Pediatrics mgr april 2011


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  • Identify where Achham is, and point out that most development, funding, tourism is in the KTM valley/east of the country – i.e. NOT the FW. Can also mention Achham (FW generally) was epicenter of Maoist conflict => even more destitution. Don’t spend more than 90 secs on this slide though, our goal is not to give a history of Nepal hehe
  • “ ICU” = intensive care unit (we should spell this out for the audience as many people likely won’t know what that is)
  • Maru, Duncan “Death by HIV”
  • CHWs and CHWLs at the training session on mental health at BH.
  • Wiki posited as Nyaya’s mechanism for transparency  accountability & collaboration within GHD community Next slide to be posited as inter-team communication tools to facilitate GHD community TA&C DAI speaker: orgs often say “we don’t want to do that – we want to do something new… ” – Nyaya’s not trying to do anything new, we’re trying to encourage replication of the usage of technologies that are already available to enhance collaboration as a field “ 80/20 rule – 80% of what’s relevant in Zambia can be used in Malawi”
  • Pediatrics mgr april 2011

    1. 1. <ul><li>Building Health Systems in Rural Nepal </li></ul><ul><li>The Case of Nyaya Health </li></ul><ul><li>Duncan Maru, MD, PHD Co-Founder| Nyaya Health </li></ul><ul><li>Pediatrics Mini Grand Rounds </li></ul><ul><li>April 1, 2011 </li></ul>
    2. 2. Overview <ul><li>Nyaya Health and Achham Overview </li></ul><ul><li>Case: HIV and Respiratory Distress </li></ul><ul><li>Public Sector Strengthening </li></ul><ul><li>Case: Visceral Leishmaniasis </li></ul><ul><li>Community Health Worker Program </li></ul><ul><li>Case: Perforated Viscous </li></ul><ul><li>Transparency and Accountability </li></ul><ul><li>Inputs, Outputs, and Next Steps </li></ul>
    3. 3. <ul><li>The ultimate arbiter of epidemiological truth is death. </li></ul>
    4. 4. Nyaya Health: Who We Are <ul><li>Social justice-oriented mission: </li></ul><ul><li>To provide free community-based healthcare in rural Nepal that strengthens the public sector </li></ul><ul><li>To develop and disseminate effective strategies of healthcare delivery in resource-poor settings throughout the world </li></ul><ul><li>Started working in Achham in 2006; public-private partnership with Nepali Ministry of Health & Population since 2009 </li></ul><ul><li>Nyaya Team: </li></ul><ul><ul><li>29 full-time employed Nepali staff + ~50 CHWs </li></ul></ul><ul><ul><li>1 full-time US-based Executive Director </li></ul></ul><ul><ul><li>Volunteer Executive Team, Board of Directors and Board of Advisors </li></ul></ul><ul><li>Core Approach: Transparency, Public-Private Partnerships, and Community-Based Care </li></ul>
    5. 5. Where We Work: Nepal – Achham District, Far Western Region
    6. 6. Achham: Demographics <ul><ul><li>~270,000 people </li></ul></ul><ul><ul><li>99.6% Hindu </li></ul></ul><ul><ul><li>60% agricultural </li></ul></ul><ul><ul><li>>80% of men migrate to India, and 35% of families rely on remittances from India </li></ul></ul><ul><ul><li>33% adults literate: 54% men, 14% of women </li></ul></ul><ul><ul><li><$1USD is daily per capita income </li></ul></ul><ul><ul><li>Maternal Mortality officially 230 deaths per live births </li></ul></ul>
    7. 7. Achham: Infrastructure <ul><li>2007: </li></ul><ul><ul><ul><li>>90% of houses did not have electricity </li></ul></ul></ul><ul><ul><ul><li>45% had access to clean water – 2.5x worse than national average </li></ul></ul></ul><ul><ul><ul><li>Hydroelectric plant functioning <50% capacity </li></ul></ul></ul><ul><ul><ul><li>Extremely limited landline telephone capacity, one cell phone tower </li></ul></ul></ul><ul><ul><ul><li>Paved road ended in Sanfe Bagar </li></ul></ul></ul><ul><ul><ul><li>Airport destroyed during war </li></ul></ul></ul><ul><ul><ul><li>Hospital 5 hours, surgery 6 hours, ICU 14 hours </li></ul></ul></ul>
    8. 8. HIV and Sepsis: April, 2007 <ul><li>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. </li></ul>
    9. 9. <ul><li>Infrastructure Matters  Public-Private Partnerships </li></ul>
    10. 10. Sanfe Bagar Primary Health Center <ul><li>Opened for service April 6, 2008 </li></ul><ul><li>Served over 17,000 patients between April ’08 and May ‘09 </li></ul><ul><li>Transitioned to government June ‘09 </li></ul>Sanfe Bagar Health Center: Before Sanfe Bagar Health Center: After
    11. 11. Nyaya Health at Bayalpata Hospital <ul><li>Mission: infrastructure development in collaboration with the government, not only care provision </li></ul><ul><li>Government partnership contract for 5 years signed June, 2009 – June, 2014 </li></ul><ul><li>Over 60,000 patients treated to date </li></ul>
    12. 12. Nyaya Health Team
    13. 13. Approach: Public Sector Strengthening <ul><li>District Hospital: Direct Management of Bayalpata Hospital </li></ul><ul><li>Health Posts: Accountability </li></ul><ul><li>Community Health Workers: Incentives and training </li></ul>
    14. 14. Key Challenges <ul><ul><ul><li>Human resources </li></ul></ul></ul><ul><ul><ul><li>Supply chain management </li></ul></ul></ul><ul><ul><ul><li>Energy systems </li></ul></ul></ul><ul><ul><ul><li>Telecommunications </li></ul></ul></ul><ul><ul><ul><li>Community relationships, outreach </li></ul></ul></ul><ul><ul><ul><li>Public sector relationships </li></ul></ul></ul>
    15. 15. Visceral Leishmaniasis <ul><li>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. </li></ul><ul><li>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 </li></ul><ul><li>End November: Transport via ambulance to Dhangadi than via Buddha Air to Kathmandu. Diagnosed with Kala-Azar, started on amphotericin, worsened, intubated, died. </li></ul>
    16. 16. Community Health Worker Program <ul><li>Builds off of government’s existing female community health volunteer program </li></ul><ul><li>Pays incentives for their work; not salary as per government mandate </li></ul><ul><li>Focuses on follow-up and referral </li></ul><ul><li>SIMPLE referral system from the hospital </li></ul><ul><li>Current Catchment of 1,357 households covered by 35 FCHVs </li></ul><ul><li>Managed by salaried community health worker leader (approximately 9-14 CHWs per leader) </li></ul>
    17. 17. <ul><li>Communities Know Who To Trust  Community-Based Care through Community Health Workers </li></ul>
    18. 18. Community Health Worker Program
    19. 19. Community Health Outreach Program
    20. 20. Challenges: Facilities-Based Deliveries
    21. 21. Challenges: Transportation Infrastructure
    22. 22. Perforated Viscous <ul><li>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. </li></ul>
    23. 23. <ul><li>To become better at medicine, we need to be more accountable  Transparency and Quality Improvement </li></ul>
    24. 24. Improving Care and Accountability <ul><li>Mortality and Morbidity Conferences </li></ul><ul><li>Include all staff </li></ul><ul><li>Meeting minutes publicly accessible </li></ul><ul><li>Systems-level approach </li></ul>
    25. 25. Nyaya Health: Wiki <ul><li>Wiki is a searchable repository of: </li></ul><ul><ul><li>Management policies </li></ul></ul><ul><ul><li>Financial data </li></ul></ul><ul><ul><li>Clinical protocols </li></ul></ul><ul><ul><li>De-identified clinical data </li></ul></ul><ul><li>All pages viewable to the public </li></ul><ul><li>A forum to share lessons-learned from Achham with organizations in similar settings around the world </li></ul><ul><li>Opportunity for critical feedback and collaboration </li></ul>
    26. 26. Inputs and Outputs Total Expenditures: $166,000 Annual Per Capita Public Health Expenditures in Achham: $5
    27. 27. Expenditures
    28. 28. Funding
    29. 29. <ul><li>The ease with which young people die in Achham and the ease with which it is accepted continues to horrify me. </li></ul><ul><li>-Ruma Rajbhandari, MD, MPH, March 22, 2011. </li></ul>
    30. 30. Continued Renovations Next Steps
    31. 31. Next Steps Surgical Services Quality Improvement Implementation Research Next Steps
    32. 32. Next Steps Solar Power Next Steps
    33. 33. Next Steps: Funding <ul><li>Philanthropic: $75K matching campaign </li></ul><ul><li>Government: $125K expansion proposal </li></ul><ul><li>Research: $300K NIH Grant </li></ul><ul><li>Social Entrepreneurial: $100K Grinnell College, Several Mid-Sized Grants </li></ul>
    34. 34. My Personal Vision for Bayalpata Hospital
    35. 35. Acknowledgements <ul><li>The staff of Bayalpata Hospital & the people of Achham, Nepal </li></ul><ul><li>The volunteers and individual donors of Nyaya Health </li></ul><ul><li>The Nepali Ministry of Health & Achham District Health officials </li></ul><ul><li>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 </li></ul>
    36. 36. Questions, Reflections, Comments? <ul><li> </li></ul>