Nyaya Health: Health care delivery for the last mile.

Nyaya Health: Health care delivery for the last mile.

Achham, NepalNew York, United States
Year Founded:
2008
Organization type: 
nonprofit/ngo/citizen sector
Budget: 
$500,000 - $1 million
Project Summary
Elevator Pitch

Concise Summary: Help us pitch this solution! Provide an explanation within 3-4 short sentences.

Nyaya Health has built an innovative public-private partnership model in Nepal across all tiers of government health infrastructure (hospitals, clinics, and community health workers) that is eliminating the delivery gap in last mile communities.

About Project

Problem: What problem is this project trying to address?

Fundamentally, we are first solving an access problem (access to care doesn’t exist where we work), and working to ensure that the access, once provided, meets the needs of patients we see. In our case, those needs are diverse – with 60% of the diseased burden being non-communicable disease, some of the highest maternal mortality rates in the world, global acute malnutrition at 18%, and the highest HIV rate in Nepal. Single or vertical solutions in this environment don’t work to create health. Only a system approach does.

Solution: What is the proposed solution? Please be specific!

Our solution involves expanding our work at all three tiers of Nepal’s health infrastructure – hospitals, clinics, and community health workers – together to create a system of care. Complex care is managed at the hospital, primary care at the clinics, and referral, follow-up, disease surveillance, and preventative care is managed by community health workers. The linchpin solution is connecting a network of clinics to each other and the central hospital hub. Public clinics are responsible for seeing more patients than any other infrastructure, but they currently are largely non-operational and disconnected from the electricity grid.
Impact: How does it Work

Example: Walk us through a specific example(s) of how this solution makes a difference; include its primary activities.

Our business model uses a combination of philanthropic and public sector funding (revenue) alongside a new set of crowdfunding revenue mechanisms to provide comprehensive health care to those that cannot afford to pay users fees at the point of care and for which a system of insurance does not exist. Our objectives are: • Use philanthropic capital to create the infrastructure for health care delivery. • Use data and transparency to prove impact and catalyze further government investment. • Shift majority funding responsibility to the public sector over the long-term. • Create supplementary revenue through innovative crowdfunding partnerships for individual patients.

Impact: What is the impact of the work to date? Also describe the projected future impact for the coming years.

Since 2008, Nyaya Health has delivered care to over 131,000 patients, catalyzed $140,000 of investment from the Nepali government, and currently employs 160 Nepalis. Additionally, the organization has been the first in the world to successfully crowdfund rural referral care through a partnership with Watsi and is expanding by providing a menu of crowdfunding options through partnerships with Samahope and Kangu.
Sustainability

Financial Sustainability Plan: What is this solution’s plan to ensure financial sustainability?

We view our growth timeframes over three years, and we plan across 1000, 90, and 30 day cycles with a planning focus on program impact, funding needed, and talent needed. Our milestone are as follows: 1-Year: Complete basic infrastructure investments at hospital, 5 clinics operational, 140 community health workers, 1.7 million funding, 190 staff (FT & PT). 65,000 patients treated annually. 2-Year: Complete basic infrastructure investments at hospital, 10 clinics operational, 280 community health workers, 2.7 million funding, 360 staff (FT & PT). 95,000 patients treated annually. 3-Year: Rural teaching hospital status initiated, 38 clinics operational, 400 community health workers, 4 million in funding, 600 staff (FT & PT). 200,000 patients treated annually.

Marketplace: Who else is addressing the problem outlined here? How does the proposed project differ from these approaches?

Our competitors are local private medical practitioners. While a few have respect in the community because of a long work history, these lower-level trained individuals provide dubious care by falsely promoting themselves as doctors and over-prescribing and over-charging patients. These competitors pose problems because they create false expectations about what “good care” looks like in an environment of no accountability. As a result, our patients often complain if they do not receive excessive diagnostics or pharmaceuticals because that is incorrectly linked to quality in the mind of those who have interacted with this category of provider.
Team

Founding Story

Here is a segment of the email written by Co-Founder Jason Andrews after witnessing a harrowing health situation in rural Nepal. “…One night I was having dinner in a room full of the women I had been providing my meager medical advice to and it struck me that they would almost all be dead within 5 years. Since that moment, I’ve felt wholly compelled but completely adrift..."
Organization Name

Nyaya Health

About You
About You
First Name

Mark

Last Name

Arnoldy

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Innovation
Explain what the "innovation" is about, e.g., is it the idea and/or the model you use to accomplish the idea, or your understanding of the target population, etc.?

Our innovation is about creating a model to address the systemic health care delivery gap in last mile communities – the hardest to serve areas that are on the edge of the market.

Global health has long been defined by incomplete approaches that leave a delivery gap between health care and the world’s poorest. Mission-based health care models create isolated islands of care. Pure government models don’t have the combination of funding and functionality to deliver alone. And dramatic increases of vertical funding aimed at specific diseases haven’t translated intro broad-based health care systems that can respond to the full burden of disease impacting the poor.

Nyaya Health has built an innovative public-private partnership model across all tiers of government health infrastructure (hospitals, clinics, and community health workers) that is eliminating the delivery gap in last mile communities.

The model involves:
1. Leveraging existing government infrastructure to reduce costs.
2. Leveraging local staff to create durability.
3. Leveraging “tools of transparency” to generate revenue and catalyze further government investment.

Describe how your innovation model is distinct from any other organization in your field?

Our model of innovation is built on three key principles that are distinctive compared to broken global health models of the past.

Government Partnership:
We partner with Nepal’s government at all tiers of health infrastructure—hospitals, clinics, and community health workers—to deliver comprehensive health care aligned with national health care plans.

Durability:
Long-term durability is found in employing and training local health care providers and non-clinical staff.

Big “T” Transparency:
We layer powerful tools of transparency on top of government systems of management, accounting, and reporting to make our work public and make a compelling case for further government investment.

What type of operating environment and internal organizational factors make your innovation successful?

The innovation is only made successful by the depth of our partnership with the Nepali government and a coalition of Nepali private sector partners that make once-impossible targets -- like a 100% solar powered hospital located 36 hours by bus from Kathmandu -- possible.

Our team has a lean, entrepreneurial mindset and at the same time, has respect and patience for the process of developing a deep and pragmatic partnership with the government as a critical systematic path to scale.

Our work to date has demonstrated impact against all odds and generated the goodwill necessary to take on an ambitious and innovative expansion into a new tier of health infrastructure – a network of malfunctioning clinics.

How do you make sure you constantly innovate in light of (potential) external challenges, or your growth plan?

The short answer is: by force. Working in such a resourced deprived community – a place 36 hours by bus from the capital of Kathmandu where the average income is only $141 per year – forces our team into operating in a constant environment of extreme uncertainty. Innovation is not a luxury or a mark of high performance in this kind of environment, but instead a daily necessity for progress both large and small.

Organization Country

, NY, New York, New York County

Business Model
The systemic challenge you are trying to overcome (select one)

Bring accessible healthcare to communities in emerging markets

Health area (target market) where the need is [select only one]

Primary healthcare services

Categories along the health continuum you are covering [select all that apply]

Prevention, Detection, Intervention, Follow-up, Long-term care.

Stage that best applies to your solution [select only one]

Established (past the previous stages and has demonstrated success)

Core strategies of your business model [select all that apply]

Redesign of the public healthcare system for more efficiency (in terms of processes, structure etc.), New/redefined roles for healthcare service provision, Unconventional partnerships (between traditional healthcare players and players outside healthcare), New financing strategies for health.

If other, specify here:
Most relevant tools you are using to implement the strategies outlined above [select only two]

Technology, Community financing.

If other, specify here:
What is your value proposition?

We deliver high-quality health care to those who don’t have it where no one else can. And we deliver that care on average, in 2011, for $8.13 USD per patient.

Who is your customer(s)?

Our primary customer is a poor patient living in rural Nepal. Where we work, that individual makes $141 dollars on average annually, is most likely not educated beyond a primary level, and is required to walk 59 minutes one-way on average to reach a clinic and 135 minutes one-way on average to reach a hospital.

Our secondary customer is the Nepali government. Our impact evaluation system is built on top of the government’s data system because it is designed to catalyze further investment from the government based on performance of our public-private partnership.

Our last set of customers are investors and partners.

What approaches to you use to reach your customers?

We use a multitude of approaches to reach our primary customer: FM radio station announcements, mobile-phone based referral systems, house calls, and word of mouth distribution from patients who have received care. Most importantly, we use a network of female Community Health Workers armed with mobile phones who report data weekly on the 50 households they oversee in their village community. Based on their house visits, they act as a primary referrer of these customers.

What are your primary activities?

Hospital-based health care delivery.
Clinic-based primary health care delivery.
Community health worker-led preventative care, disease surveillance, referral, and follow-up.

What other challenges - individual, organizational, or environmental – are you currently facing or might hinder future success of your business, and how do you plan to overcome those?

The list of our challenges is long: lack of water, electricity, roads, human resources for health, broken supply chains, government volatility, and an inability of patients to pay for care. These are the fundamental external challenges we face in Nepal as entrepreneurs in the field of global health delivery.

We counter those challenges through partnership with private sector companies that allow us to leapfrog infrastructural challenges (e.g. a Nepali solar power company that has worked with us to create a 100% solar-powered hospital) and by bringing on talent that can help us appropriately manage government relationships (e.g. our Nepal Board President is the President of Nepal's Chamber of Commerce and Industries).

Briefly describe your growth strategy going forward

Our growth strategy involves:
• Growing philanthropic capital to create the infrastructure for health care delivery.
• Using data and transparency to prove impact and catalyze further government investment.
• Shifting funding responsibility to the public sector over the long-term.
• Creating supplementary revenue through innovative crowdfunding partnerships for individual patients.

What dimensions for growth are you currently targeting for your innovation [select all that apply]

New regions(s).

What makes your business "ready" for growth?

We've completed building our hub (the hospital), have experience at the clinic level after starting our work in a clinic, and have a substantial base of community health workers (100).

Programmatically, we possess the experience. In terms of funding, we have already started to grow by increasing funding five-fold between 2010 and 2012. Lastly, the government has invited us to expand.

What are your key growth objectives?

In the next three years, we will:

1. Build Bayalpata Hospital into a rural teaching hospital capable of generating revenue as a rural site for clinical education programs of Nepal's major medical teaching institutes.
2. Encircle the hospital hub with a network of 38 clinics connect by long-range WiFi and mobile GSM networks.
3. Quadruple the number of community health workers to over 400.

Organization's Country of Operation

, SE, Achham

Social Impact
What methods for quantification of social impact are you applying (if at all)?

We have, to date, publicly tracked all volume and outcomes metrics openly on our public wiki.
In preparation for growth and replication, we are currently re-tooling our system of impact evaluation and developing a comprehensive impact dashboard to capture the full extent of metrics (volume, process, and outcome metrics) we believe are fundamental to last mile health care delivery across the hospital, clinic, and community health worker tiers of care. This is being done by clinical and public health leaders that belong to Harvard’s new Global Health Delivery Partnership.

Could your solution work in other geographies or regions? If so, where?

Yes. Traditional private and public sector approaches are failing patients in the last mile across the globe. The demand is undoubtedly there. Our team feels it is most strategic to expand within South Asia. Key cross-border partnerships have already been established and regional co-location will decrease the cost and increase the effectiveness of cross-border collaboration in the future.

What is your projected impact over the next 1-3 years?

During the next 3 years, the organization will be building out its rural hospital hub to be the first teaching hospital in a region of 2.2 million people, encircling the hospital with 38 clinics, and integrating its work in prevention, disease surveillance, and follow-up care by supporting over 400 women as community health workers. This will all be done via government infrastructure and complemented by an implementation science arm of the organization to rigorously evaluate impact through Harvard’s new Global Health Delivery Partnership. By 2016, we expect the Nepali government to share 40% of the costs of the model.

Sustainability
Elaborate on your current financing strategy

We have a diversified pool of global philanthropic dollars which currently provide about 80% of the total funding of the organization. Our public-private partnership service contract with the government provides 15% of the total organizational funding. And newly established crowdfunding partnerships which cover expenses related to individual patient treatments generates roughly 5% of the total.

Our strategy (stated in the section on growth as well) is to shift from the majority of the funding being philanthropic capital to the majority being provided by the public sector. By 2016, we expect for the government to share in 40% of the funding total, and we expect the percentage of our total funding from crowdfunding partnerships to grow to be 10%, which places the philanthropic funding need at 50% by 2016.

Share of revenue generation in total income of organization (in percent)

20%

Direct sales to patients or other beneficiaries (in percent)

5%

Of the possible sources of these sales listed below, check all that apply to your current strategy

Other beneficiaries.

Licensing fees, e.g., for technology/franchise model (in percent)

0%

Of the possible sources of these licensing opportunities listed below, check all that apply to your current strategy

Service contract with organizations, e.g., government, NGOs (in percent)

15%

Of the possible sources of the service contracts listed below, check all that apply to your current strategy

Regional government, National government.

Explain your revenue generation strategy in more detail

Currently, we generate 15% of our total funding via a contracted public-private partnership with the central and district-level Nepali government. We generate about 5% of our total funding through established crowdfunding relationships with Watsi, Samahope, and Kangu that focused on covering costs related to individual patient treatments across a wide spectrum of care.

Share of philanthropy in total income of organization (in percent)

80%

Philanthrophy strategies you are using

Diversified strategy.

Explain your philanthropic approach in more detail

We have a diverse philanthropic strategy with income coming from within and outside of Nepal with the following breakdown.

- 50% foundations and partners
- 45% individuals
- 5% corporate funding

Expand on your selections; explain how you will sustain funding over the next 1-3 years.

We believe the only expansion needed here is to emphasize that we are very realistic in our financing strategy. The world has struggled, and continues to struggle, to find financing solutions for last mile communities. Data shows that it is detrimental to health outcomes to charge user fees at the point of care. Experience also shows NGO-led micro-insurance systems are impossible unless integrated as part of a larger national system of micro-insurance (no such national system of insurance exists in Nepal). And there is a limit of reimbursable services within the structure of Nepal's health care system at the current time (though it is important to share that the government has invited us to contribute to designing a performance-based incentive system).

Thus, we are looking to share the financing responsibility with the government through philanthropic capital at a reasonable percentage, and complement that source of revenue with innovative crowdfunding platforms focused on patient care.

Years in Operation

Operating 1-5 years

Has the organization received awards or honors? Please tell us about them

- Nyaya Health’s model was validated and the organization was distinguished as a "Standout Organization" (top 1% of over 800 organization's examined) by the rigorous nonprofit evaluator GiveWell for ability to treat Nepal's poorest and do so with "unusual transparency."
- Won 8th of over 7000 organizations in the 2012 Chase Community Giving Contest.
- Selected as a recipient of the 2012 Yale Philanthropy in Action course grant.
- Exeutive Director Mark Arnoldy is an Aspen Ideas Festival Scholar, Bluhm/Helfand Social Innovation Fellow of Chicago Ideas Week, and a Cordes Fellow of Opportunity Collaboration.

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