Nyaya Health

Posted by Bibhav Acharya

Through our experiences caring for the community in Achham, and through our discussion with the local community and government, it has become clear that all health services cannot simply be centralized at one clinical site. Many patients are carried to Nyaya’s clinics by dozens of family members and neighbors, sometimes rotating in shifts as they move patients on make-shift stretchers across mountainous terrain. Often, sick persons are transferred across hills and valleys for so long that they become septic or otherwise too ill to be helped by clinic staff upon arrival. Furthermore, the prevalence of diseases requiring chronic maintenance, such as HIV and tuberculosis, necessitates interventions to improve adherence to medication regimens. Finally, since we are establishing the first formal, allopathic medical system in the area, patients are understandably uninformed and skeptical about medical care in general.

For all of these reasons, Nyaya Health has initiated a community health worker (CHW) program. This program trains local paramedics in medical triage, transportation of patients to our central clinic, outreach to and education of community members about modern medicine, and provision of home-based care for chronic diseases. We have worked with and trained nine female health workers in the local area. Starting in July, we initiated a pilot project involving four of these workers. These CHWs are women who live in the communities they serve and provide essential care, communicate needs of the community to Nyaya and tell people about services at Nyaya and also identify pregnancies and high-risk cases to refer them to the clinic. Each CHW is covering two village wards that are at least a 2 hour walk from the clinic, and we have selected some of the most populous regions of Achham so each CHW is responsible for about 1500 people. This provides care to a geographically-dispersed population, beyond the 100 patients per day that typically visit the Nyaya clinic.

Currently, CHWs are visiting every household in their target region, introducing themselves as Nyaya’s CHWs, informing patients about the high-quality, free care at Nyaya’s clinic, and conducting a short survey to learn about family profile, death in the last year, health of children and pregnant women and family planning of every family. They are also looking for signs of malnourishment and danger signs and referring patients to the clinic. They are looking for signs of dehydration in children, distributing Oral Rehydrating Salts for free and showing mothers how to safely prepare this life-saving solution. We have generated a schedule to slowly add responsibilities that involve disbursing medicine over time, as the CHW training program expands.

The following story illustrates the utility of this approach. Pavitra Kunwar, a Community Health Worker, found a 73 year old man who was coughing profusely and had severe wasting. He had been in this condition for 4 months as he paid thousands of rupees on checkups and medications from very poorly trained private practitioners with only a few months of training. The entire family was literally waiting for him to die. After Ms. Pavitra convinced the family to bring him to Nyaya’s clinic, they came the next morning. Dr. Thapa diagnosed him with TB and started him on the World Health Organization-recommended treatment program, called directly-observed therapy, short course (DOTS). Since he is very frail, Pavitraji brought the medicine to his home everyday and watched him take it to ensure that he does not become drug-resistant.

Next Steps
CHWs are trained in a stepwise fashion, in which they first are deployed as outreach workers who solely act to recruit and refer patients to the central clinics. Their clinical capacity will gradually grow over time to include adherence support for patients evaluated and followed up at the clinic, and then further increased to include triage and treatment.

Initial Stage: Outreach (Ongoing)
Given that CHWs in the beginning are untrained in medicine, the first step is to help to utilize them as local outreach workers. This serves to familiarize them with working with patients and to develop some rapport and respect within their local communities. The activities at this stage include:

• follow-up of patients treated at the central clinic, encouraging patients treated for pneumonia, abscess, malnutrition, etc. to return to the clinic as requested by the clinical team.
• detection of pregnancy and recruitment of patients to attend antenatal care visits at the clinic.
• detection of malnutrition using a simple survey that includes a color-coded band that measures mid-upper-arm-circumference
• referring of patients to the clinic for vaccination

Note that during this stage, the CHW has only minimal medical skills since all she is doing is encouraging patients to follow up at the clinic. She does need to understand the mission of the clinic and why medical services are important. Though she may not be able to communicate by voice-phone with the clinic, she needs to report to the clinic once a week to update her list of patients and discuss any issues. For many CHWs, this will involve 2-4 hours of walking to reach the central clinic.

Middle-term Stage: Adherence Support (starting November, 2008)
The next stage will involve a slightly higher layering on of clinical capacity that should include some clinical knowledge. The activities at this stage include:

• providing directly observed or modified directly observed therapy for tuberculosis and HIV
• providing weekly follow-up of chronic diseases such as congestive heart failure or COPD
• providing weekly follow-up of antenatal patients for adhering to antenatal vitamins and for screening for complications and any clinical or psychosocial issues

Note that during this stage, the CHW does no independent evaluation or treatment. In all cases, the CHW does the work through simple forms that inquire about issues that would require follow-up at the clinic.

Long-term Stage: Triage and Treatment (starting February, 2008)
This third stage involves the CHW functioning as a true, albeit still limited, paramedic that undertakes the following activities:

• implementation of a basic triage and treatment protocol to manage non-critical issues symptomatically and refer ill patients to the clinic
• performance of the integrated management of childhood illness
• execution of basic first aid in the field
• follow-up of symptomatic postpartum patients
• follow-up of newborns and administration of vaccinations

In this stage, it is critical that the communications infrastructure has been improved to allow for real-time voice discussions between the CHW and the central clinic.

Web materials
CHW wiki page: http://nyayahealth.pbwiki.com/CHWs
CHW registry (English version): http://www.nyayahealth.org/Library/CHWregistry.pdf