Three decades in, is the Cuba-SA doctor training programme still worth the expense?

Almost 30 years since the Cuba-SA doctors’ training programme was launched, it still divides opinion.

This year only Gauteng and North West interviewed candidates for the bursary programme that sends students from South Africa to be trained in the island country.

Critics say the dwindling interest shows the Nelson Mandela-Fidel Castro medical training programme has passed its sell-by date. But supporters remain committed to its ideals, and some beneficiaries of the programme still think of it as the opportunity of a lifetime.

Between the differing views, what can be glimpsed is a chequered story of three decades of trying to transform South Africa’s healthcare system. The programme has its origins in the ANC’s political fraternity with Cuba and the laudable ideal of boosting doctors numbers in under-serviced rural areas. But it is also a tale of political inertia arguably blurring overtime into a blind spot as conditions changed. In the background is the stranglehold of corruption and maladministration in the health sector, shrinking provincial health budgets, the transformation of doctors’ training, and changing curricula.

One concern is that little is actually known about the programme’s impact. There is a lack of clear data on the costs and the numbers of doctors produced. Shockingly, for such a long-running programme, no comprehensive evaluation reports have been published, as far as Spotlight has been able to establish.

A comprehensive evaluation would weigh the benefits of the programme against its costs, compare it to other options for training medical doctors, and contextualise it within the current reality of very tight health budgets in provincial health departments — as it is, not all the doctors we are training are being employed.

Given this context, it is not surprising that the national Department of Health recommended a scaling back of the programme a decade ago. While most provinces have taken this advice, the Gauteng and North West health departments have instead pushed ahead with the programme.

Old histories and old allegiances

The agreement that put in place the medical training programme was signed in 1996, with the first cohort of students leaving for Cuba a year later, in 1997. It was a mere two years into democracy and South Africa urgently needed to address the gaps in the provision of healthcare. Under apartheid, services prioritised a white minority mostly in urban settings and healthcare had a strong slant towards hospital or tertiary care. There was a shortage of doctors, and those with the least access to healthcare services were rural communities made up mostly of black South Africans.

Medical schools mostly had curricula designed for the status quo, and there were few academic pathways for underprivileged students who had good marks at school but were not top achievers, leaving them overlooked for scholarships and bursaries.

So the new government looked to Cuba.

With its focus on primary healthcare, preventive medicine and community-based training, the Cuban approach to healthcare ticked many of the boxes for the South African government then led by Nelson Mandela.

Since the communist revolution in Cuba in 1959, it has provided free healthcare to all its citizens. While there remains some scepticism over data collection and interpretation, the politicisation of medicine, and limited freedom to criticise the state, Cuba’s healthcare system is also widely lauded.

According to the Primary Health Care Performance Initiative, the country registers average life expectancy at 78 years (South Africa is at about 66), infant mortality dropped from 80 deaths per 1,000 live births in 1950 to just 5 deaths per 1,000 by 2013, and it has one of the world’s highest doctor to patient ratios. In 2021, it was at 9.429 physicians per 1,000 people, according to World Bank Open Data. In the same year, South Africa tracked at 0.8 per 1,000.

Since the 1960s, Cuba has established itself as a hub for training international fee-paying students and sending them back to their mostly lower-income countries as graduate doctors. One of its biggest universities, the Latin American School of Medicine, has graduated more than 30,000 students from 118 countries in the 21 years since it was established.

Another tick was Cuba’s staunch support for the ANC. SA History Online emphasises the depth of solidarity. It notes: “Cuba was a state in alliance with provisional governments and independent states on the African continent. Cuba’s military engagement in Angola kept the apartheid state in check, foiling its geopolitical strategies and forcing it to concede defeat at Cuito Cuanavale, and ultimately forcing both PW Botha and FW de Klerk to the negotiating table.”

Costs and benefits 

The political and historical bonds sealed the doctors’ training deal. But from the start, the bursary programme, funded by provincial budgets, came under fire. The estimated costs over nearly three decades are massive, but the details remain fuzzy.

Spotlight’s questions to the national health department were “answered” in one paragraph by department spokesperson Foster Mohale. 

“More than 4,000 [lower numbers are quoted by government in other instances] doctors have been produced through this medical programme since its inception. The programme is still relevant today and complements the local medical schools to produce more doctors. Qualified doctors have options of joining either public or private health sector,” he wrote.

But discrepancies have shown up in the government’s own figures. In November 2022, Haseena Ismail, the then DA member on the portfolio committee of health, raised concerns about the quality of government data.

The Minister of Health at the time, Dr Joe Phaahla, said the preparatory year, including a stipend, cost $4,400 per student, and each of the following five years cost $7,400 per student. But a separate table from the health department listed higher figures — $8,400 for the preparatory year and up to $15,900 per student by the fifth year. Added to this, the department listed annual costs of $6,472 per student for food, accommodation, and medical insurance. There were also expenses for two return flights over six years, plus the cost of 18 months of tuition and accommodation for clinical training at a South African medical school.

Phaahla said that as of November 2022, 3,369 students had been recruited into the programme, and 2,617 had graduated. However, he noted there was no information on what happened to these doctors or where they were employed. Each bursary student was required to work for the state for the same number of years for which they received funding.

The programme also faced criticism over selection criteria for bursary candidates and for requiring two extra years of training compared with local medical programmes. Students spend one year learning Spanish, five years training in Cuba, and then return to South Africa for an additional 18 months of clinical training at a local medical school.

Controversies have dogged the programme over the years. In 2013, the Afrikaans newspaper Beeld reported that by 2009, only half of the students enrolled in the programme during its first 12 years had completed their studies.

In 2012, the government ramped up the numbers of students it sent abroad. In 2018, this backfired when about 700 fifth-year students returned home only to find they could not be accommodated at any of the then 10 medical schools in the country.

It was at about this time that the national health department issued recommendations for the provinces to phase out the programme.

Gauteng and North West

Despite all of the above, the Gauteng Department of Health continues to fund students — about 20 last year and an expected 40 this year.

Spotlight’s questions on this to the Gauteng health department went unanswered.

Compounding the administrative and planning blunders for returning students is the impact of deepening corruption and mismanagement in Gauteng’s health department. It has been under routine Special Investigating Unit scrutiny as well as coming under fire for service delivery issues such as the ongoing backlog of cancer patients lingering on treatment waiting lists. In March, the South Gauteng Division of the High Court in Johannesburg ruled that the Gauteng health department had failed in its constitutional obligation to make oncology services available.

In April, the department failed to pay its doctors their commuted overtime pay on time. These payments ensure there are doctors for 24-hour coverage at hospitals and make up as much as a third of doctors’ take-home pay.

The situation in the North West is also bleak. It’s health facilities routinely face medicine stock-outs and understaffing. Its health department regularly struggles with accruals and paying suppliers on time.

Given all these challenges, it is puzzling that these two provinces in particular are so committed to sending students to Cuba, at what we understand to be higher cost than for training doctors locally.

‘Better investments’

Professor Lionel Green-Thompson, now the dean of the faculty of health sciences at the University of Cape Town, was involved in managing returning students from the Cuba-SA programme between the mid-2000s and 2016. At the time, he was a medical educator and clinician at Wits University, where he oversaw the 18-month clinical training of more than 30 returning students.

“Some of these students were among the best doctors that I’ve trained, and I remain a stalwart supporter of the ideals of the programme. But at this point, there are better investments to be made, including directly funding university training programmes in South Africa,” he said.

“A programme that’s rooted in our nostalgic connection with Cuba and its role in our change as a country is now out of step with many of the healthcare settings and realities we face in South Africa,” said Green-Thompson.

He added that a proper evaluation of the programme needed to be conducted.

There were also lessons to learn, he said, including a review of admissions programmes. How some students who entered a programme at 20% below the normally accepted marks and exited the programme as excellent doctors, offered clues on how great doctors could be made, he said.

Green-Thompson also suggested that we needed to ask why specialisation had become a measure of success for many doctors in South Africa, often at the expense of family medicine. This, he said, took away from the impact doctors made at the community healthcare level as expert generalists.

But changing the perspectives of healthcare professionals required early and sustained exposure to working in community healthcare settings, said Professor Richard Cooke, the head of the department of family medicine and primary care at Wits. Cooke is also the director of the Wits Nelson Mandela-Fidel Castro Collaboration since 2018 and serves on the Nelson Mandela-Fidel Castro Ministerial Task Team.

“I’m not in support of further students being sent to Cuba for the undergraduate programme, because these students are not being trained in our clinical settings,” he said, speaking in his Wits capacity.

“The Cuban system is far more primary healthcare based than South Africa’s, but that doesn’t necessarily translate into these students ending in primary healthcare,” said Cooke.

And curricula at Wits were shifting, for instance, towards placing students at district hospitals for longer periods of time, rather than weeks-long rotations, he said.

“When students become part of the furniture at a hospital, they become better at facilitating, at critical thinking, problem solving, teamwork and collaboration,” Cooke said.

But making this kind of transformation in local training took government funding and commitment. Students and doctors needed to be attracted to the programme and needed reasons to stay. But the money and resources to make this happen were simply not there — even as the Cuba training programme continued.

Cooke added: “There hasn’t been definitive data on the Nelson Mandela-Fidel Castro programme. But even if the programme over 30 years has done well and met its targets, it’s not been cost efficient. What’s needed now is to leverage expertise and establish partnerships in different, more cost-effective ways like in research, health systems science and health science education.”

Up to three times more expensive?

Professor Shabir Madhi, the dean of the faculty of health sciences at Wits, said the Nelson Mandela-Fidel Castro programme costs an estimated three times more than it cost to train a student in South Africa. This, he said, should be enough reason for a beleaguered health department like Gauteng’s to stop sending students to Cuba.

He added: “The government is aware that it simply can’t absorb the number of medical graduates being produced.” Madhi says some trainee doctors were sitting at home while others trying to finish specialisations were being derailed.

Broadly, he pinned the blame on the mismanagement of resources, including the department underspending R590-million on the National Tertiary Service Grant meant to subsidise specialised medical treatment at tertiary hospitals.

Madhi said universities had worked hard to close the gaps identified by the Nelson Mandela-Fidel Castro programme 30 years ago, but now student doctors were being let down by the government not playing its part.

“Across the universities, there’s been a complete overhaul of the curriculum to be focused on primary healthcare. Students are also getting community exposure as early as first-year training,” he said.

He added that when it came to admissions, the majority of students entering medical schools across the country were now black South Africans, and additional changes had been made to the selection process. 

“We used to have a race quota, but in further revisions we have introduced criteria that focus on the socioeconomic component, with 40% of the admissions coming from students in quintile 1, 2 and 3 schools [no-fee public schools],” he said.

South Africa had 11 medical schools, with the most recent addition being North West University — specifically focused on rural health — and the University of Johannesburg in the pipeline to join the list. So the number of doctors being trained and graduating was increasing. Madhi estimated that the total number being trained was above 900 per year for Gauteng alone.

The bottleneck of getting doctors into clinics and hospitals, he maintained, was not a shortage of doctors, but the government's inability to pay doctors’ salaries or to create functioning, well-resourced workplace environments.

‘You can’t put a price on that’

For Dr Sanele Madela, the ongoing challenges could not detract from the goal to get doctors into communities — including through the Nelson Mandela-Fidel Castro programme. Today, he is the health attaché at the Havana Mission for the Nelson Mandela-Fidel Castro training programme. Madela was also at one time a schoolboy with a dream of becoming a doctor.

Growing up in Dundee in KwaZulu-Natal, he remembers almost never seeing a doctor in his community. 

“Then when we did see a doctor, it was a white person or an Indian person and they never spoke our language — a nurse would have to translate,” said Madela, who was part of the 2002 Nelson Mandela-Fidel Castro intake.

The six years abroad, he said, exposed him to very different reasons for becoming a doctor.

“When people finish medical school, they say thank God it’s over, but in Cuba people say thank God for the knowledge and information so they can give back to their country,” he said.

When Madela got back to South Africa, his journey eventually led him to work in Dundee district hospital. It was the same hospital where his mother had worked as a cleaner.

The Nelson Mandela-Fidel Castro programme, Madela said, still played a vital role because of its objective to get more doctors into rural and township areas — “and you can’t put a price on that”.

“We are used to seeing the Nelson Mandela-Fidel Castro programme from the point of view of adding human resources, but it’s also about the impact it makes for a community,” he said. It’s the impact of a community finally getting their own doctor. His argument is that, thanks to the Nelson Mandela-Fidel Castro programme, he got to be that person for his community. DM 

This article was first published by Spotlight – health journalism in the public interest. Sign up to the Spotlight newsletter.