources available.  All systems of medical education produce ‘pluri-potential’ doctors who may become family doctors, eye surgeons or psychiatrists. So the cat-dog analogy doesn’t work for me.  Neil Squires, Deputy Director, Public Health England, asked whether the global shortage of family doctors and an imperative for universal health care, would leverage medical schools to focus their core curriculum on graduating functional family doctors.  John Ashton, President of the Faculty of Public Health, described such a scheme operating in the rural mid-west states of USA.

Jim Campbell, Director of WHO’s Health Workforce Department, described the WHO Initiative on transforming and scaling up health professionals’ education and training which has compiled regional case studies.  These provide a substantial evidence base from which to work.  WHO’s commitment to universal health coverage and the new sustainability development goals that will do away with targets, replacing them, for example, with zero acceptance of neonatal and maternal deaths and 100% access to primary care provide compelling reasons for solving the primary care workforce crisis.  The massive growth in health care in high income countries is likely to suck markedly large flows of doctors from low income countries.[Crisp & Chen, 2014] Global action to create primary care doctors and community health workers on an industrial scale is needed now to offset workforce crises in primary care, which in turn provide fertile soil for epidemics of preventable communicable and chronic diseases.

Evaluations of the Cuban model have been conducted in the past but questions of selection of students, training of faculty, competences at graduation, impact on distribution and retention of doctors in disadvantaged and rural communities need to be answered to provide better evidence for policy making.  A DfID funded policy programme grant has been awarded to support Cuban, African and UK collaborative research on the Cuban approach.  In the UK, NICE International, Public Health England and LSHTM are involved.  The research aims to answer these questions:

• Does the Cuban system of medical education result in more equitable distributions of doctors? And in stronger retention of doctors in rural and disadvantaged communities?
• Are doctors trained in the Cuban model equipped with an appropriate set of skills and competencies for primary care? Are they better equipped than doctors trained in conventional ways?
• What lessons can we learn for health professional capacity building from a development perspective? And what can we learn for the NHS here in England?

Medical schools should be capable of assimilating and retaining the lessons learned over the last 40 years: redesigning selection processes to improve access for disadvantaged students; early and long-term contact with patients and their families; shifting teaching into primary care; integrated core training of doctors, nurses and other health professionals. [Frenk et al, 2010]  General Medical Councils may make accreditation more difficult for highly innovative education but they are not the barrier.  Deans of medical schools have more room for initiating change as demonstrated by the Training for Health Equity network (THEnet) and other networks, one of them arising in Africa,  the Consortium of New Southern African Medical Schools.  Once again we have to “turn the world upside down”, asking rich countries to learn these lessons from Cuban medical schools which show how doctors with vision, resilience, relevant competencies and the motivation to work with the most disadvantaged people can be created.

Prof Shah Ebrahim, Honorary Professor of Public Health at LSHTM, is collaborating with NICE International, Public Health England, PAHO and the Cuban Ministry of Health on the DfID-supported project on Cuban medical education model for Africa.

References

Nigel Crisp, Lincoln Chen. Global supply of Health Professionals. N Engl J Med 2014;370:950-7

Julio Frenk, Lincoln Chen, Zulfiqar A Bhutta, Jordan Cohen, Nigel Crisp et al. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. Lancet 2010;376:1923–58