Gender roles in Achham are often unequal and disempowering, marginalizing women from opportunities to receive formal education and thus relegating them to dependency on their husbands for income.

One of the most entrenched forms of gender inequality in Achham is that of illiteracy.  The literacy rate amongst young girls aged six to fifteen is only 16% compared to 54% among boys of the same age group. Adult literacy among women in Achham is an appalling 7% compared to 48% among men.  A wealth of epidemiological data throughout the world shows that literacy rates among women correspond to key indicators such as fertility rate, maternal mortality, and infant and child mortality.  The education of women, in brief, helps to drive the health of entire communities.   As healthcare providers and advocates in Achham, we are confronted by this reality on a daily basis.

A 20 year old, pregnant with her first child, has never gone to school. The second of four children, she has an elder brother who studied until 9^th grade and is now sitting at home with his wife, not working. She has two sisters following her. When asked when she got married, she explains that she got married at 17. She wants to study but never got the chance because her brother went to school. She is now working as a health aide and cook — work that her brother, despite his education, is not doing.

Another case: a 24 year old, pregnant with her 4^th child, studied until the 7^th grade. Born in India, she was married at 13. She had her first child at 15. When asked if she wanted to study, she said she had to get married. She now has three girls and is working as a health aide, struggling to teach herself to read Nepali (using the signs and posters on the walls) during her breaks at the hospital. In the rural areas, the literacy rate is very low amongst females. Girls are meant to learn to cook and to help with the farming, and then get married.

Education–symbolized by a professional degree or certificate—is considered a basic right; unfortunately, making it a “right” does not necessarily make it so. In the two instances above, despite only limited formal education, these women have learned—through their own experiences–a different form of education: that of gender inequity and the hierarchical positions that they occupy in society because of these norms. It is important to note that culture, personal views, and decisions will vary for all individuals, and that, indeed, regardless of formal education, many women will take the initiative to learn themselves, following their own principles and morals. That being said, it is also important to recognize the sad, overarching reality that, when women are treated as less than men, when education is given to a man at the expense of a woman’s labor, and when women’s voices are silenced in the wake of a male-dominated society, the future of not only a woman and her children, but that of the whole community, is in great peril. The empowerment and emancipation of a woman is the empowerment and emancipation of her children, and her society as a whole.

Nyaya was recently invited to deliver one of the “Partnerships in Global Health Equity” workshops at the 2010 GlobeMed Summit in Chicago. GlobeMed is a network of university students which partner with grassroots organizations to improve the health of people of the impoverished. This year, their summit featured keynote addresses and workshops by several of Nyaya’s closest friends, including Paul Farmer and Evan Lyon (both from PIH), and Raj Panjabi (Tiyatien Health). From Nyaya, Dan Schwarz presented a workshop entitled “The challenges of transparency, accountability, and collaboration in global health.”

Click here to view the Powerpoint presentation from the workshop

Nyaya would like to thank GlobeMed for its support of our work and we encourage our own supporters to support and contribute to their important work as well. Learn more about them at: http://www.globemed.org/

Nyaya’s work has been featured in an article and photo essay on the Harvard FXB Center’s Health and Human Rights Open Forum blog. Guest-writing for the blog, Dan Schwarz highlights the development of Nyaya’s work at Bayalpata Hospital, and documents many of the logistical challenges involved, in both narrative and photographs.

Read the narrative post and photo essay

Thanks to our colleagues at the Open Forum for their support and publicity! We encourage our supporters to read their blog and forward it to anyone else who may be interested as well.

]]> http://blog.nyayahealth.org/2010/03/06/nyaya-featured-on-harvards-health-and-human-rights-open-forum/feed/ 0 http://blog.nyayahealth.org/2010/03/01/nyaya-awarded-uptodate-grant/ http://blog.nyayahealth.org/2010/03/01/nyaya-awarded-uptodate-grant/#comments Mon, 01 Mar 2010 06:47:44 +0000 admin http://blog.nyayahealth.org/?p=1158 Posted by Dan Schwarz

Nyaya has been awarded one of the first-round

UpToDate International Grant Subscriptions! UpToDate is an online clinical reference software, commonly used in many American teaching hospitals, but rarely accessible in the developing world. Through an exciting new granting program, UpToDate has teamed up with the Global Health Delivery Project to provide free subscriptions to healthcare facilities throughout the developing world.

With access to this new technology, our clinical staff at Bayalpata Hospital in Achham will now be able to reference the most current evidence-based medicine at the click of a button. In addition to informing day-to-day clinical decision making, this will facilitate on-going clinical education (CME)—-translational technology empowering our hospital to not only provide care, but to build local capacity and strengthen the overall health system.

Nyaya would like to express its gratitude to UpToDate and to the Global Health Delivery Project for this award, and to you for continuing to walk with us in our journey for health equity. We will update this blog in the months to come with stories about how UpToDate is helping us to push our vision further.

All countries have different structures of health care staff based based on their particular local government system. We understand that reading Nyaya blog entries which discuss the different staff at Bayalpata Hospital can be confusing for our readers. In this entry we hope to clarify the different roles and qualifications of staff who work in the Nepali health care system.

Nyaya currently employs 1 Accountant/Administrative Assistant, 1 ambulance driver, 5 Auxiliary Nurse Midwives, 4 Community Health Workers, 2 doctors (MBBS), 3 Health Aides, 2 Health Assistants, 1 Lab Assistant, 1 night guard,  2 Office Assistants and 1 Pharmacist.

Don Bogati (left) is the Bayalpata Hospital Outpatient Department Assistant and Hiusan Kamal (right) is the Hospital security guard

We hope the below descriptions will be helpful in understanding how the Bayalpata Hospital runs day to day – it is these staff who make Nyaya’s work possible. You can read more about each of them on our Personnel page here. We have also listed descriptions of other health care positions in the Nepali health care system, including Auxiliary Health Workers, Staff Nurses, and Lab Technicians, however Nyaya does not currently employ any persons in these roles.

The Accountant/Administrative Assistant requires an individual to have a university degree (Bachelor in Business Studies) which is a three year full time course after completing the 12^th grade. This person helps in the logistics and administrative aspects of the hospital, ensuring financial statements are balanced, medicines are properly ordered, and all vouchers are appropriately filed. Furthermore, this person monitors inventory at the hospital and keeps track of the ambulance usage.

(left to right) Kamala Sharma (ANM), Urmila Basnet (ANM), Sangeeta Nepali (ANM) and Rambha Kamal (Health Aide)

The ambulance driver does not require a formal education after the 8^th grade. This role offers critical service to the hospital by driving patients too ill to be cared for at Bayalpata Hospital safely to their referral centers upon the request of the Medical Director.

The Auxiliary Health Worker (AHW) is not a formal academic training. The duration of the course is 1 and a half years after 10^th grade. This role operates in a similar but smaller capacity to that of Health Assistant; AHWs are able to see patients for minor medical conditions, handle prescription medications and function in the health and sub-health posts throughout Nepal.

Auxiliary Nurse Midwives (ANM) function below the role of the Staff Nurse. The course duration is 1 and a ½ years after 10^th grade. ANMs at Bayalpata handle much of the obstetric and maternal care, and act generally as nurses assisting the other health care workers.

Community Health Workers (CHW) are lay-community members who receive training from Nyaya Health. CHWs work in their communities, following up with patients who have been seen at the hospital, providing medication and offering health education.

Doctors – An individual with the Bachelor of Medicine and Bachelor of Surgery (MBBS) is a certified medical doctor which is the equivalent to a Medical Doctor in the USA. This position requires 5 and a ½ year formal academic training after 12^th grade. The role of the doctor is to examine patients, write prescriptions, perform Ultrasounds and carry out minor surgical and obstetric procedures. Nyaya’s two doctors also act to oversee and train other members of the health care team.

Jhapat Thapa (left, Medical Director) and Lal Bahudur Kunwar (right, Health Assistant) tend to Bayalpata Hospital's water reservoirs.

Health Aides have no academic training. Their education is below 10^th grade. Their responsibilities are to assist with the daily logistics of the hospital, including cooking, cleaning, and registering patients.

The training of a Health Assistant is a formal academic training 3 years after 10^th grade. This position is for mid level health care staff who treat common diseases. Their role is to carry out the triage system, write prescriptions and consult doctors for complicated cases.

A Lab Assistant requires usually 1 and a half years after 10^th grade. The responsibility is to conduct and provide lab tests for the hospital. They may work independently or under the supervision of a Lab Technician.

A Lab Technician is a formal academic training 3 years after 10^th grade. The role is to conduct and provide lab tests and has the ability to conduct advanced tests.

Nurses play a very big role in Nepali health care delivery. The position of a Staff Nurse is a formal academic training 3 years after 10^th grade. The role entails providing medication according to prescriptions, conducting deliveries, providing nursing care and consulting the physician when required.

The position of a pharmacist is a 3 year formal training after 10^th grade. The role of the pharmacist is to dispense medicines.

South Asia has no shortage of water stories.  A hydro-electric dam project diverts a sacred river and displaces millions.  The morning hustle at a slum’s communal tap breaks into a fatal fight.  A monsoon rain blesses an inter-caste wedding.  I began asking about Nyaya’s water story when I witnessed our night-watchman Kansa Biswokarma seal our infrastructure’s central pipe with a plastic bag.  What happened?

A precondition for Bayalpata Hospital’s reopening in 2009 was a reliable water supply.  The District Water Office provided funds for the Bhageswar community’s water committee to hook us up to their supply.  The work they were to complete had three components: to build a concrete tank set high enough on the hospital property to provide adequate pressure to the facility’s taps; to dig a well a few kilometers away that would be fed by a mountain spring; and to bury pipe that would carry the well water downhill under farmland and beneath footpaths to fill the hospital’s tank.  They finished the work on time (fifteen days flat) but complaints arose just as fast.  Sections of pipeline spiraled out of the ground, tripping passersby.  Later, the well cracked, pipes burst at their seams, and a farmer tapped into an exposed meter of pipe.  Rumors of corruption started to trickle in.

Our medical director Dr. Jhapat Thapa was thrust into the position of hospital counsel, mediating and interrogating the various parties involved.  The government inspector was called back to justify his approval, formal complaints were registered at the District Water Office, the water committee was asked to account for its expenses.  Though some questions remained unanswered, in the end, the water committee agreed to contribute to periodic repairs that would sustain the hospital until another community water initiative would connect the hospital to a more robust and reliable source of water (currently underway).  For now, it has worked—the pipe mended with twigs, plastic bags, and dozens of store-bought sockets miraculously ensures a steady flow.  If the current ceases, a two-day reserve of water buys enough time to fix it.

Collaborations are never easy and you might wonder why Nyaya didn’t construct on its own.  Nyaya chooses to work with government and community because it believes that such partnerships can strengthen this local infrastructure battered by a decade-long war and improve Nyaya’s relationship with neighbors.  A water committee gathers more experience.  An inspector becomes more conscientious.   We know a few more farmers by name.  Together we will confront the next challenge that our fragile water supply presents.  A question persists, though: How do we make progress without some sense of fairness?

Nyaya operates in Achham in the absence of a robust judicial system.  Access to legal arbitration is poor, courts are often slow, and the human rights abuses witnessed in war have undermined a people’s faith in justice.  Perhaps the first steps toward a reconstruction are taken not on a national stage, but in rural communities that struggle with simple, important matters, like how to share water.  We communicate, we expect each other’s best effort, and we learn how to resolve disputes peacefully and ethically.

Our attempt at holding our partners accountable represents a modest contribution to small-town justice.  We subject ourselves to high standards, too, by inviting the people we serve in Nepal to scrutinize our transparent systems and to judge the quality and equity of our health services.  Nyaya has also considered introducing a more formal mechanism of accountability—in the form of a community oversight board.   This representative entity would guide and evaluate major hospital decisions, liaising with a soon-to-be appointed Nyaya-Nepal Director and Program Coordinator.  The oversight board would also advise our collaborations with local institutions, perhaps obviating the sort of injustice that prompted this post.

A request to readers: In the comments section below, tell a water story or share a resource on water politics in Nepal or elsewhere.  For now, I leave you with Fela Kuti’s ten-minute meditation on the matter, Water Get No Enemy.

The past year was one of great success, and inspiring challenges. We began 2009 in the Sanfe Bagar Primary Health Center, and in June, in partnership with the Nepali Ministry of Health and Population, moved our operations to The Bayalpata Hospital. It has been an exciting transition, and we are honored to be joining in this project with the people of western Nepal.

Today, we are excited to share with you our 2009 Annual Report. We hope you will find it as enjoyable and inspiring as we do — it tells the stories of the people of Achham, of our work with them thus far, and our plans for the future.

Please tell us what you think — as always, we would love to hear from you and deeply value your feedback!

On Thursday, under a banyan tree that has sheltered generations, the village of Ridikot assembled to discuss its annual development goals. Dr. Jhapat Thapa, Nyaya’s Medical Director, was invited to sit with community leaders including representatives of the major political parties, Dalit and women’s rights groups, and the sole member of the Ridikot Village Development Committee (VDC).

Community meetings are a critical part of the local governance. In this picture, Nyaya Co-founders Jason Andrews and Duncan Maru meet with community members to discuss the opening of the first Nyaya clinic (2007).

The VDC system of local governance has crumbled across Nepal under the constant pressure of political turmoil.  For most VDCs, the only position that is filled is the one that the central government salaries—the secretary.  Despite the absence of a formal governing body, here in Ridikot the whole community had gathered.  Teenage boys and girls dressed for the occasion.  Though most young men migrate south for work, their elders were present. Women arrived with notebooks, suckling babies, some with loaded baskets. Toward the end, the community allocated 50,000 rupees to Bayalpata Hospital and pledged to create an emergency fund that would pay for patient transfers from Bayalpata to the district hospital.

Nyaya Health seeks to engage this vibrant civil society in Ridikot and in the many other VDCs in its catchment. Though Nyaya has focused on smoothing its hospital’s basic operations during this inaugural year, a key component of its work in the coming years will be the development of robust community health programs.

I invite you all to offer your thoughts on how Nyaya can fulfill this mission.  Tell a story from your own experience.  Share a link to your community health blog.  Offer a book recommendation on the subject…

I’ll close with my own book recommendation.

Jamkhed: A Comprehensive Rural Health Project

Recently, we asked our friend and colleague, Dr. Subhas Sitaula, to discuss his work and the work of Nyaya, and the interrelated impact of both in the Far Western region where we work.

Biographical background: Dr. Subhas Sitaula is originally from the central region of Nepal, and completed his MBBS from BP Koirala Institute of Health Sciences, Dharan, in 2007. Since then, he has been working for several different public health programs in the Far Western region where Nyaya works. Currently, he works for The Program for Vaccine-Preventable Diseases in the regional “Zero-reporting” campaign investigating reportable diseases such as measles and polio. Through this work, he has travelled extensively throughout the Far West, working with numerous hospitals, health posts, and regional health bodies, thereby giving him an expert public health opinion of the particular needs of the region.

***

Interview with Dr. Subhas Sitaula

Could you please describe your work to us?

I am currently working in the Far Western Region of Nepal for more than two years on the health programs focused on Surveillance, Vaccination and HIV treatment and care programs. In addition to that, I provide technical assistance in immunization programs in the Far West Region. The most prevalent diseases in the region include water-bourne diseases, malnourishment, and HIV.

Could you describe the current status of health services in the Far West, and the degree to which the local peoples can access these services?

In general, there is a lack of access to health services in the Far West because of the geographical remoteness of the region. In comparison to the Terai regions [located to the South of Achham], the upper regions are hilly and mountainous, and far less developed. Because of the overall lack of access to services, patients tend to present to the clinic or hospital later, with more severe and complicated disease, worsening the morbidity and mortality of their illnesses.

In addition, there is an inconsistent supply of well-trained health personnel. Traditional faith healers play a large role in the delivery of care in the Far West. They are often the first outlet for care, especially for the “lowest” Dalit caste who are often the most disadvantaged of the region. When compared to the rest of the population, Dalits have lesser access to health services and worse overall health indicators, such as maternal mortality, immunization rates, and HIV prevalence.

Could you discuss your thoughts on the Bayalpata Hospital, and your thoughts on its future directions?

In my opinion, the strengths of the hospital include the fact that it is run in an evidence-based manner, adhering to universal standard practices. Additionally, the hospital is one of only two hospitals in the area with a consistent presence of trained medical doctors. Its strategic geographic location allows it to serve three to four districts, and the fact that there is free access to care – including medications — increases health equity amongst the poorest.

However, the hospital still lacks both surgical and radiological services, which is a significant weakness. In addition to these, when thinking about expanding the hospital services, the most important services to offer would be complete HIV/AIDS care and comprehensive reproductive health, including obstetrical care. Nyaya can also do better in regards to improving staff compensation, as well as offering more training and exposure opportunities to its staff so as to increase staff education and staff retention.

In terms of obstacles that I foresee for the hospital, I think the two most important ones would be maintaining a trusting relationship with the local people, as well as developing strong community ownership of the hospital and its work.

***

Nyaya appreciates the insight of informed experts such as Dr. Sitaula, and makes a continued effort to solicit input from both health professionals such as himself and also our stakeholders at the community level. In response to concerns such as these, Nyaya has continually revised and further developed its programming, so as to best serve the needs of the people of Achham. In regards to Dr. Sitaula’s comments in particular, we have recently received funding to develop X-ray services at Bayalpata Hospital, and expect these to be operating shortly. The addition of an X-ray will also enable us to become a comprehensive HIV/AIDS-care provider, including the provision of antiretroviral therapy (ART).

Nyaya Health is pleased to announce it has received an anonymous gift of $25,000 to purchase an X-ray machine for Bayalpata Hospital. Nyaya is honored to receive this gift and is excited to offer our patients better care through this program!

X-ray diagnostic services will offer critical support to the clinical team at Bayalpata Hospital. Patients in this photo wait in line to see Nyaya clinicians at the Bayalpata Outpatient Department.

Currently, there is no X-ray machine in the area where Nyaya Health works. The importance of X-ray technology is critical for the diagnosis and management of many diseases and medical emergencies. In Achham, where road traffic accidents and other traumas are frequent, and infectious diseases such as HIV and tuberculosis are prevalent, the addition of an X-ray machine will be critical to improved clinical care at Bayalpata Hospital.

Nyaya will aim to implement X-ray services in the first half of 2010, and scale-up services expanding to a teleradiology program in late 2010 and 2011. We aim to create a model X-Ray program that can be scaled up throughout Nepal and South Asia, and serve as an instructive pilot system for governmental health ministries. The X-Ray program will build upon Nyaya’s existing ultrasound program, which utilizes teleradiology for quality assurance purposes. As our X-ray program expands, Nyaya aims to develop collaborations within Nepal for future telemedicine services in a continued effort to expand capacity within the Nepali healthcare infrastructure.

Nyaya is deeply appreciative of this generous gift and will ensure 100% of it goes to work towards equity in health care in Nepal!

Nyaya volunteer Ranju Sharma recounts a day she spent in the summer of 2009 with two of Nyaya’s CHWs

Achham had recently had the first few rainfalls of this year’s monsoon when we went for a community visit with two of Nyaya Health Community Health Workers (CHWs). The day was not an ideal depiction of a typical day for a CHW. This year, monsoon started late in Achham and following a rainy day, family members of almost every household were out working in the fields. Most of the houses in the villages were empty – we met only a few children and old women at their houses, however we met people from most of the households while they were working in the fields or carrying out their daily chores such as fetching water or washing at the communal water sources, or collecting fodder for their cattle.

Nyaya community health workers provide critical health outreach in the communities surrounding Bayalpata Hospital.

The CHWs said that during monsoon, which is the planting season in Nepal, the families leave home as early as dawn and return after dusk, so it is hard to collect data from every household every visit. Typically, every week the CHWs are responsible for completing a general surveillance of each household in the communities they are assigned to. Each week, they are expected to report data giving a picture of the basic health status of their respective communities.

For general health surveillance, CHWs monitor for illness in their communities, they note the type and duration of sickness, inquire if any medical attention has been given, and encourage ill patients to visit the hospital accordingly. CHWs also monitor pregnancies in the community and ensure that the pregnant women are advised about ANC (Antenatal Checkup) and PNC (Postnatal Checkup) visits. They ensure that the parents are aware of the different immunizations their children require, and encourage them to get their children immunized. CHWs also screen children for the signs of malnutrition and encourage parents to take the child to the hospital when necessary. Other major duties of CHWs is follow up for patients who have been recently seen in the hospital, to check if the patient is taking the medicines correctly, inquire about their continued health status, and collect feedback on the doctor/staff and comments/suggestions for improvement of service provision. For patients with tuberculosis, CHWs also provide DOTS (Directly Observed Treatment Strategy) – the medical treatment process to cure tuberculosis – in their assigned communities. Another major responsibility for Nyaya’s CHW program is the distribution of ORS (Oral Rehydration Solution) packets to patients suffering from diarrhea. ORS is a mixture of salt that helps the body retain water, and can be lifesaving for patients suffering from diarrheal illness. As diarrhea is a common disease in these communities, especially in the monsoon, distribution and teaching of proper utilization of ORS by the CHWs is an effective way to prevent death from dehydration due to diarrhea.

CHWs often distribute oral rehydration solution to combat diarrheal illness in the communities. This woman places ORS in her basket to keep for use at home for her children.

The day of our visit, we visited all the villages that two of our CHWs would normally cover in a week’s time because we aimed to get an overview of how they conducted their work. As all Nyaya CHWs live in or around the communities they work with, every household is well acquainted with their CHW. Upon meeting community members, CHWs conversed informally with them, asking after the health of each person in their household. In some instances, when the CHW knew that the person was ill on their previous visit, they asked if there had been any improvement and if they sought any kind of medical attention in the interim.

During our visit, we came across a few cases of diarrhea, a case of fever, two pregnant women, and a few recent mothers requiring post-natal care visits. Of all the people we met, most had positive responses to CHW services and the potential of using the hospital’s services when necessary. However, others were apathetic to CHW efforts and stated they had no interest in walking a few hours to the hospital when there was no guarantee of them being fully treated. A few older women we met – who were suffering from asthma – complained that the medicine that they were given previously had not worked, so why should they return again? Asthma is one of the most commonly observed diseases in rural Nepal, mainly in the older population, and due in large part to indoor cooking stoves that cause significant air pollution. The commonly prescribed drugs for asthma are administered using inhalers. Inhalers are difficult for many of Nyaya’s patients as the large majority of our population is illiterate – if  they are not properly counseled on the right way to use the inhalers, the drugs aren’t effective at all. The women we met had previously visited Nyaya’s SanfeBagar Clinic (which operated prior to the opening of Bayalpata Hospital), and had received the inhalers there. The CHWs told us it was likely that the women had received no relief from the inhalers because they were using them improperly.

By regularly visiting the homes in their local communities, CHWs develop close relationships to the community and offer Nyaya Health important feedback on community needs, desires and concerns.

Unfortunately, even though the CHWs tried to explain this to the women, and encouraged them to visit the hospital again, they replied they wouldn’t walk so many hours to get medicine that might not work again. Instead, they suggested the CHWs bring them the medicine. This suggestion was quite common as it meant the patient wouldn’t have to travel themselves to the hospital. However, as CHWs are not trained health professionals, they are unable to distribute medications in the community. The role of the CHW is instead to ensure that medications are being used in an effective manner, and to refer patients to the hospital in the case that further medication is required. Some community members understand this limitation of the CHWs, however it can be extremely difficult to make others understand why distributing medications is not as simple as distributing ORS (which has no side effects or danger of overdose). Following this visit, the CHWs were trained on the usage of inhalers so that they could properly counsel asthmatic patients in their community.

Nyaya CHWs come to Bayalpata weekly to report their week's work, offer community feedback for ongoing services, and receive further training.

Nyaya’s CHWs are a means of outreach to the community served by Bayalpata hospital. They act as a bridge connecting Nyaya Health to the community; CHWs both monitor their communities for health problems, and also teach their fellow community members about the health services available to them. It has been a little more than a year since the Nyaya CHW program began. Even in this short time period, the CHW program has played an important role in ensuring effective usage of Nyaya Health’s services. However, there are still great challenges to overcome, many lessons to be learned and vast possibilities of improvement and modification. As Nyaya grows, and expands our services, our CHWs will be a critical component in ensuring our programs are rooted in the community, and responsive to their needs.

At this time of great crisis, Nyaya Health would like to express its solidarity with the people of Haiti, and the various NGOs and governments who are currently working in these crucial hours in the rescue and relief operations. We hope that our supporters will contribute to these efforts, either by making a financial donation or otherwise, in whatever way you are able to.

In particular, we would like to highlight the work of Partners In Health, who have been a model for Nyaya, and continue to be an inspiration for our work in Nepal. PIH is currently at the forefront of the rescue and relief operations in both Port Au Prince (near the epicenter of the earthquake) and also in the Central Plateau where their work is based. Please consider making a donation to support this important work.

We thank you for your continued support, and will continue to work for equity for all — from Nepal to Haiti.

]]> http://blog.nyayahealth.org/2010/01/14/in-solidarity-earthquake-crisis-in-haiti/feed/ 1 http://blog.nyayahealth.org/2010/01/14/medgadget/ http://blog.nyayahealth.org/2010/01/14/medgadget/#comments Thu, 14 Jan 2010 06:14:05 +0000 admin http://blog.nyayahealth.org/?p=1071 Posted by Duncan Maru

Nyaya Health Blog was recently nominated for medgadget.com’s 2009 Best Medical Weblog competition.

To our writers and readers: thank you for your continued support and solidarity!  Please help support us by making sure to cast your comments about our blog prior to the January 24 deadline.

For Nyaya Health, a steady water supply is essential for delivering health care services at Bayalpata Hospital. Ridikot, the village development committee (VDC) where Bayalpata Hospital is located, is an especially dry VDC with limited water supply. Communities surrounding Bayalpata Hospital – and even most of the district of Achham – do not have running water. Instead, people rely on communal taps or natural water springs – muhan in Nepali – for their family’s water supply. However, access to these sources of water is sometimes difficult and burdensome. While water from muhan is used for general domestic purposes, most people depend on the seasonal monsoon rains for agriculture. During the dry season, people plant crops that do not require much water or the fields are left empty.

Bayalpata Hospital’s water is supplied from a natural spring in the neighboring Bhageshwor – a relatively water-rich VDC. A 5-6 km long pipe supplies water to a central tank where it is then pumped to the hospital storage unit. The black polyurethane pipe – originating from the hilltop spring – runs alongside anything from roads and houses to rice paddies and cliffs before reaching Bayalpata Hospital.

Bayalpata Hospital's water supply faces many challenges due to the lack of local running water, and the rough terrain the pipe must traverse

However, maintaining this supply has many challenges. This past summer was especially dry (see blog The Danger of Delayed Monsoon Rains by Ranju Sharma about the affects of delayed monsoon on Achhami agriculture) and Achham, much like other regions in Nepal, experienced a late monsoon. During the dry summer, hospital staff experienced situations where the pipes were cut in multiple locations to divert water to local communities. This significantly impacted daily operations at the hospital and at one point the staff had to shut off the water supply to all other buildings to maintain a sufficient level for the main clinical building that houses the emergency room and the inpatient/outpatient departments. Floods and landslides were also frequent due to heavy rains in the late monsoon, and these natural disasters have also disrupted Nyaya’s water supply. The staff experienced many cases where the pipe was ripped or snapped due to the impact of falling rocks. In some regions where a landslide had occurred, the pipe was exposed and further damaged by the falling mud and boulders.

Water supply will play a critical role in the expansion of Bayalpata Hospital. Nyaya’s water supply for the hospital was established from a partnership between Bayalpata Hospital and the surrounding communities. Since Ridikot is an especially dry VDC, Nyaya Health has

constructed a public tap for general water use. Bayalpata hospital also lies along the walking route from Sanfe Bagar, a major transportation hub, and Mangalsen, Achham’s district headquarters. The public water tap has also served many travelers who frequent this route by foot.

Currently, community members from surrounding VDCs help Bayalpata Hospital maintain its water supply. Members inform hospital staff of any leakage or pipe damage. Another neighboring VDC – Janalikot – has also agreed to supply water to Bayalpata Hospital.

Nyaya Health staff members must fix the water pipe regularly to ensure proper water supply at the hospital

Constant monitoring and maintenance is required to maintain a continuous supply of water and this undertaking must be a partnership between the community and the hospital. As Nyaya Health continues its operations at Bayalpata, and plans for future expansion, its strong relationship with the local communities will be critical to maintaining such services as water supply.

As a Nyaya volunteer, my recent travel to Bayalpata Hosptial was delayed by a week due to national and regional strikes called by the various political parties. The political situation in Nepal is in constant flux, and these strikes – typically in the form of road blockades and business closures, and more commonly referred to as bandhs – have become a common occurrence in the lives of Nepalis. During bandhs, everything from schools to public transportation to shops are closed, completing halting daily life. The last bandh lasted for more than a week in Dhangadi, a major city in southern Nepal that serves as the entry point and distributor of food and other supplies for many surrounding districts. Achham (where Nyaya works) and its neighboring districts get the majority of their supplies from Dhangadi.

Recent protests in Kathmandu. Protests and bandhs throughout the country can have significant impact upon business and transport, limiting resources even for hospitals.

I was traveling to Achham with medical and food supplies for Bayalpata Hospital via Dhangadi. I began my journey in Kathmandu but my trip to Dhangadi had already been delayed due to another nation-wide three-day bandh. After my arrival, I was told that the regional district bandh had been called for an indefinite amount of time and that my departure for Bayalpata Hospital would be furthered delayed for an unknown period of time. Locals informed me that multiple meetings had taken place between the political parties but no agreement had been reached. Dhangadi, usually a bustling business center, was now a quiet town with shuttered shops. Large rocks and burnt tires – typical elements of bandhs – lined the streets blocking all vehicular movement. Lorries packed with supplies for northern districts were parked alongside the roads waiting. The bus station was filled with stranded passengers hoping for a political agreement.

After three days, the bandh in Dhangadi was lifted. It was during my ride from Dhangadi to Achham that I witnessed the effects of the weeklong bandh. Food and supplies in the stores alongside the highway had run out. While stopping for lunch, the shopkeeper informed me that he had run out of vegetables and other items since they are normally sent from Dhangadi. Similarly, the surrounding shopkeepers were eagerly waiting for the arrival of supplies. The bandh had also affected Nyaya’s team at Bayalpata Hospital. Hospital supplies, especially lab test kits and kitchen supplies, were running very low while some items had already run out. Our biochemical blood analyzer, used daily for investigations, was in need of a software upgrade. Without the upgrade, the machine could no longer function. Our clinical team went 3 days without the i-stat analyzer since I was carrying the upgrade package and my arrival was delayed due to the bandh.

Bandhs are so common throughout Nepal that the website NepalBandh.com documents known scheduled bandhs for the public to plan their lives around.

Currently, there is news about future potential bandhs. A sense of uncertainty about whether tomorrow is a bandh is always present, and with it, an uncertainty of what supplies, food or basic materials will be available. For Nyaya Health, bandhs pose a significant challenge as we rely on shipments from Dhangadi to operate a hospital in a very resource-poor region. As more bandhs are certain in the immediate future, Nyaya Health works to maintain its medical and pharmaceutical supplies so that clinical service at Bayalpata Hospital is not compromised.