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report “Improving health at home and abroad”, which
highlights the importance of volunteers having the cor-
rect skills, attributes and experience for the task (25).
Support from Ministry of Health and Faculty of Medi-
cine. The DU programme was part of the University of
Antananarivo’s Faculty of Medicine, but was develo-
ped with the close involvement of key members of the
Malagasy MoH. This ensured that it was institutionally
embedded, locally appropriate and relevant. It also
guaranteed the necessary logistical and administrative
support.
Strategic vision and integration into national policy.
The training was seen as providing a crucial contri-
bution towards the coordinated vision set out in the
PNDSR 2010–2015, the MoH’s first national plan for
the rehabilitation sector, which was developed with
local partners in consultation with the WHO (37). In
addition, the training programme benefitted from the
support of international non-governmental organisa-
tions, with leadership from the MoH, thus helping to
effect change (Fig. 1).
Sustainability. Following the DU, volunteers from
Leeds returned to Madagascar twice in 2014 and in
each subsequent year to consolidate the learning and to
train those who will be training rehabilitation clinicians
in the many other centres. The UK and Malagasy teams
have developed a strong relationship with ongoing
regular contact between individuals.
Barriers to success
Costs. The overall costs of the programme were modest,
and represented “exceptional value for money, compa-
red with the costs of comparable training by commercial
trainers” (16). However, doctors were required to pay
tuition fees for the DU and there were additional travel
and accommodation costs. It is perhaps an indicator of
their enthusiasm that many were prepared to meet these
costs, although some expressed discontent.
Lack of accreditation/recognition. A source of dissatis-
faction for the physiotherapists was the lack of certifica-
tion. Although the doctors received DU accreditation,
this did not translate to any career advancement or
formal institutional recognition for the skills gained.
Need to formalize ongoing training. The DU was de-
livered as a series of short courses, in part due to the
availability of UK volunteers. (To date, the DU course
has not been repeated, but discussions are ongoing for
the DU programme, as developed by Opt In and the
teaching hospitals, to be continued by the newly formed
Global Rehabilitation charity www.globalrehabilitation.
org). There now needs to be a focus on succession
planning, to identify local programme leaders with the
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requisite skills and commitment to carry the training
forward. This may be in the form of a formal and ac-
credited Continuing Professional Development (CPD)
model, whereby regular training is embedded within
ongoing service plans (38). Training in leadership and
management emerged as a significant need. Many of
the doctors now have managerial responsibilities, but
few have undergone formal training in this area.
Wider conditions. The remit of the training programme
was highly focused towards skills transfer. However,
there remain wider limiting factors and material needs,
which are key to overall improvement of the rehabilita-
tion service. In addition, there remains a lack of trained
staff in allied health professions, with only 8 qualified
occupational therapists in Madagascar. There are cur-
rently no speech and language therapists in the public
sector, but strong awareness of the need.
Limitations of the evaluation
This evaluation used only qualitative methodology.
Only change at the level of the direct beneficiaries of
the training was considered. The impact on indirect
beneficiaries, such as patients and families, was not
assessed, although evidence from these was included.
The evaluation did not aim to include any national or
international data to assess for macro-level change.
Conclusion
The success of this programme is a source of great pride
to all those involved. It enhanced the trainees’ clinical
knowledge and skills, attitudes and working practices.
UK volunteers gained skills applicable to their NHS
practice. Strong leadership with a clear vision based
around local needs was key to the programme’s suc-
cess, as was the mutual respect and enthusiasm of
all involved. The programme also benefitted from its
integration within a wider, coherent plan for the reha-
bilitation sector. Rehabilitation training programmes
fulfil a need to strengthen the healthcare workforce,
particularly in LMICs, where the burden of disability
is greatest. These programmes can be undertaken at
modest cost through global health partnerships, with
significant benefit to both parties. It is hoped that the
key learning points from this evaluation may serve
in developing a model of implementation for future
training programmes in other settings.
ACKNOWLEDGEMENTS
The authors would like to acknowledge all participants and
organizations who contributed to the evaluation, included those
mentioned in Table III. In particular we thank Dr Sonia Andria-
nabela, Professor Luc Samison and Professor Gaétan Duval So-