APPROACH AND METHODOLOGY
The implementation of surgical services will occur within a quality improvement framework. Methods include regular data management reviews based on a Plan-Do-Study-Act (PDSA) strategy, clinical- and operations-level checklists, and a mortality and morbidity conference program. Bayalpata Hospital's existing network of CHWs will follow-up post-surgical patients to detect and prevent complications. Within each political subdivision, these health workers report to a community health advocate; the advocates themselves report to a hospital-based coordinator. Bayalpata Hospital maintains an active database of outcomes for its clinical programs and uses these data to drive PDSA programs. Additionally, checklists will serve as the basis for ongoing quality improvement including facilities maintenance, biomedical engineering, and provider-level clinical care. Finally, an ongoing mortality and morbidity review program conducted at the hospital serves as an institutional quality improvement mechanism. Within this program, deaths and morbidities are reviewed by staff to identify systems-level areas and action items for improvement.
Nyaya Health estimates that they will engage 35 total people in this project, including volunteers in the US who are actively engaged in fundraising and communications for this project (12 people), on-site volunteers like those from Harvard's Center for Surgery and Public Health who have been traveling and working within Nepal (8 people). Additionally, several Nepali staff will be directly involved as the only care providers on-site at Bayalpata Hospital (10 people). Lastly, partners from the solar energy sector are involved in more than doubling Bayalpata Hospital's solar power capacity in order to provide for the electrical needs of the new center (5 people).
IMPLEMENTATION, TIMELINE AND DELIVERABLES
Nyaya Health is planning renovations in two phases in order to expedite the delivery of emergency surgical care.
In Phase 1 (Jan 2012-April 2012), they will renovate the operating room, scrub sink, gowning areas and sterile storage room. These are the areas that are required to start carrying out surgeries.
In Phase 2 (April 2012-2014), they will renovate pre-operation (pre-op) and post-operation (post-op) areas. Until the pre-op and post-op areas are completed, the inpatient male and female wards will be used as pre-op and post-op wards. They anticipate the operating room to be fully functional by May 2012, and Bayalpata Hospital's first C-section will be completed during that month.
Nyaya Health estimates 9,244 women will be directly impacted over the next three years by the increased access to additional providers and services. Additionally, Nyaya Health commits to engage 35 people in the United States and Nepal to promote this project.
Pregnancy is often referred to as a 'gamble with death' in rural Nepal, where maternal mortality rates are some of the highest in the world. Nyaya Health, in partnership with the Nepali government, is working to dramatically reduce that risk and to protect the health and human rights of women in one of Nepal's most remote, impoverished, and war-affected districts, Achham. Achham is consistently ranked as 1 of the 5 poorest districts in all of Nepal with a per capita income estimated to be USD 0.40 per day. When Nyaya Health began working in Achham, there was not a single doctor to serve over 260,000 people. Even today, Achhamis must travel at least 6 hours by bus to the nearest operating room capable of carrying out a C-section and 12 hours to be admitted to an intensive care unit. Women and girls, owing to various forms of gender marginalization, have borne much of the burden of disease and lost opportunities in Achham. Almost 1 in 125 women die in childbirth, most women are sent to cattle sheds during menstruation and childbirth, and abortion and contraceptive services are nearly nonexistent. Widespread power inequalities between men and women in the region manifest as domestic violence, economic dependency, and gender preference and selection. While Bayalpata Hospital currently offers full inpatient and outpatient services, emergency and obstetric care, laboratory, pharmacy, radiology, and ambulance services, and a community health worker (CHW) program in local communities, the development of a surgical center at Bayalpata Hospital will allow Nyaya Health to improve the quality of healthcare provided to the most impoverished and vulnerable citizens.