The University of Pretoria (UP) had its first intake of Bachelor of Clinical Medical Practice (BCMP) students in 2009. The objectives of this study were to examine the trends in geographical practice intentions and preferences of the first nine cohorts of BCMP students. We also assessed sector and level of care preferences of six BCMP cohorts.
Cross-sectional studies were conducted 2011, 2014 and 2017. First-, second- and third-year UP BCMP students were invited to complete a electronic questionnaire. Our analyses consisted of calculating proportions for the practice intentions and preferences for each surveys, and performing multiple logistic regression on the aggregated date to determine their associations with sociodemographic and training characteristics.
The proportion of participants intending to practise as a clinical associate in a rural area in South Africa directly after graduating was 62.5% in the 2014 survey and 69.7% in the 2017 survey, compared to 59.6% in the 2011 survey. The majority in all three surveys (53.4% in 2011, 56.6% in 2014 and 59.8% in 2017) indicated a preference for rural practice. Both rural practice intention and rural practice preference were found to be significantly associated with respondent’s self-description of having lived most of her/his life in a rural area, and rural district hospital exposure during training. In 2014 and 2017, approximately two-thirds of the participants selected a public sector option as their most preferred work setting. District hospitals were the most preferred setting of 30.3% participants in 2014 and 32.0% in 2017.
Most participants across the three surveys intended to work in rural settings. Considering that this could provide a sustainable solution to the shortage of health care workforce in rural areas, policy makers in both higher education and health need to promote and ensure the viability of the training of this category of health care providers.
Clinical associates are mid-level medical workers who have completed a 3-year Bachelor of Clinical Medical Practice (BCMP) degree.
The University of Pretoria (UP) conducted its first intake of BCMP students in 2009. A survey conducted in 2011 amongst the first three cohorts to enter the BCMP programme at UP found that 59.6% of the participants intended to practise in a rural area following graduation.
The initial survey by Moodley et al.
The objectives of this study were therefore to examine trends in geographical practice intentions, geographical practice preferences and future study plans of the first nine cohorts of BCMP students at UP by repeating the 2011 survey in 2014 and 2017. An additional objective in 2014 and 2017 was to determine work setting preferences based on sector (public or private or non-governmental organisation [NGO]) and level of care choices. We also aggregated the data from the different surveys in order to determine factors associated with practice intentions and preferences.
Three cross-sectional studies were conducted at 3-year intervals in 2011, 2014 and 2017. First-, second- and third-year students registered for the BCMP course at the UP were invited to participate in each of the surveys. All three surveys were conducted in the last quarter (October to December) of the respective years.
Data were collected using a self-administered electronic questionnaire originally developed for the 2011 survey. The questionnaires were delivered using the university’s computer-based training (CBT) platform. Although the CBT platforms in 2014 and 2017 had a different developer (QuestionMark) to the one in 2011 (Umfundi), this did not impact the format of the questionnaire in any significant way. The questionnaire has been described by Moodley et al.
Our outcome variables included practice intentions directly after graduating from the BCMP programme, the preference to work in South Africa or abroad (if the BCMP degree was internationally recognised), their preference for working in an urban or rural area (if they had complete freedom of choice) and having a public or private sector option (from a list of possible work settings) as their preferred work setting. The sociodemographic variables we considered included gender, age, race, self-description of area they had lived most of their life (urban or rural) and funding source(s) for the degree. The training variables analysed included year of study and rural district hospital exposure during training. In addition, the participants’ interest in pursuing further training was assessed using a series of Likert-scale questions. The ‘strongly agreed’ and ‘agreed’ categories were aggregated for the purposes of our analysis. Our descriptive analyses consisted of calculating proportions for the variables for each of the three surveys.
In order to determine the factors associated with our outcome variables, we aggregated the data from the different surveys. This was done to increase the statistical power. Because of the possibility that some students who had failed would have had an opportunity to complete the survey on two occasions (e.g. a student who failed first year in 2011 would be in third year in 2014), we identified the classes with these students using class registers. In total, 27 students could potentially have completed the survey twice. It was not possible to identify individual students (if any) who completed the survey twice as the survey was anonymous. We, therefore, performed two sets of analyses, namely, one consisting of a reduced data set eliminating the possibility of double counting by excluding certain classes and the other consisting of the full data set. Prior to univariate logistic regression, categories were combined for race (mixed race, Indian, white and other were combined because of their small numbers) and BCMP year (1st and 2nd years were combined). For each of the outcome variables, univariate logistic regression was conducted to determine the association with gender, age, race, self-description of area they had lived most of their life (urban or rural), year of study and rural district hospital exposure during training. In addition, for practice intention, we assessed its association with bursary funding. Independent variables with
We used Stata version 15 (Statacorp;
The three surveys formed part of an overarching study, ‘A multidisciplinary investigation of authentic learning in the BCMP curriculum’, which was approved by UP’s Faculty of Health Sciences Research Ethics Committee (#56/2011). The survey questionnaire was reviewed and approved by the committee prior to the first survey in 2011. Some modifications to the questionnaire (not affecting the key variables from 2011) were approved by the committee prior to the 2014 survey.
The proportion of registered BCMP students who participated in the 2014 and 2017 surveys were 48.5% and 58.2%, respectively. Student participation in the three surveys is compared and presented in
Participation in the 2011, 2014 and 2017 surveys.
Year of study | 2011 survey |
2014 survey |
2017 survey |
||||||
---|---|---|---|---|---|---|---|---|---|
Number of registered students | Students participating |
Number of registered students | Students participating |
Number of registered students | Students participating |
||||
% | % | % | |||||||
BCMP I | 77 | 43 | 55.8 | 88 | 33 | 37.5 | 66 | 24 | 36.4 |
BCMP II | 92 | 64 | 69.6 | 84 | 34 | 40.5 | 82 | 51 | 62.2 |
BCMP III | 47 | 42 | 89.4 | 63 | 47 | 74.6 | 65 | 49 | 75.4 |
All | 216 | 149 | 69.0 | 235 | 114 | 48.5 | 213 | 124 | 58.2 |
BCMP, Bachelor of Clinical Medical Practice.
The sociodemographic characteristics of the participants in each of the three surveys are shown in
Sociodemographic and training characteristics of participants.
Characteristic | 2011 Survey |
2014 Survey |
2017 Survey |
|||
---|---|---|---|---|---|---|
% | % | % | ||||
Female | 73/149 | 49.0 | 67/109 | 61.5 | 68/123 | 55.3 |
Male | 76/149 | 51.0 | 42/109 | 38.5 | 55/123 | 44.7 |
18–21 years | 59/149 | 39.6 | 51/112 | 45.5 | 53/124 | 42.7 |
≥ 22 years | 90/149 | 60.4 | 61/112 | 54.5 | 71/124 | 57.3 |
Black African | 131/149 | 87.9 | 106/113 | 93.8 | 110/123 | 89.4 |
Mixed race | 4/149 | 2.7 | 3/113 | 2.7 | 2/123 | 1.6 |
Indian | 2/149 | 1.3 | 1/113 | 0.9 | 2/123 | 1.6 |
White | 11/149 | 7.4 | 3/113 | 2.7 | 8/123 | 6.5 |
Other | 1/149 | 0.7 | 0/113 | 0.0 | 1/123 | 0.8 |
Bursary only | 134/149 | 89.9 | 96/113 | 85.0 | 80/124 | 64.5 |
Other source(s) |
15/149 | 10.1 | 17/113 | 15.0 | 44/124 | 35.5 |
Gauteng | 36/138 | 26.1 | 14/112 | 12.5 | 15/124 | 12.1 |
KwaZulu-Natal | 28/138 | 20.3 | 34/112 | 30.4 | 60/124 | 48.4 |
Mpumalanga | 24/138 | 17.4 | 46/112 | 41.1 | 22/124 | 17.7 |
Limpopo | 16/138 | 11.6 | 10/112 | 8.9 | 16/124 | 12.9 |
Other South African provinces | 34/138 | 24.6 | 7/112 | 6.3 | 10/124 | 8.1 |
Outside South Africa | 0/138 | 0.0 | 1/112 | 0.9 | 1/124 | 0.8 |
District/local | 93/136 | 68.4 | 86/112 | 76.8 | 96/120 | 80.0 |
Metropolitan | 43/136 | 31.6 | 25/112 | 22.3 | 23/120 | 19.2 |
Outside South Africa | 0/136 | 0.0 | 1/112 | 0.9 | 1/120 | 0.8 |
Rural | 75/149 | 50.3 | 61/113 | 54.0 | 80/123 | 65.0 |
Urban | 74/149 | 49.7 | 52/113 | 46.0 | 43/123 | 35.0 |
BCMP I | 43/149 | 28.9 | 33/114 | 29.0 | 24/124 | 19.4 |
BCMP II | 64/149 | 43.0 | 34/114 | 29.8 | 51/124 | 41.1 |
BCMP III | 42/149 | 28.2 | 47/114 | 41.2 | 49/124 | 39.5 |
None | 91/148 | 61.5 | 57/112 | 50.9 | 46/123 | 37.4 |
At least some | 57/148 | 38.5 | 55/112 | 49.1 | 77/123 | 62.6 |
BCMP, Bachelor of Clinical Medical Practice.
, Includes those funded by bursaries in combination with other sources.
, Based on where the participant has lived most of her/his life.
, Participant perception of whether the area they have lived most of their life is urban or rural.
Similar to the 2011 survey, the majority of participants in both the 2014 (62.5%) and the 2017 (69.7%) surveys intended to practise as a clinical associate in a rural area in South Africa directly after graduating (
Geographical practice intentions and practice preferences of Bachelor of Clinical Medical Practice students.
Practice intentions and preferences | 2011 Survey |
2014 Survey |
2017 Survey |
|||
---|---|---|---|---|---|---|
% | % | % | ||||
Practise as a clinical associate in a rural area in South Africa | 87/146 | 59.6 | 70/112 | 62.5 | 85/122 | 69.7 |
Practise as a clinical associate in an urban area in South Africa | 41/146 | 28.1 | 26/112 | 23.2 | 24/122 | 19.7 |
Remain in South Africa but not practise as a clinical associate | 16/146 | 11.0 | 13/112 | 11.6 | 12/122 | 9.8 |
Emigrate from South Africa | 0/146 | 0.0 | 2/112 | 1.8 | 1/122 | 0.8 |
Not intending to complete the BCMP degree | 2/146 | 1.4 | 1/112 | 0.9 | 0/122 | 0.0 |
Within South Africa | 111/148 | 75.0 | 85/113 | 75.2 | 89/122 | 73.0 |
Outside South Africa | 37/148 | 25.0 | 28/113 | 24.8 | 33/122 | 27.0 |
Rural | 79/148 | 53.4 | 64/113 | 56.6 | 73/122 | 59.8 |
Urban | 69/148 | 46.6 | 49/113 | 43.4 | 49/122 | 40.2 |
More than 70% of the participants in each of the three surveys indicated a preference for working in South Africa even if their qualification allowed them to work abroad (
Approximately two-thirds of the participants in 2014 (67.0%) and 2017 (67.2%) selected a public sector option as their most preferred work setting. District hospitals were selected as the most preferred option by more than 30% of all the participants in 2014 and 2017 (
Sector and level of care practice preferences of Bachelor of Clinical Medical Practice students.
Most preferred setting | 2014 Survey |
2017 Survey |
||
---|---|---|---|---|
% | % | |||
Ward-based outreach team | 2 | 1.8 | 2 | 1.6 |
Primary health care clinic or community health centre | 21 | 19.3 | 23 | 18.9 |
District hospital | 33 | 30.3 | 39 | 32.0 |
Secondary hospital | 8 | 7.3 | 7 | 5.7 |
Tertiary hospital | 9 | 8.3 | 11 | 9.0 |
Own private practice | 10 | 9.2 | 16 | 13.1 |
Work with a general practitioner in private practice | 5 | 4.6 | 3 | 2.5 |
Work with a medical specialist in private practice | 6 | 5.5 | 1 | 0.8 |
Private hospital | 8 | 7.3 | 9 | 7.4 |
Work with an NGO in male medical circumcision | 4 | 3.7 | 4 | 3.3 |
Work with an NGO in other medical work | 3 | 2.8 | 7 | 5.7 |
NGO, non-governmental organisation.
We assessed the factors associated with rural practice intention, preference for working in South Africa, rural practice preference and preferred work setting in the public sector using a reduced data set (specified classes excluded to eliminate double counting that may have resulted from students participating in two surveys) and the full data set.
Factors associated with practice intention and preferences.
Characteristic | Odds ratio | 95% confidence interval | |
---|---|---|---|
Lived most of their life in a rural area (self-description) | 6.23 | 3.34–11.64 | < 0.001 |
Rural district hospital exposure | 3.54 | 1.89–6.65 | < 0.001 |
Black African race | 3.71 | 1.42–9.74 | 0.008 |
Lived most of their life in a rural area (self-description) | 2.28 | 1.37–3.82 | 0.002 |
Rural district hospital exposure | 2.94 | 1.77–4.89 | < 0.001 |
Black African race | 2.85 | 1.35–6.03 | 0.006 |
Age ≥ 22 years | 2.14 | 1.16–3.95 | 0.015 |
, Excludes first- and third-year students in 2014.
, No data for 2011 and excludes first-year students in 2014.
The majority of the participants in each of the three surveys indicated that they intended to pursue a further degree or diploma in the future. The proportion of participants intending to pursue further studies (part-time or full-time) was 93.9% (139/148) in the 2011 survey, 84.1% (95/113) in the 2014 survey and 82.6% (100/121) in the 2017 survey. The proportion of participants interested in pursuing a 1-year clinical specialisation was 77.9% in the 2014 survey, which was the highest of the three surveys (
Bachelor of Clinical Medical Practice students’ interest in pursuing further training.
Statement | 2011 Survey Agree and strongly agree |
2014 Survey Agree and strongly agree |
2017 Survey Agree and strongly agree |
|||
---|---|---|---|---|---|---|
% | % | % | ||||
I would be interested in pursuing a 1-year specialisation in a specific clinical discipline (e.g. orthopaedics, obstetrics) following completion of my BCMP degree | 94/146 | 64.4 | 88/113 | 77.9 | 85/122 | 69.7 |
I would be interested in pursuing a diploma in public health or community-oriented primary care | - | N/A |
70/112 | 62.5 | 66/121 | 54.5 |
I am interested in pursuing a 6-year medical degree (MBChB/MBBS) following completion of my BCMP degree | 74/147 | 50.3 | 62/113 | 54.9 | 54/120 | 45.0 |
I am interested in pursuing a 4-year medical degree (e.g. 4-year MBBS programme at Wits) following completion of my BCMP degree | 68/146 | 46.6 | 54/112 | 48.2 | 63/121 | 52.1 |
I would consider leaving the BCMP programme prior to completion if I was accepted to study medicine (MBChB/MBBS) | 62/146 | 42.5 | 46/112 | 41.1 | 47/118 | 39.8 |
BCMP, Bachelor of Clinical Medical Practice; Wits, University of the Witwatersrand; MBChB/MBBS, Bachelor of Medicine, Bachelor of Surgery.
, This question was not part of the 2011 questionnaire. Included in 2014 for the first time.
The proportion of BCMP students intending to practice as clinical associates in a rural area in South Africa was found to be substantial in our 2011 survey at approximately 60%.
The proportion of students who intend to practice in a rural area is a result (at least in part) of the large number of BCMP students from rural areas. A number of studies amongst medical students have found a link between rural practice intention and rural background.
The increase in rural-origin students was achieved by purposeful selection. As from the 2014 first-year cohort, the calculation of the merit point score used in the selection of BCMP students at UP included additional points for rural students on the basis of their rural origin and rural schooling. Furthermore, since 2010, seats in the programme are allocated according to the provinces from which applicants originate, and provinces with large rural populations are allocated more seats. Both these measures reduce the chances of urban students displacing rural students from the selection list. Our results suggest that changes in the UP BCMP selection policy have achieved one of its desired outcomes of providing a sustainable rural health workforce.
A plausible explanation for the large number of BCMP students intending to practice in rural areas directly after qualifying is that the majority were solely funded by bursaries. Bursaries are usually linked to mandatory employment post-qualification in the funding province (where provincial governments provided the bursary). However, being funded solely by a bursary was not found to be significantly associated with rural practice intentions in our multivariable analysis. We repeated our analysis combining those with full and partial bursaries and, again, did not find a significant association. Bursaries, therefore, did not explain the high proportions of students intending to practise in rural areas. Based on our overall findings, provincial governments (and other bursary funders) wanting to address rural workforce shortages should be directing their bursaries to students from rural backgrounds.
Practice preferences (the choice they would make independent of obligations such as bursaries, family, etc.) indicated a majority preferring rural practice in all three surveys, suggesting a substantial proportion of the BCMP students had an intrinsic motivation to work in rural areas. While findings by Burch et al.
In our study, gender was not associated with intention to practice in a rural setting. Similarly, there was no association between current practice choice and gender in the study by Monareng et al.
In addition to a rural background, we found that both rural practice intention and preference were significantly associated with rural district hospital exposure during training. This is consistent with the literature, as there is some evidence that the inclusion of a rural rotation in the curriculum of medical students has a positive impact on influencing rural practice choice.
Migration is not considered to pose a significant threat to South Africa’s clinical associate workforce, as the qualification is not currently automatically accepted internationally for registration to practice. In the event it were to be internationally accepted, a clear majority of participants (above 70%) in each of the three surveys indicated a preference for remaining and working in South Africa. This finding is in contrast to a study on the migration intentions of South African medical and nursing students.
We found that the majority of UP BCMP students (more than 60%) would opt for a public sector facility as their most preferred work setting. In comparison, only 28% of South African medical students in the study conducted by Burch et al.
Across all three surveys, more than 80% of participants planned on further studies. A one year post-qualification clinical specialisation was a popular choice in all three surveys. Currently, only the University of the Witwatersrand has met this training need with a honours degree in emergency medicine for clinical associates. Specialisations in anaesthesia and obstetrics are currently being explored by various role-players. All three surveys found a high proportion of participants interested in pursuing a medical degree. While the 6-year medical degree was the more popular option in 2011 and 2014, the 4-year medical degree was the more popular option in 2017. The reason for this change is unclear but may be a function of the information they have about the entry requirements and selection process for the 4-year degree.
The limitations with respect to the first survey have been discussed by Moodley et al.
The three surveys have confirmed that a majority of BCMP students at UP intend to practise in rural areas immediately following graduation and have a longer-term rural practice preference. Both rural practice intention and rural practice preference proportions increased over the three surveys, reflecting the increasing proportion of rural students in the programme. The use of purposeful selection criteria clearly results in achieving the goal of recruiting rural-origin students, and by extension the provision of a rural workforce.
Participants had strong aspirations to study further and the interest to study medicine has not reduced over the nine cohorts of students. The interest to study medicine remains a concern, and if universities do not respond to the need for clinical specialisation options – especially those most needed by rural populations – these students are likely to explore other options. Clinical associates can provide a sustainable solution to South Africa’s rural health workforce shortages if adequate numbers of funded posts are created and if their career aspirations can be met. These students are clearly willing to meet the health needs of rural populations, but it will require political will to ensure that they will be able to do so.
The authors wish to thank Ms Thino Rajab (2014) and Ms Erika de Bruyn (2017) of the Department of Education Innovation, University of Pretoria, for their assistance with the administration of the questionnaire using UP’s computer-based training platform.
The authors have declared that no competing interest exists.
S.V.M. developed the original concept. J.E.W., J.M.L. and J.H. provided conceptual contributions. S.V.M., J.E.W. and J.M.L. developed the questionnaire. S.V.M. conducted the data analysis and wrote the methodology and results, with J.E.W., J.M.L. and J.H. being responsible for interpretation of findings.
This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
The data analysed in this study are available upon reasonable request from the corresponding author.
The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors.