Strengthening Equitable Health Care in Rural Nepal

Nyaya Health Nepal has established its own organizational vision and strategy to continue improving equitable healthcare for underserved communities in far west of Nepal. 

The program delivers municipal integrated healthcare through the hospitals, households, and uses its digital platform to integrate both services for the catchment area of 230,000 pupolations of Achham and neighbouring district of far west Nepal. 

NHN team of approximately 207 staff provides almost 1,00,000 lakh facility visits, above 6,000 surgeries, and more than 1,00,000 lakh home visits each year

Nyaya Health Nepal is an exceptional health care services delivery organization implementing municipal integrated health care services in rural Nepal in collaboration with three tiers of Government of Nepal to serve the underserved communities. The model also includes: a community-based mobile application using Dimagi’s Android-based CommCare platform that equips CHWs with decision support tools to guide case-identification, care provision, counseling and referrals to the facility. In addition, NHN have introduced several innovations into its model to enhance the provision of longitudinal, rather than acute, facility- based, disease-focused care. 

NHN aim is smooth integration between the hospital-based services and the community based health care services to the underserved communities of Achham district, far west Nepal. At the same time, NHN will bring together government stakeholders, other implementers and development funders to advance policies and practices encouraging to integrated healthcare delivery. For example, NHN have collaborated with the Government of Nepal to implement municipal integrated health care services in far west of Nepal.

NHN is customizing existing, open-source technologies to link health care at the facility- and community- levels through municipal integrated health care model. The proposed program will align with Nepal’s development objective: disaster risks in human lives, livelihoods, health, economy, and social aspects. The program will have the following outcome:

Strengthen frontline healthcare worker's capacity

• Advance core hospital functions
• Improved recording and reporting of the community health care worker's intervention for early recognition and management of epidemic diseases and similar communicable and non communicable diseases.
• Maintenance of existing physical structure/ medical equipment's used during containment and treatment of COVID cases. 

NHN innovations include:

• The deployment of paid, trained CHWs for timely case identification and health promotion in the communities;
• Staffing structures that utilize task shifting to utilize mid-tier providers (e.g., health assistants, general practitioners) to make health care service delivery more efficient and cost-effective;
• Protocols for chronic disease management (e.g., COPD, diabetes); and
• A Continuing Medical Education (CME) curriculum for doctors and other healthcare. 

NHN workforce represents diversity in gender, caste, ethnicity, differently able and age of each.

Hospital Team

1. Dr Mandeep Pathak (Medical Director) - Dr. Mandeep Pathak, is currently leading NHN as Medical and Surgical Director. With especial interest in improving Primary health care, he as actively worked to create standard protocols for task sharing and shifting around primary trauma care at Bayalpata Hospital. 

 2. Dr Biplav Shrestha (Staff Physician) - Dr. Biplav has worked as staff physician with NHN for past 4 years. A very dedicated and approachable person and always going extra mile for patient benefits. He is actively taking lead role from medical team lead for the management of COVID-19 patient as well at Bayalpata hospital.

 3. Dr Amul Singh (Staff Physician) - Dr Amul is young and energetic staff physician at NHN and worked at Bayalpata Hospital for past 2 years. With interest in improving medical care at primary health care level he has supported multiple quality improvement projects and helped created SOP (Standard Operating Protocols) for patient care at Bayalpata Hospital.

4. Himal Kumal (Health Assistant) - Himal has been providing exceptional primary care at Bayalpata hospital for past 5 years.  With active participation in government vertical programs and excellent clinical skills, he has been playing pivotal role in patient care at Bayalpata Hospital. He also actively provided care to COVID-19 patients since the start of first wave.

5. Hirdaya Dhamala (Health Assistant) - With extensive experience working at government health posts and medical clinics, Hirdaya joined Bayalpata Hospital four years ago. Since he has been an integral part of medical team with active participation in continuing medical education and patient care. He also leads the only Drug Resistant Tuberculosis program in Achham district through Bayalpata Hospital. Always dedicated to patient care and keen interest in preventing communicable diseases, he has overall improved the quality care at Bayalpata Hospital.

6. Sanjhana Saud (Auxiliary Nurse Midwife) - Sanjhana is working as Auxiliary Nurse Midwife at Bayalpata Hospital for last 4 years. She has extensive experience with patient care and conducting birth deliveries. She has been an integral part of nursing team and has been substantially involved in quality improvement projects.

 7. Laxmi Bhatta (Staff Nurse) - Laxmi is working as Staff Nurse at Bayalpata Hospital for last 2 years. She is actively involved in patient care at inpatient department and also versed with patient management at operating theatre. She is always putting effort to improve her knowledge and skills to better her patient care.

 8. Kamal Bista (Lab TeChnician) - Kamal works as lab technician at Bayalpata Hospital for past 3 years. He is very diligent and widely involved with quality improvement projects and other projects to improve the patient care and experience at BH. With trainings on different microscopic techniques and lab procedures, he has gained extensive experience in laboratory skill and has been an integral part of laboratory team at BH from his early days.

 9. Milan Adhikari (Radiographer) - Milan is working as Radiographer at Bayalpata Hospital for past 2 years. Very committed to his work he mostly oversees proper functioning of radiology department and passionately involved with patient care with frequent quality improvement projects and reviews.

10. Bharat Kumar Kadayat (psychosocial counsellor) - Bharat Kumar Kadayat is psychosocial counsellor Incharge at Nyaya Health Nepal, Bayalpata Hospital for past 6 years. He is providing direct psychosocial care and support as a mental health counsellor and oversee the functioning of psychosocial counselling of mental health at Bayalpata Hospital. 

11. Janaki Rawal (psychosocial counsellor) - Janaki Rawal is psychosocial counsellor at Nyaya Health Nepal, Bayalpata Hospital for past 7 years. She is providing direct psychosocial care to the patients and support PSC team as a mental health counsellor.  

Community Health Team

1. Pratiksha Dhungana (Community Health Program Lead) -  Dr Pratikshya leads Nyaya Health Nepal community health program in Achham. She is raising awareness and delivering an evidence-based integrated oral, reproductive, maternal, newborn, child, and nutritional interventions in rural Nepal, working with community health workers. 

2. Bhawana Bogati (Community Health Program Associate) -  Bhawana ensures a robust implementation of community healthcare programs, manages a team, and provide mentorship to the community healthcare team under her area of responsibility to execute community healthcare programs and ensure utilization of data and metrics to monitor, evaluate and guide program implementation for Bayalpata hub Achham. She had completed her proficiency certificate level as a staff nurse from CTEVT. 

3. Sharada Bohara (Community Health Nurse) - Bhawana's responsibility at NHN is to supervise, train and support Community Health Workers (CHWs) to implement home visits, group care programs, and review data on a monthly basis to improve targeted health indicators. 

4. Sunita Kumal (Community Health Worker) - Sunita provides health services to the community, coordinates between community and health posts or hospitals to manage the patient's statistics and information. She has a personal interest in changing the tradition of delivering babies at home. She works in Sanfebagar Municipality providing health care services to the population of nearly (331 households number) 1,985 people with health education, referral, and follow-up services.

5. Kakashi Bogati (Community Health Worker)- Kakashi's main responsibility is to provide home-based care and counseling in the community. She acts as a bridge between health institutions and the community to provide quality health services to all the community-targeted people by maintaining good coordination with health institutions. Also, she has played a vital role in reducing the mortality rate and increasing the different health Indicators of her catchment area. 

Partnerships Team

1. Srijana Devkota (Sr Partnerships Lead) - Srijana Devkota is a Senior Partnerships Lead who is leading partnerships and Nyaya Health National Team. Srijana has more than 12 years of experience in partnership and program management in different national and international organsiations. She is also leading the communication activities, netowrking and reporting. 

2. Dharma Raj Kadayat (Senior Communication Officer) - Dharma Raj Kadayat manages communication program of NHN in Achham. Dharma supports in program development and reporting by capturing, success stories, beneficiaries' interviews, implementation pictures, videos and audio. Dharma envisions a world free of gender based violence.  

M&E Team 

1. Sarita Sharma (M&E Manager) - Sarita Sharma is Monitoring and Evaluation manager at Nyaya Health Nepal (NHN). Sarita has brought her diverse experience to NHN; she has worked as a Health Assistant in rural Nepal, as a healthcare quality assurance and improvement coordinator in a large community clinic in the US and as a research officer in the Nepal Health Research Council (NHRC). In NHN, she is working with multiple team members to build and strengthen the monitoring and evaluation system which ultimately paves the way for building a high-quality healthcare that works for all. Sarita believes that affordable and high-quality healthcare should be right of all, not just the privileged few. 

2. Ved Prasad Bhandari (M&E Officer) - Ved's major responsibilities are to monitor and supervise community health workers (CHWs) through digital tool (commcare). Besides, he conducts regular meetings, track implemented activities and maintain data quality and evaluate progress regularly. 

EHR Team

1. Deepak Prasad Neupane (Implementation Engineering Managar) - Deepak leads NHN NepalEHR program. He oversees implementation, EHR product management, monitoring, technology research and development support for the electronic health record system in Kathmandu. Deepak holds a Bachelor of Science in IT and currently pursuing his Masters Degree in e-Governance. He also holds the global IT certification in MCSE, MCP, MCTS, CCNA, JNCIA-ER, MTCNA, Linux training and certification from Linux foundation.

2. RameshMahar (Senior EHR Associate) -  Ramesh manages and oversees troubleshooting, implementation as well as monitoring and development of Electronic Health Record (EHR) in Achham. Ramesh holds a Bachelor in Health and Physical Education from Tribhuvan University.   

Admin Team

 1. Ram Raj Khakurel (Sr. Finance Officer) - Ram Raj is over 18 years experienced in finance and management. He oversees financial planning, financial transaction processing, financial recording and reporting in Nyaya Health Nepal. Prior to joining Nyaya Health Nepal, he served as the Accountant in Special Trading Co. WLL, Doha, Qatar where he led financial bookkeeping and management. He earned a Bachelor’s Degree in Financial Management from Tribhuwan University.

NHN’s municipal integrated health care approach is a unique model in Nepal, it offers an essential move in how health care services are delivered, from hospital based, disease-focused, self-contained interventions to patient-centered, integrated solution to improve primary health care services of needy communities. NHN model combines technological innovation with coordinated facility and home-based care and continuous quality improvement within the public sector health system. 

Nyaya Health Nepal solution "Municipal Integrated Health Care Model" aims to improve equitable health care services of underserved communities of far west Nepal in collaboration with three tiers of Government of Nepal (Federal, Provincial and Local Government). 

NHN has been implementing its model by operating and building systems in government facilities to improve healthcare quality and efficiency; operating a network of CHWs to deliver home-based maternal and child health and chronic disease services in surrounding communities; and through NHN integrated electronic health record (EHR), integrating data between the facility and community levels to better target and continually improve healthcare delivery. NepalEHR also seamlessly enables key functions mandated by the Government of Nepal. It can be used for Health Management Information Systems Reporting (DHIS2) and for managing the National Health Insurance Scheme (IMIS).

NHN provided care to more than 1 million patients who visited the hospitals and over 480,000 people were served in the communities through Community Health Workers. NHN has continued providing quality healthcare delivery services despite COVID-19 global pandemic challenges. Ensured no collateral damage by continuing to care for COVID and non-COVID patients. Successful adoption of Charikot Hospital in Dolakha in 2020 by Bhimeshwor Municipality as per NHN’s DBOT model is an achievement of NHN program. 

NHN’s impact goals for the next year and the next five years, is to strengthen municipal integrated health care approach in far west Nepal. It is a unique model in Nepal, it offers an essential move in how health services are delivered, from hospital based, disease-focused, self-contained interventions to patient-centered, integrated solution to improve primary health care services of needy communities. NHN model combines technological innovation with coordinated facility and home-based care and continuous quality improvement within the public sector health system. 

NHN’s healthcare solution is transformative because;  

1) NHN offers an inclusive solution addressing gaps across the entire health system, not just at the facility or community;

2) NHN municipal integrated model digitally link with the care delivered at the facility and within the community;

3) The geospatial and household-level data combined with facility data enables NHN to provide data-based healthcare; and

4) Collaboration with the Federal, Provincial and Local Government, to sustain and scale up NHN healthcare model in other provinces of Nepal.

NHN’s integrated model of healthcare served the beneficiaries of 2 municipalities and 4 rural municipalities of Achham district through hospital based care services and community health care program. NHN’s care delivery had been affected by the waves of COVID 19 pandemic, forcing the CHWs to stop regular home visits and increase level of counseling and follow up via phone calls. Likewise, hospitals had to close different services and prioritized emergency services and COVID 19 care response during pandemic. Below table shows the overall impact of NHN care delivery during 2021

Indicators

Achievement

Institutional Birth Rate

94%

Surgical Complication Rate

8%

Chronic Disease Control Rate

4 %

Post-Partum Contraceptive Prevalence Rate

32%

Neonatal Death

13 per 1000 live birth 

NHN use NepalEHR, an open source Electronic Health Record (EHR) platform, to integrate data across points of care. The software is customized for healthcare systems in Nepal and designed for use in limited resource settings. NepalEHR integrates registration, clinical diagnosis, investigations, prescriptions, reporting, and stock management. It facilitates care coordination between clinicians in all facilities (hospitals, healthcare center and health posts) and Community Health Workers in community health programs. With the use of EHR, NHN integrate data to map disease, target care and continuously improve healthcare services. NHN system can also be define as service indicators and provide health mapping services. The information recorded at NHN EHR system will be very critical for equitable access to health care services in Nepal.

Similarly, NHN will use CommCare (community health mobile tool) to collect and analyze the data to monitor the program outcome and improve the care, both in the communities and in the facility. Majority of data from communities will be collected through mobile based app, CommCare during household visits by community health workers. 

Nyaya Health Nepal workforce comprised of multiple races, ages, genders, ethnicities, and orientations.NHN diverse team are robust in treating program team, patients and communities equally.

NHN’s municipal integrated health care model improves the health care services for the underserved communities of far west Nepal in partnerships with Government of Nepal is unique than other NGOs of Nepal.  Besides, NHN implement below activities for municipalities to adopt NHN’s DBOT model

• A technology-enabled comprehensive healthcare system solution.
• Improve patient experience and population health while reducing cost
• Work across the health system, from the facility to the home through community health workers
• Use data to create a dynamic health system that evolves based on patient and Data integration through EHR allows precision healthcare delivery
• Collaboration with the Government to adopt NHN healthcare model that scale up in other provinces of Nepal
• Make healthcare solution financially sustainable as our health system innovations are based on our experience as a provider.

NHN believes that healthcare is a fundamental human right and that no one should have to pay at the point of care. To ensure sustainable funding of NHN’s healthcare model, the organization strives to co-fund most of its expenses from the Government of Nepal resources like financing, staffing, supplies as well as infrastructure. Similarly, NHN efforts are geared to make Nepal’s national health insurance functional to ensure the costs of treating patients at the hospitals are reimbursed from the insurance. 

NHN operates under a partnership model, where the public facilities NHN manages are owned, regulated, and co-funded by the Government of Nepal and as an implementing partner, NHN manages and co-finances the operations. NHN partnerships extend in all three tiers of the Government of Nepal (federal to provincial and local). Similarly, NHN apply for grants from different donors and Philanthropic partners. 

NHN 2021-2022 Budget (August 2021- July 2022)

Funding Plan                         Amount (US$)
 
MoSD Far-west                        689,655.17
Local Government                     86,206.90
In-kind Support                         60,344.83
Health Insurance                       43,103.45
Intl Philanthropic Fund             898,486.68
Total                                      1,777,797.02