A metaphysical framework for transforming South Africa’s undergraduate medical curricula is proposed within a transformative research paradigm

A metaphysical framework for transforming South Africa’s undergraduate medical curricula is proposed within a transformative research paradigm | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article A metaphysical framework for transforming South Africa’s undergraduate medical curricula is proposed within a transformative research paradigm Nathaniel Mofolo, Priscilla Mpho Jama, Gina Wisker This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6494452/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 20 Sep, 2025 Read the published version in Advances in Health Sciences Education → Version 1 posted 10 You are reading this latest preprint version Abstract South African medical education is challenged by the dual challenges of meeting accreditation standards while addressing pressing community health needs amid healthcare reform demands. The AfriMEDS framework, adapted from CanMEDS, incorporates community-based education (CBE) and community-oriented primary care (COPC) to bridge these gaps. Using a transformative mixed-methods approach as a metaphysical framework—including curriculum mapping, document analysis, educator semi-structured interviews, and intern surveys—this study evaluates AfriMEDS implementation at the University of the Free State (UFS). Findings reveal systemic challenges: misaligned assessments, faculty development gaps, and competence deficiencies. Integrating competencies shows uneven emphasis, with significant disparities in health advocacy, leadership, and CBE roles. Educator interviews highlight structural barriers such as resource constraints and compressed timelines in UFS’s five-year program, while intern surveys reflect gaps in preparedness for non-clinical competencies. The transformative metaphysical framework paradigm proves effective in exposing structural inequities and fostering stakeholder co-creation, positioning CBE as essential for sustainable reform. The study concludes with recommendations for systemic reforms, including decolonial pedagogies that integrate indigenous languages and knowledge, faculty capacity building in competency-based assessment, and structural alignment with national healthcare priorities. These insights emphasise the need to transcend technical curriculum adjustments, centring transformative paradigms that address power dynamics and cultural complexities in medical training. metaphysical framework transformative paradigm curriculum reform medical education CBE COPC Figures Figure 1 Introduction South African undergraduate medical education faces a critical juncture, grappling with the dual imperatives of meeting regulatory accreditation standards while addressing pressing community health needs, especially in rural areas (Slaven, 2017). This tension causes a fundamental reimagining of curriculum frameworks to reconcile these demands. The CanMEDS physician framework was adapted in 2014 by the Health Professions Council of South Africa (HPCSA) and the South African Committee of Medical Deans (SACoMD) to create AfriMEDS. This is an integrated community-based education (CBE) with a community-oriented approach to healthcare training (De Villiers et al., 2017). However, implementing this framework has revealed systemic challenges in aligning the curriculum with South Africa's complex healthcare landscape. The CanMEDS framework, established by the Royal College of Physicians and Surgeons of Canada in 1996 and endorsed internationally by the International Community-Based Medical Education (ICBME) collaborators in 2009, provides a comprehensive competency-based medical education model (Frank et al., 2010b). This framework identifies seven essential physician roles: 1) medical expert (the integrating role), 2) communicator, 3) collaborator, 4) leader (formerly manager), 5) health advocate, 6) scholar, and 7) professional. The transition from "manager" to "leader" role in 2012 reflected the evolving healthcare environment's need for reform-oriented practitioners (Dath et al., 2015). AfriMEDS responds to South Africa's persistent healthcare inequalities shaped by historical structures of apartheid. Despite democratic reforms, both public and private sectors continue addressing complex challenges related to socioeconomic backgrounds, language barriers, and literacy levels, necessitating curriculum reform that addresses population needs and health inequalities (World Health Organization, 2013). CBE in this context refers to "decentralised training" occurring outside tertiary academic complexes, including healthcare centres, primary care clinics, and district hospitals (De Villiers et al., 2017). This approach is described as "encouraging and engaging people throughout life into learning that is based on what they are interested in and that emerges in relation to problems and issues experienced daily" (Department of Higher Education and Training, 2012, p.54). Community oriented primary care (COPC) addresses disease burden through health promotion, prevention, early detection, and community-based management (Bam et al., 2013). This approach recognises that health outcomes are determined by social environments, requiring interventions that address both individual needs and community contexts. AfriMEDS provides South African medical schools the framework to develop curricula addressing prevalent social challenges including poverty, inequality, and unemployment (Statistics South Africa, 2013), though comprehensive implementation and assessment strategies remain under development (Reid & Cakwe, 2011). The researcher developed the AfriMEDS framework diagram as illustrated in Figure 1, which expands on the CanMEDS framework: community-oriented care and CBE complement the seven roles of CanMEDS. Not only is community emphasised in Figure 1, but it is also important to show how CBE is integrated with COPC and seven key competencies in the proposed AfriMEDS framework diagram (Fig. 1). The UFS medical school in Bloemfontein, South Africa, provides the primary setting. This study examines South African medical education and its ongoing efforts to address healthcare disparities and community health needs, especially in rural areas. The time is contemporary, reflecting the current challenges and evolving landscape of medical training in South Africa as it transitions towards national health insurance (NHI) and confronts a quadruple burden of disease. The need for curriculum transformation in South African medical education is urgent and multifaceted. Medical schools must produce practitioners equipped to address the country's quadruple burden of disease while navigating resource constraints and persistent health workforce shortages (Mayosi et al., 2009). According to Mayosi et al. in their 2009 study, the quadruple burden of disease in South Africa refers to four major health challenges facing the country: 1) non-communicable diseases, 2) perinatal- and 3) maternal disorders, 4) injury-related disorders. Recent studies have revealed significant impacts on mental health in South Africa following the COVID-19 pandemic and related lockdowns (Hlongwane & Lowton, 2024), which makes the burden of disease to be quintuple. As South Africa transitions toward NHI, the imperative for multidisciplinary, and primary care has never been greater (Republic of South Africa, Department of Health, 2017). Interprofessional education (IPE) and multidisciplinary care are closely linked in the collaborator competency of AfriMEDS. Yet, current pedagogical approaches often struggle to bridge the gap between theoretical competencies and the realities of practice in diverse, underserved communities. This study aimed to establish a transformative mixed-methods as a metaphysical framework necessary for medical curriculum redesign in South Africa, integrating philosophical paradigms, methodological structures, and analytical processes. Centred to stakeholder co-creation, the framework addresses South Africa's healthcare equity imperatives while critically evaluating the implementation of the AfriMEDS competency framework within the undergraduate medical curriculum. The transformative metaphysical framework research paradigm underpinning this study is crucial in addressing the power dynamics and cultural complexities inherent in medical education reform. The traditional hierarchical structure of medical education inherently creates power imbalances that can impede transformative curriculum reform. Senior faculty and administrators often hold disproportionate decision-making power, control budgets and resource allocation, which might marginalise the perspectives of junior educators and students. Educators’ control over curriculum and assessment can strengthen existing power structures, potentially overlooking community skills highlighted in AfriMEDS. The relationship between provincial and local government health authorities and academic institutions creates a complex power dynamic. These authorities control resources for the clinical training platform, which can lead to tensions between prioritising patient care, service delivery, and medical education. This power imbalance often results in competing demands that must be carefully balanced to meet both healthcare and training needs. The practical implementation of competency frameworks is shaped by assessment designers, who may mis-align evaluation methods with AfriMEDS principles. The relative powerlessness of students in curriculum design processes can hinder the implementation of learner-centred approaches central to AfriMEDS. Acknowledging: The power imbalance is already recognised in the reflexivity section, which acknowledges the principal investigator’s senior managerial position and its potential influence. This study implemented several strategies to mitigate this power differential. South Africa's rich sociocultural diversity, with 12 official languages, presents significant healthcare challenges. These challenges include communication barriers, integrating traditional and Western healing systems, and persistent socio-economic inequalities stemming from apartheid in South Africa (Hussey, 2012/13). Rural-urban healthcare disparities, coupled with diverse cultural beliefs influencing health behaviours, further complicate the situation. To prepare physicians for effective cross-cultural communication and developing cultural competence, it is crucial to address these complexities within medical curricula (Knight et al., 2017). This approach enhances students' ability to provide culturally competent care and navigate the unique healthcare challenges in South Africa's diverse communities. By using the metaphysical framework, the study deliberately challenges traditional research boundaries by examining structural inequities while re-imagining medical education that authentically serves the public good. By positioning stakeholders as knowledge co-creators, levelling the power imbalances, the transformative paradigm offers methodological insights for researchers investigating complex societal dimensions of health professions education, particularly in contexts where educational reform intersects with social transformation agendas. Through the lens of the metaphysical framework, the study critically evaluates the implementation of the AfriMEDS competency framework, offering recommendations for transforming pedagogy and curriculum delivery for enhanced community-level healthcare outcomes. By employing mixed methods within this paradigm, the research captures diverse perspectives on curriculum alignment, pedagogical challenges, and graduate preparedness, providing a comprehensive evaluation of competency-based education in resource-constrained settings. Methods Transformative Research Paradigm as a metaphysical framework for curriculum reform Critically examining and aligning the South African undergraduate medical programme’s outcomes with both regulatory expectations and societal demands is imperative to ensure the programme meets HPCSA accreditation standards and addresses pressing community health needs. This study employed a transformative metaphysical framework using mixed-methods to evaluate implementing the AfriMEDS competency framework within the UFS’s MBChB curriculum. The transformative research paradigm integrates quantitative and qualitative approaches to address complex societal issues in medical education. It employs triangulation, combining methods like interviews, observations, document reviews, and surveys to collect diverse data types and capture multiple perspectives from participants (Mertens, 2005). This approach allows researchers to examine complex phenomena in medical education comprehensively. Research paradigms serve as essential philosophical frameworks that guide scholarly inquiry in health professions education. These paradigms represent the implicit worldviews researchers bring to their investigations, influencing methodological choices, analytical approaches, and interpretations of findings (Guba & Lincoln, 2005). By integrating various methods, researchers gain a comprehensive understanding of complex social phenomena and validate findings across different data sources. The transformative paradigm was chosen for its emphasis on examining power dynamics, cultural complexities, and structural inequities while positioning stakeholders as knowledge co-creators (Turner et al., 2013). This approach aims to reimagine research that authentically serves the public good while illuminating community health challenges. Research paradigms in health professions’ education are underpinned by four core philosophical assumptions that collectively define a study’s conceptual framework. These assumptions, articulated by Guba and Lincoln (2005), guide researchers in structuring inquiries, interpreting findings, and addressing ethical complexities inherent in medical education contexts. The transformative research paradigm provided a critical metaphysical framework for this study on medical curriculum redesign in South Africa. This paradigm guided our approach to addressing systemic inequities and power dynamics in medical education while amplifying the voices of the stakeholders. Here, we elaborate on the key assumptions of the transformative paradigm and how they shaped our research design and analysis. (a) Ontological Assumptions: The Nature of Reality Ontological assumptions interrogate the nature of reality, asking: What makes up evidence of reality in health science education? This assumption focuses on determining what is “real” and the evidence required to validate phenomena, such as clinical competencies or learning outcomes (Guba & Lincoln, 2005). In medical education, ontological perspectives often reflect a tension between positivist views (universal truths, e.g., anatomical facts) and constructivist interpretations (context-dependent realities, e.g., learned experiences). For instance, while biomedical knowledge may be treated as real, patient care competencies often cause a relativist ontology, where reality is shaped by individual and cultural contexts (Guba & Lincoln, 2005). In the current study, this meant: Stakeholders, including educators, students, and those conducting document analysis, hold diverse perspectives on medical education. This research examines the influence of social, political, and economic factors on curriculum design and implementation. A critical analysis of power dynamics within healthcare and education systems reveals their impact on learning experiences and outcomes. These assumptions were incorporated by conducting stakeholder interviews and surveys to capture varied realities, and by contextualising curriculum analysis within broader societal structures. (b) Epistemological Assumptions: Researcher-Participant Dynamics Epistemological assumptions address the relationship between the researcher (“knower”) and participants (“would-be known”). Key questions include: Should investigators maintain neutrality or engage with participants to interpret experiences? While traditionally aligned with positivist distancing, objectivity in medical education research is approached through constructivist methods, emphasising the co-creation of knowledge via immersive engagement (Creswell, 2014). For example, studying empathy in clinical training may require participatory observation to capture subjective learner-patient interactions, challenging the notion of detached neutrality (Creswell, 2014). This guided the approach through: Stakeholders should be positioned as co-creators of curriculum knowledge, rather than as subjects. Valuing experiential and sociocultural issues alongside academic expertise. Critically examining whose knowledge is privileged in current curriculum frameworks. Inputs were drawn from the curriculum mapping workshops and incorporating accreditation recommendations into assessment design. (c ) Methodological Assumptions: Systematic Inquiry Approaches Methodological assumptions determine the alignment of research design—quantitative, qualitative, or mixed methods—with ontological and epistemological foundations. Researchers should select robust approaches, including longitudinal surveys to assess skill retention and phenomenological interviews to explore resilience in trainees, to capture human experience. Methodological rigour in health professions education demands an explicit justification of paradigm choices to ensure findings reflect the complexity of educational realities (Creswell, 2014). In our study, this meant: The study employed both quantitative surveys and qualitative semi-structured interviews. Curriculum changes are implemented by translating research findings through action-oriented components. This study’s mixed-methods design allowed for triangulation of data while focusing on stakeholders in developing recommendations. (d) Axiological Assumptions: Ethical Frameworks Axiological assumptions address the ethical principles that guide research, especially in diverse cultural contexts. Questions include: 1) How are power imbalances addressed in interprofessional education studies? 2) What ethical dilemmas arise when researching marginalised communities? Axiology requires researchers to navigate informed consent, data confidentiality, and cultural sensitivity, ensuring ethical coherence across all study phases (Mertens, 2010). For instance, digital professionalism frameworks must balance transparency in data collection with privacy concerns in online learning environments (Mertens, 2010). These values were upheld by: Addressing power imbalances between researchers and participants. Ensuring cultural responsiveness in data collection and analysis methods. Framing recommendations to advance health equity and social accountability. This ethical stance informed the collaborative approach with the UFS medical school and emphasis on decolonial pedagogies and addressing sociocultural inequities in our findings. Language policies in medical education can reinforce power hierarchies, perpetuate decolonial power perspectives in multilingual contexts like South Africa. These transformative assumptions led this study beyond a technical curriculum alignment evaluation to a critical examination of how medical education can address systemic inequities in South African healthcare. This paradigm enabled the researchers to not only describe current challenges but also co-create actionable pathways for transformative change in partnership with diverse stakeholders. Synthesis and Implications These assumptions collectively shape paradigm selection, influencing how medical educators investigate phenomena—from competency assessments to equity in training. Explicitly articulating ontological, epistemological, methodological, and axiological foundations enhances methodological transparency, rigour, and reproducibility in research (Nieuwenhuis, 2007). As health science education evolves, paradigm awareness remains critical for advancing pedagogies that reflect both scientific and humanistic dimensions of learning. Social science research operates within quantitative and qualitative paradigms (Mills et al., 2010). Researchers may favour one approach or combine both, with proponents arguing combined approaches enhance a phenomenon of understanding (Atieno, 2009). However, mixed methods present a philosophical paradox: quantitative research assumes a single, independent reality, while qualitative research presupposes multiple contextual realities (Harrison et al., 2017). These fundamental ontological assumptions shape all research endeavours, including mixed-methods case studies. This study employed a mixed methods approach and triangulated data, with Bhatta (2018) noting that misunderstandings often surpass challenges in mixed-methods research. Within the transformative paradigm, the researcher's role is pivotal in recognising societal inequalities and challenging the status quo (Mertens, 2007). Positioned within this paradigm, the study examines community-based medical education transformation, exploring how the UFS medical school, through AfriMEDS as a transformative pedagogical tool, can enhance curriculum delivery and improve community-level healthcare services. The transformative paradigm reframes worldviews and informs methodological decisions (Mertens, 2005). This study adopted a mixed methods approach, emphasising community participation to address cultural complexities, build trust, validate data, and implement findings (Mertens, 2007). Triangulation enabled integrating qualitative and quantitative approaches—document reviews, interviews and surveys—to capture diverse perspectives (Mertens, 2007). Positioned within this paradigm, the study critically evaluates the UFS MBChB program’s implementation of AfriMEDS physician competency framework, offering recommendations to transform pedagogy and curriculum delivery for enhanced community-level healthcare outcomes. There are different mixed-methods designs, which are convergent parallel, explanatory sequential and exploratory sequential (Creswell & Clark, 2011). In this study, the convergent parallel design was used as an example of a triangulation process (Creswell, 2014), integrated both qualitative and quantitative approaches in the research. This allowed for simultaneous collection and analysis of multiple data streams, followed by integration, to provide a comprehensive understanding of curriculum alignment and implementation challenges of the AfriMEDS competency framework. Stakeholder Engagement Process The study employed a multi-faceted approach to stakeholder engagement, including: Document analysis of curriculum materials and policy documents. Semi-structured interviews with 15 educators. Cross-sectional surveys of 71 medical interns. This comprehensive stakeholder (educators and interns) engagement approach supported by document analysis aligns with best practices in curriculum development, as outlined by Iwasiw and Goldenberg (2015), who emphasise the importance of diverse stakeholder input. Qualitative methods included: Document analysis involved word searches across UFS phase guides, the 2018 HPCSA accreditation report, and MBChB rules to assess AfriMEDS competency implementation and assessment. Frequencies of competencies, main themes (with various subthemes) emerged from the data. At this stage, it is important to mention the rigour of the HPCSA accreditation process for medical schools and what it entails: Self-evaluation by the institution. Site visits by an accreditation team. Review of curriculum, facilities, faculty, and resources. Assessment of compliance with standards. Recommendations for improvement. Granting of accreditation status. Semi-structured interviews with 15 educators, selected through purposive sampling to capture diverse pedagogical roles. Participants were introduced to the study, provided with consent forms, and interviews were scheduled on UFS-approved Blackboard Collaborate, ensuring convenience and privacy. Written and verbal consent was obtained, and all interviews were recorded. The method involved four steps: Transcription: Interviews were audio-recorded and transcribed verbatim using Otter.ai. Initial impressions and keywords were identified. Coding: Transcripts were analysed using NVivo 12 software, grouping related data into themes and subthemes through manual coding. Theme Development: Verbatim nodes were exported from NVivo, and recurring keywords elevated themes or subthemes based on frequency and intent. Triangulation: Themes were refined by cross-referencing data from educator interviews, intern surveys, and document analysis. Quantitative methods involved : A cross-sectional survey of 71 UFS medical interns (31% response rate) to assess perceived competency preparedness. Quantitative data was gathered using an online survey targeting first- and second-year medical interns registered with the HPCSA in 2020. The researcher accessed a database of 240 eligible UFS graduates, but after removing duplicates and invalid email addresses, 225 invitations were sent. Interns were given six weeks to complete the survey on EvaSys, with reminders sent weekly. Participation was voluntary, with confidentiality assured, though the survey was not anonymous. Ultimately, 71 interns responded, yielding a 31% response rate, below the target of 50%. The response rate was analysed using Nulty’s (2008) framework, which compares "Liberal conditions" (10% sampling error, 80% confidence level) and "Stringent conditions" (3% sampling error, 95% confidence level). Under liberal conditions, the response rate exceeded expectations (12%), but it fell short of stringent benchmarks (73–77%). Challenges like outdated contact details and the COVID-19 pandemic likely contributed to the lower response rate. Despite these limitations, the response rate was deemed acceptable for an online survey during a pandemic. Literature confirms that online surveys generally achieve lower response rates than paper-based ones (33% vs. 56%). The study highlighted the importance of ensuring representativeness in survey results. Ethical considerations Ethical approval was granted from the University of the Free State Health Sciences Research Ethics Committee (UFS-HSD2020/1420/2710) and the University of Bath (S20-068). Additional clearances were secured from national and provincial health departments (NHRD 202009_009). All participants provided informed consent, and data were anonymised to ensure confidentiality. Reflexivity In health sciences education, reflexivity plays a crucial role in ensuring the integrity and validity of research (McIntosh, 2023). The example provided shows several key aspects of reflexivity: 1. Acknowledging their positionality , the principal researcher recognised their role as a senior manager at the UFS School of Medicine and its potential influence on the study (Alexander et al., 2020). Researchers can critique their own position in relation to the research process and participants through reflexive self-awareness ( McIntosh, 2023). 2. Potential bias from the researcher’s senior position was mitigated by assigning an external research assistant (McIntosh, 2023) to conduct the interviews. This decision reflects a conscious effort to minimise undue influence on junior colleagues participating in the study. 3. Standardising data collection : The use of a standardised interview guide/questionnaire helped mitigate potential bias introduced by the external researcher assistant's expertise in curriculum studies (Ho, & Limpaecher, 2022). This approach ensures consistency in data collection across all participants. 4. Ensuring participant anonymity : The study design incorporated measures to anonymise and blind participant responses to the principal researcher (Denniston, 2023). This practice helps maintain objectivity and reduces the risk of bias in data analysis and interpretation (Denniston, 2023). 5. Triangulation: The study employed robust triangulation methods to address inherent biases while capturing nuanced stakeholder experiences (Denniston, 2023). Triangulation enhances the credibility and trustworthiness of the research findings by cross-verifying data from multiple sources (Denniston, 2023). 6. Transparency and reflexivity are showed in the study through the explicit reporting of the researcher’s role, potential biases, and mitigation strategies (Alexander et al., 2020). This openness enables readers to evaluate the research process and findings critically (Alexander et al.; 2020). 7. Critical Reflexivity: Encouraging all stakeholders to engage in ongoing reflection on how their positions of power influence educational practices and outcomes(McIntosh, 2023). These reflexive practices contribute to the rigour and credibility of the research, aligning with the principles of reflexivity in health sciences education. By engaging in this critical self-examination process, researchers can better understand and account for how their own perspectives, biases, and experiences influence their work, leading to more robust and trustworthy research outcomes. The South African medical education landscape continues to operate in what Reid (n.d) describes as a "reproductive rather than transformative mode," perpetuating historical inequities despite policy imperatives for transformation. This disconnect between transformative policy intentions and reproductive educational practices signals the need for critical reflexivity at institutional and system levels. Without explicit attention to social reflexivity in particular, medical curriculum redesign risks maintaining what Ajani identifies as "affirmative rather than transformative" approaches that address redistributive justice while neglecting issues of misrecognition and representation (Ajani, 2024). The transformative potential of reflexivity lies in its capacity to reveal and challenge the "fitness of purpose" rather than merely the "fitness for purpose" of medical education (Reid, n.d). When applied to curriculum redesign, reflexivity enables educators to question not just how effectively they are achieving predetermined objectives, but whether those objectives themselves serve the needs of the South African society. This critical orientation aligns with calls for medical educators to "put South Africa first" and "place transformation at the heart of the educational process (Reid, n.d). Reflexivity makes up more than a cognitive skill—it represents an ethical stance that acknowledges the socio-political dimensions of medical education and practice(McIntosh, 2023). South African medical education can better serve transforming healthcare and society by prioritising reflexivity in curriculum redesign, moving beyond mere technical reforms to address fundamental questions about its role (Hickman et al., 2022). Findings Document analysis The following points were raised as matters of concern in the HPCSA accreditation report of 2018 : a) “Sesotho training should be formally introduced in the curriculum in the faculty to enhance student-patient communication.” b) Increasing interaction and greater use of the platform for interprofessional learning. c) The phase reviews of the curriculum should be formalised and feedback given to the faculty. d) Expansion of CBE activities. e) Develop a parallel course to assess student suitability for medical school admission, without disadvantaging new Learning development Programme (LDP) admissions. The LDP is a remedial programme, a program designed to support student academic development and success, focusing on enhancing learning skills and providing necessary support. f) Increasing student and staff numbers. g) Consistency in assessment needs to be ensured. h) There is no opportunity in the curriculum for students to experience continuity of care, and primary care rotations are mostly short. i) Development of a longitudinal integrated programme in several sites for a few students. Document analysis shows that health advocate, leader, manager, and scholar competencies are underrepresented in all phases of the UFS undergraduate medical program, and professional and health advocate assessment tools are absent from the program’s phase guides(Table 1). Table 1. Comparison across Phases I-III and LDP on the number of times core competencies were mentioned in the phase module guides CORE COMPETENCIES PHASE I PHASE II PHASE III LDP Communicat or 10 10 3 6 Collaborat or 12 1 1 12 Professional 15 7 1 1 Scholar 5 0 1 4 Leader and manager 5 0 1 5 Health advoca te 0 0 1 0 Community-based education 6 32 6 1 Notes: LDP=learning development programme Table 2 shows the key findings across educators and interns, highlighting each AfriMEDS competency how is it perceived and sufficiently assessed: Table 2. Summary of key findings across educators and interns, highlighting each AfriMEDS competency how is it perceived and sufficiently assessed. Competency And Category Educator Interviews AfriMEDS core competencies included and assessed in modules n= 15 Intern Survey on perceived sufficient assessment of core AfriMEDS competencies in the undergraduate programme and open-ended questions online survey subcategories n=71 1. Scholar 93% agree Key theme category No formal assessment 90 % satisfaction Insufficient assessment subcategory: Limited teaching and training 2. Professional 100% agree Key theme category Sufficiently assessed 84 % satisfaction Insufficient assessment subcategory: Difficulty in assessment Limited attention No formal assessment 3. Collaborator 86% agree Key theme category No formal assessment 72 % satisfaction: Insufficient assessment subcategory: No formal assessment No effective collaborator Task shifting 4. Communicator 93% agree Key theme category • No formal assessment agree 78 % satisfaction Insufficient assessment subcategory No formal assessment Lack of face-to-face assessment Communicator is not formally taught Limited counselling lessons 5. Leader & Manager 53% agree Key theme category: • No formal assessment agree Lowest satisfaction rating (63%) Insufficient assessment subcategory: No formal assessment Lack of platforms for assessment Limited skills assessed Practice opportunities granted to the select few 6. Health Advocate (Community engagement) 73% agree: (It was reflected under community-engagement by educators.) Over 78 % satisfaction Insufficient assessment subcategory: No formal assessment 7. Community-Based Education 66 % agree Key theme category: • No formal assessment agree 71% satisfaction Insufficient assessment subcategory: No formal assessment Language barrier 8. Medical Expert 80% agree (Educators felt that medical expert was an integrating role that incorporate all other 7 competencies therefore was calculated as a percentage average score) Highest satisfaction (91%) Insufficient assessment subcategory: No formal assessment Lack of clinical exposure Insufficient time for assessment Subjective assessment Here is a tabulated summary of challenges and gaps identified in the implementation and assessment of AfriMEDS competencies at the UFS, based on findings from document analysis, educator interviews, and intern surveys (Table 3). Table 3. Summary of challenges and gaps identified in the implementation and assessment of AfriMEDS competencies at the UFS, based on findings from document analysis, educator interviews, and intern surveys. Competency Document Analysis Challenges/Gaps Educator Interviews Challenges/Gaps Intern Survey Challenges/Gaps Scholar "Core competencies of... scholar feature less prominently across all phases." "Incomplete implementation of the scholar role, focusing mainly on research methodology but neglecting teaching and dissemination." Interns noted gaps in research skills: "Limited ability to critically evaluate evidence and apply it in clinical settings." Professional "Professional role assessment tools are not mentioned in phase guides." "Professionalism is taught informally through role modelling rather than structured assessments." Interns felt professionalism was learned through observation: "No formal evaluation mechanisms for professional behaviour." Collaborator Limited evidence of assessment tools for collaboration skills. "Interprofessional education exists but lacks formal assessment methods." 72% satisfaction: "Insufficient opportunities to practice team leadership and conflict resolution." Communicator Communicator competencies mentioned but lacked aligned assessment tools. "Challenges in assessing complex communication scenarios like breaking bad news or addressing language barriers." 79% satisfaction: "Difficulty communicating with families and across language barriers during internship." Leader & Manager "Leader and manager competencies feature less prominently in curriculum documents." "Uncertainty about how to teach leadership effectively; resource management skills are underemphasized." Lowest satisfaction (63%): "Unprepared for administrative responsibilities, resource allocation, and team leadership." Health Advocate "Health advocate assessment tools are absent from phase guides." "Advocacy training lacks systematic integration into the curriculum; focus remains on individual patient advocacy rather than systemic change." Interns reported limited preparation for systemic advocacy: "Few opportunities to engage with community-level health interventions." Community-Based Education Implicitly included but not explicitly mapped to COPC (Community-Oriented Primary Care). "Challenges include staff shortages, increasing student numbers, limited time, COVID-19 disruptions, and insufficient clinical exposure." 71% satisfaction: "Limited exposure to diverse community settings; insufficient time for meaningful engagement with communities." Medical Expert No major challenges reported; central competency well-represented in documents. No major gaps reported; educators emphasized rigorous assessment through OSCEs and case presentations. Highest satisfaction (>85%): Interns felt well-prepared for clinical diagnosis and management tasks. Key Observations from Table 3: 1. Underrepresented Competencies: Leader and Manager, Health Advocate, Collaborator, Community engagement and CBE were consistently identified as problematic across all data sources. 2. Assessment Misalignment: Document analysis revealed that existing tools did not align with recommended methods for assessing AfriMEDS roles. 3. Contextual Barriers: Educators highlighted systemic issues such as staff shortages, COVID-19 disruptions, and lack of time as significant barriers to competency development. 4. Intern Feedback: Interns expressed dissatisfaction with preparation in non-medical expert roles, particularly leader and manager (63%) and collaborator (72%). This summary emphasises the need for better curriculum alignment, enhanced assessment strategies, and targeted interventions to address underrepresented competencies. Grounded in a transformative metaphysical framework here is the summary of key insights from using the convergent parrel design triangulation approach: Consistent gaps: Leader/manager, health advocate, community engagement and CBE competencies were underdeveloped across all data sources. Assessment misalignment: Documents, educators, and interns all noted a disconnect between curriculum goals and assessment tools for non-clinical roles. Contextual barriers: COVID-19, staff shortages, and time constraints disproportionately impacted CBE and collaborative training. These findings highlight the need for systemic curriculum reform to realise the potential of the AfriMEDS framework in preparing physicians for South Africa's healthcare needs. Misaligned assessment tools, insufficient faculty training, limited clinical exposure, and inadequate time are some issues which reflect the larger national challenges in medical education reform. To bridge the gap between institutional goals and community health needs, the analysis emphasises the importance of decolonial teaching methods and collaborative efforts with stakeholders. This work advances discourse on context-responsive curriculum design, proposing dynamic implementation frameworks that harmonise regulatory standards with transformative healthcare equity goals. It highlights the imperative for iterative curriculum renewal processes, faculty development initiatives, and integrated community engagement to cultivate physicians equipped for South Africa’s evolving healthcare landscape. Through the use of the metaphysical transformative framework, the study critically evaluated AfriMEDS competency integration within the MBChB curriculum, examining systemic implementation and assessment challenges. By analysing curriculum alignment with South Africa's healthcare needs, it highlights barriers to preparing physicians for community-oriented care amidst evolving pedagogical paradigms. Discussion The study findings highlight gaps in implementing and evaluating AfriMEDS graduate competencies, including insufficient clinical time dedicated to CBE, inadequate quality in clinical supervision, training, and assessment, as well as limited opportunities for students to learn patients' languages, develop essential soft skills, and gain the attributes necessary for effective counselling and community engagement. Implications for Systemic Reform and Transformative Pedagogies This study's findings illuminate critical challenges in implementing the AfriMEDS competency framework within South African medical education at the UFS. The transformative metaphysical framework using a mixed-methods approach revealed systemic barriers to aligning curriculum with national healthcare priorities, echoing broader challenges in medical education reform across resource-constrained settings. The study showed that adopting a transformative research paradigm can catalyse curriculum redesign by harmonising pedagogical objectives with South Africa’s healthcare equity imperatives. This approach, integrating critical reflection and stakeholder co-creation, aligns with evidence from Lochner et al. (2018), where transformative learning (TL) frameworks enabled residents to address systemic health inequities through social change-oriented curricula. Transformative learning frameworks can facilitate developing competencies in health advocacy, leadership, CBE and COPC by: Encouraging critical reflection on societal health inequities. Challenging students' assumptions about healthcare delivery. Fostering perspective transformation through community immersion experiences. Promoting dialogue between students and diverse community stakeholders. Integrating reflective practices to connect theory with lived experiences. Utilising problem-based learning focused on real community health challenges. Incorporating participatory action research projects. Emphasising the social determinants of health in curriculum design. These approaches can help students develop a critical consciousness about health systems and their role as change agents, essential for effective advocacy, leadership, and community-oriented practice. CBE emerged as a linchpin for sustainable transformation, consistent with findings from Stellenbosch University’s Ukwanda Rural Clinical School, where extended rural immersion increased graduates’ readiness for underserved practice (Talib et al., 2013). However, structural barriers persist: fragmented assessment tools and faculty capacity gaps hinder AfriMEDS implementation, echoing challenges identified in Community-based education and service (COBES) programs across Africa (Amalba et al., 2020). To address this, the study advocates for reflexive curriculum design—a pragmatic approach combining competency benchmarks with iterative feedback loops, as validated in the Medical Education e-Professionalism “MEeP” framework’s emphasis on researcher reflexivity and stakeholder validation (Guraya et al., 2023). Curriculum Alignment and Implementation Challenges Document analysis and educator interviews revealed uneven emphasis across AfriMEDS competency roles, with deficiencies in health advocate, community engagement, leadership, and CBE. This aligns with Whitehead et al.'s (2015) findings that intrinsic roles like health advocate and collaborator are challenging to assess because of their contextual nature. The study's identification of misaligned assessment tools and insufficient faculty development mirrors challenges reported in implementing competency-based frameworks. A potential mismatch exists between curriculum goals and results, as shown by the difference between how educators perceive interns’ preparedness and how interns assess themselves. While over 80% of interns felt prepared overall, lower ratings for leader/manager (63%) and CBE (71%) roles suggest areas for targeted improvement. These findings resonate with broader discourse on the complexities of translating competency frameworks into practice, in settings with resource constraints and evolving healthcare landscapes. Transformative Paradigm Insights Employing a transformative research paradigm proved effective in illuminating structural inequities while reimagining medical education that serves the public good. This approach enabled: Stakeholder co-creation: By positioning educators and interns as knowledge co-creators, the study captured nuanced perspectives on curriculum alignment and implementation challenges. Power dynamics examination: The method revealed how institutional constraints and faculty capacity gaps impact translating policy into practice. Cultural complexities: The study highlighted the need for responsive pedagogies that address South Africa's unique healthcare challenges and social determinants of health. The transformative research paradigm employed in this study illuminated how power dynamics and cultural complexities inherent in medical education reform create implementation barriers. As one educator noted: "The relative powerlessness of students in curriculum design processes can hinder implementing learner-centred approaches central to AfriMEDS." This paradigm aligns with calls for decolonial approaches to medical education in Africa, emphasising prising community-engaged learning and social accountability. Decolonial Pedagogies for Transformative Medical Education The concept of decolonial pedagogies offers a crucial framework for transforming medical education in South Africa beyond technical curricular reforms. Decolonial pedagogies challenge dominating Western epistemologies and recognise diverse knowledge systems, those marginalised through colonial processes. These approaches move beyond mere inclusion of cultural content to reconsidering what makes up valid knowledge, who produces it, and how it is taught and assessed (Wong et al., 2021). Decolonial pedagogies in medical education cause a shift from what Reid (n.d) describes as a "reproductive rather than transformative mode" that has perpetuated historical inequities despite policy imperatives for transformation (Reid, n.d). This aligns with our findings that despite adopting the AfriMEDS framework, implementation challenges persist, in areas that require engagement with local health contexts and community needs. Specific examples of decolonial pedagogies that can be integrated into the medical curriculum include: Community-based participatory learning : This approach involves students learning directly from community health workers and traditional healers, valuing their knowledge as legitimate and complementary to biomedical perspectives (Lawrence et al., 2022). For example, Walter Sisulu University has implemented programs where students engage with community health priorities through collaborative projects co-designed with community members (Osman & Maringe, 2019). Critical reflection on medical epistemologies : Structured reflective exercises that prompt students to examine the historical and cultural assumptions underlying medical concepts and practices. This could include a critical analysis of how medical conditions are defined, diagnosed, and treated across different cultural contexts (Mbaki et al., 2021). Integrating indigenous healing traditions : Formal incorporation of African healing traditions into the curriculum, not as historical artifacts but as living knowledge systems with ongoing relevance (Swidrovich, 2020). The University of KwaZulu-Natal has developed modules where traditional health practitioners co-teach with medical faculty to provide students with a comprehensive understanding of complementary approaches to healing (Hlongwane & Lowton, 2024) Decolonial case-based learning : Adapting case studies to reflect the lived realities of diverse South African communities, ensuring representation of health conditions as they manifest across different population groups (Perkins, et al. 2023). This includes cases that address social determinants of health unique to post-apartheid South Africa (Hlongwane, & Lowton, 2024). Language-inclusive clinical training : Incorporating multilingual approaches to clinical education that validate and utilise South Africa's diverse languages (English et al., 2022). This could include training in healthcare interpretation and development of multilingual clinical resources that bridge communication gaps between healthcare providers and patients (Koch et al., 2024). These pedagogical approaches address the cultural competence gaps identified in the present study. The current AfriMEDS implementation at UFS revealed significant deficiencies in preparing graduates for health advocacy and community engagement, in understanding and responding to diverse cultural perspectives on health. By integrating decolonial pedagogies, medical education can move beyond superficial cultural awareness to develop what Wong et al. (2021) term "cultural safety" – the ability to recognise and respect the cultural identities of others and meet their needs, rights, and expectations. By integrating specific decolonial pedagogies, such as community-based participatory learning, critical reflection on medical epistemologies, and incorporating indigenous healing traditions, into the curriculum. This should involve collaborations with community health workers, traditional healers, and other stakeholders. These approaches promote health equity by acknowledging and addressing power imbalances in healthcare relationships. As Chandanabhumma and Narasimhan (2020) argue, decolonial approaches in health education confront the structural determinants of health inequities by equipping future practitioners with the tools to recognise and challenge systemic barriers to care. The findings of the current study on the uneven emphasis across AfriMEDS competencies in health advocacy and leadership roles suggest that decolonial pedagogies offer a pathway for strengthening these critical domains. Impact on Recommendations Stakeholder input influenced the study's recommendations for curriculum redesign: Community-based participatory learning should be integrated throughout the curriculum, not just in the final years. Development of culturally responsive assessment methods. Enhanced faculty development programs focused on community engagement and decolonial pedagogies. Strengthened partnerships with rural healthcare facilities for longitudinal student placements. These recommendations reflect a synthesis of stakeholder perspectives and align with global trends in medical education reform, as noted by Guraya et al. (2023). Systemic Reform Implications The study's findings underscore needing transcending additive curriculum reforms in favour of paradigm shifts that centre social accountability. Three critical areas for systemic reform emerge: Participatory Curriculum Design : Implementing collaborative processes that involve students, junior faculty, and community representatives in curriculum decisions. Bridging cultural competence gaps through decolonial pedagogies that integrate traditional health systems and community-engaged learning models. Faculty development should prioritise training in competency-based assessment and transformative learning methodologies. Structural alignment involves advocating for HPCSA accreditation reforms requiring granular curriculum audits and iterative improvement processes. These recommendations align with global trends in medical education reform, emphasising the need for dynamic implementation frameworks that harmonise regulatory standards with transformative healthcare equity goals. Limitations and Future Directions As a single-case study focused on UFS—South Africa’s sole five-year medical program—findings are context specific, limiting direct generalizability. Institutions facing similar resource constraints can learn from insights into competency-based curriculum reform (Mertens, 2010). The 31% survey response rate, though below the 50% target, aligns with Nulty’s (2008) “Liberal conditions” (10% sampling error, 80% confidence), with post-hoc power analyses confirming detectability of key outcomes. COVID-19 disruptions and December/January 2020/21 recruitment timing likely impacted participation, underscoring challenges in longitudinal health professions research. To mitigate potential bias, the external qualitative researcher used standardized interview protocols and anonymized data. Although small sample sizes limit broader conclusions about the population, combining the findings with document analysis and educator interviews increased the study’s trustworthiness (Creswell, 2014). Conclusion Context-Responsive Curriculum Design and Future Directions This mixed-methods case study, grounded in a transformative research paradigm, examined the integration of the AfriMEDS competency framework within the UFS MBChB curriculum. Methodologically, it combined document analysis, which included the accreditation report informed by the HPCSA accreditation process, educator interviews, and intern surveys to triangulate findings on curriculum alignment and pedagogical challenges. The transformative mixed-methods approach proved effective in illuminating structural inequities while reimagining medical education that authentically serves the public good. By positioning stakeholders as knowledge co-creators, the study captured nuanced perspectives on curriculum alignment and implementation challenges, offering a model for evaluating complex educational interventions in resource-limited settings. Specific examples discussed—community-based participatory learning, critical epistemological reflection, integration of indigenous healing traditions, decolonial case-based learning, and language-inclusive clinical training—provide concrete pathways for curriculum redesign. These approaches address cultural competence gaps by moving beyond tokenistic inclusion of cultural content to reconsidering what makes up medical knowledge and practice (Koch et al., 2024). The promotion of health equity through decolonial pedagogies requires structural commitment, including faculty development initiatives focused on decolonial teaching methods, revision of assessment strategies to validate diverse forms of knowledge, and institutional policies that support community engagement as core to medical education rather than peripheral (Ajani, 2024). As Osman and Maringe (2019) emphasise, without coherent understanding and frameworks, decolonisation efforts will not contribute meaningfully to the transformation of higher education in South Africa (Lawrence et al., 2022). Recommendations for future research and implementation include: Developing context-specific assessment tools for intrinsic competencies, particularly those aligned with COPC. Revise the curriculum to ensure a more balanced integration of all AfriMEDS competencies. Increase the focus on health advocacy, leadership, community engagement and CBE by incorporating dedicated modules, practical experiences, and assessments tailored to these roles. This should involve reviewing learning objectives, teaching materials, and assessment methods to ensure balanced coverage of all AfriMEDS roles. Develop context-specific assessment tools for intrinsic competencies like health advocate, leader/manager, collaborator, community engagement and CBE aligning them with the specific skills and knowledge required for COPC. Ensure these tools capture both theoretical knowledge and practical application. Implement a system for formalised curriculum phase reviews. This system should include regular evaluations of each phase, mechanisms for collecting feedback from educators, students, and stakeholders, and processes for incorporating feedback into curriculum revisions. Introduce new evaluation methods, like standardised patient encounters for communication skills and interprofessional simulation activities, to assess the effective application of knowledge and skills relevant to these roles. Standardize assessment practices across the curriculum, ensuring that all competencies are evaluated using valid and reliable methods. Provide faculty with training on implementing standardised assessment procedures and interpreting results. Develop a parallel admissions course that assesses student suitability for medical school without disadvantaging LDP admissions. This course should evaluate essential skills and attributes, such as critical thinking, problem-solving, communication, and ethical reasoning. Longitudinal cohort studies will investigate the long-term effects of curriculum reforms on healthcare outcomes. Implement longer primary care rotations or integrated clerkships that allow students to follow patients over time and develop skills in managing chronic conditions and promoting preventative care. This program should provide extended clinical placements in a variety of settings, allowing students to follow patients over time, experience continuity of care, and integrate their learning across disciplines. Evaluate the outcomes of this pilot program and consider expanding it if successful. Increase the duration and quality of community-based rotations. Develop partnerships with rural healthcare facilities to provide students with longitudinal placements and enhanced mentorship opportunities, enabling deeper engagement with communities and practical application of CBE principles. Exploring innovative pedagogical approaches that integrate indigenous knowledge systems with evidence-based practice, addressing cultural competence gaps. Integrate a more explicit focus on social determinants of health into the curriculum. Develop modules and case studies that address issues like poverty, inequality, access to care, and cultural factors that influence health outcomes. By integrating IPE frameworks, AfriMEDS can better prepare graduates to work effectively in multidisciplinary teams, improve patient outcomes, and address the social determinants of health through collaborative, community-oriented approaches. Increase opportunities for interprofessional learning by integrating IPE activities into the curriculum. Design collaborative projects, simulations, or case studies that require students from different healthcare disciplines to work together, fostering communication, teamwork, and shared decision-making skills. This integration aligns with AfriMEDS' emphasis on CBE and primary care. We advocate for HPCSA accreditation reforms that mandate detailed curriculum audits and support iterative improvement. Develop specific, actionable recommendations for HPCSA accreditation standards. These could include requiring medical schools to demonstrate integration of decolonial pedagogies, CBE, and assessment tools aligned with AfriMEDS competencies, emphasising cultural safety and social accountability. Ensure that these tools capture both theoretical knowledge and practical application of skills in areas like health advocacy, leadership, community engagement and CBE. Prioritising faculty development initiatives focused on competency-based assessment and transformative learning methodologies. This should include training in teaching and assessing non-clinical skills, community engagement strategies, and culturally responsive pedagogies. Structural alignment of curriculum with national healthcare priorities through collaborative processes that meaningfully involve students, junior faculty, and community representatives. Integration of decolonial pedagogies that bridge cultural competence gaps and address power imbalances in healthcare relationships. Implement specific language training programs tailored to the needs of the communities served by UFS graduates. Integrate soft skills development into the curriculum through role-playing, simulations, reflective exercises, and community engagement activities. While acknowledging the context-specific nature of the findings, we suggest future research that could explore the applicability of the study's findings to other medical schools in South Africa. This could involve comparative case studies or multi-institutional surveys. While response rate supports the validity of findings, acknowledge this limitation and we propose strategies for improving response rates in future research, like offering incentives, using multiple follow-up reminders, or exploring alternative data collection methods. Integrated budgeting and resource allocation to harmonise the power dynamics between health authorities and universities and better support clinical training in AfriMEDS, CBE, and COPC. Developing a joint strategic plan between the university and the health authority to address staffing needs and ensure adequate resources are available to support an increased student body. This could include hiring additional faculty, expanding teaching facilities, and investing in educational technology. Future research should evaluate the implementation and impact of decolonial pedagogies in medical education, particularly their effect on graduate preparedness for practice in diverse communities and their contribution to addressing health inequities. Collaborative work across South African medical schools to develop context-specific frameworks for decolonial curriculum development would strengthen the coherence and sustainability of these approaches. By reimagining medical education through a transformative paradigm that challenges traditional hierarchies and centres’ community engagement, South African medical schools can move beyond reform to true transformation—preparing physicians equipped not only with clinical expertise but with the critical consciousness necessary to address the country's complex health challenges. This study advances discourse on context-responsive curriculum design in medical education, proposing a framework for iterative curriculum renewal that balances competency benchmarks with community health imperatives. By illuminating the complexities of implementing transformative pedagogies in post-apartheid South Africa, it offers valuable insights for medical educators navigating similar challenges globally, particularly in settings where educational reform intersects with social transformation agendas. Declarations Acknowledgements. The authors would like to acknowledge the University of the Free State, Faculty of Health Sciences, for their support during the project and Mrs Nicoleen Smit from the University of Pretoria, Department of Family Medicine for her assistance in finalising the manuscript. The author’s contributions. NM conceptualised the project, completed the data collection, analysed and interpreted the data, and prepared the manuscript. PMJ and GW supervised the project from conception to publication. Funding . UFS Postgraduate Research support grant. Competing interests: The authors declare that there are no conflicts of interest. References Ajani, O. A. (2024). Exploring curriculum transformation in higher education institutions: A critical analysis of equity and social justice perspectives. Research in Educational Policy and Management, 6 (1), 217–237. https://doi.org/10.46303/repam.2024.14 Alexander, S. A., Jones, C. M., Tremblay, M. C., Beaudet, N., Rod, M. H., & Wright, M. T. (2020). Reflexivity in health promotion: A typology for training. Health Promotion Practice, 21 (4), 499–509. https://doi.org/10.1177/1524839920912407 Amalba, A., Abantanga, F. A., Scherpbier, A. J. J. A., & van Mook, W. N. K. A. (2020). The role of community-based education and service (COBES) in undergraduate medical education in reducing the mal-distribution of medical doctors in rural areas in Africa: A systematic review. Health Professions Education, 6 (1), 9–18. https://doi.org/10.1016/j.hpe.2019.09.003 Atieno, O. P. (2009). An analysis of the strengths and limitations of qualitative and quantitative research paradigms. Problems of Education in the 21st Century, 13 , 13–18. Bam, N., Marcus, T., Hugo, J., & Kinkel, H. F. (2013). Conceptualizing community-oriented primary care (COPC) – The Tshwane, South Africa, health post model. African Journal of Primary Health Care & Family Medicine, 5 (1), a423. https://doi.org/10.4102/phcfm.v5i1.423 Bhatta, T. P. (2018). Case study research, philosophical position and theory building: A methodological discussion. Dhaulagiri Journal of Sociology and Anthropology, 12 , 72–79. https://doi.org/10.3126/dsaj.v12i0.22182 Chandanabhumma, P. P., & Narasimhan, S. (2020). Towards health equity and social justice: An applied framework of decolonization in health promotion. Health Promotion International, 35 (4), 831–840. https://doi.org/10.1093/heapro/daz053 Creswell, J. W., & Clark, V. L. P. (2011). Designing and conducting mixed-methods research (2nd ed.). Sage Publications. Creswell, J. W. (2014). Research design: Qualitative, quantitative, and mixed methods approaches (4th ed.). Sage Publications. Dath, D., Chan, M.-K., Abbott, C., & CanMEDS. (2015). From manager to leader(pp.1-9) . The Royal College of Physicians and Surgeons of Canada. Denniston, C. (2023). Sharpening reflexive practice in health professional education research. Focus on Health Professional Education: A Multi-Professional Journal, 24 (1), 85–94. https://doi.org/10.11157/fohpe.v24i1.734 Department of Higher Education and Training. (2012). Report of the task team on community education and training centres Retrieved May 4, 2020, from https://www.dhet.gov.za/Adult%20Education%20and%20Training%20Programmes/CETC%20summary%20report.pdf De Villiers, M. R., Blitz, J., Couper, I., Kent, A., Moodley, K., Talib, Z., Van Schalkwyk, S., & Young, T. (2017). Decentralised training for medical students: Towards a South African consensus. African Journal of Primary Health Care & Family Medicine, 9 (1), a1449. English, W., Gott, M., & Robinson, J. (2022). Being reflexive in research and clinical practice: A practical example. Nurse Researcher, 30 (2), 30–35. https://doi.org/10.7748/nr.2022.e1833 Frank, J. R., Snell, L. S., Ten Cate, O., Holmboe, E. S., Carraccio, C., Swing, S. R., Harris, P., Glasgow, N. J., Campbell, C., Dath, D., Harden, R. M., Iobst, W., Long, D. M., Mungroo, R., Richardson, D. L., Sherbino, J., Silver, I., Taber, S., Talbot, M., & Harris, K. A. (2010). Competency-based medical education: Theory to practice. Medical Teacher, 32 (8), 638–645. https://doi.org/10.3109/0142159X.2010.501190 Guba, E. G., & Lincoln, Y. S. (2005). Paradigmatic controversies, contradictions, and emerging confluences. In N. K. Denzin & Y. S. Lincoln (Eds.), The Sage handbook of qualitative research (3rd ed., pp. 191–216). Sage Publications Ltd. Guraya, S. S., Harkin, D. W., Yusoff, M. S. B., & Guraya, S. Y. (2023). Paradigms unfolded - developing, validating, and evaluating the Medical Education e-Professionalism framework from a philosophical perspective. Frontiers in Medicine, 10 , Article 1230620. https://doi.org/10.3389/fmed.2023.1230620 Harrison, H., Birks, M., Franklin, R., & Mills, J. (2017). Case study research: Foundations and methodological orientations. Forum: Qualitative Social Research, 18 (1), Article 19. https://doi.org/10.17169/fqs-18.1.2655 Hickman, A. C., Johnson, R. L., & Lawler, S. P. (2022). Health-promoting pedagogy: Using reflexivity to support learning and action in planetary health education. Health Promotion Journal of Australia, 33 (S1), 22–26. https://doi.org/10.1002/hpja.648 Hlongwane, N. A., & Lowton, K. (2024). Descriptive study of mental health care users 12 months pre- and post-COVID-19 lockdown. South African Journal of Psychiatry, 30 , Article a2301. https://doi.org/10.4102/sajpsychiatry.v30i0.2301 Ho, L., & Limpaecher, A. (2022). The importance of reflexivity in qualitative research . Delve. Retrieved February 25, 2022, from https://delvetool.com/blog/reflexivity Iwasiw, C. L., & Goldenberg, D. (2015). Curriculum Development in Nursing Education (3rd ed.). Jones & Bartlett Learning. Knight, S. E., Ross, A. J., & Mahomed, O. (2017). Developing primary health care and public health competencies in undergraduate medical students. South African Family Practice, 59 (3), 103–109. https://doi.org/10.1080/20786190.2016.1272229 Koch, R., Pool, J., & Heymans, Y. (2024). The nature of decolonisation in health sciences curricula: A scoping review. South African Journal of Higher Education, 38 (4), 81–106. https://doi.org/10.20853/38-4-5893 Lawrence, C., Bollinger, J., Stewart, K. A., & Moshabela, M. (2022). Improving South African medical curricula related to traditional health systems. African Journal of Health Professions Education, 13 (2), 95–97. https://doi.org/10.7196/ajhpe.2021.v13i2.1246 Lochner, C., Roos, J., Taljaard, L., Bantjes, J., Saal, W., & Stein, D. (2018). The Caring Universities Project [Conference presentation]. SU DSAf Research Programme. McIntosh, G. L. (2023). Nurse researcher identity and reflexivity in interpretive phenomenological analysis: A personal narrative. Nurse Researcher, 31 (2), 28–35. https://doi.org/10.7748/nr.2023.e1870 Mayosi, B. M., Flisher, A. J., Lalloo, U. G., Sitas, F., Tollman, S. M., & Bradshaw, D. (2009). The burden of non-communicable diseases in South Africa. The Lancet, 374 (9693), 934–947. https://doi.org/10.1016/S0140-6736(09)61087-4 Mbaki, Y., Hlongwane, N. A., Bolden, S., & Makhubele, J. (2021). Decolonising healthcare education: Perspectives from postcolonial theory. Health SA Gesondheid, 26 (0), Article a1647. https://doi.org/10.4102/hsag.v26i0.1647 Mertens, D. M. (2005). Research and evaluation in education and psychology: Integrating diversity with quantitative, qualitative, and mixed methods (2nd ed.). Sage Publications. Mertens, D. M. (2007). Transformative paradigm: Mixed-methods and social justice. Journal of Mixed Methods Research, 1 (3), 212–225. https://doi.org/10.1177/1558689807302811 Mertens, D. M. (2010). Transformative mixed methods research. Qualitative Inquiry, 16 (6), 469–474. https://doi.org/10.1177/1077800410364612 Mills, A. J., Durepos, G., & Wiebe, E. (Eds.). (2010). Encyclopedia of case study research . Sage Publications. Nieuwenhuis, J. (2007). Qualitative research designs and data gathering techniques. In K. Maree (Ed.). First steps in research (pp. 69–97). Van Schaik. Nulty, D. D. (2008). The adequacy of response rates to online and paper surveys: What can be done? Assessment & Evaluation in Higher Education, 33 (3), 301–314. https://doi.org/10.1080/02602930701293231 Osman, R., & Maringe, F. (2019). The decolonisation of higher education in Africa: Perspectives from hybrid knowledge production . Routledge. Perkins, S., Nishimura H., Olantunde P.F. & Kalbarczyk A. (2023). Educational approaches to teach students to address colonialism in global health: A scoping review. BMJ Global Health, 8 (4), Article e011610. http://dx.doi.org/10. 1136/bmjgh-2022-011610 Reid, S. J., & Cakwe, M. (2011). The contribution of South African curricula to prepare health professionals for working in rural or under-served areas in South Africa: A peer review evaluation. South African Medical Journal, 101 (1), 34–38. Reid, S. J. (n.d.). The transformation of medical education in South Africa. UKZN Research Space Library Archive. Retrieved March 15, 2025, from https://researchspace.ukzn.ac.za/server/api/core/bitstreams/2c974964-139a-4886-a6b6-921ca338dc7a/content Republic of South Africa, Department of Health. (2017). White paper: National Health Insurance policy. Towards universal health coverage (Government Notice 627, Government Gazette 40955, 30 June 2017). Retrieved April 21, 2020, from https://www.gov.za/sites/www.gov.za/files/40955_gon627.pdf Slaven, F. (2017). Report on the Doctors for Primary Healthcare Symposium . Foundation for Professional Development. Retrieved March 28, 2017 from https://www.foundation.co.za/document/publications/reports/113037.20171109064251288.113037.2017110906425128841Mps.pdf Hussey, N. The Language Barrier: The overlooked challenge to equitable health care South African Health Review. (2012/13). Retrieved March 20, 2025, from https://journals.co.za/doi/pdf/10.10520/EJC133688 Statistics South Africa, 2013 Swidrovich, J. (2020). Decolonizing the medical model: Creating spaces for indigenous knowledge. Health Science Inquiry, 11 (1), 77–79. Talib, Z. M., Baingana, R. K., Sagay, A. S., Van Schalkwyk, S. C., Mehtsun, S., & Kiguli-Malwadde, E. (2013). Investing in community-based education to improve the quality, quantity, and retention of physicians in three African countries. Education for Health, 26 (2), 109–114. Turner, T. L., Balmer, D. F., & Coverdale, J. H. (2013). Methodologies and study designs relevant to medical education research. International Review of Psychiatry, 25 (3), 301–310. https://doi.org/10.3109/09540261.2013.790310 Whitehead, C. R., Kuper, A., Hodges, B., & Ellaway, R. (2015). Conceptual and practical challenges in the assessment of physician competencies. Medical Teacher, 37 (3), 245–251. https://doi.org/10.3109/0142159X.2014.993599 Wong, S. H. M., Gishen, F., & Lokugamage, A. U. (2021). Decolonising the Medical Curriculum: Humanising medicine through epistemic pluralism, cultural safety and critical consciousness. London Review of Education, 19 (1), 1-22. World Health Organization. (2013). Transforming and scaling up health professionals’ education and training: WHO guidelines. Retrieved April 9, 2021, from https://www.who.int/publications/i/item/transforming-and-scaling-up-health-professionals’-education-and-training Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 20 Sep, 2025 Read the published version in Advances in Health Sciences Education → Version 1 posted Editorial decision: Revision requested 18 Jul, 2025 Reviews received at journal 18 Jul, 2025 Reviewers agreed at journal 11 Jul, 2025 Reviews received at journal 11 Jul, 2025 Reviewers agreed at journal 10 Jul, 2025 Reviewers agreed at journal 10 Jul, 2025 Reviewers invited by journal 09 Jul, 2025 Editor assigned by journal 02 May, 2025 Submission checks completed at journal 02 May, 2025 First submitted to journal 21 Apr, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6494452","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":484382036,"identity":"b9576722-eb24-473b-81eb-5569685a7696","order_by":0,"name":"Nathaniel Mofolo","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAwklEQVRIiWNgGAWjYFACxgcMD4AUPwlamA0YEoCUZAPJWgwOEKtBt72Z8UFCBUOe8Y3cAww/ahjs+QlZZ3bmMLNBwhmGYrMbeQmMPccYmCUIWWd2I/+YRGIbQ+K2GzkGDLwNDGwMhLUks4G1bJ6RY8D4t4GBR55oLRskcgyYgbZIEAwHqF8kEmeceZdwWOaYhIEhQS3HgSH2ocImsb899+DDNzU29nKEtECBBBDzgDwuQZx6KOAhSfUoGAWjYBSMIAAAgl08lHR6bjAAAAAASUVORK5CYII=","orcid":"","institution":"University of the Pretoria","correspondingAuthor":true,"prefix":"","firstName":"Nathaniel","middleName":"","lastName":"Mofolo","suffix":""},{"id":484382037,"identity":"8c59e46d-a6c6-4e53-a38c-da0af3cba9b1","order_by":1,"name":"Priscilla Mpho Jama","email":"","orcid":"","institution":"University of the Free State","correspondingAuthor":false,"prefix":"","firstName":"Priscilla","middleName":"Mpho","lastName":"Jama","suffix":""},{"id":484382038,"identity":"36772e41-1b2c-41d5-b4d4-4e4752b7ab05","order_by":2,"name":"Gina Wisker","email":"","orcid":"","institution":"University of Bath","correspondingAuthor":false,"prefix":"","firstName":"Gina","middleName":"","lastName":"Wisker","suffix":""}],"badges":[],"createdAt":"2025-04-21 09:08:29","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6494452/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6494452/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s10459-025-10474-z","type":"published","date":"2025-09-20T15:57:23+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":86668211,"identity":"1a5bf5b8-dd31-430d-95c2-4fc9bc04ebfa","added_by":"auto","created_at":"2025-07-14 11:18:47","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":301807,"visible":true,"origin":"","legend":"\u003cp\u003eThe CanMEDS diagram in a South African context is called the AfriMEDS framework.\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;1. *Copyright © 2015 The Royal College of Physicians and Surgeons of Canada.\u0026nbsp;https://www.royalcollege.ca/rcsite/canmeds/canmeds-framework-e. Reproduced with permission.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6494452/v1/f80bef8420b4fd87cbe13cb8.png"},{"id":91889794,"identity":"9cd4efa7-47ce-4471-b99b-921e0e146d51","added_by":"auto","created_at":"2025-09-22 16:02:12","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1683592,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6494452/v1/8a3176e0-8241-49cc-a0ec-3b39c8ab251d.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"A metaphysical framework for transforming South Africa’s undergraduate medical curricula is proposed within a transformative research paradigm","fulltext":[{"header":"Introduction","content":"\u003cp\u003eSouth African undergraduate medical education faces a critical juncture, grappling with the dual imperatives of meeting regulatory accreditation standards while addressing pressing community health needs, especially in rural areas (Slaven, 2017). This tension causes a fundamental reimagining of curriculum frameworks to reconcile these demands. The CanMEDS physician framework was adapted in 2014 by the Health Professions Council of South Africa (HPCSA) and the South African Committee of Medical Deans (SACoMD) to create AfriMEDS. This is an integrated community-based education (CBE) with a community-oriented approach to healthcare training (De Villiers et al., 2017). However, implementing this framework has revealed systemic challenges in aligning the curriculum with South Africa\u0026apos;s complex healthcare landscape.\u003c/p\u003e\n\u003cp\u003eThe CanMEDS framework, established by the Royal College of Physicians and Surgeons of Canada in 1996 and endorsed internationally by the International Community-Based Medical Education (ICBME) collaborators in 2009, provides a comprehensive competency-based medical education model (Frank et al., 2010b). This framework identifies seven essential physician roles: 1) medical expert (the integrating role), 2) communicator, 3) collaborator, 4) leader (formerly manager), 5) health advocate, 6) scholar, and 7) professional. The transition from \u0026quot;manager\u0026quot; to \u0026quot;leader\u0026quot; role in 2012 reflected the evolving healthcare environment\u0026apos;s need for reform-oriented practitioners (Dath et al., 2015).\u003c/p\u003e\n\u003cp\u003eAfriMEDS responds to South Africa\u0026apos;s persistent healthcare inequalities shaped by historical structures of apartheid. Despite democratic reforms, both public and private sectors continue addressing complex challenges related to socioeconomic backgrounds, language barriers, and literacy levels, necessitating curriculum reform that addresses population needs and health inequalities (World Health Organization, 2013).\u003c/p\u003e\n\u003cp\u003eCBE in this context refers to \u0026quot;decentralised training\u0026quot; occurring outside tertiary academic complexes, including healthcare centres, primary care clinics, and district hospitals (De Villiers et al., 2017). This approach is described as \u0026quot;encouraging and engaging people throughout life into learning that is based on what they are interested in and that emerges in relation to problems and issues experienced daily\u0026quot; (Department of Higher Education and Training, 2012, p.54).\u003c/p\u003e\n\u003cp\u003eCommunity oriented primary care (COPC) addresses disease burden through health promotion, prevention, early detection, and community-based management (Bam et al., 2013). This approach recognises that health outcomes are determined by social environments, requiring interventions that address both individual needs and community contexts.\u003c/p\u003e\n\u003cp\u003eAfriMEDS provides South African medical schools the framework to develop curricula addressing prevalent social challenges including poverty, inequality, and unemployment (Statistics South Africa, 2013), though comprehensive implementation and assessment strategies remain under development (Reid \u0026amp; Cakwe, 2011).\u003c/p\u003e\n\u003cp\u003eThe researcher developed the AfriMEDS framework diagram as illustrated in Figure 1, which expands on the CanMEDS framework: community-oriented care and CBE complement the seven roles of CanMEDS. Not only is community emphasised in Figure 1, but it is also important to show how CBE is integrated with COPC and seven key competencies in the proposed AfriMEDS framework diagram (Fig. 1).\u003c/p\u003e\n\u003cp\u003eThe UFS medical school in Bloemfontein, South Africa, provides the primary setting. This study examines South African medical education and its ongoing efforts to address healthcare disparities and community health needs, especially in rural areas. The time is contemporary, reflecting the current challenges and evolving landscape of medical training in South Africa as it transitions towards national health insurance (NHI) and confronts a quadruple burden of disease.\u003c/p\u003e\n\u003cp\u003eThe need for curriculum transformation in South African medical education is urgent and multifaceted. Medical schools must produce practitioners equipped to address the country\u0026apos;s quadruple burden of disease while navigating resource constraints and persistent health workforce shortages (Mayosi et al., 2009). According to Mayosi et al. in their 2009 study, the quadruple burden of disease in South Africa refers to four major health challenges facing the country: 1) non-communicable diseases, 2) perinatal- and 3) maternal disorders, 4) injury-related disorders. Recent studies have revealed significant impacts on mental health in South Africa following the COVID-19 pandemic and related lockdowns (Hlongwane \u0026amp; Lowton, 2024), which makes the burden of disease to be quintuple. As South Africa transitions toward NHI, the imperative for multidisciplinary, and primary care has never been greater (Republic of South Africa, Department of Health, 2017). Interprofessional education (IPE) and multidisciplinary care are closely linked in the collaborator competency of AfriMEDS. Yet, current pedagogical approaches often struggle to bridge the gap between theoretical competencies and the realities of practice in diverse, underserved communities.\u003c/p\u003e\n\u003cp\u003eThis study aimed to establish a transformative mixed-methods as a metaphysical framework necessary for medical curriculum redesign in South Africa, integrating philosophical paradigms, methodological structures, and analytical processes. Centred to stakeholder co-creation, the framework addresses South Africa\u0026apos;s healthcare equity imperatives while critically evaluating the implementation of the AfriMEDS competency framework within the undergraduate medical curriculum.\u003c/p\u003e\n\u003cp\u003eThe transformative metaphysical framework research paradigm underpinning this study is crucial in addressing the power dynamics and cultural complexities inherent in medical education reform. The traditional hierarchical structure of medical education inherently creates power imbalances that can impede transformative curriculum reform. Senior faculty and administrators often hold disproportionate decision-making power, control budgets and resource allocation, which might marginalise the perspectives of junior educators and students. Educators\u0026rsquo; control over curriculum and assessment can strengthen existing power structures, potentially overlooking community skills highlighted in AfriMEDS. The relationship between provincial and local government health authorities and academic institutions creates a complex power dynamic. These authorities control resources for the clinical training platform, which can lead to tensions between prioritising patient care, service delivery, and medical education. This power imbalance often results in competing demands that must be carefully balanced to meet both healthcare and training needs. The practical implementation of competency frameworks is shaped by assessment designers, who may mis-align evaluation methods with AfriMEDS principles. The relative powerlessness of students in curriculum design processes can hinder the implementation of learner-centred approaches central to AfriMEDS. Acknowledging: The power imbalance is already recognised in the reflexivity section, which acknowledges the principal investigator\u0026rsquo;s senior managerial position and its potential influence. This study implemented several strategies to mitigate this power differential.\u003c/p\u003e\n\u003cp\u003eSouth Africa\u0026apos;s rich sociocultural diversity, with 12 official languages, presents significant healthcare challenges. These challenges include communication barriers, integrating traditional and Western healing systems, and persistent socio-economic inequalities stemming from apartheid in South Africa (Hussey, 2012/13). Rural-urban healthcare disparities, coupled with diverse cultural beliefs influencing health behaviours, further complicate the situation. To prepare physicians for effective cross-cultural communication and developing cultural competence, it is crucial to address these complexities within medical curricula (Knight et al., 2017). This approach enhances students\u0026apos; ability to provide culturally competent care and navigate the unique healthcare challenges in South Africa\u0026apos;s diverse communities.\u003c/p\u003e\n\u003cp\u003eBy using the metaphysical framework, the study deliberately challenges traditional research boundaries by examining structural inequities while re-imagining medical education that authentically serves the public good. By positioning stakeholders as knowledge co-creators, levelling the power imbalances, the transformative paradigm offers methodological insights for researchers investigating complex societal dimensions of health professions education, particularly in contexts where educational reform intersects with social transformation agendas.\u003c/p\u003e\n\u003cp\u003eThrough the lens of the metaphysical framework, the study critically evaluates the implementation of the AfriMEDS competency framework, offering recommendations for transforming pedagogy and curriculum delivery for enhanced community-level healthcare outcomes. By employing mixed methods within this paradigm, the research captures diverse perspectives on curriculum alignment, pedagogical challenges, and graduate preparedness, providing a comprehensive evaluation of competency-based education in resource-constrained settings.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTransformative Research Paradigm as a metaphysical framework for curriculum reform\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCritically examining and aligning the South African undergraduate medical programme\u0026rsquo;s outcomes with both regulatory expectations and societal demands is imperative to ensure the programme meets HPCSA accreditation standards and addresses pressing community health needs.\u003c/p\u003e\n\u003cp\u003eThis study employed a transformative metaphysical framework using mixed-methods to evaluate implementing the AfriMEDS competency framework within the UFS\u0026rsquo;s MBChB curriculum. The transformative research paradigm integrates quantitative and qualitative approaches to address complex societal issues in medical education. It employs triangulation, combining methods like interviews, observations, document reviews, and surveys to collect diverse data types and capture multiple perspectives from participants (Mertens, 2005). This approach allows researchers to examine complex phenomena in medical education comprehensively.\u003c/p\u003e\n\u003cp\u003eResearch paradigms serve as essential philosophical frameworks that guide scholarly inquiry in health professions education. These paradigms represent the implicit worldviews researchers bring to their investigations, influencing methodological choices, analytical approaches, and interpretations of findings (Guba \u0026amp; Lincoln, 2005).\u003c/p\u003e\n\u003cp\u003eBy integrating various methods, researchers gain a comprehensive understanding of complex social phenomena and validate findings across different data sources. The transformative paradigm was chosen for its emphasis on examining power dynamics, cultural complexities, and structural inequities while positioning stakeholders as knowledge co-creators (Turner et al., 2013). This approach aims to reimagine research that authentically serves the public good while illuminating community health challenges.\u003c/p\u003e\n\u003cp\u003eResearch paradigms in health professions\u0026rsquo; education are underpinned by four core philosophical assumptions that collectively define a study\u0026rsquo;s conceptual framework. These assumptions, articulated by Guba and Lincoln (2005), guide researchers in structuring inquiries, interpreting findings, and addressing ethical complexities inherent in medical education contexts.\u003c/p\u003e\n\u003cp\u003eThe transformative research paradigm provided a critical metaphysical framework for this study on medical curriculum redesign in South Africa. This paradigm guided our approach to addressing systemic inequities and power dynamics in medical education while amplifying the voices of the stakeholders. Here, we elaborate on the key assumptions of the transformative paradigm and how they shaped our research design and analysis.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e(a) Ontological Assumptions: The Nature of Reality\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eOntological assumptions interrogate the nature of reality, asking: What makes up evidence of reality in health science education? This assumption focuses on determining what is \u0026ldquo;real\u0026rdquo; and the evidence required to validate phenomena, such as clinical competencies or learning outcomes (Guba \u0026amp; Lincoln, 2005). In medical education, ontological perspectives often reflect a tension between positivist views (universal truths, e.g., anatomical facts) and constructivist interpretations (context-dependent realities, e.g., learned experiences). For instance, while biomedical knowledge may be treated as real, patient care competencies often cause a relativist ontology, where reality is shaped by individual and cultural contexts (Guba \u0026amp; Lincoln, 2005).\u003c/p\u003e\n\u003cp\u003eIn the current study, this meant:\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eStakeholders, including educators, students, and those conducting document analysis, hold diverse perspectives on medical education.\u003c/li\u003e\n \u003cli\u003eThis research examines the influence of social, political, and economic factors on curriculum design and implementation.\u003c/li\u003e\n \u003cli\u003eA critical analysis of power dynamics within healthcare and education systems reveals their impact on learning experiences and outcomes.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eThese assumptions were incorporated by conducting stakeholder interviews and surveys to capture varied realities, and by contextualising curriculum analysis within broader societal structures.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e(b) Epistemological Assumptions: Researcher-Participant Dynamics\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eEpistemological assumptions address the relationship between the researcher (\u0026ldquo;knower\u0026rdquo;) and participants (\u0026ldquo;would-be known\u0026rdquo;). Key questions include: Should investigators maintain neutrality or engage with participants to interpret experiences? While traditionally aligned with positivist distancing, objectivity in medical education research is approached through constructivist methods, emphasising the co-creation of knowledge via immersive engagement (Creswell, 2014). For example, studying empathy in clinical training may require participatory observation to capture subjective learner-patient interactions, challenging the notion of detached neutrality (Creswell, 2014). This guided the approach through:\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eStakeholders should be positioned as co-creators of curriculum knowledge, rather than as subjects.\u003c/li\u003e\n \u003cli\u003eValuing experiential and sociocultural issues alongside academic expertise.\u003c/li\u003e\n \u003cli\u003eCritically examining whose knowledge is privileged in current curriculum frameworks.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eInputs were drawn from the curriculum mapping workshops and incorporating accreditation recommendations into assessment design.\u003c/p\u003e\n\u003cp\u003e(c\u003cem\u003e) Methodological Assumptions: Systematic Inquiry Approaches\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eMethodological assumptions determine the alignment of research design\u0026mdash;quantitative, qualitative, or mixed methods\u0026mdash;with ontological and epistemological foundations. Researchers should select robust approaches, including longitudinal surveys to assess skill retention and phenomenological interviews to explore resilience in trainees, to capture human experience. Methodological rigour in health professions education demands an explicit justification of paradigm choices to ensure findings reflect the complexity of educational realities (Creswell, 2014). In our study, this meant:\u003c/p\u003e\n\u003cp\u003eThe study employed both quantitative surveys and qualitative semi-structured interviews.\u003c/p\u003e\n\u003cp\u003eCurriculum changes are implemented by translating research findings through action-oriented components.\u003c/p\u003e\n\u003cp\u003eThis study\u0026rsquo;s mixed-methods design allowed for triangulation of data while focusing on stakeholders in developing recommendations.\u003c/p\u003e\n\u003cp\u003e(d) \u003cem\u003eAxiological Assumptions: Ethical Frameworks\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAxiological assumptions address the ethical principles that guide research, especially in diverse cultural contexts. Questions include: 1) How are power imbalances addressed in interprofessional education studies? 2) What ethical dilemmas arise when researching marginalised communities? Axiology requires researchers to navigate informed consent, data confidentiality, and cultural sensitivity, ensuring ethical coherence across all study phases (Mertens, 2010). For instance, digital professionalism frameworks must balance transparency in data collection with privacy concerns in online learning environments (Mertens, 2010). These values were upheld by:\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eAddressing power imbalances between researchers and participants.\u003c/li\u003e\n \u003cli\u003eEnsuring cultural responsiveness in data collection and analysis methods.\u003c/li\u003e\n \u003cli\u003eFraming recommendations to advance health equity and social accountability.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eThis ethical stance informed the collaborative approach with the UFS medical school and emphasis on decolonial pedagogies and addressing sociocultural inequities in our findings. Language policies in medical education can reinforce power hierarchies, perpetuate decolonial power perspectives in multilingual contexts like South Africa.\u003c/p\u003e\n\u003cp\u003eThese transformative assumptions led this study beyond a technical curriculum alignment evaluation to a critical examination of how medical education can address systemic inequities in South African healthcare. This paradigm enabled the researchers to not only describe current challenges but\u003cem\u003e\u0026nbsp;\u003c/em\u003ealso co-create actionable pathways for transformative change in partnership with diverse stakeholders.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSynthesis and Implications\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThese assumptions collectively shape paradigm selection, influencing how medical educators investigate phenomena\u0026mdash;from competency assessments to equity in training. Explicitly articulating ontological, epistemological, methodological, and axiological foundations enhances methodological transparency, rigour, and reproducibility in research (Nieuwenhuis, 2007). As health science education evolves, paradigm awareness remains critical for advancing pedagogies that reflect both scientific and humanistic dimensions of learning.\u003c/p\u003e\n\u003cp\u003eSocial science research operates within quantitative and qualitative paradigms (Mills et al., 2010). Researchers may favour one approach or combine both, with proponents arguing combined approaches enhance a phenomenon of understanding (Atieno, 2009). However, mixed methods present a philosophical paradox: quantitative research assumes a single, independent reality, while qualitative research presupposes multiple contextual realities (Harrison et al., 2017). These fundamental ontological assumptions shape all research endeavours, including mixed-methods case studies.\u003c/p\u003e\n\u003cp\u003eThis study employed a mixed methods approach and triangulated data, with Bhatta (2018) noting that misunderstandings often surpass challenges in mixed-methods research. Within the transformative paradigm, the researcher\u0026apos;s role is pivotal in recognising societal inequalities and challenging the status quo (Mertens, 2007). Positioned within this paradigm, the study examines community-based medical education transformation, exploring how the UFS medical school, through AfriMEDS as a transformative pedagogical tool, can enhance curriculum delivery and improve community-level healthcare services.\u003c/p\u003e\n\u003cp\u003eThe transformative paradigm reframes worldviews and informs methodological decisions (Mertens, 2005). This study adopted a mixed methods approach, emphasising community participation to address cultural complexities, build trust, validate data, and implement findings (Mertens, 2007). Triangulation enabled integrating qualitative and quantitative approaches\u0026mdash;document reviews, interviews and surveys\u0026mdash;to capture diverse perspectives (Mertens, 2007). Positioned within this paradigm, the study critically evaluates the UFS MBChB program\u0026rsquo;s implementation of AfriMEDS physician competency framework, offering recommendations to transform pedagogy and curriculum delivery for enhanced community-level healthcare outcomes.\u003c/p\u003e\n\u003cp\u003eThere are different mixed-methods designs, which are convergent parallel, explanatory sequential and exploratory sequential (Creswell \u0026amp; Clark, 2011). In this study, the convergent parallel design was used as an example of a triangulation process (Creswell, 2014), integrated both qualitative and quantitative approaches in the research. This allowed for simultaneous collection and analysis of multiple data streams, followed by integration, to provide a comprehensive understanding of curriculum alignment and implementation challenges of the AfriMEDS competency framework.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eStakeholder Engagement Process\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe study employed a multi-faceted approach to stakeholder engagement, including:\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eDocument analysis of curriculum materials and policy documents.\u003c/li\u003e\n \u003cli\u003eSemi-structured interviews with 15 educators.\u003c/li\u003e\n \u003cli\u003eCross-sectional surveys of 71 medical interns.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e\u003cem\u003eThis comprehensive stakeholder (educators and interns) engagement approach supported\u003c/em\u003e by document analysis aligns with best practices in curriculum development, as outlined by Iwasiw and Goldenberg (2015), who emphasise the importance of diverse stakeholder input.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eQualitative methods included:\u003c/em\u003e\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eDocument analysis involved word searches across UFS phase guides, the 2018 HPCSA accreditation report, and MBChB rules to assess AfriMEDS competency implementation and assessment. Frequencies of competencies, main themes (with various subthemes) emerged from the data. At this stage, it is important to mention the rigour of the HPCSA accreditation process for medical schools and what it entails:\u003c/li\u003e\n \u003cli\u003eSelf-evaluation by the institution.\u003c/li\u003e\n \u003cli\u003eSite visits by an accreditation team.\u003c/li\u003e\n \u003cli\u003eReview of curriculum, facilities, faculty, and resources.\u003c/li\u003e\n \u003cli\u003eAssessment of compliance with standards.\u003c/li\u003e\n \u003cli\u003eRecommendations for improvement.\u003c/li\u003e\n \u003cli\u003eGranting of accreditation status.\u003c/li\u003e\n \u003cli\u003eSemi-structured interviews with 15 educators, selected through purposive sampling to capture diverse pedagogical roles. Participants were introduced to the study, provided with consent forms, and interviews were scheduled on UFS-approved Blackboard Collaborate, ensuring convenience and privacy. Written and verbal consent was obtained, and all interviews were recorded.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eThe method involved four steps:\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eTranscription: Interviews were audio-recorded and transcribed verbatim using Otter.ai. Initial impressions and keywords were identified.\u003c/li\u003e\n \u003cli\u003eCoding: Transcripts were analysed using NVivo 12 software, grouping related data into themes and subthemes through manual coding.\u003c/li\u003e\n \u003cli\u003eTheme Development: Verbatim nodes were exported from NVivo, and recurring keywords elevated themes or subthemes based on frequency and intent.\u003c/li\u003e\n \u003cli\u003eTriangulation: Themes were refined by cross-referencing data from educator interviews, intern surveys, and document analysis.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e\u003cem\u003eQuantitative methods involved\u003c/em\u003e:\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eA cross-sectional survey of 71 UFS medical interns (31% response rate) to assess perceived competency preparedness. Quantitative data was gathered using an online survey targeting first- and second-year medical interns registered with the HPCSA in 2020. The researcher accessed a database of 240 eligible UFS graduates, but after removing duplicates and invalid email addresses, 225 invitations were sent. Interns were given six weeks to complete the survey on EvaSys, with reminders sent weekly. Participation was voluntary, with confidentiality assured, though the survey was not anonymous. Ultimately, 71 interns responded, yielding a 31% response rate, below the target of 50%.\u003c/li\u003e\n \u003cli\u003eThe response rate was analysed using Nulty\u0026rsquo;s (2008) framework, which compares \u0026quot;Liberal conditions\u0026quot; (10% sampling error, 80% confidence level) and \u0026quot;Stringent conditions\u0026quot; (3% sampling error, 95% confidence level). Under liberal conditions, the response rate exceeded expectations (12%), but it fell short of stringent benchmarks (73\u0026ndash;77%). Challenges like outdated contact details and the COVID-19 pandemic likely contributed to the lower response rate.\u003c/li\u003e\n \u003cli\u003eDespite these limitations, the response rate was deemed acceptable for an online survey during a pandemic. Literature confirms that online surveys generally achieve lower response rates than paper-based ones (33% vs. 56%). The study highlighted the importance of ensuring representativeness in survey results.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e\u003cstrong\u003eEthical considerations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was granted from the University of the Free State Health Sciences Research Ethics Committee (UFS-HSD2020/1420/2710) and the University of Bath (S20-068). Additional clearances were secured from national and provincial health departments (NHRD 202009_009). All participants provided informed consent, and data were anonymised to ensure confidentiality.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eReflexivity\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn health sciences education, reflexivity plays a crucial role in ensuring the integrity and validity of research (McIntosh, 2023). The example provided shows several key aspects of reflexivity:\u003c/p\u003e\n\u003cp\u003e1. \u003cem\u003eAcknowledging their positionality\u003c/em\u003e, the principal researcher recognised their role as a senior manager at the UFS School of Medicine and its potential influence on the study (Alexander et al., 2020). Researchers can critique their own position in relation to the research process and participants \u003cem\u003ethrough reflexive self-awareness\u003c/em\u003e( McIntosh, 2023).\u003c/p\u003e\n\u003cp\u003e2.\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Potential bias from the researcher\u0026rsquo;s senior position was mitigated by assigning an external research assistant (McIntosh, 2023) to conduct the interviews. This decision reflects a conscious effort to minimise undue influence on junior colleagues participating in the study.\u003c/p\u003e\n\u003cp\u003e3. \u003cem\u003eStandardising data collection\u003c/em\u003e: The use of a standardised interview guide/questionnaire helped mitigate potential bias introduced by the external researcher assistant\u0026apos;s expertise in curriculum studies (Ho, \u0026amp; Limpaecher, 2022). This approach ensures consistency in data collection across all participants.\u003c/p\u003e\n\u003cp\u003e4. \u003cem\u003eEnsuring participant anonymity\u003c/em\u003e: The study design incorporated measures to anonymise and blind participant responses to the principal researcher (Denniston, 2023). This practice helps maintain objectivity and reduces the risk of bias in data analysis and interpretation (Denniston, 2023).\u003c/p\u003e\n\u003cp\u003e5.\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Triangulation: The study employed robust triangulation methods to address inherent biases while capturing nuanced stakeholder experiences (Denniston, 2023). Triangulation enhances the credibility and trustworthiness of the research findings by cross-verifying data from multiple sources (Denniston, 2023).\u003c/p\u003e\n\u003cp\u003e6.\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Transparency and reflexivity are showed in the study through the explicit reporting of the researcher\u0026rsquo;s role, potential biases, and mitigation strategies (Alexander et al., 2020). This openness enables readers to evaluate the research process and findings critically (Alexander et al.; 2020).\u003c/p\u003e\n\u003cp\u003e7.\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Critical Reflexivity: Encouraging all stakeholders to engage in ongoing reflection on how their positions of power influence educational practices and outcomes(McIntosh, 2023).\u003c/p\u003e\n\u003cp\u003eThese reflexive practices contribute to the rigour and credibility of the research, aligning with the principles of reflexivity in health sciences education. By engaging in this critical self-examination process, researchers can better understand and account for how their own perspectives, biases, and experiences influence their work, leading to more robust and trustworthy research outcomes. The South African medical education landscape continues to operate in what Reid (n.d) describes as a \u0026quot;reproductive rather than transformative mode,\u0026quot; perpetuating historical inequities despite policy imperatives for transformation. This disconnect between transformative policy intentions and reproductive educational practices signals the need for critical reflexivity at institutional and system levels. Without explicit attention to social reflexivity in particular, medical curriculum redesign risks maintaining what Ajani identifies as \u0026quot;affirmative rather than transformative\u0026quot; approaches that address redistributive justice while neglecting issues of misrecognition and representation (Ajani, 2024).\u003c/p\u003e\n\u003cp\u003eThe transformative potential of reflexivity lies in its capacity to reveal and challenge the \u0026quot;fitness of purpose\u0026quot; rather than merely the \u0026quot;fitness for purpose\u0026quot; of medical education (Reid, n.d). When applied to curriculum redesign, reflexivity enables educators to question not just how effectively they are achieving predetermined objectives, but whether those objectives themselves serve the needs of the South African society. This critical orientation aligns with calls for medical educators to \u0026quot;put South Africa first\u0026quot; and \u0026quot;place transformation at the heart of the educational process (Reid, n.d).\u003c/p\u003e\n\u003cp\u003eReflexivity makes up more than a cognitive skill\u0026mdash;it represents an ethical stance that acknowledges the socio-political dimensions of medical education and practice(McIntosh, 2023). South African medical education can better serve transforming healthcare and society by prioritising reflexivity in curriculum redesign, moving beyond mere technical reforms to address fundamental questions about its role (Hickman et al., 2022).\u003c/p\u003e"},{"header":"Findings","content":"\u003cp\u003e\u003cstrong\u003eDocument analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe following points were raised as matters of concern in the \u003cem\u003eHPCSA accreditation report of 2018\u003c/em\u003e:\u003c/p\u003e\n\u003cp\u003ea)\u0026nbsp; \u0026nbsp;\u0026ldquo;Sesotho training should be formally introduced in the curriculum in the faculty to enhance student-patient communication.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eb)\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Increasing interaction and greater use of the platform for interprofessional learning.\u003c/p\u003e\n\u003cp\u003ec)\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;The phase reviews of the curriculum should be formalised and feedback given to the faculty.\u003c/p\u003e\n\u003cp\u003ed)\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Expansion of CBE activities.\u003c/p\u003e\n\u003cp\u003ee)\u0026nbsp; \u0026nbsp;Develop a parallel course to assess student suitability for medical school admission, without disadvantaging new Learning development Programme (LDP) admissions. The LDP is a remedial programme, a program designed to support student academic development and success, focusing on enhancing learning skills and providing necessary support.\u003c/p\u003e\n\u003cp\u003ef)\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Increasing student and staff numbers.\u003c/p\u003e\n\u003cp\u003eg)\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Consistency in assessment needs to be ensured.\u003c/p\u003e\n\u003cp\u003eh)\u0026nbsp; \u0026nbsp;There is no opportunity in the curriculum for students to experience continuity of care, and primary care rotations are mostly short.\u003c/p\u003e\n\u003cp\u003ei) \u0026nbsp; \u0026nbsp;Development of a longitudinal integrated programme in several sites for a few students.\u003c/p\u003e\n\u003cp\u003eDocument analysis shows that health advocate, leader, manager, and scholar competencies are underrepresented in all phases of the UFS undergraduate medical program, and professional and health advocate assessment tools are absent from the program\u0026rsquo;s phase guides(Table 1).\u003c/p\u003e\n\u003cp id=\"_Toc27303\"\u003e\u003cstrong\u003eTable\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;1.\u003c/strong\u003e Comparison across Phases I-III and LDP on the number of times core competencies were mentioned in the phase module guides\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"83%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCORE COMPETENCIES\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePHASE I\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePHASE II\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePHASE III\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLDP\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCommunicat\u003c/strong\u003e\u003cstrong\u003eor\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCollaborat\u003c/strong\u003e\u003cstrong\u003eor\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eProfessional\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eScholar\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLeader and manager\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHealth advoca\u003c/strong\u003e\u003cstrong\u003ete\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCommunity-based education\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003e\u003csup\u003eNotes: LDP=learning development programme\u003c/sup\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eTable 2 shows the key findings across educators and interns, highlighting each AfriMEDS competency how is it perceived and sufficiently assessed:\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2.\u003c/strong\u003e Summary of key findings across educators and interns, highlighting each AfriMEDS competency how is it perceived and sufficiently assessed.\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" align=\"\" width=\"588\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCompetency\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eAnd\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eCategory\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eEducator Interviews\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eAfriMEDS core competencies\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eincluded and assessed in modules\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003en= 15\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eIntern Survey on perceived sufficient assessment of core AfriMEDS competencies in the undergraduate programme and open-ended questions online survey subcategories\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003en=71\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e1. Scholar\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e93% agree\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eKey theme category\u003c/strong\u003e\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003e\u003cem\u003eNo formal assessment\u003c/em\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e90 % satisfaction\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eInsufficient assessment subcategory:\u003c/strong\u003e\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eLimited teaching and training\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e2. Professional\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e100% agree\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eKey theme category\u003c/strong\u003e\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003e\u003cem\u003eSufficiently assessed\u0026nbsp;\u003c/em\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e84 % satisfaction\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eInsufficient assessment subcategory:\u003c/strong\u003e\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eDifficulty in assessment\u003c/li\u003e\n \u003cli\u003eLimited attention\u003c/li\u003e\n \u003cli\u003eNo formal assessment\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e3. Collaborator\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e86% agree\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eKey theme category\u003c/strong\u003e\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003e\u003cem\u003eNo formal assessment\u003c/em\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e72 % satisfaction:\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eInsufficient assessment subcategory:\u003c/strong\u003e\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eNo formal assessment\u003c/li\u003e\n \u003cli\u003eNo effective collaborator\u003c/li\u003e\n \u003cli\u003eTask shifting\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e4. Communicator\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e93% agree\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eKey theme category\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026bull;\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/strong\u003e\u003cem\u003eNo formal assessment agree\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e78 % satisfaction\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eInsufficient assessment subcategory\u003c/strong\u003e\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eNo formal assessment\u003c/li\u003e\n \u003cli\u003eLack of face-to-face assessment\u003c/li\u003e\n \u003cli\u003eCommunicator is not formally taught\u003c/li\u003e\n \u003cli\u003eLimited counselling lessons\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e5. Leader \u0026amp; Manager\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e53% agree\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eKey theme category:\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026bull;\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/strong\u003e\u003cem\u003eNo formal assessment agree\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eLowest satisfaction rating (63%)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eInsufficient assessment subcategory:\u003c/strong\u003e\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eNo formal assessment\u003c/li\u003e\n \u003cli\u003eLack of platforms for assessment\u003c/li\u003e\n \u003cli\u003eLimited skills assessed\u003c/li\u003e\n \u003cli\u003ePractice opportunities granted to the select few\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e6. Health Advocate (Community engagement)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e73% agree:\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e(It was reflected under\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003ecommunity-engagement by\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eeducators.)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eOver 78 % satisfaction\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eInsufficient assessment subcategory:\u003c/strong\u003e\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eNo formal assessment\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e7. Community-Based Education\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e66 % agree\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eKey theme category:\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026bull;\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/strong\u003e\u003cem\u003eNo formal assessment agree\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e71% satisfaction\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eInsufficient assessment subcategory:\u003c/strong\u003e\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eNo formal assessment\u003c/li\u003e\n \u003cli\u003eLanguage barrier\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e8. Medical Expert\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e80% agree\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e(Educators felt that medical expert was an integrating role that incorporate all other 7 competencies therefore was calculated as a percentage average score)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eHighest satisfaction (91%)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eInsufficient assessment subcategory:\u003c/strong\u003e\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eNo formal assessment\u003c/li\u003e\n \u003cli\u003eLack of clinical exposure\u003c/li\u003e\n \u003cli\u003eInsufficient time for assessment\u003c/li\u003e\n \u003cli\u003eSubjective assessment\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u0026nbsp;Here is a tabulated summary of challenges and gaps identified in the implementation and assessment of AfriMEDS competencies at the UFS, based on findings from document analysis, educator interviews, and intern surveys (Table 3).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3.\u0026nbsp;\u003c/strong\u003eSummary of challenges and gaps identified in the implementation and assessment of AfriMEDS competencies at the UFS, based on findings from document analysis, educator interviews, and intern surveys.\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" align=\"\" width=\"671\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCompetency\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDocument Analysis Challenges/Gaps\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eEducator Interviews Challenges/Gaps\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eIntern Survey Challenges/Gaps\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eScholar\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;Core competencies of... scholar feature less prominently across all\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003ephases.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;Incomplete implementation of the scholar role, focusing mainly on research methodology but neglecting teaching and dissemination.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eInterns noted gaps in research skills: \u003cem\u003e\u0026quot;Limited ability to\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003ecritically evaluate evidence and apply it in clinical settings.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eProfessional\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;Professional role assessment tools are not mentioned in phase guides.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;Professionalism is taught informally through role modelling rather than structured assessments.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eInterns felt professionalism was learned through observation: \u003cem\u003e\u0026quot;No formal evaluation mechanisms\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003efor professional behaviour.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCollaborator\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eLimited evidence of assessment tools for collaboration skills.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;Interprofessional education exists but lacks formal assessment methods.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e72% satisfaction: \u003cem\u003e\u0026quot;Insufficient opportunities to practice team leadership and conflict resolution.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCommunicator\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCommunicator competencies mentioned but lacked aligned assessment tools.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;Challenges in assessing complex communication scenarios like breaking bad news or addressing language barriers.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e79% satisfaction: \u003cem\u003e\u0026quot;Difficulty communicating with families and across language barriers during internship.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eLeader \u0026amp; Manager\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;Leader and manager competencies feature less prominently in curriculum documents.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;Uncertainty about how to teach leadership effectively; resource management skills are underemphasized.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eLowest satisfaction (63%): \u003cem\u003e\u0026quot;Unprepared for administrative responsibilities, resource allocation, and team leadership.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eHealth\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eAdvocate\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;Health advocate assessment tools are absent from phase guides.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;Advocacy training lacks systematic integration into the curriculum; focus remains on individual patient advocacy rather than systemic change.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eInterns reported limited preparation for systemic\u003c/p\u003e\n \u003cp\u003eadvocacy: \u003cem\u003e\u0026quot;Few opportunities\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eto engage with community-level health interventions.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCommunity-Based\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eEducation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eImplicitly included but not explicitly mapped to COPC (Community-Oriented\u003c/p\u003e\n \u003cp\u003ePrimary Care).\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;Challenges include staff shortages, increasing student numbers, limited time, COVID-19 disruptions, and insufficient clinical exposure.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e71% satisfaction: \u003cem\u003e\u0026quot;Limited\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eexposure to diverse community settings; insufficient time for meaningful engagement with communities.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMedical\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eExpert\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNo major challenges reported; central competency well-represented in documents.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNo major gaps reported; educators emphasized rigorous assessment through OSCEs and case\u003c/p\u003e\n \u003cp\u003epresentations.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHighest satisfaction (\u0026gt;85%): Interns felt well-prepared for clinical diagnosis and\u003c/p\u003e\n \u003cp\u003emanagement tasks.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eKey Observations from Table 3:\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e1.\u0026nbsp; \u0026nbsp;Underrepresented Competencies: Leader and Manager, Health Advocate, Collaborator, Community engagement and CBE were consistently identified as problematic across all data sources.\u003c/p\u003e\n\u003cp\u003e2.\u0026nbsp; \u0026nbsp;Assessment Misalignment: Document analysis revealed that existing tools did not align with recommended methods for assessing AfriMEDS roles.\u003c/p\u003e\n\u003cp\u003e3.\u0026nbsp; \u0026nbsp;Contextual Barriers: Educators highlighted systemic issues such as staff shortages, COVID-19 disruptions, and lack of time as significant barriers to competency development.\u003c/p\u003e\n\u003cp\u003e4.\u0026nbsp; \u0026nbsp;Intern Feedback: Interns expressed dissatisfaction with preparation in non-medical expert roles, particularly leader and manager (63%) and collaborator (72%).\u003c/p\u003e\n\u003cp\u003eThis summary emphasises the need for better curriculum alignment, enhanced assessment strategies, and targeted interventions to address underrepresented competencies.\u003c/p\u003e\n\u003cp\u003eGrounded in a transformative metaphysical framework here is the summary of key insights from using the convergent parrel design triangulation approach:\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eConsistent gaps: Leader/manager, health advocate, community engagement and CBE competencies were underdeveloped across all data sources.\u003c/li\u003e\n \u003cli\u003eAssessment misalignment: Documents, educators, and interns all noted a disconnect between curriculum goals and assessment tools for non-clinical roles.\u003c/li\u003e\n \u003cli\u003eContextual barriers: COVID-19, staff shortages, and time constraints disproportionately impacted CBE and collaborative training.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eThese findings highlight the need for systemic curriculum reform to realise the potential of the AfriMEDS framework in preparing physicians for South Africa\u0026apos;s healthcare needs. Misaligned assessment tools, insufficient faculty training, limited clinical exposure, and inadequate time are some issues which reflect the larger national challenges in medical education reform. To bridge the gap between institutional goals and community health needs, the analysis emphasises the importance of decolonial teaching methods and collaborative efforts with stakeholders. This work advances discourse on context-responsive curriculum design, proposing dynamic implementation frameworks that harmonise regulatory standards with transformative healthcare equity goals. It highlights the imperative for iterative curriculum renewal processes, faculty development initiatives, and integrated community engagement to cultivate physicians equipped for South Africa\u0026rsquo;s evolving healthcare landscape. Through the use of the metaphysical transformative framework, the study critically evaluated AfriMEDS competency integration within the MBChB curriculum, examining systemic implementation and assessment challenges. By analysing curriculum alignment with South Africa\u0026apos;s healthcare needs, it highlights barriers to preparing physicians for community-oriented care amidst evolving pedagogical paradigms.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe study findings highlight gaps in implementing and evaluating AfriMEDS graduate competencies, including insufficient clinical time dedicated to CBE, inadequate quality in clinical supervision, training, and assessment, as well as limited opportunities for students to learn patients\u0026apos; languages, develop essential soft skills, and gain the attributes necessary for effective counselling and community engagement.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eImplications for Systemic Reform and Transformative Pedagogies\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study\u0026apos;s findings illuminate critical challenges in implementing the AfriMEDS competency framework within South African medical education at the UFS. The transformative metaphysical framework using a mixed-methods approach revealed systemic barriers to aligning curriculum with national healthcare priorities, echoing broader challenges in medical education reform across resource-constrained settings. The study showed that adopting a transformative research paradigm can catalyse curriculum redesign by harmonising pedagogical objectives with South Africa\u0026rsquo;s healthcare equity imperatives. This approach, integrating critical reflection and stakeholder co-creation, aligns with evidence from Lochner et al. (2018), where transformative learning (TL) frameworks enabled residents to address systemic health inequities through social change-oriented curricula.\u003c/p\u003e\n\u003cp\u003eTransformative learning frameworks can facilitate developing competencies in health advocacy, leadership, CBE and COPC by:\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eEncouraging critical reflection on societal health inequities.\u003c/li\u003e\n \u003cli\u003eChallenging students\u0026apos; assumptions about healthcare delivery.\u003c/li\u003e\n \u003cli\u003eFostering perspective transformation through community immersion experiences.\u003c/li\u003e\n \u003cli\u003ePromoting dialogue between students and diverse community stakeholders.\u003c/li\u003e\n \u003cli\u003eIntegrating reflective practices to connect theory with lived experiences.\u003c/li\u003e\n \u003cli\u003eUtilising problem-based learning focused on real community health challenges.\u003c/li\u003e\n \u003cli\u003eIncorporating participatory action research projects.\u003c/li\u003e\n \u003cli\u003eEmphasising the social determinants of health in curriculum design.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eThese approaches can help students develop a critical consciousness about health systems and their role as change agents, essential for effective advocacy, leadership, and community-oriented practice.\u003c/p\u003e\n\u003cp\u003eCBE emerged as a linchpin for sustainable transformation, consistent with findings from Stellenbosch University\u0026rsquo;s Ukwanda Rural Clinical School, where extended rural immersion increased graduates\u0026rsquo; readiness for underserved practice (Talib et al., 2013). However, structural barriers persist: fragmented assessment tools and faculty capacity gaps hinder AfriMEDS implementation, echoing challenges identified in Community-based education and service (COBES) programs across Africa (Amalba et al., 2020). To address this, the study advocates for reflexive curriculum design\u0026mdash;a pragmatic approach combining competency benchmarks with iterative feedback loops, as validated in the Medical Education e-Professionalism \u0026ldquo;MEeP\u0026rdquo; framework\u0026rsquo;s emphasis on researcher reflexivity and stakeholder validation (Guraya et al., 2023).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCurriculum Alignment and Implementation Challenges\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDocument analysis and educator interviews revealed uneven emphasis across AfriMEDS competency roles, with deficiencies in health advocate, community engagement, leadership, and CBE. This aligns with Whitehead et al.\u0026apos;s (2015) findings that intrinsic roles like health advocate and collaborator are challenging to assess because of their contextual nature. The study\u0026apos;s identification of misaligned assessment tools and insufficient faculty development mirrors challenges reported in implementing competency-based frameworks.\u003c/p\u003e\n\u003cp\u003eA potential mismatch exists between curriculum goals and results, as shown by the difference between how educators perceive interns\u0026rsquo; preparedness and how interns assess themselves. While over 80% of interns felt prepared overall, lower ratings for leader/manager (63%) and CBE (71%) roles suggest areas for targeted improvement. These findings resonate with broader discourse on the complexities of translating competency frameworks into practice, in settings with resource constraints and evolving healthcare landscapes.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eTransformative Paradigm Insights\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eEmploying a transformative research paradigm proved effective in illuminating structural inequities while reimagining medical education that serves the public good. This approach enabled:\u003c/p\u003e\n\u003cp\u003eStakeholder co-creation: By positioning educators and interns as knowledge co-creators, the study captured nuanced perspectives on curriculum alignment and implementation challenges.\u003c/p\u003e\n\u003cp\u003ePower dynamics examination: The method revealed how institutional constraints and faculty capacity gaps impact translating policy into practice.\u003c/p\u003e\n\u003cp\u003eCultural complexities: The study highlighted the need for responsive pedagogies that address South Africa\u0026apos;s unique healthcare challenges and social determinants of health.\u003c/p\u003e\n\u003cp\u003eThe transformative research paradigm employed in this study illuminated how power dynamics and cultural complexities inherent in medical education reform create implementation barriers. As one educator noted:\u003c/p\u003e\n\u003cp\u003e\u0026quot;The relative powerlessness of students in curriculum design processes can hinder implementing learner-centred approaches central to AfriMEDS.\u0026quot;\u003c/p\u003e\n\u003cp\u003eThis paradigm aligns with calls for decolonial approaches to medical education in Africa, emphasising prising community-engaged learning and social accountability.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eDecolonial Pedagogies for Transformative Medical Education\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe concept of decolonial pedagogies offers a crucial framework for transforming medical education in South Africa beyond technical curricular reforms. Decolonial pedagogies challenge dominating Western epistemologies and recognise diverse knowledge systems, those marginalised through colonial processes. These approaches move beyond mere inclusion of cultural content to reconsidering what makes up valid knowledge, who produces it, and how it is taught and assessed (Wong et al., 2021).\u003c/p\u003e\n\u003cp\u003eDecolonial pedagogies in medical education cause a shift from what Reid (n.d) describes as a \u0026quot;reproductive rather than transformative mode\u0026quot; that has perpetuated historical inequities despite policy imperatives for transformation (Reid, n.d). This aligns with our findings that despite adopting the AfriMEDS framework, implementation challenges persist, in areas that require engagement with local health contexts and community needs.\u003c/p\u003e\n\u003cp\u003eSpecific examples of decolonial pedagogies that can be integrated into the medical curriculum include:\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003e\u003cem\u003eCommunity-based participatory learning\u003c/em\u003e: This approach involves students learning directly from community health workers and traditional healers, valuing their knowledge as legitimate and complementary to biomedical perspectives (Lawrence et al., 2022). For example, Walter Sisulu University has implemented programs where students engage with community health priorities through collaborative projects co-designed with community members (Osman \u0026amp; Maringe, 2019).\u003c/li\u003e\n \u003cli\u003e\u003cem\u003eCritical reflection on medical epistemologies\u003c/em\u003e: Structured reflective exercises that prompt students to examine the historical and cultural assumptions underlying medical concepts and practices. This could include a critical analysis of how medical conditions are defined, diagnosed, and treated across different cultural contexts (Mbaki et al., 2021).\u003c/li\u003e\n \u003cli\u003e\u003cem\u003eIntegrating indigenous healing traditions\u003c/em\u003e: Formal incorporation of African healing traditions into the curriculum, not as historical artifacts but as living knowledge systems with ongoing relevance (Swidrovich, 2020). The University of KwaZulu-Natal has developed modules where traditional health practitioners co-teach with medical faculty to provide students with a comprehensive understanding of complementary approaches to healing (Hlongwane \u0026amp; Lowton, 2024)\u003c/li\u003e\n \u003cli\u003e\u003cem\u003eDecolonial case-based learning\u003c/em\u003e: Adapting case studies to reflect the lived realities of diverse South African communities, ensuring representation of health conditions as they manifest across different population groups (Perkins, et al. 2023). This includes cases that address social determinants of health unique to post-apartheid South Africa (Hlongwane, \u0026amp; Lowton, 2024).\u003c/li\u003e\n \u003cli\u003e\u003cem\u003eLanguage-inclusive clinical training\u003c/em\u003e: Incorporating multilingual approaches to clinical education that validate and utilise South Africa\u0026apos;s diverse languages (English et al., 2022). This could include training in healthcare interpretation and development of multilingual clinical resources that bridge communication gaps between healthcare providers and patients (Koch et al., 2024).\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eThese pedagogical approaches address the cultural competence gaps identified in the present study. The current AfriMEDS implementation at UFS revealed significant deficiencies in preparing graduates for health advocacy and community engagement, in understanding and responding to diverse cultural perspectives on health. By integrating decolonial pedagogies, medical education can move beyond superficial cultural awareness to develop what Wong et al. (2021) term \u0026quot;cultural safety\u0026quot; \u0026ndash; the ability to recognise and respect the cultural identities of others and meet their needs, rights, and expectations. By integrating specific decolonial pedagogies, such as community-based participatory learning, critical reflection on medical epistemologies, and incorporating indigenous healing traditions, into the curriculum. This should involve collaborations with community health workers, traditional healers, and other stakeholders.\u003c/p\u003e\n\u003cp\u003eThese approaches promote health equity by acknowledging and addressing power imbalances in healthcare relationships. As Chandanabhumma and Narasimhan (2020) argue, decolonial approaches in health education confront the structural determinants of health inequities by equipping future practitioners with the tools to recognise and challenge systemic barriers to care. The findings of the current study on the uneven emphasis across AfriMEDS competencies in health advocacy and leadership roles suggest that decolonial pedagogies offer a pathway for strengthening these critical domains.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eImpact on Recommendations\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStakeholder input influenced the study\u0026apos;s recommendations for curriculum redesign:\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eCommunity-based participatory learning should be integrated throughout the curriculum, not just in the final years.\u003c/li\u003e\n \u003cli\u003eDevelopment of culturally responsive assessment methods.\u003c/li\u003e\n \u003cli\u003eEnhanced faculty development programs focused on community engagement and decolonial pedagogies.\u003c/li\u003e\n \u003cli\u003eStrengthened partnerships with rural healthcare facilities for longitudinal student placements.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eThese recommendations reflect a synthesis of stakeholder perspectives and align with global trends in medical education reform, as noted by Guraya et al. (2023).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eSystemic Reform Implications\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study\u0026apos;s findings underscore needing transcending additive curriculum reforms in favour of paradigm shifts that centre social accountability. Three critical areas for systemic reform emerge:\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003e\u003cem\u003eParticipatory Curriculum Design\u003c/em\u003e: Implementing collaborative processes that involve students, junior faculty, and community representatives in curriculum decisions.\u003c/li\u003e\n \u003cli\u003eBridging cultural competence gaps through decolonial pedagogies that integrate traditional health systems and community-engaged learning models.\u003c/li\u003e\n \u003cli\u003eFaculty development should prioritise training in competency-based assessment and transformative learning methodologies.\u003c/li\u003e\n \u003cli\u003eStructural alignment involves advocating for HPCSA accreditation reforms requiring granular curriculum audits and iterative improvement processes.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eThese recommendations align with global trends in medical education reform, emphasising the need for dynamic implementation frameworks that harmonise regulatory standards with transformative healthcare equity goals.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eLimitations and Future Directions\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAs a single-case study focused on UFS\u0026mdash;South Africa\u0026rsquo;s sole five-year medical program\u0026mdash;findings are context specific, limiting direct generalizability. Institutions facing similar resource constraints can learn from insights into competency-based curriculum reform (Mertens, 2010).\u003c/p\u003e\n\u003cp\u003eThe 31% survey response rate, though below the 50% target, aligns with Nulty\u0026rsquo;s (2008) \u0026ldquo;Liberal conditions\u0026rdquo; (10% sampling error, 80% confidence), with post-hoc power analyses confirming detectability of key outcomes. COVID-19 disruptions and December/January 2020/21 recruitment timing likely impacted participation, underscoring challenges in longitudinal health professions research.\u003c/p\u003e\n\u003cp\u003eTo mitigate potential bias, the external qualitative researcher used standardized interview protocols and anonymized data. Although small sample sizes limit broader conclusions about the population, combining the findings with document analysis and educator interviews increased the study\u0026rsquo;s trustworthiness (Creswell, 2014).\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003e\u003cem\u003eContext-Responsive Curriculum Design and Future Directions\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis mixed-methods case study, grounded in a transformative research paradigm, examined the integration of the AfriMEDS competency framework within the UFS MBChB curriculum. Methodologically, it combined document analysis, which included the accreditation report informed by the HPCSA accreditation process, educator interviews, and intern surveys to triangulate findings on curriculum alignment and pedagogical challenges.\u003c/p\u003e\n\u003cp\u003eThe transformative mixed-methods approach proved effective in illuminating structural inequities while reimagining medical education that authentically serves the public good. By positioning stakeholders as knowledge co-creators, the study captured nuanced perspectives on curriculum alignment and implementation challenges, offering a model for evaluating complex educational interventions in resource-limited settings.\u003c/p\u003e\n\u003cp\u003eSpecific examples discussed\u0026mdash;community-based participatory learning, critical epistemological reflection, integration of indigenous healing traditions, decolonial case-based learning, and language-inclusive clinical training\u0026mdash;provide concrete pathways for curriculum redesign. These approaches address cultural competence gaps by moving beyond tokenistic inclusion of cultural content to reconsidering what makes up medical knowledge and practice (Koch et al., 2024).\u003c/p\u003e\n\u003cp\u003eThe promotion of health equity through decolonial pedagogies requires structural commitment, including faculty development initiatives focused on decolonial teaching methods, revision of assessment strategies to validate diverse forms of knowledge, and institutional policies that support community engagement as core to medical education rather than peripheral (Ajani, 2024). As Osman and Maringe (2019) emphasise, without coherent understanding and frameworks, decolonisation efforts will not contribute meaningfully to the transformation of higher education in South Africa (Lawrence et al., 2022).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eRecommendations for future research and implementation include:\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eDeveloping context-specific assessment tools for intrinsic competencies, particularly those aligned with COPC.\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eRevise the curriculum to ensure a more balanced integration of all AfriMEDS competencies. Increase the focus on health advocacy, leadership, community engagement and CBE by incorporating dedicated modules, practical experiences, and assessments tailored to these roles. This should involve reviewing learning objectives, teaching materials, and assessment methods to ensure balanced coverage of all AfriMEDS roles.\u003c/li\u003e\n \u003cli\u003eDevelop context-specific assessment tools for intrinsic competencies like health advocate, leader/manager, collaborator, community engagement and CBE aligning them with the specific skills and knowledge required for COPC. Ensure these tools capture both theoretical knowledge and practical application.\u003c/li\u003e\n \u003cli\u003eImplement a system for formalised curriculum phase reviews. This system should include regular evaluations of each phase, mechanisms for collecting feedback from educators, students, and stakeholders, and processes for incorporating feedback into curriculum revisions.\u003c/li\u003e\n \u003cli\u003eIntroduce new evaluation methods, like standardised patient encounters for communication skills and interprofessional simulation activities, to assess the effective application of knowledge and skills relevant to these roles. Standardize assessment practices across the curriculum, ensuring that all competencies are evaluated using valid and reliable methods. Provide faculty with training on implementing standardised assessment procedures and interpreting results.\u003c/li\u003e\n \u003cli\u003eDevelop a parallel admissions course that assesses student suitability for medical school without disadvantaging LDP admissions. This course should evaluate essential skills and attributes, such as critical thinking, problem-solving, communication, and ethical reasoning.\u003c/li\u003e\n \u003cli\u003eLongitudinal cohort studies will investigate the long-term effects of curriculum reforms on healthcare outcomes. Implement longer primary care rotations or integrated clerkships that allow students to follow patients over time and develop skills in managing chronic conditions and promoting preventative care.\u003col style=\"list-style-type: lower-alpha;\"\u003e\n \u003cli\u003eThis program should provide extended clinical placements in a variety of settings, allowing students to follow patients over time, experience continuity of care, and integrate their learning across disciplines. Evaluate the outcomes of this pilot program and consider expanding it if successful.\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/li\u003e\n \u003cli\u003eIncrease the duration and quality of community-based rotations. Develop partnerships with rural healthcare facilities to provide students with longitudinal placements and enhanced mentorship opportunities, enabling deeper engagement with communities and practical application of CBE principles.\u003c/li\u003e\n \u003cli\u003eExploring innovative pedagogical approaches that integrate indigenous knowledge systems with evidence-based practice, addressing cultural competence gaps. Integrate a more explicit focus on social determinants of health into the curriculum. Develop modules and case studies that address issues like poverty, inequality, access to care, and cultural factors that influence health outcomes.\u003c/li\u003e\n \u003cli\u003eBy integrating IPE frameworks, AfriMEDS can better prepare graduates to work effectively in multidisciplinary teams, improve patient outcomes, and address the social determinants of health through collaborative, community-oriented approaches. Increase opportunities for interprofessional learning by integrating IPE activities into the curriculum. Design collaborative projects, simulations, or case studies that require students from different healthcare disciplines to work together, fostering communication, teamwork, and shared decision-making skills. This integration aligns with AfriMEDS\u0026apos; emphasis on CBE and primary care.\u003c/li\u003e\n \u003cli\u003eWe advocate for HPCSA accreditation reforms that mandate detailed curriculum audits and support iterative improvement. Develop specific, actionable recommendations for HPCSA accreditation standards. These could include requiring medical schools to demonstrate integration of decolonial pedagogies, CBE, and assessment tools aligned with AfriMEDS competencies, emphasising cultural safety and social accountability. Ensure that these tools capture both theoretical knowledge and practical application of skills in areas like health advocacy, leadership, community engagement and CBE.\u003c/li\u003e\n \u003cli\u003ePrioritising faculty development initiatives focused on competency-based assessment and transformative learning methodologies. This should include training in teaching and assessing non-clinical skills, community engagement strategies, and culturally responsive pedagogies.\u003c/li\u003e\n \u003cli\u003eStructural alignment of curriculum with national healthcare priorities through collaborative processes that meaningfully involve students, junior faculty, and community representatives.\u003c/li\u003e\n \u003cli\u003eIntegration of decolonial pedagogies that bridge cultural competence gaps and address power imbalances in healthcare relationships. Implement specific language training programs tailored to the needs of the communities served by UFS graduates. Integrate soft skills development into the curriculum through role-playing, simulations, reflective exercises, and community engagement activities.\u003c/li\u003e\n \u003cli\u003eWhile acknowledging the context-specific nature of the findings, we suggest future research that could explore the applicability of the study\u0026apos;s findings to other medical schools in South Africa. This could involve comparative case studies or multi-institutional surveys.\u003c/li\u003e\n \u003cli\u003eWhile response rate supports the validity of findings, acknowledge this limitation and we propose strategies for improving response rates in future research, like offering incentives, using multiple follow-up reminders, or exploring alternative data collection methods.\u003c/li\u003e\n \u003cli\u003eIntegrated budgeting and resource allocation to harmonise the power dynamics between health authorities and universities and better support clinical training in AfriMEDS, CBE, and COPC. Developing a joint strategic plan between the university and the health authority to address staffing needs and ensure adequate resources are available to support an increased student body. This could include hiring additional faculty, expanding teaching facilities, and investing in educational technology.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eFuture research should evaluate the implementation and impact of decolonial pedagogies in medical education, particularly their effect on graduate preparedness for practice in diverse communities and their contribution to addressing health inequities. Collaborative work across South African medical schools to develop context-specific frameworks for decolonial curriculum development would strengthen the coherence and sustainability of these approaches.\u003c/p\u003e\n\u003cp\u003eBy reimagining medical education through a transformative paradigm that challenges traditional hierarchies and centres\u0026rsquo; community engagement, South African medical schools can move beyond reform to true transformation\u0026mdash;preparing physicians equipped not only with clinical expertise but with the critical consciousness necessary to address the country\u0026apos;s complex health challenges.\u003c/p\u003e\n\u003cp\u003eThis study advances discourse on context-responsive curriculum design in medical education, proposing a framework for iterative curriculum renewal that balances competency benchmarks with community health imperatives. By illuminating the complexities of implementing transformative pedagogies in post-apartheid South Africa, it offers valuable insights for medical educators navigating similar challenges globally, particularly in settings where educational reform intersects with social transformation agendas.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAcknowledgements.\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eThe authors would like to acknowledge the University of the Free State, Faculty of Health Sciences, for their support during the project and Mrs Nicoleen Smit from the University of Pretoria, Department of Family Medicine for her assistance in finalising the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eThe author\u0026rsquo;s contributions.\u003c/em\u003e\u003c/strong\u003e NM conceptualised the project, completed the data collection, analysed and interpreted the data, and prepared the manuscript. PMJ and GW supervised the project from conception to publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/strong\u003e. UFS Postgraduate Research support grant.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCompeting interests:\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eThe authors declare that there are no conflicts of interest.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAjani, O. A. (2024). Exploring curriculum transformation in higher education institutions: A critical analysis of equity and social justice perspectives. \u003cem\u003eResearch in Educational Policy and Management, 6\u003c/em\u003e(1), 217\u0026ndash;237. https://doi.org/10.46303/repam.2024.14\u003c/li\u003e\n\u003cli\u003eAlexander, S. A., Jones, C. M., Tremblay, M. C., Beaudet, N., Rod, M. H., \u0026amp; Wright, M. T. (2020). Reflexivity in health promotion: A typology for training. \u003cem\u003eHealth Promotion Practice, 21\u003c/em\u003e(4), 499\u0026ndash;509. https://doi.org/10.1177/1524839920912407\u003c/li\u003e\n\u003cli\u003eAmalba, A., Abantanga, F. A., Scherpbier, A. J. J. A., \u0026amp; van Mook, W. N. K. A. (2020). The role of community-based education and service (COBES) in undergraduate medical education in reducing the mal-distribution of medical doctors in rural areas in Africa: A systematic review. \u003cem\u003eHealth Professions Education, 6\u003c/em\u003e(1), 9\u0026ndash;18. https://doi.org/10.1016/j.hpe.2019.09.003\u003c/li\u003e\n\u003cli\u003eAtieno, O. P. (2009). An analysis of the strengths and limitations of qualitative and quantitative research paradigms. \u003cem\u003eProblems of Education in the 21st Century, 13\u003c/em\u003e, 13\u0026ndash;18.\u003c/li\u003e\n\u003cli\u003eBam, N., Marcus, T., Hugo, J., \u0026amp; Kinkel, H. F. (2013). Conceptualizing community-oriented primary care (COPC) \u0026ndash; The Tshwane, South Africa, health post model. \u003cem\u003eAfrican Journal of Primary Health Care \u0026amp; Family Medicine, 5\u003c/em\u003e(1), a423. https://doi.org/10.4102/phcfm.v5i1.423\u003c/li\u003e\n\u003cli\u003eBhatta, T. P. (2018). Case study research, philosophical position and theory building: A methodological discussion. \u003cem\u003eDhaulagiri Journal of Sociology and Anthropology, 12\u003c/em\u003e, 72\u0026ndash;79. https://doi.org/10.3126/dsaj.v12i0.22182\u003c/li\u003e\n\u003cli\u003eChandanabhumma, P. P., \u0026amp; Narasimhan, S. (2020). Towards health equity and social justice: An applied framework of decolonization in health promotion. \u003cem\u003eHealth Promotion International, 35\u003c/em\u003e(4), 831\u0026ndash;840. https://doi.org/10.1093/heapro/daz053\u003c/li\u003e\n\u003cli\u003eCreswell, J. W., \u0026amp; Clark, V. L. P. (2011). \u003cem\u003eDesigning and conducting mixed-methods research\u003c/em\u003e (2nd ed.). Sage Publications.\u003c/li\u003e\n\u003cli\u003eCreswell, J. W. (2014). Research design: Qualitative, quantitative, and mixed methods approaches (4th ed.). Sage Publications.\u003c/li\u003e\n\u003cli\u003eDath, D., Chan, M.-K., Abbott, C., \u0026amp; CanMEDS. (2015). \u003cem\u003eFrom manager to leader(pp.1-9)\u003c/em\u003e. The Royal College of Physicians and Surgeons of Canada. \u003c/li\u003e\n\u003cli\u003eDenniston, C. (2023). Sharpening reflexive practice in health professional education research. \u003cem\u003eFocus on Health Professional Education: A Multi-Professional Journal, 24\u003c/em\u003e(1), 85\u0026ndash;94. https://doi.org/10.11157/fohpe.v24i1.734\u003c/li\u003e\n\u003cli\u003eDepartment of Higher Education and Training. (2012). \u003cem\u003eReport of the task team on community education and training centres\u003c/em\u003e Retrieved May 4, 2020, from https://www.dhet.gov.za/Adult%20Education%20and%20Training%20Programmes/CETC%20summary%20report.pdf\u003c/li\u003e\n\u003cli\u003eDe Villiers, M. R., Blitz, J., Couper, I., Kent, A., Moodley, K., Talib, Z., Van Schalkwyk, S., \u0026amp; Young, T. (2017). Decentralised training for medical students: Towards a South African consensus. \u003cem\u003eAfrican Journal of Primary Health Care \u0026amp; Family Medicine, 9\u003c/em\u003e(1), a1449.\u003c/li\u003e\n\u003cli\u003eEnglish, W., Gott, M., \u0026amp; Robinson, J. (2022). Being reflexive in research and clinical practice: A practical example. \u003cem\u003eNurse Researcher, 30\u003c/em\u003e(2), 30\u0026ndash;35. https://doi.org/10.7748/nr.2022.e1833\u003c/li\u003e\n\u003cli\u003eFrank, J. R., Snell, L. S., Ten Cate, O., Holmboe, E. S., Carraccio, C., Swing, S. R., Harris, P., Glasgow, N. J., Campbell, C., Dath, D., Harden, R. M., Iobst, W., Long, D. M., Mungroo, R., Richardson, D. L., Sherbino, J., Silver, I., Taber, S., Talbot, M., \u0026amp; Harris, K. A. (2010). Competency-based medical education: Theory to practice. \u003cem\u003eMedical Teacher, 32\u003c/em\u003e(8), 638\u0026ndash;645. https://doi.org/10.3109/0142159X.2010.501190 \u003c/li\u003e\n\u003cli\u003eGuba, E. G., \u0026amp; Lincoln, Y. S. (2005). Paradigmatic controversies, contradictions, and emerging confluences. In N. K. Denzin \u0026amp; Y. S. Lincoln (Eds.), \u003cem\u003eThe Sage handbook of qualitative research\u003c/em\u003e (3rd ed., pp. 191\u0026ndash;216). Sage Publications Ltd.\u003c/li\u003e\n\u003cli\u003eGuraya, S. S., Harkin, D. W., Yusoff, M. S. B., \u0026amp; Guraya, S. Y. (2023). Paradigms unfolded - developing, validating, and evaluating the Medical Education e-Professionalism framework from a philosophical perspective. \u003cem\u003eFrontiers in Medicine, 10\u003c/em\u003e, Article 1230620. https://doi.org/10.3389/fmed.2023.1230620\u003c/li\u003e\n\u003cli\u003eHarrison, H., Birks, M., Franklin, R., \u0026amp; Mills, J. (2017). Case study research: Foundations and methodological orientations. \u003cem\u003eForum: Qualitative Social Research, 18\u003c/em\u003e(1), Article 19. https://doi.org/10.17169/fqs-18.1.2655\u003c/li\u003e\n\u003cli\u003eHickman, A. C., Johnson, R. L., \u0026amp; Lawler, S. P. (2022). Health-promoting pedagogy: Using reflexivity to support learning and action in planetary health education. \u003cem\u003eHealth Promotion Journal of Australia, 33\u003c/em\u003e(S1), 22\u0026ndash;26. https://doi.org/10.1002/hpja.648\u003c/li\u003e\n\u003cli\u003eHlongwane, N. A., \u0026amp; Lowton, K. (2024). Descriptive study of mental health care users 12 months pre- and post-COVID-19 lockdown. \u003cem\u003eSouth African Journal of Psychiatry, 30\u003c/em\u003e, Article a2301. https://doi.org/10.4102/sajpsychiatry.v30i0.2301\u003c/li\u003e\n\u003cli\u003eHo, L., \u0026amp; Limpaecher, A. (2022). \u003cem\u003eThe importance of reflexivity in qualitative research\u003c/em\u003e. Delve. Retrieved February 25, 2022, from https://delvetool.com/blog/reflexivity\u003c/li\u003e\n\u003cli\u003eIwasiw, C. L., \u0026amp; Goldenberg, D. (2015). \u003cem\u003eCurriculum Development in Nursing Education\u003c/em\u003e (3rd ed.). Jones \u0026amp; Bartlett Learning.\u003c/li\u003e\n\u003cli\u003eKnight, S. E., Ross, A. J., \u0026amp; Mahomed, O. (2017). Developing primary health care and public health competencies in undergraduate medical students. \u003cem\u003eSouth African Family Practice, 59\u003c/em\u003e(3), 103\u0026ndash;109. https://doi.org/10.1080/20786190.2016.1272229\u003c/li\u003e\n\u003cli\u003eKoch, R., Pool, J., \u0026amp; Heymans, Y. (2024). The nature of decolonisation in health sciences curricula: A scoping review. \u003cem\u003eSouth African Journal of Higher Education, 38\u003c/em\u003e(4), 81\u0026ndash;106. https://doi.org/10.20853/38-4-5893\u003c/li\u003e\n\u003cli\u003eLawrence, C., Bollinger, J., Stewart, K. A., \u0026amp; Moshabela, M. (2022). Improving South African medical curricula related to traditional health systems. \u003cem\u003eAfrican Journal of Health Professions Education, 13\u003c/em\u003e(2), 95\u0026ndash;97. https://doi.org/10.7196/ajhpe.2021.v13i2.1246\u003c/li\u003e\n\u003cli\u003eLochner, C., Roos, J., Taljaard, L., Bantjes, J., Saal, W., \u0026amp; Stein, D. (2018). \u003cem\u003eThe Caring Universities Project\u003c/em\u003e [Conference presentation]. SU DSAf Research Programme.\u003c/li\u003e\n\u003cli\u003eMcIntosh, G. L. (2023). Nurse researcher identity and reflexivity in interpretive phenomenological analysis: A personal narrative. \u003cem\u003eNurse Researcher, 31\u003c/em\u003e(2), 28\u0026ndash;35. https://doi.org/10.7748/nr.2023.e1870\u003c/li\u003e\n\u003cli\u003eMayosi, B. M., Flisher, A. J., Lalloo, U. G., Sitas, F., Tollman, S. M., \u0026amp; Bradshaw, D. (2009). The burden of non-communicable diseases in South Africa. \u003cem\u003eThe Lancet, 374\u003c/em\u003e(9693), 934\u0026ndash;947. https://doi.org/10.1016/S0140-6736(09)61087-4\u003c/li\u003e\n\u003cli\u003eMbaki, Y., Hlongwane, N. A., Bolden, S., \u0026amp; Makhubele, J. (2021). Decolonising healthcare education: Perspectives from postcolonial theory. \u003cem\u003eHealth SA Gesondheid, 26\u003c/em\u003e(0), Article a1647. https://doi.org/10.4102/hsag.v26i0.1647\u003c/li\u003e\n\u003cli\u003eMertens, D. M. (2005). \u003cem\u003eResearch and evaluation in education and psychology: Integrating diversity with quantitative, qualitative, and mixed methods\u003c/em\u003e (2nd ed.). Sage Publications.\u003c/li\u003e\n\u003cli\u003eMertens, D. M. (2007). Transformative paradigm: Mixed-methods and social justice. \u003cem\u003eJournal of Mixed Methods Research, 1\u003c/em\u003e(3), 212\u0026ndash;225. https://doi.org/10.1177/1558689807302811\u003c/li\u003e\n\u003cli\u003eMertens, D. M. (2010). Transformative mixed methods research. \u003cem\u003eQualitative Inquiry, 16\u003c/em\u003e(6), 469\u0026ndash;474. https://doi.org/10.1177/1077800410364612\u003c/li\u003e\n\u003cli\u003eMills, A. J., Durepos, G., \u0026amp; Wiebe, E. (Eds.). (2010). \u003cem\u003eEncyclopedia of case study research\u003c/em\u003e. Sage Publications.\u003c/li\u003e\n\u003cli\u003eNieuwenhuis, J. (2007). Qualitative research designs and data gathering techniques. In K. Maree (Ed.). \u003cem\u003eFirst steps in research\u003c/em\u003e (pp. 69\u0026ndash;97). Van Schaik.\u003c/li\u003e\n\u003cli\u003eNulty, D. D. (2008). The adequacy of response rates to online and paper surveys: What can be done? \u003cem\u003eAssessment \u0026amp; Evaluation in Higher Education, 33\u003c/em\u003e(3), 301\u0026ndash;314. https://doi.org/10.1080/02602930701293231\u003c/li\u003e\n\u003cli\u003eOsman, R., \u0026amp; Maringe, F. (2019). \u003cem\u003eThe decolonisation of higher education in Africa: Perspectives from hybrid knowledge production\u003c/em\u003e. Routledge.\u003c/li\u003e\n\u003cli\u003ePerkins, S., Nishimura H., Olantunde P.F. \u0026amp; Kalbarczyk A. (2023). Educational approaches to teach students to address colonialism in global health: A scoping review. \u003cem\u003eBMJ Global Health, 8\u003c/em\u003e(4), Article e011610. http://dx.doi.org/10. 1136/bmjgh-2022-011610\u003c/li\u003e\n\u003cli\u003eReid, S. J., \u0026amp; Cakwe, M. (2011). The contribution of South African curricula to prepare health professionals for working in rural or under-served areas in South Africa: A peer review evaluation. \u003cem\u003eSouth African Medical Journal, 101\u003c/em\u003e(1), 34\u0026ndash;38.\u003c/li\u003e\n\u003cli\u003eReid, S. J. (n.d.). The transformation of medical education in South Africa. UKZN Research Space Library Archive. Retrieved March 15, 2025, from https://researchspace.ukzn.ac.za/server/api/core/bitstreams/2c974964-139a-4886-a6b6-921ca338dc7a/content\u003c/li\u003e\n\u003cli\u003eRepublic of South Africa, Department of Health. (2017). \u003cem\u003eWhite paper: National Health Insurance policy. Towards universal health coverage\u003c/em\u003e (Government Notice 627, Government Gazette 40955, 30 June 2017). Retrieved April 21, 2020, from https://www.gov.za/sites/www.gov.za/files/40955_gon627.pdf\u003c/li\u003e\n\u003cli\u003eSlaven, F. (2017). \u003cem\u003eReport on the Doctors for Primary Healthcare Symposium\u003c/em\u003e. Foundation for Professional Development. Retrieved March 28, 2017 from https://www.foundation.co.za/document/publications/reports/113037.20171109064251288.113037.2017110906425128841Mps.pdf\u003c/li\u003e\n\u003cli\u003eHussey, N. The Language Barrier: The overlooked challenge to equitable health care South African Health Review. (2012/13). Retrieved March 20, 2025, from https://journals.co.za/doi/pdf/10.10520/EJC133688\u003c/li\u003e\n\u003cli\u003eStatistics South Africa, 2013\u003c/li\u003e\n\u003cli\u003eSwidrovich, J. (2020). Decolonizing the medical model: Creating spaces for indigenous knowledge. \u003cem\u003eHealth Science Inquiry, 11\u003c/em\u003e(1), 77\u0026ndash;79.\u003c/li\u003e\n\u003cli\u003eTalib, Z. M., Baingana, R. K., Sagay, A. S., Van Schalkwyk, S. C., Mehtsun, S., \u0026amp; Kiguli-Malwadde, E. (2013). Investing in community-based education to improve the quality, quantity, and retention of physicians in three African countries. \u003cem\u003eEducation for Health, 26\u003c/em\u003e(2), 109\u0026ndash;114.\u003c/li\u003e\n\u003cli\u003eTurner, T. L., Balmer, D. F., \u0026amp; Coverdale, J. H. (2013). Methodologies and study designs relevant to medical education research. \u003cem\u003eInternational Review of Psychiatry, 25\u003c/em\u003e(3), 301\u0026ndash;310. https://doi.org/10.3109/09540261.2013.790310\u003c/li\u003e\n\u003cli\u003eWhitehead, C. R., Kuper, A., Hodges, B., \u0026amp; Ellaway, R. (2015). Conceptual and practical challenges in the assessment of physician competencies. \u003cem\u003eMedical Teacher, 37\u003c/em\u003e(3), 245\u0026ndash;251. https://doi.org/10.3109/0142159X.2014.993599\u003c/li\u003e\n\u003cli\u003eWong, S. H. M., Gishen, F., \u0026amp; Lokugamage, A. U. (2021). Decolonising the Medical Curriculum: Humanising medicine through epistemic pluralism, cultural safety and critical consciousness. \u003cem\u003eLondon Review of Education, 19\u003c/em\u003e(1), 1-22.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. (2013). \u003cem\u003eTransforming and scaling up health professionals\u0026rsquo; education and training: WHO guidelines.\u003c/em\u003e Retrieved April 9, 2021, from https://www.who.int/publications/i/item/transforming-and-scaling-up-health-professionals\u0026rsquo;-education-and-training\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"advances-in-health-sciences-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ahse","sideBox":"Learn more about [Advances in Health Sciences Education](http://link.springer.com/journal/10459)","snPcode":"10459","submissionUrl":"https://submission.nature.com/new-submission/10459/3","title":"Advances in Health Sciences Education","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"metaphysical framework, transformative paradigm, curriculum reform, medical education, CBE, COPC","lastPublishedDoi":"10.21203/rs.3.rs-6494452/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6494452/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eSouth African medical education is challenged by the dual challenges of meeting accreditation standards while addressing pressing community health needs amid healthcare reform demands. The AfriMEDS framework, adapted from CanMEDS, incorporates community-based education (CBE) and community-oriented primary care (COPC) to bridge these gaps. Using a transformative mixed-methods approach as a metaphysical framework\u0026mdash;including curriculum mapping, document analysis, educator semi-structured interviews, and intern surveys\u0026mdash;this study evaluates AfriMEDS implementation at the University of the Free State (UFS). Findings reveal systemic challenges: misaligned assessments, faculty development gaps, and competence deficiencies. Integrating competencies shows uneven emphasis, with significant disparities in health advocacy, leadership, and CBE roles. Educator interviews highlight structural barriers such as resource constraints and compressed timelines in UFS\u0026rsquo;s five-year program, while intern surveys reflect gaps in preparedness for non-clinical competencies. The transformative metaphysical framework paradigm proves effective in exposing structural inequities and fostering stakeholder co-creation, positioning CBE as essential for sustainable reform. The study concludes with recommendations for systemic reforms, including decolonial pedagogies that integrate indigenous languages and knowledge, faculty capacity building in competency-based assessment, and structural alignment with national healthcare priorities. These insights emphasise the need to transcend technical curriculum adjustments, centring transformative paradigms that address power dynamics and cultural complexities in medical training.\u003c/p\u003e","manuscriptTitle":"A metaphysical framework for transforming South Africa’s undergraduate medical curricula is proposed within a transformative research paradigm","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-14 11:18:42","doi":"10.21203/rs.3.rs-6494452/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-07-18T21:32:49+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-18T11:59:07+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"123270622316521748452834565688087000842","date":"2025-07-11T18:40:31+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-11T14:36:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"32859801646660883421179964440459943239","date":"2025-07-10T10:55:20+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"30653869064400759822452470864687488516","date":"2025-07-10T06:29:26+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-09T18:17:11+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-05-02T11:27:25+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-02T11:26:41+00:00","index":"","fulltext":""},{"type":"submitted","content":"Advances in Health Sciences Education","date":"2025-04-21T09:06:08+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"advances-in-health-sciences-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ahse","sideBox":"Learn more about [Advances in Health Sciences Education](http://link.springer.com/journal/10459)","snPcode":"10459","submissionUrl":"https://submission.nature.com/new-submission/10459/3","title":"Advances in Health Sciences Education","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"b04edf74-729e-49ef-a235-49507488d218","owner":[],"postedDate":"July 14th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-09-22T15:59:22+00:00","versionOfRecord":{"articleIdentity":"rs-6494452","link":"https://doi.org/10.1007/s10459-025-10474-z","journal":{"identity":"advances-in-health-sciences-education","isVorOnly":false,"title":"Advances in Health Sciences Education"},"publishedOn":"2025-09-20 15:57:23","publishedOnDateReadable":"September 20th, 2025"},"versionCreatedAt":"2025-07-14 11:18:42","video":"","vorDoi":"10.1007/s10459-025-10474-z","vorDoiUrl":"https://doi.org/10.1007/s10459-025-10474-z","workflowStages":[]},"version":"v1","identity":"rs-6494452","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6494452","identity":"rs-6494452","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}