The report on development of community-oriented primary care training for family physicians

1. Summary

In 2004 work has been progressed in two major ways: development of COPC curriculum and training trainers for COPC curriculum implementation and start of model intervention. Start of hepatitis C model intervention in Pontonnaja village brought about unexpectedly high prevalence results (9% (95%CI=6.2-11.8%)). Preliminary analysis results show that the epidemics could be connected to health care transmission. More studies are necessary to prove or disprove this hypothesis and start appropriate control measures. This intervention, implemented by family physicians with expert help is a good illustration of major COPC concept – population thinking and approach to health problems in the community. The COPC curriculum that will help family physicians to gain understanding and get tools for population approaches to health care in community has been developed in 2004 after several draft versions discussions among Russian and Finnish experts. To help in training COPC trainers five courses were organized in 2004: Epidemiology and biostatistics; Evidence-based medicine and biostatistics; Advanced biostatistics; Behavioral sciences and COPC and Evidence-Based Prevention. Those courses concentrated on the most difficult aspects of COPC curriculum – use of epidemiological approaches and quantification of research hypothesis. Training in evidence-based medicine has been continued during the year and now all teachers of family medicine and residents (and also students on CME courses) are expected to take seminars in evidence-based medicine (ranging 10-26 hours). As a support for COPC trainers a Web-site with training materials has been set-up and more than 400 pages of materials were translated and put to this site. A draft version of distance-learning course on epidemiology for family medicine students has been developed. In summary, the project progressed according to the plan and all necessary for success measures has been undertaken and all intermediate goals attained.

Short list of activities in 2004

Objectvie Tree 1.2.1 Implementation of model COPC intervention

Questionnaires developed

Population sample selected

Screening started

Very high prevalence of hepatitis C infection is found during screening (about 9%) need more attention to causes and control measures

Objectvie Tree 1.1 Improving Capacity of trainers

Winter School on Evidence-Based Medicine and Biostatistics (February-March 2004)

COPC and Evidence-Based Prevention (May 2004)

Summer School on Epidemiology and Biostatistics (June 2004)

Behavioral Sciences (March 2004)

Advanced Biostatistics (December 2004)

Objectvie Tree 2.1.1 Organizing of courses on epidemiology

COPC and Evidence-Based Prevention (May 2004)

Introduction to Biostatistics and Behavioral Sciences (September, 2004)

Objectvie Tree 1.1.2 Developing of Curriculum

Curriculum is developed and will be approved I quartile of 2005

Objectvie Tree 1.3.1 Developing of Library

Library growth 12%

Objectvie Tree 1.3.2 Web-Resources Available

Materials for translation selected

More 400 pages translated

COPC pages created and filled with materials (including translations and presentations)

Number of hits 11000, number of visitors 3500 per month

Objectvie Tree 1.3.3 Developing of distance learning courses

Draft version of epidemiology course developed, planned for first review

First draft version of environmental medicine course developed

Objectvie Tree 3.1.2 Seminars for GP faculty on EBM

Courses organized in September-October 2004

2. Proposals for changes in project

Due to seriousness of the results obtained during pilot phase of model COPC intervention on hepatitis C study (prevalence of 9% (95%CI=6.2-11.8%)) it was decided to concentrate more on this project and to postpone stroke rehabilitation model intervention. Preliminary data for stroke rehabilitation project has been obtained which showed that effect size for two compared rehabilitation programs (early rehabilitation and usual care) are more close to each other than was anticipated. As a result a planned study size will be too small to detect differences. The project lacked possibility to implement both interventions in the same time. Taking into account public health consequences of health care induced hepatitis C epidemics (details see in Results section) it was decided to concentrate resources on Pontonnaja (hepatitis) project.

3. Results by Objective Tree

Objective Tree 1.2.1 Implementation of model COPC intervention

The model intervention in Pontonnaja village has brought about unexpected results regarding very high prevalence of hepatitis C in this village. Chronic liver disease represents one of the major public health problems in Western countries. Hepatitis B and C viruses are becoming the main causes of cirrhosis and primary liver carcinoma. Hepatitis C virus (HCV) accounts for approximately 20% of cases of acute hepatitis, 70% of chronic hepatitis, and 30% of end stage liver disease in the United States. Currently, there is no post-exposure treatment that will prevent infection, nor is there treatment for acute Hepatitis C infection. In Russia the prevalence of hepatitis C is considered to be in range of about 2% (based on studies of blood donors).

It is known that Hepatitis C is transmitted by exposure to blood from an infected individual. Donated blood is screened for antibodies to Hepatitis C. Transfusion now accounts for very low percentage of acute Hepatitis C infection. The risk of transmission by household contact and sexual contact has not been well defined, but the efficiency of these risk factors appears to be low. Transmission from mother to child also appears to be uncommon.

Some studies done in Russia (Reshetnikov et al., Sexually Transmitted Infections 77:463 (2001)) showed, that in reality prevalence of HCV is much higher: among adults in Novosibirsk it was 5.3% and among medical students 6.4%. It is also important to note that among adults HCV was more frequently in males (8.8%) comparing with females (3.3%), which strongly suggest intravenous drug use (IDU) as the source of infection.

In Pontponnaja village first round of screening (400 young adults and adolescents) showed prevalence of 9% (95%CI=6.2-11.8%) which is on the high side even comparing with Novosibirsk data. Important were absence of gender gradient and some presence of infection even among girls aged 11-14 years. If those data will hold with larger sample (and increase in sample size mostly leads to updating prevalence figures to higher) then it means that Pontonnaja epidemics is quite different from, for example Novosibirsk.

The absence of gender gradient and presence of infection among early teenage girls mean that IDU is not a major source of infection in Pontonnaja village. The second important source for high-prevalence HCV infection could be health care system, as sexual transmission is not primary route for HCV. This hypothesis is especially plausible taken anecdotal evidence that before start of mass immunization against hepatitis B there were frequent cases of this infection in Kolpino district (part of which is Pontonnaja village) associated with delivery. The nosocomial epidemics of blood-borne infection which take place in second-largest Russian city severely struck by IDU-epidemics of HIV is not the thing that should be taken lightly, especially as recent Russian history shows good potential for nosocomial spread of HIV (Elista and Rostov accidents). Data obtained by Favorov (CDC Central Asia program) show that in Moscow outpatient treatment has population attributable risk (PAR) for HCV of 34%. The important question is also whether it is a new epidemics or just ‘light of a dead star’ – meaning that 14-years-old were born about 1990, when Russia and St.Petersburg experienced shortage of medical supplies including syringes which were frequently re-used.

The nosocomial hypothesis of HCV epidemics in Pontonnaja village unfortunately could be shown to be true only by exclusion of other plausible sources of infection, including IDU and even sexual transmission. To exclude those sources the data from questionnaire that has been filled by participants at the time of blood taking will be used, but taking into account grave consequences of the reality of health care generated epidemics the data should be more ‘bullet-proof’. The analysis of other infections (hepatitis B and HIV), questionnaires and possible geographical ‘hot-spots’ could help to exclude or gain support to IDU hypothesis of HCV spread. The analysis of questionnaires and physical exam looking for tattoo could help to look for yet another risk factor of HCV infection (though the tattooing is more of risk factor for HBV infection). Also questionnaires and seromarkers of bacterial STD could help to exclude sexual transmission as an important contributor to the ongoing epidemics. Also extending scope of screening to other districts of St.Petersburg is important task for 2005.

If nosocomial source of infection will be supported strict infection control measures should be implemented in Pontonnaja village and Kolpino hospitals. Also other measures will be implemented basing on study results, for example:

In any case more information is needed and so it was decided that in 2004-2005 more attention will be paid to hepatitis C project with increase in its scope and size at expense of stroke rehabilitation project.

In 2004 preliminary data for stroke rehabilitation project has been obtained which showed that effect size for two compared rehabilitation programs (early rehabilitation and usual care) are more close to each other than was anticipated. As a result a planned study size will be too small to detect differences. The project lacked means for increasing study size apart from taking it from other studies (hepatitis C) which in turn demanded more means and manpower. In effect it was decided that the results of hepatitis C project are more important for well-being of citizens of St.Petersburg and public healthy, so rehabilitation project has been postponed. To continue balance the interests of younger generation and older generation in framework of this project it has been decided in 2005 to implement smaller project on nutrition and cardiovascular diseases risk.

Objective Tree 1.1.2 Developing of curriculum

The development of COPC training took several stages. On the first stage the preliminary draft version of the curriculum has been prepared, discussed in Russian workgroup and sent to Finnish experts. During workgroup meeting in Helsinki in March this draft version has been discussed and several changes to it has been proposed. Next meeting was scheduled for August. During time between two meetings the content of training has been discussed among Russian experts and preliminary division between face-to-face training and distance learning courses has been made. A major barrier to preparing residents to practice COPC is that those responsible for teaching and modeling COPC have not done so either from a common theoretical base or from informed experience in the practice of COPC. Attempts to teach concepts and provide COPC experiences in medical school and residency have been conceptually fragmented and inconsistent. Consequently, it appears that current graduates of most family practice residencies are not adequately prepared to implement fully functioning COPC practices. What then is needed in family medicine to promote interest and motivate physicians to undertake COPC practices or activities? Family practice faculty must develop expertise in COPC concepts and practice. Faculty should understand the classic definitions of COPC and the utility of the less precise definitions that followed. Faculty must understand community epidemiology, that is, epidemiology related to community health needs. Perhaps most importantly, faculty are needed who are champions of the COPC process and who are role models both within the residency and within the community. Faculty and learner involvement in community health action groups, coordinated by public health agencies or other health-related social agencies, can provide a vehicle for learning new interactive, multidisciplinary team skills that are unavailable in traditional medical educational settings. This is why model intervention project was deemed so important for the development of the curriculum. Because importance of model intervention for COPC training when it was found that full implementation project will demand much more resources that was evident at the planning stage (effect size from early intervention in stroke victims was smaller than anticipated) it was decided to pay more attention to one project – Pontonnaja intervention, which will in future be indispensable part of residency training.

Second, program or institutional support structures must assist in this effort. Programs can recruit faculty and trainees who exhibit a demonstrated interest in community involvement and who exhibit existing leadership and organizational skills. Training sites can model population-based care with emphasis on addressing specific health care problems in the community. Programs can model prevention and health promotion activities and provide dedicated faculty time for community health activities. Patient databases can be structured to describe trainees' patient panels, complete with demographics and problem lists. To address those challenges it was necessary to get in more tight contacts with Pontonnaja health care (which was made by making them part of ongoing project) and by including into curriculum questions of health informatics, which should help to structure patients’ databases. 

Third, important point was to determine basic COPC competencies for family medicine residents. Those competencies where defined in August 2004 during workgroup meeting. They has included the following:

(1)   Understand that patients' physical and social environment and their health and well-being are related

(2)   Understand the impact of the community upon the health of the population

(3)   Understand the impact of the community upon a physician's practice

(4)   Understand the epidemiologic techniques to determine health problems in a community

(5)   Determine the health promotion techniques and interventions to address community health problems

(6)   Evaluate outcomes research for validity

(7)   Define COPC and its core content and process

(8)   Define COPC elements in a family practice

(9)   Define and characterize a given population using secondary data

(10)                      Recognize a community health problem using either subjective or objective data

(11)                      Design an intervention to address a recognized community health problem

(12)                      Know which community resources address a recognized problem

(13)                      Contribute to an organized community action group and monitor the group's progress

(14)                      Determine roles of attending and faculty physicians in community action groups

(15)                      Locate local, state, and national databases for common or chronic disease states

(16)                      Exhibit group leadership skills in a multidisciplinary setting

(17)                      Understand the utility of personal computers and electronic medical records in COPC

(18)                      Analyze activities of a community action group in COPC terms

(19)                      Understand the difference between health promotion and disease prevention projects and a COPC practice

According to those competencies the core COPC theoretical courses has been defined. They included:

· Introduction to COPC

· Epidemiology with Clinical Epidemiology

· Basics of Biostatistics with outcome studies evaluation and design

· Behavioral sciences

· Health Informatics

· Environmental Health

The detailed description of courses has been made in August 2004 and also it was decided that full length of core theoretical courses will be 144 hours of face-to-face training, which a trade-off between necessary knowledge and limitation of the time for residency training, which should, in Russian situation, give large amount of additional professional information to residents undergoing specialization in family medicine (due to width and breadth of the profession). Some basic disciplines were transferred to DE courses (including Basic Epidemiology, Basic Biostatistics, Health Economics and Basic Health Informatics). Due to extreme importance of preventive medicine for COPC it was decided that major part of face-to-face course on COPC will be dedicated to Health promotion and Disease Prevention. The curriculum has been created and will be presented to Curricular Committee of St.Petersburg MAPS after more detailed data of model intervention will be obtained to clearly define role and place of this project in the curriculum as well as after GP trainers will undergo training in Health Informatics

Objective Tree 1.1 Improving capacity of trainers

The first task after creation of the curriculum will be to prepare GP trainers for training in basic COPC disciplines. Though project itself is joint venture between St.Petersburg School of Public Health and Department of Family Medicine of MAPS from the very beginning it was clear that for successful implementation of COPC training it is necessary to prepare trainers from the Department of Family Medicine. It was made easier by the fact, that Department of Family Medicine currently employ all but one persons trained to MPH degree at the Brown School of Public Health in Jerusalem, who are also frequently involved in training at the School of Public Health. Nevertheless it was decided that additional training necessary for other both active and prospective trainers. To increase impact of training it was decided not limit participation only by family medicine trainers but to open courses to other specialists (due to low marginal cost of additional trainee). Several such courses were organized:

1)      Advanced Biostatistics and Evidence-Based Medicine (February-March 2004)

2)      Introduction to COPC and Evidence-Based Preventive Medicine (May 2004)

3)      Introduction to Biostatistics and Clinical Epidemiology(June 2004)

The number of trainees in those courses is 55 in Winter course, 25 in Summer course and 15 in Introduction to COPC and Evidence-Based preventive Medicine.

Apart from special courses several other courses were organized where COPC ideas were presented and that were used as planning to implementation of core COPC courses. The reason for inclusion of the later in the report is that it is envisioned that some family medicine residents could choose to take face-to-face training on those courses that are made permanent at the MAPS. Those courses included in this year:

1.      Behavioral Sciences (March 2004)

2.      Introduction to Biostatistics and Behavioral Sciences (September, 2004)

3.      Advanced Biostatistics (December 2004)

Number of trainees on those courses was 12, 26 and 11 correspondingly (total number of trainees is 49 and total number of training hours is 432). It should be noted, though that discussion with trainees on those courses showed that they are too much detailed for family medicine residents, so it was decided, that they will be open to residents if they which to get more deep training, but in general it will be reserved for trainers in family medicine that will teach COPC. 

Objectvie Tree 3.1.2 Seminars for GP faculty on EBM

During this year teaching of EBM has been probed on several courses, for example

Evidence-based medicine for GP (Moscow, April, 2004) and on several courses for GP, organized at SPb MAPS. The lecturers that has been participating in those courses were probing level of knowledge of family physicians and tried to adopt existing lectures and training sessions to their level and their interests. The experience gained in those courses will be used for organizing courses for family medicine residents in framework of COPC training.

It was found that short seminar could include about three days work and it should be less technical (i.e. how to do statistical meta-analysis is not very well meet by family medicine practitioners) and more emotional, especially as majority of family medicine physicians and residents are females. More examples from women’s health are usually very gratefully met by this audience. 

Objectvie Tree 1.3.1 Developing of Library

One of the important tasks for the year 2004 was to continue to develop library of the School of Public Health which would be used as library for development the COPC training materials. This is not a general-purpose library, but a public health library and so relatively small.

The purchasing of the books was organized throughout the year, and mostly was connected with two priority themes for this year training – statistics and epidemiology. Presently library includes 481 volumes mostly English-language literature (library grow 12% last year, whereas from 2001 compound yearly growth was about 68%). Major donors participating in the library creation are:

STAKES – 39%

OSI – 22.7%

USAID - 7.9%

DFID – 7.7%

SEEC – 4.8%

The themes which are most frequently presented in library:

Statistics – 18.1%

Epidemiology – 9.1%

Psychology – 6.2%

Sociology – 5.0%

Economics – 4.6%

General Public Health – 2.5%

Environmental Sciences – 1.2%

As is seen from the data presented Statistics is already fairly well represented in the library, whereas Environmental Sciences are not.

Objectvie Tree 1.3.2 Web-Resources Available

Library materials together with materials from Russian literature and Internet are used for development Web-based resources. As was stipulated under 2004 plan of activities, the special COPC pages at the site of the St.Petersburg School of Public Health has been created. It has been structured according to the theoretical part of COPC curriculum and divided into

Because Evidence-Based Medicine has its own pages at the Web-site it was decided not to move materials from them to COPC pages.

In 2004 owing to growing size of site (it is already almost 200 megabytes) and very high popularity (about 100 hits per day) it was decided that necessary limit access to some materials on the site to students only (to protect copyrights of the authors) and so use it as the virtual library for students and trainers only. To implement this decision, all materials at the site training sections (mostly DE-courses) which very not taken from open sources were password protected. For students were prepared open (off-line) versions of the site, that do not demand any password. Correspondingly, presently outside visitors can access only part of the site, but not all materials. This practice will be continued with materials prepared under COPC project.

Presently most of COPC materials are in open access (because they were taken from open sources or their authors waived their right to restrict access), but DE course on epidemiology that is under preparation (see below) will be password protected. One reason for open access to introductory materials on COPC was importance of those materials and scarcity of such resources in Russian language.

Presently in preparation of Web-resources about 400 pages of text has been translated (1 page = 1800 characters), which is sometimes taken to be equivalent to providing material for 40-60 hours of training (using conversion factor of 7-10 pages per hour reading speed). But as it turned out during Winter School speed of understanding such material like epidemiology and biostatistics is much slower, order of 4 pages per hour. Correspondingly the already translated materials are enough for 100 hours of training. Because curriculum calls for 216 Full-Time Hours Equivalent of Distance Learning and taking into account that not all materials are included into DE courses (especially in obligatory reading – some parts go into introductory readings and advanced concepts) so it could be estimated that translation in the first year of the project has provided with a bit less than one-third of necessary materials.

Translated materials included:

Apart from translated materials the COPC pages of the site include presentations on the following themes:

Those presentations are fairly detailed and could be used both by teachers and students for self-study. Use of those presentations in teaching shows that they contain material for about 48 training hours.

At present School site contains four large parts with information that could be used for training in COPC, most of them in Preventive Medicine course:

In off-line version this information already available to trainers, in on-line version it is closed until completeness.

In a half year since COPC part of the site has been created the site has been accessed almost 64’000 times. The average number of visits per day was about 150 persons, each person looking for at least 2-3 pages. In November-December there was significant increase in number of hits per month (from about 9’000 in August-October to 13’000 in November-December which is probably resulted from publishing new COPC-oriented information on the site).

More than 1000 persons has used site several times (ranging from accessing it 2-4 times per month (13% of the core users) to ‘constant users’ accessing it materials more than 2 times per week (61% of the core users)). The analysis of audience shows that majority of them from Russian Federation (67% of visitors) but more than 9% are from the USA, 4% from Ukraine and 3% from Belorussia.  Visitors from Russian Federation were mostly from Moscow (36.5%), but 15% were from St.Petersburg, about 2% from Krasnodar, Ekaterinburg, Nijnii Novgorod and Novosibirsk (each), totally there were visitors from 172 cities of Russia. More than 300 persons used the site as place for training by attentively studying presented materials, spending in reading materials more than 20 minutes during each visit (the number is an underestimate, as if person download page and not hitting ‘reload’ button his time of reading is not taken into consideration, correspondingly that data are only for persons that read more than one page and spent more than 20 minutes reading first page). Almost 100 persons spent more than one hour studying materials published on site. Most users accessed materials published on the site 10 am to 12pm, spanning the whole working day and evening and showing that this system does offer more convenient access to materials than usual library or campus.

In general it could be stated that Web-site has enjoyed popularity and was serving as training opportunity to as much persons as COPC face-to-face training at MAPS at a fraction of cost both to trainees and institution.

Objectvie Tree 1.3.3 Developing of distance learning courses

As a result of combining newly prepared data with materials used for training at the School of Public Health draft version of distance learning course has been prepared in November 2004. It follows structure of other DE courses developed and developing at the School of Public Health. It consists of:

Those parts are obligatory reading. Later voluntary reading should be added.

Introduction gives overview of epidemiological concepts and methods. Presenting them in form that would be clear for medical person. General Epidemiology gives description of main epidemiological designs and demonstrates what answers they are ale to give. Special Epidemiology demonstrates application of epidemiological ideas and methods in different fields – from environmental hazards to nutrition. Selection of materials are not random. The themes most frequently causing interest in general public were selected for inclusion (genetics, nutrition and environment). The themes were selected according to the frequency of citing in the popular press, after discussions with patients and medical personnel and finally get support during course on health for journalists (50 participants from different regions of Russia, December 2004, Moscow). The most frequently asked questions (apart from economical) were about environment, followed by genetics and nutrition (which is sometimes connected with environmental pollutants in food and food chains).

Course is still not completed. It would be necessary to create tasks for the participants, give them possibility to self-rate understanding of the epidemiological concepts and methods. Formal exam should also be though about. Then setting up discussion board for students is obligatory. In general draft version of completed course could be presented in first quartile of 2005 (before or immediately after start of formal COPC training). 

Another course that is now under preparation and which will be used for COPC training is environmental health. The environmental health occupies a special position in COPC. First it is one of most frequently mentioned cause of unhealthy which population start to worry about (interesting to note that even examples of COPC approach in the US show how family practitioner could dispel fears on environmental cause of breast cancer. Second it is really serious problem in Russia with well-known Soviet disrespect for environment. Third it possible cause of high cancer mortality in St.Petersburg where it is among highest in Russian Federation. From the other side very frequently environmental hazards are used as excuse not to change health behavior and in this respect environmental medicine course could be seen as prerequisite for Preventive medicine and Health Promotion course. In the same time in previous years Environmental Health was not much discussed at the courses organized by School of Public health for medical professionals.

Because among some health professionals too frequent mentioning of environmental hazards led to impression of hoax, the course should start with attitude-changing reading (this approach has been used in courses on HIV/STD where L.Garrett books were used or EBM, where Medical Nemesis by I.Illich was used, anecdotal evidence – interview with trainees and other PH trainers - show that approach works well). As such a book “that changed the world” – Silent Spring by Rachel Carson has been selected. Despite fact that it is more than 40 years old, many ideas spelled there very clearly and it shows importance of environment protection for human health and survivor. After reading Carson first testers were much more attentive to the materials on environmental health study that were presented to them and not considered environmental health as “half-hysterical babble of fiends of technical progress”.

So obligatory introduction is followed by introduction to environmental health and environmental epidemiology. It is important to note that environmental epidemiology included into two courses, because of importance of the theme for COPC trainees.

Environmental Epidemiology is expected to be completed by June 2005.

4. Possible changes in project environment (assumptions and risks)

The following assumptions and risks were named in LFA project matrix:

5. Sustainability and compatibility

5.1. Compatibility with the strategic goals for Finnish development collaboration

The Action Plan for Finnish-Russian Neighbouring Area Co-operation in Social Protection and Health (2003-2005) gives five priority objectives for collaboration with St. Petersburg. One of them is to increase general practitioner education and the family-centredness of health care services. This project is very well compatible with this objective, as it gives post-graduate education to general practitioners and health administrators, working in city district primary health care. GPs and administrators will be educated in community oriented primary care, which means that they will be better able to take into account in their work the needs of families in their district.

Important priority areas are health promotion and disease prevention, e.g. support to healthier life styles among young population. These areas will be important components in the education of health professionals.

These priority areas are also mentioned in the planning documents of the Northern Dimension Partnership in Public Health and Social Well-being. There is also emphasis on training and education on public health issues.

5.2. Policy environment

The development of community-oriented primary care training curriculum took place on a backdrop of several important changes in Russian Federation:

All those changes are directed to making social sphere and health care (which is significant consumer of scientific results – Russian Academy of Medical Sciences is one of three academies still getting direct budgetary support (along with Russian Academy of Sciences and Russian Academy of Agriculture).

It is important to notice that all discussions of health care are presently focus on development of primary care both as cost containment measure and a mean to increase availability of health care. In December 2004 Concept of Health Care development for the next 5 years has been adopted by Government of St.Petersburg. This concept calls for rapid development of family medicine together with more attention to preventive medicine.

The same task has been formulated by Economics Committee of St.Petersburg Government which is now prepares set of so-called “standards of living” in St.Petersburg. In those documents Economics Committee tries to predict amount of the resources that are needed to provide free, high-quality care to citizens of St.Petersburg. Reaching of this goal is impossible without detailed analysis of the population structure, data on health care consumption and morbidity pattern, that is without understanding basic data of COPC.

Correspondingly, situation in 2004 has clearly shown that development of COPC training is an important and sensible thing to do in contemporary political atmosphere, though it should be viewed as part of general approach to health care management and public health that could not be separated from more active training in basic public health for policy-makers and senior health officials. Importance of retraining of existing workforce coupled with proposed development of health informatics (as stipulated under Concept of Health Care Development) shows importance of technology-dependent training, like distance learning.

5.3. Economic and financial feasibility

Match by activity

 

Behavioral Sciences Course

3232

Advanced Biostatistics Course

3232

COPC and prevention Course

1616

Winter Course

2010

Summer Course

1609

Offica lease, project

2480

Local Staff, project

1297

Books

300

Model Intervention

1012

DE staff

1638

Total

18426

The screening of 400 villagers in Pontonnaja was also made in most cost-efficient way. The number of trainees in all courses was 139 and total number of training hours is 432.

There is much value for limited resources. The developed modules of education will be useful for all future family doctors and health administrators who will study in MAPS. The new courses are continuously organized in School of Public Health and Family medicine department of MAPS. The Kolpino project is supported both by MAPS and Health Care authorities of Kolpino District. Also it is envisioned that after results of Pontnnaja project will go out of preliminary stage they will be presented to Health care Committee of St.Petersburg which will support its further implementation.

This makes the results of the project sustainable in the future.

5.4. Institutional capacity

MAPS has great institutional capacity to offer for the use of the project. In addition to this part of the project will be dedicated to training of trainers. This will increase MAPS capacity, especially at School of Public Health and Family medicine department.

In pilot area, Pontonnaja, there are educated GPs working, and they give a good basis for the project to start. The human resources development in the health care of these city districts is one of the objectives of this project.

5.5. Socio-cultural aspects

In St. Petersburg, as in whole Russia, in Soviet period people were used to listen to authorities and to think that the system solves all their problems and takes care of them. Since period of Perestroika more and more responsibility has been transferred from the central administration to the local level. This process of decentralisation continues, even though there may be seen some steps backwards - e.g. tightening control by representative offices of president around the country and attempts to strengthen role of the federal medical insurance fund in delivering health care.

The COPC project will increase the capacity of local health care professionals to respond to the needs of people in their community. Health professionals will be educated in health promotion, where one of the main principles is the responsibility of individual for his/her own health. The idea is to help people to help themselves.

5.6. Participation and ownership

The main responsibility for implementing the project will be given to MAPS. Project director is planned to be Prof. S. Plavinski, who is the director of the School of Public Health and Dean of the MAPS Colllege of Public Health. Together with him will work prof. Olga Kuznetsova, who is vice-rector of MAPS and director of Family medicine department.

The local health care professionals from the pilot districts will be active participants in planning and implementing interventions. The Pontonnaja project is managed by N.Zlatieva who has graduated St.Petersburg School of Public Health. Big part of COPC education in MAPS will be given using active learning methods

On all levels of the project planning and implementing the local initiatives and active inputs will be encouraged.

5.7. Gender and poverty reduction

The gender aspects will be taken into attention during the whole project. The project management is harmonic in gender aspects, both sexes are well represented also among experts. Due to the Russian reality, main part of the educated health professionals will be female. This education will increase their competence at work and it can make them more appreciated in the community.

In Russia the health of a family is mostly on responsibility of the female family members, mothers and wives. When public health services are more accessible for people, and general practitioners are more prepared to meet the needs of families, it makes this responsibility easier for women. Also the responsibility of the individual for his/her own health is emphasized, and this may encourage men to be more active in their health questions.

The hepatitis project has shown that females are as severely struck by epidemics as males despite the fact that blood-borne infections in Russia have predilection for male gender. If the source of hepatitis C is maternity-associated care then infection control will help to protect female health during pregnancy and delivery.

This project will also give its input to poverty reduction, as it supports public health services and increases capacity of public health physicians, i.e. general practitioners to serve customers. If project is successful, people in pilot districts will have less need to access to specialized health care. This will save their money for other purposes.

The hepatitis B/C prevention will result in fewer spending by family for antiviral drugs and in future for the treatment of chronic hepatitis B not to mention antiretroviral drugs in case of HIV prevention.

6. Assessment of efficiency of the implementation

The project implementation went according to the plan. More people have been trained in public health foundations of COPC than was planned and the COPC site enjoyed popularity.

The model intervention project created more important data that was anticipated which can have even longer lasting effect on health care in the community. In general, efficiency of the project was very high taking modest financial input.