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pants felt that it led to improved morale, motivation and
confidence in dealing with an increasing caseload and
leading a multidisciplinary team: “The knowledge we
received from them in different training sessions, for
example how to run the department, how to manage
the staff, manage patient records, relationships with
colleagues in other departments”.
Working practices are now changing. There is a
newly learned emphasis on regular multidisciplinary
team meetings and case conferences, with all patients
routinely reviewed by a doctor, and rehabilitation pres-
criptions used to plan and tailor therapy appropriately.
“Every Monday morning all the staff meet. We have a
discussion, exchange information and … if there are
physios or doctors who have received training, we
try to share that with the others. And when there is a
problem, for example with patients’ treatment, either
here or in the other departments, we discuss these
difficult cases together”. New links have been forged
with other, related hospital specialties, for example
neurosurgery and orthopaedics.
The doctors trained have become more aware of the
needs of patients and their families. Most units are now
accessible; all are clean, better maintained and more
patient- and child-friendly. In the absence of resources,
some of the rehabilitation staff were inspired to make
their own improvements at their own expense (Table IV).
The many changes made have contributed to a better
understanding and acknowledgement of the value of
rehabilitation within the wider hospital environment
and the health sector. “It is really very important to be
in contact with the different hospital services because
there are many patients [in these] who need our [re-
habilitation] interventions”.
Based on audit, data collection and basic research
skills learnt in the DU, the clinicians now routinely col-
lect clinical data that contributes to a national database
(11) and are lead authors on a number of published
journal articles. Rehabilitation trainees from the UK
are now actively involved with their counterparts in
Madagascar in conducting research and development
work. Recent projects have looked at trauma rehabilita-
tion services in Madagascar (22) describing the current
service and identifying barriers to accessing treatment.
Continuing support will be required to strengthen these
Table IV. Individual initiatives by doctors, physiotherapists
and their teams to improve accessibility and environment of
rehabilitation centres
• Ramp built by one of the OPT IN trained physiotherapists using his own
resources, to improve access to CHRD Anosy Avaratra rehabilitation
centre.
• Signage created by one of the physiotherapists at SAR Majanga to
improve visibility and accessibility of the centre.
• Garden for use by staff and patients cleared and planted by the
rehabilitation team at HJRA.
www.medicaljournals.se/jrm
developments along with research capacity, a vital
component of long-term development (23, 24).
Benefits to individual volunteers and their institutions
The advantages to volunteers of their working abroad
are well recognized (25). This evaluation highlighted
several reported benefits to UK volunteers and their
employers, the teaching hospital and the NHS. Expe-
rience gained on the Madagascar programme contribu-
ted to enhanced skills within their current professional
role; for example, in teaching and training. Many of the
volunteers took an active role in developing the train-
ing materials and presentations. They learned to adapt
their teaching style to suit the Malagasy audience and
deliver the training through interpreters, demonstrating
an ability to be flexible and cope with challenging si-
tuations: “I have learned to work through interpreters
much more effectively in Leeds, checking meaning and
understanding and getting feedback from the patient”.
Volunteers also reported improvements in work-
place attitudes and overall morale and motivation.
The volunteers developed a new appreciation for, and
commitment to, their clinical roles after seeing the
commitment of their Malagasy counterparts working
in poorly resourced situations. They reported a heighte-
ned awareness of the opportunities available to them in
the UK and placed greater value on the infrastructure,
facilities and equipment in UK hospitals.
Sustainability and ongoing impact beyond the
evaluation
There has been much positive ongoing work since the
evaluation was carried out. Whilst these examples are
not directly as a result of the DU, they flow from the
graduates of the course who are setting up services,
identifying needs and developing plans with the sup-
port of colleagues in Madagascar and the UK.
Following completion of their training, the 8 rehabi-
litation doctors went on to form a professional organi-
zation, the Association of Physical and Rehabilitation
Medicine Madagascar (AMPR Mada) (26). They held
their first international teaching congress in 2014, fo-
cussed on rehabilitation of children with cerebral palsy.
The UK team provided support for the development
and delivery of this congress, including the produc-
tion of a workbook, which forms the basis for national
guidelines on the topic. Further congresses focussed on
stroke rehabilitation in 2016, and management of club
foot in 2018. The Malagasy rehabilitation doctors were
also supported to attend the African Spinal Cord Injury
Network (AFSCIN) meetings (27) and the Southern
African Spinal Cord Association (SASCA) conferences
(28). These meetings have brought networking oppor-