QUALITY HEALTH CARE in COUNTRIES of FORMER SOVIET UNION

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QUALITY HEALTH CARE inCOUNTRIES of FORMER
SOVIET UNION

• Malkhaz Jalagonia, MD
• Association Esculapius
• GEORGIA

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PROBLEM STATEMENT

• After breakdown of Soviet Union the state of
  public health has deteriorated significantly in
  some postsoviet countries due to various reasons,
  but even before collapse of communist system
  public health was plagued with different problems.

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Learning Objectives

• What is quality health care?
• Identifying some problems with quality health
  care in FSU countries
• Main causes of these problems
• How to overcome the obstacles?

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What Is Quality Health Care?

• "Doing the Right Thing at the Right time in the
  Right way for the Right Person and Having the
  Best Possible Result" US Agency for Healthcare
  Research and Quality. This is one definition of
  quality health care, but there are many others.

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Appropriateness of Health Care

• Appropriateness means that required care is
  provided and unnecessary or harmful care is
  avoided, so appropriateness is linked with safety.

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When does a Postsoviet Person Meet with
Inappropriate and Unsafe Health Care?

• You could expect the following answer soon
  after BIRTH,
• but in fact the correct answer is before BIRTH.

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VACCINATION SAFETY

• Vaccines are frequently injected into the
  buttocks and not in the antero-lateral part of
  the thigh in children. The injections in the
  upper outer quadrant of buttocks in children
  cannot guarantee safety of sciatic nerve.

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PREVENTIVE MEDICINE

• There is very low priority for preventive
  medicine in the region. The attention of the
  policy-makers as well as of the population itself
  is more directed to curative services.

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Surgical Interventions

• Minor surgical interventions could be more
  dangerous than major surgery, because they are
  mostly performed in primary health care clinics.
  These facilities are underequipped and also have
  poor access to electric power needed for proper
  sterilisation.

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Surgical Interventions (cont'd)

• Due to shortage of surgical material
  it is not rare that disposable items
  (endotracheal tubes, scalpel blades, etc) are
  reused after cleansing with alcohol. Multiuse
  Lidocaine bottles are also dangerous
  because the doctors can insert used needles
  into them.

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Modes of Transmission For Hepatitis B in Georgia
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Modes of Transmission For Hepatitis C in Georgia
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Safety of Blood Transfusions

• Blood is misused. Most doctors think that if
  blood is HIV, Syphilis, Hepatitis B and C
  negative, then it is microbiologically safe.
• Sometimes even blood untested for infectious
  diseases is used in emergences due to lack of
  blood bank refrigerators.

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Safety of First Aid

• Some first aiders, including doctors, during CPR
  press not on the sternum but on the left side of
  the chest close to the sternum.
• Many first aiders use tourniquet instead of
  direct pressure to stop external bleeding.

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Diagnostic Procedures

• Upper gastrointestinal endoscopy and
  sigmoido/colonoscopy are not safe because the
  fiberscopes are not usually properly disinfected.
  
• Due to shortage of speculums prenatal and
  gynecological examinations are also unsafe in
  some places.

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Diagnostic Procedures (cont'd)

• The diagnostic centers often do not ask if the
  procedures were ordered by the doctor. So the
  patients can undergo tests and investigations on
  their own will.
• The patients often do not receive proper
  information about diagnostic procedures.

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Diagnostic Procedures (cont'd)

• Due to poor qualifications and limited experience
  of X-ray technicians, poor quality of
  X-ray films and power surges, the X-ray
  examinations sometimes need to be repeated
  several times.

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Prescribing Habits of
the Doctors

• Preference for nonessential and nongeneric
  medicines
• Many drugs at one time
• Expensive ones
• New ones
• Antibiotics
• Vitamins
• and of course, injections

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DRUG SAFETY

• Pharmaceutical market is flooded with counterfeit
  and poor quality drugs. Only in few CIS countries
  MOH is willing and able to address the problem
  adequately.

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DRUG SAFETY (cont'd)

• The doctors like to prescribe drugs, which
  "boost" immunity. Some of them are of animal or
  human origin.

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DRUG SAFETY (cont'd)

• To decrease health-related costs, patients often
  bypass doctors and go directly to drugstores,
  where almost everything could be bought without
  prescription, except maybe control drugs.

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DRUG SAFETY (cont'd)

• The outpatients rely mainly on Metamizole
  (Analgin), NSAIDs and Paracetamol for pain
  relief. Metamizole has been taken off the market
  in many countries due to fatal cases of
  agranulocytosis.

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Illness and Family Budget

• A 1999 World Bank report identified the illness
  of a family member as one of the main causes of
  impoverishment in Georgia (source "Health Care
  Systems in Transition Georgia").

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The Main Causes of Problems

• Development in isolation
• Low priority for health
• Shortage and inappropriate use of resources
• Shortage of new reliable medical information and
  refresher courses for health professionals
• Widespread use of ineffective diagnostic
  procedures and treatments

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The Main Causes of Problems (cont'd)

• Unrestricted dictatorship of pharmaceutical
  companies on the market
• Well-developed black market for pharmaceuticals
• Lack of consumer orientation
• Frustration, lack of motivation

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The Difference between Postsoviet and Western
Medical Concepts Does Also Matter

• Due to this gap health professionals in FSU often
  refuse to accept ideas of western medicine. The
  main difficulty arises from rejection of
  evidence-based medicine.

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Is Everything in Postsoviet Medicine unacceptable?

• Of course, not. Some ideas of postsoviet or
  Eastern European medicine are getting acceptance
  abroad. We can give two examples use of
  Neostigmine for Acute colonic pseudo-obstruction
  (Ogilvie's syndrome) and considering the role of
  probiotics in the management of
  Irritable Bowel Syndrome.

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How to overcome the obstacles?

• First of All We Should Reinforce Education
• Refresher courses for health professionals
• Health education for public

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POLICY-MAKERS

• This should change

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Once More about Quality Health Care

• Definition of quality health care by US Institute
  of Medicine "The degree to which health services
  for individuals and populations increase the
  likelihood of desired health outcomes and are
  consistent with current professional knowledge".

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Acknowledgments

• I'd like to express deep gratitude
  to my colleagues and friends
  (listing is alphabetical)
  for their help
• Botsvadze Eteri (Georgia)
• Cunningham Fiona (UK)
• Fry Catherine (Australia)
• Jalagonia Maka (Georgia)
• Jones Terry (Canada)
• Krebs Verena (Switzerland)
• Malone Teri (Australia)
• Revel Jean Pierre (France)