A molecular map of chloroquine resistance in Mali.

Plasmodium falciparum chloroquine resistance (CQR) transporter point mutation (PfCRT 76T) is known to be the key determinant of CQR. Molecular detection of PfCRT 76T in field samples may be used for the surveillance of CQR in malaria-endemic countries. The genotype-resistance index (GRI), which is obtained as the ratio of the prevalence of PfCRT 76T to the incidence of CQR in a clinical trial, was proposed as a simple and practical molecular-based addition to the tools currently available for monitoring CQR in the field. In order to validate the GRI model across populations, time, and resistance patterns, we compiled data from the literature and generated new data from 12 sites across Mali. We found a mean PfCRT 76T mutation prevalence of 84.5% (range 60.9-95.1%) across all sites. CQR rates predicted from the GRI model were extrapolated onto a map of Mali to show the patterns of resistance throughout the participating regions. We present a comprehensive map of CQR in Mali, which strongly supports recent changes in drug policy away from chloroquine.

Appropriate training and retention of community doctors in rural areas: a case study from Mali.

BACKGROUND: While attraction of doctors to rural settings is increasing in Mali, there is concern for their retention. An orientation course for young practicing rural doctors was set up in 2003 by a professional association and a NGO. The underlying assumption was that rurally relevant training would strengthen doctors' competences and self-confidence, improve job satisfaction, and consequently contribute to retention. METHODS: Programme evaluation distinguished trainees' opinions, competences and behaviour. Data were collected through participant observation, group discussions, satisfaction questionnaires, a monitoring tool of learning progress, and follow up visits. Retention was assessed for all 65 trainees between 2003 and 2007. RESULTS AND DISCUSSION: The programme consisted of four classroom modules--clinical skills, community health, practice management and communication skills--and a practicum supervised by an experienced rural doctor. Out of the 65 trained doctors between 2003 and 2007, 55 were still engaged in rural practice end of 2007, suggesting high retention for the Malian context. Participants viewed the training as crucial to face technical and social problems related to rural practice. Discussing professional experience with senior rural doctors contributed to socialisation to novel professional roles. Mechanisms underlying training effects on retention include increased self confidence, self esteem as rural doctor, and sense of belonging to a professional group sharing a common professional identity. Retention can however not be attributed solely to the training intervention, as rural doctors benefit from other incentives and support mechanisms (follow up visits, continuing training, mentoring...) affecting job satisfaction. CONCLUSION: Training increasing self confidence and self esteem of rural practitioners may contribute to retention of skilled professionals in rural areas. While reorientations of curricula in training institutions are necessary, other types of professional support are needed. This experience suggests that professional associations dedicated to strengthening quality of care can contribute significantly to rural practitioners' morale.

[Neighbourhood rural medicine: an experience of rural doctors in Mali]. / Une médecine rurale de proximité: l'expérience des médecins de campagne au Mali.

The main constraint to improving access to health services of quality in rural areas is to attract qualified health personnel in these areas. A fifteen years experience in rural health in Mali has shown that it is possible to develop community medicine practices in an African context that do integrate individual care and public health activities. The policy of decentralization of health services encouraged local communities and municipalities to recruit rural doctors themselves. An initiative of rural doctors materialized with this event as they founded a national association and adhere to the principles of a Charter to provide quality health care at an affordable cost. A mechanism of quality improvement was established with the participation of several partners: a professional association, a funding non-governmental organization, and groups of academic staff and health managers. This paper describes the evolution of the rural doctors' experience, its philosophy, conditions that made it successful, constraints it had to overcome and the attitude of partners. It highlights the potential of health care personnel in Africa to provide primary health care well beyond traditional programs on prevalent diseases and to respond to both urgent individual needs and pressing public health requirements.