Armenia and UTMB Partnership in Primary Care1999-2004

Jamal Islam MD MSAssociate ProfessorResearch Director

Department of Family and Community Medicine

TTUHSC Permian Basin

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

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

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

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

Demographics

M F

Median 28.8 34.4

Years % 0-14 18.2 289,119 252,15015-64 71.1 986,764 1,123,70865> 10.6 122,996 192,267

Health Problems

CVD HTN Smoking related lung disease Maternal and child health Breast Cancer Respiratory disease in children

Common DiseasesMortality (Per 100,000)

USA(Whites)

CVDOverall death 350 324MI death 225 187Stroke 94 44

Cancer death 98 187 MVA death 41 15 Intoxication 41 13 Infectious disease 8.5

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

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

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

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

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.

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) 16:183–190

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/

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).

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

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

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

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

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

Armavir and UTMB Partnership

Goal

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

ARMAVIR

Distance from capital: 30 miles Area: 483 sq mile Population 330,000 3 general hospitals 2 maternity hospitals 11 polyclinics 7 health centers

REGIONAL HEALTH CARE

Armavir– Physician 131– Nurses 333– Field visitors 25– Lab assistant 14– Technical staff 234

Vagharshapat Metsamor Baghramyan

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

Service

Biochemistry ECG Xray EGD

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

Intervention

Educate a core number of health professionals on screening, monitoring, using treatment guidelines, and patient education:– Cardiovascular disease – Diabetes– Breast cancer– Disaster preparedness

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.

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

Baseline Survey

Multistage cluster sampling Hybrid self and interviewee administered 1019 household 3 towns 16 villages

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%

Perception of health

Own health status– Satisfied 14.3%– Dissatisfied 49.8%

Children – Fair 52%– Poor 17.3

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

Depression Measured20 scale CES-D

< 17 No depression 22.3 % 17- 22 Possible 22.3 % > 23 Probable 55.4 %

Addiction

Tobacco 28.5%

male:female 22:1

Alcohol 14.2%

Drug addiction 0.3%

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%

RESULTS:

Established LRC with trained person

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

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

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

Interventions

Results

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

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

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

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

Thank you

QUESTIONS?