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Posted by Duncan Maru

The AMD/OAN award was a huge victory for our organization and was achieved largely because of Sanjay’s persistence with pursuing any potential grant opportunity that has come our way. The AMD/OAN for their part saw in Nyaya Health a young but innovative organization working in one of the more remote and poorest places in the world. Indeed, if we can develop a model of reliable and affordable connectivity and community access, effective telemedicine support to otherwise isolated rural doctors, and using telecommunication to better equip, train, evaluate, retain, and utilize community health workers, then our model should be achievable in just about anywhere. The AMD/OAN site visit was a brief but inspirational and informative period of focused planning and creative period. See our current design strategy here.

In these kinds of “impossible” projects, logistics is everything. So it is worth mentioning that even before the site visit started, we faced a formidable logistics challenge: how to transport a very busy executive from one of the world’s leading companies (Dan Shine of AMD and the 50×2015 initiative) to our quite remote place in only two days. We explored various options by land and air from Delhi and crossing the border at mahendra nagar, by commercial plane to Nepalganj then chartered plane from Nepalganj to Sanfe (requiring the first flight to Sanfe’s broken airport in over five years), plane to Dhangadi and then a ten hour jeep ride over uncertain roads (how our staff usually does it). Ultimately, we settled in on helicopter as the most efficient mode of transportation to our remote area.

[youtube=http://www.youtube.com/watch?v=SuY8jV41Kao&rel=1]

Manindra accompanied us to serve as a guide for the AMD/OAN team, consisting of OAN founder Cameron Sinclair, Dan Shine, and Nobelity founder and accomplished documentary filmmaker Turk Pipkin. A motley crew indeed, but it did make for some amazing conversations spending time with three quite brilliant and creative people with such different backgrounds and perspectives. Each of course had their own insights. Mr. Shine discussed mapping the entire district with GPS and connecting all the villages with CDMA and Wi-Fi, Cameron discussed sustainable design and how to prepare for all kinds of natural and human-made disasters, and Mr. Pipkin was, quite appropriately, reeling in every encounter, location, and dialogue. For my part, at that point I was getting a little giddy over the potential power we could unleash for training and connecting community health workers.

So after 3 hours of breathtaking scenery at the foothills of the Himalayas in the helicopter, we arrived in Sanfe Bagar. It is hard to keep a low profile with a helicopter and camera crew. The visit itself commenced with a helicopter landing at the abandoned hospital in Bayalpata. The hospital looked quite different from the air and I didn’t at first notice Rajan waving his t-shirt in the air, so we passed the hill the first time and then back-tracked after I had realized my mistake.

At the start of the visit, Dr. Bishnu, Ana, and I had all started to think that both for the sake of politics and for long-term planning the Bayalpata site would be ideal. The problem remained the infrastructure and logistical difficulties of reaching the hospital particularly in the monsoon season.

The site visit really presented us with an opportunity to refine our conception of the whole design project. Prior to the site visit, our team had developed a draft proposal of our telemedicine strategy that left more questions than answers. Through seeing the area with the experienced perspectives of the AMD/OAN team, we were able answer some of those questions. The first, at a most basic and general level, was what kinds of activities we would house at the center. Mr. Shine’s emphasis on modularity and scalability and Cameron’s attention to the potential dangers and pitfalls helped us to better frame what exactly would go on at the center. We arrived at a major decision not to include direct patient care activities at the center. The central reason for this was that it would be much easier to incorporate into existing (typically government but also private) hospital structures if patients were seen at the hospital only. The second was that the ease and low cost of intranet connectivity between clinic and telecomm center made it such that the building didn’t even have to be on hospital grounds. This added a degree of financial, bureaucratic, and political flexibility. Finally, and more specifically to our case, we imagine expanding services all that much in Sanfe Bagar but it was much more practical for us to build the telecom center near to the clinic. As such, we needed to make the telecomm center in such a way that it could be appropriate to the current needs of the clinic as well as the future needs of the hospital. We thus decided upon a modular center where the ground floor consisted of community educational laboratory space and the top floor consisted of staff quarters and the room for basically ISP server that would serve to do both intranet and internet. Having staff quarters on site is a practical necessity in a place where attracting long-term higher-level staff (doctors, technical specialists) depends a lot on some of the amenities, such as nice housing with reliable internet. The ISP would then be connected affordably via Wi-Fi to any clinical buildings or anywhere else that we needed connection.

The single most important function of the telecom center in terms of using it as a tool for expanding internet and healthcare access in the region is as an ISP. The absolute number of citizens served, particularly from the lowest socioeconomic groups, directly at the center is limited by geography. The total number of healthstaff who use the center itself will be small. The community educational laboratory should itself be thought of more as a small-scale experimental factory as well as a place to offer higher-level services to a select, more empowered population. Given Achham’s rural location with poor transportation infrastructure, more important for achieving equitable outcomes is developing a communication network that reaches the most remote and marginalized communities. At the forefront of our intranet connectivity strategy are the community health workers. They are the footsoldiers of the healthcare equity battle are the community healthworkers. We hope will be seriously boosted by our telemedicine activities. This is the subject of a subsequent post.

Building the Clinic

Posted by Duncan Maru

A brief history about the current Nyaya Health clinic. This history parallels the birth of our Achham program from a very loose concept of working with the government to improve health infrastructure in a district with high HIV and maternal mortality rates to a concrete plan of action.

Jason Andrews had originally convinced medical school classmates Sanjay and I in March, 2006 of the need to work in Achham. Over the next year, we slowly started to develop additional Nyaya members and achieved a small funding base. It was not until the next year, in April, 2007, however, that the work of Nyaya Health really began.

Jason’s original vision after his trip with his wife Roshani in February of 2006 had been to renovate the abandoned hospital up the hill from Sanfe Bagar. On our initial site visit, Jason, Roshani, and I realized that, although the hospital was a beautiful structure that would be great for long-term expansion of higher-level services, it was not feasible for our initial operations. For one, the water access was a politically dicey issue (and still is). For another, the paved road had yet to be completed (to date it still hasn’t started). Finally, obtaining the rights to run the hospital seemed out of the question at the moment for our young NGO.

We discussed the options over with several local leaders individually and then with the broader citizenry at a community meeting. We ultimately settled in on a former grain shed that was structurally quite sound and had five appropriately-sized rooms. One of our main contacts in Achham, Rajan Kunwar, agreed to arrange for the contracting. Over a period of about five days in between conducting our rapid health assessment, I outlined with Rajan the details of the contracting and provided him the initial payment. At that time, the clinic looked like this:

This was how our clinic appeared to us in April 2007, before renovations

This was how our clinic appeared to us in April 2007, before renovations

Subsequently, over the summer, Chris, Bibhav, Dr. Bishnu, and Andrew, along with a team from Engineers without Borders—Nepal, came in and checked on the progress and further worked with Rajan. They had to work out late payments, the collapse of the initial bathroom, insufficient tiling, contractor’s demands for more payments. During that time, they also conducted a health economics survey, worked out an energy production plan, and attended to various bureaucratic and business tasks. You can see a description of much of their work in previous posts.

Constructing the Nyaya Health clinic toilets

Constructing the Nyaya Health clinic toilets

When I returned after in December, the building had been fundamentally transformed. Rajan had constructed two beautiful bathrooms, a large septic tank, developed the essential plumbing, added floor tiles and fans, fixed the doors, and performed a paint job. Also, our supplies from Kathmandu had arrived unscathed.

How the clinic looked following the initial renovations

How the clinic looked following the initial renovations

There were several pieces missing, however, that required some serious attention. The first issue was the lack of furniture. We had two local carpenters come and assess our need for shelves, laboratory tables, desks, and stools. Finding the correct durable wood in Sanfe took some time, although we ultimately found the right stuff. Certain furnitures we would bring with us from Dhangadi. We would also bring a new refrigerator; we had been planning on using a machine from the DHO, but ultimately we realized it was best to have our own given some logistical delays. In general, we have been learning that, at least in the beginning, we have to provide everything ourselves if we want to start in a timely fashion. Slowly, however, we will be able to improve the logistics and increasingly collaborate with the DHO in supplies procurement.

Following interior renovations and outfitting

Following interior renovations and outfitting

The next issue was the lack of clinical sinks in the delivery and procedure rooms. At the time in April when I had originally made the contracting agreement with Rajan, we didn’t have a doctor to discuss the exact lay out of the rooms. Now with Ana and Dr. Bishnu, we were better able to plan the layout of the rooms and the locations of the sinks. For obtaining sufficient pressure, we also needed one 1000L rooftop water tank (the previous one had broken), two 500L water tanks, and the requisite piping. We would receive these supplies on the same lorry with the contractor who would do the plumbing and assist in building the incinerator.

The Delivery Suite, after Renovations and Outfitting

The Delivery Suite, after Renovations and Outfitting

Posted by Duncan Maru

The AMD/OAN award has catalyzed for Nyaya Health the development of our telecommunication strategy. This is critical given how remote we are, in a hilly region with minimal communication infrastructure and over eight hours (and nearly a month’s per capita income) from the nearest functioning operating theatre. In this post, I will describe some of the processes that we have been engaged in to develop connectivity in our project. See also our strategy brief here.  Additionally,  I’ll provide our mission statement taken from the most recent version of our telecomm strategy.

Our approach to information technology and telecommunications involves incremental amplification of available tools to match the expanding information available to describe the local epidemiological information and institutional capacity of the Saphe Bagar clinic. Telemedicine does not replace professional staff, effective generalist physicians, or an accountable health system; rather, its success relies on these very factors. We will use telecommunications as a tool to improve health services delivery and empower populations in the area to obtain access to vital resources that will serve as platforms for further economic improvement of the area.

Specifically, we will integrate a “telecommunications center” into an overall development strategy of the Nyaya Health, with a four-fold broad vision: (i) economic empowerment for the community, (ii) increased efficiency and effectiveness of clinic services, (iii) enhanced epidemiological and outcomes monitoring and evaluation systems, (iv) democratization of medical, economic, and political knowledge

To meet this vision, we plan to conduct a number of telecommunications activities, under the sponsorship of the computer company AMD and their Open Architecture Network:

i. perform a baseline assessment of the perceived knowledge, attitudes and behaviors of clinical staff and community members around the issue of perceived telecommunications, computing and information technology needs;

ii. determine the associated training requirements that new technology would require for both staff and community members;

iii. itemize appropriate phone, email, and file transfer systems that are cost- and power-efficient;

iv. introduce the technology and associated new staff in a manner that facilitates its easy maintenance, training, and potential future replacement or updating of technologies;

v. use telecommunications to improve staff training, enhance job performance and the ability to communicate with other Nyaya members regarding clinic performance, maintain stock of key supplies and pharmaceuticals, improve morale and retention in remote areas, and exchange expertise with healthcare workers in other areas;

vi. integrate telemedicine technologies into the design and daily function of the center, to facilitate rapid and reliable tertiary recommendations and expert opinion for clinic staff;

vii. rigorously develop epidemiological performance monitors and costing tools to assess the impact of our interventions.

Due to the highly dispersed nature of the site and the location of the poorest villages typically at least 2-4 hours by walk to the clinic, a distributed network of cost-effective technology and personnel is required to ensure equitable access. This is similar to our overall clinical and public health model, in which we use our physician-run clinic as a main referral center for the network of community health workers. As such, the building to be designed for the competition should best be conceived of as a “telecommunications hub”, which houses the main equipment for internet connectivity (internet service provider, ISP) and relay (via Wi-Fi typically) to peripheral sites. Additionally, it should have some community space and community labs for centralized educational activities and experimentation. The community spaces and community labs would be located on the bottom floor; the technology for the ISP would be located on the top floor, along with staff quarters. This approach mirrors our general strategy for expanding healthcare access in the region in which a central clinic provides specialized services and trainings but the main public health activities happen at the village level. The design should be scaleable to other locations throughout Nepal, in which the telecom hub is centered at a district hospital or primary health centre.

For our purposes, telecommunications hub will be based in Sanfe Bagar in a wooded area about seven minutes by foot from the clinic. This location has a line-of-site to the clinic, to the hospital site at Bayalpada, and to another hill that is the location of a proposed CDMA repeater tower by Nepal Telecom (NTC).

There are two satellite options available to us: Very Small Aperture Terminal (VSAT) and Broadband Global Area Network (BGAN). VSAT has a high up-front cost at around $6000 for a 1.2 meter dish. Through the consortium Sustainable Networks, which pools together several hospitals and other NGOs, guaranteed 32 kbps is available for approximately $160 per month. The reliability and maintenance issues of VSAT in rural areas has been problematic in Achham, however.

In the short-term, assuming that CDMA would not be available, we had purchased a BGAN terminal with usage from Inmarsat from I4Technologies. For short-term emergency purposes, given the absolute need for our Achham-based staff to communicate with the US-based technical assistance team, we had decided that this was the best option that required the lowest up-front costs. Subsequently, when we reached Achham, the BGAN device was not as reliable as expected. It did connect most of the time with good speeds, however. More importantly, we were able to achieve a dial-up CDMA connection with a special 12 dB antenna and fixed wireless terminal provided by NTC to us because of a personal connection that Bijay had with one of the directors. The internet only works during the low-usage hours between 9PM and 7AM, but this is sufficient to achieve basic email connection for now. Incidentally, the antenna also gave us a reliable phone connection which had previously been elusive. Finally, Rina had been pursuing several options for getting subsidized MBs and was running into the basic obstacle that BGAN is just not designed for high-MB routine use. Given this, the BGAN started to seem like an incredibly wasteful proposition even in the short-term and certainly in the long-term. I thus brought it back with me to KTM and have returned it. I4Technologies was gracious in providing us a refund for the unused MBs. It was a technical mistake that fortunately didn’t hurt us in the end.

So back to CDMA. The AMD/OAN team during their site visit emphasized that CDMA was the long-term solution. AMD 50×2015 director Dan Shine even suggested that they could pay NTC for the construction of a CDMA tower in Bayalpata. Even with the tower, however, the connection would be dial-up speeds, worse during the peak hours when CDMA bandwidth was decreased. Mr. Shine suggested some strategy of linking several CDMA connections in parallel to achieve broadband connectivity even over the first generation towers found in our area. Rina is actively pursuing this possibility.

The next issue is intranet connectivity, connecting the villages to our telecomm center via Wi-Fi…

Posted by Duncan Maru

Here’s the challenge. In order to have continuous services running in a highly isolated and rural area, we need to develop a reliable and affordable means of transporting supplies across an over two-day journey across the country along challenging roads that additionally suffer from frequent bandhs (political strikes). This system therefore needs to be capable of accurately predicting our usage, preferably in three-to-six month intervals, to bring sufficient supplies for clinical use. To cut down on transit costs (as high as $800 per truckload), we need to minimize the number of trips without ordering medicines destined to expire. We also need to have some forecasting foresight, given that for processing and transit at least three weeks must be allocated to ensure the timely arrival essential supplies.

The wonderful thing about Nepal (and most so-called developing countries) is that if you look hard enough you will find that other people more experienced than you have already created the solutions locally. For example, our software solution did not come from USAID’s supply chain management strategy (which by the way is impressive) but rather from a local Nepali organization, Sustainable Solutions. Originally started by a Missionary pharmacist who wanted to improve the efficiency of his procurement organization, Sustainable Solutions has developed into a small but important player in providing supply chain management software. We found them first at the telemedicine conference and then through our pharmaceutical supplier (they used their software). The software, called mSupply, is completely free in a fully functional version to small single users like ourselves. They make money off of the bigger users (great business model of universal access plus economic sustainability).

After searching around some for the optimal suppliers, we decided upon the Medical Supplies Management Trust, a pharmaceutical house which supplies most of the mission hospitals in KTM. They are reliable and are honest about their costs. For surgical and laboratory supplies, we went with Bikash Surgical Concern, which has an excellent reputation for speed and integrity.

With some amount of forecasting from the available epidemiological data and a whole lot of common sense, we arrived at our initial order. We will use mSupply to monitor usage. It is quite likely that for the beginning we will have to make at least a few orders monthly. Over time, we hope to become better at forecasting usage and can decrease the extra transit costs.

Posted by Duncan Maru

The breaking point for me in the bureaucratic process was the day, after four weeks of being stuck in Kathmandu awaiting for a signature-of-a-signature-of-a-signature, I lodged a silent protest in the office of the Ministry of Women, Children, and Social Welfare. I sat working on various grants and planning documents in the general secretary’s office (i.e., the head of the ministry) waiting for an audience with him. At the end of the day, he finally emerged, said to me “Your presence is not needed” and left as I tried to apologize. That was definitely a low point, but as with any failure, it brought with it an opportunity to re-think our strategy.

What brought me to this process, and its ultimate resolution, requires some clarification. Briefly, we had submitted our project proposal in April, with assurances that all necessary approvals would be finalized within one month of submission. What went wrong over the ensuing months is unclear, other than that we had had several different members go to the government with little success. What is clear is that when I arrived back in Nepal at the end of October, we had in fact taken a step backwards: the Ministry of Women, Children, and Social Welfare, I was informed, had lost our application. We printed and delivered the proposal that day; some of our colleagues from ANMF made some calls, and within a week the agreement was approved by the committee. This was when the real saga began.

Once the approval was made by the committee, a letter was written addressed to the Social Welfare Council stating their positive response. For this letter to be forwarded to the SWC, however, it needed to be signed by the sub-secretary who had chaired the meeting. Our bad luck was such that the day after the meeting the sub-secretary had left his post and had not had a chance to sign. We were assured repeatedly that he would come back tomorrow. Tomorrow kept on not coming, until finally we were informed that he had gone for the holidays and he we would have to wait for a few days. During this time, we were attending to other matters in Kathmandu (pertaining mostly to supply chains management and telecommunications), but still this was seriously delaying the start of our services.

Eventually, we learned, that the sub-secretary had in fact gone to Japan and it was not known when he might return. At this point, Dr. Bishnu and I tried to lobby with another sub-secretary to sign the document, but this too failed. So we waited. Finally, after over three weeks apparently he had returned and had signed the agreement. Now it only needed the general secretary’s signature. Yet when we went to the general secretary’s office nobody knew where the document was other than that maybe it was on the general secretary’s desk. In frustration, I finally raised that (in retrospect, quixotic) protest in his office.

Enter two critical players that came to our rescue. The first was Manindra Malla. By pure coincidence the very day that I was sitting in the general secretary’s office, Ana had met Mr. Malla while purchasing a voltage stabilizer at his electronics shop. Mr. Malla is an IT and computing entrepreneur, with his hand in VOIP, electronics, and solar panels businesses in Nepal. Mr. Malla took interest in what Ana had to say and decided to have us meet with one of the NGOs he was working with to discuss our problem. Due to his business background, he had extensive experience working with and contacts in various government ministries. We met with him at his NGO’s office, and then over the next few days several times more at his electronics shop. We agreed to take him on as our (unpaid) interim Administrative Director.

Simultaneously enter Gagan Thapa, a long-time political leader originally affiliated with the Nepali Congress Student Union. He is friends with our Clinic Superintendent, Rajan Kunwar. Rajan lives close to the clinic in Achham and carries significant weight in local and district politics. He had repeatedly offered to lobby on our behalf, but, owing to concerns about getting involved in political games we had been holding off. That evening, after receiving Manindra dai’s counsel and talking with Rajan again, I decided to give Mr. Thapa a call. He said that tomorrow he would look into it.

Thus the new strategy was as follows. Myself (a foreigner) and Dr. Bishnu (a doctor) were too intimidating and not experienced diplomatically to get the job done. As such, Manindra dai would go alone to the Ministry and discuss the issues. With Mr. Thapa’s political pressure and Manindra dai’s diplomacy, we had the signed agreement in hand within three days.

The next step was receiving SWC approval. This was much less painful, mostly because it was only Manindra dai who interacted with the bureaucrats. It took about a week of small haggling in which Manindra dai would go, they would say, oh take out every reference to poverty, please use a different format for your literature references, please add a few lines to your description of the visa requests, the director’s name must start with doctor, etc. I had in fact left for Achham with the AMD/Open Architecture team by the time it was actually signed. Manindra dai had a grand time with a press conference and invitations to dinner of all the bureaucrats.

After all of this, we learned an important lesson: the international NGO as an institution doesn’t work all that well in Nepal. This was a difficult lesson for us to learn, and in fact it took us six months of struggle to realize. During that time, however, we have put together a fantastic Nepalese team who are now developing a domestic NGO—Nyaya Health Nepal. This NGO will consist of Board Members of the INGO and from a bureaucratic standpoint will receive funding and technical assistance from the INGO to implement projects. For us, given that the NGO is run entirely by INGO board members and decision making is shared in the same way, there is really no functional difference. For the government, however, there is a huge difference in the bureaucratic hurdles they will put in our way. We will discuss more about the Nyaya Health Nepal NGO in another post.

One final note to our current and prospective donors. This post may indicate to you the dangers of investing in a young organization. I would argue that in fact, although this process did delay us somewhat, it actually cost us very little money and only at most two months worth of time. Seven months is in fact not a long time for most organizations to get approval. Most organizations take at least one year. Nobel-peace-prize-winning Doctors without Borders required two years of approval for one of their projects; recently one of the best hospitals in the entire Seti Zone that had been operating for forty years was shut down because of a delay of over a year and a half in getting approval. During the seven months of delay, we raised an additional over 40,000 dollars, conducted another health survery, refined our supplies chain system, expanded our internet presence, built our volunteer base, and won the highly competitive AMD/Open Architecture award. So this has been a productive planning period indeed.

Dr. Robert A. Levine, Clinical Professor of Laboratory Medicine at Yale School of Medicine, and QBC Diagnostics donate Dr. Levine’s invention, Autoread Plus, a hematology centrifuge system, to Nyaya Health Clinic in Saphe Bagar. This essential technology is rugged and easy-to-use, perfectly suited for evaluating patients for anemia, infection, and other conditions at our rural clinic.