1. Primary Care Strengthening in Southeast Asia Laura Goldman MD Jeff Markuns MD EdM FAAFP

2. 2 Activity Disclaimer ACTIVITY DISCLAIMER It is the policy of the AAFP that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/invitation of participation. Disclosure documents are reviewed for potential conflicts of interest (COI), and if identified, conflicts are resolved prior to confirmation of participation. Only those participants who had no conflict of interest or who agreed to an identified resolution process prior to their participation were involved in this CME activity. Laura Goldman and Jeff Markuns have indicated they have no relevant financial relationships to disclose.

3. Objectives After this session, you should be able to: Describe differences in the state of primary care development in southeast Asia Outline steps for completing a needs assessment for designing a program in primary care development tailored to the local environment Perform a SWOT analysis in a specific case example 3

4. Outline Asia-Pacific review The case of Vietnam –Needs assessment –SWOT analysis –Designing a program –Outcomes Laos Myanmar 4

5. 5 http://ashleylaurenturner.wordpress.com/c ategory/asia-pacific-region-map/

6. Primary Care Principles Access or first-contact care Comprehensiveness Continuity of care Coordination Prevention Family-orientation Community-orientation Patient-centeredness From The Contribution of Family Medicine to Improving Health Systems: A Guidebook from the World Organization of Family Doctors, 2 nd Ed. 2013

7. The Case of Vietnam In 1994, the vice-director of the Ministry of Health (MOH) Health Strategy and Policy Institute published an article on the need for reform of primary care In 1995, we were invited to collaborate with leadership in the MOH on a proposal to reorganize the primary health care system 7

8. 5 Step Approach Goal Needs assessment –SWOT analysis Strategic objectives Implementation methods Program evaluation 8

9. Goal of Consultation “ To explore the feasibility of introducing family medicine as the core specialty of primary care in Vietnam” Developed collaboratively by MOH Health Policy and Strategy Institute of Vietnam and consultant 9 Montegut, Family Medicine 2007

10. Needs Assessment Needs assessment focused on: –Review health care delivery system –Role and function of primary care within the health system –Educational system for training in primary care –Local capacity to achieve improvement 10

11. Needs Assessment Involved key stakeholders from 3 regions in the country, including –Ministers of health –Deans, department chairs of medical schools –Hospital directors –Local board of health directors –Physicians, rural and urban –Patients in various settings 11

12. Primary Care System The 1950s began the building of 10,000 commune health centers staffed with health care teams of PAs, nurses and midwives. By 2004, 50% were staffed by generalist physicians. These physicians had no post-graduate training, no training in ambulatory care, and no access to CME. 12

13. Primary Care System Commune health centers –low professional self esteem –low utilization of services –patients bypass and self-refer to a limited supply of specialists in urban areas Traditional district to provincial to central hospital system, but CHCs lack connections and hospitals are overcrowded 13

14. Health System Primary care in public sector delivered by poorly trained health care workers, often not physicians Primary care in private sector delivered by specialists, or by generalists and traditional healers. None have primary care training. 14

15. Medical Education in SE Asia European model Hospital focused Specialty focused Medical school 6 years –2 years basic science –2 years medical science –2 years clinical rotations in medicine, surgery, ob/gyn, pediatrics 15

16. Medical Education in Vietnam 16

17. SWOT Analysis Strengths Weaknesses Opportunities Threats 17 http://en.wikipedia.org/wiki/SWOT_analysis

18. SWOT Strengths –Remarkable grassroots infrastructure –Government funding throughout the country –Organized hospital system –Strong cultural family orientation –Political climate inviting international consultation –Strong support from MOH in primary health care reform 18

19. SWOT Weaknesses –Lack of competent staff in CHCs –Lack of trust in grass roots providers –Lack of continuity between levels of care –Small amount of GDP spent on health care –Outdated teaching methods 19

20. SWOT Opportunities –Ability to devise new educational system to upgrade primary care training –Receptiveness to new paradigm Threats –Changing political climate –Cultural differences between regions –Limited resources 20

21. Strategic Objectives Create project model for the development of Family Medicine as the core specialty dedicated to primary care in Vietnam 21

22. Implementation Family Medicine approved as first degree specialty 2001 Academic Departments of Family Medicine –faculty development fellowships –MSc and PhD Post-graduate (CK1) training –Focus on re-training –Develop FM curriculum based on primary care principles –Recruit health authorities to enroll participants 22

23. Program Evaluation in Vietnam Review of outputs –Eight faculty completed Masters level training –Pilot CK-1 training programs successful with rapid expansion to 6 of 8 medical universities –Began 2002, over 600 CK1 grads today Quality –Initial satisfaction surveys 23

24. Addressing Current Needs in Vietnam Successive rounds of analyses –Piloted rural training program, now exploring CME Government circular 2014 –Regulations for the family medicine centers 30 new centers in HCMC alone this year –Regulations for retraining and certification of practicing physicians in family medicine –Required continuing medical education programs, now in development 24

25. The Case of Laos MOH would like to retrain physicians in Family Medicine to provide care to underserved rural citizens We were asked to help them develop a pilot program. 25

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27. Goal of Consultation “Demonstrate an effective model for training of family physicians to care for the rural 75% of the population that live in rural Laos” 27

28. Needs Assessment Stakeholders involved –Ministry of Health Director of Community and Population Health Lao Coordinator for Enhancement of Primary Rural Health Care who was also the Director of Tropical Medicine and Malaria Research –Lao Natl Univ Faculty of Medical Sciences Vice Dean Division of Research and Post-graduate Studies University of Calgary Faculty of Medicine 28

29. Laos Needs Assessment Laos has 6 million residents with 75% of its population living in rural areas and 50% living below US$1.25 per day. Infrastructure is limited, with poor roads, no railway, electricity limited to urban areas, limited telecommunication. 29

30. Laos: Health Care Measures Life expectancy is 61 Infant mortality is 60/1000 births. 0.3 physicians per 1000, below the WHO critical threshold of 2.23 Health expenditures of the government in 2007, was US$10 per capita per year. 30 UNDP Human Development Report 2013 Lancet 2011

31. Laos: Health Care Disparity Difference in skilled birth attendance between urban (60%) and rural (10%) Laotians is the highest in SE Asia –DPT rates: urban 40% rural 20% –Antenatal care: urban 70% rural 20% –ORT: urban 65% rural 25% Antenatal care for other SEA countries (except Cambodia) >90% 31 Lancet Vol 377 webappendix p16 2011

32. Laos: Health System Delivery Commune level basic health care, comprised of health care workers, nurses and birth attendants. District hospitals some staffed by a generalist physician. Provincial hospital staffed by generalist physicians, with no specialty care. 4 specialty hospitals highest level of care in the capital Vientiane 32

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34. Laos: Medical Training Medical students study for 6 years A one year post-graduate internship in a district hospital is required Specialist in pediatrics, ob/gyn, internal medicine, ophthalmology 34

35. Family Medicine Post-Graduate Training One year post-graduate training began in 2005 –Teachers not trained in primary care –Graduates do not practice Family Medicine in rural areas after graduation, but stay in Vientiane and train as specialists 35

36. SWOT Strengths –Government mandate to strengthen abilities of health care providers –MOH focus on primary care –Already familiar with Family Medicine –Curriculum for rural based training program developed by Laos FMS with Thammasat University, Thailand and Maastricht University, Netherlands 36

37. SWOT Weaknesses –Poor medical infrastructure –Logistical concerns: roads, lack of internet –Lack of qualified teachers 37

38. SWOT Opportunities –Interest in adopting retraining approach used in Vietnam –Recognition that new model is needed 38

39. SWOT Threats –Family Medicine not yet recognized as specialty –Very low resourced country –Lack of funding to train teachers –Outpatient training model may not be feasible –Potential loss of trainees to more lucrative specialties –Inability to leave very low resourced district hospitals for long periods for training 39

40. Strategic Objectives Development of Academic Department at Laos National Faculty of Medical Science Identification of and advanced training for academic faculty Faculty development at provincial hospital Create distance learning model to allow trainees from rural district hospitals to continue learning while remaining at work and home 40

41. Implementation Methods Centers of Family Medicine –Located at FMS for development of specialty –3 additional centers in provincial hospitals Equipped with library, conference room and internet Faculty development –Scholarship for 5 Masters of FM in Thailand –Mini-fellowships in US –TOT programs in provincial hospital 41

42. Implementation Methods Masters in Family Medicine AUNP Program –experienced physicians in district hospital –3 months in referral provincial hospital –3 months in home district hospital –Community based projects in district hospital –Instruction in teaching and conferencing –Visiting professors from FMS 42

43. Evaluation of Program Quantitative data derived from surveys on self-reported knowledge and confidence 360 evaluation done of trainees Qualitative data derived from semi- structured interviews

44. Evaluation Results Updated clinical skills Improved working relationships with other doctors, nurses and community health workers Teachers and disseminated knowledge 44

45. Evaluation results Manage more patients at the district level before referring to provincial hospital Improved computer skills, including PowerPoint and use of internet Graduates, supervisors and faculty recommend program for expansion

46. The Case of Myanmar Approached by the General Practice Society seeking assistance with developing Family Medicine postgraduate training opportunities 46

47. Goal 47

48. Needs Assessment 48

49. Strengths 49

50. Weaknesses 50

51. Opportunities 51

52. Threats 52

53. Strategic Objectives 53

54. Implementation Methods 54

55. Evaluation Plan 55

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