boston university family medicine global health collaborative

Boston University Department of Family Medicine

Global Health Collaborative

CASE STUDIES

V I E T N A M

BUILDING A NEW MODEL OF FAMILY MEDICINE IN THE DEVELOPING WORLD

partners in family medicine dr. ho thanh tiengPAGE 10

Strengthening health care systemsdr. nguyen thi lanhPAGE 12

DEVELOPING EDUCATIONAL PROGRAMSdr. dang ngoe sonPAGE 14

Our goal is to provide a competent primary care provider for every person in the world.

table of contents

Why Primary Care? 03

Our Global Impact 05

Case Study: Partners in Family Medicine 08

Case Study: Strengthening Health Care Systems 10

Case Study: Developing Educational Programs 12

Our Path Forward 14

GLOBAL HEALTH COLLABORATIVE 02

Friends and Supporters,

As a family doctor at a “safety net” hospital in Boston, I work daily to help patients get the most out of a complicated health system. Even here, surrounded by many of the most prestigious medical specialists, academic hospitals and public health institutions in the world, primary care remains a patient’s key to getting the highest quality health care. Yet on a global scale, primary care has been largely overlooked. As a medical educator, I can understand why. A primary care provider must be capable of dealing with 80% of anything that might walk through their clinic door, something that can’t be taught overnight. And

training alone isn’t enough—effective primary care depends on a comprehensive, integrated system for promoting health that starts at a grassroots level. Like developing great doctors, changing entire health systems takes time.

So in the face of years or even decades of hard work, it’s easy to see the appeal of focusing instead on a single disease or the crisis of the day. But truly improving health care for all is a goal worthy of the commitment.

Most importantly, we know greater investment will help accelerate the process. Our work has proven

investment in primary care—including people, programs and policies—to be a profoundly powerful, efficient way to achieve meaningful and sustainable improvements in health for everyone, everywhere. The Vietnam story highlighted in this brochure received roughly $10 million in investment from a

handful of insightful philanthropists over a 20-year period—a figure that pales compared to other large global health single-disease initiatives. As you read these stories, consider what could be accomplished if these out-of-the-box donors had company.

At the Global Health Collaborative, we believe everyone—not just those in the highest income

countries—deserves a health care provider of their own: accessible, skilled in treating a wide range of problems, and able to see you as more than just your diseases. For transformational change like this there are no shortcuts. But there certainly is a path, and we are proud to be leading the way.

Sincerely,

Jeff Markuns

While quantifiable progress was made towards the Millennium Development Goals in health through vertically-oriented and narrowly directed programs, many people have still been left behind. In order to improve health for all, a new target was set—a total person’s health and wellness—in order to achieve the next step in health equity and improve health outcomes around the world.

At the Global Health Collaborative, we have been advancing this same agenda for more than 20 years. Across the globe, we have developed programs specifically designed to improve health care for all by creating comprehensive improvements at the grassroots

WHY PRIMARY CARE?

In 2016, the United Nations proposed a new paradigm - the Sustainable Development Agenda, a collection of 17 goals intended to change our world by 2030.

For the world of healthcare, the UN set forth one overarching goal:

“TO ENSURE HEALTHY LIVES AND PROMOTE WELL-BEING FOR ALL AT ALL AGES.”

level in order to strengthen health systems with a better foundation overall. Through long-term capacity building and policy advances in primary care, we believe health systems can be transformed. Using family medicine as a cornerstone, systems can provide the highest quality health care to all, regardless of age, gender, income, geography, ethnicity or illness.

- SOURCE: UN SUSTAINABLE DEVELOPMENT AGENDA

01Without a strong foundation of primary care in both urban center and rural communities, access to the health system becomes distorted and disjointed. Patients seek care wherever they can find it—traditional healers, pharmacies, subspecialist clinics, or tertiary hospitals. Family medicine clinics offer financially and geographically accessible points of care where patients can go for help when they need it.

02Patients shouldn’t have to choose between treatment for their acute infection or their chronic disease—comprehensive care lays the groundwork for equitable care. When patients access care, they want to know their primary problem will be dealt with, whatever it is. And when a patient has more than one issue or another family member is also sick, a family doctor can manage that too.

03Patients want to be treated like a person, not a collection of diseases. Vertically-oriented disease-based programs are often ill equipped to manage the complexities of a whole person—family medicine-oriented health care teams work with patients to learn about their own health goals and help them in accessing all the care and programs they need.

ACCESSIBILITY FOR ALL: PRIMARY CARE PROVIDES A RELIABLE FIRST CONTACT POINT OF CARE

COMPREHENSIVE COVERAGE:80% OF ALL MEDICAL ISSUESCAN BE HANDLED AT FAMILYMEDICINE CLINICS

PERSON-CENTERED CARE:FAMILY MEDICINE TEAMS FOSTERLASTING PROVIDER/PATIENTRELATIONSHIPS


APPROACH

HERE ARE A FEW OF THE APPROACHES WE USE TO ACHIEVING THIS ESSENTIAL GOAL:

APPROACH APPROACH

OUR GLOBAL IMPACT

cambodiaFocusing on core curriculum development, integration with Ministry of Health policy, and education and system-level research support with the University of Health Sciences in Phnom Penh.

The Global Health Collaborative builds local capacity over time through close partnerships with important local institutions, both public and private, academic and governmental. We help develop the educational programs and infrastructure needed for a sustainable native pipeline of primary care expertise and talent.

Simultaneously, GHC engages governments on the national and local levels. Building agencies’ and officials’ understanding of primary care is key to creating policy support for its long-term nationwide growth and stability.

laosGHC has sponsored and trained trainers from the University of Health Sciences in the capital city of Vientiane and created a highly successful pilot retraining program in family medicine for rural doctors working in isolated district hospitals.

WHERE WE WORKOUR GLOBAL IMPACT

MYANMARGHC is partnering with the 50-year-old General Practice Society and the newly established Myanmar Academy of Family Physicians to develop new curricula and implement new grassroots training programs. Work continues to build collaborations between civil society and the Myanmar government and universities as the country undergoes its historic opening.

OUR KEY ACTIVITIES

01 NEEDS ASSESSMENTSBefore anything else, we perform thorough assessments of both health delivery and education systems to identify strengths and gaps. We then engage in strategic planning with partners to integrate their immediate and long-term goals with local health system needs.

02 CREATING CURRICULUM, TRAINERS AND LEADERSWe have extensive expertise helping our partners literally write a new book for comprehensive competency-based training programs that target the practical, job-based needs of the doctors on the ground. And because quality curriculum deserves great teachers, we provide local, regional and U.S.-based training for current and future faculty, trainers and health system leaders in everything from clinical teaching to primary care policy to delivery system management.

03 CLINICAL SERVICE DELIVERY DESIGNBased on experience with our own community health center network and academic patient-centered medical home, we assist with design and reform of both primary care clinic service delivery systems and point-of-care training facilities.

04 RESEARCH AND PROGRAM EVALUATIONOur research initiatives answer practical questions on how and where to target systems for change, and are paired with robust program evaluations to guide the ongoing implementation of that change.

05 POLICY CONSULTATION AND ADVOCACYOur belief, affirmed through decades of experience, is that improvements in primary care human resource capacity only realize their full benefit with wider structural and political support. We put equal emphasis on primary care policy development and comprehensive health system reforms to ensure lasting, fully effective change.

lesothoIn a unique partnership with the Boston University School of Public Health, GHC established a local nongovernmental organization—with local leadership—to assess health systems and develop comprehensive primary care training in family medicine. This work assisted in creating Lesotho’s first public-private hospital partnership; developed the first fully accredited post-graduate medical specialist training program in the country; and for the first time ever successfully recruited six native Basotho physicians living elsewhere to return home to practice medicine and receive post-graduate training in their home country.

OUR WORK IN VIETNAM

Engaged in Vietnam for more than 20 years, GHC continues to engage in primary care system strengthening and family medicine development with a wide range of partners, including leading universities, the Ministry of Health, the Health Strategy & Policy Institute and other international organizations. This work has resulted in family medicine

programs at Vietnam’s leading medical schools; the nation’s first hospital-based family medicine clinics; a new flagship Family Medicine training center in Hue, and hundreds of newly trained family doctors and nurses working in local health centers and hospitals throughout the country.

hai phonghanoi

thai nguyen

khanh hoa

Ho chi minh city

can tho

HUE


PARTNERS INFAMILY MEDICINE

01CASE

STUD

Y DOCTOR HO THANH TIENG

HO CHI MINH CITYVIETNAM

Dr. Ho Thanh Tieng has been at this for five decades. His medical career started under fire as an emergency doctor at war, continued with a specialty in internal medicine, and carries on today as head of his own Thanh Cong Clinic, which he’s always had reason to feel pretty darn good about.

The name itself means “successful,” and a growing roster of 31,000 patients in a bustling industrial corner of Ho Chi Minh City would seem to confirm truth in labeling.

So when the steadily growing specialty known as Family Medicine first came to his attention, he wasn’t necessarily looking for a partner. But it was hard not to notice that the BU Global Health Collaborative had successfully forged a coalition from three of

Vietnam’s most prominent and competitive medical universities in three of its most vital cities. Even harder to miss was that they were now all working not just with each other—astonishing in itself—but hand in hand with a fully supportive Ministry of Health. If they were ready to invite yet another friend into the sandbox by partnering with clinics on the ground, then his five decades were telling him to say yes.

Since Family Medicine is as much about prevention and good health management as it is about treatment, it offered an improved, systematic approach to managing the screenings, immunizations and other aspects of managing a mostly healthy population, like the thousands of factory workers that make up the bulk of Dr. Tieng’s patient base. And beyond those practical advantages was the opportunity to fill a persistent vacuum.

“Patients come to the clinic because of their own problems,” he explains, “but very often they ask about their children and other family members.”

Here would be a space in the clinic where the answer to those questions was a focal point.

So Dr. Tieng would enroll in Ho Chi Minh City University of Medicine and Pharmacy’s “short course” program—a three-month primary care boot camp for doctors from other specialties—and open his clinic’s Family Medicine office.

Among the first things to catch everyone’s attention was an increase in a very particular patient behavior: crying.

“The family medicine doctor cares about social history, emotional history, wants the patients to express not only medical problems but others,” says Dr. Tieng. “Many patients feel they can share their difficulties, and they can cry.”

This deeper patient-doctor connection is a byproduct of two Family Medicine elements:

Recognizing patients as more than their diseases, and time. In Dr. Lieng’s clinic, FM patients average more than twice as much one-on-one time with the doctor per appointment than in other parts of the clinic.

“It was rare for them to cry before because the doctor only had time for medical problems,” he says. “With more time they have confidence in showing their emotion to the doctor.”

It isn’t just about being warm and fuzzy. Within any family, how one person is feeling impacts all those around them, and by extension how the doctor manages their care. Dr. Tieng’s mind leaps immediately to the family with five daughters all struggling with diabetes and their overwhelmed parents; or the elderly woman left paralyzed after a slip in the tub, a shock to an entire family that had to process the tragedy while learning about gastric tube feeding and other elements of her long-term care. For these patients, treating the condition can’t be separated from the health of the family unit.

But while feedback on the clinic addition started and stayed positive, the most important talking patients do is with their feet. Clinic visitors jumped from 15 per morning in the beginning to roughly 50 today, with long-term patients swelling to 200, then 500. At Thanh Cong Clinic, they’re speaking clearly and often.

“People,” he says, “love to see the family doctor.”

100% OF PROVINCES WILL HAVE FM CLINICS BY 2020When Ho Chi Minh University of Medicine and Pharmacy needed the right place to pilot a Family Medicine clinic, the bustling Thanh Cong Clinic stood out as a natural, sensible fit.

Perhaps it went under appreciated that the man in charge was also a perfect match. Moved to action by more than the practical benefits, he carries experiences from a lifetime ago that make him uniquely able to appreciate the power of universal access to quality primary care; experiences that launched a 50-year medical career and today fuel a personal advocacy for delivering Family Medicine to every corner of his country.

Dr. Tieng grew up in tiny, rural Tan Phu Ward in southern Vietnam, with the nearest doctor too far to see regularly. When his grandmother developed tuberculosis, the lack of modern medicine or profes-sional care turned what should have been a treatable illness into something else.

“She passed away,” he says, recalling his father’s commitment to doing what he could as caretaker, and the seed it planted in a young boy. “I had a dream about learning medicine to serve the people in my home town.”

So today, the future of Family Medicine for him is about more than the success in his clinic, far beyond how many people it helps in Ho Chi Minh City. He thinks about all of Vietnam; about the Global Health Collaborative’s foundational belief that great doctors should never be limited to a country’s great cities; and the Ministry of Health target that makes him smile: A Family Medicine clinic in 100 percent of provinces by 2020.


STRENGTHENING HEALTH CARE SYSTEMS

02CASE

STUD

Y

HueVIETNAM

DOCTOR NGUYENTHILANH

Imagine if every visit to your doctor was the reason they got out of bed that day. Every chance to treat your fever, your son’s cough, your mother’s joint pain: each one a small but meaningful episode of life-long wish fulfillment.

Imagine what those visits—what that relationship—would be like.

The people of Hue’s Thuy Phuong district don’t have to. They have Dr. Nguyen Thi Lanh. While her high school classmates were doing what most teenagers do—escaping the specter of looming grown-up responsibilities with daydreams about careers on stage, screen or sports fields—all she fantasized about was bringing people happiness in the way she knew she could.

“I didn’t want to be famous,” she says now. “I just wanted to be a doctor.”

But we often forget to dream the details, and Dr. Lanh realized quickly after her 1997 medical school graduation that people don’t put their health and happiness in your hands because you’re a doctor. They do it because they believe you’re a good doctor, which happens to be a title you both need to agree on.

Dr. Lanh was assigned to one of the roughly 10,000 local health centers that are designed to form the foundation of the Vietnamese public health care system, each one typically staffed by a single doctor responsible for primary care of, potentially, the entire local population. There is no limit to the range of patient demographic or healthcare need that may walk through the door. But with almost no primary care focus and even less hands-on practice, the standard Vietnamese medical school education has historically left these doctors—including this one—painfully unprepared for the demands.

“At the clinic you have to know every discipline, to be able to care for the baby and care for the elderly,” explains Dr. Lanh, who went to work each day with a heart-sinking self-awareness of her limitations.

“I didn’t believe in myself, and the comprehensive care was not there.”“I didn’t believe in myself, and the comprehensive care was not there.”

Since it doesn’t take a medical license to diagnose a lack of confidence, patient trust becomes scarce, and soon so do many patients. In a scenario too common across the country, patients lacking faith in the local clinic take their health care needs elsewhere. They will pay to visit a private clinic; travel to a more distant, already overburdened regional hospital; or they will go to the worst place of all, the place where small medical problems go to become big ones—nowhere.

Dr. Lanh’s next stop became obvious to her when she learned that Hue University of Medicine and Pharmacy was filling its first ever class of Family Medicine doctors. These doctors would be trained in a new primary care curriculum—soon to become the

national model—developed in partnership with the BU Global Health Collaborative.

The family-oriented, prevention-focused, top-to-bottom approach to treatment wasn’t just right for clinics. It was the perfect fit for a doctor who put a premium on patient relationships; who sometimes refused to leave the clinic for regional administrative meetings because she couldn’t stop thinking of the patients going unseen; who can proudly tell you about the family she has treated her entire career, now 15 people in three generations over 20 years.

That doctor came away from training two years later with new skills, new confidence, and happy patients. They responded to the focus on the entire household, on their emotional as well as physical health. They also noticed the hospital would confirm her diagnosis when she sent them for referrals; that she consistently, quite simply, made the right call.

Patient by patient, day by day, month by month, Dr. Lanh’s clinic has become another portrait of successful change on the ground level: A busy day used to be 30 patients; today it is typical to see 60.

That isn’t abstract. That’s twice as many people, every day, seeing a doctor who only ever wanted to help them, and finally truly knows how.

“To see so many people trust me,” she says, “my dream came true.”


TRAINING DOCTORS AND LEADERS

03CASE

STUD

Y


DOCTOR DANGNGOE SON


The way Dr. Dang Ngoe Son remembers it, it was about 10 seconds. Ten seconds standing in a fourth floor hallway on the campus of Ho Chi Minh University of Medicine and Pharmacy, silently staring at a simple office door.

He had no appointment at the Center for Training Family Medicine. He had no connections to anyone inside. Not even a name to ask for. And so he froze, trying to decide if he should knock.

“I knew I needed to meet someone, but I wondered who I would meet,” he recalls. “I wondered what would happen behind that door.”

But anybody familiar with the path that led him there could have told him that was a waste of 10 perfectly good seconds. He had pushed through family trauma brought by war, through religious intolerance that cut off educational avenues, through years of learning-by-doing before finally—in 2005, at the age of 42—achieving his dream of graduating from medical school. So 10 seconds, 10 minutes, 10 hours—he was always going to knock. Because on the other side of that door he was a better doctor, and that was the only thing he needed to know.

“It was a dream that was interrupted and challenged many times, but after I finished medical school my heart was open,” he says now. “I had to learn more.”

It was a revelation to learn there was a specialty for primary care providers right in his city’s university, training doctors in the Family Medicine discipline that he had been intrigued by ever since hearing about it from relatives who had visited the U.S. A little exploring convinced him this was where his future lay, and that led him inexorably to that door in 2012, counting the seconds.

When it opened, he had the good fortune of being greeted by Professor Pham Le An. The department head and one of the BU Global Health Collaborative’s most committed university partners, An’s welcome was the perfect reflection of everything Family Medicine strives to be for patients. All of Son’s instincts—that he needed more training to be the doctor he knew he wasn’t yet, and this was the training to take him there—were confirmed.

“I never came into a room with a friendly atmosphere like the Center,” he says. “Professor An treated me like a family member.”

There was tea. There was cake. Before long there was a successful entrance exam to the first-degree specialty program for aspiring family medicine doctors. And by the time he had completed the two-year course, Son would embody the depth of dedication to be found in the ranks of the country’s clinic doctors perhaps as well as any one person could when given the appropriate support

and training. In yet one more would-be interruption to his career and education, he developed a rare type of leukemia, paired with the kind of prognosis that makes people set aside long-term planning.

“I was not confident I would live long enough if I delayed taking the final exam,” he explained.

So despite four months of chemotherapy, he graduated with his family medicine class on time, and today is the beneficiary of what he’d insist on calling a miracle.

Healthy and grateful for it, he now works in Vietnam’s first district-based Family Medicine teaching clinic in Saigon. He cares for countless patients every day, seeing and feeling the difference Family Medicine training makes both in his practice and their response. And most notable of all, Dr. Son is a proud teacher of Family Medicine to doctors following his footsteps - now one of the warm, welcoming faces on the other side of that door.


Boston University Family Medicine Global Health CollaborativeDepartment of Family MedicineRoom 102085 East Newton StreetBoston, MA 02118

Boston University Department of Family Medicine

Global Health Collaborative

www.bu.edu/[email protected]

617-414-6322

boston university family medicine global health collaborative

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