Strengthen Municipal Integrated Health Care System in Nepal

As per Demographic and Health Survery (DHS) 2016, Nepal, neonatal mortality rate in Sudoor Pachim province is 41/1,000 live birth and only 29 per cent of the population has access to the government health facility within 30 minute distance. Health facilities and health care staffs with specialization are rarely available. Though it seems that the number of women getting Antenatal care by skilled health workers was highest in Sudoor Pachim, there is still room to improve in institutional delivery. Only 66% of deliveries in Sudoor Pachim were in health facilities. The rest of the deliveries were either occurred at home or on the road. The use of modern contraceptive method in the area is 48 % compared to National Health Sector strategy 2016-2021’s goal to reach the modern contraceptive prevalence rate of 52 % by 2020. Nepal has committed to doing its part to achieve the SDGs but severe inequities in maternal healthcare access and utilization and the poor quality of care are hurdles in the Country’s path to achieving the ambitious MMR and other health targets. Without significant investment in health system, particularly to improve quality of care at public sector facilities the goal of universal health coverage will not be achieved.

Of the major service areas, NHN provides essential healthcare on reproductive, maternal, newborn and child health (RMNCH) through the facilities NHN manages and CHW networks. Women and girls are by far the most marginalized even among the underserved communities and NHN has a role to play in improving quality of care provided to women and girls through municipal integrated health care system. NHN prioritizes the further improvement of maternal, reproductive and child health care by strengthening the health system that has been implemented in the area.

 

 

 

NHN solution is NepalEHR (Electronic Helth Record) a digital platform which contains clinical and logistical information's, and results recovery (for laboratory, pharmacy, radiology, and other testing services). It helps to improve the health care services with reducing the time of service accompanying with increase in efficiency and effectiveness. 

Electronic Health Record (EHR) platform, to integrate data across points of care. The software is customized for health care 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, health care center and health posts) and Community Health Workers in community health programs. The EHR platform helps NHN integrate data to map disease, target care and continuously improve healthcare services. Moreover, electronic records can be linked with health care surveillance, which may be extremely important in emergencies.

How EHR benefits:

• Efficiency in patient tracking: The system will bring all records of patients in a single search to find the history and up to date information. Transformation of information of existing paper-based information management systems in computerized system.
• Health alerts and recommendations: Will alert medical team to immediately remedy hazardous situations.
• Time saving and reduce cost: Will allow medical team to give more time to patients then paper documentations.
• Improve care coordination and communication: System gives the healthcare provider instant access to other clinicians’ evaluations. EHR helps clinicians to coordinate and track patient care across the facilities.

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Nyaya Health Nepal (NHN) is providing free of cost, quality primary health care services to underserved communities of rural part of Nepal, mainly through integrated healthcare model. NHN has network of community health workers who are integrating primary health care with facility based services through the counseling and care coordination services. Since this program has been implemented in the remote part of Nepal, it has been proved to be very impactful to serve the people residing in the region. NHN’s work has already shown to improve the institutional birth rate, a critical process indicator for maternal mortality, from 30% to 95% within the Achham district and has been able to save the lives of the people including the people who needed the emergency, surgical and mental health care services. 

Based in Achham, NHN’s integrated health care program currently serving rural communities of Achham district of Sudoorpachim Province, through hospital based programs and community health care programs regardless of their financial and social conditions. Located in Sudoor Pachim, Achham is one of the remotest and underserved districts in Nepal. Most of the people rely on agriculture and are temporarily migrated to India as workers in low income job to sustain their lives. As it is widely known, the health indicators of Sudoor Pachim are very low. People have to often travel long distance to get health services, sometimes at a cost of their lives. Only a few hospitals are providing care to the people in the area including Bayalpata Hospital. Health facilities with specialization care can hardly be found. Nyaya Health Nepal is working to improve the healthcare of this area since 2008 with its focus in integrated health care model. Apart from Achham, communities from surrounding communities of Bajura, Dailekh, Doti and Bajhang are also benefited from the Nyaya Health Nepal’s Hospital based program provided by Bayalpata Hospital. Bayalpata has been proved to be one of the best hospitals in the rural Nepal providing quality health care services including orthopedic surgery.The healthcare needs in the rural districts of Nepal are dire. The government has made efforts to address these needs, but the available resources and capacity of the public sector fall short of what is required.

NHN represents diversity in gender, caste, ethnicity, differently-abled and age in each tier, function and location of the staff.  

1. Dr. Mandeep Pathak: Medical and Surgical Director: Dr. Mandeep Pathak, is the consultant orthopedic surgeon and leader in trauma and surgical care in rural Nepal. Prior to joining Nyaya Health Nepal, He served as the senior resident in Southern Philippines Medical Centre. He earned a masters in Orthopedic Surgery from Southern Philippines medical center, Philippines, a fellowship in orthopedic oncology from University Malaya Medical Center, Malaysia. He envisions a world to get quality and affordable orthopedic and trauma care and is driving the change forward.

2. Srijana Devkota: Senior Partnership Lead: MBA degree with experienced in project and partnership management in different nationala nd international organsiations. Have an organisational and interpersonal skills; along with professional experiences across a wide range of sectors including Governance, Humanitarian, WASH, Social Protection and income generation of Urban Poor community, Urban Management, Transport Management and Media Communications Projects. Highly committed to professionalism, organised and exhibits excellent communication skills. 

3. Ram Raj Khakurel: Finance Lead: Ram Raj oversees financial administration in Nyaya Health Nepal. He is serving to Nyaya Health Nepal from last 5 years. He has expertise in financial data analysis, planning, transaction processing, administration, fund management and financial reporting.  He holds 20+ years of work experience in financial management & administration at different organizations throughout his career. He has earned Bachelor’s Degree in Financial Management from Tribhuwan University and awaiting the result of MPA with HR & Finance.

4. Sarita Sharma: M&E Manager: Sarita coordinates all the functions based in Kathmandu to ensure timely achievement of organization’s deliverables, works to strengthen monitoring and evaluation system and maintains the registrations and approvals required from government to run the organization smoothly. She has obtained Master of Public Health at Louisiana State University, and has worked for 3 years in southern USA as a healthcare quality assurance and improvement coordinator in a large community clinic. 

5. Deepak Bahadur Bista: IT lead: Before joining Nyaya Health Nepal, Deepak had been working at many Indian IT companies as an IT manager. He joined NHN in 2008 and started EHR - Electronic Health Record system first time in Bayalpata Hospital in 2015. He has more than 18 Years of experience in the IT sector.

6. Utsav Deshar, Implementation lead: Utsav works as an Implementation Lead at NHN and has more than 10 years of experience as an IT professional. He completed his Bachelors in Business Studies from Nepal Commerce Campus and holds a global IT certification in Server Virtualization with Windows Server Hyper-V and System Center, Programming in HTML 5 with Java Script and CSS 3 and MCP with IT professional training and skills on A+, MCSE, CCNA and RHCE. 

Direct beneficiaries: 80,000 from hospital services and community health program.

Free health care to the underserved communites is possible through a public-private partnership in collaboration with Government of Nepal and philanthropic partners to make a change happen in rural health care sector in Nepal. 

The intervention should focus on the following areas to manage health financing to meet the targets of the Sustainable Development Goals:

• Increase public sector healthcare investmentto reduce external aid.
• Empower people to make communicable and non communicable diseases treatment more strategic.
• Focus on primary health care and improve services.
• Enhance health insurance coverage. 

Nyaya Health Nepal solution is to create a digital platform where services provided from hospital through the hospital medical personnel and from community through the network of community health care workers are integrated together for an individual to improve the health care services of underserved communites of far west Nepal. 

Nyaya Health Nepal (NHN) free of cost health care services through integrated healthcare model can make the change happen to changes the lives of rural communties of Nepal. NHN operates a 50- bed hospital and primary healthcare center with 15 beds and runs community health programs in 6 different municipalities of Achham district of Nepal. In each of these 6 municipalities, NHN has network of community health workers who are integrating primary health care with facility based services through the counseling and care coordination services. Since this program has been implemented in the remote part of Nepal, it has been proved to be very impactful to serve the people residing in the region. NHN’s work has already shown to improve the institutional birth rate, a critical process indicator for maternal mortality, from 30% to 95% within the Achham district and has been able to save the lives of the people including the people who needed the emergency, surgical and mental health care services. 

NHN will use a digital platform where all the person in the community have unique ID, which will be used for active surveillance and parameters noted in a mobile based device, which gets integrated to the hospital based digital system. This will serve as a unique digital health identifier for each individual and interventions can be directed to specific target population. 

Besides other major services, NHN provides essential healthcare on reproductive, maternal, newborn and child health (RMNCH) through the facilities NHN manages and CHW networks. Women and girls are the most marginalized even among the underserved communities and NHN has a role to play in improving quality of care provided to women and girls through municipal integrated health care system. NHN prioritizes the further improvement of maternal, reproductive and child health care by strengthening the health system that has been implemented in the area.

Program Goal:

• To increase institutional birth rate to 95% as targeted by national commission for planning (baseline 95%)
• To reduce Neonatal Mortality Rate to 12 per 1000 live birth defined by SGD (baseline 13%)
• To maintain surgical complication rate below <5% as recommended by WHO (baseline 5.4%)

To maintain Cesarean-section (CS) rate to 10 to 15% as recommended by WHO recommendthe project will impact 85,000 people, of which, 30,000 are under the age of 25. 

NHN use electronic health record system (NepalEHR) and community mobile health tool to track the number of people served and the people who are enrolled for community health care services. While determining the target NHN uses the number of people served in the hospital in previous year and the number of people who are enrolled in the community health program for home based care at the time of baseline. The total number of patients served by facility care is 49,254 and people enrolled for the community health program for next year are 35,784 which make total of 85, 000. The number has been broken down by age i.e total of 30,000 under 25 years old population. These numbers have been projected for next year target.

However, this number is for direct impact, while indirectly it affects more than 200,000 populations of Achham district and another 200,000 of the surrounding Doti and Bajura district. 

The overall objective of the program is to sustain integrated health care model through digital care model and empower health care workers to provide equitable healthcare for all.

Specific objective:

• Strengthen an integrated approach to address the health care need of the underserved communities of Achham district;
• Establishing a stronger health care quality improvement support structure to assist rural health systems and professionals in collaboration with Provincial and Local Governments of Achham district;
• Enhancing the human resource capacity of health care professionals in rural communities and expanding the preparedness in improving health care services;

Social Impact: The program will effectively respond to reduce morbidity and mortality in Achham district. In addition, the impact will also reduce the economic and psychosocial burden of the diseases.

Project Beneficiaries.

The targets beneficiaries are the affected communities especially underserved and vulnerable, including children, women, elderly, people with disabilities, people with communicable and non-communicable diseases, and those from far west Nepal with poor access to health care services.

Project Outcomes

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:

• Improve health outcome of targeted beneficiaries
• Healthcare worker's capacitated in providing quality care
• Patients cared through High Dependency Unit (HDU)
• Improved recording and reporting of the community health care worker's intervention for early recognition and management of communicable and non-communicable diseases.

Through integrated health care services, NHN is continuing to improve health of the needy communities in Achham. Since its operation in 2008, NHN has provided care to more than 1 million visits through its hospital based services and more than 654,558 home visits are made by community health workers in the catchment area. In the area of maternal and child health, Institutional birth rate has been increased to >95 and hence has already met SGD’s goal. Acceptance of modern family planning method has been increased since the beginning of the program in the area. Bayalpata Hospital serves as a center for best medical and surgical practices as we have well trained physicians, orthopedic surgeon and health workers committed to put the patients first.

NHN has integrated Hospital based care services, community based care services and Digital health system to build integrated healthcare model. The approach is to connect the health care services from households to Hospitals with enhanced care using digital tools. NHN’s goal is to provide equitable healthcare services to underserved communities of Nepal. 

The objectives of the integrated healthcare model are to

• Improve institutional birth
• Reduce neonatal mortality
• Improve chronic disease control rate
• Increase use of contraception among the married women
• Reduce surgical complication

IMPACT on the Problem 

• Help health care provider to make well informed decision for the patient's care thorugh digital health care services;
• Reduce medical error;
• Increase effective communication between different departments of health services within the facilities;
• Encourage practice of paperless health information recording system;
• Facilitate the reporting to government Nepal; and
• Serve as a data collection tool for research and monitoring and evaluation. 

NHN implement a digital health platform (NepalEHR) where all the person in the community have unique ID, which will be used for active surveillance and parameters noted in a mobile based device, which gets integrated to the hospital based digital system. This will serve as a unique digital health identifier for each individual and interventions can be directed to specific target population.

All data collected will be of the active community population in the benefit of the community and people within it.

The digital intervention will improve the active disease surveillance system and helps improve intervention from “home to hospital”.

NHN represents diversity in gender, caste, ethnicity, differently-abled and age in each tier, function and location of the staff.  

Nyaya Health Nepal is managing Bayalpata Hospital in Achham district,Far West Nepal through a public-private partnership model. 

In line with organization’s program, NHN is collecting real time data through Electronic Health Record System (EHR) in the hospital and Mobile based app (CommCare) by the community health worker. Primarily, data is collected to monitor and evaluate the programs and use the data for improvement of the programs and secondarily is to report the program to different government entities and to the donors. NHN has been reporting to the ministry of health and population in monthly basis and also providing the data to local municipalities. These data have been used for health program planning in local level and in national level for developing health strategy and policy and planning of nationwide health programs.

 

NHN Financail Plan

Source Amount (USD) MoSD Far-west                                 381,355.93 Local Government                                   84,745.76 In-kind Support                                   59,322.03 Health Insurance                                   42,372.88 Intl Philanthropic Fund                                 755,000.00 Others                                 520,681.44 TOTAL                            1,843,478.05

NHN has been achieveing financial support from 3-tiers of Government of Nepal and internaitonal donors.