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Primary care is a framework that allows both past and ongoing AIHA initiatives Alina Kushkyan, director of Erebuni Medical College (EMC), described the

Assessing 13 Years of Collaboration, Caucasus Partnership

    Conference Demonstrates AIHA's Leading Role in Healthcare

    Reform in the Region

Editor’s Note: The countries of Armenia, Azerbaijan, and Georgia share not only the same

    geopolitical location but also many similar social and economic challenges. In healthcare,

    these challenges include cardiovascular diseases as the number one killer of the population,

    rising rates of TB, HIV/AIDS, and other infectious diseases, and high infant and maternal


Therefore, AIHA's cross-cutting initiatives in the

    region have been specifically designed to develop

    meaningful solutions to these problems and address

    the healthcare reform priorities of the Caucasus

    nations. In the early 1990s, the first round of these

    initiatives focused on neonatal resuscitation,

    reproductive health, emergency medical services,

    infection control, nursing leadership, healthcare

    management, and information technology. By the

    end of that decade, as the success of these

    programs was recognized, new initiatives based on

    the primary care partnership model were created

    to further enhance health reforms in the region. US Ambassador to Georgia John Tefft (second from left) welcomes conference More than 70 members of AIHA's current and participants while Georgia's Minister of graduated partnerships from Armenia, Azerbaijan, Labor, Health, and Social Affairs Vladimir

    Chipashvili, past chairman of AIHA's and Georgia gathered October 18-19 in Tbilisi, Board of Directors Larry S. Gage, and Georgia, to participate in a conference that marked Robert O'Donovan, regional director of

    the Eurasia Foundation's South Caucasus the 13th anniversary of AIHA's activities in the Cooperation Program, look on. (Photo:

    Caucasus region. Vira Illiash)

The meeting provided a forum for sharing lessons learned, disseminating successful approaches

    to improving the quality of healthcare services in these countries, and discussing ideas of

    future cooperation with nationalas well as internationalhealthcare communities. The delegates also provided reports to USAID, other international donors and implementing

    agencies, national health ministries, and local governments about the progress and impact that

    AIHA's programs have made in the Caucasus for more than a decade.

At the event, US Ambassador to Georgia John Tefft, Georgia's Minister of Labor, Health, and

    Social Affairs Vladimir Chipashvili, Head of the Department of Medical and Preventive Services

    of the Ministry of Health of Azerbaijan Amiran Gurbanov, and Deputy Minister of Health of

    Armenia Tatul Hakobyan presented welcoming remarks. George Mataradze, health management

    specialist at USAID/Tbilisi, Larry S. Gage, past chairman of AIHA's Board of Directors, AIHA

    Executive Director James P. Smith, and Robert O'Donovan, regional director of the Eurasia

Foundation South Caucasus Cooperation Program, were some of the key-note speakers. First

    Lady of Georgia, Mrs. Sandra Roelofs was present as an honorable guest.

In their presentations, the healthcare leaders of the three countries acknowledged the critical

    impact AIHA programs have had on bringing about positive changes and accelerating nationwide

    healthcare reforms. In particular, the Georgian Minister of Health indicated that over the

    period of 13 years as many as nine partnership projects were implemented in Georgia alone,

    through which thousands of healthcare professionals received training in such priority areas as

    primary healthcare, women's health, nursing, hospital administration, health management,

    emergency medical services, and infection control.

"For us "13" is a lucky number because these 13 years have brought about extremely effective

    changes. AIHA came to Georgia at the time when the country's healthcare system was

    experiencing severe economic and political distress. The partnership programs not only helped

    us build up substantial intellectual capacity, but also streamlined our infrastructure making it

    more responsive to the healthcare needs of our people. AIHA's training programs provided a

    strong impetus to the ongoing capacity-building process and enhanced institutional changes in

    the country's healthcare system," Vladimir Chipashvili told participants.

    In his overview of AIHA programs in Caucasus, Smith

    indicated that for the past 13 years the region has

    received in excess of $26 million worth of

    contributed professional time, donated supplies,

    equipment, and monetary grants from participating

    private American institutions and health

    professionals, which significantly complemented a

    very generous USAID contribution. "This unique

     public-private partnership is a hallmark of the James P. Smith discusses some of the partnership program; it helped our colleagues in accomplishmnents of AIHA's partnership

    programs in Caucasus Region. On his Armenia, Azerbaijan, and Georgia mobilize their left, Gegi Mataradze, a project scarce resources and created a tremendous management specialist with

    USAID/Caucasus's Health and Social investment in healthcare reform in the region," he Development Office, looks on. (Photo: emphasized. Vira Illiash)

Common Challenges, Common Goals

    The plenary sessions focused on such key healthcare issues as primary healthcare reform,

    healthcare management and financing, and community health. Current and former partners

    had a chance to discuss their accomplishments and the many positive outcomes of cross-partnership collaboration, as well as the role USAID and AIHA have playedand continue to

    playin assisting Armenia, Azerbaijan, and Georgia with their health-sector reforms. The

    conference also featured break-out sessions where the delegates concentrated on specifics of primary care and community health reform implementation and other salient topics such as continuous quality improvement, nursing development, emergency medical services, and reproductive health.

Azeri Program Creates a Comprehensive Model of Healthcare Delivery

    Primary care is a framework that allows both past and ongoing AIHA initiatives such as nursing reform, women's wellness programs, and emergency medical services to be integrated to promote meaningful health reform. The partnership program in Azerbaijan started later than in the other two countries of the region but, nevertheless, it is a good example of what can be accomplished in terms of sustainable impact in a five-year period.

According to Saadat Mahmudova, coordinator with

    the National Office on Family Medicine and head of

    the Family Medicine Chair of Azerbaijan State

    Institute of Postgraduate Medical Education, AIHA

    partnership programs have played a critical role in

    introducing new and highly successful primary

    healthcare (PHC) models to the country and in

    creating conditions favorable to the emergence of

     the profession of family doctor.

    Azeri partners during the plenary session. (Photo: Vira Illiash)

    In her presentation she emphasized the role of three

    AIHA PHC partnerships and several cross-partnership initiatives that have provided advanced training in various aspects of primary care to a large number of nurses and physicians from Baku. A good example is the Baku/Portland partnership, which created a highly successful Primary Healthcare Centera community-based health education and resource center that

    supports the operation of programs on women's health, addictions among youth, asthma, and mental health. The center now serves as a clinical training site for the newly-created Family Medicine Chair of the State Medical University and a similar department of the State Institute of Postgraduate Medical Education established with the support of the US partners. The latter also helped develop a three-month training curriculum introduced in both educational institutions. To date, more than 500 physicians and 20 nurses have become certified as family

medicine practitioners. To replicate the success of the PHC center, its model has already been

    disseminated in five pilot regions of Azerbaijan.

    The conference highlighted the lead role

    partnerships have taken in disseminating and

    implementing evidence-based treatment protocols,

    quality improvement programs, and clinical practice

    guidelines (CPGs) both in the capital city and nearby

    regions. As a result, primary healthcare partners

    have reported a 19 percent increase in the early

    detection of preventable health conditions. In addition, the introduction of CPGs at several Saadat Mahmudova speaks about AIHA's member institutions of the Baku/Richmond contribution into PHC reform in

    Azerbaijan as Julie Giorgadze, outreach partnership that serve not only the population of and development coordinator of the Binagadi District, but also some 33,000 refugees or Eurasia Foundation's South Caucasus

    Cooperation Program, looks on. (Photo: internally displaced persons (IDPs), has resulted in Vira Illiash) improved asthma management outcomes in 70 percent of patients diagnosed with the condition. These institutions also reported a drastic

    decline in the number of arterial hypertension and gastric and duodenal ulcer-related

    hospitalizations, as well as a decline in childbirth-related complications.

Kamal Hajiyev, a consultant with the Pediatric Medical Rehabilitation Center in Baku,

    presented an excellent example of successful bronchial asthma CPG implementation at his

    institution, where the number of ambulance calls about the condition plummeted from 80 to 20

    percent, while the number of hospitalizations decreased by 30 percent. Hajiyev acknowledged

    a notable improvement in the overall performance of physicians and nurses and their

    willingness to advance their skills by learning new treatment protocols.

AIHA's partnership between "Mir Kasimov" Republican Clinical Hospital in Baku and Baylor

    College of Medicine in Houston, Texas, has also made great strides in improving access to high-

    quality clinical services and health education programs, particularly for the more than 20,000

    IDPs and refugees served by Mir Kasimov and Sabirabad Rayon Hospital. The Baku/Houston

    partners established a Women's Wellness Center (WWC) and a Neonatal Resuscitation Training

    Center (NRTC) at each hospital, thereby facilitating many positive changes in maternal and

    child health indicators. Reproductive health screening services such as Pap smears, diagnostic

    coloscopy, and ultrasoundcoupled with state-of-the-art equipment provided by the US

    partners and the advanced staff training that occurred because of the partnershiphave

resulted in a 50 percent reduction in neonatal mortality. Partners also produced Azeri-language

    patient education materials on topics such as monthly breast self examinations , Healthy Baby,

    WIC Program, Pap Smear education materials for women, Taking Control of your pain, which

    have been distributed in three IDP/refugee camps. Additionally, Learning Resource Centers

    established by partners at each facility enable clinicians to access the most up-to-date clinical

    research and consult on difficult cases.

When commenting on the program of the

    Ganja/Livermore PHC partnership, Jeyhoun

    Mamedov, AIHA country coordinator for Azerbaijan,

    emphasized that the majority of the programs

    developed in Azerbaijan are based on the principles

    of diverse citizen participation, community

    investment, and local "ownership" of the programs.

    The US partners trained their Azeri counterparts in

     skills-sharing techniques and improved methods of

    Lala Ahmadova, information directing interests and managing resources in the coordinator of the Ganja/Livermore

    communities. Speaking about the role of community partnership, speaks about CAB's role in

    improving health of the in improving health, partnership information community. Larisa Muradyan, coordinator Lala Ahmadova provided a good example coordinator at Armavir Regional

    Healthcare and Social Services of how the operation of the Community Health Department and deputy governor of the Advisory Board (CAB) in the city of Ganja "brings the Armavir Region, and Vakhtang

    Barbakadze, head of the Department of partnership resources closer to the population." Internal Medicine at the National Regular CAB meetings of participating local health Institute of Therapy, also participated in

    the panel discussion. (Photo: Vira officials, government leaders, and community Illiash) representatives allow the partners to better meet

    healthcare needs in the city and generate support for the PHC initiative. (For more information

    on the Ganja/Livermore programs, please see: "Ganja/Livermore Partnership Introduces High-Quality Neonatal Resuscitation Services and Community Health Advisory Board")

Armenian Programs Demonstrate Effective Capacity-building Efforts and Sustainable


While the programs in Azerbaijan are the most recent, Armenia is one of the first countries of

    the former Soviet Union to have collaborated with AIHA beginning in 1992. The country has also

    been among the first to participate in many AIHA-sponsored regional initiatives and cross-

    partnership programs. The first WWC and the first Emergency Medical Services Training Center

    (EMSTC) were established in Armenia. Building on the success of the EMSTC, a network of

    regional nuclear disaster preparedness centers was established by the recently graduated Armavir/Galveston partnership. Similarly, due to the efforts of the Yerevan/Boston partners, emergency care is now part of the postgraduate education of medical professionals, including primary healthcare practitioners. The training module has been disseminated throughout the country as part of the capacity-building efforts of the Department of Emergency Care established with the partnership support at the National Healthcare Institute.

The innovative programs implemented in Armenia

    have also resulted in the development of models for

    comprehensive diagnostic and treatment services for

    women. With the first WWC center opened in 1992

    under the aegis of the Yerevan/Los Angeles

    partnership, the women's health component has

    been introduced at almost all partnership institutions

    leading to increased patient satisfaction and improved health outcomes for women.

    Ruzanna Yuzbashyan, head of the Primary Healthcare Department at the

    Armenian Ministry of Health, describes Sonya Aroustamyan, Director of Vanadzor Policlinic

    AIHA's contributions to sustaining PHC No.4 presented a great example of successful cross-reform in Armenia, while Larry S. Gage,

    past chairman of AIHA's Board of partnership collaboration during her talk about how

    Directors, looks on. (Photo: Vira Illiash) the staff of the Erebuni WWC, which was opened

    through the Yerevan/Los Angeles partnership in 1992, assisted the staff of Vanadzor Policlinic No. 5 (Lori/Milwaukee partnership) to develop women's health services for the rural population. These services, including Pap smears, clinical breast exams, contraception counseling, and STD diagnosis and treatment, are now being rolled out in northern Armenia through a reproductive health NOVA project supported by USAID.

    As highlighted during the conference, the introduction of AIHA's women's health programs in Armenia has resulted in the 25 percent decrease in the abortion rate at the partnership institutions and a significant increase in early-stage breast and cervical cancer detection. For example, the mammography and wellness center opened by the Yerevan/Washington, DC, partnership has greatly advanced screening and diagnostic capabilities. Its state-of-the art laboratory performs on-site mammograms and blind biopsy procedures and offers skills-based training to local clinicians. As a result, approximately 20,000 patients have been examined over the four years of the partnership program. More than 1,800 cases of breast and cervical cancer were detected at early stages, which has in turn led to decreased mortality rates.

In keeping with AIHA's efforts to develop the nursing profession as one of the focus areas of

    primary healthcare reform, Armenia has also taken the lead in creating the first regional

    baccalaureate program and establishing quality improvement programs in nursing at Yerevan's

    two major hospitals-Erebuni Medical Center and St. Grigor Medical Center. Both institutions

    were recognized as Magnet centers of excellence in nursing. (For more information about the

    nursing excellence program, please see: "Four AIHA Partnerships Receive International Award for Excellence in Nursing").

Alina Kushkyan, director of Erebuni Medical College (EMC), described the Yerevan/Los Angeles

    partnership's efforts to develop a four-year bachelor's program in nursing, which was

    recognized by the Armenian Ministry of Health. Since 1999, 118 students have graduated from

    this program and received diplomas. Moreover, seven of those college graduates underwent

    further training to become the first nursing faculty. Before that, nurses were trained

    exclusively by physicians. Kushkyan also noted that the nursing college graduates are in great

    demand with various medical institutions in Armenia as well as with international organizations

    working in the region.

    Looking at some recent examples of how the partnership

    programs in Armenia have contributed to capacity-building

    efforts, the Armenian partnership representatives briefed

    the audience on new PHC training programs focusing on

    continuous education for family physicians and nurses. Larisa

    Muradyan, coordinator at Armavir Regional Healthcare and

    Social Services Department and deputy governor of the

    Armavir Region, provided an account of the local

    government's role in sustaining community initiatives in the

    Armavir region with the population of some 276,000.

Ruzanna Ginosyan, chief nurse Between 2000 and 2002, 11 physicians and nine nurses at St. Grigor Lusavorich Medical

    Center in Yerevan, reports on completed train-the-trainers courses in the United States some of the many achievements and have become the faculty at the partnership-established AIHA partners in the region have

    Armavir Training Center, which subsequently provided made in the field of

    nursing. (Photo: Vira Illiash) hands-on training to 183 physicians, 352 nurses, and 15 additional instructors. Course topics at the center include cardiovascular disease, breast cancer,

    diabetes, disaster preparedness, asthma, and respiratory and GI infections with an emphasis on

    pediatric care. A survey conducted by the partners revealed that more than 70 percent of

    respondents felt that the services in the Armavir polyclinic had improved since the partnership

was established and the majority felt that services at the polyclinic were better than at the

    other government-run healthcare facilities.

Nationwide, partnership programs introduced in different regions of Armenia built a foundation

    for the scale-up phase in primary healthcare reform. Ruzanna Yuzbashyan, head of the Primary

    Healthcare Department at the Armenian Ministry of Health, covered this topic in her

    presentation. Particularly, the departments of Family Medicine and Family Nursing were

    established at the National Institute of Healthcare, State Medical University, and Yerevan

    Medical College.

The government also decided to expand the model developed by the three partnership-

    sponsored primary healthcare centers to 12 other medical facilities. She spoke about the

    importance of continuing the comprehensive PHC training program, which includes a health

    services management component, designed by the recently graduated Yerevan/Birmingham

    partnership and later offered by the American University of Armenia. Health management and

    administration have also been introduced through a series of training modules at the School of

    Healthcare Management. The school was established by the partnership to prepare professional

    healthcare administrators capable of leading the health system reform effort in Armenia.

     AIHA Programs in Georgia Generate Steady

    Progress on All Fronts

The role of the community has been a key aspect of

    all AIHA programs in Georgia as partners worked

    together to build healthier communities, engaging

    and mobilizing other stakeholders in the process.

    Working with individual institutions, the partnership

    programs placed particular emphasis on responding

    to the various healthcare reform needs of the Ketevan Loria (far left), Mary Anderson,

    nursing consultant with World Services country. In the mid-1990s, primary healthcare began of La Crosse; Alina Kushkyan, director of to emerge as a primary focus. Erebuni Medical College, and Jessica

    Jordan, nursing director at Valley Care Health System in Livermore, California, In support of the national strategy to build a cadre of participate in a break-out session on

    quality outcomes in nursing. (Photo: family medicine healthcare professionals, the Vira Illiash) specialists from now-graduated Mtskheta/Milwaukee

    partnership worked closely with the Georgian Ministry of Health and Social Affairs and the

    greater donor community to create the first Family Medicine Practical Center outside of Tbilisi.

Previously, five of such centers were created in the capital city under a World Bank grant and

    were providing training for local family medicine specialists.

Speaking at the conference, the center's director Ketevan Loria emphasized that the faculty of

    the center was comprised not only of physicians but also of nurses who completed an intensive

    six-week family health nurse training program at Marquette University College of Nursing. This

    specialized training program was based on the WHO primary healthcare curriculum and tailored

    to the needs of the Mtskheta community. The nursing curriculum contains 18 modules covering

    topics ranging from management and leadership skills to care for terminally ill patients,

    management of chronic diseases, women's health issues, and disease prevention, among other

    things. In her presentation, Loria explained that the physician and nursing staff at the center

    are now retraining specialists from adjacent areas, thus enhancing the skills of rural family

    medicine specialists and replicating a successful clinical and training center model throughout

    the region.

    Built upon the experience of Mtskheta/Milwaukee

    partnership, two new PHC training centers have

    been established by two current community-based

    partnerships: Gori/Milwaukee and Guri/La Crosse.

    These centers will be used for regional training and

    retraining purposes and will fill the capacity-

    building needs in these two regions.

    As is the case with the other two countries in Nurses from rural areas in Georgia's Shida

    Kartli Region attend a training session at Caucasus, chronic cardiovascular disease is the the Family Medicine Practical Center in

    primary cause of morbidity and mortality in Georgia. Mtskheta. (Photo: Vira Illiash)

    According to official data, 35 percent of the country's healthcare expenses are directed toward

    the treatment of arterial hypertension and its complications. All PHC partnerships have been

    able to implement effective methods of addressing chronic diseases through the their projects.

The Mtskheta/Milwaukee partnership, for example, developed a successful healthy heart

    program by closely monitoring blood pressure of some 500 patients for 3.5 years. When

    presenting the program and its outcomes, Vakhtang Barbakadze, head of the Department of

    Internal Medicine at the National Institute of Therapy, noted that active antihypertensive

    treatment based on standardized methods, continuous training of medical professionals, free

    provision of medications to patients, and their continuous observation yielded a 33-point

    decrease in systolic blood pressure and a 14-point drop in diastolic pressure in participating

patients. According to Barbakadze, such results give partners hope that in the next two years

    they will be able to potentially decrease the stroke rate by 40 percent, congestive heart failure

    by 50 percent, and total mortality rate by more than 20 percent. He also noted that the

    program had already been replicated in two other districts of the Shida Kartli regionKareli

    and Gori.

     Reflecting on the numerous achievements of the

    graduated partnerships, the WWCs established in

    Tbilisi and Kutaisi exemplify the sustainability of

    AIHA programs. Each of them continues to provide a

    comprehensive range of clinical services in

    ambulatory settings as well as a wide variety of

    health promotion, disease prevention, and

    educational programs.

    Natela Partskhatadze, nursing program The development of EMS, NRP and Infection Control coordinator at the Georgian NGO training centers has been a key aspect of the Partners for Health NGOwhich was

    established through the Tbilisi/Atlanta region's programmatic strategy for replicating and partnershipdiscusses continuing

    scaling up the new services introduced by individual education and its role in improving

    hospital nursing practices. (Photo: Vira partnerships. These centers have been officially Illiash) designated by the ministries of health as

    preeminent institutions for postgraduate and continuing education. In addition to these training

    centers, four Nursing Resource Centers have been established to support advanced nursing

    training and education.

Conference speakers clearly indicated that evidence-based medicine has been an important

    area of focus for many partnerships. For this purpose, 10 Learning Resource Centers (LRCs)

    have been established to provide technological and information support in medical research for

    evidenced-based practices. The Georgian National Information Center, which coordinates these

    centers, has developed 18 clinical practice and quality management guidelines in collaboration

    with Atlanta/Tbilisi partnership. These guidelines have been disseminated to a number of the

    nation's medical institutions.

The lessons learned by the Tbilisi/Atlanta partnership in the practical application of various

    innovative programs in Georgia were discussed at virtually every conference session. For

    instance, the partnership ushered in significant sustainable improvements in hospital

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