Posted by Shefali Oza

Nyaya Health has posted its update for May through August of this year. In this update, we document our opening of Bayalpata Hospital in collaboration with the Nepali Ministry of Health and Population and provide up-to-date statistics of our first 2 months of hospital operation. We discuss some serious challenges we have faced, including an ongoing cholera outbreak, a weakened monsoon season, and severe power outages. We also highlight some recent successes, such as the donation of an ambulance to Nyaya Health by the Indian Embassy in Kathmandu.

Our May to August 2009 update.

We are honored to have the opportunity to open Bayalpata Hospital after providing health services at the Sanfe Bagar Clinic for over a year. With the increased space and our establishment as a long-term government and community partner in Achham, we plan to further expand our services in the coming months. Some of the critical next steps include a much-needed x-ray machine, the provision of anti-retroviral therapy to a growing HIV/AIDS population, and increased community programs and accountability.

We are extremely grateful for your support, and in this trying time, ask that you continue to help us provide and expand services in one of the poorest regions of South Asia. The opening of Bayalpata Hospital is an important milestone for the organization, our supporters, and most importantly, the people of Achham. Nyaya Health remains volunteer-run, with over 99% of funding going directly to service provision in Nepal. Donations of any size go a long way in helping us serve the Achham population – to donate, please visit http://www.nyayahealth.org/donate/.

Please continue to follow us on this blog as we post news updates, patient stories, and information about our work in Achham.

Posted by Sushant Wagley

* Note: This is the fourth in a series of Nyaya Health staff member profiles. Through these profiles, which are posted on Saturdays, we hope to give you a better idea of the people who are working on the ground to implement Nyaya’s vision on a daily basis.

Dhan Bahadur was born and raised in Masuriya, Kailai, located in the far-western region of Nepal. After passing his School Leaving Certificate and completing his exams, Dhan Bahadur taught English and math at his village school. Three years later, in the midst of the civil war, Maoist forces shut down the school. Dhan Bahadur left his village, moving to Maharashtra and seeking out migrant labor work to sustain himself and his family. With his earnings, he provided financial supported to his family in Nepal and paid for his brother’s school fees. Speaking of that difficult period, Dhan Bahadur says, “I did not want to stay in someone else’s country and wanted to come home but fighting between the Nepalese Army and the Maoist forces had intensified when I returned home after a year.”

Dhan Bahadur Bogati, our cook, makes meals for on-call staff and assists with general maintenance at Bayalpata Hospital.

Dhan Bahadur was forced to leave for India once more in search of work; during his second visit he began running a small restaurant with a business partner. Though initially successful, the restaurant ran into problems. Dhan Bahadur says, “Our business was doing great; however my business partner wasted all the restaurant earnings on alcohol, which eventually bankrupted us. So, I decided I would come back home.” Upon returning to Nepal, Dhan Bahadur joined Nyaya.

Among Nyaya team members, Dhan Bahadur is known as some one who is always willing to help, often volunteering to do tasks that fall outside of his job description. Aside from cooking meals for the staff, he assists in the out-patient department and helps to maintain hospital equipment, building, and grounds. Among his many other talents, Dhan Bahadur speaks and understands Nepali, Achhami, Hindi, Marathi, and some English! He says, “In the year and half that I have been here, I have met many different people from different parts of the world. Our volunteers come from different parts of the US and from different countries. I love hearing their stories and experiences. This is what I love most about working at Nyaya.”

Posted by Shefali Oza

Given the remote location of many households in Achham, our community health workers (CHWs) represent a critical bridge to the community. CHWs are primarily responsible for providing health education, conducting general surveillance, and visiting patients who require follow-up. The lack of roads and communication networks, which make this program an important step in improving population-level health indicators, also result in management difficulties that require innovative solutions.

For example, our current CHWs live up to two hours away from Bayalpata Hospital by foot. Thus, we have structured the program so they come to the hospital once a week for a feedback meeting. During this time we can evaluate their work, provide them with patient information for the next week’s follow-up visits, and conduct weekly training courses on a range of diseases and patient education topics. Because there are no cellphones, landlines, or community-wide internet structures in Achham, it is difficult to efficiently contact the CHWs during the rest of the week.

Pavitra Kunwar (left), one of our CHWs, visiting a patient at home during a follow-up visit.

A well-designed program needs oversight in order to guarantee that desired results are being achieved efficiently. Numerous programs throughout the world – ranging from within governments to international organizations to local NGOs – have demonstrated the waste of precious time, resources, and opportunities that can result from a lack of such oversight, no matter how great the original idea was. Thus, over the coming months, we are aiming to develop innovative strategies that can bypass the transportation and communication challenges present in Achham and allow us to effectively monitor and evaluate the work of our CHWs.

Here we share an example of an aspect of the CHW program requiring oversight and a proposed solution. Due to the difficult terrain and lack of roads, patients sometimes do not return to the hospital for follow-up, which can be dangerous for a number of conditions. Each week, the CHWs are given a list of patients in their catchment area whose illnesses require follow-up. One of the main responsibilities of our CHWs is to visit such patients and counsel them to return to Bayalpata Hospital if their condition is not improving. During the visit, they record basic data on the patient’s condition that can then be evaluated at the hospital.

We are currently piloting a basic “ticket” system that will allow us to confirm that our CHWs are actually performing these patient visits. When patients comes to the outpatient department at Bayalpata Hospital, they are seen by one of our doctors or health assistants. Each healthcare provider has been trained on a list detailing the conditions requiring CHW follow-up and the names of the CHW catchment wards. When a patient is seen who meets these criteria, a “ticket” is attached to the medical record that the patient takes home. At the following CHW meeting, the names of all patients with such tickets are given to the relevant CHWs. The CHWs then collect the tickets from the patients during the home-based follow-up visit that week and return the tickets to the hospital at the next CHW meeting.

The CHW follow-up ticket we are piloting to improve oversight of our community health workers.

We will assess the effectiveness of this simple oversight system in the coming 1-2 months and post an update about our experiences. While not completely full-proof, this method is relatively easy to implement and is not time intensive for medical staff, patients, or management. Outpatient visits generally only require one follow-up visit; in order to collect the ticket the CHW will have to see the patient at least once. We are working to develop alternative oversight mechanisms for conditions that require more than once weekly follow-up, as oversight through this ticket-based system can be more easily bypassed in such scenarios.

As always, we welcome your thoughts and suggestions on ways we can improve our services.

Posted by Ranju Sharma

* Note: This is the third in a series of Nyaya Health staff member profiles. Through these profiles, which are posted on Saturdays, we hope to give you a better idea of the people who are working on the ground to implement Nyaya’s vision on a daily basis.

Sangeeta Nepali, one of Nyaya’s longest-standing staff members, was born in Sanfe Bagar. She married a man living in the neighboring district of Doti at approximately the time that Nyaya was opening the Sanfe Bagar Clinic and hiring its first two auxiliary nurse midwives (ANMs). Though Sangeeta was interning at a government health post, her supervisor encouraged her to apply for the Nyaya position. She passed the interview with Nyaya but took a government job at a rural health post instead, as the Sanfe Clinic was not ready to initiate services. When Sangeeta learned that Nyaya was beginning its operations, she returned and accepted the ANM position.

Sangeeta Nepali, one of our Auxilary Nurse Midwives, performs safe deliveries at Bayalpata Hospital and provides other patient care.

When asked if she dreamed of doing this work as a child, Sangeeta laughs shyly and says that she would have loved to be a singer if she could. She merrily adds, “I used to hum one song or the other all the time instead of studying. I would have 15-minute long ‘study breaks’ between 5-minute long study sessions when I would sing all the songs I loved.” Sangeeta also admits that she always admired the way ANMs and staff nurses wore white coats and helped patients. Yet, she never seriously considered pursuing a nursing career. She ended up enrolling in an ANM training course largely because of her husband’s encouragement and the fact that a friend of hers was also joining. If she had not undergone the 1.5 year training, Sangeeta says she probably would have done what an “ideal wife” is supposed to do, staying at home and looking after children.

Working with the Nyaya team, Sangeeta has grown as an ANM. She has had the chance to provide services to those who need it the most, and she feels proud of her work. Sangeeta says, “The best thing about Nyaya is that I am learning with the senior staff and doctors that care to supervise and teach at the same time.”

(Sangeeta delivered a baby girl in July 2009. She is currently taking maternity leave and enjoying her time as a new mother. Sangeeta is missed dearly at Bayalpata Hospital, and the Nyaya team looks forward to her return!)

Posted by Bibhav Acharya

One of Nyaya Health’s board members, Bibhav Acharya, reflects on a patient’s story from the summer of 2008.

She went into cardiac arrest as she was carried into the clinic. The men carrying her said she had been bitten by a snake. We put everything on hold and rushed to assist her. There was no pulse and she was having difficulty breathing. Epinephrine was administered. A non-specific anti-venom was injected. Endless chest compressions were started and her heart started beating again. The team worked on her for five hours, after which, she died.

Her husband rushed out, wailing. We stared at each other in muted shock. Her relatives waiting outside the clinic started crying. The screams were not loud but still deafening. The medical staff swiftly made their way out of the room. Some were weeping. I was staring at her, still in disbelief. Her right arm was hanging off the examination bed. Her eyes were closed and her mouth was gaping. She looked lifeless. It was the first death at Nyaya’s health center.

Jason Andrews, one of Nyaya Health’s co-founders, was still in the room, his eyes welling with tears. I asked him if there was anything we could have done to save her. Did we lack equipment? Did we lack a particular medicine, an antidote? Did we allow her death by not raising enough money?

Jason wondered about her chances of survival even at the most plentiful institutions of the world. She had been bitten by Krait (Bungarus), which is about 15 times more poisonous than a cobra, and arrived at the clinic eight hours after being bit. She had several factors working against her that had drastically decreased her chances of survival, even if she had come to the kind of US institutions where Jason and I receive medical training.

A Krait snake, which is extremely poisonous and relatively common in Achham (photo courtesy of http://wildindia.org/wiki).

It was not a reassuring thought. Was the poison her killer or was it the fact that her nearest medical care center, Nyaya’s clinic, was an 8 hour walk from her home?

We went outside to speak with the family. As rehearsed when learning to deliver bad news, I told the weeping husband that he had done everything he could have to help her – he had carried his wife on his back through mountains for hours. I told him her death was not his fault. The deadly poison was the cause of death.

Other family members started consoling him. We asked how a nocturnal snake had bitten her. The snake had attacked her at 3 a.m. when she was sleeping in a temporary shed in the woods. We wondered why she was sleeping in the woods. Dr. Jhapat Thapa, Nyaya’s physician and an Achhami native, explained: it is not uncommon in Achham and its neighboring districts that women bring the family’s cattle to the woods and stay there for weeks during the monsoon season. The caretakers stay in temporary sheds in the middle of thick vegetation while the cattle feed day and night on the lush foliage following several months of starvation due to the dry winter. Dr. Thapa told us about his childhood days when he had also spent several nights in such sheds. They are bamboo structures with walls and floors of hay. Injuries, falls and snake bites are known – and (helplessly) accepted – prices for feeding the cattle.

We called the phone nearest to their home so the woman’s relatives could be informed. They would have to walk overnight to reach Sanfe Bagar for her cremation ceremony the next morning. The family members began to collect materials for her cremation at a river bank a few hundred meters from our clinic. Next, we had to fill out her Death Report. Cause of death was going to erroneously say cardiorespiratory arrest secondary to neurotoxin from krait bite.

She died because she was bit by an extremely poisonous snake. She died because it takes 8 hours to reach the nearest health center from her home. She died because she was forced to risk her life by living in the woods so her starving buffalo could get food.

Posted by Ranju Sharma

* Note: This is the second in a series of Nyaya Health staff member profiles. Through these profiles, which are posted on Saturdays, we hope to give you a better idea of the people who are working on the ground to implement Nyaya’s vision on a daily basis.

Though Chandrika is in her twenties, she looks after a family of 10 people, including 3 of her own daughters. She married at an early age, but took an unconventional path by opting for a love marriage. A very forthright person, Chandrika does not believe in hiding the truth. She, therefore, did not conceal the fact that she had fallen in love with her dance partner in school, even though such an action was considered taboo. When asked if she was punished for it, she confidently answers, “I did not think about it in terms of liking it or not. I was sure that he was the only one I would be happy to spend the rest of my life with. There was no reason to hide it. My brother loved me too much so he did not like it when I ran away but everyone else in my family was happy about my choice.”

Chandrika Tamrakar, a health aide, plays a critical role in infection control and general cleanliness at the hospital.

Chandrika has been working with Nyaya since the opening of the Sanfe Clinic. The walk between her home and clinic entailed a daily three hour round-trip through steep hills. Eventually, the commute became too exhausting for her and she decided to rent a room in Sanfe. Chandrika is happy with the shift to Bayalpata – now that the hospital is closer to her home, she only has to walk half an hour each way, which she considers to be manageable.

When asked if she ever expected to become a health aide, Chandrika says that though she never considered that specific career, she wanted to become educated and get a job. She adds, “Even though I did not get to complete my studies, I have a good job. I couldn’t have asked for more.” Those who know Chandrika admire her ability to be content with who she is and what she has. “I have my own sorrows but no one is without one, the important thing is how you deal with them. You can either complain or you can do what you can to make the situation better.”

Posted by Shefali Oza

The diarrhea epidemic which we reported in July has continued over the course of the last month. So far, a few thousand have been infected and the number of reported deaths has reached 26. Unfortunately, given the poor health infrastructure and communication networks in the district, these may be underestimates.

At Bayalpata Hospital, we have now treated nearly 400 patients with mild to severe diarrhea in the outpatient and emergency departments. Several of these patients have had to remain in the hospital for 1-3 days under observation. To make sure we can continue to treat the large number of patients coming to our site, we have ordered additional emergency medicines.

While the exact organism causing the outbreak is yet to be determined, most believe that, based on the symptoms, this is indeed a cholera epidemic. A worker from the Nepali government is currently at our hospital collecting stool samples. The analysis of these samples may help determine the organism.

We will provide additional updates in the coming weeks.  As the monsoon season ends, we are hoping that this outbreak will end soon.  Unfortunately, based on average 10-20 diarrhea cases we see per day, the epidemic still appears to be raging. The true number of patients who need treatment is likely far larger, many of whom cannot make it to our hospital because of poor roads and planting season.

Posted by Sushant Wagley

* Note: This is the first in a series of Nyaya Health staff member profiles. Through these profiles, which will be posted on Saturdays, we hope to give you a better idea of the people who are working on the ground to implement Nyaya’s vision on a daily basis.

For a helping hand in almost any area, members of the Nyaya team know to turn to Lal Bahadur Kunwar. “During the reconstruction of Bayalpata Hospital Dr. Thapa and I used to be in Dhangadi, my hometown, but I would never have a chance to relax at home with family. We were constantly running on my motorcycle from one vendor to another, getting quotes for electrical wiring, plumbing, painters, etc… But I am happy to see that our work has transformed the hospital and now we can utilize these buildings to provide quality care,” he reflects.

Lal Bahadur Kunwar, a health assistant, is one of Nyaya's key healthcare providers.

Lal, one of two health assistants (HAs) hired by Nyaya, was born in the neighboring district of Doti, but spent most of his life living in Dhangadi. He completed his School Leaving Certificate from Galaxy High School and continued his education in Dhangadi. Several years later, Lal was certified as an HA from Bhageshwor Academy and went on to attain his Bachelor’s degree in education. Upon completing his training Lal worked in Achham as an HA, managing one of the government sub-health posts. After spending 1.5 years in Ghajra, Lal joined Nyaya while operations were underway at the Sanfe Clinic.

Besides seeing patients in the outpatient and emergency departments, Lal has been highly involved with medicine and material procurement for the hospital. He contacts various pharmaceutical and medical suppliers to ensure that Nyaya’s stores are sufficient and reliable, often working after-hours and on weekends. When asked about his work with Nyaya, Lal says, “I have always wanted to be a health assistant. My brother is a health assistant and I too had strong interests in this field. Working with Dr. Thapa for the past year has taught me a lot about medicine and the high patient volume at the clinic and the hospital has exposed me to many different and interesting cases. I am very happy and thankful for all that I have learned during my time at Nyaya. I am sure this will continue as we see more patients everyday at Bayalpata.” Lal hopes to eventually work as a professor, training others to become HAs.

Posted by Piali Mukhopadhyay and Astha Ramaiya

Nyaya’s medical team has encountered a substantial number of fall injuries over the course of its operation in Sanfe Bagar and now Bayalpata Hospital. Such injuries are common in Achham due to the mountainous geography and poor road infrastructure. Most residents must navigate the challenging terrain on a daily basis, walking along steep hillsides and frequently carrying large loads of firewood or other supplies strapped to their backs. Children also suffer falls, often from playing in precarious locations or traveling long distances for the purposes of school or household chores. Bone and other injuries that result from falls can cause life-long disabilities if not addressed in a timely fashion. Because of the severe paucity of health facilities in this area, many patients with fall injuries do not have access to the services that they critically need to recover. In fact, the most common reason our clinical staff refer patients to other medical facilities is fall injuries.

The difficult terrain is a leading cause of fall injuries in Achham.

A nine year old male arrived at the hospital today with a severe head injury, resulting from a fall. The boy was carried from a village that was two hours away from Bayalpata Hospital. The child had blood coming out of his ears and nose and was unconscious with his eyes rolled up. Relatives reported that he had fallen from a height of approximately four feet and landed on his head. Given the nature of the injury, Nyaya’s medical team realized immediately that a CT scan was critically needed to detect which part of the brain had suffered trauma. Because Bayalpata Hospital is not equipped with such a scanner, staff were unable to provide the necessary care.

The only action that could be taken was to place the child on antibiotics to prevent infection. He was referred to a hospital in either Kathmandu or Lucknow for further care. Unfortunately, the prognosis for this boy is not promising, as the cost of transportation to these locations is likely prohibitive for his family. In general, facilities for supporting complex medical procedures such as CT scans are not available in the Far Western region of Nepal. Even for basic management of broken bones, the closest facilities are in Dhangadi or Doti, both 10-15 hour drives from Bayalpata. As mentioned above, the associated financial cost of transporting patients to these locations is often impossible for families to shoulder.

While Bayalpata Hospital will most likely not be equipped with a CT scanner in the near future, a critical expansion step will be to develop basic surgical capacity in the next two years. This will allow our clinical team to manage patients with broken bones resulting from fall injuries, as well as to offer other commonly-required procedures such as appendectomies and cesarean sections. In the interim, Nyaya is grateful for the donation of an ambulance from the Indian Embassy in Kathmandu. While we are in the process of expanding our own capacity at Bayalpata Hospital, this vehicle will enable us to transport emergency patients to other facilities that can provide necessary services.

Posted by Shefali Oza

Nyaya Health thanks the Indian Embassy in Nepal for its generous donation of an ambulance. With the addition of this ambulance, we will now be able to transport patients free of charge to regional hospitals between 5 and 15 hours away for life-threatening conditions we are unable to treat at Bayalpata Hospital. Additionally, this donation allows us to access patients in our catchment area who are too ill or injured to reach our hospital without such transport.

The ambulance, which will help transport emergency patients through difficult mountainous terrain.

In hilly districts like Achham, difficult geographic terrain – alongside the lack of adequate roads and transportation – is a significant barrier for patients. As a result, many patients are forced to travel for hours on foot in the hopes of receiving medical care. Additionally, the nearest referral sites range from between 5 to 15 hours away by road, with the closest surgical center approximately 10 hours from Bayalpata Hospital. Such long distances, combined with the large financial costs and travel times involved in reaching these regional referral hospitals, is prohibitive – and sometimes deadly – for patients.

Pregnant women are a key group we hope will benefit from our new ambulance. Women in our communities die of birth complications that can be easily avoided through in-hospital deliveries. The ambulance will help facilitate getting these women to our hospital. Additionally, for severe complications, we will now be able to transport the women to the nearest hospital (5 hours away) that performs emergency obstetric procedures, including caesarian sections.

Rajesh Rai, Nyaya's Kathmandu representative, receives the ambulance from the Indian Ambassador to Nepal.

The ambulance was presented to Nyaya by the Indian Embassy on the 15th of August, marking the occasion of India’s Independence Day. While Nyaya’s expansion plans include a surgical facility in the coming years, the ambulance is and will remain an important tool for saving lives. We are extremely grateful to the Indian Embassy for their generous donation, and are confident that through their support we will be better able to help patients of the Far West.

Posted by Piali Mukhopadhyay

Nyaya Health is grateful to Ten Friends for the generous donation of three light-weight patient stretchers, for use in Bayalpata Hospital’s catchment area. Ten Friends is a registered US non-profit, founded by two school teachers living in the state of Oregon. Over the period of its operation in Nepal, Ten Friends has been involved with a variety of programs, such as distributing light-weight stretchers to remote locations with poor health infrastructure, creating water purification systems in orphanages, and building libraries in rural villages.

The stretcher program originated when Rand Runco, co-founder of Ten Friends, observed the severe challenges of transporting a sick patient while on a trek in Nepal. The injured patient, who was being carried on a heavy-weight, poorly-constructed stretcher, was unable to reach a health facility in time and died. Rand recognized the need for improved equipment and began designing a new stretcher with a team of people, including his students in Oregon. The design had several key features, including durable and light-weight material and easy-to-use handles. Once a prototype was created, donations were mobilized to fund construction and several stretchers were distributed in remote Nepali villages.

One of the three light-weight portable stretchers donated to Nyaya by Ten Friends.

The positive response that ensued encouraged Ten Friends to manufacture and distribute additional stretchers. At this stage, over 100 stretchers have been successfully disseminated in remote mountainous areas of Nepal. Feedback from users suggests that the stretchers are flexible, durable, and effective at reducing patient transport time by more than 50%. Ten Friends recently established a local manufacturing site in Kathmandu to facilitate more cost-effective production.

In Achham, the need for light-weight stretchers is critical. Patients often come to Bayalpata Hospital from areas between 2 and 6 hours away, and sometimes even over 24 hours away. The majority of patients either walk or are carried on the backs of relatives or community members. A minority are brought to the hospital in heavy, inflexible metal stretchers. The mountainous terrain and lack of road infrastructure amplify the difficulty and danger of the transportation process. For individuals with severe illnesses and injuries, the length of travel time can make the difference between life and death.

The donated stretchers will be distributed in three villages that fall within Nyaya’s community health worker catchment area. The stretchers will be kept by the CHWs, as this provides both access to the general public and oversight of their use. Since our CHWs already have a strong presence in these communities, we will be able to advertise the stretchers to the community, train villagers on how to properly use them, and receive regular feedback. Stretchers that are used to transport patients to the hospital must be returned to the village storage site.

Distribution will occur in the month of September and reports of subsequent progress will be posted on this blog. The Nyaya team is excited about the prospect of introducing this essentially-needed device within communities in Achham, as well as collaborating with Ten Friends.

Posted by Shefali Oza

A diarrhea epidemic is spreading through Nepal, particularly in the Mid- and Far-Western regions. Recent news stories have reported that the district of Jajarkot, two removed from Achham, is the current epicenter of this outbreak. Many believe this is a cholera epidemic, though this theory is unlikely to be tested in the immediate future due to limited lab capacity in the country.

In the last several days, we have started seeing severe diarrhea cases coming to Bayalpata Hospital. The first cases were three young children from the same family. Each child stayed in the hospital for 3-4 days in life-threatening condition. Fortunately, all three children recovered after receiving regular doses of medicine and IV fluids. However, the youngest daughter was carried back to our hospital two days after being discharged. Though she no longer had diarrhea, she was now unable to move her limbs due to the sudden and extreme loss of electrolytes from her system. Fortunately, our health providers were able to treat this side effect of severe diarrhea and she made a full recovery.

The youngest of the three children with severe diarrhea. Her parents brought her outside for fresh air after she appeared to be recovering at Bayalpata Hospital.

While we have successfully treated most diarrhea cases thus far, we have had one death at the hospital from this outbreak. A woman in her 60s was carried over a distance of three hours to reach our hospital in the evening. She was one of our first diarrhea patients from this outbreak, alongside the three children mentioned above. Her symptoms (severe diarrhea and vomiting) began twelve hours prior to her arrival at Bayalpata. At the hospital, she was unable to keep IV fluids in her system and kept having continuous diarrhea and vomiting. By the third day, lab tests indicated that her kidneys were beginning to fail. In the US, a dialysis machine would have saved her life. But instead, she died on the fourth day, unable to retain any fluid. This preventable death and the scores of near-deaths that have occurred due to this recent outbreak underscore the vast inequities that underlie the living conditions in Achham. This patient died because she did not have access to clean water and because her family members had to carry her on their backs for hours to reach our hospital.

The dangers of a widespread cholera epidemic are frightening. If left untreated, patients can die within as few as three hours. In areas like Achham, this is particularly concerning as many people live hours from their nearest health facility. Initial treatment is as simple as adding oral rehydration solution (ORS) to water. However, with continuing diarrhea but no ORS, patients can quickly dehydrate and need IV solution at a health facility. Daily we are witnessing a rise of patients coming to Bayalpata Hospital with severe diarrhea. And daily our staff are saving numerous lives through the simple interventions that can stop severe diarrhea/cholera in its tracks. And yet the question remains: how many people are dying because they cannot reach medical care quickly enough? We suspect that in the coming days and weeks, we may witness the unfortunate answer to this question.

Posted by Duncan Maru, MD, PHD

EquityEditors Association (EEA), a non-profit organization, co-founded by Nyaya Health, is a network of socially conscious medical, scientific, and technical editors, and is currently recruiting new writers and volunteers.

The members of EEA are a group of professional editors who leverage their writing skills to help finance innovative solutions to global health problems. Writers earn personal income by providing writing services, and then put a percentage of that income to work for the world’s poor, by donating (from 1-100% of editing income) to creative, effective, and transparent global health organizations. Through EEA, writers are able to earn an income, improve scientific writing, and help address global health inequalities.

The funds raised by EEA are distributed directly as ongoing funding to EEA beneficiaries — innovative social enterprises that advance global health equity. Currently, the sole beneficiary is Nyaya Health, and EEA has generated over $13,000 to date to fund Nyaya’s work in Nepal. This revenue is an ongoing, sustainable, and flexible source of funding for enterprises such as Nyaya Health. EEA chooses beneficiaries that are transparent, pro-poor, and open-source to ensure that the revenue generated improves the health of marginalized populations. EEA monitors and ensures that each dollar donated is used to advance healthcare in resource-poor settings throughout the world.

Interested editors/writers can apply here.

If you are interested in contributing to EEA as a volunteer board member in finance or marketing, please apply here.,

Posted by Ryan Schwarz

The America Nepal Medical Foundation, a continued supporter of Nyaya’s work invited Nyaya to present our work at the recent 13th Annual ANMF Conference in Columbus, Ohio, USA. Through our collaboration with ANMF, Nyaya has been able to expand its services, in particular focusing on its community health worker network. As we continue to expand our services at Bayalpata Hospital, ANMF’s support will enable us to buildthe crucial community health worker system to support our patients. You can view and listen to our talk here:

Posted by Dennis Feehan

The staff at Bayalpata Hospital keep meticulous records of each patient’s visit to the facility. These records allow us to improve clinical services, track simple measures of activity, forecast future clinical needs, and fulfill our reporting requirements to the government. They also give us a window into the health and epidemiology of the population in the surrounding area.

The data are first generated on paper by members of the clinical staff over the course of a patient’s visit. Later, they are entered into a computer database which organizes and archives the hospital’s clinical history.

Clinical Record Keeping
A patient who arrives at the hospital for the first time is entered in the General Register, which contains basic demographic information such as name, age, sex, and village. The patient is also assigned a unique identifier, called an IP number, which is included on all of his or her records. The staff member in charge of registration then determines where to direct the patient. The majority of people who visit the hospital are managed as outpatients and sent to see a clinician (a doctor, health assistant, or an auxiliary nurse midwife). Once a clinician has reached a diagnosis and decided upon a treatment plan, he or she enters that information into a form called the OPD ticket.

The OPD ticket used at Bayalpata Hospital.

If the clinician requires lab tests in order to determine the diagnosis, he or she fills out a Laboratory Requisition Form, which is sent to the lab so that the appropriate tests can be performed. The lab personnel record the results of the tests on the form, which is sent back to the clinician.

Because not all of the hospital’s visitors are outpatients, there are other special forms for Emergency Visits, Inpatient Visits, and Antenatal Care Visits. There are also registers for patients who must be tracked over time, such as TB patients and malnourished children.

After the day’s patients have been seen, the general register and OPD data that have been generated are entered into an MS-Access database that has several tables roughly corresponding to the forms and registers used to collect data on paper during the day. (For a description of another MS-Access database used at the hospital, read the blog post about the Inventory Supply Database.) Typically, a health assistant uses the registration computer to enter the days OPD information, while the lab technician and pharmacist enter the information from their registers on databases stored in the appropriate computers. The result is a detailed electronic summary of the clinical services provided by the hospital that is then available in the database for analysis.

Community Record Keeping
If a clinician indicates that a patient requires follow-up after being treated at the hospital, the patient’s name and address will be given to a Community Health Worker who later visits the patient’s home to ensure that the treatment is progressing well. Ideally, this would happen for every patient who requires follow-up, but the current budget only supports four CHWs. Until we can expand the CHW program, the data we collect on patient follow-up is restricted to those patients who live in the these CHW catchment areas (approximately 16,000 people).

Once a week, the CHWs meet at the hospital and report a set of summary measures detailing the number of households and patients they visited since the last report. They also keep track of the number of community members they referred to the hospital, and the number of iron pills and packets of anti-dehydration powder they distributed. These data are then entered into our computer system by the auxiliary nurse midwife in charge of the CHW program, Gauri Sunwar. The CHWs also report on specific patients in a separate database, where the results of the follow-up can be linked back to the patient’s clinical records, allowing us to understand and evaluate the entire course of therapy.

Future Improvements
In the future we intend to continue improving our data collection and management systems, as well as our methods of analyzing existing data. MS Access allows us to perform simple analytical tasks, like computing totals and retrieving individual records for review. To answer more complicated questions, we can use a statistical package like R or Stata. A more in-depth look at the data we collect will allow us to better evaluate our services and identify the need for new interventions.

The age-sex distribution of patients over one month. Collecting data on our patients allows us to see, for example, that the clinic treated many more women than men, except at the very youngest ages.

We also intend to more thoroughly consider issues of patient confidentiality. Although we restrict access to the database files and use the IP number in of the database tables except the General Register, future versions will use more sophisticated measures to ensure that specific patient details are not revealed.