Bikash Gauchan

Partnerships in mental healthcare service delivery in low-resource settings: developing an innovative network in rural Nepal

BackgroundMental illnesses are the largest contributors to the global burden of non-communicable diseases. However, there is extremely limited access to high quality, culturally-sensitive, and contextually-appropriate mental healthcare services. This situation persists despite the availability of interventions with proven efficacy to improve patient outcomes. A partnerships network is necessary for successful program adaptation and implementation.Partnerships networkWe describe our partnerships network as a case example that addresses challenges in delivering mental healthcare and which can serve as a model for similar settings. Our perspectives are informed from integrating mental healthcare services within a rural public hospital in Nepal. Our approach includes training and supervising generalist health workers by off-site psychiatrists. This is made possible by complementing the strengths and weaknesses of the various groups involved: the public sector, a non-profit organization that provides general healthcare services and one that specializes in mental health, a community advisory board, academic centers in high- and low-income countries, and bicultural professionals from the diaspora community.ConclusionsWe propose a partnerships model to assist implementation of promising programs to expand access to mental healthcare in low- resource settings. We describe the success and limitations of our current partners in a mental health program in rural Nepal.

Visceral Leishmaniasis in Far Western Nepal: Another Case and Concerns about a New Area of Endemicity

Dear Sir: Pandey and others reported the first case of visceral leishmaniasis (VL) in the Far Western Hills region of Nepal.1 At our hospital in the Achham district, which neighbors the Doti district described in the Pandey and others report, we recently had a case of VL in a 17-year-old woman who presented with advanced disease. We transferred her to a hospital in Kathmandu where she received amphotericin and required intensive care, but unfortunately ultimately succumbed to her illness. Like the patient Pandey and others described, our patient had never traveled to known VL-endemic areas. As the authors pointed out, VL has been thought to be limited to south-eastern Nepal, far from where these cases occurred. It is possible that these cases were due to Leishmania infantum, which has a canine reservoir and has been seen in Himachal Pradesh in India, Pakistan, and throughout Central Asia.2,3 However, it is also possible that the Phlebotomine sandfly is making inroads in other parts of Nepal, and with it Leishmania donovani. With climate change, we have seen other vector-borne diseases spreading to new areas. Dengue was first seen in southern Nepal in 2004 and has moved north to Kathmandu, where Aedes aegypti was not previously seen.4,5 Given extreme poverty and poor healthcare infrastructure in the remote western part of Nepal, passive case detection for VL may be inadequate for surveillance. To achieve the goal of VL eradication agreed upon by the governments of Nepal, India, and Bangladesh, we concur with Pandey and others that active surveillance in Nepal should be urgently expanded.

Design and implementation of an affordable, public sector electronic medical record in rural Nepal

Introduction Globally, electronic medical records are central to the infrastructure of modern healthcare systems. Yet, the vast majority of electronic medical records have been designed for resource-rich environments and are not feasible in settings of poverty. Here, we describe the design and implementation of an electronic medical record at a public sector district hospital in rural Nepal and its subsequent expansion to an additional public sector facility. Development The electronic medical record was designed to solve for the following elements of public sector healthcare delivery: 1) integration of the systems across inpatient, surgical, outpatient, emergency, laboratory, radiology and pharmacy sites of care; 2) effective data extraction for impact evaluation and government regulation; 3) optimization for longitudinal care provision and patient tracking and 4) effectiveness for quality improvement initiatives. Application For these purposes, we adapted Bahmni, a product built with open-source components for patient tracking, clinical protocols, pharmacy, laboratory, imaging, financial management and supply logistics. In close partnership with government officials, we deployed the system in February of 2015, added on additional functionality and iteratively improved the system over the following year. This experience enabled us then to deploy the system at an additional district-level hospital in a different part of the country in under four weeks. We discuss the implementation challenges and the strategies we pursued to build an electronic medical record for the public sector in rural Nepal. Discussion Over the course of 18 months, we were able to develop, deploy and iterate upon the electronic medical record, and then deploy the refined product at an additional facility within only four weeks. Our experience suggests the feasibility of an integrated electronic medical record for public sector care delivery even in settings of rural poverty.

Developing a scalable training model in global mental health: pilot study of a video-assisted training Program for Generalist Clinicians in Rural Nepal

Background. In low- and middle-income countries, mental health training often includes sending few generalist clinicians to specialist-led programs for several weeks. Our objective is to develop and test a video-assisted training model addressing the shortcomings of traditional programs that affect scalability: failing to train all clinicians, disrupting clinical services, and depending on specialists. Methods. We implemented the program -video lectures and on-site skills training- for all clinicians at a rural Nepali hospital. We used Wilcoxon signed-rank tests to evaluate pre- and post-test change in knowledge (diagnostic criteria, differential diagnosis, and appropriate treatment). We used a series of ‘Yes’ or ‘No’ questions to assess attitudes about mental illness, and utilized exact McNemars test to analyze the proportions of participants who held a specific belief before and after the training. We assessed acceptability and feasibility through key informant interviews and structured feedback. Results. For each topic except depression, there was a statistically significant increase (Δ) in median scores on knowledge questionnaires: Acute Stress Reaction (Δ = 20, p = 0.03), Depression (Δ = 11, p = 0.12), Grief (Δ = 40, p < 0.01), Psychosis (Δ = 22, p = 0.01), and post-traumatic stress disorder (Δ = 20, p = 0.01). The training received high ratings; key informants shared examples and views about the trainings positive impact and complementary nature of the programs components. Conclusion. Video lectures and on-site skills training can address the limitations of a conventional training model while being acceptable, feasible, and impactful toward improving knowledge and attitudes of the participants.

Power, potential, and pitfalls in global health academic partnerships: review and reflections on an approach in Nepal

ABSTRACT Background: Global health academic partnerships are centered around a core tension: they often mirror or reproduce the very cross-national inequities they seek to alleviate. On the one hand, they risk worsening power dynamics that perpetuate health disparities; on the other, they form an essential response to the need for healthcare resources to reach marginalized populations across the globe. Objectives: This study characterizes the broader landscape of global health academic partnerships, including challenges to developing ethical, equitable, and sustainable models. It then lays out guiding principles of the specific partnership approach, and considers how lessons learned might be applied in other resource-limited settings. Methods: The experience of a partnership between the Ministry of Health in Nepal, the non-profit healthcare provider Possible, and the Health Equity Action and Leadership Initiative at the University of California, San Francisco School of Medicine was reviewed. The quality and effectiveness of the partnership was assessed using the Tropical Health and Education Trust Principles of Partnership framework. Results: Various strategies can be taken by partnerships to better align the perspectives of patients and public sector providers with those of expatriate physicians. Actions can also be taken to bring greater equity to the wealth and power gaps inherent within global health academic partnerships. Conclusions: This study provides recommendations gleaned from the analysis, with an aim towards both future refinement of the partnership and broader applications of its lessons and principles. It specifically highlights the importance of targeted engagements with academic medical centers and the need for efficient organizational work-flow practices. It considers how to both prioritize national and host institution goals, and meet the career development needs of global health clinicians.

Role of the general practitioner in improving rural healthcare access: a case from Nepal

BackgroundThere is a global health workforce shortage, which is considered critical in Nepal, a low-income country with a predominantly rural population. General practitioners (GPs) may play a key role improving access to essential health services in rural Nepal, though they are currently underrepresented at the district hospital level. The objective of this paper is to describe how GPs are adding value in rural Nepal by exploring clinical, leadership, and educational roles currently performed in a rural district-level hospital.Case presentationWe perform a descriptive case study of clinical and non-clinical services offered at Bayalpata Hospital prior to and following the initiation of GP-level services in 2013. Bayalpata is a district-level public hospital managed through a public private partnership by the nonprofit healthcare organization Possible. We found that after general practitioners were hired, additional clinical services included continuous emergency obstetric care, major orthopedic surgeries, appendectomy, tubal ligation, and vasectomy. This time period was associated with increased emergency department visits, inpatient admissions, and institutional birth rate in the hospital’s catchment area. Non-clinical contributions included the development of a continuing medical education curriculum and implementation of a series of quality improvement initiatives.ConclusionsGPs have potential to bring significant value to rural district hospitals in Nepal. Clinical impact may include expanded access to surgical and emergency obstetric services, which would more fully align with local health needs, and could further reduce Nepal’s maternal mortality rate. Task-shifting and structured training programs would be required to increase orthopedic surgery capacity, but this would contribute to meeting local healthcare needs. Non-clinical impact may include supervision of health workers and leadership in continuing medical education and quality improvement initiatives. These changes can lead to improved health worker recruitment and retention in rural posts. Limitations include generalizability of our results to other district hospitals in Nepal and lack of data from control hospitals. This analysis provides an additional perspective on the potential value GPs can add in rural Nepal, through provision of a wide range of clinical and non-clinical services. It supports the expansion of GPs to additional district hospitals in Nepal’s public sector.