Project Description

Project ID

09NH001

Project Type

Funded Project - Development Project

Project Title

Building Healthcare Resources for Comprehensive Emergency Obstetric Services in Achham, Nepal

Project Summary

This project is a continuation of development project 06NH001.

To combat crisis-level maternal mortality rates, Nyaya Health is currently building a hospital with local citizens and government officials to provide comprehensive emergency obstetric services in Achham. Nyaya has arranged for funding for the renovations, infrastructure, supplies, and medicines from other sources, including the Ministry of Health and Populations of Nepal. We are requesting $21,473 from ANMF to support the health worker training and salaries to staff the hospital for one year. By supporting local Nepali health providers, ANMF can have a significant long-term impact on the healthcare system in the region. Namely, ANMF will support:

1. The training, equipping, and ongoing support of village-level paramedical providers known as community health workers (CHWs). These workers are the front-line providers of care in the geographically isolated villages. They perform outreach, follow-up patients, and communicate essential health messages to their local communities.
    
2. The training, equipping and ongoing support of auxiliary nurse midwives (ANMs). These midwives are at the core of our healthcare service expansion plan. Through training and equipping them, Nyaya will be able to expand the current “Basic Obstetric Care Package” to “Comprehensive Emergency Obstetric Services” specified in the AMDD (Averting Maternal Death and Disability) model. In addition to services presently provided, the Comprehensive Package will include blood transfusion and the operating capacity and facilities for cesarean sections.

This fourteen minute video describes Nyaya's projects in Achham.

Location

Achham

Time Frame

2009

Institution

Nyaya Health

Contact

Duncan Smith-Rohrberg Maru
Nyaya Health
135 College Street, Suite 323
New Haven, CT 06510 USA

Cell phone:    1-203-687-8615
Land phone:  1-203-775-1906
Fax:                  1-630-604-8615

email: dsr446gmail.com

ANMF/Nepal Project Manager

Dr. Prativa Pandey
PrativaPandeyanmf.net

ANMF/America Project Manager

Bob Gerzoff
BobGerzoffanmf.net

Richard Katzmann, MD
RichardKatzmannanmf.net

Project Description

Building Healthcare Resources for Comprehensive Emergency Obstetric Services in Achham, Nepal

Mission and Background

Nyaya Health is a 501(c)(3) nonprofit organization working to improve the health of poor communities in Nepal through the provision of medical and public health services. We are a unique assembly of Nepal- and US-based public health experts who develop scalable models for expanding health equity and access to marginalized populations. Nyaya Health operates the regional health center and community outreach services in Achham, a large district in Nepal. Achham is one of the poorest regions in South Asia, and shoulders some of the world’s highest mortality rates, particularly among women. Following a decade-long civil conflict, the health infrastructure of the region has been ravaged. Nyaya provides essential primary care to the region, as requested and directed by community members. Working in partnership with local government officials, we construct healthcare infrastructure, train local health workers, and provide direct medical services. Our organization employs an all-Nepali staff with supervision and training from volunteer public health experts. We maintain an “open source” approach involving complete transparency in our budgets, expenditures and operations protocols, which are detailed on this website.

Objectives of Grant Request

To combat crisis-level maternal mortality rates, Nyaya Health is currently building a hospital with local citizens and government officials to provide comprehensive emergency obstetric services in Achham. Nyaya has arranged for funding for the renovations, infrastructure, supplies, and medicines from other sources, including the Ministry of Health and Populations of Nepal. We are requesting $21,473 from ANMF to support the health worker training and salaries to staff the hospital for one year. By supporting local Nepali health providers, ANMF can have a significant long-term impact on the healthcare system in the region. Namely, ANMF will support:

1. The training, equipping, and ongoing support of village-level paramedical providers known as community health workers (CHWs). These workers are the front-line providers of care in the geographically isolated villages. They perform outreach, follow-up patients, and communicate essential health messages to their local communities.
    
2. The training, equipping and ongoing support of auxiliary nurse midwives (ANMs). These midwives are at the core of our healthcare service expansion plan. Through training and equipping them, Nyaya will be able to expand the current “Basic Obstetric Care Package” to “Comprehensive Emergency Obstetric Services” specified in the AMDD model. In addition to services presently provided, the Comprehensive Package will include blood transfusion and the operating capacity and facilities for cesarean sections.

Context and Need

Nyaya Health has begun to address the lack of healthcare infrastructure through our primary care clinic. With seed money from The America Nepal Medical Foundation, we are expanding maternal health services in the region stepwise, focusing on establishing a community-oriented health program, prenatal preventive care, and delivery services including the treatment of obstetrical complications. Our all-Nepali team of one MBBS physician, 5 midwives, 3 health assistants, and 2 laboratory technicians have implemented the model of the "Averting Maternal Death and Disability" (AMDD) program, thus far providing the “basic” package of emergency obstetric care for routine non-surgical deliveries including:

• Intravenous and oral antibiotics for perinatal infections
• Intravenous and oral oxytocin for postpartum hemorrhage
• Intravenous and oral anticonvulsants for perinatal seizures
• Intravenous and oral antihypertensives for perinatal hypertension
• Removal of retained products of conception
• Manual removal of placenta
• Vacuum- or forceps-assisted vaginal delivery for obstructed labor

In providing these services, we expect to significantly reduce maternal mortality, specifically by preventing mortality from the five most prevalent causes of maternal mortality: hemorrhage, sepsis, unsafe induced abortion, hypertensive disorders of pregnancy, and obstructed labor. While we are currently delivering over 15 healthy babies a month and have successfully treated labor non-progression, eclampsia, placenta previa, and retained placenta, we are rapidly reaching capacity. Through our experiences caring for the communities of Achham, and ongoing discussions with the local community and government, we have determined that inpatient and surgical services must be provided to make a significant and comprehensive public health impact in the region.

To meet these needs, local citizens and government officials have offered Nyaya an abandoned hospital to renovate and deploy essential inpatient and surgical services, as well as training programs for mid-level practitioners, nurse-midwives, and community health workers (CHWs). The Nepali Ministry of Health and Populations is agreeing to pay 50% of operating costs of the hospital. In keeping with the mission of Nyaya, our expansion will complement general primary care and serve as a community-driven initiative to provide training, sustainable infrastructure, and high-quality medical standards for health service delivery in the region.

This expansion involves the following key goals, listed in the order of their planned implementation:

• renovating the abandoned government hospital in the neighboring village of Bayalpata;
• expanding primary care, delivery services, and CHW programs to the hospital;
• expanding our diagnostic ultrasound program (currently only available in our primary care clinic to a region of over one million people);
• establishing X-Ray services;
• building a 14-bed inpatient ward to support our existing 24-hour maternal services;
• establishing blood transfusion capacity;
• expanding our existing high-quality laboratory services, including culture microbiology;
• developing a surgical team capable of delivering essential surgical services including Cesarean sections, appendectomies, and basic orthopedic procedures. This team will be led by a generalist Nepali physician trained through the national MD-GP (general practitioner) program.

To achieve our objectives, we have created a step-wise plan of implementation and assigned project directors to oversee these steps. These are publicly available online at: http://wiki.nyayahealth.org/SurgicalServices. Nyaya has arranged for funding for the renovations, infrastructure, supplies, and medicines from other sources, including the Ministry of Health and Populations of Nepal. We are requesting ANMF to support the health worker training and salaries to staff the hospital for one year.

Aims of the Program

To bolster those services currently being developed and implemented at Bayalpata Hospital, we aim to create teams of auxiliary nurse-midwives and community health workers who will subsequently bolster the reach and capacity of the regional health system. The role of ANMs will be primarily in the hospital, assisting in the care of obstetric inpatients or in operating room care and procedures. Conversely, the role of the CHWs will be to act as community-level paramedics and public health practitioners, tackling issues of maternal mortality including ante- and post-natal monitoring and care, as well as associated problems such as child malnutrition and socio-economic barriers affecting access to care.

Our program will target patients seen through our primary care clinic or encountered by active monitoring of communities through our CHW program. Furthermore, in both cases, through continued monitoring and home visits by our CHWs, these patients will be followed longitudinally. Through the further development of our healthcare worker staff, we will tackle maternal mortality both at the emergency level – including clinic and hospital-based medications, treatment and/or surgical capacities as appropriate – and at the community level. Our ANMs and CHWs will be equipped to provide the necessary education, treatment, referrals, and follow-up necessary to ensure that women in the Achham region have access to comprehensive obstetric services. Rather than simply treating emergency obstetric complications at time or presentation to our clinic or hospital, our project aims to affect lasting change on the practices, knowledge, and health-seeking behaviors of individuals and communities. By also addressing maternal mortality in the community where it begins, and not exclusively in the clinical context, we hope to affect the community understanding and engagement in healthcare, and in particular, in the those issues affecting maternal mortality.

Specific Program Activities and Implementation Metrics

Community Health Workers

Through our community base in Achham, Nyaya Health is developing a scaleable, culturally-appropriate, equitable, and effective model to train and support CHWs. They will be supported by each other, through our existing social networks, and through a developing telemedicine program that will connect neighboring villages, and their respective CHWs, to each other.

CHWs are presently being trained in a stepwise fashion, in which they first are deployed as outreach workers who solely act to recruit and refer patients to the central clinics. Their clinical capacity grows gradually over time to include adherence support for patients evaluated and followed up at the clinic, and ultimately it includes triage and treatment. The CHWs are generalist providers, and in describing them below we reference the full spectrum of their work, even though for the purposes of this grant we are focused on their role in maternal health care.

Level One Training Stage: Outreach (ongoing)

Given that beginning CHWs have no formal training in medicine, the first step is to utilize each CHW as a local outreach worker. This serves to familiarize training CHWs with patients and to develop rapport and respect within their local communities. The activities at this stage include:

1. detection of pregnancy and recruitment of patients to attend antenatal care visits at the clinic;
2.  follow-up of patients treated at the central clinic, encouraging patients to return to the clinic as requested by the clinical team;
3. detection of childhood malnutrition using a simple survey that includes a color-coded band that measures mid-upper-arm-circumference; and
4. referring of adult and pediatric patients to the clinic for vaccination.

During this stage, the CHW has minimal medical skills and is responsible primarily for the encouragement of appropriate clinical follow-up. CHWs are required to report to the clinic weekly with updates and concerns.

Level Two Training Stage: Adherence Support (to be implemented in 2009)

The next stage of training involves a higher degree of clinical capacity that necessitates some clinical knowledge. The activities at this stage include:

1. providing weekly follow-up of antenatal patients for adherence to antenatal vitamins and for screenings for clinical complications or psychosocial issues;
2. providing directly observed or modified directly observed therapy for tuberculosis and HIV;
3. providing weekly follow-up of chronic diseases such as congestive heart failure or COPD.

During this stage, CHWs do no independent evaluation or treatment. In all cases, the CHW performs their work through simple forms determine the necessity of further follow-up at the clinic.

Level Three Training Stage: Triage and Treatment (to be implemented in 2009)

This third stage involves the CHW functioning as a true, albeit limited, paramedic who is capable of the following responsibilities:

1. clinical and psychosocial follow-up of postpartum patients;
2. follow-up of newborns and administration of vaccinations;
3. implementation of a basic triage and treatment protocol to manage non-critical issues and refer ill patients to the clinic;
4. execution of basic first aid in the field.

To implement this stage, it is critical that the communications infrastructure has been improved to allow for real-time voice discussions between the CHW and the central clinic.

CHW Evaluation and Monitoring

Our assessments are grouped according to three primary objectives, and can be downloaded from our wiki: http://wiki.nyayahealth.org/CHWs.

• Clinical skills of the CHWs. These are measured through our existing quantitative skills assessment, and take place prior to hiring, and every nine months thereafter.
• Utilization of CHW services. We track the following markers of CHW primary care services, in terms of both number and percentage with the catchment area of:
  • pregnant women seen prenatally and retention rates among these women;
  • pregnant women receiving folic acid and iron supplementation;
  • pregnant women receiving tetanus immunization;
  • children receiving malnutrition assessments at each six-month interval;
  • children suffering from severe acute malnutrition receiving treatment; and
  • children receiving anti-helminthic treatment and vitamin A supplementation.

We will also gather qualitative feedback from family members, health workers, and our doctor, which will serve as an important tool for assessing and improving upon our work.

• Population Impact. Each child’s nutritional, health, and developmental status will be carefully recorded by CHWs and clinic staff on standardized forms. These will be input into our electronic database and analyzed by our epidemiology team, as we do for other programs. We will assess the extent to which areas that receive our intervention are impacted on the following key markers:
  • prevalence of maternal anemia and malnutrition at delivery;
  • prevalence of mild, moderate, and severe malnutrition; and
  • prevalence of under-five-percent growth on weight, head circumference and length-for-weight growth curves.

This is a long-term project for which we anticipate identifying a significant impact after three years.

Auxiliary Nurse-Midwives

Currently Nyaya Health employs five auxiliary nurse-midwives in our primary care clinic whose responsibilities include:

• Prenatal evaluation of anemia and provision of folic acid and iron, vaccination with tetanus toxoid, and macronutrients, where necessary;
• Routine prenatal check-ups;
• Routine delivery attended by trained midwives or doctor;
• Promotion and support of immediate postpartum breastfeeding when appropriate;
• Recognition of obstetrical emergencies;
• Referral for HIV voluntary counseling and testing and, if necessary, administrative of antiretrovirals to prevent the transmission of HIV from mother to child;
• Screening and referral of common gynecological conditions;

As we expand into Bayalpata Hospital, our services will increase to include the Comprehensive AMDD Package of Emergency Obstetric Care, including both blood transfusion and Cesarean-section capabilities. To provide such services to an increasing patient population, our ANMs will undergo further training in order to provide assistance with these new procedures, under the oversight of the Nyaya Medical Director. This training will be comprised of two main components:

1. In-service trainings – these trainings will be required for all ANMs, with an initial training at the opening of the hospital or beginning of any new ANM, as well as a subsequent training session upon completion of 20 hours of operating-room experience. The trainings will be lead by the Medical Director, and include:
   1. education regarding indication for blood transfusions and C-sections;
   2. instruction on techniques and equipment necessary for such procedures;
   3. mandatory observation of 2 procedures prior to certification of proficiency.
2. Obstetric-Surgical Camps – During these Camps, Nyaya will host volunteer expatriate physicians with significant OB/Gyn experience, to offer treatment as well as expanded training to ANMs and other staff in Achham. The first of these camps will take place for two weeks in April, 2009, led by Nyaya member Dr. Rasik Nagda, MD. During this time, expanded training for our ANMs will take place, enabling them to continue to utilize the knowledge and the skills attained after volunteer physicians leave Nepal.

ANM Evaluation and Monitoring

We will implement assessments for each of the key learning objectives listed previously, which will be evaluated prior to training, immediately following each training session and/or Surgical Camp, and six months following each respective training. Additionally, our epidemiological teams will monitor morbidity and mortality data from both the clinic and Bayalpata Hospital, examining main output indicators of:

• Number of women treated for a reproductive tract infection, by type;
• Number of women screened for pelvic-organ prolapse;
• Number of first-degree, second-degree and third-degree pelvic-organ prolapses;
• Number of blood transfusions, by indication;
• Number of antenatal care visits;
• Number of deliveries;
• Number of live infant births;
• Number of vaccuum-assisted deliveries, by indication;
• Number of Cesarean-sections, by indication;
• Number of maternal deaths, by cause; and
• Number of infant deaths, by cause.

Global Impact and Dissemination

This model will be applicable not only to rural Nepal, but throughout rural South Asia and beyond. Achham shares five main factors that make it an ideal testing ground for maternal programs: severe, entrenched poverty; extremely rural and remote geography; lack of public sector health services; chronic neglect by the central government; being in a post-conflict setting. Programs that we develop will be applicable throughout the world in communities suffering from similar condtions.

As we do with all our programs, we will make the results of this work freely accessible to the public via our website. Nyaya has set up a rapidly-editable webpage, or wiki (http://wiki.nyayahealth.org), on which we post all our clinical protocols and data. This wiki already receives significant amount of use from the global public health community. Through these means, we will ensure the rapid dissemination of our innovations and achieve a broad impact. Additionally, we aim to publish our results in peer-reviewed academic journals which will ensure that our results are not only widely disseminated but also subject to scientific scrutiny.

Timeline for Project Implementation

Activity

2009

J

F

M

A

M

J

J

A

S

O

N

D

Community Dialogue, Evaluation, Implementation

Government Negotiations re: Bayalpata Hospital

Bayalpata Renovations

Surgical Services (including C-sections)

Blood Transfusion

Inpatient Obstetric Services

Expansion of CHW Network (n=15)

Initial Training

Mid-Level Training

Long-term Level Training

Expansion of ANM Staff (n=7)

In-service training

OB-Surgical Camps

Targets for 2009

Indicator	Goal 2009
CHW Training Indicators
CHWs trained at level one	20
# CHWs trained at level two	20
# CHWs trained at level three	10
Clinical Skills Assesment	All CHWs performing at over 85% proficiency on verbal and practical tests
CHW Output Indicators
Recruiting pregnant patients into clinical care	In each village covered by CHWs, 80% of expected pregnant women receive first antenatal visit
Retaining pregnant women in antenatal care	In each village covered by CHWs, 60% of expected pregnant women receive four antenatal visit
Conducting deliveries at hospital	In each village covered by CHWs, 45% of expected pregnant women deliver at the hospital
Screening for severe acute malnutrition (SAM)	In each village covered by CHWs, 90% of all children under five years screened for malnutrition
Retaining malnourished children on treatment	85% of all children treated for SAM complete therapy
ANM Training Indicators
ANMs trained in In-Services	8
ANMs trained in Ob-Surg Camps	8
Clinical Skills Assesment	All ANMs performing at over 85% proficiency on verbal and practical tests
Antenatal Care	Each ANM providing 60 antenatal visits per month
Deliveries per ANM	Each ANM delivering at least 12 babies per month
ANM Output Indicators
# of surgeries conducted for uterine prolapse	80
Antenatal Care Visits	2800
Deliveries performed by a skilled medical attendant	600
Pregnancies requiring management of severe anaemia	40
Pregnant women requiring treatment for syphilis	25
Pregnant women requiring treatment of other STDs	300
Births requiring management of eclampsia	8
Births complicated by postpartum haemorrhage	100
Births requiring caesarean	75
Blood Transfusions, maternal indication	90

Material Requested

None

Training Requested

None

Advisors/Instructors Requested

None

Travel/Expenses Requested

None

Grants/Stipends Requested

None

Other Items Requested

None

Total Funds Requested

$21,473

Budget

With the continued support of ANMF, Nyaya will implement expanded maternal health services in parallel with the opening of the newly renovated Bayalpata Hospital, and bolstered by expanded community health worker and auxiliary nurse-midwife staffs. Funds will be utilized to support ongoing trainings and evaluations, and to ensure the continued retention of Nyaya health workers in Achham. Note that since Nyaya Health is volunteer-run, 100% of donations go directly to medical training, delivery and service. In the spirit of full transparency, anyone can view our line-by-line budget and expenditures at: http://wiki.nyayahealth.org/Budget.

Staff Compensation--2009
Position	Annual Salary + Incentives (NRs)	Number	Total Costs (NRs)	Total Costs ($)
Community Health Worker	36,000	20	720,000	$9,114
ANM Nurse Midwife	84,000	8	672,000	$8,506
Staff Training--2009
Expenditure	Item Costs	Number	Total Costs (NRs)	Total Costs ($)
CHW Expansion
Supplies & food for 3-day CHW Initial Training course	600 NRs/CHW	20 CHWs	12,000	$152
Supplies & food for 5-day CHW Mid-Level Training course	1100 NRs/CHW	20 CHWs	22,000	$278
Supplies & food for 5-day CHW Long-Term Training course	1100 NRs/CHW	20 CHWs	22,000	$278
Medical equipment for one CHW for one year	7500 NRs/CHW	20 CHWs	150,000	$1,899
Travel stipend for CHWs walking weekly to clinic/hospital	3000 NRs/CHW/year	20 CHWs	60,000	$759
ANM Expansion
Supplies & food for 2-day ANM In-Service (Initial) Training	600 NRs/ANM	8 ANMs	4,800	$61
Supplies & food for 2-day ANM In-Service (Follow-up) Training	600 NRs/ANM	8 ANMs	4,800	$61
Supplies & food for 2-day ANM Surg-Camp Training	600 NRs/ANM	8 ANMs	4,800	$61
Food for monthly community forums	2000 NRs/month	12 monthly meetings	24,000	$304
	Total Costs (NRs)	Total Costs ($)
Staff Compensation	1,392,000	$17,620
Staff Training	304,400	$3,853
Total Expenditures	1,696,400	$21,473

Additional Information

This fourteen minute video describes Nyaya's project in Achham.

Project Status

1/5/09	Request received by ANMF
1/18/09	ANMF Board approves funding $10,000 and making efforts to raise an additional $11,473
1/27/09	Annual report received from Nyaya
3/18/09	Funds transferred to Nyaya Health
5/1/09	Update from Nyaya Health