Strengthening the prevention and management of NCDs in health settings 29.05.2019



translation yes I'm fine thank you so there will be some presentations which are in English in this session so again please make sure you have the headphones if you need to so in this session we're going to really until about lunchtime looking at the strengthening of prevention and management of LCDs in the healthcare settings and we have a series of presentations which we'll be reporting back on some of the projects that have been taking place within Ukraine and supporting this work and a lot of this work has been focused on cardiovascular diseases on screening of hypertension and for cancer and diabetes within the primary care setting and I recognize some of you from the different trainings that we've been involved in over the last few years that the World Bank Swiss and w-h-o have been working together in the I won't go back that will introduce each speaker I think as we go along but we also have a colleague from the World Bank dr. Tanya do me do me Tishchenko who's a practice manager for europe and central asia who's with us for a little while this morning and she's going to take an opportunity just to share some of the work that the World Bank is doing in support of this area very happy to be here I should start by saying that despite my name I'm not a Ukrainian I'm Brazilian but of but have some Ukrainian descent I just want to say that the work that the bank is doing in support of the government's health reforms really fits in the in the context of broader work on investment in human capital studies that the bank has done shows that more developed countries in in more developed countries human capital represents about seventy percent of a nation's total wealth compared to only three percent for natural resources for example whereas in low-income countries a human capital represents only 42 percent of a nation's total wealth so we see there the importance of investing in human capital for the development of a nation and in that regard we've calculated a human capital index where we look at the full potential to reach its full productivity if it had full health and a full education and when what we see when we look at the Ukraine is that it's ranked about 50 in the total ranking of nations compare for example to 34 Poland or 34 for Russia the human capital index in in the Ukraine shows that a child born today is only likely to achieve about 65 percent of the productivity it would have enjoyed if it had full health and full education and when we look at what are the bottlenecks in the Ukraine we see that child survival is quite high we see that children are not stunted very few children are stunted but what we do see as as a constraint is that life expectancy is below what it should be so life expectancy is almost 10 years lower than it is in countries of comparable income and and that the principal reason for morbidity and mortality and early mortality is non-computer coal diseases so for us investments in improving prevention and treatment for non communicable diseases is critical for Ukraine to reach its full potential so in that respect we have been supporting the government in its health reforms through a Health Project that that has a principal objective of supporting improving improvements in the quality of non communicable diseases at the primary and secondary level we've also been working in under that project in close collaboration with w-h-o in supporting the Public Health Program in in the country and building capacity of government counterparts to deliver their Public Health Program in in in promotion activities to prevent the risk factors for non communicable diseases we've also been working very closely with Swiss counterparts in the implementation of for example the telemedicine program and in in general in support for for the health reforms and in the country so we're very pleased to be here and to be working in in close collaboration both of the w-h-o and and our Swiss counterparts thank you thank you very much is there a report that which has the information that you've described that would be available to counterparts in Ukrainian and in English if they were interested sure first one of the reports was citing is the World Bank publication called the changing wealth of nations was published in 2018 and that's available in the World Bank website as well as information on the human capital project and the human capital index is also this information is publicly available in the World Bank website thank you and we talked yesterday a little bit about how we increasingly make economic arguments it sounds perhaps a bit weird because of your family doctor or family nurse you've got a patient in front of you who's got a disease who needs help or you're trying to prevent a disease but also at the policy level we're trying to make the case of a greater investment in health and the work that you're doing and so we switch between the individual patient and the macroeconomic arguments try and help further the cause in terms of preventing emerging non communicable diseases so thank you very much I know that also functional Fung I've got news yeah sure yeah look where we were you're working also in a number of countries that were working on in similar projects for example in Moldova we were there reporting on the work they've been done there so thank you for your input and collaboration and if I could just add that I mentioned that under the warming project the support of the government we're working on public health also on strengthening primary care but I'll have also completed work with with in collaboration with the Swiss counterparts on a hospital master plan so looking at sort of the whole continuum of care and and so that work is also I think critical to for the effective treatment of communal called diseases across the whole continuum so no Nicola here this voltage acaba David Russia we mean with their colleagues and let me thank you on behalf of myself on behalf of our colleagues there for your support of Ukrainian projects in health care reform as well and let me mention that the data that you have just outlined they are quite stressful I would say in terms of our statistics even for such a well-informed audience like we have it here so let me reiterate that our conference is quite a relevant event because the issues and questions were going to discuss are quite relevant and topical and now under this given context as we give the floor to deliver presentation on improving and city clinical practice and DWG or a European region to dr. Jill Farrington please Jill the floor is yours okay thank you very much I was asked to make a sort of introductory lecture presentation about the sort of frameworks for some of the things which we will touch upon in the project reports why have we set up these projects the way that we have how do we think that we can bring about a change an improvement in the clinical practice but as all also been asked to refer back to some of the broader work on strengthening health systems about the distribution of tasks between doctors and nurses the teamwork and some of the monitoring mechanisms that we use so I will try to cover this broad selection of things I will also try and change the slide okay we saw this slide yesterday I think and it's just trying to keep a focus on what are we trying to achieve we're trying to reduce early deaths from these four non communicable diseases and we also have a set of global targets and non communicable diseases and for our work in health settings in clinical prevention were particularly focused on the ones on the right of the slide so around reducing hypertension increasing the identification and management of people who are at high risk and also about increasing the access to medicines and we heard a lot yesterday about the work that Ukraine has been doing on access to medicines but also in the clinical setting we have an opportunity for Public Health for health promotion health counseling and so we also can have an impact on some of those other ones around risk factors like tobacco helping people to stop smoking to eat more healthily reduce salt in their diet and so on so your work is impacting on all of these targets to a greater or lesser extent and as we said yesterday we have a a set of best buys that was the phrase that was used so WH o has identified a set of cost effective and effective interventions so these are the mo this is a list of the most cost effective ones though if you see again on the bottom right hand side they're particularly focused around cardiovascular disease and cancer but we also have a set of effective ones around managing blood sugar control in diabetes preventing complications and so on so to get the best outcomes we want to make sure that we're implementing these at scale across the whole country within the primary healthcare system where it were it's the clinical intervention we also mentioned yesterday the work that we've been doing to try and identify what are some of the barriers to achieving those outcomes and w-h-o over the last few years has been carrying out a series of assessments within countries Ukraine was not one of those countries but I know there have been some in-depth assessments since we finished this work which also give us insights to the situation in Ukraine so for those 12 countries we looked at how well they were implementing those best buys that I showed you and what were some of the things in the health system which were preventing them doing that but also what were some of the things which were going well some of the opportunities or some of those strengths in their systems and then we brought it together in an analysis and had a big conference last year and Ukraine actually deputy minister participated in a session there were we with a series of experts looked in some detail at the situation in Ukraine and he reported back on some of the healthcare reforms that he was participating in as Janos said yesterday we identified nine particular barriers but also nine areas where we could strengthen the health system response and these were in areas like the governance Public Health Services primary health care what my glasses on to read them all how the specialist services are organized the human capacity the health workforce health financing access to medicines and information solutions and then also about making the health care system more people centered and what we've called these are the sort of nine cornerstones of a comprehensive and aligned response because each of those are important but they're also important about how they fit together so it can be that we put in such in place incentives performance targets for family doctors and we have economic incentives but we might actually make the situation worse because we haven't thought through how are we going to measure those incentives we don't have good information systems or were trying to get people to do more hypertension screening but there's no access to medicines or we're trying to do a cycle cancer screening but there's no treatment specialist services in place so we identify people and potentially do more harm than good so all the parts of the system need to fit together in a more aligned way and that's where we use this image of the different blocks building together into a tower that fits together and and and works well I'm going to pick out a few of those which are particularly relevant to the projects that we're going to discuss today so the first is was around primary care how we have to shift from just having a doctor or a doctor and a nurse or just an or felcher in some countries to trying to have a bigger group practice with multiple disciplines in place other non doctors perhaps social workers nutritionists physiotherapists healthy lifestyles counselors for example who know well the population they've serving so that their work is appropriate to the the community of registered patients and that they are working together in a coordinated way and with the other health care providers so that if somebody has a heart attack or stroke they go into and they go into hospital that they then come back to primary care and they're working together to prevent another heart attack or stroke so that's a coordinated care between the health care providers in the support of the patient we also need to have a health workforce that is fit for purpose and we talked a bit about that yesterday so we need to have an increased availability of health workers but it's not just about quantity it's also about making sure we have people with the right skills and we talked yesterday about the real changes that that chronic conditions can mean and also as people age that having multiple conditions means that it may need a different way of working with patients so we're not just training new workers but we also need to use those workers more effectively and maybe more efficiently so we're looking at what is it that the doctors doing that only the doctor can do and what is it that the nurse is doing and what is it that the receptionist is doing the manager is doing and any other health workers within that practice I remember when we were doing the training for trainers for the Swiss whu-oh project and we refreshed how do you measure blood pressure and the nurses were just as good as the doctors at measuring the blood pressure but when we got to the end of the training the nurses were actually quite frustrated I remember it got very animated in the session because they said we can do all this but we're not allowed to do all this and we can try and change that we can see as we look at what is the role of nurses within European region there are many things that nurses can do that they're perhaps not being allowed to do which they can do as effectively or more effectively than the family doctors this is a list of the broad some of the broad range of contributions of nurses but it's you know many of these are relevant to non communicable diseases and chronic conditions like patient education supporting self-management supporting compliance with medicines helping people to how do they take the medicines helping them to develop a care plan and supporting them in using that rehabilitation and support people when they return from hospital for example after they've had a stroke and so on so many things that nurses can contribute on but it may mean that there have to be changes in the regulations in the standards in the education in the insurance that supports nurses I was in a in Central Asia in Kyrgyzstan last week and we had a whole session on nurses and non communicable diseases and we had examples from the UK and Finland and Uzbekistan and they had said that really it had taken them between sort of two and twenty years sort of development to get all the regulations and systems in place to enable nurses for example to prescribe medicines to have clinics by themselves some things could be done shortly and some things took a bit longer depending on some of the barriers and problems in the way the other thing within the that's particularly relevant for the non communicable diseases is around people centered health services so shifting from services that are focused on the provider that are convenient for the institutions the professionals to having ones which are more focused on the patients and we heard yesterday from the Deputy Minister about the the change that they were trying to bring in Ukraine to have a more consumerist approach to allow people choice to allow people to change doctors if they were not satisfied and in a way this was a revolution or evolution within the Ukrainian system and then in the care of the patient to shift from having this biomedical approach just focused on the disease to having one which is focused on the goals what are we trying to achieve and asking not is what is the matter with you but what matters to you so what is valuable to the patient and how do we fit your diabetes care around that do you want to do sport okay let's talk about that or you do have a busy day how do we manage your medications to fit with that but that can require quite a change in terms of communication and again I think when we were doing the training of trainers and we did the first pilot training some of the communication skills were quite difficult to to do that sort of newer communication skills that we need to be able to communicate differently as healthcare providers but we also need to help the patients communicate differently with us and tell us more about what they actually need and sometimes it's not just about tools or techniques but it's also about changing sort of skills and attitudes of patients and providers this is an example that we were using in a in a session at a conference last year this was is from Denmark and they were explaining how do they do patient-centered diabetes education and they said the health educator which might be the nurse is at the center but they're actually the job they so called them the health educated juggler they have many balls that they're juggling because they're trying to form different types of communication when they're having the encounter with the patient so they're trying to be empathetic the embrace' they're trying to be reassuring and positive they're trying to be inspiring to inspire them and motivate to change behaviors they may call the translator that trying to translate some of the medical terms or knowledge into words that the patient can understand and they're the facilitator they're kind of trying to manage the process so they have many roles within one encounter just to give an idea of how complex it can be if we're really trying to take a patient-centered approach within the European region we've got a number of projects where we are within countries where we've been trying to change clinical practice and the ways that were doing things at the primary care level I think three of these have been funded co-funded by the Swiss Development Group I think in Moldova we had the equivalent conference two weeks ago and we reported back on their findings and we also have a project ongoing in Kyrgyzstan and we have been using in those countries the w-h-o simple protocols so again you've done the same thing in Ukraine where there's been a simple protocol that's been created by on the pen w-h-o pen tools what we have found in those countries and also from the literature are that there are barriers to implementing evidence-based approaches and these can be a range of for a range of different reasons so it might be that the actual evidence-based practice the innovation that we bring in is it's difficult to understand it's not attractive so if we think of the example with Ukraine they tried to make the protocols attractive simple to follow accessible so you had a version that was available on the desk to try and break down some of those barriers to make them easier to understand and feasible to use in a daily practice there can also be barriers around the professional themselves we talked about the importance of the knowledge the skills the attitudes and the training programs tried to work on those issues but there also can be about motivation to change so once the adopter the doctor or nurse went back to their clinic did they actually were they motivated to change their practice and to put into practice what they had learned on the training course and to change the routines the ways that they did things the beneficiary the patient as we said may need to also change to learn new ways of communicating or new things they need to comply with and often in these countries on these projects we find that initially there's a great increase in workload for the doctor or nurse as they're trying to manage these new tools fit them into their normal routine and they say and then the patient's outside the waiting room grows as the patients are waiting so then the patient comes in and they're angry that they waiting for 15 minutes instead of five minutes and then I start asking them whether they are smoking and they asked what I might so it can also be a negotiation between doctor and patient or nurse and patient to transform understanding of value of prevention and health promotion and then there's a sort of barriers within the broader context and some of those I've talked about in the health systems barriers about access to medicines and so on the financing numbers of staff and so on if I just go through some of the things which we've again picked out from the evidence and then try to use within this project some of the proven interventions which can improve knowledge so for example we education materials or have an effect on clinical practice particularly if they're combined with other methods so within the training sessions we provided educational materials and things for you to take away with you educational materials are more effective if they're active rather than passive and more small-scale so when we started this project we changed the nature of the training program from being very driven by lectures to being smaller groups and more interactive in the training interventions that promote social influence so for example having visits connections visiting the workplace regularly can have a small impact on practice and involving respected local colleagues local opinion leaders so again with this project we try to change the trainings so that family doctors and nurses were training family doctors and nurses and that was a bit of a revolution at the time and to try to have family doctors and nurses who could be leaders for other family doctors and nurses they knew the world that you were working in and then tailored reminders decision support systems are effective in changing behaviors so again as I mentioned we had the laminated cards that were available on the desk we didn't have the option of the electronic records in all places and in this project we didn't have financial incentives because the effect of financial incentives on performance is quite variable in terms of of the evidence for effect and it also was not an option in audit and feedback also have small moderate effects on our professional practice Anastacia we'll talk later about how much that was a part of this practice and I'm not sure if that was implemented in this project in Ukraine in some of the other countries we've had regular visits to every quarter giving doing audits of clinical records discussing the results tracking indicators feeding back that information to the doctors and nurses so that they can see how their performance improved I'm not sure that was a option within the last few years but it may well be an option going forward as I mentioned we have a number of different projects and and what we've tried to do with each of these projects where we can is to monitor change and also to evaluate what has happened as a result and then we're publishing and sharing that information so you have got two presentations today which will specifically report on it for this project and then what we've been doing this is an example from Kyrgyzstan is trying to put together that the information that comes out of the quantitative analysis that's in the center the dark blue with what we find from the qualitative to try and understand what worked why did it work what didn't work and so on and then to again give that information back I won't go into the detail of this I'll leave this you can get the slides in afterwards because I can see I have zero minutes left but again many of the things which we learned from this we can then again go back to the evidence for how can we improve the way that we are implementing the guidelines there's no minutes left so I won't go into the detail I'll just acknowledge some of my colleagues who've been involved in this work and thank you Jack Ramon thank you Thank You Jill now let me give the floor to the Health Authority director of portable regional administration Victor Lisa who present on the main challenges of controlling and severe the primary level and that includes teamwork II have affordable medicines first of all dear colleagues I apologize that they couldn't be available couldn't present at the conference here yesterday I had some urgent issues in Volterra but first and foremost I would like to say thanks to all the partners the legacy thanks to everybody and I would like to emphasize let's look at these small curve of the changes that happen at the moment in healthcare sector and it's only the beginning it's only the beginning of the changes that people need that healthcare workers need and health care workers might have some dissatisfaction or they have some then they study the situation then they look at it and they will accept and it's a cycle on the cycle of course is going on so overall in the country the transformation of the system the changes it requires a complex approach and the main challenges in fighting in cities at the primary level we should not only talk about the primary level today because this system is transformed on all the levels and I think Tilda partners to the Swiss agency the world and the WTO when I was preparing this when I looked at all the partnership wouldn't be able to do anything without the part I said neither the national nor the local level because as the colleague said we need to re-educate it all we need to teach them the teamwork approach and what happens now at the primary level it's important for us and well I'm a pediatrician and I have a first-hand experience and in order to change this system well we had to start of course the premier level if you look at this slide know that the state of Ukraine has taken a decision and the partners know there's to change this system of payment for the primary care physicians this is going on but it is not only about the financial resource we have to rework the whole process from quantitative indicators getting to the qualitative indicators and you see that that Poltava the region of alt-tab now is among the leaders and if we look at how much resource we got it was in 2013 when we've started delineating the primer in this secondary level because you know have originally been in 1998 there were first first attempts to reform the promoter level and this is of course very important but in order for it all to work we need to train the staff we really need to train the health care providers and here I would like to say thanks to partners who have created this and this is very important for us we have created the network of these training classes and this network is working now and many colleagues who come from other regions will look at us we have created basically this system of training all the specialists they all will learn how to learn teamwork not only the primary level but those informational policy specialists from different specialists from other services and he is also very important because unless we train the colleagues and then practically we won't get anything and today we have this regional training class and there are practical sessions that are very important now to change the approaches and the tactics not just it's not only different of the financial resource but we really can make the changes tangible for the patients this is very important and we do this comprehensively we do this jointly with the World Bank project jointly with the Swiss Development Agency project it's a comprehensive approach which is very important you know nobody believed in this program and nobody believes some people don't believe in it now I remember one of the partners has said as the task for example you want to have a program for the patients with hypertension but you calculate we have the costs we will have the funds because you had the reimbursement program and then it was cancelled and then we took the statistics can people afford these medicines so we were sitting for several hours and we tried to calculate if now we do the screening if we start working with patients at the primary level can we do this and yes we can and even our households have it we'll find it affordable but of course the specialists now shouldn't be dependent from the pharma companies and this is very important yesterday was coming here and the journalists were asking me oh we need this medicine and that medicine and a color specialist is it available on the affordable medicines problem and they say yes is possible so we can do it but who for example thought that they so called a prescription system would work in the affordable medicines program the a prescription is working ready this is important I won't even mention the training problems in the primary level because the project has all the merits on this and actually my colleagues said that I lost a little bit of weight recently basically I use this table and I can give an example there's a phone call from the Canadian representative is they want to come to one of the primary clinics in our region to look at how the World Bank project is done how we transform the primary level and also mrs. su prune is coming there's a delegation they come in and there is a health care provider at a primary level and he is using this stable presenting what has happened in the system and this is very important we understand today like last week miss elaina was there when the aspects conducted in Ness serve a sociological survey and yeah we don't understand them things yet but still we have we have started these and we are treading the path when the system is being transformed and it's important I won't feed you all other slides you all know this stuff and just the main thing I would like to show you know the primary in the secondary level there was a question how can we help people change the system how can we make primary level work so we'll be a preparing a project with the World Bank with the partners and they have a lot of them and we appreciate their support we've started with simple things the experts told them victim why do you want to have such a large project pick a small district work it there I say we have to have a comprehensive approach from simple elementary things it's a headache for us today but we've took this path and we took it from simple elementary things this is only the beginning we could give it to people to show that things are going on it things I changed but we don't have back your timers here and of course was a problem of the deliveries of the biosamples but we could show that these is possible and I have one thing that I really memorized very well when expressed from Swiss project came to awesome and we had a meeting that was an expert evaluation or something like that I just dropped in and there was a question and a nurse who worked for 10 years in England she get back and she said that the vacutainer is procured were not very proper ones and something like that and she said like the more we trained the more we communicated the better it will be but what what actually happened is that we managed will be to show to the people how much has been done very simple things and before at the PhD level because now we speak about very comprehensive approach in terms of prevention and such read cetera before people would have to wait to be tested for controlled arterial blood pressure measurements and people would have really to wait for 3 to 4 months before they would get those measurements to get their disability category now the change is that every family physician now has all these equipment at his disposal and that is quite important because it has been done all over the territory of the Oblast and but we had to train our staff how to do that how to make use of it and as of today Jer colleagues idea Frances dear colleagues from international level you are our partners without you support from the support from WTO the World Bank we could never be able to do that but these are really very simple things though very important in Poltava region were performed a really unique pilot within the World Bank we project we all know that when an individual comes with test results from outpatient clinic or family not in clinic nobody usually trusts the test results so we developed a standardized approach to that now all the test results are really similar similarly obtained in every region of the Oblast this is a very cost effective solution to the problem at the PhD level because when you work as a team we discussed how to do that for HIV how to do that for TB and now that was for the first time when we started teaching our teamwork approach at the PhD level and the support of the whu-oh and the World Bank thank you very much miss anaesthesia by the way for that and we will definitely continue doing that and colleagues you remember these are like the old things which might already be forgotten but these are good practices and I really saw that the people were very much satisfied with that approach and when you go out it looks like this is an outreach it work when you go out to people you do collect the specimen for testing you perform some blood pressure measurements some other measurements that this is also a very important component of MCD preventive activities Amit you look into portable blasts almost 500 settlements that do not have any health care worker and they have to go something like 20 30 kilometer distance from their site so we can have a kind of a mobile or outreach team that could go out to the settlements and that has become a really important piece of a very comprehensive work because of today and that all became very possible became possible due to support the from our colleagues and I'm not going too deep into that because it was already died someone or someone already touched upon that mister phone when he suggested us an idea like you implement a big project and we focused on five main pillars emergency care hospital regions NCD master plans this is something that we are really focusing on and if you look now into that cascade approach this is what we can do this is what we can analyze as of today but this is a very good approach actually willing to teach the people how to tackle the entities when we started doing that it was in vivre and in our hablas by the way now we're quite ready to show the results to show the outcomes but these are really the good approaches to hypertension to diabetes mellitus type 2 and today when we started analyzing the situation with those conditions including breast cancer cervical cancer I will just briefly skip those slides not focusing but imagine that but these outcomes these findings really showed us what they are the Fuuka says what are the points of our attention a special attention that we need the relative focus on as managers in the health care system speaking about communication that is the topic which we call today to be really super great and super huge we had to prove to the audit chamber why we developed hypertension self control register we did develop it it is really true but we suggested that idea that it is not enough definitely but you can see I will briefly leave through these slides and so that you could see some of them and our colleagues say we do have quite enough of information and material collected which enables us really to make decisions so thank you very much dear colleagues thank you very much for your support it is very important truly g/b a good communicator bringing these information to the public and understanding the proper ways how to resolve those issues and problems thank you very much thank you very much for that very positive report with very positive findings I do really hope you will publish the report of your activities and with your analysis overheard you have training centers available you started to train your staff we would really like to see how it impacted the health indicators and health determinants sorry no microphone is used no microphone is used sorry today and that is a big mistake I would say in the in the country that you want to reduce the disability rate and the mortality rate like today right of the spot you need to have proper indicators first you're quite correct let's let's do it let's work on that but work on indicators and the way we can impact those yes thank you very much for that and now a representative from the World Bank Alana doroshenko was a report on cascade approach data for decision-making now we can hear some findings I guess well thank you very much for an opportunity to deliver my presentation during the conference these issues are quite important and we are quite happy that we have substantial progress in improving accessibility to services thank you very much for your very positive feedback regarding everything that has been made and how much has been achieved together with our colleagues in cooperation with the WTO the Swiss cooperation and development and cooperation agency I will really share with you with some findings and this is a kind of a component a piece of work which were working upon together with the regions and our colleagues and and some of the slides it could already already were presented some of them will be scripted but I want to show you one of those that you already saw here we will speak about an additional analysis format in order to understand how effective are we in achieving the targets how effective are we in working with our planned patients and what are the results the Cascade analysis 'm it's really important really to understand the whole chain there are four simple questions here is the patient diagnosed it is a patient diagnosed has a hospital vision is a patient linked to appropriate house care if the patient monitored on the care regimen and thus the patient achieve disease control very simple questions but there are good findings and there are some good results you will really have to work upon just for the sake of simplification let me focus on a couple of slides and you might remember that slide from a previous day it tells you that who in Ukraine who have quite high level of risks high blood pressure as a result of that unfortunately quite many people died or people have hypertension condition they might get the disability condition and they lose their productivity if we compare this data to developed countries of the world we have some good models for action because in Ukraine the mortality following the preventable diseases is still pretty high and we're yet working upon challenges which have already been overcome and have been already resolved by many other countries and that means that we still have a good let's say room for perfection and we can improve really the health of our friends relatives and the people you come across on a daily basis I think it is worth saying that the cascade method was used in the beginning for chronic diseases like TB and the HIV infection but the method is very demonstrative very illustrative I would say so we decided relate to make the following step and understand how it can be used in regard to other conditions and the previous speaker already mentioned these four conditions hypertension diabetes breast cancer and cervical cancer and I would like to speak a bit about the findings not maybe that much of no the findings I mean actually which are quite important I would say for further activities at the level of project planning for us and for you at the level of managing such patients and managing your projects in improving communication with the patients when you speak about hypertension and I think this is one of the most prevalent conditions in Ukraine that we come across on a daily basis we have here two cascades that illustrate the situation in a live and Ulta haul blast and these columns in Ukrainian version it might be a better explanation it explains what happens to every 2j a patient at different stages and so it basically gives the estimated number of hypertension patients how many people know about their problem was half how many of them know there are diagnosis and how many of them have a regular monitoring which means they present regularly themselves to a doctor and the doctor knows what is happening to the patient and also from the point of view of way of life treatment efficacy how many of them achieve the controlled level of blood pressure and how many and to what extent we can associate with the that number of patients with the number of hospitalizations admissions to hospital as well as their life expectancy and their healthy condition you see these columns are quite different in size that means we have quite many losses and they are most substantial at some stages you might see it here there is a big gap between the light green and the gray Collins which means regardless of the number of diagnosed patients with hypertension there is a problem really to ensure a regular monitoring for this patients especially this is true for the most complicated conditions for whom it is not really easy to achieve the controlled level of blood pressure you know there are clinical guidelines that recommend really are more often monitoring for those patients who cannot achieve 140 to 90 figures and that means it such patients require more attention but usually what happens is that these patients stay out of sight of health care professionals they either do not want to go to hospital or it is not easy to negotiate with them really to make them take their pills properly and come on follow-up visits and thus we basically lose quite an important group of patients and this group is not properly followed it is not properly monitored and that is the group that really leads that you have the highest number of hospitalizations and this is the group of patients that is really suffering from the highest level of threat before losing their house and high mortality rate column number two you can see there is a big difference between the control the treatment and monitoring and there is quite a substantial gap there as well which means if you follow up your patients and they do actually present themselves to a doctor in some regular period of time the problem here would be really to ensure control the blood pressure level regardless of the fact that the accessibility to medicines is quite good now as of today the situation has improved some patients are quite diligent I would say but still something is going wrong still there and you can see that the you can see it on the basis of this very demonstrative data we have collected that statistical data we have worked upon many records them and if you take that very at that cascade approach and you basically filter the patients during each of the next stages you can say that only five to six percent are fully fledged lis have been monitored followed up and really achieved the control the level of a blood pressure which is a very low figure I would say I will not go too much into details regarding other conditions but with the way we know that hypertension is really associated with a large number of hospital admissions and as of today this is quite a huge number of patients that we have in hospitals who are treated against hypertension and we see that the number that these cases might be prevented because the people who are admitted that they actually were supposed or ready to be on the radar of a family doctor because usually these are the patients that would have high blood pressure for a long period of time they would have some concomitant conditions they would have overweight problem they are quite elderly people and they would really require more attentive support so even they were paid more attention at the PhD level we could be able really to support the health care system better saving more resources to be reallocated to more aggravated cases acute cases and definitely we can prevent patients being admitted in a crisis situation that could easily be prevented I will skip a couple of conclusions here I think you will be able to lead to read them very easily yourself in your use upon your USBs and and they're still there is one issue you need to really focus your attention on one were mentioned will work with many records and patient records that what we saw is that not enough time is paid by the doctors to the risk factors and quite often the case we have we don't have any situation even information here if we're this is a smoker patient what is the weight of a patient are there any changes in weight and Anastasia will show you these really measuring strips soon and our colleagues know from the regions how much time we have been fighting really with the physicians at the PhD level really to make sure that they have these very complicated equipment available but these are really simple things that really save lives this is kind of a promo slogan just for comparison let me mention another disease the diabetes and this is a problem that often is is common concomitant with hypertension so managing both conditions is important just pay attention to this cascade and later we'll be able to have along the local list this is the COS capability and portal you see that the columns lose a lot of patients at every stage if you break down all the cycle of care such as following the patients up checking in their allocated hemoglobin is in the norm and you see that the patients who are followed up in portable they have access to people gated hemoglobin and which is a good resource for the negatives but still they don't achieve they indicate and this was quite a surprise for us that in the system there is a significant resource and huge spend a lot of time to talk to patients to prescribe treatment to write new recipes to refer them to then the chronology sound of lab tests and I wouldn't want to say that this all is in vain that we should know that quite often all these efforts do not lead to the results that which is having the controlled sugar level and blood and another thing we've looked at the ABC Diagnostics for the cholesterol and located hemoglobin and pressure and these patients with diabetes quite often have no notes about these parameters and this is a problem as such and also the comprehensive attention is not paid to this because such a patient needs to be also followed up comprehensively and the patient must be aware of all the issues related to their condition and how they can influence them through lifestyle changes or treatment good I think well I have a minute right on breast cancer here I think the conclusions are more or less the same but what's important here on breast cancer when this term that the screening program is not set up everywhere Oh 15 minutes ago anyway in the vivo blissful but there is the possibility to take the screening but the invitation system is not worked out here the patients do not get invited for rescreening on time like there are issues overall in Ukraine but even when we have the capacity or even when we have a certain bias quite often the Gynaecologists they see same women who go to regular checkups and this is about a half of women not half of one probably cares about the health less they see doctors less often and they never are in the scope of the attention until they have a complicated case or later stage of cancer this is a huge loss for the health care system because if we find later stages then of course the treatment is more like well the exception of life is not that long so how do we change the system how do we detect the diseases at earlier stages how do we change the lifestyle in patients who food and do it this is still the challenge that needs to be addressed and I will not go into this you can look at this slide if you haven't heard about this before it might be interesting for you there was just one more thing that is not really about prevention as we've taught that prevention a lot this is about treatment and here once again and there are nuances this is by cervical cancer stages into ah blasts Poltava is on the right and the vivre is on the left you see it's written down there do you see also the legend they break down by type of treatment and you see how and with you you see the variation and once again it sets a lot of questions do we have standardized treatment can we provide standardized treatment yeah but anyway it influences the result and this is what we think should be noticed even if we say that okay this is treated in this indium come on ecology hospitals and this is their thing but once again these patients then come back to you to the family doctors who really take care to extend the life of the patients for the next five or ten years and we don't really know the survival rate for the patients with oncology diseases here and all these tiny details then they adapt to this huge huge set of ten CDs which is the subject of the conference so I probably will stop here even we have although I have one more interesting slide but you can find it in if you look at the slides you are also writing that up as a report that people can access darkness yeah yes we have a brief policy brief so a brief document that outlines all who are diseases challenges identified you have them on the pen drives and the slides are there on the phone the pen drives and the bigger report is being prepared now there will be more detailed recommendations and what should be done citations fitted well together where we have a directive in Poltava talking about the importance of information one many because they're short Oh actually they talked they told me that all these briefs are also published at they're published online I had the National at the World Bank projects I'd well is if you we put those on the slide at the end so the ones that you mentioned so that we have all those web links together might be useful it would be easy for us to put up because I don't have us thank you very much I'm conscious that we have two more speakers before coffee can we just stand up and just kind of move in our seats I'm not going to do this my colleague is there waiting for me move around a little bit west and the stasi otherwise we will have no energy okay so we introduced I think you all know anastasiya dumped River a national professional officer in the w-h-o country office if you want to stand during the presentation as long as you're not blocking feel free to do so I did that yesterday and I took time to go and stand at the back because I find sitting for a long time quite exhausting so if you want to stand at the back course move on the spot at the back feel free I'm sure it will fit well with her presentation so anastasiya the floor is yours the Bronco Cahuilla rather watch this uranium good morning Nicholas it's a pleasure to welcome you all here and my task here today is to remind all of us what is the path that we've taken with this joint project by the MOH WTO insidious prevention and health promotion in Ukraine supported by this Swiss development and cooperation we have taken quite a serious path we've did and we've done a lot and when was preparing the presentation I was trying to remember all the things we've done and I look at always stages starting from 2015 and I divided them into three main phases the preparation phase as part of the project the implementation phase when we've started implementing our events in the outlets and and also important part was the evaluation phase for our results only one to remind you about what was done but after the presentation will be additional presentations by the colleagues who helped us conduct these and analyze the data so the preparation phase let me remind you about the purpose of this project the project by the the Swiss development cooperation agency the goal was to improve the capacity of the primary level to provide services to prevent timely diagnose effectively manage and support patients with an CDs with the focus on cardiovascular diseases why and did we have this focused I would like to remind and you probably have heard about it and you probably have seen different graphs and visualizations but I think here on this slide we can clearly see the the share of the N CDs to all the daily yes the daily means years of lives adjusted for the disease rate and mortality and you see how many daily years cause the in CDs so this shows that the primary care providers they have more patients with these issues than with others so the fact that you are busy every day it's because you see many patients with this pathology oh I'm sorry there's some lag when I click and change the slides I try to learn how to use the click so this graph once again shows why in our project the focus was on cardiovascular pathologies because in Ukraine have one of the highest premature mortality rates in Europe from cardiovascular disease which is four times higher than in the EU countries you can see it in the chart the red line shows the indicator for Ukraine the Green Line shows the indicator for the EU and what really is worrying for us this is the early mortality of men which is three times higher than in women the next slide shows our pilot regions this component of the project which were talking about now we've implemented it in our seven pilot augustson lives given live even a frank Yves could be need support other Harkey Tim Petrovic Oblast and the city of Kiev when we've been preparing this project and planning the interventions we have looked and how many primary level providers who do we have in these regions you see the thing about 20,000 professionals and then that have includes family doctors nurses and junior providers that work in the district so we had to train at least 50% which is basically 10,000 it was when the student from the beginning we have to Train 10,000 people which was quite a challenge honestly and we've started on started thinking what can be done how they gonna do this how can we do it and do this in the most effective way what we've started with at first with the support of the WHL Europe and our cooperation Center for example the Finnish cooperation centre and with other experts we prepared a training course that is what's called essential training for primary health care workers on the integrated management on hypertension and diabetes what was special in this training the people who are working in the primary care level already know things and we don't want to tell them what or didn't know so the goal was to use evidence-based approach to teach the primary care workers those things that they definitely don't know and that are going to be useful and effective for their patients the first thing we've understood we have to do we have to teach of care providers doctors and nurses together have to train teams so that they would have shared understanding in order to achieve their shared also this helped during the trainings this helped trying to find solutions to redistribute their functions because effective management defence CDs will involve these specific changes in the functions of who does what when the nurse and the doctors really start working together and they have a most energetic approach they redistribute the functions as they were training together and they started thinking of how to make their work more effective they also thought what is required in terms of reorganization of their working conditions we understand that there are limitations we understand that some things couldn't be changed on some size but at least it was a first step to give new ideas so that then later maybe they could inform the authorities so that something could at least be tried so changes in the patient management what was the innovation in the training we've focused on assessing the total cardiovascular risk for many of our participants it was not part of common sense because doctors are used to treat as soon as the patient has any complaint but here we start explaining that you have to assess the cardiovascular risk overall and that you should use certain criteria even when the patient has no complaint yet so over in cardiovascular system or another system also timely detection of the risks factors on an CDs regardless of the diagnosis yet and really working with the primary care to reduce the risk factors then treatment depending on the risk of it was not that of the innovative approach but still the doctors understood that the patient management would depend on there is also integrated management of hypertension and diabetes we've also focused on this a lot in the training and another component was integrating in the training sessions is how to work with the patient or so that the patient would be able to provide self-care here I would like to focus once again that working with in C D risk factors through shortened dimensions through the advices through trying to reduce the behavioral risks they own them in the scope of the training and also motivational counseling we've included this in between sessions and the feedback was very very good after people started using this technique for almost all the participants in the training this was and you think they had never ever heard about this in the previous medical training so the motivational counseling was a really key component in our trainings and yeah the behavioral risk factors you see them on the screen we've talked about this and we've told they provide us how to work with the patients how to motivate them to reduce these behavioral factors other useful interventions besides the content of the training we've also created this tool that helps change if it helps them clinical decision making we've laminated this tool and put them on the table of every doctor and nurse so the day will be available for a long time so they would be handy and so that they would be actually used in practice and you have them in your folders if you haven't seen this before please feel free to take a look and also we've developed this very nice measurement tape you might have seen it yesterday already you see it has colors that basically we took the idea from Finland when we were in Finland for a workshop on NCDs we've seen a similar they did it differently it was a similar measurement tape and we took this idea from there and then we're giving out these measurement tapes on the training sessions so that at primary level the nurses and doctors will be able to use them and the next stage would be the implementation phase note here that we really cooperated close with the Oblast Health Department I'm really grateful to all of them all the experts from Oblast level who were involved into your activities and into interventions planning here on the next slide I just decided to add a couple of photos for you to see that we did visit every Oblast that we did have a meeting was like all partners in the Oblast and really discussed in a joint manner what would be the most effective and the most efficacious approach relative implement as its activities and interventions in the sides and we did that jointly with our colleagues from World Bank who have been working in floral blossom and out of 700 blasts four have been and they are still do blast were the World Bank is very active who would also invite experts from the World Bank we knew they were really very active in the field of MCD control so we really coordinated our activity to make sure we did not have any overlaps and we would be able to really to make use of our resources the most effective way so let me reiterate really my gratitude to everyone who was involved their planning was a very serious piece of work it was not very easy I must tell you because teaching and training so many people in a very limited period of time really required very exhaustive efforts I would say the world definitely peculiarities in all regions and we managed to really do approximate let's say to bring the trainers and trainings as close to the sides as possible we would usually pick a district center which would be quite a good place to come for the majority of districts around the and on the plans would be approved by the Oblast the department's of halfa right after that we also trained the trainer's the number of trainers was calculated on the basis of already developed or lost plans and we had first to develop the plan understand how many people would go where and how many trainers would be required for that to you three deities were conducted we trained 52 oblast level trainers from the pilot of blasts you see here it was 2016 and then they started really to fair cascade of training Walter cooperated very actively with the medical chairs and departments of the medical universities and colleges so that they could be able really to integrate components of that those trainings into their training curriculum the outcomes following the number of trainings and number of people trained in Cascades who have conducted a two-day training some implemented in seven pilot regions we never allowed more than 30 participants per training session otherwise it would negatively impact the quality we have conducted around 400 training sessions in those seven Oblast during these two years we have trained more than 10,000 beach BHC healthcare professionals which equals to about 55% coverage of the total healthcare stuff under here this is a kind of a summary table and and there below in red color this is the total number of people trained and here this is a visual demonstration of what actually happened in every Oblast I must tell you the progress was quite different in different published we trained more physicians in some other Oblast we trained more nurses the physicians but in general all Oblast but one have achieved the target indicator of 55 55 percent what was done next definitely conducting trainings was good enough but what else had to be done following that we got the feedback forms we have analyzed them evaluation forms after the training center and according to the feedbacks collected were really updated and revised our training sessions and based on the feedback from our participants and in compliance with the ongoing reform who have implemented some changes mm now we're working jointly with the World Bank developing an online training that would be accessible to everyone who would like to have it in the online mode and the most important thing who also conducted analysis of feedback from teachers of both graduate departments of medical universities and colleagues who completed this training and my colleagues I guess later today will tell us how interesting to an extent it was interesting relate to the faculty staff and really looked into the changes that really took place at the PhD level after the nurses and health care staff physicians were trained during our training set there will be a presentation from Professor Tina Lottie Kynan from collaborative Center in Finland and also our partner organization that will assisted us in data collection and analysis from the Institute for public health policies thank you everyone who participated in this work with us who supported us I'm really really grateful to D WH original office Europe for European Farington namely because it all happened under a very high level expert support I'm grateful to our national experts and very grateful to our colleagues here from the World Bank the Oblast Department of Health seven plus three means seven pilot of let's say plus three additional sites from which we had a chance to collect data I'm also grateful to original coordinators and definitely our regional trainers Thank You evident everyone thank you very much everyone thank you for this cooperation what a long journey it was it started in 2015 and we've been around all of those years we proposed to take a coffee break now because it's due at about 10:30 and then we will continue with the presentations well as moderators were aware there are many presentations and but we do want time for questions and answers so can we suggest we just take about 15 minutes for coffee and then come back in or and we continue take the opportunity to keep moving and we see you soon thank you you education and she's going to explain about the integration of the NCD training into postgraduate education passion on ukulele she rose de Rohan Yamuna doozerium dear colleagues good morning again it is really my real pleasure to see familiar faces and it is really my pleasure really to continue these the Daisy brand talking about positive examples positive best practices I would say available not only the global level in the field of foreign city control but also available in Ukraine being a faculty stop that means I would like to speak about some global trends in the field of training in the primary care workers and the mid-level medical staff on the integrated management of NCD racism this is what Anastasia has been talking about we have conducted two trainings in seven regions of Ukraine and in the end of recent year we have conducted a kind of questionnaire or survey among the trained staff on how they implemented those new approaches that they have been trained for we had 25 teachers and medical workers from seven regions of Ukraine involved in that nurses and doctors education there were five doctors of medical science chaos and they were they provided their feedback and they were quite similar I would say so our responders were teachers and trainers involved into training general practitioners and family doctors as well as nurses and part of them work the both at the pre diploma and postgraduate training and they trained both physicians and nurses and what were their specialties these were specialties that under their competences would be involved in two risk factors finding correction and management of patients with NC jeez and chronic diseases and this is both true for the internal medicine as we call it all our family physicians and these were the questions included into the survey these are the questions regarding personal data there was some data regarding the evaluation of the training components and some recommendations as well so what were the responses that we got and they really made us very happy and we want to share it with you 100 percent of people said it was a very useful training for them for their professional activity and it is also necessary to note that regardless of their level of training let it be the hat off your head of department or their assistants majority of respondents responders as mentioned that they really got lots of novelties and reliever in new pieces of information though it was quite a basic training I would say what topics were in you for them this is what must I say mentioned about that was a motivational interview 21% of responders replied like that that is very important because it really indicates you us about the gaps in their training even for the highest level faculty stuff quite interesting aspects in terms of clinical work with entities this is true for ban tool from W Joe 10% of people who are quite positive about that he issued that question they indicated also the methodological aspects of training that was something that they liked very much that they liked it very much in terms of methodology they're going to use it in their activity methodology in terms of presentation development and preparation so basically we managed to relate to bring to deliver this information even to the most highly trained experts one-third of people said that the most valuable information for them was information about clinical a component which is management of patients with hypertension and diabetes and some more sub topics were indicated and the top three here was also motivational interview component regardless of the fact that we have not been taught to do it in my medical school even when I was in like on the highest level of my training I didn't receive anything like that like pedagogics trainings of etc and this is exactly what it showed was also true for the majority of our responder I said what the information we could add really to improve the training even more so was asked what kind of information could be added to the workshop to make it even more valuable and we got the following answers the fact that the part of people said that all the necessary information who was adequately resembled which means that was quite an adequate approach to the amount of information amount of new information importance of this information to their teaching practice and at about 14 percent of respondents mentioned they would like to add an issue regarding nonspecific chronic pulmonary diseases which is a good actually topic attributable to NCD and would you realize though that in order to add one more condition it really will take another piece of time for us it will really enlarge and make the training workshop be more extensive so to same be more lengthy the worlds are some issues that they wanted Willie to include on metabolic syndrome emergency care part of people would be interested in alternative methods of treatment but we decided to focus on the fact that we are going to make use only of evidence-based medicine and all kinds of alternative treatment methods need to be trained there elsewhere speaking of expansion of methodology blockers this is very important so basically the teachers the faculty staff asked us to teach them teach better what we found also is that we got some information regarding the implementation of the training materials into the teaching practice which is basically their direct responsibility on a daily basis it was very positive when were asked like do you make use of these materials of the obeah on your day in your bed daily practice 100 percent of respondents they said yes no one said no but the use of those training materials was a partial in 20 percent of people would use these distributed materials about 20 percent of them would make use of the Oh radical didactic part of the training and about 45 to 50 percent used the all materials around the training we also wanted to learn if our faculty staff managed to approve official adopt officially any training agenda training syllabus with the use of components or fully of the training workshop and that was really a nice thing to hear that up to 50% of faculty staff who work in way well the family physicians and nurses at the postgraduate education level managed to approve these trainings as a cycle of their continuous medical education cycle and that was very important I would say that was a very important step forward that would facilitate the distribution and spreading of this information among healthcare professionals and nurses speaking of trained specialists what we achieved actually this is both true for physicians and nurses we have good achievements for both specialties this is the data that we got in 2017 and 2018 and this is a good result of Gaza so what are the conclusions and these trainings became a very useful tool to promote the further implementation of ancillary specific questions and it enables really to go on working within the existing curricula but also enables willing to approve the new ones a further improvement of trained can be implemented through widening of clinical problems and including different NCT's thank you very much see how the training was used afterwards great and which we keep moving so we have time for discussions so if we move next to finding the results of the evaluation if I introduce professor Tina Lata Kenan who's the director of our w-h-o collaborating Center for non communicable diseases in Finland based at National Institute for Health and Welfare is it that keeps changing its name but yeah I think that's what it's called at the moment so team of the floor is yours Thank You children dear audience I have a pleasure to present you the first preliminary results of the evaluation of the project what actually Dasia very clearly explained to you already earlier and i have to remind you that we actually got the data in april so it has been quite short period and we are already in this face that we can present however something could I get my slides please and the English ones so I think the English ones will come soon as well but maybe I'll start so as explained what what has been done is that we did an evaluation survey to the seven intervention regions and three control regions evaluating the pen implementation protest the training project here in Ukraine and data call we we with the local w8 so experts and the international experts kind of created the protocol and manual how the evaluation study is done and the data was collected by the Ukranian Institute on own public health policy and the data collection happened now in the beginning of this year so the protocols and plans were done during the last year and the sampling was done last autumn but the actual data collection happened this year so there were altogether seven intervention regions and three control regions from which the data was collected and the data was collected from patient records so the paper-based patient records so that we collected data from free intervention period and post intervention period kind of having a mark a day from which backwards the data collects collectors were collecting those that information and variables we were interested in and it happened between January and April this year and the target population patient population where males who were aged 40 years or over and females aged 50 years or over which is also the target population to target for example the total risk assessment according to the pen protocol and these patients had to have to visit the medical facility during the last 12 months and that was the eligibility criteria for the data collection so when there were seven large regions with heavy having many many rayon's in them the sampling frame was so that we randomly picked for Ryan's from each seven regions and from these for Ryan's 20 doctors who we're trained during the intervention and of course in the control regions they were not trained and then from each doctor 24 patients so that half of them were men and half of them were women and we had especially developed a data collection tool kind of indicating what variables we are interested in like has the patient been diagnosed for hypertension can you find a blood pressure recording can you find a value for cholesterol and and so on so these here you can just see what were those intervention regions and control regions and these table shows you how much data was finally collected and I would like to pay your attention that there was huge amount of data collected so like all together for 4000 observations both for the baseline and follow-up so actually 8,000 patient records we went through during the data collection which was a major work done by the Ukrainian Institute on on public health policy and here you can see that the sampling procedure kind of worked pretty well and AIDS and gender distribution both in the control and intervention areas were very similar and so we can kind of think that the data what we have is reliable to remind that really the purpose of this evaluation was to try to get information has there happened changes in the intervention regions in terms of the processes of total risk SMS assessment or the management of non communicable diseases or the treatment outcomes but also you have to remember that it's extremely interesting to see what is the overall performance what is all in overall happening in primary healthcare Ukraine because I believe such data doesn't exist before so based on those different variables we have planned to collect we kind of created predefined indicators that we were then supposed to calculate I don't go this through because it takes forever to read this but but you will get this material so you can see what kind of indicators where but however we collected information on risk factors and the diagnosis levels so how many patients had certain diagnosis for example we collected information on different process indicators so whether certain risk factors were recorded documented in the patient files and according to the and especially we were interested on those topics that were trained during the training in the intervention and then we also assessed some outcome indicators among the whole patient population but also separately for certain patient groups because there was kind of enough data to also do some subgroup analysis for cardiovascular disease persons hypertension patients and entire beta's patients so some some data here this is about smoking and smoking status recorded in control regions there was no not a single recording of smoking status not at the baseline nor after the follow-up so it seems that it's not the practice of recording the smoking status of patients to patient records at all in intervention richness there were some recordings already at baseline so probably there are regions where there already has been certain activities going on and there has become a happy to record smoking status as well but there was a big variety between these intervention regions also there were reasons where we had zero recordings but then they were regions where there were more so and actually in the intervention regions a clear improvement happened also in the smoking recordings of smoking status recordings the next figure shows what was the prevalence of smoking among those who smoking status was recorded of course this is not fully reliable when we don't have data from a hundred percent of patients but it gives you some kind of an understanding that actually thirty percent of males this males over forty years are smokers in the patient material which is quite a big prevalence anyway among women the smoking seemed to be not so common but anyway these tend to be high risk individuals as I will show you later on these are similar figures for BMI and waist circumference so in the baseline quite low values both in intervention areas and very very low values in in control regions in the issue how many times we could find the bio BMI recorded or waist circumference recorded and there was clearly significant improvement in intervention areas how these risk factors were recorded in the post intervention phase so remarkable increase in BMI recordings and also invest circumference recordings we also had in the protocol or in the training the tools to use audit for alcohol abuse and the European Society of Cardiology score for the total risk assessment and here you can see the changes in those in control regions again there were no recordings at all not nor on the baseline or after after the intervention but at the baseline audit and risk score was all it was recorded for one percent of patients in intervention regions and it increased up to fifteen percent in follow-up and the risk score was recorded to about a little bit less than twenty percent of the patients and it increased up to sixty percent during the follow-up which is of course a major increase blood pressure was quite regularly measured both in intervention and control areas for for most of the of the paces and they didn't happen any major changes during this one year follow-up what was remarkable was that very big percentage of the patients in the in the patient populations had hypertension so if you for example pay attention to the intervention area women so eighty percent of the patients in these patient populations had hypertension diagnosis in they're patient files so it seems that the patient population is quite high risk individuals who are regularly visiting the services or those who are regularly visiting the services are high-risk individuals we need to figure out this more how how so big percentage of the patients really can have hypertension but maybe it's that they have more frequent visits than others and they are then more likely to be selected to the sample nothing happened in systolic or diastolic blood pressure levels and they were very similar in intervention and control areas in the beginning and in the end of the intervention I have to say that I wouldn't have expected any major outcome changes in one or one and a half year period so getting that kind of changes in in treatment outcomes is quite challenging and doesn't very usually happen very quickly in clinical practice but what I would pay you attention to in this slide is that however the mean blood pressure level is quite high so systolic about 140 diastolic more than 80 and there's clearly placed for improvement in in this fasting glucose measurements significantly improved in the intervention areas they actually improved a little also in control areas but there was a big increase significantly bigger increase in intervention areas in fasting glucose measurements the proportion of those having having diabetes diagnosis seem to be about 10 percent among males and about 15 percent of females which I think it's quite how does they expect it and they happened a small increase in the intervention region in the proportion of those patients who have the diabetes diagnosis recorded usually that happens when you start to pay attention so then you start to detect patients to the treatment it doesn't necessarily mean that you have more diabetes patients in the population it's just that you have detected more patients who have been earlier undiagnosed but this difference between the intervention and control regions was not statistically significant so total cholesterol was measured about from about 20% in the beginning and and the measurement rates increased significantly in intervention regions nothing happened in control regions and this happened in the overall population but it also happened among the patients having cardiovascular disease and it also happened among patients having diabetes studying prescriptions were also looked at and they kind of happened didn't happen very much in the intervention regions to the prevalence of cardiovascular disease patients or diabetes patients who we think are high risk individuals in the prevalence of prescribing statins but there was some decline seen in the control regions instead so the risk what what we observed from the data was that the risk assessment and the NCM the management processes were already at the beginning quite different in the intervention regions and the control region so there seems to be big variety in these processes in primary healthcare in general maybe these intervention regions are partly or there or among them there are regions which have already earlier been involved in some similar activities and that's why the baseline situation was a little bit better not not very much better however the risk assessment during this intervention period improved significantly in intervention areas but many of these risk factors were not recorded at all or the total risk was not recorded at all in control areas to the patient files so it doesn't seem to be part of the like a management at the moment so NCDs seem to be very common in these patient populations especially the hypertension levels were very high and the assessment of biological risk factors so total cholesterol fasting glucose and similar they also improved significantly in intervention areas while no improvement was observed in in control areas on the prescription of statins improved among CVD patients actually it improved both in intervention and control areas and among women with diabetes in in intervention areas but in this short period follow-up or evaluation we were not able to see significant changes in treatment outcomes not at least yet and for the for the future it would be good to at some point to repeat similar analysis to see how these improvements in total risk screening and paying attention to these risk factors does it then finally also affect the treatment outcomes but there is also an implementation issue very easily when we set up an intervention we and then we try to implement those things in in real-world situation there happens an implementation gap and kind of a voltage drop but even we know what to do then the intention is is not as high as we would like it to be and that needs like a continuous auditing and going back and reinforcing the work what is done but I will stop here because then tatiana will tell you more about the qualitative part of this study and i think it explains a lot some of these observations what we were able to see from the quantitative data thank you so we continue immediately to dr. tatyana carriers over who's the dough can we do the questions after both of these because i because they prevent together and one might help explain the other dr. Brookner ee-yup hello let me continue I would like to yes yes so let me tell you about the qualitative component of this study we had the purpose to hand the gold look not only at the results for the manage to do but also to look at the context and the personal component the factors which also influenced the infants how we could implement in real practice what we talked to the providers the sampling included four types of providers the managers of the facilities doctors nurses and junior doctors and so-called Celsius and the managers took part when either they underwent the training personally or some of their staff or five minutes on me well that's you know and the doctors nurses or the cultures they all attended the trainings and we worked with the audience from all the sides from all seven regions of the interventions and we had these groups four regions for the central region of several Oblast in handle Ukraine for the southern eastern and the western bigger region we have used the thematic analysis to find the factors which influence the quality of the implementation of these newer approaches the results in the following 74 providers to button focus groups 10 men that the rest were women and the average age of the providers was about 40 over 40 and overall if the doctors and the managers were from big cities orchestra in cities and for example cultures naturally they were from rural areas and nurses came mostly from Ryan capitals and the patients were like 40 to 70 two-thirds of them were married a third was male and five of them said that they were smoking speaking of positive moments participated in the training very positively all provided very positive feedback following the trainings we really liked that they really focused on prevention component where the very friendly atmosphere the really behaved like peer to peer for example in Poltava oblast m21 of trainers was a a well-known expert in the oblast a well recognized specialist and quite many of participants sad they the really took that lady as a great model for action they also mentioned them that the training made them look more careful into prevention issues and they sad if before they would mostly look into prescribing some pills and drugs and now they switched more to thinking about the facts about potential ways how to really change the lifestyle and suggest something else as to the patient that you correct his lifestyle it was more effective approach when nurses and their physicians who would the work as a team and trained as a team it was also very important that their managers health care managers would also be there afterward they would become more supportive to implementation of these new approaches and folder monitoring speaking of for clinical practice impact as I mentioned that a lot of the main focus wasn't prevention and they also mentioned that that early diagnostics and preventive activities have improved as well as case finding both true for hypertension and diabetes the score tool the score table was very supportive very good a feedback we got from our participants on that and decided was very easily to persuade the patient in these are that issues when you have a table and you show it demonstrate to the patient like if you switch to the red zone to the gray zone then the quality of life will be improved them another point is that many people mention that the patient started to visit doctors more often because they like the idea that you can be tested for cholesterol for glucose in one place and it made rola patients to be more interested in regular visits to the clinic's the patient's sad that really it is true that the accessibility has improved in terms of accessibility to testing and what they also liked is that they were counseled on a potential ways to correct our lifestyle and one of the patients mentioned now I feel that the doctor is very much motivated and interested in the fact that the day he become healthy speaking of impact on clinical practice another important aspect was that nurses and vultures who really started to feel more confident when talking to a patient and we will discuss it a bit later these are as a group of health providers who usually consider themselves to be a second level of importance so to say they're not so important they think in terms of a services provision because they think this should be the task of a doctor willing to do the counseling and their role would be like very mmm hello and really not very important but after the training both the nurses and the vultures underlined that they felt that as of now they feel that their knowledge level of knowledge has improved and now they're capable of providing information to a patient which they do not simply collect or find on the internet but they have evidence-based data at their disposal and that was provided to them by the Minister of Health that significantly improved their level of self confidence and they also mentioned that this was one of the first intermediate results but in some Oblast they also reported about the primary findings and outcomes regarding the wider access to services provision it lad to a higher level of finding of diabetes and hypertension cases compared to the first quarter of 2017 apart from those quite positive moments we also found the large number who came across a large number of barriers and challenges while implementing the project who also could observe significant differences between among institutions and all blasts and we can see in the project results the main barriers that people complained about was the limitation of time for one patient and the excessive overlord of narcissism limited time is 12 to 15 minutes per patient majority of provider is mentioned like that they got back from the training and very much motivated and they started religion employment what they were taught and then in about half a year period of time after the training the kind of you know that spark kind of went down because of too much paperwork as they said and they say it in Russia and they say like I have to do lots of write in handwriting so lots of paperwork and lack of time these were the reasons that really prevented people from doing what they tried to do and definitely when the patient enters the room before talking about his lifestyle you need to install you need to find some mutual contact some personal contact and then you build trust and then the person definitely can tell you of rephaim excessive what lot of nurses them you can see it all on the slide I'm not going to enumerate everything but those top doctors and nurses mentioned that the nurses are very busy they have lots of different functions and tasks and quite often they stay after the working hours religious finish their paperwork sometimes they can go out with the houses of their patients and unfortunately the workload has only doubled when they introduce the electronic documentation because unfortunately all of them mentioned that no one stopped the use of a paper-based documents this is sad this is funny in a way but the nurses mentioned I have actually just spent a couple of hours every day religious copy this electronic data – the paper-based documents and and the authorities say usually when we ask about that they say like what if a computer goes down what if there is a failure and no one didn't and no one ever issued a decree to stop doing that it it was already mentioned that the motivational interview was in place but only by few people only a couple of people mentioned that majority of people stopped doing that they didn't have proper skills like of confidence I was one of the reasons – that lack of confidence in this discussing some sensitive issues like consumption of alcohol and almost no one reported about the fact that they make use of this audit questionnaire or audit survey they said people simply laugh at those questions they do not feel very comfortable about that and definitely this is a rural area everybody knows who smokes who consumes alcohol and if they don't usually people hide it in such a way and that you will never I told about so nurses complained that they have to do the measurements and still after that they usually listen to the doctor not to the nurse this is what they complained about speaking of equipment available in the healthcare facilities it's like they are quite different I would say one of the representatives sad like we have everything available you just need to have your will to do it others would say well I have some pediatric scales only I have only the tape and that say the other say will have only the BP measuring device and I remember our work with focus groups and one of the patients that when I asked him like what does a doctor usually use during a visit he said a Fernandez cope with the measurement device that I usually see and a kind of a holy picture the holy icon on the wall this is what they use during the patient visits speaking of challenges and barriers again limited access to examinations at rural health posts what they complained about as I mentioned already they are not very well equipped often they see and one of the soldiers mentioned well you know when I came to work there in 1988 I still have the same equipment there at the same scales the scale the same tapes etcetera and this she said I received the core geography device but it is not operational and they have to refer patients that you go to another settlement something like 30 40 kilometers away definitely I can find you with more I can find more examples like that both positive and negative but these are the most interesting cases so to same on improper conditions of work in a rural house both are quite often the case and definitely some people were satisfied with their working conditions but they many of them mentioned actually these can working conditions are really inappropriate and they would say we don't have any nurses positions we don't have any cleaners position and the soldier is the only person there and sometimes they have to provide service to about 2,000 people in the area and some people said like well some repair needs to be done because during the winter time I have to wear some outer clothes with me inside and if a patient presents and you want to do some choreography a cardiogram you cannot ask a person really to take his or her clothes off for because it's too cold and that definitely prevents rural population from getting high-quality medical services and and the final two slides about recommendations for the next trainings it is recommended only to invite the heads of facilities health care facilities or chief physicians or managers actually as well as we need to engage the team of doctor and the nursing it is very nice when you train physicians in the first wave so to say than they would really take the idea of selecting participants or more carefully because sometimes we would hear like one out of 24 or three nurses out of 18 were trained it is very good idea actually to develop the training agenda appropriately definitely need to make sure that training as I didn't mention that actually that majority of nurses and Fulcher is mentioned that that was their first training in life some people have been working since 1985 we need to focus more on practical sessions and especially in terms of motivational interview without the practice and you lose your skills very quickly and definitely training nurses on communication skills and overcoming stereotypes when it definitely to organize additional workshops I would say because people were very happy and they thanked us very much for those focus groups that really became a good chance for them to get together share their best practices and experiences they learned how these processes are organized in other regions and other settings so it would really be a good idea before they have a chance really to exchange their points of view they expect says them this would support their motivation to change a gas a time allocation and stuff responsibilities should be optimized really to address excessive workload of narcissism family doctors and all regions suggested apart from increase in time per patient up to 25 30 minutes a day also suggested to equip additionally their work in rooms and maybe have rooms before three doctor help like three pre-miracle helps it is a premarital care so that they would have a chance will it to be measured tested by a nurse and then they would have a possibility to be counseled by a doctor and definitely the conditions in the Ross house post need to be addressed to make sure that the people in the rural areas have proper level of quality service provision and let me finish my presentation with one of the statements from a manager in the Eastern Region she said we as far as where the doctors were all responsible actually for the first time House of the whole nation is in our hands and this is not a slogan that's a true and we are now able to impact the situation if we really want to do that thank you very much thank you very much everything who participated in data collection so we've had three presentations which have really Illustrated the positive changes that have come about through this project and that's also down to your hard work in making this happen and it's also highlighted some of the challenges that remain and there were a lot of sort of practical issues it mentioned in the last presentation which are actually can be fixed I would think given some of the things so really very positive findings but can we hear from you how do what's your impression of the what you've just heard does this fit with your own experience or the things that you think were misrepresented or which you think need to be added or more emphasized and are there any questions that you have for any of those three presenters so any comments or questions from the floor the protium hello my name is yogge and Kozik he was representing the denim manual on internal diseases and mr. telling you remember the evidence medicine and this is the evidence-based menu and I would like to present this is the first menu evidence-based many of our internal diseases over 600 authors were working on this it's been published I think in the US with McMaster a university in Chile and gatina and this yet has been translated into Ukrainian it's very good that now these trainings for the doctors are conducted and from our side we would be really interested to work on the further publication because this is the first edition so may and may be there are some flaws and the adaptation even though the doctors haven't reported this yet so we are open for cooperation and if anyone wants to talk about the development of evidence-based medicine in Ukraine we are happy to cooperate and if you're interested come to me and in a small presentation I will tell you that it is available just please for you to use it it's a good resource it's a good tool to use James on the presentations we know we had somebody who was trying to ask questions Ramon eucalyptus dear colleagues see if anyone would like to share also their experience positive and not so positive experience and using these tools that has been presented or any of the questions on the information over about the any feedback on how to improve these trainings once again I'm Philip Eli I was the original trainer for Poltava Oblast and also was a researcher so everything I've heard the conclusions of DT Anna this is also what we've had in my research so Stahl is lovely this is this situation is changing in the regions and as the channel said well at least on those trainings that I've conducted we did try to provide some recommendations and how to change the teamwork approach for example how these doctors we decided for example to open them to save time for the nurse and the doctor so that there would be high quality care provided to the patients and of course there are challenges one of them is there's really not enough time for these preventive consultations like yesterday we discussed for example doctors we now have 1,800 patients indeed they're overloaded it's a lot and for example I am in charge of the clinic and I can't really balance the time of seeing patients in such a way so that doctors would really have better time to talk rotations and in future I don't know if we'll be able to make the visit time longer for example in winter we had 12 minutes per patient now we have an improvement we have 15 minutes per patient we have changed the number of patient visit hours but still it's a lot we are thinking how we can influence the psychology of the patients cause patients somehow feel that if they come they should be seen immediately although we have and the way to register for for the certain time and we have there also we have the internet registration so that they dick register for the appointment and plan it a little bit more ahead also the e-prescriptions debt is very useful because then the patients would have to come every month or a few months to get a new prescription now it's it's very easy it's like 40 minutes I think and I have a group of patients who have been treating for many years and now if the patient needs the medicine that the patient just places a phone call and the nurse without me seeing the patient without me wasting time on that so we the nurse does this a prescription so we have started improving on the techniques but there are still a lot that has to be done there is another thing that is not of mentioned about the accountability if there's no accountability you know any initiative would be in vain what we said yeah it's good that we have the assistance of the World Bank and in our region the situation is not as bad as in those regions that were not part of this pilot we have a lot of equipment a lot of improvements with a lot of research but still somebody has to do it somebody has to the nurses in such a way so that every nurse would know how to do all sorts of things for example in my clinic and all the trainings I shared my experience I have an addict well it might be better of course an adequate number of nurses now I have 25 staff 25 people and staff most of them are nurses but I have said the tasks that every nurse you must be able to do all the procedures for example measuring intraocular pressure taking blood samples taking ECG sending it with eating telecard and all my nurses are able to do all the procedures they need to do to improve the working to improve the Diagnostics that's true but of course a lot of things must be done because the accountability is the key like every doctor and every nurse report to me daily how many procedures with how many NIC relations we're done if there is no accountability and then of course the effectiveness goes down so this there should be a leader in the clinic a manager that's why you said that we have to start with managers and the first thing we've started there's no even feather which present here but when we came back from the training the from gear we got together chief physicians the deputies in the Health Care authority but we gave them some presentation it was supposed to be brief but it took five hours to basically teach them what we've learned and care back there and it was quite an eye-opener for many and we've invited the nurses and the doctors for the training and said that the managers of the healthcare facilities should also come for the trainings that is why we've got some results thank you thank you for this good and comment I'm a regional trainer Allen Adham Bob Scott Vinnitsa region I also was assessing clinical outcomes and gene changes and practices and I really like this because now I see what did we have to pay attention to in the first phase and with the systems of the WTO we managed to achieve the main thing to switch the primary level through the prevention and from the beginning we've been saying that we try to have complicated things like ultrasound but let's just start with basic measurements like the BMI the waist circumference they see that yeah it's there as well it's working at the primary care in our region we have for example these electronic and the paper sheet for risk factors excessive weight hypertension high cholesterol from these and now we are forming these study groups six to eight people because there are if there are over eight people it's this more difficult to study we call it health school so it's patients education and we for example select for patients with obesity so that they could discuss their problem we organize classes for school children when knows some facilities provided rooms for these health schools have provided files for the posters and now it's basically what the showcase so it's not something really formal people get excited with these health schools and I would like to appreciate I'd like to express my gratitude to the WTO to them Institute for public health policies for doing this we hope this initiative continues because there are many other doctors who want to take these trainings for example one of the good things was that in health schools we we use those health care providers who underwent these trainings and for example we already had doctors coming from one village and they said but we didn't attend any of your trainings but we've heard good things about your health school we want to have a health school in our place so and it really changed it really change to everything we're doing thank you the Anika Val star from l'viv original trainer and also a practicing family doctor I would like to support everyone and to say thanks for this huge work we're doing and she agrees with all this and indeed 15 minutes per the visit it's really a little and we have online prescription system and indeed sometimes the week schedule is full if some doctors were active if there are a lot of professions and of course it is really not enough time that is why in our clinic we had a nurse coming in and if the patient needs an ECG done the nurse does this achieve the glucose needs to be measured the nurse does the measurement but the nurse inputs all the informations in the database the nurse also issues an e prescription and the nurse also does the paperwork for these declarations because the doctor needs to talk to the patient needs to figure out the condition provided interventions and there's not enough time so I think we need to have some intervention so that the doctor would choose the time for the visit I know that it should be possible perhaps maybe when the patient is making an appointment do you are asking are you here to just get a new prescription for a chronic disease or get as a certificate but if it's like a initial visit and the patient wants to really figure out to find some answer and to have more attention then there should be probably a longer visit definitely because otherwise people actually where people were very happy with the trainings initially but now they just are not able to use it all they are not able to implement the so cuz they don't have time even though all the 504 says that the patients that the doctors responsibility is to manage the patients within CDs – more or less in the context of the of the trainings this is one of the main tasks that's also have to plan inoculations we have to follow up with the children if it's a family coming to visit a doctor if it's like a grandmother mother and a child it really it features a lot so maybe on some higher level this could be sorted out another thing about this each prescription we are seeing this problem that now the C prescription can be made by only a doctor a doctor who a doctor who signed the declaration with the patient for example now I'm hearing here at the conference in these two days my patients might need a prescription and my nurse who has no right to issue petition even though she is doing it but anyway another thing when the patient comes the basically the answer is but sign a different declaration with a different doctor so for example if a doctor goes on sick leave they might lose like a third of their patient in in a few weeks some may I make a short comment there has been discussion today related to like good indicators of quality of care there has been lots of discussion related to there is not enough resources there's not enough time and then there was in Tatiana's presentation observations that some professionals are not recording or assessing things because they think they know and there's no need to then record it because they know that the patient is smoker or is not a smoker but but however if you are not recording the things to the patient files somebody else won't know you can't derive any proper quality indicators if you don't have the data there and if you can't derive proper quality indicators you can't trust the treatment processes according to them we tend to have the practice that we have currently guidelines or clinical guidelines and we can give the same treatment to everyone whether they need it or not and it's unnecessary to follow patients who are in good control every three months you can follow them once a year or even once in two years if they are already in good control it's better to pay attention to those who really need the follow-up who really need the intensification of the treatment and if you have good data in your patient records and if you can then derive this quality of care indicators you can do patient segmentation and find those patients who need more follow-up and more treatment and then to rest with the ones who are already in the code control so these all things are going hand in hand have good data to be able to follow the patient the performance through the data to be able to deliver or to adjust your process according to what you find from the data and then you can really do the sharing between the nurses and doctors who is doing and what whose competence we need in each of these stages and steps under Stacy I would like to add to what Tina said when we talk about the indicators today indeed there was a training of an indicator proposed by a World Bank and now there's been discussion on how this tool can be switched Oblast in our trainings we have remembered foolish indicators but what we did is part of our project we understood that the information on this is it's not enough for the primary level – that further trainings must be organized for the managers and in particular we must explain the list of qualitative indicators has to be probably endorsed by the National Health Service because now this works so far it was not among the first priorities there was no need first of all to have the first phase of the reform to sign the declarations but now we can talk about improving the quality the care provided and monitoring of these indicators is the thing to improve the quality so when this standard in our training for us we didn't allocate enough time for this we said that this is important but this is what we have to do we need to get the data to make it clear and to make it also a uniform nd stood by everyone so that everyone could see it where are we going what are the priorities and what are the priority indicators for in CDs at primary level need to move towards the last part of the session and there's opportunity to speak and discuss again if if I just summarize some of what I've heard so far sort of through this session evidence-based approaches exists for changing clinical practice and we have tried to use those in these different projects within Ukraine and we've actually demonstrated that improvements we've demonstrated changes in the training processes in the recording of the information has even been comments around improvements in patient satisfaction for monitoring and evaluation data is important but it's also really important for clinical practice so that we are managing patients according to their need organization of care is is critical at that point we mentioned earlier about the distribution of tasks between doctors and nurses and we've also highlighted some really practical barriers that need to be overcome which relate to time or equipment for example and then I've also taken from this session that there is a lot of willingness from the different broader partners involved the w-h-o the Swiss and World Bank to continue to work together in support but we also see leaders from amongst you institutions family doctors nurses managers fellows who are enthusiastic to continue to work on this and make the changes and and I like very much Tatyana's last quote around there was it the health of Ukraine in our hands and we've also we've managed to switch primary health care towards prevention which was been the purpose of this so those are my kind of concluding comments so far from this session but what we're going to do now is look at recommendations for further priority actions in Ukraine and to start our thinking professor kim yeon is going to do a short presentation and then again we'll have a round of discussion we have to finish at 12:30 for sure because everyone will come back in this room and then we will start the final plenary alayhim so wouldn't you observe with your colleagues in you have already heard them to these recommendations today you have heard these recommendations from each other you know it based on your personal experience of what we actually need to do as really primary priorities in order to improve the situation in the sides in the healthcare setting 'some so for the purpose of discussion just like Jill Jill did it right now in very brief statements just and very wide brushes so to say let me enumerate a couple of issues which are still there being a family doctor what I can tell you we need to keep in mind that the responsibility for prevention and health is carried out by all levels of social public life starting from the president and high-level politicians the community in general and the community in the side work they all are responsible for health of our community members if the community doesn't care about pollution of river set if you did not have safe food if a moonshine action is really blossoming a family physician can hardly fight it all himself but the family doctor needs to remember that he or she is actually a leader in organizing this safe and healthy practices and the teach in the community those healthy approaches now who have a new profession in Ukraine a public health doctor basically and the family physician is supposedly to have good contacts with the organization working in the field of public health in their area there must be a unit or Department for McD's and they are supposed to relate to assist us in organizing proper activities willing to cope with that problems education we already talked about that and what is actually the role from our side we are the specialists in primary healthcare this is why we work at the PhD level the main component of PHC is by default prevention we are the experts in prevention and we must realize that the most important activities for profit profit prevention should be carried out in our outpatient clinic because this is the point where the contact first contact happens with the patient and this is the place where you are supposed to perform this kind of activity so Ludmilla mentioned there is no activity without proper recording audit system must be there don't think it shall be an audit from the World Bank or some other Global Partner say it can be some internal local audit you can just get together once a month or discuss your parameters and indicators discuss what you want to achieve and go on doing that this is an audit as well why we need that because our global systemic aim is definite to expand lifespan improve quality of life by means of stopping the spreading of preventable conditions and reducing the burden of NCDC and definitely I'm not going to read everything from this slide but what we currently lack we definitely like that regulatory framework and dual-sim give us tools into the hands of a family doctor so that a doctor within the range of those 15 minutes and be able only to perform his role give him a kind of a card or something like that electronic card they want the patient to present the doctor once a year for example and it prompts to adult-like measure B be asked for these and do that so give us tools to do the job teach the patients really help you work online with the school of patient great example from school of how they give a chance to patients really to learn about that and do that I saw these schools of Health inhibitors for example and it would indicate very clearly like every second Wednesday for example of the month there is a special meeting with the overweight patients and it should not be the task of a doctor specifically it should be it might be a nurse or a volunteer who is well trained on some physical fitness activities or something else for example but this is the family doctor who literally to be the leader of this process and the needs to have access to the resources of the community we need to teach the families that this is the responsibility of the family willing to keep in the proper health of all family members we already talked about technologies what I really liked it today and let me reiterate that all the team members must learn together as a team and they need to have a chance really to repeat those training cycles to update themselves and to refresh their knowledge we should train not only physicians we should be also teach them how to delegate authority to nurses and also this is true for administrators and it has already been mentioned by our colleagues and this is the right way this is the right way to go by the way and for us this is your issue and I know that the educators are working upon that this is the establishment of all open wide educational platform for students doctors nurses and other team members so that everyone could be able to find a good place include the possibility really to implement that into their daily activity and everyone would really have a chance to master those competences and skills which are being shared by the wgo of experts and colleagues the problem here is that it needs to be done very quickly and Simmel 10 years with many other activities why international donors and the experts cooperate with us so so actively this is because we have very critically low parameters and figuration and you remember our colleagues Assad that the European region really needs to speed up with some activities because they cannot achieve those goals sustainable development goals by 2030 Ukraine has to speed up even more a relativity of data and we definitely need to master these skills and activities like right now simultaneously with other charities we're definitely grateful to double HR experts and other colleagues whose tools were using very widely thank you very much for providing us a chance to learn from you but we talked about evidence-based medicine to make it really be used in the clinical practice it is necessary as Jill mentioned for a doctor to have a very brief clear and concise manual for activities and sorry but it not it cannot be in English and the Minister of Health can not should not say to us like well you being the physicians can make use in your practice of any other clinical guidelines and you can use any English document for this purpose and you can share it with the patient sorry guys but we are talking about Ukraine it needs to be a clear accessible brief concise understandable unambiguous document and it would will be even a better idea when you have it on the e database electronic database if you use some ICPC code immediately you get a pop-up window that provides you with some idea where to go who of you makes use of electronic version of I CPC other any people great great but still majority of us still use the paper-based documents it is a quite a complicated way to go by the way it puts on additional barriers if we improve our work it will become much easier for us and I do really hope it will happen very soon it will really enable us ability to perform very quick reporting and recording and then the deputy chief physician for example can go into on the database and can see immediately what is the number of prescriptions what is the levels of cholesterol in the target groups and then immediately can have these quality indicators for your preventive activities and if they promise provide you some bonuses to that then you will be happy absolutely very much with that been an educator being a faculty stuff now let me also tell you that we definitely need to improve training in phc field for doctors at the pre diploma stage because as of today a family doctor is really one of the most required professions in Ukraine would not have that deficit in any other field of medicine each Ukrainian has the right and has the need to have a family doctor and the deficit is about 30% in some regions it might reach as high as a 60% so how can you talk about proper work and until now we do not have as I unify the training program for family physicians do not have a standardized curriculum but we need to train them properly we need to teach them we need to teach the physicians to work with healthy patients because we keep we have been telling our physicians for decades how to work with the ill patient we need to teach them now how to do the same thing how to prevent the conditions in healthy people when did you bring them bring that idea to their understanding we need to support them and now as far as we have deficit in human resources maybe we need to think about reprofiling some other professions into that speaking of a continuous professional development I think it includes all types of training including workshops seminars trainings etc and definitely you need to ensure that there is a possibility for remote learning distance learning electronic based learning if it is paid then it can be paid and it should definitely be in Ukrainian a BMG great project and but it is an English and that is a significant limitation I would say and if a person made a little mistake even a minor mistake it might not be very good when that minor mystery would be used in his clinical practice now we have a bit of time for a short feedback so maybe you have some suggestions suggestions for discussions or maybe issues because I'm done actually asked to make recommendations for further priority actions in Ukraine on NCD interventions and health settings which we feedback if listening to you and and and also with you in terms of recommendations for further priority actions I think we need to consolidate what has come out of these projects so far so we don't lose the learning and improvement that's already happened and there's been a strong emphasis on recording data so that we can demonstrate improvements and quality of care you've spoken strongly about the importance of education and teaching to make sure that we have health workers who are really equipped with the knowledge skills and attitudes needed for this work on non communicable diseases and prevention and management I can't read my writing I we need to voice about these barriers so we've highlighted a number of barriers and some of the very difficult circumstances that people are working within and we need to make sure that the authorities are aware of those to see if any change can be brought about we need to complete this evaluation and make sure that we communicate the results so it informs change and I think we need to build on what works well because we've got so much energy and in the room and so many people who are enthusiastic who are champions who've got good ideas for how they've organized care and I think they having the opportunity the continuing opportunity to share that information with each other would be good I know that's something we've done in some of the other countries that we've regularly brought together the people involved in this works also in peer to peer learning so that they have an opportunity to share with each other the good practise so those are some of the things I've heard from what you said any other comments about recommendations for further priority actions you do matter what do you think about yes miss Ludmilla you let me remind everyone here maybe you don't do it in your Oblast but let me remind you about risk factors when we started this work in identifying the risk factors we use the icd-10 that included those risk factors so now on a quarterly basis who analyzed by each physician by each healthcare facility what is the salt intake what is the level of physical activity what is the tobacco use and that actually stimulates our physicians first of all to identify and find these respecters and once you ask the patient like her what is your salt intake then you are kind of supposed to provide the recommendation if you want it or not right because you have to do it actually you need to look for those risk factors because there was a degree from the Department of Health that went down to the PhD level that was one of the first stimulating factors and I'm not sure if you if everyone has it in there or blossom but this is a good idea I guess that we can go on whether we can do the same for district levels or local levels and we can investigate if actually the family physicians do identify those risk factors if they can impact that this is a huge amount of work I'm sure but the truly leads to improvement of the situation because whether you want it or no the physicians and nurses are supposed really to do it even talking about such really easy going and easy to understand things I think the that kind of work could be easily simplified if we had an electronic based system that would be available at the level of region sorry no microphone is used but we do have the electronic system it's a statistical system based on the icd-10 and we were the first ones who implemented that back in 2010 a yes and no 2007 starting from 2007 not a single physician or nurse can imagine their work without a computer we do not have anything any kind of paper-based calculations and just as many people still do it we have an electronic software available I also have a kind of a sub software our applications available for proper calculations and we also have software for IC PC which is integrated into our electronic software unfortunately we do not have proper integration with the eHealth program and we are now awaiting for changes thank you very much dear colleagues by the way that is a very positive piece of experience so we need to share and we need to talk about them if not patient clinics are properly equipped they are properly staffed and they have proper training in the field of IT Sam it leads all to a more fruitful work basically so this could be a good requirement let's say when we speak about the list of equipment of essential equipment so to say in the outpatient clinic and you cannot sign a contract which they make a cranium and a chassis without that then we can talk us about the standardized approaches to equipment of a working place of a doctor it needs to include all the proper equipment that really there facilitates the work of a doctor in terms of statistics recording and reporting which is both true for the doctor and for the I think it would be a very topical and relevant activity really to improve the efficiency thank you to continue to the colleagues said I see that they are leaders already and they would like us all to introduce some administrative mechanisms to support this give is to support the trainers who are already already so that they could inspire their colleagues for example when I talk to practicing doctors they say that yeah the decent that I was successful so the colleagues they come to me so this peer education I think it's a very important component and just like I've been remembering this example when well it was example from American colleagues they were wearing the badges and