Tell us about the community that you engage? eg. economic conditions, political structures, norms and values, demographic trends, history, and experience with engagement efforts.
Nyaya was founded in and currently works in Achham District located in the hills of far-western Nepal. Achham itself is consistently ranked as 1 of the 5 poorest districts in all of Nepal and accordingly, it is regarded as one of the poorest regions in all of South Asia. The daily per capita income is estimated to be USD 0.40 per day. When Nyaya Health began work in Achham, there was not a single doctor to serve over 250,000 people, and 36% of people had gone into debt paying for poor quality private sector care by inadequately trained providers. Even today, to be admitted to an intensive care unit, Achhamis must still travel at least 12 hours by bus to the Terai (flatland area in south Nepal). Only 14% of women and 54% of men are literate. An estimated 80% of men have been forced to work in India at some point in their lives, and 33% of the local economy is supported by remittances from India. This forced economic migration has also resulted in Achham being home to 7% of Nepal’s national HIV burden despite the fact that it is only 1 of 75 districts in the country. A disturbingly high percentage of births result in a mother’s death (some estimate up to 1 out of 125), and 90% of deliveries still take place outside the assistance of a trained health work.
The people of Achham have historically been victims of resource denial because of the harsh topography of Nepal, distance to Kathmandu (some 35+ hours by vehicle) and thus inability to influence policy and advocate for their own health, underdeveloped communications infrastructure and more recently, the deep human and physical devastation of Nepal’s 10-year civil war that in many ways stemmed from the historical inequities of Achham and far-western Nepal.
This is not to say that Achhamis are immune, resistant or unprepared for engagement efforts. In fact, Nyaya has achieved successes in this area. A few examples include a local family who gifted land and a large home to Bayalpata Hospital, a local Village Development Committee that has donated money to the hospital, the CHW program that has developed community-based advocates for the services we provide, and local citizens employed by Nyaya have come to value the structures we have established and often publish pieces related to advocacy and the conditions of Achham via our blog or other publication systems.
There is a shared feeling between Nyaya team members and Achhamis that they ought and can be provided with quality health services through an effective public health system.
Share the story of the founder and what inspired the founder to start this project
It may be most useful, perhaps, to share the content directly from the email which originally cast the vision for Nyaya. This was written by Co-Founder Jason Andrews in 2006 after visiting Achham District.
“…While I was staying there, I literally had 10 women a night knocking on my door asking for medical help for themselves or their children. All but one of their husbands had worked in India and half of them were widows at 25-40 years old. Among those that knew their [HIV] status, all were positive. There are no medical services available to them beyond the most basic primary care (and that is often geographically and financially inaccessible)… It was very difficult to talk with these women because there was nothing I could offer or recommend to them. The nearest facility providing HIV care (and doing so incredibly poorly) is a 12 hour bus-ride away… It's not just HIV that's a problem, of course. 95% of births (or more) take place in a home without a health worker present… Malnutrition is a major problem, with >60% of children in those two districts having moderate-to-severe malnutrition… One night I was sitting, 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 five years, given their symptomaticity and prospects for treatment. Since that moment, I’ve felt wholly compelled but completely adrift…”
Following that experience, Jason recruited two highly talented colleagues at Yale University Medical School, Duncan Maru and Sanjay Basu, and they together co-founded NH.