Concept Document, draft 2, 17/06/2010


Introduction to needs in Nepal and incidence of ear disease
Deafness and chronic ear disease are the commonest disabilities in Nepal.

Key Targets, summary
Provide 1st class care for acute and chronic ear conditions including infection and deafness. Medical, surgical and hearing aids.
Provide training for health personnel.
Provide a base and referral centre for rural ear camps in Western Nepal.
Provide local community ear care and health education.
Train in and use appropriate techniques, drugs and equipment for developing country situation
Research low cost and appropriate interventions to help developing world patients
Maintain close links with national medical centres and health services .

Target 1. Specialist hospital care
A small hospital with space for expansion.
Excellent facilities
Ultimately direct medical care self funding through private beds and training programmes.
Charitable work including ear camps and community programme will require external donor support.
Consistent first class care for all including poor patients.
Open access.
In future to develop access to new developments such as cochlear implantation, bone anchored hearing aids and their long term care, seeking appropriate cost sensitive appliances

Target 2. Training
Access to international and national high quality medical and ancillary staff, and trainers
Excellent IT, e.g. video teaching of live surgery in local classroom and by IT links to other centres nationally and internationally.
Training community health workers in primary ear care
Training in care, fitting and maintenance of hearing aids

Target 3 ear camps centre
Link closely with staff and ideology of current ear camps programme
Interchange of facilities and equipment
Joint and mutual training opportunities

Target 4. Community ear care
To develop a public health ear programme in targeted local communities.
To train paramedics and volunteers in primary ear health.
To educate public, health and other services about common preventable causes of deafness e.g. overuse of ototoxic drugs, rubella vaccination of girls, noise exposure.
To educate public on facilities available for deaf and hard of hearing children and adults.

Target 5. Appropriate care development
Cost effective treatments, e. g. ear drops, ossicular middle ear prostheses, hearing amplification
Quick and effective surgical methods e.g. for perforated ear drum
Care of equipment

Target 6. Research
Primary ear care
Encourage links with international centres to facilitate high quality research and interchange of experts and students.

Target 7. Integration with local, national and international ear care services
Link with local health services including western Regional Hospital ENT, Manipal ENT, deaf schools and associations, diagnostic facilities.
Develop links with national services e.g. ENT and audiology centres in Kathmandu and other cities, to include joint training of surgeons and paramedics e.g. participation in MS courses and postgraduate training.
Joined up working with centres of excellence internationally e.g. exchange of training and teaching personnel
Offer courses for training.

Long term planning
This centre should be developed with the physical facilities being potentially multi-purpose, so that other specialist services like V-V fistulae repair in women would have the option to be initiated in parallel or even to replace ear services if that service were to fail.

The possibility of land at the GP site being available would be very beneficial. That site has many positive aspects including lack of capital cost and security of tenure. The training facilities at GP may be useful.
One donor has put aside a substantial sum of money that could be used to initiate building work, stage one. Current camps equipment can provide much of the initial short-term basic surgical and outpatient needs.
Significant investment will be required to provide the excellent surgical, diagnostic and training facilities required in the medium term to encourage paying patients.

Choice of site in Nepal
Placement of the centre raises several issues and goals.

Ideally the centre should have following possibilities:
Sufficient population of people with ear problems;
A needy population unable to readily access affordable/free care elsewhere;
A more wealthy population either locally or by good transport links who can afford paid care, to support the centre’s finance;
Sufficient local medical support infrastructure such as other medical specialists, CT and or MRI scanning;
Relative ease of access by public transport for both patients and medical staff, including international trainers;
A place that would be reasonably attractive as a destination for visiting teachers;
Ease of access for trainees with local support such as schooling and good accommodation, a place that trainees such as MS ENT trainees could be posted to from their normal training centres in Kathmandu or elsewhere;
Access to both poor rural and urban populations for community ear work;
No direct competition for paid work with national surgeons such as those in Kathmandu;
Complementing local services by providing specialist expertise.

Various options such as Surkhet or Nepalganj in Mid West were considered. Surkhet has insufficient local facilities and travel is too lengthy.
Nepalganj has visiting ear camp teams from Kathmandu and UK already. We have good links with these teams and they have some community based ear work established there, they are useful contacts and resources for training some of our own team. Discussions with them suggest that they are keen for us to establish our work in western region and continue our outreach work in the hills of mid and far west but linking into their work in Nepalganj is probably not viable. There is also some similar community work being done from Lahan in the east by Impact UK and Impact Nepal, with help from CBM through contact with TUTH, again we have good personal relations with the leadership but we have no plan to work in eastern Nepal, though some exchange of ideas, trainees and expertise should be possible.
Pokhara seems a natural base for an INF project, with its history in the area and local infrastructure meeting most if not all the criteria above.

Links with local health services
The point has been fairly made that the centre might be based within local health services such as the Western Regional Hospital. There are several reason why we feel that this may not be viable. It seems unlikely that they will be able to offer tertiary level ear care or community ear care work as priorities in the near future.
We would certainly wish to develop good and mutually supportive relations with the other local medical facilities with exchange of patients and trainings, case conferences etc; being independent should be no bar to this.