Building and Developing People and Programs for Sustainability Kyrgyzstan and Albania Inis Jane Bardella, M.D., FAAFP Associate Dean for Faculty Development and Global Health Initiatives Chicago Medical School Rosalind Franklin University of Medicine and Science

Objectives Discuss the contribution of family medicine models in Kyrgyzstan and Albania to health system improvement; Identify and discuss initiatives and activities that have the potential to facilitate sustainable health system improvement; Develop strategies for building and developing people and programs in the countries where you are working that will facilitate sustainable health system improvement.

Introductions Who are you?

Contributions: Kyrgyzstan Acknowledgement: Drs Contributions: Kyrgyzstan Acknowledgement: Drs. Barton Smith and Paul Fonken 1996 to Present Govt Goal: Comprehensive health system reform Primary healthcare core Activities Family medicine residency Retraining other specialists Faculty development Primary care nurses Policy development CME Quality improvement Medical school curriculum

Contributions: Kyrgyzstan Process Leadership Ministry of Health Science Technology Language Institute USAID UK Dept for International Development Focus on Need Rural communities first

Contributions: Kyrgyzstan Process con’t Multipronged Approach Physicians New Other specialties Faculty Nurses Policy Licensure/certification Health system

Contributions: Kyrgyzstan Accomplishments Family medicine Residency Regional FM centers FP association National faculty National and expatriate involvement National leadership, faculty Long term expatriate faculty Visiting faculty

Contributions: Kyrgyzstan Accomplishments Continuing medical education Required Quality improvement Evidence-base national guidelines Improved outcomes – Asthma, HTN, ulcer Regional impact Tajikistan – Center of Excellence Kazakhstan Uzbekistan

Contributions: Kyrgyzstan Accomplishments Many partners Kyrgyz Association of Family Group Practices and Family Nurses Kyrgyz State Medical Institute for Retraining and CME Other specialists International Former long-termers Potential Fulbright Scholar Study medical school curriculum to develop primary care physicians

Contributions: Kyrgyzstan Impact on System Improved health outcomes Certification/recertification Quality Improvement Decreased cost Medical school curriculum reform Hospital reform

Contributions: Kyrgyzstan Remaining Challenges Resistance to family medicine Other specialists Polical leaders Distinctions of physicians Residency Retrained Untrained Faculty clinical practice Academic family medicine Funding Payment for FM, primary care CME Professional migration

Contributions: Kyrgyzstan Lessons Learned National ownership and leadership. Development, advancement of nationals Start where the need is greatest. Do not waste resources where no perceived need Health system reform Physician payment Utilization Quality of care Integrate EBM

Contributions: Kyrgyzstan Lessons Learned Academic family medicine Medical school department Clinical practice Physician training distinction Residency trained Retrained No postgraduate training Pilots with roll-outs Center of Excellence model Supports evidence based decision making

Contributions: Kyrgyzstan Lessons Learned Supportive supervision (Proctoring) Expanding scope of services Changing behavior Multi-involvement Levels Systems Professions Partners Evolving very long term relationship

Contributions: Kyrgyzstan Key elements for worthwhile, sustainable development Health system reform Payment Care delivery Policy National financial ownership Evidence based medicine approaches Quality care Decision making

Contributions: Kyrgyzstan Key elements for worthwhile, sustainable development Strong family medicine infrastructure Association Academic department Work within national institutions Coordinate NGOs, donors Long term on the ground expatriates

Contributions: Albania Acknowledgement: Drs Contributions: Albania Acknowledgement: Drs. Eralda Turkeshi and Guy Eshelman University residency 1997 to Present ABC Health Foundation 1995 NGO Goals Introduce FM Train professionals Provide quality PC Focus Prepare Albanians Encourage FM residency Develop national FPs/GPs

Contributions: Albania Activities Model family medicine practice Tirana clinic Visiting nurses Roma outreach Internship Final year medical student clinical training Mentoring Albanian GPs and FPs Family medicine and GP CME Develop teachers of FM Develop leaders

Contributions: Albania Process Leadership National Expatriate Employment of nationals Progressive multi-level involvement Physician Nurse Medical school Residency Government

Contributions: Albania Process Education Students Residents CME Leaders Partnerships UK USA Germany Mentoring nationals

Contributions: Albania Accomplishments Model FM practice Clinical care Active teaching of students and interns Internship expansion to 2 years Interns entering residencies Family medicine Other specialties Interest in FM Students GPs Specialists

Contributions: Albania Accomplishments Students and doctors engaged in learning CME expansion to semi-annual Resource and skills center Multispecialty Multidiscipline Multinational support Albania US UK Germany FM teachers

Contributions: Albania Accomplishments FM Leaders First family physician faculty in DFM Leading medical school curriculum reform Starting PhD work Government leaders supporting family medicine Partnerships, resources for reform Health system Medical education Bridging community and university

Contributions: Albania NGO Impact on Health System Improved preparation of GPs and FPs Medical school curriculum reform GPs and FPs becoming involved in health system reform Development of system leaders

Contributions: Albania Family Medicine Impact on Health System Cornerstone of health system reform Influencing hospital and CME reform

Contributions: Albania Remaining challenges Resistance to family medicine Politics Fear Family medicine association Distinction of physicians FP GP Funding Payment for FM, primary care Expansion of residency Professional migration

Contributions: Albania Lessons Learned Training, education activities crucial Clinical Management Nursing Recurrent CME Abilities, skills family physicians increased more rapid than system support for role Frustration Barrier to care Mentoring and support from international “experts”

Contributions: Albania Lessons Learned Time for “mindset” change Repeated exposure and models over years Team work crucial. Best taught through modeling Hand-in-hand physician training and system change Comprehensive plan more effective than fragmented, unrelated interventions Hospital specialists should be: Educated about FM Involved in FM training Not be the only trainers

Contributions: Albania Lessons Learned Create a network of organizations Avoid duplication Ensure complementary interventions. In spite of the system challenges, the doctors being trained are inspired and report small changes in their practices. The best focus/starting points with limited resources: Local building of human resources Equipping the doctors to change the system Periodic, recurrent training, mentoring

Contributions: Albania Key elements for worthwhile, sustainable development Low level of corruption Integrity Consistency Value for: Life Patients Education Service to others Professionalism

Contributions: Albania Key elements for worthwhile, sustainable development Coordination of interventions/activities Efficient use of local resources Relevant to practice Accessible to physician, staff Training targeted to local needs

Contributions: Albania Key elements for worthwhile, sustainable development Expatriate mentoring and support A holistic view Match system and training interventions Consider the complexity of the health care system Involve all agents – patient, doctor, nurse, manager, etc

Discussion Considering these models and others of which you are aware, what are FM initiatives and activities that have the potential to facilitate sustainable health system improvement?

Small Group What specific strategies can be applied where you are working to build, develop, cultivate people and programs for sustainable health system improvement? What are the steps necessary to implement these strategies?

Summary What will you do? Strategies? Steps?

Shum falemindarit Murakoze chane Thank you so much inis Shum falemindarit Murakoze chane Thank you so much inis.bardella@rosalindfranklin.edu