Bring healthcare to thousands in rural Nepal

GYNECOLOGICAL TRAINING:
Since 2018 with the support of Chao Foundation and TFish Fund, HHC has conducted vital trainings for midwives and other women health providers who are at the forefront of women health care service and often the only providers in rural Nepal. The first three trainings in 2018, 2019, 2020 were provided in the remote corners of Dhading district namely, Ruby Valley first, Gajuri second and then Benighat Rorang Rural Municipality.

 After many discussions over the phone with the District Health Office during the heat of the pandemic and finally in person with the chief officer, as the shutdown was eased, in regards to expansion of this training in other parts of Dhading District, Benighat Rorang Rural Municipality was identified and finalized. Benighat had put in a formal request but it was finalized for the training when the survey was carried out and several remotely located village health posts were identified. We concluded that the gynecological training would be well suited for this rural municipality and would give continuity to HHC’s vision of serving women patients who were the most deprived. Request from Ruby Valley, Gajuri and Benighat Rorang RM for those midwives who either were newly transferred or missed the previous training were included in this training. Two of three Chao Supported ANMs (2018-2019) namely Niri M T of Sertung and Hima G of Lapa villages were also included in this training.

 HHC estimates that 5,000 girls and women patients will be served better in the 2-3 years after this training. These are girls and women from Dalit and other minority communities, ages 10-90+, in remote and neglected villages of the Benighat Rorang RM of Dhading District, Nepal, who currently receive little or no care. A follow-up training will follow in December of 2021 to help the trainees discuss about their post-training practice of medicine, the challenges and questions that they have faced along with case presentations. The experts will provide additional new instructions on prevailing diseases to follow-up on all that was taught in the first training which will help boost their confidence so that they are able to serve more independently.  

 The three training venues were chosen as they are three hour drive from Kathmandu and are an hour from the Dhading District HQ of Dhadingbesi and lies at the center of the each municipalities. But still the trainees traveled for several hours in public buses to reach these centers from village sites that are spread out in the region. HHC officer Nabin M escorted the specialists from Kathmandu for the training. They all were provided food and stay at a local hotel during the 4 day training period.

 The trainees were divided into three groups, with 5 in each so that each trainee would have more one-on-one time with the expert (table below). Group A was instructed by Dr. Rakshya U, Gajuri RM, group B by Dr. Unnati A, Benighat Health Post and group C by Anita M, Charaudi Basic health Center, Benighat RM. As all the trainers were from the Paropakar Maternity and Women’s Hospital, they had prepared all the training materials and handouts in advance together which saved time and was well done.

 Group A: Dr. Rakshya U, Gajuri Rural Municipality: 

1. Pushpa , ANM(Auxiliary Nurse Midwife) Pakhure Community Health Unit (CHU) ward # 4
2. Samjhana B, ANM, Simpani CHU ward # 6
3. Anjana S, ANM, Sunsari CHU, ward # 3
4. Saphalta T, ANM, Kiranchowk Health Post, ward # 8
5. Dil M KC, ANM, Petare CHU, ward # 7 

Group B: Dr. Unnati A, Benighat Health Post

1. Laxmi W, ANMBenighat HP, ward # 5, Benighat RM
2. Hima G, ANM, Kupchet CHU, ward # 6, Ruby valley RM
3. Rita K, ANM, Khading BHC, ward # 6, Ruby Valley RM
4. Pratima G, ANM, Tenchet CHU, ward # 5, Ruby Valley RM
5. Anjali K, ANM, Dundethati CHU, ward # 2, Gajuri RM 

Group C: Dr. Anita M, Charaudi Basic Health Center

1. Niri MT, ANM,Borang Basic Health Unit, ward # 4, Ruby Valley RM
2. Karuna T, AHW (Auxiliary Health Worker), Neber CHU, ward # 5, Ruby Valley RM
3. Anu T, AHW, Hendung CHU, ward # 4, Ruby Valley RM
4. Shanti S, AHW, Dhusa HP, ward # 8, Benighat RM
5. Tika K G, AHW, Charaudi BHC, ward # 6, Benighat RM

 First day of Training (18Aug) 

Due to incessant rain, landslide and road block in Khanikhola, the trainers arrived late in the afternoon at 3.00 pm. The first day of training was limited to introduction only. No official inauguration was planned due to ongoing covid situation. HHC supervisor Kul MB shared information on the trainers, training, subject matter and the importance of the training. Likewise, the name list of trainees under each trainer and venue was shared. HHC had a van in standby to transport the trainers and trainees to 3 different training venues.

 Day 2 of training (19Aug)

 As the 3 trainers belonged to the same hospital, they had consulted and prepared the training material (slides) and used the same slide in all 3 centers. The trainers gave their individual feedback at the end of each training day. The training started at 8:00 am in the morning and ended at 5:00 pm as they had to cover some of the topics of day 1 also.

 Basic history taking and examination of gynecological cases

 History taking 1

1. Introduction
2. Chief complaint
3. Menstrual history
4. Obstetric history, GPAL (gravid, para, abortion, living), any problem during birth, delivery place - health institution or home
5. Contraceptive history, temporary OPC, Depo, Norplant , IUCD or permanent vasectomy and laparoscopic
6. Past or present medical history: Any chronic diseases like TB, HTN, diabetes, thyroids and medication
7. Personal history: Smoking, alcohol and diet like veg or non-veg
8. Occupational history: Which profession?
9. Family history: Any disease in family member

EXAMINATIONS

General Physical examination:

Vitals with JALCCOLD (jaundice, anemia, cyanosis, clubbing of fingernails, edema of the ankles, lymph nodes, dehydration)

 Specific Examination

Per Abdominal examination, any mass or tenderness

Inspection / Palpation / Percussion / Auscultation

Per speculum Examination: technique and matters to be observed

Per Vaginal Examination: technique and matters too be observed

Resuscitation of newborn baby with respiratory distress problem

 Vaginal Discharge

Types of vaginal discharge:

1. Physiological- reproductive age, menstrual and hormonal

2. Pathological - infected and non-infected

Infected: Sexually infected- TV, Chlamydia, Gonorrhea, Syphilis, HSV Non sexual infected- BV, Candida (mostly below 25 Years)

Non-infected: Foreign body, atrophic (dryness) and

3. Malignant Diseases

Major Causative Agent and Nature of Discharge:

1. Candida fungal agent with curdy discharge with itching
2. Bacterial vaginitis causes by chlamydia bacteria with grayish white discharge
3. Trichomonas protozoal agent with greenish discharge with frothy nature
4. Gonorrhea bacteria discharge Fishy odor
5. Syphilis bacterial ulcer on vagina

 Day three of Training (20 Aug):

The third day of training also started at 8:00 am and ended at 5:00 pm. As per the demand of the trainees various topics such as abortion, ectopic pregnancy, postpartum hemmorage, medical and non-medical management as well as use of condom balloon tamponade were discussed.

 Abortion:

Definition of Abortion

Types of abortion

1. Spontaneous: Isolated and recurrent
2. Induced: MTP and Illegal (explained with colored pictures of all types of abortion including management and legal issues)

Ectopic Pregnancy:

 Definition of Ectopic Pregnancy (the fertilised ovum implanted and developed in a site other than normal uterine cavity)

Types of ectopic pregnancy

1. Tubal ectopic:

Acute/ruptured tubal ectopic

Spontaneous resolution

Persistent trophoblastic tissue and chronic ectopic
        2. Non tubal ectopic:

Cervical pregnancy

Ovarian pregnancy

Abdominal pregnancy

Interstitial pregnancy

Inter-ligamentous pregnancy

Heterotopic pregnancy

Multiple ectopic and pregnancy after hysterectomy

Postpartum Hemorrhage (PPH):

Postpartum hemorrhage (PPH) being the major cause of women death in Nepal, the participants were taught on how to manage PPH

Definition:

An estimated blood loss of >500ml of blood from the genital tract at vaginal delivery & >1000 ml at caesarean section or 1500 ml at caesarean hysterectomy.

 Classification:

1. Primary: within the first 24 hours after delivery
2. Secondary: when it occurs between 24 hours to 6-12 weeks postpartum

Causes:

4Ts (tone 80%, trauma, tissue and thrombin)

The principles of management:

ABC- Airway, breathing & circulation

Replace circulating blood volume &

Stop blood loss

Medical management: Oxytocin, Ergometrine, Carboprost and Misoprostol

Non-medical management:

Uterine massage

Bimanual uterine compression

Compression of aorta against sacral promontory

Anti-shock garment and Intra uterine pressure

  The condom balloon tamponade

Condom Foley's catheter tamponade is simple, easy to use and is believed to give effective results. This technic is applicable in any health institutions. It is simple and does not require expertise to use it, so it can have wide application even in resource poor settings.

Briefing: Trainers informed in detail about materials and instruments to be prepared prior to the procedure, importance of condom tamponade and technic of procedure.

Demonstration: Trainers demonstrated how to set up, technic of procedure and possible errors by using artificial uterus.

Practical: After the demonstration, all participants were asked to show the set up procedure as taught by the trainers.

Day four of Training (21 Aug)
Pelvic Organ Prolapsed (POP)

Definition of POP: Descent of one or more genital organs below their normal anatomical position and occurs due to weakness of the structure supporting the organs in the position.

Classification of POP

1. Uterineprolapse:1st,2nd,or3rd,degree

1 cm decent from normal position is called 1^st degree
1cm up or down of hymen level is called 2^nd degree
Uterus partially out from the vaginal opening is called 3^rd degree
Uterus totally out from the vaginal opening is called 4^th degre

       2. Vaginal prolapse:

Anterior vaginal wall prolapse
Posterior vaginal wall prolapse

       3.  Vaginal Vault prolapse: This occurs when the upper portion of the vagina loses its normal shape and sags and droops down into the vaginal canal or outside of the vagina. This usually occurs in women who have had a hysterectomy

Management of POP:

Surgery, kigle exercise or ring pessary support

 Cervical Cancer

 Cancer of the cervix is the second most common cancer in women worldwide, with about 500,000 new cases and 250,00 deaths each year. Almost 80% of cases occur in the developing nations.

Age group: Age specific cervical cancer incidence is bimodal

Peaks at: 35 and 75 years, women aged 30-40 years more likely to be diagnosed with early stage whereas over 60 years more commonly diagnosed with advance stage

Nepal: Strategies for Cervical Cancer Screening

Focal Point: Family Health Division
Program: Cervical Cancer Screening Program (CCSP)
Target population: 30-60 year
Screening Interval: 5 year
Screening modality: VIA/SVA

Management:
       1. Preventive: HPV vaccine and awareness to predisposing factors
       2. Chemo therapy
       3. Radiotherapy and
       4. Surgery

 VIA (visual inspection with acetic acid):

Screening carcinoma of cervix with simple technic is called VIA. This is the technic applicable in all level of health institutions.

Acidic acid with normal saline applied around the cervix and leave for a minute then observe the color.

 Result: Color change, positive and no change, negative.

(Due to lack of time and no patient on Saturday, it was not possible to carry out the practical of VIA by the participants. As per the plan, this will be conducted during the follow up training in December 2021)                                        

Trainer’s Note:

Dr. Anita M

It was a great experience working with Himalayan HealthCare. The gynecological training camp for ANM and paramedics funded by CHAO Foundation and TFISH FUND in coordination with rural Benighat Municipality provided the female local health workers an opportunity to deal with gynecological cases in their local setup. It was mainly focused on gynecological examinations(history taking and physical examination), identifying and treatment of commongynecological infections, management of uterine prolapse Abortion and Ectopicpregnancy, screening methods such as VIA,PAP smear and postpartum hemorrhage(PPH) and demonstration of Condom Tamponade.

The trainees were enthusiastic,hardworking and actively participated indiscussions and provided good patient care at the gynecological outpatient under supervision. undersupervision.The trainees were comfortable in managing obstetrical patients but had confusions in managing gynecological patients. Hence, I believe these kind of trainings should be held regularly as it will help them in providing quality of care to the gynecological patients and improving the standard of care. Thanks to CHAO Foundation and Himalayan HealthCare for giving me an opportunity to share some of my knowledge with participants and share some of my experiences. Hope all the participants had got more knowledge and able to cure the patients.

Dr. Unnati A

It was really a wonderful experience working with Himalayan Health care, as it was my first time collaborating with HHC. The gynecological training camp for midwives and female health worker funded by CHAO Foundation and TFISH Fund in coordination with rural Benighat Rorang Municipality provided the female local health workers an opportunity to deal with gynecological cases in their local setup. It helped in identifying the local health problem of female and approach to deal with it. All the participants were highly enthusiastic and dedicated. I feel that this was definitely one of the best programs that helps not only in diagnosing and treating the disease at rural level but will definitely help rural women to get more concerned about their disease and problem in developing country like ours. Thanks to CHAO foundation and Himalayan HealthCare. Working with them felt really like working in a very hospitable environment. They further need other trainings such as pediatrics diagnosis and treatment. Hope we will be able to work together in future trainings program. Hope there will be more patients for practical workshops. I would suggest HHC to conduct the training for 3 days and 1-2 day of real camp of patients.

Dr. Rakshya U

It was a great experience working with Himalayan HealthCare once again. The gynecological training camp for midwives and female health worker funded by CHAO Foundation and TFISH FUND in coordination with rural Gajuri Municipality provided the female local health workers an opportunity to deal with gynecological cases in their local setup. It helped in identifying the local health problem of female and approach to deal with it. All the participants were highly enthusiastic and dedicated. I feel that this was definitively one of the best program that helps not only in diagnosing and treating the disease at rural level but will definitely help rural women to get more concerned about their disease and problem in developing country like ours. Thanks to CHAO foundation and Himalayan HealthCare. Working with the health providers felt like working in a very hospitable environment.

Closing Program:

During the closing, the chairman of Gajuri Rural Municipality thanked HHC and the trainers for the effective training provided to the participants. He hoped that the trainees would impart the knowledge to the best of their abilities in helping the rural women. Likewise, In Benighat, the health in-charge was present during the closing program as the chairman was not able to come due to some personal problems. He thanked the trainers and participants for the great learning experience and highlighted that the region is populated by one the most backward communities and that such a quality training would help them immensely. The closing ceremony was carried out ensuring Covid-19 protocols with minimum people and certificates and health check kits (table below) were handed over to the participants.

 Representatives of HHC, Kul M B & Phe DT asked all health participants to submit a monthly report on patients they serve at their respective centers post-training to help us better assess and improve the training in the future. They were also asked to make notes on all patients and cases and have questions ready for the follow-up training session scheduled to be held in December 2021. After the briefing by HHC representative, the chairman announced the conclusion of the training.

One Home One Toilet

Project Site:

Shertung Village, Ward 3 & 4 of Ruby Valley Rural Municipality in central Nepal where Himalayan HealthCare (HHC) works since 1992. Tamang and Dalit communities live in mountainous villages. There is no road and only minimal basic infrastructure.

Introduction

In remote mountainous villages of northern Dhading District, Tamang and Dalit (formerly “untouchable”) community members live in extreme poverty, suffering long-term marginalization, the legacy of Nepal’s caste system, lack of access to health care and neglect due to geographical isolation. This has been severely exacerbated by the devastation of the 2015 earthquake and the current pandemic.

Project Outcome:

Our target outcome is to save lives by preventing diseases, improve overall health outcomes and contribute to an improved standard of living as healthy community members have increased capacity to engage in educational and income-generating pursuits. Every household that has a sanitized toilet with septic tank reduces water/food contamination and increases public health. Installing toilets and training villagers is one of the most important public health steps we can take. 

 A related target outcome is safety: the ease of access of home toilets provides safety for vulnerable community members (e.g. children, elderly, those with physical disabilities) who no longer need to go into the forest where they face risks such as falling, heavy monsoon rains, encounters with wild animals or snakes, etc.

Local Partnership:
As stakeholders, the recipients provide their land and build their own toilets using local materials under HHC's supervision thus giving the recipients dignity and ownership. Materials not resourced locally like pipes, rebar, cement, fixtures, tin sheets, etc., was transported and provided by HHC through this grant.

Toilet Building Process:
The beneficiary submits an application for a toilet and when confirmed begins to build the toilet building (housing) and the septic tank using HHC’s specification. Locally resourced rocks are used for the walls and wood for the rafters and the door. Once the building is completed, HHC supervisors/technicians inspect and then provide a coupon to access toilet pan, pipes, cement, rebar, tin sheets and other fitting materials from the nearest hardware store in Dhundurey which is two days walk away. The hardware store is paid in advance by HHC through the grant. HHC technicians help the beneficiary make the cemented septic tank cover and also to correctly position the toilet pan. It takes at least three months of hard labor to complete a toilet.

Project Beneficiaries:

A total of 108 people from 20 households directly benefited from the 20 toilets built including 71 children. More than 5,000 community members of Shertung village will also be protected from fly-borne diseases like typhoid, cholera, dysentery, etc.

Please see table of beneficiaries attched.

Project Effectiveness and Sustainability:

Since the toilet project is ongoing, its effectiveness is self-evident. Our community-based, trained local supervisors check for open-defecation around the recipient households which should decrease automatically as the new toilets quickly become convenient and a way of life for the family especially the children, old people and the sick. Toilet in this region now is a status-symbol giving pride to the recipient family and also saving lives. 

Delays and Challenges:

• Supply of construction materials is difficult because of the temporary dirt road in this region which goes only part way up the valley from which point the purchased toilet materials are carried by porters or mules for two days. Coordinating this transfer and helping goods reach the recipients is time-taking and difficult but HHC has 28 years of experience in this difficult region and the local staff has been both efficient and timely.

The pandemic and the national lockdown delayed the project by 10 months

• Toilet_grant_recipent_2021_report_to_Globalgiving.xlsx (XLSX)