February 1, 2019 - April 30, 2019
Photo: Health Assistant Kamala Swar checks the blood pressure of a patient in Chaurmandu Primary Health Center, where we started services in February 2019
One of the most humbling aspects of health systems is the extent to which people go to access even the most basic and inadequate of healthcare.
The woman from Humla who walked a day to get evaluated for uterine prolapse. The expectant mother who traveled ten hours from the remote Achhami village of Khaptad only to have her premature infant die for our lack of advanced neonatal supportive care. The teenager from Ramaroshan who missed school for a year owing to chronic osteomyelitis and who limped her way for miles to reach Bayalpata Hospital.
These stories highlight a core tension in global health: quality hospital services save lives, yet population impact demands community-based outreach.
A hospital builds up surgical capacity but can't access individuals living remotely who need a femur fracture fixed or a cesarean section. A community health worker reaches remote areas, only to refer someone to a minimally staffed dispensary or clinic offering only the most basic of services. In the former, those lives who are reached can be saved but the systems question is about access; in the latter, community-level access is achieved but very few lives are saved without hospital infrastructure.
We obsess about: how to scale high quality facility-based inpatient, surgical, and outpatient care integrated with community health worker systems? How to scale this within Nepal's newly decentralized health system, where care is delivered through its more than 750 municipalities?
Our partnership with the Chaurpati municipality in Achham tries to answer this very question. It includes the strengthening of facility-based service delivery at the municipal primary health center as well as integration with the first-aid clinics via the NepalEHR.
We have designed our partnership with one goal in mind – determining how to sustain quality integrated care delivery within the resource constraints inherent in Nepal’s public health system so that the approach may be adopted by other municipalities across Nepal. And we will study the impact of services in this "municipal unit", with a focus on reducing neonatal mortality.
There are always compromises, when you are confronted with constraints, but we stay committed to our endgame: realizing quality healthcare across Nepal's 30 million population.
Thank you, as always, for being with us on this journey.
Photo: CHW discusses hypertension with an elderly patient in their community, while children watch on, reinforcing how health is a community affair.
In February of this year, as part of our 10-year partnership with Chaurpati municipality, we supported the roll-out of regular services at Chaurmandu Primary Health Center (PHC). The collaboration leverages the trust and relationships built through running a community healthcare program in the district over the past two years, and draws from the infrastructure and support from Bayalpata Hospital, 10 kilometers away (a 2-3 hour walk).
This new partnership will allow us to evaluate the impact of an integrated care delivery system within the “municipal unit”.
In the first three months, we have seen a doubling of patient volume at the PHC, from twenty patients a day to forty. The initiation of regular operations at Chaurmandu PHC will help relieve some volume at Bayalpata Hospital as people increasingly access care at Chaurmandu for non-emergency conditions.
The immediate feedback from the partnership has been positive: patients have welcomed a more regular presence of a physician, the ability to get lab tests and medicines closer to home, and follow-up to prevent conditions from becoming acute.
And, the partnership has allowed for a deeper integration of services from the onset. The partnership includes facility-based services, community healthcare and the NepalEHR.
Our work with Chaurpati municipality allows us to operationalize and evaluate an integrated "home-to-facility" integrated delivery system. This lays the ground for a robust integrated healthcare model to test in the eight municipalities in which we have long-standing partnerships with the local government around community healthcare.
Chaurpati therefore is an important step towards our ultimate goal of integrated healthcare systems for quality care for all across Nepal.
Patients Treated in Chaurmandu PHC
7,216Community Health Visits
in Chaurpati Municipality
2/1/19 - 4/30/19
As we continue to iterate on our approach to integrated care delivery, we are monitoring our KPIs to understand the impact of our efforts on population health. For our newest municipality, Chaurpati, we recorded at baseline a low institutional birth rate, low postpartum contraception prevalence, and high neonatal mortality, compared to other municipalities in the district. While these data highlight the challenging road ahead, we have seen some improvements in Chaurpati, observing a 51% increase in institutional birth rate at one-year follow-up.
Through our integrated NepalEHR, we track high-risk pregnancies, chronic diseases control measures, and surgical outcomes through multiple touch points, including those at Chaurmandu PHC, Bayalpata Hospital, and via Community Health Worker home visits.
Over time, the insights gained through connecting data within and across sites will help us generate robust evidence to better understand the impact of our integrated primary care model, and how we might continue to strengthen and replicate municipal healthcare systems across Nepal.
Identify and develop interventions that fill gaps in existing healthcare systems.
Integrate interventions into the existing healthcare system.
Evaluate the impact of component interventions and the overall healthcare system on population health and quality of care.
Use evidence and experience to improve the design of scalable integrated delivery systems.
Sustain integrated care within the municipal system through strong fiscal, data and governance mechanisms.
Distribute practices, policies, and findings around integrated healthcare systems, and their operation and impact in resource-constrained settings.
Train health system staff and frontline health workers on global best practices, adapted to local contexts.
Engage government, civil society and partners to inform policy and scale.
February 1, 2019 - April 30, 2019
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