Partnering with Academia: Visioning Church Hospitals Towards Educational Excellence

1. Partnering with Academia: Visioning Church Hospitals Towards Educational Excellence Bruce Dahlman MD Director, Institute of Family Medicine (INFA-MED) African Christian Health Association Conference Kampala, Uganda 25 February 2009

2. Objectives 1. One human resource challenge: physician leadership retention in your hospitals 2. Discuss the strengths and issues of forming partnerships between universities and faith-based health institutions towards Family Medicine development in Africa

3. Medical Leadership: Is it a Crisis in Your Hospitals? • Who is the leader of the medical staff at your 70 – 150 bed hospital(s)? • How long do they serve? • Specialization? Think of yourself as a new Medical Officer

4. Your Career ladder: • Internship – 1 year • Assigned Government service in rural District Hospital – or your smaller church hospital which often: • Is in the Remotest place • Has Poorest working environments • Little or no clinical back-up • Poor professional advancement opportunities Meanwhile . . .

5. Your medical school classmates . . . • Who landed at larger hospitals have been working under a surgeon/ obs-gynae/ paediatrician for 2-3 years • They have their referee letter to apply for speciality training • Look forward to consultancy position; university lecturer post; secure future

6. What would you do? • Ask for sponsorship for speciality training from your church hospital? • Join the PEPFAR project in your area? • Join a friend’s private practice? • Continue serving joyfully year after year in the lowest paid Medical Officer cadre with no professional rank?

7. Family Medicine Training:Who is a Family Physician? Definition from Kenya Ministry of Health Family Medicine Policy (2007): “A family physician is a medical doctor • providing competent and comprehensive clinical care (usually in a primary care consultancy role) • over a wide range of patient conditions • considering the person’s physiologic, psychological, socio-economic, cultural and spiritual dimensions • within the context of their family and community and • not limited by the person’s age, gender, organ system or disease entity.”

8. Roles of a Family Physician • Provide continuous, comprehensive, cost-effective and coordinated care to individuals, families and communities; primary care consultant • Engage in life-long learning to improve health care delivery • Teach effectively members of the health care team, the patient and the community • Act as a team player and a leader • Manage health care resources

9. Why Family Physicians? • “Given the need to provide primary care services to the entire population, as well as the family doctor’s ability to manage most medical problems, it makes sense that a majority of physicians should be trained to practice as family doctors. This may be even more important in developing countries, where it may be prudent to limit the utilization of costly hospital-based technology” (WHO, 1994).

10. Why are Family Physicians Needed? National Health Strategic Plan (2005-2009) “To contribute to the reduction of health inequalitiesand to reverse the downward trend in the health related impact and outcome indicators, “To achieve Millennium Development Goals to reduce child mortality, improve maternal health and reduce communicable diseases like malaria, HIV/AIDS & TB, “Medical Officers are currently not sufficiently trained to provide general, comprehensive care to the Kenyan people.”

11. Family Medicine:Especially important to achieve improvement in equity of access The Family Physician will: • “Improve quality of care, particularly for the underserved Kenyans • “Improve patient satisfaction and continuity of care • “Provide comprehensive specialist care at District and Sub-district levels • “Improve preventive care”From Kenya Ministry of Health Family Medicine Policy Document (2007)

12. Kenya MoH Family Medicine Policy:(Echoing WHO) “The MoH recognizes that the Family Physician is the most appropriate person to respond to the challenges of the Kenyan health care delivery system.”

13. The African Family Doctor: A summary • Clinical specialist in Primary Care; leader of the medical team • 3-4 year Master of Medicine training • Competent emergency surgeon • “Bridge” to the primary care team • Gains the professional respect of peers as the primary care consultant specialist • Equipped to stay & “build” your hospital

14. Where Is This Doctor Mentored? • Probably will not do this training in the National Referral Hospitals • Because they will need mentoring by dedicated doctors who have the same call to service and in a place where the greatest needs are That place would be?

15. Your rural church hospital!

16. Why Does Your Hospital Need to be a Teaching Hospital? • Because these hospitals are serving in the places where Family Medicine training needs to exist – in the rural areas • Because they contribute a significant portion of the clinical care in most sub-Saharan African countries – and will continue to do so • Because they are often already well-respected by patients

17. Church Hospitals:Role in Education • Your church hospitals likely already have a nursing school to meet the needs of nursing staffing . . . • Can there be a corollary in the medical education realm?

18. Church Hospitals:Are You Ready for “Prime Time”? Objections . . . • “We’re not big enough” • “They don’t need us . . .” • “What would we have to offer?” • “We couldn’t pay for it”

19. But what if . . . You step outside . . . of the box

20. Africa Inland ChurchKijabe Hospital - 265 beds outside view of inpatient wards

21. Educational Resource From Rural Church Hospitals: Example of AIC Kijabe Hospital • 1916 - Hospital started as infirmary to a boarding school for missionary kids • 1959 – Separate facility built to serve the community – 30 beds; 1 doctor • 1970s – Expanded to 120 beds; 2 doctors; Expatriate medical student rotations • 1980 – 210 beds, 3 doctors; KECHN nursing school; Kenyan medical student electives

22. AIC Kijabe Hospital:Becoming Part of the Answer • 1995 – Medical staff of 7; No Kenyans – Gov’t medical internship started • 2005 – Medical staff of 16; 2 Kenyan – Family Medicine residency started with Moi University • 2006 - Agreements with Pan-African Academy of Christian Surgeons and University of Nairobi - general and paediatric surgery externships • 2008 – COSECSA orthopaedic residency • 2009 – Medical staff of 27; 11 Kenyan

23. But How to Begin? “Take First Steps . . .

24. The Kenyan Case Towards Family Medicine Training • March 1995 – MAP Int’l. consultation with hospitals from Kenya and Zaire resolves to start family medicine post-grad. programme • 1996 – 2000: Kijabe, Chogoria and Tenwek Hospitals begin College of Family Medicine (COFAMED) and pursue accreditation with Commission for Higher Education

25. But . . . in most sub-Saharan contexts: • The model for post-graduate education requires partnership with a medical degree-granting academic institution • Master of Medicine Degree • Includes Master’s research thesis

26. Kenyan Family Medicine Development • Sept. 2003: Moi University Senate approves the curriculum that had been through numerous revisions over 3 years. • January 2005: Moi University Family Medicine begins with three registrars • July 2008: First class graduates; all take teaching positions

27. Your Partner is: TheUniversity Medical School • You need to partner with your University that does medical training – Dean, Comm. Med. department • You may be suggesting something new to them • You may need to engage Ministry of Health, Professional Boards

28. Resource on how to engage the process: Improving Health Systems: the Contribution of Family Medicine – A Guidebook • WONCA – World Org. of Family Doctors • www.globalfamilydoctor.org

29. Africa Christian Health Associations

30. African Family MedicineExpansion • 1980s - Nigeria and South Africa • 1988 – Uganda 1996 – DR Congo • 2004? – Ghana • 2005 - Kenya, Tanzania • 2009 - Rwanda, Lesotho • Investigating - Ethiopia, S. Sudan • Interest – Malawi, Mozambique

31. Institute of Family Medicine (INFA-MED) • Support and assistance organisation to assist the development of the community-based church hospital teaching sites for the Moi programme • Faculty development • Integrating continuing medical education with post-graduate needs • Scholarship support

32. Institute of Family Medicine:Mission INFA-MED is committed to advancing family medicine in the developing world by training and mentoring doctors to be clinicians, teachers, leaders and life-long learners, who will provide comprehensive and wholistic health care, relevant to community needs

33. Institute of Family Medicine:Strategic Goals 1. To establish and expand family medical education in developing countries 2. To facilitate the sharing of evidence-based, relevant primary health care information 3. To actively engage church congregations to become healing communities 4. To promote and support continuing professional development and life-long learning 5. To build the capacity of INFA-MED as an institution, and mobilize resources for the advancement of family medicine in developing countries

34. Institute of Family Medicine:Accomplishments in Kenya • 2000 – Assist Moi University to start Kenya’s first Family Medicine program • 2002 – Helped launch KAFP • 2003 – Brought Advanced Life Support in Obstetrics course (ALSO) to Kenya; contributing to Global ALSO refinements • 2005 – Assist with initial Moi Univ. lecturer salaries • 2006 – Began small group CPD courses with KAFP • 2009 - Adapting Comprehensive Advanced Life Support (AfriCALS) to East Africa • 2010 – Digital African Health Library – Health information tools to use at the point of care

35. Questions and comments? • Bruce Dahlman MDInstitute of Family Medicine (INFA-MED)bdahlman@aimint.net +254-736-450-915 Pan-African College of Christian Surgeons Dr. Bruce Steffes bruce@brucesteffes.net

36. Kenya: The People