0 2011 2012 2013 2014

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0 2011 2012 2013 2014
MON
(NAGALAND)
Secondary
Healthcare
MAP OF INDIA SHOWING THE
LOCATION OF MSF’S PROJECT
IN MON DISTRICT IN THE
STATE OF NAGALAND
TABLE of CONTENTS
Introduction to MSF . . . . . . . . . . . . . . . . . . . . . . . 2
Acknowledgement . . . . . . . . . . . . . . . . . . . . . . . . 3
Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . 4
Introduction to Mon . . . . . . . . . . . . . . . . . . . . . . . 6
Four years of change . . . . . . . . . . . . . . . . . . . . . . . 8
Main areas of focus . . . . . . . . . . . . . . . . . . . . . . . . 10
• Hospital hygiene and infection control . . . . . . . 10
• Health promotion . . . . . . . . . . . . . . . . . . 12
• Integrated laboratory . . . . . . . . . . . . . . . . 13
• Sterilisation . . . . . . . . . . . . . . . . . . . . . 14
• Stock management . . . . . . . . . . . . . . . . . 14
• Sexual and reproductive health . . . . . . . . . . . 15
• Triage . . . . . . . . . . . . . . . . . . . . . . . . 16
• TB: DMC and chest ward . . . . . . . . . . . . . . . 17
• Medical waste management . . . . . . . . . . . . 18
Challenges Ahead . . . . . . . . . . . . . . . . . . . . . . . . . . 19
• Engagement of the community . . . . . . . . . . . 20
• Work ethics and human resources . . . . . . . . . . 21
• Case finding, diagnosis and treatment of TB . . . . 21
• Maternal and child health . . . . . . . . . . . . . . 22
• Relevance of logistics, water and sanitation . . . . . 23
• Transparency and accountability of funds . . . . . . 23
• Availability of drugs and medical consumables . . 24
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Staff Memories . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
1
Introduction
To MSF
Médecins Sans Frontières/Doctors Without Borders (MSF) is an international, independent, medical humanitarian organisation that delivers emergency aid to people affected by armed conflict, epidemics,
exclusion from healthcare and natural disasters. MSF offers assistance
to people based on need and irrespective of race, religion, gender or
political affiliation. When MSF witnesses serious acts of violence, neglected crises, or obstructions to its activities, the organisation may
speak out about this.
MSF has worked in India since 1999 and has provided free medical
treatment to hundreds of thousands of patients in Andhra Pradesh,
Bihar, Chhattisgarh, Jammu and Kashmir, Maharashtra, Manipur and
Nagaland. MSF has responded to different emergencies in the last
14 years in India; from the Gujarat earthquake in 2001 to the Uttarakhand floods in 2013.
MSF received the Indira Gandhi Prize for Peace, Disarmament and Development in 1996 and was awarded the Nobel Peace Prize in 1999.
2
© Rey Anicete
Acknowledgement
We would like to express our gratitude to the various organisations
and individuals who have contributed towards the MSF supported programme in Mon. We thank the Government of Nagaland, the Department of Health & Family Welfare (DoH&FW) with National Rural Health
Mission and other vertical programmes, the District Planning & Development Board and district authorities, the apex Konyak organisations
including Konyak Union (KU), Konyak Nyupuh Sheko Khong (KNSK),
Konyak Student Union (KSU), Konyak Baptist Bumeinok Bangjem (KBBB)
and other local and international NGOs working in the district and the
state.
This programme has achieved the numerous successes outlined in this
report due to the dedicated work and commitment of the staff working
for the DoH&FW and MSF.
Most importantly, thanks are due to the people of Mon who have come
forth to use the facilities at the Mon District Hospital and the Mon Designated Microscopy Centre. We gladly thank all those who have also encouraged friends and family to seek early treatment and care.
Special thanks to the staff for contributing their photographs and for
supporting the production of this report.
3
Since 2010, MSF in partnership with the DoH&FW
has worked on improving the availability of quality
primary and secondary healthcare for people living in Mon and the bordering areas of Arunachal
Pradesh and Myanmar.
The story of change of Mon District Hospital demonstrates how a successful partnership between a Government and an NGO can bring good quality healthcare even in an isolated area such as Mon. While MSF
invested in infrastructure, equipment and training
on the one hand, the DoH&FW supported the increase in number of hospital beds to 100, opened
up to new job roles such as that of a waste zone attendant and a logistician, adapted itself to new protocols and handed over more responsibility to the
community through the recognition of the Hospital
Management Committee. Mon District Hospital today is a story of revival, a point of reference for the
whole of Nagaland.
Through this document, we aim to share the story
of this change and the successes of this partnership.
and inform the community about the importance of
their role. Lastly, this document also highlights some
challenges that still remain but can be conquered
provided the community and authorities continue
taking interest in the constant revival of the hospital.
4
© Elin Erland
Executive
Summary
KEY SUCCESS INCLUDE:
services like family planning,antenatal and postnatal
CHALLENGES AHEAD
• Rehabilitation of the infrastructure to provide
services and vaccination
• Engagement of the community to increase the
good working conditions for the staff and a clean
• Triage to set priorities of patients on the basis of
role of the community in supporting the hospital,
and comfortable environment for the patients
their medical needs and urgency with a very simple
both with direct activities in the hospital and also to
• Training of staff to skill the healthcare workers so
system of colors and shapes
help lobby for provision of resources needed in the
that the knowledge lasts even after MSF leaves
• DMC and Chest Ward in the Hospital to ensure
hospital, Works ethics and human resources as only
• Improved hygiene and infection control to re-
that all potential TB patients are diagnosed and test-
commitment of the staff can ensure that quality of
duce the risk of potential infections that patents,
ed in time to start the treatment as soon as possible,
services continues
visitors and healthcare workers can contract
to give all patients the needed support with coun-
• Case finding and diagnostic as not all patients are
• Health promotion activities to enable people to
selling and DOT providers, to provide adequate
getting the best regimen for their strain of TB and
increase control over their health by increasing their
drugs with no ruptures that could jeopardize the
also a stronger support to patients through counsel-
knowledge about diseases and being able to pre-
treatment in an environment that focuses on infec-
ling, better DOT providers network and inclusion of
vent them
tion control
the psychosocial support component
• Integrated laboratory where staff from different
• Medical Waste Management to ensure that the
• Continuous and affordable mother and child
vertical programs can work together to cover the
waste inside the hospital is correctly segregated, treat-
health through a better controlled system of avail-
needs of all patients, going beyond specific tests
ed and disposed
able incentives and availability of life saving obstet-
provided by the individual vertical program, and
rics procedures such as C-section
sharing responsibilities and skills
• Relevance of logistics and wastan activities that
• Sterilization to avoid potentially life threatening
are not standard under DoH&FW but necessary to
infections by the utilization of an autoclave machine
ensure water, electricity, working equipment and
and implementation of protocols
infrastructure in good conditions
• Stock Management to provide necessary drugs
• Transparency and accountability of funds which
and consumables through periodic
monitoring
will be key with the implementation of the user fees
of consumption patterns, a comprehensive list of
to ensure that funds are used efficiently and the al-
items needed in a hospital, a good ordering system
location is shared by all stakeholders
through validated suppliers and finally a cold chain
• Drugs availability in terms of quality and quantity,
to ensure that sensitive drugs are kept in the ideal
supply needs to be adapted to needs for both and
temperature not to loose efficacy
should be planned to limit out of pocket expenses
• Sexual and reproductive health with a new state
of the art delivery room and OT to enable elective
and emergency obstetrical surgery and additional
5
In 2009, when an MSF exploratory team visited Nagaland, Mon was documented as one of the places in
need of MSF intervention. It was because within Nagaland, Mon was one of the most isolated districts in
terms of education, representation in central administration, geographical distance, resource allocation
and healthcare1.
STATE OF HEALTHCARE BEFORE 2010
An attempt to understand the functioning of the
health system in the district revealed that the population had limited or no access to healthcare. Lack of
transport, lack of affordability and a culture of selfmedication usually discouraged patients from seeking medical care. On the other hand inadequate staff,
quality services, equipment, medicine and expertise
in the only Government run secondary healthcare
provider- Mon District Hospital, made it almost redundant. The absence of resident anaesthetists and
specialised doctors limited the capacity of the hospital to respond to emergencies. Patients were often
referred out to private facilities, which many could
not even afford. The hospital would often run out of
supplies and the patients would be asked to pay for
drugs, gloves, syringes, sutures and other disposable
supplies on arrival.
6
1
*Disclaimer: As per data collected from personal
testimonies and experiences of those interviewed.
© MSF
Introduction
to Mon
This uncertainty of receiving proper medical atten-
MON DISTRICT HOSPITAL NOW
Total number of
consultations
tion, weak management of the existing structure in
addition to the inability of patients to bear unreasonable costs resulted in a loss of faith in the prevailing
102,006*
Total inpatient admissions
10,772*
MSF INTERVENTION
Total number of deliveries
2,157*
Total antenatal care visits
7,753*
Patients on drug sensitive
TB treatment
648
Patients on MDR-TB
treatment- 20 since 2013
20
© Dominique Beels
© Dominique Beels
healthcare system among the people.
In a period of four years, MSF refurbished the infrastructure and significantly upgraded key areas of the
district hospital. Extensive trainings were conducted
to improve the management and quality of services.
(since April 2012)
(since 2013)
*Figures from August 2010 till May 2014
All medical and surgical activities with a focus on sexual and reproductive health, TB and drug-resistant TB
MSF began to support the District Hospital in Mon,
treatment were also improved. MSF set up a waste
Nagaland in 2010 after exploring the healthcare seek-
management facility which is seen as a replicable mod-
ing behaviour and needs, gaining an understanding
el for other district hospitals in the state.
of the limitations of the existing structure, and defin-
The ‘’boost’’ provided by MSF to Mon District Hospital
ing the areas of intervention.
has eventually increased the utilisation of this health
MSF signed a Memorandum of Understanding (MoU)
facility and rekindled the faith of the community in the
with the Government of Nagaland to support the
state healthcare system.
hospital for the next three years and extended it for
another year to ensure a planned and sustainable
handover. MSF also collaborated with various organisations to revive the minimally functioning hospital.
MSF’s contribution
• National staff employed in four years-80
• International staff employed in four
years-71 (8 full time equivalent)
• Expenditure on drugs, medical & lab
consumables-1,049,932€
• Total donation towards biomedical
equipment-220,897€
• Expenditure on rehabilitation 198,445€
• Total amount of fuel used to ensure
24/7 power supply- 24.311 litres
7
2010
2011
© Malika Gupta
© Dominique Beels
2009
MSF explores and understands the
functioning of Mon District Hospital
An MoU to support the hospital for next 3 years
is signed with the Government of Nagaland
An in depth assessment of the hospital is
started
A base is established in Mon
Support to OPD and IPD
activities is started
Four Years
of Change
8
Training of hospital staff is started to improve
skills and management
Rehabilitation of the hospital buildings is started
First baby is born in the new delivery room
furnished with new new state-of-the-art
equipment
An integrated laboratory is constructed and
furnished with new equipment to increase
possible diagnostics
A waste zone is constructed for proper
segregation of waste to avoid infection
A 7.5 kva generator is installed to ensure 24/7
power supply in the hospital
A campaign on vaccination for measles is
conducted to spread awareness in the entire
district
The number of beds in the hospital is increased
to improve capacity
2014
© Malika Gupta
© Malika Gupta
2013
© Malika Gupta
2012
A digital X-ray machine is installed
Support to the operation theatre is begun
First C-section in the hospital is performed
Logistic and water and sanitation sustainability
inside the hospital is improved
A separate section for laundry is constructed
and electric washers are installed
A handover workshop is conducted for the
community and the hospital staff to define the
future set up of the hospital
TB programme is integrated within the hospital
and the Designated Microscopy Centre and the
Chest Ward are inaugurated
The community participates in the Big Cleaning
Day at the hospital for the first time
A voluntary blood donation campaign is started
in collaboration with the District AIDS
Prevention and Control Unit (DAPCU)
All construction and refurbishment inside the
hospital is completed
A few support activities are handed over
The TB programme is handed over in entirety
Workshops on mass casualty, TB and stock
management are conducted in Kohima
An MoU for one year extension is signed with
the Government of Nagaland
A user’s fee system is proposed with a focus on
exemptions for the most vulnerable and
transparency
Handover of management, medical and
support activities is started
MSF project in Mon, Nagaland is closed
Management role of MSF is increased
9
© MSF
Main areas
of focus
1. HOSPITAL HYGIENE & INFECTION CONTROL
Continuous attention to hospital hygiene and infection control measures is central to a healthy and safe hospital environment. Effective and well maintained
hygiene practices keep hospital infections to an absolute minimum.
MSF’s involvement in Mon District Hospital led to the following positive changes. MSF:
• Installed new water flushing latrines.
• Installed a water chlorination system to provide clean water to all wards.
• Improved water provisioning from the Public Health & Engineering Department (PHED) and increased the water storage capacity to collect more rain
water in order to tackle the issue of inadequate water supply in the hospital.
• Built separate isolation areas for patients needing isolation to prevent infection.
• Trained the staff on Post Exposure Prophylaxis (PEP) and Personal Protective
Equipment (PPE). This included the implementation of use of uniforms for different services and other personal protective equipment like gloves, masks and
goggles wherever needed.
• Introduced various infection control measures like dedicated protocols for
cleaning hospital furniture and surfaces, enhanced ventilation especially in TB
wards, a hygiene committee to discuss daily problems and solutions.
• Introduced waste zone management to segregate biomedical and nonbiomedical waste.
While DoH&FW’s sanitation inspector has taken over most of the infection
control activities, more staff is needed in the team to maintain the above men-
10
© MSF
tioned essential services.
HOSPITAL KITCHEN
“We had a hard time cooking before MSF intervention. There was never enough water to cook,
© Malika Gupta
© Beatrice Barbot
BIG CLEANING DAY
forget cleaning! We used fire wood which would
often make it stuffy here. We did not follow any
dietary plan for patients and would mostly make
daal and rice every day. Meat or eggs were a delicacy served only on special occasions like Independence Day, Christmas etc. A lot has changed
after MSF came in. The adequate water supply
has made both cooking and cleaning possible.
We provide meat thrice a week and eggs for TB
Big Cleaning Day was initially observed once every
patients on a daily basis and even serve tea! It’s
month to instil a sense of ownership among the hos-
easier to work in this fully equipped kitchen with
pital staff to keep the hospital clean. Closer to the end
MSF constructed a new kitchen building, introduced
bowls, cookers, fridge, almirah for storage, gas
of the project, MSF made the concept more inclusive
proper infection control measures and equipped the
cylinders and much more!”
and attractive.
kitchen with more staff, sufficient water supply and
The idea was to attract more volunteers from the com-
storage space and better utensils. A proper dietary
munity to participate in the maintenance of general
structure was also prepared for all patients.
hygiene and infection control in the hospital. As this
One pressing issue that remains pending is an ef-
concept evolved, staff from MSF and DoH&FW be-
fective diet menu for patients at the hospital. De-
came active volunteers enabling more work in shorter
spite changes in the initially offered diet, the menu
time. While we sincerely hope that this positive initia-
still does not provide for the required calories and
tive will continue after MSF leaves, a lot will depend on
nutrients. Lack of monitoring in the past resulted in
the motivation of the staff and community.
improper ordering of supplies which further jeop-
Similarly, a campaign called ‘I LOVE MY HOSPITAL’
ardized the patients’ diet. Even after the revision of
was launched in March 2014 with an objective to nur-
budget as per MSF’s recommendations, the current
ture a sense of ownership of the hospital among the
compensation of Rs 32 per patient is inadequate. We
community members. A dedicated Facebook page, “I
thus hope that funds will soon be made available to
LOVE MY HOSPITAL, KONYAK NAGA INITIATIVE” has
improve further the meals provided.
Nyuphen, a cook at the hospital
© Malika Gupta
HOSPITAL LAUNDRY
been created to encourage the youth to get involved
Before MSF built a comprehensive laundry section,
in hospital management.
the entire hospital laundry was done by one person.
11
2. HEALTH PROMOTION
developed visual tools in line with the local context,
dirty hospital linen and would take a lot of time to
Health promotion is the process of enabling people
both in English and Konyak, the local dialect, for easy
deliver washed material. He would often clean the
to increase control over their health. The concept em-
communication and better understanding. Daily ses-
laundry by the riverside risking infections to himself
braces health education and disease prevention with
sions in the form of one-on-one interactions, group
and the population living around. MSF installed two
a focus on information and education on prevalent
discussions and dialogues were conducted in OPD
industrial-grade washers along with two dryers and
diseases. MSF strongly believes in the power of a well-
and IPD. The major focus of these sessions was family
built a separate laundry room. Staff were appointed
researched and targeted health promotion campaign
planning, tuberculosis, general hygiene and risk fac-
and hygiene and infection control measures were
that can impact community’s health by bringing a
tors during pregnancy.
also incorporated into the service. As a result, the
positive change in people’s behaviour.
In the recent past, health promotion sessions were
hospital linen and staff uniforms are now regularly
With a similar objective, to promote lessons on
also conducted in schools and churches in order to
cleaned thereby minimising the spread of infection.
healthy living and prevention and cure of diseases,
reach out to the larger community. The hospital has
The handover of the laundry service to the DoH&FW
the Information, Education and Communication
witnessed an increase in the number of women walk-
was successful. A regular follow up on management is
(IEC) department of the state government produces
ing in for ANC check-up and family planning after
needed to ensure that the procedures and protocols
leaflets, brochures and other communication mate-
these sessions were held.
are well adhered to in the future. The major challenge
rial. These materials are then distributed in the com-
The continuity of these important health promotion
that remains is the continuous supply of electricity or
munity. However, most of them are printed in Eng-
services is one of the challenges ahead. There is no
effective power back-ups without which, the equip-
lish- a language that very few people understand in
existing NGO or community group that is ready to
ment provided by MSF will be unusable. The admin-
the district - and there are no individual or group ses-
spearhead health promotion in the hospital or in the
istration therefore needs to ensure adequate supply
sions/discussions for detailed explanations.
community. The regular production of IEC materials
of power to run the generators.
The introduction and integration of health promotion
is also another challenge. While hospital staff has tak-
activities was thus part of MSF’s strategy to improve
en over the basic health promotion activities for now,
quality in healthcare at Mon District Hospital. MSF
it might not be a sustainable solution.
© Dominique Beels
He would visit the hospital twice in a month; collect
12
ally Transmitted Infections (STI), National Vector Borne
4. STERILISATION
Before MSF arrived, there was no central laboratory in the
Disease Control Program (NVBDCP) and National Lep-
hospital. Each vertical programme had its own laboratory
rosy Program (NLEP) now make up the staff of the inte-
corner in the OPD complex. Laboratory technicians would
grated hospital laboratory. This has facilitated sharing
perform specific tests relevant to their programmes and no
of responsibilities and expansion of activities making
other. This was limiting as there was no room and responsi-
the laboratory more functional and efficient than ever.
bility to conduct general lab tests for OPD and IPD patients.
Another major achievement was the installation of a
MSF thus saw the advantages of bringing lab techni-
digital X-Ray machine in a dedicated room with infec-
cians from different programmes together. An integrat-
tion control measures in place for TB patients as well as
ed lab meant efficiency by gaining on technician time,
a lead door to protect the operator and others.
more physical space, lab reagents and equipment. In-
Maintenance of biomedical equipment is a concern for
vestment was thus made to design a modern labora-
the future. MSF believes that this responsibility should
tory where the focus was on cross-training of skills and
lie not only with the hospital staff but also with tech-
Sterilisation of medical devices, surgical instruments,
sharing of resources. The proposal materialised in 2011
nical experts from DoH&FW and hopes that the inte-
supplies and equipment used in direct patient care
and the technicians from programmes including Inte-
grated laboratory continues to function the way it has
is a critical aspect of the modern healthcare delivery
grated Counselling and Testing Centre (ICTC), Sexu-
been designed.
system. This prevents transmission of potential life
© MSF
3. INTEGRATED LABORATORY
© Dominique Beels
threatening infections and requires strict compliance
to hygiene policies and appropriate cleaning and disinfection of medical equipment. MSF saw an immediate need to address this issue in the hospital.
All equipment was initially sterilised in an autoclave
machine run either on electricity or kerosene, depending on their availability. Hospital linen, reused gloves
and gauze were put into the autoclave machine while
sharps would be soaked in ‘Cidex’ (A solution used
for sterilisation of products). All surgical instruments
would be sterilised in an electric boiler in bulk, without
packing them in separate sets, post which they would
be stored in one big linen-lined container.
This improper sterilisation process hence always ran
the risk of contributing to surgical site infection, pos-
13
5. STOCK MANAGEMENT
MSF advocated for staff education, adherence to es-
Maintaining a regular record of the available stock of
tablished policies and procedures and observance
drugs, consumables, equipment and other daily items is
of appropriate precautions. MSF also equipped the
essential for uninterrupted medical activities in any hos-
hospital with better biomedical equipment needed
pital. Previously, Mon District Hospital would receive a
to carry out these procedures. The hospital today has
supply without any reference to the specific needs of
a central sterilisation service with trained staff that
the hospital and with no stock management system in
demonstrates its competency. Instruments required
place. This would often result in insufficient supply of
for different medical procedures are sterilised and
some lifesaving drugs or delivery of non-essential drugs
packed separately, ready for use. In order to keep up
in excessive quantity. As a result, patients were often
the quality of service, the hospital staff will have
asked to pay for drugs or consumables required for their
to consistently follow the recommended processes
medical procedures.
introduced by MSF.
MSF introduced a simple stock card system to ensure
© Malika Gupta
ing a serious threat to the patient’s safety and welfare.
regular inventory entries and exits of all stock. This enabled easy monitoring of monthly consumption pat-
I have seen change happen. I have
been here at the hospital for 11
years. MSF has provided many
facilities like buckets, medicines,
gloves etc.. Gloves were initially
being re-used but now I use one
pair per patient. I now have 5
dressing kits and hence sterilization
happens as per protocol since I
don’t have to worry about running
short of them.
Mr Mantah, Dresser
14
terns and helped pre-empt future needs so that orders
for required items could be placed in time.
drugs are now available (In the IPD and OPD approxi-
MSF also introduced another important aspect of stock
mately 70 per cent of required drugs are now available
management- “cold chain”. Cold chain is the controlled
in comparison to 30per cent availability earlier), there
transport of goods that are especially temperature sen-
is better regulation of ‘controlled drugs’ and there are
sitive from the factory to the intermediate storage lo-
both paper and computer based records of the avail-
cations to finally the end user in a health structure. For
able stock.
example, the polio vaccine is very sensitive and loses its
A consumption-based order system has also been set
potency to provide the desired protection from polio if
up for different departments while an essential drug
not stored at a certain temperature. While the irregular
list for a hospital this size has been shared with the
power supply in Mon made it difficult to maintain cold
DoH&FW and officials in Kohima. We believe this will
chain in the hospital, MSF installed fridges, inverters/
help the DoH&FW supply larger quantities of essential
chargers with batteries and generators so that the chain
drugs required in the hospital. Besides this, MSF has also
is not disrupted in the absence of power.
conducted training workshops on stock management
MSF’s support to this component has brought in a lot
to build capacity of the hospital staff as well as of the
of positive changes. The supply is constant, essential
whole state.
6. SEXUAL AND REPRODUCTIVE
HEALTH (SRH)
The high maternal mortality rate in India was reason
enough for MSF to focus on preventive and curative
sexual and reproductive health services in this isolated region where even general healthcare was difficult to access. Educating people - especially women
about their sexual and reproductive health (SRH) is
fundamental for an overall healthy society. MSF’s SRH
programme focused on providing quality antenatal,
postnatal and neonatal services. These included counselling and treatment for STI (Sexually Transmitted Infections), HIV, family planning, basic care for normal
and assisted deliveries, elective and emergency obstetrical surgeries, antenatal and postnatal check-ups,
vaccinations, safe Medical Termination of Pregnancy
(MTP) and care for victims of sexual violence.
While these services are being offered at the hospital,
challenges remain. As per the Nagaland State AIDS
liveries, HIV testing should also be available in the delivery rooms for patients with an unknown HIV status.
© MSF
Control Society (NSACS), in order to ensure safe de-
However, the supply of rapid tests used for testing the
HIV status was only limited to peripheral Community
another accomplishment of MSF. The hospital has been
The neonatal unit has been functional since 2013, but
Health Centres (CHCs) and Primary Health Centres
providing this as a free service and has witnessed over
human resource issues have persisted. MSF has been
(PHCs) in Mon. MSF highlighted the need for authori-
85 per cent acceptance rate. Unfortunately, such con-
lobbying for a specialist to be posted at the hospital to
ties to provide HIV testing in the hospital, which was
traceptives are not available for free for public use in
maintain and improve the quality of care provided to
duly responded to. Fortunately the hospital has been
India and do not feature in the essential drug list of the
newborns.
receiving a regular supply of these tests since March
DoH&FW. MSF has been lobbying with the State Gov-
MSF has also contributed to infrastructure develop-
this year.
ernment to adopt this as a formal protocol and we hope
ment. The hospital now has a central operation theatre
The introduction of free injectable contraceptives was
its importance and demand will be recognised soon.
where C-sections and other lifesaving operations can
15
be performed. A new delivery room and a small opera-
7. TRIAGE
© Malika Gupta
tion theatre were also built for performing deliveries
and minor surgeries where state-of-the-art biomedical equipment such as oxygen concentrators, delivery
beds, suction pumps were installed.
To attend to patients in the gynaecology and mater-
Patients are currently classified
according to the following:
Emergency Room
nity wards, nurses need specialised skills. While the
constant rotation of nurses has facilitated cross-train-
Antenatal Care
ing, it has affected core skills development and delivery of quality services. MSF suggests and requests the
management to keep a dedicated pool of keen nurses
Medical triage is a system of prioritising patients on
especially for this department.
the basis of their medical needs and urgency. Within
MSF was sent three nurses/midwives for Advanced Life
a hospital system, this is the first step after the pa-
Support in Obstetrics (ALSO) training, two of whom
tients arrive. MSF introduced this system in Mon Dis-
have been granted an internationally-recognised cer-
trict Hospital. Earlier, patients were attended to on
tificate. These trained nurses, it is hoped, would be
first-cum-first serve basis or personal preference, ir-
able to pass on their knowledge to others in the future.
respective of their medical condition. This would put
Family Planning
Paediatric OPD
Medical OPD
to risk patients that needed immediate attention as
It was here a year and a half
back for the delivery of my baby.
Delivering here is so much safer
than a home delivery since
nurses take such good care of a
mother! I am now here for polio
vaccination for my son, which I
learnt about at the hospital itself
in one of my post natal sessions.
Khaozu, Patient
16
their condition deteriorated while they waited. Limit-
Gynea OPD
ed staff and limited working hours further aggravated
the problem.
It was thus essential to put in place a system that
would make the OPD more efficient by prioritising
patients on the basis of their need. MSF introduced a
colour-based triage system that not only streamlined
the patient flow but also benefited the patients.
Surgery OPD
History of 2 weeks cough
or previous TB treatment –
Designated Microscopy Centre
The patients initially found it difficult to understand
the concept but are now comfortable using it. While
The patients, however, still do not respect the differ-
the system is efficiently working in the OPD, a simi-
ence between OPD and ER. They tend to visit the ER
lar system needs to be introduced for the emergency
even for minor problems. This has, in the past, resulted
room (ER) as well.
in having a comparable number of OPD and ER cases.
8. TB: DMC AND CHEST WARD
MSF launched its TB programme in the hospital in
March 2012. Back then, the Designated Microscopy
Centre (DMC), responsible for sputum collection,
microscopy and treatment for category 1 and 2 TB
was located near the police station, a little far off from
the hospital. MSF thus renovated and refurbished a
vacant building to serve the purpose. While patient
counselling and sputum collection happened here,
specimens were still sent to a lab in the District Tuberculosis Centre (DTC) for analysis. The DTC also
provided treatment and category 1 and 2 treatment
regimens. Also, in the absence of a proper stock management system, supply of drugs was sometimes erratic causing stock-outs. MSF then, mostly filled the
gap for paediatric fixed dose medicines.
culosis Officer (DTO) and MSF, the DMC was shifted
in the hospital premises in March 2012. While it
helped the DMC become fully functional and more
© Malika Gupta
Thanks to an agreement between the District Tuber-
integrated, follow ups for diagnosis and treatment
also became easier. Over the next few months, MSF
sation drives and inaugurated its chest ward in July
There have been evident successes after MSF’s inter-
concentrated on increasing the diagnostic capacity of
2012 as some patients needed admission in the hos-
vention. Increased awareness has resulted in improved
the new DMC and trained the staff in proper collec-
pital. MSF also began to support the drug-resistant
screening for TB which means people are gradually
tion of sputum and assessment of the quality of the
TB component in the last quarter of 2012 after diag-
becoming more proactive regarding its diagnosis. The
sample collected. Soon treatment for drug-sensitive
nosing a few cases in the district for the first time .
location of the new DMC as also contributed to the
TB along with infection control also started being
To address the need for TB patient education, MSF
increase by simplifying access to care. Treatment num-
administered in the hospital. Patient education and
undertook counselling services at the hospital. While
bers have increased significantly in the last three years.
installation of non-electric exhaust vents were new
the counsellors mainly served as DOT providers ini-
MSF also assured packing and sending of samples to
introductions by MSF. MSF actively began to raise
tially, counselling was added to their responsibility
other locations in the state for TB testing (GeneXpert)
awareness on TB in the community through sensiti-
especially to counsel defaulting DR-TB patients.
and other tests that cannot be performed locally.
17
9. MEDICAL WASTE MANAGEMENT
After MSF intervention,
to an underground concrete pit. The crushing re-
Responsible management of waste is of paramount
• Designated waste baskets, health promotion
duces the volume of the vials so that the pit can
importance in maintaining hospital hygiene. Improp-
messages and clear signs to encourage patients,
last for longer.
er management of waste generated by any health-
caretakers and visitors have been placed in and
• ‘Soft’ medical waste is burnt in a De Montfort
care facility causes a direct health impact on the com-
around the hospital to segregate waste as per the
incinerator. This special incinerator, with its dual
munity, healthcare workers and the environment.
classification.
chamber and an internal layer of refractory bricks
Proper collection, transport, processing and disposal
• Sharps/needles are now collected in a dedicated
and cement, can reach much higher temperatures,
of waste materials produced at the hospital are im-
reusable hard plastic container and then disposed
thus reducing the quantity of toxic fumes.
perative to a responsible waste management system.
in a tube connected to a concrete underground pit.
• Organic medical waste is directly disposed in a
Before MSF built a medical waste zone in the hospi-
This has reduced the risk of exposure through con-
dedicated organic pit as it cannot be burnt.
tal, waste was often collected and burnt in the hos-
tact with a used needle for all health operators.
• Domestic organic waste is collected in plastic
pital premises, irrespective of the type of waste. This
• Glass vials and other relatively bulky sharps are
bags and disposed through the normal municipal
posed a serious health hazard as burning of waste
destroyed in a crusher which is directly attached
garbage collection process.
© Malika Gupta
Waste inside the Mon District
Hospital is now divided into
four categories:
© Malika Gupta
caused spread of infections and toxic fumes.
© Malika Gupta
18
© Malika Gupta
• Sharps: (needles, scalpels, ampoules,
broken glass etc.)
• ‘Soft’ waste: (dressings, packaging,
paper, cardboard, plastic, syringes without
needle)
• Domestic organic waste: (leaves, fruits
peels, leftover food)
• Organic medical waste: (placentas and
other medical organic material)
Challenges
Ahead
The relentless support lent by the Government
of Nagaland and the DoH&FW coupled with the
efforts of hospital staff made it possible for MSF
to achieve the various successes listed in this
document. While a lot of positive changes saw the
light of day, a number of challenges remain.
For the population in and around Mon, to have
access to quality and affordable healthcare,
it is important that efforts continue to meet
these challenges. Furthermore, Mon District
Hospital is the only Government-run secondary
healthcare provider in the district, making the
entire population dependent on it for all kinds of
healthcare services. For this reason, it is absolutely
essential that the hospital continues to be
functioning well for the health of the people of
© Dominique Beels
Mon.
1. ENGAGEMENT OF THE
COMMUNITY
This will not only help provide essential services but
tinue as long as people are committed to care about
also instil a sense of ownership and accountability
their hospital. With just a little of each person’s time,
MSF foresees a pivotal role that the community will
within the community. The hospital requires that
the community can really make a difference!
have to play in helping the DoH&FW run the hospi-
community engagement and support to thrive. The
Lastly, in order to guarantee quality service, a check-
tal after the organisation departs. MSF has played a
community has also started a Facebook page “I Love
list for all hospital departments has been shared with
crucial part in revitalising the hospital and equipping
My Hospital, Konyak Naga Initiative” to gather sup-
the civil society to facilitate periodic checks. Any indi-
it with necessary infrastructure and medical facilities,
port for the campaign and serve as a platform to dis-
vidual can be part of this formal monitoring process.
contributing to it being fully operational today. It is
seminate information about the various activities to
All these initiatives aim at greater involvement of the
now for the local authorities and the community to
be held at the hospital.
local people in the hospital administration with an in-
maintain this key provider of healthcare in the district.
This campaign is just a starting point and will con-
creased sense of ownership.
With this objective, a Hospital Management Committee (HMC) was formed in 2010. This committee comprises medical staff, district administration and civil
society (through local NGOs) to equally represent
interests of the people of Mon while taking management decisions for the hospital.
MSF and the Konyak Naga Groups also launched ‘I
Love My Hospital’, a campaign that seeks to further
encourage community members, especially the
youth from colleges, churches and local NGOs, to
come together to strengthen community initiatives
at the hospital. This group has accepted the responsibility to spearhead and manage this campaign. Various activities are already ongoing to improve health
and hygiene including monthly cleaning days, voluntary blood donations, donation of old newspapers
and used books for spit collection. The campaign also
provides a platform for the community to volunteer
20
© Beatrice Barbot
as DOT providers for TB patients in and around Mon.
direction with the implementation of Internal Regula-
MSF has invested a lot of resources in refurbishing the
tions (IR) that applies to all hospital staff. The IR in-
hospital with improved infrastructure, new equip-
cludes regulations on working hours, management
ment, sanitation installations and a lot more. Equal
of leaves, disciplinary actions and should facilitate the
amount of efforts have been put into training the staff
management of the team.
to be able to make proper use of the equipment pro-
Lastly, the key for success of any institution is its man-
vided. Over the years, national and international staff
agement. Mon District Hospital will need support
from MSF have focussed on experience sharing and
from the DoH&FW and the Government of Nagaland.
conducted both formal and informal trainings for the
Regular visits to the hospital by officers from Kohima
hospital staff. All facets of training including techni-
will help in the development of the hospital.
cal, theoretical and on-the-job were provided for the
3. CASE FINDING, DIAGNOSTIC AND
TREATMENT OF TUBERCULOSIS
© Malika Gupta
2. WORK ETHICS AND
HUMAN RESOURCES
staff to understand the new protocols linked to the
Despite the innumerable achievements, the DMC and
Just as the infrastructure would need periodic main-
the TB chest ward are still gripped with some major
tenance, continuous capacity building efforts for the
concerns. Firstly, there is no mechanism for a culture
staff will have to be ensured to assure optimal use of
follow up for patients already on treatment making
available resources. This, however, is already a chal-
it difficult to decide the end of their intensive phase.
lenge with reduced manpower.
There is also no provision for conducting second-line
While MSF has been instrumental in recruiting staff
(doctors, nurses, medical attendants, counsellors,
cleaners), the isolated location of this district has al-
© Malika Gupta
new equipment and processes put in place.
Drug Susceptibility Testing (DST) in the hospital. For
any such test, a request has to be first sent by a testing centre in Imphal (outside the state) to the National
ways made employment of qualified medical staff a
Reference Lab (NRL), Delhi. Since this testing centre
challenge. This makes it even more important to en-
does not conduct first-line DST, random samples are
sure that the recruited staff remains committed to the
chosen and sent for second-line DST. It is thus required
hospital and practices appropriate work ethics. This
to implement a process for conducting second-line
includes strict adherence to specific number of work-
DST for patients in North-East India especially as more
ing hours, planning leaves judicially, arranging for a
and more cases of MDR-TB are being identified.
proper handover when planning a long leave as this
Another future challenge is the uninterrupted supply
will not affect the functioning of the hospital in their
of drugs, stationery and other medical supplies. In the
absence. A big step has already been achieved in this
past, supply of paediatric drugs has not been as regu-
21
lar as Category 1 and Category 2 treatment regimens.
4. MATERNAL AND CHILD HEALTH
representatives of NRHM thus pushed for direct payment to the patients immediately after delivery, by
of airborne particles and are designed to be more air
the nurses. This is however not enough if the funds
tight) in comparison to the masks supplied by RN-
are not released in time. In addition to this, the pa-
TCP, have recently been made available but in limited
tients are also asked to pay for using ambulance ser-
amounts. The supply of disposable cups used for daily
vices. Unfortunately the fixed sum provided by JSSK is
dosage for the patients (introduced as part of hygiene
too low to cover this cost. MSF requests an increase
and infection control measures), stationery needs for
in the funding to facilitate free ambulance service in
the DMC and the chest ward after the MSF supply is
the district, and relieving patients from trouble.
depleted are all concerns for the staff.
The availability of qualified gynaecologists and anaes-
Provision of counselling support to the TB patients is
a must to ensure adherence to the prolonged and dif-
© Malika Gupta
N95 respirators, (masks that filter at least 95 per cent
ficult treatment. While RNTCP has recently recruited a
thetists at the duty station is a major concern. There
are regular occurrences of staff taking leave without
intimation thereby putting into question the surgical
senior treatment supervisor and senior TB laboratory
MSF introduced free injectable contraceptives for the
capacity of the hospital; halting necessary services
supervisor who are also trained counsellors, dedicat-
population of Mon. The hospital has been providing
like C-section and making expensive referral the only
ed counsellors also need to be employed in non-ur-
this as a free service and has witnessed over 85 per
option. In the absence of any such health facility in
ban settings. MSF, unfortunately hasn’t been able to
cent acceptance rate. Unfortunately, medical officers
the entire district, it becomes important to ensure
achieve enough in this regard. Nagaland witnesses a
are not willing to provide emergency contraceptives
that the existing staff follow appropriate work ethics,
high rate of drug users. This adversely affects the de-
or other safe abortion methods on religious grounds.
considering finding replacements is an issue.
fault rate as it is difficult to make such patients stick to
In the absence of such measures, it remains a major
their treatment regimen. MSF believes that increased
challenge to control deaths of pregnant women as
sensitisation among the population as well as counsel-
other dangerous pregnancy termination methods are
ling for the patients and families with a focus on adher-
the only available solution.
ence can help improve this situation. There is also a
Another challenge is the transparent implementation
need to maintain a database of DOT providers trained
of Janani Suraksha Yojana (JSY)/Janani Shishu Surak-
by MSF and RNTCP to use their effective skills and train
sha Karyakram (JSSK) schemes. These schemes were
new fellow DOT providers.
established to incentivise pregnant women to utilise
While there exists a procedure for contact tracing
the services at the hospital to ensure safe deliver-
(testing patients friends and family in close contact
ies. However, reports confirm that most of the time,
with the patient), improvements need to be done in
there is a delay in paying the women coming through
this area as well.
these programmes. MSF together with the district
22
5. RELEVANCE OF LOGISTICS, WATER
AND SANITATION ACTIVITIES IN THE
HOSPITAL
these important support activities are met. However,
for a hospital this size and numerous errands under
6. TRANSPARENCY AND
ACCOUNTABILITY OF FUNDS
the logistics and watsan department both, there is a
Financial transparency and proper management of
It is an established fact that proper maintenance and
need for two additional logistical/watsan staff.
funds is critical to ensure smooth functioning of any in-
constant power and water supply would be needed
It is also the responsibility of the community to play
stitution. Since Mon District Hospital plans to charge
to keep all the equipment in the hospital functional.
an equally important role in supporting the hospital
user fee from incoming patients and is also asking other
Hence, MSF together with the DoH&FW has taken
staff for maintenance. They can do so by closely mon-
departments like District Planning and Development
keen interest in the roles and responsibilities of the
itoring the running of generators, efficient working of
Board (DPDB), Rogi Kalyan Samiti (RKS) and other
logistics and the water and sanitation (Watsan) de-
all equipment so it’s not taken for other purposes and
NGOs to support it after MSF leaves, it becomes all the
partment in the hospital. It is to their credit that the
making sure that all the changes introduced for the
more important.
DoH&FW has created two new positions to ensure
good of the community are not lost with time.
Transparency of accounts will benefit both the hospital and the community- while the hospital will be in a
better position to justify the expenditure and choice in
allocation of the funds collected from the community,
the community will better understand the use of their
money. We strongly believe that quarterly presentation
of the budget and expenditure of the hospital to the
© MSF
HMC will benefit the efficient running of the hospital.
“ 90% of the equipment at the
hospital has been provided by
MSF. I have been working with
MSF since the beginning and
have seen all renovation of beds,
tables, curtain hangers and other
furniture take place. The hospital
earlier only got city power. MSF
has now installed generators and
invertors to keep the supply of
power constant.
Annah Konyak, Logistician
7. AVAILABILITY OF DRUGS AND
MEDICAL CONSUMABLES
While the hospital now has a pharmacy and an efficient stock management system, minimum stock
of essential drugs and medical supplies still remains
a challenge. The hospital receives a supply without
any reference to the specific needs on the basis of a
quota system.
MSF identified this issue, replenished the pharmacy
whenever needed in the past four years and has now
shared a proposal for a revised essential drug list
with officials in Kohima. The DoH&FW and NRHM
also recognise the issue and aim to solve it. MSF recommends the use of a dedicated software for better
stock management to ensure that the purchasing
cycle is needs based.
Lastly, the DoH&FW does not include lab reagents
essential drug list. As a result, the hospital will have
to charge fees, even for basic diagnostics services
such as drawing of blood or haemoglobin in order
to sustain this service.
24
© Malika Gupta
and consumables required for various tests in their
Conclusion
The situation in Mon today is very different from four
years ago when MSF began supporting the District Hospital. New infrastructure, trained staff, improved protocols and processes, additional medical and non-medical
equipment, better facility for water and electricity, stock
management have all equipped the hospital to function
well and serve the people of Mon.
The partnerships with the Government of Nagaland,
DoH&FW, NRHM and civil society made it possible for
MSF to achieve its objective of making the district hospital resume its role in providing basic healthcare. While a
few challenges still remain, we are sure that the existing
political will and resources will never let the hospital re© Mensan Konyak
turn to the condition it was in four years ago.
During the handover ceremony of the hospital from MSF to the DoH&FW, Mr Imkong L. Imchen (former
Minister of Department of Health & Family Welfare) said “I would like to thank MSF for the exceptional and
wonderful services rendered to our people and bringing Mon hospital to a reasonable standard of healthcare delivery
system. If we compare pre-2010 to today, there is an ocean of change!”
25
Staff
Memories
It was a great honour and a proud moment for MSF to receive the Governor’s Gold medal award at the Independence day
ceremony in Kohima in 2013 for ‘MSFs distinguished duties in Mon district’. I was pleased to see the Nagaland Government
recognize the hard work and commitment of our team in Mon.”
Luke Arend, MSF India Country Director
“I joined the hospital in January 2011. Back then, we used to wash everything including blood stains, stool, vomit etc. with our hands.
At times, we even found some organic medical waste in the laundry that came from the OT. We are so glad to have washing machines
installed here. Since we don’t have washing machines in our homes, we learnt how to operate them here at the hospital. We hope the
supply of cleaning material like detergents, soaps, chlorine will continue after MSF leaves.”
Ngonle, Hygiene agent
“Before MSF, there were barely any facilities. Patients had to pay for their medicine. MSF has brought a tremendous change
to this hospital. The trainings have not only skilled us but have also changed our attitudes. Since there is an increased number
of doctors and services, the hospital is much more functional now. We used to spend out own money on our uniforms but
now MSF has provided for it all.”
Mary, Medical Attendant
“The patients who I deal with on an everyday basis are people who do not know how to read or write. Since people come from far
off places and usually do not even have a telephone facility, following up is a huge challenge! Ever since MSF came in, the defaulter
rate has surely dipped down. The counselling sessions and house visits have helped achieve this. Since there are numerous dialects
within Nagaland, explaining and talking during these counselling sessions sometimes becomes difficult. People walk distances for
these sessions, sometimes all the way from the India Burma border! I hope these facilities keep running even after MSF leaves.”
Shoiang, Counsellor
26
“Before MSF introduced this digital X-ray machine, we used a manual one. It took me ten minutes to prepare for the X-ray
alone. Patients were charged Rs 120 for each X-ray but now it’s free of cost. The final film along with approvals for buying film
rolls for X-Rays took anywhere between two weeks and a month earlier. As a result, the patients would have to wait for long
before the results were shown to them for any diagnosis. Now, I finish the entire procedure in less than an hour. The patients
and the staff hence does not have to suffer anymore!”
Mr Khojei, X-Ray Technician
“I was working as the nurse supervisor with MSF. After the handover of the management to the Department of Health and
Family Welfare, I have been absorbed by NHRM as a nurse at the OT. I wish MSF could stay longer but I will try my best to
keep what MSF introduced- quality care to all patients. I will continue to motivate the staff around me just like MSF did!”
Helling, Nurse OT
“Before joining the hospital as an employee, I was volunteering for MSF. I work in the lab. Before MSF, lab technicians
from different vertical programs would conduct specific tests. With the new integrated lab, all tests happen under
one roof. There is greater sharing of responsibility and hence greater efficiency.” Tongmeth, Lab Technician
“MSF had already arrived before I joined here as a doctor. I don’t know how it was before MSF but have heard that the
hospital was minimally functional. MSF has improved not just the infrastructure but also patient management. We have learnt
a lot about hygiene practices, isolation ward, chest ward etc. Even after MSF leaves, I am sure we have learnt enough to not
let the hospital get back to how it was.”
Dr Nuksang, Doctor
“The provision of everyday cleaning material like brooms, brushes, chlorine etc makes my work much easier. I feel sad
about MSF leaving us and fear the supply of cleaning material, medicines and other goods is going to suffer.”
Minyuh, Sweeper
27
Keep the Change