1. Lessons Learned from 20 years experience in Sub-Saharan Africa Presenter: Timothy L. Herrick, MD, MS Assistant Professor Department of Family Medicine, OHSU s

2. 2 Activity Disclaimer ACTIVITY DISCLAIMER It is the policy of the AAFP that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/invitation of participation. Disclosure documents are reviewed for potential conflicts of interest (COI), and if identified, conflicts are resolved prior to confirmation of participation. Only those participants who had no conflict of interest or who agreed to an identified resolution process prior to their participation were involved in this CME activity. Timothy Herrick has indicated they have no relevant financial relationships to disclose.

3. Topics 1. The training of generalists in France, and its impact on such training in francophone Africa. 2. Full-scope family medicine in a bush hospital, including what the future may look like, and the role of family medicine in that future. 3

4. Topics 3. Community medicine; elements of a successful program 4. Training of physician extenders 5. Social entrepreneurism; matching resources to needs, letting others stand on your shoulders. 4

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7. Generalist training in the French- speaking world After high school: First cycle of three: 1 st year of common trunk, with “numerous clausus” exam, followed by 2 more years of university studies 7

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9. Generalist training in France Second cycle is largely clinical; called “externat.” Up to 2004, at the end of the cycle; concours de l’ internat, those who score highly choose a specialty [“internat”] Those who don’t score highly or don’t even take the test go into “residanat” of general medicine. 9

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11. Generalist training in France After 2004, the concours de l’ internat is replaced by l’epreuve classante nationale, Based on results one chooses one’s “internat” including general medicine. This change took place to provide greater emphasis to general medicine. 11

12. Random facts All trainees are students until they are licensed graduate specialists. [hence, post-graduate?] The third cycle involves a required thesis; medical school ends with an individual thesis defense [and celebration] 12

13. Thesis defense 13

14. Generalist training random facts –Generalists do not practice in hospitals –Generalists do not deliver [60% midwife/ 40% ob] –General medicine is filled by some of the highest, and some of the lowest scoring students, but fills with more than half the slots available. 14

15. What does this have to do with Africa? In many ways, Africa takes its lead from France. Worldview changes in Africa lag behind changes in France, sometimes by decades This informs the thinking of African medical schools in their training of physicians. 15

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18. Generalist Training in French- speaking Africa Similar three cycles Third cycle is largely concerned with writing the thesis. Clinical experiences of the 2 nd and 3 rd year are largely university hospital based, or situations with minimal supervision. The finished product is considered a generalist, with no actual general training scheme. 18

19. Implications In Africa, French-speaking policy-makers may not be aware of the possibilities for vocational generalist training, in terms of the process, or the end result. 19

20. The “Bush” Hospital 20

21. Characteristics Rural Founded by expats Religious Subsidized Highly sought after 21

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27. Present to future Availability of qualified local staff But mis-distribution Pluripotential physicians needed Specialist training also needed Appreciation for academic family medicine needs variable 27

28. Training! 28

29. Personal lesson You don’t have to do it all You will often have a chance to do a variety of things Through negotiation and compromise, you can choose what’s in your basket. 29

30. Community health lessons 30

31. Community health An agenda driven by the community Clearcut communities function best Culturally compatible communicators 31

32. Dedicated culture-savvy leadership 32

33. Locally recruited trainers 33

34. Community-selected local team 34

35. Training in the community 35

36. Evidence-based priorities 36

37. Evidence-based priorities 37

38. Evidence-based priorities 38

39. De-emphasize the curative 39

40. Training extenders 40

41. Networking 41

42. Realities of Practice In Africa, much of what we call primary care is performed by those who do not have a medical degree, or even what we think of as physician extender training. Usually, these people are nurses Nursing training schemes vary greatly in terms of rigor; the profession itself bears little resemblance to American nursing. 42

43. Ecole Nyeta Sabati 43

44. Students at work 44

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47. Medical Entrepreneurship My definition of medical entrepreneurship is not engaging in creative money-making projects in the medical arena, but rather, social entrepreneurship in the healthcare domain. 47

48. Social Entrepreneurship …the process of pursuing innovative solutions to social problems. More specifically, social entrepreneurs adopt a mission to create and sustain social value. They draw upon appropriate thinking in both the business and nonprofit worlds and operate in a variety of organizations: large and small; new and old; religious and secular; nonprofit, for-profit, and hybrid. J. Gregory Dees, quoted in Wikipedia 48

49. Medico-social Entrepreneurship Identifying prioritary needs, locating and mobilizing resources, and connecting these resources to local actors able to bring them to bear on the identified needs. 49

50. Changing Assumptions Old: complete dependence on foreign know-how and resources; I identify the needs, bring the stuff, and do the work to meet the need. Maybe I teach along the way. New: communities are capable of identifying their own prioritary needs. They have many of the required resources, and the workforce needed to effect change. 50

51. Examples; Street kids 51

52. Examples; Street kid center 52

53. Examples; Leper ladies 53

54. How this works? Leper ladies identify their own health needs and reach out to someone to help [via a social entrepreneur intermediary.] Sory and I reach out to a local NGO We treat the leper ladies in the context of this NGO We use locally available generic drugs when feasible With the NGO we create a new structure for treatment. 54

55. Container-clinic 55

56. Preparing the clinic 56

57. First patients 57

58. Critique Not entirely self-sustainable Still involving some outside inputs. Much more sustainable that the traditional structures Affirming local capacities 58

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60. Review: Difficulties of facilitating vocational generalism in the francophone world. Changing face of benevolent hospitals in developing world, and FamMEd role Elements of a successful community health program 60

61. Review: Practicality of training physician extenders “Medico-Social Entrepreneurship” as a model for health care impact in the developing world. 61