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International Newsletter

The South Asia MRCGP[INT]

Issue 35 Summer 2007



his issue of the International Newsletter shows readers how versatile our contributors are and how Primary Care throughout the world is thriving. First we have an article about the great success of the South Asia MRCGP[INT] which is a remarkable achievement. It is a great accolade for all those concerned in bringing together doctors in the sub-continent to agree on a shared standard of Primary Care; it is the culmination of a great deal of behind-thescenes hard work by all involved. Some of this is revealed in Professor Riaz Qureshi's piece about a Continuing Professional Development course which stimulated participants to improve their standards and illustrates that good Assessment can drive Learning. Not far away, we have a report about teaching in Nepal and another about improving community health in Bangladesh, as well as an article about setting up an STI Clinic in East Timor. What is striking about the experiences of the authors is that they were enabling local people to cope with their problems and thus starting a process that will continue and develop. In each site it is obvious that the local doctors and care workers only needed a stimulus and encouragement to start doing things for themselves and that augurs well for the future of the different projects.

Doctors sitting the MRCGP[INT] exam in South Asia


e've made it! The South Asia MRCGP[INT] exam has now been formally accredited by RCGP and, as of April 2007, 50 South Asian candidates are eligible to become International Members of the College. Started originally as the vision of Professor Riaz Qureshi of Aga Khan University in Karachi, six countries of South Asia ­ Afghanistan, Bangladesh, India, Nepal, Pakistan and Sri Lanka ­ agreed to work together to try to develop an internationally accredited family medicine exam throughout the region. Afghanistan was at too early a stage of development to participate fully, but it has remained as a Member of the South Asia Board (SAB), family medicine continues to develop in the country, and we remain hopeful that in years to come we can welcome Afghan candidates to the process. A series of workshops were held over a three year period, where a number of questions had to be addressed. Would the curriculum differ significantly from the UK? Infectious diseases such as dengue and typhoid fever, malaria and tuberculosis had a high profile. Chronic disease management and preventative issues were comparable. Patient centred consultation, evidence based medicine, shared management decisions and professionalism were owned by all.

Research methodology and practice management were felt to be less relevant. Ultimately the real challenges related to the assessment and were more subtle.

Across the world in Guatamala you will read about Dr Campion's experiences there and later, A two part examination was agreed. Dr Houston's involvement with Family Practice First an applied knowledge multiple Training in Tanzania. We also read about the Sri choice test. Second an Objective Lankan experience with an established system Structured Clinical Examination of training in General Practice. Nearer home Dr Sherin describes his visit on an International Travel (OCSE) of 14 ten minute simulated Scholarship to study General Practice in the UK. consultations. World Health As we have often stated in these pages there Organisation guidelines were adopted is much that we can learn from each other and as the gold standard for management. many doctors who have come to the UK have Debate frequently centred on returned home with ideas that they can apply in therapeutics as drug availability differed. their own communities.

The British National Formulary became the accepted reference. English was the language universally used in South Asia for medical education. Would it be possible to conduct the clinical exam in English? OSCE stations were piloted in Karachi and Bangladesh. Enthusiastic authentic simulated patients were found and the cultural contexts of the scenarios proved common to all countries.

Finally, news from HQ! Dr John Howard's term of office as Chair of the International Committee has come to an end. He has been succeeded by Dr Iona Heath who has a wealth of experience with WONCA and on Council of the RCGP. John will continue as Chair of the Board of MRCGP[INT] so his energy and enthusiasm for developing General Practice throughout the world will still be used. My own terms on the International Committee are also drawing to a close so this is the last issue of the International Newsletter which I have had the pleasure of editing. Dr Garth Manning tells me that the Newsletter is read with interest by our colleagues It's a given that assessment drives throughout the world so I will take comfort in learning, but in so many of the countries this, in spite of my lack of success in setting up a of South Asia eligibility to sit a country "correspondence page"! It has been a privilege exam was often limited to the very few, to write to you all for the last few years and I am sure you will continue to enjoy and learn from and the vast majority of family doctors future editions of this bulletin. had no opportunity to undertake

any form of continuing professional development. Now, at last, they were

Au revoir! Dr Rob Caird

RCGP International Newsletter Summer 2007

being given that chance, and many grasped it enthusiastically. In Karachi, for example, about 150 doctors each week attended a CPD session ­ at their own expense and on their one day off each week ­ so hungry were they to upgrade their knowledge and skills. Several of these doctors didn't even plan to take the exam, but just revelled in the new-found educational opportunities available to them. Finally in November 2006 we had a written paper, developed entirely by our South Asian colleagues. The written papers were held at five British Council centres throughout the region, with 219 candidates taking the paper. The overall pass rate for this was almost 39%, with good validity and reliability factors, and the SAB was reassured that they seemed to have got it right so far. The next challenge was to finalise a rigorous but fair and relevant OSCE exam, again developed entirely by South Asians for the regional context. The OSCEs were held in late March 2007 in Colombo, Sri Lanka, with enormous help and support from our colleagues in the College of GPs of Sri Lanka, and we were hugely gratified ­ and relieved ­ when candidates reported that the simulation was so good they felt they were consulting in their own surgeries! A total of 73 candidates sat the OSCEs, with 50 ultimately successful ­ a pass rate of almost 69% and again with excellent validity and reliability quotients. The College's Examination Development Assessors (EDAs) recommended that the exam be fully accredited for three years and this was endorsed at a full MRCGP[INT] Board meeting in London in early April. We had made it!

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Plans are already well advanced for the next diet of the exam, with the next MCQ scheduled for late November 2007 and the OSCEs in late March or early April 2008 ­ again in Sri Lanka. We hope very much that as the question banks develop it will become possible to run the exams twice yearly ­ especially relevant for those who fail and who want an early opportunity to resit ­ and also to run the OSCEs at more than one centre in the region, to make it more convenient for the candidates. And we're also getting a number of requests from South Asian doctors in the Middle East, and from doctors in Central Asia, who all want to sit the exam. So, the SAB is certainly not resting, and continues to press ahead with further development ­ but with just a little basking in the triumph of a magnificent achievement.

Dr Garth Manning, IDP Medical Director [email protected] Professor Val Wass [email protected]

Examiners with an OSCE candidate and his patient

Country Profile - South Asia

People Population Population growth (annual %) Life expectancy at birth, total (years) Fertility rate, total (births per woman) Mortality rate, infant (per 1000 live births) Mortality rate, under 5 (per 1000) Births attended by skilled health staff (% of total) Malnutrition prevalence, weight for age (% of children under 5) Immunisation measles (% of children ages 12 - 23 months) Prevalence of HIV, total (% of population ages 15 - 49) 2000 1.4 billion 1.8 62.6 3.3 72.4 100.0 ... ... 58.1 ... 2005 1.5 billion 1.6 63.5 3.1 62.0 82.9 37.3 ... 64.0 0.7

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The Impact of a CPD Course for Family Physicians of Karachi, Pakistan

Background ollowing the approval of the concept of MRCGP[INT] South Asia examination by the International Committee of RCGP and the board members representing Family Medicine organisations in the South Asia region, it was agreed that there would be a need for courses and workshops in each country in the region (India, Pakistan, Bangladesh, Sri Lanka, Nepal, Afghanistan, Maldives and Bhutan) for practicing GPs before they take the MRCGP[INT] South Asia examination.


5. End of session evaluation by participants 6. End of course evaluation by participants Each presentation included a pre and a post-test. The Single Best Answers (SBA) were the same in both test papers. Pre-tests were administered and collected from the participants before the start of each educational session. The educational material were also distributed after the pre-test was taken. Post-test papers were collected after the end of each lecture before discussion of the SBA with the participants. The course participants also provided feedback by filling a structured evaluation form. Out of 120 lectures 17 were selected by simple random method for analysis. On an average 102 completed forms of each lecture were analysed. Six lectures included in analysis were conducted by FPs and eleven lectures were conducted by specialists in various fields. Data was doubly entered on EPIDATA and analysed on SPSS 14. Feedback by Participants "It was a great course and it really helped us improve on our current practices. Even if we don't take the exam it doesn't matter because our approach toward patients care has improved a lot" "Very organised course. The topics were very well selected and were relevant to general practice in our region". "I would never have learned the GP consultation models if I would not have attended this course" Recommendations / Conclusions · The analysis of our data clearly shows significant improvement in knowledge acquired by the Family Physicians attending this course. · This is also evident from the analysis of MRCGP[INT] exam results. · In addition, the feedback from the candidates indicates that the introduction of MRCGP[INT] South Asia examination has provided a significant stimulus towards the process of learning for Family Physicians in Karachi.

· Academic Family Medicine departments in the region of South Asia can make a significant impact in the teaching and training of Family Physicians in collaboration with existing organisations of General Practitioners. · Collaborations which include an international academic body of repute such as the RCGP can further enhance the efforts to improve the primary care standards in developing countries. · We strongly recommend that such CPD courses should be held throughout the South Asia region on a regular basis.

Professor Riaz Qureshi, Dr Waris Qidwai, Dr Raheem Dhanani and Dr Marie Andrades

Objectives 1. To assess the impact of a Continuing Medical Education (CME) course for Continuing Professional Development (CPD) of GPs / family physicians in Karachi. 2. To find out if assessment in the form of MRCGP[INT] examination helped these GPs / FPs to focus on their learning. 3. To also assess the need for further improvement in areas identified during this preparatory CME course for MRCGP[INT] South Asia examination. Methods Taking into consideration the feedback by interested GPs in Karachi regarding their CME requirements and the approved curriculum for the MRCGP[INT] South Asia, a weekly programme (every Sunday) of 3½ hours was developed by the Family Medicine faculty of Aga Khan University (AKU). The implementation of the CME activity was carried out under the banner of the College of Family Medicine, Karachi Pakistan. Course Structure and Contents 1. Interactive Lectures - Clinical-based on symptoms, systems and evidence - Epidemiology and basic bio statistics - Ethical issues and confidentiality - Generic management in family pactice 2. Consultation skills workshops 3. Regular pre and post tests 4. Three mock exams followed by individual feedback

international travel scholarship winners

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Linking general practices in Dhaka and Bradford : The Horton Park - Shushasthya Link



Paediatrics in General Practice : Indications for specialist referral and hospitalisation



ChONGChAROENkuNAWOOTI Primary Care in the UK



Visit to Shushasthya Clinic, Dhaka



Exploring Primary Care in the UK

RCGP International Newsletter Summer 2007

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Teaching in Nepal


fter retiring from General Practice two years ago I picked up a flier from the international group of the RCGP asking for a volunteer to go to Nepal to teach Gynaecology skills. It seemed that the Gynae focus they wanted was just the tip of the iceberg and their needs had broadened to a wider agenda. On the rim of the Kathmandu valley, Pharping was on a small plateau high above the city about 90 minutes travel away. I refreshed my supply of books for use in the developing world, having a particular focus on teaching aids. The newest edition of "Where Women have no Doctor," manuals on leprosy, and the new, small Oxford Handbook of Tropical Medicine (recommended) were key purchases. My book "Hindu and Buddhist Myths," to refresh cultural knowledge, knitting, music tapes and small radio for the BBC world service and my PC completed my luggage.

midwife led three Nepalese staff-grade nurses, pathology and radiology technicians, two acting-up basic nurses coped with the pharmacy, plus two essential cleaners and part-time ambulance drivers were the backbone of the hospital. A young Nepalese doctor, brought up in the village, was just on the point of being full time there, backed up by two mornings of senior doctors visiting for a couple of hours from the city. A visit by the gynaecologist once a week was intermittent, but at the end we did seem to have recruited a most pleasant young woman of consultant standing. Her main function was to be in the antenatal clinic, but also she did a termination or two. Another NGO came once a month and provided an eye clinic, and, as a surprising but financially successful extra, we had a visit from an ultrasound technician who had trained in Portsmouth. Making a project plan for my work, I allowed one week for fact finding, speaking with all staff, and observing all the departments.

Queuing for the gynae clinic

I offered six sessions of their choice, and then I would do one of my choice: "what you don't know, you don't know". We started with subjects that they chose. The teaching sessions were designed to be adult focused, assessing at the start their level of knowledge, with each saying what they wanted to know. The end of the session was always personal reflection on one thing they would do differently. Teaching methodology was touched on, as they are the health educators too. I kept sane in my six and a half day week by good reflection time in pleasant, if simple surroundings, warm, friendly people, local walks, with evenings of medical and non-medical reading, BBC news and a little sketching and music. My young doctor has just sent me an email. After 4 months he says "Though it was very short time I had opportunity to be with you. But I have learned lot of ideas to run the hospital perfectly. It is not a matter of relation between doctor and patients but also between the staff and administration which I am trying to improve. Every body got their third dose of hepatitis B vaccination .Cleaning commete also working smoothy. we are modify it every month...." (sic) With continued frustration in the NHS, it is good to feel creative and unencumbered by paper, computers and red tape.

Dr Penny Aeberhard FRCGP [email protected]

Washing gloves on the hospital roof, prior to resterilising

I found myself in a scenically stunning area marred somewhat by changeable mountain weather, overlooking the smog of the Kathmandu valley. Manmohan Community hospital had been built two years earlier by a partnership of two Nepalese NGOs. The local people had identified the need in this area of 16 villages and 63,000 people. Without reliable transport, sick, poor people relied on a variety of government health workers in the health posts, local private pharmacists, and herbal physicians. The villages in the mountains south of us could be two days trek away. We had officially seven general beds, three maternity plus the labour bed, Xray and basic pathology. An experienced

After a week I presented my thoughts to the management committee and it was agreed that the Gynae remit should be expanded and I would focus on management and teaching. Management had become stuck and didn't know which direction to take. The inadequate income from poor clientele and the wide range of services stretched the staff and there was low morale due to long hours and poor rates of pay even by local standards. My teaching was really in two parts. Mornings were ward rounds, outpatients, and antenatal clinic and were very much like "sitting-in" with registrars or nurses in the UK. My other teaching was the formal two-hour slot, three afternoons a week.

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from them - would improve still further the care provided to the indigenous communities, and increase cross-cultural understanding. Another aim is to attract more Guatemalan doctors to provide a sustainable service without such rapid staff turnover. I found that GP training, incorporating obstetrics, paediatrics and emergency medicine, provided good preparation for overseas work (although I wish I had done more normal deliveries). Also I was very impressed by the skills of my US family practitioner colleagues. Although many countries now benefit from having trained primary care physicians, in Guatemala Family Medicine tends to be seen as a basic skill for undergraduates, the domain of mid-level health workers rather than doctors. While good quality health care is available in cities for those who can afford it, provision in rural areas can be woefully inadequate. Although the war is over, Guatemala remains a country with significant economic and social problems. Despite this, and the deprivation and disaster in Santiago, the people could not have been more friendly and welcoming. I look forward to returning.

Dr Daniel Campion MRCSEd DTM&h [email protected]

Primary Care in Guatemala


etween May and July 2006 I worked as a volunteer in the Hospitalito Aititlán in Guatemala. Their small hospital is the only local facility to offer inpatient and maternity services in an area with a longstanding lack of health facilities. Santiago Aititlán is in the south west of the country, on the shores of Lake Aititlán. During hurricane Stan, a mudslide hit the town, killing 500 people in one of Santiago's poorest communities. The hospital was partly

The majority of our outpatients were subsistence farmers, who presented to the morning clinics with the whole spectrum of acute and chronic primary care conditions, exacerbated by poor nutrition and extreme poverty. Diabetes, pneumonia and enteric illness were common; tuberculosis and HIV fortunately were not. Many of the poorest patients spoke no Spanish, only the local Mayan language Tzutujil. Usually a nurse or other staff member was able to translate, although

The site of the old hospitalito, buried in mud

buried and the area has now been declared a mass grave. Within two weeks of the catastrophe, a temporary facility was located and the hospital reopened, where it remains today. The clinic is staffed by two long-term US volunteers and a part-time Guatemalan physician. The rota is made manageable by a fairly constant flow of short-term volunteers, usually American emergency medicine and family practice residents. Clinical workload was not too heavy, and much of the overnight on-call involved management of high-risk obstetric cases, as well as a wide variety of emergency attendances. There was a small operating theatre for emergency sections and elective surgery by visiting surgeons from the state capital. X-ray, ultrasound and basic laboratory tests were usually available.

it did take a little bit longer to explore `ideas, concerns, and expectations'! Health care provision generally was fragmented, although we did our best to maintain some continuity. Patients had often attended the clinic as a last resort, having already seen a shaman or bone-setter in the community, or self-medicated from a local pharmacy (including potent and dangerous medications `over-the-counter'). Tragically, ill babies thought to be suffering from `mal de ojo' - evil eye - would usually be left to die at home. Longer-term, it is hoped the volunteers will form stronger links with the local government's public health service (which provides vaccines and sends health workers to remote areas) as well as the traditional midwives and the volunteer ambulance crews. Providing training for these groups - and learning

Morning clinic with a nurse translator

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REPORT ON GlOBAl hEAlTh PARTNERShIPS lORD CRISP The RCGP contributed to the consultation process for lord Crisp's report on uk support for health in the developing world. Published in February 2007, it identifies some important issues that fit the ethos of the international work of the RCGP to support the development of locally relevant programmes of general practice. The report acknowledges this in its reference to the South Asia MRCGP[INT] examination, which provides a standard for family medicine for a quarter of the world's people and is now intended to be translated to the context of Africa. While some practical barriers remain to be addressed in the report, the implementation phase will now begin with lord Crisps proposal for a Global health Partnership Centre to act as a `one-stop shop' source of information for individuals and health organisations.

Where in the World are we?

ThAIlAND RCGP was approached by an Eu-funded health Care Reform Programme in Thailand to undertake consultancy with a view to establishing greater links with the Royal College of Family Practitioners of Thailand and to assist them in a number of areas. Dr Garth Manning undertook the initial assessment visit in March, and further discussions will be held between RCGP and RCFP during World WONCA in Singapore in July. Dr Alan Dellow, as Thailand liaison Officer, is also involved in ongoing discussions. Our previous work in Thailand, helping to develop a curriculum for distance learning and in service training for rural GPs, continues to progress. We are awaiting approval from the Medical Council of Thailand and are hopeful that the programme can soon be piloted in a number of areas.

INDIA As well as our ongoing collaboration with the Apollo hospitals Group, overseen by Dr Annette Steele, our India liaison Officer, Dr Chayan Datta, has held very useful discussions with Calcutta Medical Research Institute (CMRI) and RVM hospital in kolkata. We continue to negotiate with them regarding development and RCGP accreditation of their teaching programmes.

SOuTh ASIA The written papers of the South Asia regional MRCGP[INT] exam took place at 5 British Council Centres on 24 November 2006. Almost 39% of the 219 candidates passed and were eligible for the OSCE clinical skills assessment exam, held in Colombo, Sri lanka, in late March 2007. 73 candidates undertook the OSCE exam, with almost 69% passing ­ the exam was accredited by the Examination Development Assessor and ratified by the MRCGP[INT] Board in April, so these candidates are now eligible for MRCGP[INT]. Plans are well under way for the next diet of exams, due in late November 2007.

JAPAN Dr Roger Neighbour visited Japan in March 2007 to further links with our colleagues in Family Medicine there. A meeting was held at the Japanese Embassy to meet delegates on 20 March 2007.

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ChINA Our excellent relations with a number of Chinese provinces continues. Dr Grant Blair and Jenny Stock visited Nanjing, hangzhou and Shanghai in February 2007, to run a series of Primary health Care (PhC) seminars funded by the British Consulate in Shanghai. In March 2007 we welcomed an inward mission from Nanjing, hosted by Dr Jag Dhaliwal from Warwick Medical School, giving them a short orientation to the uk health system, with particular emphasis on general practice. During this visit a Memorandum of understanding between RCGP (represented by Dr Garth Manning) and the health Bureau of Jiangsu Province was signed. Finally in March we also welcomed a small group from Shanghai Municipal health Bureau for a 6-week visit to uk, looking in greater depth at general practice in both clinical and academic settings. The visitors were mentored by Dr Grant Blair.

kOSOVO Dr Graham Rawlinson, International Development Advisor (IDA) for kosovo, visited in February with Mr Richard Wakeford to run workshops on Quality Assessment (QA) and exam development. This will be followed up by a visit of 2 kosovans to the uk in July, who will attend and observe a 3-day simulated surgery in Cambridge. Professor David haslam and Dr Tom Garrett visited in April to explore regional collaboration including a regional conference. A satellite meeting between kosovo and collaborating countries (Montenegro) took place in london on 21 May 2007, with the summer conference following in kosovo in June 2007 where Professor Frank Dobbs and Dr Edward Parry-Jones gave keynote lectures on behalf of the College.

EGyPT RCGP and the Ministry of health in Egypt had ongoing collaboration some years ago, which was not possible to develop further. however it now appears that further development of family medicine is back on the agenda, and we have been holding preliminary discussions with Dr Samieh Ahmed Amer MD, Medical Counsellor at the Egyptian Embassy in london. Correspondence has been re-established with the Egyptian Ministry of health, and we will soon be sending a College advisor to Cairo to assess the current status and to recommend a path forward for further collaboration.

kuRDISTAN Discussions have taken place with the Minister of health for the kurdistan region of Iraq. A former general practitioner in South london, he fully understands the many advantages of a primary care-based health system, and is keen to collaborate with the College on family medicine development in kurdistan. Discussions and negotiations continue.

Dr Garth Manning FRCGP

Medical Director International Development Programme [email protected]

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Training in Family Medicine :

Sri Lankan Experience

in Sri Lanka and in the four other countries that comprise the South Asia MRCGP[INT]. The introduction of MRCGP[INT] will greatly enhance the training of family practice in Sri Lanka and all the South Asia region.

Dr Antoinette Perera [email protected]


edical education in Sri Lanka began with the establishment of the Ceylon Medical College in 1870. Postgraduate training was held in the UK and the degrees granted by the Royal Colleges were recognised for consultant appointments. In 1979 the government decided that postgraduate training should be more relevant to the country's needs and the postgraduate institute of medicine (PGIM) was established. The Board of Study in Family Medicine drew up programmes to train doctors in different competencies including family practice. A diploma was awarded after one year of clinical training and a doctorate (MD) after a further 2-4 years of research. The Ceylon College of General Practitioners established in 1974 also had a very active and committed Council who worked hard towards improving the training of generalist doctors who took up family practice. In Sri Lanka Family Practice is carried out on a fee for service basis and is available in the private sector. It was the hard work of some senior members of the RCGP that has enabled us to achieve the heights that have been reached today, particularly Professor David Metcalfe and the late Dr Michel Varnam who helped set up the initial training

programmes. The first undergraduate family medicine programme was introduced in the curriculum of the Faculty of Medical Sciences of the University of Sri Jayewardenepura situated south of Colombo in 1993 followed soon after by the University of Kelaniya. A purpose built family practice centre for teaching postgraduates and undergraduates was established by the same faculty in 1997 and the first Department of Family Medicine was in 2004. The University of Kelaniya has its own training programme with a separate department of Family Medicine and the Colombo medical faculty has introduced Family Medicine in their curriculum as a separate programme. The PGIM conducts its Diploma and MD in family medicine in Sri Lanka as well as in Chennai and Hydrabad, India. The pathway to obtaining the MD is now available through training based in general practices and hospital rotations and is assessed by a clinical examination as well as by research. In the UK the RCGP conducts a training course which leads to an exam for membership of the College. The RCGP, in collaboration with the Ceylon College of General Practitioners, now offers the international version of the College Membership exam, MRCGP[INT]

WhO ARE WE? International Committee, RCGP WhAT WE DO Support overseas members and represent them at RCGP Council Aid educational exchange Represent the interests of general practice at European and World level via Wonca, ESGP / FM, UEMO, etc. Manage the International Family Medicine Development Programme (IDP) and MRCGP[INT] hOW Through Curriculum Development, Course and Seminars, Quality Assurance Programmes, Training, Accrediation and Assessment Visits, Research, Study Visitsm, Travel Scholarships and the Development of Educational Materials WhERE For example, we work with partners in Bangladesh, India, China, Kosovo, Kuwait, Malta, Nepal, Pakistan, Afghanistan, Sri Lanka and more

14 Princes Gate Hyde Park London SW7 1PU Tel : +44 (0)207 344 3142 Fax : +44 (0)207 973 0056 Email : Inte[email protected] Website :

What is MRCGP[INT]?


ccreditation for MRCGP[INT], the International Membership exam for the Royal College of General Practitioners, was developed in response to the wishes of overseas colleagues and the world-wide need for development of high quality post-graduate assessments. It enables a country or region to develop an examination at the same level and academic rigour as the MRCGP in the UK, appropriately tailored to local needs, culture, health practices and education systems. The aim is to provide a clear framework for locally relevant assessments, with the availability of RCGP advice and support. MRCGP[INT] was launched in October

2001 and Oman, the first pioneer country, achieved accreditation in November 2001, followed by Brunei in November 2003, Kuwait in April 2005, Dubai in April 2006 and finally, the first regional collaborative exam in South Asia in April 2007. Various other sites are still in development. Each year an exam development seminar, MRCGP[INT] Development Days, is held at the College, where new and experienced examiners meet to exchange knowledge and experiences.

The South Asia team and others at the MRCGP[INT] Development Days 23 May 2007

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BRAC. To date a total of 30,000 health workers have been trained covering about 70 million people, almost half the population of Bangladesh. Gonoshashthya kendra (Gk) The Peoples' health Centre GK began by providing preventative and primary health care services for the surrounding villages where there was no access to health care. This service is provided by trained community health workers, called paramedics, who are predominantly young, unmarried women actively recruited from the villages. They cover many basic tasks which might fall within the domain of a doctor but because their training is shorter and more focussed it is more cost-effective particularly given that doctors are in short supply (one doctor for approximately 30,000 population).

Lessons from Bangladesh

Children at a hearing impaired preschool in Dhaka


his report describes a quest to grasp the essence of an effective community-based system in Bangladesh for motivating and empowering poor communities to improve their own health. The purpose of this study tour was to see community-based systems in action, to meet people at grass roots level in their work and whilst being trained, and to learn directly from them in the light of their experience of the system. The first field visit was to Bogra in the north west, about 200 kms from Dhaka, The second site visited was in Savar, 40 kms north of Dhaka city, Introduction Bangladesh is one of the poorest countries in the world, ranked by the World Bank as 174/208, with a population nearing 140 million. This is almost three times the population of England and Wales which is geographically of a similar size. Bangladesh Rural Advancement Committee (BRAC) BRAC was established in Bangladesh in 1972 and was borne out of the plight of resettled families in Bangladesh who had been displaced by the Liberation War. BRAC's Essential health Care Programme (EhC) At the heart of the EHC are a cadre of trained Community Health Volunteers, Shastho Shebika (SS). The SS are selected by the women of the individual

villages.They are thoroughly trained in a limited number of aspects of health education e.g. immunisation, family planning, pregnancy care, clean water and sanitation, personal hygiene, nutrition, tuberculosis, and also to diagnose and treat ten common prevalent health conditions (anaemia, diarrhoea, dysentery, common cold, helminthiasis, roundworms, scabies, dyspepsia, angular stomatitis (vitamin B deficiency) and goitre due to iodine deficiency). Anything complex can be referred to the local Government or private health services. No formal education is required to be an SS whilst some have completed secondary education many are illiterate. Each SS is responsible for about 300 households, visiting 15 households per day, they get to know families extremely well. The SS makes a small income by selling, at an affordable price, a limited range of good quality essential health commodities (paracetamol, vitamins, antihistamines, oral rehydration therapy, antacids, antihelminthics, contraceptives (combined pill and condoms), birth delivery kits, soap, iodised table salt, sanitary towels and vegetable seeds). The SS gives health education in the course of her daily visits and is also the first point of contact, day or night, if villagers have any health problems. Shastho Shebikas are supervised by Community Health Workers called Shastho Kormi (SK); each SK overseeing the work of ten SS. The SKs are recruited, trained and employed by

In Bangladesh there is an acknowledgement of the gap between grass roots communities and the formalised health service. The BRAC SS system closes this gap by involving respected people (critically the women) from the heart of the communities they serve and empowering them (with knowledge and defined function) to improve the health of their fellow villagers. The GK paramedic system relies on educated women who are recruited and employed within local communities, but not necessarily their own, so they lose to some extent the grass roots credibility of the SS. Recommendations In order to bridge the `community - health establishment' gap a cadre of health volunteers, similar in role to the Shastho Shebika, should be established. They should be selected by the neighbourhoods that they live in and will serve and be trained to raise the awareness of their own immediate communities, by giving a limited number of simple, concise and consistent health messages, based on the key local determinants of health. They should also be able to signpost people to relevant health services, including the Health Trainers. This could be organised with the help of the Primary Care Trust's Public and Patient Involvement Team.

Dr Sheila Webb FRCGP [email protected]

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International Travel Scholarship Report

Setting up a primary care STI detection and treatment service in Dili, East Timor


ast Timor (Timor Leste) is a small half island almost directly north of Darwin, Australia. It remains the poorest country in Asia with a life expectancy of 47 and high rates of infant and maternal mortality. I had always wanted to work abroad but was unwilling to commit to the year-long contracts required by most international NGOs. In 2005 I found some information about Bairo Pite clinic and worked there for three months; which was interesting but terrifying. There was a huge epidemic of dengue haemorrhagic fever and most of my time was spent struggling to cope with desperately ill children. This time, in 2006, I wanted to get more involved in the running of the clinic. The main problem with the clinic, lack of management. Our arrival coincided with that of Liz, an experienced NGO manager on a two year volunteer placement. She quickly assessed all that needed to be done. The first step was to organise the pharmacy and medical stores. Several hot and humid days later the pharmacy was arranged in alphabetical order, a stock take undertaken, and drugs low in stock identified and ordered. We began the long process of teaching staff how (and why) to recognise what we needed, and how to order it before we ran out.

there is no way of telling what you are treating. This means each patient taking a huge number of drugs. With a largely illiterate population the chance of understanding and compliance is low, and the more drugs prescribed, the more the chance of non compliance. Secondly, we had no idea of the epidemiology of what we were treating Luckily, our visit coincided with Peter's, an Australian Air Force lab official with a long history of involvement in Timor Leste. His team had put together a lab in response to the tsunami in Aceh. Suddenly we had a lab with state of

One week later our worst fears were realised. Dili descended into violence and disorder. Our clinic turned into a refugee camp, our staff had belongings looted and their houses burnt down, and some have simply disappeared. My heart aches for beautiful Timor and its lovely people. Despite the sad ending, this was a wonderful experience. There are many frustrations and challenges in working in such an environment but also many rewards. The relaxed attitude to time keeping, different clinical priorities, heat, humidity, dirt - all had the potential to drive us insane. But every frustration would be balanced by joy. The Timorese people are wonderful - polite, friendly and warm - never complaining despite their suffering. Watching a malnourished child eating again, wading across rivers to visit dignified tribal elders with TB, being welcomed every morning by smiles and `Bondia!' from patients and staff - all are experiences that will stay in our hearts. My advice to anyone planning a similar project? Don't be too ambitious. Don't assume that your priorities and standards are the same as those of the country visited. Remember that barriers to behaviour change can be enormous and, however hard you try, you may never actually work out what they are! Make sure that your project objective is fluid and do not be too disappointed if it doesn't go to plan. And, lastly, be incredibly adaptable, wear comfortable shoes and make sure, whatever the security situation that you always have what you need to make a good gin and tonic...

Dr Olivia hum and Mr Andrew Day [email protected]

We looked at the feasibility of our STI project. Alarico, the social worker, had been trained in voluntary counselling and testing (VCT) for HIV and ran regular groups with sex Dr hum with patient workers and those identified as HIV the art equipment. Peter imposed a positive. We worked together to provide military regime of training and the a system for referral between Alarico lab became a source of pride to all. and the medical team. When we saw We discussed with him the feasibility patients with symptoms suggesting an of diagnosis of vaginal and urethral STI they could be sent straight to him discharge. We worked out that although for VCT, contact tracing, and advice about sexual behaviour. In the same way diagnosis of chlamydia was too complex it would be within the lab's reach to he could refer anyone from his groups do gram staining, candida and wet directly to us. They could then jump the preps for trichomonas. He planned to queue to see a doctor, without risking start training for this once the staff had losing them to follow up. mastered the new equipment. As no diagnostic facilities existed at the time we were treating people empirically Then things started to collapse around us. In February 600 army members went using the WHO formulas. The on strike and were subsequently sacked. disadvantages of this are many. Firstly, Demonstrations started occurring daily.

RCGP International Newsletter Summer 2007

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International Travel Scholarship Report

Developing Family Physician Training in Tanzania

Why Tanzania? n 2006 I had a two month sabbatical from my practice. The International Department at the RCGP pointed me in the direction of Dr Azim Jiwani in Dar es Salaam in Tanzania. His role has been to establish a high quality postgraduate programme for family medicine leading to a master of medicine degree at the Aga Khan Hospital. Once qualified these doctors will be able to deliver high quality comprehensive medical care relevant to the needs of individuals and families in community settings in East Africa e.g. in district hospitals, health centres, and private clinics and hospitals. I offered my time to help develop and teach on the programme and Azim responded enthusiastically.


The Aga Khan Hospital is funded through the Aga Khan Development Network and is modern and well equipped. It is the size of a small District General Hospital. It is situated by the Indian Ocean in Dar es Salaam, a city of over 3 million people.

A typical market

There is a new postgraduate centre which I used as my base and I had the luxury of air-conditioning and internet access when power allowed. The centre also had well equipped seminar rooms and helpful administrative staff. My work was threefold : to supervise and teach the senior residents in the newly established family medicine centre, by sitting in on clinics and teaching a range of skills including clinical examination, communication, appropriate investigation and patient management skills; to deliver formal teaching each week to all residents (9 in total) on topics they chose. These included clinical audit, lipid management, chronic disease management (CDM), breaking bad news, and alternative medicine amongst others. I usually came away having learnt more than I had imparted! I was asked to help set up a diabetic clinic at the hospital. We developed our own protocol from a combination of my own practice protocol and local guidelines. CDM is in its infancy in Tanzania as they struggle with the challenges of controlling communicable diseases. There are some CDM programmes for patients with diabetes but they operate from poor conditions. They have little equipment, educational material, or drugs. Follow up is haphazard and the costs of ongoing treatment are a major barrier to optimal care. Interestingly the


Fully qualified and trained GP / Family Physician? Interested in conducting research into an aspect of primary healthcare? looking to travel overseas?

International Travel Scholarships assist any general practitioner / family doctor in the world to undertake personal study of an aspect of primary health care in an international context. The awards are open to both members and non-members. They enable GPs to travel to and from the United Kingdom to study an aspect of primary health care internationally that is relevant to their country's needs, or for overseas doctors to help develop their own systems of primary care. The value of each scholarship ranges from £200 to £1,000, exceptionally more is available. In addition, the JOHN J. FERGUSON AWARD is given each August for the most outstanding application submitted in that round. CLOSING DATE : Friday 10 August 2007

only chronic disease that is managed in a coordinated and well resourced way is HIV. Antiviral therapy is funded nationally with considerable foreign aid and run at over 100 clinics throughout Tanzania, including the Aga Khan Hospital. The diabetic clinic started on the 16 January 2007. Developing Family Physicians Training in Tanzania The programme is now well established in its third year at the Aga Khan Hospital. Residents are very active in the formal teaching sessions within the hospital and are motivated and capable with sound knowledge base and good clinical skills. They are very keen to learn and participate well in formal and informal teaching sessions The concept of Family Physicians is relatively new in East Africa and the roles these doctors will play in the healthcare system once qualified is as yet unclear. As a result the curriculum is broad and the residents understandably struggle to identify exactly what they need to learn before qualifying. If we went again we would try and go when it is a bit cooler. We would read about Africa before getting on the plane and we would remember to buy Duty Free Malt Whisky for our ever helpful and long suffering friends in Dar! We underestimated the help and support we would need throughout our trip, from how to deal with live electrical appliances in the kitchen, to getting

Application forms are available on the website or contact International Email: [email protected] Website :

RCGP International Newsletter Summer 2007

stuck in the mud in a 4 wheel drive or what to do when your son develops malaria. The teaching programme is very keen to hear from other doctors with the skills, time and enthusiasm to contribute to the programme. I would be happy to provide further information, advice and contact details. I would like to thank the College for supporting my sabbatical, which has been so enriching professionally and personally.

Dr Neil houston MRCGP [email protected]

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from practice we agreed the course would be modified to four months distance learning on-line, followed by two months of clinical contact in a series of rotations through a number of specialties. The one year programme has proven less popular, though we remain in discussion about possibly expanding it into a full time three year residency programme. Finally the emergency medicine programme has developed to include much more evidence of practical skills, as well as theoretical knowledge. Geographically too there has been major expansion. From Hyderabad, the courses have also been established in Chennai (Madras), Delhi and Kolkata (Calcutta) and most recently in Colombo, Sri Lanka. Annette Steele continues to visit every six months to quality assure the programmes. The College has been privileged to work with Apollo in helping to offer programmes of continuing professional development to Indian doctors, particularly in family medicine, and looks forward to many more years of fruitful collaboration.

Dr Garth Manning [email protected]

RCGP & Apollo Hospitals



The International Newsletter is published twice yearly by the International Department, Royal College of General Practitioners. The views expressed in this publication are not necessarily that of the Royal College of General Practitioners or its International Committee. While the latter has taken every care with regard to the accuracy of the material, it cannot be held responsible for any errors or omissions contained therein.

pollo Hospitals Group is one of the biggest private groups in India, with hospitals also in Dubai, Sri Lanka and Bangladesh. Our association with them goes back to the late 90s, when Dr Philip Evans visited their hospital in Hyderabad as part of a UK Trade and Industry mission to India. Philip detected an interest in collaborating with the College on developing courses in family and emergency medicine. A three month Diploma in Family Medicine, one year Fellowship in Family Medicine and one year Fellowship in Emergency medicine were developed and implemented. In the earlier days of our collaboration I visited regularly as the Development Adviser, but that role was passed to Dr Jim Cox and more recently to Dr Annette Steele. A number of developments have took place over the years. The three month Diploma course remains popular, but to help Indian doctors to reduce their time away

Study of the Quality Assurance System for Primary Health Care in the UK


am a doctor working in public health in a rural area of India. I had just completed my postgraduation in Community Medicine in December 2003 and I was fascinated by what I had learnt about the NHS being a system which was able to deliver high quality primary health care to every citizen in the UK. The International Travel Scholarship served as an opportunity for me to see the NHS from closer quarters and to experience the theoretical aspects, which I had learnt, in practice. In addition, would serve as an opportunity to share ideas on the development of quality assurance for primary health care with the other trustees of Health for All, an organisation involved in the development of primary health care services in Bihar, India. My visit began with an orientation to primary health care services under the aegis of the NHS at the Bridge Health Centre, Canterbury. The centre is situated in the village and provides medical services to patients from Bridge, South Canterbury and villages within a surrounding radius. I was particularly

impressed by how the staff (including GPs, nurses, administrative staff and complementary medical practitioners) with diverse backgrounds worked as a team to provide an array of medical services. I noted the large number of patients suffering from non-communicable diseases, which is in sharp contrast to India where the primary health care system is over-burdened by patients with communicable diseases. I was also fortunate to have a first-hand experience of health care delivered on home visits. I was amazed by the progress achieved in domiciliary geriatric care as well as the various protocols and guidelines developed for the nursing practices. In addition, I was able to observe a baby clinic at the surgery which showed me how the team collaborate to provide an umbrella of child health services including health check ups, immunisation and growth monitoring. I also visited the Canterbury & Coastal PCT in order to understand the administrative and management issues related to primary health care and the

role of the PCT in helping individual practices to achieve desirable standards. I was given an opportunity to make a presentation about my work in India to the trustees of Health for All and other team members of Bridge Health Centre. I also visited the RCGP. I was particularly impressed by the initiatives taken by the College towards improving the professional standards and uplifting the cause of GPs. My experiences in the UK have helped me forge lasting friendships and I have learnt important lessons to take home. I realised the importance of periodic reviews and participatory appraisals as tools for quality improvement. Thanks to the NHS, I am also going back with a reaffirmed faith that a better, more cost-effective way to improve the health status of a population is to improve the quality of primary health care services delivered by a family physician, rather than concentrating on improving secondary & tertiary care services.

Dr Sherin Varkey Programme Coordinator ­ ClICS Program Department of Community Medicine M.G.I.M.S. Sewagram, India


12 pages

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