Iraq-U.S. Physician Partnership Program Health Resources and Services Administration s Role

1. Iraq-U.S. Physician Partnership Program Health Resources and Services Administration’s Role RADM Kerry Paige Nesseler CAPT Nita Sood Office of International Health AffairsJune 1, 2009

3. Map of Iraq

4. Background Iraq’s health care system once regarded as one of the best in the region Over the last 25 years, the health care infrastructure has deteriorated due to neglect and war Violence and emigration have decreased the number of physicians Physicians that remain are not up to date on the latest evidence-based medicine and technologies necessary to provide high-quality care

5. Physicians in Iraq Iraqi Physicians Registered Before 2003 - 34,000 Iraqi Physicians Who Have Left Iraq Since 2003 - 18,000 (est.) Annual Graduates from Iraqi Medical Schools - 1,800 Percentage of Work Outside of Iraq- -higher than 20%, many still leave the country to get specialized training  Average Salary of an Iraqi physician- $12,000 per year, higher for specialists

6. HHS Initiative In May 2008, Department of Health and Human Services Secretary meeting with Iraqi Minister of Health (MOH) MOH requested a physician training program in order to understand the U.S. primary healthcare model

7. Goals of the HHS Initiative Promote Health Diplomacy and provide hope and inspiration to the Iraqi people; Educate the Iraqi physicians on the U.S. primary health care system and strengthen their ability to provide quality care; Learn from the Iraqi people; and Enhance the cultural competencies of the U.S. physicians.

8. Iraqi Physician Training: Goals and Objectives To build upon current Iraqi health care promotion activities in Iraq- Centers for Disease Control and Prevention (CDC) partnership with non-governmental organization, International Medical Corps (IMC) to develop the Centers of Excellence; The Iraqi Government had already invested $8 million dollars on physician training; The Basra Children’s Hospital was under construction with health emphasis on pediatric oncology; 134 renovated Primary care facilities in Iraq needed healthcare provider staffing.

9. Iraq-U.S. Physician Partnership Program HHS Coordination through Office of Global Health Affairs (Jaime Burke and CDR Dan Singer) and U.S. Embassy in Iraq (Dr. Terry Cline, Health Attaché); Iraqi physicians were selected by the MOH Out of 41 physicians, 27 were able to participate; 6 physicians were slated for HRSA; 3 were able to participate; Observership training- no patient contact; 4-week timeframe.

10. Iraq-U.S. Physician Partnership Program (cont’d) Host Training Sites: Children’s Hospital, Washington, DC; Health Resources and Services Administration (HRSA); Henry Ford Hospital, Detroit, Michigan; Indian Health Service, Arizona; Johns Hopkins Hospital, Baltimore, Maryland.

11. Iraq-U.S. Physician Partnership Program (cont’d) HRSA Sites: Community Health Centers (CHC): Two sites selected; rural and urban sites affiliated with teaching universities The CHC sites: Sunset Park Medical Center, Brooklyn, New York Greene County Health Care Inc., Snow Hill, North Carolina

12. Physician Training Schedule All physicians attended 2-day HHS orientation Physicians assigned to HRSA received additional 2-day HRSA orientation on Prevention, Primary Health Care and Chronic Disease Management Remaining time (~ 3 weeks) spent at CHC sites

13. HRSA: Physician Training Schedule HRSA Orientation, Day 1 Prevention and Primary Care Expert Panel: Oral Health Maternal & Child Health and Children with Special Health Care Needs Cancer Prevention and Anti-Smoking Campaign Chronic Disease Management Expert Panel: Diabetes Control Hypertension and Cardiovascular Disease Control HIV/AIDS Care and Treatment Quality and Evidence Based Care Site Visit to Urban CHC: Unity Health Care, Washington D.C.

14. HRSA: Physician Training Schedule (cont’d) HRSA Orientation, Day 2 Site Visit to Rural CHC- Eastern Panhandle of West Virginia: Shenandoah Valley Medical System, Martinsburg, WV War Memorial Hospital (critical access hospital), Berkeley Springs, WV Then to Observership Training Sites Two Iraqi physicians (pediatrician and general practitioner) at Brooklyn, New York One physician (orthopedics) at Snow Hill, North Carolina

15. HHS Debriefing One day debriefing in Washington DC Overall the physicians were very satisfied with their experience and would like to see this happen again in the future Breakout Group Sessions discussed 3 topics: Alternate Models for the Physician Partnership Program Application of Lessons Learned in Iraq Maintaining Links and Sustaining Partnerships

16. HHS Debriefing (cont’d) The breakout group discussed several issues related to the effectiveness of the current Iraqi model There are two specific needs that must be addressed: improving provision of care (training, access to new technology), and improving the overall health care system Improve the health care infrastructure; Improve the ability of health care providers to function as a team; interdisciplinary model Enhance the relationship between the health care system and the community; Improve the skills of individual practitioners (practitioners must be motivated to change and seek out opportunities); Enhanced involvement of planners and policymakers.

17. Alternate Models for the Physician Partnership Program Bring teams of U.S. physicians to Iraq Implement the model described above in a site outside of Iraq Train Iraqi physicians in the United States; extend to 6-8 weeks Bring teams of U.S. physicians to Iraq Teams should focus on a specific specialty (e.g., surgery). The teams should bring the latest equipment and establish a clinic. The U.S. physicians would work in Iraq for a period of time (at least 6 weeks) and Iraqi physicians and other health care workers could observe them (and fully participate in care) as they treat Iraqi patients. At the end of the training period, the equipment would remain in Iraq. The benefits of this model include: ability to train all providers on the health care team; hands on training opportunities for Iraqi providers; reduced travel costs (only the U.S. physicians must travel); and establishment of functional clinics with the latest technology. Implement the model described above in a site outside of Iraq If circumstances (e.g., security concerns) prevent the implementation of the model described above in Iraq, the same model could be implemented in another country in the Middle East. This would require travel for both U.S. physicians and Iraqi health care providers. Train Iraqis in the United States If training is provided in the United States, the amount of training time should be extended to at least 6 to 8 weeks. A drawback to this training model is that the Iraqis may not have access to the same equipment on which they received training once they return to Iraq.Bring teams of U.S. physicians to Iraq Teams should focus on a specific specialty (e.g., surgery). The teams should bring the latest equipment and establish a clinic. The U.S. physicians would work in Iraq for a period of time (at least 6 weeks) and Iraqi physicians and other health care workers could observe them (and fully participate in care) as they treat Iraqi patients. At the end of the training period, the equipment would remain in Iraq. The benefits of this model include: ability to train all providers on the health care team; hands on training opportunities for Iraqi providers; reduced travel costs (only the U.S. physicians must travel); and establishment of functional clinics with the latest technology. Implement the model described above in a site outside of Iraq If circumstances (e.g., security concerns) prevent the implementation of the model described above in Iraq, the same model could be implemented in another country in the Middle East. This would require travel for both U.S. physicians and Iraqi health care providers. Train Iraqis in the United States If training is provided in the United States, the amount of training time should be extended to at least 6 to 8 weeks. A drawback to this training model is that the Iraqis may not have access to the same equipment on which they received training once they return to Iraq.

18. Application of Lessons Learned in Iraq Develop a clear strategy for delivery of health care (e.g., financing); Establish short-, middle-, and long-term strategies for managing challenges; Address the technology gap - Incorporate the use of information technology; Improve the level of nursing care; Adopt electronic medical records; Establish an independent regulatory authority for the health care system, medical societies, licensing, and continuing medical education.

19. Application of Lessons Learned in Iraq (cont’d) Facilitate the adoption of evidence-based practices; Develop a system for the referral of patients; Focus on primary health care to reduce the burden on hospitals; Rehabilitate sub-specialty centers; Control medicine management and use; Improve patient management systems; Improve communication (within service settings).

20. Maintaining Links and Sustaining Partnerships Participants exchanged e-mail addresses with their U.S. colleagues and will remain in contact via e-mail; Webcams and telemedicine provide opportunities for communication; HHS to explore ways to conduct long-term follow up with participants; HHS learn how participants disseminate what they have learned in the United States to their Iraqi colleagues.

21. Follow-up Several follow-up items are being coordinated by HHS, including issues of connectivity between the host-sites and their respective participants; Information from this pilot will be used to evaluate this particular model and to formulate next steps to continue collaborative relationships between the two countries.

22. Acknowledgements Anthony Achampong Dr. Jay Anderson Tara Balsley Dr. Marcia Brand Jaime Burke John Cafazza Gina Capra Tina Cheatham CAPT Gail Cherry-Peppers Dr. Terry Cline Tom Coughlin Loretta Ellison Diana Espinoza Dr. Kaytura Felix LT Ulgen Fideli Tanya Gadzik Kate Guzzone Sandy Harris Joanne Howard Dr. Therese Hughes CAPT Donna Hutten Jim Macrae Dr. Daniel Mareck Tim Montgomery Tom Morris Shawir Nawruz Dr. Tanya Pagán Raggio-Ashley RADM Deborah Parham Hopson Sara Rue Richard Sayre Leslie Shah CDR Dan Singer Dr. Peter van Dyck RADM Donald Weaver Maureen Williams Sunset Park Medical Center, Brooklyn, NY Greene County Health Care, Snow Hill, NC

23. Iraq- U.S. Physician Partnership Program Contact Information RADM Kerry Paige Nesseler CAPT Nita Sood301-443-2741 KNesseler@hrsa.gov NSood@hrsa.gov