Implementing Diagnostic Imaging Services in a Rural Setting of Extreme Poverty: Five Years of X-ray and Ultrasound Service Delivery in Achham, Nepal

Journal of Global Radiology, Mar 2015

Introduction: Diagnostic radiology services are severely lacking in many rural settings and the implementation of these services poses complex challenges. The purpose of this paper is to describe the implementation of diagnostic radiology services at a district-level hospital in Achham, a rural district in Nepal. Methods and Materials: We conducted a retrospective review of the implementation of diagnostic radiology services. We compiled a list of implementation challenges and proposed solutions based on an internal review of historical data, hospital records, and the experiences of hospital staff members. We used a seven-domain analytic framework to structure our discussion of these challenges. Results: We documented the first five years of challenges faced and lessons learned by the non-profit organization Possible while implementing and providing diagnostic radiology services for the first time in a remote location. Additionally, we documented the uptake of these services through the first five years of operations. During this time, the number of X-rays performed increased 271%, while ultrasounds increased 258%. The main challenges included educating the community about the appropriate use of these services, recruiting trained providers, and coordinating referral care and consultations for higher-level diagnostics and treatment. Finally, investments in training providers and technicians, as well as investments in infrastructure, primarily the installation of solar panels to maintain a power supply, were critical to sustaining services. Discussion: This experience demonstrates that reliable and sustained services can be deployed even in extremely remote areas and identifies challenges that other implementers may face in similar program implementation.

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Implementing Diagnostic Imaging Services in a Rural Setting of Extreme Poverty: Five Years of X-ray and Ultrasound Service Delivery in Achham, Nepal

Word count: Implementing Diagnostic Imaging Services in a Rural Setting of Extreme Poverty: Five Years of X-ray and Ultrasound Service Delivery in Achham, Nepal Malina Filkins 0 Scott Halliday 1 2 3 Brock Daniels 4 Roshan Bista 5 Sudan Thapa 5 Ryan Schwarz 1 2 6 Dan Schwarz 1 2 6 Bikash Gauchan 1 Duncan Maru 1 2 6 7 0 Partners HealthCare System , Information Systems, Boston, MA , USA 1 Possible, Bayalpata Hospital , Badelgada, Ridikot-2, Achham , Nepal 2 Brigham and Women's Hospital, Department of Medicine, Division of Global Health Equity , Boston, MA , USA 3 University of Washington, Henry M. Jackson School of International Studies , Seattle, WA , USA 4 Yale-New Haven Hospital, Department of Emergency Medicine , New Haven, CT , USA 5 Tribhuvan University, Institute of Medicine , Kathmandu , Nepal 6 Boston Children's Hospital, Department of Medicine, Division of General Pediatrics , Boston, MA , USA 7 Harvard Medical School, Department of Global Health and Social Medicine , Boston, MA , USA Introduction: Diagnostic radiology services are severely lacking in many rural settings and the implementation of these services poses complex challenges. The purpose of this paper is to describe the implementation of diagnostic radiology services at a district-level hospital in Achham, a rural district in Nepal. Methods and Materials: We conducted a retrospective review of the implementation of diagnostic radiology services. We compiled a list of implementation challenges and proposed solutions based on an internal review of historical data, hospital records, and the experiences of hospital staff members. We used a seven-domain analytic framework to structure our discussion of these challenges. Results: We documented the first five years of challenges faced and lessons learned by the non-profit organization Possible while implementing and providing diagnostic radiology services for the first time in a remote location. Additionally, we documented the uptake of these services through the first five years of operations. During this time, the number of X-rays performed increased 271%, while ultrasounds increased 258%. The main challenges included educating the community about the appropriate use of these services, recruiting trained providers, and coordinating referral care and consultations for higher-level diagnostics and treatment. Finally, investments in training providers and technicians, as well as investments in infrastructure, primarily the installation of solar panels to maintain a power supply, were critical to sustaining services. Discussion: This experience demonstrates that reliable and sustained services can be deployed even in extremely remote areas and identifies challenges that other implementers may face in similar program implementation. diagnostic imaging; radiology; Nepal; global health; implementation science - OPEN ACCESS Introduction PATIENTS in low- and middle-income countries lack adequate access to safe and appropriate medical machines within their local healthcare systems ( 1 ). Even where the required technology is available, machines are often unreliable. Machine malfunctions lead to wide gaps in the provision of these critically needed services. Globally, best estimates are that 47% of the X-ray machines in developing country settings do not work ( 2 ). Ultrasound and X-ray are ideal diagnostic tools because they can meet 70-80% of all clinical diagnostic needs ( 3 ). Their absence increases the risk of misdiagnoses, treatment delays, and negative healthcare outcomes. This is of great concern for patients who have traveled long distances, at substantial cost, to receive life-saving health care. As previously discussed ( 4 ), the development of standards for ultrasound and X-ray machines deserves global attention, with consideration of the following criteria: a) reliable functionality in harsh environments, b) operational ability with unstable electricity, c) minimal emission of dangerous radiation, d) ability to be operated by nonspecialists, and e) high quality imaging capabilities. However, demand for these machines has been insufficient to warrant their production ( 4 ). The non-profit healthcare organization Possible works via a public-private partnership with the Nepali Ministry of Health and Population. Possible works in Achham District in the Far-Western Development Region of Nepal, and operates a district-level hospital, six rural health care clinics, and a Community Health Program with 174 Community Health Workers (CHWs). Currently, there is only sparse literature on the difficulties of implementing diagnostic radiology services in low- and middle-income countries ( 5-7 ). In this paper, we will review Possible’s responses to the challenges faced over the last five years of the implementation of diagnostic imaging in Achham, Nepal. Methods and materials Overview of implementation We have previously described Possible’s deployment of radiological services ( (...truncated)


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Malina Filkins, Scott Halliday, Brock Daniels, Roshan Bista, Sudan Thapa, Ryan Schwarz, Dan Schwarz, Bikash Gauchan, Duncan Maru. Implementing Diagnostic Imaging Services in a Rural Setting of Extreme Poverty: Five Years of X-ray and Ultrasound Service Delivery in Achham, Nepal, Journal of Global Radiology, 2015, pp. 2, Volume 1, Issue 1,