Bringing Primary Care to Turkmenistan: The Achievements of the Ashgabat/North Dakota Partnership Lay the Groundwork for Successful Healthcare Reform

By Vira Illiash

Family medicine is something new for all the countries of the former Soviet Union. After some initial skepticism, however, there is growing confidence that it is an approach that will work.

In the second half of the 1990s, a wave of healthcare reform rolled through Eastern Europe and Eurasia. The resultant innovations involved a transition from a health system based on narrow specialization, to a system of general primary care, which is considerably more cost-effective, while at the same time more efficient because it focuses not only on the patient, but also his or her entire family. Despite these obvious benefits, at the time, healthcare professionals and even patients were highly skeptical about the possibilities for this approach to succeed.

Their initial cynicism was a response to the prospect that the services previously provided by a wide range of medical specialists would be handed over to a single physician. It was evident that this system would be convenient because it would relieve the frustration and exhaustion that patients frequently experienced as they shuttled from one specialist's office to another at local clinics. Nevertheless, people were plagued with nagging doubts that a single general practitioner would never be capable of handling the problems that a cardiologist or neurologist may have dealt with in the past.

As the ranks of family practitioners grew and the concept of primary care began to develop and gain momentum, attitudes toward its viability changed. People discovered its advantages and—as is case with most progressive innovations—more and more people began to advocate for family medicine.

For the Meredovykhs, a Turkmen family with four children ranging in age from 7 to 17, having the same team of clinicians watch over the health of all six family members has greatly streamlined the care process. All members of the family are clients of the Model Primary Healthcare Unit, which was opened in 2002 at Health House #1 in the Central Asian nation's capital of Ashgabat. There they are under the care of family physician Bibi Baylyyeva, who works in close collaboration with primary care nurse Marina Padalka.

"The fact that our district doctor and nurse know the detailed medical histories of all the members of my family really means a lot to me because they can always provide very prompt and skilled care," explains Artykach Meredova. "Following their instructions always results in a positive outcome and sometimes I don't even have to take the children to the Health House because the doctor and nurse periodically make house calls to give complete check-ups. They have all the equipment needed to conduct these remote visits and, as a mother of three sons and a daughter, the home visits are especially convenient for me."

Marina Padalka and Bibi Baylyyeva consult with a patient at the Model Primary Healthcare Unit. (Photo courtesy of Myakhri Nedirova.)

Stressing that Baylyyeva and Padalka truly treat them as a family unit, Meredova notes, "I can contact these clinicians any time not only for medical care, but also for all kinds of advice ranging from how to prevent diseases or common ailments to coping with some psychological or age-related problems the children have. They always listen attentively to my questions and take my concerns seriously, so we completely trust each other. When we used to get healthcare services at the regular clinic, nobody had this attitude and the healthcare personnel were not as skilled," she concludes.

How the Seeds of Family Medicine Were First Planted
The principles of family medicine were first introduced in Turkmenistan in 1996 when Saparmurad Niyazov, the country's president initiated a national healthcare reform program called "Health."

Implementation of this program entailed the identification of priority areas that were in need of immediate improvement. Some of these priority areas included maternal and child health, tuberculosis and other infectious diseases, cardio-vascular disease, sexually transmitted infections, and problems associated with lifestyle choices such as smoking. All of these issues could be effectively addressed at the primary care level, but that meant shifting the existing specialized system to the more generalized family medicine principles. By doing so, healthcare professionals could look at the root causes of various ailments rather than just trying to deal with the resultant symptoms as they arose. This would allow practitioners to study the reasons behind the appearance of a given family's main health problems in more detail and to act accordingly to more effectively manage their conditions and prevent recurrences.

With the idea of shifting to family medicine came the need to train personnel capable of meeting the population's growing needs for high-quality medical services. Because the family medicine concept was such a new field within the healthcare system of Turkmenistan, it was important to draw on the knowledge and experience of specialists from other countries where family medicine had already proven successful and a system of educating clinicians had already been established.

The first people to offer assistance for Turkmenistan's fledgling primary care reform efforts were a group of family medicine specialists from North Dakota who began to work with their colleagues from Health House #1 in 1999 through an American International Health Alliance partnership in primary healthcare. This partnership had two offspring right away—the Ashgabat Primary Care Training Center (PCTC), which uses the clinical facilities at Health House #1 to teach doctors and nurses the rudiments of family medicine, and the Model Primary Healthcare Unit, which now functions as a full-service family medicine center at that same institution.

Creating a Training Center to Ensure High-quality Care and Promote Sustainability
Recounting the partners' collaborative efforts to ensure the development—and the sustainability—of the family medicine model in Turkmenistan, PCTC Director Myakhri Nedirova is quick to admit that they took a very serious approach toward practitioner training from the very beginning of the project. "We wanted the Center's staff to be specialists who support family medicine heart and soul, so we announced a competition to select four doctors and three nurses who would work at the PCTC. Once the selection process was over, the prospective trainers all traveled to North Dakota to learn about adult teaching methods and they visited several US cities to become familiar with the American system of medical education and how family doctors and nurses work together as a team."

PCTC trainer Oraznabat Saparmamedova conducts a session on peak flow meters. (Photo courtesy of Myakhri Nedirova.)

In addition, Nedirova notes, the American partners made sure that the training would pay off by providing the Center with all the necessary equipment that a family doctor uses in daily practice, including otoscopes, ophthalmoscopes, and peak flow meters. They also supplied appropriate teaching aids, such as mannequins, displays, and audio-video materials containing training programs on modern methods of patient examination.

The partners from North Dakota also helped set up a library containing up-to-date medical literature, so teachers and students at the Center could improve their knowledge through independent study. A Learning Resource Center (LRC) was created and equipped with computers and Internet access to further enhance the possibility for the Turkmen healthcare professionals make use of the latest medical technologies during training sessions and in their day-to-day practice. According to Nedirova, the LRC makes the constant exchange of knowledge and experience among medical professionals in Turkmenistan, the United States, and other countries in the region possible. In addition, these capabilities have made it possible for the Center's staff to help clinicians from other healthcare institutions in Ashgabat find materials they need for their own practice, as well as to provide methodological consulting services to people at Turkmenistan's Ministry of Health and Medical Industry and the Ashgabat City Health Administration.

Collaboration Leads to the Development of a Family Medicine Training Program
In addition to preparing Center staff for the task of training—and in some cases retraining—healthcare providers in the art of family medicine, another key task undertaken by the Ashgabat/North Dakota partners was developing an innovative educational program for PCTC students.

Describing the training process, Nedirova explains that the four-week course was built around the principles of evidenced-based medicine. Course topics are based on the latest scientific achievements and designed to encourage practitioners to look at each family as a system and each family member as an individual. "We tried to construct the program in a way that focuses students' attention on the simplest and most accessible methods for evaluating a patient's condition before initiating more detailed diagnostics, treatment, and follow-up care," she points out, stressing the importance of taking each patient's physical, psychological, social, and behavioral condition into account before proceeding with a care plan.

The training curricula emphasizes a team approach based on an active partnership between physician and nurse, Nedirova continues. "During the classes, the physician-nurse teams have the opportunity to conduct patient examinations together then, using an evidence-based clinical approach, they discuss the diagnosis and a treatment plan. In addition, the training period provides time for the teams to observe patients of various ages ranging from infants to elderly people, as well as to learn how to establish ways of communicating with an entire family," she observes. "This gives practitioners the chance to conceptualize which educational techniques work best with one age group or another and helps them improve their ability to get patients more interested in matters of health promotion and disease prevention."

Nedirova and Saparmamedova discuss the results of graduation tests. (Photo courtesy of Myakhri Nedirova)

Nedirova also stresses that the LRC plays a special role in the learning process by giving students an opportunity to learn to use the latest information technologies. In the future, this will enable them to conduct teleconsultations and exchange information with their colleagues around the globe, as well as to continue their own education independently.

Although training at the PCTC is often seen by Ashgabat's medical community as an interesting and attractive thing to do, Nedirova is quick to point out that the course is very difficult and requires significant effort to complete successfully. "We have former general practitioners, pediatricians, neurologists, gynecologists, surgeons, and other specialists undergoing retraining, so our course rosters are extremely full. Moreover, the learning process is constantly monitored through specific activities, role-play and situational problem-solving exercises, and weekly examinations. We also regularly evaluate students on their practical skills and medical note-taking and, at the end of the course, they are given a two-part exam to measure both their theoretical knowledge and hands-on skills," she explains. Only after the students have passed all these stages of testing do they receive the right to practice family medicine.

Each month, eight physician-nurse teams from various healthcare institutions in Ashgabat are trained at the PCTC. Since its opening in 2001, 517 primary care professionals have passed their exams and been certified as family medicine specialists. And, despite the fact that the training model was something entirely new for the local medical education system when it was first introduced, today the program has been accepted and approved at the national level.

The Model Primary Care Department: A Pathway to Improving Family Health
The establishment of the Model Primary Healthcare Unit at Health House #1 represents yet another stellar accomplishment of the partners. Likening the facility to a mirror that reflects the impact of their collaboration with the medical professionals from the United States, Nedirova calls the unit unique for both its structure and its capabilities.

Opened in 2002, the Model Primary Healthcare Unit is staffed by 10 physician-nurse teams—all trained by the PCTC—who tend to the healthcare needs of some 10,000 local residents. All of its family medicine specialists are equipped with medical bags that enable them to conduct complete physical examinations during house calls, as well as during the times they see patients on site.

The staff collaborates closely with PCTC personnel, using the Training Center's Internet access and other information resources to keep abreast of the latest research on preventive, diagnostic, and treatment methods, as well as to conduct joint consultations with patients and prepare seminars on topical themes.

The department also has a training room equipped with models and visual aids where staff members teach patients about topics ranging from proper nutrition and the harmful nature of substance abuse to breastfeeding techniques and the importance of conducting monthly breast self-examinations. The interactive nature of these discussions make them very popular with patients because they come to feel that they, too, are part of the healthcare team.

New Approaches to Care Yield New Opportunities
From a practitioner's standpoint, the most fundamental change that has occurred in Turkmenistan since the primary healthcare reform efforts were launched is evidenced by a shift in the country's approach to public health problems, according to Bibi Baylyyeva, a former pediatrician, and Marina Padalka, who worked for many years as a district medical nurse. The pair trained together at the PCTC and now work together as a physician-nurse team at the Model Primary Healthcare Unit.

Describing what has changed since their retraining as family medical specialists, Baylyyeva explains, "We have refocused our mindset to treat not merely the specific diseases that patients have as was the case in the past, but to pay attention to the patient as an individual. Now we listen to his or her problems that may go above and beyond the physical, yet may still affect how he or she feels."

Baylyyeva says that an attentive and respectful attitude toward patients—coupled with the desire to dig deeper into the problems they face and learn more about their families and the environment in which they live—has gone a long way in gaining people's trust. Even though the department is relatively new, its family practice specialists can already see the positive results of their work, she notes, stating, "The rate of compliance with our recommendations has noticeably risen, which has a positive impact on both treatment and prevention. Consequently, we have observed a reduction of acute episodes in patients with chronic illnesses and we've also reduced the need to send patients to specialists or the hospital.

Baylyyeva conducts a prenatal class with future mothers. (Photo courtesy of Myakhri Nedirova)

Baylyyeva credits many of these successes to the tremendous amount of work that primary care nurses like Marina Padalka now do, particularly when it comes to preventive measures. Padalka herself admits that upgrading her professional skills has led to an enhanced role for her in improving the health of the population. "Besides my responsibilities at the clinic, I also give educational talks on the prevention of cancer and tuberculosis, work with adolescents, brief young mothers on the right way to care for their newborns, and lead prenatal classes for pregnant women," she reports. "These activities keep me in constant touch with patients from all age groups and really help me to better understand the needs of different people. This understanding, in turn, helps me give patients the information they need to know and teach them to pay closer attention to their own health, as well as that of their families."

Expanding the Horizons for Turkmen Healthcare Professionals
Commitment, mutual understanding, and striving for constant professional growth, Nedirova says, are what have made the common cause of the Ashgabat/North Dakota partners both more fruitful and more meaningful. "I am very proud that our work clearly illustrates that family medicine is the foundation upon which a healthy future can be built for every family. What's more, all of our partnership's initiatives were highly rated at the national level. In fact, the success of the PCTC's program for retraining family medicine specialists helped government officials decide to replicate our model in other regions of the country," she says, noting that there are plans to open a second, similar training center for doctors and nurses from other areas of Turkmenistan in the spring of 2005 and, later on, to create a national network of such centers.

"We hope this is only the beginning," Nedirova concludes. "After all, a patient's rapid and complete recovery depends on his receiving competent primary medical care. Because the family doctor is the one who first encounters the health problems that members of any given family have, it is very important to create a well-trained cadre of primary care practitioners who has the patience and skills necessary to find the right approach for each family, win the trust of their patients, and work together with them to improve their health."

— Vira Illiash is AIHA's Staff Writer based in Kiev, Ukraine.

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