History of Family Medicine in Malawi

The idea of “Family Medicine” or “General Practitioner” (GP) as a unique type of doctor, with its own differentiated postgraduate training, has been around for a long time. The first professional associations of Family Doctors or GPs were formed in the 1940s and 1950s in Canada, the U.K., and the U.S.A. Family Medicine or General Practitioner postgraduate training in some form exits in 65% of the worlds’ countries.

Inception of the idea of Family Medicine in Malawi and how it has evolved 

The Malawi College of Medicine (COM) was founded in 1991 as a constituent college of the University of Malawi. The first postgraduate programs at COM in the form of Masters in Medicine Degrees (MMED) were started in 2005.

2008 – 2011

The Family medicine concept started as inspiration to improve the practice in rural medicine by Dr Jonny Kumwenda in early 2001. This came from the understanding that doctors sent for district attachment lacked skills to meet the challenges of the district hospital, hence most medical officers sent for community service in district hospitals became frustrated and did not remain there to work. Those who wished to remain and serve in the district hospitals lacked support and mentorship, and their career path looked bleak.

In 2008 a team comprising of academics from Edinburgh Scotland, Witwatersrand University, and Stellenbosch University from South Africa, as well as stakeholders from Malawi (see picture above) met in Blantyre, Malawi. The aim was to discuss introducing family medicine and engaging with stakeholders to start Family medicine in Malawi. The discussion was fruitful and it came up with the following realizations: the need for FM was recognised and envisaged as a vehicle for improving the primary health needs of poor Malawians. Furthermore, the role of the other key players in primary health care (PHC) was recognised, along with the need to integrate their skills into a healthcare team to improve PHC.

In 2009, the main stakeholders providing PHC in Malawi; namely Christian Hospitals Association of Malawi (CHAM) and Ministry of Health (MOH) requested consultation on the process of creating a plan for a family medicine education and training program, and how to improve primary health care . The forum realised that that to achieve the stated goal, they needed health-workers with multi skilled expertise to improve service at district hospital level and beyond = Family Medicine! This came at the same time that the World Health Organization (WHO) re-affirmed that the broad based stance of a generalist provides good skills and attitudes for provision of primary health care. Of particular note was the fact that, at the time, there was a critical human resource shortage at the national level, and even more so, critical at district hospital level. The few doctors that were placed at District hospitals in Malawi largely assumed administrative roles. Those doctors also felt poorly prepared in their training to ably face the challenges before them. The committee then confirmed their case for family medicine and drew up prerequisite and partnerships needed for starting FM in Malawi.

By March 2009, the idea of Family Medicine was agreed in principle by the Malawi Medical council. Later, exposure to international family Medicine bodies like Primafamed served as a catalyst to starting family medicine at the Malawi College of Medicine.

2011 – 2014

February 2011 saw the appointment of 1 full time and 1 part-time Lecturer in family medicine by Malawi College of Medicine. At the start of the Academic year in 2011, the first FM clerkship block was introduced in the MBBS 4th year with an aim to exposing undergraduate students to principles of family medicine .

Seen in the picture (left) , the first cohort of students completed 6 week course, with a lecture week at the College of Medicine Blantyre Campus, then proceeded to one of several District Hospital settings within Malawi to learn first hand about person-centered care at the district level, and what role Family Medicine doctors play in providing that care. The course has continued annually since that time.

The undergraduate rotation has undergone  continuous updates, with the goal of  improving the educational program to meet our high standards. Yearly the Faculty and core stakeholders, including Preceptors (Faculty teachers) based at the district hospital sites have met together to make sure the teaching material is updated and relevant for students. A group (picture right) is seen updating the student logbook at the end of the first year of the rotation, in April  2011.

During the years of development and improvement of the undergraduate program, the idea of postgraduate training was never far from the surface. Most of the 2012 saw the start of the development of a postgraduate curriculum. Critical to this process was the development of training sites as well as trainers and securing funding for the program. Continuing in 2013, in conjunction with the International Training and Education Center for Health, a curriculum was formalized for the postgraduate program and submitted to the University of Malawi Faculty Senate. In early 2014 the University of Malawi Faculty Senate approved the Curriculum for the MMED Program in Family Medicine.

2015 and Beyond

In January 2015 the first class of 3 postgraduate MMed registrars started training based at Mangochi District Hospital.  Registrars who begin the MMed start a 4 year journey that will teach them to be competent clinicians with broad range of clinical skills and position them to be leaders in the health system. At present (February 2019) Faculty at Mangochi District Hospital site include one Full-time Faculty lecturer employed by the College of Medicine, Dr. Lutala, and 2 full-time Physician Faculty from partner organizations. Dr. Nettleton, from the United States, is supported by the NGO SEED Global Health. Dr Hofland, from the Netherlands, is supported through the organization Tweega Medica. From 2015 to now we have partnered with various individuals and organizations to support teaching at Mangochi District hospital including the previous version of the Global Health Service Partnership program.

In October 2016, the Department started training postgraduate Family Doctors at a second district-based training site, Nkhoma Mission Hospital, a CHAM (Christian Health Association of Malawi) partner hospital. Nkhoma Mission Hospital has a long history with Family Medicine in Malawi, being one of the first sites to accept undergraduate medical students during their rotation.

At present we anticipate we will have a first crop of graduates from the 4 year program in 2019! We continue to accept interested candidates into the program, and at present (February 2019) have 5 active registrars across years 1-4. We anticipate starting 2 new registrars in March 2019, and continue to engage with individuals who express interest in postgraduate family medicine training. We look forward to continuing to build and grow an excellent district based postgraduate family medicine program.

We are happy to connect with individuals or organizations regarding further details or answering questions!

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Family Medicine Research Priorities

Family Medicine is a relatively new clinical specialty in the country of Malawi. The training produces a broadly capable physician specialist with competencies in a range of clinical areas including: adult, pediatric, obstetric, and surgical disciplines, as well as competences in public health and district leadership.

Globally there is a strong interest in the strengthening of primary care health delivery systems. There is a belief that a family doctor can add great value to health service delivery as a part of the district health team. To that end the Malawi Ministry of Health has planned that 2 Family Doctors should be posted at the district hospital level. At this point there is not a robust body of literature describing the value that family medicine trained physicians contribute to health delivery in sub-Saharan Africa.

A goal of this research theme for the Department of Family Medicine is to develop this type of evidence as part of implementation of the new postgraduate training program.

Collaborations welcomed. Please email research lead Dr Prosper Lutala or HOD Dr John Parks for further inquiry.

Here is a link to descriptions of ongoing research projects: Click here

Undergraduate (MBBS) Program

The clerkship in Family Medicine aims to introduce students to a thinking process that puts the family and the context of a patient’s illness at the centre of person-centered care. By giving the student responsibility to take history from the patient or guardian, perform a physical examination, writing the findings and participating in the process of further investigations and treatment under the guidance of a qualified clinical teacher, family medicine allows students to learn principles of holistic care and translate theoretical medical knowledge into practical skills. The module also gives students an opportunity to experience and to practice integrated primary care medicine that is responsive to patients, their families and communities.

The Family Medicine clerkship, a six week rotation, starting with lectures at the main campus followed by four weeks spent at a clinical preceptor site and a final week at campus. The aim of the clerkship is to expose you to the practice of family medicine and primary care in the setting of a district or rural site.

In this rotation, students will learn different models of consultation, communication, principles of chronic care and continuity of care, Integrated Management of Childhood Illness (IMCI), adolescent health, family health, geriatric care, palliative care, and ethics in the context of primary care.

This clerkship is distinct from others in the MBBS curriculum. The patients students evaluate may not have seen a health care worker before ―i.e., they are undifferentiated. They may have no diagnosis or may be presenting with new symptoms, giving the student an opportunity to make first impressions. Each of the patients students evaluate are considered as an integrated whole, and all of his/her problems will be attended to within the context of his/her family and community.

During the district hospital attachment the students are expected to be self-directed with a large portion of their learning. The student logbook, acts as a learning diary for students’ to record undifferentiated cases, antenatal visits, chronic care consultations and much more. Guided by the logbook, the student is encouraged to think of every patient encounter as a learning opportunity.

Postgraduate (MMED) Program

The postgraduate training program in Family Medicine started with the first trainees at the University Of Malawi College Of Medicine in January 2015. The postgraduate program is four (4) years in length, and upon successful completion leads to the award of a Masters of Medicine (MMED) degree as laid forth and approved by the University of Malawi. The MMED-Family Medicine is a specialist qualification at par with other clinical specialties in Medicine in Malawi.

The aim of the MMED-Family Medicine program is to provide high quality postgraduate education in family medicine, which will produce specialists who have the broad range of competencies necessary in the management of the primary care team and in the provision of integrated, comprehensive, continuous and person-centred care.