Med peds noon conference dec 2010
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  • Stress the “success” of being approached by the gov’t for collaboration – this slide should really just be “a few months after opening the clinic, we were approached by the government and local community, and offered to join in a public-private partnership to re-open the Bayalpata Hospital
  • Stress the importance of our philosophy in how we approach our work
  • 50,000 patients to date
  • Make the point that even tho we have these problems, relative to other regional facilities, we are actually totally in line with the standards (Jason says he thinks we’re even in line with WHO guidelines, but likely better not to cite it cuz you might get into an argument re policy details), and that when (for example) you spoke w/mark zimmerman (NSI/PH) about this, he said that they were doing the exact same thing. It’s not that you were doing a bad job relative to what everyone said you were supposed to be doing, it’s that the standards are simply too low and thus, we needed to move outside the regional area for intl expertise on how to push the envelope forward, setting new precedents
  • - This slide should be used to summarize Nyaya’s goals and highlight our next steps (which are key fundraising initiatives).


  • 1. Implementation Gaps and Quality Chasms: Building Health Systems in Rural Nepal
    Duncan Maru, MD, PHDCo-Founder| Nyaya Health
    Med-Peds Noon Conference, December 16, 2010
  • 2. Learning Objective
    Think critically about healthcare delivery and quality in resource-poor areas
  • 3. Where We Work: Nepal – Achham District, Far Western Region
  • 4. Achham District, Far Western Region, Nepal
  • 5. Achham District, Far Western Region, Nepal
  • 6. Achham District, Far Western Region, Nepal
  • 7. Achham District, Far Western Region, Nepal
  • 8. Achham District, Far Western Region, Nepal
  • 9. Achham, Nepal
    population of Achham
    number of allopathic doctors in Achham before Nyaya
    hours in bus to reach the nearest operating room
    hours in bus to reach the nearest intensive care unit
    6% & 54%
    Female and male literacy rates, respectively
    1 in 125
    deliveries results in the mother’s death
    number of stillborns for every 1,000 live births
    of men migrate to India for work; over 7% return with HIV
    of babies are born in homes and cattle sheds
    average daily per capita income in Achham
    of children are chronically malnourished
  • 10. NyayaHealth Snapshot
    Social justice-oriented mission:
    • To provide free community-based healthcare in rural Nepal that strengthens the Nepali Ministry of Health’s public sector
    • 11. To develop scalable models of healthcare delivery in resource-poor settings throughout the world
    • 12. Founded in 2006; public-private partnership with Nepali Ministry of Health & Population in 2009
    • 13. Managed by a volunteer Board of Directors and 27 full-time employed Nepali staff
    • 14. Over 99% of all funds used directly in Nepal
  • 15. SanfeBagar Primary Health Center
    Sanfe Bagar Health Center: After
    Sanfe Bagar Health Center: Before
  • 16. BayalpataHospital
  • 17. BayalpataHospital
  • 18. 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
  • 19. BayalpataHospital
    • All health care services free of charge:
    • 20. Inpatient & Outpatient services
    • 21. 24-hour emergency and obstetric services
    • 22. Laboratory & Pharmacy
    • 23. Radiology: X-Ray & Ultrasound
    • 24. HIV, TB treatment programs
    • 25. Malnutrition treatment (RUTF)
    • 26. Ambulance services
    • 27. Community Health Worker (CHWs) services
    • 28. 2011 Expansion Plans:
    • 29. Comprehensive surgical suite
    • 30. Solar energy
    • 31. Expanded CHW network
    • 32. Teaching hospital status
  • Challenges
    But doing things and doing things well are two different things…
  • 33. Case 1: Nosocomial Tuberculosis
    27yo M lab tech from BH presenting with cough x3wks and hemoptysis
    Considered high-risk for TB exposure (3-4 sputa examinations per day)
  • 34. Case 2: Infant Pneumonia
    An 8-month-old boy with severe respiratory distress and five-day history of pneumonia presented to the BayalpataHospital. 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.
  • 35. Key Challenges
    Human resources
    Supply chain management
    Energy systems
    Community relationships, outreach
    Public sector relationships
  • 36. Achieving Excellence in Healthcare Delivery…
    InstitutionalizeReflectiveDialogue: Mortality and MorbidityReviews
    InstitutionalizeTransparency in Reporting: Data Program
  • 37. M&M Review: Nosocomial tuberculosis
    • Issue 1: Lab Ventilation
    • 38. Lack of local and regional infection control; BH met standards!
    • 39. Director of Medicine at foremost teaching hospital in Nepal: “never seen a safety hood in Kathmandu”
    • 40. Solution 1a: Collaboration with international partners via GHDonline to design newly-constructed TB-specific lab space with negative pressure
    • 41. Solution 1b: Collaboration with MOH & District to conduct infection control trainings
    • 42. Issue 2: Personnel Safety
    • 43. Solution 2: Procurement of N95s, and trainings
  • M&M Review: Infant Pneumonia
    • Oxygen in ambulance
    • 44. Oxygen protocol for ER
    • 45. Dedicated ambu bag
    • 46. CPR training for staff
    • 47. ER crash trolley
  • Nyaya Data Program: Local System
    • Open-Source Access Database, Gnucash
    • 48. Challenges in electricity, human resources, retention
  • Nyaya Data Program: Wiki
    • Wiki is a searchable repository of:
    • 49. Management policies
    • 50. Financial data
    • 51. Clinical protocols
    • 52. De-identified clinical data
    • 53. All pages viewable to the public
    • 54. A forum to share lessons-learned from Achham with organizations in similar settings around the world
    • 55. Opportunity for critical feedback and collaboration
  • 56. Concluding Thoughts and Next Steps
    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’sNext Steps:
    Larger community health worker network
    Surgical capacity
    Solar energy systems
    Implementation Research
  • 57. My Personal Vision for Bayalpata Hospital
  • 58. Acknowledgements
    • The staff of Bayalpata Hospital & the people of Achham, Nepal
    • 59. The volunteers and individual donors of Nyaya Health
    • 60. The Nepali Ministry of Health & Achham District Health officials: Dr. Deepak Gaylal, Mr. SailendraShrestha, Mr. JhanakDhungana
    • 61. 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