QUALITY HEALTH CARE inCOUNTRIES of FORMER

SOVIET UNION

Malkhaz Jalagonia, MD

Association Esculapius

GEORGIA

PROBLEM STATEMENT

After breakdown of Soviet Union the state of public health has deteriorated significantly in some postsoviet countries due to various reasons, but even before collapse of communist system public health was plagued with different problems.

Learning Objectives

• What is quality health care?

• Identifying some problems with quality health care in FSU countries

• Main causes of these problems

• How to overcome the obstacles?

What Is Quality Health Care?

"Doing the Right Thing at the Right time in the Right way for the Right Person and Having the Best Possible Result" – US Agency for Healthcare Research and Quality. This is one definition of quality health care, but there are many others.

Appropriateness of Health Care

Appropriateness means that required care is provided and unnecessary or harmful care is avoided, so appropriateness is linked with safety.

When does a Postsoviet Person Meet with Inappropriate and

Unsafe Health Care?

You could expect the following answer: soon after BIRTH,

but in fact the correct answer is: before BIRTH.

VACCINATION SAFETY

Vaccines are frequently injected into the buttocks and not in the antero-lateral part of the thigh in children. The injections in the upper outer quadrant of buttocks in children cannot guarantee safety of sciatic nerve.

PREVENTIVE MEDICINE

There is very low priority for preventive medicine in the region. The attention of the policy-makers as well as of the population itself is more directed to curative services.

Surgical Interventions Minor surgical interventions

could be more dangerous than major surgery, because they are mostly performed in primary health care clinics. These facilities are underequipped and also have poor access to electric power needed for proper sterilisation.

Surgical Interventions (cont'd)

Due to shortage of surgical material it is not rare that disposable items (endotracheal tubes, scalpel blades, etc) are reused after cleansing with alcohol. Multiuse Lidocaine bottles are also dangerous because the doctors can insert used needles into them.

Modes of Transmission For Hepatitis B in Georgia

0.9

6.6

10.8

32.4 33.6

15.7

0

5

10

15

20

25

30

35

Modes of Transmission For Hepatitis C in Georgia

2.33

9.712

54.67

21.3

0

10

20

30

40

50

60

Safety of Blood TransfusionsBlood is misused. Most doctors

think that if blood is HIV, Syphilis, Hepatitis B and C negative, then it is microbiologically safe.

Sometimes even blood untested for infectious diseases is used in emergences due to lack of blood bank refrigerators.

Safety of First AidSome first aiders, including

doctors, during CPR press not on the sternum but on the left side of the chest close to the sternum.

Many first aiders use tourniquet instead of direct pressure to stop external bleeding.

Diagnostic ProceduresUpper gastrointestinal endoscopy

and sigmoido/colonoscopy are not safe because the fiberscopes are not usually properly disinfected.

Due to shortage of speculums prenatal and gynecological examinations are also unsafe in some places.

Diagnostic Procedures (cont'd)

The diagnostic centers often do not ask if the procedures were ordered by the doctor. So the patients can undergo tests and investigations on their own will.

The patients often do not receive proper information about diagnostic procedures.

Diagnostic Procedures (cont'd)

Due to poor qualifications and limited experience of X-ray technicians, poor quality of X-ray films and power surges, the X-ray examinations sometimes need to be repeated several times.

Prescribing Habits of the Doctors

• Preference for nonessential and nongeneric medicines

• Many drugs at one time• Expensive ones• New ones• Antibiotics• Vitamins• and of course, injections

DRUG SAFETY

Pharmaceutical market is flooded with counterfeit and poor quality drugs. Only in few CIS countries MOH is willing and able to address the problem adequately.

DRUG SAFETY (cont'd)

The doctors like to prescribe drugs, which "boost" immunity. Some of them are of animal or human origin.

DRUG SAFETY (cont'd)

To decrease health-related costs, patients often bypass doctors and go directly to drugstores, where almost everything could be bought without prescription, except maybe control drugs.

DRUG SAFETY (cont'd)

The outpatients rely mainly on Metamizole (Analgin), NSAIDs and Paracetamol for pain relief. Metamizole has been taken off the market in many countries due to fatal cases of agranulocytosis.

Illness and Family Budget

A 1999 World Bank report identified the illness of a family member as one of the main causes of impoverishment in Georgia (source: "Health Care Systems in Transition: Georgia").

The Main Causes of Problems• Development in isolation • Low priority for health • Shortage and inappropriate use

of resources• Shortage of new reliable medical

information and refresher courses for health professionals

• Widespread use of ineffective diagnostic procedures and treatments

The Main Causes of Problems (cont'd)

• Unrestricted dictatorship of pharmaceutical companies on the market

• Well-developed black market for pharmaceuticals

• Lack of consumer orientation• Frustration, lack of motivation

The Difference between Postsoviet and Western Medical

Concepts Does Also Matter

Due to this gap health professionals in FSU often refuse to accept ideas of western medicine. The main difficulty arises from rejection of evidence-based medicine.

Of course, not. Some ideas of postsoviet or Eastern European medicine are getting acceptance abroad. We can give two examples: use of Neostigmine for Acute colonic pseudo-obstruction (Ogilvie's syndrome) and considering the role of probiotics in the management of Irritable Bowel Syndrome.

Is Everything in PostsovietMedicine unacceptable?

How to overcome the obstacles? First of All We

Should Reinforce Education:

• Refresher courses for health professionals

• Health education for public

POLICY-MAKERS

Thi

s sh

ould

cha

nge

Once More about Quality Health Care

Definition of quality health care by US Institute of Medicine: "The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge".

AcknowledgmentsI'd like to express deep gratitude

to my colleagues and friends (listing is alphabetical) for their help:

Botsvadze Eteri (Georgia) Cunningham Fiona (UK) Fry Catherine (Australia) Jalagonia Maka (Georgia) Jones Terry (Canada) Krebs Verena (Switzerland) Malone Teri (Australia) Revel Jean Pierre (France)