Building Primary Care Infrastructure in Rural Nepal The Experience of Nyaya Health Jason Andrews June, 2009
Overview <ul><li>Brief history of health care in Nepal </li></ul><ul><li>Birth(pangs) of Nyaya Health </li></ul><ul><li>Ge...
<ul><li>Population: </li></ul><ul><li>28 million </li></ul><ul><li>(>80% Rural) </li></ul><ul><li>Religion: </li></ul><ul>...
Brief History of Nepal <ul><li>One of few countries in world (and only country in South Asia) never colonized by West </li...
The People’s War 1996-2006 Over 13,000 Died Hundreds of thousands displaced
Maoists Demands <ul><li>“ Girls should be given equal property rights to those of their brothers” </li></ul><ul><li>“ All ...
Health Care in Nepal <ul><li>21 doctors/100,000 (India: 60, Haiti: 25) </li></ul><ul><li>96% of doctors in Nepal work in K...
Births Attended by Skilled Health Personnel  <ul><li>Worldwide: 62% </li></ul><ul><li>The Bottom 10: </li></ul>
Founding a Nongovernmental Organization <ul><li>1st step: Incorporation in a State </li></ul><ul><li>Need: Mission Stateme...
Choosing a name - Nyaya Health <ul><li>“ Nyaya” - sanskrit word for justice </li></ul><ul><li>Amartya Sen: “Nyaya stands f...
The Location: Achham
 
 
 
 
Getting to Know Achham <ul><li>Population: 250,000 </li></ul><ul><li>Estimated 40-80% of Men Work in India </li></ul><ul><...
 
 
Community Meetings
Community Surveys - Rapid Health Assessment <ul><li>Goals:  </li></ul><ul><li>Obtain a Rough Snapshot of Socioeconomics, S...
Rapid Health Assessment - Continued <ul><li>Surveyed 58 HH, 384 People </li></ul><ul><li>Median HH Income: $30/month </li>...
 
 
Building the Clinic
 
 
4.6 kV inverter 12 - 12V 120mAMP-h batteries
Finding Staff!
 
Setting up Lab
Lab Capacity <ul><li>CBC (QBC Autoread) with differential </li></ul><ul><li>Colorimetry - AST/ALT, Bili, Creatinine, Gluco...
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. ...
Ultrasound Program
Rigorous Data Monitoring and Open Source Everything <ul><li>De-identified patient databases available on our website with ...
 
Other Data and Information <ul><li>Line-by-line expenditures </li></ul><ul><li>Future budgets </li></ul><ul><li>Financial ...
Challenges: Conflict, Political Upheaval
 
 
 
 
January, 2006 April, 2006 Sindhupalchowk District Hospital
Political and Economic Rights in Nepal <ul><li>Sen and Dreze: Why is it that China hosted the largest famine in history bu...
<ul><li>“ We know, of course, there’s really no such things as the voiceless ones. There are only the deliberately silence...
The consequences of being preferably unheard? <ul><li>60,000 Children under 5 die/year in Nepal </li></ul><ul><li>Nepal’s ...
Woman with fever and abdominal pain <ul><li>35 yo woman carried in by stretcher, complaining of two weeks of weight loss, ...
<ul><li>HIV test done: Positive </li></ul><ul><li>IV Fluids and Antibiotics given </li></ul><ul><li>Patient sent to hospit...
Young Man with Gunshot Wound <ul><li>18 yo man from neighboring district, was hunting with his family and accidentally sho...
 
<ul><li>On arrival: systolic BP in 60s </li></ul><ul><li>2 Large bore IVs placed </li></ul><ul><li>IVF given wide open </l...
<ul><li>Family members hadn’t yet arrived. Team arranged a jeep for him to go to hospital for surgery, 12 hours away </li>...
<ul><li>15 yo boy fell out of tree onto branch.  Had evisceration, with omentum hanging out. Repaired at clinic, given IV ...
Woman with a Snake Bite <ul><li>50 yo woman bit by a krait snake at 3 am while sleeping in a barn in neighboring district....
 
Patient: Snake Bite (cont) <ul><li>Gave several vials of anti-venom. </li></ul><ul><li>She had rapidly progressive neuropa...
<ul><li>10 yo boy with epilepsy. Had seizure, fell into fire. Presented to clinic 14 hours later. Gave IV fluids, antibiot...
What can we learn from these patients? <ul><li>These stories and images are just as horrifying as the images of police bru...
Challenges in building horizontal programs <ul><li>Donors don’t fund them - so have to divert funds from vertical programs...
What is needed? <ul><li>+ </li></ul>
 
Thank you
<ul><li>Visit us at www.nyayahealth.org </li></ul>Thank you to the staff and volunteers of Nyaya Health and for the patien...
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Building primary care infrastructure in rural Nepal

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This is an overview of Nyaya Health's work in Nepal, starting with some basics of Nepal's health, economics, and history. This talk was given by Jason Andrews at UCSF/San Francisco General Hospital on 6/4/2009.

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  • Building primary care infrastructure in rural Nepal

    1. 1. Building Primary Care Infrastructure in Rural Nepal The Experience of Nyaya Health Jason Andrews June, 2009
    2. 2. Overview <ul><li>Brief history of health care in Nepal </li></ul><ul><li>Birth(pangs) of Nyaya Health </li></ul><ul><li>Getting off the Ground </li></ul><ul><li>Innovations of Nyaya Health </li></ul><ul><li>Patient Stories </li></ul>
    3. 3. <ul><li>Population: </li></ul><ul><li>28 million </li></ul><ul><li>(>80% Rural) </li></ul><ul><li>Religion: </li></ul><ul><li>90% Hindu </li></ul><ul><li>5% Buddhist </li></ul><ul><li>3% Muslim </li></ul><ul><li>Per Capita </li></ul><ul><li>GDI: $340/yr </li></ul><ul><li>(India: $950/yr) </li></ul>
    4. 4. Brief History of Nepal <ul><li>One of few countries in world (and only country in South Asia) never colonized by West </li></ul><ul><li>Existed as a number of kingdoms until late 18th Century </li></ul><ul><li>Essentially closed to the West until 1950s </li></ul><ul><li>Multiparty Democracy with Constitutional Monarchy in 1991 </li></ul><ul><li>1996 Communist Party of Nepal (Maoist) declared People’s War </li></ul><ul><li>2005 King Dismissed Government, Assumed Executive Powers, Declared State of Emergency </li></ul><ul><li>2006 Popular Protests Overthrew the King, Democracy Reinstated </li></ul><ul><li>2008 Maoists won government in landslide </li></ul>
    5. 5. The People’s War 1996-2006 Over 13,000 Died Hundreds of thousands displaced
    6. 6. Maoists Demands <ul><li>“ Girls should be given equal property rights to those of their brothers” </li></ul><ul><li>“ All kinds of exploitation and prejudice based on caste should be ended” </li></ul><ul><li>“ The homeless should be given suitable accommodation. Until [the govt] can provide such accommodation they should not be removed from where they are squatting” </li></ul><ul><li>“ Poor farmers should be completely freed from debt” </li></ul><ul><li>“ All should be given free and scientific medical service and education and education for profit should be completely stopped.” </li></ul>
    7. 7. Health Care in Nepal <ul><li>21 doctors/100,000 (India: 60, Haiti: 25) </li></ul><ul><li>96% of doctors in Nepal work in Kathmandu valley (<10% of the population lives there) </li></ul><ul><li>Public expenditure on health: 1.5% of GDP </li></ul><ul><li>Public expenditure on military: 2.1% of GDP </li></ul><ul><li>Richest 20% of pop 10x more likely to have birth attended by skilled health personnel than poorest 20%. </li></ul>
    8. 8. Births Attended by Skilled Health Personnel <ul><li>Worldwide: 62% </li></ul><ul><li>The Bottom 10: </li></ul>
    9. 9. Founding a Nongovernmental Organization <ul><li>1st step: Incorporation in a State </li></ul><ul><li>Need: Mission Statement, Articles of Incorporation, Bylaws, Board of Directors </li></ul><ul><li>2nd step: 501(c)3 Status </li></ul><ul><li>Demonstrate sources of funding </li></ul><ul><li>Provide evidence of expenditures </li></ul><ul><li>Narrative of charitable activities </li></ul><ul><li>Additional Requirements: </li></ul><ul><li>Register in the country </li></ul>
    10. 10. Choosing a name - Nyaya Health <ul><li>“ Nyaya” - sanskrit word for justice </li></ul><ul><li>Amartya Sen: “Nyaya stands for actual social realizations, going beyond organizations and rules.” </li></ul><ul><li>“ 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.” </li></ul>
    11. 11. The Location: Achham
    12. 16. Getting to Know Achham <ul><li>Population: 250,000 </li></ul><ul><li>Estimated 40-80% of Men Work in India </li></ul><ul><li>PCI: $141 </li></ul><ul><li>~5 to 8% of Homes Have Electricity </li></ul><ul><li>Average Education: 1-1.5 years schooling </li></ul><ul><li>Income in Kathmandu is 4.5x that of Achham and rose $300 in PPP between 1996 and 2001, while falling $7 in Achham </li></ul><ul><li>55% of Population without access to safe drinking water (2.5x national average) </li></ul><ul><li>Closest hospital with basic OR ~8 hours away by jeep/bus </li></ul><ul><li>1 Ayurvedic Doctor in the district, No Allopathic Doctor </li></ul><ul><li>1 in 200 births take place in hospital </li></ul>
    13. 19. Community Meetings
    14. 20. Community Surveys - Rapid Health Assessment <ul><li>Goals: </li></ul><ul><li>Obtain a Rough Snapshot of Socioeconomics, State of Health, Disease, and Health Services in the Community </li></ul><ul><li>Complete survey and analysis in 2 weeks </li></ul><ul><li>Complete this in under $100 </li></ul><ul><li>Tool: Adaptation of survey used by Satia et al (HPP 1994) </li></ul><ul><li>2 Pages, 10-20 Minutes </li></ul><ul><li>Success: Completed in 2 weeks, Total Budget $45! </li></ul>
    15. 21. Rapid Health Assessment - Continued <ul><li>Surveyed 58 HH, 384 People </li></ul><ul><li>Median HH Income: $30/month </li></ul><ul><li>76% of women and 13% of men reported illiteracy </li></ul><ul><li>45% of men labor migrants to India </li></ul><ul><li>30% of homes had a toilet (none with functioning septic tank) </li></ul><ul><li>19% of HH had member go to India for medical care in last year alone; Amount spent was ~6 months median HH income </li></ul><ul><li>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 </li></ul><ul><li>8 Abortions - only 2 by trained provider </li></ul>
    16. 24. Building the Clinic
    17. 27. 4.6 kV inverter 12 - 12V 120mAMP-h batteries
    18. 28. Finding Staff!
    19. 30. Setting up Lab
    20. 31. Lab Capacity <ul><li>CBC (QBC Autoread) with differential </li></ul><ul><li>Colorimetry - AST/ALT, Bili, Creatinine, Glucose, Albumin </li></ul><ul><li>Microscopy - Gram stain, wet mount, KOH, Ziehl-Nelson </li></ul><ul><li>RPR </li></ul><ul><li>HIV rapid </li></ul><ul><li>Anti-ABD (pregnancy) </li></ul><ul><li>Urine HCG </li></ul><ul><li>Urinalysis </li></ul>
    21. 32. IStat! (thank you Abbott)
    22. 33. Opening! Day 1: 8 patients Day 2: 26 patients Day 10: 90 patients
    23. 34. First Two Months: 2,546 visits First Year: Over 20,000 visits
    24. 35. Programs and Innovations
    25. 36. 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
    26. 37. Ultrasound Program
    27. 38. Rigorous Data Monitoring and Open Source Everything <ul><li>De-identified patient databases available on our website with demographics, diagnoses, pharmaceutical prescription, and outcomes data </li></ul>
    28. 40. Other Data and Information <ul><li>Line-by-line expenditures </li></ul><ul><li>Future budgets </li></ul><ul><li>Financial account balances </li></ul><ul><li>Funds raised by source and date (donors kept anonymous) </li></ul><ul><li>Detailed Clinical protocols </li></ul>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.
    29. 41. Challenges: Conflict, Political Upheaval
    30. 46. January, 2006 April, 2006 Sindhupalchowk District Hospital
    31. 47. Political and Economic Rights in Nepal <ul><li>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? </li></ul>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.
    32. 48. <ul><li>“ We know, of course, there’s really no such things as the voiceless ones. There are only the deliberately silenced, or the preferably unheard.” </li></ul><ul><li>--Arundhati Roy </li></ul>
    33. 49. The consequences of being preferably unheard? <ul><li>60,000 Children under 5 die/year in Nepal </li></ul><ul><li>Nepal’s under 5 mortality: 76/1000 </li></ul>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
    34. 50. Woman with fever and abdominal pain <ul><li>35 yo woman carried in by stretcher, complaining of two weeks of weight loss, abdominal swelling, vomiting. </li></ul><ul><li>Temp 103 </li></ul><ul><li>Large Abdominal Mass </li></ul><ul><li>Further history: severe burn to abdomen several months prior with chronic open wound </li></ul>
    35. 51. <ul><li>HIV test done: Positive </li></ul><ul><li>IV Fluids and Antibiotics given </li></ul><ul><li>Patient sent to hospital </li></ul>
    36. 52. Young Man with Gunshot Wound <ul><li>18 yo man from neighboring district, was hunting with his family and accidentally shot through abdomen, transection genitalia, exiting right thigh. </li></ul>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.
    37. 54. <ul><li>On arrival: systolic BP in 60s </li></ul><ul><li>2 Large bore IVs placed </li></ul><ul><li>IVF given wide open </li></ul><ul><li>Patient had peritoneal signs on abdominal exam </li></ul><ul><li>Staff gave IV Ceftriaxone and flagyl </li></ul><ul><li>BP came up, pt feeling better </li></ul><ul><li>Fluid and stool began coming out of his abdominal wounds </li></ul>
    38. 55. <ul><li>Family members hadn’t yet arrived. Team arranged a jeep for him to go to hospital for surgery, 12 hours away </li></ul>
    39. 56. <ul><li>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. </li></ul>12 yo boy charged by bull with abdominal wound and evisceration. Carried 2 hours on stretcher. Omentum replaced, wound closed. Antibiotics, fluids, observation, home!
    40. 57. Woman with a Snake Bite <ul><li>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 . </li></ul>5 minutes after she arrived, she lost consciousness and went pulseless. Received CPR and Epi. Regained pulse, answering basic questions
    41. 59. Patient: Snake Bite (cont) <ul><li>Gave several vials of anti-venom. </li></ul><ul><li>She had rapidly progressive neuropathy, including respiratory depression, requiring continued bag-ventilation. </li></ul>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
    42. 60. <ul><li>10 yo boy with epilepsy. Had seizure, fell into fire. Presented to clinic 14 hours later. Gave IV fluids, antibiotics, silver sulphadiazine. Referred. </li></ul>
    43. 61. What can we learn from these patients? <ul><li>These stories and images are just as horrifying as the images of police brutality and the war. </li></ul>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.
    44. 62. Challenges in building horizontal programs <ul><li>Donors don’t fund them - so have to divert funds from vertical programs </li></ul><ul><li>Much more difficult to make simple algorithms for the myriad of conditions - TB, malaria, malnutrition relatively easy </li></ul><ul><li>Defining successful outcomes more challenging </li></ul><ul><li>There is no semblance of a QI movement in rural resource-poor primary care </li></ul>
    45. 63. What is needed? <ul><li>+ </li></ul>
    46. 65. Thank you
    47. 66. <ul><li>Visit us at www.nyayahealth.org </li></ul>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

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