Strengthening Chronic Disease Management in Rural Far-West Nepal – An intervention at the District Healthcare System in Achham, Nepal

Abstract: Most district health care systems in resource-limited settings are poorly oriented towards providing longitudinal care for patients with chronic diseases as they are structured towards hospital or clinic based single-delivery interventions. Linking community based resources with hospital and clinic systems using the well-studied Chronic Care Model promises to ensure patients are not lost to follow-up, but more importantly, are detected before serious disability results. By using the Chronic Care Model in Achham, Nepal, we aim to improve the longitudinal management of pediatric chronic diseases through coordinating between the district health system and community health network. This research study will study the implementation of this intervention.


IRB Status: Nepal Health Research Council: #125/2013, Dhulikhel Hospital Institutional Review Committee: #93/14, Partners IRB: #2015P000599. #NCT02331082


Data Status: Integrated Electronic Health Record implemented at Bayalpata Hospital and Charikot Hospital; heath record integration between mobile and facility data streams ongoing; data analysis workplan under development; data collection ongoing.


Funding: All research-related expenses are covered by the NIH Director’s Early Independence Award and the Charles H. Hood Child Health Research Prize.


Principal Investigator: Duncan Maru

Health Post Strengthening to Reduce Under 2 Child Mortality

Abstract: A central challenge in the delivery of evidence-based interventions to promote under-five child survival is the coordination of care across the multiple tiers of the health system, from frontline health workers, to primary care clinics, to district hospitals, to specialty providers. Additionally, children who survive or avoid once-fatal diseases such as congenital and rheumatic heart diseases, prematurity, neurodevelopmental conditions, and disabilities sustained from traumatic injuries, are increasingly living well into adolescence, young adulthood, and beyond. Healthcare delivery systems in resource-limited settings, however, are ill-equipped to manage such patients’ care. Mobile technologies, coupled with effective management strategies, may enhance implementation and coordination of evidence-based interventions, but few controlled trials exist that assess such strategies in an integrated manner across the health system.


We are evaluating the implementation of a novel healthcare system strengthening project on the under-two child mortality rate in Achham District, Nepal.  The intervention includes 2 primary components:


1) Structured quality improvement at the Health Post-level and Community Health Worker-level in tandem with mobile phone-based care coordination. We will attempt to increase the timely engagement in acute care for children under the age of five to receive evidence-based World Health Organization protocols aimed at reducing child mortality—Integrated Management of Pregnancy and Childbirth, Integrated Management of Childhood Illness, Integrated Management of Emergency and Essential Surgical Care, and Community-based Management of Severe Acute Malnutrition.


2) Implementing the Chronic Care Model for pediatric patients under the age of twenty suffering from a chronic disease (congenital and rheumatic heart disease, diabetes, depression, epilepsy, asthma, musculoskeletal and neurodevelopmental disabilities, and pre- and post-surgical conditions).


IRB: Nepal Health Research Council #79/2012; Partners IRB #2015P000599 #NCT02331082


Status: Baseline household census to measure population health outcomes of interest completed and data analyzed. Planning for next stages of quality improvement intervention at health posts throughout Achham District.


Funding: All research-related expenses are covered by the NIH Director’s Early Independence Award and the Charles H. Hood Child Health Research Prize.


Principal Investigator: Duncan Maru



Group antenatal care: the power of peers for increasing skilled birth attendance in Achham, Nepal

Abstract: In Achham District of Nepal, the major drivers of underutilization of skilled birth attendance are poverty, poor social support and inadequate birth planning. Drawing from similar programs that have been shown to improve maternal and neonatal outcomes, we have designed a group antenatal care program that uses a participatory learning and action process to engage women in identifying and solving problems accessing maternity care services and create a supportive social network. We are testing a group antenatal care program that will change antenatal care in three major ways:

1) conduct care in a group setting with women matched by gestational age,

2) incorporate participatory learning and action, and

3) provide expert and facilitated peer counseling.


IRB Status: Nepal Health Research Council: #133/2014, Dhulikhel Hospital Institutional Review Committee #81/14, Partners IRB: #2015P000058. #NCT02330887


Data Status: Data collection finalized; data analysis in process; research write-up in process.


Funding: Salary, travel, and research-related expenses for Dr. Maru are covered by the Brigham and Women’s Hospital Global Women’s Health Fellowship. Travel and research-related expenses for Alex Harsha are covered by the Harvard Medical School Center for Primary Care Fellowship. All remaining research expenses for local Nepal-based staff are covered by Possible.


Principal Investigator: Sheela Maru


Effectiveness of online educational modules in improving knowledge-base in mental illness among primary care providers in Nepal

Abstract:  In Nepal, mental health is a highly ignored discipline in health professional schools (e.g. Bachelor of Medicine, Bachelor of Surgery-trained physicians, Health Assistants, Auxiliary Health Workers) and post-graduate trainings are also very limited. However, the prevalence of mental illness is estimated to be between 20-30% of all primary care visits, leading to a large treatment gap. Training primary care providers (PCPs) is an appropriate first step to address this gap. We are implementing the use of computer-based, online educational modules with PCPs to improve mental health training. Effectiveness of PCPs’ comfort level, knowledge, and skills in evaluating, diagnosing and managing mental illness will be assessed by administering pre- and post-tests. Acceptability, feasibility and PCPs’ comfort-level with the educational modality will also be assessed. Data from the tests will be analyzed using paired t-tests. Additionally, data from the focus group discussions will be analyzed to assess for themes that might be common among PCPs in other parts of rural Nepal, or regions where access to psychiatrists is very limited. We will conduct the study with PCPs at Bayalpata Hospital and other healthcare facilities in Achham District.


IRB: Nepal Health Research Council: #288/2014, UCSF: # 066667 #NCT02376062


Status: Online modules are being pilot tested and administered to Primary Care Providers at Bayalpata Hospital and in Achham District. Curriculum is being developed and refined in light of the earthquake and the developing burden of mental health diseases in rural Nepal.


Funding: University of California, San Francisco Resident Training Program; National Institute of Mental Health, United States.


Principal Investigator: Bibhav Acharya

Population metrics for district healthcare systems

Abstract: The performance of public sector district healthcare systems globally is inconsistent. The monitoring and evaluation systems for measuring district healthcare systems performance are also inconsistent and vary by context. Despite the differences of various district healthcare systems globally, understanding their overall impact on the health outcomes of their catchment population is critical and demands accurate and appropriate measurement. There is a need for a core set of metrics that can drive evaluation processes and create opportunities for comparisons. Historically, however, metrics for assessing district healthcare systems tend to be volume-based rather than outcome and impact-focused.


Over the past year, we have piloted the use of six population-based metrics that can form as the foundation for district healthcare systems monitoring and evaluation programs. They included: Outpatient Utilization Rate, Equitable Access Metric, Institutional Birth Rate, Contraceptive Prevalence Rate, Chronic Illness Follow-Up Rate, and the Surgical Services Access Ratio. These metrics were implemented in Achham District, Nepal and served as the basis for Possible’s programmatic monitoring and evaluation.




Status: Manuscript written and submitted; pending publication.


Funding: All research related expenses were covered by Possible.


Principal Investigator: Duncan Maru


Lead Author: Scott Halliday


Performance based financing of public-private partnership hospitals in Nepal

Abstract: Concerns over accountability and transparency at grant-receiving hospitals have been raised by various External Development Partners, thus prompting the need for performance incentives. The resulting performance-based grant agreements (PBGA), which conditionally tie funding to performance, are novel in concept and being implemented in Nepal’s health sector for the first time, creating an opportunity to study the process of implementation. This study assessed the process of implementation of the Nepal Ministry of Health and Population’s “Performance-Based Grant Agreements” at 7 public-private partnership health institutions.


Qualitative, semi-structured interviews with key informants were conducted in order to understand the relevant topics and themes associated with early-stage implementation. We concluded that there was a gradient of awareness among the implementing institutions that underscored challenges to undertaking proper monitoring and evaluation, understanding the content and purpose of the agreements, and effecting change to promote transparency and accountability. However, among stakeholders, there was a high level of optimism about the potential for PBGA to bring positive change to Nepal’s healthcare sector. These results can inform the design of future mixed methods research and impact evaluations of PBGA.


IRB: Nepal Health Research Council  #211/213, Dhulikhel Hospital Institutional Review Committee #78/14


Status: Data collected and analyzed; research write-up in-process.


Funding: This research study currently receives no funding.


Principal Investigator: Biraj Karmacharya


Lead Author: Scott Halliday


Chronic Care Model for Rural Surgical Access

Abstract: Patients in isolated rural communities typically lack access to surgical care. The effective delivery of surgical care requires systems to screen, triage, diagnose, treat, and follow up patients within a local and remote referral network. Patient navigators and care coordination programs have shown promise in improving access to services traditionally underutilized by marginalized populations. There are few examples, however, of referral systems that deliver care in an integrated manner longitudinally, from the patients’ homes to local hospitals to remote specialty centers and back again. Here, we describe a program at a district-level hospital in rural Nepal that is over fourteen hours from the nearest specialty referral center. In this program, the hospital’s Community Health Department directly manages surgical care coordination for cardiac, orthopedic, plastics, gynecologic, and general surgical conditions from screening through follow-up. Here, we use the Chronic Care Model as the theoretical framework for assessing the operations and challenges during the initial 216 patients enrolled. This experience suggests the possibilities of improved surgical access through a Chronic Care Model for remote populations.


IRB: Nepal Health Research Council # 98/2011, Expires 6/26/2015; Partners IRB #2012P000856; Expires 5/15/2014

Status: Data collected and analyzed; research write-up currently on hold.


Funding: All research related expenses were covered by Possible.


Principal Investigator: Duncan Maru


Lead Authors: Matt Fleming, Caroline King


Scale-up of essential surgical services at a district hospital in rural Nepal

Abstract: There is an acute need to expand surgical care globally. Rural district healthcare systems generally have basic infrastructure, staffing, and supplies to serve as building blocks for surgical services. Typically, such hospitals are under-staffed, -equipped, and -resourced for delivering surgical care. A key implementation challenge involves rolling out surgical services at district hospitals that provide existing general medical care. Little literature exists describing this transformation. In this study, we describe the costs, human resources, operational challenges, and initial patient outcomes of surgical services roll-out at a district hospital in rural Nepal. The surgical program includes both continuous surgical services managed by a general practitioner and intermittent services delivered by specialty teams.


IRB: Nepal Health Research Council # 98/2011, Expires 6/26/2015; Partners IRB #2012P000856; Expires 5/15/2014


Status: Data collected and analyzed; research write-up in process.


Funding: All research related expenses were covered by Possible.


Principal Investigator: Duncan Maru


Lead Author: Matt Fleming




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