There has been a global debate on the effectiveness of health care education in regards to preparing graduates for the realities of work [1]. In their landmark paper, Frenk et al (2010) [1] call for instructional changes to facilitate more efficient preparation of health professional graduates to ensure improved health outcomes and service delivery, especially within underserved areas. With this, there is a growing need to review how programs address issues of social accountability, where the responsibility of graduates is to serve as advocates for the marginalized and disenfranchised, particularly in rural areas [2,3,4]. In reviewing this, there is a need to explore the relationships and interactions between clinicians, patients and health services, as well as the university and professional expectations to strengthen various curricula [5]. Concurrent policy changes within the South African Ministry of Health call for a review of the strategies and teaching methods presently utilized to prepare health professional graduates for practice.

Within the South African context, the National Health Act (2003) [6] was pivotal in establishing a decentralized health system in the country. Within the district health system, hospital-based service delivery is offered at quaternary, tertiary and district levels. Community-based services are delivered through community health care centers and primary health care clinics. In the province of KwaZulu-Natal, the high incidence of disease (eg, HIV, tuberculosis, chronic non-communicable diseases, mental health, injury and violence, and maternal and child mortality) has inevitably placed a high burden on the public health system [7,8]. To address this burden of disease, the Negotiated Service Delivery Agreement [9] was designed to promote intersectoral performance around the delivery of identified outputs. For the health sector, this priority meant improving the health status of the entire population, with four main outputs (ie, increasing life expectancy; decreasing maternal and child mortality; combating HIV and acquired immune deficiency syndrome [AIDS], and decreasing the burden of disease like tuberculosis; and strengthening health system effectiveness). The National Health Insurance (NHI) [10] was introduced to redress the disparity between private and public access to health care. With this, the reengineering of primary health care (PHC) served as a concurrent strategy to the NHI. PHC aims to increase accessibility to health services and redress former inequalities [10]. PHC is an approach to health care that includes health promotion, disease and disability prevention, and rehabilitation [10]. This approach stresses the need to shift from a purely curative approach to health care toward encouraging health care practitioners to consider the impact of the social determinants of health. According to NHI policy [10], PHC services should focus on health promotion and prevention while still ensuring quality curative and rehabilitative services.

Despite the introduction of these policies, implementation at the grassroots level remains a problem, with limited literature around current PHC practice being available. Health professionals are challenged to provide services at both district level hospitals and the PHC level [3]. District level hospitals and PHC clinics are predominantly staffed by community service health professions. Community service is the mandatory year-long service that all South African–trained health care practitioners must undertake following their graduation. Within this community service year, health professionals are expected to work within multidisciplinary teams to deliver context-relevant services to marginalized communities in resource constrained settings in rural and peri-urban South African communities. This highlights the need for health professions educators to ensure that graduates are prepared to meet the demands of their entry into the work field, and that the teaching methods presently used are effective in developing the knowledge and skills required for professional practice.

Health education programs use service learning placements as a platform to facilitate transference of theory into practice. The practice of professional knowledge and skills during service learning placements exposes graduates to authentic working environments and equip them with technical competency, critical reasoning, ethical conduct, social attributes, and a sense of social responsibility so that they are able to serve as advocates for their clients [2,11,12,13]. Transformative learning approaches have thus been suggested as an option to promote acquisition of ethical and socially accountable practice. It is postulated that in using critical reflection of students’ experiences, the development of new concepts can be fostered. Moreover, using rational discourse where students’ assumptions are challenged and where they are expected to reason though their decisions, help to promote the development of professional reasoning and practice [14]. Within health education programs, there is growing support for decentralized service learning placements or decentralized clinical training (DCT). Current service placements are predominantly in well-resourced tertiary and district hospitals in urban areas. In contrast, rural DCT placements offer students exposure to the realities of rural practice, different levels of care (eg, PHC clinic and community health care centers) and allows for more active engagement with the community [15,16,17,18,19,20]. Van Schalkwyk et al’s study [16] revealed that medical students found that DCT placements facilitated positive experiences of working at rural district hospitals and with the local community, and allowed the students to gain confidence in their clinical skills and decision-making abilities. Despite support for DCT placements, there is limited South African literature exploring the factors that promote a successful rural placement and positively influence students learning during DCT.

The University of KwaZulu-Natal (UKZN) offers various health science programs which are housed under the College of Health Sciences (CHS). The CHS has initiated steps to ensure that UKZN produces health care professionals who are competent for practice within a PHC model. Additionally, UKZN and the KwaZulu-Natal Department of Health (DoH) have signed a memorandum of understanding (MOU), which will remain operational over the next five years [21]. UKZN’s commitment to the implementation of a decentralized training program for all cadres of health care practitioners is part of this agreement [21]. DCT in primary health care in the context of this study include service placements in DoH PHC sites.

It is envisaged that this training would enhance students’ learning through the development of positive attitudes to rural practice and community engagement. Currently, students who are engaged with family medicine and public health modules as part of their medical degree program participate in a decentralized service learning placement. However, this is executed with a small number of students and in one medical discipline. For the School of Health Sciences (SHS), there currently remains uncertainty as to how the implementation of this program will unfold, especially given the diversity of the school, which comprises of eight disciplines (occupational therapy, physiotherapy, pharmacy, optometry, dentistry, biokinetics and sports science, speech and language and audiology). Consequently, there is a need to establish strategies to ensure successful SHS DCT placements, especially exploration into the factors that need to be considered to ensure that students have a positive learning experience. The Integrated Decentralized Training (i-DecT) project has been initiated in response to this need and aims to explore the factors that will influence the roll-out of DCT placements within the SHS at UKZN in order to construct a model of practice for service learning for the school.

The overall purpose of the i-DecT project is to establish an effective, decentralized training program within the SHS at the UKZN in order to:

In order to ensure that practical solutions are sought, the research questions are exploratory in nature and are described within the specific objectives.

The overall research question (what factors will influence the roll-out of the DCT for the SHS at the UKZN?) is geared toward the development of an inclusive and context-specific model. Figure 1 highlights some of these challenges from a conceptual perspective towards addressing these via the vehicle of DCT. These will be realized by (i) exploring the pedagogical challenges; (ii) the infrastructural challenges; and (iii) the staffing challenges as well as by (iv) identifying principles and factors for inclusion in the model for DCT.

In this phase, an exploration of the pedagogical, infrastructural and staffing challenges will be explored. To ensure methodological diversity, a combination of desk and field research will be used.

In this phase, an exploration of the experiences of students and clinicians will occur within the various CTPs of the DCT program.

The data from the prepilot and pilot phases will be merged in order to establish principles that are essential for an appropriate DCT model based on an interprofessional educational rationale. The model for the DCT program will then be implemented within each of the CTPs.

Given the emergent nature of this study and the absence of a framework for research within decentralized training programs, the researchers anticipate that there may be power dynamics that will have to be negotiated. It is for this reason that the researchers have attended relevant meetings and have been transparent in the processes that are documented within this project protocol. Moreover, key role players have been approached to form part of the research team in order to contribute to the development of a framework for research in this area. Continued consultation and open communication is identified as necessary towards the ethical principle of beneficence in this study. Gatekeeper permissions have been obtained in addition to approval from a research ethics committee (HSS/0727/017). Written informed consent will be obtained from participants prior to initiating the study. Principles of autonomy and anonymity and the right to withdraw will be observed.