Reflections on Achham: Growth and Opportunity.

GROW: a : to spring up and develop to maturity.  to have an increasing influence. to promote the development of. -Merriam Webster Dictionary.

Two months in Achham. Two months a world away from what we are used to in the United States, yet still, it is only two months. Two months is hardly enough time to understand, to appreciate, and to develop. Yet time flows differently in Achham and development, both personal and otherwise, comes sooner than one expects.

Growing up

Personal development is easy when one is starting from nothing. Before this summer, the world of international development and global health was very much a rhetorical one, given life only through articles and essays. In retrospect, despite nearly a year of campaigning and raising awareness through Globemed, my view of Bayalpata Hospital was significantly flawed before I actually got there. With all the rhetoric of ‘grassroots’ and ‘community-based’ I had thrown into my prepared elevator pitch, I was a bit unprepared to see a respectable looking complex with solar panels, tiled floors, that looked, well, a lot better than what I was expecting, honestly. My mental image was tied up in the form of the small community clinic that Nyaya started with, but the hospital has grown, expanded, developed. Nyaya has changed for the better, expanding and serving more people and as such it has, without us knowing, left behind many of the phrases we use to describe it.

Growing Out

Our rhetoric emphasizes that Nyaya is a grassroots organization. It’s a good word, one that really gets people excited. It invokes images of strong community backing and involvement, small, local roots, and a personal touch to healthcare delivery. Does that word still apply when if the small regional clinic has upgraded to one of two district-level hospitals that serve patients from hours away? Does it apply to the public-private partnership that is looking to dramatically increase the amount of government funding it receives, fighting through the bureaucracy to achieve it? Does that word describe an organization which has a U.S. team of researchers that receive tens of thousands of dollars in grants to do research that often seems to fly in the face of reason for the Nepal side? What does the word “grassroots” mean when the organization grows?  

Growing In

The point of a successful campaign is, in many ways, to paint the scenario in the best light. The danger of successful campaigning is that it becomes easy to believe your own elevator pitch. One forgets that organizations are not purely corrupt and inefficient or transparent and streamlined. Problems exist. Inefficiencies gum up the works. Communication lines are often tangled and tensions sometimes run high. That is the reality, not the campaign. And while it is important to frame the organization and the fundraising goal in a light that will promote action and involvement, it is essential that delusion does not become an accepted tradeoff. A realistic assessment of strengths and weaknesses is necessary for the chapter as a whole, not only to foster a better understanding of our partner, but to better think of ways to help strengthen the partnership.  

Growing Understanding

It is often difficult to describe the demographic Nyaya serves to others, whether while giving an elevator pitch, or while campaigning. “Rural Nepal” is hopelessly inadequate. “Under-served” is difficult to visualize. “Impoverished” gives a one-sided view of the situation. In reality, no summary for an elevator pitch can capture the full nuances of the Achhami populace. What’s a short way of saying “subsistence farmer / migrant worker / tea shop entrepreneurs / impoverished but not starving / hard working and generous / indolent and self-serving / caring parents / neglectful parents / victims/perpetrators of gender inequality / happily married / domestically abusive when drunk / bearing great burdens, physical and otherwise / mild hypochondriacs believing that no pills or tests means ineffective treatment” ? How do you summarize a caste system that segregates and discriminates, and how do you give an overview of a younger generation who couldn’t care less about caste? How can you express the changes occurring, from changing age-old traditions which harmed women to improving overall health through community investments, and how can you reconcile that with the cold reality that the more things change, the more things stay the same in the sense that at the end of the day, you still have to look out for number one. In a society where males are valued more, there are parents who love and pamper and cherish their daughters. In a community where most people perform migrant work or subsistence farming, there are some who dream of studying abroad and pursuing higher education. No matter how hard one tries, there is really no way of easily encompassing the population that Bayalpata Hospital serves, who are probably the most important detail when describing the hospital’s care.

Growing Pains

If a hospital runs out of medicine in rural Nepal, does it make a sound? Poisonous snakes are, unfortunately, all too common in Achham. The problem was exacerbated by a country-wide shortage of antivenom. So when, one night, a member of the Armed Police Force came to the hospital with a snake bite, what could be done? How must it have felt, knowing that if only there was this small vial of liquid, everything would be all right? What sort of terror and anticipation must have filled that officer’s heart when, in the middle of the night, he was told that there was a chance, a CHANCE, that the other of two district-level hospitals in Achham MIGHT have antivenom. That is the stuff of nightmares. Often, donations and campaigns are run for projects that are sexy, that are popular, that are easy ways to pluck peoples’ heartstrings and their wallets. But basic issues of supplies and logistics are sometimes more complex than a single hospital can handle, and sometimes the simplest things are the ones that need the most attention.  

Growing forward

Growth can be tough, and Nyaya fits all of the descriptions of growing. It has come to maturity, both scaling up in physical size and also in scope of services, going from a small clinic in Sanfe to being awarded “Best Hospital in Nepal”. More and more, Nyaya has increasing influence in both the region, and also the nation, through its work with the government. Through both Nyaya Health Nepal’s work with the government and also through Nyaya Health International’s work in implementation science, Nyaya works to promote its core values of transparency and efficiency in delivering healthcare to those that need it most. But growing can be difficult. Growing pains are normal. Nyaya faces challenges that it must overcome, from communication to employee retention. But growing also means new opportunities, for both Nyaya’s efforts in Nepal, and also for Globemed at Tufts to be as useful as we can for our partner. Whether or not we seize these opportunities and minimize the associated growing pains is up to us. 

An Early Morning Surprise

Earlier this morning while going on rounds with the doctors at the hospital, I realized how easily we take ambulance services for granted in the US.  I was standing in the inpatient department excited to hear that the mother and child, who was delivered by Bayalpata’s second Cesearean section, were doing well, when I was asked to go to the front of the hospital to take some pictures.  A mother had just arrived and was finishing the delivery process, which had started in the jeep transporting her to the hospital.  The nurses were quick to help her out, severing the baby’s cord in order to quickly bring her to the warming table in the IPD.  Then they helped the mother out of the jeep so that she could finish the process of labor in a more sterile environment.  In a matter of minutes the baby was wrapped up with her clothes on, the mother was walking around, and the nurses were busy preparing for yet another birth.

After the craziness of the moment settled down, I began to wonder why the mother had come to the hospital, knowing that it was likely she would deliver in the jeep, clearly not an ideal situation.  Without even having to ask, one of the nurses provided me with the answer, “You know many women come here even they know its too late.  That way they can still receive the delivery incentive.  In 2005 Nepal created the Safe Delivery Incentive Program (SDIP), which provides mothers an incentive to deliver at a health facility.  Here in Achham, the incentive in 1,000 rupees.  This program was a response to the high costs associated with accessing care, particularly in rural areas as well as overall low rates of skilled-birth attendants present at deliveries.   Over the last three years deliveries have increased 350% from an average of only 6 delivers per month to an average of 26 deliveries per month since the opening the hospital.   We are now seeing about one delivery per day as more and more women choose to access these services at the hospital, but as this case demonstrates even such a well intentioned program can have unintended consequences.  

 The cord is cut and the baby is quickly wrapped in a shawl.

Two nurses help out of the jeep and into hospital.

 The baby is placed on the warming table.

 Weighing the baby....she is big! 

 The baby is brought out for everyone to see.

Welcome to our new Community Health Director!

After an intensive and competitive application process, we are pleased to welcome Sami, our new Director of Community Health, to the Nyaya Health family! The Community Health Department is an integral part of Bayalpata Hospital and we are confident that it will grow and improve under her leadership.

Good Luck Sami! 

Baylpata's First C-Section

Over a week ago on July 3rd, Baylpata's First C-Section was performed by Dr. Tewari, aided by a team of nurses and assistants.  We regret not sharing this momentous occasion earlier, but here in Achham time quickly gets away from us.  This surgery marked the end of a long commitment to provide the first surgical services at Bayalpata Hospital, and is a testament to the dedication of everyone at Nyaya Health both here in Nepal and in Boston.  As Dan Schwarz wrote to me in an email shortly after, "yet again, we have shown that the impossible is possible."  

For those who have never been to Achham, it is perhaps difficult to convey how much of a positive impact the implementation of surgical services at Bayalpata Hospital will have for the community.  In the United States one is rarely more than a thirty minute trip for a hospital. In Achham, a women is lucky if she must only walk a single our to reach a point of care, and the distance to reach a surgical center is almost always far greater.  Even more troublesome is the reality that the quality of services at many locations which patients have travel hours to reach frequently leaves much to be desired. Closer, more reliable surgical services will undoubtedly save the lives of many who previously may not have made it a hospital in time, and will reduce the burden of traveling for many. 

Nyaya Health's Amazing Surgical Team!  

 

Just Moments after Birth

The Next Day Mother and Child are Doing Well 

A Very Proud Grandmother 

Farewell to Dr. Sudan and Dr. Roshan

At the end of last week we said goodbye to two our two MBBS doctors, Dr. Roshan and Dr. Sudan. Over the course of the last year, both have inspired our staff with their hard work, and their compassionate care has benefitted countless patients.  While we are sad to see them leave, we know their connection to our work has only just begun and that their pursuit of further eduction will serve them well. Although they have yet to be replaced, we can only hope that our next round of MBBS doctors are as dedicated to serving the population of Achham with high quality compassionate care. 

Dr. Sudan Thapa, Steven (Country Director), and Dr. Roshan Bista

Below are two quotes from emails sent to Nyaya Health’s team@ list serve:

“…the smile on [patients] faces always motivate me to work at Bayalpata Hospital. This is now end of my tenure and in search of my further study with heavy heart I am leaving Bayalpata hospital this time. This is just the beginning of my attachment with Nyaya and would like continue forever and return back with more knowledge and resources. Thank you all for your support and appreciation.”

                     Dr Sudan

“I got a chance to learn a lot from you all and this is just the beginning of being the part of Nyaya.  As I go from here in the search of MD degree ...my heart always says I will return back to the needy people with more knowledge and resources.”

                     Dr Roshan 

Crowd Funding meets Healthcare

Nyaya Health operates under the belief that health is a human right. Nyaya Health has gone to great lengths to ensure that the people of Achham can enjoy that right, primarily through its public-private hospital. Although the hospital is an important step to providing health services to an underserved population, there are many services the hospital cannot yet provide, such as complex surgical services. We hope that Bayalpata Hospital will one day be able to expand its surgical services, but currently patients that cannot be treated at the hospital are referred to other facilities.

Due to the costs of travel, treatment, and multi-day or even multi-week stays at the referral facilities, many patients do not continue with treatment after being referred. Over the past year, Bayalpata Hospital has been working to overcome this challenge by experiment with an innovative strategy designed by Watsi, a nonprofit organization that aims to expand access to low-cost and high-impact interventions.

Watsi is an online crowd funding platform (www.watsi.org). A picture of the patient in need is posted to their site, along with the cost of their treatment (there is a maximum limit of 1500 USD) and a Donate button that allows visitors to donate as little as 5 dollars.

Nyaya Health has been one of Watsi’s first partners and the program has been an important addition to Bayalpata Hospital’s services. Over the past 12 months, over 50 patients at Bayalpata Hospital have received essential surgical treatment they would otherwise have not been able to obtain.

The Watsi partnership does more than just provide funding. It also provides patients with emotional support. Many of the patients that have participated in the program thus far have had to travel to Kathmandu, an urban environment they are usually not familiar with. Many patients also harbor misconceptions regarding their treatment options and do not feel comfortable going through the process alone. Bayalpata Hospital has put together an accompaniment team to be a pillar of support for patients and their families.

Watsi will not be able to replace the need for improved onsite surgical capabilities, but it does help bridge the gap between access in remote and poor communities and the rest of the world.

Thank you for (not) smoking: Bhagyashwar’s Smoke-Free celebration

Earlier this week the GROW team arrived at the office to discover an invitation had been delivered from the Bhagyashwar VDC to the country director, Stephen Petersen, to attend a ceremony celebrating this districts most recent accomplishment. Bhagyashwar has recently gone “smoke-free”, meaning that every household in their VDC (Village Development Committee) has adopted an improved cookstove. As this was a good chance to go into the surrounding community, the GROW team set off with one of the community health employees, Nirajan, to Bhagyashwar, slightly more than a half hour away.

On the way, Nirajan gave us an overview about the VDC and the ceremony. Bhagyashwar is one of the smallest of the 75 VDCs in Achham, but has an overall higher socio-economic status. Seeking to be a model VDC, Bhagyashwar has implemented several government programs. In addition to going smoke-free (100% improved cookstove implementation), Bhagyashwar is also open-defecation free (toilets installed for every household) and chaupadi-free (an end to the practice of separating women on their period, often in poor, unhygienic conditions).

The adoption of multiple voluntary government programs is more than just the fulfillment of a statistic as the community adopts them with long-term health impacts in mind. For example, the chief causes of under-five mortality in the region are pneumonia and diarrheal diseases. The open-defecation free policy, implemented earlier, has already begun to put a dent in that rate. Additionally, the elimination of chaupadi will hopefully reduce maternal mortality as it is high in part because of STIs (sexually-transmitted infections) and UTIs (urinary-tract infections), both of which are due in part to poor menstrual hygiene. And since the cause of most COPD (chronic obstructive pulmonary disease) cases are a result of the smoke from indoor cookstoves, it is hoped that the implementation of improved cookstoves will reduce the incidence of COPD in the region.

Of course, such programs can only have an effect if they are maintained over a long period of time, and they can only be maintained if the VDC is engaged in the program. In Bhagyashwar, the VDC committee organized the stove initiative, and has taken responsibility for its monitoring and followup. If the improved cookstove program expands to other VDCs, there must be a body to maintain their use so that they do not break down with nobody to repair them. When interventions such as these are left without support they become yet another useless relic of NGO subsidies.

On the way back, Nirajan told us that things are already much better than five years ago. People used to go to traditional healers, but now they come to places like Bayalpata Hospital and the local government health posts. Even the traditional healers in the region sometimes refer patients to Bayalpata Hospital. The people of this region, according to Nirajan, have become more sensitized to their health issues. Bhagyashwar saw an opportunity to use an NGO’s subsidies to improve their own health. While nobody can say for certain how this program and others like it will turn out five or ten years down the road, if the VDCs are aware of and want to improve their health, then the smoke-free program and others like it will make a real difference to the long-term health of the people of Achham. 

The Next (Budget) Generation: Performance-Based Financing at Bayalpata Hospital

Nyaya Health has always believed in working with the government of Nepal to achieve its goals. While individual donors have made up the bulk of Nyaya Health's financial assets, the Nepalese government has invested $35,000 per year since 2010 and recent budget negotiations have looked to increase government investment to $100,000 a year and more in the coming years. 

The idea for a new contract with the government, due to take effect mid-July, began when the Nepali Ministry of Health approached Nyaya Health to propose a pilot program for future funding of private-public partnerships in Nepal. For this year's contract, Nyaya Health's assets from the government will be dependent on the organization's performance on certain metrics. If Nyaya meets their targeted metrics, then they will receive increased funding the next cycle, but if they don't, their funding from the government will be cut by 20%. Performance based financing for NGOs has been tried in places such as Rwanda and Nicaragua, but this is the first attempt to implement performance based financing in Nepal and focus on outcome-based funding for health organizations.

Nyaya is responsible for formulating 40% of the metrics it will be judged on, and it has focused on measurable outcome-based metrics that will hopefully result in meaningful improvement in both quality and equity of healthcare delivery. For example, one of the metrics Nyaya chose to be measured on is the institutional delivery rate for pregnant women. Nyaya works with many health posts in the region which serve as birthing centers for pregnant women to come in and deliver their babies. However, the birthing centers are often so shabby that expectant mothers choose not to come in to deliver. The performance based financing metric, which funding will be partially based, requires Bayalpata Hospital and the health posts in the region to serve a certain portion of the expected deliveries in the region, and so the hope is that the birthing centers will improve their quality once their financial status is linked to their performance.

Of course, there will be challenges. Performance-based financing relies heavily on the quality of data collection, which, if self-reported, may not always be trustworthy. That’s why Nyaya has attempted to use metrics that can be independently verified, in order to demonstrate that improvement of performance has to be real, and not just an inflated figures on government reports.

The challenges are real, but so are the potential benefits. It’s about a change in mindset. Rather than saying, "we need $100,000 to improve our birthing center", performance-based financing says, "we need $100,000 to improve the rate of institutional births in our region to reduce maternal mortality, which we will accomplish by improving our birthing center". It's about paying for results, and depending on how the pilot program with Nyaya goes, it could mark a major shift in NGO funding strategies in Nepal. 

Microbiology at Bayalpata Hosptial

The staff at Bayalpata are always busy trying to find ways to improve and become more efficient. The focus on improvement doesn't leave much room for reminiscence. For a newcomer like myself I was preoccupied with how far the hospital has come since its opened its doors four years ago. The progress is even more impressive considering the formidable obstacles that Nyaya Health has faced and continues to face. 

Not only has Nyaya Health succeeded in establishing a free hospital in Far Western Nepal that provides basic health services, but it also continuously tries to expand its services. Take for example Bayalpata Hospital's Microbiology Lab that is currently expanding to include a bacterial culture facility. 

Bayalpata's lab is the only one of its kind in the district of Achham. It is currently staffed by four lab technicians and is equipped with an I-stat machine, a QBC Hematology Analyzer and a number of important serology tests, including HIV, Malaria, TB, and Hep-B. Having an in-house laboratory with the ability to analyze patients blood, kidney, and liver functions has allowed the physicians to more quickly and accurately diagnose their patients. The lab technicians approximate that they run biochemistry tests on 50 patients a day, at times discovering patients that are HIV+ and unaware of their condition. These patients can then be referred to Bayalpata's Anti-retroviral Therapy program. The biochemistry tests at the lab also allow the technicians to spot unusually high white blood cell counts that may be diagnosed by the doctors as leukemia. 

In the next few days, the technicians hope to begin growing and preserving bacteria cultures which will allow them to increase their diagnostic capabilities as well as pursue academic research, particularly concerning antibiotic resistant bacteria. Bayalpata is currently treating two patients that are suffering from multi-drug resistant tuberculosis. The capability of testing cultures with antibiotics can allow drug resistant strains to be more quickly recognized.

When Nyaya Health was founded in 2006, it opened a clinic in an abandoned goat shed. Today it is operating one of the few microbiology laboratories outside of Kathmandu. Hopefully similar progress is made over the next four years.

Bishnu, one of the four lab technicians working in the renovated microbiology lab at Bayalpata Hospital

A Breech Baby at Bayalpata

Yesterday I spent the morning observing Urmila, an ANM who conducts all of the exams at the antenatal clinic (ANC).   Over the course of the morning, I was struck by how different the experience pregnancy and delivery is in Achham compared to the United States.  

 

Urmila (ANM) and Dhansara (ANM) in the ANC clinic 

In the United States, prenatal exams usually include an ultrasound as soon as the fetus can be seen, the mother is asked if she would like to know the sex of the baby, and the mother and father are often able to hear the fetal heart beat.  Deliveries nearly always take place at the hospital, and most mothers need to travel only a short distance to reach their doctors.

Here in Achham, Mothers must walk hours, or even days to reach the hospital for their four recommend antenatal visits.  The father is rarely present, and instead of experiencing joy seeing their baby for the first time, many women seem nervous to be in an unfamiliar place.  In order to increase the percentage of women coming to the hospital for deliveries the government has created an incentive program, awarding 400 rupees to mothers who have received all four recommended antenatal checkups. Unfortunately, the lack of an electronic system makes keeping track of such data difficult.

Even when women do decide to come in to the hospital, the services they receive are very different from what we have come to take for granted in the US.   Although Bayalpata does have an ultrasound, it is most often in use in the inpatient department, so Urmila must do exams manually to determine that the mother and child are well.  She is very skilled, but there is no doubt that the use of an ultrasound could improve patient care, and no hospital in the US would be considered well equipped without one.  When an ultrasound is performed, the sex of the child is usually withheld from the mother for fear that she may choose to have an abortion based solely on the sex of the fetus.

Urmila and Saguna observe as Dr. Tewari performs an ultrasound in the IPD

At the end of my time observing in the ANC, I was also confronted by the potential dangers of giving birth outside of a hospital, as so many mothers do here in Achham.  One of our mothers, whose care has been funded through the online crowdfunding platform Kangu, came in for her fourth antenatal visit midway through the morning.  She thought all was well and that she would be able to return home, but she was informed that she was already 1.5cm dilated and beginning the process of labor.  Unfortunately, when Urmila completed the exam it became clear that the baby was in a breech position, with its butt coming out first, adding many risks to the delivery.   Luckily, the mother was here at Bayalpata and we were able to admit her, and eventually arrange for her to be transferred to Mangelsen, the nearest district hospital, for a Ceasarean section.  She has yet to leave Bayalpata, but I hope things will work out well.

 

Saguna and Urmala doing the paperwork to have the mother admitted

This story is both heartwarming and frustrating.  I was glad to know that the mother had come in to the hospital instead of experiencing a difficult and potentially lethal breech birth at home.  However, I was also deeply frustrated as this experience highlighted one of the main challenges Nyaya Health has been facing in recent months as we try to implement surgical services (including c-sections) here at Bayalpata for the first time.  We have been well equipped for months, yet every day there is some new barrier to completing a successful surgery.  Today in particular, we had discovered that the auto-clave was not working, and therefore the necessary equipment couldn’t be sterilized.  I look forward to seeing Bayalpata conduct its first successful surgery in the coming months.