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
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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
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Russia
Belarus
Ukraine
Moldova
Georgia
Armenia
Azerbaijan
Kazakhstan
Uzbekistan
Turkmenistan
Kyrgyzstan
Tajikistan
Estonia
Lithuania
Latvia
ARMENIA
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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
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Population
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Comparison
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2,967,004 estimate 2009
Azerbijan
Georgia
Turkey
USA
Birth rate
Death rate
Growth rate
Migration
8,041,000
5,262,000
66,668,000
283,230,000
12.65/1000
8.34/1000
- 0.03%
- 4.56/1000
In World
160th
100th
207th
162th
Health Indicators & Health
worker
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ARMENIA
Life expectancy at birth 69 (M) 76 (F)
Birth rate
12.6/1000
Infant mortality
20.2/1000
Physicians
360/100,000
Nurses
481/100,000
USA
75 (M) 81 (F)
14.0/1000
6.9/1000
416/100,000
836/100,000
Health system WHO rank
Expenditure per capita
38
$6,096
104
$63
Demographics
Median
Years
0-14
15-64
65>
%
18.2
71.1
10.6
M
F
28.8
34.4
289,119
986,764
122,996
252,150
1,123,708
192,267
Health Problems
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CVD
HTN
Smoking related lung disease
Maternal and child health
Breast Cancer
Respiratory disease in children
Common Diseases
Mortality (Per 100,000)
USA
(Whites)
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CVD
Overall death
MI death
Stroke
Cancer death
MVA death
Intoxication
Infectious disease
350
225
94
98
41
41
8.5
324
187
44
187
15
13
Health Care System in Armenia
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In 1991 dissolution of USSR placed 300
million in jeopardy for their social and health
care.
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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
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Based around hospitals
– Republic hospitals had 1000-2000 beds
– Regional and district had 50-250 beds
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Outpatient care provided by
– Polyclinics (adjacent to hospital) 1000 visits/day
– Village level primary care stations run by
paramedics and midwife
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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 noncommunicable disease control, and the
emergency healthcare program
Expansion of basic services
2006
 All services provided by polyclinic
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Services not provided is paid out of pocket
– Estimated out of pocket is 45% of service
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State owned hospitals and Polyclinics are now
semi autonomus, self-financing enterprises.
Government payment
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Hospitals bed/day in 2006
$25.7
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Outpatient per enrolled patients ?
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Average Salary state owned 2006
– General Practitioner
US$ 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”
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Targets:
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Objective
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Nation and communities with limited resources
Advance global health
Build institutional & human resource capacity
Method:
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Peer-to-peer partnership knowledge transfer
Volunteer time to the project
Logistics provided
http://www.aiha.com/en/
Funding for AIHA
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United States Agency for International
Development (USAID) Started funding in 1993
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US Department of Health and Human Services
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Health Resources and Services Administration (HRSA)
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World Health Organization (WHO)
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Global Fund to Fight AIDS, Tuberculosis and Malaria
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German Society for Technical Cooperation (GTZ).
ARMENIA PARTNERSHIPS
Cooperative Agreement Fund
USAID
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1. Yerevan/Boston, Massachusetts, 1999*
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2. Yerevan/Los Angeles, California, 1999*
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UCLA Medical Center – Nursing: faculty training, improve program
3. Armavir/Galveston, Texas, 1999-2004. **
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Boston Univ. Medical Center – training nurse and pedi
emergency/trauma
UTMB - primary care
4. Gegarkunik/Providence, Rhode Island,19992004**
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Care New England – primary care
http://pdf.usaid.gov/pdf_docs/PDACG218.pdf
Armenia Partenerships
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5. Lori/Los Angeles, California, 1999-2004**
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6. Lori/Milwaukee, Wisconsin, 2003-2004
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Center for Int. Health- Primary care training program
7. Yerevan/Birmingham, Alabama, 1999-2002**
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UCLA Medical Center- primary care
Univ of Alabama- post graduate training; administrators
8. Yerevan/Washington, DC, 2000-2004
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Armenian American Cultural Association and Washington Hospital
Center- Breast and cervical cancer prevention
THE PROGRAM IN NUMBERS
(Fiscal Years 1999-2004)
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8 = Armenia partnerships
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87 = US partner who traveled on exchanges to Armenia
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118 = Armenian partners who traveled on exchanges to US
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389 = Total individual exchange trips (in both directions)
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103,000 = Served by the 3 PHC centers established
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$8.4 million = Total USAID funding
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$10+ million = Value of in-kind contributions by US
partners
Partnership Model
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Voluntarism: significant in-kind contributions of human,
material, and financial resources
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Institution-based partnering for capacity-building and
systematic change
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Peer-to-peer collaborative relationships that build
mutual trust and respect
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Transfer of knowledge, ideas, and skills through
professional exchanges and mentoring
Partnership Model
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Benefits flowing in both directions
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Replication and scaling-up of successful models
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Sustainability of achievements and relationships
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“Partnership of partnerships” for networking, sharing,
and creating common approaches and solutions
Armavir and UTMB Partnership
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Goal
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Improve the health of individuals in the
Armavir region through primary care
services
ARMAVIR
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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
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Armavir
– Physician
– Nurses
– Field visitors
– Lab assistant
– Technical staff
Vagharshapat
Metsamor
Baghramyan
131
333
25
14
234
POLICLINIC (Our Base)
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Out patient follow-up
2000/doctor
General practitioner
Neurologists
Ophthalmologists
Dermatologist
Surgeons
Cardiologist
Endocrinologist
Infection specialist
Psychiatrist
Gastroenterologist
Clinical/Biochemistry
15
3
2
2
2
2
1
1
1
1
3
Service
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Biochemistry
ECG
Xray
EGD
Objectives
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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
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Educate a core number of health
professionals on screening, monitoring,
using treatment guidelines, and patient
education:
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Cardiovascular disease
Diabetes
Breast cancer
Disaster preparedness
Intervention
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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
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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
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Multistage cluster sampling
Hybrid self and interviewee administered
1019 household
3 towns 16 villages
Demographics
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(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
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Own health status
– Satisfied
– Dissatisfied
14.3%
49.8%
Children
– Fair
– Poor
52%
17.3
Health utilization
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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
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< 17
17- 22
> 23
No depression
Possible
Probable
22.3 %
22.3 %
55.4 %
Addiction
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Tobacco
male:female
28.5%
22:1
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Alcohol
14.2%
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Drug addiction 0.3%
Self Reported Disease
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Hypertension
29%
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Vision problem
27.8%
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Mental disorder
5.6%
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Diabetes
3.1%
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Cancer
0.1%
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Accidents that required health care
26.5%
RESULTS:
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Established LRC with trained person
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Computer installed with internet connection
to access information and establish email link
with UTMB Galveston
RESULTS
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UTMB: Eleven physician and nine nurses
completed the Train the trainers course
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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
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Increased continuing nurse education
Improved record keeping
Started Patient education on healthy life style
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Expanded diagnostic laboratory capabilities
Laboratory equipment standardization,
training on equipment
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Introduced universal precaution
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Interventions
Results
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School teachers 15 trained on hygiene,
infections, emergency preparedness,
domestic violence, smoking cessation
Disaster Planning
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Mock disaster training carried out
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150 participants were trained on the use of
defibrillators, torches, and radio telephones. They also
learned about EMS system in the United States
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Galveston Hurricane preparedness administration
model introduced
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Sister city partnership with Galveston led to promise of
donating surplus medical emergency equipments
SUCCESS?
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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
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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?