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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. Russian Socialist Federative Soviet Republic Transcaucasian Socialist Federative Soviet Republic

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Armenia and UTMB Partnership in Primary Care 1999-2004

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  1. 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

  2. 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 USSR Before 1991 and Now

  3. 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

  4. 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

  5. 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

  6. 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

  7. Health Problems • CVD • HTN • Smoking related lung disease • Maternal and child health • Breast Cancer • Respiratory disease in children

  8. 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

  9. 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

  10. 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

  11. 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

  12. 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

  13. 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.

  14. 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

  15. 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/

  16. 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).

  17. 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

  18. 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

  19. 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

  20. 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

  21. 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

  22. Armavir and UTMB Partnership • Goal • Improve the health of individuals in the Armavir region through primary care services

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

  24. REGIONAL HEALTH CARE • Armavir • Physician 131 • Nurses 333 • Field visitors 25 • Lab assistant 14 • Technical staff 234 • Vagharshapat • Metsamor • Baghramyan

  25. 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

  26. Service • Biochemistry • ECG • Xray • EGD

  27. 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

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

  29. 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.

  30. 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

  31. Baseline Survey • Multistage cluster sampling • Hybrid self and interviewee administered • 1019 household • 3 towns 16 villages

  32. 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%

  33. Perception of health • Own health status • Satisfied 14.3% • Dissatisfied 49.8% • Children • Fair 52% • Poor 17.3

  34. 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

  35. Depression Measured20 scale CES-D • < 17 No depression 22.3 % • 17- 22 Possible 22.3 % • > 23 Probable 55.4 %

  36. Addiction • Tobacco 28.5% male:female 22:1 • Alcohol 14.2% • Drug addiction 0.3%

  37. 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%

  38. 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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