13-19 February 2015 #745

Boy walked eight days to treat broken arm

"Unlike other hospitals, we want fewer patients, not more."- S P Kalaunee of Bayalpata Hospital
Tsering Dolker Gurung in ACHHAM

When his eight-year old son Dharmaraj broke his hand while grazing cattle in the remote mountains of Humla, Mansingh Thapa took him to a private clinic in Simkot. It cost Rs 4,500 just to get Dharmaraj’s hand in a cast.

But the pain in the boy’s arm did not subside. Unable to afford a second visit to the clinic, Mansingh packed his belongings, slung Dharmaraj on his shoulders and set off on an eight-day walk to Bayalpata Hospital in Achham district. 
“What could we do? We didn’t have any other choice,” said Mansingh who had heard about Bayalpata from friends who had received free treatment here.

Dharmaraj had surgery and the boy is getting better. The father and son (pictured, right) have been staying at the hospital because it is too far to go back to Humla and return for a followup. 

For Bikash Gauchan, who was among South Asian doctors to receive the Jyoti Ramnik Pareskh Award this week in Dhaka for his work as a GP in Bayalpata, this case is unremarkable. There are many patients like Dharmaraj from faraway districts that he has to treat every day in these roadless hills of mid-western Nepal.

“Many of them can’t afford treatment and stay on, so the hospital provides accommodation to the patient and caregiver because it is not possible to ask them to keep going back and forth,” Gauchan told us.

The nearby Sanfebagar airfield hasn’t been in operation since the Maoists destroyed it during the conflict 12 years ago. It takes a rugged day-long bus ride from Surkhet to reach the hospital. But although Bayalpata may feel like it is in the middle of nowhere, the patients here come from even more remote and unserved parts of Nepal.

Word that Bayalpata offers free treatment and medicines has spread far and wide, and although there are government-run hospitals in surrounding districts, most families prefer to bring members here.

“The obstacles to rural health care are accessibility and trust,” explains S P Kalaunee, operations director at Bayalpata. “Patients don’t have access to proper medical care, and don’t trust the government health posts.”

Bayalpata is actually a government hospital that has been managed since 2008 by the global non-profit,  Possible (formerly known as Nyaya Health). The hospital receives up to 300 a day patients from Achham, but more and more from surrounding districts like Bajura, Doti, Mugu and even as far away as Humla and Dolpo. In the past six years, Bayalpata has treated 235,838 patients, some 56,106 of them last year alone.

Orthopedic injuries, mental health disorders and lung infection are some of the most common ailments.  Last year the hospital also started much-needed dental services. Its Community Health Program manages and strengthens 13 village health posts with equipment and training for birthing centres and works with Female Community Health Volunteers to followup on chronic diseases.

Possible gets support from the Ministry of Health, from donors around the world, and also crowdsources funding for the treatment of individual patients through sites like Watsi and Kangu.

In 2014, Bayalpata raised enough money for 30 operations and referrals of patients to hospitals in Nepalganj or Kathmandu. Patients are identified and their stories put up online for funding from around the world overnight.

Mark Arnoldy, CEO of Possible, says, “By 2018, we are targeting philanthropy to be less than 25% of our total funding model in Nepal and will be utilising government investment, research funding, and teaching fees. We’re trying to build something better, and philanthropy plays a role, but we aren’t dependent on it.”

Possible is now working with the government to expand its services from the present 15-beds to 50, for which it has got a grant of Rs 100 million. It is expanding its current training programs and converting Bayalpata into a rural teaching hospital.

Bayalpata already gets rural placements from medical schools in Kathmandu, but the teaching hospital would allow locals to get medical training within the district and help retain them there.

Says Kalaunee: “Unlike other hospitals in Nepal, our goal is not to get more patients, but to reduce them through prevention measures and upgrading primary care in health posts.”

Read also:

Crowdfund globally, act locally

Crowding it out

Accountable to the poor, Duncan Maru and Shree Ram Tiwari

Resurrection Achham, Paavan Mathema

Fee or free?

Nepali Times spoke to Mark Arnoldy, the CEO of Possible, the non-profit that manages Bayalpata Hospital during his visit to Achham this week.

Nepali Times: What are the challenges to expand Bayalpata Hospital’s services?

Mark Arnoldy: The challenges are immense, but I’m confident we can overcome them thanks to the determination and ingenuity of our team and a wonderful set of partners. We have to meet a very quickly-growing patient demand. In 2012, we treated 21,585 patients and in 2014, 56,106. This year, the numbers continue to climb. When you are seeing numbers climb that quickly it means there is a real genuine need, patients are at least somewhat satisfied with the care provided, and it means we need to do our best to make strategic investments in expanded clinical space, housing, and team members to meet demand projections for the future. That’s why we are investing alongside the Nepal government to build Bayalpata Hospital as a teaching hospital. Another key challenge is supporting primary care at health post facilities and through Female Community Health Volunteers so that the demand on the hospital decreases -- hospital aren’t the best place to be delivering primary care in a well-functioning health system.

  Is depending on charity a sustainable model for the future?

I would challenge the idea that we are dependent on charity. There is nothing about our business model and plans for the future that suggests we  intend to be dependent. Instead, what we actually want to see happen is a public-private partnership where the government funds and regulates healthcare and allows nonprofit organisations like ours to deliver care within their infrastructure. We believe deeply we should only get funded by the government if we get results, and we are working hard on establishing this performance-based model with our partners in the Ministry of Health and Population and Ministry of Finance. But because it’s the early days, we do utilise philanthropy. However, I’m completely comfortable with that. Philanthropy is the type of capital we should be using to try bold, risky things to serve the poor and pry open other revenue options. By 2018, we are targeting philanthropy to be less than 25 per cent of our total funding model in Nepal and will be utilising government investment, research funding, and teaching fees. It would be our dream to have health insurance up and running in the country so that could be integrated as well, but that’s not in our direct control. The bottom line is we need a healthcare business model that realigns revenue with care. Fee-for-service models don’t serve the rural poor in Nepal well and they incentivise excess care. We’re trying to build something better, and philanthropy plays a role, but we aren’t dependent on it. 

How confident are you that the teaching hospital will help in retaining doctors in Bayalpata?

I’m confident that this is a great investment for the Government of Nepal and our funders from outside the country. We know from studies by great organisations like the Nick Simons Institute what keeps doctors happy and working hard in rural environments. We’ve put every single one of those learnings we can into practice with our plans for the expanded Bayalpata Hospital. There will be great housing, fast internet, and most important for our clinical team members, the proper equipment and management system to ensure that high-performing individuals will be able to do their job effectively while being offered growth opportunities through coaching and mentorship. We’ve learned that the best performers and most dedicated people really want the ability to practice their craft of clinical care without politics and distractions created by bad management. We want this to be a place where remarkable people can reliably produce remarkable results for our patients.