COMMENTARIES

 

The history of black African medical education in South Africa: A reflection on the contribution by Walter Sisulu University, 1985 - 2025

 

 

T V Makola^I; N V Khosa^II

^IMB ChB, MMed (Public Health Med); School of Public Health, Faculty of Medicine and Health Sciences, Walter Sisulu University, Mthatha, South Africa
^IIMPH, PhD; School of Public Health, Faculty of Medicine and Health Sciences, Walter Sisulu University, Mthatha, South Africa

Correspondence

 

 

As Walter Sisulu University (WSU)'s Faculty of Medicine and Health Sciences commemorates the 40th anniversary of its establishment in 1985, it is both an appropriate and opportune moment to reflect on the role of this university in the medical education of black Africans in South Africa (SA). The training of black Africans in medicine is an important societal issue given the history of limited access for and discrimination against black South Africans in the apartheid era, which resulted in systemic structural shortages of black African medical professionals in this country.

Medical education is a vital foundational ingredient upon which health systems are designed, constructed and operationalised.^[1] Medical education consists of both undergraduate medical training, which is the Bachelor of Medicine and Bachelor of Surgery (MB ChB/MB BCh), and postgraduate medical training (specialisation) in the various medical specialties. The current medical education system that has been in operation globally since the early 20th century has benefited society by producing medical professionals with appropriate clinical skills and knowledge.^[2] Training of medical professionals constitutes an essential tool for the appropriate supply and distribution of human resources for health, for the effective functioning of the health system.^[1]

The main objective of medical education is to produce doctors who are clinically trained to have the knowledge and skills to address the health challenges of their society, with a sound scientific basis. Doctors also play additional roles such as in advocacy, research and education as part of their contribution to the preservation and restoration of the health of individuals and populations. Another key consideration is the fact that medical faculties, globally, have developed medical education as a form of social contract, a trust between themselves and the societies they serve.^[1]

The current health system challenges in SA have their roots in the history of colonialism, the apartheid era, and governance failures of the democratic era. Some of these challenges are maldistribution of health resources (finance, human resources and infrastructure), pervasive gaps in quality of healthcare, patient safety challenges, medical negligence, failures in leadership and management, and persistent weaknesses in the delivery of social services such as housing, sanitation and water.^[3]

During both the colonial and apartheid eras, there was systematic, racial and legislative discrimination against indigenous South Africans, including limited medical education opportunities. Access to medical education has, historically, been an important feature through deliberate policies of exclusion from education and economic opportunities starting from the establishment of the Union of South Africa in 1910 through to the apartheid era between 1948 and 1994. The limited access to medical training opportunities for blacks had serious consequences for the availability of medical services for the black majority in SA, especially those in rural and underserved communities, leading to health inequity and poor health outcomes.^[3,4] The inequity in access to healthcare affecting health systems globally, especially in low- and middle-income countries, is partially due to the shortage and maldistribution of skilled health workers in general, but more acutely of medical doctors at generalist and specialist levels, especially in rural communities.^[5]

It was not until 1941 and 1943 that a very small number of blacks were allowed to enter historically white medical schools at the University of the Witwatersrand (Wits) and the University of Cape Town (UCT), respectively.^[6,7] Before then, black students could only study medicine abroad, mainly in the UK and the USA, and in India for South Africans of Indian descent. However, only a very small number of black Africans were able to take advantage of these opportunities during the first half of the 20th century because of costs and lack of access to funding.^[8] Even this limited opportunity for black Africans to study medicine was affected by the prevailing international geopolitical issues of the time, with World War II in the 1940s particularly notable in this regard, and very few black students being able to study medicine abroad during or in the aftermath of the war.

As a result of vigorous lobbying efforts by Dr John McCord and Dr Alan Taylor, the University of Natal was the first university to have a dedicated medical faculty, established in 1951, for the training of black medical students alongside the existing white faculty. Many black South Africans had to wait another 26 years before another faculty of medicine that would be dedicated to admitting them was opened at the then Medical University of South Africa in 1977. It is worth noting that the historically white universities, UCT and Wits, were still admitting some black students into their medical programmes, albeit a very small number with very onerous requirements, including ministerial approval.

The role of medical doctors in improving the health of populations has been argued in a seminal report by Julio Frenk et al.^[5] published in The Lancet in December 2010. In this report, they argue that the doubling of the average life expectancy in the 20th century can be partially attributed to the evolution of and effectiveness in the design and delivery of medical education following the Flexner Report of 1910.^[5] That seminal 2010 report, however, also identified that health professions education had not evolved and adapted to the changing global health needs resulting from epidemiological and demographic transitions, together with technological advances and changing health systems.^[5] The report also lamented that medical curricula had remained static and therefore produced graduates who were not suitable for a changing world that required different qualities.^[5]

There was recognition and acknowledgement by black health professionals in the 1980s that a sustainable solution to improving access to healthcare services for the majority black population in SA, including the rural areas, was to increase access to healthcare professional training, including medical training for blacks in general and black Africans in particular, so that they could serve and contribute to the development of their own communities. However, this would not be allowed to happen, as it was fundamentally in conflict with the white supremacist ideologies of the colonial and subsequent apartheid regimes in SA.

As part of the enduring commitment to political and societal struggles to improve the material conditions of black South Africans, the fight to improve access to medical education and for better healthcare services for blacks and rural communities continued. What is now the Faculty of Medicine and Health Sciences at Walter Sisulu University was founded in 1985 as part of the then University of Transkei (Unitra) with the deliberate and explicit intentions of addressing the challenge of the shortage of black African doctors in the then homeland area of Transkei and improving access to medical training for high school graduates in the area. Unitra became Walter Sisulu University in 2005 due to reforms in the higher education landscape that resulted in the merger between Unitra, Border Technikon and the Eastern Cape Technikon.^[9]

The inaugural Dean of the Faculty of Health Sciences, Prof. Marina Xaba-Mokoena, one of the people who pioneered the establishment of the faculty, had observed in her inaugural professorial address in 1986 that the medical schools existing at the time had not been successful in graduating black doctors in sufficient numbers to address the health needs of the black African population in general, and those of the rural underserved communities in particular.^[10] These reflections by Prof. Xaba-Mokoena underscored the centrality of the intentions of the faculty from its inception - that of recruiting medical students from the black African communities of the then Transkei and thereby improving the chance of retaining some of these graduates in these underserved communities.^[10]

In the 40 years of its existence, WSU's medical school has played and continues to play its role in training and producing high-quality health professionals who are making significant contributions to the health system in SA. The WSU Faculty of Medicine and Health Sciences has successfully stuck to the original mandate and purpose of producing medical professionals to provide good-quality healthcare services. In addition to requisite and appropriate clinical knowledge and skills, the graduates would also have an appreciation of and social connectedness with rural, underprivileged and underserved communities, particularly those of Eastern Cape and KwaZulu-Natal provinces.^[11,12]

WSU's approach to the recruitment and selection of students into the MB ChB programme has, since its inception, been about widening and improving access to medical education for students from predominantly rural and underserved communities of the then Transkei and now the wider Eastern Cape province and the neighbouring province of KwaZulu-Natal.^[11,12] In addition, the faculty has always been intentional in providing academic support for the students, implementing problem-based learning pedagogy for the medical curriculum, and a community-based approach to medical training with decentralisation of the clinical training platform to include regional hospitals, district hospitals and primary healthcare facilities in underserved and rural areas.

The WSU Faculty of Medicine and Health Sciences has played an important role in the recruitment of health sciences students from rural and underserved areas and has trained them in the environment that they are familiar with, thus cultivating social consciousness for these communities. This process has resulted in a high proportion of the graduates choosing to remain and practise in these areas.^[12]

SA has 10 faculties of health sciences in six provinces that offer an MB ChB or MB BCh degree. The oldest medical school is at the University of Cape Town, founded in 1900, with Nelson Mandela Metropolitan University being the most recently opened in 2021.

 

WSU Faculty of Medicine and Health Sciences - in numbers

WSU admitted its first cohort of 12 medical students in 1985. During its first 5 years from 1985 to 1989, the faculty enrolled a total of 140 medical students. All 12 students from the first class had completed some type of pre-medical training in basic sciences, and nine of them went on to successfully graduate between 1990 and 1994, while the other three dropped out. Of the nine graduates in the first intake, seven were black Africans and two were of Indian descent.

Since its inception in 1985, the WSU Faculty of Medicine and Health Sciences has enrolled over 16 000 students cumulatively between the first and final years of the MB ChB programme, according to the Higher Education Management Information System (HEMIS) database. It is important to understand this enrolment number in its proper context, as any student enrolled for the MB ChB programme will be counted for each year that they are registered for the programme. Just over 14 500 of the over 16 000 cumulative enrolments were black African students, predominantly from the greater Eastern Cape region.

In terms of students who were able to successfully complete the MB ChB programme and graduate, the number stood at just over 2 180 at the end of the 2024 academic year. Of these graduates, just over 1 900 were black Africans.

Table 1 shows a breakdown of the WSU medical graduates by ethnic group and gender, aggregated per 10-year periods from the first graduating class of 1990 to the last graduating class of 2024. During the first 10-year period between 1990 and 1999, WSU successfully graduated just over 190 doctors, of whom over 90% were black Africans.

A cumulative total of just over 2 180 have graduated from the MB ChB programme at WSU between 1990 and 2024. Black Africans constituted just over 87% of total graduates between 1990 and 2024, followed by South Africans of Indian descent at about 10%.

It is also worth noting that a significant proportion of WSU graduates went on to practise in Eastern Cape and KwaZulu-Natal provinces following completion of the programme. Some of those who pursued postgraduate medical specialisation training have returned to serve the Eastern Cape. In addition, WSU is now an accredited platform for medical specialty training and has successfully graduated medical specialists across various specialties.

 

Conclusion

WSU has played and continues to play a vital role in producing doctors with the clinical skills, medical knowledge and social consciousness required to provide healthcare services to rural and underserved communities and thereby contribute to addressing persistent structural health inequities in SA. The University's Faculty of Medicine and Health Sciences has succeeded in producing a significant number of black and African medical graduates who have contributed to improving access to healthcare services in the Eastern Cape and surrounding areas.

Medical faculties must be able to demonstrate social consciousness, connectedness and accountability as part of their societal responsibility. As the WSU medical faculty celebrates its 40th anniversary in 2025, equitable access to medical education remains an essential societal tool to produce medical doctors in sufficient numbers and of good quality, in terms of knowledge, skills and social consciousness, to address shortages in medical human resources and ultimately contribute to the overall performance of the health system.

 

References

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Correspondence:
T V Makola
tmakola@wsu.ac.za

Received 29 May 2025
Accepted 11 August 2025