Monitoring Report Of The Collaboration Between Mundo/ Whig And The Department Of Family Medicine

Monitoring Report Of The Collaboration Between Mundo/ Whig And  The Department Of Family Medicine

 Monitoring Report Of The Collaboration Between Mundo/ Whig And  The Department Of Family Medicine

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By Geraldine van Kasteren and Pieter van den Hombergh
March 2011

ACKNOWLEDGEMENTS

Our special thanks go to:
Dr. Hans and Dr. Marianne Bakker         for organizing and contributing to the success
Prof Otsyula        for meeting us twice
Prof Ayuo, Dean Medical School
Prof David Ayuku, Prof Peter Gatongi
Patrick Chege, MMed FM        for his guidance all along
All Faculty (Dr. Ray Downing, Dr. Vic Buckwalter, Dr. Janice Armstrong, Dr. Jeremia Laktabai MMed FM, Dr. Patrick Chege MMed FM)
Dr. Joseph Thigiti MMed FM and the management team of Kangundo
All FM registrars
The Community Health Workers of Naitiri
The staff of Pharmaccess

Hans and Marianne Bakker, with part two registrars,
Ouma, Tembu, Joy, Otieno, Kemei, Mugalla
        
                       

EXECUTIVE SUMMARY
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The expected output of the assignment was an evaluative report on the FM-programme with emphasis on the collaboration with Mundo/ Whig to be shared with the Dutch donors and as a starting point to seek for continuation of the support when need is felt. For this evaluation Geraldine van Kasteren and Pieter van den Hombergh visited Moi University (MU) from 21-3-2011 till 26-3-2011.
The visit included meetings with all stakeholders mentioned in the ToR, who all managed to speak to them extensively.
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Major conclusions were:
1.    The training has now 9 Family Physicians who successfully completed the training, 5 just sat for their final exams (1 did not pass), 9 are still in training and 3 dropped out.
2.    The training is vital and firmly embedded as MMed FM training in MU.
3.    Input from the Dutch support group is not required anymore for the training and curriculum development.
Based on these conclusions our support till the end of 2011 will focus on the following:
    Strengthen the chapter of KAFP    to
-    organize 2 meetings till the end of year. Also Registrars and interested MO’s can be invited
-    include CME that can be facilitated by (inter)national speakers
-    lobby to the national coordinating committee
-    continue developing an adapted MO-plan, that could be hosted by the chapter of the KAFP
    Tuition fees for the academic year 2011/2012 for registrars (max. 12) on top of the 3 students already financed by INFAMED.
    Support the community health training in Naitiri (with the assistance of Hans and Marianne) to fully use its capacity for training registrars in CH.
    Support research if requested. Exchange could be in training them in the international course in Maastricht and promote twinning to a student to jointly work on the thesis.
    Explore the possibility to present the training and the community aspect of it in Barcelona during the FESTMIH (ECTMIH European Society of Tropical Medicine and International Health)
After 2011 new projects will either be considered by the PMF (Peter Manschot Fund) or will need to be financed otherwise.
Report of the visit
From 21-3-2011 till 26-3-2011 Geraldine van Kasteren and Pieter van den Hombergh visited Moi University (MU) to evaluate the collaboration between Mundo/ WHIG and the department of Family Medicine in the School of Medicine of MU. For background information on this visit we refer to the ToR in the annex. In the various meetings in Eldoret, Webuye, Naitiri and Kangundo we interviewed administrators, faculty, graduates, registrars and health workers how they valued the programme MMed Family Medicine and how they envisage the future of Family Medicine-department and our contribution.
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After a welcome on Sunday evening 21 March 2011 by Marianne and Hans we were updated on the latest developments and next morning Patrick Chege joined us for the day:
During the first meetings the following relevant information was shared:
1.    There are 9 FPs in the field and 6 are expected to graduate this month. Currently there are 9 registrars in the Family Medicine-programme; 3 have dropped out.
2.    Tuition fees for all new applicants were suspended, because the MoH (Ministry of Health) has short of funds. In fact all MMed programmes face the same situation. This problem will be solved for the ongoing registrars. However new applicants for the MMed programmes (all MMed programmes: Medicine, Surgery, Paediatrics, Obstetrics/Gynaecology) will only get their salary from the MoH and have to pay their own tuition fees; the Family Medicine Master is no exception.  The registrars receive a salary of approx. 700 euro per month net. As of now, tuition is 193,700 KSH (€ 1.585,- ) for the first year, and 187,000 KSH (€ 1.530,- ) for each subsequent year.
3.    The MoH is employing half of the present doctors (1200 but 3000 needed). Being a specialist will not automatically lead to an increase in salary. Only years of employment determine the increment in salary.
4.    Offering scholarships for MMed Family Medicine will give this programme an edge over other specialties when MO’s have to choose.
5.    Family Medicine was not on the list of options in specialties in the booklet for MO’s but the MoH came out with a brochure (Dr Mueke). See www.whig.nl Eldoret.
6.    Aga Kahn Hospital has put the start of their training programme in Family Medicine on a hold because of lack of qualified faculty. 
7.    Elements of Family Medicine will be in the new undergraduate programme.
8.    The KAFP is an association of primarily approx. 30 mostly Nairobi based GPs.
9.    Moi University is an accredited CPD center enabling the faculty to organize accredited CPD-training.
10.    Dr. Chege and Dr. Laktabai are proposing to start a new branch of KAFP for Rural FPs/ procedural FPs that could host CPD-programs, conferences and so bring glue in the new group fo FPs.  Bruce Dahlman was active in KAFP, but since he left it is a bit silent.
11.    The National Coordinating Committee was established in 2010 to coordinate the strategic planning of FM in Kenya. Four representatives of FM from Moi University (Prof. Otsyula, Dr. Nderitu (INFAMED), Dr. Ray Downing, Dr. Thigiti) are in the committee.
12.    Infamed has no structural financial contribution, but offers two training sites. The FM department receives money from Ampath and Mundo/WHIG, but is more or less self supporting now.
13.    Health centres are under the Ministry of Public Health and that would change to Ministry of Public Services after becoming a (sub-district) hospital. 
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1. Meeting with Prof. Ayuo Dean of School of Medicine (SoM), MU
Hans, Marianne, Chege, Geraldine and Pieter met Prof. Ayuo. He had been supportive from the very start and stated that he would like to continue the collaboration. He was happy that Family Medicine had a firm position now and he was hoping that the MoH would allow MU to upgrade new sites with FPs. FPs so far have been posted everywhere and alone, being demotivating for all. Discussing the options for a MO who wants to be FP, Chege said that some experience it as being marginalized with the poor. What could be done to turn that around. He saw a regional role for Moi U in improving health care. We discussed the possible new training sites (Iten, Vehiga), the increase of FP training places to meet future demands, the training of MO’s doing compulsory service by MU, the role of insurance companies and the treatment of chronic diseases. It was a good exchange of ideas on the strategic possibilities for the Family Medicine- training to thrive:
•    Ignorance about Family Medicine programme, PR &  marketing should be done more aggressively
•    Expanding faculty is not possible (yet) but it is possible to have honorary lecturers as supervisors in affiliated hospitals. Family Medicine faculty also to teach in undergraduate and other courses to disseminate at an early stage Family Medicine approach and attract future registrars
•    In the past the internships were waived to favour a young specialty to grow. This was considered for FM as well. However, the experience with waivers in other programmes didn’t result in more graduates in public service. So this is not a solution to attract more registrars for FM.
•    1 Institute will never be able to create a critical mass of FPs. Concentration of graduates in a geographical area is felt important to feel the impact. In Webuye impact is felt (more patients).
•    Currently there are no incentives to work in rural areas
•    Distance education/evening classes could give privately sponsored doctors a way to join because they can open their practice during working hours to earn a living.

2. Meeting with David Ayuku
David Ayuku is the Head of Dept. Behavioral Sciences. He has pursued a PhD from Maastricht University with a thesis on Street children. He teaches behavioral sciences in the Medicine programme and hopefully in future also in the Family Medicine-training. All departments have the obligation to teach in SoM programmes, but there seems to be no linkage between increase in teaching responsibilities (more programmes, more students) and increase in the number of staff allocated to fulfill the obligations. He showed material he is using in a module on Communication skills (doctor-patient relation) provided by Mieke Visser. We discussed the importance but also difficulties of teaching on the many aspects of anthropology, palliative care, communication skills, giving feedback, etc. and its relevance for the consultation in Family Medicine.
The HoD FM should timely rely with the HoD Behavioral Sciences when they are supposed to teach in the FM programme to be sure staff will be available.

3. Meeting with. Prof Otsyula
Prof. Otsyula is considered to be the patron of the FM training programme. The meeting with Prof. Otsyula focused on several main topics: awareness about FM in Kenya, cooperation MoH, national coordinating committee FM. In his view MMed FM will continue struggling for a few years (like the other specialties in the past) but will come up not to disappear anymore. He was clear about his desire to continue cooperation with the Dutch support team. He made a strong plea for providing tuition fees to increase the number of students since the MoH is short of money.
He was proud that MoH was now convinced of the wisdom to post two FPs per hospital.
He was pleased with the contribution of Hans & Marianne in Naitiri and saw it as extra valuable because of its function in teaching community care to registrars. Health centres are under the Ministry of public health and that would change to the Ministry of public services after becoming a sub-district hospital.  He stressed that primary care differs in its definition for Public Health and Family Medicine.
He critically commented on the plan to train MO’s during their internship in various aspects of Family Medicine, because in his view the content of what these MO’s should be taught had yet to be developed. It needs a champion to sell the idea to the MoH. However, it would then be a way to contribute the approach of Family Medicine to this important group of generalists, who could become more interested in Family Medicine. Pieter asked Otsyula and Chege to adapt the plan to these comments and bring it forward as an initiative of the department, through the Dean, to be supported by the MoH and then seek for funding.
The need for CME is now becoming more felt since the FPs are posted in different corners of Kenya in different positions and sometimes still on their own.
He was supportive to the idea to twin students for research. Also he showed interest for the research on evaluating how well FPs are integrated in the existing health care system by a student in Master Programme in Global Health from Maastricht University, hopefully in collaboration with registrars. He also commented that the training sites should not be tertiary centres, making Tenwek and Kijabe less suitable for Family Medicine training. He will formulate with Ray a reply to the letter of Jan Ivo foundations. We made an appointment to continue the discussions on Thursday.

4. Meeting with Prof. Gatongi, dean of the School of Public Health (SoPH ), MU
The major contribution of the SoPH to the FM programme is teaching (biomed, statistics, epidemiology, health management) in the first trimester and the supervision of thesis (design research, IREC approval, implementation, analysis, write-up and defense). The SoPH has 26 own students and 26 from other department giving a lot of stress. Especially the supervision of thesis is much work (finalizing the proposal takes already at least 30 hrs), especially since the written English is getting poorer. Expanding the Family Medicine training would stress their capacity. They already had stopped the medical education program. The SoPH is not compensated financially for their work for the SoM, while staff from SoM is compensated for work they do for the SoPH. For the contribution from SoPH to the FM programme the constraints are the shortage of staff and lack of incentives.
Dr. Menya works for the DSS and they started the 5th cycle of surveys, but so far there are no students yet collecting primary data by including questions in the surveys or using secondary data. He liked the idea of twinning students to work together. The 6 DSS’s in Kenya have little cooperation, each having their own focus, but there is an umbrella committee. The DSS will be evaluated by VLIR this year.
We expressed our wish to integrate public health into Family Medicine especially on prevention and disease management.

5. Meeting with Pharmaccess
Luckily enough we could meet with the people of Pharmaccess who were in Eldoret for a meeting with stakeholders. John Dekker (manager of Lab services), Hielko Bartlema (Country manager Kenya) and Cees Stijnis (Internal medicine, infectiologist, tropical medicine AMC).
They are setting up a Health Insurance Fund (HIF) in Nandi Hills with dairy farmers and so far 5000 families of a potential 20.000 have entered the scheme. They are upgrading the health centres to provide high quality insured care. They also train the personnel and increase diagnostics. Supervision is done by a doctor from Eldoret.
The insurance company (A.A.R.) makes a contract based on performance reporting and quality of care. In Tanzania and Nigeria they already have much bigger programs and there they do site visits with a visitation method to warrant quality of care. For the next step (accreditation of the sites) they work together with KASASA in South Africa.
We explained the Family Medicine training program and its potential to cooperate by providing supervision and innovation/ quality improvement in the health centres.
We discussed the ins and outs of the HIF (covering all care including Out Patient at 200 KSH) versus the cheaper National Health Insurance Fund (NHIF;1900 KSH per family and decreasing with more children). Also the problem of equity and inequality was raised.
The program is very much in its infancy but it was good to know from each other and we can find each other when needed.   

Tuesday, 22 March
Meeting with the faculty of family Medicine in Webuye
It was quite exceptional that we could meet with all of them (Ray, Chege, Janice, Victor, Laktabai (Medical Superintendant of the hospital). Hans & Marianne were not able to attend.
Unanimously they stressed the importance of supporting tuition fees. Already 4 new applicants contacted the Faculty. In early July the application interviews will be held. There was no extra PR activity done and Ray did not think it would increase the number of good applicants. In the past according to Ray the good applicants came in by mouth to mouth PR.
He stated that the training was at a point that it would survive even without them (expatriate faculty: Ray, Vic, Janice) and without outside support. Yet, the support of AMPATH, financial support for Vic, and some smaller funds has been helpful. Chronic care (DM treatment) was well established by Vic in close cooperation with AMPATH. Presently the hospital was lacking enough registrars to meet the clinical demands, because they have to respect the teaching load and research work.  According to Vic the ideal number of registrars for Webuye is 12 (4 in each year). 
The National coordinating committee for Family Medicine is very important to work as a lobby towards the MoH. It was suggested that besides Webuye, also the training sites should be represented in this committee.
Ray mentioned that Naitiri as community health training site could go on without Hans and Marianne, although they were welcome to continue. In his view no other help is required for setting up new sites, assistance in staff, input in the program or in research.
Pieter made clear that sustaining financial support was unlikely with very little to no personal collaboration, meaning that eventually it would all end happily. It was clear that a viable and sustainable department was already quite an achievement.
A workshop with Dutch support was done to upgrade the skills of research supervisors, was evaluated as very useful. The proposed research by a Dutch medical student about the integration of FPs in the existing health care system was not timely, according to Ray. Also the permission from the IREC should be pursued before he is able to start his research. Chege offered to be his supervisor.
Ray was keen to have students and even more professors to make use of the DSS in order to make it financially sustainable. Questions could be added to the surveys to collect data for research. This will go against a certain fee.   
Due to heavy rain we had to close the session in the new Family Medicine building, a spacious and very functional construction made out of 2 containers, including a meeting room/class room and a library/ computer room. Also the DSS hold office in the third wing.

Wednesday, 23 March
Hans and Marianne, Geraldine and Pieter visited Naitiri and were received by at least 40 (out of 50) CHW’s (Community Health Workers) and the CHEW (Community Health Extension Worker) all very visible with a yellow T-shirt (the ‘golden girls’) with CHW printed on it. They showed in three acts exactly what their work was all about and shared their problems and achievements. In the village they check if people got vaccinations, went to the hospital for antenatal care, helped with HIV-drug compliance, etc.
 It was an impressive presentation and afterwards we visited two households that met all the criteria of a healthy home, with separate toilet, washing place, compost hole, clean compound, etc.
They had clear wishes 1. Refresher courses, 2. Exchange programme with neighboring CHW-programmes, 3. Training new CHW, 4. T-shirts and/or badges, 5. Kits for emergency treatment (panadol, bandage, etc) and 6. Bicycles that were promised but never given to them by the Min. of Public Health.
We took the opportunity to motivate them by explaining that we valued their work very high and that without them health for the community could never be reached. The Family Medicine programme will continue supporting their (training) needs.
We got presents (chickens, eggs, banana’s) and left impressed and touched.
       

Back in Webuye we joined to the first meeting of the FPs and registrars of Moi, chaired by Dr. Chege, secretary Dr. Lodenyo. 
Present were: Chege (1st batch graduate, faculty at Webuye), Akiruga (2nd batch, Iten district hospital, superintendant), Geoffrey (Part I registrar Webuye), Wanjala (2nd batch, Busia district hospital, clinical work in pediatrics and medicine, training coordinator, internship coordinator, member medical board), Lodenyo (final exams last week, waiting for results, trained in Webuye), Munyendo (final exams last week, waiting for results, trained in Webuye), Ngugi (Part II registrar Webuye), Mwaka (1st batch graduate, Kijabe hospital, programme coordinator), Kefa (registrar Tenwek Hospital), Omunyin (Part II registrar Webuye), Mugalla (Part II registrar Webuye), Laktabai (3st batch graduate, superintendant Webuye), Vic Buckwalter (faculty Webuye), Christine Buckwalter (wife to Vic), George Odhiambo Otieno (former teacher Health management and coauthor policy FM and strategic plan FM MU), Joy (Part I registrar, Kijabe), Tembu (Part II registrar, Kijabe), 2 medical students from Groningen University, Hans and Marian, Pieter and Geraldine.
The agenda was to evaluate the training and to discuss the start of a branch of the KAFP for rural FPs. The opinions of each participant was ventilated:
    Mwaka was one of the first 3 registrars found that the curriculum improved a lot. He worked in Kijabe as a honorary faculty and programme leader, but it was not a Family Medicine setting.  However Family Medicine was well established and specialists treated you as a colleague. Not all expat American doctors are adequate as teachers of Family Medicine here.    
    Wanjala is working alone in Busia and felt he was filling gaps left by specialist who were absent. It was also not good for maintaining the skills. He has a very successful private practice, because patients appreciated the Family Medicine approach. He was not unhappy about his posting in Busia, but warned that all freshly finished registrars would be posted, just like the other specialists, to where they were needed. Busia was Nr 1 hospital and Webuye Nr 2 in Kenya on a national ranking. When hospitals define your work as GP that is the end of the FM-specialism. Comment Chege: how can you possibly evaluate yourself to improve if you work without supervision or even colleague Family Physician? All participants agreed that there was a strong lobby needed to define the role of FP for the MoH. George reminded them that this was done very clearly in the policy document.
During the break for dinner Vic opted for the Dutch support to continue in the area of Community Health teaching. This could be improved through Naitiri.
    Akiruga is working in Iten and felt that the training had been very adequate for his work there. He was also superintendant and therefore had many administrative tasks.
    Laktabai confirmed that being a superintendant in Webuye he had too many managerial tasks and was constantly solving bushfires. In a position as superintendant you could have more impact in guiding the hospital but that only will work in the favor of Family Medicine if there are enough Family Physicians and FM registrars working in that hospital.
    Chege started his training in Chogoria first and then Kijabe, less optimal, but the curriculum has now improved. He stressed on the fact that the training sites should become more equitable and that standards should be developed and applied in selecting the training sites. This is the responsibility of the department. Another option is to make the registrars rotate to different hospitals during their training.
    Joy complained that she had a tough time with rotations, having a family and a husband in Garissa. Chege underlined that the male registrars shared her worries that rotation have a negative impact on their families.
    Alex said he was helped by the sponsorship, but said more faculty was needed also for CME. The research course by Mieke van Driel was excellent. The training should be more standardized.
    Prof. George Odhiambo stressed the lack of visibility even amongst MU medical students and argued for more aggressive PR. He said MU should support the start of Family Medicine training in Kenyatta en Methodist Universities.
    Geraldine concluded that this meeting to her was felt as very positive and important. She was impressed by all the useful information shared and proposed to continue the meeting the day after as it was getting late and all participants getting tired, some after a long travel to reach Webuye. She explained that points she is considering for future collaboration are the establishment of an organization, be it a chapter of The Kenyan Association for Family Physicians. Through this association important issues for the development of Family Medicine in Kenya can be tackled like: sharing experience with FP in the field to improve the training programme and to develop the role of FP, creating awareness about FM at various levels, organizing CME, lobbying through the national coordinating committee.
    Pieter added some points about the use of an association and promised to continue about this topic tomorrow.
    Hans motivated the gathering by using a metaphor that yet Family Medicine is only a small drop and hardly visible, but the individual FPs are working very hard and if that drop would fall in one’s eye it suddenly becomes very visible.
Meeting was closed at 10 PM.
   

Thursday, 24 March
Morning: Course: The Clinician as a teacher, facilitated by Hans, Marian and Mwaka for the 6 Part II registrars. The content of this morning was to learn more about different teaching styles and how to present.  All registrars have many teaching obligations during their programme. All participants were very active and it was perceived as very useful.

Afternoon: Continuation of the FP and registrar meeting
Participants:
Kenedy Omundi, Part II Webuye
Shadrack Kemei, Part II, Webuye
Plus yesterday’s (minus Wanjala and Akiruga)
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Continuation of sharing experience in training.
Issues mentioned yesterday: uniformity of training, visibility, extending programme to other universities, lack of teachers, learning resources were minimal in the beginning but now improved, rotation to different sites. In practice FP’s are used frequently to fill gaps, depending on positions loss of (clinical) skills, how to ensure impact felt?, Posting in pairs, concentrating in geographical area.
Ngugi: add rotation in management or medical leadership. Subspecialty within FM? Not in training, but yes in practice? A FM is a generalist defined by the context.
Chege confirms that you need to train all-round and that you have to know what is needed because you see what’s going wrong and what can be improved. So therefore you are more useful than a manager.
Concern was expressed because FM needs a critical mass and a voice to do something about the presented problems and the critical mass will not be reached soon.

Agenda point 3:
Forming Chapter of KAFP, rural or Western Kenya
KAFP is in Nairobi, difficult to attend meetings.
Proposed agenda for chapter KAFP:
    Getting together to share experiences in training and practice
    Need for increasing FM training capacity and impact rapidly. Awareness at the level of MoH, public/community (barasa) and future candidates (medical students, MO’s), colleagues in other specialties. Promote specialty through this association.
    CME, invite speakers (through dean to find other specialists), CME will be open to be attended by FPs, registrars, MO’s students, KAFP, other disciplines
    Pieter: an association will prevent getting marginalized an will have a stronger voice towards the MoH. Many examples in South Africa (Bob Mash, Steve Reid, Bruce Sparks, etc.) to learn from their experience. A training programme can not go into politics, an association can. Publications, conferences (with CPD), newsletter, etc. can be used to bring members together and to become more confident about the specialty. Develop ideas to support health care (like MO-plan) to improve training. College or society is normally the more scientific branch, but for the time being an association can do both.
KAFP looks like being hijacked by the Nairobi GPs: “We need a union” that also serves the interest of the rural FPs. Be a member because we can outnumber them in the future.
Also introducing you to the community. We have to be more visible.
The KAFP is be not a problem and we should be active from within.
It is unclear whether the KMA has been newly invented by young doctors that don’t like the vested interest.
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    [Ray and Janice join the meeting at this point.]
    Comments on establishing a rural chapter KAFP:
    Important to be able to bring FM upfront, not needing permissions. Existing KAFP is not in line with the graduates from the FM programme at MU. Not to antagonize one and other, because numbers are few. A chapter will have more members and by time get involved in KAFP and gaining influence.
    Like in the Kenyan medical women chapter there is also felt a need to establish a western Kenya chapter. KAFP has already split themselves into groups. Nancy Kegode was entitled to work for this region to work on CME. Their executive board meets about monthly, annual meeting once a year.
    Need for union to represent in KMA? KMA is transferring into KMA for Medical practitioners and Dentistry. 
    All recognize the need for a chapter. By voting unanimously ‘yes’ it is agreed to have a chapter. More info is desired about the KAFP (Kenyan Association of Family Physicians). KAFP Started 2004 Nairobi, Humphrey Belcher was first elected chair, practicing as a GP. Chege gave more background info. He tells the story of KAFP when Belcher retired and Dr Musoke took over. Bruce became treasurer, but he left for the US. Chege is in the executive committee. Nderitu has taken over from Bruce in the committee as head of INFAMED.
    Pieter stressed the necessity of a secretary. Presently that is Edith. 
    Chege is member of the executive committee of the KAFP and is not expecting any resistance to establishing a chapter. KAFP is not doing well, membership went down as well as funding.
    It is crucial for the new rural chapter to have a strong secretariat to organize and communicate.
    It was suggested to elect a working committee or interim officials right now to not loose momentum; 3 members (and 1 PR member) to get started. No volunteers, so 3 people got appointed by voting: Munyendo, Laktabai, Chege (all in Webuye).
    They will closely work with Pieter, Hans, Marian en Geraldine and through Ray with the dean. Chege will take the need to establishment a rural Chapter to the KAFP.
Exchange program in Moi was with Indianapolis with pediatrics , internal med. etc. Not with FM. Ray suggests that we exchange with SA or Nigeria. Since the curriculum is now 4 years and that makes it possible to do 8 weeks to 3 months instead of 6 weeks. (Not discussed was the research twinning idea, nor the possibility to do the international research course.) 
Ray sees two solutions to the rotation problems: more sites around Eldoret and link up with other universities starting FM. Ray hopes to accept many of the present registrars to become faculty.

Meeting with Chege about PhD in Ghent. The work with Ghent got frustrated and the data collection with DSS was not completed. Suggestion: ask second opinion of Geert-Jan Dinant. Based on his advice decide to pursue PhD in The Netherlands or Kenya or to publish papers with no degree in future. The minimal requirements to do the data collection is a fund for tests and consumables. Reason for Chege to do PhD is to bring FM to front in academic environment in Kenya. Chege will send all his work and budget to Geert-Jan this week.
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    Questions for Ray about the current programme that were raised yesterday are now addressed. South Africa would be a good country to be exposed to family medicine practice and research.  To Europe and USA it would be also interesting to widen the horizon, how they communicate to patients, what is community work in those settings? How do you set up a private practice. How to fund this? When does it fit in the curriculum? How to improve research within FM programme (agenda, supervision, resources, funds)?
    Rotation has practical limitations, but content wise it is not yet avoidable. 

Late afternoon: transfer to Eldoret by Professor George Odhiambo Otieno. He stressed again on the fact that the PR should be done more aggressively, that Kenyatta university and Nairobi university are very much interested. The awareness of FM that will be created by having a FM programma in Nairobi will be very much increased. 

Evening: meeting with Prof. Otsyula in Eldoret
We reported back the findings of this mission. The following observations were made:
The head of the division is not so interested in Dutch support. The graduates and the registrars got organized and appointed a working committee to establish the rural chapter of FM of KAFP. The need for CME was felt as well as better research support.  The registrars would like to engage in exchange visits to visit family practices in South Africa, Nigeria, USA or Europe to widen horizons. Prof. Otsyula explained that the FM programme will not disappear anymore, but that it still needs lobbying and PR. He can do this job with great impact, because the message is then coming from a superspecialist. He would like to see the chapter becoming strong enough to take over. In his view the graduates are not yet ready to take over the headship, because they need to be given time to practice.
He agreed that more research support is necessary and that the community module should be strengthened.

Friday, 25 March
Transfer to Nairobi and Kangundo
Meeting with Thigiti and the med. superintendent, the matron and the head of the administration.
Kangundo district hospital has 120 beds, 1 med. superintendent (gynaecologist), 1 physician and 1 surgeon. 8 MO’s in internship training and 9 CO’s in training. And since January this year with the first FM Registrar, under the guidance of FM coordinator Thigiti
With the introduction of FM the service has improved. The outpatient department has been changed from OPD medicine, OPD pediatrics, etc. to OPD emergency (to stabilize patients a,b,c), OPD acute care, OPD chronic care and OPD family and community care. There are for instance less emergency admissions for diabetic patients and the maternity mortality rates dropped.
Patients are first seen by a CO, if needed referred to MO, if needed referred to Family Medicine and if needed referred to specialist.
As a training site you need other specialties, but more ideally the FP –preferably two- would work as the only specialist in a subdistrict hospital. The FP is the highest trained generalist and can take over from the other specialties if needed. Community outreach will be improved, with an emphasis on patient counseling, screening, vaccination, health education and chronic medication. Katua is the first FM registrar to be in Kangundo.
Thigiti signed a contract with Kimani (DMS-MoH) that he will be a supervisor part-time and next to that job do clinical work. He is also teaching in the introduction course for part I FM registrars.
   
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Back to Nairobi, report writing

Saturday, 26 March
Departure to Amsterdam

Conclusion:
Our support till the end of 2011 will focus on the following:
    Strengthen the new chapter or rural FM of KAFP   
-    organize 2 meetings till the end of year. Also Registrars and interested MO’s can be invited
-    include CME that can be supported by (inter)national     speakers
-    lobby to the Family Medicine Coordinating Committee
-    continue thinking about an adapted MO-plan, that could be hosted by the chapter of the KAFP and propose it for funding.
    Tuition fees for one year for each student in excess of the 3 students already financed by INFAMED. Ideally we would support up to 12.
    Support the community training in Naitiri (with the assistance of Hans and Marianne) to fully use its capacity for training registrars in Community Health.
    Support research if requested. Exchange could be in training them in the international course in Maastricht and promote twinning to a student to jointly work on the thesis.
    Explore the possibility to present the training and the community aspect of it in Barcelona in the FESTMIH (ECTMIH European Society of Tropical Med and IH)


With the information we provide about   moi university fees structure

, We hope you can be helped and hopefully set a precedent with you . Or also you can
see our other references are also others which are not less good about  Neo-Pedagogical Style for Acculturating the Beginners in Architecture Schools; psycho-social issues


, So and we thank you for visiting.


open student loan :  whig.nl/.../Report_monitoring_visit_March_11_FM_Kenywith%20pictures23-4-2011...