The Best Laid Plans


The winter has begun here in Achham, bringing with it the stark distinction between day and night.  Over the course of 12 hours, one experiences both scorching heat (which verges on unbearable for those of us accustomed to a Montana climate), and an evening breeze chilly enough to inspire wool hats and scarves.  With the beginning of this month also comes the long awaited start date of Bayalpata Hospital’s surgical program—a start date that has been planned over the course of years spent struggling to fundraise, build, recruit, and stock our new surgical center.  This start date marks not only a huge step forward in our organization’s expansion, but also the provision of basic surgical services for free to thousands of patients in our catchment area.  The only problem is that we are not actually commencing surgical services.

The question that looms in the forefront of my mental stage is “why?”  It is clear that at some point, and more likely at many points, small mistakes were made during the scale-up process.  Like so many of the challenges of global health, there is no clear, glaring answer to why things go wrong—but we still have to seek some sort of answer if we are to do things better.  Herein lays the challenge: not only to find these answers, but to use them constructively; to harness mistakes and missteps as the driving power behind future successes.  This is the quintessence of implementation science, which I have moved here, to Achham, to participate in.

As it turns out, the phrase “resource-poor” does not just apply to physical, tangible resources.  From the very first step of the construction and procurement processes, there have been not only limitations in available materials, but also limitations in accountability, frankness, and follow-through.  Time and time again, building materials have been promised with very generous deadlines, and have not been delivered.  Weeks after the tiles for our surgical center were supposed to arrive, our administrative staff still had to make 3-5 phone calls per day to demand updates on the status of the shipment.  Meanwhile, the tiling crew had nothing to do but lay in the sunshine and wait for supplies.

Construction projects have dragged on for weeks or months after they were guaranteed to be complete.  One contractor actually disappeared for three months without notice, leaving one of his employees stranded at the hospital, and reappeared after his absence demanding payment for services that were not completed.  The special paint that was originally applied to the operating room floor on the recommendation of experts, proved ineffective almost as soon as it was applied, and had to be chiseled away by hand and tiled over.  Though progress has been made, and our surgical center is now complete with fresh paint, tiles, and doors, it is complete at no small cost to the hospital staff members who fought daily for it.

Knowledge as a resource has proved its own limitations.  As the start date has grown nearer, the focus has moved from construction to stocking.  Furnishings for the surgical center have been discussed and quotations have been given, but decisions have been postponed in favor of feedback from absent providers.  List after list of surgical instruments has been compiled, but at the end of the day, there is no surgeon on site to finalize these hypothetical supply orders.  Even today, the surgical center still sits unfurnished, with only a smattering of instruments or consumables in stock with which to perform basic procedures.


Though our staff provides excellent care to all of the medical patients that we treat, our existing inpatient documentation systems leave us unprepared to properly care for post-operative patients.  The process of tracking patient vital signs, inputs, and outputs is being revised, but many of our clinical staff members have not yet received training on the specific needs of surgical patients.

After nearly a year of trying to recruit a practitioner with surgical capabilities, our long-awaited generalist physician arrived, marking a huge human resource milestone for Bayalpata Hospital.  He left two days later, however, due to miscommunication and differences in expectations.

The only resource that has not proven to be limited is willpower.  Throughout all of the logistical mayhem, select clinical team members have been undergoing trainings in anesthesia, scrub technique, and sterilization.  Our administrative team has been working day and night to recruit a practitioner with surgical capabilities.  Our donors have been supporting the expansion of our power system to enable the increased electricity demand necessitated by surgery.  Our partnership with Watsi, and the generosity of its donors, has enabled a few of our patients to receive life-changing surgical care at referral centers.  Literally everyone involved in Bayalpata Hospital and Nyaya Health has played some role in preparing for the roll-out of services.  Yet still, we cannot perform surgeries.

This is not a tale of hopelessness, nor is it an admission of defeat.  It is, quite on the contrary, proof that we must not only persevere through the thicket that is global health delivery, but that we must all serve as scientists within the art of healthcare implementation.  For only by documenting, discussing, analyzing, and sharing our failures, can we hope to help ourselves and others bypass the same roadblocks that have brought us to a screeching halt.