Report and Handover document Social and Community Medicine training 2016-2017 to University of Rwanda/College of Medicine and Health Sciences (UoR/CMHS), and Partners In Health/Inshuti Mu Buzima (PIH-IMB)
Prepared by Dr. Mieke Visser,
Honorary Associate Professor Family Medicine, University of Rwanda
Kigali, May 2017
Introduction
Partners In Health (PIH) has been supportive of and involved in training social and community medicine at the University of Rwanda. In 2010 it started with the postgraduate family and community medicine training ((FAMCO), from 2012 onwards shifted towards the undergraduate social and community medicine training. The SocoMed rotation that medical students have been doing at Rwinkwavu hospital in one of their final years has been a successful program that received very good evaluations from Rwandese and international students. Over the past years approximately 500 medical students have rotated through the program at the Rwinkwavu site and more than 1000 students were trained in the programs in Butare and Kigali.
Partners In Health has been closely involved in the development of the Discipline of Primary Health care from the University of Rwanda. Due to financial constraints the sustainability of the discipline and the training that is provided is under pressure.
Discipline of Primary Health Care
In 2014 the name of the former Family Medicine and Community Health Department within the new College of Medicine and Health Sciences was changed to Discipline of Primary Health Care.
The discipline of primary health care encapsulates social and community medicine, FAMCO (family and community medicine), ambulatory care, primary care nursing, primary care medicine, and education for health in a socially accountable way.
From 2008 the University of Rwanda (UR) has been working on this aspect of care delivery. It started with a postgraduate MMed (Master in Medicine) training in Family and community medicine, delivered by the FAMCO department, this postgraduate (PG) training was put on hold in 2011. In the academic year (AY) 11-12, on request of the dean, the department developed an undergraduate (UG) training in social and community medicine training, despite the end of the PG training, the UG training continued to develop over the years with support of Partners In Health.
Since 2010 Partners in Health (PIH) was hosting Family Medicine postgraduates for the community health and clinical rotations at Rwinkwavu, and since 2012 also the undergraduates for the social medicine and community health rotations. (see for the full history the former hand-over document 2015-2016 of Dr Maaike Flinkenflogel1)
Vision To produce skilled and socially responsible health care professionals who integrate the art and science of medicine in the care of individual patients and communities.
Mission To work with undergraduate students, postgraduate residents and PhD candidates within Primary Health Care using the bio-psycho-social approach to improve the health for individuals and communities and to develop their values and competencies of patient-centred and community-oriented health care.
To train health care professionals in the vision of “the desired Rwandan health care provider”, as a patient and community care provider, with the roles as professional, communicator, collaborator, manager, health advocate and scholar as essential parts.
Objectives
To train undergraduate medical students in all aspects of primary health care
To develop physicians skilled in individual, comprehensive patient care in hospitals with outreach to health centers and communities
To develop physicians skilled in ambulatory continuous patient care, with comprehensive knowledge and skills with a specific focus on chronic diseases including palliative care
To develop skilled physicians who are excellent teachers and mentors for health care providers on all levels, specifically in the district setting
To train physicians competent in family medicine and primary health care
To train health care professionals in community medicine and population health
To train health care professionals in an inter-disciplinary way
To train health care professionals as change agents, responsive to the needs of, and advocates for their patients and communities
To undertake research in primary health care policy, practice and education
To revise curricula and develop new training where needed, in collaboration with other disciplines, with a socially accountable context
To continuously evaluate and improve existing training
To develop a Rwandan leadership cadre in Primary Health Care with competence in the teaching and administration of the Primary Health Care skills
Achievements Discipline of Primary Health Care in academic year 2016-2017:
NINE HUNDRED FOURTEEN (914) MEDICAL STUDENTS were trained in the principles of social and community medicine
Year 3 iSOCO training (2 weeks) was developed and implemented
Several new training staff were mentored and trained to become part of the team
Without the continuous financial and managerial support of Partners in Health (PIH) the community health trainings of postgraduate and undergraduate medical residents and students would not have been possible.The Peter Manschot fund contributed with stipends to some of the voluntary teachers during the previous years, and thanks to this foundation 17 voluntary lecturers were supported in the providing training in the academic year 2016-2017 as well.
The overall aim of social and community medicine training in the undergraduate medical curriculum is to develop patient-centered and community-oriented professional medical doctors. This training builds on the 3 introduction years and further prepares the medical students to use the key elements for social and community medicine of the main five sections ( Population Health, Health Systems, Social Medicine, Communication and Professionalism) in providing quality clinical care delivery as the “desired Rwandan health care provider”.
SOCOMED courses
The social and community medicine - SOCOMED – course of DOC III (year 5) medical students of the University of Rwanda (UR), in 4 weeks rotations of 10 medical students, was conducted during the whole academic year 2016-2017 in Rwinkwavu, fully supported by PIH. The total number of students was 94.
Dr Eleazar Ndabarora was appointed in August 2016 as Director SOCOMED at Rwinkwavu by PIH, DMET department under the leadership of Dr Florence Akiiki Bitalabeho, and, still pending, as honorary faculty at the University of Rwanda, Discipline of Primary Health Care. From Sept. until Oct. 2016 Dr Mieke Visser, as Consultant Social and Community Medicine training of PIH and honorary associate professor of the Discipline PHC, supported him with the start of the first SOCOMED training of the DOC III medical students in the academic year 2016-2017, and worked with Dr Ndabarora during the first 4 weeks rotation. Dr Eva Arvidsson, senior FM lecturer, Sweden, participated in this transition period as well as Dr Florence Bitalabeho and Dr Sylvia Callender, curriculum development specialist PIH.
Dr Ndabarora conducted all SOCOMED rotation courses of the DOC III medical students in the academic year 2016-2017 and is assisted by Peter Barebwanumwe as program manager2
Funding: DOC II and iSOCO 1, 2 and 3 courses
These trainings to the 1st, 2nd,3rd and 4th years medical students (including dental surgery students in year 1 and 2, and pharmacy students in year 1), were provided thanks to the participation of many voluntary lecturers, supported with stipends of the Peter Manschot foundation, at Kigali, Nyarugenge campus, Butare, medical school and at Gako, military campus.Totally 8000 euro were spent in 2017 to travel, food and accommodation allowances.
Mieke Visser, Honorary Associate Professor Family Medicine, University of Rwanda, was the only part-time paid UR faculty (4 months in 2016- 2017) by PIH, not by UR. In this position she was addressed by the Dean, School of Pharmacy and Medicine as ‘team leader’.
Prof. Philip Cotton, Vice Chancellor University of Rwanda was the only faculty paid by UR.
Voluntary lecturers:
1. Mariette de Reeper, Family Medicine physician, The Netherlands
2. Jane Namatovu, Head of Department of Family Medicine, Makerere University Kampala, Uganda
3. Maaike Flinkenflögel, MD Advisor postgraduate education International Health KIT (Royal Tropical Institute) Amsterdam; Honorary Associate Professor, University of Rwanda
4. Dr. Eleazar Ndabarora, Director SOCOMED, PIH
5. Dr. Sylvia Callender, curriculum development specialist, PIH
6. Dr. Florence Bitalabeho, Director of Mentorship, Education and Training, PIH
7. Dr Alfred Rutagengwa, Nyamata District Hospital Director
8. Richard Ndumayezu, MD assistant lecturer
9. Magnifique Irakoze, MD assistant lecturer
10. Dr. Pieter van den Hombergh, Family Medicine physician and senior lecturer FM, Vice-Chairman of the Peter Manschot fund, The Netherlands
11. Fons Mathot, FM physician, senior lecturer and palliative care specialist, Chairman of the Peter Manschot fund, The Netherlands
12. Dr. Eva Arvidsson, Family Medicine physician and senior lecturer FM, Sweden
13. Katie Cartledge, Family Medicine physician, UK
14. Peter Cartledge, Internal Medicine specialist, UK
15. Laurette Mushimiyimana, Kuzumura Ubizima, Rwanda
16. Aflodis Kagaba, MD Director Health Development Initiative (HDI)
17. Edouard Munyalmaliza, secretary Rwanda Men’s Resource Center (RWAMREC)
Paid by University:
18. Prof. Philip Cotton, Vice Chancellor University of Rwanda
Paid by PIH:
19. Honorary Associate Professor Family Medicine Mieke Visser
Social and Community Medicine Courses 2016-2017 (Summary)
Course / Description / Participants / LecturersThe ISOCO 1 and 2 courses integrated Social and Community Medicine Training.
6 March to last week of May, two days per week / Year 1 is introduction of students to social and community medicine to understand the basic principles of care, which they will need within the practice of medicine, oral health and pharmacy. This longitudinal module is divided into five main sections (Population Health, Health Systems, Social Medicine, Communication skills and Professionalism) This is continued in years 2, 3 and 4. / Year 1:
128 medical students,
91 pharmacy students,
28 dental surgery students,
Total 247 students
Year 2:
165 medical students,
21 dental students,
Total 186 students / Dr Mieke Visser & Dr Mariette de Reeper, Dr Richard Ndumayezu, Dr Magnifique Irakoze, Dr Katie Cartledge, and voluntary teachers of different organisations (RWAMREC and Health Development Initiative)
DOC I (iSOCO 3) training3
20 Feb – 3 March 2017 / Intensive module of 2 consecutive weeks (8 hrs/day). This training builds on the 2 introduction years and further prepares the medical students to use the key elements of the main five sections of social and community health to become patient-centered and community-oriented professional medical doctors. / Year3:
Total 194 medical students / Dr Maaike Flinkenflogel organising and principal teacher and voluntary teachers
DOC II old curriculum 4th year medical students
20 Feb – 3 March 2017 / Module of 2 consecutive weeks (4 hrs/day). To prepare medical students, not exposed to social and community medicine. Core topics include: primary health care, public health, basic epidemiology, population health, health education, common public health challenges, palliative care and community based research / Year4:
Total 174 medical students. / Dr Mieke Visser, Dr Jane Namatovu and Dr Mariette de Reeperand voluntary teachers
SOCOMED course, practical training 5th year medical students at the PIH-Rwinkwavu site / To train Rwandan physicians knowledgeable in social medicine and capableof delivering high quality community health care that is continuous and integrated in all levels of care in order to improve the overall health of the Rwandan community. / Year5
Total 94 medical students / Dr Eleazar Ndaborara
Rwanda Military Academy - Gako campus
At the military campus near Nyamata town 19 first year medical soldier-students were trained separately in social and community medicine following the iSOCO1 2017 course in Moodle. Dr Alfred Rutagengwa, Nyamata District Hospital Director, supported in conducting this course in semester 2 of the academic year 2016-2017 together with Dr. Mieke Visser and other voluntary teachers
Total number of students 19
Dr. Pieter van den Hombergh and Fons Mathot as visiting lecturers wrote a report about their experiences as visiting lecturers and their vision of the future of both the undergraduate and (hopefully) postgraduate FM program, after meetings and observations during this visit. They also had a chance to attend a meeting of the future association of Family Medicine physicians in Rwanda. See their extensive and exhaustive report in attachment5 and the website
General Program Description (see also description DOC I) Year 1 is a longitudinal module introducing students to social and community medicine. It will prepare them to understand the basic principles of social and community health care, which they will need within the practice of medicine, oral health and pharmacy. The module is divided into five main sections (Population Health, Health Systems, Social Medicine, Communication skills and Professionalism) that are further divided in key elements. Year 1 will be used as an introduction to the five sections. This is continued in years 2, 3 and 4. The students were divided into two groups to receive classroom teaching in the morning and afternoon, and into groups of 10 people to do group work with interactive discussions after class.
All trainings use the online Moodle website to be used by students in a participatory learning method with pre- and post-class assignments. ( , click on School of Medicine and Pharmacy, 2017 Social and Community Medicine year 2, or 2017 Social and Community Medicine year 1. use “login as a guest”).
Constraints
Financial and managerial constraints
- In FY 2016-2017 PIH hosted the SOCOMED program, but for all other courses (DOC I, DOC II and iSOCO courses) Mieke Visser was the only part-time paid faculty (total 4 months) who was responsible for coordination, organisation and facilitation.
- Because of budget constraints next year, FY 2017-2018, PIH will no longer pay forDr Mieke Visser’s position and also the Peter Manschot foundation has no financial means anymore.
- SOCOMED courses next year will be for the current 4th year (new curriculum) and 5th year (old curriculum) students as well. More than 350 students would have to rotate in these courses in Rwinkwavu.
The University of Rwanda has financial constrains as well. Although the University has embraced the social and community medicine program and the Discipline of PHC has been established within the College of Medicine and Health Sciences, the HoD of the Discipline has not been appointed yet as well as more facultyfor the Discipline.
- Classes were very big and despite dividing the students in smaller and more manageable groups to teach, this would have been an impossible task in a sole position. It is
thanks to the Peter Manschot fund that 17 voluntary teachers could be supported and taught in all courses.
- Continuation of the curriculum FY 2017-2018 of the Discipline PHC isin jeopardy
Discussions
- Strategy for continuation curriculum FY 2017-2018 Discussions with partners involved, have led to the conclusion that different donors could be identified, but that they are interested in funding postgraduate, more than only undergraduate programs in Family Medicine. Other surrounding countries (Kenya, Uganda, Tanzania) have been supported by donors because of their policy in strengthening the primary health care system by training primary health care physicians (Family Medicine physicians).
- Appointment to meet with the Minister of Health Since November 2016, the then acting Head of the Discipline PHC, Dr Vincent Cubaka and Dr Djordje Gicik, former Director of the Clinton Foundation and one of the initiators of the Human Resources for Health (HRH) program in Rwanda have tried to discuss with the newly appointed Minister of Health, Dr Diane Gashumba, the possibility of restarting a Family Medicine program in Rwandain future. See the Concept Note6
- February- May 2017 Dr Vincent was absent during this period, finishing his PhD in Denmark. Mieke Visser followed up on discussions within the University and on organising with possible donors to have an appointment with the Minister of Health.The Dean, Dr. Stephen Rulisa, Principal, Dr. Jeanne Kagwiza and Vice Chancellor, Professor Philip Cotton all emphasized the importance of continuation of the undergraduate program and restarting a Family Medicine program in future. However a discussion with the MoH could not be organized, so that it is at the moment not possible to approach donors with concrete proposals.
- Memorandum of Understanding to define mutual obligations in the collaboration between the University of Rwanda/College of Medicine and Health Sciences (UR/CMHS), and Partners In Health/Inshuti Mu Buzima (PIH-IMB)is still in the process of being signed. Availing of the Head of Department of Primary Health Care and availing of faculty and support staff for educational and mentorship for student activities in Social and Community Medicine that take place at UR in Kigali and Butare are major points in the document.
- Under PIH’s leadership of Dr. Alex Coutinho, a solution was created for the next year (FY 2017-2018) SOCOMED courses of the expected large number of medical students: the courses will be condensed without impacting the quality of the field experience during rotation at the Rwinkwavu site. There would be a review of the curriculum to suit the prevailing circumstances.
Conclusion
- PIHas organisation has supported financially and managerially the postgraduate FAMCO program since 2010 and undergraduate SOCOMED and iSOCO programmes since 2012. Without their support social medicine and community health training would not have occurred in the undergraduate and postgraduate medical trainings.
- Apart of the continuation of the SOCOMED course for 4th and 5th year medical students, the future of iSOCO courses 1,2 and 3 is very uncertain. In these circumstances, SOCOMED itself as offered presently is in jeopardy as it is part of the overal the Social and Communty Medicine program offered by the discipline of Primary Health Care,
- The University has a major role to play to guarantee also in future the trainings of medical students in social medicine and community health and in re-starting a Department of Primary Health Care, where postgraduate Family Medicine residents can be trained.
- PIH has a historical pivotal role as an advocate for social justice and has demostrated leadership in embedding the values of equitable health principles in the training of new cadres of health practitioners in this program. The gains made over the years should be continued to bridge this past into the future by PIH remaining as a Champion for this cause by partnering effectively with UR to mobilise the resources, partners and human resources needed for the continuation of the program
,