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SolidarMed support to Zambia’s Medical Licentiate Training Programme.

Author(s) Anel Bowa1, Uwe Graf2.
Affiliation(s) 1Chainama College of Health Sciences, Chainama College of Health Sciences, Lusaka, Zambia, 2Medical Licentiates Department Chainama College of Health Sciences, SolidarMed, Lusaka, Zambia.
Country - ies of focus Zambia
Relevant to the conference tracks Health Workforce
Summary The Medical Licentiate Training Programme (MLTP), adapted to Zambia’s requirements and circumstances, is one response to the severe shortage of doctors. The MLTP provides training in internal medicine, paediatrics and child health, obstetrics and gynaecology and surgery. It enables Clinical Officers (COs) to upgrade their skills so that they can perform the role of doctors (task shifting) including lifesaving operations. Since 2009 SolidarMed supports the MLTP with the assistance of the LED. SolidarMed’s association with the MLTP and cooperation with Chainama College of Health Sciences (CCHS) has already proved fruitful as intakes and practical sites have successfully been doubled.
What challenges does your project address and why is it of importance? The project supports the training of MLs at CCHS for the Ministry of Health (MoH) in Zambia. The project aims at increasing, in fact doubling, the number of trained Medical Licentiates. The Zambian health sector faces a constant shortage of human resources. Rural areas have been more disadvantaged and, while the population has been increasing, the number of Medical Officers (MOs) has remained constant. As a consequence, CCHS commenced the MLTP in January 2002. The Programme was introduced with a purpose of helping fill the void where there were no MOs, especially in rural Zambia. The purpose was to augment the functions of MOs due to their long standing shortage in rural hospitals. At that time the attrition rate for MOs was said to be at 80 per cent. The MLs are trained to work at Level I Hospitals. The aim of the MLTP is to train a first line mid-level health worker that handles medical emergencies and has skills in all the four major disciplines of medicine which are: Internal Medicine, Obstetrics and Gynaecology, Surgery as well as Pediatrics and Child Health. Therefore ML practitioners are the ideal cadre to address Millennium Development Goal 4 and 5. Candidates to the programme are COs with at least 2 years clinical experience.
How have you addressed these challenges? Do you see a solution? The Medical Licentiates Training Programme, adapted to Zambia’s requirements and circumstances, is one response to the severe shortage of doctors especially in rural Zambia. Clinical officers play an important role in the Zambian health service and are usually employed in rural health hospitals. The MLTP provides further training in internal medicine, paediatrics, gynaecology and surgery, and enables Clinical Officers to upgrade their skills, so that they can perform the role of doctors, and be able to diagnose and perform operations as well as manage and run District (Level 1) hospitals. It opens a career path for clinical officers. An additional focus of the MLTP is on emergency care, which constitutes a big need in the periphery. MLs are able to help those in need of immediate assistance such as those patients who might die if they have to wait for referral and transfer to the next level of care. This training on critical care makes MLs more suitable for rural hospitals. Stabilised patients are then referred to the next level of care if the need arises. Since the inauguration of the training programme, not a single ML has left the country. Available data suggests that brain drain for this cadre is very limited. Neither internal brain drain into the private or Non-Governmental Organisation (NGO) sector, nor external brain drain to neighbouring countries or the region can be observed, unlike with medical doctors. MLs are retained in the rural areas and in areas that are underserved and medical doctors are not to be found. SolidarMed’s involvement in the MLTP started in 2009, with the assistance of the LED. The project aims at increasing, in fact doubling, the number of trained MLs. SolidarMed’s association with the MLTP and cooperation with CCHS has already proved fruitful as intakes and practical sites have successfully been doubled. Acknowledging the professional capacities of the MLs, the MoH in 2012 increased the national ML target from 216 (3 per district) to 600.
How do you know whether you have made a difference? The first step in achieving this was to institute an annual intake of 24 students (instead of one intake every two years as before). To achieve this, the number of practical training hospitals had to be doubled. Out of the 4 new training sites, SolidarMed supported 3: St. Luke’s Mission Hospital in Mpanshya (Obstetrics and Gynaecology); Kafue District Hospital (Internal Medicine) and Livingstone General Hospital (Paediatrics). Support to these training hospitals included infrastructure development like student hostels and staff houses, targeted investments including essential medical equipment, provision of an enrolling fund and the deployment of three consultants (in Obstetrics/Gynaecology, Internal medicine, and previously in Paediatrics for which a Zambian doctor subsequently took over the position). The consultants participate in theoretical training at CCHS and are in charge of the practical training of MLs during their 4 month practical training units. The SolidarMed consultants have a dual teaching/training role. As well as holding lectures for ML students during the theoretical part of their training at CCHS in Lusaka, they are in charge of their practical, hands-on training in Obstetrics/ Gynaecology and internal medicine during their practical training attachment at St. Luke’s Mission Hospital, Mpanshya and Kafue District Hospital respectively. This dual role is unusual in the training programme, where the lecturers have little involvement in practical training and vice versa. However, knowing the demands of both the theoretical and the practical training and being able to meet both has been a unique advantage of the SolidarMed consultants. In 2011 the project underwent a comprehensive Midterm Review which acknowledged the success of the project. As a result there was a creation of a full-time position for a Technical Advisor at the CCHS and the construction of the urgently required new office building for the ML Department. The construction of the additional lecture room is underway.
Having created a database for all the MLs that have graduated from CCHS by the Project, it was discovered that all the MLs were working within the country and over 90 per cent of them were in rural based district hospitals where they are carrying out emergency surgical operations in addition to their routine job requirements.
Have you or the project mobilized others and if so, who, why and how? The Project is working closely and collaborating with various partners. The closest partners include: CCHS, MoH, Ministry of Education (MoE) through the University of Zambia School of Medicine (UNZA/SOM), and the Ministry of Community Development, Mother and Child Health (MoCDMCH). Other partners are: Johns Hopkins Program for International Education in Gynecology and Obstetrics (JHPEIGO), Clinton Health Access Initiative (CHAI), European Union (EU) through the Clinical Officer Surgical Training in Africa (COST Africa), the Volunteer Service Organisation (VSO), the Health Professions Council of Zambia (HPCZ), the Zambia Medical Licentiate Practitioner Association (ZMLPA) and the (Pan) African Network of Associate Clinicians (ANAC).
The various cooperating partners have been mobilized to play specific roles in the sustainability of the MLTP, quality assurance of the programme, deployment of the graduates, sponsorship of the students, curriculum review and improvement of the quality of theoretical and practical training. With the help of all stakeholders the curriculum for MLs was upgraded from advanced diploma level to Bachelor of Sciences (BSc) level. Enrolment into the programme is gradually increasing which shows the success of the programme.
The Project uses various strategies to reach and work with various partners. These include: networking, lobbying and advocacy work, collaboration, multilateral meetings and exchange visits.
When your donor funding runs out how will your idea continue to live? The programme is embedded into the Zambian education system. The MLTP is supported and recognised by all relevant Government Ministries (MoH, MoE, MCDMCH and Ministry of Finance (MoF)), policy stakeholders and networking partners. Active political support and recognition of the MLTP by crucial ministries like MoH, MoE, MCDMCH and MoF as well as other policy stakeholders and networking partners are key for the sustainability of the MLTP. Therefore:
 The SolidarMed Project Manager (PM)/Technical Advisor (TA) has been participating in Technical Working Groups at the MoH, in addition to meeting regularly with those responsible in order to advocate for the concerns of the MLTP.
 The SolidarMed PM/TA has pro-actively been promoting networking and exchange with the Zambia Medical Licentiate Practitioners Association (ZMLPA), as well as the Africa Network for Associate Clinicians (ANAC).
 Operational Research on the impact of MLs in Zambia will be carried out in collaboration with the SolidarMed PM/TA and the results of this shared.
The project supports an already existing programme. At the end of the project, it is expected that the programme would be strengthened further, including improvement of quality of training, strengthening of the management of the ML Department and the introduction of a Bachelor of Science degree programme. The infrastructure that has been constructed will leave a permanent mark of the support from the project and will continue to be used to produce the required category quality and number of health workers. It is envisaged that the MoH and other relevant Ministries and partners will sustain the programme.
In addition, after 2015 there will be need for a period of consolidation at all levels of the MLTP - locally within CCHS, nationally with all relevant ministries and all other relevant key stakeholders from the government sector, as well as regionally through the ANAC. The network most likely would need to be focused on with more intensified support and steering. Another key factor in the attractiveness and sustainability of the MLTP will be its ability to confer a degree.

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