Armenia and UTMB Partnership in Primary Care 19992004

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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

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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

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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

• 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

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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

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Demographics

• M F
• Median 28.8 34.4
• Years
• 0-14 18.2 289,119 252,150
• 15-64 71.1 986,764 1,123,708
• 65gt 10.6 122,996 192,267

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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 350 324
• MI death 225 187
• Stroke 94 44
• Cancer death 98 187
• 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 119324-328

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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 Practitioner US 110/month
• Nurses US 87/month
• J Public Health (2008) 16183190

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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
• Physician 131
• Nurses 333
• Field visitors 25
• Lab assistant 14
• Technical staff 234
• Vagharshapat
• Metsamor
• Baghramyan

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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

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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 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

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Perception of health

• Own health status
• Satisfied 14.3
• Dissatisfied 49.8
• Children
• Fair 52
• Poor 17.3

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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

• lt 17 No depression 22.3
• 17- 22 Possible 22.3
• gt 23 Probable 55.4

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Addiction

• Tobacco 28.5
• malefemale 221
• Alcohol 14.2
• 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?