Honouring Russel Botman’s legacy of Justice, Transformation and Inclusivity – the Ukwanda experience.

The theme of the PHASA conference ‘dignity, rights and quality: towards a healthcare revolution’ is well positioned in the global agenda. In June 2014, the University of Stellenbosch experienced the untimely death of the Rector of our university, Russell H. Botman. The theme of this paper links the legacy of Professor Botman with the conference theme.

Russell Botman was the first black Rector and Vice-Chancellor of the University of Stellenbosch –renowned for being one of the top four universities in South Africa. The university is also notorious for the role that the institution played in the architecture of the system of separate development – the political system of apartheid, which undoubtedly has left the legacy of inequality within our society more especially within the health care system. At the time of his appointment in 2007, Prof Botman challenged the university community to answer the following two questions: How do we link academic/research expertise and excellence to the international development goals (1)? How can we provide scientific solutions to tough societal challenges?

Throughout his tenure as rector he attempted, often against internal and external resistance, to address the issues of social injustice, discrimination and exclusion,  both within the community of the university as well as in the society at large. Let us not forget that in 1993, one year before the first democratic elections, only 1% of the student body was not Caucasian. Stellenbosch, like most universities today, has to grapple with the role of Universities in the 21st century. In a society as unequal as South Africa, how do we ensure inclusivity, relevance and responsiveness?

In August 2014, Dr Rajesh Tandon, one of the co-directors of the UNESCO Chair on Community Based Research and Social Responsibility in Higher Education and President of the Society for Participatory Research in Asia launched at the University of Stellenbosch the publication Higher Education in the World – Knowledge, Engagement & Higher Education: Contributing to Social Change. He warned that "If the many societal, environmental and economic challenges are not addressed, the visible and distressing inequalities of this world will, in 15 years, have increased to such an extent that an even larger number of people will be living in fear in gated communities." (2).

Adding to the feeling that all is not well with communities globally, Dr Jerome Slamat, one of the authors of the book and the Senior Director: Community Interaction at Stellenbosch University added that: "Humanity is in serious trouble. There is consensus that we are being plagued by the triple challenges of poverty, unemployment and inequality. South Africa is one of the most unequal countries in the world and our university Stellenbosch is centred in one of the most unequal towns in the country."

In 1990, Ernest Boyer (3) in this work Scholarship Reconsidered: Priorities of the Professoriate defined the scholarship of engagement as “connecting the rich resources of the university to our most pressing social, civic and ethical problems, to our children, to our schools, to our teachers and to our cities… I have this growing conviction that what’s also needed is not just more programs, but a larger purpose, a sense of mission, a larger clarity of direction in the nation’s life as we move toward century twenty-one.”. In the second decade of the 21st century the words of Boyer still ring true.

So as we approach 2015 and we reflect on the achievement of the Millennium Development Goals (MDGs), we have to ask ourselves whether we as 21st century universities are doing enough to participate in the beyond 2015 agenda. The discourse of beyond 2015 sees the emergence of a solid and ambitious development agenda, with sustainable development at its centre.

In his inaugural speech in 2007, as the Rector and Vice-Chancellor of Stellenbosch University, Prof Russel Botman (1), announced his vision for the university as a "multicultural university with a pedagogy of hope for Africa". He endeavoured to realise this vision by "gearing up the University, using the existing vision as point of departure, to an institution in Africa that does not only want to be significantly ‘different’, on the basis of our past, but also wishes to be significantly ‘better’, as viewed against our commitment with regard to the future of the people of our country and the continent." Based on the United Nations’ MDGs, five themes were identified which the University would focus on as part of its Pedagogy of Hope. These themes being:

  • Eradication of poverty and related conditions
  • Promotion of human dignity and health
  • Promotion of democracy and human rights
  • Promotion of peace and security
  • Promotion of a sustainable environment and a competitive industry

The university as a body approved this positioning and development themes and its Council approved the reallocation of existing university funds to the project: R320 million. This was regarded as seed funds to leverage additional funding. Faculties were invited to submit projects/ academic initiatives for funding with the criteria being that they should be sustainable and support one or more of development themes.

The Ukwanda Centre for Rural Health and Rural Clinical School

The Faculty of Medicine and Health Sciences (FMHS) submitted the Ukwanda initiative, specifically our Ukwanda Rural Clinical School (4). This in response to discussions regarding the social mission of medical schools over the past two decades.

Organisations like the Net argue that assessing progress towards social accountability in health professional schools is an important step in producing health professionals equipped to meet health needs and strengthen health systems (5). They go further saying that health professional schools have a responsibility to produce graduates who will address priority health needs of populations and various agencies and bodies have become to develop and test evaluation frameworks for measuring progress towards social accountability in health profession education.

In 2000 Fitzhugh Mullan and colleagues in the USA considered the Social Mission of Medical Education: Ranking the Schools (6). Their point of departure was that the basic purpose of medical schools is to educate physicians to care for the national population. And fulfilling this goal requires an adequate number of primary care physicians, adequate distribution of physicians to underserved areas, and a sufficient number of minority physicians in the workforce. They developed metric using these three goals to consider the schools’ social mission. I would venture to say that there would not necessary be consensus that these are indeed the purpose of a medical school. Their findings were that the social mission of medical schools varied. Public and community based medical schools had higher social mission scores than private and non–community-based schools.

In South Africa 20 years into our democracy approximately 50% of the populations still live in rural areas where unemployed is high. Poverty-related diseases like tuberculosis, malaria and cholera are placing a tremendous strain on South Africa's health care system, eroding attempts to improve the general health of South Africa's people. High levels of poverty and unemployment make it difficult for most people to pay for health services, which places immense strain on the public health sector. Despite a significant increase in the number of primary care facilities, challenges are still enormous.

Stellenbosch University launched the Ukwanda Centre for Rural Health in 2002. Ukwanda means ‘to grow’ and ‘develop within the community.’ Initially it was primarily a rural platform for undergraduate training. This was based on a growing recognition of the benefits of recruiting from and training within rural and remote communities. There was an awareness that the exposure of undergraduate students to rural settings would be for limited periods. The long-term intention was always to immerse students within such a rural setting aligning to what is now described as the pedagogy of place (7).

The first decade of the activities of Ukwanda, centred around these undergraduate programmes; mostly medical students doing short rotations. Over time the planning for an immersion model continued, drawing from the international experiences of Australia, Canada and the USA. It was during that time that the discipline of family medicine was registered as a speciality with the South African statutory professional council and in the Western Cape a training model for postgraduate training in Family Medicine based on a hub and spoke model was developed. This model aligned with the service plan for health in the region of strengthening the district health services.

The Ukwanda Rural Clinical School (RCS) was opened in 2011 in one of the rural health districts of the Western Cape. A hub and spoke model was developed using the regional hospital and the network of district hospitals in the region; within the hub we also established a campus with student accommodation as well as academic facilities.

There were 10 guiding principles that guided the RCS initiative:

  1. Recruit students from rural areas to encourage future retention
  2. ‘Teach where the patients are’ to ensure relevant exposure to the burden of disease and practical experience
  3. Enable continuity with patients for better learning
  4. Enable continuity with the mentor for better guidance and supervision
  5. Enable continuity with a specific community for better service orientation and contextualization of health problems
  6. Catalyze research in a rural context as the research base is limited
  7. Support multi-professional learning to foster teamwork
  8. Make use of IT solutions to overcome geographic distances
  9. Promote a community orientated approach / community engagement / sense of responsibility for a defined population
  10. Enable longer exposure to the district health system so that service learning becomes a win-win for both

The early results of our initiative are promising and prompt the institution to expand its rural training programmes using these principles.

Through the visionary leadership of Prof Botman, the FMHS have been given the opportunity through the HOPE projects (1) to engage as a university in addressing issues of social justice.

We have seen transformation happening, albeit slowly.  The institution is grappling how to  embrace inclusivity as the diversity of cultures and language increases with the changing demographics. A traditionally conservative institution, intolerance of, different sexual preferences is being addressed. In a university where the institutional culture is embedded in the DNA of the university, it will take many courageous conversations for us to become the institution that our late Rector envisaged, one where  all are welcomed. We were privileged that Prof Botman was our Rector for 7 years and that through his commitment to change, he enabled us to upscale our rural initiatives. Prof Botman we salute you.

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