ANDREW JOHN ROSS

South Africa,

Andrew is addressing the shortage and low retention rate of health personnel in rural South Africa through an education program that recruits, trains and mentors youth from rural areas in various health professions and then employs them back in the rural communities.

This profile below was prepared when Andrew John Ross was elected to the Ashoka Fellowship in 2014.

INTRODUCTION

Andrew is addressing the shortage and low retention rate of health personnel in rural South Africa through an education program that recruits, trains and mentors youth from rural areas in various health professions and then employs them back in the rural communities.




THE NEW IDEA

Andrew, a general practitioner working as a hospital supervisor in the rural areas of KwaZulu-Natal province, was confronted with the critical shortage of medical professionals in rural South Africa when he needed to staff his team. Andrew’s insight is that people from rural areas are better positioned to serve their communities, especially in the medical field, due their inherent understanding of societal dynamics and their existing sense of connection to place. However, most youth in rural areas lack education and employment opportunities and this denies them permission to dream big and pursue a medical career. In order to address this, Andrew developed a program that recruits young people in rural areas and exposes them to higher education training and employment opportunities in the medical and health-related fields. Through a comprehensive selection process, interested and passionate young people are selected into the program and are offered full scholarships through university and assisted with placement in rural hospitals upon graduation. 

Andrew works to enhance the participants’ confidence and strong connection to their communities through mentorship and community service programs run by his organization, Umthombo Youth Development Foundation (UYDF). Andrew’s objective is to develop homebred young medical professionals who embrace their careers as a calling to serve their communities rather than just a source of income. UYDF has established close relationships with local hospitals to assist with student selection and most significantly to allow students to work at the hospital during the holidays and offer employment after graduation. Since its formation, the scholarship program has been a source of hope for rural scholars and given them something to aim towards. It has also created role models for young people still in school. Students at local schools can see and talk to other scholars who went to similar schools and have succeeded in their professional lives. This enables those students still in school to dream that they too might become health care professionals in the future. 

To date, Andrew has trained and retained 185 health professionals in 13 different hospitals in the rural areas of KwaZulu-Natal and Eastern Cape, who have all completed full medical, or health-related higher-education training and practice (residency). Currently, 200 students are supported every year in 16 health disciplines. Andrew is now planning to scale out to other provinces in South Africa facing similar problems. By 2016, he plans to increase the intake to manage about 250 youth per cycle in the program. Furthermore, Andrew seeks to share the model with provincial Departments of Health and influence them to adopt what he considers to be the “critical aspects” of the program. It is hoped that this sharing of information will influence the provincial Department of Health’s policies on selection and support of rural students and will lead to greater throughput of rural students and greater work back compliance – both of which will contribute to addressing the shortages of staff at rural hospitals. In addition UYDF has been able to incorporate government-subsidized student loans as scholarship offers for rural students and hopes to expand this at a national scale. He is also creating new post-graduate training programs that ensure ongoing professional development as a way to improve the quality of the service but also to ensure high retention rates of medical professionals in rural areas.




THE PROBLEM

The shortage of healthcare workers is biggest challenge facing public healthcare in South Africa today. Seventy percent of the country’s doctors work in the private healthcare sector, which serves only 16 percent of the population. The implication being that the remaining 30 percent of South Africa’s doctors work in public healthcare, which serves 84 percent of the population. This situation is further exacerbated by the high concentration of public sector doctors in urban areas. Consequentially, the shortage in healthcare workers is most severe in rural areas where 43.6 percent of the country’s population lives but only 12 percent of doctors and 19 percent of all nurses work. This means that there are 13 doctors and two specialists available for every 100,000 people without medical aid in South Africa’s rural areas. With 22.3 million of the nation’s population living in rural areas, this translates to one general practitioner for almost every 8,000 people (South African Health Review, 2011). In some cases, vacancy rates at rural hospitals are as high as 50 to 60 percent. 

Rural communities often face considerable health challenges due to overall social and economic conditions in these areas. Most inhabitants do not have access to electricity or piped water, and live in scattered homesteads, living on subsistence farming supplemented by income from pensions, grants and wages from migrant labour. Malaria, tuberculosis, and HIV/AIDS are examples of the major health problems affecting these rural communities, while the lack of clean water and inadequate sanitation results in poor hygiene leading to health problems such as gastroenteritis and parasitic infestations. Chronic poverty and illiteracy further lead to widespread malnutrition. The enormous staff shortages in the rural healthcare system certainly have an impact on the quality of care offered to patients and restrict the ability of even the few rural health workers to address these health problems. Doctors and nurses are overworked and burnt out, causing reduced retention rates and decreasing the quality of care they can deliver. 

South Africa produces about 1,300 doctors yearly but only 35 of them end up working in rural areas in the long term. According to the South African Health Review (2011), there are many reasons why healthcare workers do not want to work in rural areas, including the poor working conditions (infrastructure and workload) and professional and personal isolation, which have a major impact on retention rates of doctors. The government attempts to address this problem by employing foreign doctors and health professionals to work at these rural hospitals. However, stringent immigration regulations only allow these doctors to work in the area for a specified period of time (12 months). Importing foreign doctors is an ineffective solution to the shortage because of this short period of stay, limited knowledge and experience of local diseases, lack of understanding of local tradition and culture as well as language barriers. 

The real key to solving this problem is surprisingly overlooked. It has been proven that rural students themselves, or those exposed to rural healthcare, are four to seven times more likely to return and work in rural areas after graduating (University of Stellenbosch) but surprisingly few do. In countries such as Australia, for instance, state subsidies to medical schools are dependent on them offering a rural clinical training module. But in South Africa, the government’s only requirement of its young doctors is that they do a year's community service after their two-year post-graduation internship, which doesn’t solve the problem of long-term retention. The lack of connection for graduating doctors to rural communities lowers retention, since their only point of connection to the rural communities is the one year community service. There are no other interventions that recruit young people right from the communities and train them to serve their communities. These young people are an untapped resource because they are already connected to problems, challenges, language and culture of the communities they grew up in and would understand that they are entrusted by the community to serve the community. 

Therefore, while the key may be to train more students from the rural areas to become health professionals and then assist them in finding work in rural settings, rural youth are precisely the segment of the population that has fewer opportunities to access medical training and employment. In fact, youth unemployment, which is already rampant in the country, is even higher amongst rural youth, reaching up to 80 percent of the population in some provinces. Even for those who manage to complete school, there are virtually no opportunities for them to access tertiary education (due to their grades and financial situation), let alone in a health-related field. Thus, young people from rural areas lack access to opportunities to become healthcare professionals due to financial constraints and would never dream of pursuing such a path due to a lack of exposure, career guidance and role models they can relate to.




THE STRATEGY

Andrew created the Umthombo Youth Development Foundation (UYDF) which identifies, trains and supports youth from rural South Africa to become qualified healthcare professionals, in order to address the shortage of qualified health care staff at rural hospitals and thus improve the quality of healthcare provided to rural communities. The investment in the training and development of local rural youth is strategic for several reasons. As corroborated by research, local youth are more likely to remain in the area once qualified since they have family attachments and commitments, in the area. They are also better equipped to communicate with patients in their mother tongue, which facilitates understanding and treatment of the problems. In addition, the community that selected them holds them in high esteem and this encourages them to stay. Lastly, and most importantly, rural youth are South Africa’s untapped potential and work hard when offered previously unavailable opportunities- graduates of the program become positive role models for other rural youth to emulate, creating a positive cycle of upliftment. 

The first step is the community selection of young people to participate in the program. Through traditional rural councils and other participatory citizen bodies, the community identifies potential applicants by selecting the young people who possess the aptitude and attitude for the program. This critical step in the process is the secret to UYDF’s success. The early acceptance, validation and trust from the community is crucial for the student’s success and to ensure that they are supported through graduation. It also changes the student’s self-perception and their view of the future because the community now expects them to succeed, and supports them to do so, in the medical field. At this point in the process, UYDF has worked with the community to create a pool of young people who, if interested in pursuing a medical profession, will be automatically eligible for participation in UYDF’s program, 

The School Outreach Program is the next step in the strategy and is the part of the process that encourages students to dream big and pursue their ambitions as medical professionals. In this program, students in rural public schools are made aware of the career opportunities in the health sciences and the course and grade requirements for these. Interested learners are invited to attend the Hospital Open Day, an event held at their local hospital. This is an opportunity for them to ask hospital staff questions and learn more about the particular discipline they are interested in. This open day is organized by UYDF graduates and they share their valuable experiences with the prospective applicants. In 21013 alone, UYDF visited 64 schools and participated in 10 career expos. All students are encouraged to apply to various universities and supported through the process. Prospective participants in UYDF’s program are specifically asked to complete at least one week of voluntary work at their local hospital before attending the UYDF selection interviews at the end of the year. 

Once learners gain acceptance from a university, the third component of UYDF’s strategy kicks in. This component is dedicated to supporting the students through their studies. One immediate benefit is that once a learner who is selected by their community for participation in this program gains acceptance into a university, they qualify for financial support and scholarships from UYDF. The Financial Support strategy is comprehensive in order to ensure that students are able to concentrate on their studies and pass. Therefore, it covers full tuition including accommodation in the university residence, a book allowance paid twice a year, a monthly food allowance, payment for holiday work and any other essential expenses required by the curriculum, such as minor equipment and compulsory excursions. 

UYDF offers ongoing Mentoring Support alongside the financial support. This is a critical component of the program’s success because rural students face many challenges at university including their poor command of English, the fast pace of the academic program, peer pressure and requests from home. The mentoring support is thus provided to help students cope and overcome these many challenges. Mentors are chosen by the UYDF mentor coordinator and are people situated close to campuses where UYDF students are studying who are interested in the support and development of young people. The network of mentors are in contact with the students monthly and hold them accountable for their academic work. In addition the UYDF mentor coordinator meets with students twice a year on campus and once a year at the district hospital where they are doing their holiday work. Alumni working at these hospitals provide additional support for students as they best identify with the struggles of the students and provide practical advice for them to overcome their challenges. The exceptionally high pass rate (92 percent) of UYDF students can be ascribed to this mentoring process. This pass rate exceeds the national average of around 50 percent for all university students and the 35 percent success rate of those that are disadvantaged. 

Additionally, all students supported by UYDF are required to do at least one month compulsory Holiday Work at their local hospital each year for which they receive a scholarship. The purpose of this is to allow them to interact with hospital staff and get a sense that “this is their hospital.” This exposure also provides students with valuable practical experience to complement their academic studies. They also participate in outreach activities in local communities, interacting with the youth and encouraging them to work hard and dream about a better future. This serves both to offer positive role models for the community and to develop the students’ change making skills. Indeed, Andrew has seen that once they start their careers, they seem to approach their work in a more proactive way than most doctors. Some of them become game-changers who creatively working around the lack of structure that exists in the rural hospitals. For instance, one graduate was struck that the hospital didn’t have an optometry facility and therefore worked with the Brain Holden Foundation (Ashoka Fellow Kovin Naidoo) to create such new posts at his hospital. 

Finally, all these strategies are complemented by the last component of the program - facilitating employment at the rural hospital once students graduate. This is almost a natural step since these young professionals are bred to serve precisely those hospitals. Their motivation to return and work in the rural setting is a result of each of the above carefully crafted strategies, as well as a formal year-for-year Work-Back Contract, which all students have to sign. This means that for every year of studies supported by UYDF, graduates must work at the rural hospitals. Currently, UYDF supports almost 200 students per year (with about 50 of them expected to graduate every year) and has to date produced 185 graduates who received degrees in 16 different health professions: the majority in medicine (40 percent), but also in nursing, optometry, social work, radiography, physiotherapy, biomedical technology and psychology. Almost 70 percent of graduates are working at rural hospitals; the remainder serve in other public hospitals and only 5 percent have gone into private practice. The retention of these professionals really works: even with no further work-back obligations, 60 percent of them continue working in the rural hospitals and the remaining are working in urban public hospitals, doing research or specializing. Only 8 percent, after the end of the work-back contract, have gone into private practice. 

UYDF is currently working with 13 rural hospitals in KwaZulu-Natal and the Eastern Cape provinces where rural staff shortages are most critical. Now that the model has been proven, Andrew is planning to scale out to other provinces in South Africa that face similar problems by sharing the critical aspects of the program and encouraging them to adapt their bursary programs which should led to greater student throughput and greater work back compliance. By 2016, he plans to increase the UYDF intake to manage about 250 students per cycle in the program. Andrew also plans to create a specific program to boost the engagement of UYDF alumni to support its efforts and increase the network of mentors. Also, UYDF has signed an agreement with the Student Financial Aid Scheme (NSFAS), of the South African government, and their annual grants will now provide loan funding to half of UYDF’s students every year. Students are issued with loans to cover their tuition and accommodation, which become repayable when they start working. UYDF is providing top-up funding to ensure that students have all the resources needed to concentrate on their studies. Finally, Andrew is working closely with the provincial Departments of Health, which are interested in adopting the model and also to use it in strengthening their few existing bursary schemes. In the next 5 years, Andrew plans to create a whole new branch of UYDF, now to concentrate also on post-graduate training opportunities for these young professionals, especially in Family Medicine and other relevant specializations for the rural setting, with the final objective of further improving the quality of rural healthcare delivery. This is also an enhancement of the retention strategy, since there is no specialization training in rural hospitals and this offers an opportunity for them to further their careers without having to leave for the urban areas.




THE PERSON

Andrew was born in South Africa to Christian parents who were both medical doctors working as missionaries in South Africa, Nigeria and Ethiopia. He grew up in these countries and went to boarding school in the UK before returning home to South Africa. As a result of his childhood in several African countries and his boarding school experience, he acquired a strong appreciation of cultural differences and developed his ability to empathize with others. Upon returning to South Africa, his father became a professor at the University of KwaZulu-Natal, which at the time had a good quality faculty of medicine that would train black students. 

These experiences and the values his parents instilled in him strongly influenced his desire to become a doctor himself and build on this legacy. He has long-since held a deep concern for serving in areas most in need, as opposed to private practice. After completing his medical training, he decided to work for a government hospital in a poor province of South Africa and was quickly faced with the challenges of poor infrastructure and service. When he first arrived at the hospital, he met a doctor from England who told him that in his country, the government was only source of funding for hospitals. This profoundly influenced him to realize that he wouldn’t wait for government to be more efficient and invest more, but would rather create the conditions to enhance the service by raising independent funds. 

In 1990, during a measles epidemic, he directly felt the effects of poor government funding and the lack of resources in the public health system and began raising the funds himself. He managed to raise private funds to buy a vehicle for the immunization service, which reduced the number of measles cases seen at the hospital from about 45 cases per week to none. After this, he was involved in raising funds for vehicles for the community health worker facilitators, an HIV/AIDS program and a sanitation program in the sub-district. 

Later, while completing his master’s degree in Family Medicine, he experienced several challenges as the superintendent of the Mosvold Hospital in rural KwaZulu-Natal. He faced the critical issue of staff shortages in his management role as he tried to build up his team. Through his part-time training program, he had the opportunity to meet and share experiences with other medical professionals working in similar situations. Other medical superintendents had similar problems with staffing and he brainstormed ideas and possible solutions together with them. This led to the making of a film about the hospitals in northern KwaZulu-Natal as a marketing and recruitment tool, as well as the development of a training program for 2,000 junior doctors to encourage them to work in the province’s rural hospitals. While the communication strategy was successful and resulted in some new hires, Andrew realized that it wasn’t a systemic solution. The only long-term solution to tackle the problem of understaffing was to develop local human capital in the rural youth and for them to become the rural medical professionals of tomorrow. This is when he started to gather support from several partners and founded the Friends of Mosvold Scholarship Scheme, the core strategy that later, in 2004, led to the creation of the full Umthombo Youth Development Foundation model.




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