Advocacy Project V ICE€¦ · We also thank the Rural Health Advocacy Project’s donors for their...

R u r a l H e a l t hA d v o c a c y P r o j e c t

JANUARY 2017Version 1

ADVOCACY FOR HEALTH: AN EDUCATORS GUIDE TO INCORPORATING

ADVOCACY INTO THE HEALTH SCIENCES CURRICULUM

V ICE

TABLE OF CONTENTS

Acknowledgements 4

Foreword 5

Glossary of Terms 6

Background 8

Who is the manual for? 10

Step Problem needs identification and general needs assessment 14

Step Advocacy needs assessment of targeted learners 20

Step Goals and Objectives for advocacy in the Curriculum 24

Step Educational Strategies for Teaching Advocacy 38

Step Implementation – Integrating Advocacy in the Curriculum 45

Step Learner and Programme Evaluation 48

Annexure 1: Websites 52

Annexure 2: Resources 53

Annexure 3: Organisations that can assist health care providers with addressing and avoiding health system failures 55

Annexure 4: Readings on health advocacy champions 56

Annexure 5: Readings on the state of health care in South Africa 59

Annexure 6: Additional Case studies 64

References 66

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In partnership with and the Voice Project partners:

Donors:

The Atlantic Philanthrophies

4 Advocacy for Health Advocacy for Health 5

Health care for the twenty-first century requires graduates who are more than the sum of their accumulated factual knowledge. It requires a cadre of health professionals able to engage with the complexity of their work and the development of a sense of advocacy is a key requisite for this.

This advocacy manual aims to provide educators with some useful and practical tips on incorporating advocacy into the health sciences curriculum. Credit is due in many places where this work is already developed. However, there are many lessons to be learnt and many skills to be developed in the realm of advocacy and this manual provides that foundation for this to take place.

We all need to empower new graduates to take up the many challenges presented in the South African health system in constructive ways as advocates of the patients they serve. This manual provides a good foundation from which the educator can reflect and debate with students on how to best approach some of the obstacles to effective patient care. The current status quo of students being clinically competent but lacking the necessary skills to conduct health advocacy does not augur well in an environment that requires these skills and competencies on a daily basis. The manual provides the framework for inclusion into a curriculum and thus ensuring that students do not only hear about patient rights advocacy after graduation, but that they have a sense of how to tackle issues whilst a student.

What South Africa requires at present are a formidable, confident, advocacy-skilled cadre of health care workers that are able to be great defenders and promoters of patient rights advocacy.

This manual hopes to empower the educators of the new generation of health professionals

in the belief that teachers of change will deliver the much needed change agents into our environment. The following students’ response in 2014 to the age old question of why advocacy should be learnt will encourage the work of this manual:

“Our compassion for patients drives our passionate advocacy efforts. Advancing equitable access is why. Promoting healthier community is why. Empowering vulnerable population is why. Our patients are why. Where we can join our voice with those in the shadows, there is nowhere else we would rather be.” - Nina Nguyen and Yan Xu

FOREWORD

Professor Lionel Green-ThompsonAssistant Dean: Teaching and LearningWits University

BOXES IN THE MANUAL

Box 1: Six stage model of Kern (1998) 11

Box 2: Definitions of Advocacy 15

Box 3: HPCSA and advocacy 15

Box 4: National Development Plan on the health system 16

Box 5: Being aware of your personal privilege 18

Box 6: Social Conscience 22

Box 7: HPCSA: Core advocacy competencies 26

Box 8: What type of graduate are you producing? 32

Box 9: What works well in teaching advocacy 44

ACKNOWLEDGEMENTSThe following people have contributed to the development of this manual, at different stages and in different capacities. Overall coordination and technical input: Samantha Khan-Gillmore. Technical inputs: Dr Julia Moorman, Marije Versteeg-Mojanaga, Dr Richard Cooke, Dr Bernhard Gaede, Dr Prinitha Pillay. Special thanks to Prof Sahiba Essack from the University of KwaZulu-Natal (UKZN) who played a pioneering role at this University in driving research, engagement and recommendations for the integration

of advocacy competencies into the health sciences curriculum. As such, the UKZN has made an important contribution to the conceptualisation stage of this manual. We also thank the Rural Health Advocacy Project’s donors for their support of this work: Atlantic Philanthrophies; Claude Leon Foundation; Open Society Foundation.

We thank the following donors who contributed to this manual: CLF, AP, OSF, MSF


Social determinants of health: The conditions in which people are born, grow, live, work and age, including the health system. These circumstances are shaped by the distribution of money, power, and resources at a global, national and local level and are themselves influenced by policy choices. The social determinants of health are mostly responsible for health inequities - the unfair and avoidable differences in health status seen within and between countries. (WHO 2015).

Transformative learning: Education that emphasises searching, analysis and synthesis of information for decision making: achieving core competencies for effective work in health systems and create adaptation of global resources to address local priorities. (Frenk et al., 2010) Transformative learning theory says that “learning involves change to meaning structures (perspectives and schemes) and that change to meaning structures occurs through reflection about content, process or premises.” (Mezirow, J, 2000)

Social justice: Broadly defined as promoting a just society by challenging injustice and valuing diversity. Social justice is about assuring the protection of equal access to freedom, rights and opportunities, as well as taking care of the least advantaged members of society.

Human rights: Moral or legal entitlements of all human beings, regardless of nationality, place of residence, gender, national or ethnic origin, colour, religion, language or any other status.

Users of the health system: Individuals who receive a health care service of any kind.

Social change agents: People working to bring about social change through campaigns and advocacy for the betterment of society. Social change agents bring about progressive, positive influences to advocate for better living, working or social conditions. Change agents act with accountability and transparency to transform a particular situation to suit the needs of a specific community or society.

Rural communities: Sparsely populated areas with varying, but limited degrees of access to services and amenities. Distances, travel time and the cost of health care and other services are generally higher. The definition of a rural community is not however, limited to geographical parameters. Communities exist in urban settings that display some rural characteristics, with respect to cultural practice and the sense of community.

Vulnerable groups: Groups that experience a higher risk of poverty, discrimination and social exclusion than the general population. These groups include ethnic minorities, migrants, people with disabilities, the homeless, rural populations, the elderly, women and children.

GLOSSARY OF TERMS AND DEFINITIONS

Community based education: Consists of learning activities that use the community extensively as a learning environment. (WHO 1987 p8)

Community engagement: Refers to the involvement of the local community in the planning and implementation of the educational curriculum. There are different degrees to which this can happen, ranging from a token peripheral involvement to a full partnership with the regular faculty members.

Competency: An educational competency is a specific measurable entity and usually relates to knowledge, skills or behaviour. (WHO 2008 a)

Continuing Professional Development: Aims to enhance knowledge and improve performance leading to quality outcomes

Curriculum: A curriculum is made up of all the experiences learners have that enable them to reach their intended achievements. The curriculum should enable learners and educators to know and fulfil their obligations in relation to the course. The curriculum should describe: intended learner achievements and the qualities of intended graduate, the content to be covered (syllabus), how the content will be taught and where learning will take place. The curriculum should also describe the assessment process.

Experiential learning: Involves concrete experiences, reflective observation, abstract conceptualisation and application of knowledge. (Kolb 1984)

Health professionals: Health care personnel who are registered with a professional regulatory body such as the Health Professionals Council of South Africa (HPCSA) or the South African Nursing Council (SANC). Although a health care worker is another generic description for health care workers, non-professionals are referred to collectively as health care workers. (e.g. community health care workers). Health care personnel have roles in health service, including as caregivers, communicators and educators, team members, managers, leaders, scholars and policy makers.

Interprofessional education: Occurs when two or more professions learn about, from and with each other to enable effective collaboration and improve health outcomes. (WHO 2010)

Lifelong learning: A continuum of learning throughout the life course aimed at improving knowledge, skills and competencies within a personal, civic, social and employment related perspective. (The Council of the European Union 2002)

Problem based learning: A way of delivering a curriculum in order to develop problem solving skills as well as assisting learners with the acquisition of necessary knowledge and skills. Students work cooperatively in groups to seek solutions to real world problems, set to engage students’ curiosity and initiative in learning about the subject matter. (WHO 2008 a)


BACKGROUNDSince 1994, there have been many advances in improving access to quality health care for South Africans. The country is famed for its progressive Constitution, which guarantees all people in South Africa access to health care services. To give effect to this right to health, many important interventions have been initiated such as the establishment of the Office of Health Standards Compliance. Numerous new equity-driven policies have been adopted, thousands of clinics have been built and various new health cadres have been introduced - all in an effort to strengthen and improve access to health care.

However, many health system challenges and inequities remain. Indeed, more than twenty years into democracy, an equitable, strong and effective health system for all South Africans has not yet been realised. The country remains far behind in meeting its maternal and infant mortality targets and chronic communicable and non-communicable diseases such as HIV, TB, diabetes and hypertension are placing an incredible strain on an overburdened and weak health system. Patient care and health outcomes vary widely nationally and inter-provincially - with rural, under-resourced and under-served settings being the most disadvantaged. Growing budgetary constraints put further strain on the health system, affecting the ability of provinces to fill vacant posts and leaving many health facilities severely understaffed.

These health system challenges have a profound effect on the quality of patient care and on health outcomes. Health care workers are faced with the very real challenge of trying to provide good patient care in a context of often inadequate infrastructure, medicine stock-outs and understaffed health facilities. Not knowing how to improve the situation can lead to powerlessness, apathy and burnout. Adverse working conditions for health care staff have an adverse effect on their health and well-being and can reduce the quality of

care for patients, including patient safety. Burn out is common in health care workers who feel emotionally exhausted by the violation of patient rights that they witness. Many experience a sense of de-personalisation and reduced personal accomplishment.

The impact of problems in the health system on patients and staff has been acknowledged by government on several occasions and is also highlighted regularly in the media. Whereas various solutions are offered to address existing inequities - such as the introduction of a National Health Insurance (NHI), leadership training for health managers and the recently released patient complaints management protocol - very little attention is given to the role health care workers could, and should, play in addressing health system failures and inequities.

Health care workers are first hand witnesses to how health care is delivered. They are experts in their field and have knowledge and skills that provide them with a unique perspective on health care. They are committed to the health of patients and are in a position to speak from an informed and realistic perspective on patients, health system needs and priorities. Health care workers are therefore ideally placed to use their knowledge and influence to advocate for, and with patients, to improve the health care system.

Health care workers can, and should be, agents of change. Their ability to advocate for and with patients is now a well-recognised critical skill for all health care professionals by the regulatory body the HPCSA. However, few health care workers have the motivation, confidence, knowledge and skills to navigate and address health system challenges and the underlying factors that lead to patient rights violations. Whist some have attempted to speak out on behalf of patients, the reality is that they have not been taught at training institutions how to advocate. Without applying

some key principles and strategies, many have had negative experiences including disciplinary action, victimisation and even dismissal, when speaking out about health system challenges. Withdrawal and loss of job motivation are often the result of such action. While the legitimate voices of health care workers are often ignored, there is also a need for them to more actively engaged and network with advocacy organisations.

The current status quo, of producing health care workers who are clinically skilled but lack the confidence and skill to conduct health advocacy, is no longer sufficient to meet the demands of an ailing and systemically malfunctioning health sector.

Recognising that clinical training which produces clinically competent but advocacy poor professionals is not sufficiently to prepare them to meet the health needs and expectations of the users of health care services, Faculties of Health Sciences in South Africa and the rest of the academic world, are embarking on a new trajectory to ensure that health sciences students are appropriately positioned to tackle the challenges that they will face. Medical training has in the past often emphasised that health care workers leave their beliefs and conscience out of clinical encounters. However, they are now turning their focus to building and nurturing the social consciousness of students and equipping them with the skills that they need to advocate for their patients’ right to access quality services. Today, universities are challenged with producing graduates who are critical thinkers, human rights-based, social change agents who are aware of their duties and responsibilities to defend and uphold patients’ rights to adequate, equitable and quality health care.

By building the active citizenry voice of health care workers, the health professions education sector acts not only in line with international good practices of social medical

accountability but, critically, in line with its own proud tradition of challenging injustice. South Africa is a country steeped in a rights-based culture in response to its past systemic denial of citizen’s basic rights including the most valuable right to dignity. Hence, it is imperative that students graduating from the health sciences have sufficient knowledge of how best to meet the country’s health needs from a rights-based perspective. This is not a “nice to have” or an “add on” but should be integral to the teaching and learning principles and outcomes of health science students – as it should be for all other students.

What South Africa needs at this crucial time in our history is a strong, well-equipped, knowledgeable cadre of health care workers who can think creatively, address problems pro-actively and be a key resource for patient rights advocacy.

This manual therefore provides principles, guidelines, tips, strategies, tools, resources and case studies to assist universities with this new mandate. We hope this will be a useful resource to South African Faculties of Health Sciences in their on-going transformation drive to remain relevant and responsive to the country’s needs.

“No matter how many individuals are educated and deployed, health professionals cannot transform population health unless they have the necessary competencies. Health professionals need to be technically competent and efficient but they also need to be able to work in teams, to adapt to a changing practice environment and to initiate change where needed“

WHO, Transformative Scale Up of Health Professional Education


BOX 1: SIX STAGE MODEL OF KERN (1998)

WHO IS THIS MANUAL FOR?

Although health advocacy is now recognised as a key component of health sciences education, it is often something that is not explicitly taught in health sciences curricula and, for many educators, there are challenges in teaching and assessing advocacy.

There is always a lack of teaching time and clinical teaching is generally prioritised. Educators and learners may struggle to see the relevance of advocacy to clinical practice.

The broad scope of advocacy couple with the absence of a structured advocacy curriculum and lack of understanding and consensus about what a health advocate should be means that advocacy is often only taught as part of public health, family medicine, ethics or primary health care rather than integrated into the curriculum as a whole. Educators themselves may have limited experience in engagement with health advocacy and, for many, it may not have been a big part of their scope of practice to date.

Teaching advocacy would perhaps be most effective when integrated across the curriculum rather than taught in isolation. This approach would enable students to see its relevance across the curriculum. However, while there are many opportunities for integrating advocacy into the curriculum and a growing interest, there is a lack of guidelines in terms of teaching and practice of advocacy at most universities.

This manual therefore is written to support those educators who are motivated to, and interested in, integrating advocacy in the health sciences curriculum. It will provide a working definition for health advocacy and explore strategies and opportunities for integrating advocacy into the health sciences curricula. The manual proposes some entry points into the curriculum and identifies possible core competencies for a

health advocate. Recognising that one of the challenges to teaching advocacy is the absence of clear parameters for evaluation of the competency, critical knowledge and skills of health advocates are proposed.

Whether you are educating or designing curricula for nurses, pharmacists, dentists, physiotherapists, doctors or any other future health care professional, this manual is a valuable tool.

Whilst it focuses primarily on health systems advocacy it also recognises that the knowledge and skills proposed can be used to advocate more broadly for healthy communities and lifestyles.

Including advocacy in the curriculum should be seen in the context of the current discourses that will shape the future of health sciences education – community based education, social accountability of higher education institutions and inter-professional education.

Targeted at all educators within the Faculties of Health Sciences nationally, this manual serves to aid decisions on curricula, teaching methods and assessments for any health sciences student. While the content is also relevant to educators of other health workers, it primarily targets educator teaching and training on university health sciences programmes. This manual reflects the approach that teaching advocacy would be most effective when integrated across the curriculum rather than taught in isolation as students’ would see its relevance across the curriculum.

Educators will be aware of a practical consideration that informs the approach taken in the manual. If a course is altered by more than 50%, then there are additional time-consuming authorisations and regulatory processes that need to be followed. This favours an approach of integrating advocacy

teaching and learning into existing course programmes.

The purpose of this manual is NOT to provide an educator with a comprehensive “how to” design and deliver a curriculum. It is important however that a curriculum design framework provides the map by which advocacy may be integrated into a curriculum. There are many different models of curriculum development that can inform the structure of this manual. The six-stage model developed by Kern in 1998 is a good choice:

The advantages of this model are: 1) it provides a simple, but systematic structure to the manual; 2) it helps provide a blueprint for content experts who are new to health

sciences education and/or curriculum development; 3) it emphasises importance of the very first step (i.e. to identify the need for advocacy to be introduced into the curriculum) which is appropriate for this first version of the manual; and 4) it specifically includes evaluation as a step – again, advantageous for the relative novelty of advocacy in the process. While it was originally conceptualised by Kern to help with the development of a new programme – and not the integration of a new topic, it is suitable for the purpose of this manual.

The alignment of the contents of the manual with the Kern curriculum development model is shown below. This same model can be used to integrate any subject into the curriculum1.

1 Another useful model or “competency map”, adapted from Kaprielien V, Silberberg M, McDonald M et al, 2013, assists educators to consider the new skills and knowledge needed to integrate a population health approach into medical training.

1. Problem Identification and General Needs Assessment- Health Care Problem- Current Approach- Ideal Approach

2. Targeted Needs Assessment- Learners- Learning Environment

3. Goals and Objectives- Broad Goals- Specific Measurable Objectives

4. Educational Strategies- Content- Method

5. Implementation- Obtaining Political Support- Securing Resources- Addressing Barriers- Introducing the Curriculum- Administering the Curriculum

6. Evaluation and Feedback- Individual Learners Program


KERN’S STEPS MANUAL CONTENT

1. Problem identification and general needs assessment

a. Backgroundb. What is advocacy?c. Why do health care workers need to be

advocates?d. The importance of advocacy in the South

African context

2. Needs assessment of targeted learners

a. Advocacy in Health Sciences Education and Training

b. Legal and Ethical Framework for advocacyc. Why do health science students need to learn

about advocacy?d. What can Faculty learn from students about

health advocacy?

3. Goals and objectives Measurable knowledge, skill/performance, attitude, and process objectives are written for the curriculum.a. What is a good advocate?b. Core Advocacy Competencies for Health Care

Professionalsc. Examples of curriculum content

4. Educational strategies (congruent with objectives)

a. Pedagogical approachesb. Maximizing the impact of the curriculum,

including examples of content and educational methods.

5. Implementation a. Faculty developmentb. Change managementc. Timelines and resources required

6. Evaluation and feedback a. Learner assessmentb. Program evaluation plansc. A plan for dissemination of the curriculum

“All labour that uplifts humanity has dignity and importance and should be undertaken with painstaking excellence.”

Martin Luther King, Jr

STEP 1: Problem needs identification and general needs assessmentSTEP 1: Problem needs identification and general needs assessment


1 PROBLEM NEEDS IDENTIFICATION AND GENERAL NEEDS ASSESSMENTSTEP

What is Advocacy?

Depending on the context, the following generic words are some that can be considered synonymous with the verb “to advocate”:

- to support / to recommend / to plead for / to enable / to influence / to lobby Health care workers can advocate for a better health system through different roles at different times: 1. Representative (speaking for people) 2. Accompanying (speaking with people) 3. Empowering (enabling people to speak

for themselves)4. Mediating (facilitating communication

between people / organisations)5. Modelling (demonstrating practice to

people and policy-makers)6. Negotiating (bargaining with those in

power)7. Networking (building coalitions)

The act of advocating for health directly implies that there is a goal in mind, generally involving improved health care outcomes, by whichever measure is decided upon. High patient satisfaction may be targeted, or improved health outcomes, or better system efficiencies, as examples. Overall, health advocacy is the application of knowledge, skills and attitudes towards positive health care changes at an individual, facility and community level.

At whom do health care personnel target advocacy efforts?

1. From a needs-based/demand-driven perspective, advocacy can be defined as the practical support for an individual’s right to quality and accessible health care. Advocacy also focuses on the needs of the population/community made up of many individuals who have many common health care needs. The opportunity at community level also exists for health care workers to advocate for effective strategies to address the social determinants of health, such as access to clean water and a tarred road to the health facility.

2. From a supply-side perspective, advocacy can take place in the immediate environment where health care is delivered, such as in communities, clinics, community health centres and hospitals. In these instances, no single individual/patient or community is supported with advocacy, rather the health care worker focuses on pushing for a functional health care system that ensures that every patient receives the health care that they are entitled to.

“Advocacy is an ongoing process to change values, attitudes, actions, policies and laws by influencing decision-makers and opinion leaders, organisations, systems and structures at different levels” (Measuring Up, 2010)

A number of definitions of health advocacy exist in literature. Regardless of the definition, we should remember that advocacy is a verb which implies that it is an action.

“….Given that health is the legitimate domain of health professionals, they can be considered the authentic champions of the right to health that is enshrined in the Universal Declaration of Human Rights and also embodied in South Africa’s Bill of Rights”

Professor Jimmy Volmink

“We each have a role to play in the realm of “advocacy”. Advocacy should not scare or daunt health care workers: it is likely that many are practising these principles on a daily basis without even realising it.”

Dr Jenny Nash, Rural Doctor of the Year 2014

BOX 2: DEFINITIONS OF ADVOCACY

• Action by a physician to promote those social, economic, educational and academic changes that ameliorate the suffering and threats to human health and well-being that he or she identifies through his or her professional work and expertise. Earnest M A et al Acad med 2010; 85:83-67

• Advocacy is about power. It means influencing those who have power on behalf of those who do not. Teasdale K. Advocacy in health care. Oxford. Blackwell; 1998

• Advocacy is using one’s voice, position and skills to work towards positive change on behalf of an individual or a group. Pinto A D Medicine, Conflict and Survival 2008; 24:4 285-295

• Purposeful action by health professionals to address the determinants of health which negatively impact individuals and communities by either informing those who can enact change or by initiating, mobilising and organising activities to make change happen, with or on behalf of individuals or communities with whom the health professionals act. Oandasan 2005

BOX 3: HPCSA AND ADVOCACY

The HPCSA includes an advocacy competence for health professionals to “Identify and use opportunities for health promotion and disease prevention with individuals to whom they provide care, incorporating ethics and human rights principles”. Health advocacy may include, but is not the same as health promotion. Health advocacy seeks to address systemic health system challenges and failures – the reasons patients do not receive the health care that the need and are entitled to: poor planning and mismanagement, insufficient resources, understaffing, corruption. Health promotion speaks to the measures that society can take to enable people to live a healthier life.



rather than shying away from working in difficult health care settings.

South Africa has one of the most unequal societies in the world. On almost every marker of inequality in the country - be it wealth, education, access to heath care, income, historical advantage and many others - there are those who are privileged and those who are not.

Health care professionals are in a position of privilege and power and hold an elevated place in society. They are generally highly educated and have access to financial and human resources. They are often looked up to by patients and stakeholders as a source of authority and a voice of good ethics. As they work inside the health care system, they are also often the first to identify challenges and solutions. Their position of privilege and authority gives them the power to effect change which they have a moral obligation to use to the advantage of patients. Universities should ensure that they promote their drive, skills and confidence to advocate with and on behalf of their patients.

Advocacy can be misunderstood as charity. There is a need to ensure that health advocacy efforts do not become “charity”. Charity would be about providing services: resources, time, knowledge and clinical services to those in need. A social justice approach requires undergraduates to focus their efforts on understanding and working to change the structural or institutional factors that contribute to inequitable and otherwise unacceptable conditions. Health advocacy enables an equal and collaborative partnership with communities; develops mutual capacity to address root causes of systemic social inequity and disparity and focuses on building social capital.

The importance of advocacy in the South African context

The context in which health care is currently delivered in South Africa requires health care providers to become stronger health advocates. The National Development Plan highlights a number of challenges facing the health care sector (Box 1), public services and the country. These challenges undermine patients’ right to health care. For many South Africans who use public sector facilities, the quality of care that they receive is poor. Patients are faced with long waiting times, frequent stock outs of essential medication, and uncaring, abusive health care workers. Health outcomes – life expectancy, infant and maternal mortality and the burden of disease - across the country are compromised and differ across districts, provinces and between urban and rural areas. Health care workers themselves often work in an unsafe environment and stories abound of managers undermining or even victimising health care workers.

Where there is an acute shortage of health care workers – especially in rural and underserved areas, pressure on the health system results. It is also important to note that the unequal distribution of health care workers between urban and rural areas is another element to advocate for students to practice in rural areas where the need is greatest.

Functioning health care systems require enough health care workers who are, not only clinically competent (the main focus of universities to date) but also caring, responsive, productive and sufficient in numbers where they are needed most. Health care professionals therefore play an integral role in improving the health care system and should see themselves as part of the solution

BOX 4

NATIONAL DEVELOPMENT PLANThe overall performance of the health

system has been poor:

• Health services between private and public sector fragmented

• Fundamental importance of community participation and the role of civil society has diminished

• Culture of valuing and respecting the expressed needs of communities has faded

• Health system is fractured, with pervasive disorder and multiple consequences: poor authority, feeble accountability, marginalisation of clinical process and low staff morale

• Many health care professionals have become less concerned about carrying out their responsibilities and duties to patients, their profession and society, than about personal benefits such as pay and working conditions.

• Resources have been inequitably distributed

The crisis of our times relates not only to technical competence, but to a loss of the historical perspective, to the disastrous divorce of competence from conscience.

Ernest Boyer, medical educator

Exercise 1:

What exactly makes a student privileged? Students can be challenged to identify their own privilege by answering a thought-provoking questionnaire. Any educator should, however, first ask the question of him / herself. See box 5.



BOX 5: BEING AWARE OF YOUR PERSONAL PRIVILEGE

Beyond professional privilege, students also have different levels of personal privilege. In order to build social consciousness and a commitment to equity and social justice, as opposed to distanced support to charity, students will benefit from an awareness of their own level of privilege.

Do this exercise in groups, but allow for anonymous answers, depending on the group setting. Facilitate a discussion on group findings.

Questions require a Yes/No answer:

1. Were there more than 50 books in your house while you were growing up?2. Do you believe that you could ever be denied employment because of your race, gender

or ethnicity?3. Do you believe that you could ever be paid less because of your race, gender or ethnicity?4. Have you ever felt uncomfortable about a joke directed at your gender?5. Were you embarrassed about your clothes or house while growing up?6. Did your parents or guardians attend a tertiary learning institution?7. Were you raised in an area with crime and drug activity?8. Have you ever tried to change your speech or mannerisms to gain credibility?9. Are you reasonably sure that you would not be denied access to jobs or political resources

because of your gender?10. Are you relatively sure that you can enter a shop/store without being followed by security

or staff personnel?11. Are you reasonably sure that you will one day be hired based on your ability and

qualifications?12. Did your family automatically expect you to attend university?13. Did your parents work nights and weekends to support your family?14. Can you buy new clothes and go out to dinner when you want to?15. Did you go to galleries, museums and attend the theatre with your family while growing

up?16. Do you have a private or Model C schooling background?17. Were you raised in a single-parent household?18. Have you ever been the victim of sexual harassment?19. Have you ever been a victim of violence because of your race, gender, class or sexual

orientation?20. Have you ever been on a family holiday?21. Can you make mistakes and not have people attribute your behaviour to flaws in your

racial / gender group?22. Do you come from a supportive family environment?23. Did you have a part-time job during your high school years and do you currently have a

part-time job?24. Are your parents able to afford your university tuition fees?25. Have you ever gone to bed hungry?

26. As a student now, do you ever go to bed hungry?27. Do you own a personal vehicle that transports you to university daily?28. Do you have more friends of your own race group than others?29. Did you grow up living with your own parents?30. Were you raised in an urban or rural community?31. Do you expect to look after your parents and/or extended family members financially

once you have graduated and found employment?32. Were you able to have breakfast every morning as a child?33. Do you feel confident that your parents would be able to financially help/support you if

you were going through a financial hardship?34. Were you were ever uncomfortable about a joke or a statement you overheard that

related to your race, ethnicity, gender, appearance, or sexual orientation but felt unsafe to confront the situation?

Reflect on the following, as an individual or a group.

1. How do you feel after participating in this exercise?2. What did it teach you personally about the differences in society?3. Were you aware of these differences?4. Do you understand the different classes and socio-economic factors that differentiate

people in society? 5. What are these?6. Are you familiar with different political ideologies in various countries? Can you list a few?7. What other questions can you think of to understand the issue of privilege? 8. How do people with privilege affect society in ways that people without privilege cannot?9. Do you think it would be appropriate for a person of colour to give a lecture on privilege

on your campus?10. Why do you think that South Africa’s wealth is so disproportionately distributed?11. What are you views on affirmative action?12. What do you think about the racial/geographical/quintile quota system on your campus?

Is it fair or not?13. Do you believe that racial discrimination is a national problem? Why or why not?

Students may be affected by the highly personal questions, some of which go back to childhood experiences. As a facilitator be prepared for some students needing debriefing. You could have confidential follow-up discussions or share the contact details of the university’s counselling services after the exercise.

STEP 2: Advocacy needs assessment of targeted learnersSTEP 2: Advocacy needs assessment of targeted learners


Advocacy in health sciences education and training

Including advocacy in the curriculum should be seen in the context of the current discourses that will shape the future of health science education – community based education, the social accountability of community-engaged higher education institutions and inter-professional education. A strong, well-equipped, knowledgeable cadre of health care workers who can think creatively, address problems pro-actively, and be a key resource for patient rights advocacy is the end goal.

Legal, ethical and regulatory frameworks to inform the teaching of health sciences students about advocacy

This is not a manual on ethics. Teaching advocacy must however be positioned within a broader legal and ethical framework. While the core competencies for advocacy specified by the HPCSA are considered later in the manual, at this point, the educator is referred to the work of the Council’s Committee on Human Rights, Ethics and Professionalism Committee. In 2005, this committee devised a curriculum framework for teaching Human Rights and Ethics. The educator must consider this document as an important reference point on advocacy.

Additional points of reference are the HPCSA ethical rules and the HPCSA Code of Conduct for the Public Service:

Why do health sciences students need to learn about advocacy?

Health sciences students need core knowledge, skills and attitudes to fulfil their role as health advocates. Students should learn how to act when they witness health care failures and be able to respond to inequities in health care and the needs of the people in society who are affected. The intent is to nurture a sense of social responsibility and accountability.

Many health professionals today do not see their role as advocates for their patients, for communities or even for themselves as health care providers. The nature and content of their professional training at university can explain this deficiency. Students are not sufficiently taught to think critically about their roles and duties as health care professionals beyond clinical care, nor are they taught the tools and strategies for safe and effective advocacy.

The problem starts from the time that applicants are selected for health sciences programmes by universities. Emphasis here focusses on academic criteria and is not balanced with others that are relevant to producing suitable graduates for serving the South African public. To rectify this problem, selection criteria are being reviewed nationwide.

The hidden curriculum

The hidden curriculum is a powerful vehicle to shape the “product” of universities, namely the graduate. While the formal curriculum is often described as the planned series of learning experiences during the programme, the hidden curriculum encompasses the unplanned activities and learning experience, which can be positive or negative. The hidden curriculum is described as the “educational

influences that shape learning at the level of organisational structure and culture, including implicit values, customs, rituals and taken-for-granted practices (Lempp, H. & Searle, C. The hidden curriculum in undergraduate medical education: qualitative study of medical students’ perceptions of teaching. BMJ, 329: 770-773).

The hierarchy between the professional (as the instructor) and the student (as the learner) is part of the structure that makes it difficult for students to advocate effectively. The power imbalance between the faculty member and student is an obstacle to the development of the student as an advocate for patients and the health system. For example, the hidden curriculum might be the influence for a student to keep quiet when medicines are out of stock at their site of training; to close their ears when the instructor verbally abuses patients; or to look away when the ward is filthy. Witnessed by students often enough, these become learned behaviours. What universities inadvertently risk doing is teaching students to focus on their own gain and retain their privileged mind-sets. Over time, this erodes the social consciousness that many of the students have when they enter their first year at university. The knock-on effect is that the majority of health sciences students eventually choose to work in the private sector, while the public sector remains understaffed and unable to meet the health care needs of the most disadvantaged patients.

This imbalance of power can be redressed if universities continuously engage and work on students’ values and willingness to serve where they are needed and to address challenges affecting health care effectively and confidently. Students need to internalise that advocacy for patient rights is not something that others do – a hospital or clinical manager, the unions and activists - but a core competency for the health care worker.

2 ADVOCACY NEEDS ASSESSMENT OF TARGETED LEARNERSSTEP

As a health advocate, health care professionals use their expertise and influence to advance the health and well-being of individuals, communities and populations (Canmeds)

STEP 2: Advocacy needs assessment of targeted learnersSTEP 2: Advocacy needs assessment of targeted learners


BOX 6: SOCIAL CONSCIENCE: THE ABILITY TO REFLECT ON DEEPLY–HELD OPINIONS ABOUT SOCIAL JUSTICE AND SUSTAINABILITY

Growing health advocates through transformative learning

Not all students are natural “health advocates” and taking on an advocacy role can make some uncomfortable. Students come from different backgrounds, influencing their outlook on life. Many students see advocacy as something that some students do in their spare time because they are particularly interested in helping people.

We all have a social conscience that defines and differentiates right from wrong. It’s the one aspect that separates us from other species on the planet. But aside from right or wrong, a social conscience also allows us to be more sympathetic and empathetic to vulnerable population groups as well as to those to whom we have a specific professional responsibility.

Transformative learning allows us to reflect on what is being taught, consider how it relates

to social justice and how effectively these opinions have worked in securing and ensuring a better health care system. It is the ability to develop critical thinking skills and to take collective action to rectify wrong - particularly in a world where moral compasses are regularly being distorted and compromised. Social conscience therefore “moves beyond personal, individual virtues and interactions, to a wider desire to contribute to a more ethical and just society.” For students, undergoing transformative learning, often through experiencing “disorienting dilemmas” lays an important platform for them to become health advocates.

Dr. Patricia Cranton, a leading writer on transformative learning, says that the “elegantly simple” definition of transformative learning includes the idea of people changing the way they interpret their experiences and their interactions with the world:

“. . . an individual becomes aware of holding

a limiting or distorted view. If the individual critically examines this view, opens herself to alternatives, and consequently changes the way she sees things, she has transformed some part of how she makes meaning out of the world.” (Cranton, P).

What can faculty learn from students about advocacy?

It is worth noting that many students are natural advocates. Extremely effective change agents emerged from within the student population in 2015/16 concerning the #RhodesMustFall, #FeesMustFall, in-sourcing of university workers, as well and loud calls for more transformation in the curriculum. Certainly, integration of patient advocacy within the health sciences curricula can follow this example.

Students will frequently verbalise that strong advocacy role models are not the norm.

There are few opportunities for debriefing on negative experiences and little avenues offered to act on patient rights violations witnessed during training. A key example is the case of a medicine student at a Rural Health Club debate on advocacy in 2016. In anger, she expressed the outrage and disempowerment that she had felt during an obstetrics rotation during which she couldn’t even offer clean sheets to a mother who had given birth the day before. Yet, there was no place she felt she could go to rectify the situation. This type of outrage needs to be channelled into positive, constructive action before it dwindles and is replaced by an acceptance of the status quo.

As the curriculum focuses more and more on primary health care, community based education and inter-professional education, the need for health care workers to become social change agents and for universities to become socially accountable increases. In this regard, students have clearly demonstrated the role they can play as transformative leaders and many are eager to learn about advocacy. During the course of their training, students are exposed to health system challenges, mistakes, and patient rights violations - yet they are seldom taught what they can do in response. Not only does this leave students distressed and disempowered but it also implies that it is “in order” not to act. Over time they learn that it is preferable to be silent about issues rather than to voice out their concerns or complaints and, by the time they leave university many have resigned themselves to accept the status quo.

Reforms in education must be informed by community health needs and evaluated with respect to how well they serve these needs. Stronger collaboration between the education and health sectors, other national authorities, and the private sector will improve the match between health professional education and the realities of health service delivery. Educational institutions need to increase capacity and reform recruitment, teaching methods and curricula in order to improve the quality and the social accountability of graduates.

WHO Transformative scale up of health professional education

Consciousness Agency

Structure

Awarenessof injustice

Social problem

Strong socialconscience

Own responsibility

Able to intervene

Unable to intervene

Another’s responsibility

Weak social conscience

(social apathy)

Individualproblem

Unaware, or injustice not considered a

problem

STEP 3: Goals and objectives for advocacy in curriculumSTEP 3: Goals and objectives for advocacy in curriculum


The different roles of the health advocate is the starting point for framing the competencies required of a health professional.

What is a good health advocate?

A good health advocate: 1. Puts patients first as they fulfil their

duties. 2. Is aware of their position of privilege and

power and uses this to call for, and effect change, in situations where the health system is failing the patient.

3. Is aware of and wants to address the inequities in people’s access to health care, often caused by socio-economic factors.

4. Has the knowledge, skills and confidence to advocate strategically and effectively with and on behalf of their patients.

5. Has leadership skills and knowledge of how to seek recourse should the need arise in their respective facilities.

6. Goes beyond providing individual patient care and addresses the underlying factors that could lead to improved access to health care.

7. Works with others to find solutions to systemic factors that cause patient rights violations, health system challenges and poor population health.

8. Seeks to understand the socio-economic conditions of their patients and how these affect their health and access to health care.

9. Understands that they can make a difference and can impact on the health outcomes of the patients and community

by acting as change agents. 10. Uses their expertise and influence to

advance the health of their patients11. Respond to individual patient needs and

issues as part of patient care.

To start this section, some examples of indicative content are provided, concerning

the knowledge, skills and attitude to be a good advocate.

3 GOALS AND OBJECTIVES FOR ADVOCACY IN CURRICULUMSTEP

“You must do the things you think you cannot do” Eleanor Roosevelt

“Never doubt that a small group of thoughtful, committed people can change the world. Indeed, it is the only thing that ever has.”

Margaret Mead

Knowledge Knowledge about the legal, ethical and regulatory frameworks that protect patients

Knowledgeable about the tools and approaches to advocate for patient rights

Knowledgeable about the determinants of health and their link to health

Skills Resourcefulness Confront a challenge and develop a strategy to arrive at a solution

Engaged scholarship Link learning outcomes to community engagement and social consciousness

Up to date Be aware of available resources and pair these with current knowledge of best practices for patients

Resilience Avoid burnout by ensuring a continued dedication to work, by maintaining the care and improvement of self

Attitude Honesty Present a truthful and legitimate argument on behalf of patients

Assertiveness Argue on behalf of patients, presenting the best case possible and presenting the facts in a cogent and direct fashion

Humility Put the interests of patients first

Exercise 2:

What knowledge, skills and characteristics does the health sciences student need to be a good advocate?

The educator is encouraged to list the different topics under knowledge, skills and attitude, building on the examples provided above. Alternatively, there are different topics referred to individually or collectively in this manual. Consider these, and whether each is categorised as knowledge, a skill or a characteristic/attitude.



Core advocacy competencies for health care professionals

In education theory, competencies are phrased as broad goals, whereas learning outcomes are more specific. Outcomes for the graduate need to be specific, measurable, achievable,

realistic, and time-bound to determine if the graduate has required the necessary mindset, knowledge, skills and confidence to advocate. The HPCSA has articulated core advocacy competencies for medical and health sciences graduates. These are summarised below:

BOX 7: HPCSA: CORE ADVOCACY COMPETENCIES FOR MEDICAL PRACTITIONERS

Health Professions Council of South Africa:Core Advocacy Competencies for medical practitioners

1. Respond to individual patient/ client health needs and related issues as part of holistic health care

a. Identify the health needs of individual patient/client, taking into account his/her cultureb. Identify and use opportunities for health promotion and disease prevention with

individuals to whom they provide care, incorporating ethics and human rights principles c. Act as an advocate for patients /client groups for particular health needs (including the

poor and marginalised members of society) 2. Respond to the health needs of the communities that they serve

a. Familiarise themselves with the communities that they serve by obtaining insight into the local health system, barriers to access care and services, and other factors not directly part of health care

b. Identify marginalised and vulnerable populations and respond appropriately with a commitment to equity, through access to care and equal opportunities.

c. Identify opportunities for health promotion and disease prevention within the context of promoting a healthy environment and lifestyle

d. Communicate effectively with communities and enable them to identify, prioritise, and address health care needs specific to them

e. Recognise and respond to competing interests within the community being served by reporting these to the relevant stakeholders in the community

f. Apply the ethical and professional principles inherent in health advocacy, including altruism, social justice, autonomy, integrity and idealism, appreciating the possibility of conflict inherent in the role of health advocate

3. Respond to the patients’ health needs by advocating with the patient within and beyond the clinical environment

a. Work with patients to address the determinants of health that affect them and their access to needed health services or resources

b. Work with patients and their families to increase their opportunities to adopt healthy behaviours

c. Incorporate disease prevention, health promotion and health surveillance into interactions with individual patients

4. Respond to the needs of communities or patient populations they serve by advocating with them for system level change

a. Work with a community or a population to identify the determinants of health that affect them

b. Improve clinical practice by applying a process of continued equality improvement to disease prevention, health promotion and health surveillance activities

c. Participate in a process to improve health in the community or population they serve



CORE

CU

RRIC

ULU

M

GO

AL

LEA

RNIN

G O

UTC

OM

ESIN

DIC

ATIV

E CO

NTE

NT

1. G

radu

ates

sho

uld

be a

ble

to d

escr

ibe

the

lega

l and

pol

icy

foun

datio

ns fo

r hu

man

righ

ts, e

quity

an

d so

cial

justi

ce in

So

uth

Afric

a.

Be a

ble

to li

st a

nd d

escr

ibe

key

law

s,

polic

ies

and

docu

men

ts p

erta

inin

g to

th

e rig

hts

of p

atien

ts a

nd c

onsti

tutio

nal

man

date

for a

dvoc

acy.

• Co

nstit

ution

of S

outh

Afr

ica

– m

anda

te fo

r adv

ocac

y•

Bill

of R

ight

s•

Nati

onal

Hea

lth A

ct•

Bath

o Pe

le p

rinci

ples

• Pa

tient

s’ R

ight

s Ch

arte

r

Be a

ble

to e

xpla

in th

e fa

ctor

s th

at

cont

ribut

e to

hea

lth, i

ll he

alth

and

the

succ

essf

ul m

anag

emen

t of p

atien

ts a

nd

popu

latio

ns.

• De

term

inan

ts o

f hea

lth

• So

cial

det

erm

inan

ts o

f hea

lth•

Risk

fact

ors

for d

iseas

e •

Prin

cipl

es o

f dise

ase

prev

entio

n•

Prin

cipl

es o

f hea

lth p

rom

otion

and

hea

lth

prot

ectio

n•

Prin

cipl

es o

f dev

elop

ing

heal

th p

olic

y

Be a

ble

to d

efine

and

disc

uss

the

reas

ons

for a

nd c

onse

quen

ces

of in

equi

ties

in

Sout

h Af

rica,

and

diff

eren

ces

in s

ocie

ty

and

how

they

rela

te to

hea

lth.

• Co

ncep

ts o

f equ

ity in

soc

ial d

eter

min

ants

of h

ealth

•

Ineq

uitie

s in

reso

urce

s, h

ealth

out

com

es•

Acce

ss to

hea

lth c

are

and

barr

iers

to a

cces

s•

Fact

ors

that

influ

ence

the

dem

and

for h

ealth

car

e•

Diffe

renc

es b

etw

een

prov

ince

s, d

istric

ts, u

rban

and

ru

ral p

opul

ation

s.

Be a

ble

to d

iscus

s an

d an

alys

e th

e ne

eds

and

lived

real

ities

of m

argi

nalis

ed

patie

nts

and

desc

ribe

the

valu

e of

ad

voca

cy fo

r pro

tecti

ng th

e rig

hts

of

thes

e po

pula

tions

.

• Co

ncep

t of v

ulne

rabl

e pa

tient

s an

d di

sadv

anta

ged

patie

nts

– re

fuge

es, h

omel

ess,

LG

BTI,

adol

esce

nts,

ru

ral

etc.

• Ad

oles

cent

pre

gnan

cy

Be a

ble

to d

iscus

s, e

xpla

in th

e po

tenti

al

for c

ompe

ting

heal

th in

tere

sts

of th

e in

divi

dual

s, c

omm

uniti

es, o

r pop

ulati

ons

serv

ed.

• Co

mm

unity

eng

agem

ent

CORE

CU

RRIC

ULU

M

GO

AL

LEA

RNIN

G O

UTC

OM

ESIN

DIC

ATIV

E CO

NTE

NT

2. G

radu

ates

sho

uld

be a

ble

to d

escr

ibe

the

lega

l and

pol

icy

foun

datio

ns fo

r the

rig

hts

and

dutie

s of

he

alth

car

e w

orke

rs.

Be a

ble

to li

st a

nd d

escr

ibe

key

law

s an

d do

cum

ents

per

tain

ing

to th

e rig

hts

and

dutie

s of

hea

lth c

are

wor

kers

. In

pa

rticu

lar t

he d

uty

of h

ealth

car

e w

orke

rs to

use

thei

r pos

ition

of p

ower

an

d in

fluen

ce re

spon

sibly

and

be

soci

ally

ac

coun

tabl

e.

• Re

ason

s w

hy c

arin

g ab

out t

he w

elfa

re o

f pati

ents

and

hea

lth

care

wor

kers

is im

port

ant,

usin

g a

hum

an ri

ghts

per

spec

tive

• H

PCSA

Eth

ical

Rul

es•

Code

of C

ondu

ct o

f the

Pub

lic S

ervi

ce•

Prac

tical

Gui

delin

es fo

r em

ploy

ees

• Co

ncep

t of p

rivile

ge

Be a

ble

to d

iscus

s cr

itica

lly th

e co

ncep

t of

dua

l loy

alty

and

app

reci

ate

the

poss

ibili

ty o

f com

petin

g in

tere

sts

betw

een

them

selv

es a

nd th

eir m

anag

ers.

• Du

al lo

yalty

– p

rofe

ssio

nal e

thic

s / d

uty

to u

sers

and

dut

y to

em

ploy

er /

stat

e

Be a

ble

to c

ritica

lly d

iscus

s th

e ne

ed

for a

war

enes

s of

soc

ial c

onsc

ious

ness

an

d em

path

y fo

r pati

ents

’ dig

nity

to b

e up

held

.

• Pr

ivile

ge e

xerc

ise•

Soci

al c

onsc

ious

ness

and

tran

sfor

mati

ve le

arni

ng

Desc

ribe

the

ethi

cal a

nd p

rofe

ssio

nal

issue

s in

hea

lth a

dvoc

acy

and

soci

al

justi

ce.

• M

edic

al e

thic

s

3. G

radu

ates

sho

uld

be a

ble

to d

efine

he

alth

adv

ocac

y, di

scus

s th

e sc

ope

of a

nd p

rinci

ples

of

heal

th a

dvoc

acy.

Be a

ble

to d

efine

adv

ocac

y an

d de

scrib

e th

e ne

ed fo

r bot

h pa

tient

-cen

tere

d ad

voca

cy fo

r eac

h in

divi

dual

as

wel

l as

enga

ge in

adv

ocac

y to

impr

ove

heal

th

care

syst

ems.

• De

finiti

ons

of a

dvoc

acy

• Sc

ope

of a

dvoc

acy

• Ex

ampl

es o

f adv

ocac

y•

Advo

cacy

in p

artn

ersh

ip w

ith p

atien

ts, c

omm

uniti

es, a

nd

popu

latio

ns s

erve

• Pr

inci

ples

of c

omm

unity

eng

agem

ent

Be a

ble

to d

efine

thei

r rol

e in

adv

ocati

ng

for i

ndiv

idua

l pati

ents

, adv

ocati

ng fo

r he

alth

syst

em c

hang

e an

d to

impr

ove

the

wor

king

con

ditio

ns o

f hea

lth c

are

wor

kers

.

• Ca

se st

udie

s pr

ovid

ing

exam

ples

of s

ituati

ons

in w

hich

hea

lth

care

wor

kers

hav

e ac

ted

to e

nsur

e th

e w

ellb

eing

of p

atien

ts

The table below provides some learning outcomes and indicative content for each curriculum goal.



CORE

CU

RRIC

ULU

M

GO

AL

LEA

RNIN

G O

UTC

OM

ESIN

DIC

ATIV

E CO

NTE

NT

Be a

ble

to d

efine

/ id

entif

y di

ffere

nt

advo

cacy

role

s fo

r diff

eren

t situ

ation

s.•

Repr

esen

tativ

e (s

peak

ing

for p

eopl

e)•

Acco

mpa

nyin

g (s

peak

ing

with

peo

ple)

• Em

pow

erin

g (e

nabl

ing

peop

le to

spe

ak fo

r the

mse

lves

)

Be a

ble

to g

ener

ate

and

com

mun

icat

e re

leva

nt e

vide

nce.

• Ev

iden

ce b

ased

med

icin

e•

Sour

ces

of e

vide

nce

Be a

ble

to id

entif

y co

mm

unity

net

wor

ks

and

who

is a

ctive

in a

dvoc

acy.

• Ke

y ad

voca

cy n

etw

orks

- in

tern

ation

al, n

ation

al a

nd lo

cal

Be a

ble

to c

omm

unic

ate

key

mes

sage

s eff

ectiv

ely

and

with

con

fiden

ce.

• De

velo

ping

key

mes

sage

s•

Com

mun

icati

on•

Conc

epts

and

tech

niqu

es o

f acti

vism

, pub

lic s

peak

ing,

co

aliti

on b

uild

ing

• Co

mm

unic

ation

ski

lls•

How

to m

obili

se a

nd n

etw

ork

with

oth

ers

• De

velo

ping

and

del

iver

ing

mes

sage

s

4. G

radu

ates

sho

uld

be a

ble

to a

ccep

t re

spon

sibili

ty

to p

rote

ct a

nd

adva

nce

the

heal

th

and

wel

lbei

ng

of in

divi

dual

s,

com

mun

ities

and

po

pula

tions

.

Hav

e a

good

kno

wle

dge

of th

e ch

alle

nges

they

will

face

and

the

cont

ext

in w

hich

hea

lth c

are

is pr

ovid

ed in

Sou

th

Afric

a (c

orru

ption

).

• O

rgan

izatio

n an

d fin

anci

ng o

f the

Sou

th A

fric

an h

ealth

car

e sy

stem

s•

Perf

orm

ance

of t

he h

ealth

car

e se

ctor

• Ch

alle

nges

face

d by

hea

lth c

are

syst

em, p

atien

ts.

• La

ck o

f res

ourc

es in

rura

l are

as

• De

finiti

ons

of q

ualit

y of

car

e, h

ow to

impr

ove

qual

ity e

tc.

• Cl

inic

al g

over

nanc

e•

Patie

nt s

afet

y, ris

k m

anag

emen

t

Be a

ble

to a

dvoc

ate

for a

bett

er h

ealth

ca

re sy

stem

on

beha

lf of

pati

ents

and

be

able

to a

dapti

ng p

racti

ce to

resp

ond

to

the

need

s of

pati

ents

, com

mun

ities

, or

popu

latio

ns s

erve

d.

• Ad

voca

cy s

kills

and

att

ribut

es•

Lead

ersh

ip s

kills

/ cl

inic

al le

ader

ship

CORE

CU

RRIC

ULU

M

GO

AL

LEA

RNIN

G O

UTC

OM

ESIN

DIC

ATIV

E CO

NTE

NT

Know

whe

n to

inte

rven

e an

d ho

w to

bu

ild c

oaliti

ons.

• Te

am b

uild

ing

• G

athe

ring

evid

ence

• O

rgan

izatio

ns th

at s

uppo

rt p

atien

t adv

ocac

y an

d th

eir l

egal

lim

itatio

ns

Know

abo

ut a

nd b

e ab

le to

use

the

mec

hani

sms

that

exi

st to

impr

ove

the

heal

th c

are

syst

em, i

nclu

ding

kno

win

g w

ho to

com

plai

n to

– b

oth

inte

rnal

and

ex

tern

al a

nd b

e ab

le to

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LINKING LEARNING OUTCOMES WITH CORE ADVOCACY COMPETENCIES BOX 8: WHICH TYPE OF GRADUATE ARE YOU PRODUCING?

A 56-year-old woman, Mrs Matokane, arrives at a rural primary health care clinic in Mpumalanga at 07h00. Living in a deeply rural area, she walked almost an hour to get to the main road. The public transport system in rural areas does not go onto the gravel roads hence the long travel time for her to arrive at the clinic. She has tuberculosis and has been on treatment for three months. She has come to pick up her medication for the following month.

A health care worker sees her at 11h40. The clinic does not have two of the drugs that she is currently taking.

• Mrs Ndlovu, a professional nurse, apologises to the woman for the lack of medication, indicates that there is nothing that she can do and asks her to come back the following week by which time she, Mrs Ndlovu, is sure that the drugs will have been delivered.

• Mrs Molobela, a professional nurse asks Mrs Matokane where she lives and she feels incredibly frustrated to learn that she has walked over an hour to get to the clinic. She complains profusely to the nurses about the lack of medication and resolves to bring this up at the next sub-district managers meeting. Once again she wonders about taking up the recently advertised position at the NGO clinic in the nearest town.

• Mrs Mlangheni, a professional nurse, rings her immediate supervisor, two neighbouring clinics and the local district hospital to find out if any of them have stock of this drug. She then asks Mrs Matokane where she lives and establishes that there are community health care workers in her village. She arranges for the community health care workers to deliver the outstanding medication to Mrs Matokane the following Thursday. The health care worker then finds out for how long the medication has been out of stock and why from clinic staff. She documents the number of TB patients who have been sent home without their drugs. Armed with this information she attends the next sub district managers meeting and raises this as a critical issue. When, the next week, the drug is still out of stock, she reports the matter to the StopStockOuts Project, and NGO, that advocates for immediate solutions to stock outs.

Advocacy should be an integral part of the curriculum and clinical teaching, not taught in isolation.

“Thinking and acting” as a health advocate needs to become part and parcel of a health care professional’s day to day work. The curriculum needs to reflect this principle by a repeated exposure, exercise and reflection on advocacy during teaching and learning. Advocacy should be included in the core competencies for all health sciences disciplines

and taught and assessed in all clinical rotations.

1. Understand what is currently being taught and what opportunities there are for integrating advocacy. A situational analysis of what is currently being taught in a curriculum will identify missed opportunities for teaching advocacy in an explicit and experiential way. This process should help identify where the competency can best be

taught and where it should not be taught. The situational analysis should include some consideration of the ideal student and actual graduate characteristics.

2. Map the curriculum, identifying where advocacy competencies can best be taught and where it is least appropriate to teach.

3. Mapping the curriculum for health sciences students should consider the following:a. Identification of a framework

for benchmarking the teaching. Examples might include:

• The context in which problems / clinical cases are presented

• The topics that are being taught• Context –Upon doing a recent

situational analysis, educators at a university, faculty of health sciences in South Africa, found that almost all lectures on patient management

assumed that all resources were available, that patients entered the health care system at a tertiary level and that all disease were complicated and managed by doctor.

• Whether advocacy is explicitly taught or not

b. Structure the curriculum into three levels of desired achievement, namely foundational, applied or proficient (guided by Blooms taxonomy for learning)

• Foundational – basic awareness of the principles and an appreciation for their impact and importance in health.

• Applied – skilled participation in advocacy activities

• Proficient - independent practice.

An example of this analysis follows, as applied to an individual advocacy competency:

ADVOCACY COMPETENCY

FOUNDATIONAL: AWARENESS

APPLIED: SKILLED PARTICIPATION

PROFICIENT: INDEPENDENT

PRACTICE

Specify how cultural and linguistic competence and health literacy influence the conduct of patients and population health interventions

Define health literacy

Identify local customs that affect health

Explain why health care providers need to understand this local health knowledge

Identify tools that are culturally and linguistically relevant and appropriate

Develop programmes responsive to the diverse needs of populations.



Examples of curriculum content

This manual will not provide exhaustive curriculum content for the teaching and training of advocacy. To help educators, however, a list of relevant content is provided in the table above. This is provided as stand-alone content, but is ideally integrated within existing curricula.

The actual approach to integrating advocacy content into existing curricula is considered within the next section.

This content is adapted from the Rural Health Advocacy Project’s Voice Manual “A Healthcare Provider’s Guide to Reporting Healthcare Challenges: Principles, Tools and Strategies”.

The process to lodge a complaint

a. As a patient The National Complaints Management Protocol (NCMP) (www.health.gov.za) sets out the stages to the process of laying, managing and responding to a patient complaint, with respect to the actions of patient and health authorities. There is a clear and well–defined process to follow. Complaints that are not addressed at facility level can be taken higher up the chain.

• The knowledge, skills and attitude required to assist the patient or his / her family to lodge a complaint about poor service received at a health care facility can be informed by the content of this manual.

• Health care professionals should advocate for the implementation of the NCMP because it assists to improve service delivery, it allows the facility to acknowledge the problem and the patient does not feel neglected or abandoned by

the health system. • A complaint must be acknowledged

within 5 working days in writing or telephonically

• If the complaint cannot be resolved sooner, a response to the complainant must be given with 25 working days about how the resolution will proceed.

• A complaints register must be available at each facility for record-keeping.

b. As a health professionalComplaints within the Department of Health (DoH) must be made with the hierarchy of the administrative authority in mind. Complaints are directed to the senior management of facility first, then to district level, to province, and finally to the Office of Health Standards Compliance.

Complaints outside the DoH will include approaching legal independent bodies (Chapter 9 Institutions such as the Public

Protector), as well as professional councils / boards, unions and advocacy organisations. It is important to recognise that the health professional may assist a patient to lay a complaint, or do so in their own capacity. In the latter case:

• for complaints concerning employment matters, a health professional may lay a grievance with the Human Resources office function within the DoH.

• for complaints against a health professional, a health professional (or patient) may lay a complaint with the relevant professional board e.g. HPCSA , the South African Pharmacy Council (SAPC) or the SANC.

Tools and strategies for patient advocacy

Health Professionals are reminded that there is no one size fits all approach. The best response depends on the context and urgency of the matter. A health professional needs to act in the best interests of the patients. Some tips are: • Start as soon as possible• Gather all the key facts• Organise to empower yourself and

others, there is strength in numbers• Use mechanisms that exist to improve the

health system for example Complaints System, the Office of Health Standards Compliance

• Report at the level closest to you (at the facility) before escalating it

• Use mortality and morbidity meetings• Cite relevant patients’ rights, ethical rules

and national core standards• Document all efforts made to improve

the situation, and communication • Liaise with others (colleagues, patients,

organisations)• You can advise patients to use the

complaints mechanism• Seek external assistance (legal, unions,

independent bodies, professional boards, advocacy organisations)

• Use the four doors of the Protected Disclosure Act to ensure legal protection when whistleblowing

What protection is there if a health professional speaks out, or “blows the whistle”?

The Protected Disclosure Act (Act no. 26 of 2000) provides protection for people who blow the whistle on conduct that is prejudicial to public interest. You can ensure you are protected by going through one of the “four doors” when you blow the whistle:

First Door: disclosure to an employer

Second Door: disclosure to a legal advisor

Third Door: disclosure to a regulatory or independent body

Fourth Door: the “general disclosure” is when you disclose to the media or the police, because you had good cause to do so

1

2

3

4



How does the health professional handle the dilemma of dual loyalty?

The South African Public Service Regulations of 2001 (updated 2012) states that:

“Health care providers are expected to raise any problems with their immediate supervisor and are not to criticise government policy “irresponsibly” in the public domain.”

BUT the same set of regulation states that “health care providers must put the public interest first in the execution of her or his duties”.

In addition, many health professionals are concerned about the confidentiality clause in their contracts. In signing this contract, the implication is that the duty to the employer is the ultimate guide. In fact, the contract is invalid if it conflicts with the Protected Disclosure Act and Public Service Act: “An employee, in the course of his or her official duties, shall report to the appropriate authorities, fraud, corruption, nepotism, maladministration and any other act which constitutes an offence or which is prejudicial to the public interest.”

Case study: Constitutional right to speak out

Health care providers may sometimes experience split loyalties. In some circumstances their work may throw up conflicts between:

• The ethics of the profession• The duty of the user or other users of the health care system• The duty of the state and/or any other employer

Dr Costa Gazi, Head of Department of Public Health at Cecilia Makiwane Hospital in Mdantsane, East London was concerned about the high numbers of infants dying of Aids-related illnesses in local clinics and the government’s failure to provide AZT, which had at the time been shown to reduce the risk of HIV transmission from mother to child. In 1999, Dr Costa Gazi criticised the Minister for refusing to provide AZT to pregnant women living with HIV and said that he should be charged with manslaughter. As a result, he was charged with misconduct under section 20 of the Public Service Act, Proclamation 103 of 1994. It was argued that he had caused prejudice to the administration of the department.

A disciplinary enquiry held in December 1999 found Dr Gazi guilty of violating section 20 (f) of the Public Service Act, which states that an employee is guilty of misconduct if he or she publicly comments to the prejudice of the administration of any national or provincial government. Dr Gazi was warned not to repeat the same “unprofessional behaviour” and ordered to pay a fine of R1000. Dr Gazi appealed. In March 2006, the Pretoria High Court overturned the finding of misconduct against Dr Gazi. The Court held that, if comments, or the widespread criticism of the policy not to supply AZT, caused prejudice to the department, such prejudice already existed when the comments were made and there could therefore be no causal link between the appellant’s actions and any prejudice the Department might have suffered.

DUAL LOYALTY AND HUMAN RIGHTS

“Lack of guidance and support for health professionals is especially poignant in an environment where the health system itself violates human rights because it fails to meet basic health needs, because distribution of existing resources is inequitable, or because of racial, gender or ethnic discrimination. Practicing in such an environment can lead the health professional to become complicit in human rights violations despite the professional’s personal commitment to human rights.”4

4This excerpt from Dual Loyalty & Human Rights In Health Professional Practice; Proposed Guidelines & Institutional Mechanisms by a collaborative initiative of Physicians for Human Rights and the School of Public Health and Primary Health Care University of Cape Town, Health Sciences Faculty gives some insight into how dual loyalty can impact the rights of users.

The full document, which gives recommendations for how to promote human rights in health practice can be found here: https://s3.amazonaws.com/PHR_Reports/dualloyalties-2002-report.pdf

STEP 4: Educational strategies for teaching advocacySTEP 4: Educational strategies for teaching advocacy


Some key points concerning education, adapted from the Paulo Freire education pedagogy, help to frame the strategies for teaching and integrating advocacy in a health sciences curriculum:

1. Education raises consciousness. To raise peoples’ consciousness of their situation helps them to become aware of how their personal experiences are linked to the larger social problems.

2. Education is for Liberation. A popular slogan but this approach essentially says that education is not neutral. One of the many goals of education is to side with the less fortunate, disadvantaged in our society and its objective is to contribute to the liberation, upliftment and improvement of vulnerable populations groups.

3. Education is a participative process. The role of the facilitator is to encourage greater participation and help the group become aware of new ideas as they emerge in the reflection of experiences. In addition, it is also important to note that education is not only for an individual, but it is there for those individuals to develop, grow and contribute positively to the communities that they come from.

4. Education is experimental. There is no absolute truth or single viewpoint therefore it’s important to critically reflect on what and how it is being taught. In this way, students develop confidence. They

begin to develop a questioning, critical mind. The objective is to help participants find answers for themselves. They need to see the world as it is and not as a picture painted for them.

5. Education is for action. The real success measure of teaching advocacy is when participants start actively changing their life situation. They are continuously engaged to promote the health, welfare and well-being of communities.

To consider the 21st century evolution of education strategies, there has been a seismic shift away from the practice of educating students in a didactic, patronising fashion.

Pedagogical approaches to teaching advocacy

Ideally, health sciences students should be exposed to a number of different teaching methods, in a number of different settings which vary throughout their training. The following table highlights appropriate teaching methods for advocacy and appropriate settings. Structured didactic learning is still commonly used across health sciences faculties. Some thought should be given to using high profile lecturers who have practical experience in advocacy. Certainly there should be input from a wide range of people with a wide range of advocacy experiences and skills.

The aim is to create educational opportunities that will enhance the learners’ knowledge and skills in advocacy. The following are offered as principles that can undergird the pedagogical approach:

Integrate advocacy learning outcomes within the clinical learning context. Advocacy should be integrated between different subjects and between basic clinical sciences and clinical sciences.

Learning advocacy is achieved through use of multiple methods, such as clinical case studies, problem-based learning, or team-based learning and others. Learning outcomes typically focus, however on profession-specific bio-medical approaches to the clinical

presentation of a patient. This is a narrow approach that does identify the opportunities for patient advocacy. Faculty can use different approaches to broaden the approach to managing a patient’s presenting complaint to achieve advocacy learning outcomes:• Adopt a bio-psychosocial approach to the

assessment and management of a patient• Situate the patient in the health

system that he/she is accessing, for which performance standards are in place, overseen by the Office of Health Standards Compliance

• Identify the patient as an individual within a community, with the corresponding social determinants of health as critical to the health of the individual and the collective

4 EDUCATIONAL STRATEGIES FOR TEACHING ADVOCACYSTEP

“The teacher is of course an artist, but being an artist does not mean that he or she can make the profile, can shape the students. What the educator does in teaching is to make it possible for the students to become themselves.”

Paulo Freire

KNOWLEDGE SKILLS AND CONFIDENCE

VALUES AND BELIEFS

Structured, didactic learning• Use a wide range of

people • Seminars and tutorials• Providing students with

key readings• Journal clubs • Some didactic learning

can take place at the bedside.

• Use of clinically relevant cases studies

• Direct observation• Structured, practical

educational experiences in the community and exposure to marginalized populations

• Clinical experience • Case presentations • Electives• Independent and guided

group work• Log books

• Simulations• Role modeling• Critical self- reflection

(portfolios)• Case studies • Electives• Story telling• Role play• Videos



already occurred. Common situations to avoid and/or remedy to which the faculty and learner can refer are:1. Patient care is compromised due to a lack

of equipment/staff/drug/poor response time by emergency medical care

2. A patient interrupts treatment due to a drug shortage

3. A patient unable to go to theatre as porter’s are on strike / no electricity

4. Patients turned away as clinic full/about to close

5. Some doctors abuse of the remuneration of work done outside of the public sector policy

6. Medication is prescribed or dispensed incorrectly, which can include the incorrect dose, site, frequency, duration or medication itself.

7. Poor communication between health care worker and patient leading to failure and/or a delay in diagnosis

8. The attitude of staff is poor9. Procedural errors – e.g. wrong patient

taken to theatre

Recognise that reflection improves learning. It is through reflection that students can critically reflect on their situation, develop ideas for change and become politically committed to taking action. This approach helps students and health care professionals become politically conscious and powerful. Over many years, the participatory approach

has been the tried and trusted method of dispensing social justice and/or human rights education because it is based on the understanding that:• All people have experience of their

situation and if they take the time to reflect on this experience they will develop the necessary action to change their situation

• Expert knowledge in an advisory and facilitating capacity is important however, to ensure that the choices and action of people bring about change

Experiential learning is a powerful tool to instil a duty of advocacy in students. This emphasises personal involvement and personal acquisition of knowledge and skills through relevant experiences.

Further to the importance of reflection as a tool of learning advocacy, Kolb conceptualises the experiential learning process as a cycle. 1. Concrete experience - such as exposure

to a patient or community member2. Reflective observation - the opportunity

to think, read and reflect on the situation encountered

3. Abstract conceptualisation – engagement with the knowledge and concepts

4. Active experimentation – active application of the concepts to further patients

There could be many opportunities for an educator to proactively raising positive health advocacy issues into lectures and discussions about patients that have been seen in the clinical environment.

Examples include: 1. Lectures on obstetric emergencies are a

good opportunity to include a discussion on access to health care services and emergency obstetric transport.

2. Discussions about the management of disabilities present an opportunity to discuss access to rehabilitation services in rural areas, the shortage of allied health care workers and wheelchairs.

3. The late presentation of children with hearing loss can be an opportunity to discuss the health system factors that result in a reduce demand for health care.

4. Students can reflect on the health system errors that have led to an adverse event in a clinic or a hospital – a maternal death, a stillbirth and the death of a child under five.

5. Paediatric clinical consultations are a good opportunity to reflect on the quality

of care. 6. Orthopaedics may be a good clinical

rotation to encourage patients to think about management of elderly patients

Focus on the patients who are the most vulnerable to receiving poor quality of care. This vulnerability will resonate with students who are taught to see beyond the presenting complaint, to see patients as persons with the broader community, attempting to access quality care. These vulnerable groups are, for example: 1. The elderly2. The mentally ill patients 3. The marginalised – the poor, rural, less

well educated, women, LGBTI4. Foreigners, particularly undocumented

migrants5. Patients with chronic diseases and

multiple problems

Recognise that the opportunities for teaching advocacy include prevention as well as remedy. Mitigation against any risk of providing sub-standard care to a patient is part of a health advocate’s role, as well as remedying an adverse situation that has

Exercise 3: Integrating problem based learning and advocacy

Consider the case of 4 year old Rebecca Ndlovu. Her mother, Rachel, is 24 years old, single and unemployed. She brings her daughter to the clinic where you work as she has a discharge from her left ear. Rebecca has been unwell for some time and Rachel has been to two health care workers already but her daughter is still unwell. The child had been sick for several days before the discharge started. The illness began with a cough, runny nose, fever and pain in the ear, which was worse at night. The pain has now improved. She has also been breathing fast. She has been seen at the clinic twice before with the same ear problem. Rachel is despondent at the uncaring attitude of the clinic staff with whom Rebecca has come into contact. Rachel says that there are no other problems with Rebecca except that she is sometimes naughty because she won’t listen.

How might the student holistically assess and manage Rebecca, thus identifying opportunities for health advocacy?

Exercise 4: Experiential learning

Consider the following student experience: A student is observing a clinical consultation with a senior health care professional. As an elderly patient enters the room, the health care professional answers a personal telephone call on her cell phone and continues to talk on the phone for a further 15 minutes while the patient patiently waits.

Discuss with students.



Reflection is an important part of experiential learning. Encouraging students to think about what they have seen and what they may do differently in the future ensures that behaviour changes.

Reflection can be encouraged by using portfolios, case presentations and asking students to reflect on what they have experienced. Portfolios are deeply rooted in the principles of experiential learning and certain key aspects are usually highlighted:

1. The experience – what has happened, what was done or not done.

2. The learning – what has significance for doing or changing things in the future

3. The evidence – how the learning is being applied in a particular context

4. Learning needs – where would it be appropriate to go next?

Key questions that students can be asked to reflect on as they encounter clinical cases are:

1. The experiencea. What have you done in this rotation

that could be considered advocacy? Why did you do it?

b. Give an example of an advocacy initiative. Describe the initiative, the target and the outcome

c. Describe a situation you have encountered in which health advocacy was practiced

d. What was the nature of the problem you observed?

e. What were the consequences of this problem?

f. How was it addressed? g. Think of one action you have, or

could have taken in the past weekh. Report on an interaction in which

advocacy was not practiced and how did it make you feel

i. Discuss reasons why you think

advocacy was not practiced in the interaction you described

j. Describe a situation when you wanted to advocate for a patient but could not. What were the barriers that you faced?

2. The learninga. What was learnt about the problem

and about myself b. What does advocacy mean to you?

As a person? As a doctor/nurse/occupational therapist?

c. Why does health advocacy sometimes feel like charity?

d. What are some of the pitfalls of a charity approach to advocacy?

3. The evidencea. How will the same or similar

situation be addressed next time?

4. Learning needsa. What I would like to have done but

couldn’t or didn’t

5. Active experimentation – active application of the concepts to further patients advocacy

Community-engaged, inter-professional experiences should be sought in developing the curriculum and approach to teaching and learning of advocacy. Advocacy principles

and skills such as alliance-building, working alongside and in support of communities, as well as advocating as a group, should be reaffirmed during the formal training.

Exercise 5: Active experimentation

A medical student may witness a maternal death. The student should be encouraged to reflect on the health system factors, which may have contributed to this adverse event. The student and the nurse in charge may have been left on his or her own without a midwife and the doctor on call had his phone switched off.

Upon discussing the incident with colleagues and the clinical manager, the student discovers that this situation of high absenteeism of midwives and the lack of doctors is the norm at the facility and regularly leads to unnecessary patient suffering and sometimes to avoidable deaths.

Students can be requested to reflect on:a. What can they do as a student?b. If they were the matron in charge, or clinical manager, what would they do?

“I never teach my pupils. I only provide the conditions in which they can learn”

Albert Einstein

STEP 5: Implementation- integrating advocacy in the curriculum

Advocacy for Health 45

STEP 4: Educational strategies for teaching advocacy

44 Advocacy for Health

BOX 9: WHAT WORKS WELL IN TEACHING ADVOCACY

What works well in teaching advocacyA review of the international literature and best practices has identified a number of pre-requisites for expanding and integrating advocacy into the curriculum for health sciences students.

Who• Identify good role models and lecturers who can talk from experience • Use guest speakers from health advocacy groups • Use practicing clinicians• Engage other faculties in the University – not just health sciences. Health sciences

students should be encouraged to engage with other students from other disciplines and fields who have experience in advocating for human rights.

• Build networks with key organizations in the field of advocacy. Work with community agencies that can help highlight issues in the community and this informs advocacy needs.

What • Be explicit in what you want students to learn and have a rationale for why you are

teaching advocacy to them.

Where• Teaching students at the patient bedside provides enormous potential for highlighting

opportunities for advocacy. Linking advocacy to clinical cases and specific to the specialty will make advocacy relevant to health sciences students. Using familiar terminology encourages participation and engagement.

• Students should work within marginalized populations as part of their learning.

How• Aim for repeated exposure to the principles, values, and applied tools and strategies of

advocacy), over an extended period of time, across modules, rotation and in a variety of different settings.

• Teach advocacy skills that broaden in scope and depth as students’ progress through their training.

• Incorporate a variety of teaching tools and methods – lectures, workshops and experiential learning.

• Create clear links between what students already learn (the determinants of health, health promotion, social justice and community engagement, medical ethics) and the knowledge skills and attitudes essential to be a health advocate. Learn how to frame poverty and action on poverty as core to medical practice.

• Identify educational opportunities already being used – electives, service learning, clinical teaching.

• Advocacy should be interwoven into daily clinical interactions. • Teaching and learning about health advocacy is most successful using a participatory and

inclusive process / approach and working closely with communities, patient groups, civil society organisations and other role-players.

• Create opportunities for dialogue and discussion.

The educator should first be aware that if a curriculum content changes more than 50%, then extensive approvals have to be sought, including from such internal entities as the Faculty Academic Planning Office, and external bodies such as the South African Qualifications Authority.

There are some other practical considerations to ensure the success of the implementation of this curriculum project. These concern proper change management and faculty development. These are inextricably linked; faculty development is a cornerstone of a broader change management strategy. Without proper planning of both, however, there is little chance of successfully integrating the teaching of advocacy into a curriculum. This is a difficult process when there are many individuals (faculty, students, community) whose commitment is important to the integration of advocacy into the curriculum.

Allow the concerns of teaching staff to be raised from the outset. Pre-empt some of the typical questions and concerns of faculty staff around the integration of advocacy into the curriculum that demonstrate how difficult such change management can be.

• Why should we integrate the teaching of advocacy into our courses when there is no space to do so?

• Who is anyone outside our Department to suggest that the topic of advocacy is more important than the current topics in our course?

• We may not be advocacy content experts, so how will our ownership of course(s) be affected?

• What will be cut from the curriculum,

and how (and by whom) will the topic be chosen?

• How will this impact the “full-time equivalents” (FTEs) that determines the share of resources that the Department receives for teaching?

Allowing the space for these concerns to be raised does not equate to addressing all of them as soon as they are raised, but a commitment must be made that these will be directly addressed during the process of change.

Seek a firm commitment from faculty staff. It is ideal to have faculty commitment from the outset but anyone can get started and build commitment by showing the value and need. Integration of advocacy into the health sciences curriculum starts with the vision and leadership by faculty management to staff and students. Teaching advocacy needs to be valued. It is important that faculty is committed to a sustained approach, as without this, few resources (if any) will be allocated to the process.

Identify a lead person to champion and integrate advocacy into the curriculum. This should be a deliberate and purposeful activity – not an ad hoc approach.

Involve students in the design of the curriculum. Faculty staff are encouraged to embrace the motivation shown by students to contribute to the design of their own learning. While faculty members must be acknowledged as the content experts with the corresponding academic authority, the focus is on student learning, not faculty teaching. Faculty can facilitate learning rather than didactically teach

5 IMPLEMENTATION- INTEGRATING ADVOCACY IN THE CURRICULUM STEP

“May your choices reflect your hopes, not your fears”Nelson Mandela

STEP 5: Implementation- integrating advocacy in the curriculum STEP 5: Implementation- integrating advocacy in the curriculum


Case study

A number of years ago, an urban clinic-based doctor motivated to the District Office to be released to conduct outreach support visits to Nurse Initiated Management of Antiretroviral Therapy (NIMART)-nurses in remotely based clinics. Her motivation was not successful despite her urban clinic being well staffed with doctors. In the meantime, the rural clinics did not receive any doctor visits to attend to difficult cases yet the nurses were only recently trained on NIMART and still had plenty of questions. The situation impacted on patient care, and drove up costs for patients with more complicated cases who now had to be referred to the urban-based centres to see a doctor.

After attempts to raise the matter through the internal channels failed, the doctor contacted a civil society advocacy organization for help in resolving the situation. The organization used its network and reached out to the District health office in the province. Two weeks later, the doctor received approval to conduct rural clinic support visits The doctor soon started visiting 5 clinics, ranging from 30km to 90km outside the urban town- seeing between 450 to 500 rural patients a month. The doctor also used the opportunity to train nurses on the spot and would continue taking calls about 4 times a day from nurses wanting advice.

content. To this end, opportunities for students to be involved in the design of the curriculum should be actively sought. Student centred learning shifts the focus of activity from the teacher to the student. Active learning engages students, encourages them to solve problem, answer questions, formulate questions of their own, discuss, explain, debate and brainstorm. Considering the South African context in particular, faculty can partner students in identifying how the teaching and learning of patient advocacy can deliver on any decolonising and/or added Afrocentrism that the curriculum requires.

Engage community from the start. This principle applies to any community-based teaching and learning. Considering that advocacy is best learned experientially, often in a community setting, early engagement with the relevant communities is vital. Faculty should be wary however of students intermittently observing communities in an “educational tourism” experience as this can lead to communities feeling abused and unengaged. Active contribution by a student in the same community over the full course of their degree is the gold standard.

Raise the awareness of the importance of advocacy. Advocacy events can be planned in support of the day-to-day teaching and learning of advocacy. For example, an

Advocacy Day can be held for all first year health sciences students, where the following events can be offered:

1. A session introducing the basic principles of health advocacy.

2. An inspiring high profile speaker on health advocacy - sharing initiatives in his/her particular clinical disciplines / departments, or organisation.

3. A video of high profile health advocates in the community;

4. Interactive games linked to advocacy principles, tools and strategies;

5. Local guest speakers who present on different health advocacy programmes within the department;

6. A workshop to develop a students’ advocacy project;

7. A public debate with students, lecturers, government and patient groups on the issue of “dual loyalty”

Using “stand-alone” case studies of advocacy in practice can be useful to trigger learning. While this manual stresses the importance of integrating advocacy learning outcomes in existing curricula, case studies, combined with reflection, provide important opportunities to use real life examples and health advocacy. Case studies should not only reflect or describe disaster stories, so called “war stories”, but should be selected to illustrate specific issues.

Exercise 6:

After reading the above two case studies, let us reflect on the following:• What do you think inspired the doctors to take this initiative in the first place?• Was the doctor obliged to request permission from her manager to act as she did?• Did she follow a sound advocacy strategy in your view, why?• How can we inspire more doctors to lead with such commitment to patient care and

equity? As a university? You as an individual?• Why would it be that in some cases it takes an outside voice to effect change?• When do you seek external help and when do you try to resolve the problem internally?

Case study

In 2008, Manguzi Hospital employee, Dr Colin Pfaff was facing misconduct charges from the DoH for implementing dual therapy to save babies from HIV. Pfaff had widespread support from health care providers for his implementation of improved prevention of mother to child transmission (PMTCT) regimens in a rural area. The charges sparked a huge outcry countrywide and a large petition, coordinated by Dr David Cameron, as well as letters, emails and meetings at multiple levels by the South African HIV Clinicians Society, South African Medical Association, the Rural Doctors Association of South Africa, the AIDS Law Project and the Treatment Action Campaign contributed to the withdrawal of charges. It was one of the largest health care worker campaigns ever seen in South Africa.

STEP 6: Learner and programme evaluation STEP 6: Learner and programme evaluation


BOX 9: MILLER’S PRISM OF CLINICAL COMPETENCE

Miller’s Pyramid/Prism of Clinical Competence (1990)

6 LEARNER AND PROGRAMME EVALUATION STEP

“Advocacy not only means endorsing a cause or idea, but recommending, promoting, defending, or arguing for it.”

John Capecci and Timothy Cage

The student will need to demonstrate the measurable learning outcomes at different points during the curriculum, and again at the end of the programme as an exit outcome.

Assessment of students

Once the core competencies have been identified, methods of assessment can be defined. Different methods of assessment should be used. Some ideas are given in the table below.

Reflecting on this framework, the CanMEDS Assessment Tools Handbook suggests that the best methods of assessing advocacy competencies are: 1. Essays2. Short answer questions3. In-training evaluation reports4. OSCE5. Multi-source feedback6. Portfolios

Examples of short answer questions

• What is advocacy?• What is the value of health care

advocacy? What responsibility do

you have to engage on behalf of your patients?

• What are some of the ethical, personal and emotional challenges faced by health advocates?

• Are you allowed to speak to the media? If yes, when?

• What is dual loyalty?• Describe some of the root causes for

the inequities in access to health care in South Africa

Reliability and Validity of Assessment

Advocacy is considered by the CanMeds authors2 as an intrinsic role, suggesting that

In addition, Miller (1990) has proposed a structure for categorising methods of assessment, which provides a useful starting point to think about how students should

be assessed. The competence is defined as “clinical”; this needs to be broadened in meaning to include advocacy.

KNOWLEDGE SKILLS AND CONFIDENCE

VALUES AND BELIEFS

Assessment • Written exam• Formative

assessment (assessment used as learning opportunity)

• Essays• Short answer

questions• Quiz• Log books

• Debates• Exercises• Research • Writing and

presenting case studies and projects

• Direct observation• Objective structured

clinical examination (OSCE)

• In training evaluation – systematic observation and feedback on habitual performance in real clinical settings

• Oral examinations

• Reflection on lessons learned

• Portfolios• Videos• OSCE• Written reports• Questionnaires

2 http://www.academia.edu/18290307/_Intrinsic_Roles_rather_than_armour_renaming_the_non-medical_expert_roles_of_the_CanMEDS_framework_to_match_their_intent

Psychologist George Miller proposed a framework for assessing levels of clinical competence.

It is only in the ‘does’ triangle that the doctor truly performs

Performance Integrated Into Practiceeg through direct observation, workplace based assessment

Demonstration of Learningeg via simulations, OSCEs

Interpretation/Applicationeg through case presentations, essays,extended matching type McQs

Fact Gatheringeg traditional true/false MCQs

DOES

KNOWLEDGE

SKILLS

ATTITUDES

SHOWS

KNOWS

KNOWS HOW

Based on work by Miller GE. The Assessment of Clinical Skills/Competence/Performance: Acad. Med. 1990; 65(9); 63-67 Adapted by Drs. R. Mehay & R. Burns. UK (Jan 2009)

Cogn

ition

Beha

viou

r

Expert

Novice

Professional authenticity

STEP 6: Learner and programme evaluation STEP 6: Learner and programme evaluation


assessment of a student competence is not as simple as observing a skill, such as the clinical examination of a knee, or performing a procedure.

An intrinsic role must manifest, however, extrinsically for assessment. Careful consideration must be given to the assessment methods for assessing advocacy in a valid (accurate) and reliable (reproducible) manner.

Students should be encouraged, where possible, to engage with community and community groups and to work in communities during rotations or for practical experience in their relevant chosen fields. Possible settings for this experience are working with community based advocacy organisations, and quality of care managers in institutions. Students should undertake a practical project.

• Select an issue / Identify a topic• Understand the political context• Build an evidence base• Engaging others• Elaborating strategic plans• Communicating messages and

implementing plans• Seizing opportunities• Being accountable• Presenting• Writing

Assessment of the programme integrating advocacy into the curriculum

This should involve some evaluation of the training and the curriculum itself. Reflection for educators is important to document:

• Provide an example of when you tried to teach advocacy

• What was effective about your teaching?• What was not effective?• What were the barriers and enablers to

teaching advocacy?• What could you have done differently?Metrics will need to be chosen on which the success of the integration of advocacy into the programme can be measured. These will need to be decided in broad consultation with faculty and student members.

Exercise 7:

As a faculty member, what measures do you think should be included in a score card measuring the social accountability of a Faculty of Health Sciences? What measures should reflect a faculty’s commitment to producing graduates who are patient health advocates?


1. www.fawu.org.za2. www.rhap.org.za3. www.who.org4. www.hpcsa.co.za 5. A guest lecture Voice presentation can be downloaded here: www.rhap.org.za 6. Situational analysis tool can be downloaded here: www.rhap.org.za

Annexure 1: WebsitesAnnexure 2: ResourcesAnnexure 3: Organisations that can assist health care providers with addressing and avoiding health system failuresAnnexure 4: Readings on health advocacy championsAnnexure 5: Readings on the state of health care in South AfricaAnnexure 6: Additional Case studies

ANNEXURE 1

ANNEXURE OVERVIEW

WEBSITES

Additional Readings / Templates

World Medical Association Statement of Patient Advocacy and Confidentiality (Revised 2006)

Adopted by the 45th World Medical Assembly, Budapest, Hungary, October 1993 and revised by the 57th WMA General Assembly, Pilanesberg, South Africa, October 2006

Medical practitioners have an ethical duty and a professional responsibility to act in the best interests of their patients without regard to age, gender, sexual orientation, physical ability or disability, race, religion, culture, beliefs, political affiliation, financial means or nationality.This duty includes advocating for patients, both as a group (such as advocating on public health issues) and as individuals.

Occasionally, this duty may conflict with a physician’s other legal, ethical and/or professional duties, creating social, professional and ethical dilemmas for the physician. Potential conflicts with the physician’s obligation of advocacy on behalf of his or her patient may arise in a number of contexts:

1. Conflict between the obligation of advocacy and confidentiality: A physician is ethically and often legally obligated to preserve in confidence a patient’s personal health information and any information conveyed to the physician by the patient in the course of his or her professional duties. This may conflict with the physician’s obligation to advocate for and protect patients where the patients may be incapable of doing so themselves.

2. Conflict between the best interest of the patient and employer or insurer dictates: Often there exists potential for conflict between a physician’s duty to act in the best interest of his or her patients, and the dictates of the physician’s employer or the insurance body, whose decision may be shaped by economic or administrative factors unrelated to the patient’s health. Examples of such might be an insurer’s instructions to prescribe a specific drug only, where the physician believes a different drug would better suit a particular patient, or an insurer’s denial of coverage for treatment that a physician believes is necessary.

3. Conflict between the best interests of the individual patient and society: Although the physician’s primary obligation is to his or her patient, the physician may, in certain circumstances, have responsibilities to a patient’s family and/or to society as well. This may arise in cases of conflict between the patient and his or her family, in the case of minor or incapacitated patients, or in the context of limited resources.

4. Conflict between the patient’s wishes and the physician’s professional judgment or moral values: Patients are presumed to be the best arbiters of their best interests and, in general, a physician should advocate for and accede to the wishes of his or her patient. However, in certain instances such wishes may be contrary to the physician’s professional judgment or personal values.

Recommendations1. The duty of confidentiality must be paramount except in cases where the physician is

legally or ethically obligated to disclose such information in order to protect the welfare of the individual patient, third parties or society. In such cases, the physician must make a

ANNEXURE 2 RESOURCES


reasonable effort to notify the patient of the obligation to breach confidentiality, and explain the reasons for doing so, unless this is clearly inadvisable (such as where telling the patient would exacerbate a threat). In certain cases, such as genetic or HIV testing, physicians should discuss with their patients, prior to performing the test, instances in which confidentiality might need to be breached. A physician should breach confidentiality in order to protect the individual patient only in cases of minor or incompetent patients (such as certain cases of child or elder abuse) and only where alternative measures are not available. In all other cases, confidentiality may be breached only with the specific consent of the patient or his/her legal representative or where necessary for the treatment of the patient, such as in consultations between medical practitioners. Whenever confidentiality must be breached, it should be done so only to the extent necessary and only to the relevant party or authority.

2. In all cases where a physician’s obligation to his or her patient conflicts with the administrative dictates of the employer or the insurer, a physician must strive to change the decision of the employing/insuring body. His or her ultimate obligation must be to the patient. Mechanisms should be in place to protect physicians who wish to challenge decisions of employers/insurers without jeopardizing their jobs, and to resolve disagreements between medical professionals and administrators with regard to allocation of resources. Such mechanisms should be embodied in medical practitioners’ employment contracts. These employment contracts should acknowledge that medical practitioners’ ethical obligations override purely contractual obligations related to employment.

3. A physician should be aware of and take into account economic and other factors before making a decision regarding treatment. Nonetheless, a physician has an obligation to advocate on behalf of his or her patient for access to the best available treatment. In all cases of conflict between a physician’s obligation to the individual patient and the obligation to the patient’s family or to society, the obligation to the individual patient should typically take precedence.

4. Competent patients have the right to determine, on the basis of their needs, values and preferences, what constitutes for them the best course of treatment in any given situation.

5. Unless it is an emergency situation, physicians should not be required to participate in any procedures that conflict with their personal values or professional judgment. In such non-emergency cases, the physician should explain to the patient his or her inability to carry out the patient’s wishes, and the patient should be referred to another physician, if required.

Organisations that can assist health care providers with addressing and avoiding health system failures

• Rural Health Advocacy Project (RHAP)• Rural doctors Association of South Africa (RuDASA)• SECTION27• Budget and Expenditure Monitoring Forum• Medecins Sans frontiers South Africa (MSF)• Treatment Action Campaign (TAC)• Rural Rehab South Africa (RuRESA)• The Professional Association of Clinical Associates South Africa (PACASA)• Southern African HIV Clinicians Society• Eastern Cape Health Crisis Action Coalition (ECHAC)• Stop Stock Outs project (SSP)• Black Sash• African Centre for Migration and Society (ACMS)• Lawyers for Human Rights (LHR)• Legal Resources Centre (LRC)• Legal Aid South Africa• Centre for Applied Legal Studies (CALS)• Medical Protection Society• South African Medical Association (SAMA)• Junior Doctors Association of South Africa (JUDASA)• Democratic Nursing Education Organisation of South Africa (DENOSA)• Health and Other Services Personnel Trade Union of South Africa (HOSPERSA)• National Education Health and Allied Workers Union (NEHAWU)• Public Service Association (PSA)

ANNEXURE 3 ORGANISATIONS THAT CAN ASSIST HEALTH CARE PROVIDERS WITH ADDRESSING AND AVOIDING HEALTH SYSTEM FAILURES


Taung Hospital has a TB unit that serves Taung sub-district, however surrounding sub-districts in Dr RSM district do send complicated cases. The MDR-TB unit is located at Taung Hospital but serves the whole Dr RSM district.

Dr Mphothulo has managed 8000 TB patients and 500 MDR-TB patients in the 12 years since being at Taung Hospital in the North West. Patients are mostly from Taung but there are referrals from surrounding sub-districts. Dr Mphothulo also took up the challenge of decentralising MDR-TB treatment by managing the satellite unit at the hospital which went from 20 beds to 33 beds in January 2011.

In addition to these grand achievements, this MEDUNSA graduate is also the author of a book titled: “TB cases from Taung – A perspective from a rural district hospital”. The book highlights the management of difficult TB cases in a rural setting with scarce resources.

Dr Maphothulo’s hard work, dedication and patient-centred work ethic allowed him to receive the Rural Doctor of the Year 2015 award. He acknowledged that his achievements thus far would not have been possible without a supportive team of healthcare workers and the political will of the district health services.

4.3 How can Dr Neil Aggett’s spirit of activism inspire health care workers today?

Neil Hudson Aggett was born in 1954 in Kenya. He was the first -born child of Aubrey and Joy Aggett and one of three children. His family owned farming land in Kenya and had been farming since before the First World War.

He started his early education at a school in Kenya as a weekly boarder and then attended Nyeri Primary School. His family’s farm was sold in 1964 and later the family moved to South Africa. His parents settled in Somerset West while Neil attended a private Methodist school, Kingswood College, in Grahamstown in the Eastern Cape from 1964 until 1970. He excelled as a student and received various awards and certificates from the school.

In 1971 until 1976 he attended the Medical School at the University of Cape Town where he obtained his medical degree (MB ChB).

In 1977 he was doing his internship at the Umtata General Hospital in Transkei. He then moved to work in the Tembisa hospital in East Rand, Johannesburg, a hospital for blacks. Here, Neil became aware of the hardships of black people under the apartheid rule. Being aware of these, he became involved in the black trade union movement and was asked to establish the Transvaal branch of the Food and Canning Worker’s Union (now FAWU). Neil was becoming deeply involved with union work and supported himself by performing weekend duties in the Casualty department of Soweto’s Baragwanath hospital. At this hospital, Neil earned the respect and trust of both staff and patients through his enthusiasm for his job. He even learnt an African language, Zulu, to communicate better with his patients.

4.1 Coalition Building in Action

Through the brave work of organisations like the Treatment Action Campaign (TAC) and health care worker initiatives such as Save Our Babies, founded by Haroon Saloojee, Ashraf Coovadia and Keith Bolton, health care workers today are able to deliver the ARV drug Nevirapine in the public health care system freely. After years of resistance by Government, causing thousands of avoidable deaths and suffering, in April 2003 the Department of Health included PMTCT programmes in their budget. In November that year Cabinet resistance to a national ARV programme was broken. In April 2004, the public health system began rolling out treatment to people with Aids.

Save Our Babies was started to declare the stance of paediatricians on HIV/Aids issues, particularly in relation to children. The campaign arose from the perception that although paediatricians dealt with the effects of the HIV/Aids epidemic on a daily basis, their opinions on these issues were not being effectively voiced and where they had been communicated to the Ministry of Health, their suggestions had been ignored.

The campaign collected 273 signatures of paediatricians and child health practitioners from around the country in support of the implementation of a mother to child transmission reduction programme and held a widely publicised march and press conference on World Aids Day 2000. This serves as an example of what coalition building can do in the face of an unresponsive government.

Furthermore, Save Our Babies, together with TAC and the Children’s Rights Centre, filed a constitutional claim against government in order to compel the provision of Nevirapine to pregnant women. Economic, scientific, legal and moral arguments against the government policy were made through affidavits from a range of people, including the doctors and health professionals who were impacted by this policy. This played an important role in the success of the case as the input of doctors helped to shape the framework of a sound government policy with regard to PMTCT.

4.2 Patient Health Advocate: Dr Ndiviwe Mphothulo

Dr Mphothulo’s dedicated work in the fight against TB in Taung district is truly outstanding. It all began in 2003 when this Soweto born and bred junior doctor was placed at Taung Distric Hospital for his community service year. Since then he has never looked back and his passion for public health has strengthened his resolve to fight TB in the community starting with the TB ward in the hospital from 2004. His passion took him to the MDR-TB Unit since 2009 at Taung District Hospital and he has been there ever since.

Dr Mphothula has been instrumental in developing protocols, setting up a TB/HIV co-infection treatment programme with more than 95% collaboration, providing telephonic advice to local clinics and medical officers from other hospitals in the district.

ANNEXURE 4 READINGS ON HEALTH ADVOCACY CHAMPIONS


Neil became more and more involved in fighting for workers’ rights while being with the Transvaal branch of the FAWU and was later appointed as an organizer in the organization. He was passionate about workers’ rights, such as company supported medical aid schemes. It was said that he would at times use from his own money to further the cause of workers and often assisted in transporting union officials to and from factories.

He played an enormous role in organizing the successful Fatti’s and Moni’s strike in Isando which eventually spread to Tembisa. It is after this that he became a target of the security branch of the South African police for his participation in strikes. The state labelled him a communist. In 1981 he was asked to organize a mass action campaign for workers in Langa, a black township in Cape Town. He very much wanted to see trade unions united in a mass democratic movement mobilizing for the health and prosperity of workers.

On November 27 in 1981, Dr Neil Aggett was detained for his role in labour movement under the Terrorism Act. He was held at Pretoria Central Prison and later transferred to John Vorster Square in Johannesburg. He died in detention on February 5, 1982, allegedly by hanging himself with a scarf. No charges were ever laid against him. After a six -month long inquest into his death, George Bizos. S.C. a lawyer who represented the Aggett family, claimed that security police, by brutal interrogation methods, had broken Aggett and destabilized his personality to such an extent that they drove him to commit suicide. The methods included assaults, torture by electric shock treatment and days of non-stop interrogation. Other reports state that a June 29 inquest revealed his death was as a result of police torture.

Neil Aggett became the first white person to have died while in Security Police detention and the 51st person to have died in detention. He was 28 years old.

He was buried in West Park Cemetery, Johannesburg on 11 February 1982. His funeral was filmed and about 15 000 people attended. The Food and Canning Workers’ Union issued a call that all workers would stay away from work on the day of his funeral.

On that day, the presence of police did not stop thousands of workers and fellow trade unionists to sing revolutionary songs and reaffirm their commitment to the struggle for which Neil died.

Source: www.fawu.org.za

5.1 “Doctors should champion the cause of poor people”, by Jimmy Volmink

DESPITE improvements in medical treatment and the continuing production of excellent doctors and specialists in SA, we have yet to achieve the health gains hoped for.

We still see far too much unnecessary suffering, debilitation and death from preventable or treatable illness. Mothers are still dying in childbirth and children continue to succumb to measles, gastroenteritis and malnutrition.

HIV/AIDS continues to ravage young women and violence and homicide too often snuff out the lives of men in the prime of their lives. Alarmingly, all this is happening as the rising tsunamis of diabetes, stroke and mental illness are breaking on our shores.

Why does a country that spends so much on healthcare and produces so many superb health practitioners still experience such poor health?

What does it say about our society and our healthcare system? Do we have the right strategy for dealing with our problems? What are we missing?

One issue frequently overlooked in debates about health and health care is poverty.

Statistics SA reported in February that 54% of the population (27-million people) were living in poverty (defined as having an income of less than R779 per month). Of these people, 11-million were living in extreme or abject poverty, that is, with an income of R335 a month or less.

How is it possible for a relatively rich country such as SA to have half of its population trapped in poverty and one in four of its inhabitants going hungry?

Statistically, this can only arise in a context in which the gap between rich and poor is spectacularly large.

What we often seem to forget is that poverty and inequality are flip sides of the same coin. Both need to be tackled if we are to make progress in improving health and wellness in our country.

THESE issues should be the concern of every health professional because we ought to be in the business of improving health, not just treating disease. It is people’s lived experience, rather than the pills and procedures we offer them, that matters most for health.

Given that social and economic factors are the most important drivers of health and disease, we will only improve the health of our nation if we urgently deal with the basic problems of access to housing, sanitation, food, safe water, education and employment.

We need to keep in mind that these social and economic factors also influence the quality of healthcare we receive.

ANNEXURE 5 READINGS ON THE STATE OF HEALTH CARE IN SOUTH AFRICA


Sadly, our public health system is often little more than a vehicle for delivering poor services to poor people. There is indeed a wide gulf between the health services enjoyed by the “haves” and they “have nots” in our beautiful land.

How can health professionals help tackle these challenges?

I suppose, we could respond by taking the view that these problems are not for us, but for the government, to solve.

Unfortunately, by adopting this mind-set, we would simply restrict ourselves to the act of dishing out chemical cures while averting our gaze from the social conditions at the root of the patient’s condition.

Patients understand the important connection between their living conditions and their health status, and hope healthcare providers will acknowledge this and show some solidarity.

A second way we might respond is to engage in victim blaming. Here we would adopt the view that the patient is to blame for his or her problem. This outlook frequently overlooks the fact that while people may understand the risk associated with a certain lifestyle or behaviour, they may not be able to run from the risk.

Thirdly, we could succumb to a form of learned helplessness. We might care deeply about the upstream factors affecting our patients’ health and want to do more, but may feel so overwhelmed by the magnitude of the challenge that we give up before even starting.

It becomes easier to ignore the elephant in the examination room rather than acknowledging it and trying to do something about it.

We need an “upstream health professional” movement to break down the divide between clinical medicine and public health.

Since doctors are accorded intimate exposure to human suffering caused by destructive social, economic and political forces in society, they are the ones who are well placed to address the root causes of their patients’ health problems and have often done so with great effect over the years.

FURTHERMORE, given that health is the legitimate domain of health professionals, they can be considered the authentic champions of the right to health that is enshrined in the Universal Declaration of Human Rights and also embodied in SA’s Bill of Rights.

Yet, 21 years after the birth of our democracy, we seem further from realising this right than before. Undoubtedly, it will take a combined effort from all role players to fix the problem, but health professionals can play an important part.

Doctors are held in high regard in society. As such, their voice, whether individually or collectively, is more likely to be heard than that of others. Doctors must not neglect to use their formidable social capital in the struggle for health and equality in SA.

By serving as advocates for the poor, we will make SA better for everyone, including ourselves and our children.

• Prof Volmink is the dean of the Faculty of Medicine and Health Sciences at Stellenbosch University. This is an abridged version of a recent address at the admission ceremony of the South African Colleges of Medicine

5.2 “We have enough medics, but they are in the cities”, by Lekan Ayo-Yusuf

MILLIONS of South Africans are missing out on basic healthcare because of a skewed system that fails to make use of all the country’s skilled health professionals.

It is public knowledge that there are not enough doctors in the public health system. For every 1,000 people, SA has less than one doctor available. Brazil, with a gross national product per capita similar to SA, has nearly two doctors for every 1,000 people.

What is less well known is that if SA’s total health workforce is tallied, a critical shortage of human resources is not evident. The combined national average is 2.9 doctors, nurses and midwives for every 1,000 people. This is similar to Thailand, which has a comparable economic environment and counts 2.7 doctors and nurses for the same number of people.

Both figures are well above the World Health Organisation’s suggested 2.28 doctors and nurses for every 1,000 people as the critical shortage threshold.

So what’s the problem? The challenge with the health workforce in SA is twofold: a skewed distribution of skilled staff and an imbalance of skills.

Doctors are mostly in private practices located in urban areas and the skills imbalance means there is limited use of the mid-level health workforce.

Distribution needs urgent intervention. Even if the number of healthcare workers increases, the urban-rural imbalance may be worsened, particularly with doctors.

THERE is also a need to shift some tasks from doctors to nurses. This can be done without having a detrimental effect on quality.

For every doctor in SA, there are just under five nurses, which is higher than the global average of 2.1 nurses for each doctor. This suggests a potential for some efficiency gains.

If less reliance is placed on doctors for healthcare delivery and nurses are given these responsibilities, there would be fewer shortages in underserviced areas.

One of the most common reasons for the shortage of doctors is the fact that not enough are produced annually by the country’s medical schools. SA’s eight medical schools each produce


about 200 doctors a year — not enough to serve a population of 50-million.

Cuba, with a population of about 11-million people, has 22 medical schools.The stumbling block is in the production line.

The government has established a ninth medical school in Limpopo, which should have its first intake next year. It has also continuously encouraged medical schools to increase their intakes. But a significant increase in medical students would require clearing a number of hurdles.

Medical schools are accredited by the Health Professions Council of SA to train only the number of students that their existing infrastructure can accommodate. Any increase in student intake needs the council’s approval.

The council will give the nod only if the faculty can guarantee high quality training. This would involve expanding the number of staff, lecture room seats and hospital facilities.

Approval would also require public hospitals to increase the number of posts for two-year intern training so that there are enough senior staff to supervise.

Universities are caught in a double bind. Expanding teaching facilities requires a significant cash injection. But 60%-80% of their funding comes in the form of a major block grant based on the number of full-time students they took in two years earlier. This means that even if they increased their students now, the increase in subsidies would be realised only in 2017.

Institutions also need to rethink admission policies skewed towards students from better-off urban areas. Refining the admission criteria to attract more students from rural and under-serviced areas would correct this imbalance because doctors in rural areas would be more likely to return home after graduation. The latest medical training curriculum adopted by the council emphasises this social accountability back home.

Medical school tuition would also have to become cheaper to enable rural students to afford the cost of a medical degree. This remains a challenge despite the government’s intervention through the National Student Financial Aid Scheme.

It has been suggested that the shortage of doctors poses a challenge to the government’s ambitious plan to create universal access to healthcare, which is to be rolled-out over the next 10 years.

This does not need to be the case. More doctors are needed, and sending 1,000 students to Cuba for medical training every year is helping to fill the gap.

BUT this needs to be accompanied by a re-engineering of the primary healthcare system to focus on preventive care. Ward-based teams could be deployed to communities, assigned to a number of households.

The teams would be made up of several community health workers and led by a nurse coordinating the visits. This would ensure the maintenance of health, and care would be provided before a doctor’s intervention was needed.

Improving the availability of the health workforce and not just doctors would go a long way, particularly in rural areas.

This would require training more mid-level clinicians, such as clinical associates, and providing a policy that reduces the over-reliance on doctors — thus shifting some of the clinical functions and responsibilities to the lower cadre of clinical staff.

• Ayo-Yusuf is interim executive dean at Sefako Makgatho Health Sciences University. This article first appeared on The Conversation.


6.1 Case study: hearing loss

Nomfundo is a 16-year-old girl with significant hearing loss in both ears, following an illness in early childhood. She has regular discharges from her ears, chest infections and ear pain, which the clinic has been unable to treat successfully. Several years ago she was referred by the district hospital to the audiology service at the tertiary hospital, several hours drive away, but there was no room on the planned patient transport for her mother to accompany her, and so they missed the appointment. To rebook the appointment, they would have had to travel once again from their rural village to the district hospital 60km away, taking an entire day and costing R100 for the return trip, which they cannot afford. Nomfundo’s mother buys her cough and pain medication from the retail pharmacy in town, but this does not help. There is no school for learners with hearing loss in the district, and no training available in sign language for Nomfundo and her family. She attends the local school, but struggles in class and cannot communicate with her peers.

When some researchers arrive to study healthcare access for people with disabilities in this area, they meet Nomfundo and her family. They cannot understand why she has not been referred by the clinic to the audiologist who has recently begun working at the district hospital – it seems the nurses have not been made aware of this new service. Nomfundo is given a referral, and goes to see the audiologist soon after. Unfortunately, because the district has not allocated resources for audiology equipment at this hospital, he has to ask her and her mother to travel on a different day to the next town, where there is a testing booth he can use for diagnostics. Once she has had a thorough assessment, he takes moulds for hearing aids, and arranges an appointment for her with the ENT specialist at the tertiary hospital. Although this is yet another costly trip, it proves worthwhile, as the ENT drains Nomfundo’s ears and prescribes the correct antibiotics to treat the recurrent infections.

With her new hearing aids, Nomfundo is suddenly able to communicate with her family, hear her teacher in class, and make friends. Her marks shoot up, and the family is delighted by her changed life. Unfortunately, the ongoing costs of maintaining these gains are not small: she must travel to town every time she needs a new hearing aid battery, and periodically make the trip to the tertiary hospital to see the ENT. The family makes sacrifices to afford these costs, but when finances are too tight she must sometimes go for several months without being able to hear. The district does not consider audiology a priority service, but without these interventions, Nomfundo is denied her right to an education and the opportunities this affords. Without her hearing aids, she is socially isolated, and becomes depressed and ultimately a burden on her family, instead of an active and contributing member of society.

Questions: a. As a healthcare worker, what are some of the specific advocacy tools that you could use to

improve Nomfundo’s situation? b. What exactly would you be advocating for?

ANNEXURE 6 ADDITIONAL CASE STUDIES

6.2 Case study: mental health services

Phindile is a 34-year-old man who lives in a rural village in the Eastern Cape. He dropped out of school at the age of 16 after developing a severe mental illness, and is cared for by his brother, sister-in-law and their family. During periods of psychosis, he behaves strangely, talking to himself and sometimes becoming violent towards his family. At other times, he becomes withdrawn, spending his days wandering in the location and smoking dagga. Because there is no psychiatrist in the district, Phindile has never received a proper assessment or diagnosis, although the doctors at the district hospital have prescribed him medication. He refuses to take the pills, possibly because of their side effects, and is now becoming increasingly aggressive, not only towards his family but also to others in the neighbourhood. The clinic staff do not have the skills or authority to change his treatment, and the nearest hospital is 50km away. Public transport goes only once a day to town, and the family cannot physically contain him or force him to go. They are also afraid he will endanger other passengers. They have tried calling the ambulance, but not only are emergency medical services (EMS) heavily under-resourced in this area, but the drivers insist they will not transport psychiatric patients, because this is the responsibility of the police. The police, who also only operate from town, will not involve themselves unless a crime has been committed. The family does not have the money to pay for a private vehicle, which can cost up to R500 for a return trip to town.

Eventually, the family become desperate and arrange a private car to go to hospital. Unfortunately, at the district hospital there is no dedicated psychiatric ward or staff, so the ward doctor and nurses sedate Phindile heavily to prevent him from harming the other patients. After the statutory 72 hour “observation” they discharge him home again, with the same medication as before. The family cannot afford enough food for the next three months while they pay back the transport costs, but Phindile’s situation is the same. The eldest son drops out of school so that he can watch Phindile in the day, and prevent him from causing trouble in the location.

This case study demonstrates how existing PHC services fail to address the complex needs of someone with mental illness, with serious consequences for rural communities. The failures in this story include not only access to specialist services (psychiatry), but also the necessary support and infrastructure to keep him well and prevent relapse in the community. Drug stock-outs, lack of EMS and general staffing shortages all affect mental health services, but even without these issues, the lack of psychosocial rehabilitation at community level prevents people like Phindile from participating in community life in ways that keep them well, for example through inclusion work, learning and social roles. Rehabilitation cannot simply be tacked on to existing job descriptions, but require cadres with specialist skills: mid-level rehabilitation workers, occupational therapists, social workers and psychologists, among others.

Questions:a. How would you go about advocating for increased mental health services at PHC level?b. Who needs to speak out for Phindile and advocate for his health needs and why?


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REFERENCES

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Nelson Mandela

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Acknowledgements 4

Foreword 5

Glossary of Terms 6

Background 8

Who is the manual for? 10

Step Problem needs identification and general needs assessment 14

Step Advocacy needs assessment of targeted learners 20

Step Goals and Objectives for advocacy in the Curriculum 24

Step Educational Strategies for Teaching Advocacy 38

Step Implementation – Integrating Advocacy in the Curriculum 45

Step Learner and Programme Evaluation 48

Annexures 52

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