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Armenia and UTMB Partnership in Primary Care 1999-2004. Jamal Islam MD MS Associate Professor Research Director Department of Family and Community Medicine TTUHSC Permian Basin. Russian Socialist Federative Soviet Republic Transcaucasian Socialist Federative Soviet Republic

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Armenia and utmb partnership in primary care 1999 2004 l.jpg

Armenia and UTMB Partnership in Primary Care1999-2004

Jamal Islam MD MS

Associate Professor

Research Director

Department of Family and Community Medicine

TTUHSC Permian Basin


Ussr before 1991 and now l.jpg

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

USSR Before 1991 and Now


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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


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Demographics

  • Population2,967,004 estimate 2009

    • Comparison

      • Azerbijan 8,041,000

      • Georgia 5,262,000

      • Turkey 66,668,000

      • USA283,230,000

        In World

  • Birth rate12.65/1000 160th

  • Death rate 8.34/1000100th

  • Growth rate- 0.03%207th

  • Migration- 4.56/1000162th


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Health Indicators & Health worker

ARMENIAUSA

  • Life expectancy at birth69 (M)76 (F)75 (M)81 (F)

  • Birth rate12.6/100014.0/1000

  • Infant mortality20.2/10006.9/1000

  • Physicians360/100,000416/100,000

  • Nurses481/100,000836/100,000

  • Health system WHO rank10438

  • Expenditure per capita$63$6,096


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Demographics

M F

Median28.834.4

Years%

0-14 18.2289,119 252,150

15-6471.1986,7641,123,708

65>10.6122,996 192,267


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Health Problems

  • CVD

  • HTN

  • Smoking related lung disease

  • Maternal and child health

  • Breast Cancer

  • Respiratory disease in children


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Common DiseasesMortality (Per 100,000)

USA

(Whites)

  • CVD

    Overall death 350324

    MI death 225187

    Stroke 94 44

  • Cancer death 98187

  • MVA death 41 15

  • Intoxication 41 13

  • Infectious disease 8.5


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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


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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


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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


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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


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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.


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Government payment

  • Hospitals bed/day in 2006 $25.7

  • Outpatient per enrolled patients ?

  • Average Salary state owned 2006

    • General PractitionerUS$ 110/month

    • Nurses US$ 87/month

      J Public Health (2008) 16:183–190


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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/


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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).


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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


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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


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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


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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


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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


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Armavir and UTMB Partnership

  • Goal

    • Improve the health of individuals in the Armavir region through primary care services


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ARMAVIR

  • Distance from capital: 30 miles

  • Area: 483 sq mile

  • Population 330,000

  • 3 general hospitals

  • 2 maternity hospitals

  • 11 polyclinics

  • 7 health centers


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REGIONAL HEALTH CARE

  • Armavir

    • Physician131

    • Nurses333

    • Field visitors 25

    • Lab assistant 14

    • Technical staff234

  • Vagharshapat

  • Metsamor

  • Baghramyan


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POLICLINIC (Our Base)

  • Out patient follow-up

  • 2000/doctor

  • General practitioner 15

  • Neurologists3

  • Ophthalmologists2

  • Dermatologist 2

  • Surgeons2

  • Cardiologist2

  • Endocrinologist1

  • Infection specialist1

  • Psychiatrist1

  • Gastroenterologist1

  • Clinical/Biochemistry3


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Service

  • Biochemistry

  • ECG

  • Xray

  • EGD


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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


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Intervention

  • Educate a core number of health professionals on screening, monitoring, using treatment guidelines, and patient education:

    • Cardiovascular disease

    • Diabetes

    • Breast cancer

    • Disaster preparedness


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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.


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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


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Baseline Survey

  • Multistage cluster sampling

  • Hybrid self and interviewee administered

  • 1019 household

  • 3 towns 16 villages


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Demographics

(S.D)

  • Mean age years35.6 (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%

  • Automobile20%


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Perception of health

  • Own health status

    • Satisfied14.3%

    • Dissatisfied49.8%

  • Children

    • Fair52%

    • Poor17.3


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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


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Depression Measured20 scale CES-D

  • < 17No depression22.3 %

  • 17- 22Possible22.3 %

  • > 23Probable55.4 %


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Addiction

  • Tobacco 28.5%

    male:female22:1

  • Alcohol14.2%

  • Drug addiction 0.3%


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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%


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RESULTS:

  • Established LRC with trained person

  • Computer installed with internet connection to access information and establish email link with UTMB Galveston


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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


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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


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Interventions


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Results

  • School teachers 15 trained on hygiene, infections, emergency preparedness, domestic violence, smoking cessation


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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


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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


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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


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Thank you

QUESTIONS?


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