Overview
The city of Shamakhi lies in a mountainous region of Azerbaijan with many remote villages. The region has experienced multiple primary health care (PHC) challenges partly due to its remote location, including workforce constraints: 54% of physician positions in rural PHC facilities are vacant. The COVID-19 pandemic has exacerbated PHC equity and resilience challenges, including in women’s health.
Funds from the WHO SDG3 recovery challenge supported a collaborative project in Shamakhi led by the government with support from WHO and UNICEF. Three tranches of funding facilitated a PHC training fellowship for healthcare workers and students in Shamakhi, as well as national PHC workforce development.
One project strand was women’s health. Azerbaijan has a disproportionately high maternal mortality rate in the WHO European Region with significant disparities between urban and rural areas. Dedicated safe spaces for women within PHC clinics have allowed women to talk and learn about specific issues related to their health. Participating fellows praised the project and some have remained working in PHC in rural areas.
The project contributes to progress towards several Sustainable Development Goals (SDG) indicators and is integrated with the national PHC strengthening project known as PROACT-Care that is led by the government and WHO with collaboration from UNFPA and UNICEF and funded by international partners including the Universal Health Coverage Partnership.
The PROACT-Care project initiated in 2020 with the aim to prevent excess mortality in the Shamakhi District, Azerbaijan. ©WHO/Azerbaijan Country Offic
PROACT-Care and Shamakhi Fellowship Programme
“You never knew if you were going to survive,” recalls a man from rural Azerbaijan as he recounts painful journeys to the nearest functioning health facility while he was ill.1 Providing high-quality PHC is one of the main challenges facing the Azerbaijani health system. PHC is the main entryway to healthcare, an important avenue for disease prevention, key to limiting health costs and in Azerbaijan’s polyclinic model covers some specialized outpatient treatment. For women, comprehensive PHC is critical to improving health outcomes across the life course and promoting health and economic equity in order to make progress on SDG indicators such as maternal and child mortality. Current gaps in PHC provision therefore negatively impact Azerbaijan’s population in multiple ways, with particular disparities in rural areas.
Not far from the capital Baku, in the region around Shamakhi, over half the population is rural. PHC services here are either closed or barely used with a dire shortage of trained PHC workers, a lack of clinical equipment and crumbling infrastructure further limiting the care available. Healthcare workers trained in Azerbaijan tend to not seek employment in PHC or rural areas and workforce shortages have worsened in the last decade. When COVID-19 struck, the lack of resilience in PHC had damaging consequences for the wider health system.
In light of these challenges, PHC has been identified as a key mechanism to strengthen Azerbaijan’s health system. To improve PHC resilience with local solutions, the PROACT-Care project was launched in 2021.2 Building on PROACT-Care, a pilot to specifically improve PHC workforce development launched in July 2021 with support from WHO SDG3 recovery challenge funds.
This pilot project funded 164 Shamakhi fellows to live in the area and learn, train in and deliver community-orientated PHC for 6 months. Fellows were selected from medical students, nurses and international experts with specialties including women’s health. The project supported PHC workforce development nationally with conferences and healthcare education training. Funding also supported an emergency care (EMC) week in collaboration with Turkey’s Ministry of Health and a diverse group of stakeholders. The importance of robust connections between EMC and PHC has been strongly illustrated in the pandemic.
By building on PROACT-Care, fellowships were implemented quickly using structures already in place, such as well-equipped PROACT-Care mobile clinics. The project supported other PHC-strengthening work such as UNICEF’s universal-progressive home visiting programme, led by the Government of Azerbaijan with funding and technical support from UNICEF. The home visiting programme also sought to increase access to PHC, providing home visit services for pregnant women and young children in Shamakhi between May 2021 and January 20223 by training and monitoring PHC workers, nurses and midwives, who worked in tandem with Shamakhi fellows.
Taken together, the human impact of all these projects includes more PHC delivery for rural populations, reduced inequalities due to PHC service gaps, increased health literacy and better training for healthcare workers nationally to improve PHC for underserved populations in the short, medium and long term.
“I am grateful to them for they have come and are serving us well. It is accessible for everyone,” recalls a woman seen in a mobile clinic.4 Some women had potentially serious conditions referred for further investigation, such as breast lumps, illustrating the importance of PHC for prevention and early diagnosis. Healthcare workers discussed steps that women could take themselves, such as self-examination and contraception, boosting PHC resilience and health literacy.
Travelling to remote populations in need, some fellows worked from the mobile clinics. Training materials were translated into Azerbaijani for wider reach. Fellows developed training modules themselves including in maternal and child health and conducted research, data collection and standards development. National development activities raised the profile of PHC and promoted PHC as a career path. The inclusion of student fellows helps to embed PHC awareness and experience in the next generation of healthcare workers. EMC week produced a range of implementation plans linking EMC improvement with PHC strengthening.
Many fellows praised the Shamakhi project for increasing their interest in PHC, with a third of Azerbaijan fellows remaining to work in rural PHC settings. “I did not have an understanding of what primary healthcare was until I came to Shamakhi. Now I understand its importance,” one fellow said of the experience.
Both PROACT-Care and the Shamakhi project involved GAP partner agencies UNFPA and UNICEF, government at multiple levels, universities and other Member States. UNICEF noted that “we value the strong partnership and coordination with WHO and UNFPA to build the capacity of PHC personnel, strengthen the overall PHC system, improve its resilience and preparedness, while supporting the Government to ensure its sustainability.”
WHO SDG3 recovery funds supported expansion and acceleration of the Shamakhi pilot project, with 3 tranches of funding providing continuity that enabled the project to develop and progress. The training modules developed will be used from autumn 2022 and the fellowship model has been proposed for other rural areas, providing innovative ways to improve PHC workforce development and address workforce shortages. Partners including Azerbaijan’s government, the WHO country office and UNICEF are currently securing funding to support this rollout.
Through its efforts to strengthen PHC, Azerbaijan is now in a better position to make progress on SDG3 indicators including maternal and child health and to accelerate the provision of resilient and high quality PHC for everyone in the country, regardless of where they live.
What is the SDG3 GAP?
The Global Action Plan for Healthy Lives and Well-being for All (SDG3 GAP) is a set of commitments by 13 agencies that play significant roles in health, development and humanitarian responses to help countries accelerate progress on the health-related SDG targets.
The added value of the SDG3 GAP lies in strengthening collaboration across the agencies to take joint action and provide more coordinated support aligned to country owned and led national plans and strategies. A recovery strategy (Oct 2021) serves as a strategic update on the SDG3 GAP in the context of achieving an equitable and resilient recovery from the COVID-19 pandemic to the health-related SDG targets.
The purpose of GAP case studies is to monitor SDG3 GAP implementation at country level.
References
- Source: USAID/WHO Azerbaijan
- Azerbaijan strengthens its health workforce to boost primary health care, Universal Health Coverage Partnership, 12 October 2021.
- Home visiting by nurses – new model of services benefits 2000 families, UNICEF.
- Source: USAID/WHO Azerbaijan