Building Primary Care Infrastructure in Rural Nepal The Experience of Nyaya Health Jason Andrews June, 2009

Overview Brief history of health care in Nepal Birth(pangs) of Nyaya Health Getting off the Ground Innovations of Nyaya Health Patient Stories

Brief history of health care in Nepal

Birth(pangs) of Nyaya Health

Getting off the Ground

Innovations of Nyaya Health

Patient Stories

Population: 28 million (>80% Rural) Religion: 90% Hindu 5% Buddhist 3% Muslim Per Capita GDI: $340/yr (India: $950/yr)

Population:

28 million

(>80% Rural)

Religion:

90% Hindu

5% Buddhist

3% Muslim

Per Capita

GDI: $340/yr

(India: $950/yr)

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

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

The People’s War 1996-2006 Over 13,000 Died Hundreds of thousands displaced

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.”

“ 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.”

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%.

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%.

Births Attended by Skilled Health Personnel Worldwide: 62% The Bottom 10:

Worldwide: 62%

The Bottom 10:

Founding a Nongovernmental Organization 1st step: Incorporation in a State Need: Mission Statement, Articles of Incorporation, Bylaws, Board of Directors 2nd step: 501(c)3 Status Demonstrate sources of funding Provide evidence of expenditures Narrative of charitable activities Additional Requirements: Register in the country

1st step: Incorporation in a State

Need: Mission Statement, Articles of Incorporation, Bylaws, Board of Directors

2nd step: 501(c)3 Status

Demonstrate sources of funding

Provide evidence of expenditures

Narrative of charitable activities

Additional Requirements:

Register in the country

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.”

“ 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.”

The Location: Achham

Getting to Know Achham Population: 250,000 Estimated 40-80% of Men Work in India PCI: $141 ~5 to 8% of Homes Have Electricity Average Education: 1-1.5 years schooling Income in Kathmandu is 4.5x that of Achham and rose $300 in PPP between 1996 and 2001, while falling $7 in Achham 55% of Population without access to safe drinking water (2.5x national average) Closest hospital with basic OR ~8 hours away by jeep/bus 1 Ayurvedic Doctor in the district, No Allopathic Doctor 1 in 200 births take place in hospital

Population: 250,000

Estimated 40-80% of Men Work in India

PCI: $141

~5 to 8% of Homes Have Electricity

Average Education: 1-1.5 years schooling

Income in Kathmandu is 4.5x that of Achham and rose $300 in PPP between 1996 and 2001, while falling $7 in Achham

55% of Population without access to safe drinking water (2.5x national average)

Closest hospital with basic OR ~8 hours away by jeep/bus

1 Ayurvedic Doctor in the district, No Allopathic Doctor

1 in 200 births take place in hospital

Community Meetings

Community Surveys - Rapid Health Assessment Goals: Obtain a Rough Snapshot of Socioeconomics, State of Health, Disease, and Health Services in the Community Complete survey and analysis in 2 weeks Complete this in under $100 Tool: Adaptation of survey used by Satia et al (HPP 1994) 2 Pages, 10-20 Minutes Success: Completed in 2 weeks, Total Budget $45!

Goals:

Obtain a Rough Snapshot of Socioeconomics, State of Health, Disease, and Health Services in the Community

Complete survey and analysis in 2 weeks

Complete this in under $100

Tool: Adaptation of survey used by Satia et al (HPP 1994)

2 Pages, 10-20 Minutes

Success: Completed in 2 weeks, Total Budget $45!

Rapid Health Assessment - Continued Surveyed 58 HH, 384 People Median HH Income: $30/month 76% of women and 13% of men reported illiteracy 45% of men labor migrants to India 30% 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

Surveyed 58 HH, 384 People

Median HH Income: $30/month

76% of women and 13% of men reported illiteracy

45% of men labor migrants to India

30% 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

Building the Clinic

4.6 kV inverter 12 - 12V 120mAMP-h batteries

Finding Staff!

Setting up Lab

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

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

IStat! (thank you Abbott)

Opening! Day 1: 8 patients Day 2: 26 patients Day 10: 90 patients

First Two Months: 2,546 visits First Year: Over 20,000 visits

Programs and Innovations

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

Ultrasound Program

Rigorous Data Monitoring and Open Source Everything De-identified patient databases available on our website with demographics, diagnoses, pharmaceutical prescription, and outcomes data

De-identified patient databases available on our website with demographics, diagnoses, pharmaceutical prescription, and outcomes data

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.

Line-by-line expenditures

Future budgets

Financial account balances

Funds raised by source and date (donors kept anonymous)

Detailed Clinical protocols

Challenges: Conflict, Political Upheaval

January, 2006 April, 2006 Sindhupalchowk District Hospital

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.

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?

“ 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

“ 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

The consequences of being preferably unheard? 60,000 Children under 5 die/year in Nepal Nepal’s under 5 mortality: 76/1000 Japan / Singapore U5 mortality: 4/1000 United Stated U5 mortality: 8/1000 Sri Lanka’s under 5 mortality: 14/1000 Kerala’s under 5 mortality: 18/1000 Nepal Rural U5 mortality: 84/1000 Nepal Urban U5 mortality: 47/1000 Nepal mother no education: 93/1000 Nepal mother passed 10th grade: 13/1000

60,000 Children under 5 die/year in Nepal

Nepal’s under 5 mortality: 76/1000

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

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

HIV test done: Positive IV Fluids and Antibiotics given Patient sent to hospital

HIV test done: Positive

IV Fluids and Antibiotics given

Patient sent to hospital

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.

18 yo man from neighboring district, was hunting with his family and accidentally shot through abdomen, transection genitalia, exiting right thigh.

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

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

Family members hadn’t yet arrived. Team arranged a jeep for him to go to hospital for surgery, 12 hours away

Family members hadn’t yet arrived. Team arranged a jeep for him to go to hospital for surgery, 12 hours away

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!

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.

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

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 .

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

Gave several vials of anti-venom.

She had rapidly progressive neuropathy, including respiratory depression, requiring continued bag-ventilation.

10 yo boy with epilepsy. Had seizure, fell into fire. Presented to clinic 14 hours later. Gave IV fluids, antibiotics, silver sulphadiazine. Referred.

10 yo boy with epilepsy. Had seizure, fell into fire. Presented to clinic 14 hours later. Gave IV fluids, antibiotics, silver sulphadiazine. Referred.

What can we learn from these patients? 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.

These stories and images are just as horrifying as the images of police brutality and the war.

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

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

What is needed? +

+

Thank you

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

Visit us at www.nyayahealth.org