Rural hospital an affordable model?


Bayalpata_Hospital_community_health_worker_patient_(c)_Marty_Logan

Bayalpata Hospital Community Health Worker Bhajan Kunwar checks the blood pressure of Namsara Tamrakar at her home in Chandika village, Achham district, Nepal, Feb. 2018.

Below is the article I wrote for Nepali Times after visiting Bayalpata Hospital in Nepal’s Achham district. Achham is often described as “remote” but we drove there easily in 9 hours from a main city, paved roads all the way, and jolted by fewer potholes than you’ll suffer driving in Kathmandu.

Though it appears long for the Times, the article leaves out a lot that I would have liked to say about Bayalpata.

First, the hospital provides an even more impressive list of services than I described, using an array of technical tools. These include:

  • a digital x-ray machine
  • dental services
  • hip replacement surgery
  • mental health treatment.

Bayalpata is also exceeding three of the four targets set with the Government of Nepal (GoN) in order to qualify for increased grants. These are:

  • the numbers of patients giving birth in a facility and with a qualified health worker
  • the number of surgical complications
  • contraceptive prevalence.

The one target the hospital hasn’t reached is control of chronic (noncommunicable) diseases (NCDs). I asked Director of Medical Education Dr Bikash Gauchan about this: his answer is likely to be featured in an upcoming video by NCD Alliance.

The article’s main omission concerns the question of whether the hospital is a good model for Nepal, and for other so-called developing countries. Dr Gauchan is confident that it’s on the way to becoming one, as you can see in the video below.

I’ll briefly describe how the hospital operates: it is run by a US-based NGO (Possible, which also runs a hospital in Dolakha district, east of Nepal’s capital Kathmandu). Possible is funded mainly by donations, with the second largest funder being the GoN, which provided just 9% of the hospital’s US$4.8 million operating expenses in 2017.

Right to health = free services

Possible doesn’t charge patients: all services are free. The NGO believes that health care is a right that should be available to everyone regardless of means, including the mainly rural population in Achham and Dolakha. It notes that this right is enshrined in Nepal’s constitution.

Possible’s vision (again, as set out by Dr Gauchan in the video below) is that the GoN will begin investing more in health care – in part after realising the effectiveness of the Bayalpata model – eventually reaching $20 per patient. (Today the GoN spends roughly $4-5 per capita on health). Possible estimates that in 2017 it will be able to provide all of the services in its hospitals for roughly $20 per capita. That figure was almost $37 in 2017.

To me, those numbers generate a major question: how long will it take the GoN to increase its health care investment to the amount needed to operate the Bayalpata model? I could speculate, but that would just be grasping figures from the air, so I won’t bother, but given Nepal’s economic situation, I think it’s fair to say it won’t happen within the next couple of years.

A second question about the sustainability of the model, which I mentioned in the Times article, is the cost of building another Bayalpata. The hospital is spending $4 million on its current, badly-needed expansion, with $1.5 million of that coming from the GoN.

Construction is being done with ‘rammed earth’, which is basically just what it sounds like: dirt that has been highly compressed. One reason this method was chosen was to keep the cost of shipping building materials low, says a project designer and planner. Another is because of the rammed earth’s passive heating and cooling properties.

The project also includes rooftop solar, which will be the main source of power, rainwater collection and wastewater treatment.

Affordable model?

When I returned to Kathmandu I mentioned my trip to a builder I know. He said that he had spoken to people involved in the Bayalpata expansion, who told him that for the cost of the project two rural hospitals could have been built. I asked Dr Gauchan about this, and have reproduced his answer at length below because I think this is an important issue, that goes to the heart of evaluating the ‘Bayalpata model’.

“The existing infrastructure for health care, especially in rural areas, is way less than minimum. We want to directly say to the government that this is inadequate to address the emerging burden of NCDs, road traffic accidents and infectious diseases. It looks like our initial investment is very high, but in the long run if we compare the outcome with regards to capacity to deliver more healthcare services … ultimately the cost of health will be low compared to not investing in good infrastructure in rural areas.

“We obviously have lessons learned and would be happy to share them with the Ministry of health… including if there are ways to minimise the cost of the expansion. We are not saying that each project should be spending on infrastructure the way we are: it’s not like this blueprint should be replicated in each district.”

There’s no doubt that Bayalpata is a very ambitious project, nor that it is an impressive one. I can’t offer an expert opinion about its viability but I certainly hope that Possible’s vision can be realised at its hospitals in Nepal, in part because that would represent a significant investment in health care by the government. That would be money well spent.

Nepali Times article:

State of the art rural hospital

Marty Logan March 30, 2018

Rounding a steep curve on the road to the district capital of Mangalsen a startling set of modular structures comes into view. The modern buildings look out of place in this scenic, but underserved, region of western Nepal.

The construction is part of a $4 million expansion of Bayalpata Hospital, a unique medical facility that is a model for public-private partnership to improve medical care in Nepal’s remote interior.

Inside the ward, orthopaedic surgeon Mandeep Pathak is examining an elderly man with a swollen knee. Clearly visible on an x-ray monitor is a short pin inserted by a general practitioner a few weeks ago, after the patient fell and broke his kneecap.

In the same room with the surgeon today is Community Medical Assistant (CMA) Khagendra Pant, who is wrapping plaster around the arm of a small boy. Thanks to training at the hospital, Pant was able to diagnose the boy’s injury as a clean fracture that did not require an operation.Such training means Bayalpata now has to refer just 10-20% of orthopaedic cases to hospitals in Dhangadi and Nepalganj, compared to nearly 70% two years ago.

“I am proud to say that all the basic trauma care can now be done by general practitioners. Plus they can diagnose cases and decide which need to be referred to outside centres,” says Pathak.

Training is integral to Bayalpata’s mission, says Director of Medical Education Bikash Gauchan: his hospital has continuing medical education for clinicians, and on the job training for future nurses and other staff. General practitioners from various centres learn rural surgery at Bayalpata while mid-level staff come to improve their clinical knowledge.

For some patients who travel many days to reach Bayalpata, access to basic surgery here means avoiding an expensive trip to the city. People whose limbs were fractured as long as three years ago delayed treatment until surgery was available at the hospital because they couldn’t afford the trip to a city hospital.

Treatment at Bayalpata and at another hospital in Dolakha run by the non-profit Possible, is free. The group believes healthcare is a fundamental human right protected by Nepal’s Constitution, and should have no cost at point of delivery.

Possible is funded by donations and Nepal government grants, which will grow as its hospitals attain clinical targets, such as the percentage of women who give birth in a facility with a trained clinician. Operating expenses last year were $4.8 million, of which 9% came from the government.

Arrivals are registered in the hospital’s Electronic Health Record (EHR), which puts patients’ information at the fingertips of clinicians throughout the hospital, and eliminates bulky paper records.

One patient already on the EHR is Namsara Tamrakar. Sitting cross-legged on a raised, wooden platform outside her home in Chandika village (left), the elderly woman shows visiting hospital staff that she knows how to use her inhaler, but it is empty.

Three years ago, a doctor at Bayalpata diagnosed her with chronic obstructive pulmonary disease and prescribed medicine via inhaler. Now Community Health Worker Bhajan Kunwar visits regularly to follow up. Like others, Tamrakar’s house has a small blue metal tag on an outside wall with a unique household ID. The houses are also geo-tagged.

Kunwar’s visit is guided by CommCare, a software developed by Dimagi and customised by Possible that includes counselling information and checklists for each patient. Plans are to integrate CommCare with the EHR so that field followups are immediately reflected in the hospital’s system. Eventually, Bayalpata’s EHR will be linked to a national data system.

Kunwar takes Tamrakar’s blood pressure: 120 by 80. The woman is happy to hear the news and to see Kunwar again: “She comes, does a check-up, and tells me what sickness I have, and if it is getting better or worse. She insists I go to Bayalpata for a follow-up.”

The hospital’s community health program focuses on maternal and child health as well as non-communicable diseases such as hypertension, diabetes and respiratory ailments. Possible employs 56 community health workers looking after more than 80,000 people in Achham and Dolakha. It is planning to more than quadruple that number next year.

Bayalpata Hospital started in 2009, when the group Nyaya Health (now Possible) took over an abandoned government facility. Then it had five beds and treated up to 12,000 patients a year. Last year, Possible saw 86,000 patients at Bayalpata: the goal is to treat 150,000 people annually after the new wards, emergency room, administration building, a dormitory and remaining small houses for on-call staff are added.

“Our integrated, hospital-to-home approach will be a model for Nepal, and beyond,” explains Gauchan, “and we will be proving that in a resource-limited setting, health care expansion, providing universal health coverage to people is possible.”

But is the Bayalpata model really replicable? Skeptics say that two hospitals could have been built for the cost of the new buildings, which feature rammed earth technology, solar energy and rainwater collection, and that only substantial donor support made the expansion possible.
Gauchan admits that the initial investment may seem high but says it will be more cost-effective in the long run.

He adds: “The existing infrastructure for rural health care is way less than the minimum needed to address the emerging burden of non-communicable diseases and road accidents as well as infectious diseases. That is why we are investing in a very robust infrastructure.”

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