SANFE MEDICAL CLINIC , ACHHAM

Mission Statement/Vision
Nyaya Health is an international NGO partnering with the Ministry of Health and Population of Nepal and the District Health Office of Achham to improve healthcare infrastructure in Achham. Achham is a rural agricultural district with some of Nepal's highest poverty, infant mortality, maternal mortality, and HIV rates. The mission of the project is two-fold: to establish essential public health services in one of Nepal's most underdeveloped areas, and to develop a model of scaling-up and management of health services in remote areas. We are currently developing a primary health centre focusing on antenatal care, normal deliveries, provision of basic emergency obstetric care, prevention of mother-to-child transmission of HIV, and pediatric care. Within the next year, we plan on expanding operations to a long-abandoned government hospital in Bayalpata, with the aim of providing comprehensive emergency obstetric care and inpatient services.

Capacities of the Clinic:
1. Prenatal and Perinatal Care
In the first year, a physician with obstetric experience will be hired to set up basic prenatal and routine delivery services at the main clinic which will include:
* Prenatal evaluation of anemia and provision of folic acid and iron, vaccination with tetanus toxoid, anti-helminth treatment with albendazole, and macronutrients, where necessary
* Routine prenatal check-ups
* Routine delivery attended by trained midwives or doctor
* Promotion and support of immediate postpartum breastfeeding when appropriate
* PMTCT program with routine antenatal HIV testing

The expansion of maternal services in the region will proceed stepwise, focusing in the beginning on establishing a community-oriented health program, prenatal preventive care, and delivery services including the treatment of minor obstetrical complications. For medical services, we will 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
All of these services can be provided by an adequately trained physician. Providing these basic services, we expect to significantly reduce maternal mortality in these communities, specifically by preventing mortality from the five most prevalent causes of maternal mortality: hemorrhage, sepsis, unsafe induced abortion, hypertensive disorders of pregnancy, and obstructed labor.

2. Neontal Care:
The protocol that we will follow for neonatal patients will be 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
* Recognize and treat neonatal infections

3. Pediatric Care:
The pediatrics component will focus on high-impact interventions to reduce under-five mortality. The generalist physician, working together with community health workers, will implement basic community-level child health interventions. The client-level interventions will largely follow the Integrated Management of Childhood Illness (IMCI) model, including the following components, all managed through a community-based, team, case management approach with point of entry generally being the community health worker:
* 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
* Screening and treatment of helminthic infections with albendazole and mebendazole
* Promotion of breast feeding where appropriate
* Screening and treatment of micronutrient deficiencies
* Screening and treatment of failure to thrive/macronutrient deficiencies
* Treatment of otitis media with appropriate antibiotic use
* Management of pediatric fever, with evaluation and management of malaria, meningitis, measles, and other infectious processes

These relatively simple, low-tech strategies, implemented by a CHW-centered team pproach to community public health, can cost-effectively markedly reduce malnutrition and child mortality in this area.

The community health workers will be trained adapting from the Integrated Child Development Services model whereby the CHWs engage individual families in the following core activities:
* Malnutrition evaluation, provision of supplementary feeding, and referral of acute malnutrition cases
* Regular height and weight monitoring
* Education and engagement of families and communities in nutrition and health support for young children
* Scheduling and check-up of routine vaccinations and well-baby and well-child visits
* Engagement in non-formal pre-school educational activities

In addition to these curative activities, we will administer vaccinations and other public health nterventions in collaboration with the DHO.