AHEC in the United States

The US Area Health Education Centers Program was first funded by Congress in 1971 to help address the shortage of physicians in rural areas. A Carnegie Commission report recommended the creation of AHECs at regional hospitals to offer some of the functions of academic medical centres, such as teaching and continuing education, suggesting that this would encourage physicians to remain in small towns nearby. As funded by the federal government, AHEC evolved into a pipeline program designed to attract rural and minority schoolchildren into the health professions, provide a portion of their professional training in underserved communities (communities with inadequate health services), and support them after graduation through continuing education and other activities once they had established practices in communities similar to those from which they had come.

In the current model, federal funds flow through medical schools to affiliated AHEC centres, which are organizations either housed in regional hospitals (as in the original Carnegie proposal) or independently incorporated as not-for-profit corporations. The AHEC centres have advisory boards (those that are hospital based) or boards of directors (those that are independent corporations) on which are represented nearby hospitals, medical practices, public health departments, community health centres, and other health care organizations, as well as consumers. The centres conduct presentations on health careers to schoolchildren, arrange preceptorships for medical and other health professions students, and sponsor continuing education programs. Support and general oversight of the centres is provided by the program office at the medical school. An AHEC Program may have as few as one or as many as nine affiliated centres. Interprofessional training is encouraged and may be achieved through partnerships between the medical school and the other professional schools in the academic health centre (Figure 1).

Currently, federal funding is intended to be focused on start-up activities and initial support. After a specified number of years, each program is expected to obtain the majority of its funding elsewhere. Typically, this is from state government, although support may be obtained from private sources. If the program is successful in obtaining non-federal funding, it remains eligible for limited federal dollars.

AHEC in South Africa

In 2010, the Stellenbosch University Faculty of Medicine and Health Science (FMHS) received a grant from the United States Health Resources and Services Administration (HRSA) to support its participation in the Medical Education Partnership Initiative (MEPI). MEPI was a component of the President’s Emergency Program for AIDS Relief (PEPFAR) that supported medical schools in 13 sub-Saharan African countries, with academic partners in the United States to “advance PEPFAR’s goal of increasing the number of new health care workers by 140,000; strengthen in-country medical education systems; and build clinical and research capacity in Africa as part of a retention strategy for faculty of medical schools and clinical professors” [8]. In 2011, the MEPI grant at Stellenbosch was augmented with another HRSA grant to establish an AHEC Program. Morehouse School of Medicine was designated as a partner on the grant with chief responsibility for evaluation; Morehouse had had an AHEC Program since 1984.

The main Stellenbosch University campus is located in the town of Stellenbosch, 35 kilometres from Cape Town, while FMHS is housed in Cape Town in the 1,384-bed Tygerberg Hospital and adjacent buildings. The faculty offers degree-granting programs in medicine, nutrition, nursing, occupational therapy, physiotherapy, and speech-language and hearing therapy. Entry to these programs, including medicine, normally follows graduation from secondary school (i.e., completion of grade 12).

In recent years, Stellenbosch has become a bilingual institution with some lectures given in Afrikaans and others in English, and in the post-apartheid era, it has become racially integrated. FMHS has taken steps to become more “socially accountable” [9]. One element of this effort has been the development of the Ukwanda Rural Clinical School (RCS), which includes a mini-campus located in the town of Worcester, 113 kilometres from Cape Town. It is near Avian Park, a large, low-income community where some vineyard workers live, in addition to many families with no source of employment. The mini-campus has an educational building and comfortable housing for 40 students. Clinical teaching sites are accessed through partnerships with the nearby regional hospital, a tuberculosis hospital, 7 more distant regional hospitals, and 70 clinics, both fixed and mobile. The RCS provides interdisciplinary educational opportunities for students in all of the fields that are part of FMHS; all final-year medical students rotate briefly through the school, and year-long rotations are offered on an elective basis.

An additional element of the socially accountable strategy at Stellenbosch is the development of a pipeline to encourage and facilitate the enrolment of underrepresented population groups in its educational programs. The MEPI grant provided financial support for the pipeline but did not provide financial support for the first component, the portion that encourages and helps prepare schoolchildren from underserved communities and population groups to compete for places in professional school. The AHEC grant enabled the development and implementation of this component.

The AHEC Program was centred at the RCS, but unlike the US AHEC model, the RCS was not independent of the university. The program’s advisory board included representatives of the government’s Departments of Health and of Education, the Stellenbosch University Faculty of Medicine and Health Sciences, its Center for Educational Pedagogy (SUNCEP), and a representative of the Morehouse School of Medicine (Figure 2).

The AHEC intervention served schools in three rural districts of the Western Cape Province: Caledon, Malmesbury, and Worcester. It represented a collaboration between FMHS and the Stellenbosch University Center for Educational Pedagogy (SUNCEP). Over four years, 400 (mostly coloured, with few blacks or Indians) with above-average grades and 150 teachers enrolled in an intervention that offered the following:

• Grades (school years) 7–9: Bi-weekly after-school sessions in which teachers served as tutors to provide additional instruction in science and mathematics. Thirty students per district participated each year.
• Grades (school years) 10–12: Thirty students per district attended “holiday school” – additional instruction in science and mathematics in one-week sessions offered three times per year during vacation periods.
• Life skills: All participating students received career counselling, visits to Stellenbosch University, instruction on study skills, information about scholarships and the university application process, and other supports to help them prepare for university entry.
• Teacher continuing professional education: Training sessions in mathematics and science were provided by SUNCEP faculty to teachers participating in the intervention. This was followed by classroom observation and feedback.

Comparison of the Two Models

Table 4 compares and contrasts, the two models. As noted above, the US model calls for an independent AHEC centre with its own governance structure that is remote from the medical school, whereas in the South African model, the remote site is a mini-campus of the medical school. Most US AHEC programmes attempt to “recruit” black and Hispanic children from rural or inner-city communities into health professions through presentations at their schools and summer and weekend activities. These initiatives do not usually affect the schools’ teaching programmes. In South Africa, by contrast, the focus is on the education of the students; this is impacted through teacher training and supplemental educational opportunities for the students.

Both the United States and South African AHEC programmes have advisory boards or similar structures, but the US committees are more diverse and include institutions and agencies outside of the medical school, as well as consumers. Both models call for an interdisciplinary approach, and the stakeholders are essentially the same.

Reflections on Changes since AHEC Inception

SUNCEP Stakeholders. The SUNCEP stakeholders reported that the type of communication for teacher/learner selection changed since AHEC integration. Communication that previously had been initiated by SUNCEP or school administrators now involved increased district participation in teacher and learner recruitment and selection. The first year’s efforts included review of national performance levels and assessment of rural versus non-rural schools and communities. Because of district “buy in”, the program model is now well recognized and growing.

Education Stakeholders. Tutors of seventh and eighth grade AHEC learners stated that they are able to teach and manage their classrooms differently when teaching AHEC students as compared to their regular students. A smaller class size and more advanced students were mentioned as reasons for this difference. Tutors who are part of the 10th to 12th grade program stated that they have little to no contact with parents of students in the program. Alternatively, tutors for grades 7–8 had more contact with parents.

AHEC Greatest Progress to Date

SUNCEP Stakeholders. Staff reported progress in stakeholder buy-in by students, parents, and tutors related to program implementation. Staff described the progress as “new beginnings” and cited activities that supported this progress. Selected responses related to these results are included below:

“People quickly saw the benefit of the program which helps with buy-in.”

“[We are] getting almost 100% attendance at parent meetings.”

“Teachers are coming to professional learning sessions over weekends.”

Education Stakeholders. For tutors who had been a part of the program for more than one year, seeing their students progressing and being successful were regularly cited. Some of the tutors who were new to the program stated that having fewer “bad” behaviour issues and having students willing and ready to learn was a good accomplishment. Hearing positive feedback from those in the community was also mentioned as one of the greatest progress areas to date. Selected responses related to these results are included below:

“They [students] e-mail me and said no, the final exam was good. And I’m really proud of myself about that. I must be proud of myself because I did something right.”

“[I] see learners achieve and doing great. And kind of let me say people are talking about it – yeah … weekends I normally go fishing, and I meet people. And so we started talking and they would say – talk about the program, and I say, okay, yes, I know the program.”

Parent/Caregivers Stakeholders. Parents’ reported satisfaction with the AHEC program was high. Parents expressed that the most important parts of the AHEC program were the motivation that the program gave their child to succeed and the opportunity the program provided for their children. By participating in the AHEC program, they noted, their children were not limited to their parents’ financial resources or the community in which they lived. Parents observed that their children were more focused on their school work and that their grades improved as a result of participating in this program. Selected responses related to this result are included below.

“For my son, it was a huge motivation ’cause his marks increased last year in math from about 14 to 17. He’s more committed to it. He loves to study.”

“And at the end of the day, it’s an opportunity for our children, my daughter in particular, to achieve that goal that she had since age six. Like she says, she’s always told us at a young age she wants to become a doctor. And now she’s been given the platform to start reaching out to [achieve that goal].”

“It’s given her lots of self-confidence, and it’s given her motivation.”

AHEC Challenges

SUNCEP Stakeholders. Program timing and logistics were frequently cited challenges. The program initially started late in the school year, which meant administrative and teaching staff were charged with developing their roles and responsibilities within a truncated time period. Logistically, participants in and from rural areas had to travel great distances in order to participate. This created a hardship for a number of learners, their parents, and their tutors. Representative responses are included below:

“Increasing the contact time at holiday schools. At the holiday schools, we see students for five consecutive days, and then won’t see them again for another two months [until the next holiday]. This is too long a time for students to go with no contact.”

“Locations are more dispersed [rural areas – up to 400 kilometres/250 miles between schools], so getting the parents together is much more difficult than in grade seven intervention, where all of the schools are located in similar areas.”

Education Stakeholders. Tutors and curriculum advisors discussed challenges related to their new roles with AHEC. Tutors indicated that lack of familiarity with the students in the program includes current school performance in addition to the general rapport they have through more extended daily interaction as noteworthy. The biggest challenge cited by curriculum advisors was the travel cost for students who lived far from the site of the holiday school. Additionally, advisors noted that communication from students’ regular schools was poor, making it difficult to arrange food and lodging. Selected responses related to these results are included below:

“I need the schools to really realize that say [they should tell me] the fact around the numbers – the total of learners and that they should step up their feedback to me. That is one of the greatest challenges, I think.”

“I don’t know what their marks [are at] school. I thought that that might be something that we could work from, but [it is not] … But it would be good to see them.”

Parents/Caregiver Stakeholders. When parents were asked to discuss things that make participating in the AHEC program difficult, conflicts with other activities were cited. Parents generally placed a high priority on the AHEC program and were forced to find alternatives to the activities with which it conflicted. Selected responses related to this result are included below.

“So, there are clashes with other activities at the school, but we as parents wanted to – this is more important to take part in this program than anything else that’s happening on Tuesdays or Thursdays at the school. Like, for instance, she had a leadership meeting, which she had to miss because of this program, which did agitate her somewhat. But we’ve dealt with that and said that this program is more important. That meeting will have to take place some other time, or we’ll have to catch up some other way.”

Political, Educational, Historical, Economic, and Cultural Realities Critical to Working with Constituents

SUNCEP and education stakeholders also discussed the relevance of South African history, politics, education, economics, and cultural realities and challenges. The historical implications of class, race, and economic realities of the present were positioned as related to challenges in the educational system and the need for AHEC. Most learners were from low-income or working-class families, with parents who sacrificed their wants for their children’s best interests. Other issues that were positioned as both community and school problems were gangs, violence, and drugs. Most directly related to AHEC were questions related to how certain groups were apparently selected to participate in the programs and others were not. Selected responses from SUNCEP and education stakeholders related to these results are included below:

“Crisis in education in South Africa.” (SUNCEP Stakeholder)

“Big divide between the well-performing schools and the schools that are not doing that well.” (SUNCEP Stakeholder)

“Teacher professional training [is important] because a lot of teachers that are coming from those schools are sometime de-motivated.” (SUNCEP Stakeholder)

“I think through all the processes that SUNCEP is involved, part of what we’re doing is to make access to the University of Stellenbosch possible for people who were excluded in the past.” (Educational Stakeholder)

“Communities are not affluent – low SES.” (Educational Stakeholder).

“For instance, if you look at the communities nowadays, we have problems with violence, gangsterism, and especially what is really killing society, especially in Cape Town and in [Malmesbury], is what they call meth. It’s really killing people, and what children are doing to get money for the drug – wow. So, on the one end, it’s great opportunities for learners to be part of this program and keep them away from, say, the violence and stuff, and keep them out to realize there is a better life after all. Because if you take a look at our school now, it’s a lot of learners – it’s as if they have lost hope, so they just go [drop out of school].” (Educational Stakeholder)

Student Interviews

Most student results were associated with their general impressions of the program. Learners discussed and detailed perceived benefits of the program, which included improved marks, the ability to achieve goals, investment in their future success, and the opportunity to receive a bursary for university. Perceived benefits included the tutors’ styles of teaching, different methods that are taught for solving problems, the ability to build relationships with learners and tutors, the challenge the program provides, and the sheer amount of learning that takes place during the program. Recommendations towards proposed improvements in the program included wanting see more children having the opportunity to experience the program, based on their own satisfaction as participants. They also described the transport they currently have (or lacked) as being a challenge. Learners also cited the need to add more experiments and use of technology or visuals to prepare them for university.

Outcomes

Of 165 AHEC Programme alumni, 83 (50.3%) were known to be enrolled in institutions of higher education in 2017 (78 at Stellenbosch; the others at the University of Western Cape, University of Cape Town, or Cape Peninsula University of Technology). Of the 85, 11 were pursuing an MB, ChB degree, and 8 were in other health profession bachelor degree programmes. Other BSc degrees were sought by 17 students, and engineering degrees were pursued by 16 students. The other 32 were enrolled in a wide variety of programmes.

Eleven alumni were classified as prospective students at Stellenbosch. The remaining 71 were lost to follow-up; they were not enrolled at Stellenbosch but might be enrolled in another institution of higher education.

Limitations

Although the views of AHEC program participants are documented here, limitations of this study are acknowledged. Due to constraints of convenience, proximity, and time, not all AHEC sites were engaged for participation in key informant interviews and focus groups, limiting the degree to which results are representative of those AHEC sites not visited by the evaluators and do not necessarily reflect the views of all stakeholders. Additionally, in the parent groups there was a language barrier, which required the use of an interpreter. The interpreter sometimes added clarifications or additional comments, but this was not consistent across groups.