Content

Strengthening capacity of anaesthesiologists and resuscitation specialists in Kyrgyzstan and Tajikistan


1. Working title for the proposed publication

 ‘Strengthening capacity of anaesthesiologists and resuscitation specialists on maternal health in Kyrgyzstan and Tajikistan through regional expertise and networking’

2. Applicants

Name of German programme(s) submitting this application:
Regional Programme ‘Health in Central Asia’ Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH

Name, title, organisation, email and phone number of main applicant from German Development Cooperation:
Evi-Kornelia Gruber, Director Regional Health Programme in Central Asia, Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH

Name, title, organisation, email and phone number of main applicant from the partner organisation(s):
Dr. Guljan Dshuzumalieva, Chief specialist in resuscitation and anaesthesiology under the   Ministry of Health, Kyrgyz Republic

3. Responsible experts

Name, title, organisation, email of responsible partner expert:
Anara Eshhodjaeva, Head of the management healthcare department at the Ministry of Health, Kyrgyzstan

Dinara Mambetalieva, Head of the resuscitation and intensive care unit, Bishkek city perinatal centre

Name, title, organisation, email and phone number of responsible German Development Cooperation expert:
Cholpon Asambaeva, Team Leader, Regional Health Programme in Central Asia/Kyrgyzstan

Name, title, organisation, email and phone number of the German Development Cooperation staff member who will be our contact for organising the logistics of the writer’s mission in your country, setting up meetings and visits to programme sites etc.:

Aigul Tokocheva, Programme Officer, Regional Programme “Health in Central Asia/Kyrgyzstan”, Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH,

Halima Boboeva, Programme Officer Regional Programme  “Health in Central Asia/Tajikistan" Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH

4. Description of the approach
Describe the approach that the GHPC should document as good practice or promising practice: Which challenge(s) does it address, and how, and what have been the particular contributions of German Development Cooperation.

The challenge

Despite significant achievements in maternal and child health in recent years, both Kyrgyzstan and Tajikistan are struggling to reduce the high maternal mortality rates. In Kyrgyzstan, maternal mortality declined at an average annual rate of only 0.2 per cent between 1990 and 2010, compared with a global average of 3.1 per cent. With a maternal mortality rate of 38.2 deaths per 100,000 live births in 2013, the country is unlikely to meet the national MDG target of 15.7 deaths per 100,000 live births by 2015. In Tajikistan, official statistics place the maternal mortality rate at 33.3 deaths per 100,000 live births, but the World Health Organization estimates that the actual rate may be twice as high.

In both countries, more than half of maternal deaths in recent years are considered to be preventable. Approximately 80 per cent are due to direct obstetric causes, including post-partum haemorrhage, hypertensive disorders, post-partum infections (mainly sepsis) and obstructed labor.[1] Most of these cases have arisen as a result of improper and inadequate Emergency Obstetric Care (EmOC), as well as the lack of access to such services. The quality of EmOC directly affects the process of delivery, as untimely and inappropriate actions during pregnancy complications of pregnancy may pose a threat to the life of a pregnant woman. With early diagnosis of complications and surgical interventions, however, a lethal outcome can often be prevented. The inadequate and belated provision of anaesthetic and resuscitation care is one of the main contributing factors to the high maternal death rates in both countries. 

The main challenges in provision of EmOC in Kyrgyzstan and Tajikistan include:

  • Major shortage of anaesthesiologists and resuscitation specialists in rural areas, aggravated by health worker emigration;
  • Concentration of anaesthesiologists and resuscitation specialists in urban settings due to the lack of motivation and incentives in rural areas;
  • Inadequate system of postgraduate and continuous medical education of anaesthesiologists and resuscitation specialists  (e.g. no training programme focused specifically on EmOC, limited attention to practical skills, teaching not in accordance with international standards);
  • Inadequate referral system among primary health care facilities and secondary and tertiary levels of perinatal care;
  • Low capacity of health staff involved in EmOC (i.e. teams of anaesthesiologists, neonatologists, obstetricians, gynaecologists and midwives) and weak culture of teamwork; and
  • Poor infrastructure and lack of essential equipment.

A number of development partners, including WHO, UNICEF, UNFPA, USAID and GIZ, have committed themselves to support the Ministries of Health and national partners in both countries to improve the quality of EmOC through:

  • The development and introduction of legal regulations, standards, clinical guidelines and protocols, and tools for routine monitoring of EmOC; and
  • Quality management improvement of EmOC services and supply of essential resources for the provision of EmOC;

The approach

The GIZ regional programme ‘Health in Central Asia’ supports the Ministries of Health in Kyrgyzstan, Tajikistan, and Uzbekistan to implement national strategies and policies, with a particular focus on reproductive health. In 2012 the programme began to implement capacity building measures on EmOC for anaesthesiologists and resuscitation specialists from Kyrgyzstan and Tajikistan, in line with the respective governments’ strategies to improve maternal health. At the heart of the approach was the innovative idea to build upon regional knowledge and expertise by engaging the services of specialists from the National Perinatal Centre in Uzbekistan who have been part of a successful nationwide effort to improve the skills of anaesthesiologists and resuscitation staff in that country.[2]

The capacity development measures supported by GIZ are aimed to improve emergency services to women with complicated deliveries. The approach is modelled on the Uzbek experience and is focused on building the practical skills of Kyrgyz and Tajik anaesthesiologists and resuscitation staff and on developing clinical guidelines, standards and protocols on EmOC for the application in Kyrgyzstan and Tajikistan. Activities conducted to date have included:

  • A rapid assessment of EmOC in Kyrgyzstan and Tajikistan, conducted by Uzbek experts, to revel challenges and training needs;
  • The development of a 6-day training curriculum on EmOC for anaesthesiologists and obstetrician/gynaecologists by a working group of Uzbek, Kyrgyz and Tajik colleagues;
  • A practical training programme, facilitated by Uzbek experts and trainers, for 50 Kyrgyz and Tajik specialists in anaesthesiology and intensive care, focused on the team-based provision of EmOC.
  • A 10-day study tour to the Republican Perinatal Center in Uzbekistan for a group of 10 Kyrgyz anaesthesiologists and obstetrician/gynaecologists, including training and practical sessions on the management of anaesthesia during surgery, respiratory support and the rational use of medicine and equipment. 
  • Practical trainings for specialists from maternity facilities in both Kyrgyzstan and Tajikistan on key clinical practices, with a focus on team work and resolving clinical situations.      

The second phase of the approach will be implemented between now and December 2015. In Kyrgyzstan, activities will focus on sustainability: preparing a cadre of qualified Kyrgyz trainers (anaesthesiologists and obstetrician/gynaecologists) who can provide ‘cascade on-the-job trainings’ to colleagues at the national level; improving the existing postgraduate training programme for anaesthesiologists, obstetricians/gynaecologists and intensive care specialists in the country; establishing an EmOC training and resource centre for continuous education at the national level; advising the Ministry of Health on a national mentoring system for anaesthesiologists and intensive care specialists; and developing a monitoring and evaluation system which facilities can use to assess the quality of EmOC services.

In Tajikistan, the focus will be on preparing a group of Tajik EmOC trainers; undertaking a monitoring and quality assessment of EmOC in the country; integrating the EmOC training curriculum for anaesthesiologists and obstetrics/gynaecologists into Tajik medical training institutions; and supporting the development and adaptation of local clinical protocols and standards on anaesthesia and resuscitation in obstetrics care.

The leading specialists in anaesthesia and resuscitation in obstetrics care in both countries under the leadership of the MoH have been working jointly, as a team, in capacity development measures. By supporting measures in the above areas, the Programme has enhanced their skills and increased the demand for sustaining and improving EmOC measures.

Arguments why this approach should be documented in the GHPC

Describe in what ways this approach is

  1. innovative;
  2. ‘state of the art’ in its field;
  3. relevant to the priorities of German Development Cooperation (you may want to refer to sector strategies, position papers etc.) and contributes to raising the international profile of German Development Cooperation;
  4. in accordance with the other GHPC criteria of transferability to other contexts, participation and empowerment, gender-sensitivity, sustainability

GIZ’s approach to build the capacity of anaesthesiologists and obstetric/gynaecologists in Kyrgyzstan and Tajikistan is innovative in a number of ways. First, it draws upon regional expertise which is relevant, available and cost-effective. Kyrgyzstan, Tajikistan and Uzbekistan are facing many similar challenges in their efforts to reduce maternal deaths; they also share a common language and historical legacy as former Soviet republics. Following a series of lengthy discussions, GIZ secured agreement from all three Ministries of Health to support this transfer of regional expertise – the first time such an approach has been endorsed in the area of EmOC.

Second, the approach not only focuses upon improving health workers’ clinical skills, but also focuses upon thorny issues of workplace processes and culture. The failure of various specialists – anaesthesiologists, neonatologists, obstetricians/gynaecologists and midwives – to work together as teams to address complicated deliveries is a major contributing factor to maternal deaths. The GIZ approach seeks to demonstrate the potential of teamwork to produce better maternal health outcomes.

Third, the approach lays the groundwork for long-term changes by working at multiple levels (i.e. from training for specialists to promoting clinical guidelines and improvements in the system of medical education) and by establishing a regional network of qualified specialists who can share their expertise with others.

The approach is relevant to the priorities of German Development Cooperation, most notably the BMZ’s ‘Initiative on Rights-based Family Planning and Maternal Health,’ which aims to strengthen health systems in partner countries with high maternal and child mortality rates. In the GDC sectoral paper, special attention is focused on improving the availability and quality of sexual and reproductive health (SRH) services, including better access to perinatal obstetric care and emergency obstetrics; improving the quality of SRH services through training for obstetric/gynaecological health professionals; and taking into account evidence-based methods and ensuring work of medically appropriate quality. In terms of content, the programme is aligned with the position papers Sexual and Reproductive Health and Rights, and Population Dynamics (August 2008).

The GIZ programme makes a direct contribution to securing basic social services as one of the three priorities specified by BMZ in its Central Asia strategy (2005). The programme implements major elements of the paper, including a commitment to better networking of existing bilateral projects, transfer of knowledge and experience, and cross-border exchanges between experts and other partners. The related transfer of knowledge and experience may influence other areas of relevance to development policy and provide incentives for political and economic modernisation. The cross-boundary exchange between expert staff and relevant groups of actors as promoted by the strategy may ‘contribute to reducing political tension between individual countries and have a direct crisis prevention effect’.

The approach is well-aligned with the Kyrgyz and Tajik governments’ strategies and frameworks for improving maternal and child health. In Kyrgyzstan, these include the Den Sooluk national health reform programme (2012-2016), which highlights MCH as a priority area, and the MDG Acceleration Framework, which aims to identify and overcome bottlenecks to achieving MDG5 (such as the availability of high-quality EmOC). In Tajikistan, the approach supports the national plan on safe pregnancy, as well as the implementation of evidence-based approaches to care during pregnancy, labour and delivery which the Ministry of Health promotes countrywide.

The approach described here is also aligned with other GHPC criteria. It is:

  • Transferrable: The idea of drawing upon relevant regional expertise could be an effective and cost-effective solution in other settings and in relation to other health issues.
  • Participatory and empowering: It seeks to empower anaesthesiologists to think about their jobs differently, to work more closely with obstetric/gynaecological colleagues, and to benefit from and contribute to the growing regional expertise on EmOC. Many aspects of the approach are participatory, including the creation of working groups of different health specialists to develop clinical protocols and guidelines.
  • Gender sensitive: The approach is explicitly aimed at reducing the number of preventable deaths among pregnant women, and also promotes active male involvement in safe motherhood through the support and care for pregnant and delivering women. Care was taken to ensure that all capacity building measures included the equal participation of male and female health professionals.     
  • Sustainable: Many of the measures are aimed at the sustainability of the approach, including the introduction of clinical guidelines and protocols with application at the national level; changes in the medical education system; and the development of regional training expertise and professional networks across three countries. The approach is also well-harmonised with existing efforts, thereby avoiding duplications and the use of parallel structures. 
5. Evidence on results and scaling up
What documented evidence on outputs, outcomes and impact is available to show that this approach is effective? Can you show that it has been scaled up to cover a significant proportion of the partner country’s population?

List all internal monitoring and evaluation reports, external evaluations and other studies that provide evidence for the effectiveness of this approach and summarize the results that they found. Also, please explain how long this approach has been implemented and to what level/coverage it has been scaled up.

Capacity development measures on EmOC for anaesthesiologists and resuscitation specialists have been focused at the national level in both countries with the active involvement of leading health professionals from key maternity and perinatal centres. More than 150 anaesthesiologists and resuscitation staff have been equipped with sound knowledge and skills in EmOC management and have gained training skills, which has allowed them to conduct on-the job trainings at facility level for a large number of non-trained anaesthesiologists. They now do this with the active involvement of obstetricians/gynaecologists, who have begun working in intensive care units as one team.

There is already some indication that the number of facilities using regional anaesthesia for Caesarean deliveries in Kyrgyzstan is growing as a result of GIZ’s interventions.  While in 2011 it was only used at private clinics and a few public maternity hospitals, by 2014 more than 10 out of 53 facilities (18%) used it.[3]

Another notable result is that intensive care in relation to the main obstetric emergencies (pre-eclampsia, haemorrhage, sepsis) is now being conducted according to accepted clinical protocols and guidelines.

New clinical protocols and recommendations for EmOC, developed on the basis of Uzbekistan’s practical guidelines by a regional working group of anaesthesiologists and obstetrician/gynaecologists, have been adopted in both Kyrgyzstan and Tajikistan. In Kyrgyzstan, the Ministry of Health has approved them as mandatory clinical protocols; in Tajikistan they serve as clinical recommendations. Also in Tajikistan, a training package on EmOC for anaesthesiologists was developed and approved by the Ministry of Health, and integrated into the medical education system; a group of leading health professionals from pilot regions was already trained using the approach.

Practical trainings on the use of medical equipment in EmOC, simulations of emergency cases, and mentoring at the facility level have enhanced the knowledge and skills of anaesthesiologists and created a huge demand to sustain these measures at the national and regional level. Based on the feedback from the MoH and MCH partners, there exists a great interest to continue capacity development measures on EmOC for anaesthesiologists and obstetric/gynaecologists and to institutionalise it further at the national level. The innovative approach developed and tested by the programme will be included in national policies and implemented countrywide. In both countries a partnership agreement has been reached with UNFPA, UNICEF and USAID to introduce EmOC training for anaesthesiologists nationwide.

These achievements were discussed and profiled at a national forum entitled ‘Towards Achieving the MDGs 4 and 5 in Kyrgyzstan,’ held in Bishkek in June 2014, which included the participation of Tajik and Uzbek anaesthesiologists as well as Kyrgyz officials, development partners and MCH partner organisations.

Measuring results

The approach described in this proposal has been implemented since 2012 and most achievements to date are at the output level. In the longer term, four indicators will be used to measure the results of the approach by the end of 2015[4]:

  1. Reduction in percentage of women requiring blood transfusion for treatment of post-partum haemorrhage;
  2. Increase in the proportion of Caesarean deliveries performed with regional anaesthesia;
  3. Increase in the number of natural deliveries among women with severe hypertensive disorders; and
  4. Increase in the proportion of facilities using regional anaesthesia for Caesarean deliveries (target: from 15% to 30%)  

There is a set of indicators developed for each clinical standard and protocol that will help to measure and evaluate quality of EmOC provided by anaesthesiologists and resuscitation staff at facility level. At each facility, an internal monitoring and quality assessment system will be developed and introduced by a quality assurance multidisciplinary team (managers, obstetricians/gynaecologists, leading anaesthesiologists, midwife, nurse, etc.) who will monitor the quality of services against the indicators. At the national level a team of certified trainers (anaesthesiologists and resuscitation staff, obstetricians/gynaecologists) will visit facilities twice a year to mentor and coach on EmOC. This will be supported by Development Partners (UNFPA, GIZ, and UNICEF) and coordinated by the MoH[5].

6. Photo and film material
What kind of photo and film material is available for the documentation? If selected for documentation, you will be requested to provide 15-20 high resolution photographs of your programme context and your programme in action.

Within the GIZ health programme we could provide the photos of capacity development measures on EmOC for anaesthesiologists and resuscitation specialists from the:

  • Study tour of Kyrgyz health professionals to Uzbekistan, May 2013;
  • Practical trainings for specialists from maternity facilities in both Kyrgyzstan and Tajikistan on key clinical practices, with a focus on team work and resolving clinical situations, 2013-2014;
  • National Forum “Towards achieving MDG 4 and 5”, June 2014;
  • Programme website - in English: http://health-centralasia.org/en/
  • Publications in programme infochannel of GIZ website;     
7.  Supplementary materials
Which didactic or operational materials (manuals, guides, IEC materials, protocols etc.) can be made available for download as part of an online toolbox to accompany the publication?

Within the GIZ health programme we could provide the following products of capacity development measures on EmOC for anaesthesiologists and resuscitation specialists:

  • Training manual for participants on intensive care and anaesthesia in EmOC, Uzbekistan, 2010 (in Russian);
  • 6-day training introductory curriculum on EmOC for anaesthesiologists and obstetrician/gynaecologists developed by a working group of Uzbek, Kyrgyz and Tajik experts, 2013 (in Russian);
  • Clinical Protocols on EmOC for anaesthesiologists, resuscitation specialists and obstetrician/gynaecologists in Kyrgyzstan, July 2014 (in Russian);
  • Clinical recommendations on EmOC for anaesthesiologists and resuscitation specialists and obstetrician/gynaecologists in Tajikistan, June 2014 (in Russian);
  • Training package on EmOC (training program, training manual for participant and trainer, evaluation forms) for anaesthesiologists, resuscitation specialists and obstetrician/gynaecologists, Tajikistani, August 2014 (in Russian);
  • Presentations of trainings, conferences and regional events on EmOC for health professionals,  2013-2014 (in Russian and English);
8. Indicative itinerary for documentation
Which itinerary and schedule would you recommend for the writer who will visit your programme to do the necessary journalistic research for this GHPC report? Whom should he or she meet and interview? Which sites should he or she visit?

Kyrgyzstan:

Name of organizations

Contact person

Duration

Ministry of Health, health care management department

Anara Eshhodjaeva, Head

1 hour

Professional association of anaesthesiologists and resuscitation specialists of Kyrgyzstan, NGO

Members of the associations actively involved into GIZ measures 

3 hours

Bishkek city Perinatal Centre

Dinara Mambetalieva, head of Intensive Care Unit 

0,5 day

Chuy oblast maternity hospital

Lilya Kiyzbaeva, head of Intensive Care Unit 

0,5 day

Resource Center on EmOC for anaesthesiologist and resuscitation specialists

Head of the Resource Centre

3 hours

Department of anaesthesiology and intensive care of continuous medical education institute

Head of the department

2 hours

Development partners (UNFPA, UNICEF)

Programme staff

2 hours

TOTAL

 

3 days + 2 days travelling

 

Tajikistan:

Name of organizations

Contact person

Duration

Ministry of Health, Maternal and Child health department

Head

2 hours

Dushanbe city maternity hospital 

Head of Intensive Care Unit 

3 hours

Sogd oblast maternity hospital

Head of the Intensive Care Unit 

1 day (in-country traveling)

Department of anaesthesiology and intensive care of continuous medical education institute

Head of the department

3 hours

Development partners (UNFPA, UNICEF, USAID)

Programme staff

2 hours

TOTAL

 

3 days + 2 days travelling

 

9.  Publication audiences and languages

At which occasions, to which audiences and in which language (in addition to English) would your partner organisation and you like to distribute the publication? Name upcoming conferences and routine events and information channels through which you hope to distribute the publication. Please note that we will contact you some months after the publication date to find out whether you were able to distribute the report as planned.

The distribution of the publication will be at the different levels (in English and Russian):

Policy level

  • During the annual Ministry of Health national conferences and events on Maternal and Child health in all three countries (e.g. Perinatal Forums, Conferences on Confidential Enquiry into Maternal Death, conferences and events of the professional association of anaesthesiologists and resuscitation specialists, etc.);   
  • During the joint annual review meetings on implementation of health sector programme in Kyrgyzstan (SWAp mechanism) and Tajikistan (JAR mechanism); 

Service delivery level including continuous medical education system

  • At pilot maternity hospitals and Perinatal Centres in all three countries;
  • At department of anaesthesiology and intensive care of qualification improvement  and continuous medical education institutes in Kyrgyzstan and Tajikistan;

GIZ health programme (in English and Russian)

  • Programme website: http://health-centralasia.org/
  • GIZ Intranet
  • Programme Fact Sheet on best practice of the regional measures;
  • SN HESP, Task Team 5: Hospital Management, Quality Improvement;
  • Programme evaluation;

Target Audience:

  • Ministry of Health key decision makers;
  • Members of professional association of anaesthesiologists and resuscitation specialists;
  • Heath professionals in EmOC;
  • Development Partners;
  • GIZ management and national staff in all three countries;   
  • GIZ HQ;

Footnotes:

[1] MDG Acceleration Framework, Improving Maternal Health in the Kyrgyz Republic, November 2013

[2] Over the period 2008-2012 more than 600 Uzbek anaesthesiologists were trained with the support of UNFPA, a mentoring system was established at the national level, and a new training module on Anaesthesia for Emergency Obstetric Care (developed at the University of California) was integrated into the country’s training institutions. With financial support from the Asian Development Bank, more than 190 maternity and perinatal centres were renovated and equipped with modern and essential equipment. As a result of these measures, clinical protocols on EmOC for anaesthesiologists were developed and introduced into routine practice; the proportion of Caesarean section deliveries taking place under regional anaesthesia rose to 45% countrywide; and the knowledge and practical skills of anaesthesiologists in dealing with the main EmOC challenges, including hypertensive disorders, sepsis and obstetric haemorrhage, increased significantly.

[3] Full anaesthesia during Caesarean deliveries was a more suitable approach in past and this is an example of how medical education has not been following international norms. Regional anaesthesia is the WHO recommendations on Safe Motherhood programme, one of the leading and priority programme in Central Asia. Regional anaesthesia has become the preferred technique for Caesarean delivery. Compared to general anaesthesia, regional anaesthesia is associated with reduced maternal mortality, the need for fewer drugs, and more direct experience of childbirth, faster neonatal-maternal bonding, decreased blood loss and excellent postoperative pain control through the use of neuraxial opioid. This is the approach to change the routine practice according to the WHO recommendations and international standards.

[4] It is not possible to provide clear data on progress regarding maternal deaths at national/regional or facility level that could be archived by GIZ programme by the end of 2015. Therefore, in the longer term the programme include four indicators that will be used to measure the results of the approach.

[5] Summary of annual reports of the health facilities, internal partners data, interviews of health professionals and progress reports of Development Partners will be used to provide evidence for the effectiveness of this approach.   



 

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