Nyaya Health:Nyaya Health:Providing healthcare Providing healthcare

in rural Nepalin rural Nepal

Shefali OzaShefali Oza

shefali@nyayahealth.orgshefali@nyayahealth.org

� Outpatient department (OPD), maternity suite, 24-hour emergency care, laboratory, and pharmacy

� Community health worker network

� No user fees

� 20 all-Nepali staff, including one doctor

� Treated over 17,000 patients in 14 months

The Sanfe Bagar Medical Clinic

(April 2008 –June 2009)

Bayalpata HospitalBayalpata Hospital�� Abandoned hospital in Achham built 20+ years agoAbandoned hospital in Achham built 20+ years ago

�� 55--year contract signed with MOHP to renovate and operate year contract signed with MOHP to renovate and operate

the hospital the hospital

�� Services will begin midServices will begin mid--June 2009June 2009

�� Current goal (2009Current goal (2009--

2010): OPD, 242010): OPD, 24--hour hour

emergency, inpatient emergency, inpatient

maternity care, VCT, maternity care, VCT,

PMTCT, DOTS, XPMTCT, DOTS, X--Ray, Ray,

expanded CHW networkexpanded CHW network

�� 22--55--year goals: ARVs, year goals: ARVs,

surgical services with surgical services with

blood transfusion, blood transfusion,

inpatient wardinpatient ward

Our model: 5 key pillarsOur model: 5 key pillars

� Free healthcare for all patients

� Full Transparency– All data, line- by- line expenditures, and protocols are available at http://wiki.nyayahealth.org

� Working together with community and government

� Clinical services and community care/outreach must be integrated

� Evidence-based medicine through rigorous data collection and evaluation

Operational budget

From our wiki: http://wiki.nyayahealth.org

Breakdown by category

Monthly expenditure

Current key prioritiesCurrent key priorities

�� Maternal and child healthMaternal and child health

�� CommunityCommunity--based initiativesbased initiatives

�� HIV/AIDS and tuberculosisHIV/AIDS and tuberculosis

�� TechnologyTechnology

Maternal and child health

�� Maternal Mortality Ratio (deaths Maternal Mortality Ratio (deaths

per 100,000 live births) in per 100,000 live births) in

Achham: 800Achham: 800

–– 200x that of areas in USA200x that of areas in USA

�� Nearest CNearest C--section facility is 5 section facility is 5

hours by bushours by bus

�� 99.5% of deliveries occur outside 99.5% of deliveries occur outside

a health centera health center

�� 60% of children are chronically 60% of children are chronically

malnourished in Achhammalnourished in Achham

�� Nyaya Health patient data:Nyaya Health patient data:

–– 68% chronically malnourished68% chronically malnourished

–– 35% severely malnourished35% severely malnourished

Our maternal and child health program

�� Safe delivery and abortion servicesSafe delivery and abortion services

�� Maternal inpatient and preMaternal inpatient and pre--delivery bedsdelivery beds

�� Antenatal and postAntenatal and post--natal servicesnatal services

�� Community and clinicCommunity and clinic--based monitoringbased monitoring

�� Outcome tracking and evaluationOutcome tracking and evaluation

�� Targeting malnutrition Targeting malnutrition

at the clinic and at the clinic and

community levelcommunity level

–– Pregnant women and Pregnant women and

young childrenyoung children

�� Community health Community health

workers provide workers provide

education, treatment, education, treatment,

referrals and followreferrals and follow--upup

Some of our community-based initiatives

�� Paid Community Health Worker Paid Community Health Worker

network for multiple programs network for multiple programs

�� Reducing indoor air pollution Reducing indoor air pollution

through clean stove technology through clean stove technology

(planned)(planned)

�� Providing clean water by Providing clean water by

distributing hospitaldistributing hospital--generated generated

chlorine solution chlorine solution (planned)(planned)

�� Community accountability Community accountability

structures for improved health structures for improved health

carecare

Our Community Health Workers (CHWs)Our Community Health Workers (CHWs)

�� Main reasons for CHW networkMain reasons for CHW network

–– limited transportation but long limited transportation but long

distancesdistances

–– high prevalence of chronic high prevalence of chronic

diseases requiring longdiseases requiring long--term term

medication adherencemedication adherence

–– social challenges in accessing social challenges in accessing

existing healthcare services, existing healthcare services,

especially among the vulnerableespecially among the vulnerable

–– lack of highly trained healthcare lack of highly trained healthcare

personnelpersonnel

�� Nyaya’s CHW programNyaya’s CHW program

–– monitoring community for illnesses, pregnancy, and malnutritionmonitoring community for illnesses, pregnancy, and malnutrition

–– general patient followgeneral patient follow--up and antenatal/postnatal followup and antenatal/postnatal follow--upup

–– directly observed treatment (DOTS) for TB patientsdirectly observed treatment (DOTS) for TB patients

–– communitycommunity--based malnutrition programbased malnutrition program

–– health education and awareness outreachhealth education and awareness outreach

HIV/AIDS and TuberculosisHIV/AIDS and Tuberculosis�� Migrant labor to India Migrant labor to India

leading to rapid rise in leading to rapid rise in

Achham’s HIV incidenceAchham’s HIV incidence

�� Risk of multiRisk of multi--drug resistant drug resistant

TB increasing due to TB increasing due to

prescribing practices and prescribing practices and

incomplete TB treatmentincomplete TB treatment

�� RollRoll--out of VCT, PMTCT, and ARVs at Bayalpata Hospitalout of VCT, PMTCT, and ARVs at Bayalpata Hospital

�� CommunityCommunity--based education and nutritional support programs through based education and nutritional support programs through

CHWsCHWs

�� CHWCHW--based Directly Observed Treatment (DOTS) for TBbased Directly Observed Treatment (DOTS) for TB

�� Strengthening TB diagnostic capacity, including drug sensitivityStrengthening TB diagnostic capacity, including drug sensitivity

�� Piloting active TB case finding in the communityPiloting active TB case finding in the community

Our use of technologyOur use of technology

�� DiagnosticsDiagnostics

–– UltrasoundUltrasound

–– XX--ray (by 2010)ray (by 2010)

–– Laboratory equipment (ILaboratory equipment (I--Stat machine, QBC machine)Stat machine, QBC machine)

�� Data collectionData collection

�� ConnectivityConnectivity

–– TelemedicineTelemedicine

–– CHW networkingCHW networking

Some key challengesSome key challenges

�� TransportationTransportation

–– Hilly region with Hilly region with

one road that ends one road that ends

in Sanfe Bagarin Sanfe Bagar

–– Restricts access to Restricts access to

health facilities and health facilities and

patient followpatient follow--upup

�� CommunicationCommunication

–– No areaNo area--wide cell phone tower, internet, or landlineswide cell phone tower, internet, or landlines

�� Unreliable electricity gridUnreliable electricity grid

�� Deficits in water quantity and qualityDeficits in water quantity and quality

Our funding sourcesOur funding sources

�� Private donorsPrivate donors

�� Foundation grants Foundation grants

�� Nepali governmentNepali government

�� InIn--kind donations of equipment and kind donations of equipment and

suppliessupplies

�� Collaborations with NGOsCollaborations with NGOs

Our online presenceOur online presence

�� Website (Website (http://www.nyayahealth.orghttp://www.nyayahealth.org))–– Provides general information about our organization Provides general information about our organization and directs visitors to contacts and/or further and directs visitors to contacts and/or further informationinformation

�� Wiki (Wiki (http://wiki.nyayahealth.orghttp://wiki.nyayahealth.org))–– All of our data, lineAll of our data, line--byby--line budget expenditures, line budget expenditures, protocols, and expansion plansprotocols, and expansion plans

�� Blog (Blog (http://blog.nyayahealth.orghttp://blog.nyayahealth.org))–– UpUp--toto--date posts about our work, including news date posts about our work, including news events, patient stories, and logistical/management events, patient stories, and logistical/management issuesissues

Thank you from Nyaya HealthThank you from Nyaya Health