This page provides an overview of the clinical services provided by Nyaya Health.

Strategy and Vision

Nyaya Health’s operates a community health center focusing on comprehensive primary care, including maternal and child health, infectious disease prevention and treatment, and management of chronic conditions.  The health center is located in the major transit hub for the region.  It is run by an all-Nepali staff including physicians, community healthcare workers, nurse midwives, lab technicians, pharmacists, and project managers. The center includes a comprehensive laboratory, pharmacy, clinical diagnosis and treatment rooms, infusion space, a delivery suite, capacity for wet and dry storage, and safe medical waste incineration and disposal. We have additionally developed a network of community health workers who constitute mobile teams providing outreach, triage, treatment and follow-up services to a geographically dispersed population. All medical care is provided free-of-charge, with a focus on health equity and outreach to the poorest and most marginalized patients.

The approach we have taken to addressing inequities in access to healthcare has been to develop a general clinical care infrastructure on which we layer on additional condition-specific programs.  The model we are developing aims to rapidly address treatable conditions with a high, measureable public health impact that a nascent health system needs to focus on (and subsidize medicines for).  This allows us to develop a broader health infrastructure that can address the evolving needs of the community while maintaining a rigorous monitoring of condition-specific outcomes.   In other words, we are pursuing a “diagonal” strategy of building a comprehensive primary care system by adding on disease-specific programs to our general healthcare infrastructure. The problem with exclusively “vertical” programs, where disease-specific programs for TB, HIV, maternal care, and vaccinations run largely independent of each other, is that they fail to build an integrated health system capable of meeting a population’s evolving health problems. The benefit of such programs, however, is that they have well-defined budgets and public health outcomes. Fully “horizontal” programs, on the other hand, where a generalist primary care team is expected to address whatever comes through the door, are plagued by wasteful expenditures on conditions that are not necessarily public health priorities.

To provide some context, we have one physician (the only one for area of approximately 500,000 people), three mid-level practitioners known as health assistants, two lab technicians, five midwives, and several community health workers. The nearest surgical and inpatient referral facility is 10 hours away. Approximately 60% of our patients walk from over 2 hours away to get to the clinic. We are essentially the only serious medical care for a large area spanning several hours and tens of thousands of patients.

Prenatal and Perinatal Care

We currently provide essential prenatal and routine delivery services including:

• Regular prenatal care, including evaluation of anemia and provision of folic acid and iron, vaccination with tetanus toxoid, anti-helminth treatment, and macronutrients, where necessary
• PMTCT program with routine antenatal HIV testing
• Routine delivery attended by trained midwives or physician
• Management of peripartum complications including pre-eclampsia, obstruction of labor, breech deliveries, gestational diabetes, post-partum hemorrhage, infections.
• Promotion and support of immediate postpartum breastfeeding when appropriate

Our expansion of maternal services will proceed stepwise, focusing initially on establishing a community-oriented health program, prenatal preventive care, and delivery services including the treatment of minor obstetrical complications. Specifically, we follow the model of the “Averting Maternal Death and Disability” (AMDD) program, first establishing normal delivery services and the “basic” package of emergency obstetric care, including:

• Intravenous and oral antibiotics for perinatal infections
• Intravenous and oral Oxytocin for postpartum hemorrhage
• Intravenous and oral anticonvulsants for perinatal seizures
• Intravenous and oral antihypertensives for perinatal hypertension
• Removal of retained products of conception
• Manual removal of placenta
• Vacuum- or forceps-assisted vaginal delivery for obstructed labor

These interventions aim to reduce maternal mortality from the five most prevalent causes of maternal mortality: hemorrhage, sepsis, unsafe induced abortion, hypertensive disorders of pregnancy, and obstructed labor.  Subsequent to this, we will implement cesarean sectiona and blood transfusion to further reduce maternal mortality. 

Neonatal Care

The protocol that we follow for neonatal patients is Managing Newborn Care from the WHO’s Integrated Management of Pregnancy and Childbirth (IMPAC).  The main components of this protocol involve:

• Resuscitation of asphyxiated neonates
• Prevent and treat hypothermia
• Neonatal ocular prophylaxis to prevent blindness from chlamydia infection
• Recognize and treat neonatal infections
• Identify low birth weight infants for continued community-based monitoring and nutrition interventions      

Pediatric Primary Care

Our generalist team provides care to a range of outpatient conditions affecting children.  Additionally, we focus our data monitoring and pharmaceutical resources on high-impact interventions to reduce under-five mortality. These interventions largely follow the Integrated Management of Childhood Illness (IMCI) model as well as additional conditions that are driven by local epidemiological need:

• Treatment of pneumonia, with appropriate use of antibiotic and bronchodilators
• Management of diarrheal diseases, with low-osmolarity Oral Rehydration Solution and use of antibiotics for bloody diarrhea
• Evaluation and expansion of vaccination programs and Vitamin A supplementation, integrated within the government's existing programs
• Screening and treatment of helminthic infections with albendazole and mebendazole
• Promotion of breast feeding where appropriate
• Screening and treatment of micronutrient deficiencies, notably iron, vitamin A, and B12.
• Screening and treatment of severe acute malnutrition
• Treatment of otitis media with appropriate antibiotic use
• Management of pediatric fever, with evaluation and management of malaria, meningitis, measles, and other infectious processes

Adult Primary Care

There are a large range of adult conditions for which our generalist primary care team provides evaluation and treatment.  We are incrementally expanding these primary care services to focus on conditions for which evidence-based treatments exist.  These are detailed further on our primary care protocols page. 

Inpatient and Emergency Services

We additionally offer inpatient and emergency services to address acute needs.  These include abdominal and orthopedic trauma, snake bites, COPD and asthma exacerbations, sepsis, severe pneumonia, and heart failure.  Our central objective with our inpatient and emergency services is to stablize patients, preferably for discharge to community-based care and if not for referral to a higher level facility, the nearest of which is approximately ten hours away by jeep.  Owing to space and resource constraints, our inpatient capacity is limited.  Our census from inpatient and emergency services is provided on our wiki clinical data page.

Mobile Medical Care

We currently employ community health workers who perform the following tasks:

• follow-up of patients treated at the clinic
• detection of pregnancy and outreach to improve rates of antenatal care and delivery at the Nyaya health center
• detection of severe acute malnutrition for referral to the clinic

Protocols and plans for this program are available at our CHW wiki page. 

Program Evaluation and Monitoring

A central aspect of our work is using patient-level outcomes to drive the improvement of our clinical services.  Please visit our data pages by clicking on the links in the left-hand sidebar, to see outcomes of the various programs that we have developed.