med peds noon conference dec 2010
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Nyaya Health 2010
Implementation Gaps and Quality Chasms: Building Health Systems in
Rural NepalDuncan Maru, MD, PHDCo-Founder| Nyaya Health
Med-Peds Noon Conference, December 16, 2010
Nyaya Health 2010
Learning Objective
Think critically about healthcare delivery and quality in resource-poor areas
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Nyaya Health 2010
Where We Work: Nepal – Achham District, Far Western Region
Nyaya Health 2010
Achham District, Far Western Region, Nepal
Nyaya Health 2010
Achham District, Far Western Region, Nepal
Nyaya Health 2010
Achham District, Far Western Region, Nepal
Nyaya Health 2010
Achham District, Far Western Region, Nepal
Nyaya Health 2010
Achham District, Far Western Region, Nepal
Nyaya Health 2010
Achham, Nepal
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250,000 population of Achham
0 number of allopathic doctors in Achham before Nyaya
6+ hours in bus to reach the nearest operating room
14 hours in bus to reach the nearest intensive care unit
1 in 125 deliveries results in the mother’s death
64 number of stillborns for every 1,000 live births
6% & 54% Female and male literacy rates, respectively
>80% of men migrate to India for work; over 7% return with HIV
99.5% of babies are born in homes and cattle sheds
50¢ average daily per capita income in Achham
60% of children are chronically malnourished60%
Nyaya Health 2010
Nyaya Health Snapshot
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Social justice-oriented mission: To provide free community-based healthcare in rural
Nepal that strengthens the Nepali Ministry of Health’s public sector
To develop scalable models of healthcare delivery in resource-poor settings throughout the world
Founded in 2006; public-private partnership with Nepali Ministry of Health & Population in 2009
Managed by a volunteer Board of Directors and 27 full-time employed Nepali staff
Over 99% of all funds used directly in Nepal
Nyaya Health 2010
Sanfe Bagar Primary Health Center
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Sanfe Bagar Health Center: Before
Sanfe Bagar Health Center: After
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Bayalpata Hospital
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Nyaya Health 2010
Bayalpata Hospital
Nyaya Health 2010
Bayalpata Hospital
Infrastructure development and capacity building, not care provision alone Government collaboration: Government partnership contract for 5 years signed June 2009
– June 2014 Currently one of the highest levels of clinical care in the Far West (2 million people) 50,000 patients seen to date
Nyaya Health 2010
Bayalpata Hospital All health care services free of charge:
Inpatient & Outpatient services 24-hour emergency and obstetric services Laboratory & Pharmacy Radiology: X-Ray & Ultrasound HIV, TB treatment programs Malnutrition treatment (RUTF) Ambulance services Community Health Worker (CHWs) services
2011 Expansion Plans: Comprehensive surgical suite Solar energy Expanded CHW network Teaching hospital status
Nyaya Health 2010
Challenges
But doing things and doing things well are two different things…
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Case 1: Nosocomial Tuberculosis
27yo M lab tech from BH presenting with cough x3wks and hemoptysisConsidered high-risk for TB exposure (3-4 sputa examinations per day)
Nyaya Health 2010
Case 2: Infant Pneumonia
An 8-month-old boy with severe respiratory distress and five-day history of pneumonia presented to the Bayalpata Hospital. Previously, the boy had been seen by untrained private “clinicians” in the community three times over four days. At presentation, the child was seen by one of Nyaya's mid-level practitioners who provided an initial course of antibiotics. Despite the child's ill appearance, supportive treatment including intravenous fluids and supplemental oxygen was not provided until discussion with the Medical Director three hours later. That evening, the hospital lost power – the public electricity grid shut off for its usual daily blackout, and the hospital generator had been improperly maintenanced and broken several days prior – so the electric nebulizer did not work. The oxygen canister was missing its regulator and therefore no oxygen could be provided during the power outage, nor could the patient be transferred via ambulance without oxygen. Additionally, due to the high costs of other regional health facilities the family refused transfer (our facility provides free services). That evening, after not being examined for some time by on-call staff, the child was found unresponsive with a thready pulse. CPR was not initiated for over ten minutes as the midwife managing the ward did not know the procedure and the AMBU bag was not at bedside. Following fifteen minutes of unsuccessful resuscitation, the child was declared dead.
Nyaya Health 2010
Key Challenges
Human resourcesSupply chain managementEnergy systemsTelecommunicationsCommunity relationships,
outreachPublic sector relationships
Nyaya Health 2010
Achieving Excellence in Healthcare Delivery…
Institutionalize Reflective Dialogue: Mortality and Morbidity Reviews
Institutionalize Transparency in Reporting: Data Program
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M&M Review: Nosocomial tuberculosis
Issue 1: Lab Ventilation Lack of local and regional infection control; BH met standards! Director of Medicine at foremost teaching hospital in Nepal: “never seen a safety hood in
Kathmandu” Solution 1a: Collaboration with international partners via GHDonline to design newly-
constructed TB-specific lab space with negative pressure Solution 1b: Collaboration with MOH & District to conduct infection control trainings Issue 2: Personnel Safety Solution 2: Procurement of N95s, and trainings
Nyaya Health 2010
M&M Review: Infant Pneumonia
Oxygen in ambulance Oxygen protocol for ER Dedicated ambu bag CPR training for staff ER crash trolley
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Nyaya Data Program: Local System
Open-Source Access Database, Gnucash Challenges in electricity, human resources, retention
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Nyaya Data Program: 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
Nyaya Health 2010
Concluding Thoughts and Next Steps
Summary
Supporting public sector builds sustainable healthcare systems
Quality healthcare relies on energy, telecommunications, logistical systems—management innovations are needed in both the clinical and non-clinical realms
Commitment to place can drive global insights
Nyaya’s Next Steps:
Larger community health worker network
Surgical capacity
Solar energy systems
Implementation Research
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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: Dr. Deepak Gaylal, Mr. Sailendra Shrestha, Mr. Jhanak Dhungana
Institutional Supporters: 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), Ella Lyman Cabot Trust, EquityEditors Association, Ford Foundation, Frederick Lovejoy Foundation, Google Grants, Nepal Ministry of Health and Population (MOHP), New Aid Foundation, Partners in Health, 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, Yale University