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Electronic Medical Record (EMR) is the digital tool to keep records of valuable information on computer or computer-like equipment, regarding health systems, including patient’s records and stock management which can provide real time evidence for better patient record, clinical care and health policy making. As Nepal does not have a national EMR system, and it is a challenge to get real time data, information and evidence required for effective health policy making. With an effective national EMR system in Nepal, the health system can be improved with reliable information of patients for the continuity of clinical care. There are existing scientific evidence of EMR on the lessons of implementation in Nepal, opportunities for the use of EMR in Malaysia, perspectives of health care workers on EMR after its implementation in Canada, on the development of success measuring tools and the use of questionnaires for the EMR implementation in Canada, best practices, impact of EMR on physician practice, and barriers for EMR implementation. EMR can improve the quality, effectiveness, transparency and efficiency of healthcare services and its management. Gandaki province is one of seven provinces in Nepal and is exploring ways to implement EMR in all the hospitals operated under the province government. There can be step wise approach to have EMR in all of these hospitals. This can give more strategies for the national EMR system.

Introduction: Nepal is a low-to-middle-income country (LMIC) with a predominantly rural population. Almost 10-20% of patients presenting to hospital require surgical care. The availability of skilled human resources in managing surgical care in rural areas of Nepal has to expand to meet this need. The objective of this study is to describe and demonstrate how General Practitioners (GPs) can be upskilled to provide surgical care in rural district hospitals in Nepal. Method: It is a retrospective review of all surgical procedures performed by GPs from 1st February 2016 to 31st January 2021 at Charikot hospital. Data was collected from a prospectively maintained Electronic Health Record (EHR) system (Bahmini). Details of data collected included name of the procedure and its respective specialty. GP Task shifting and targeted surgical training programs for common orthopedic procedures and pediatric herniotomy were described in detail. Result: A wide range of surgical procedures were performed by GPs over 5 years. This included interventions for obstetric emergencies, trauma and orthopedics, gynecological issues, general surgery of adult and childhood. A total of 2037 surgeries were performed by GPs including: Cesarean section 25%, 19.7% were orthopedics surgeries followed by 13.5% of mesh repair for abdominal hernia, 9.3% eversion of sac for Hydrocele, 8.7% appendectomy, 5.2% hysterectomy, 3% of pediatric herniotomy and others. Conclusion: GPs can be further trained to perform important common surgical procedures to improve access to surgical care for rural communities. Keywords: Continuing medical education, general practitioner, leadership, rural surgery

BackgroundThe economic burden and cost-related evidence from primary data of road traffic crashes (RTCs) in Nepal are limited.AimThis study assessed the disability-adjusted life years (DALYs), the cost associated with RTCs, and socio-demographic and injury related factors.MethodsWe carried out a retrospective cross-sectional, institution-based survey of the RTC victims in the last one year to 45 days prior to the survey, in Pokhara and the surroundings in Kaski district, a mid-hilly district and the headquarter of Gandaki province of Nepal. A sample of 107 RTC victims, registered in different hospitals, police offices and health insurance offices, were retrospectively approached. A semi-structured interview schedule was used to collect data. Data were entered into EpiData before being imported, and analysed in the Statistical Package for Social Sciences (SPSS) and MS-Excel. Descriptive statistics were generated by calculating costs and DALYs, and inferential analysis was used to investigate the relationship between DALYs and independent variables.ResultsMore than one-third (37.4%) of the 107 victims were between the ages of 25 and 44, and more than half (60.7%) were men. The cost per million person-years of RTC was around US $ 82,800. Similarly, around 1021 DALYs per million person-years are attributed to RTC, and more than 99% of them are shared by YLL. We observed the highest number of frequencies of young (pConclusionThe cost and DALYs associated by RTC of Kaski district were around US $ 82,800 and 1021 per million person-years in 2017, respectively. Young unemployed motorcyclists were the most frequent victims. Victim’s indirect cost is increased with DALYs, suggesting a policy implication.

Author(s): Rimal, Pragya; Choudhury, Nandini; Agrawal, Pawan; Basnet, Madhur; Bohara, Bhavendra; Citrin, David; Dhungana, Santosh Kumar; Gauchan, Bikash; Gupta, Priyanka; Gupta, Tula Krishna; Halliday, Scott; Kadayat, Bharat; Mahar, Ramesh; Maru, Duncan; Nguyen, Viet; Poudel, Sanjaya; Raut, Anant; Rawal, Janaki; Sapkota, Sabitri; Schwarz, Dan; Schwarz, Ryan; Shrestha, Srijana; Swar, Sikhar; Thapa, Aradhana; Thapa, Poshan; White, Rebecca; Acharya, Bibhav | Abstract: IntroductionDespite carrying a disproportionately high burden of depression, patients in low-income countries lack access to effective care. The collaborative care model (CoCM) has robust evidence for clinical effectiveness in improving mental health outcomes. However, evidence from real-world implementation of CoCM is necessary to inform its expansion in low-resource settings.MethodsWe conducted a 2-year mixed-methods study to assess the implementation and clinical impact of CoCM using the WHO Mental Health Gap Action Programme protocols in a primary care clinic in rural Nepal. We used the Capability Opportunity Motivation-Behaviour (COM-B) implementation research framework to adapt and study the intervention. To assess implementation factors, we qualitatively studied the impact on providers' behaviour to screen, diagnose and treat mental illness. To assess clinical impact, we followed a cohort of 201 patients with moderate to severe depression and determined the proportion of patients who had a substantial clinical response (defined as ≥50% decrease from baseline scores of Patient Health Questionnaire (PHQ) to measure depression) by the end of the study period.ResultsProviders experienced improved capability (enhanced self-efficacy and knowledge), greater opportunity (via access to counsellors, psychiatrist, medications and diagnostic tests) and increased motivation (developing positive attitudes towards people with mental illness and seeing patients improve) to provide mental healthcare. We observed substantial clinical response in 99 (49%; 95% CI: 42% to 56%) of the 201 cohort patients, with a median seven point (Q1:-9, Q3:-2) decrease in PHQ-9 scores (pl0.0001).ConclusionUsing the COM-B framework, we successfully adapted and implemented CoCM in rural Nepal, and found that it enhanced providers' positive perceptions of and engagement in delivering mental healthcare. We observed clinical improvement of depression comparable to controlled trials in high-resource settings. We recommend using implementation research to adapt and evaluate CoCM in other resource-constrained settings to help expand access to high-quality mental healthcare.

In December 2019, Sudden deaths of people due to pneumonia caused by the new Coronavirus (SARS-Cov-2) in Wuhan, China and its rapid spread to other countries forced World Health Organization to declare pandemic on 12 March 2021. With first case on 13 January 2020, Nepal started preparing to manage COVID – 19. The government of Nepal made historic decision to establish an infectious and communicable disease hospital in each province. The Gandaki province government decided to establish provincial infectious and communicable disease hospital on 12th April 2020. The newly established hospital has now become Nepal’s first provincial infectious and communicable disease hospital. Future research will establish the effectiveness of provincial dedicated infectious and communicable disease hospital.

Background In Nepal, the burden of non-communicable, chronic diseases is rapidly rising, and disproportionately affecting low- and middle-income countries. Integrated interventions are essential in strengthening primary care systems and addressing the burden of multiple comorbidities. A growing body of literature supports the involvement of frontline providers, namely mid-level practitioners and community health workers, in chronic care management. Important operational questions remain, however, around the digital, training, and supervisory structures to support the implementation of effective, affordable, and equitable chronic care management programs. Methods A twelve-month, population-level, type 2 hybrid effectiveness-implementation study will be conducted in rural Nepal to evaluate an integrated non-communicable disease care management intervention within Nepal’s new municipal governance structure. The intervention will leverage the government’s planned roll-out of the World Health Organization’s Package of Essential Non-communicable disease interventions (WHO-PEN) program in four municipalities in Nepal, with a study population of 80,000. The intervention will leverage both the WHO-PEN and its cardiovascular disease specific technical guidelines, HEARTS, and include three evidence-based components: 1) non-communicable disease care provision using mid-level practitioners and community health workers; 2) digital clinical decision support tools to ensure delivery of evidence-based care; and 3) training and digitally-supported supervision of mid-level practitioners to provide motivational interviewing for modifiable risk factor optimization, with a focus on medication adherence, and tobacco and alcohol use. The study will evaluate effectiveness using a pre-post design with stepped implementation. The primary outcomes will be disease-specific, “at-goal” metrics of chronic care management; secondary outcomes will include alcohol and tobacco consumption levels. Discussion This is the first population-level, hybrid effectiveness-implementation study of an integrated chronic care management intervention in Nepal. As low- and middle-income countries plan for the Sustainable Development Goals and universal health coverage, the results of this pragmatic study will offer insights into policy and programmatic design for non-communicable disease care management in the future.

Background: Strategic purchasing mechanisms, including national health insurance, provide opportunities to improve quality and progress towards universal health coverage. Nepal’s health insurance program (HIP), begun in 2016, is a national insurance platform aiming to improve financial risk protection, and efficiency, quality, and access to health services. HIP also further engages private-sector providers through strategic purchasing, potentially improving quality, regulation, and accountability. Bayalpata Hospital is a public-private partnership (PPP) hospital run jointly by the Ministry of Health and Population and Nyaya Health Nepal and is one of the first PPP hospitals enrolled in HIP. We evaluated Bayalpata Hospital costs and HIP guidelines to understand how HIP rates compare to health delivery costs incurred.Methods: We employed a top-down costing methodology to analyze costs for fiscal year 2017-2018. We compared costs to HIP reimbursement rates during the same period, and projected overall coverage for costs assuming full HIP enrollment given the compulsory nature of HIP.Results: Our data suggest HIP, as one payment mechanism in Nepal’s mixed provider payment system, would cover 57% of hospital costs with full enrollment, with variation across services. Among inpatient services, 64% of costs would be covered, including 105% reimbursement for fee-for-service, 87% reimbursement for bundled packages, but only 23% - 40% for certain surgical services. For outpatient services, 59% would be covered, and for emergency services, 32% would be covered. Conclusions: HIP is an important strategic purchasing foundation; however, payments may be insufficient to match provider costs and cover a larger percentage of inpatient-based and fee-for-service delivery than outpatient services. These dynamics may inappropriately incentivize fee-for-service health care utilization, in particular for private-sector providers without access to other public-sector payment mechanisms, while potentially disincentivizing outpatient or community-based approaches to health care, which are less well reimbursed through HIP. HIP policy revisions, and further expansion of mixed provider payment mechanisms, may more effectively incentivize primary health care approaches, while also deepening private-sector engagement. The data and experience of Bayalpata Hospital and HIP offer practical insights for Nepali policymakers and those in similar settings globally employing strategic purchasing to improve progress towards UHC and quality health delivery.

BackgroundIn Nepal, the burden of noncommunicable, chronic diseases is rapidly rising, and disproportionately affecting low and middle-income countries. Integrated interventions are essential in strengthening primary care systems and addressing the burden of multiple comorbidities. A growing body of literature supports the involvement of frontline providers, namely mid-level practitioners and community health workers, in chronic care management. Important operational questions remain, however, around the digital, training, and supervisory structures to support the implementation of effective, affordable, and equitable chronic care management programs.MethodsA 12-month, population-level, type 2 hybrid effectiveness-implementation study will be conducted in rural Nepal to evaluate an integrated noncommunicable disease care management intervention within Nepal’s new municipal governance structure. The intervention will leverage the government’s planned roll-out of the World Health Organization’s Package of Essential Noncommunicable Disease Interventions (WHO-PEN) program in four municipalities in Nepal, with a study population of 80,000. The intervention will leverage both the WHO-PEN and its cardiovascular disease-specific technical guidelines (HEARTS), and will include three evidence-based components: noncommunicable disease care provision using mid-level practitioners and community health workers; digital clinical decision support tools to ensure delivery of evidence-based care; and training and digitally supported supervision of mid-level practitioners to provide motivational interviewing for modifiable risk factor optimization, with a focus on medication adherence, and tobacco and alcohol use. The study will evaluate effectiveness using a pre–post design with stepped implementation. The primary outcomes will be disease-specific, “at-goal” metrics of chronic care management; secondary outcomes will include alcohol and tobacco consumption levels.DiscussionThis is the first population-level, hybrid effectiveness-implementation study of an integrated chronic care management intervention in Nepal. As low and middle-income countries plan for the Sustainable Development Goals and universal health coverage, the results of this pragmatic study will offer insights into policy and programmatic design for noncommunicable disease care management in the future.Trial registrationClinicalTrials.gov,NCT04087369. Registered on 12 September 2019.

DOI: https://doi.org/10.3126/jkahs.v1i3.24155 Background: Complex partial seizure with sudden onset in near term pregnancy can be challenging to the attending clinician and it is essential to proceed with a presumptive diagnosis of eclampsia, especially in resource poor settings. Unlike generalized tonic clonic seizures, which are more common in eclampsia, complex partial seizures may not jeopardize the fetus with the same severity. However the associated postictal aggression manifested in self-inflicted trauma poses an imminent risk onto the fetus. Case presentation: A nineteen year old gravida two para one living zero woman presented with seizure at thirty six weeks and three days of gestation in a district hospital. The blood pressure recordings during her entire pregnancy were normal and proteinuria was not present. Her previous pregnancy had a similar course, with self-inflicted trauma to her abdomen in a postictal state and resulted in loss of fetus. She did not have any seizures in between then and the current admission. While being managed in the labor ward, the family physicians witnessed complex partial seizure with postictal aggression. The delivery was expedited with caesarean section and she had no further seizure activity. Conclusion: Complex partial seizures with postictal aggression in pregnancy are rare but can be an atypical presentation of eclampsia and poses a diagnostic dilemma to the clinician. Keywords: Complex partial seizure, postictal aggression, atypical eclampsia, district hospital

Small, well-implemented, well-evaluated community health worker programs can provide useful insights and inspiration. Testing, learning, and adapting at progressively larger scale can ultimately lead to national-scale programs that achieve sustainable impact., Key Message Small, well-implemented, well-evaluated community health worker programs can provide useful insights and inspiration.Testing, learning, and adapting at progressively larger scale can ultimately lead to national-scale programs that achieve sustainable impact.

Background In Nepal, the burden of non-communicable, chronic diseases is rapidly rising, and disproportionately affecting low- and middle-income countries. Integrated interventions are essential in strengthening primary care systems and addressing the burden of multiple comorbidities. A growing body of literature supports the involvement of frontline providers, namely mid-level practitioners and community health workers, in chronic care management. Important operational questions remain, however, around the digital, training, and supervisory structures to support the implementation of effective, affordable, and equitable chronic care management programs. Methods A twelve-month, population-level, type 2 hybrid effectiveness-implementation study will be conducted in rural Nepal to evaluate an integrated non-communicable disease care management intervention within Nepal’s new municipal governance structure. The intervention will leverage the government’s planned roll-out of the World Health Organization’s Package of Essential Non-communicable disease interventions (WHO-PEN) program in four municipalities in Nepal, with a study population of 80,000. The intervention will leverage both the WHO-PEN and its cardiovascular disease specific technical guidelines, HEARTS, and include three evidence-based components: 1) non-communicable disease care provision using mid-level practitioners and community health workers; 2) digital clinical decision support tools to ensure delivery of evidence-based care; and 3) training and digitally-supported supervision of mid-level practitioners to provide motivational interviewing for modifiable risk factor optimization, with a focus on medication adherence, and tobacco and alcohol use. The study will evaluate effectiveness using a pre-post design with stepped implementation. The primary outcomes will be disease-specific, “at-goal” metrics of chronic care management; secondary outcomes will include alcohol and tobacco consumption levels. Discussion This is the first population-level, hybrid effectiveness-implementation study of an integrated chronic care management intervention in Nepal. As low- and middle-income countries plan for the Sustainable Development Goals and universal health coverage, the results of this pragmatic study will offer insights into policy and programmatic design for non-communicable disease care management in the future.

Introduction: Thyroid disorders are among the common endocrine disorders and may approximate diabetes in prevalence. District hospitals are in frontline to manage chronic disorders including thyroid. Primary care workforce of physicians and mid-level providers together deliver care in these hospitals. Few hospitals are equipped with tests to diagnose thyroid disorders. The objective of the study is to find the burden of thyroid disorder in a district hospital of Nepal.Methods: This was a descriptive cross sectional study conducted in Bayalpata Hospital. One year data from July 2017 to June 2018 was collected from the electronic health record system. Data was collected from 999 patients through convenient sampling where thyroid function test was done. Subgroup analysis was done on basis of gender, symptoms at presentation and comorbidities.Results: Prevalence of thyroid disorder in a district hospital of Nepal was 171 (17.11%) at 95% confidence interval, range occurring from 14% to 20%. Among them, 130 (76%) had hypothyroidism and 41 (24%) had hyperthyroidism. Prevalence of thyroid disorder among female was 147 (14.7%) and among male was 24 (2.4%). The most common symptom was depressed mood followed by nonspecific pain disorder, thyroid swelling, paresthesia and menstrual disturbances and common comorbidities reported were depression, diabetes, hypertension, anxiety disorder and chronic gastritis. Conclusions: Our study showed the burden of thyroid disorders in a primary care district hospital with hypothyroidism being more common than hyperthyroidism. Thyroid disorder must be addressed on time to lower the burden. However, most of the rural population of Nepal lack in matters of lack of resources. So, it is suggested for the need to equip the health centers with thyroid tests and integrated workforce of physicians and mid-level providers in care delivery of thyroid disorders.

Background Traditional medical education in much of the world has historically relied on passive learning. Although active learning has been in the medical education literature for decades, its incorporation into practice has been inconsistent. We describe and analyze the implementation of a multidisciplinary continuing medical education curriculum in a rural Nepali district hospital, for which a core objective was an organizational shift towards active learning. Methods The intervention occurred in a district hospital in remote Nepal, staffed primarily by mid-level providers. Before the intervention, education sessions included traditional didactics. We conducted a mixed-methods needs assessment to determine the content and educational strategies for a revised curriculum. Our goal was to develop an effective, relevant, and acceptable curriculum, which could facilitate active learning. As part of the intervention, physicians acted as both learners and teachers by creating and delivering lectures. Presenters used lecture templates to prioritize clarity, relevance, and audience engagement, including discussion questions and clinical cases. Two 6-month curricular cycles were completed during the study period. Daily lecture evaluations assessed ease of understanding, relevance, clinical practice change, and participation. Periodic lecture audits recorded learner talk-time, the proportion of lecture time during which learners were talking, as a surrogate for active learning. Feedback from evaluation and audit results was provided to presenters, and pre- and post-curriculum knowledge assessment exams were conducted. Results Lecture audits showed a significant increase in learner talk-time, from 14% at baseline to 30% between months 3–6, maintained at 31% through months 6–12. Lecture evaluations demonstrated satisfaction with the curriculum. Pre- and post-curriculum knowledge assessment scores improved from 50 to 64% (difference 13.3% ± 4.5%, p = 0.006). As an outcome for the measure of organizational change, the curriculum was replicated at an additional clinical site. Conclusion We demonstrate that active learning can be facilitated by implementing a new educational strategy. Lecture audits proved useful for internal program improvement. The components of the intervention which are transferable to other rural settings include the use of learners as teachers, lecture templates, and provision of immediate feedback. This curricular model could be adapted to similar settings in Nepal, and globally. Electronic supplementary material The online version of this article (10.1186/s12909-019-1492-3) contains supplementary material, which is available to authorized users.

The collaborative care model can deliver high-quality mental health care. In rural regions, clinical supervision is conducted remotely rather than in person. The authors implemented a remote teleconsultation model in rural Nepal, where the consulting psychiatrist is over 30 hours away. This column describes strategies for several challenges: poor mental health competencies and high turnover among primary care providers; need for urgent consultations; psychiatrist discomfort with lack of direct patient contact; unreliable electricity, technological tools, documentation, and delivery of treatment recommendations; on-site clinicians' low motivation to accept psychiatrist recommendations; and mismatch between the psychiatrist's recommendations and the site's capacity to implement them.

International audience; Low-income and middle-income countries are struggling with a growing epidemic of non-communicable diseases. To achieve the Sustainable Development Goals, their healthcare systems need to be strengthened and redesigned. The Starfield 4Cs of primary care—first-contact access, care coordination, comprehensiveness and continuity—offer practical, high-quality design options for non-communicable disease care in low-income and middle-income countries. We describe an integrated non-communicable disease intervention in rural Nepal using the 4C principles. We present 18 months of retrospective assessment of implementation for patients with type II diabetes, hypertension and chronic obstructive pulmonary disease. We assessed feasibility using facility and community follow-up as proxy measures, and assessed effectiveness using singular ‘at-goal’ metrics for each condition. The median follow-up for diabetes, hypertension and chronic obstructive pulmonary disease was 6, 6 and 7 facility visits, and 10, 10 and 11 community visits, respectively (0.9 monthly patient touch-points). Loss-to-follow-up rates were 16%, 19% and 22%, respectively. The median time between visits was approximately 2 months for facility visits and 1 month for community visits. ‘At-goal’ status for patients with chronic obstructive pulmonary disease improved from baseline to endline (p=0.01), but not for diabetes or hypertension. This is the first integrated non-communicable disease intervention, based on the 4C principles, in Nepal. Our experience demonstrates high rates of facility and community follow-up, with comparatively low lost-to-follow-up rates. The mixed effectiveness results suggest that while this intervention may be valuable, it may not be sufficient to impact outcomes. To achieve the Sustainable Development Goals, further implementation research is urgently needed to determine how to optimise non-communicable disease interventions.This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial.

Background There 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 presentation We 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. Conclusions GPs 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.

Patient navigation programs have shown to be effective across multiple settings in guiding patients through the care delivery process. Limited experience and literature exist, however, for such programs in rural and resource-constrained environments. Patients living in such settings frequently have low health literacy and substantially lower social status than their providers. They typically have limited experiences interfacing with formalized healthcare systems, and, when they do, their experience can be unpleasant and confusing. At a district hospital in rural far-western Nepal, we designed and implemented a patient navigation system that aimed to improve patients' subjective care experience. First, we hired and trained a team of patient navigators who we recruited from the local area. Their responsibility is exclusively to demonstrate compassion and to guide patients through their care process. Second, we designed visual cues throughout our hospital complex to assist in navigating patients through the buildings. Third, we incorporated the patient navigators within the management and communications systems of the hospital care team, and established standard operating procedures. We describe here our experiences and challenges in designing and implementing a patient navigator program. Such patient-centered systems may be relevant at other facilities in Nepal and globally where patient health literacy is low, patients come from backgrounds of substantial marginalization and disempowerment, and patient experience with healthcare facilities is limited.

International audience; 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.

International audience; IntroductionGlobally, 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.DevelopmentThe 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.ApplicationFor 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.DiscussionOver 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.

International audience; 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.

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 McNemar's 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 training's positive impact and complementary nature of the program's 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.

Nepal, a mountainous country in South East Asia, still lags in increasing access to healthcare and reducing health inequity. Possible Non Government Organization based in Achham, Nepal, which is a sister organization of Possible International Non Government Organization based in New York, USA recognized the increasing health needs in the far western rural hilly parts of Nepal, where extreme poverty and illiteracy was creating a vulnerable picture especially in Achham. Possible (previously named Nyaya Health) started to operate Bayalpata Hospital in 2009 after completing more than one year of free health services in Sanfe-Bagar, Achham, in partnership with the Nepalese Ministry of Health and Population. It supports the idea that free health service has its own challenges but a public-private partnership can thrive while promote equity in health services. Keywords: achham; free health care; nepal; nyaya health; possible.

BackgroundChronic obstructive pulmonary disease accounts for a significant portion of the world’s morbidity and mortality, and disproportionately affects low/middle-income countries. Chronic obstructive pulmonary disease management in low-resource settings is suboptimal with diagnostics, medications and high-quality, evidence-based care largely unavailable or unaffordable for most people. In early 2016, we aimed to improve the quality of chronic obstructive pulmonary disease management at Bayalpata Hospital in rural Achham, Nepal. Given that quality improvement infrastructure is limited in our setting, we also aimed to model the use of an electronic health record system for quality improvement, and to build local quality improvement capacity.DesignUsing international chronic obstructive pulmonary disease guidelines, the quality improvement team designed a locally adapted chronic obstructive pulmonary disease protocol which was subsequently converted into an electronic health record template. Over several Plan-Do-Study-Act cycles, the team rolled out a multifaceted intervention including educational sessions, reminders, as well as audits and feedback.ResultsThe rate of oral corticosteroid prescriptions for acute exacerbations of chronic obstructive pulmonary disease increased from 14% at baseline to >60% by month 7, with the mean monthly rate maintained above this level for the remainder of the initiative. The process measure of chronic obstructive pulmonary disease template completion rate increased from 44% at baseline to >60% by month 2 and remained between 50% and 70% for the remainder of the initiative.ConclusionThis case study demonstrates the feasibility of robust quality improvement programmes in rural settings and the essential role of capacity building in ensuring sustainability. It also highlights how individual quality improvement initiatives can catalyse systems-level improvements, which in turn create a stronger foundation for continuous quality improvement and healthcare system strengthening.

Background Globally, access to mental healthcare is often lacking in rural, low-resource settings. Mental healthcare services integration in primary care settings is a key intervention to address this gap. A common strategy includes embedding mental healthcare workers on-site, and receiving consultation from an off-site psychiatrist. Primary care provider perspectives are important for successful program implementation. Methods We conducted three focus groups with all 24 primary care providers at a district-level hospital in rural Nepal. We asked participants about their concerns and recommendations for an integrated mental healthcare delivery program. They were also asked about current practices in seeking referral for patients with mental illness. We collected data using structured notes and analyzed the data by template coding to develop themes around concerns and recommendations for an integrated program. Results Participants noted that the current referral system included sending patients to the nearest psychiatrist who is 14 h away. Participants did not think this was effective, and stated that integrating mental health into the existing primary care setting would be ideal. Their major concerns about a proposed program included workplace hierarchies between mental healthcare workers and other clinicians, impact of staff turnover on patients, reliability of an off-site consultant psychiatrist, and ability of on-site primary care providers to screen patients and follow recommendations from an off-site psychiatrist. Their suggestions included training a few existing primary care providers as dedicated mental healthcare workers, recruiting both senior and junior mental healthcare workers to ensure retention, recruiting academic psychiatrists for reliability, and training all primary care providers to appropriately screen for mental illness and follow recommendations from the psychiatrist. Conclusions Primary care providers in rural Nepal reported the failure of the current system of referral, which includes sending patients to a distant city. They welcomed integrating mental healthcare into the primary care system, and reported several concerns and recommendations to increase the likelihood of successful implementation of such a program. Electronic supplementary material The online version of this article (doi:10.1186/s12913-016-1768-9) contains supplementary material, which is available to authorized users.

Problem In hospitals in rural, resource-limited settings, there is an acute need for simple, practical strategies to improve healthcare quality. Setting A district hospital in remote western Nepal. Key measures for improvement To provide a mechanism for systems-level reflection so that staff can identify targets for quality improvement in healthcare delivery. Strategies for change To develop a morbidity and mortality conference (M&M) quality improvement initiative that aims to facilitate structured analysis of patient care and identify barriers to providing quality care, which can subsequently be improved. Design The authors designed an M&M involving clinical and non-clinical staff in conducting root-cause analyses of healthcare delivery at their hospital. Weekly conferences focus on seven domains of causal analysis: operations, supply chain, equipment, personnel, outreach, societal, and structural. Each conference focuses on assessing the care provided, and identifying ways in which services can be improved in the future. Effects of change Staff reception of the M&Ms was positive. In these M&Ms, staff identified problem areas in healthcare delivery and steps for improvement. Subsequently, changes were made in hospital workflow, supply procurement, and on-site training. Lessons learnt While widely practiced throughout the world, M&Ms typically do not involve both clinical and non-clinical staff members and do not take a systems-level approach. The authors' experience suggests that the adapted M&M conference is a simple, feasible tool for quality improvement in resource-limited settings. Senior managerial commitment is crucial to ensure successful implementation of M&Ms, given the challenging logistics of implementing these programmes in resource-limited health facilities.

Background: Diabetes ranks fourth among the noncommunicable diseases (NCDs) in terms of proportional mortality in Nepal and is increasingly diagnosed in rural population. We aimed to evaluate the care delivery in diabetes patients in a rural primary care hospital that had implemented the World Health Organization's Package of essential NCDs interventions (PEN) protocol. Subjects and Methods: This was a descriptive study in a rural district hospital. The study was conducted over 5 months and was undertaken as a part of the quality improvement project in the hospital. Data were extracted from the electronic medical record of the hospital after approval from hospital administration. Results: The total diabetic patient visits during the study period were 682 of 30,758 total outpatient visits (2%). There were 240 unique diabetic patients. The age ranged from 25 to 82 years with the median age of 52. Glycated hemoglobin was done in 15 of 59 new cases and in 33 of 181 follow-up cases. Urine protein was assessed in 65 of 240 patients. Comorbidities and complications were documented in 96 of 240 patients (40%), hypertension being the most common. Fifty-six patients (23%) had obtained control as per the target levels with different modalities of treatment, 69 (29%) had partial control, 85 (35%) struggled to reach targets, and 30 (13%) failed to appear in follow-up visits. Conclusion: The study described our adherence to the PEN protocol and identified several areas of improvement in our diabetes care delivery such as continuous medical education activities and monitoring of care delivery with similar study in future after implementation of proposed interventions.

Introduction: Diagnostic radiology services are severely lacking in many rural settings and the implementation of these services poses complex challenges. The purpose of this paper is to describe the implementation of diagnostic radiology services at a district-level hospital in Achham, a rural district in Nepal. Methods and Materials: We conducted a retrospective review of the implementation of diagnostic radiology services. We compiled a list of implementation challenges and proposed solutions based on an internal review of historical data, hospital records, and the experiences of hospital staff members. We used a seven-domain analytic framework to structure our discussion of these challenges. Results: We documented the first five years of challenges faced and lessons learned by the non-profit organization Possible while implementing and providing diagnostic radiology services for the first time in a remote location. Additionally, we documented the uptake of these services through the first five years of operations. During this time, the number of X-rays performed increased 271%, while ultrasounds increased 258%. The main challenges included educating the community about the appropriate use of these services, recruiting trained providers, and coordinating referral care and consultations for higher-level diagnostics and treatment. Finally, investments in training providers and technicians, as well as investments in infrastructure, primarily the installation of solar panels to maintain a power supply, were critical to sustaining services. Discussion: This experience demonstrates that reliable and sustained services can be deployed even in extremely remote areas and identifies challenges that other implementers may face in similar program implementation.

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.