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Posted by Jesse Brady

As the death toll rises following last Sunday’s earthquake in India and Nepal, the Nyaya Health team sends encouragement to all those affected by the disaster.  During the years since its establishment, Nyaya has assisted those affected by landslides, earthquakes, and other natural phenomena.  Such events have not only taken numerous Achhami lives, but have also affected operations at Bayalpata Hospital by impeding transportation and medical supply chains.

As we move forward following this tragic event, we at Nyaya Health will continue to uphold the Nepali government’s work to improve infrastructure and emergency preparedness.  Through systems-building and collaborative approaches, it may be possible to minimize the damage and injury caused by future natural disasters.

This map shows the epicenter of the September 18, 2011 earthquake that impacted residents of India and Nepal.*

*Image from MSNBC

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Jesse Brady is the Blog Editor of Nyaya Health and is currently pursuing her MS in International Medicine at Montana State University.

Posted by Astha Ramaiya

Two women carrying harvested mustard greens through a local field. Women in Achham are the primary agricultural workers, due to the migration of men to India for seasonal employment.

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Astha Ramaiya is the Blog Manager for Nyaya Health and a student pursuing her MSc Public Health at the London School of Hygiene and Tropical Medicine

Posted by Jason Andrews

Nyaya Health is pleased to be a signatory of the NGO Code of Conduct for Health Systems Strengthening.  This code was promulgated by several notable nongovernmental organizations (NGOs) to guide organizations to “limit their harmful effects and maximize their contributions to strengthening public health systems.”  Our team at Nyaya Health has a long-standing set of values and principles that have guided our work in rural Nepal, and we were delighted to see many of these principles discussed in the code.  For example, we have maintained a firm commitment to our partnership with the government of Nepal for all of our programs, despite political turmoil during Nepal’s democratic transition.  This has become a core aspect of our organizational values and identity.  The Code similarly enumerates principles by which NGOs should act to support Ministries of Health and promote the public sector, both as partners and advocates.  The Code also contains important guidance on hiring practices, employee compensation, and human resources training, to ensure that NGOs contribute to building human resource capacity within countries.

However, one topic that is absent from the NGO Code of Conduct is the importance of transparency, which has been an emphasis of our work.  There is little guidance in codes, written or unwritten, on how NGOs should conduct themselves with regards to the transparency of their operations.  It may seem obvious that work that not only relies heavily on public financing, but is also carried out in collaboration with the public sector, should be highly transparent.  However, the 2008 Global Accountability Report revealed that nearly all major NGOs perform extremely poorly on this metric, with most ranking lower than private, for profit corporations.  We believe that more attention is needed on this issue, including standards and guidance for practices relating to transparency.

Nevertheless, we believe that the NGO Code of Conduct contains an important, core set of principles and guidelines for organizations working to strengthen public health systems throughout the world.

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Jason Andrews, MD is the co-founder and Chief Medical Officer of Nyaya Health.  He is currently a fellow in the Division of Infectious Diseases at Massachusetts General Hospital.

Posted by Jason Andrews

Once every five years, a trove of data on the state of Nepal’s population health is released, often to very little fanfare.  Each of the national dailies picks a key statistic or two to point out whether the country is ahead or behind target on a select Millennium Development Goal.  For those interested in tracking the progress of health status and health systems of the country, this rich data tells stories of progress and of stagnation, of narrowing global gaps and of persistent internal inequities.  This month, the preliminary report of the 2011 Nepal Demographic and Health Survey (DHS) was released.  A nationally representative, cross-sectional survey of 10,826 households, the DHS is a standardized survey that facilitates analysis of trends over time as well as cross-country comparisons.  The final report will present disaggregated data on a number of key indicators that reflect the health of the population and the successes and failures in health-related development since 2006.  The key findings in the 2011 Nepal survey include the following:

1.  Steady decline in fertility rates. In 1996, the fertility rate was 4.6 births per woman.  By 2006, this had fallen to 3.1, and the current estimate is 2.6. However, the rate among women living in rural areas (2.8) is markedly higher than that among women living in urban areas (1.6).  Use of contraception has risen from 26% to 43% and is 24% higher in women living in urban areas as compared with women in rural areas.
2.  Moderate improvements in women’s health.  Substantial gains were seen in this area, but Nepal still ranks poorly in global comparison.  88% of women in rural areas and 55% of women in urban areas had at least one antenatal care (ANC) visit (the WHO recommends 4 visits for women whose pregnancies are progressing normally).  The proportion of births attended by a skilled provider has risen from 19% to 36% over the past five years, nearly doubling. However, almost 2/3 of women still deliver without skilled attendants and only 28% of women delivered in a health facility during this time span.  The rural-urban disparities are striking for these figures: 55% (urban) vs. 25% (rural) delivered at a health facility, 73% (urban) versus 32% (rural) had a skilled provider present at delivery.

3.  Very modest improvements in child health.  Mortality of children under 5 dropped from 61 to 54 per 1,000 since the last survey, while infant mortality scarcely changed (48 to 46 per 1,000), and neonatal mortality remained flat at 33 per 1,000.  Stunting (defined as height-for-age more than 2 standard deviations below a healthy reference population) fell form 49% to 41% of children, and wasting (low weight-for-height) dipped slightly from 13% to 11%, which is the same level it was measured at in 2001.  Acute malnutrition, or wasting, remains a significant problem, particularly in rural areas and for children of women without formal education (13% compared with 7% among women with secondary school education or above).

Overall, the preliminary DHS report paints a picture of moderate gains in maternal health and modest gains in child health, amidst persistent inequalities between urban and rural areas.  When the full report is accessible, and more disaggregated data is available on outcomes by income and region, we will be able to gain a clearer picture of these disparities.  It will also contain more detailed data on health-seeking behavior, family planning, environmental health, domestic violence, and other key health issues.  These data will help policy makers and practitioners identify and celebrate areas of progress, while also taking heed of major disparities between national figures and global ones, and between populations within Nepal.  Ultimately, none of the statistics in this report illustrate adequate or acceptable levels for the health status of the nation.  We at Nyaya Health will continue to work with our colleagues to address these inequities.

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Jason Andrews, MD is the co-founder and Chief Medical Officer of Nyaya Health.  He is currently a fellow in the Division of Infectious Diseases at Massachusetts General Hospital.

Posted by Duncan Maru

I have recently written about the problems we have had in getting consistent, high-quality data from Achham.  I will not re-hash here the logistical problems we have had in getting data, but suffice it to say that, despite being an organization populated by a solid number of very data-minded individuals, a somewhat self-adulatory manifesto on “Global Health Delivery 2.0” published in a premier medical journal, and a clear mission statement on this, we have gone months without any real data.  Again, transparency is all about implementation, and implementation is hard.

 I am pleased to report that our data program is back and running, and you can see some re-vamped data on our wiki, owing to the heroic efforts of staff and volunteers such as Deepak Bista, Jen Garnett, Dan Schwarz, and Dr. Aditya Sharma, and others.    The challenge will be to sustain the data flows from achham to the wiki.

 These data, in the form of tables and charts and graphs, start to get at the accessibility component of transparency, in that they can summarize our services.  But what of our impact?  That is the next, central question of data transparency.  The Givewell folks catalyzed some thinking for us on this, pushing us, as any good foundation or donor should, to do better.  We put together an impact evaluation sheet to at least outline an approach, which is available via a dropbox link on the wiki.

 We outline the problem as follows:

“Nyaya Health has a broad impact on health in Achham.  Some of our non-quantifiable impacts may indeed be our most profound.  The purpose of this document is to focus on those impacts that are specifically quantifiable.  As with any endeavor that involves data and analysis, there are uncertainties.  The true impact of an action can only be estimated in statistical terms.  This is true even in medicine where the outcome appears straightforward.  As one example, take the case of a child who presents with a ruptured appendix.  Mortality approaches 100% in cases of untreated ruptured appendicitis.  A surgeon removes the appendix, washes the abdominal cavity, and provides intravenous fluids and antibiotics.  The child survives without any disability.  Even here, the impact of the intervention is not 100% clear.  Firstly, human biological phenomena are always characterized by some form of bell curve or otherwise non-linear function.   Secondly, medical science’s ability to capture any single individual’s biology is incomplete.  Perhaps this child was at the tail end of the bell curve and could survive with antibiotics and fluids.  Furthermore, all surgeries carry some small chance of morbidity; even if that morbidity did not evidently occur, the very act of placing the child at risk was a cost.  So, in the uncertain worlds of medicine, public health, and human societies, one can never save a life with 100% certainty.  If a health system performs 1000 appendectomies for ruptured appendicitis, the statistical distribution estimating the number of lives saved will be less than 1000. This problem is compounded when outcomes are more difficult to measure, diagnoses are less clear, and data are incomplete.

As of March 2011, Nyaya Health had provided care to over 60,000 patients.  There is no question that this has had a large impact on the communities in which we work.  Our mission indeed is horizontal—that is, we aim to have a population-wide impact by constructing health systems rather than achieving disease-specific outcomes alone. Quantifying the impact at a population level, however, is more difficult.  For quantitative evaluation, we must take a vertical approach, where we study the impact of our work on specific conditions.  We choose to focus our initial evaluation efforts on the following domains:

  • Maternal Mortality
  • Neonatal Mortality
  • Pediatric Diarrheal Diseases
  • Pediatric Acute Respiratory Tract Infections
  • Pediatric Malnutrition
  • HIV
  • Tuberculosis”

The following table summarizes our framework.  I’ll refer the reader to the actual document for more details.  The framework is very simple, but getting the data inputs is by no means easy.  The biggest bottleneck is identifying the base case, as we describe in the text:

“For example, our pneumonia patients may do excellent, but there is uncertainty in what the marginal impact of our intervention is.  Even in a rural area with few if any professional healthcare providers, patients with community acquired pneumonia may do relatively well, since antibiotics are readily available and dispensed, even if oftentimes inappropriately.   That is, a base case of community “standard of care” needs to be established, but that can be extremely challenging where traditional/lay providers do not keep records.”

Over the coming years, as our community health worker program continues to expand, we will do a better job of assessing that base case, and be better able to quantify our real impact.  That, we hope, will get us to a point of understanding our outcomes that our patients, our staff, our volunteers, and our supporters, truly deserve.

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Posted by Gregory Karelas

Landslide blocking a road in Achham

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Gregory Karelas is the country director of Nyaya Health. He has graduated with a MSc in Medical Anthropology. 

Posted by Andy Moon 

In May 2011, Duncan reflected on the current state of Nyaya’s energy system, which has miraculously been able to provide enough electricity for our medical operations despite broken equipment, dead batteries, and stray wires.  Nyaya Health is pleased to announce a huge step forward in our quest for clean, reliable energy – we have successfully installed a 3.33kWp solar system at Bayalpata Hospital.  We hope that this milestone represents the beginning of a much larger solar energy system.

Solar energy systems are ideal for rural settings because they do not require expensive and unpredictable fuel deliveries, they are easier to maintain than traditional power generators, and the equipment lasts up to 25 years.  However, the track record of rural solar systems has been mixed – in some cases, improperly maintained systems have delivered far less energy than expected.

In light of these challenges, Nyaya Health opted to start with a 3.33kWp “pilot” solar system.   Our team will be closely monitoring the system, with bi-weekly maintenance reports from Bayalpata Hospital staff, to make sure energy is being delivered and batteries are being well maintained.  After 3-6 months of successful performance, we will begin planning the next phase of solar energy, which we hope will provide a significant amount of the energy for Nyaya’s medical and surgical operations.

So what exactly was installed in our new solar energy system?

  • 18 solar panels: solar panels were mounted to the roof of Bayalpata Hospital.  These panels collect energy directly from the sun and convert them to electricity
  • 24 battery units: electricity generated by the solar system is sent to the battery system for storage
  • Wiring  / inverter: electricity produced by the solar panels and sent to the batteries is DC electricity.[1]  Since electronics and appliances run on AC electricity,[2] the DC electricity is sent through an inverter which converts the energy to AC which can be used inside Bayalpata Hospital
  • Other electronics: a voltage stabilizer and charge controller[3] were installed to regulate the flow and voltage of energy, maximizing power output and battery life

Solar panels

Solar energy will be used to power a variety of devices at Bayalpata Hospital:

  • Medical equipment (3 oxygen concentrators, 2 nebulizers, 2 vital machines and a QBC machine)
  • Lighting (22 lighting units)
  • Computer equipment (Internet connection and router, 5 computers and 1 printer)
  • Other appliances (1 microscope, 1 refrigerator)

The price tag for the current system was approximately $24,000, and funding and technical support for this project came from a diverse group of individuals and organizations.   The Alternative Energy Promotion Centre (AEPC) of the Nepali government provided a generous subsidy, and donations from the MEMC Foundation and Youth for Nepal provided the balance of the project funding.  Gham Powerled the installation and will provide ongoing maintenance, and a

Battery units

team of engineers from SunEdison Solar (USA) provided technical assistance and will be helping us independently monitor how the system is performing.

Today’s solar system is the first step towards a Balaypata Hospital that has access to clean, reliable energy.  We look forward to sharing our progress with you, and will write about lessons learned from our “pilot” system in a future post.  Details of the installation can be found here.

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Andy Moon, previously Senior Manager of Product Development and Finance at SunEdison Solar, founded the Rural Electrification Initiative at SunEdison and works with Nyaya Health on energy issues and grants

 



[1] DC, or direct current, is the type of electricity generated from solar panels, and is used to charge batteries

[2] AC, or alternating current, is used in the vast majority of electronics and appliances.   Therefore, electricity from solar panels or a battery must be converted from DC to AC electricity using an inverter

[3] A voltage stabilizer ensures that the proper level of voltage is being supplied.  A charge controller regulates the flow of energy to batteries, preventing battery overcharging (a major cause of shortened battery life)

Posted by Pritam Shah

I vividly remember the days when I used to walk past Bayalpata Hospital with wild bushes, ruined old buildings, and a herd of grazing cattle. I now contemplate on those memories when I recently visited Bayalpata Hospital. The hospital has transformed into a fully running hospital with landscaped grounds, painted buildings and a patients either waiting in the OPD for a doctor or the pharmacy for medication. Here I update for you a slideshow of the hospital:

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Pritam Shah was born and brought up in Achham. He is a volunteer with Nyaya Health and currently pursuing his Bachelors at Bremen University

Posted by Astha Ramaiya

Confidentiality and Hippocratic Oath state that a doctor should do no harm and keep all patient information a secret. This oath has been followed since the dawn of medicine. However, working in the field of reproductive health and infectious diseases, I regularly question if this law holds true when your disclosure is in question.

Let’s presume a migrant worker from Mumbai enters into the clinic and complains of chronic cough, night fevers, significant weight loss and diarrhea. You take his sputum for a TB test and venous blood for a HIV test. Both results come back positive. You offer counseling and explain to him to bring his wife for further explanation. He refuses and says he doesn’t want to disclose. According to Hippocratic Oath, the results of the test will stay confidential between you and the patient. Although disclosure to partner is recommended, it is not a necessity.

Now, let’s try and picture this from a woman’s perspective in terms of gender roles and social support required. Working in Tanzania with HIV positive mothers and their infants, facilitated disclosure has been brought up multiple times to prevent mother to child transmission and ensure there is a social support in the community. Until now, facilitated disclosure has primarily been between a husband and wife. An article from Nepal outlines the gap in facilitated disclosure in Achham. This gap has led to an increase in infections amongst vulnerable populations, in this case migrant workers. Achham being one of the poorest regions, experiences a lot of migration to India particularly amongst men. These men work for years without seeing their families in an attempt to support their family.

Going back to our initial question, if it is the man’s responsibility to support the family, shouldn’t it be his responsibility to disclose his status if he knows he is infected? Many arguments can be made to and fro. Both in Tanzania and in Nepal, it is considered an honour to give birth to a son. This honour leads to a stereotype where all men should be respected. Women should not look up or speak against her husband or partner. If the husband doesn’t want to disclose his status it is okay, but his wife should keep him satisfied and happy. However, when the wife is illiterate and is dependent on her husband, does she have a right to know? What are her rights and how can she protect herself?

Currently, she has no way. In an era where billions have been invested into HIV/AIDS, we still ask the question, whose responsibility is it to inform the woman that her partner is infected? Is it her partner’s, her partner’s family or the doctors? How does she prevent herself and her child from being infected?

I answer the questions myself. Every individual has a right to keep information to themselves even if they are infected. However I also argue that to decrease the spread of communicable diseases and attain the WHO definition of health, there is a need to promote disclosure within partners and families to protect and decrease incidence, mortality and morbidity linked with a disease.

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Astha Ramaiya is the Blog Manager for Nyaya Health and a student pursuing her MSc Public Health at the London School of Hygiene and Tropical Medicine

 

Posted by Gregory Karelas

Auspicious signs for the year ahead...view of the surrounding hills from Bayalpata Hospital

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Gregory Karelas is the country director of Nyaya Health. He has graduated with a MSc in Medical Anthropology. 

We are recruiting a full time Research Coordinator (RC) to oversee a program of hospital and community-based research in Achham, Far Western Nepal. This research program will complement the service and advocacy of international NGO Nyaya Health. The RC will be responsible for management of research projects, coordination with hospital and community health staff, and communication with investigators, who are based at Harvard Medical School (Boston, USA). The RC will report directly to the Principal Investigator. Onsite in Achham, the RC will work closely with the Nyaya Health Country Director, Director of Community Health, Hospital Administrator and clinical staff on research pertaining to epidemiology and implementation of health services in rural and resource-poor settings. The candidate should be prepared for the challenges and rewards of working in a remote, underdeveloped setting, while also spearheading a research program in a young and dynamic non-profit organization. The application for the RC can be accessed here.
The Assistant to the Country Director will report to the Country Director and participate in developing Bayalpata Hospital and community health operations. The position will include elements of project planning and oversight, financial management, and community, partner and international staff communications. This is a full-time position based in Achham, Nepal with specifications and application accessible here.

Posted by Duncan Maru

In a speech recently on his government’s funding of the Global Alliance for Vaccine and Immunizations, British Prime Minister David Cameron’s delivered some welcome statements about the importance of transparency in global development aid [1].   Notably, all recipients of British foreign aid “must publish what they do, where they get their money and where it goes”.  Such leadership is timely in light of the recent corruption scandal in which millions of dollars were stolen from the Global Fund’s coffers in Mali, and the Global Fund’s subsequent soul searching about what to do about their own transparency initiatives [2,3].

I’m wondering, however, whether he and others are missing a broader point about the role of transparency in fostering integrity and honesty in global development operations.  Transparency is a more profound notion than a shared set of data outputs, and one that cuts deeply into how organizations work.  While publishing open-access data is a tremendous step forward, it is but a small step towards improving the field of global development.

I am writing from the perspective of the President of a small international non-profit organization, Nyaya Health. We provide the only physician-run health services for a large population in remote rural Nepal that lacks legal, social, or economic mechanisms to hold our work accountable.  Our donors rarely can make the 3-4 day one-way trip to our site.  The government, who owns our hospital and is our primary partner in our work, is stretched too thin and seated two days away in Kathmandu.  In such an environment, effective transparency mechanisms are not only about efficient resource allocation; as Global Fund head Micheal Kazatchkine articulated, “transparency saves lives” [4].   If one of our patients dies owing to our mistake, we and the government suffer little consequence and may not change our practices.  In the short-term, from a systems-level, the only safeguard protecting our patients from abuse is our own integrity.  Integrity perhaps is a very local and individual characteristic, but it is one, I believe, that can be fostered by more bold international standards on transparency.

The forum that the British government has decided upon for mandated publishing among its aid recipients is the International Aid Transparency Initiative (IATI) [5].  This was an excellent move.  The aid community needs a set of standards and shared language for reporting inputs and outputs, and IATI provides an appropriate and well-reasoned mechanism.  In a certain sense, however, IATI is misnamed.  Its reporting mechanism is largely about accountability rather than transparency.  Accountability asks the question of practitioners: how well did you do and what did you spend to get there, so I can evaluate your value, your cost-benefit ratio, and decide whether to fund you or not?  This is hugely valuable.  Transparency, however, poses a different question: how do you actually operate on a day-by-day basis?  It is the means rather than the ends.

This is an important distinction because IATI will not prevent the kinds of frauds and abuses that happened in Mali.  The Mali crime, and other corruption cases, is the result of systemic practices within organizations.  If we only compel practitioners to publish budgets and outcomes, we miss an opportunity to building integrity within organizations.

So, how do we implement transparency as a process of our operations and not merely an output?   The answer is obvious, though the logistics of doing so are extremely challenging: open up our operations to the public.  The fact that so much gets done and documented electronically, even in resource-denied settings, presents a tremendous opportunity for practitioners to open up.  Our organization has taken a somewhat extreme position: we are starting to publish many of our emails (see, for example [6,7]), our errors and deaths [8-10], our protocols [11], our outcomes data [12] and line-by-line budgets [13] on a monthly basis, and our organizational documents [14].  Where, for confidentiality reasons, we need to keep documents private, we state so [15].  This is an active work-in-progress for us [16], and it remains to be seen whether we actually will become a better organization because of it.  I am not presenting this to boast, but rather to present one organization’s attempt to inculcate a greater sense of openness and integrity within our team and our operations.  It certainly is a leap going from a series of public electronic documents to improved operations.  After all, for a healthcare organization, the bottom line is whether dignified and effective care is provided, and that occurs in private interactions between clinicians and their patients.

I’m also not saying that most donors are going to care to read our emails, our protocols, or our line-by-line budgets, or even that evaluating our work can be efficiently achieved through those means.  Most donors will be rightfully interested in the bottom-line, and that is well represented by the IATI standards.  But the fact that an organization’s ongoing work are publicly available, in real-time, and that built into basic organizational operations is a mechanism and strategy of openness, can go a long ways towards building a culture of transparency and integrity.  That, of course, is an empirical hypothesis, but one that I think the development community needs to be considering.  At this critical juncture in the history of global development, with so many resources, so many new ideas and opportunity, yet so many risks, we cannot risk inaction or business-as-usual.

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REFERENCES

1. Cameron D. Speech at Vaccine Summit.  2011. [accessed 2011]. Available from: http://www.number10.gov.uk/news/speeches-and-transcripts/2011/06/speech-at-vaccine-summit-64686

2. Malian ex-minister indicted over misuse of aid.  2011. [accessed 2011]. Available from: http://af.reuters.com/article/maliNews/idAFLDE7520V420110603

3. Associated Press. Global Fund rethinks transparency.  2011. [accessed 2011]. Available from: http://www.mail.com/int/scitech/health/406284-ap-exclusive-global-fund-rethinks-transparency.html

4. Kazatchkine M. Transparency Saves Lives.  2011. [accessed 2011]. Available from: http://www.huffingtonpost.com/michel-d-kazatchkine/transparency-saves-lives_b_871073.html

5. Development Initiatives. Implementing-IATI: Practical Proposals.  2011. [accessed 2011]. Available from: http://www.aidtransparency.net/wp-content/uploads/2009/06/Implementing-IATI-Jan-2010-v2.pdf

6. Nyaya Health. Nyaya Health Internal Team List Archive.  2011. [accessed 2011]. Available from: http://nyayateam.blogspot.com/

7. Nyaya Health. Nyaya Health Website Development Email Archive.  2011. [accessed 2011]. Available from: http://groups.google.com/a/nyayahealth.org/group/website/topics?pli=1

8. Maru D. Nyaya Health’s Mortality Review Program.  2009. [accessed 2010]. Available from: http://blog.nyayahealth.org/2009/10/29/mortalityreview/

9. Nyaya Health. Nyaya Health Wiki Mortality Data Page.  2011. [accessed 2011]. Available from: http://wiki.nyayahealth.org/w/page/4682721/MortalityData

10. Nyaya Health. Nyaya Health Blog Mortality Review Series.  2011. [accessed 2011]. Available from: http://blog.nyayahealth.org/category/mortality-reviews-2/

11. Nyaya Health. Nyaya Health Wiki.  2011. [accessed 2011]. Available from: http://wiki.nyayahealth.org/w/page/4682674/FrontPage

12. Nyaya Health. Data Management Wiki Page.  Available from: http://wiki.nyayahealth.org/w/page/4682655/Data%20Management

13. Nyaya Health. Nyaya Health Wiki Budget Page.  2011. [accessed 2011]. Available from: http://wiki.nyayahealth.org/Budget

14. Nyaya Health. Nyaya Health Organizational Documents.  2011. [accessed 2011]. Available from: https://www.dropbox.com/s/2kmxj8wj4eraywy

15. Nyaya Health. Nyaya Health Transparency Wiki Page.  2011. [accessed 2011]. Available from: http://wiki.nyayahealth.org/w/page/35369836/Transparency

16. Nyaya Health. Nyaya Health Blog Transparency Series.  2011. [accessed 2011]. Available from: http://blog.nyayahealth.org/tag/transparency-series/
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Duncan Maru, MD, PhD is a resident physician in Internal Medicine and Pediatrics and a fellow in Global Health Equity at Harvard Medical School, Brigham and Women’s Hospital and Children’s Hospital of Boston.  He is a co-founder and current President of the non-profit organization Nyaya Health.

Notes from Achham

Posted by Agya Poudyal

Each week, over the Nyaya Health team list, both a hospital update and community health worker program update is sent for reflections.  Although there has only been one weekly update published in the past,  the blog team would like to increase the frequency of notes from Achham to inform readers about our operations. This is going to be a series of monthly updates. Please find below my notes from last week:

PROGRAM DEVELOPMENT
We held a meeting with Dr. Amir Bista, Dr. Ramesh Kandel, staff physicians; Taraman Kunwar, Uday Kshatriya, Health Assistants; and Megha Giri, staff nurse concerning the distribution of the follow-up cards to the patients. The clinicians were positive concerning the idea and all agreed that it would be doable. I have finished the coding of the cards and once we receive the drop boxes for the registration desk in our hospital and the health posts we are ready to start the system.

COMMUNITY MANAGEMENT OF ACUTE MALNUTRITION

The weighing scales for Community Health Worker Leaders (CHWL) have arrived this week. I will hand them over to the CHWLs on Friday and ask them to start with the universal screening. Considering that there are 9 wards in each Village District Councils (VDC), we initially planned to weigh and measure all children by the end of 9 weeks. This means that we want to give one week to one Community Health Worker (CHW)/Female Community Health Volunteer (FCHV) to screen all children in their wards. But some wards are bigger than the others and the CHWs/FCHVs would probably need more than one week in these cases. Taking this into account it would perhaps be a good idea to set the time frame a little longer. It would be really helpful, if
you have any suggestions regarding how to carry out the screening and
by when to complete it.

ANECDOTE

Last week on Sunday, one of our CHWL came to our office room. At first, I was happy to see her on a day that wasn’t a normal CHWL meeting day. But when I saw the state she came in, my expression changed.  The normally smiling didi was really pale and unable to move. The sweat beads dropping from her forehead said that she had a tough time reaching the hospital. She told me that she had been pregnant for two months and was now bleeding very badly. I asked if she had already seen one of our clinicians. She explained to me how she didn’t know if she was supposed to go to the Out Patient Department or to the emergency. We took her to the emergency room immediately.

***

Similarly, few weeks ago, we met a girl on the way to Bayalpata. She was lying on the road unable to move due to a stomachache. We asked her to come to the hospital as soon as possible. She came the next day and I saw her outside the OPD. After her meeting with the clinicians, I luckily spotted her going outside the hospital. I ran to ask her what she had been advised. She told me that she was supposed to get her urine tested but was going home because she didn’t know where she could do so.

***

Our CHWL didi (sister)  and the girl had different ailments but they both shared a common problem. Neither of them could navigate around the hospital without help. I felt that patient navigation is one area that we really need to pay attention to, especially because our own CHWL didn’t know where to go in her situation. With things as simple as putting up signs we can do wonders. We have started to write down the names of the offices in each department but if we could come up with simple signs  for people who cannot read and write and also to make it more intuitive for all patients, it would be wonderful.

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Agya Poudyal is currently the Community Health director at Bayalpata Hospital. She has graduated with a MA in International Relations.

Nyaya’s Co-Founder, Dr. Sanjay Basu recently published an article in the New York Times on the health needs of illegal immigrants in San Francisco, USA. Undocumented immigrant workers in the USA frequently have greatly limited access to healthcare services, similar to patients we serve in Achham, and people in other impoverished communities throughout the world. Nyaya believes strongly that health care is a basic and fundamental right and will continue to advocate for the provision of free and equitable care from Achham to San Francisco.

Devsara Thapa(ANM) and Shanti Awasthi, wife of Drona Awasthi (Lab Assistant) in the process of cleaning the hospital grounds. One Saturday, all the staff at Bayalpata Hospital came together for a day of cleaning

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Ranju Sharma was previously the Program Coordinator at Bayalpata Hospital. She recently completed her BSc at Mount Holyoke and is currently a volunteer with Nyaya Health.