This guide has been developed to help you (the student) through the MMed (Family Medicine) program. The hardcopy of this guide and its appendices will be available to students who successfully enrolled in the MMed (Family Medicine) program.
Malawi, a signatory of the Ouagadougou declaration, has an estimated population of 15 million, 85% of which is in the rural. Malawi’s district health system is built around 28 district hospitals, each with an average of 20 health centres. This forms the delivery vehicle for the essential health package (EHP) and primary health care.
With an estimated population growth rate of 2.8%, extrapolation from the 2008 population census indicates that district populations may range from 100,000 (Mwanza) to 1,300,000 (Lilongwe rural). This district level population is served by a range of health care workers. Health centres are staffed with clinical officers, nurses and medical assistants, who have received three to two years of clinical training. District hospitals are also staffed with clinical officers and nurses and medical officers who have undergone three and five year training programs. The best-staffed district hospitals have four medical officers, but many districts have less medical officers. In district hospitals, some medical officers have administrative rather than clinical roles.
Although evidence from around the world indicates that strong district hospitals are the cornerstones of good primary health care delivery, as they are able to address a large part of the populations’ medical care and preventive health care needs. However many developing countries including Malawi continue to focus proportionally more resources in specialized care, which is often anchored in central hospitals. This leads in many district and community-level services being over-reliant on central hospitals, which have eventually become congested with patients and most them requiring long-distance travel.
Hence there are renewed calls to focus on primary health care; for example, The 2008 WHO report on Primary Health Care, calls for strengthening services at the district and community levels, raising the quality of services that are most accessible to the people. W.H.O. also advocates expanding the concept of primary care to encompass people-centred comprehensive care, driven by the health needs of the communities. Furthermore, the recommendations suggest that primary care should move beyond episodic clinical contacts to provide continuity of care for patients, building the provider-patient relationship and improving health outcomes. African states showed commitment to implementing the recommendations of the report through the 2008 Ouagadougou Declaration on Primary Health Care and Health Systems in Africa: Achieving Better Health for Africa in the New Millennium.
The College of Medicine, established in 1991, is the only medical school in Malawi. It currently has an intake of about 100 students per year into its five year MBBS program and has postgraduate Master of Medicine (M Med) programs in Internal Medicine, Paediatrics, Surgery, Anaesthesia and Orthopaedics. The majority of the specialists have established practices in Malawi. Despite Malawi’s problems with brain drain, an estimated 70-80% of Master of Medicine graduates remain in Malawi 5 years after graduation.
To be effective, this district-level physician needs competence-based clinical training, including skills in mentoring and teaching to support front line primary care workers.
The family physician is a medical doctor with competent and comprehensive clinical care skills over a wide range of common conditions and diseases; considering the patient’s physiological, psychological, socio-economic, cultural and spiritual condition within the context of their family and community. The family physician is not limited by the person’s age, gender, and organ system or disease entity. The family physician is distinct from other specialists; as a physician with a working knowledge of many specialty areas, the family physician is a “generalist.” In this way the family physician is able to offer comprehensive and quality care to 90% of patients who come to the facility for care.
Currently, there are only eight family physicians in Malawi, five are expatriates and three are Malawi nationals. Three of the five expatriates are working in Mission hospitals, one is attached to the College of Medicine and another attached to a central hospital; and of the three Malawian nationals, one is full time faculty member in the College of Medicine, one is a part-time faculty member and in part-time private practice; and the third is a full-time private practitioner.
The Family Medicine training programme at the College of Medicine is established on the belief that assigning at least two postgraduate-level Family Medicine Physicians to each district holds the potential to improve primary care through the provision of comprehensive promotive, preventive and curative care not only at the district hospital, but also for the entire catchment area.
- In the “Minimum standards of clinical services for Malawi” the Ministry of Health published in June 2013 that there should be 2 Family Physicians for each district hospital.
- A World Health Organization Assembly resolution 62.12 in 2009 also urges member states to train Family Physicians to work in a multidisciplinary context of a team of primary health workers with different appropriate skill mix in order to respond effectively to people’s health needs.
- Additional imperatives to be implemented by the Ministry of Health are stipulated by policy papers such as the Growth and Development Strategy (MGDS- II) and the Millennium Development Goals (MDGs); the introduction of the training of Family Medicine Physicians (M Med: Fam. Med) in Malawi by the College of Medicine will contribute to the implementation of these strategies and ensure sustainability of the achievements attained.
- In 2012, Malawi’s doctor-patient ratio was 1:50,000 (WHO country profile, 2012) with an even greater disparity at the district level. The few doctors that exist in Malawi are concentrated in the 3 central hospitals in Lilongwe, Blantyre and Mzuzu. The WHO country profile clearly indicates that there is a need to improve human resource capacity. The introduction of the training of Family Medicine Physicians will improve the human resource capacity and significantly improve primary care delivery.
- Integration of Family Medicine in Malawi’s Health care system will reduce the morbidity and mortality rates by improve efficiency and equity in health care delivery thereby improving the health status of individuals, families and communities. This will result in maximizing people’s productivity and ultimately Malawi’s National Economic Growth.
- The Family Medicine Physicians are already making important contributions to improve health care. To fully realize the changes that are envisioned and ensure that Malawi is able to retain these specialists, it will be important for the College of Medicine to begin training its own Family Medicine Physicians. In addition, medical practitioners trained in their home countries tend to practice in their home countries. During postgraduate training, practitioners develop networks that facilitate career advancement and lifelong mentorships.
The Family Medicine Physician is a member of the hospital management team and after successfully completing the course the graduate will be able to display high professional behaviour at all times and be able to perform at the district-level in two primary roles as follows: –
- As a Clinical Specialist:
- Serve as clinical consultant for the clinical team at the district hospital and its catchment area.
- Provide clinical services with a high level of competence
- Lead clinical care in the district from the hospital to the community level
- Promote comprehensive care practices
- Integrate services to ensure more efficient, effective care
- Teach health care staff at all levels in continued professional development
- Provide mentorship to health care staff at all levels
- As a Manager:
- Participate in the development of district systems as a member of the District Health Management Team
- Manage human, financial and other resources
- Identify barriers to quality care
- Analyse the overall direction of clinical health services in the district
- Identify strategies for improving outcomes, positioning the district for growth and excellence.
The aim of the M Med (Fam. Med) programme 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.
By the end of the course Family Medicine Physician will be able to:
- Improve quality of patient care and the integration of individual and community health care through provision of comprehensive promotive, preventive and curative care
- Strengthen district health management teams in the rational use of resources for increasing cost-effectiveness with responsibility for quality care in the district hospitals and health centres
- Enhance conduction of research
- Improve referral systems
- Apply principles of professionalism in the provision of health care services
EXPANDED PROGRAMME OBJECTIVES
- Manage common medical disease and conditions in adult and paediatric patients at the district hospital level.
- Apply a holistic approach to clinical management that incorporates the context of the family in the health of individual patients
- Apply principles of bio-psycho-social and evidence-based medicine to clinical patient care
- Identify how the individuals’ health can lead to larger community health problems and how interventions at community level can impact on individual health
- Facilitate the health and quality of life in the community
- Integrate the roles of a Family Physician in the medical and academic communities, and in society at large
- Investigate health care hypotheses for the provision of evidence based changes in clinical practice and, or policy for the improvement of health outcomes for individual patients and, or their communities
- Evaluate a District Health system in which Family Medicine is an integral part
- Manage public health resources for the improvement of health outcomes in individual patients and their communities
- Manage himself or herself and his or her practice effectively with visionary leadership
Character of the Course
The training will lead to the award of Master of Medicine degree in Family Medicine abbreviated as M Med (Fam. Med) after successful assimilation of principles learnt in didactic and theoretical sessions through extensive hands-on site experience in the various clinical areas as well as management and primary care settings. This is a specialist qualification at par with other clinical specialties in Medicine in Malawi.
Duration of the course
The training is a 4 year program. The students will also be required to undertake research study, and have the opportunity to do an elective period at a foreign hospital of not less than 3 months.
Location of the course
The College of Medicine campus will be the centre for coordinating the implementation of the training programme. The initial 2-week didactic contact session to introduce the program and prepare them for the first clinical rotation and other contact sessions will be conducted at the College of Medicine campus.
The students will be attachment to practical sites where they will remain for the bulk of the program as a competence based approach. In this regard, in the first two years, Mangochi District hospital will be used as one teaching complex while Lilongwe District Health Office and Daeyang Luke hospital will form a second and Nkhoma and Dedza will be used as the third teaching complex.
Specifically the following criteria will be used:
- MBBS degree or its equivalent
- Completion of prescribed internship and full registration with Medical Council of Malawi
- Must be in a training position approved by Ministry of Health and College of Medicine
Mode of selection
Procedures for selection into the M Med (Fam. Med) program will follow the General Academic regulations for postgraduate Masters Degree programs in the College of Medicine as submitted to Senate in September, 2010 and effected in October 2010.
The M Med (Fam. Med) postgraduate training program recognizes the value of enrolling candidates from diverse backgrounds. Candidates will be admitted to the program based on their academic merit and will not be excluded on the basis of sex, tribe, religion, geographical region, socioeconomic status, age or other factor.
The curriculum consists of 21 core modules organised into four main components as outlined below:
- Fundamentals of Family Medicine: CODE: FAM MED 601. This component has four modules:
- Principles of Family Medicine
- Evidence based Medicine
- Family Oriented Primary Care
- Community Oriented Primary Care
- Clinical Family Medicine: CODE: FAM MED 602. This consists of 14 modules:
- Child health
- General Adult Medicine
- Infectious diseases
- ENT, Ophthalmology and Dermatology
- Women’s Health
- Adolescent Medicine
- Palliative Care
- Emergency Medicine
- Mental Health
- Clinical Pharmacology
- Research Dissertation: CODE: FAM MED 603.
- Health Systems Management and Electives: CODE: FAM MED 604.
- Health Systems Management in Malawi
- Elective Topics in Integrated Health System
A Family Physician must have a functional knowledge of many specialty areas in medicine; ideally a Family physician should be able to manage 90% of patients at the district level. To achieve this breadth of knowledge, the M Med (Fam. Med) training program must include a wide range of topics in a progressive manner. As such, years one and two focus on helping the student to grasp a basic understanding in key topic areas. Year three and four focuses on a more complex mastery of the same topic areas.
Throughout the 4-year program, students will see patients during a series of clinical placements. Each clinical placement is preceded by a 1-week didactic contact session. Fundamentally, the contact sessions provide the student with what to focus on during their clinical placements.
District and CHAM Hospitals, Health Centres and Community Attachment
Over the 4 years, students will rotate through departments at the hospital, health centres and communities served by the district. Upon completion of each rotation, a one-week classroom-based contact session is held to prepare students for their next rotation.
The Clinical practice will be facilitated by specialists at the host hospital. The host hospital has a site team comprising of a specialist Family Physician (site supervisor) and three to five other specialists. This forms the core teaching team. The students will be in the site for at least 40 weeks in a year.
Central Hospital Attachment
Students will also rotate at a Central Hospital to gain specialized skills not currently available at District training sites (e.g. anaesthesia, orthopaedics Intensive Care Services etc.).
For the elective period in the third year, a process has been started to work with Witwatersrand University in South Africa, which has been a partner in the development of the Family Medicine program in Malawi since 2009.
|PRACTICAL AREAS||NUMBER OF WEEKS|
|General Adult Medicine||10||8|
|Ear, Nose and Throat||3|
|Health Systems Management||12|
|CODE||MODULE NAME||THEORY HOURS||PRACTICAL HOURS||TOTAL HOURS||WEIGHT %|
|Fundamentals of Family Medicine||60||60||1.1|
|General Adult Medicine||52||630||682||12.2|
|ENT, Ophthalmology, Dermatology||21||315||336||6|
|Health System Management||21||420||441||7.9|
The aim of assessment is to monitor students’ progress during specific modules and rotations to ascertain whether the objectives for each module and rotation have been achieved. The methods of assessment will therefore be consistent with module objectives and will take into consideration the competencies to be performed by the graduates in the workplace.
- A Candidate who fails marginally (45-49%) in one examination will be recommended to take a supplementary pass/fail examinations in six months in the papers that the candidate failed before the start of the new academic year. This is subject to approval by the University Senate.
- Supplementary examinations for the written and or clinical components shall be held in accordance with the General Academic Regulations at the discretion of the Faculty or Board of Examiners.
- A Candidate who fails marginally (45-49%) in more than one paper will be recommended to repeat a year subject to approval by the University Senate.
- A candidate who obtains a clear fail (less than 45%) in one examination will be recommended to repeat a year subject to approval by the University Senate.
- Candidate who fails in any supplementary examination(s) will be recommended by the Faculty Board of Examiners to Senate to repeat a year.
- The student will continue rotations in clinical Family Medicine and re-sit both written papers and clinical exams after 6 months
- A Candidate who fails in all examinations and their average mark is below 45% will be recommended for withdraw. Such recommendations shall be subject to approval by the University Senate.
- A Candidate who repeats a year and fails the examinations will be recommended for withdraw.