Sund og Bælt har valgt at donere 30 computere (+10 i reserve), 30 skærme, 2 printere, 2 servere, 6 netværksudstyr og diverse kabler, mus og tastaturer til Dhulikhel Hospital i Nepal.
Alt udstyret sendes af sted fra Halsskov i uge 35, og det forventes at være 40 – 45 dage undervejs. Først bliver det kørt til Hamborg, hvor det udskibes den 01.09 til Calcutta i Indien. Skibet vil ankomme til Calcutta den 02.10, og herfra køres udstyret med lastbil de sidste 1.000 km til byen Dhulikhel, der ligger ca. 40 km øst for Kathmandu hovedstaden i Nepal. Udstyret forventes at ankomme til Dhulikhel Hospital den 16.10.
Som en del af gaven er IT-hjælp på stedet også inklusiv (opsætning, konfigurering og undervisning), og jeg rejser derfor til Nepal for at installere udstyret i uge 45 eller 46.
Computerne skal blandt andet opsættes med 8 stk. i deres bibliotek, 5 stk. i administrationen, 8 stk. i det de kalder ”Out Patient Department”. Derudover skal der også sættes 5 – 9 stk. ’standalone’ maskiner op på forskellige lægeklinikker (kaldes Outreaches) i området.
Storebælts IT-afdelingen har klargjort og installeret alle computere med Linux Mint 13, som er et gratis styresystem, der også indeholder en officepakke, som hedder LibreOffice. Servere er installeret med CentOS 6, der er et gratis styresystem til servere.
Hospitalet ligger i en mindre by ca 40 km øst for hovedstaden Kathmandu i Nepal. Se hvor det ligger på Google Maps.
Kontakten er skabt igennem NepaliMed Denmark – læs mere her
Nedenfor kan læses mere om hospitalet og direktøren og grundlæggeren Dr. Ram K.M. Shrestha, som jeg mødte til et møde i København den 13. juni 2012.
With the purpose of presenting Dhulikhel Hospital in brief to a wider Danish audience, including potential members of NepaliMed Denmark, this paper was prepared by Mr. Henning Nilausen. The Dhulikhel Hospital management is very happy for this effort, to which we have contributed as much as possible. Although brief, we think the presentation provides an adequate picture of our endeavour at Dhulikhel Hospital. It describes very well “The Dhulikhel Way” as a 2012 status for our journey so far.
Dhulikhel Hospital (DH) can best be described as a comprehensive, value-based, community, not-for-profit health care organization with quality levels that compare to European standards, including accessibility for all.
“This is a centre for the poorest of the poor, but it is not at place to practice poor medicine”. DH founder, Dr. Ram Shrestha made this statement, which condensates the entire endeavour of the DH organization in order to provide quality health care services to those in need – no matter their financial ability.
In this capacity DH represents a living proof that it is indeed possible to run quality health care organizations in a poor country like Nepal. This fact distinguishes DH form many other health care organizations in Nepal and in many other less wealthy countries throughout the world.
The following brief description of the DH organization includes:
• Background and history;
• The DH values and logic of intervention;
• The organization and the management;
• The business model and financial structure.
1. Background and history
All people in Nepal are granted free admission to public health care. However, the capacity of the public health care system is limited and cannot in practice meet the actual demand for health services.
The founder of DH, Dr. Ram Shrestha, got his medical education at the University of Vienna, Austria. He did his residency in general surgery at the City Hospital of Feldkirch in Austria and worked there as a surgeon for 2 1/2 years before returning to Nepal in 1994 after 14 years abroad. The ambition and plan of Dr. Ram Shrestha was to establish a hospital in his hometown of Dhulikhel. As the son of a rice farmer of Dhulikhel, and having, at the age of nine years, experienced the loss of his mother, Dr. Ram Shrestha had first hand knowledge of the need for health care services in the town of Dhulikhel and the rural villages all over the District of Kavre, where Dhulikhel is the capital town.
Via his father and a number of key actors from the Dhulikhel community, a suitable location was identified and the land acquired. Well-wishers from the network of Dr. Ram together with other sources provided the necessary funds, equipment and a number of other in kind support. As a result of this comprehensive effort of many dedicated people it was possible in 1996 to have the official inauguration of DH, which was done by the late King Birendra.
From the very beginning it was clear that the DH organization had to build capacity to provide basic health care close to where people live. The first outreach centre in Baluwa was inaugurated in 1998 and is currently in 2012 undergoing modernization in order to enhance its capacity regarding health care services and community development. Since Baluwa’s inauguration 12 more outreach centres have been established together with development of primary health care capacities, public health interventions together with community activities such as micro-finance, micro-insurance, training in farming methods, small-size manufacturing, education, etc. All 13 outreach centres are to the maximum degree built by local people using local materials, thus creating local jobs and turnover.
King Birendra’s participation in the inauguration ceremony indicates DH’s clear commitment to collaboration and partnership with public health care institutions in Nepal, as well as any other health care enterprise. In a number of cases DH has conducted training for team members from other hospitals. DH consider itself as part of the health care system in Nepal and it is an explicit ambition of DH to contribute relevant knowledge, methods and concepts from DH to other hospitals and institutions throughout Nepal. Today, the DH organization runs a number of partnerships with hospitals in Nepal, and Dr. Ram Shrestha acts as advisor to the Prime Minister regarding health care sector issues.
Part of the DH organization’s commitment to the development of the health care sector in Nepal is being a University Hospital in collaboration with The Kathmandu University. This commitment results in producing an increasing number of qualified health care professionals: Doctors, nurses, physiotherapists, paramedics, etc. – available in Nepal. Moreover, it also constitutes valuable partnerships with universities and hospitals abroad, namely in Europe, South-East Asia and USA. Exchange of students, education of foreign medical students at Kathmandu University/DH, exchange of scholars and medical experts contribute to a growing integration of Nepal’s health care professional community into global health care cooperation and exchange.
In 2012, thus, the DH organization covers services in the range from a “phylogenetic tree”-understanding of general health cause-effect impact stemming from people’s conditions of life and to specialized surgery or medical therapy at tertiary level. In addition, DH is engaged with education of health care professionals as well as research and general academia with a clear practice-oriented perspective. During the past 15 years DH has connected to other parts of the health care sector in Nepal in order to develop the sector to the benefit of the people in Nepal.
2. The DH values and logic of intervention
There are no connections or commitments for the DH organization to any specific religious views. Being located in Nepal means of course being part of Nepalese culture with its entire impact. In this context, the DH organization works with commitment to strong values. These are not written down in official documents. The values are lived and communicated through the daily practice, reports, pamphlets, videos, presentations, newspaper articles, education activities, introduction for new staffs, etc.
However, in order for outsiders to understand the DH core values these could be phrased as follows :
• All individuals have the right to a healthy life and access to quality health care service;
• Any individual shall be met and treated with equal respect no matter their financial ability;
• We are committed to do the best of our ability in the strive for excellence;
• We strive for continuous improvement through learning;
• We focus on cost-effectiveness;
• We focus on prevention;
• We participate in the development of our community and the health care sector in our nation;
• We believe in quality, research based education and we are part of the global health care professionals’ community.
DH is one of the fastest growing organizations in Nepal. Over the past 15 years since the start in 1996 the organization has experienced growth in all areas. Increase in numbers of team members, activities, intervention areas, educational and research activities and of course also financial turn over has made a very committed and strong leadership a necessity. The values and leadership combine with a clear rationale for the growth in interventions executed by DH.
The DH rationale and logic of intervention is not written down in documents. It was formed in action, almost as an immanent logic and consequence of the initial outset and values. In brief the rationale consists of:
• Quality health care requires size. The notion “critical mass” is key to understand quality development. The professionals develop qualifications through practice, which in turn requires an up-scaled patient flow;
• Quality health care requires specialization, which also in turn requires size in order to reach an efficient level of patient flow;
• Quality health care requires an organization to connect itself to the international health care community in order to profit from the newest knowledge and technology;
• Rapid growth requires access to qualified team members;
• Economy of scale is a precondition for keeping cost-per-unit at a low level;
• Prevention focused interventions enhance healthy day-to-day life, including occupational health, which in turn keeps costs down;
• Improved understanding of healthy living among local people can only be achieved through a long-term steady effort carried through by persons, who are accepted in the local communities. DH connects to communities through existing structures – using the local opinion makers as ambassadors for the message and change of practice;
• Part of connecting to the community lies in creating jobs and activity. Thus, local people build and maintain the outreach centres;
• Livelihood and hardships impact health conditions. Means to improve livelihood in the community are brought into action, e.g. micro-finance, micro-insurance, training in agricultural methods, small scale manufacturing, etc.
3. The organization, activities and management
The DH organization encompass 13 outreach centres, the central hospital and the educational branch KUSMS – Kathmandu University School of Medical Sciences.
Although, KUSMS is an autonomous, independent academic institution established in collaboration between Kathmandu University and DH it should also be considered an integrated, logical part of the DH complex.
3.1. Outreach centres
The 13 outreach centres have been established successively since the start of DH. (For location of the centres click here: http://www.dhulikhelhospital.org/index.php/community-services/outreaches)
The centres provide basic health care (primary and secondary level) for people in the area covered. Several of the centres are capable of undertaking emergency and trauma treatment as well as surgery, which do not require full anaesthesia. In case more specialized interventions are required such cases are referred to the central hospital (tertiary level) in Dhulikhel.
Frequent health camps are carried out at the centres. The camps can be general or e.g. focused on (tertiary level) eye surgery, ENT, gynaecology, etc. Cases, which are evaluated to demand long lasting specialized treatment, are referred to the central hospital in Dhulikhel.
Examinations and treatments at the outreach centres are provided at a minimal fee. Cost for medicine is lower than in local pharmacies in Kathmandu or any bigger city. In practice, this means a very fair price, since the local people are spared for transport costs and time – often a two-day travel – to go a big city to buy the medicine.
The outreach centres form the basis for public health interventions aimed at improving health conditions and prevention. In this effort the DH organization connects with the local people via already existing structures such as e.g. mothers groups. Also, in some areas the outreach centres are engaged with establishing kinder gardens and supporting all children to attend school. Other means are micro-finance and micro-insurance arrangements, which are aimed at improving local people’s possibilities for providing for themselves. Moreover, training of different kinds, e.g. in agricultural and small-scale manufacturing is offered. This would also include aspects regarding occupational health in order to bring down the number of incidents of e.g. intoxication.
The community based development approach of the DH organization implies that as much as possible of the construction and maintenance work connected with the outreach centres is carried out by locals. Besides creating nice quality buildings it also creates a high level of local ownership where local people consider the DH organization as part of their local community.
All outreach centres refer to Department of Community Programmes on a weekly basis. Monthly reports on the centre activities are submitted. The staffs at the outreach centres attend training on a continued basis through a systematic training programme.
(For more information click here: http://www.dhulikhelhospital.org/index.php/community-services/department-of-community-programmes)
3.2. Dhulikhel Hospital – the central hospital
DH – the central hospital – is a tertiary level hospital. In 2012 the key-disciplines of health care are available together with state-of-the-art facilities such as e.g. lithotripsy machine (breaking kidney stones without surgical interventions), digital X-ray systems, CT scan, operating microscopes, endoscopic machines, etc. (For more information click here: http://www.dhulikhelhospital.org/ – use the menu “Services” and the sub-menu “Hospital Services”.)
DH has planned to continue the expansion of the central hospital. For the years 2012 – 2016 the plans cover:
• Trauma Centre (To be Constructed)
• Pulmonological Centre (To be Constructed)
• Public Health Centre (To be Constructed)
• Skill Lab (Under Construction)
• Dental Institute (Under Construction)
• Birthing Centre (Under Construction)
• Out Patient Department Block (Under Construction)
3.3. KUSMS – Kathmandu University, School of Medical Sciences
DH is university hospital for The Kathmandu University . As collaboration between the hospital and the university the independent Kathmandu University School of Medical Sciences (KUSMS) run the following programs:
1. MBBS
2. BSc. Human Biology (four years).
3. BSc. Nursing (four years).
4. Bachelor in Nursing Sciences (BNS).
5. BPT.
6. Certificate in Nursing under Dhulikhel Medical Institute .
7. Postgraduate program in basic and clinical sciences.
8. DM and MCh program in Cardiology, Neurology, Nephrology, Cardiothoracic and Neurosurgery in affiliated college.
The KUSMS provides quality health educations using a learner-centred approach, which is also problem-oriented, integrated with practical challenges as well as systematic. This type of educational practice is innovative and advanced compared to standard norm in the Nepali (and Regional) context. The credo for KUSMS’ educational activities seems to be: Tomorrow’s health care practitioners and leaders must be capable of taking responsibility, thinking independently and innovative, while at the same time being great team-members.
3.4. The Partners
DH has several public and private partner hospitals in Nepal. (For a list of partner hospitals in Nepal click here http://www.dhulikhelhospital.org/index.php/community-services/partnership-programmes)
The objective of this partnership is to provide a framework for professional collaboration and disbursement of experiences. For DH it is a specified objective to provide a model that can be exported to other hospitals and regions of Nepal. (For location of the partner hospitals click here: http://www.dhulikhelhospital.org/index.php/community-services/outreaches)
Internationally, DH collaborates with hospitals and universities in Asia, USA and Europe.
3.5. The management
Dr. Ram K.M. Shrestha is medical director of the DH organization. Together with Dr. Rajendra Koju, Administrative Director, Dr. Biraj Karmacharya, who is in charge of community programmes, Dr. Ram Shrestha form the overall management of DH.
An officer in charge heads each department and outreach centre. They all refer to Dr. Ram Shrestha in medical affairs.
An extraordinary strong sense of leadership permeates the DH organization. Thus, the leadership and the shared values create a strong dedication and motivation, which in its very own way supports much of the day-to-day management operations. At present the DH organization is run with a management practice, which is at a very informal, loosely structured and less documented level.
The entire management and key-members of the staff meet on a daily basis in the morning conference. At this conference relevant medical cases and business affairs are discussed and handled. The entire group attends part of the conference, while the segment relevant to the matter at stake may only attend other parts of the conference.
4. The business model and financial structure
The overall business model of DH is to provide quality health service at the lowest possible cost per unit – which in turn is a precondition for making quality health services accessible for most people. (Charity programmes are available for people without financial means. No patients are refused.)
To achieve this objective DH must develop economy-of-scale and grow to the volume that provides the necessary critical mass.
Currently DH runs the day-to-day operations on a financially independent basis. The hospital has a high level of efficiency and patient flows, which results in high turn over and low cost per unit. The revenue from operational activities balances the running costs.
The continuous expansion in infra structure and equipment, however, has to a large degree been funded by external gifts, grants and contributions. External funds also contribute to the low patient fees (since capital costs connected with investments are “free”) and the charity programme for the poorest of the patients. The external funds are also used in connection with various projects on water, environment, education, microfinance etc., which are running mostly in rural areas.