Filling Gaps

December 8, 2014 - Duncan Maru

We were attending a group antenatal care session at one of Nepal’s government health clinics when the midwife asked our team member, Dr. Bishal, to examine a five-day-old baby. The baby had not been latching well to her mother’s breast.

The midwife did an excellent job showing the mother how to position the baby, express milk, and encourage latching.

In many situations, that would have been sufficient guidance. For this baby, however, it wasn’t enough.

Dr. Bishal suggested she try to express milk and feed it to the baby. She was able to express a small amount, and the baby could take the milk.  That was a good sign; while the baby was too weak to do the more complex oral movements of breast-feeding, she was strong enough to drink from a bottle.

The problem, though, was her mother couldn’t hand-express milk, and there was no place in the district where a mechanical breast pump was available. Meanwhile, the baby was clearly too weak and sleepy to be able to breastfeed.

Ultimately, with night falling, Dr. Bishal recommended transport to our hospital in Bayalpata for hydration. After some debate with her mother-in-law, who wanted to take the three-hour trek to the hospital the next day, she finally agreed.

The “Easy” Part

In district healthcare systems, district hospitals are the “easy” part.

The heart of the durable healthcare challenge is connecting primary clinics and community health workers together to the hospital and to raise the standard of care at each of those clinics.

This baby was a testament to the opportunity and the challenge.

The midwife, employed by the government, had a basic skill set that currently only goes so far. Had Dr. Bishal not been present, she would have sent the mother and her baby home, with potential mortal consequences. While the hospital is “available” to provide the basic hydration needs of dehydrated neonates, the hospital is not “accessible” in the sense of long travel or coordination.

We Make the Road By Walking It

These are the kinds of gaps we are filling, and, as with all things in healthcare, “we make the road by walking it.”

Part of the reason we engage at the health clinic level is to deliver concrete deliverables, like improved antenatal care. Yet a larger part of the day-by-day and month-by-month work is identifying gaps that we then seek to fill.

Healthcare delivery is an ongoing process of service, reflection, and refinement. It is a humbling process—people literally die as they await those gaps to be filled.

I do hope this baby survives the next few days. I think she will.  But there are 74 other government clinics in the district where similar gaps are being missed every day.

“Scaling up” our work is partly about quickly simplifying and focusing our delivery model, while simultaneously finding the unforeseen gaps—and then filling them.