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The content we created for Nyaya Health in 2011 appears below. This content is likely to be no longer fully accurate, both with respect to what it says about Nyaya Health and with respect to what it implies about our own views and positions. With that said, we do feel that the takeaways from this examination are sufficient not to prioritize re-opening our investigation of this organization at this time.
In 2011, we declared Nyaya Health a "standout organization," which meant that we found it to be an outstanding opportunity to accomplish good but that we rated our top charities above it.
Published: July 2011
Nyaya Health operates a hospital and system of community health workers in partnership with the government in the district of Achham, Nepal.
We feel that Nyaya Health is a standout organization because of its:
Our full review, below, discusses our full assessment of Nyaya Health, including what we see as its strengths and weaknesses as well issues we have yet to resolve.
In May 2012, Nyaya Health provided the following updated information, which we have not yet reviewed:
Our evaluation of Nyaya Health consisted of reviewing publicly available information, speaking by phone with Nyaya Health board members and volunteers, and reviewing information that Nyaya sent to us in response to our questions.
Nyaya Health operates a hospital and system of community health workers in the district of Achham, Nepal.2
Below, we provide basic figures for Bayalpata Hospital for the period of January 15, 2010 to December 15, 2010. Nyaya Health does not have hospital registries for before this period:5
Nyaya has also shared data from a limited time period (February 15 – April 15, 2011) on the primary diagnoses of patients seen at the hospital (see footnote).8
Nyaya Health also provides ambulance services.9
According to Nyaya Health's website, its hospital is staffed by 24 Nepalese employees, including a doctor, 6 midwives, 4 health assistants and aides, 4 Community Health Workers, a lab assistant, an x-ray aide, an ambulance driver, and 6 support staff.10 Nyaya Health informed us that as of March 2011, it employed an additional doctor, as well as 45 Female Community Health Volunteers (FCHVs) under the leadership of the Community Health Workers.11 Nyaya gives details of where each staff member received his/her training and what he/she did before working for Nyaya.12
In our view, the key questions for Nyaya Health's effectiveness are:
We have limited information to answer this question. Nyaya Health conducted an informal assessment of the health and available services in the area before starting its work, consisting of "site visits to several of the health posts, hospitals, private medical offices, pharmacies, and government offices in the region [and interviews with] 1) administrators, politicians, leaders, local headmasters; 2) community-based outreach workers; 3) healthcare providers, health assistants, midwives, pharmacists, private practitioners; 4) members of the target population."13
However, at the time the survey was conducted, Achham was likely in a particular poor position due to the end of a 10-year-long civil war in 2006.14
The Nepali government has improved the district hospital15 that was minimally staffed and inaccessible when Nyaya Health entered Achham, and we have little information regarding the degree to which the populations served by Nyaya Health and the district hospital overlap.
Nyaya Health also sent us a document stating that the Nepal Ministry of Health allocates doctors on a per-facility rather than on a per-area or per-person basis. The document shows that Achham has 4 full-time doctors while two other nearby districts have 2 and 1 respectively.16 This document does not resolve our question about the counterfactual because it is unclear to us (a) whether additional doctors led to patients receiving services that they would not have otherwise received; and (b) whether the Ministry of Health would have staffed this second hospital (i.e., the one Nyaya now operates) on its own if Nyaya did not exist.
We see two reasons to be cautiously optimistic about the quality of Nyaya Health's care: (a) it has told us that it has frequent visits from developed-world medical professionals unaffiliated with Nyaya Health; (b) Nyaya Health publicly reports an unusual degree of information on its outcomes, including poor outcomes.
Nyaya Health stated to us that its site is fairly regularly visited by developed-world medical professionals.17 Were we to continue our review, we would seek additional information on how often Nyaya has had outside visitors in the past and what their experiences have been.
The following are accounts of visits to Nyaya Health's facilities in Achham by medical professionals who are not employed by or on the board of Nyaya Health. Because these accounts are by self-selected people (people who chose to invest time and money to travel to Nyaya) and because in many cases their accounts were chosen for public posting by Nyaya Health, they are not unbiased accounts. Names and brief biographies are below; quotes follow in footnotes.
Nyaya posts detailed reports on some of the morbidity and mortality cases that occur at its facilities. Nyaya told us that, since July 2010, its staff have examined one case each week and sent their reports to an email list of 15 medical professionals working in Nepal, the U.S., and elsewhere for review and comments.23 As of April 1, 2011, there were 20 reports online dated after July 22, 2010 (as well as six mortality reports from before this period), over a span of 36 weeks. We summarize the first 16 cases since the start of the morbidity and mortality review program and some of the problems Nyaya Health identifies in each report (see footnote; note that we have not yet reviewed the more recent reports).24
As stated at our discussion of impact analysis, we are generally concerned about charities' potential diversion of skilled labor, interference with government responsibilities, and/or diversion of limited government funding.
These concerns are difficult to systematically evaluate and/or quantify. Below are Nyaya Health's statements on these concerns.
Possible diversion of skilled labor: Nyaya Health told us:
We remain concerned about the possibility that medical staff may be drawn from limited pool of staff willing to work in rural areas.
Possible interference with government services: Nyaya Health reports (above) that government health services were largely non-existent in the area prior to Nyaya Health's arrival. Nyaya Health also notes that government investment in health in the region has increased since its arrival, and has not increased at the same rate in surrounding regions (we have not seen data on this).27
Possible diversion of limited government funding: Nyaya Health receives funding from the government of Nepal.28 We worry that these funds may have been reallocated from other regions in Nepal, rather than being additional investments in health. It is possible that while funding may have been reallocated from other regions, this may have resulted in more funding going to regions with greater needs.29 We have not been able to determine whether this is the case, as we have not seen data on health spending by region over time. Nyaya notes:30
Other concerns: We also asked Nyaya Health about potential sources of reduced impact, specifically security concerns and its geographic isolation. Nyaya Health told us that security has not been a concern to date and that the location for the hospital was chosen because it is "centrally located for a very rural and dispersed population." However, "Achham is an extremely rural area with limited roads/transport access and the population is very poor making travel even more challenging."31
We have not completed a cost-effectiveness estimate for Nyaya Health.
Because it provides comprehensive care, Nyaya is likely not as cost-effective in a $-per-lives-saved or per-DALYs-averted sense as programs that distribute vaccines or bednets. We weigh cost-effectiveness among other considerations when evaluating a charity, though we try not to put undue weight on this one factor. (For more, see our perspective on using cost-effectiveness metrics).
Update: In May 2012, Nyaya Health provided updated budgets for its Nepal and U.S.-based operations and updated funding scenarios (see above). We have not yet reviewed these documents.
Nyaya Health's funding gap for 2011 is estimated at $85,000 and for 2011-2013 at about $920,520. Details below.
Nyaya Health told us on March 14, 2010:32
As of June 2011, it appears that Nyaya has raised about $315,000 of the target $400,000 for 2011.33 Thus, we estimate Nyaya's funding gap for 2011 at $85,000.
Nyaya Health provides regular updates on its website on how much it has in the bank.34
Nyaya Health provided details of what it would do at each level of funding:35
Nyaya Health provided a budget for its expansion plans over 2011-2013. Expansion costs and expected outputs included:36
Nyaya Health's total expansion in 2011-2013, were it to receive sufficient funding, would cost $1,073,026. Above, we estimate that Nyaya has raised about $315,000 in the first half of 2011, or about $152,500 more than the amount needed to cover expenses at the 2010 level of operations. Thus we estimate that Nyaya has a funding gap for its 2011-2013 expansion of $920,520.45
In evaluating Nyaya Health, we sought to understand the counterfactual: what health services would exist in the area Nyaya operates if it did not exist? We have not been able to answer this question with high confidence.
In addition, we have not fully answered the following questions:
Nyaya Health’s activities in Achham are centered at the Bayalpata Hospital. The hospital, run as a collaboration between Nyaya Health, local citizens, and the Nepali government, centers around a model of comprehensive primary care, including maternal and child health, infectious disease prevention and treatment, and management of chronic conditions for an expanding catchment population of a quarter million people. The hospital is located in the major transit hub for the region and treats over 3,000 patients per month on average. It is run by over twenty Nepali staff including physicians, community healthcare workers, nurse midwives, lab technicians, pharmacists, and project managers. The hospital includes a comprehensive laboratory, pharmacy, clinical diagnosis and treatment rooms, infusion space, a delivery suite, capacity for wet and dry storage, and safe medical waste incineration and disposal. Community health workers constitute mobile teams providing outreach, triage, treatment and follow-up services to a geographically dispersed population. All medical care is provided free-of-charge." Nyaya Health, "Overview."
Nyaya Health, "Budget."
Data from Nyaya Health, "Nyaya Health Budget," Sheet Budget Input. Data analysis in GiveWell, "Nyaya Health Expenses (2010)," Sheet Analysis.
Data from Nyaya Health, "GiveWell HMIS Summary."
"We unfortunately do not have any old General/Outpatient Registers prior to Magh 2066 [January/February 2010], nor do we have any record of the HMIS summary reports from that time." Nyaya Health, "GiveWell HMIS Summary." Nyaya Health does present numbers of emergency patients and abortions performed starting in June 2009, when the hospital opened, but for consistency only tallies starting January 15, 2010 are presented here. See Nyaya Health, "Nyaya Health opens Bayalpata Hospital in Achham" for date of hospital opening.
Nyaya Health, "Developing an X-ray Program in Achham."
Nyaya Health, "ART Enrollment by Month."
Nyaya sent data for the two months February 15 to April 15, 2011, the Nepali months of Falgun and Chaitra, the first of which includes outpatient diagnosis, and the second of which includes diagnosis for outpatients, emergency patients, and inpatients. Nyaya initiated a new data collection system starting February 2011, and we do not know whether this data was being collected prior to that. There is diagnosis data from an earlier period, 2008-2009, on Nyaya'a website (see Nyaya Health, "Outpatient Data"), but we haven't seen it for the intervening period. Below we have reproduced data from the March 15 to April 15 report, which is the only report we have seen that includes diagnosis from outpatients, inpatients, and emergency patients (from Nyaya Health, "Calculations for Chaitra 2067," Sheets NH OPD ICD, NH Emergency ICD, and NH IPD ICD.) Note that the data may contain some errors: "You will see that there are still inconsistencies / discrepancies in some of our automatically generated data, as compared to the hand-recorded data, which is a result of several data entry problems some of which are due to user-entry error and some of which are due to our own inability (thus far) to account for complicated data algorithms, for example avoiding duplicate or triplicate counting when one patient has more than one diagnosis." Dan Schwarz, email to GiveWell, May 5, 2011.
10 most common outpatient diagnoses:
5 most common emergency patient diagnoses:
5 most common inpatient diagnoses:
"The ambulance is used both to pick patients up from surrounding communities as well as to transport patients from Bayalpata Hospital to other facilities for higher-level care...360 patients = the total number of patients provided services." Nyaya Health, "Report of Ambulance Services at Bayalpata Hospital," Pgs 2-3.
Nyaya Health, "Personnel."
Nyaya Health, "Comments on GiveWell Draft Review of Nyaya Health."
Examples from Nyaya Health, "Personnel":
Nyaya Health, "Health Services Assessment in Five Village Development Committee Areas Surrounding Sanfe Bagar, Achham," Pg 1.
The report from this survey implies that at that time (2007), access to public medical facilities was poor - specifically:
"I know that the district hospital in Mangalsen has a few more employees. There are two doctors where previously there weren't any. They have some additional equipment. Hypothetically, their supply chain and medication stocks are a bit better. It's hard for me to say with confidence." Ryan Schwarz, phone conversation with GiveWell, March 31, 2011.
"In terms of investments however, as Nyaya has increased infrastructure (a health center, a hospital, a CHW network) in the region, we have provided further opportunity for government investment than previously existed. Ministry HR policy allocates staff per facility and therefore gross numbers of facilities drives number of staff funded for each district. As the table below demonstrates, there are now 4 MBBS physicians in Achham, 2 of whom are at the Ministry district hospital, and 2 of whom are supported by the Ministry to work at our hospital. Neighboring districts, Bajura and Doti - similar in size, population, geographic isolation and development indices to Achham - during the same time period, also saw an increase in number of physicians. However, as each district has only one hospital, they have necessarily received fewer staff." Nyaya Health, "Nyaya Health’s Impact in Public-Sector Strengthening: Addressing the Counter-Factual Hypothesis."
GiveWell: What is the schedule of visits by non-staff medical professional to the hospital, i.e. how often are observers there?
Nyaya Health: Our Executive Director is an ex-pat who lives there and that's a critical communication link for us. People go out there pretty regularly. We have a reasonable constant ex-pat presence, and when I say ex-pat, I also include Nepalis who are part of the Nepali diaspora in the US. The value added of someone like Michael Polifka is huge. The staff loved him. His biggest impact comes from modeling professionalism.
We normally have 1 or 2 out there at all times, though it's not part of our model. They're not there to provide direct medical care, but they're there to train. They're only there for a few weeks, but they have an impact on knowledge dissemination."
Duncan Maru, phone conversation with GiveWell, March 17, 2011.
Michael Polifka, phone conversation with GiveWell, March 14, 2011.
She continued, "Most government health facilities have very high rates of staff absenteeism. What you'll find is that the doctor might be present for 1-2 months of the year at the district hospitals. Having doctors on-site and providing continuity of services are key quality indicators. Nyaya Health provides continuous services and has 2 doctors on site for 12 months of the year...
In a case we had last night a middle-aged woman who was grazing her animals was about to tie up her bull when it attacked her...Dr. Amir cleaned the wound, controlled the bleeding, provided IV and local pain meds, and did an excellent job of suturing the muscle and skin. She's now doing well as an inpatient. If this hospital weren't here, she would have had to travel another 6 hours (by jeep)....The hospital is good at handling cases of severe pneumonia in children under 5. These cases are excellently managed with IV antibiotics, inhalers, and oxygen as needed...People have started hearing about the hospital and the free care, and have started to come after other facilities were unable to solve their problems.
One of the main things that is not handled well is pain control...Doctors are hesitant to use morphine for example. We recently had a case of acute heart failure where I would have thought first about morphine, but that's not how the doctor handled it...Most of the time it's not so much that a case was badly managed but that the staff don't have the tools to make a diagnosis." Ruma Rajbhandari, phone conversation with GiveWell, March 18, 2011.
Dr. Rajbhandari also wrote on the Nyaya Health blog about two traffic accidents that the Bayalpata Hospital staff responded to while she was there. She identified both strengths and weakness in the way the cases were handled: "The teamwork among the staff in dealing with a disaster such as this was absolutely remarkable. I smiled as our Hospital Administrator went around making sure that everyone had gotten their Tetanus booster shots...That’s not to say there weren’t problems. There were many things that could have gone better. Infection control in our procedure room needs to be improved. Many of our suture kits do not have the proper instruments. We lack certain supplies like face shields, booties and sufficient gowns to protect our doctors and nurses from coming into contact with bodily fluids. We also did not have sufficient staffing to deal with a disaster such as this and attend to the one-hundred or so OPD patients that had walked many hours to see a doctor that day." Nyaya Health, "'We can only take the severely injured right now…'"
Nyaya Health, "Norwegian Group Visit to Bayalpata Hospital."
She continued, "I have been very impressed with the dedication, volunteerism of almost everyone involved with Nyaya who work hard under difficult conditions to bring quality health care to the people of Achham." She does not discuss observing patient care. Nyaya Health, "Interview with Nyaya Donor Dr. Prativa Pandey of CIWEC Clinic."
He continued: "The illnesses that come through the door are amazing: many people with active TB; a 16-year-old with severe rheumatic heart disease; women with traumatized pelvic organs from a traditional healer placing a stick in the uterus and leaving it there to produce sterility or induce an abortion. There are many fractures of arms, legs, and wounds that resist healing. The inpatient ward is mostly women with severe end stage emphysema from breathing smoke during cooking." Lichtenstein and West 2011.
Ryan Schwartz, phone conversation with GiveWell, March 31, 2011.
The following is from Nyaya Health, "Cases."
|Overview of case||Date of report||Problems identified||Report|
|Fetal demise in 20-year-old||July 22, 2010||Low supplies, lack of staff training, difficulty of travel||Nyaya Health, "Mortality Report: Intrauterine Fetal Demise in a 20yo Primagravid (July 22, 2010)."|
|19-year-old woman came in a few days after childbirth with fever and was transferred||July 28, 2010||Absence of lab assistant, disorganization of emergency area, lack of follow up after delivery, dosing guidelines, electrical infrastructure, and staff organization||Nyaya Health, "Mortality Review: 19 Year Old Woman with Retained Products of Conception (July 28, 2010)."|
|Two young brothers died of poisoning||August 4, 2010||Lack of protocols for emergency care, equipment in inconvenient location, lack of advanced equipment, inconvenient location of electrical outlets, and lack of staff training.||Nyaya Health, ""MMC: 12 and 6 Year Old Brothers Dead of Unknown Poisoning (July 27, 2010)."|
|28-year-old male attempted suicide||August 10, 2010||Some medicines not on pharmacy list, lack of psychiatrist in the area||Nyaya Health, "Morbidity review: Suicide attempt by 28 year-old male (August 10, 2010)."|
|87-year-old male died after 6 weeks in the hospital he was transferred to||August 18, 2010||Low stock of one medicine due to supply chain issues||Nyaya Health, "Mortality Review: COPD."|
|35-year-old female with prolonged labor and stillbirth||August 25, 2010||Lack of some laboratory services, and lack of training for some staff in forcep and vacuum delivery and for CHWs in danger signs.||Nyaya Health, "M&M Review (August 25, 2010)."|
|8-month-old infant died at hospital||September 6, 2010||No electricity, disorganization, lack of staff skills and intensive care||Nyaya Health, "Mortality Review: Septic Shock (September 6, 2010)."|
|Adult female victim of a road traffic accident died at hospital||September 17, 2010||No electricity and lack of x-ray, ECG, and certain supplies||Nyaya Health, "Mortality Review: Motor Vehicle Death (September 17, 2010)."|
|22-year-old female required manual removal of her placenta||September 30, 2010||Equipment malfunction||Nyaya Health, "Manual Placenta Removal (September 30, 2010)."|
|17-year-old girl died of parasitic disease||October 11, 2010||Lack of needed testing materials, blood transfusion capacity, and funding for further care||Nyaya Health, "Mortality Review: Kala-azar (October 11, 2010)."|
|25-year-old female stable after procedure for incomplete abortion||November 5, 2010||Limited laboratory capacity||Nyaya Health, "Molar Pregnancy vs. Incomplete Abortion (November 5, 2011)."|
|30-year-old female came in with an infected abortion and was transferred for surgery||January 17, 2011||Lack of staff training||Nyaya Health, "M&M: 30 y/o Infected Abortion (January 17, 2011)."|
|60 year-old male diagnosed and treated for TB||January 24, 2011||Staff away, not enough time for seeing outpatients, disorganization, lack of some equipment, miscommunication||Nyaya Health, "M&M: 60 y/o male with TB (January 24, 2011)."|
|11-month-old female died of malnutrition and diarrhea||January 31, 2011||Lack of supplies and community awareness.||Nyaya Health, "Mortality Reivew: 11 Month Old with Severe Acute Malnutrition and Diarrhea (January 31, 2011)."|
|17-year-old male brought dead after a fall||February 5, 2011||Expired medicines, emergency materials unorganized, too few beds, delay in calling the ambulance, and poor roads.||Nyaya Health, "Mortality Review: 17yo Male with Head Trauma (February 7, 2011)."|
|65-year-old male with suspected liver failure||February 15, 2011||Broken or missing supplies, ambulance unavailable||Nyaya Health, "Mortality Review: 65yo COPD with Suspected Liver Failure (February 14, 2011)."|
"In Katmandu, there's no shortage of healthcare and there are plenty of doctors and surgeons. Convincing those doctors to come to rural areas – where there aren't good schools for their children, for example – is difficult. The hope is that by developing more infrastructure capacity in rural areas, we shift surgeons from urban areas to rural ones." Ryan Schwarz, phone conversation with GiveWell, February 17, 2011.
Ryan Schwarz, email to GiveWell, March 14, 2011.
"GiveWell: How would you respond to the possibility that health would have gotten better without Nyaya's involvement?
Nyaya Health: Things would have gotten better and have gotten better outside of what we've done. I do think that Nyaya's presence has had a very positive impact on the support Achham has been offered. Our contract with government alone is an infusion of almost $50,000 per year that otherwise would have not have been there. Other districts in the region have not received the same investment because they don't have an NGO that the government is partnering with." Ryan Schwarz, phone conversation with GiveWell, March 31, 2011.
For example, Nyaya Health, "Financial Statements (2009)," Pg 2 show that Nyaya Health received $22,500 from the Nepal government in that year.
"Government funding has historically been centered in the eastern and central regions of Nepal." Ryan Schwarz, email to GiveWell, March 14, 2011.
Chin, Montana, and Basagña 2011 present data suggesting that health care access and health outcomes (pre-2006) were worse in the Far Western region in which Nyaya works than in the eastern and central regions.
Nyaya Health, "Nyaya Health’s Impact in Public-Sector Strengthening: Addressing the Counter-Factual Hypothesis."
Ryan Schwarz, email to GiveWell, March 14, 2011.
Ryan Schwarz, email to GiveWell, March 14, 2010.
Nyaya Health stated (above) that it had raised about 35% of $400,000 (i.e. about $140,000) between the start of the year and mid-March 2011. On June 8, 2011, Nyaya Health announced that it had raised $175,000 since April 1, 2011: "On April 1st, The Nick Simons Foundation generously donated $25,000 to Nyaya and offered an additional matching donation of $75,000 more – the total donation, if Nyaya was able to raise $75,000 ourselves, would equal $175,000! I write today to announce that with your support Nyaya has not only reached that goal, but done so in record time! While we had set what we thought was an overly ambitious deadline of July 1st, 2011, to raise the $75,000, with your commitment to this work we were able to raise the money in only 2 months!" Nyaya Health, "Nyaya raises $75,000 to be matched by Nick Simons Foundation in 2 months!"
Nyaya Health, "Budget." See heading "Current Account Balances."
Nyaya Health, "Differential Funding Scenarios (2011)."
Nyaya Health, "Expansion Costing."
From Nyaya Health, "Expansion Costing," Sheet Demography:
Minor Surgery, >15 years old: 30 minutes
Major Surgery, >15 years old: 100 minutes
Orthopedic surgery, non-trauma: 100 minutes
Cesarean Section: 50 minutes
Trauma/Accident: 80 minutes
This is likely to be an underestimate as it assumes that the proportion of total spending on community health in 2010 was the same proportion of total spending in 2011. We have estimated it this way because we do not have a figure for the cost of the community health program in 2010. However, it is our understanding that the community health program is a key priority of Nyaya Health's and, therefore, is likely being scaled up at a faster rate in 2011 than other programs (surgical and transfusion excluded).
GiveWell, "Nyaya Health Funding Gap Analysis."
Nyaya Health, "Expansion Costing," Sheet Operating. Note that the meanings of the acronyms VDC and FCHV were checked by searching Nyaya's blog for those terms.
GiveWell, "Nyaya Health Funding Gap Analysis."
GiveWell, "Nyaya Funding Gap Analysis" and Nyaya Health, "Expansion Costing," Sheet Operating. Note that we have included the costs labeled "FCHV Program Costs: Achham" in Community Health rather than General as it is in the planning document.
GiveWell, "Nyaya Health Funding Gap Analysis."
Nyaya Health, "Expansion Costing," Sheet Operating. Note that an exchange rate of 72 NRs. per USD was used as indicated in Nyaya Health, "Expansion Costing," Sheet Demography.
Nyaya Health's expenses in 2010 were $162,494. Subtracting this amount from what (we estimate) has been raised in the first half of 2011, leaves a surplus of $152,506 to be used toward expansion. Subtracting $152,506 from the total budget for expansion ($1,073,026) leaves $920,520 to be raised.
Note that this analysis assumes that (a) Nyaya can expect to maintain funding from current sources at its 2010 level in 2011-2013; and (b) that sources of additional funding in 2011 are not expected to be renewed. We consider these to be reasonable assumptions given the information we have. They have not been confirmed by Nyaya Health.
"We know in the development field that the development of primary health care structures is very important for enhancing health across the population. We're the only facility doing it and the only facility doing it for free...The government hospital does charge for all of its services. The user fees there are a significant barrier...We are working with the government and we want to show the government that more people show up when you don't charge." Ryan Schwarz, phone conversation with GiveWell, March 24, 2011.
"Since January 2009, under the "New Nepal, Healthy Nepal" initiative of the Government, all citizens are able to access District Hospitals (DH) and Primary Health Care Centres (PHCC) without having to pay for registration: they are eligible for free outpatient, emergency and in-patient services, as well as drugs. A second universal programme commenced in January 2008, aimed at the provision of free essential health care services to all citizens, whether poor or not, at Health Posts (HP) and Sub-Health Posts (SHP) nationwide. There are no charges for registration or for the dispensation of 32 essential drugs at the HP level and of 22 drugs at the SHP level...Utilization increased substantially after the policy was implemented." Though the report also notes, "At present, there are shortages of doctors and of hospital beds...There were drug stock-outs in 29 percent of the cases...Many people remain unable to reach a health facility because of distance, cost of transport, and, for some, lack of knowledge that services are free of charge. Waiting times at facilities and poor quality of treatment at facilities may also remain as barriers for disadvantaged groups...Budget for free care [is] unlikely to meet full needs." GTZ, "Free Health Care in Nepal: Findings of a Rapid Assessment."