Journal of Rehabilitation Medicine 51-11 | Page 34

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H. N. Locke et al.
number may be much higher (9–11). Access to healt-
hcare for people with disability is limited. For most of
the population, the distance to a rehabilitation centre is
long, and travel is hampered by poor road and trans-
port infrastructure. Services lack modern equipment,
and patients frequently struggle to meet the costs of
treatment, as few have access to health insurance.
Despite this, the rights of persons with disabilities are
increasingly recognized in Madagascar. This is exem-
plified by the ratification of the UN Convention on the
Rights of Persons with Disabilities (UNCRPD) in 2014
and the publication of the National Strategic Plan for
Physical Rehabilitation (PNSRP) 2017–2021 (12, 13).
Andrianabela et al. (14) described the Madagascar
rehabilitation training programme (2011–13), a training
partnership facilitated by the University of Leeds and
Leeds Teaching Hospitals Trust (LTHT) and funded
by Opt In, a UK-based charity (14, 15). This paper
describes the methods, results and learning points
from a full evaluation and impact assessment carried
out in 2014, a year after completion of training (16),
and incorporates an overview of activities that resulted
from the programme in the 5 years after the evaluation.
MATERIAL AND METHODS
Training programme
The training was jointly devised by the Malagasy and UK leads,
and had support from the Malagasy Ministry of Health (MoH).
Direct impact
MOU=Memorandum of Understanding
DU=University Diploma (Diplôme Universitaire)
LTHT=Leeds Teaching Hospitals Trust
MoH=Ministry of Health
ICRC=International Committee of the Red Cross
CBM=Christian Blind Mission
Training and distance
coaching of 1 doctor
and 1 physiotherapist
from each regional
rehabilitation centre
Training curriculum
and MOU → DU
To develop and deliver a training programme in musculoskeletal and neurological
rehabilitation to 8 doctors and 10 physiotherapists from major rehabilitation
centres, leading to the doctors obtaining a mid-level university diploma (DU).
A Memorandum of Understanding (MoU) between LTHT, the
University of Leeds and the University of Antananarivo ensured
a collaborative approach, with both countries having local coor-
dinating groups (14). The training was delivered in the format
of a mid-level university diploma (Diplôme Universitaire; DU),
with 3 sections: the general principles of rehabilitation practice,
rehabilitation of neurological conditions, and rehabilitation of
musculoskeletal conditions (Table I). The programme was deli-
vered over 400 h of face-to-face teaching, with projects, audits,
self-directed and collaborative learning, equating to a European
diploma (120 credits) (17). The aim was to train at least one
doctor and one physiotherapist from each of the national and
regional rehabilitation centres. In total, 8 doctors from 6 centres
and 10 physiotherapists began the course.
Training was delivered by volunteers, most of whom worked
in clinical roles within teaching hospitals in Yorkshire, who gave
their annual leave for extensive preparation and delivery of the
training. Malagasy interpreters were recruited locally and paid
from training programme funds.
Evaluation
A combination of qualitative methods was used for the eva-
luation, with informants from the UK and Madagascar. The
evaluation was carried out by an independent international
development, education and human resources consultant from
the UK, Dr Simone Doctors (16) (Table II).
The evaluation used a Theory of Change model (Fig. 1),
developed by the evaluator, which set out the change pathways
by which the activities undertaken were designed to produce
Indirect impact
Doctors & physios
from each regional
centre are sharing new
skills and knowledge
with colleagues
Other factors/ changes over which
OPT IN has no influence:
Financial resources available
Improved management of services
Improved infrastructure
Improved financial access
Improved geographical access
Human resources motivated and
benefit from improved career
structure and management
Improved equipment
Doctors and
physiotherapists at
regional rehab centres
have improved skills
1
Doctors &
physiotherapists from
each regional centre
have improved
knowledge and skills
Improved rehab
medical care is
provided using a
multidisciplinary
approach
5
,
6
Improved
rehabilitation
services
(access & quality)
People with temporary or
permanent disability
achieve maximal functional
autonomy leading to
improved socio-economic
participation
2,3,4
Sponsoring and implementing partners
Opt In, LTHT, MoH, Faculty of Medicine
Other national/regional stakeholders
Regional hospitals, Regional rehab centres,
Regional health services, ICRC, Handicap
International, CBM, civil society groups,
etc.
Fig. 1. Theory of Change model for the training programme (12).
www.medicaljournals.se/jrm
Table I. Objectives of the rehabilitation training programme
Improved recognition
of rehabilitation
medicine
7
Assumptions ( )
1 training leads to improvement of skills and knowledge
2 willingness to transmit training/skills
3 transmission is done appropriately
4 colleagues are receptive to transmission
5 improved skills and knowledge lead to improved practice
6 after training, doctors and physios remain in health centres
7 improved recognition leads to improved services
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