Constructing and equipping a pediatric surgical ward ... - Nyaya Health

Constructing and equipping a pediatric surgical ward in Nepal
Proposal for the Schering-Plough Corporation

Contents
1 Who we are.............................................................................................................................................3
2 Location and need...................................................................................................................................6
3 Project description...................................................................................................................................8
Primary conditions to be treated............................................................................................................8
Timeline.................................................................................................................................................9
Planning Process....................................................................................................................................9
Design details.......................................................................................................................................10
Blueprint...............................................................................................................................................12
Laboratory support ..............................................................................................................................13
Water Supply........................................................................................................................................14
Supply Management............................................................................................................................14
Energy Generation...............................................................................................................................15
Waste Management..............................................................................................................................16
Heating, Cooling, & Ventilation...........................................................................................................17
Fire safety ............................................................................................................................................17
Fuel storage..........................................................................................................................................18
Medical Records..................................................................................................................................18
Staffing ................................................................................................................................................18
Key Personnel......................................................................................................................................18
Board of Advisors................................................................................................................................19
Board of Directors................................................................................................................................19
Outcomes analysis................................................................................................................................19
Sustainability........................................................................................................................................19
3 Project budget.......................................................................................................................................21
Operating room supplies .....................................................................................................................22
Inpatient rehabilitation supplies...........................................................................................................27
Laboratory supplies..............................................................................................................................28
4 Nyaya Health General Organization Budget ........................................................................................30
Sources of financial support.................................................................................................................30

1 Who we are
Nyaya Health is a 501c3 non-profit organization that provides health services to children and families
in Nepal. Our mission in Nepal is two-fold: to establish essential public health services in one of the
world's most underdeveloped areas, and to develop a model program that establishes how to scale-up
and manage comprehensive healthcare services in remote, resource-deprived areas.
We are a group of American South Asian epidemiologists, physicians, and nurses with personal ties to
Nepal, who hire and train Nepalese doctors and nurses to provide high-quality healthcare services to
their local communities. Over the past few years, we have built a major treatment center in a region that
previously had only 1 doctor to care for several hundred thousand people. Now, we are seeking
assistance to build a pediatric surgical ward in order to address pediatric trauma, congenital and
rheumatic heart disease, and infectious abscesses in the region we serve.
The heart of Nyaya Health activities in Achham is a primary care treatment center located at the major
transit hub in the region. Our clinic is run by an all-Nepali staff consisting of physicians, community
healthcare workers, nurses, lab technicians, and project managers. We are expanding a network of
community health workers who provide essential outreach and triage services to our geographically
dispersed population. These services have been developed in collaboration with the government of
Nepal; our ultimate goal is full integration of our services with the developing public-sector health
program. Over the next year, we are constructing a community education center, applying information
and communication technologies in innovative ways to improve the livelihoods of people in the
surrounding area. Additionally, we are exploring mechanisms of sustainable, accountable financing
through microfinance and community-based insurance. All of our programs are supervised by a
community board consisting of patients and their families, which ensures our accountability to people
of this region.
Figure 1: Entrance to Nyaya's Sanfe Bagar Health Center.

Nyaya (which means “justice with logic”) strives towards the highest standards of transparency and
accountability. In this pursuit, we have adopted an entirely "open source" organizational approach.
Our budget, activities and plans are all online, and fully accessible to the public. We employ both
electronic and paper-based methods that provide full disclosure to donors and the general public. This
includes our central website (www.nyayahealth.org), which acts as a source for general news and
information; an online "wiki" (nyayahealth.pbwiki.com), or rapidly-editable webpage, which provides
extensive details about our clinical protocols and operations; and our blog
(nyayahealth.wordpress.com), where we post stories about the community and our efforts to improve
healthcare services.
In addition to standard outpatient pediatrics, our community-based interventions follow the Integrated
Management of Childhood Illness (IMCI) model, including the following components:
• Treatment of pneumonia, with appropriate use of antibiotic and bronchodilators;
• Management of diarrheal diseases with low-osmolarity Oral Rehydration Solution and use of
antibiotics for bloody diarrhea;
• Evaluation and expansion of vaccination programs and Vitamin A supplementation;
• Screening and treatment of helminthic infections with albendazole and mebendazole;
• Promotion of breast feeding where appropriate (a separate protocol for HIV-positive mothers
has been established based on the Partners in Health management guidelines, and is available
on our website);
• Screening and treatment of micronutrient deficiencies;
• Screening and treatment of failure to thrive/macronutrient deficiencies;
• Treatment of otitis media with appropriate antibiotic use; and
• Management of pediatric fever, with evaluation and management of malaria, meningitis,
measles, and other infectious processes.
Figure 2: Nurse triaging patients at Nyaya's Sanfe Bagar health center.
Through our experiences caring for the community in Achham, and through our discussion with the
local community and government, it has become clear that essential inpatient and surgical services
must be added to this list to make a significant and comprehensive public health impact in the region.
The child health situation is particularly dire in this area, with best estimates indicating that one out of

three sick children require some form of minor or major surgery. The high infant mortality rate,
coupled with the lack of essential health delivery infrastructure, has been our primary motivation for
working in the region. We have begun to address the lack of infrastructure through our primary care
health center. The center currently provides care to approximately 100 patients a day (at least 60 of
whom are children) and includes 24-hour emergency services. We are rapidly reaching capacity,
however, and will expand in a timely and responsible manner to meet the growing need for both
healthcare delivery services, and the training of new Nepali healthcare workers.
Local citizens and government officials have offered to us an abandoned hospital near to our current
clinic to renovate and deploy essential inpatient and surgical services, as well as training programs. In
keeping with the model we have developed at our clinic, the expansion to provide these services will
complement general primary care and serve as a community-driven initiative to provide training,
sustainable infrastructure, and high-quality medical standards for service delivery in the region. While
the majority of the hospital can be used to expand our primary care services, one critical project
requires funding to renovate the facility and equip it: the need for a pediatric surgical ward. We are
seeking assistance to build a pediatric surgical ward in order to address pediatric trauma, congenital and
rheumatic heart disease, and infectious abscesses among children in the region we serve.

2 Location and need
Achham is one of the poorest districts in South Asia and has been severely affected by war and poverty.
It is home to 250,000 people who are served by only one doctor. In this distrist, a decade-long civil
war has ravaged the health system. Years ago, fighting occurred between a rebel army and the King.
Achham was a community caught between the territories of the rebels and King. As a result, it faced
incredible violence, which has left a mark on the community. The King attempted to convince local
villagers of his compassion by building a hospital in the area. But before the hospital opened, the rebel
army moved north, and the King decided to move all of the equipment and resources out of the hospital
to a more northern community. The villagers protested and surrounded the building to prevent the
King's army from moving the equipment; they were shot by the King's army, and many died.
Figure 3: The abandoned Bayalpata hospital complex.
Now, after the new democratic government came to power last year, the local community has asked
Nyaya Health to re-open the hospital. We have obtained the deed for the facility, and inspected the
grounds as well as checked the basic functioning of the facility through our civil engineers and
architects. We have established that most of the facility can be used to expand our primary health care
needs. But one critical public health venture—to treat the surgical conditions faced by our pediatric
patients—will require new construction and equipment.
Decades of war have left this region with the worst pediatric health conditions in all of Asia. We treat
over 60 children per day in our clinic for ambulatory conditions, including infectious diseases and
malnutrition. This has resulted in a major decline in child mortality. Before we arrived, there were no
vaccination services. But there has been a large gap in our services: the inability to care for trauma,
abscesses, and other surgical conditions. Many children are maimed or mutilated from the war. Nearly
every family we see has lost at least one child to congenital heart disease, trauma or respiratory disease.
Several children have rheumatic heart disease and infectious abscesses that require immediate
attention. Nearly a third of the children that we see are suffering from some form of these conditions,
and typically require minor or major surgery. They are usually referred to Kathmandu city, to an urban
hospital that most of their parents cannot afford.

Local statistics:
• Number of citizens: 250,000
• Number of doctors (excluding Nyaya Health): 1 (located 5 hours away)
• Number of ultrasound machines: 0 (none in an area with over 1 million people)
• 99.5% of babies are delivered outside a health center
• 1 in 125 deliveries result in death of the mother
• 60% of children are chronically malnourished
• Average person makes $150 a year
• About half of the men migrate to India in search of work
• Over 7% of the men returning from Mumbai are HIV-positive
• Nearest functioning airport and hospital: 10 hours by bus, costs 1-2 months' income
Frequency of pediatric surgical needs in Achham:
• Infectious abscesses: daily
• Serious bone fracture: weekly
• Serious head trauma: weekly
• Burn or blunt trauma: weekly
• Osteomyelitis (bone infection): bi-weekly
• Major structural heart defect: Monthly
At Nyaya, we have been advocating for these children by bringing public attention to their plight:
publishing reports on their condition, drawing attention from journalists, and rallying international
donors for support. But our advocacy can be seen as hypocritical when we are unable to provide critical
services to heal these children in our clinic. If we can establish a pediatric surgical ward, we would no
longer be neglecting a critical mass of our patients.
Figure 4: Child with a perforated abdomen and intestinal evisceration following trauma.

3 Project description
We have realized that we must add an operating room and child surgical facilities to the local hospital
in order to provide proper medical care to children of this region. We have mobilized a surgical team
led by Dr. Aditya Sharma of Cornell-New York-Presbyterian Hospital, and supervised by Dr. Selwyn
Rogers of Harvard-Brigham and Women's Hospital to provide training and oversight to a new pediatric
surgical care program. Dr. Sharma will be permanently stationed at the site, and will be performing
surgeries along with a local Nepali physician. Both receive independent salary support, hence the costs
of this program are entirely for construction and equipment.
We have conducted a detailed epidemiological survey of pediatric surgical needs in the region, which
were input into a demand estimation model to plan the ward and determine the supplies and equipment
needed to provide sufficient pediatric services to the region.
Primary conditions to be treated
• head trauma (burr hole)
• cleft palate
• tracheo-esophageal fistula
• repair of congenital heart disease
• repair of rheumatic heart disease
• intussusception
• volvulus
• appendectomy
• evisceration
• splenectomy
• repair of liver laceration
• inguinal hernia repair
• percutaneous nephrostomy / removal of nephrolithiasis
• chronic osteomyelitis (excision of dead bone)
• abscess drainage
• foreign body removal
• amputation
• burn graft
• thorocostomy for pneumothorax / hemothorax
• open reduction / internal fixation
• closed reduction / external fixation

Figure 5: 10-year-old boy with severe burn.
In cooperation with the group Architecture for Humanity, we have generated a plan for the construction
and equipment of the surgical ward based on this epidemiological information. The site for construction
will be the West wing of the previously-abandoned Bayalpata hospital. This hospital is a 50-bed
facility that overlooks Sanfe Bagar, the major transit hub in the region. This hospital was constructed in
the mid-1980s and remains structurally intact. The pediatric surgical ward will provide a 4 bed facility
and operating room extended from the existing structure.
Timeline
Period
February 2008
March 2008
April 2008
May 2008
June 2008
July 2008
August 2008
September 2008
October 2008-February
2009
March 2009-July 2009
August 2009-December
2009
January 2010
Activities
Community planning meetings
Architecture draft plans
Civil engineering agreements &
inspections
Finalized community plans
Government approvals
Initial budgeting
Epidemiological demand model
Final budgeting
Initial contracts and supply chains finalized
Renovations: walls, electrical, water
Renovations: equipment and laboratory
Begin patient services
Planning Process
Throughout the planning process, we have involved our Nyaya staff, donors, government officials,
local leaders, and outside contractors to plan the hospital's operations. The process aims to both
develop local capacity and build long-term infrastructure and human resources. The planning process
proceeds in the following overlapping phases:
• Needs and resources assessment. This has been ongoing through our work at the Sanfe Bagar
Medical Center. We have already established a strong demand, community mobilization, and

government interest in renovating, equipping, and staffing the hospital. We will continue to
quantify demand, further engage the community, and negotiate with the government to ensure
long-term sustainability of the program.
• Design brief preparation. A series of design plans have culminated from several discussions
among the team members, and will continue to evolve as the planning process proceeds.
• Renovations. The renovations will be led by a set of identified local contractors and in
collaboration with the government, with oversight from our designated team leaders.
• Commissioning. Finally, our team has generated an implementation plan to staff the hospital;
commission and procure the necessary equipment, furniture and supplies; and supervise and
streamline the actual service delivery including its training, evaluation and improvement
components.
Key team members have been participating during this process, including:
• Project managers who have begun to assess the needs and resources for the hospital, its role in
the community and the services it will offer. These planners have determined the functioning of
the different departments and of the hospital as a whole, producing budgets and identifying
earmarked funds for the project, and establishing the relationship between the hospital and the
surrounding villages it serves.
• Construction managers and architects who have identified the resources and contractors to
ensure that the project is completed on time and within the budgeted allocation. Architects also
provide guidance on design aspects of the renovations. In addition to paid contractors, local
government civil engineers who have assisted us as volunteers in surveying lands adjacent to
our clinic in Sanfe Bagar are assisting in site surveying, planning, and renovations. Through our
alliances with the Open Architecture Network and Architecture for Humanity, we have recruited
teams of hospital architects who are providing pro-bono consultations during the course of the
renovations.
• Civil and mechanical engineers who provide guidance on the safety of structures and the layout
of technical wirings, water mains, and gas lines. This includes guidance on waste management,
construction of septic tanks, incinerators, and burial pits.
• Quantity surveyors who assist in site assessment and planning, and work with our procurement
staff to ensure safe, cost-effective, and reliable supply chains.
• Clinical care staff who will be directly involved in providing services. These include doctors,
nurses, nurse midwives, health assistants, and laboratory technicians.
The following sections summarize the design constructed by these teams.
Design details
Achham is located at latitude 29N and longitude 81E, at a locale with temperate climate having annual
temperature variations between 3 to 42 degrees Celsius, no snow fall but heavy rains. During the early
morning of the winter months, 5-100C is typical, but the temperature then rises over the day to up to
250C. The peak summer months’ temperature is typically up to 400 Celsius. Rainfall is approximately
1250mm per year. The region experiences monsoon rains from June to September. The site is not
located in a flood plain, being situated on a hill about 600 vertical meters above the river level.

Figure 6: Map of Nepal, showing location of Achham.
The pediatric surgical ward will consist of 2 pre-operation beds (18 m 2 ), 2 post-operation beds (18 m 2 ),
and an operating room (48 m 2 ). We have also designated a sterile supply area (40 m 2 ) and 2 bathrooms
(10 m 2 ). There is a neighboring space for a generator and central electrical wiring (16 m 2 ), as well as
grounds maintenance equipment and tools (20 m 2 ). Based on a 45,000 person catchment area, a typical
annual incidence of admission of 1 in 35 in this area, and an average hospital stay of 4 days, we expect
to have approximately 1,300 total admissions consisting of 5,200 hospital-days.
The beds will be housed in separate rooms to facilitate infection control. Inpatient services provide
accommodation for patients who are dependent on others because of their illness. Due to extended
travel times for families and patients to reach our facility, provision must be made for the comfortable
and safe overnight stays of family members, which can improve adherence to medical therapy upon
release. Administrative and support services are just adjacent to the community-encounter spaces,
including accounting, pharmacy, and outpatient.
The overall design of the operating room takes into account the following requirements for a safe
operation: aseptic technique; intravenous infusion; and appropriate anesthesia. The anesthesia program
will be led by our current anesthesiologist nurse. The main functions of the anesthesia team include
provision of local, regional, and general anesthesia; airway management; resuscitation; and pain relief.
The operating room has been designed to be comfortable and unobstructed by the movement of other
staff, with a table that is strong enough to hold patients and easy to clean, and provide basic services of
water, light and medical gases. The center of the operating theater will be the cleanest area, with the
requirement for cleanliness decreasing towards the perimeter of the department. Thus, any space for
handling sterile supplies will be in the central area, and any space for transporting patients, general staff
movement and removal of used material will be placed on the perimeter.
The location of the operating room follows the guidelines that it:

• be connected to the surgical ward by the simplest possible route;
• adjoin the central sterile supply department;
• be easily accessible from the emergency department;
• be easily accessible for the delivery suite;
• adjoin the intensive care unit;
• be located in a cul-de-sac, so that entry and exit can be controlled;
A single corridor will be used to carry patients, staff and clean and used equipment (suitably bagged) to
and from the operating theaters. This corridor leads to each operating theater via an anesthetic room, a
scrub-up facility, and a separate theater exit. Rooms are arranged in continuous progression from the
entrance through zones of increasing sterility, following the concept of progressive asepticism. Staff
within the department will be able to move from one clean area to another without passing through
unprotected or unclean areas. Patients, staff and services will enter through the same control point. Unit
room air-conditioners (window type, with 1 ton capacity per 18 m2, at least one per theater) can be
provided as a stand-by. Ventilation and air conditioning will have outside exhaust. Furthermore, the
operating theatre will be at positive pressure in relation to adjacent rooms. Air movement in the
operating theatre will be vertically transferred so that airborne infections do not reach the patient.
Windows are neither needed nor desirable. All surfaces in the operating theatre will be smooth and
washable. Static electricity and related hazards will be avoided. Special anti-static floors will be
provided, since floors in which the electrical resistance is below the intended limits can result in
electric shocks. When inflammable anesthetics are used regularly, the anti-static requirements will
extend to the walls, or at least 2 m from any possible location of the patient and the anesthetizing
apparatus.
Full outside air, filtered to a high quality, will be provided. The integrity of the air-handling system
must be preserved by careful placement of the main air intake and exhaust. The main air intake will be
located to avoid uptake of any obvious airborne contamination, such as dust and road fumes, and well
clear of the main exhaust duct, and the placement will take into account the direction of the prevailing
wind. Temperature and relative humidity should be controllable by this unit.
Most instruments and equipment will be sterilized in the adjoining central sterile supply department.
Dressings and gowns will be sterilized in the central unit to minimize the requirements for additional
large, expensive autoclaves. A small "dropped instrument" sterilizer will be located within each theater.
The area provided at the center of the theater for storing sterile supplies and instruments will also be
used as a set-up room for laying out the sterile instruments and supplies required for an operation on
the trolley (central trolley preparation). This system requires that the central working area be large
enough to park several theater trolleys.
The entrance to the operating department has been designed to have a reception and transfer point that
enables control of unauthorized, unsupervised entry into the area and ensures the principles of aseptic
conditions.
Blueprint
• Reception and office.
• Transfer area. This area is large enough to allow for the transfer of a patient from a bed to a
trolley. A line will be clearly marked in red on the floor, beyond which no person from outside
the operating department will be permitted to set foot without obtaining authority and putting on
protective clothing.

• Holding bay. This space is required when the corridor system is used and will be located to
allow supervision of patients waiting to go into the theater.
• Staff changing rooms. Access to staff changing rooms are designed from the entry side of the
transfer area. At both the transfer area and the theater side of the changing rooms, space must be
provided for the storage, putting on and removal of theater shoes.
• Operating theater. The operating theater has access from the 1 anesthetic room, scrub-up room
and supply room. Separate exit doors will be provided. There should be space for an
immediately adjacent operating theater once we expand beyond the initial MD-GP-led
emergency surgical capacity.
• Scrub-up room. A clear area within the scrub-up room of 2.1 x 2.1 m is available for gowning
and for trolley or shelf space for gowns and masks.
• Sub-sterilizing. An area for sterilizing dropped instruments is next to the theater.
• Trolley parking. Parking space outside the theater and clear of all doorways will be provided
for patient trolleys and beds.
• Recovery room. The recovery room will be located on the hospital corridor near the entrance to
the operating department.
Figure 7: Pediatic ward design.
Laboratory support
In order to properly manage surgical patients, the attendant laboratory (build into the hospital, but in
need of equipment for the pediatric surgical ward) will be functionally supporting the following tests:
1) Colorimetry-Based Tests
• AST (DNPH), primarily for evaluation of patients on antimycobacterial therapy for patients
with tuberculosis abscesses

• Bilirubin (DMSO), primarily for triage and evaluation of neonatal jaundice
• Creatinine (Jaff), primarily in triage of acutely ill patients
• Glucose, Serum (Glucose Oxidase)
• Albumin (BCG), use in evaluation of protein deficient states
• Routine Microscopy:
• Gram Stain
• Wet mount
• KOH prep
• Sputum for acid fast bacilli (integrated within Nepal government's national quality control
system-- we send all positives and 10% of negatives to national lab)
2) QBC AutoRead Plus Tests:
• hematocrit
• hemoglobin
• mean corpuscular hemoglobin concentration
• platelet count
• white blood cell count
• granulocyte count and percentage
• combined lymphocyte/monocyte count and percentage
3) Rapid Kit-Based Tests:
• RPR
• Glucometer and cuvettes
• Urine, 9-panel, for use in urinary tract infection evaluation
The AutoRead system has been obtained via a donation from the QBC company. All other equipment
must be purchased for this laboratory support system to the pediatric operating room. The existing
portion of the hospital also has a developed blood transfusion capacity, hence the pediatric surgical
ward expenditures do not require this additional cost.
Water Supply
A safe, clean water supply is critical to the functioning of the hospital. Given that the water lines to the
hospital have long been abandoned, Nyaya Health has worked with the community to reconnect new
water lines for sufficient supply. The amount of water required is approximately 150 liters per person
per day, including that needed for grounds maintenance and in the case of fire. In initial phases of
hospital use, this will cover all staff and inpatients. The typical pressure required is 3.5 kg/cm2; for fire
protection, we will need pressures capable of 7.0 kg/cm2. Storage facilities for treated water will aim to
have a 48-hour supply. The exact details of the water supply system (collection, treatment, and
distribution) are detailed in a separate document by our collaborating civil engineers from the
government.
Supply Management
The current supply chains utilized by Nyaya Health at the Sanfe Bagar Center are of high quality,
reliable, and insured. These will provide the base from which to build the hospital logistics system. In
our system, we take a redundant approach in which we prefer to receive supplies from the Ministry of
Health, but have private vendors available on-call in Kathmandu (Bikash Surgical Concern and
Medical Services Management Trust) and Dhangadi (Western Pharma) to ensure a consistent flow of
supplies in the event of government supply chain interruptions. Supplies are also supplemented by inkind
donations from international sponsors. We have signed an agreement with the airline company

Buddha Air for free cargo shipments on all flights from Kathmandu to the nearby airport in Dhangadi.
A main objective with our work at both the clinic and the hospital is to work with the central
government to improve supply chain management, foster investment by the government and
confidence of local people in their officials.
For management of supplies, we will have used a centralized and electronic supply system that intakes,
records, and checks all supplies as they arrive at the hospital. As we do at the Sanfe Clinic, trained
logistics managers oversee the process and record all supplies through mSupply, a software program
developed in Nepal. We detail our supply chain on our wiki through the budget portal:
http://nyayahealth.pbwiki.com/Budget.
Energy Generation
We will build upon our experiences at the Sanfe Bagar clinic in providing sufficient and reliable power
for our operations in a remote area. The base of the system will be the electricity grid with back-up
diesel generators. To the extent possible, however, we will attempt to replace this with solar and other
renewable technologies. Through a combination of electrical grid, solar photovoltaic, wind, and
generator, we will aim to have a reliable system capable of delivering 30 kWh per day. Present
estimates of energy needs for the hospital are as follows:
Sufficient battery storage is critical for efficiency and reliability. In procuring batteries, consideration
of the ultimate life-cycle, and how to dispose of them following use (typical life of 5-10 years), is
critical in ensuring environmental and human health. A system is being implemented for safe
processing of these batteries in Kathmandu, Nepal. We are also working with companies based in
Nepal and elsewhere to identify renewable technologies appropriate to our rural setting, which are
capable of being brought to scale in other areas. Some energy is likely be generated through local
technologies, such as micro-hydropower and biogas fuel. Our energy team has developed a detailed
plan required for the implementation of these approaches, and has procured an initial set of long-use
batteries to supplement our generator system.

Waste Management
Waste management strategies will build off of the ecological and cost-effective approach we have taken
at the clinic. The details of our waste management strategy, including costing and construction for
incinerators and waste pits, are available here: http://nyayahealth.pbwiki.com/Waste-Management
Most of the operating procedures and protocols are available in the waste management page document;
here we will provide an overview of the main considerations relevant to planning, design, and costs.
Wastewater is the liquid waste generated by the hospital. Given the presence of laundry facilities and an
operating room, the amount of liquid waste is significant. The processes of disposing of wastewater
involve:
• Treatment of raw wastewater. This is achieved through a large septic tank system in which
storage of the raw wastewater in a contained environment allows for bacterial digestion of
biologically harmful agents. Although the resources for oxidation pools are likely to be beyond
our means at the present time, they are a desirable alternative to be considered as land,
financial, and human resources permit.
• Effluent discharge. The effluents from properly designed, operated and maintained wastewater
treatment units can be safely injected into the ground or discharged on the land. Wastewater
treatment plant effluent constitutes a valuable source for recharging groundwater. However, the
points of recharge will be well-arranged and the quantities limited so that there is no threat to
the quality of the groundwater.
• Solid waste is separated into categories on the basis of the relative hazard to public health and
the means of disposal. Typically over 80% of waste generated in health care establishments is
non-hazardous, general waste. In order to reduce the cost of waste management, it is essential to
segregate the hazardous waste from the nonhazardous component at the point of generation.
Non-hazardous waste consists of:
• General domestic-type waste: household-type wastes from offices, corridors, public areas,
supplies departments, newspapers, letters, documents, packing materials, cardboard containers,
plastic bags/films, food wrappings, metal cans, food containers, flowers, floor sweepings.
• Kitchen waste: food waste, swills, etc.
• Non-hazardous waste does not require special treatment and can be disposed of as normal
household or office waste. As we do at the Sanfe Bagar clinic, this will be done through a burial
pit.
As described in our waste management protocol, the hazardous health care waste will be categorized
and subject to different color-coded containers and disposal methodologies:
• Infectious wastes other than contaminated sharps include: 1) soiled surgical dressings, cotton
wool, gloves, swabs and all other contaminated waste from treatment areas; plasters and
bandaging which have come into contact with blood or wounds; cloth and wiping materials
used to wipe body fluids and spills of blood; 2) material other than reusable linen from patients
having infectious diseases; 3) pathological waste, including human tissues, organs, limbs, body
parts, placenta and human fetuses; and tissues from laboratories and all related swabs and
dressings; and 4) waste arising from laboratories and postmortem rooms.
• Sharps include discarded syringes, needles, cartridges, broken glass, scalpel blades, saws and
any other sharp instruments that could cause a cut or puncture and could be infected.
• Pharmaceutical waste includes expired drugs, vaccines and sera, including expired drugs that
have been returned from wards, drugs that have been spilled or contaminated, and drugs that are
no longer required.
• Chemical waste arises from a variety of sources within health care services, but results

primarily from clinical laboratories and associated services. Chemical waste comprises
discarded solid, liquid and gaseous chemicals, such as those from diagnostic and experimental
work, cleaning, housekeeping and disinfecting procedures.
• Pressurized containers include compressed gas cylinders, aerosol cans and disposable
compressed gas containers.
A combination of incineration and burial will be used for these wastes. The incinerator will be based
upon the design used at the Sanfe Bagar clinic (adapted for local conditions from the Montfort design).
Heating, Cooling, & Ventilation
Together with our engineers, we are developing design strategies that maximize energy efficiency.
Throughout the year, temperatures in Achham range from 44ºF in the summer to 3ºC in winter.
We are pursuing strategies for cooling during summer such as optimizing air flow, appropriately using
natural ventilation and shade, and maintaining proper insulation. Apart from energy efficient design,
fans are probably the only additional machines needed for cooling. Additional strategies for heating
during the winter will include solar positioning of the inpatient ward, proper insulation, and use of
natural heating sources for warming. Locally-distributed heating systems are being considered for use
primarily for early morning and evening events during the winter. Locally-distributed air conditioning
(particularly for operating rooms) will likely be pursued as opposed to central air conditioning. All
rooms, particularly those housing digital equipment, should be designed appropriately to protect
equipment from excess moisture and extreme temperatures. The desired temperatures are:
• Operating theater: 21-25ºC
• Recovery room: 23-25ºC
• Inpatient unit: 20-26ºC
Air supply and air exhaust systems should have mechanical operation. Areas such as the operating
theater, delivery room, nursery, and sterile rooms should be equipped with at least two filter beds. The
circulation and pressure requirements are shown below. Filter frames should provide an airtight fit with
enclosing ducts and should be gasketed or sealed.
Fire safety
A minimum of two fire safety compartments will be provided on the floor, with standardized fire doors
and facilities to stop fire and smoke. Larger continuous floor areas on any story require more fire
compartments to ensure greater opportunity for progressive evacuation. During the renovations

process, maximum amounts of fire-resistant materials should be used in constructing the buildings,
false ceilings and partition walls, to have the requisite fire resistance and flame-spread ratings as
outlined in the code.
Fuel storage
The space will be allotted next to the site of generator use. The designers have maintained a space
sufficient for two days stock (20 m 2 ).
Medical Records
We have moved from a paper clinical record system to an electronic medical records system that
follows a few basic principles:
• the forms serve as concise, efficient cues to remind providers of the appropriate approach to
patient management;.
• data recorded are easily entered and analyzable;
• data are not redundant; and
• data are useful for follow-up and continuity of care
Our clinical forms are downloadable from http://nyayahealth.pbwiki.com/Clinical_Records. We have
customized the open-source PatientOS software (http://www.patientos.org/) for the electronic medical
record that we are starting to use at both at the Sanfe Bagar Clinic and at the Bayalpata hospital.
Staffing
Well-paid, well-supported, professional staff members are the heart of clinical services. Developing and
retaining an excellent administrative, maintenance, and clinical team is perhaps the single greatest
challenge to achieving equity and access in global health delivery. Staff recruitment has proceeded
with the open, non-political process that Nyaya has undertaken at the Sanfe Bagar clinic. At the clinic,
we have successfully recruited a nearly all-Achhami staff from all political and caste backgrounds. We
have now successfully recruited the persons with sufficient pediatric surgical expertise to serve as 2
nurses and 2 doctors for the pediatric surgical ward. Their salaries are funded by our central Nyaya
Health grants.
Key Personnel
• Project manager: Dr. Aditya Sharma, Weill-Cornell Medical School/New York Presbyterian
Hospital. Dr. Sharma has worked extensively in this local community and will be supervising
the surgeries and associated programs, working full-time as a permanent surgeon on this
project. As with the other personnel on this project, he receives separate academic salary
support, and thus does not require new funding for his position.
• Project supervisor: Dr. Selwyn Rogers, Harvard Medical School/Brigham Hospital. Dr. Rogers
is an expert in the logistics of developing pediatric surgical programs in resource-poor settings
and monitoring their outcomes.
• Local surgeon: Dr. Jhapat Thapa has been employed by Nyaya Health as a full-time permanent
generalist physician and surgeon who is working with Dr. Sharma to perform necessary
procedures. He is fully licensed and trained, and has received stellar performance ratings in all
evaluations.
• Epidemiologist: Dr. Duncan Maru, Yale School of Medicine, is the chief epidemiologist on this
project, and will be monitoring project performance, outcomes, and appropriate use of
protocols. He has a Ph.D. in epidemiology and an M.D. with a specialization in clinical
protocols in resource-poor settings.
• Staff supervisor: Shefali Oza, Harvard School of Public Health, is the key staff supervisor at the

site and in charge of all nursing, charting, and medical supply. She has a master’s degree in
epidemiology and has run numerous programs with the Harvard Global Health program.
As with all Nyaya Health programs, this project will be monitored through quarterly independent
review by our Board of Advisors and weekly review by our Board of Directors.
Board of Advisors
• Paul Farmer, M.D., Ph.D., Professor, Harvard Medical School
• Gerald Friedland, M.D., Professor, Yale University School of Medicine
• Kaveh Khoshnood, Ph.D., Assistant Professor, Yale University School of Public Health
• Fernet Leandre, M.D., Project Director, Clinique Bon Saveur
• Sheldon Campbell, M.D., Ph.D., Assistant Professor, Yale University School of Medicine
• Michael Rich M.D., M.P.H., Professor, Harvard School of Public Health
• Alfred Sommer, M.D., M.H.S., Dean Emeritus, Johns Hopkins School of Public Health
• Christopher Moore, M.D., Assistant Professor, Yale University School of Medicine
Board of Directors
• Bibhav Acharya, Executive Vice President
• Bijay Acharya, M.B.B.S., Director of Medical Planning
• Jason Andrews, M.D., UCSF School of Medicine, Co-Founder and President
• Sanjay Basu, Yale University School of Medicine, Co-Founder and Chief Operating Officer
• Duncan Smith-Rohrberg Maru, Yale University School of Medicine, Co-Founder and Chief
Executive Officer
• Ana Serralheiro, M.Sc., Director of Laboratory Services
• Aditya Sharma, M.D., Country Director and Director of Surgical Services
• Tenzing Tekan, Harvard Business School, Director of Finance
• Jhapat Bahadur Thapa, Medical Director
Outcomes analysis
To monitor the progress of our program, we have assembled a team of epidemiologists at the Yale
School of Public Health (led by Dr. Duncan Maru, M.D., Ph.D.) who will assemble the data from our
program and monitor key outcomes statistics, which will be published in our online quarterly reports:
• mortality rate ratio
• wound infection/nosocomial infection incidence
• antibiotic use accuracy
• time from admission to operation
• anesthesia duration
• healing rate
• complication rate
• hematocrit changes
• blood transfusion frequency and quantity
Sustainability
While Nyaya Health is in charge of building new facilities, providing training to local Nepalis, and
ensuring high standards of medical care, ultimately we desire the local government to be responsible

for its citizens' health. As such, we have entered into an agreement with the government, which
currently supports our Saphe Bagar Center, to also pay for the actual day-to-day operations and service
requirements for our facility. This is part of the new democratic government's comprehensive public
health program, which includes full public insurance for medical care for all Nepalis.

3 Project budget
Unfortunately, our annual operating budget alone cannot cover the costs of this new program. We hope
you will consider supporting our program. The full cost of this initiative is US$23,738 (note that
construction costs in Nepal are much lower than in the United States). Our summary budget is provided
below.
Line item Cost (US$) Sub-total (US$)
Renovation
Electrical wiring $3,750.00
Plumbing renovation & filters $2,250.00
Walls, paint and tiling renovations $2,130.00 $8,130.00
Equipment
Operating room supplies $8,250.00
Post-operative rehabilitation supplies $2,608.00
Laboratory support supplies $4,750.00 $15,608.00
TOTAL $23,738.00
The following pages detail the equipment expenditures included in this budget.

Operating room supplies
Item
Per Total
Pack
Air condenser unit 1 1
Operating Table, Hydraulic 1 1
Operating table, accessories (stirrups, lithotomy poles, arm rests) 1 1
Main lamp, 8 shadowless lamps 1 1
Auxiliary lamp, 4 shadowless lamps 1 1
Equipment Trolley 4 4
Automatic Suction Device 2 2
Emergency Lighting 1 1
Diathermy unit/electrosurgical unit 2 2
Instrument autoclave 2 2
Spring type dressing forceps (stainless steel) 3 3
Kidney basin (stainless steel) 10 10
Sponge bowl (stainless steel) 10 10
Clinical oral thermometer ( dual Celsius/fahrenheit scale ) 10 10
Low reading thermometer (dual Cel/Fah scale ) 10 10
Surgeon's hand brush with white nylon bristles 20 20
Heat source 2 2
Oxygen cannister (backup) 5 5
Oxygen concentrator 2 2
Vaporizer 2 2
Oxygen delivery system (hoses, valves) 2 2
Bag bellows ventilator 4 4
Face masks (sizes 00–5) 1 1
Resuscitator set, adult 3 3
Resuscitator set, pediatric 3 3
Pulse oximeter 2 2
Laryngoscope Macintosh blades 1-3(4) 5 5
IV pressure infusor bag 2 2
Magills forceps, pediatric 2 2
Magills forceps, adult 2 2
intubation stylet and/or bougie 10 10
Respirator 1 1
Respirator 1 1
Scalpel handle and blade 1 1
Curved dissecting scissors 1 1
Long dissecting scissors 1 1
Suture scissors 1 1
Small, curved artery forceps 4 4
Small, straight artery forceps 4 4
Large, curved artery forceps 4 4
Large, straight artery forceps 4 4
Needle holder, long 1 1
Needle holder, short 1 1

Retractors (Langenbeck), medium 1 1
Retractors (Langenbeck), narrow 1 1
Retractors (Deaver), medium 1 1
Retractors (Deaver), narrow 1 1
Self-retaining retractor 1 1
Dissecting forceps, toothed 1 1
Long dissecting forceps, non-toothed 1 1
Tissue forceps (Allis) 2 2
Tissue forceps (Duval) 2 2
Tissue forceps (Babcock) 2 2
Sponge forceps 4 4
Malleable copper retractors (spatulae) 2 2
Syringe, 10 mL with needle 1 1
Syringe, 20 mL with needle 1 1
Suction nozzle 1 1
Diathermy electrode 1 1
Flexible probe, with round point 1 1
Towel clips 6 6
Stainless steel bowls 2 2
Kidney basins 2 2
Gallipots 2 2
Gauze swabs 15 15
Abdominal packs 5 5
Scalpel blade size 10 1 2
Scalpel blade size 11 1 2
Scalpel blade size 12 1 2
Handle Size 3 1 2
Handle Size 3 1 6
Needle holder 1 4
Scissors Blunt Points 1 6
Scissors Dressing 1 4
Forceps Lister's sinus straight 120mm 1 4
Forceps Lister's sinus straight 150mm 1 4
Probe Silver 1 2
Tourniquet Samway-page modified 1 4
Specula nasal 1 2
Syringe Ear all metal 1 2
Sound uterine 1 2
Speculum vaginal medium 1 2
Speculum vaginal small 1 2
Speculum vaginal duckbill, sims-medium 1 2
Speculum vaginal duckbill, sims-small 1 2
Splint Cramers metal wire 600x80 mm 1 2
Splint Cramers metal wire 800x100 mm 1 2
Splint Cramers metal wire 1000x120 mm 1 2
Wire cutting, tungest.carbide inserts 180 mm 1 1
Dressing set large 1 2

Boyles apparatus
Oxygen cylinder 660 L 1 5
EMO machine
Defibrillator 1 1
Ventilator 1 1
Catgut chromic 0, 75cm, 1/2circle, round body taper,30mm 12 500
Catgut chromic 0, 75cm, 1/2 circle, round bodied 37mm 12 290
Catgut chromic 0, 75cm, 1/2circle, round body 40mm 12 480
Catgut chromic 1, 75cm, 1/2 circle, round body heavy 45mm 12 400
Catgut chromic 1, 75cm, 1/2 circle, round body heavy 50mm 12 300
Catgut chromic 1, 75cm, 3/8 circle, round body 45mm 12 320
Catgut chromic 1, 75cm, 3/8 circle, blunt round body 63mm 12 310
Catgut chromic 2, 75cm, 1/2 circle, round body,45mm 12 470
Catgut chromic 2, 75cm, 1/2 circle, round body taper, 50mm 12 470
Catgut chromic 2/0, 75cm, 1/2 circle, cutting 25mm 12 270
Catgut chromic 2/0, 75cm, 1/2 circle, round body 40mm 12 440
Catgut chromic 2/0, 75cm,1/2circle, round body,taper - cut, 60mm 12 200
Catgut chromic 3/0, 75cm, 1/2circle, round body, 20mm 12 200
Coated polyglycolic acid 0, 75cm, 1/2 circle, round body, spatulated 31mm 12 390
Coated vicryl 2/0, 75cm, 1/2 circle, round bodied taper, 26mm 12 390
Coated polyglycolic acid 3/0, 75cm, 1/2circle, round body taper, 26mm 12 190
Monofilam polyam 2/0, 70cm, 3/8 circle, reverse cutting 45mm 12 160
Monofilam polypropylene 0,1m, 1/2 circle, taper-cut 35mm 12 170
Monofilam polypropylene 1,1m, 1/2 circle, heavy trocar point 30mm 12 160
Monofilam polypropylene 2/0,100cm, straight-cutting 75mm 12 90
Monofilam polypropylene 2/0, 90cm, 1/2circle, taper-cut 17mm 12 80
Silk braided 0, 75cm, 3/8 circle, reverse - cutting 45mm 12 800
Silk braided 2/0, 75cm, 3/8circle, cutting 16mm 12 200
Silk braided 3/0, 75cm, 1/2 circle round body 20mm 12 110
Silk braided 3/0,75cm, 3/8circle, round body, 20mm 12 70
Monofilam polypropylene 3/0, 45cm, 3/8 circle, reverse cutting, 26mm 12 30
Monofilam polypropylene 3/0, 90cm, 3/8 circle, cutting 17mm 12 30
Coated polyglycolic acid 2, 75cm, 1/2 circle, round body, taper-cut, 50mm 12 40
Coated polyglycolic acid 2/0, 70cm,1/2circle, round body, taper, 26mm 12 70
Umbilical cotton tape 3mm; 100m roll 1 600
Gloves examination latex non-sterile disposable large 100 6,000
Gloves examination latex non-sterile disposable medium 100 12,000
Gloves surgical lates rubber sterile size 7.5 50 6,670
Gloves surgical lates rubber sterile size 8 50 3,330
Gloves surgical lates rubber sterile size 6.5 50 330
Syringe disposable with needle 2cc 100 8,000
Syringe disposale insulin 1cc with needle 100IU 100 200
Venous blood collection tubes for plasma 4.5mls (with EDTA) 100 100
Venous blood collection tubes for serum 5mls 100 100
Mult-sumpling sterile needles (equivalent to vacutainer needles) 100 50
Venous blood collection tubes for serum 10ml (equivalent to vaccutainer tubes
10ml)
100 40

Holder for vaccum blood collecing tubes systems 25 20
Gloves gynaecological disposable small size 50 40
Gloves gynaecological disposable medium size 50 100
Gloves gynaecological disposable large size 50 50
Blood bag single 450ml 5 2,000
Blood giving set 25 800
I.V. giving set for paediatric - measured volume (burrette) 20 330
I.V. canula 14G 50 200
I.V. canula 16G 50 270
I.V. canula 18G 50 830
I.V. canula 20G 50 730
I.V. canula 22G 50 500
I.V canula 24G 50 430
Spinal needles, sterile, disposable, 18G 50 10
Spinal needles, sterile, disposable, 22G 50 20
Spinal needles, sterile, disposable, 23g 50 10
Spinal needles, sterile, disposable, 25g 50 10
Airway guedel rubber child size 67mm 50 10
Airway guedel rubber small adult size 82mm 10 20
Colostomy bag 20 100
Foley balloon catheter 30cc 14, sterile, two ways 10 170
Foley balloon catheter 30cc 18, sterile, two ways 10 400
Scalp vein set 21G 100 500
Scalp vein set 23G 100 500
Scalp vein set 25G 100 70
Tube nasal feeding adult CH14 50 50
Tube nasal feeding adult CH8 50 40
Tube suction yankauer 270mm/10 3/4'' 1 120
Urine collection bag for adults 2000 cc 10 900
Folley baloon catheter two way size 6FR 10 20
Folley baloon catheter two way size 12FR 10 110
Folley baloon catheter three ways size 16FR 10 30
Folley baloon catheter three ways size 18FR 10 30
Folley baloon catheter three ways size 20FR 10 30
Folley baloon catheter three ways size 22FR 10 20
Folley baloon catheter three ways size 24FR 10 10
Suction catheter 3.5FG, 40cm disposable sterile 10 20
Neonate feeding tube 3.5FG 30cm disposable sterile 50 80
Endotracheal tube disposable, size 4.5 20 10
Endotracheal tube disposable, size 5 20 10
Suction catheter, sterile, disposable size 6FG 10 10
Suction catheter, sterile, disposable size 8FG 10 20
Suction catheter,sterile,disposable size 10FG 10 20
Suction catheter,sterile,disposable size 12FG 10 20
Suction catheter,sterile,disposable size 14FG 10 20
Bandage crepe 7.5cm x 4m 12 600
Bandage elastic adhesive 4cm x 4m 12 150

Bandage elastic adhesive 7.5cm x 4.5m 12 250
Bandage hospital quality size 12.5 cm x 4 m 12 900
Bandage hospital quality size 15cm x 4m 12 1,050
Bandage plaster of paris bpc 15cm x 2.7m 12 1,000
Cotton wool absorbent 500gm 1 10,500
Gauze absorbent bpc 90cm x 100m 1 9,000
Parafin gauze dressing 10cm x 10cm 10 600
Tape plastic adhesive microperforated 2.5 cm x 5 m 12 650
Tape plastic adhesive microperforated 5 cm x 5 m 12 350
Plaster zinc oxide 2.5cmx5m 12 230
Plaster zinc oxide 5cmx5m 12 390
Plaster zinc oxide 7.5cmx5m 12 900
Cloth cotton/visc sky blue (push) 25meters 200
Theatre boots size.7 1 100
Theatre boots size.8 1 300
Theatre boots size.9 1 200
Theatre boot size 12 1 40
Autoclave, 70 L 1 1

Inpatient rehabilitation supplies
Item Per pack Total
Hospital Bed back rest 1 4
Bed hospital 1 4
Bed side arm 1 8
Strand drip 1 6
Couch examination 1 6
Instrument cabinet 1 2
Cupboard metal steel 1 6
Utility trolley 1 2
Viewer X-ray wall mounted box 1 6
D.D.A. cupboard 1 1
Gynecological labor bed 1 1
Gynecological examination couch 1 1
ENT. Examination lamp single perfecting mobile on castors 1 1
Examination lamp, mobile on castors 1 6
Trolley anesthetist injection (OT) 1 1
Trolley case note 1 2
Trolley dressing 1 4
Trolley instrument 1 2
Trolley linen 1 2
Trolley Mayo table 1 2
Trolley medicine 1 2
Trolley plaster of Paris 1 1
Stretcher for patient removable top 1 3
Patient wheel chair 1 2
Mattress foam 1 30
Ward Screen 1 10
Stool Anesthetist 1 2
Rack (40) swab (OT) 1 1
Leak operation soap valve 1 1
Scale 1 2
St. st. single bowl stand 1 2
St. st. double bowl stand 1 2
Bed pan rack wall mounted st. st. tray 1 1
Stand sterilizer 1 1
Office desk double side drawer 1 6
Office desk small 1 8
Office chair with armrest 1 14
Coffee table 1 14
Fixed chairs with armrest 1 56
Color TV system 1 1
Video player 1 1
Clothes hanger stand type 1 20
Scale, for baby 1 2

Laboratory supplies
Item Per Pack Total
Thermometer, general purpose, -10-110C, red spirit 2 20
Gram's Stain Kit, 4x100ml 2 20
Slide rack, plastic, 12-25 slides 2 20
Slide storage box 2 20
sputum pot, plastic 100 1,000
Test tubes 1000 10,000
Glucometer-- One-touch SensoLite Nova 2 20
Glucose test strips for the SensoLite Nova 1000 200
Centrifuge, 8-well [Indian] 1 10
counting chamber 1 10
Hemoglobin test strips-- cuvette for hemocue 500 100
hemoglobin, automatic machine (hemocue) 2 20
Laboratory weighing paper 1000 100
Micro lens (100x objective 20mm fitting) 1 10
Slide, microscope, frost 1000 100
Ultrasound Machine, B/W screen with 3.5MHz convex transducer 1 10
ALT (SGPT) test kit 100 1,000
AST (SGOT) test kit 100 1,000
Creatinine test kit 100 1,000
Bilirubin test kit 100 1,000
Haemocytometer set (Neubauer) 3 30
Cover slips, haemocytometer, 1 pkt 3 30
Bottle Wash 500 ml 5 50
Bottle, Glass, With Dropper, 60 ml 5 50
Bottle, Glass, With Dropper, 125 ml 5 50
Bulb pipette (pastette), 1ml, graduated 30 300
Bulb pipette (pastette), 3ml, graduated 30 300
Calibrated capillary tube, 20 microliter (20 cmm) 50 500
Calibrated capillary tube, 40 microliter (20 cmm) 50 500
Capillary and micropipette (combined) filler 1 10
Haemocytometer (Fuchs Rosenthal) 1 10
Immersion oil, 125 ml 1 10
Bottle, Glass, with Screw Top, Opaque, 500mL 3 30
Bottle, Glass, with Screw Top, Translucent, 500mL 3 30
Bottle, Glass, with Screw Top, Opaque, 250mL 5 50
Bottle, Glass, with Screw Top, Translucent, 250mL 5 50
20% Potassium Hydroxide with DMSO, 100 ml 1 10
Funnel, polypropylene, 10 cm 2 20
Cylinder, graduated, polypropylene, 250 ml 2 20
Cylinder, graduated, polypropylene, 100 ml 2 20
Petri Dish, Glass 2 20
Filter paper, 15 cm diameter, No. 1 100 1,000
Bunsen burner, butane 1 10
Butane gas cylinders for bunsen burner 1 10

Spatula, stainless steel, 140 mm long 2 20
Wire loop (Nickel-Chromium), reusable, loop Diameter 2 mm 2 20
Drabkin's Diluting Solution with Standard, 5000 mL 1 10
Platelet Dilutiing Solution, 100 mL 1 10
WBC Diluting Solution, 500 mL 1 10
Ground glass polished microscope slide 100 10
Wright's Stain with buffer, 2x100 ml 1 10
pH indicator, 2-10.5 100 10
MultiStrip (10-panel urine) 100 10
RPR Test Kit 500 50
Prolix Protective Mask 5 50
Measuring cup, 20 ml 5 50
Measuring cup, 60 ml 5 50
EDTA K3 Concentrate, 150 ml 1 10
Distilled Water, 5 L 1 10
Albumin colorometric test kit (BCG), 4x50 ml 2 20
laboratory microscope with 10x, 25x, 40x objective lens 1 10
acetone, 500 ml 1 10
Anti A-B-D serum ,1 pkt 3 30
Ethyl Alcohol 99% 500ml 1 10
Flask Conical glass 500ml 3 30
Glycerin 450ml 1 10
Iodine Crystal 500gm 1 10
Lens Paper 2 20
Hydrochloric acid, concentrated, technical grade 2 20
Ethanol, 95%, technical grade 2 20
Sulfuric acid, concentrated, technical grade 2 20
Methanol, absolute, 125 ml 1 10
Basic fuschin pwd 25gm 1 10
Gentian violet pwd 25gm 1 10
Rapid Gonorrhea Test 200 2,000
Rapid Chlamydia Test 200 2,000
Potassium Hydroxide pwd 500gm 1 10
Potassium Iodide pwd 500gm 1 10
Safranine powder 25gm 1 10
Microhematocrit centrifuge 0 0
Analytical balance (up to 2000g) 1 10
Phenol, Crystals, Powdered, 100 grams 1 10
Ammonium Oxalate, 10 grams 1 10
Dimethylsulfoxide (DMSO), 40 ml 1 10
EDTA, dipotassium, 100 grams 1 10
Microscope 1 1
Colorimeter/spectrophotometer 1 3
Water bath 1 4
Incubator/oven. 1 2
Refrigerator, 70 L 1 4
Distillation and purification apparatus. 1 2

4 Nyaya Health General Organization Budget
(excluding this proposal)
Item
Year
2007 2008 2009
General Budget
Clinic Utilities and Maintenance $4,259.00 $10,020.00 $12,100.00
Personnel $2,400.00 $6,175.00 $9,200.00
Medical Supplies $4,750.00 $5,353.00 $7,737.00
Pharmaceuticals $4,892.00 $8,921.00 $12,895.00
Subtotal $16,301.00 $30,469.00 $41,932.00
Maternal Health-Specific Costs
Outpatient Department $4,800.00 $1,200.00 $1,200.00
Public health programs $4,800.00 $5,000.00 $6,500.00
Subtotal $9,600.00 $6,200.00 $7,700.00
Pediatric-Specific Costs
Public health programs $2,000.00 $3,829.00 $7,659.00
Outpatient Department $10,000.00 $10,800.00 $13,200.00
Subtotal $12,000.00 $14,629.00 $20,859.00
Adult Primary Care-Specific Costs
Outpatient Department $10,000.00 $0.00 $0.00
Public health programs $2,063.00 $6,000.00 $28,800.00
Subtotal $12,063.00 $6,000.00 $28,800.00
Total $49,964.00 $57,298.00 $99,291.00
Sources of financial support
• Private individual donors: 32% ($17,029 in 2006-07)
• EquityEdit (Nyaya's sustainable financing mechanism): 19% ($10,219 in 2006-07)
• Foundations: 47% ($25,448 in 2006-07)
o Ford Foundation
o America Nepal Medical Foundation
o Buddha Air
o William Prusoff Foundation
o AMD and the Open Architecture Network
o The Shelley and Donald Rubin Foundation
o QBC Diagnostics
o The International Foundation
o Google Grants
o Yale University
o Cents of Relief
• Interest: 2% ($1,027 in 2006-07)

The following IRS 501(c)(3) ruling is currently in full force and effect.
Sanjay Basu, COO

Proof of ownership (title) to property, from Government of Nepal: