The Gezira Family Medicine Project (GFMP). A scientific evaluation of a Master program for family physicians in Gezira, Sudan

Abstract

Background: Family medicine based health systems are accepted worldwide as the best suitable model to provide integrated, high quality health services. In Sub-Saharan Africa, there is a recent movement towards implementing family medicine in health system; consequently, high up scaling of family medicine training is targeted and is going on like a fast track. Sudan faces the same challenges found in other Sub-Saharan African countries including the predominance of the tropical diseases that over-shadow the emerging problem of Non-Communicable Diseases (NCDs). The Gezira Family Medicine Project (GFMP) was established in 2010 as a collaboration project between several local partners including the State Ministry of Health and the University of Gezira. The project aimed to train qualified family physicians who can participate in providing high quality, accessible, and affordable primary health care services in Gezira. A twoyear Master curriculum was designed as an “in-service” model of training to meet both service provision and training's goals. A total of 207 candidates were enrolled in the first batch of the program in 2010. The project used information and communication technology (ICT) in a comprehensive way; it is used to provide health care in a distance (telemedicine), to facilitate and increase the accessibility in medical education (e-learning) and to manage patients' information (Electronic Medical Records- EMR). Study objectives: This study aimed to: Describe the GFMP during its first batch (2010-2012), its implementation, curriculum structure, baseline data of the trainees and their health centres. Assess the candidates' utilization of information and communication technology at the GFMP, and their perception of its use. Assess the impact of the Master programme on candidates' confidence to perform certain manual and cognitive clinical skills. Assess the impact of the GFMP on candidates' adherence to the core values of family medicine including patient-centeredness. Methods: Three comprehensive questionnaires were used to collect data both at the start of the Master program for the first batch and again at its end. The first questionnaire included background data regarding the candidates and their self-assessment of confidence to perform certain skills. The second questionnaire was a checklist for the health centres including the buildings, available equipment and provided services. The third questionnaire aimed to assess candidates' practice including adhesion to the core values of family medicine during patient consultations. A cross sectional, questionnaire and administrative data based observational design was used in paper 1 and paper 2. Self-evaluation questionnaire was used to collect data about the trainees' skills, while a checklist was used to collect data from the health centres. Administrative data was used to describe the project implementation, its curriculum design and candidates' utilization of ICT during the master period. A prospective cross sectional study with a before-and-after design was used in paper 3 and paper 4 to assess the progress change of the trainees during the Master period 2010-2012 (cohort observational design). Self-evaluation questionnaire and practicebased data were used to assess trainees' confidence in performing certain clinical skills and to assess their adhesion to some family medicine core values. The Patient- Practitioner Orientation Scale (PPOS) was used to assess patient-centeredness. Results: The 2-year in-service Master program at the GFMP could recruit 207 physicians to be trained in family medicine and to provide health services in 158 health centres, of which, 84 centres had never been served by a doctor before. The mean age of the enrolled trainees was 32.5 years, 57% were males and one third of them were graduated from the University of Gezira. Self-evaluation in confidence to perform certain clinical skills showed significant variations between individual skills, between medical disciplines, and between genders. Health centres were generally equipped to deal with tropical diseases, but poorly equipped to deal with Non Communicable Diseases (NCDs) Information and communication (ICT) reports showed a performance of 3808 online telemedicine consultations in the period April 2011 to December 2012. Over 165000 new patients' electronic medical records (EMRs) were established by the candidates at their graduation (N: 125 candidate). Candidates were generally highly satisfied with the use of ICT during their master period. They highlighted some patients' concerns regarding the use of EMR and telemedicine during consultations. To assess candidate’s improvement after the Master program, self-assessment of 46 clinical skills was done before and after the master program using a five-grade Likert scale (1-5). It showed an overall improvement of 21.7% from 3.23 (before) to 3.92 (after). Improvement variation is observed between the different medical disciplines. Males have constantly scored higher confidence than females, while females showed higher progress percentage in improvement compared with males. Statistically significant improvement is also detected regarding candidates' development in certain role skills like leadership, health promotion, and communication with colleagues and the community. In contrast, there was an overall significant decrease in orientation towards patient-centred care by 4% using the Patient-Practitioner Orientation Scale (PPOS). Conclusion: GFMP represented a good model for local collaboration, which resulted in performing training goals and providing high quality primary health care services. The in-service model of training was attractive for trainees (207 joined the program) and promising for health service provision (158 health centres were served by GFMP, of which 84 had never been served by physicians before). Information and communication technology (ICT) supported both training goals and service provision goals at the GFMP. The GFMP curriculum had a positive impact on candidates' confidence to perform the targeted clinical skills. Practice data showed a positive impact of the Master program on candidates' adherence to family medicine core values. Patient centred care was a weak point in candidates' training that needs more attention in future curriculum planning and implementation. Recent assessment of the status of the GFMP and family medicine training in Sudan as a whole done in Apr 2018, showed still high up-scaling of family medicine training in the whole country, presented by several institutes including the University of Gezira and the National Public Health Institute (PHI). The development of the GFMP as a project is affected by economical challenges and a decline in the political commitment, which affected the partnership between the University of Gezira and the State Ministry of Health