pediatrics mgr april 2011
TRANSCRIPT
Nyaya Health 2011
Building Health Systems in Rural Nepal The Case of Nyaya Health
Duncan Maru, MD, PHDCo-Founder| Nyaya Health
Pediatrics Mini Grand RoundsApril 1, 2011
Nyaya Health 2011
Overview
1. Nyaya Health and Achham Overview2. Case: HIV and Respiratory Distress3. Public Sector Strengthening4. Case: Visceral Leishmaniasis5. Community Health Worker Program6. Case: Perforated Viscous7. Transparency and Accountability8. Inputs, Outputs, and Next Steps
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The ultimate arbiter of epidemiological truth is death.
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Nyaya Health: Who We Are
Social justice-oriented mission: To provide free community-based healthcare in rural
Nepal that strengthens the public sector To develop and disseminate effective strategies of
healthcare delivery in resource-poor settings throughout the world
Started working in Achham in 2006; public-private partnership with Nepali Ministry of Health & Population since 2009
Nyaya Team: 29 full-time employed Nepali staff + ~50 CHWs 1 full-time US-based Executive Director Volunteer Executive Team, Board of Directors and
Board of Advisors Core Approach: Transparency, Public-Private
Partnerships, and Community-Based Care
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Where We Work: Nepal – Achham District, Far Western Region
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Achham: Demographics
~270,000 people
99.6% Hindu
60% agricultural
>80% of men migrate to India, and 35% of families rely on remittances from India
33% adults literate: 54% men, 14% of women
<$1USD is daily per capita income
Maternal Mortality officially 230 deaths per live births
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Achham: Infrastructure 2007: >90% of houses did not
have electricity 45% had access to clean
water – 2.5x worse than national average
Hydroelectric plant functioning <50% capacity
Extremely limited landline telephone capacity, one cell phone tower
Paved road ended in Sanfe Bagar
Airport destroyed during war
Hospital 5 hours, surgery 6 hours, ICU 14 hours
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HIV and Sepsis: April, 2007
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During our rapid health assessment, an elderly woman asked us to come by the house of a relative who was sick. She was a young, single mother of two, her husband already having died. She herself was infected with HIV. When we saw her, she was nutritionally wasted and tachypneic. We tried to help get her to the nearest hospital, four hours away, but only made matters worse when her husband’s family balked at her transport.
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Infrastructure Matters Public-Private Partnerships
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Sanfe Bagar Primary Health Center
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Sanfe Bagar Health Center: Before
Sanfe Bagar Health Center: After
• Opened for service April 6, 2008
• Served over 17,000 patients between April ’08 and May ‘09
• Transitioned to government June ‘09
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Nyaya Health at Bayalpata Hospital
Mission: infrastructure development in collaboration with the government, not only care provision
Government partnership contract for 5 years signed June, 2009 – June, 2014
Over 60,000 patients treated to date
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Nyaya Health Team
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Approach: Public Sector Strengthening
District Hospital: Direct Management of Bayalpata Hospital
Health Posts: Accountability Community Health Workers: Incentives
and training
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Key Challenges
Human resourcesSupply chain managementEnergy systemsTelecommunicationsCommunity relationships,
outreachPublic sector relationships
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Visceral Leishmaniasis
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Early October 2010: 17 year old woman presented with high fevers x 4 weeks and massive hepatosplenomegaly. Referred at that time to a hospital 14 hours away for evaluation. Returned without a diagnosis.
End October: On home visit, Dr. Gauchan found her critically ill and anemic and re-admitted her to the hospital. Accompanied her to a hospital about 4 hours away for a blood transfusion. Father brought her to local faith healer. Several home visits and discussions with
End November: Transport via ambulance to Dhangadi than via Buddha Air to Kathmandu. Diagnosed with Kala-Azar, started on amphotericin, worsened, intubated, died.
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Community Health Worker Program
Builds off of government’s existing female community health volunteer program
Pays incentives for their work; not salary as per government mandate
Focuses on follow-up and referral
SIMPLE referral system from the hospital
Current Catchment of 1,357 households covered by 35 FCHVs
Managed by salaried community health worker leader (approximately 9-14 CHWs per leader)
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Communities Know Who To TrustCommunity-Based Care through Community Health Workers
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Community Health Worker Program
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Community Health Outreach Program
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Challenges: Facilities-Based Deliveries
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Challenges: Transportation Infrastructure
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Perforated Viscous
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March 2011: 25 year old woman three months post-partum presented with acute abdomen and in shock to the emergency department. There were several delays in identifying shock, in notifying the doctor on call, in fluid resuscitation and antibiotics. A paracentesis was performed which drained purulent fluid. She was transferred for surgery and died en route.
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To become better at medicine, we need to be more accountableTransparency and Quality Improvement
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Improving Care and Accountability
Mortality and Morbidity ConferencesInclude all staffMeeting minutes publicly accessibleSystems-level approach
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Nyaya Health: Wiki
Wiki is a searchable repository of: Management policies Financial data Clinical protocols De-identified clinical data
All pages viewable to the public
A forum to share lessons-learned from Achham with organizations in similar settings around the world
Opportunity for critical feedback and collaboration
http://wiki.nyayahealth.org
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Inputs and Outputs
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Total Expenditures: $166,000
Annual Per Capita Public Health Expenditures in Achham: $5
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Expenditures
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Funding
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The ease with which young people die in Achham and the ease with which it is accepted continues to horrify me.
-Ruma Rajbhandari, MD, MPH, March 22, 2011.
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Continued Renovations
Next Steps
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Next Steps
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Surgical Services
Quality Improvement
Implementation Research
Next Steps
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Next Steps
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Solar Power
Next Steps
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Next Steps: Funding
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Philanthropic: $75K matching campaign
Government: $125K expansion proposal
Research: $300K NIH Grant
Social Entrepreneurial: $100K Grinnell College, Several Mid-Sized Grants
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My Personal Vision for Bayalpata Hospital
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Acknowledgements
The staff of Bayalpata Hospital & the people of Achham, Nepal
The volunteers and individual donors of Nyaya Health
The Nepali Ministry of Health & Achham District Health officials
Institutional Supporters Including: Abbot Laboratories, AMD and the Open Architecture Network, America Nepal Medical Foundation (ANMF), BWH COE in Quality and Safety, Buddha Air, Cents of Relief, Child Health Foundation, CIWEC Clinic (Menlha Nursing Home), Editage, Ella Lyman Cabot Trust, EquityEditors Association, Ford Foundation, Fred Lovejoy Education and Research Foundation, Google Grants, Martin P. Solomon Foundation, MEMC Foundation, Nepal Ministry of Health and Population (MOHP), New Aid Foundation, Partners in Health, ProEdit Japan, QBC Diagnostics, Quidel Corporation, Singapore Internet Research Center, Ten Friends, The Hunger Site, The International Foundation, The Shelley and Donald Rubin Foundation, Until There's a Cure Foundation, UpToDate, William Prusoff Foundation, Wizfolio, Yale University
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Questions, Reflections, Comments?
www.nyayahealth.org