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Schwarz, Ryan

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Schwarz, Ryan

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2014 - 20187

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Author's Publications: search.filters.isAuthorOfPublication.3f9d9d27-04d2-4cd1-89eb-9cd02a3c3c4c

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    Strengthening Nepal’s Female Community Health Volunteer network: a qualitative study of experiences at two years
    (BioMed Central, 2014) Schwarz, Dan; Sharma, Ranju; Bashyal, Chhitij; Schwarz, Ryan; Baruwal, Ashma; Karelas, Gregory; Basnet, Bibhusan; Khadka, Nirajan; Brady, Jesse; Silver, Zach; Mukherjee, Joia; Andrews, Jason; Maru, Duncan
    Background: Nepal’s Female Community Health Volunteer (FCHV) program has been described as an exemplary public-sector community health worker program. However, despite its merits, the program still struggles to provide high-quality, accessible services nation-wide. Both in Nepal and globally, best practices for community health worker program implementation are not yet known: there is a dearth of empiric research, and the research that has been done has shown inconsistent results. Methods: Here we evaluate a pilot program designed to strengthen the Nepali government’s FCHV network. The program was structured with five core components: 1) improve local FCHV leadership; 2) facilitate structured weekly FCHV meetings and 3) weekly FCHV trainings at the village level; 4) implement a monitoring and evaluation system for FCHV patient encounters; and 5) provide financial compensation for FCHV work. Following twenty-four months of program implementation, a retrospective programmatic evaluation was conducted, including qualitative analysis of focus group discussions and semi-structured interviews. Results: Qualitative data analysis demonstrated that the program was well-received by program participants and community members, and suggests that the five core components of this program were valuable additions to the pre-existing FCHV network. Analysis also revealed key challenges to program implementation including geographic limitations, literacy limitations, and limitations of professional respect from healthcare workers to FCHVs. Descriptive statistics are presented for programmatic process metrics and costs throughout the first twenty four months of implementation. Conclusions: The five components of this pilot program were well-received as a mechanism for strengthening Nepal’s FCHV program. To our knowledge, this is the first study to present such data, specifically informing programmatic design and management of the FCHV program. Despite limitations in its scope, this study offers tangible steps forward for further research and community health worker program improvement, both within Nepal and globally.
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    Practical issues in the measurement of child survival in health systems trials: experience developing a digital community-based mortality surveillance programme in rural Nepal
    (BMJ Publishing Group, 2016) Harsha Bangura, Alex; Ozonoff, Alexander; Citrin, David; Thapa, Poshan; Nirola, Isha; Maru, Sheela; Schwarz, Ryan; Raut, Anant; Belbase, Bishal; Halliday, Scott; Adhikari, Mukesh; Smith-Rohrberg, Duncan
    Child mortality measurement is essential to the impact evaluation of maternal and child healthcare systems interventions. In the absence of vital statistics systems, however, assessment methodologies for locally relevant interventions are severely challenged. Methods for assessing the under-5 mortality rate for cross-country comparisons, often used in determining progress towards development targets, pose challenges to implementers and researchers trying to assess the population impact of targeted interventions at more local levels. Here, we discuss the programmatic approach we have taken to mortality measurement in the context of delivering healthcare via a public–private partnership in rural Nepal. Both government officials and the delivery organisation, Possible, felt it was important to understand child mortality at a fine-grain spatial and temporal level. We discuss both the short-term and the long-term approach. In the short term, the team chose to use the under-2 mortality rate as a metric for mortality measurement for the following reasons: (1) as overall childhood mortality declines, like it has in rural Nepal, deaths concentrate among children under the age of 2; (2) 2-year cohorts are shorter and thus may show an impact more readily in the short term of intervention trials; and (3) 2-year cohorts are smaller, making prospective census cohorts more feasible in small populations. In the long term, Possible developed a digital continuous surveillance system to capture deaths as they occur, at which point under-5 mortality assessment would be desirable, largely owing to its role as a global standard.
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    Combining Healthcare-Based and Participatory Approaches to Surveillance: Trends in Diarrheal and Respiratory Conditions Collected by a Mobile Phone System by Community Health Workers in Rural Nepal
    (Public Library of Science, 2016) Meyers, David J.; Ozonoff, Alexander; Baruwal, Ashma; Pande, Sami; Harsha, Alex; Sharma, Ranju; Schwarz, Dan; Schwarz, Ryan; Bista, Deepak; Halliday, Scott; Maru, Duncan
    Background: Surveillance systems are increasingly relying upon community-based or crowd-sourced data to complement traditional facilities-based data sources. Data collected by community health workers during the routine course of care could combine the early warning power of community-based data collection with the predictability and diagnostic regularity of facility data. These data could inform public health responses to epidemics and spatially-clustered endemic diseases. Here, we analyze data collected on a daily basis by community health workers during the routine course of clinical care in rural Nepal. We evaluate if such community-based surveillance systems can capture temporal trends in diarrheal diseases and acute respiratory infections. Methods: During the course of their clinical activities from January to December 2013, community health workers recorded healthcare encounters using mobile phones. In parallel, we accessed condition-specific admissions from 2011–2013 in the hospital from which the community health program was based. We compared diarrhea and acute respiratory infection rates from both the hospital and the community, and assigned three categories of local disease activity (low, medium, and high) to each week in each village cluster with categories determined by tertiles. We compared condition-specific mean hospital rates across categories using ANOVA to assess concordance between hospital and community-collected data. Results: There were 2,710 cases of diarrhea and 373 cases of acute respiratory infection reported by community health workers during the one-year study period. At the hospital, the average weekly incidence of diarrhea and acute respiratory infections over the three-year period was 1.8 and 3.9 cases respectively per 1,000 people in each village cluster. In the community, the average weekly rate of diarrhea and acute respiratory infections was 2.7 and 0.5 cases respectively per 1,000 people. Both diarrhea and acute respiratory infections exhibited significant differences between the three categories of disease rate burden (diarrhea p = 0.009, acute respiratory infection p = 0.001) when comparing community health worker-collected rates to hospital rates. Conclusion: Community-level data on diarrhea and acute respiratory infections modestly correlated with hospital data for the same condition in each village each week. Our experience suggests that community health worker-collected data on mobile phones may be a feasible adjunct to other community- and healthcare-related data sources for surveillance of such conditions. Such systems are vitally needed in resource-limited settings like rural Nepal.
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    Partnerships in mental healthcare service delivery in low-resource settings: developing an innovative network in rural Nepal
    (BioMed Central, 2017) Acharya, Bibhav; Maru, Duncan; Schwarz, Ryan; Citrin, David; Tenpa, Jasmine; Hirachan, Soniya; Basnet, Madhur; Thapa, Poshan; Swar, Sikhar; Halliday, Scott; Kohrt, Brandon; Luitel, Nagendra P.; Hung, Erick; Gauchan, Bikash; Pokharel, Rajeev; Ekstrand, Maria
    Background: Mental illnesses are the largest contributors to the global burden of non-communicable diseases. However, there is extremely limited access to high quality, culturally-sensitive, and contextually-appropriate mental healthcare services. This situation persists despite the availability of interventions with proven efficacy to improve patient outcomes. A partnerships network is necessary for successful program adaptation and implementation. Partnerships network We describe our partnerships network as a case example that addresses challenges in delivering mental healthcare and which can serve as a model for similar settings. Our perspectives are informed from integrating mental healthcare services within a rural public hospital in Nepal. Our approach includes training and supervising generalist health workers by off-site psychiatrists. This is made possible by complementing the strengths and weaknesses of the various groups involved: the public sector, a non-profit organization that provides general healthcare services and one that specializes in mental health, a community advisory board, academic centers in high- and low-income countries, and bicultural professionals from the diaspora community. Conclusions: We propose a partnerships model to assist implementation of promising programs to expand access to mental healthcare in low- resource settings. We describe the success and limitations of our current partners in a mental health program in rural Nepal.
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    An integrated community health worker intervention in rural Nepal: a type 2 hybrid effectiveness-implementation study protocol
    (BioMed Central, 2018) Maru, Sheela; Nirola, Isha; Thapa, Aradhana; Thapa, Poshan; Kunwar, Lal; Wu, Wan-Ju; Halliday, Scott; Citrin, David; Schwarz, Ryan; Basnett, Indira; KC, Naresh; Karki, Khem; Chaudhari, Pushpa; Smith-Rohrberg, Duncan
    Background: Evidence-based medicines, technologies, and protocols exist to prevent many of the annual 300,000 maternal, 2.7 million neonatal, and 9 million child deaths, but they are not being effectively implemented and utilized in rural areas. Nepal, one of South Asia’s poorest countries with over 80% of its population living in rural areas, exemplifies this challenge. Community health workers are an important cadre in low-income countries where human resources for health and health care infrastructure are limited. As local women, they are uniquely positioned to understand and successfully navigate barriers to health care access. Recent case studies of large community health worker programs have highlighted the importance of training, both initial and ongoing, and accountability through structured management, salaries, and ongoing monitoring and evaluation. A gap in the evidence regarding whether such community health worker systems can change health outcomes, as well as be sustainably adopted at scale, remains. In this study, we plan to evaluate a community health worker system delivering an evidence-based integrated reproductive, maternal, newborn, and child health intervention as it is scaled up in rural Nepal. Methods: We will conduct a type 2 hybrid effectiveness-implementation study to test both the effect of an integrated reproductive, maternal, newborn, and child health intervention and the implementation process via a professional community health worker system. The intervention integrates five evidence-based approaches: (1) home-based antenatal care and post-natal care counseling and care coordination; (2) continuous surveillance of all reproductive age women, pregnancies, and children under age 2 years via a mobile application; (3) Community-Based Integrated Management of Newborn and Childhood Illness; (4) group antenatal and postnatal care; and 5) the Balanced Counseling Strategy to post-partum contraception. We will evaluate effectiveness using a pre-post quasi-experimental design with stepped implementation and implementation using the RE-AIM framework. Discussion This is the first hybrid effectiveness-implementation study of an integrated reproductive, maternal, newborn, and child health intervention in rural Nepal that we are aware of. As Nepal takes steps towards achieving the Sustainable Development Goals, the data from this three-year study will be useful in the detailed planning of a professionalized community health worker cadre delivering evidence-based reproductive, maternal, newborn, and child health interventions to the country’s rural population. Trial registration ClinicalTrials.gov Identifier: NCT03371186, registered 04 December 2017, retrospectively registered. Electronic supplementary material The online version of this article (10.1186/s13012-018-0741-x) contains supplementary material, which is available to authorized users.
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    Surgical referral coordination from a first-level hospital: a prospective case study from rural Nepal
    (BioMed Central, 2017) Fleming, Matthew; King, Caroline; Rajeev, Sindhya; Baruwal, Ashma; Schwarz, Dan; Schwarz, Ryan; Khadka, Nirajan; Pande, Sami; Khanal, Sumesh; Acharya, Bibhav; Benton, Adia; Rogers, Selwyn O.; Panizales, Maria; Gyorki, David; McGee, Heather; Shaye, David; Maru, Duncan
    Background: Patients in isolated rural communities typically lack access to surgical care. It is not feasible for most rural first-level hospitals to provide a full suite of surgical specialty services. Comprehensive surgical care thus depends on referral systems. There is minimal literature, however, on the functioning of such systems. Methods: We undertook a prospective case study of the referral and care coordination process for cardiac, orthopedic, plastic, gynecologic, and general surgical conditions at a district hospital in rural Nepal from 2012 to 2014. We assessed the referral process using the World Health Organization’s Health Systems Framework. Results: We followed the initial 292 patients referred for surgical services in the program. 152 patients (52%) received surgery and four (1%) suffered a complication (three deaths and one patient reported complication). The three most common types of surgery performed were: orthopedics (43%), general (32%), and plastics (10%). The average direct and indirect cost per patient referred, including food, transportation, lodging, medications, diagnostic examinations, treatments, and human resources was US$840, which was over 1.5 times the local district’s per capita income. We identified and mapped challenges according to the World Health Organization’s Health Systems Framework. Given the requirement of intensive human capital, poor quality control of surgical services, and the overall costs of the program, hospital leadership decided to terminate the referral coordination program and continue to build local surgical capacity. Conclusion: The results of our case study provide some context into the challenges of rural surgical referral systems. The high relative costs to the system and challenges in accountability rendered the program untenable for the implementing organization. Electronic supplementary material The online version of this article (10.1186/s12913-017-2624-2) contains supplementary material, which is available to authorized users.
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    Power, potential, and pitfalls in global health academic partnerships: review and reflections on an approach in Nepal
    (Taylor & Francis, 2017) Citrin, David; Mehanni, Stephen; Acharya, Bibhav; Wong, Lena; Nirola, Isha; Sherchan, Rekha; Gauchan, Bikash; Karki, Khem Bahadur; Singh, Dipendra Raman; Shamasunder, Sriram; Le, Phuoc; Schwarz, Dan; Schwarz, Ryan; Dangal, Binod; Dhungana, Santosh Kumar; Maru, Sheela; Mahar, Ramesh; Thapa, Poshan; Raut, Anant; Adhikari, Mukesh; Basnett, Indira; Kaluanee, Shankar Prasad; Deukmedjian, Grace; Halliday, Scott; Maru, Duncan
    ABSTRACT Background:: Global health academic partnerships are centered around a core tension: they often mirror or reproduce the very cross-national inequities they seek to alleviate. On the one hand, they risk worsening power dynamics that perpetuate health disparities; on the other, they form an essential response to the need for healthcare resources to reach marginalized populations across the globe. Objectives:: This study characterizes the broader landscape of global health academic partnerships, including challenges to developing ethical, equitable, and sustainable models. It then lays out guiding principles of the specific partnership approach, and considers how lessons learned might be applied in other resource-limited settings. Methods:: The experience of a partnership between the Ministry of Health in Nepal, the non-profit healthcare provider Possible, and the Health Equity Action and Leadership Initiative at the University of California, San Francisco School of Medicine was reviewed. The quality and effectiveness of the partnership was assessed using the Tropical Health and Education Trust Principles of Partnership framework. Results:: Various strategies can be taken by partnerships to better align the perspectives of patients and public sector providers with those of expatriate physicians. Actions can also be taken to bring greater equity to the wealth and power gaps inherent within global health academic partnerships. Conclusions:: This study provides recommendations gleaned from the analysis, with an aim towards both future refinement of the partnership and broader applications of its lessons and principles. It specifically highlights the importance of targeted engagements with academic medical centers and the need for efficient organizational work-flow practices. It considers how to both prioritize national and host institution goals, and meet the career development needs of global health clinicians.