According to the WHO, approximately two-thirds of the world’s population lacks access to diagnostic X-Ray. Nyaya Health has deployed a World Health Imaging System for Radiology (WHIS-RAD) X-Ray machine.  We hope that our data and experiences can be of assistance to other healthcare workers and groups who are trying to ensure diagnostic radiology access to rural populations throughout the world.

Program Overview and Rationale

Approximately two-thirds of the world’s population lacks access to diagnostic X-Ray services. Nyaya Health aims to develop a scaleable model for X-Ray that can reach the rural poor by utilizing its experience in Nepal to inform best practices in similar settings around the world. Digital x-ray, combined with teleradiology for complex cases and quality assurance, promises to meet the need by decreasing long-term operating costs, improving programmatic quality, and mitigating environmental and safety hazards. We aim to create a model digital X-Ray program that can be scaled up throughout Nepal and South Asia, and serve as an instructive pilot system for governmental health ministries. The X-Ray program will build upon Nyaya's existing ultrasound program, which utilizes teleradiology for quality assurance purposes. While currently teleradiology services for our ultrasound program are strictly through Yale University, USA, Nyaya aims to develop collaborations within Nepal for future telemedicine services in a continued effort to expand capacity within the Nepali healthcare infrastructure.

Approach

Our digital x-ray program will proceed in two phases. The first phase is the deployment of a World Health Imaging System for Radiology (WHIS-RAD). We have negotiated discount pricing, installation, and training terms with the Spanish supplier SEDECAL for the system. Designed by the World Health Organization, the WHIS-RAD is largely considered the gold-standard x-ray system for rural resource-poor settings. The primary design characteristics include:

1) fixed tube column that is always centered on the cassette to guarantee minimal scatter radiation;

2) 11 kW battery system that can be charged even in extremely unstable electricity environments, charged by a typical 10 amp/220V wall outlet;

3) minimal moveable parts that minimize servicing needs and reduce the risk of malfunction;

4) high quality and safety largely independent of the operator;

5) owing to minimal scatter radiation risk, there are few additional site requirements;

6) x-ray tube ratings sufficient to reliably produce high-quality images.

In the first phase, we will create analogue film images in a darkroom to be read on-site by our clinical team.

Following the first phase, Nyaya will incorporate a digital processor to the WHIS-RAD system. During the first 6-12 months of Phase 1, we will have established the essential clinical workflows to operate our x-ray system effectively. The digital component will allow Nyaya to implement teleradiology services with collaborating institutions in the USA and within Nepal. The teleradiology process will require the ability to digitize all images, which will be obtained through the purchase of a digital cassette (which receives the x-ray beam) and a processor, which processes the image. The images can then be sent to collaborators who will advise on complex cases, as well as provide continual quality assurance. Nyaya's ongoing digital ultrasound program will provide a model for establishing this system.

Projected Capital and Operating Costs

Additional Materials

• Bayalpata Hospital X-Ray Exposure Chart
• First three months report 
• Ongoing data from our x-ray program
• Blog posts about our X-Ray program
• Nyaya's Health's X-Ray materials folder 
• Original installation work-plan 
• X-ray Manuals 
• Nyaya Health's academic article on the need for global radiology services 
• WHO Diagnostic Imaging Page
• Manual of Diagnostic Imaging for Small Clinics and Hospitals