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