Our journey to Charikot started as any normal trip, a little off schedule. We met in front of Singha Durbar and left for our destination at exactly 1:20 pm. There was a long traffic jam just after driving for 20 seconds; where we spent another 15 minutes basking under the hot summer sun. Luckily, the AC was out too. (A couple weeks ago the compressor took a hit and consequently the air conditioning was not working.) That’s lucky for the car as the battery was not functioning exceptionally for the past few weeks too; this AC load could cause potential trouble. Fair to say it was not going to be the smoothest ride to a never been before destination. Our team of four decided to stay two days in Charikot so that we could firstly, observe the PHC program managed by Possible and secondly, get to see around the a bit.
We arrived in Dhulikhel quite fast therefore decision was made to not stop there for lunch; instead we wanted to enjoy some freshly fried fishes in Dolalghat. Yes, inadvertently we chose to take that route; which also was shorter in distance. That route is a total of 132 km from Kathmandu to Charikot passing through Dhulikhel, Paachkhal, Dolalghat, Sukute, Khadichaur, Mude and finally Charikot; while the other is 50km plus that. And also we didn’t know about the other longer route until we were half way through.
The road is alright up until a bridge near Khadichaur that connects one normal terrain to other pulverizing one. We took a break in front of the bridge to ask the way, as there were two paths to choose from. One gentleman was kind enough to show us the way. He also asked to travel 3 kilometers with us on our vehicle. There was room for one so we took him in.
As we went uphill, we could feel that the car was having difficulty to drive up. It wasn’t a steep climb throughout but the road was windy; with lots of curves and twists. One sharp turn after the other; up to 7 turns in succession at one time. The road was dug up and left unattended for 2 years. There were lots of big rocks in the middle of the road. A couple of meters of concrete was scarcely spared on the sides at some points, but that did little to alleviate any road rage. It took us nearly an hour to reach the gentleman’s house. After bidding farewell, we took on the rest of the treacherous road uphill with a valuable parting message, “bistarai janu hola”. This turned out to be the key to not spoiling the cars undercarriage.
The nearest rest stop was still 24km from there. We somehow got there on time before closing hours. That was another problem on the back of our minds. We were sure we couldn’t cover the whole remaining distance to Charikot with 5km per hour speed and end up not having to sleep in the car. Wisely, we made contact with a guest house owner and requested him to wait for us to get there.
At some points we had to make the car lighter to drive up the slope and also avoid hitting stones. So, the rest of the crew got out of the vehicle and let the car drive up. We did this many times for the 24km stretch and finally arrived in Mude just when the fog was starting to grow thicker.
It was 9:50pm and most shops were closed, only a few guest houses had their lights on. . We ate dinner there and spent the chilly night taking about the road ahead.
The next morning we were fresh and hopeful of a new start. Most importantly, the car also was in condition; after a quick check it was ready to cover the remaining miles. Our breakfast was steamed potatoes and tea; with that we took off from Mude at 8:30 am. The rest of the road was alright, it had a few bumps and uneven surfaces but overall much better than the previous night. Plus, the scenery on the way in some places was precious. There are many waterfalls on the way and of course the omnipresent fog in the area at the time was exiting too. We took breaks to soak in the view and take some breath at 2 stops in between. It was noon by the time we got to Charikot so, we directly went to the health post.
The first impression was that it was well managed. Patients were queuing up outside for registration without overcrowding the place. The center at any day handles over 400 patients. This PHC (Public Health Center) is one of a kind run by Possible in partnership with the government of Nepal. This partnership extends to a 10 year contract. This center was built after the devastating earthquake of 2015, which did massive damage in Dolakha district. It is part of a vision by Possible; to deliver low-cost and high-quality health care in rural parts of Nepal.
Although we planned the trip well over a month ago, the date was not fixed. When the whole team sat down a couple days earlier and just went for it. A valuable lesson is that next time we should make an official announcement and request for time at the center. This allows the center to prepare for your arrival and take their time out to attend to you. Despite our unannounced arrival, we were met with friendly and cordial reception.
Mr. Deepak Neupane, who oversees system implementation at Possible, was generous enough to give us time and speak about the challenges and ongoing work at the center. After speaking to Deepak dai, we went around the center and briefly through the departments. After spending good three hours at the hospital it was time to book hotel rooms and get some food. That was pretty much the end of the day, we retired to our rooms and rested to prepare for another day of work.
Thanks to our meeting with Deepak dai, we were able to connect with Dr. Binod Dangal (Medical Director) the next day. We took a tour of the center. A member of the EHR implementation team took us through their workflow.
Starting at the registration, where every patient, new and old, came in and got their appointment for the day. The ticket window to book an appointment is 10-12 noon. Sometime ago it was 10-2pm which translates to a large influx of patients Decreasing this registration window smartly allowed the center to manage the number of patients inside the hospital. And it was a bonus that the waiting area outside was way less crowded. There is also a green light above the front entrance that signals when it’s time to let a group of 15 waiting patients inside the building. This is seemingly a very simple idea, but one with great implications.
A team of three personnel manage the entry of patient data at the registration after which the system relays it on to respective clinical departments depending upon the cases. There is a total of 18 departments including registration, administration, laboratory, X-ray, in and out patient, emergency, chronic diseases, dental, and pharmacy among others. These are all independent departments run by a total of one hundred plus staff; all including doctors, nurses, clinicians, IT personnel, technicians, pharmacist and helpers.
The center is using an Electronic Medical Record system throughout. This system is a conjunction of open source MRS (Medical Record System) now NepalEHR, made available by Bahmni with customization done by ThoughtWorks, community based Commcare and data visualization tool DHIS2. All technicians and clinicians are trained to use this system. There is software platform for laboratory information such as openELIS and inventory management system openERP that keep track of supplies and resources. All of these underlying platforms work together combining technology to everyday healthcare. The goal is to improve patient care and solve real world problems in rural healthcare delivery.
NepalEHR is running so far in Bayalpata Hospital, Accham since 2015; Charikot PHC, Dolakha since 2016 and recently Trisuli Hospital.
PHC, district health posts, and other private institutions are the existing health care facilities in Charikot area. These serve as the healthcare center to tens of thousands of people from Dolakha district. This PPP (public-private partnership) model facility is free of cost. Therefore, a lot of patients come in and find means to resolve their ailments just by putting in effort of appearing at the center.
The difficult terrain and a lack of good access road is as major obstacle for locals coming in to seek medical attention. That said, the effort put in by the Possible team is highly commendable. From establishing good work practice to organizing bi-monthly patient involvement programs; all the complexities of running an electronic medical system to all simple ideas that overcome management issues is evident in their reports. It’s good to see that all the stakeholders take their responsibilities with ownership. This type of attribute can be seen in every department that works in symphony to make this digital transition come alive.
We left Charikot the same day at 3pm after a quick meal. This time we took the longer route. The longer road is less challenging, and in the words of locals it is “sararara Dhulikhel samma”. And so, we left Charikot and drove downhill to pursue that route. On our way back we came across a young undergraduate who was waiting for her bus to get home. Her home was 27km from Charikot where she came to study Agricultural Science. She said that she had to travel 2 hours (to and fro) every day to get to college. Despite staying with relatives nearer to college, she still faces this challenge every day. We dropped the young lady in front of her house and went on our way through that sararara bato to reach Kathmandu at 10pm. There we stopped for dinner and later parted our ways having captured some beautiful sceneries and some valuable knowledge along the way.