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.
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.