CCNEPal concept paper for Strengthening a decentralized health system in Terai of Nepal May 15th 2017


Notice of Funding Opportunity

The Ministry of Health and USAID have proposed a new project in Nepal which will focus on “Health Systems Strengthening” over a five year period.  To inform the groups that will apply for the funds, USAID published a very interesting document called Notice of   Funding Opportunity (NFO) describing the goals.

Three main Goals

  1.  Improved access to and utilization of equitable healthcare services
  2. improved quality of healthcare services, and
  3. Improved health system governance, including within the context of decentralization and federalism ( from page 6).

https://www.grants.gov/web/grants/view-opportunity.html?oppId=293419 At the beginning the NFO includes a summary of USAID-funded programs in Nepal. The portfolio of current USAID projects in Nepal was authoritatively summarized. If you are interested in the health status of Nepal, this is a must-read.

CCNEPal will not be applying

The USAID rules require that anybody applying for this grant show a track record of three prior grants of ten million USD or more, and also meet requirements to document where the money went and how the program was evaluated. For that reason, CCNEPal is not eligible to apply. Most Nepal-based entities are also ineligible unless they have a foreign partner.

What the 2017 NFO has minimized or omitted

First, a few facts. Twenty one of the proposed districts in the service area are in the Terai, the flat part of the country bordering India.

revised_suaahara_map_1

Suaahara is the main USAID project for nutrition and MCH n Nepal. This map does not depict the relative population density of the various districts.

Fifteen million people (half the population of Nepal) live in Terai. When USAID started work in Terai there were no medical colleges and few nursing colleges. USAID has worked there for years to develop nutrition programs and a system of Community Health Workers (CVHWs).

Why These areas?

This becomes easy to explain if you were to superimpose another map over the above:

stunting_in_Nepal

The Government of Nepal prioritizes these areas due to childhood stunting. “Food Security” or the lack thereof, has lifetime consequences. I wrote about this in another blog  http://www.dailykos.com/story/2015/9/28/1425296/-The-Siege-of-Kathmandu-day-five-special-food-shortage-issue-Sept-28th last year.  The above graphic comes from a study published in 2015. http://pubs.sciepub.com/ajphr/3/2/7/

infographic of medical education in Nepal 5

Half the population of Nepal lives in Terai. All the medical schools in Terai are non-governmental, i.e., “private” – and I should add, in this region of Nepal there is a higher per centage of Hindi speakers.

Over the past ten years there is dramatic change. Today there are nine medical colleges in Terai alone, producing about three hundred and fifty new MBBS doctors per year just from this region. (there are thirteen other medical colleges in Kathmandu and elsewhere. Nepal produces about six hundred new doctors a year overall). The strategic assumptions of improving access to health care in rural Nepal as outlined in the NFO is written as if this system does not exist.

The current USAID projects are focused on Maternal-Child Health (MCH) and this proposed project will continue to focus on reducing MCH mortality.

PHC-nepal

Map of health Posts in Nepal. These are primary care centers. from: http://medchrome.com/extras/facts/health-system-nepal/

Any plan to improve health systems strengthening needs to include the medical colleges and needs to include a plan for the doctors they produce, especially the  newly-graduated doctors.  A quick websearch turns up articles from WHO as far back as 1996 http://www.who.int/hrh/en/HRDJ_2_1_05.pdf  that explore the idea of how many doctors Nepal needs. At that time, there were only two medical colleges in the entire country. The career path of new doctors in Nepal has been an ongoing discussion, since the government subsidizes medical education yet most new doctors are reluctant to practice in rural areas.  CCNEPal has worked with newly-graduated MBBS doctors to provide confidence-building skills.

Spoke-and-wheel approach

In a decentralized (federalized) health system, the stated goal of Nepal’s Ministry of Health (MoH) and USAID is to support a spoke-and-wheel arrangement, where there is a referral center in each province and the smaller outposts refer patients to the larger center when warranted. This trend is already occurring. The flow along the spokes is conceptualized as one-way, with patients from the periphery flowing inward to each referral center. What is needed is to build a two-way system where medical knowledge is shared from the regional center outward. This is presently not happening enough.

What is the system to train new doctors in Nepal?

MBBS education is set up differently than medical school in USA.

MBBS is an undergraduate degree and is focused on reading and book work. All learning is in a very traditional classroom. There is new interest in “problem-based learning” but even this is still very didactic. Students do not incorporate “bedside manner” into their education.

  1. Minimal clinical experience is given during the undergraduate study.  A person graduates from medical college but has never written a doctor’s order, participated in an actual emergency, spoken with a nurse, or prescribed a medication let alone examined for side effects.
  2. At graduation, a one-year internship is taken, during which the new doctor gets a crash course in practical aspects of being a doctor.
  3. After internship, MBBS doctors become a “Medical Officer” for a year or two.  Some continue as Medical Officers forever, as in government service ( “Lok Sewa”).
  4. after a year or two of being a Medical Officer the MBBS doc goes for Post-Graduate (“PG”) training, the equivalent of a Master’s degree after which they become an M.D., also known as a Senior Doctor.

Right at this present time (2017) there is now pressure for more medical colleges to be designated as sites for PG training,  as a natural consequence of turning the spigot a few years back to produce more MBBS graduates.

IMG_20150420_141846

MBBS interns at CMC in Bharatpur. These young docs were willing and enthusiastic. A bright spot for Nepal’s future. In the recent exams, the aggregate scores for CMC were among the highest in the country.

The weak link in the chain is the internship year and the transition to being a Medical Officer. In USA, every incoming new intern would already have a CPR course, and Advanced Cardiac Life Support (ACLS) a Pediatric Advanced Life Support (PALS), and perhaps other short courses that share a hands-on practical approach to patient care. In Nepal, none of these are offered until PG training. Until recently, the model has been oriented to primary care and the idea has been that Nepali doctors do not need these skills. As Nepal transitions to a system of regional medical centers, the skill level of both doctors and nurses needs to rise. CCNEPal once estimated that to reach a level of training equivalent to western expectations, 30,000 doctors and nurses around Nepal need to upgrade their skill level with these trainings.  This is a daunting scale of operation. Individual hospitals that offer these trainings are not equipped to expand programming to meet the need, and an organic system of train-the-trainer will take years to develop.

The main point is that systems need to be set in place for each medical college to address this weak link and train hundreds of persons each year. Each medical college needs incentives to promote “continuing education” for the doctors ( and nurses) in their region, that would not be the same as “PG education.”  This is still a new concept for Nepal.

Health Professions Education and Research Center in Bharatpur.

CCNEPal is a shoestring operation that focuses on one thing: continuing clinical education for doctors and nurses in Nepal.  CCNEPal focuses on this kind of training, but we are not the only ones who have recognized the need for continuing education at the level of intern. Chitwan Medical College (CMC) has already started their Health Professions Education and Research Center (HPERC) with the goal of providing the types of hands-on courses needed by MBBS interns as well as nurses. This was piloted in 2014 when CCNEPal trained CMC’s  entire graduating batch of MBBS docs in BLS and ACLS. CMC required their entire group to take the BLS and ACLS training with CCNEPal (120 individual MBBS doctors and 90 nurses). Students reported increased confidence in decisionmaking and clinical judgement as well as willingness to take the lead in emergency situations.  The CCNEPal course as presented also includes a segment on “situational awareness” that teaches counseling skills and emphasizes pro-active strategies to de-escalate during emotional situations.

What is ACLS? PALS? ATLS? NNR? AOLS?

These courses all use manikins and equipment to include psychomotor skills, teamwork skills, and knowledge of protocols in what we would call a nontraditional pedagogy approach, very different and new from the usual teaching methods of South Asia.  The JHPIEGO website characterizes this as “LDHF training” – Low Dose, High Frequency. These courses teach resuscitation protocols but also impart “soft skills” of leadership, judgement, team work, communication under stress, and priority setting. These courses have been universally required in USA for decades but are still quite new in Nepal.  In the past, these courses were reserved for the PG level but it is clear that first-year interns need this knowledge since they are on the front lines.

Other medical colleges have also worked with CCNEPal to train their graduates in this skill – Nobel (Biratnagar), Lumbini Medical College ( Palpa), Universal College of Medical Science ( Bhairawaha), College of Medical Sciences (like CMC, also in Bharatpur), and Janaki Medical College (Janakpur).  Many have begun to investigate ways to incorporate this mode of training into skill development of nurses and doctors. Nepali MBBS graduates who trained in China also need this skill set when they return as Medical Officers in Nepal.

CCNEPal’s concept

The proposed concept is to build on the HPERC idea from CMC and expand it throughout Terai. Part of the Health Systems Strengthening grant would be used to support a system of continuing education specifically targeted at interns and medical officers who will be in the rural areas, by setting up a HPERC at four or five selected sites in Terai or rural areas associated with Medical Colleges. Each would be equipped with manikins and simulation capacity for scenario-based learning. Most of the host sites in Terai are private colleges and would need to contract with the government to train personnel from the health posts.

The Medical City of Terai

It should be noted that Bharatpur is already known as The Medical City of Terai due to the cluster of hospitals and medical colleges along with government facilities. http://wp.me/p1pDBL-1ef

What would they teach?

Each HPERC would provide training in BLS, ACLS, neonatal resuscitation, Obstetric Emergencies, ATLS, mass casualty triage, and other courses based on certifications from existing western models, including Helping Mothers Survive from JHPIEGO. https://youtu.be/Hu8Na5gqnog Each would rely on simulation equipment and scenario-based training for these short courses. Each HPERC would develop their own faculty to teach these. Each would become the hub for all nursing schools to send their students without duplicating effort ( for example, there are fourteen schools of nursing in Bharatpur alone, only two presently enroll their nursing students in ACLS).

It should be noted that in the standard B Sc nursing curriculum in Nepal, 16 hours has been allocated for ACLS training since 2008, but this is widely ignored since most nursing faculty do not know what it is or what the teaching methods entail.  Nursing schools in Nepal do not have up-to-date skills labs or the system of knowledge needed to organize a skills lab.  If you go to my YouTube Channel, you can view videos of nursing skills lab from around the country of Nepal. https://www.youtube.com/playlist?list=PL05C15E3E2862A608

Future course content could be developed ( for example, Nepal should consider widespread adoption of NAPPI http://nappi-training.com/ ) but the point is to develop the infrastructure for training. This cuts across all discplines. MCH personnel and critical personnel may have different clinical focus, but the training system needs to not be duplicative.

Supporting rural placement for doctors  and the issue of “thrashing”

There are many issues why young doctors are reluctant to enlist in service in rural areas, and among them is the risk of harm from family members of patients who die. This is a bonafide concern, and this blog has published many entries to raise awareness of the issue. Lancet, the UK medical journal, has published a series of articles exploring the way doctors in India are coping with this as well. All new MBBS doctors in Nepal need to have training in de-escalation of anger during  patient party counseling. The standard courses taught by CCNEPal since 2011 have always addressed this issue through role play and discussion.

Browsing this blog

This blog has more than two hundred entries on topics of critical care education in Nepal and the reader is invited to look at all of them.

IMG_20150108_112956

All the props, packed up and ready to travel. CCNEPal 2016 was essentially one loooong road trip. What will we do in 2017?

Summary

CCNEPal  has trained 2,885 Nepali nurses and doctors in critical care skills since 2011 with especial attention to the Terai region. We have expertise in cultural aspects of Nepal health care and health professions pedagogy that few other outside contractors can match. We offer our expertise to those leading the process of designing Health Systems Strengthening activities. We would be honored to work alongside the successful Lead Agency for this USAID project, whoever that may be.

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About Joe Niemczura, RN, MS

These blogs, and my books, and videos are written on the principle that any person embarking on something similar to what I do will gain more preparation than I first had, by reading them. I have fifteen years of USA nursing faculty background. Add to it fifteen more devoted to adult critical care. In Nepal, I started teaching critical care skills in 2011. I figure out what they need to know in a Nepali practice setting. Then I teach it in a culturally appropriate way so that the boots-on-the-ground people will use it. One theme of my work has been collective culture and how it manifests itself in anger. Because this was a problem I incorporated elements of "situational awareness" training from the beginning, in 2011.
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