1. Supporting Progress in Primary Care System Strengthening: The Example of Family Medicine Development in Myanmar Jeff Markuns, MD, EdM, FAAFP Laura Goldman, MD Christoph Gelsdorf, MD Malwina Carrion, MPH

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. Jeff Markuns, Laura Goldman, Christoph Gelsdorf and Malwina Carrion have indicated they have no relevant financial relationships to disclose.

3. Objectives On completion of this presentation, participants should be able to: Perform a needs analysis using the example of the current primary care training system in Myanmar Identify existing system gaps impacting primary care physicians and potential strategies for improvement in low- resourced settings using Myanmar as an example Outline strengths, weaknesses, opportunities and threats as they apply to developing strategies for Family Medicine development using Myanmar as a case example 3

4. Outline Issues review The case of Myanmar –Needs assessment –SWOT analysis –Designing a program –Outcomes 4

5. 5 https://www.ncafp.org/ncafp/wp- content/uploads/2014/07/Myanmar_Politic al.png

6. The Case of Myanmar Dr. Christoph Gelsdorf attended the GPS Scientific Conference in Taunggyi and started visiting GP clinics in 2011. No other international partners at that time. In 2012, he presented on Family Medicine Training in the U.S. and then started building the idea with the GPS from there. In 2013, Dr. Gelsdorf reached out to other international consultants with permission of local partners for support in building FM in Myanmar. 6

7. 5 Step Approach Goal Needs assessment –SWOT analysis Strategic objectives Implementation methods Program evaluation 7

8. Goal of Consultation “ To assist in developing Family Medicine post-graduate training in Myanmar” Developed collaboratively by the General Practice Society and consultant 8 Montegut, Family Medicine 2007

9. 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 9

10. Needs Assessment Focused on existing GPs as key stakeholders Sought to determine attitudes of: –Ministers of health –Deans, department chairs of medical schools –Hospital directors –Local board of health directors –Physicians, rural and urban –Patients in various settings 10

11. Health Care System 70% of population lives in rural areas 66 out of 1000 children die before 5 th birthday Every third child is undernourished or moderately stunted Maternal mortality 240/100,000 live births 70% deliver with untrained birth attendant in rural areas 11

12. MOH MOH developed two objectives: To enable every citizen to attain full life expectancy and enjoy longevity of life. To ensure that every citizen is free from diseases. 12

13. Health Care System Government-based health care system plus private 1504 rural health centers (RHCs) covering more than 65,000 villages Refer to station hospital, township hospital (serves 100-200k population), district hospital (50-200 beds) or specialist hospital Parallels system of villages, townships, districts, divisions, states 13

14. Primary Care System Each township has one to two station hospitals and four to seven RHCs RHC is basic health unit for a village operated by a health assistant, rural nurse (lady-health-visitor) and four to seven midwives Each RHC has 4 sub-centers 14

15. Role and Function of Primary Care RHCs provide health services to village people through a primary health care strategy consisting of eight components: health education nutrition water and sanitation maternal and child health immunization prevention of locally endemic diseases treatment of common diseases and injuries provision of essential medicines 15

18. Primary Care System 15,000 GPs throughout Myanmar GP defined as a physician working in the private sector to provide curative and other health services to wide range of patients Usually in solo practice These physicians have no post-graduate training, no training in ambulatory care, and virtually no access to CME. 18

19. Medical Education in SE Asia European model Hospital focused Specialty focused Medical school 6 years (now 7 in Myanmar) –2 years basic science –2 years medical science –2 years clinical rotations in medicine, surgery, ob/gyn, pediatrics 19

20. Educational System To practice as GP, one must provide at least one month of government service To pursue specialty training, one must work as a township district officer for three years Existing residencies include Internal Medicine, Pediatrics, General Surgery and OB/Gyn 20

21. Educational System No specialty-equivalent postgraduate program in FM but Diploma of Family Medicine offered One year program, 30 slots per year Under-enrolled due to travel distance, quality and perceived value Taught in major cities exclusively by subspecialist faculty from universities Practical training exclusively in hospital 21

22. Capacity for Primary Care Improvement General Practice Society (and now Myanmar Academy of Family Physicians) under Myanmar Medical Society GPS has offered distance-based CME programs in past through 39 training sites Receiving support from RCGP and other international visitors Distrust between GPS and government 22

23. SWOT Analysis Strengths Weaknesses Opportunities Threats 23 http://en.wikipedia.org/wiki/SWOT_analysis

24. Strengths organized GP Society with substantial membership long-standing reputation of MMA committed technical consultant on the ground efforts at CME already in place several physicians already pursuing advanced training in Malaysia expressed government support from MOH 24

25. Weaknesses weak ties to university and government, with no real foothold within universities relatively weak ties to NLD as well weak connections between GPs in private sector and public sector system nearly all GPs in country without basic competency in many aspects of primary care no clear clinical training infrastructure in place for GPs lack of any systematized incentive for CME or FM post-graduate training 25

26. Opportunities opening up of government new expression of government support heightened interest from NGOs and funders human rights champions active in international scene in leadership of GPS Johns Hopkins pushing for outpatient training of medical students technical consultant on the ground looking for activities and work Emergency Medicine provides a model 26

27. Threats distrust between GPS & government/universities GPS leadership could be at risk for continued close government oversight and surveillance many NGOs competing for attention and resources GPS so firmly established in private sector and outside of public system that it may be difficult to effectively integrate specialists eager to protect private practice turf risk of government shutdown, or alternatively complete government turnover with NLD 27

29. Strategic Objectives - TMMEP Strengthen primary care in Myanmar by preparing primary care leaders for developing and implementing new training programs in primary care and Family Medicine Assist primary care leadership within Myanmar in planning and preparing for the development of Family Medicine as a complete medical specialty Promote public-private partnership and collaboration between primary care leadership and institutions and governmental and academic leaders and institutions 29

30. The Contribution of Family Medicine to Improving Health Systems: A Guidebook from the World Organization of Family Doctors and the World Health Organization. 2 nd Edition, WONCA. Access or first- contact care Comprehensiveness Continuity of care Coordination Prevention Family-orientation Community- orientation Patient-centeredness

31. TMMEP – Key Activities Train a group of General Practitioner (GP) trainers through a training-of-trainers (TOT) program, Establish outpatient clinical training sites for Family Medicine training Develop a Family Medicine training curriculum for private GPs in practice Promote integration with key public and private health care planners, educators and administrators to support collaboration with government and academic institutions 31

32. Evaluation Proposed outputs include: A training-of-faculty course implementation Twenty locally-trained GPS leaders prepared to participate in Family Medicine education Four GPS leaders exposed to primary care system implementation in Taiwan Four ambulatory Family Medicine training centers: three in Yangon and one in Mandalay A strategic plan for primary care system improvement 32