Family medicine in Bosnia & Herzegovina

From training to sharing expertise and capacity building

Von Nicolas Perone, Dejan Sredic, Louis Loutan & Sigiriya Aebischer Perone / Hôpitaux Universitaires de Genève

In the wake of the Balkan war, Bosnia & Herzegovina embarked upon an ambitious health sector reform. The Swiss Agency for Cooperation and Development was quick to offer support for this process of rebuilding and reorganization which underpins a paradigm shift towards family medicine. Financial support was used to facilitate training courses to upgrade doctors’ and nurses’ knowledge in family medicine. Additional efforts were made to build institutional capacity and ensure local expertise lay at the heart of suggested areas of change and improvement. The involvement and commitment has been extremely positive, with additional spin-offs of team-building and joint learning serving to encourage the local health work force to stay and actively participate in the rebuilding of BiH health services.

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