Armenia and UTMB Partnership in Primary Care 1999-2004

							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
USSR Before 1991 and Now
   Russian Socialist Federative Soviet      Russia
    Republic                                 Belarus
   Transcaucasian Socialist                 Ukraine
    Federative Soviet Republic               Moldova
   Ukrainian Soviet Socialist Republic      Georgia
   Byelorussian Soviet Socialist            Armenia
    Republic
   Tuvan People's Republic                  Azerbaijan
   Kresy                                    Kazakhstan
   Bessarabia                               Uzbekistan
   Finnish Karelia                          Turkmenistan
   Estonia                                  Kyrgyzstan
   Latvia                                   Tajikistan
   Lithuania                                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     252,150
  15-64   71.1   986,764   1,123,708
  65>     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 Diseases
Mortality (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
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 PARTNERSHIPS
Cooperative 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 Measured
20 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?