Globally there is a need for well-trained primary health care physicians at the district
level. Physicians who focus on ambulatory care will be in greater demand in addressing
the global burden of chronic disease and multi-morbidity, which are on the increase
in Africa. Not surprisingly, family medicine has grown stronger on the African continent
in the past decades.
1,2,3
In Rwanda, education of health professionals has recently undergone several changes.
Postgraduate training in medical and surgical specialties has been further developed
in a constructive and inclusive way with support of American universities.
4
Although postgraduate training in family and community medicine has been temporarily
halted, the need to develop and enhance undergraduate training in social and community
medicine was identified and efforts have since commenced. This raises the question
whether postgraduate training was developed too early, at a time when undergraduate
training did not yet embrace the concept of primary health care.
Rwanda is a small, landlocked, low-income country in central East Africa and the most
densely populated country on the continent.
5
The majority of the population live in rural areas. The 2010 Demographic Health Survey
showed dramatic gains in life expectancy, although infectious diseases were still
the leading cause of death.
6
Chronic non-communicable diseases are on the rise and presently constitute 25% of
Rwanda's burden of disease, which makes the need for chronic care urgent.
7
At present Rwanda has four national referral hospitals, over 40 district hospitals
and about 450 health centres. In addition, approximately 45 000 community health workers
provide health promotion activities as well as preventive and curative care to rural
communities.
8,9
Faced with a similar shortage of health workers as in other African countries, Rwanda
has successfully embarked on pre-service and in-service training programmes at all
levels of care delivery.
History of family and community medicine training in Rwanda
In 2008, the then National University of Rwanda (now University of Rwanda) started
the postgraduate family and community medicine (FAMCO) training programme. The objective
was to train family physicians capable of providing comprehensive, continuous health
care of good quality, which is person centred, family oriented and community based,
using the biopsychosocial model of care at the district level.
10
Rwanda already had a robust structure and organisation in primary care through a network
of community health worker teams and health centres. The FAMCO department, working
with external partners, saw this as an opportunity for preparing a generation of well-trained,
expert generalists able to work at the district level. However, by 2011 the programme
was facing difficulties owing to stakeholders, from undergraduate students to policy
makers, being unfamiliar with the new model of ‘African family medicine’. Faced with
a national need to focus resources on training hospital-based specialists, the FAMCO
residency programme was suspended in 2012.
Training undergraduate medical students in community medicine
When the postgraduate training started in 2008, primary health care was not part of
the undergraduate medical curriculum, except for a module in public health. Students
had little exposure to district health care. In 2011, the FAMCO department developed
a programme aimed at teaching community medicine as part of the undergraduate curriculum.
The training consisted of a two-week theoretical module in the fourth year and a four-week
practical module in the fifth year. The objective of this training was to prepare
students, in small groups, to understand the unique issues and challenges of health
in the community and medical care at the community level through experience at community
health centres and district hospitals to enable them to function more effectively
in the Rwandan health system.
11
Both training content and teaching methods, which involved peer education, reflection
and mentorship, were highly appreciated by the students.
During their review of the undergraduate curriculum in 2014, the Discipline of Primary
Health Care (formerly the FAMCO department) advocated for students to be exposed to
the concepts of social and community medicine earlier. In the emergent five-year curriculum,
a new approach to social and community medicine (referred to as iSOCO) was developed
and integrated from the first year of training. According to this training approach,
students are taught in a multidisciplinary way (together with pharmacy and dentistry
students) using the flipped classroom model,
12
which includes e-learning methods. iSOCO aims to prepare each future Rwandan medical
doctor to be patient centred and community oriented, to provide health care in a biopsychosocial
way, to understand the importance of and having skills in communication, collaboration,
advocacy, management, being a scholar and developing a professional attitude.
13
Graduates will also appreciate the role of clinical information systems, decision
support systems and referral pathways, the virtues of planned and coordinated care,
and the role of self-management through exploration and appreciation of commonly held
health beliefs.
Conclusion
The new curriculum will use the biopsychosocial approach to develop a new generation
of Rwandan doctors who are patient-centred and community-oriented change agents and
are able to practise interpretive medicine and support patients to maintain their
health. These attributes are described as the making of the desired Rwandan doctor.
13
These doctors will be able to use the principles of primary health care in later medical
or surgical specialisation or other career development paths.
To train postgraduate residents in primary health care and family medicine, it is
essential to create awareness already at the undergraduate level so that there will
be a critical mass of physicians who are able to apply these principles in their daily
work at any level of the health care system. The new approach will prepare physicians
to work in the primary health care setting to serve the needs of the Rwandan community
and to mitigate the burden of disease at a lower level of care.