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Daily Maverick
31-07-2025
- Health
- Daily Maverick
Three decades in, is the Cuba-SA doctor training programme still worth the expense?
The Nelson Mandela-Fidel Castro medical training programme has been controversial from the start. It's had high points, low points, and now many say it should have an end point. Almost 30 years since the Cuba-SA doctors' training programme was launched, it still divides opinion. This year only Gauteng and North West interviewed candidates for the bursary programme that sends students from South Africa to be trained in the island country. Critics say the dwindling interest shows the Nelson Mandela-Fidel Castro medical training programme has passed its sell-by date. But supporters remain committed to its ideals, and some beneficiaries of the programme still think of it as the opportunity of a lifetime. Between the differing views, what can be glimpsed is a chequered story of three decades of trying to transform South Africa's healthcare system. The programme has its origins in the ANC's political fraternity with Cuba and the laudable ideal of boosting doctors numbers in under-serviced rural areas. But it is also a tale of political inertia arguably blurring overtime into a blind spot as conditions changed. In the background is the stranglehold of corruption and maladministration in the health sector, shrinking provincial health budgets, the transformation of doctors' training, and changing curricula. One concern is that little is actually known about the programme's impact. There is a lack of clear data on the costs and the numbers of doctors produced. Shockingly, for such a long-running programme, no comprehensive evaluation reports have been published, as far as Spotlight has been able to establish. A comprehensive evaluation would weigh the benefits of the programme against its costs, compare it to other options for training medical doctors, and contextualise it within the current reality of very tight health budgets in provincial health departments — as it is, not all the doctors we are training are being employed. Given this context, it is not surprising that the national Department of Health recommended a scaling back of the programme a decade ago. While most provinces have taken this advice, the Gauteng and North West health departments have instead pushed ahead with the programme. Old histories and old allegiances The agreement that put in place the medical training programme was signed in 1996, with the first cohort of students leaving for Cuba a year later, in 1997. It was a mere two years into democracy and South Africa urgently needed to address the gaps in the provision of healthcare. Under apartheid, services prioritised a white minority mostly in urban settings and healthcare had a strong slant towards hospital or tertiary care. There was a shortage of doctors, and those with the least access to healthcare services were rural communities made up mostly of black South Africans. Medical schools mostly had curricula designed for the status quo, and there were few academic pathways for underprivileged students who had good marks at school but were not top achievers, leaving them overlooked for scholarships and bursaries. So the new government looked to Cuba. With its focus on primary healthcare, preventive medicine and community-based training, the Cuban approach to healthcare ticked many of the boxes for the South African government then led by Nelson Mandela. Since the communist revolution in Cuba in 1959, it has provided free healthcare to all its citizens. While there remains some scepticism over data collection and interpretation, the politicisation of medicine, and limited freedom to criticise the state, Cuba's healthcare system is also widely lauded. According to the Primary Health Care Performance Initiative, the country registers average life expectancy at 78 years (South Africa is at about 66), infant mortality dropped from 80 deaths per 1,000 live births in 1950 to just 5 deaths per 1,000 by 2013, and it has one of the world's highest doctor to patient ratios. In 2021, it was at 9.429 physicians per 1,000 people, according to World Bank Open Data. In the same year, South Africa tracked at 0.8 per 1,000. Since the 1960s, Cuba has established itself as a hub for training international fee-paying students and sending them back to their mostly lower-income countries as graduate doctors. One of its biggest universities, the Latin American School of Medicine, has graduated more than 30,000 students from 118 countries in the 21 years since it was established. Another tick was Cuba's staunch support for the ANC. SA History Online emphasises the depth of solidarity. It notes: 'Cuba was a state in alliance with provisional governments and independent states on the African continent. Cuba's military engagement in Angola kept the apartheid state in check, foiling its geopolitical strategies and forcing it to concede defeat at Cuito Cuanavale, and ultimately forcing both PW Botha and FW de Klerk to the negotiating table.' Costs and benefits The political and historical bonds sealed the doctors' training deal. But from the start, the bursary programme, funded by provincial budgets, came under fire. The estimated costs over nearly three decades are massive, but the details remain fuzzy. Spotlight's questions to the national health department were 'answered' in one paragraph by department spokesperson Foster Mohale. 'More than 4,000 [lower numbers are quoted by government in other instances] doctors have been produced through this medical programme since its inception. The programme is still relevant today and complements the local medical schools to produce more doctors. Qualified doctors have options of joining either public or private health sector,' he wrote. But discrepancies have shown up in the government's own figures. In November 2022, Haseena Ismail, the then DA member on the portfolio committee of health, raised concerns about the quality of government data. The Minister of Health at the time, Dr Joe Phaahla, said the preparatory year, including a stipend, cost $4,400 per student, and each of the following five years cost $7,400 per student. But a separate table from the health department listed higher figures — $8,400 for the preparatory year and up to $15,900 per student by the fifth year. Added to this, the department listed annual costs of $6,472 per student for food, accommodation, and medical insurance. There were also expenses for two return flights over six years, plus the cost of 18 months of tuition and accommodation for clinical training at a South African medical school. Phaahla said that as of November 2022, 3,369 students had been recruited into the programme, and 2,617 had graduated. However, he noted there was no information on what happened to these doctors or where they were employed. Each bursary student was required to work for the state for the same number of years for which they received funding. The programme also faced criticism over selection criteria for bursary candidates and for requiring two extra years of training compared with local medical programmes. Students spend one year learning Spanish, five years training in Cuba, and then return to South Africa for an additional 18 months of clinical training at a local medical school. Controversies have dogged the programme over the years. In 2013, the Afrikaans newspaper Beeld reported that by 2009, only half of the students enrolled in the programme during its first 12 years had completed their studies. In 2012, the government ramped up the numbers of students it sent abroad. In 2018, this backfired when about 700 fifth-year students returned home only to find they could not be accommodated at any of the then 10 medical schools in the country. It was at about this time that the national health department issued recommendations for the provinces to phase out the programme. Gauteng and North West Despite all of the above, the Gauteng Department of Health continues to fund students — about 20 last year and an expected 40 this year. Spotlight's questions on this to the Gauteng health department went unanswered. Compounding the administrative and planning blunders for returning students is the impact of deepening corruption and mismanagement in Gauteng's health department. It has been under routine Special Investigating Unit scrutiny as well as coming under fire for service delivery issues such as the ongoing backlog of cancer patients lingering on treatment waiting lists. In March, the South Gauteng Division of the High Court in Johannesburg ruled that the Gauteng health department had failed in its constitutional obligation to make oncology services available. In April, the department failed to pay its doctors their commuted overtime pay on time. These payments ensure there are doctors for 24-hour coverage at hospitals and make up as much as a third of doctors' take-home pay. The situation in the North West is also bleak. It's health facilities routinely face medicine stock-outs and understaffing. Its health department regularly struggles with accruals and paying suppliers on time. Given all these challenges, it is puzzling that these two provinces in particular are so committed to sending students to Cuba, at what we understand to be higher cost than for training doctors locally. 'Better investments' Professor Lionel Green-Thompson, now the dean of the faculty of health sciences at the University of Cape Town, was involved in managing returning students from the Cuba-SA programme between the mid-2000s and 2016. At the time, he was a medical educator and clinician at Wits University, where he oversaw the 18-month clinical training of more than 30 returning students. 'Some of these students were among the best doctors that I've trained, and I remain a stalwart supporter of the ideals of the programme. But at this point, there are better investments to be made, including directly funding university training programmes in South Africa,' he said. 'A programme that's rooted in our nostalgic connection with Cuba and its role in our change as a country is now out of step with many of the healthcare settings and realities we face in South Africa,' said Green-Thompson. He added that a proper evaluation of the programme needed to be conducted. There were also lessons to learn, he said, including a review of admissions programmes. How some students who entered a programme at 20% below the normally accepted marks and exited the programme as excellent doctors, offered clues on how great doctors could be made, he said. Green-Thompson also suggested that we needed to ask why specialisation had become a measure of success for many doctors in South Africa, often at the expense of family medicine. This, he said, took away from the impact doctors made at the community healthcare level as expert generalists. But changing the perspectives of healthcare professionals required early and sustained exposure to working in community healthcare settings, said Professor Richard Cooke, the head of the department of family medicine and primary care at Wits. Cooke is also the director of the Wits Nelson Mandela-Fidel Castro Collaboration since 2018 and serves on the Nelson Mandela-Fidel Castro Ministerial Task Team. 'I'm not in support of further students being sent to Cuba for the undergraduate programme, because these students are not being trained in our clinical settings,' he said, speaking in his Wits capacity. 'The Cuban system is far more primary healthcare based than South Africa's, but that doesn't necessarily translate into these students ending in primary healthcare,' said Cooke. And curricula at Wits were shifting, for instance, towards placing students at district hospitals for longer periods of time, rather than weeks-long rotations, he said. 'When students become part of the furniture at a hospital, they become better at facilitating, at critical thinking, problem solving, teamwork and collaboration,' Cooke said. But making this kind of transformation in local training took government funding and commitment. Students and doctors needed to be attracted to the programme and needed reasons to stay. But the money and resources to make this happen were simply not there — even as the Cuba training programme continued. Cooke added: 'There hasn't been definitive data on the Nelson Mandela-Fidel Castro programme. But even if the programme over 30 years has done well and met its targets, it's not been cost efficient. What's needed now is to leverage expertise and establish partnerships in different, more cost-effective ways like in research, health systems science and health science education.' Up to three times more expensive? Professor Shabir Madhi, the dean of the faculty of health sciences at Wits, said the Nelson Mandela-Fidel Castro programme costs an estimated three times more than it cost to train a student in South Africa. This, he said, should be enough reason for a beleaguered health department like Gauteng's to stop sending students to Cuba. He added: 'The government is aware that it simply can't absorb the number of medical graduates being produced.' Madhi says some trainee doctors were sitting at home while others trying to finish specialisations were being derailed. Broadly, he pinned the blame on the mismanagement of resources, including the department underspending R590-million on the National Tertiary Service Grant meant to subsidise specialised medical treatment at tertiary hospitals. Madhi said universities had worked hard to close the gaps identified by the Nelson Mandela-Fidel Castro programme 30 years ago, but now student doctors were being let down by the government not playing its part. 'Across the universities, there's been a complete overhaul of the curriculum to be focused on primary healthcare. Students are also getting community exposure as early as first-year training,' he said. He added that when it came to admissions, the majority of students entering medical schools across the country were now black South Africans, and additional changes had been made to the selection process. 'We used to have a race quota, but in further revisions we have introduced criteria that focus on the socioeconomic component, with 40% of the admissions coming from students in quintile 1, 2 and 3 schools [no-fee public schools],' he said. South Africa had 11 medical schools, with the most recent addition being North West University — specifically focused on rural health — and the University of Johannesburg in the pipeline to join the list. So the number of doctors being trained and graduating was increasing. Madhi estimated that the total number being trained was above 900 per year for Gauteng alone. The bottleneck of getting doctors into clinics and hospitals, he maintained, was not a shortage of doctors, but the government's inability to pay doctors' salaries or to create functioning, well-resourced workplace environments. 'You can't put a price on that' For Dr Sanele Madela, the ongoing challenges could not detract from the goal to get doctors into communities — including through the Nelson Mandela-Fidel Castro programme. Today, he is the health attaché at the Havana Mission for the Nelson Mandela-Fidel Castro training programme. Madela was also at one time a schoolboy with a dream of becoming a doctor. Growing up in Dundee in KwaZulu-Natal, he remembers almost never seeing a doctor in his community. 'Then when we did see a doctor, it was a white person or an Indian person and they never spoke our language — a nurse would have to translate,' said Madela, who was part of the 2002 Nelson Mandela-Fidel Castro intake. The six years abroad, he said, exposed him to very different reasons for becoming a doctor. 'When people finish medical school, they say thank God it's over, but in Cuba people say thank God for the knowledge and information so they can give back to their country,' he said. When Madela got back to South Africa, his journey eventually led him to work in Dundee district hospital. It was the same hospital where his mother had worked as a cleaner. The Nelson Mandela-Fidel Castro programme, Madela said, still played a vital role because of its objective to get more doctors into rural and township areas — 'and you can't put a price on that'. 'We are used to seeing the Nelson Mandela-Fidel Castro programme from the point of view of adding human resources, but it's also about the impact it makes for a community,' he said. It's the impact of a community finally getting their own doctor. His argument is that, thanks to the Nelson Mandela-Fidel Castro programme, he got to be that person for his community. DM
Daily Maverick
27-06-2025
- Health
- Daily Maverick
Frustrated Free State doctors face unemployment after Cuban medical training in systemic crisis
A cohort of young doctors whose training was funded by the Free State government through the Nelson Mandela-Fidel Castro Bursary programme have been unable to find work in the public health sector upon completing their community service, despite a contractual obligation to serve the province that supported their studies. More than 20 young doctors from the Free State who received training in Cuba through the Nelson Mandela-Fidel Castro (NMFC) Bursary programme, funded by the provincial health department, have been unable to find work in the public health sector due to a lack of posts. Across South Africa, provincial health departments provide funding for individuals from their respective regions to study medicine through the NMFC Bursary programme. Upon returning from Cuba and completing their internship, beneficiaries are required to serve their local government in the health sector for the number of years for which they were funded. However, about 24 Free State NMFC Bursary holders who completed their community service requirement over the past year have not been able to fulfil their contractual obligation to continue working in the province's public sector, according to *Thabo, a beneficiary of the programme who chose to remain anonymous out of concern for backlash. 'We've been to the [health] MEC's office. We've been to the premier's office. We've spoken with the [head of the Free State health department], and no one seems to be taking accountability. It's just one person bouncing you to the next person… and there's no real sense of urgency about what's happening on the ground in the hospitals, with the [staff] shortages, the patients or even us, as their investments,' he said. Waiving obligations The cohort of NMFC Bursary beneficiaries sent a memorandum of demands to the Free State premier and MEC for health in January, pushing for immediate appointments in local health facilities. In a letter responding to this memorandum, seen by Daily Maverick, head of the Free State health department Masechaba Sesing stated: 'It is true that the bursary policy places a contractual obligation on both parties to either offer employment to bursary holders upon completion of their studies, provided that there are vacant funded posts in the department, and on the bursary holder to work back the bursary for the period of the bursary granted, should the department offer a post within three months from date of completion of the studies. 'Should the department not be in a position to offer employment within three months from date of completion, the bursary holder is released from the bursary obligation.' Thabo claimed that the three-month limit on the state's obligation to employ post-community service bursary holders was a new development, not featured in beneficiaries' original contracts. In a second letter from the NMFC Bursary cohort, addressed to Sesing and dated 7 March 2025, the graduates entreated the provincial health department to find a strategy to retain them in the public sector. 'For [the] Free State, each graduate costing approximately R1,137,500 to R1,750,000 is a tailored asset to address our province's dire healthcare gaps. Yet, without a robust retention strategy, we risk losing these doctors to urban centres or other provinces, undermining… the province's investment, the ANC mandate and the vision of Mandela and Castro,' stated the letter. Thabo claimed that the Free State health department had not advertised any positions for young, post-community service doctors since January. Driving away assets It's not only NMFC Bursary holders who are struggling to get public sector posts, but also those from other state-funded bursary programmes that support medical training in Russia, China and South Africa, according to Thabo. 'We're adults now — some of us have families, some of us are married, some of us have kids. Even if you have savings and you're projecting that for at least three months you'll be okay… then three months pass by and there's still nothing,' he said. 'With the number of unemployed post-community service medical officers, you can only imagine how many of us are looking for work.' The situation had taken its toll on the mental wellbeing of graduates, said Thabo, with many experiencing depression and anxiety. 'You become hopeful and it gets crushed. You reach out for help and you're treated like… a nobody, like you don't have any value… And you know the skillset you possess, you know the impact you make,' he said. 'You hear from your colleagues [in the public sector]… how overwhelmed they are, and you have the ability to help, but you can't because you're not in the system.' Since completing his community service last year, Thabo has found work outside the Free State in the private sector. However, he noted that the large number of young doctors flocking to private facilities increased the likelihood of exploitation. 'The issue with private, now, is… they know we're unemployed, we're desperate. Instead of giving us the rate per hour that they normally give, they reduce it because they know we'll take whatever we can get. So, it's tough financially,' he said. 'I'd love to come back home [to the Free State]. There's so much potential. We're running behind on so many things — the infrastructure, the development. I'd like to be there and be able to contribute to the primary healthcare system in general… But if I'm not allowed the opportunity, then obviously self-preservation is going to come into play.' Free State Department of Health Mondli Mvambi, the spokesperson for the Free State Department of Health, acknowledged that there were graduates of the NMFC Bursary programme that the department hadn't been able to employ. 'The necessary human resources processes must be followed in appointing the students. Posts must be advertised and each person [has] to apply. The department does not get enough funding from the Division of Revenue to meet all its human resources and other pressing service delivery needs,' said Mvambi. 'The department has commenced the process to identify savings within the Compensation of Employees' budget to identify posts that can be filled within the [Medium-Term Expenditure Framework] period.' If the Free State Department of Health is unable to employ bursary beneficiaries within three months of them completing their studies, the young doctors are permitted to 'ply their trade' in other provinces, the private sector, the national Department of Health or overseas, according to Mvambi. 'This [NMFC Bursary] programme contributes immensely to the human resources development strategy of the country… The role of the state is… to create an enabling environment, and training is one such enabling environment. The creation of employment opportunities is beneficial to the development needs of all our provincial citizens, South Africans, Africans and the international community,' he said. Broader challenges The Free State is not the only province struggling to provide posts for state-funded bursary holders who have completed their community service requirement. Dr Percy Mahlathi, deputy director-general for hospital services and human resources in the national Department of Health, told Daily Maverick that the department was 'fully aware' of the issue. 'It is not limited to students who were studying overseas or in Cuba. Even those who are studying in our own medical schools, funded by the various provinces, are facing the same challenge,' he said. Health officials, including the current and previous ministers of health, have engaged with the National Treasury about prioritising doctors who have just completed their community service, according to Mahlathi. However, he noted that employing these young professionals after internship and community service was not a statutory obligation. 'The moral obligation is there, but a contractual obligation is no longer there. I'm saying moral obligation because when you've got such a huge… patient load in the public health system, you would like to have… as many health professionals as possible. But the problem we then have is: When you don't have enough financial resources, what do you do?' said Mahlathi. Processes around the budget that was tabled on 21 May have yet to be finalised in Parliament. Once complete, Mahlathi said he hoped there would be a funding allocation that would allow the health departments to employ 'most, if not all' the doctors who had recently completed their community service. 'I do know that once the provinces get funding allocations, they are going to prioritise those who they have funded to study… I know when you are a doctor out there, funded or not, you want a job, but if we look from the public value point of view, there's been an investment in those who are given bursaries, and therefore they should be prioritised,' he said. At this stage, Mahlathi was unable to confirm when budget allocations would allow for the employment of post-community service doctors, or how many young professionals would receive opportunities. He estimated there were close to 1,300 such doctors awaiting employment. 'With all these ups and downs with the budget… it actually became a serious problem for the provinces. Very few people were able to be employed,' he said. The national Department of Health had asked provincial health departments to work on 'various scenarios' pending the finalisation of funding allocations in the budget, according to Mahlathi. 'They must work out the scenarios so that they don't wait until the allocation lands to start doing the technical work. That's what they are busy with now,' he said. Mahlathi said he was against any changes to the country's bursary programmes for medicine, such as a reduction in the number of beneficiaries. 'There are young, brilliant minds of all races that would not be able to study if they did not have that bursary… I don't think it would be a good idea for governments to say, 'Look, we don't have money now, we're going to stop educating South Africans', because we will feel a terrible impact in about eight to 10 years, when we've actually got less [graduates],' he said. Dr Aslam Dasoo, the convenor of the Progressive Health Forum, said unemployed graduates of the NMFC Bursary programme were 'organising themselves', and that the forum had reached out to them. 'The bursary is underwritten by the state and the forum will support their stance on the bursary being written off, provided [the graduates] take up positions in the public service for a specified period when posts become available,' said Dasoo. 'It's really the inchoate health department and its political heads who are the obstacle here.' DM
