Introduction
The richness of the family medicine discipline goes beyond its encompassing many aspects of other disciplines, because it is an approach where family physicians consider patients’ own values, their beliefs and environments while also collaborating with many specialists.1 2 Leaders in healthcare in Africa are increasingly realising the importance of family physicians, especially for rural areas.3 Family physicians are often the first contact for patients regardless of age, gender or religion. Global reports indicate there are disparities in cancer and non-communicable disease prevention, and therefore mortality, between low-income and middle-income countries and high-income countries.4 Policy makers seeking an efficient health system need to focus on community health, a task adeptly handled by primary care physicians.
Developing a new residency programme in sub-Saharan Africa is a challenging undertaking, and its success is at least partially reliant on local and regional collaboration.5 On one hand, main challenges are developing appropriate and culturally customised curriculum as well as ensuring there are resources for its success.6 On the other hand, comparisons between Ethiopia and the USA, Japan and the USA and from China, suggest that resident perspectives about fundamental training challenges in family medicine are more similar than dissimilar.7–9 The residency programmes’ curricula periodically undergoes formal review and changes when the need arises, especially when needs are expressed by the current trainees in the setting of dedicated, supportive and transparent faculty members. Residency programmes ideally should undergo some formal evaluation in order to be sure they are providing adequate teaching and supervision for trainees.10 Residents are an important constituency as the training is designed for their development and their perspectives on training merit consideration.
The population in Ghana is ageing rapidly with a concomitant increase in complexity of medical care and chronic illnesses.11 Previous research has shown there is limited care access for critical conditions such as stroke and large variability in the quality of care.12 Chronic medical conditions such as hypertension, coronary artery disease and diabetes are prevalent, and the population faces access challenges for achieving delivery of high-quality care and preventive services.13 14 The success of Ghana’s health system is dependent on having qualified primary care doctors especially in rural areas.15 Family physicians can handle the majority of the health needs of patients in rural districts. Moreover, they are crucial in tertiary centres where they can serve the primary care needs of the large population centres and serve as a gateway for specialists, a feature that contributes to cost effective care for the Ghanaian health system without compromising the quality of care.16 Unfortunately, previous data suggest Ghanaians have much worse cardiovascular health compared with the European population.17 18 Additionally, research has shown that having a health system that allows access, awareness and education to diabetes and hypertension resources will improve the outcome of these illnesses.19 While a system based on family medicine seems an obvious solution, family medicine faces a significant challenges.
In Ghana, medical school graduates can practice primary care once they complete a 2-year internship even without completing formal residency training programme in primary care afterwards. This is important first because there are many medical school graduates who opt to leave the country, despite the establishment of the Ghana College of Physicians and Surgeons and proactive efforts to retain medical school graduates.20 Ghana needs to retain its medical school graduates to train and practice. Unfortunately, graduates increasingly have been leaving Ghana to practice in high-income countries, though some opt to enter family medicine training programmes.21 22 While medical schools are proud of their emigrants’ achievements and success abroad, a national health priority is to retain these graduates and provide them with opportunity to progress in their career inside their home country.23 In contrast to many high-income countries, medical student graduates in Ghana are licenced to work as clinicians after a 2-year internship as formal residency training is not required to practice. Among speculated reasons for why medical students chose to enter residency programmes is the extra training and supervision that they will obtain to support them when they practice independently. Pursuing such training abroad will potentially confer financial benefits and prestige. Engaging in teaching and scholarly activities could prove to be an appealing factor for enrolling in formal training programmes in the homeland. Given the need to minimise brain drain from Ghana and to retain medical school graduates for training in family medicine, research to better understand motivations of trainees who remain in Ghana for training in family medicine is needed.
While establishing a family medicine residency training programme in Ghana faces many challenges as in many other countries in sub-Saharan Africa, the need is great.5 24 This is especially true in rural district hospitals of West Africa.25 26 Like many other sub-Saharan African countries, family physicians’ responsibilities in Ghana are evolving especially given advances in healthcare, an increasing prevalence of chronic diseases, and an ageing population.27 Family physicians’ roles differ substantially among physicians practising in the same country depending on whether they practice in urban versus rural areas.28 Their potential varies based on where they completed their postgraduate training.29 There is a good evidence to support the effectiveness of population health programmes and their role in improving community health in Ghana.30 31 Given the rise of chronic non-communicable diseases in Ghana, there is even more concern about the need for expansion as the available programmes are already inadequate to handle the need.32 These circumstances further emphasise the need for family medicine residency training in Ghana.
The family medicine residency in Ghana started in 1999 and has experienced remarkable development with limited resources. Residents often need a sponsor who will financially support them during residency training. This is a critical issue because sponsored residents need to payback the financial support received by working for the sponsor after completing residency. This limits a resident’s ability to pursue an academic career in family medicine despite the dire need for faculty. The Ghana family medicine training programme has two components. The first is a 3-year training programme that can be initiated after completing the 2-year required internship. Residency graduates earn prestigious membership of the Ghana College of Physicians and Surgeons. Regarding the second, they can subsequently apply for an optional 2-year research-based fellowship (such a trainee is called a senior resident in Ghana and is comparable with a fellow in the US model). At the time of this research, there had been nearly 100 family medicine training programme graduates from the three training sites in Accra, Kumasi and Mampong. The fund for family medicine training in Ghana is primarily through the Ministry of Health, which receives its funds from the Ghanaian Government.
In Ghana, licenced medical officers may not undergo further formal training after internship. They are generalists who rise through the ranks by informal training and years of service. Medical officers do practice broad-spectrum primary care, but they gain different expertise depending on their location of practice and their years of practice. Family physicians with further formal training after internship are designated as specialists (after residency) and senior specialists (after completing senior residency known as fellowship in US systems).
Practice scope, professional recognition and remuneration are therefore different for the two groups although they both work in primary care facilities.
The family medicine department at the University of Michigan, USA began collaborating with their Ghanaian colleagues in 2008 to support and sustain primary care education and research in Ghana. This collaboration has proven a productive one given extensive scholarly activities and publications.33–39 The collaboration has involved faculty exchanges between Michigan and Ghana. Faculty from the University of Michigan have provided lectures and supported the certifying examination process in Ghana. Ghanaian faculty have participated in research and faculty development in the University of Michigan. Moreover, the Department of Family Medicine at the University of Michigan helped coordinate a collaboration between the Geriatric Division of the University of Michigan and Department of Family Medicine in Ghana that fostered the establishment of the first training programme in geriatric medicine in Ghana.40 These efforts not notwithstanding, there remains a need for adequate faculty development resources in Ghana to support faculty growth and their endeavours teaching and supporting their trainees.41 42 The critical need is for more faculty development resources that currently are both limited and challenging to access even when they become available.43
It is not well known what is needed for the programme success and sustainability and why medical school graduates would choose additional family medicine training when they can practice primary care after the 2-year internship. Moreover, information is lacking about how Ghanaian family medicine trainees view the teaching they receive and what teaching formats are needed most. Thus, we conducted research to understand current trainees’ and recent graduates’ views about their education and interest in teaching.
