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Building Primary Care Infrastructure in Rural Nepal
The Experience of Nyaya Health
Jason Andrews
June, 2009
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Overview
I. Brief history of health care in Nepal
II. Birth(pangs) of Nyaya Health
III. Getting off the Ground
IV. Innovations of Nyaya Health
V. Patient Stories
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Population:
28 million
(>80% Rural)
Religion:
90% Hindu
5% Buddhist
3% Muslim
Per Capita
GDI: $340/yr
(India: $950/yr)
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Brief History of Nepal One of few countries in world (and only country in South Asia)
never colonized by West Existed as a number of kingdoms until late 18th Century Essentially closed to the West until 1950s Multiparty Democracy with Constitutional Monarchy in 1991 1996 Communist Party of Nepal (Maoist) declared People’s War 2005 King Dismissed Government, Assumed Executive Powers,
Declared State of Emergency 2006 Popular Protests Overthrew the King, Democracy Reinstated 2008 Maoists won government in landslide
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The People’s War
1996-2006
Over 13,000 Died
Hundreds of thousands displaced
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Maoists Demands
“Girls should be given equal property rights to those of their brothers”
“All kinds of exploitation and prejudice based on caste should be ended”
“The homeless should be given suitable accommodation. Until [the govt] can provide such accommodation they should not be removed from where they are squatting”
“Poor farmers should be completely freed from debt”
“All should be given free and scientific medical service and education and education for profit should be completely stopped.”
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Health Care in Nepal• 21 doctors/100,000 (India: 60, Haiti: 25)• 96% of doctors in Nepal work in Kathmandu valley
(<10% of the population lives there)• Public expenditure on health: 1.5% of GDP• Public expenditure on military: 2.1% of GDP• Richest 20% of pop 10x more likely to have birth
attended by skilled health personnel than poorest 20%.
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Births Attended by Skilled Health Personnel Worldwide: 62%The Bottom 10:
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Founding a Nongovernmental Organization 1st step: Incorporation in a StateNeed: Mission Statement, Articles of
Incorporation, Bylaws, Board of Directors 2nd step: 501(c)3 StatusDemonstrate sources of fundingProvide evidence of expendituresNarrative of charitable activities Additional Requirements:Register in the country
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Choosing a name - Nyaya Health “Nyaya” - sanskrit word for justice Amartya Sen: “Nyaya stands for actual social
realizations, going beyond organizations and rules.”
“Whatever else Nyaya may demand, the reasoned humanity of the justice of Nyaya can hardly fail to demand the urgent removal of these terrible deprivations in human lives.”
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The Location: Achham
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Getting to Know AchhamPopulation: 250,000Estimated 40-80% of Men Work in IndiaPCI: $141~5 to 8% of Homes Have ElectricityAverage Education: 1-1.5 years schoolingIncome in Kathmandu is 4.5x that of Achham and rose $300 in
PPP between 1996 and 2001, while falling $7 in Achham55% of Population without access to safe drinking water (2.5x
national average)Closest hospital with basic OR ~8 hours away by jeep/bus1 Ayurvedic Doctor in the district, No Allopathic Doctor
1 in 200 births take place in hospital
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Community Meetings
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Community Surveys - Rapid Health AssessmentGoals: a. Obtain a Rough Snapshot of Socioeconomics,
State of Health, Disease, and Health Services in the Community
b. Complete survey and analysis in 2 weeksc. Complete this in under $100Tool: Adaptation of survey used by Satia et al (HPP
1994)2 Pages, 10-20 MinutesSuccess: Completed in 2 weeks, Total Budget $45!
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Rapid Health Assessment - Continued
Surveyed 58 HH, 384 PeopleMedian HH Income: $30/month76% of women and 13% of men reported illiteracy45% of men labor migrants to India30% of homes had a toilet (none with functioning septic tank)19% of HH had member go to India for medical care in last
year alone; Amount spent was ~6 months median HH income
63% of births were performed by friend or relative; 1 (3%) by a doctor (likely ayurvedic). 26% of births involved use of a safe delivery kit
8 Abortions - only 2 by trained provider
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Building the Clinic
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4.6 kV inverter
12 - 12V
120mAMP-h
batteries
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Finding Staff!
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Setting up Lab
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Lab Capacity• CBC (QBC Autoread) with differential• Colorimetry - AST/ALT, Bili, Creatinine, Glucose,
Albumin• Microscopy - Gram stain, wet mount, KOH, Ziehl-
Nelson• RPR• HIV rapid• Anti-ABD (pregnancy)• Urine HCG• Urinalysis
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IStat! (thank you Abbott)
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Opening!
Day 1: 8 patients
Day 2: 26 patients
Day 10: 90 patients
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First Two Months: 2,546 visits
First Year:
Over 20,000 visits
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Programs and Innovations
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Community Health Workers
1. Administer Surveys
2. Identify pregnant women, severely malnourished children, TB suspects
3. Follow-up patients from clinic; bring to clinic, take them meds
4. Communicate health issues of the community to clinic and vice versa
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Ultrasound Program
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Rigorous Data Monitoring and Open Source Everything
De-identified patient databases available on our website with demographics, diagnoses, pharmaceutical prescription, and outcomes data
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Other Data and Information• Line-by-line expenditures• Future budgets• Financial account balances• Funds raised by source and date (donors kept
anonymous)• Detailed Clinical protocols
But transparency of this sort is no substitution for accountability to the community in which we work. Empowering communities with their own data is a whole other challenge.
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Challenges: Conflict, Political Upheaval
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January, 2006
April, 2006
Sindhupalchowk
District Hospital
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Political and Economic Rights in Nepal
Sen and Dreze: Why is it that China hosted the largest famine in history but maintained otherwise low levels of chronic malnutrition, while India has never had a famine but has high levels of chronic malnutrition?
China took aggressive measures to provide for elementary needs of the poor, but suppressed media and dissent, which allowed famine to develop unchecked.
India has a vibrant civil society and relative political freedoms, allowing dissent that checks acute hunger crises, but it took liberal, monetarist economic policies that failed to protect the economic rights of poor, enabling chronic malnutrition to go unchecked.
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“We know, of course, there’s really no such things as the voiceless ones. There are only the deliberately silenced, or the preferably unheard.”
--Arundhati Roy
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The consequences of being preferably unheard?
60,000 Children under 5 die/year in NepalNepal’s under 5 mortality: 76/1000Japan / Singapore U5 mortality: 4/1000
United Stated U5 mortality: 8/1000Sri Lanka’s under 5 mortality: 14/1000Kerala’s under 5 mortality: 18/1000
Nepal Rural U5 mortality: 84/1000Nepal Urban U5 mortality: 47/1000Nepal mother no education: 93/1000Nepal mother passed 10th grade: 13/1000
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Woman with fever and abdominal pain
35 yo woman carried in by stretcher, complaining of two weeks of weight loss, abdominal swelling, vomiting.
Temp 103
Large Abdominal Mass
Further history: severe burn to abdomen several months prior with chronic open wound
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HIV test done: Positive
IV Fluids and Antibiotics given
Patient sent to hospital
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Young Man with Gunshot Wound
18 yo man from neighboring district, was hunting with his family and accidentally shot through abdomen, transection genitalia, exiting right thigh.
Family carried him for 10 hours to the district hospital: no doctor
Army stationed nearby, flew him in helicopter to Sanfe Bagar. He was carried over to our clinic.
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On arrival: systolic BP in 60s
2 Large bore IVs placed
IVF given wide open
Patient had peritoneal signs on abdominal exam
Staff gave IV Ceftriaxone and flagyl
BP came up, pt feeling better
Fluid and stool began coming out of his abdominal wounds
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Family members hadn’t yet arrived. Team arranged a jeep for him to go to hospital for surgery, 12 hours away
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15 yo boy fell out of tree onto branch. Had evisceration, with omentum hanging out. Repaired at clinic, given IV antibiotics, monitored for a
week.
12 yo boy charged by bull with abdominal wound and evisceration. Carried 2 hours on stretcher. Omentum replaced, wound closed. Antibiotics, fluids, observation, home!
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Woman with a Snake Bite
50 yo woman bit by a krait snake at 3 am while sleeping in a barn in neighboring district. Carried for 9 hours by stretcher to our clinic.
5 minutes after she arrived, she lost consciousness and went pulseless. Received CPR and Epi.
Regained pulse, answering basic questions
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Patient: Snake Bite (cont)
Gave several vials of anti-venom.
She had rapidly progressive neuropathy, including respiratory depression, requiring continued bag-ventilation.
She arrested again and died.
Questions / M and M:
What if we had a ventilator, an ICU, etc?
What if she hadn’t had to be carried 9 hours for anti-venom, an essential medicine for primary care in this region
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10 yo boy with epilepsy. Had seizure, fell into fire. Presented to clinic 14 hours later. Gave IV fluids, antibiotics, silver sulphadiazine. Referred.
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What can we learn from these patients?
1. These stories and images are just as horrifying as the images of police brutality and the war.
2. Even so, media and civil society in Nepal have not been able to translate the shock of chronic deprivations into public action
3. Vertical, stand alone programs like HIV, TB, nutrition cannot address these problems. High quality horizontal health systems need to be built up, starting with primary care.
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Challenges in building horizontal programs
Donors don’t fund them - so have to divert funds from vertical programs
Much more difficult to make simple algorithms for the myriad of conditions - TB, malaria, malnutrition relatively easy
Defining successful outcomes more challenging
There is no semblance of a QI movement in rural resource-poor primary care
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What is needed?
+
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Thank you
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Visit us at www.nyayahealth.org
Thank you to the staff and volunteers of Nyaya Health and for the patients for sharing their stories.
Board of Directors
Bibhav Acharya
Bijay Acharya, MBBS
Jason Andrews, MD
Sanjay Basu, MD, PhD
Chhitij Bashyal
Duncan Maru, MD, PhD
Shefali Oza, MSc
Ryan Schwarz
Aditya Sharma, MD
Jhapat Thapa, MBBS