From Kiev to Budapest: Paving the Road to Primary Healthcare

By Barbara Ruben

As new primary healthcare (PHC) partnerships begin to implement their work plans with the collective goal of improving the health and well-being of their communities, AIHA is working to help partners establish primary care centers and facilitate regional information networks for the providers of this innovative service of community-based healthcare.

With this goal in mind, partners from the eight primary healthcare partnerships in Ukraine, Belarus, and Moldova attended a three-day workshop in Kiev February 15-17 to learn more about primary care issues and discuss the process for implementing change. Building on some of the universal themes identified at this workshop, approximately 250 healthcare professionals representing more than 30 AIHA PHC partnerships will meet in Budapest this July to explore community-based approaches to primary care.

Primary Healthcare Partners Outline Plans for the Future
At the Kiev workshop, Marilynn A. Schmidt, director of the Office of Democracy and Social Transition at USAID's Regional Mission for Ukraine, Moldova, and Belarus, emphasized the importance of primary healthcare, stating, "It allows citizens to make decisions about their own healthcare, and that's democratic. Community members will be able to say that they have modern care because of these partnerships."

The workshop also provided a forum for regional officials to discuss the emerging role of primary care in healthcare systems throughout West NIS. For example, Vladimir Orekhovsky, first deputy minister of health of Belarus, noted that a network of primary care facilities is being established in his country, saying that primary healthcare reform will be implemented in stages for at least the next 10 years, depending upon the nation's financial situation.

During the conference, representatives from each partnership presented their work plans and several outlined their strategies for creating primary care centers and explained existing services. They also attended sessions on topics such as evaluating the delivery of primary care services and conducting a community health assessment. In addition, panel discussions were held on model primary care centers, disease prevention, financing a primary care system, primary care training, and integrating mental health into basic primary care services. A final session examined the needs of special populations, such as occupational health, student health services, and rural healthcare delivery.

Establishing Model PHC Centers

Representing AIHA's Kiev/Philadelphia partnership and discussing their goals, Dr. Stephen R. Permut, chairman of the Department of Family and Community Medicine at Temple University's School of Medicine, said the new family practice center in the Kharkiv Rayon of Kiev will have three functions: It will serve as a model healthcare delivery site for a wide range of services; it will train and retrain physicians for family practice; and it will be a laboratory for extensive outcomes analysis. According to Permut, the primary healthcare team will consist of physicians, nurses, social workers, and pharmacists. The doctors will train in a variety of settings--including homes, polyclinics, and daycare facilities--to observe the different ways people exhibit symptoms of both physical and psychological problems and will gain an extensive range of knowledge that encompasses both general medicine and pediatrics specialties.

Dr. Volodymyr V. Zagorodniy, first deputy head of the Kiev City Health Administration and coordinator of the Kiev/Philadelphia partnership, said the partnership plans to create a model primary care center that is expected to open in September. Some of the goals of the new facility include professional training and improved data management, as well as integrating mental health issues into primary healthcare.

Another model center--the Odessa Healthcare Alternative--has already opened its doors. Family doctors at the clinic take on the roles of some of the sub-specialists and are responsible for both disease prevention and education. The shift from specialist-driven care to primary healthcare is achieved through financing, said Dr. William Aaronson, assistant director of the Center for European Studies at Temple University in Philadelphia. Strengthening the primary healthcare system, bolstering healthcare financing, and improving the quality of care are all integral components of a three-pronged path to healthcare reform, he explained.

According to Dr. Vyacheslav Veres, chief physician at the Zhovkva Central Regional Hospital in L'viv, primary healthcare provides an efficient use of resources--the cost is much lower than other forms of healthcare services and a larger percentage of patients can be effectively treated at the family medicine level. Primary healthcare is especially cost-efficient because it doesn't use expensive technology or encourage unnecessary inpatient treatment. This can reduce costs by as much as 30 percent, which can then be invested in primary care systems, Veres said.

Training and Residency Highlighted

Training is the most important indicator of quality of care and success of family practice in general, said Professor Galina Popik, chief of the Family Medicine Department at Odessa State Medical University. Established in 1998, the department incorporates 20 sub-specialties focusing on different diseases. Through the AIHA-sponsored Odessa/Boulder partnership, a new curriculum that highlights disease prevention as well as residency training or on-the-job practice under the mentorship of a family practitioner has been implemented.

In Moldova, family medicine with residency training was established as part of a legislative health reform package some three years ago. Sixty percent of the doctors in Moldova are specialists and 4,000 need to be retrained as family physicians, explained Dr. Ion Ababii, rector of the Chisinau State University of Medicine and Pharmacy. The family medicine curriculum incorporates specialty needs such as training of rural family physicians.

Serving Rural Populations

Other partnerships are also addressing the special needs of rural populations. Dr. Leonid Maharyta, from the Uzhgorod/Corvallis partnership said that the rural medical district in his region has been reorganized into a network of primary healthcare practices, emergency medical services, and home visits. A mobile unit and feldsher and obstetrical stations also help serve rural mountain residents. As a result, there has been a consolidation of hospitals, while more regional primary care centers have been established. Although staff has been reduced, treatment and diagnostics have increased, he said.

Integrating Mental Health Into PHC

Mark D. Lyons, clinical director of performance improvement and program development at Delaware Valley Community Health Inc. in Philadelphia, stressed the importance of having mental health services integrated into primary healthcare systems. Representing the Kiev/Philadelphia partnership, Lyons outlined several collaborative models ranging from minimal collaboration with mental health providers, where there are separate facilities, separate systems, and referrals made with no feedback, to full integration, where there are shared sites, systems, and a vision of delivering care, along with shared treatment plans and programs, community involvement, and complex cases that focus on work, school, family, and community. More integrated models require primary care providers to be trained to recognize disorders using standard screening and diagnostic questionnaires and to learn about treatment options, medications, and brief supportive interventions, Lyons noted.

Dr. Yuriy B. Yudin, head of the mental health department for the Kiev City Health Administration and member of the mental health task force, detailed his plan for reforming the psychiatric care system in Kiev. This includes collaboration between primary healthcare and specialized psychiatric care services, an increase in the role of school personnel in mental health promotion and disorder prevention, and interaction between local authorities, executive bodies, scientific and methodological facilities, and mental healthcare systems in the decision-making process.

Common Goals and Strategies to be Discussed in Budapest

West NIS partners will share their progress in implementing primary care strategies with other healthcare professionals from across the NIS and CEE from July 16-19 at the AIHA Partnership Conference and Workshops on Primary Care-related Topics in Budapest. The theme of the 2000 Conference, "Developing Common Strategies for Improving Community Health," is in keeping with the partnership program's reliance on community volunteerism and current emphasis on developing community-based approaches to primary care. Building on this theme, conference sessions, workshops, and skills building sessions will give partners the opportunity to share their experience and develop common strategies for

• community mobilization,
• community health assessment,
• health promotion and disease prevention (including smoking cessation programs),
• developing indicators and collecting data,
• patient management (including patient flow and scheduling),
• communication skills building (including counselor training),
• evidence-based practice guidelines, and
• clinic management.

Barbara Ruben is a freelance writer based in Maryland.

Return to the menu of articles