Health Care in Tibet /Yushu

 
$45,435
$29,565
Raised
Remaining

By Janis Whang Tseyong-jee, with Drs.Phuntsok Dongdrup, Sonam Drogha

Introduction

Our partnership calls for exporting our Surmang Prototype to the rural public health system. One part of this is provider training in the township clinics. Another is the exporting of our Community Health Worker (CHW) project. Within the rural public health system there is an incipient system called Village Health Workers. Training VHWs was the main work we accomplished this summer.

The 2012 VHW training started early in July, three training sessions were conducted. One in Xiewu Township, one in Rongbo Township, and one in an ecological migration village of Rongbo, where people from three former villages have been moved to. The village is about 30 km from the township.

13 new VHWs were recruited in total. One was added to the Xiewu VHW team and 12 from Rongbo, basically we have 2 VHWs from each village of Rongbo. Now there are 19 VHWs outside Surmang area. Making our total corps of CHW/VHWs 59.

Thanks to the support of Yushu Prefecture Public Health Bureau, Yushu County Health Bureau, and Rongbo Township government, the whole VHW training project this summer was very successful. The help we got from the township clinics was extremely important, for without it the trainings wouldn't have been so successful. 

Xiewu VHW Training

The first training was done in Xiewu, one of the eight townships of Chengduo County, which is about 46 km to the northeast of Jyekudo. The training took place on the fifth of July; the original plan was to start in June. However, it was postponed till July due to the fact that it was the season for digging caterpillar fungus (cordyceps sinesis) the main income local families rely on for living. The training was done in a conference room at the Xiewu Township Clinic building, which was a kind offer from the director of the clinic.

Who were trained

Out of the 7 VHWs from last year, 6 attended the training. For the seventh, the clinic director tried to contact the other one to inform her about the training, but unfortunately couldn't reach her. It seemed no any other VHW knows anything about her; we didn't even get her name. However, instead of her we had a new VHW this year. Songcho, a 63-year-old village doctor who has been practicing medicine in the community for more than 4 decades. She has shown great interest in learning, and her rich experiences were shared with the other village doctors throughout the training. We had her to demonstrate many times in the training how to help delivering a baby, how to do CPR, and etc.

The training design

The training in Xiewu was designed a bit differently from our previous training. for all the other VHWs are literate and 6 of them were trained in Jyekundo (Yushu, Chn.)for 6 months by the Jinpa Project, a local NGO in that is also dedicated to health related issues in Yushu. It was different in a way in that the training was more detailed and included more medical terms and professional skills. After the training by Jinpa, they returned to Xiewu and interned at the township clinic for 1-3 years respectively. Some of them didn't return to their own community after their internship due to the fact that there weren’t yet village clinics. However, they are still paid by the government annually, and each of them received 3,000 Yuan since last year. According to the clinic director, 3 new clinics are being built in the villages where there had never been clinics. They are Bamba, Adroronba, and Xiasayba, hopefully the new village clinics will be in use this fall.

Problem with Meds supply from the Township Clinics

At the village level clinics, they will be providing a few kinds of vaccinations for newborns, including TB, Measles, DTP, and Hepatitis B, if power isn’t a problem. Another interesting thing we heard was that the village doctor got the medicine to use at their clinics from the township clinic, and then they decide the price of the medicine when they prescribe the medicine to the patients. However, Zuncho told us that they don't make profit out of it, because the price of the medicine they get from the township clinic is higher than the retail pharmacies.

Record Keeping

The record forms they were given last year to keep track of their work was collected, however the main four columns, including place where the births took place, the mother’s condition, the baby’s condition and the number of visits, were left blank probably due to miscommunication last year. They kept the record of newborns that got vaccination, not necessarily the deliveries they attended. We explained how to record and the beneficiary of keeping not only a record of the newborns and mothers, but also for all the patient they see, hopefully it will build up their interest and confidence in keeping patient records which might contribute to the electronic records keeping in the future.

Donation of Equipment

At the end of the training, each one of the VHWs received birthing kits, soups, eye ointments, and Surmang caps. They were all very satisfied with the training, and they request that we offer more training in the future and they wish to learn more about gynecological problems. They were also suggesting that providing gynecological books might also be very beneficial since they are all literate and will able to use the book as reference.

Rongbo VHW Training

Rongbo is about 70 km from Jyekudo, and it was the second most seriously damaged town during the April 14, 2010 earthquake. It was estimated that the earthquake killed around 100 people and most of the houses here were destroyed. Therefore, the whole town Rongbo was reconstructed, and many houses are still under construction.

The training began on the 13th of July. The training in Rongbo couldn't be organized right after Xiewu, because of the damage the township clinic suffered from the earthquake in 2010. The new building was completed early this year, but it was not yet ready. It was decided to give the first training be given in the township, because three villages of Rongbo are located near by and it was within walking distance for most of the VHWs. The second training was given in an ecological migration village that is about 30 km from the township. There lives 617 families from three former villages of Rongbo Township, that’s why the community is called ‘617.’

All the VHWs from Rongbo were illiterate except for one, which is similar to our CHW in Surmang area. Both of the training sessions started in an awkward atmosphere, all the VHWs were shy to speak and became embarrassed easily when talking about pregnancy. However, the whole situation changed on the second day, probably because they started to realize that there’s nothing to be embarrassed about when comes to life and death. Addition to the regular neonatal care we often do in Surmang, we included information about HIV/AIDs and basic CPR in the training at Rongbo this year. In fact, one of the reasons for that is that there is confirmed case of HIV in Rongbo, however no further information was known.

Gayjee Zongkou Village

According to the VHWs, Gayjee Zongkou had the highest maternal and child mortality among all the six villages of Rongbo, and the accessibility of the village still remains a problem for the year around.  Unfortunately, we were not able to get anyone from that village. New VHWs from this village should definitely be recruited in the near future.

Despite the fact that almost none of the VHWs has been to school, they are mostly quick learners and they were all very active in the role play during the training and asked lots of questions regarding assistance in deliveries. Besides, they required to be trained in blood pressure measuring and the use of pregnancy testing sticks. And the VHWs from an ecological migration village, where using thermometer wasn’t included in the training, asked to add it in the training next year.

Having our Surmang CHW, Dadren, from Surmang, at the training this year was helpful, because people tend to listen more carefully when it’s based on first-person accounts, their own true stories. She shared her own experience about the deliveries that attended before and after she became a community health worker. Some of the stories were very sad, one of them was about her daughter lost her baby when she was seven months pregnant. 

She also shared a story of how she saved one of her grandchildren, who was not breathing, when he was born by using what she had learned from the training.

She emphasized many times how much she appreciate that she was trained as a CHW, and told how very important it is for a woman to be able to assist deliveries. She said that almost every woman has sisters, and will probably have daughters and granddaughters. Being able to help them in risky moments like giving birth makes you not only a better sister, mother or grandmother, but also a life saver.


CHW training
CHW training

Last year we reduced infant and maternal mortality to zero in a region that has some of the highest in the world.

For our foundation, we believe that when you have something that works –share it. That was the inspiration behind our post-earthquake government partnership.  We want to expand our network of Community Health Workers to the 4 most severely damaged township clinics in Yushu Prefecture:  Mozhang, Xialaxu, Xiewu and Longbao. So this summer so far, we concentrated on this.

We began our government partnership project in June under the auspices of Janice Tse-Yongjee. Janis is a Khampa Tibetan who has worked for us every summer since 2004. She is entering her second year as an MPH student in the US, and when she graduates next May we hope she will be able to add her expertise on a full time basis.  She is fluent and literate in Tibetan, Chinese and English.

Together with Drs. Phuntsok Dongdrup (Surmang Clinic Director) and So Drogha (Associate Director), and one of our senior Surmang Community Health Workers (CHWs) Palmo, they trained 20 new CHWs. Xiewu is 40 km north of Yushu/Jiegu and 4 hours north of Surmang. Longbao at 4500m, was near the epicenter of the 2010 earthquake, and is about 8 hours from our Surmang Clinic and 4 hours from Yushu/Jiegu.

It is very difficult to describe the logistical and environmental challenges they had to overcome. To set up the training in these areas, you don’t exactly call to make an appointment.  Most of this region is without telephone or electricity. In most of June most women were gone, collecting “worm grass,” cordyceps sinesis. The roads are unpaved, and wet from the summer monsoonal rains which come over the Himalayas from India. Even for Tibetans, it is still Tibet.

Our biggest accomplishment was not just that our foundation trained new CHWs, but that they –Janis, Phuntsok and Drogha, and Palmo-- did it by themselves. This is the first time any foundation has had accomplishments such as these, without any foreign oversight.   

They did it on their own. This impressed our senior public health consultants and me. It was this kind of dedication and grit that was the reason we have so many patients and why we treated so many mothers and children last year at Surmang. Now is our chance to expand this work 4 times. With your help we can succeed.

If you read the news, you know the difficulty the current situation and how lucky we are to still be operating in a Tibetan area at all...and are one of the few International foundations to do so. I feel confident that with your continued support, we will continue to help the women and children in our catchment.

Janis training a CHW
Janis training a CHW
our clients
our clients
well baby exam
well baby exam
baby whose birth was attended by CHW
baby whose birth was attended by CHW
CHW Training
CHW Training
CHW Training
CHW Training
CHW Training
CHW Training

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Dr. Drogha treating a patient
Dr. Drogha treating a patient

Charlene Chan is an In-The-Field Representatives for GlobalGiving. She is visiting projects throughout China. Here is her most recent "postcard" from Yushu, China:

Recently, Mari and I visited the project site of Surmang Foundation, a clinic in the remote Tibetan plateau providing free medical services. The project also aims to train local women to become midwives or as the clinic calls them, CHWs (Community Health Workers), with the objective of reducing infant and maternal mortality. 

Upon arrival, we were warmly greeted by the two doctors running the clinic, Dr. Phuntsok Dongdrup and Dr. So Drogha, as well as a translator, Janis Tseyongjee. The two doctors live at the clinic, housed in temporary housing after the devastating earthquake that hit the region in 2010 destroyed their homes. The clinic itself was established in 2000, and while the CHW project is relatively new, the two doctors have been treating patients from all over the Tibetan plateau for a long time. 

The next day, Dr. Drogha very kindly allowed Mari and I to observe while she treated patients. She saw about 20 patients that day, with ailments ranging from arthritis to tumors. Throughout the day, Dr. Drogha patiently answered all our questions and her patients kindly consented to us being in the room while undergoing treatment. I was most impressed by the patience, warmth and dedication the doctors displayed toward their patients despite their busy schedule - their patients were like family to them, and many of them stayed after receiving treatment to chat and play with Dr. Drogha's young daughter. When asked, they expressed fondness and gratitude for the clinic. Besides the free medical treatment, the clinic provided a more effective alternative to the traditional Tibetan medicine that most Tibetans resorted to when sick. Many patients had also traveled from afar to seek treatment, some as far as four hours away by motorcycle! 

While we were not able to observe the CHW project in action, we managed to see a patient who was under the care of a CHW, and had come to the clinic for her free ultrasound. Dr. Drogha explained to us that each CHW was expected to perform 3 prenatal visits, deliver the baby and perform 3 postnatal visits to check on both the mother's and the infant's health. The CHW would be paid 200RMB (about 30 USD) per patient. There has been great demand for CHWs in neighboring villages, and while Surmang Foundation is looking to expand the program, funding has become their main obstacle. 

Both Mari and I were sad to leave the clinic, its beautiful surroundings and the warm and wonderful people that run the clinic. We hope the clinic will be able to obtain more funding to expand its program and operations, to improve the lives of the inhabitants of the Tibetan plateau! 

We met a really shy CHW on the way to the clinic
We met a really shy CHW on the way to the clinic
The entire team!
The entire team!
CHW training Surmang
CHW training Surmang

At the Clinic

In the last 3 months, Surmang Foundation has continued the training of Community Health Workers in the area within a 50-mile radius of the Surmang Clinic. At the same time, the CHWs have continued to treat pregnant women, attend to births, do well baby examinations and refer patients that demand more complex services to the Surmang Clinic. We are continuing the momentum gained last year, when maternal mortality was reduced to zero.

Clinic use continues to be busy – with about 1000 patient visits per month.

 

Expanding the Catchment to include a Nunnery

Surmang Foundation has also taken the first steps in a strategic partnership with a large Nunnery in Yushu Prefecture.   This nunnery has experienced high levels of TB and hepatitis in the past year. The extension of services to this nunnery and the nearby village will comprise an extension of our strategic  government partnership. These first steps in this direction included sending our lead doctor, Phuntsok Dongdrup, and our Mother and Child Health Director, So Drogha, both ethnic Tibetans, there to conduct a preliminary assessment.  Their drive from Surmang took over 14 hours.

According to preliminary reports, the situation is dire:  cramped unheated housing, lack of sanitary conditions.  Our next steps will be to develop a strategic plan to address the more severe problems related to health and health care.  This will undoubtedly result in a CHW-like program there, as well as recommendations related to basic hygiene.  Surmang Foundation has already begun talks with Village People Foundation about the feasibility of bathhouse construction there and at 3 other locations in Yushu Prefecture. 

Finally, Surmang Foundation has acquired the rights to distribute –for free—the Tibetan version of Our Bodies, Our Selves.  This book along with similar references from Jinpa Foundation and One Heart foundations, completes our written Tibetan language resources for village health worker training.

CHW training
CHW training

Links:

Mother and children we treated
Mother and children we treated

Overview.

It is very difficult to communicate the kinds of geographic (think 13,800 ft, bad roads), language and cultural challenges that we work with.  Even the advent of air transport in Yushu doesn’t mitigate that fact.  When I left Surmang in late September, it was 8:30 in the morning.  When I arrived at Beijing it was 1:30 the next morning. It is a shorter ride from LA to Beijing than from Yushu.

Generally in 2011 we continued to go about our business operating a remote/high performance clinic and CHW public health outreach projects. But there was a twist. Unlike previous years, 2011’s activities were framed by strategic objectives defined in our government partnership --because of the Boston Consulting Group (BCG) Strategic Plan.  It was not just a matter of getting doctors or MPHs to our site, it was a matter of looking at our work so that its successes could be exported, where appropriate, to the 4 other clinics we are now partnered with. So our doctor training became prototype doctor training; our CHW training became more of a prototype for Village doctor training in the four townships we are partnered with.

In addition we were lucky to get the hands-on participation of very high-level MD/PH experts such as Ray Yip, Amy Levi, Dawn Factor, Mary Wellhoner, Mariette Wiebenga, Karen Deutsch, Tim and Cat Silbaugh. Joining us from the business community were John Holden of Hill & Knowlton, Jim Zimmerman of Sheppard Mullin, Rachel Lee of BCG, Ed Sun of Milbank, Bill Valentino of Beijing City University, and Julie Hu, Nike.  So we expanded our connection to stakeholders, both in the government, PH profession, and business community. Thanks to all for a remarkable year.

What we tried to achieve.

General: 

  • continued support and expanded capacity of  clinic and clinic doctors continued input and training of CHWs.

  • continued and expanded capacity of CHWs

  • Strategic: a shift from training of Clinic docs and CHWs to prototype training of docs and CHWs to use across our 4 township partner clinics

  • Including broad sectors of stakeholders from public and government

How we went about it.

  • Treating about 1,000 patients per month for free including meds, no questions asked
  • Maintaining low-cost clinic services (about $7/patient visit vs. $35 for government township clinics).
  • Maintenance of Clinic: Repair of Clinic roof and Clinic solar electrical system
  • Gathering information about the catchment from BCG and summarized in their Strategic Report
  • Continued CHW training focusing on maternal risk factors, prenatal counseling, delivery
  • Gathering information on needs and opportunities for our partnership from the on-site work at Xiewu Township Clinic by Ray Yip and Dawn Factor.
  • Gathering 80 people for China’s first Rural Health Festival
  • Using the results and recommendations of the Festival to focus on mobilizing community public health through CHW and Village doctor training.
  • Changing the training of our Clinic docs from pure primary care to managing training of docs (Phuntsok) to managing the training of CHWs (Drogha).
  • Hiring the retired Yushu Director of Public Health to manage Village doctor and the Xiewu Clinic training and Surmang prototype implementation.

History of Success.

  • Generally, advancing the legitimacy and respect among the stakeholders:  patients, CHWs, doctors (our own & at Xiewu), government buy-in (through open-ended participation in transparent process and analysis.

  • 1000 patient visits/month at Surmang Clinic

  •  High number of CHW (home) deliveries:  126

  • Low infant mortality 9.8% vs. 16% for hospital deliveries

  • Low maternal mortality  -- 0%

  • Providing training at the Xiewu Clinic for clinic doctors and village doctors.

Thanks to all our supporters on Globalgiving. 

We could not do this without your help. Your share of support is your share in our success story. Please contact me so that we can get your input and advice on how we can be more successful, and how we can work together to attract wider support.

best wishes for 2012,

Lee Weingrad

Birth of little girl last day of festival
Birth of little girl last day of festival
Mother and Child we treated
Mother and Child we treated
Training of CHWs at Zatch
Training of CHWs at Zatch

Links:


Attachments:

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Organization

Surmang Foundation

Boulder, CO, United States
http://www.surmang.org

Project Leader

Lee Weingrad

Founder
Beijing, Beijing China

Where is this project located?

Map of Health Care in Tibet /Yushu