The former Yugoslavian health system was centrally planned and specialists-oriented
with little or no emphasis placed upon patient centred family medicine. Primary
care physicians were mainly performing triage and providing little long term
follow-up of patients. As a result of the 1992-1995 war, basic health infrastructure
was severely damaged and many health professionals experienced severe trauma
or left the country altogether. After years of isolation and much suffering
in Bosnia & Herzegovina (BiH), the international community stepped in and
provided strong support for health care reform. By 1999, the BiH Ministry of
Health established Family Medicine (FM) as a priority, reorganizing the health
care system and reallocating resources to strengthen primary care.
Retraining doctors and nurses in family medicine
In this context, the Swiss Agency for Cooperation and Development (SDC) decided
to support health care reform by financing a training programme for doctors
and nurses. Since 1998, SDC has given substantial financial support to permit
the Geneva University Hospitals (HUG) to organize several training courses in
partnership with Project HOPE Switzerland (now Foundation Partnerships in Health).
The objectives were to upgrade doctors’ and nurses’ knowledge and provide them
with the necessary tools to practice family medicine. Much emphasis was put
on team building and establishing complementary skills to implement patient
centred clinical activities. Initially, general practitioners running their
own practice in Geneva and doctors from the HUG provided most of the teaching
and training for Bosnian colleagues. Soon, training of trainers courses were
initiated so that by year 3 of the programme, all courses were given by local
doctors and nurses. This transfer of expertise had many positive consequences:
the promotion of local expertise and capacity building, the establishment of
a sustainable retraining programme, the reduction of the training costs, the
scaling up of the number of courses given with a substantial increase in the
number of doctors and nurses trained. From a capacity for training 40 participants
in 2000, 250 were trained in 2006. This retraining effort has continued to gain
momentum and led to the development of new concepts in continuous medical education
in family medicine and other health sectors.
The transfer of expertise to motivated and skilled health professionals was
very rewarding and useful. Looking at long term perspectives and the future
challenges of this reform, it was decided to strengthen not only the capacity
of the individual health professionals, but also to invest in local health institutions,
using their expertise to run project components. Since 2001, local institutions
were mandated to organize and manage most training courses. They took charge
of coordinating the courses, including the selection of the trainers and of
the participants, with the support of the health authorities (Ministry of Health
and/or faculty of medicine). Adapting and integrating all of the project's components
into existing structures improved ownership and sustainability of training activities.
Four training centres were created and supervision of the training activities
were decentralised to the municipal level. Since 1998, over 800 doctors and
nurses have been trained in family medicine and accredited by the Ministry of
Health.
From training to implementing family medicine
Soon it became apparent that training alone is not sufficient to change everyday
practice. Despite the growing interest and motivation of health professionals
to attend the family medicine courses, doctors and nurses had difficulty putting
their newly acquired knowledge into practice. From 2001 on, stronger support
was provided to family medicine by the SDC to actually implement what health
professionals had learnt. The project invested in key institutions such as major
medical centres and institutes of public health to promote long term capacity
to implement change. Working groups including all stakeholders were organised
to establish implementation plans, define responsibilities and monitor progress.
This model was first tested in three municipalities and then progressively extended
to others. It increased the coverage of the population by medical services,
reallocated doctors and nurses from various sectors to family medicine services
and trained them. The concept and content of family medicine was also explained
to the local population and promoted to gain their support. In a further step,
inhabitants from specific locations were assigned to family medicine teams.
SDC support allowed the reconstruction of local medical centres and the provision
of the necessary basic equipment. Medical practices were also reorganised to
promote continuity of care by establishing adequate appointment systems, patient
files, telephone advice, patient education and individual or group counselling.
Team building was encouraged by defining task division promoting the role and
responsibilities of nurses, through regular staff meetings. Health promotion
activities and outreach services were also reinforced.
Combining training with the reconstruction and the reorganisation of medical
services was crucial in the overall success of each component of the project.
Soon family medicine activities accelerated. Requests came from different sites
and the geographic zone of project activities expanded considerably. This rapid
scaling-up benefited from other Swiss sources of funding and from BiH public
funds. Project co-financing by local municipalities became almost the rule.
At the beginning or 2007, the project is active in four cantons and three regions
in both entities of BiH in a total of 38 municipalities.
Strengthening local partner institutions
The Paris Declaration provides a strong conceptual framework for local capacity
building. This approach was used by the project. Instead of testing a model
and then transferring it to local partners, local institutions were identified
at an early stage and given responsibilities to assess needs and identify priorities
at their regional or cantonal level. If needed, the necessary technical or organizational
support was provided. Institutions were then formally contracted to implement
the specified activities with responsibilities clearly defined. A total of six
institutions were contracted to start and run projects in community nursing,
palliative care, smoking cessation counselling and continuous medical education.
Exchange of expertise between partners from both entities of BiH was encouraged
to improve the promotion of successful local initiatives and maintain the overall
project coherence.
The impact of these projects was much higher than expected. The commitment
of the contracted institutions and the Family Medicine Implementation project
(FaMI) team was remarkable. Furthermore, through their activities they not only
came to enjoy more visibility, but also gained greater credibility. The Ministry
of Health strongly supported this endeavour by actively promoting the use of
BiH expertise in specific fields. Best practices and models were disseminated
and sometimes adopted by institutions in other geographical locations.
As it enters its final phase, the project is moving towards the creation of
an independent platform, a locally run foundation which will implement projects
funded by national or international organisations. This foundation will serve
as an interface between donors such as the SDC and the health care institutions,
managing projects on its own. During the initial phase, technical and administrative
support will be provided until full independence can be attained.
Conclusion
This project is about building trust between local and international partners.
It is about setting common objectives and sharing responsibilities to contribute
to BiH’s overall health care reform, according to needs identified in the various
locations where the project was active. By mutual strengthening of each others’
capacities through innovative initiatives nurtured by previous international
experience and in-depth knowledge of local specificities, the project has contributed
significantly to the ongoing health care reform process in BiH. After years
of isolation and lack of professional recognition of general practitioners,
change is now seen as an opportunity for gaining expertise and improving the
quality of practice. The health care financing of the reform still needs to
be strengthened to establish a long term sustainable system. But one of the
most important achievements of this project is giving family medicine practitioners
access to knowledge and tools, raising their skills and self-esteem in order
to provide quality care to those who most need it. The local capacity of health
services will thus be reinforced to respond to current and future challenges
in this sector. Improved working conditions will also encourage the local health
work force to stay and actively participate in the rebuilding of BiH health
services.
*Nicolas Perone has been assigned by the Geneva University Hospitals (HUG)
to manage health projects in Bosnia and Herzegovina since 2001. He is currently
working in the community medicine department and primary care of the Geneva
University Hospitals. Contact: nicolas.perone@hcuge.ch.
Sigiriya Aebischer Perone was the medical supervisor of the family medicine
projects in Bosnia and Herzegovina for the HUG since 2001. She is currently
working for the ICRC headquarters in Geneva as a medical advisor. Dejan Sredic
has been working with Médecins sans Frontière since 1995 in humanitarian assistance.
In 2001 he joined SDC health supported programmes as the deputy project manager
of the f Family Medicine Implementation project (FaMI project) in Bosnia Herzegovina.
Contact: dejan@fondacijafami.org.
Louis Loutan is head of the Travel and Migration Medicine Unit at the Department
of Community Medicine and Primary Care and coordinates international health
projects implemented by the HUG. He is the senior medical advisor and coordinator
for the successive family medicine projects in BiH since 1998. Contact: louis.loutan@hcuge.ch
