armenia and utmb partnership in primary care 1999-2004 jamal islam md ms associate professor...
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Armenia and UTMB Partnership in Primary Care1999-2004
Jamal Islam MD MSAssociate ProfessorResearch Director
Department of Family and Community Medicine
TTUHSC Permian Basin
USSR Before 1991 and Now
Russian Socialist Federative Soviet Republic
Transcaucasian Socialist Federative Soviet Republic
Ukrainian Soviet Socialist Republic Byelorussian Soviet Socialist
Republic Tuvan People's Republic Kresy Bessarabia Finnish Karelia Estonia Latvia Lithuania
Russia Belarus Ukraine Moldova Georgia Armenia Azerbaijan Kazakhstan Uzbekistan Turkmenistan Kyrgyzstan Tajikistan Estonia Lithuania Latvia
ARMENIA
Over 4000 years as a state First Christian state Independence from USSR September 1991 Area 11,483 sq mile Landlocked Administrative division: 11 Region Capital: Yerevan Population 3.79 million (2000)
https://www.cia.gov/library/publications/the-world_factbook/geos/am.html
Demographics
Population 2,967,004 estimate 2009– Comparison
Azerbijan 8,041,000 Georgia 5,262,000 Turkey 66,668,000 USA 283,230,000
In World Birth rate 12.65/1000 160th
Death rate 8.34/1000 100th
Growth rate - 0.03% 207th Migration - 4.56/1000 162th
Health Indicators & Health worker
ARMENIA USA Life expectancy at birth 69 (M)76 (F) 75 (M)81 (F) Birth rate 12.6/1000 14.0/1000 Infant mortality 20.2/1000 6.9/1000 Physicians 360/100,000 416/100,000 Nurses 481/100,000 836/100,000
Health system WHO rank 104 38 Expenditure per capita $63 $6,096
Demographics
M F
Median 28.8 34.4
Years % 0-14 18.2 289,119 252,15015-64 71.1 986,764 1,123,70865> 10.6 122,996 192,267
Health Problems
CVD HTN Smoking related lung disease Maternal and child health Breast Cancer Respiratory disease in children
Common DiseasesMortality (Per 100,000)
USA(Whites)
CVDOverall death 350 324MI death 225 187Stroke 94 44
Cancer death 98 187 MVA death 41 15 Intoxication 41 13 Infectious disease 8.5
Health Care System in Armenia
In 1991 dissolution of USSR placed 300 million in jeopardy for their social and health care.
Armenia 3.75 million people were affected
Annals of Internal Medicine 1993; 119:324-328
USSR health care system
The Semashko model Centrally financed through the state Public owned facilities State totally controls the distribution of all health
resources. planning, allocation of resources and managing
capital Expenditures through central, regional and local
administrator No public debate or input allowed
Health Care Delivery System
Based around hospitals– Republic hospitals had 1000-2000 beds– Regional and district had 50-250 beds
Outpatient care provided by– Polyclinics (adjacent to hospital) 1000 visits/day– Village level primary care stations run by paramedics and
midwife
OTHER– Military, transportation and Elite hospitals– Maternity hospitals at republic level and occasionally at
other levels too
Health care system in transition
2005 Basic Package: hygiene and anti-epidemic control, primary
healthcare, medical care for children, obstetrics, care for socially vulnerable groups, communicable and non-communicable disease control, and the emergency healthcare program
Expansion of basic services
2006 All services provided by polyclinic
Services not provided is paid out of pocket– Estimated out of pocket is 45% of service
State owned hospitals and Polyclinics are now semi autonomus, self-financing enterprises.
Government payment
Hospitals bed/day in 2006 $25.7
Outpatient per enrolled patients ?
Average Salary state owned 2006– General Practitioner US$ 110/month – Nurses US$ 87/month
J Public Health (2008) 16:183–190
American International Health Alliance
“A nonprofit organization that facilitates and manages twinning partnerships between institutions in the United States and their counterparts overseas” Targets:
– Nation and communities with limited resources Objective
– Advance global health– Build institutional & human resource capacity
Method:– Peer-to-peer partnership knowledge transfer– Volunteer time to the project– Logistics provided
http://www.aiha.com/en/
Funding for AIHA
United States Agency for International Development (USAID) Started funding in 1993
US Department of Health and Human Services
Health Resources and Services Administration (HRSA)
World Health Organization (WHO)
Global Fund to Fight AIDS, Tuberculosis and Malaria
German Society for Technical Cooperation (GTZ).
ARMENIA PARTNERSHIPSCooperative Agreement Fund USAID
1. Yerevan/Boston, Massachusetts, 1999* – Boston Univ. Medical Center – training nurse and pedi emergency/trauma
2. Yerevan/Los Angeles, California, 1999* – UCLA Medical Center – Nursing: faculty training, improve program
3. Armavir/Galveston, Texas, 1999-2004. ** – UTMB - primary care
4. Gegarkunik/Providence, Rhode Island,1999- 2004**
– Care New England – primary care
http://pdf.usaid.gov/pdf_docs/PDACG218.pdf
Armenia Partenerships
5. Lori/Los Angeles, California, 1999-2004** – UCLA Medical Center- primary care
6. Lori/Milwaukee, Wisconsin, 2003-2004 – Center for Int. Health- Primary care training program
7. Yerevan/Birmingham, Alabama, 1999-2002** – Univ of Alabama- post graduate training; administrators
8. Yerevan/Washington, DC, 2000-2004 – Armenian American Cultural Association and Washington Hospital
Center- Breast and cervical cancer prevention
THE PROGRAM IN NUMBERS (Fiscal Years 1999-2004)
8 = Armenia partnerships
87 = US partner who traveled on exchanges to Armenia
118 = Armenian partners who traveled on exchanges to US
389 = Total individual exchange trips (in both directions)
103,000 = Served by the 3 PHC centers established
$8.4 million = Total USAID funding
$10+ million = Value of in-kind contributions by US partners
Partnership Model
Voluntarism: significant in-kind contributions of human, material, and financial resources
Institution-based partnering for capacity-building and systematic change
Peer-to-peer collaborative relationships that build mutual trust and respect
Transfer of knowledge, ideas, and skills through professional exchanges and mentoring
Partnership Model
Benefits flowing in both directions
Replication and scaling-up of successful models
Sustainability of achievements and relationships
“Partnership of partnerships” for networking, sharing, and creating common approaches and solutions
Armavir and UTMB Partnership
Goal
– Improve the health of individuals in the Armavir region through primary care services
ARMAVIR
Distance from capital: 30 miles Area: 483 sq mile Population 330,000 3 general hospitals 2 maternity hospitals 11 polyclinics 7 health centers
REGIONAL HEALTH CARE
Armavir– Physician 131– Nurses 333– Field visitors 25– Lab assistant 14– Technical staff 234
Vagharshapat Metsamor Baghramyan
POLICLINIC (Our Base)
Out patient follow-up 2000/doctor General practitioner 15 Neurologists 3 Ophthalmologists 2 Dermatologist 2 Surgeons 2 Cardiologist 2 Endocrinologist 1 Infection specialist 1 Psychiatrist 1 Gastroenterologist 1 Clinical/Biochemistry 3
Service
Biochemistry ECG Xray EGD
Objectives
Increase training and training capacity. Increase continuing education for nurses. Improve record keeping. Expand diagnostic laboratory capabilities in areas
including management, calibration of equipment, blood safety, and infection control.
Encourage healthy lifestyles. Expand a multidisciplinary approach to disaster
preparedness
Intervention
Educate a core number of health professionals on screening, monitoring, using treatment guidelines, and patient education:– Cardiovascular disease – Diabetes– Breast cancer– Disaster preparedness
Intervention
Medical record keeping (medical cards) Standardization of laboratory and quality
control
School teacher education on hygiene, infections, emergency preparedness, domestic violence, and smoking cessation.
Performance indicator to be measured
Establishing a learning resource center Training of 56 physicians and credentialing
them through the national institute of health of Armenia
Training 112 nurses and credentialing Identify 80% of patients with diabetes, breast
cancer and cardiovascular disease and monitor
Proportion of medical cards completed
Baseline Survey
Multistage cluster sampling Hybrid self and interviewee administered 1019 household 3 towns 16 villages
Demographics
(S.D) Mean age years 35.6 (10.6) Mean years of living in area 26.1 (13.0) Mean Household member 5.3 (2) Mean room 3.3 (1.2) Cooking(%) Pipe Gas 35.8, Tank Gas 18.5,
Electric 36.6, Coal 4.8 Washing machine 44% Indoor toilet 38% Color TV 43% Telephone 43% Computer 1.5% Automobile 20%
Perception of health
Own health status– Satisfied 14.3%– Dissatisfied 49.8%
Children – Fair 52%– Poor 17.3
Health utilization
69% never sees doctor for preventive exam 11.9% ever checked cholesterol 12% ever screened for HTN 47% female never had pap smear 6.3% female ever had mammogram
Depression Measured20 scale CES-D
< 17 No depression 22.3 % 17- 22 Possible 22.3 % > 23 Probable 55.4 %
Addiction
Tobacco 28.5%
male:female 22:1
Alcohol 14.2%
Drug addiction 0.3%
Self Reported Disease
Hypertension 29%
Vision problem 27.8%
Mental disorder 5.6%
Diabetes 3.1%
Cancer 0.1%
Accidents that required health care 26.5%
RESULTS:
Established LRC with trained person
Computer installed with internet connection to access information and establish email link with UTMB Galveston
RESULTS
UTMB: Eleven physician and nine nurses completed the Train the trainers course
Armavir: 183 physicians, 352 nurses were trained by the trainers in several diseases: CVD, CVA, breast cancer, diabetes, personal safety, infection control, substance abuse, pediatric asthma and GI infection
RESULTS
Increased continuing nurse education Improved record keeping Started Patient education on healthy life style
Expanded diagnostic laboratory capabilities Laboratory equipment standardization, training
on equipment
Introduced universal precaution
Interventions
Results
School teachers 15 trained on hygiene, infections, emergency preparedness, domestic violence, smoking cessation
Disaster Planning
Mock disaster training carried out
150 participants were trained on the use of defibrillators, torches, and radio telephones. They also learned about EMS system in the United States
Galveston Hurricane preparedness administration model introduced
Sister city partnership with Galveston led to promise of donating surplus medical emergency equipments
SUCCESS?
Left a new concept of health care delivery Creation of local capacity for “change” Physicians exposed to a broader aspect of
health care delivery Nurses understanding and appreciation of
their increased role in healthcare delivery Importance of outreach services, screening
and prevention
Lessons Learned
Resolving health care delivery is very complex Nurse training crucial Buy in from physicians essential Working with administration essential Do not undermine partners pride Patience needed Teaching institutes need to provide time and effort
for helping to improve health of the world population
Proactive team needed in all teaching institutions for International Health
Thank you
QUESTIONS?