Nyaya Health

Posted by Aram Harrow

Running a clinic or a hospital constantly requires large amounts of supplies, from medicine and syringes, to patient registration stationary and generator fuel. Managing these supplies is a crucial, but unglamorous, job. Since supplies of different types are used at very different rates, and often by more than one member of staff, the task of inventory management is difficult to perform without a computer. This post will describe some of the design criteria for inventory systems, the solutions we’ve adopted so far, and some ideas for improving them in the future.

Goals of an inventory system

• Any inventory system should be easy to operate by staff with varying levels of computer skills, and should be easy to maintain by administrators so that the system doesn’t depend on any one person.
• It should be able to summarize stock usage in ways that facilitate both reordering and audits (for example, breaking down costs of drugs by category, or disease category, or prescriber).
• There should be clear protocols and clearly delineated responsibilities for entering transactions into the system. In other words, an inventory system is not only a computer system, but also a management system.
• Where possible, the system should make it difficult to introduce errors, for example by linking inventory transactions to other data being entered.

Our approach
The inventory system we have been using so far (built mostly by volunteer Dr. Aditya Sharma) is for the pharmacy. It is a single Microsoft Access database containing several tables. The two main tables are Items, which contains the inventory, and Transactions, which contains a list of every prescription that has been issued. Some other supporting tables include lists of 1) patients, 2) staff who can issue prescriptions, 3) suppliers, and 4) drug names. These help prevent errors by forcing transactions, such as adding new stock or issuing prescriptions, to correspond to valid drug names, patient identifiers, and so on. Using Access, it is straightforward to automate useful queries, such as listing all of the expired drugs that need to be returned to the supplier, or estimating which drugs will run out in the next three months and need to be reordered.

Some of the entries in our pharmacy supply database.

An important part of keeping the database accurate is controlling who has access to it. Stock is only removed from the pharmacy after our pharmacist, Tara Man Kunwar, enters a transaction in the database. Even when supplies are delivered from the pharmacy to other parts of the hospital (e.g. out-patient department or delivery room), this is recorded as a prescription to the appropriate room. Having one person with primary responsibility helps the system run consistently, and means that not all staff need to be trained on the system.

The interface to the pharmacy inventory used by our pharmacist, Tara Man Kunwar.

Future goals
We plan to soon create similar inventory systems for other consumable supplies used in the laboratory (run by our lab personnel), and for office supplies (run by the hospital administrator). One complication of these systems is that supplies which come from Kathmandu or the U.S. will need to be reordered farther in advance. Also, we would like to link the lab inventory system to the database of lab tests, so that when it is appropriate, entering test results also prompts the user to indicate which lab supplies were consumed by the test.

As our services at Bayalpata Hospital expand, we plan to modify our inventory databases so they remain effective and user-friendly. Such inventory systems, when done well, are time-saving and can help reduce costs by allowing for easier monitoring of our supplies and usage.

Posted by Shefali Oza

A bandh, which literally means “closed”, is a type of strike commonly used in Nepal and other South Asian countries. Such strikes often involve the closing of roads, businesses, and schools and can last anywhere from a day to several weeks. In Nepal, recent bandhs have been called for a variety of reasons, ranging from the political to the personal. Unfortunately, such bandhs can seriously hamper the provision of health services. In this post, we describe some of the major challenges we face during prolonged bandhs.

Shortage of supplies
Since there is only one road to Achham, a bandh along any portion of that road can shut down our supply chain. Most of our pharmaceutical, laboratory, and medical supplies come from Dhangadhi, a relatively large town in the southern region of Far Western Nepal. Unfortunately, bandhs originating in Dhangadhi or between Dhangadhi and Achham are fairly common. Even the few supplies we order from Kathmandu need to go through Dhangadhi to reach us. Therefore, if we do not have a sufficient surplus of supplies, we can quickly run out of essential medicine and lab tests that are critical for our patient services. A recent lengthy bandh, lasting a few weeks, prevented us from receiving any pharmaceutical supplies to our Sanfe Bagar clinic during that time. At Bayalpata Hospital, we will have large storage areas where we can store at least 3 months of supplies, which should help attenuate the effect of the bandhs on our supply chain.

Our supply chain is broken when this single road, which goes for hundreds of kilometers, is closed due to bandhs.

Fuel supply
During serious power outages, we sometimes have to depend on our generator for back-up power. This is especially necessary for lab tests and for emergency patients, such as when the nebulizer is needed for those who have difficulty breathing. However, extensive road closings mean that the local markets have no access to new fuel. During a recent long bandh, only one shop in the market had any fuel remaining, and they were nearly out. At the same time, the main electricity grid had a major glitch. Thus, had the bandh continued for even a couple more days, we would have likely run out of all options for electricity at our clinic.

Food shortage
The hilly district of Achham, where we work, does not produce enough food to be self-sufficient. Thus, food is imported from the southern region of Nepal, which is situated in a flatter area with a warmer climate. Unfortunately, bandhs that block our supply route also block food coming into the district. Thus, prolonged bandhs can lead to food shortages. This is an especially large problem during a year like this one when crop output has been dramatically lower due to drought. Since the single road to Achham ends in Sanfe Bagar and there are no further paved roads, districts to the north suffer even more (as they also produce less than Achham).

Food shortages are a constant concern as the terraced farmland in Achham does not produce enough food.

Travel
The road closings also restrict travel. Bandhs have frequently interrupted travel of our volunteers and staff members. A recent bandh nearly stopped our doctor from returning from Kathmandu, where he was receiving an important government health training. While people sometimes attempt to bypass bandhs, many of these strikes can turn violent quickly. Stories of vehicles being burned for defying a bandh order are not infrequent. Such interruptions in travel require us to be very flexible with our planning, which can be a challenge since each staff member is essential for our services to function properly and many of the international volunteers are on very tight schedules.

Patient travel and referrals
While most patients walk to our clinic, Sanfe Bagar is a hub with a central bus station. Thus, the lack of transportation services reaching Achham during a bandh may result in some patients not coming to our clinic. Similarly, bandhs can greatly restrict our ability to refer patients to other health facilities. While bandh organizers generally allow ambulances through, some recent cases of ambulance burnings have frightened patients. Additionally, we do not yet have an ambulance so our patients, who travel by bus or jeep for distant referrals, have lower chances of passing through a bandh. We are currently working to get a donated ambulance, which should help this situation.

In general, bandhs are a regular part of life in Nepal at this time. Unfortunately, their consequences for health services can be quite serious. As we learn more about the impact bandhs have on our operations, we are trying to put safeguards in place such as maintaining a large surplus of supplies and fuels. However, the possibility of prolonged bandhs is a constant fear because of the disruption they cause.

Posted by Duncan Maru

Operating a professional global health organization on all-volunteer power requires solid management structures. Our donors, our staff, and the communities we serve all demand professionalism. Our purpose in this post is to describe the distinct approach that Nyaya Health has taken to achieve efficiency, professionalism, and reliable results while maintaining the philosophical and economic benefits of a volunteer team. Through the strategies described below, Nyaya Health has been able to quickly build and operate a rural health center in Nepal which treats over 1000 patients per month, employs twenty Nepali healthcare professionals, and is opening the only physician-run hospital for a population spanning over 500,000 people.

We rely on a network of volunteer supporters to generate the financial, material, and technical resources to achieve this, while spending nearly 100% of our funds within Nepal. None of our non-Nepali directors, grant writers, clinical consultants, and fundraisers are paid. We have no office space outside of our health center in Achham. The few expenditures that we make outside Nepal — server fees for our websites, printing costs for grant applications, shipping costs for equipment– are typically paid for by our volunteers. In 2008, in which Nyaya spent $112,805 on operating our health center (click here to view our public access line-by-line-budget), our costs totaled only $266 on equipment shipping, $5000 on processing costs for a newly donated GE ultrasound machine, and $125 on outgoing wire fees.

Go open-source
Transparency is efficient. An all-volunteer organization does not have the time or resources to waste on documents that are hidden behind passwords. The centerpiece of our open-source strategy is the Nyaya Health wiki, on which our staff and volunteers post protocols, data, and program details. Our wiki manager periodically reviews the wiki to ensure quality and consistency. Since the wiki is open-access, we can quickly dialogue with new volunteers and collaborators without worrying about managing extensive user access controls. Furthermore, our volunteers can also be assured and inspired that their work will be available to global health collaborators and practitioners throughout the world.

A snapshot of the budget data page on the Nyaya Health wiki.

Develop rapidly-editable web content
We have aimed to make the Nyaya Health website professional, dynamic, and compelling. Being a critical function of our United States-based operations, it is powered by an all-volunteer team. We use wordpress.org as our content managament system for our website. This allows a select group of non-technical Nyaya members to easily make text edits without requiring any software downloads or particular expertise. Editing is as easy as writing a blog post. This still requires a dedicated webmaster, but empowering a few additional volunteers to make minor text edits can significantly decrease the webmaster’s workload. Since the webmaster has an immensely valuable skill and pro-bono web developers are hard to find, having the webmaster focus on the technical back-end and then utilizing non-technical volunteers for front-end content makes the whole enterprise efficient and feasible.

A snapshot of the Nyaya Health website homepage.

Utilize user-driven materials to drive dynamic homepage content
In addition to our wiki and website, we also maintain an blog, to which any of our volunteers can write posts or put up pictures. The headlines of the blog posts are automatically linked to the website homepage using feedburner and the pictures are linked to a gallery on the homepage using wowzio. This strategy allows us to maintain an up-to-date, engaging homepage without requiring any editing of the page itself. To ensure quality and overall consistency, we have a volunteer blog manager who approves and edits all blog posts.

A snapshot of the Nyaya Health blog.

Construct specific, time-limited deliverables for volunteers
Since our volunteers are busy with multiple competing duties, we try to discretize tasks into manageable chunks to utilize their unique skills. We also electronically sign contracts with all our volunteers. These contracts are available publicly on our wiki. Ultimately, our aim is to maintain a system where we identify the comparative strengths and passions of our different volunteers and focus these into circumscribed, discrete roles.

Utilize a small core of long-term directors to provide sufficient oversight
Although crowd-sourcing of our wiki and utilizing a relatively non-hierarchical volunteer network is an important strategy philosophically and practically, we also need to ensure there is sufficient leadership, oversight, and structure within our organization. Our long-term leaders need to be effective at delegating tasks, at listening to our volunteers, and at fostering creativity. They also need to be able to quickly identify and solve problems when volunteers do not meet their tasks.

Create efficient file sharing strategies for volunteers
We rely on a few different collaborative technologies for file sharing, each one serving a unique purpose. We use Windows Live Sync, a free application, to share our 2000+ organizational files amongst our volunteers. All our agreements, grants, and protocols are available in this shared file cabinet. We additionally use Nyaya Health’s Google Apps account to share collaborative spreadsheets. This is particularly useful for publishing data onto our wiki. We use Evernote for our volunteers in Achham because it is a low-bandwidth program that helps us maintain an institutional memory on-site while allowing us to keep detailed practical information about our various programs, contacts, and plans organized.

A snapshot of the Evernote program Nyaya uses for Achham-based operations management.

Maintain a transparent internal operational structure
We believe it is important for our new volunteers to understand how key organizational priorities are set and critical decisions are made. Nyaya achieves this through several mechanisms. New volunteers join our internal team listserve, over which we discuss new initiatives, work through key problems, and report our failures and successes to each other. Our volunteers have access to all of our internal documents through our internal file sharing system, as well as all the content on our blog and our wiki. All of our organizational emails are kept in a single Google Apps mail archive that is accessible to all of our volunteers.

Deploy a streamlined volunteer application management system
We use Google Apps to efficiently manage volunteer applications we receive. Specifically, we use forms that are completely customizable, which have a professional appearance with an underlying simple and non-technical Google forms architecture. This also increase our management efficiency because we can quickly send templated rejection letters to reduce the inefficiencies of responding to the large number of applicants to whom we cannot provide a position.

Some have recently argued that non-profit organizations must be managed more like for-profit corporations for attention to efficiency and real results. There has, in fact, been a trend among non-profits to recruit executives from the for-profit sector in the hopes of transforming our industry and reducing waste. We certainly welcome such developments, and for many non-profits, professionalizing on the fundraising side indeed makes sense. However, we hope that this post demonstrates a model that can achieve efficiency and accountability while remaining true to the ideals of non-profit work.

Posted by Shefali Oza

For the last two weeks, we have been working on renovating Bayalpata Hospital, which we plan to open early this summer. We requested costing estimates from different contractors to find the most competitive pricing scheme for the phase 1 renovations, which include a main hospital building, a mess hall, and staff quarters for on-call personnel.

In the end we have decided on a renovation model that we believe stays true to the core values of Nyaya – namely providing healthcare to this population while using donor money in the most efficient way possible and, additionally, providing complete transparency of our operations and costs. Instead of renovating the hospital through a contractor, we have decided to independently hire the necessary skilled and unskilled labor and buy the supplies ourselves.

The main clinical building at Bayalpata Hospital before renovation.

We chose to not use an independent contractor for a few reasons. Contractors here serve as middle-men who take a large chunk of the full renovation cost into their own pockets. Due to large levels of corruption, the contractor’s actual costs are rarely, if ever, transparent. By cutting out the contractor, we are able to reduce the cost of the renovation and maintain transparency. This also helps us make sure that our supplies are of good quality since we will be buying them ourselves.

We have spent the last week reviewing recommendations and cost estimates for the different skilled labor required for this phase of our hospital renovations. We will hire the following:

• Carpenter – will repair existing wooden doors and windows and make new ones where necessary.
• Electrician – will repair existing wiring and install new wires, fuses, lights, and fans where necessary.
• Mechanic – will repair existing metal structures for windows and doors, and will pour cement for the septic tanks and other necessary areas.
• Painters – will repaint the interiors and exteriors of the phase 1 buildings.
• Plumber – will install water lines from the central tank near the hospital grounds to the phase 1 buildings. Will also repair and/or install new septic tanks, water tanks, toilets, sinks, and showers.
• Unskilled labor – will help clean the hospital buildings and grounds.

An example of a room in Bayalpata Hospital that we will renovate in the coming weeks.

With this approach, the money for the renovation is spread within the community for labor and supplies instead of a large chunk going into the pockets of a single contractor. The renovation will be more time-intensive for our team since we will now be coordinating it. However, we think this is an ideal way to maintain the quality of the renovations while being fair to the community and our donors. While this decision is context-specific, we hope this blog post may help others in similar situations to think of ways to maximize the reach of donor money while maintaining transparency. Our full renovation costs, along with our other line-by-line expenditures, can be found on our wiki. We will also continue to post more blog entries about our renovation process throughout this coming month.

Posted by Shefali Oza

The district of Achham, where our clinic is based, is currently suffering from one of the most severe power outages in recent memory. In this blog post, we provide an update on how Nyaya Health’s energy systems are functioning and what we do during severe power outages to ensure the best possible patient care.

Nyaya has two backup systems in place for when the external power lines (grid) goes out, which happens fairly regularly. The first is our battery and inverter energy system from Lotus Energy in Kathmandu that we installed at the clinic last fall. After charging the battery for approximately 12 hours, this system can provide power for over 24 hours if we are conservative with our power consumption. In our experience thus far, this system combined with the external grid has usually been enough to provide us with electricity 24 hours per day.

The inverter energy system with battery at our clinic.

However, for more prolonged external grid outages, the inverter battery is unable to charge sufficiently. We then use our 5-kilowatt diesel generator. Given the current severe power outages, we run the generator for approximately 1-2 hours per day, which is enough for lab tests and charging the computers that are needed for patient registration and recording lab and pharmacy data. As an additional backup, we keep paper copies of all the registration and data collection forms. The information from these forms can then be entered into the computer databases once the power is back on. We also turn on the generator temporarily during these severe power outages when an emergency patient comes in needing treatment from medical devices that require electricity, such as a nebulizer.

Our diesel generator.

When the inverter system or generator is turned on, we have developed a protocol to limit the use of equipment that requires lots of power. For example, during these times we do not operate the incubator or autoclave in our lab. We are currently in the process of acquiring a lower-power centrifuge and colorimeter for the lab which will help us reduce our energy needs. The lights and computers have relatively minimal impact on the battery charge or generator fuel consumption as they require little power.

With these backup systems, we have been able to ensure that the clinic has reliable electricity for all but the most severe power outages. The protocol we have developed allows us to maintain patient care while keeping fuel costs at a minimum during the more severe outages when the generator is needed.