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.

North-South exchange and professional development: experience from Mali and France.

BACKGROUND: Developing countries are facing the challenge of developing a family practice culture in a context in which clinical practice remains strongly associated with hospital practice. To what extent can professional exchange between GPs from North and South fuel novel professional identities in family practice? OBJECTIVES: Assess to what extent a North-South professional exchange programme involving rural GPs from Mali and France affected practice development and professional identity formation of Malian GPs. METHODS: Qualitative analysis of 19 exchanges between rural GPs from Mali and France based on (i) interviews; (ii) retrospective report analysis; (iii) field observation of three exchanges; (iv) workshop with Malian GPs; and (v) workshop with French GPs. RESULTS: Malian GPs reported increased self-esteem, increased concern for doctor-patient communication and innovations in practice organization. Although Malian participants considered a transfer from France's general practice irrelevant, the experience was thought provoking. The interpersonal and professional interaction was crucial. The Malian Rural Doctors Association provided a platform to capitalize on individual experiences in a process of collective professional identity construction. Costs of the programme were kept low, limiting possible side expectations of participants. CONCLUSIONS: North-South professional exchange can contribute to professional development. Exchange programmes should be designed as mutual learning processes, rather than unilateral assistance or transfer of practice models. Southern family practitioners are likely to improve primary care to individuals and families, while Northern GPs can draw lessons from the community perspective of primary health care in the South. Recruitment and preparation of participants are crucial, as well as collective reflection upon return.

Interface flow process audit: using the patient's career as a tracer of quality of care and of system organisation.

OBJECTIVES: This case study aims to demonstrate the method's feasibility and capacity to improve quality of care. Several drawbacks attached to tracer condition and selected procedure audits oblige clinicians to rely on external evaluators. Interface flow process audit is an alternative method, which also favours integration of health care across institutions divide. METHODS: An action research study was carried out to test the feasibility of interface flow process audit and its impact on quality improvement. An anonymous questionnaire was carried out to assess the participants' perception of the process. RESULTS: In this study, interface flow process audit brought together general practitioners and hospital doctors to analyse the co-ordination of their activities across the primary-secondary interface. Human factors and organisational characteristics had a clear influence on implementation of the solutions. In general, the participants confirmed that the interface flow process audit helped them to analyse the quality of case management both at primary and secondary care level. CONCLUSIONS: The interface flow process audit appears a useful method for regular in-service self-evaluation. Its practice enabled to address a wide scope of clinical, managerial and economical problems. Bridging the primary-secondary care gap, interface flow process audit's focus on the patient's career combined with the broad scope of problems that can be analysed are particularly powerful features. The methodology would benefit from an evaluation of its practice on larger scale.