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UZBEKISTAN –USA: MAKING A BRIDGE Dr. Nadira B. Muratova, M.D., MHA., PhD. FSU COM September, 29 2011
UZBEKISTAN –USA:
MAKING A BRIDGE
Dr. Nadira B. Muratova,
M.D., MHA., PhD.
FSU COM
September, 29 2011
2
STRUCTURE OF PRESENTATION
Brief overview of the Fulbright program
General information about Uzbekistan
The most famous doctor from Oriental Renaissance
Uzbekistan Health care system
Inheritance from Former USSR
Healthcare reforms and achievements
Medical Education
Future goals
THE FULBRIGHT PROGRAM
After World War II, Senator J. William Fulbright, from
the state of Arkansas, sponsored the legislation that
laid the foundation for the Fulbright Program.
President Harry S. Truman signed it into law on
August 1, 1946.
Subsequent laws have refined and expanded the
program
3
BASIC GOAL
to promote mutual understanding
between the people of the United
States and the people of other
countries
4
THE OBJECTIVES & STRATEGY
TO ACHIEVE
THE MUTUAL UNDERSTANDING
―Beyond the academic and professional pursuits, we
encourage scholars to live the goals of the Fulbright
Program by learning about the United States—its
society, customs, history and culture—and sharing
knowledge about their own country with Americans.
Your dedication to cultural exchange contributes to the
ongoing realization of the Fulbright Program’s goal of
mutual understanding.‖
5
FULBRIGHT GRANT CATEGORIES
The Fulbright U.S. Scholar Program sends
approximately 1,100 American scholars and
professionals per year to approximately 125 countries,
where they lecture and/or conduct research in a wide
variety of academic and professional fields.
The Fulbright Specialist Program, a short-term
complement to the core Fulbright Scholar Program,
sends U.S. faculty and professionals to serve as expert
consultants on curriculum, faculty development,
institutional planning and related subjects at overseas
academic institutions for a period of 2 to 6 weeks.
6
FULBRIGHT GRANT CATEGORIES
The Fulbright Visiting Scholar Program provides
grants to approximately 850 foreign scholars from
over 95 countries to lecture and/or conduct
postdoctoral research at U.S. institutions for an
academic semester to a full academic year.
The Fulbright Scholar-in-Residence (SIR) Program
enables U.S. colleges and universities to host
foreign academics to lecture on a wide range of
subject fields for a semester or academic year.
Preference is given to institutions developing an
international agenda and/or serving a minority
audience, Approximately 50 grants are awarded
annually.
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RELATED FULBRIGHT PROGRAMS
The Fulbright U.S. Student Program offers fellowships
for U.S. graduating college seniors, graduate students,
young professionals and artists to study abroad for one
academic year.
The Fulbright English Teaching Assistantships (ETA)
Program, an element of the Fulbright U.S. Student
Program, to improve foreign students’ English language
abilities and knowledge of the United States, and
enhance US scholars language skills and knowledge of
the host country.
8
RELATED FULBRIGHT PROGRAMS
The Fulbright Foreign Language Teaching Assistant
(FLTA) Program, a component of the Fulbright Foreign
Student Program, provides young teachers of English as
a Foreign Language the opportunity to refine their
teaching skills and broaden their knowledge of American
culture and customs while strengthening the instruction
of foreign languages at colleges and universities in the
United States.
The International Fulbright Science and Technology
Award, a component of the Fulbright Foreign Student
Program, is for doctoral study at prestigious U.S.
institutions in science, technology, engineering or related
fields for approximately 40 outstanding foreign students
per year. 9
10
UZBEKISTAN
11
Location of Uzbekistan
12
Border countries: Afghanistan, Kazakhstan,
Kyrgyzstan, Tajikistan, Turkmenistan
Florida’s area
is 65,755 square miles (170,305 km2)
Uzbekistan’s area:
total: 447,400 km² (in 3 times more than Florida) land: 425,400 km² water: 22,000 km²
Population - about 28 mln. people
Population of ≈18,800 mln. people
14
POPULATION
GENERAL OVERVIEW ABOUT
UZBEKISTAN
16
THE GREAT SILK ROAD
The Silk Road is the network of trade routes across the Asian continent connected
East, South, and Western Asia with the Mediterranean world, as well as North, East
and Northeast Africa and Europe for almost 3,000 years.
17
18
TASHKENT –
THE CAPITAL OF UZBEKISTAN
19
TASHKENT THE CAPITAL OF UZBEKISTAN
20
FAMOUS CITIES
SAMARKAND
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BUKHARA & KHIVA
FAMOUS CITIES
22
THE MOST FAMOUS DOCTORS’ NAMES
OF THE ORIENTAL RENAISSANCE
ABU BAKR MUHAMMAD BIN
ZAKARIA AL RAZI (10th century AD)
ALI IBN ABBAS MAJUSSI AHWAZI
(?-994 )
ABU ALI IBN SINA (AVICENNA) (980 – 1037)
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ABU ALI IBN SINA (AVICENNA) (980 – 1037)
Medicine and pharmacology
Astronomy and astrology
Chemistry
Earth sciences
Physics
Mathematics
Avicennian philosophy
THE CANON OF MEDICINE
It was the main textbook for doctors in Asia
& Europe during 500 years.
The Canon consists of 5 books:
Book 1 – Theory of Medicine. It is divided to
four chapters – 1) Definition of Medicine; 2)
Nosology and diseases; 3) How to save a
health (Health prevention and prophylaxis) 4)
Methods of treatment .
Book 2 – Pharmacology, with descriptions,
preparation recipes, keeping and storing rules &
conditions, rules of prescription & dosages of
811 drugs and medicines from plants &
minerals 24
THE CANON OF MEDICINE
Book 3 Pathology & Therapy of
different diseases with
Topographic Anatomy
Book 4 included chapters on the
Surgery, the Traumatology, the
Fever and Poisons.
Book 5 included the descriptions
of ―complicated‖ medicines,
poisons and antidotes
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BEFORE & AFTER REFORMS
HEALTH CARE SECTOR:
HEALTHCARE SYSTEM,
INHERITED FROM
FORMER USSR
STRUCTURE
Well organized sanitary control system
Well organized vaccination system & preventive work against infection diseases
Huge, but not very efficient system of non-infection diseases prevention
28
EDUCATION AND HUMAN
RESOURCES ALLOCATION
SYSTEM High number of physicians
High number of physicians in hospital division
Mandatory (compulsory) allocation of young doctors to
remote areas with lack of workforce, especially for
deficient specialties
Education was provided on 3 stages:
– undergraduate,
– post-graduate,
– CME 29
30
COMPARATIVE DATA OF MEDICAL STAFF
PROVISION (WHO data, Density per 1000 of population)
US UK UZB Nicaragua India
Nurses 9.82 10.3 10.81 10.7 1.3
Physicians 2.67 2.74 2.62 3.7 0.6
Ratio 3.68 3.76 4.13 2.89 2.17
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Source: The World Health Report 2006 http://www.who.int/whr/2006
* - Countries where System of General Practitioners/Family Doctors is already implemented
MANAGEMENT & FINANCE
Health care was organized, planned and managed centrally.
State budget for all system
Universal coverage, with almost no charges to the patient at the point of access.
Allocation of finance and recourses was under responsibility of Ministry of Finance & Government Planning Ministry (GosPlan) and supervision of Ministers Council (Soviet of Ministers)
32
MANAGEMENT & FINANCE
High number of hospital beds
Long stay of patients in hospitals
Comprehensive data-collection system
Well-developed drug distribution system
33
ISSUES AFTER INDEPENDENCE
Double burden of diseases:
– High prevalence as non-infection diseases, such as stroke, AMI, cancer
– As well infection diseases: diarrhea, infection pulmonary diseases, increasing incidence of hepatitis, Tb & etc.
Increasing of IMR & MMR
Low access to healthcare services, especially in rural areas
34
ISSUES AFTER INDEPENDENCE
Lack of all kind of recourses in healthcare sector & inefficient use of available ones (finances, workforce, etc) on the all level of management
No experience in market economy and management in modern market conditions
Drain of qualified doctors from healthcare:
immigration,
migration,
movement to other well paid economic sectors,
abolishment of mandatory allocation system for young doctors
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DEMOGRAPHY
AND HEALTH
STATISTICS
36
DEMOGRAPHY
Region Population
(millions)
Births per
1000
Population
Deaths per
1000
Population
Rate of
Natural
increase (%) IMR
Total
Feritility rate
UZB 28.1 23 5 1.8 48 2.8
US 309.6 14 8 0.6 6.4 2
South
Central
Asia 1,755 24 7 1.6 55 2.8
LESS
DEVELOPED
(excl. China) 4,318 25 8 1.7 54 3.1
MORE
DEVELOPED 1,237 11 10 0.2 6 1.7
WORLD 6,892 20 8 1.2 46 2.5
37
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Peak rate in Uzbekistan was in 1992 - 52.8 maternal deaths per 100 000 live births
In 2006 – 30.8 maternal deaths per 100 000 live births
BIRTHS BY AGE OF MOTHER
6.7 5.7 5.2 4.9 4.7 4.2 3.6
76 83.6 82.7 83.4 82.9 82.2 82.5 84.3
11.9 9.7 11.6 11.4 12.2 13.1 13.3 12.1
12.1
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
1995 1998 2000 2001 2002 2003 2004 2005
31-35 & >
20-30
Under 20 years
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THE MORBITY RATE
(to 100 000 population)
40 0 5000 10000 15000 20000 25000
Oncology
ENT
Psych. Dis
Infect. Dis
Ophtal. Dis
Neurolog. Dis
CVS dis
Urologic dis
Endocrin. & metabolic dis
Gastroenterol. Dis
Respir. Sys did
Hematologic. Dis
THE MORTALITY RATE CAUSED BY INFECTIOUS
AND NON-INFECTIOUS DISEASES (to 100 000 population)
41 0.0 100.0 200.0 300.0 400.0 500.0 600.0 700.0 800.0
Circuatory sys.
IHD
CVA
Cancer
Respiratory sys.
Infec.¶sit. dis.
Liver cirrhosis
Endocrine, nutr.& metab. Dis.
DM
Tb
KEY OBJECTIVES OF GOVERNMENT
REFORMS IN HEALTH CARE SERVICES (1998-2005)
To develop emergency health care (free of charge)
To improve child and maternal health (free of charge)
To provide accessibility of primary health care (development of general practice) (free of charge)
To reform undergraduate and post-graduate medical education and develop system of general practitioners preparation
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KEY OBJECTIVES OF GOVERNMENT REFORMS
IN HEALTH CARE SERVICES
(2003-2015)
To develop private sector in health care services to reduce the public share of health care financing, exploring additional resources
To fund the health care system and decentralizing and enhancing resources
To allocate properly existing resources (financial, human, medications & etc.)
To make available to population qualitative specialized care with the use of contemporary medical technologies (reform of tertiary healthcare)
To achieve full financial sustainability of high specialized (tertiary level) facilities
To improve CME (continued medical education) 43
HEALTH CARE REFORMS
& ACHIEVMENTS
STRUCTURE OF HEALTHCARE
45
HEALTHCARE
PUBLIC HEALTHCARE
PRIVATE HEALTHCARE
PARALEL HEALTHCARE (NATIONAL COMPANIES’ FACILITIES, MINISTRIES’ FACILITIES)
THE ADMINISTRATION & FINANCE STRUCTURE
OF PUBLIC HEALTHCARE SYSTEM
Province’s
Healthcare Providers
Referral system
for patients
Administration
Financing
Government
budget
Ministry of Health Ministry of Finance
Cabinet of Ministers
PRESIDENT
Province’s
Finance
Division
District’s
Finance
Division
Republican (National)
Healthcare Providers
GPs GPs GPs GPs
District’s
Healthcare Providers
Province
healthcare
administrative
division
District healthcare
administrative
division
LEGEND
HEALTH CARE DELIVERY & REFOMS
IN RURAL AREAS
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1224 outpatient polyclinics
13 regional hospitals
163 central disrtict (county)
hospitals
23 disrtict (county) hospitals
321 rural community hospital
619 rural medical centers
5251 feldsher-midwifery points
Republican facilities
OLD STRUCUTRE NEW STRUCUTRE
a Most of the rural hospitals will be closed or reorganized, but some will most likely remain in remote areas such as mountains and semi-desert
regions.
b Most of the feldsher–midwifery posts will be closed or reorganized, but some will remain in remote areas.
Rural medical centers (SVPs)
13 Regional hospitals
Central disrtict hospitals (CDHs)
feldsher-midwifery points
Republican facilities
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RURAL DOCTORS’ POINTS
SVP (II type)
SVP (III-d type)
49
RURAL DOCTORS’ POINTS SVP’s laboratory
SVP’s laboratory
50
Another main priority of health
care reforms is development of
Republican Emergency Health
Care Service, which is free of
charge for everybody
Namangan branch Syrdarya branch
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Republican Research Centre of Emergency Medicine
Province branch (hospital)
Emergency unit in Rural District (County) Hospital
GPs
THE STRUCTURE OF EMERGENCY HEALTH
SERVICE IN THE REPUBLIC OF UZBEKISTAN
13 branches
in each province
163 branches
in each district
Emergency Health Care Service works very closed with Sanitarian Aviation Services. In cities
and towns Ambulance service “03” is working also.
In rural areas this Ambulance service is included to CDH structure (Central District Hospital).
Head institution
in Tashkent
≈ 2000 rural doctors
points
BASIC BENEFITS PACKAGE
Emergency health care
Health care services for some “socially significant and hazardous” conditions
Child and maternal health care
Primary health care (general practice & hospital care on the district level)
Specialized care for groups of the population classified by the Government as vulnerable (Law for Health Protection, Republic of Uzbekistan 1996) (12 categories)
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MEDICAL EDUCATION STRUCTURE
Post-graduate education
Master degree study - 2- 3 years
Under-graduate education :
General practitioner - 7 years
• Pediatrician - 7 years
• Preventative medicine and Hygiene specialist - 6 years
• Dentist - 5 years
•Nurse with higher education– 3 years
Academic lyceum
- 3 years
Medical college - 3 years
Secondary school - 9 years
Higher
education:
Second level
Secondary
Specialized
Education
Secondary
education
Higher
education: First level
CONTINUED MEDICAL EDUCATON
54
EDUCATION & WORKFORSE
ALLOCATION
Actually residenceship and internship are absent for most
graduates of medical institutes (officially 6-7 years of
undergraduate school are considered as analog of internship)
– Post graduate education is only in Master degree course and
clinical ordinature (institution something between the
Residenceship and Master degree course in the past) and
available only for about 40% of graduates
Lack of young doctors, especially in rural areas
No effective economical motivation to work in rural areas for
healthcare specialists, especially general practitioners and
doctors for district hospital, including Image and lab
specialists
It was dismissed in 2000. Since 2008 the new Order on primary and
secondary specialization, including changing status of the Clinical Ordinature
has been launched
TIPME had been established in 1932.
Main goal was to update professional skills and knowledge
of the specialists and to give second specialization for
professionals from all over Central Asia and Eastern
Siberia
FORMAL CME IS PROVIDED BY TIAME
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THE MAIN PROJECTS & NATIONAL
PROGRAMS IN HEALTH CARE SECTOR
57
Primary health care development (since 1998)
Emergency health care development (since 1998)
Maternity & childhood health care development (since 1998)
National Tb. Controlling Program (DOTS, since 2000)
National AIDS Controlling program (since 2003)
National Blood Transfusion Controlling program (since 2003)
National Program of iron fortification (since 2004)
National program on iodine supplementation
58
CHALENGES
FOR FUTURE
IMPROVEMENT
& REFORMS
59
Neither social nor private health insurance systems for most of population
Improvement of quality of medical services in all levels
Improvement of quality of medical education and effectiveness of system of human recourses allocation, especially for rural areas
Implementation of modern management, including financial management principals and approaches
Health promotion & improvement of general population’s knowledge & health education
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Strange, is it not that of the myriads who
Before us passed the door of Darkness
through,
Not one returns to tell us of the Road,
Which to discover we must travel too.
THANK YOU FOR ATTENTION!
THE QUESTIONS & COMMENTS ARE
WELLCOME!!!
