Charikot PHCC : Redefining Rural Health Care

When I first got my appointment letter from Department of Health Services(DoHS) for Charikot Primary Health Care Center (PHCC) three months back I had assumed it would be like any other PHCC in the country – an impoverished center, lacking basic services and serving 30 people a day. Fast forward 3 months and I have witnessed dozens of live saving emergency obstetric surgeries, seen more than 30 orthopedic operations including 1 total hip replacement and have probably attended more patients in OPD than most doctors at other PHCC would do in a year.

The condition of most Primary Health Care Centers(PHCC) in Nepal is miserable. There are currently 200 PHCC  in Nepal. Most of them lack basic infrastructure, management, diagnostics and essential medications to work as preventive, promotive, curative and rehabilitative health care center as envisioned by 1991 National Health Policy. 

According to NCDI Poverty Commission 2018 Report only 5.1% of PHCCs in the country had facility to measure serum blood glucose. Essential medications for management of common Non Communicable Disease like Diabetes Mellitus (DM), Cardiovascular Disease(CVD) and Chronic Obstructive Pulmonary Disease(COPD) were dramatically lacking. For instance Metformin for management of Diabetes was available in only 19.1% of PHCC, Aspirin for CVDs in 14% and Inhaled Beclomethasone for COPD in just 11% of PHCCs. First line drugs for treatment of Anxiety and Depression like Escitalopram and Fluoxetine are universally unavailable at PHCCs. 

Basic diagnostic radiology like X-Ray and USG were present at 10% and 5% PHCCs respectively according to Nepal Facility Survey of 2015.  Physiotherapy which is the fundamental aspect of rehabilitative health is unheard of at not just PHCC but even at district hospitals. 

As a result PHCCs across the country cannot work as comprehensive health care centers as proposed and attract very few patients. Although staffed by average of 3.5 doctors the average number of patient in PHCC according to 2073/74 DoHS report was merely 35 per day. 

Charikot PHC

Charikot PHCC is the largest health care facility in Dolakha District. The healthcare center, run jointly by Nepal government and an INGO - Possible Health, receives over 70,000 (~3% of all PHC visits in Nepal) PHC visits annually. The center is staffed by over 100 people – 18 from Nepal government and the remaining from the INGO. Twelve doctors, including 2 MDGP, 1 MDGP 

Charikot PHCC. Photo - Twitter

resident from National Academy of Medical Science(NAMS) and 1 dental surgeon are stationed here. We receive periodic visits from an orthopedic surgeon 2- 3months at a time twice a year. Handicap International also runs a separate physiotherapy unit.

Services

The PHCC provides advanced diagnostic and therapeutic services. Over 100 diagnostic tests and 300 medications including aforementioned for DM, CVD, COPD and mental health are available here. It also runs 30 bedded inpatient service, radiology unit and an operation theater for Cesarean Sections(CS), Major Orthopedic surgeries and other major non-orthopedic surgeries like Appendectomies, Hernia repair etc.  

OPD cell with USG.

Orthopedic procedures including orthopedic surgeries are vital to health care services in rural Nepal due to high volume of traumatic fractures. The PHCC receives around 100 orthopedic cases every month. 5-10 of those cases, majority of whom cannot afford to go to higher center require surgery. The PHCC has performed over 200 major and minor orthopedic surgeries in last 2 years.

Medico legal Center and OCMC

Charikot PHCC is one of two medicolegal center in Dolakha for performing autopsies and managing cases of rape and gender based violence (GBV).  One Stop Crisis Management Center (OCMC) was established here 2 years back to specifically manage cases of GBV. Annually 200 GBV survivors including rape victims and those affected by GBV receive health services, legal aid, counseling and rehabilitative services as well as other services required through the OCMC. 

Mental Health Program

After the 2072 Earthquake, prevalence of mental health illness had peaked in the district. The number of suicide cases autopsied in the PHCC climbed from 28 to 40. A targeted mental health service program was started in the PHC with help from Patan Mental Hospital with a psychiatrist operating mental health OPDs once every month. The PHCC ran series of training on mental health for Health Care Providers for over a year preparing staffs for mental health Gap Action Program(mhGAP). Now, this PHCC is one of the first health centers to implement WHO’s mhGAP program in the country. There are counsellors trained in psychosocial, family counselling, and stress management to ensure comprehensive mental health care. 

Community Health Service

Charikot PHCC recently introduced community health service to strengthen the services provided by Female Community Health  Volunteers(FCHV). Community health services includes active screening of pregnancy, post natal care, contraceptive counseling, mental health counseling and referrals to Health Posts and PHCC for treatment when necessary. 

Free of Cost

All these medical, surgical, diagnostic, pharmaceutical and rehabilitative services are provided free of cost to all people.  

Possible Health which assumed the management of PHCC in January 2016 spends over 100 Million rupees annually in Charikot PHCC using funds from the Government of Nepal and other 610 public, philanthropic, and private foundation sources to eliminate out of pocket spending of users for these services. The same fund is used to operate similar service through Balaypatta Hospital in Achham. 

The free health care service has been boon to people in Dolakha. It has significantly improved the health status as well as health seeking behavior of the people. However, it’s a bigger gift to clinicians like us.

Not needing to think about the financial burden of any intervention on the patient we can practice freely. Our judgements are not restrained by cost of the intervention. We do not need to differentiate the management of an illness based on financial status of the patient. At Charikot PHCC the Chief District Officer of Dolakha gets the same care as a poor farmer from Kalinchowk

This is equity in its truest sense. All doctors and patients deserve a health care system like this. 

Empowering Health Care Workers

The clinical work force at Charikot PHC is backed by highly skilled management team of Possible Health which strictly maintains logistics, and works to cut off beaurocratic hassles for the medical team. They focus on empowering medical team through constant trainings. 

The MDGPs and MBBS doctors receive constant on site trainings from orthopedic surgeon and psychiatrist. Possible health also operates strict daily Continuing Medical Education (CME) classes to ensure paramedics and doctors are constantly learning. All doctors are provided access to UptoDate, one of the best point of care medical resource in the world.  

They maintain retention of rural work force by prioritizing hiring of local residents. Most paramedics, nurses and community health workers are residents of Dolakha district. 

Using Technology

Charikot PHCC is the first Electronic Medical Record(EMR) based health care center in the country. An EMR includes information on demographics, medical history, lab investigations, procedures and treatment of the patient assigned to a unique identification number. Each time one visits the PHC the attending health care worker adds the visit record on one EMR through chrome books available at point of contact – Emergency, Out Patient Service, In Patient Service, OT, Lab, and Radiology.

EMR are managed through Bahmni, an open source hospital system. These EMRs of the population are integrated into Electronic Health Records(EHR) and can be shared across various platforms. The information generated through EHR is used for reporting to Nepal government through District Health Information System 2(DHIS2), Ministry of Health’s official electronic reporting channel.

Comprehensive Primary Health Care

Charikot PHCC provides Primary Health Care in truest sense as imagined in Amla Ata declaration of 1978. All aspects of primary health – preventive, promotive, curative, and rehabilitative are universally and equitably accessible free of cost. The PHCC is constantly pushing boundaries with partnership and technology to make services even more comprehensive, accessible and equitable.

Charikot PHCC is evidence that with adequate resource and motivated management our PHCCs can achieve all objectives of Primary Health Care and more. Nepal Government should seek inspiration from this health care center work to emulate similar services in other PHCCs. This should be the new standard of rural health care in Nepal.

MoH revising directive to punish Scholarship Students

After completing my MBBS studies under government scholarship at KIST Medical College, I joined Charikot Primary Health Care Centers(PHCC) under government’s contract two months back.

 Nepal’s rural health care delivery system relies hugely on doctors like me who studied on scholarship. Each doctor studying under Ministry of Education’s scholarship has to serve 2 years under government contract of which 1 year has to be in a rural setting. Currently over 400 doctors who studied under scholarship are working in 200 plus Primary Health Care Centers (PHCCs) across the country.  They represent over 70% of all doctors in PHCCs. PHCCs are often located in remote setting making these under contract doctors backbone of our rural health care.

This however comes at a hefty cost. 1) We are barred from pursuing any professional courses (MD/MS) in these two years. 2) The salary is nominal - I currently work in Charikot PHCC run jointly by Nepal Govt and an INGO -possible health. The medical officers from the INGO make 3 times as much as I do.   3)We get 30 days off in year – 2.5 days per month which gives one no family time because for many of us getting to our workplace takes more that.  

The ministry of health (MoH) is now working to revise directives pertaining to dissemination doctors who studied under scholarship. Increasing the contract duration from 2 to 5 years is a popular stance in the ministry.   They are spreading myths, redefining scholarship to introduce new directive that will  jeopardize careers of students who studied under scholarship while the people & government get little to no benefit.  

Spreading myths: 40 lakh worth of scholarship

No, the government doesn’t spend 40 lakhs . First the government doesn’t even spend a penny in our fees.  All private medical colleges have 10% seats reserved for scholarships, because a 10% increase in students adds insignificant operational cost to the institutes.  

Second, the price is hugely inflated to benefit the private colleges. A team lead by Dr.Bhagwan Koirala determined the fees to be Rs.38,50,000 for public institutes like IOM with 50% seats reserved for scholarships effectively cutting the 40 lakh figure to half. A public institute like IOM pays has significantly higher number of academic staffs and also pays these staffs double of what private medical colleges do.  Hence, The cost of MBBS in private institute is hence significantly lower.

The government paying hefty fees with poor man’s taxes is a hoax perpetrated by the MOH and local leaders alike to make us feel unnecessarily indebted and justify MOH harsh directives for scholarship students.

 Government’s loss

The health care system will get nothing extending the contract, except crowding PHCCs with huge numbers of frustrated doctors. The number of doctors in PHCCs is already thrice the sanctioned post. The condition is so bad that MOH exhausted its finances allocated for paying salaries of these staffs this year. We have not received salaries for months.

Increasing the contract will increase the number of doctors by nearly 3 folds. That’s taxpayer’s money wasted on unnecessary human resource over essential facilities – like measuring serum glucose – and only 7% of the PHCCs(and only 20% of district hospitals) have lab facilities to measure serum glucose. 

Also, barring Nepal’s top graduate from pursuing their education will also weaken our academic institutes.

Redefining scholarship as Investment

Getting a MOE scholarship or an admission in Institute of Medicine/BPKIHS used to be a matter of pride because they were academic scholarship handed to the best. Academic institutions all across the globe reward outstanding students with scholarships and expect nothing in return except maintaining the outstanding record.

However, our Ministry of Health (MoH) has always defined our scholarships as an investment and our contract duration as return.

The MOH has been very clear that we have to pay it back. With limited benefit to our healthcare system we are paying it back with our careers just for the sake of paying it back as if our scholarship was a loan. This attitude from the MOH makes us feel like we are being punished for being outstanding students.

Jeopardizing careers

Working 5 years under MOH’s harsh contract will have catastrophic impact not just our careers but also family and social life. Unable to join MD/MS program after 5 years is frowned upon in medical field. Also one’s ability to learn new skills fades with time – joining post graduate program at age of 30-35 years will shape the once best students of the country into only mediocre clinicians.

Dr. Bishal Gyawali, who is now one of the most renowned oncologist in the world, graduated from IOM in 2012 and finished his PhD within 5 years of that. Imagine where he would have been if he was tied down like rest of us.  Since 2016, all IOM graduates have 2 years of mandatory government contract where they are barred from studies. Now, it could be 5. Ridiculous!


Opportunity
Introducing a new directive is also an opportunity for MOH to design a contract that respects our efforts.
No doctor should be barred from pursuing a post graduate degree during the contract. If paying back for the scholarship is important for MOH, one could be asked to complete it after PG. Also, increasing the duration of the contract is unnecessary not cost effective.

We should not be punished for studying under scholarships.

The story was published on MyRepublica on 2018/01/03 - A doctor's complaints
This is the unedited raw form. 

The Real Real Life Heroes

Our world is going hither and thither with political instability, risk of domestic war, skyrocketing prices of food, health, clothes and education, high level corporate crimes, global warming(while I write this Nepal has recorded one of the hottest year in its history) and an economy that seems to befit only rich and ruthless. The time is such that we feel nothing at all is in our hand. It is difficult to combat these alarming concerns when day to day demand for job (and education for it) and family require much of our time.

The shutdowns a few days back- I didn’t want to walk to my college but there was nothing I could do. We cannot do anything when politically privileged announce impunity of their scandalous carders but still we live with the fact that much of our lives (and thus addressing the concerns) is much determined by these untrustworthy and recalcitrant (mis)leaders. In such condition feeling of impotency is understandably inevitable-will our stand on these critical common problem make any difference? Why should we continue making the effort?

Amidst these we cannot neglect those great changes that the world has witnessed.The civil right movement of USA (Rosa parks and Martin Luther King Jr.), fall of apartheid (Nelson Mandela and Archbishop Desmond Tutu),Indian subcontinent's fight for freedom against East India Company (Mahatma Gandhi) (We might not know much about the movements but we do know about these people and its through their life stories we witness these great achievements) . BUT WHO AM I COMPARED TO THESE GREAT PEOPLE? 

'Invictus', biographical sports drama film, depict Nelson Mandela as a perfect human being and mentions very little about his family life. The story of Rosa Parks (probably in 4th grade Gulmohar) pictures her as a black woman who on one lucky day decides to take stand (or the seat) against the unjust system in America. Mahatma Gandhi, he is a person who never lies; does all his work by himself and does nothing wrong! This is how most people see these real life heroes. 

The unreal stories of the real life heroes set up standards that are impossible to meet by an ordinary person. I have friends that don’t even know that Nelson Mandela did too have a family like a normal person and despite having to meet the same day to day demands he managed to get himself involved for justice. He was an ordinary person with ordinary flaws. The conventional telling however portrays him as saint who always fought for justice and never as an ordinary person. This gives us an idea that these people were never ordinary like us. They were gifted and that’s why they made the difference- an unreal story with ending up a misleading moral, making it harder for us to get involved.
The real story, however are very ordinary and thus less intriguing.

Conventional telling of Rosa parks' story presents her as a virgin to politics, and one day just like that she decides to not to give her seat to the white guy. The real story is lot different. Before refusing to give up her seat, she had been active for 12 years n local NAACP (National Association for Advancement of Colored People) serving as its secretary. She was motivated by her husband (so she does too have a family like all of us) to be a part of NAACP in the first place. So parks didn’t make a spur-of –the-moment decision and started the civil right moment in USA, but was a part of an existing moment of change. 

Also the lesson of the conventional telling seems to be that if any one of us suddenly do something heroic, that would be just as great. That might sound powerful but it doesn’t happen in real life. the real story however tells us a that she started with modest steps(and so did Mandela and Gandhi), that all of us can take. Hesitant, at first she slowly gained confidence and keeps on despite a profoundly uncertain context. 

Parks story tells us that change is a product conscious, incremental action, where all of us join together (see how she is motivated by her husband to join NAACP) and not something that comes just in an instant. Also her story tells us about the "chain of inspiration", throughout her term as a NAACP member she must have been inspired and helped by so many people that we don’t know(just like her husband, ED Nixon who served as one of her mentor). May be its difficult achieve something that Rosa park did however we can always be part of that" chain of inspiration" that made Rosa Park.
Once we know that all these great people were ordinary people with ordinary flaws and yet they were able to bring critical change and the chain of inspiration we know that our stand will make a difference. feels like even i have a shot at bringing a change!!!

Read
Real Rosa Park by Paul Rogat Loeb