Nyaya Health: Building a strong, open and efficient public sector health system in rural Nepal.

Nyaya Health: Building a strong, open and efficient public sector health system in rural Nepal.

Nepal
Organization type: 
nonprofit/ngo/citizen sector
Budget: 
$100,000 - $250,000
Project Summary
Elevator Pitch

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

Nyaya Health wants to provide high-quality health care to some of the poorest patients in Nepal and also to redefine the standard by which healthcare NGOs operate in order to build strong, open and efficient public sector health services that are responsive to the demands of local communities. Hence, Nyaya (meaning 'justice' in Nepali), delivers hospital- and community-based care via a public-private partnership with the Government of Nepal and in parallel, utilizes the only open-access operations model in Nepal in order to increase efficiency, collaboration, transparency and accountability while building an accessible platform for replicability to be used by other organizations across the world.

About Project

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

NH’s innovation includes 2 major components: a public-private partnership (PPP) with the Government of Nepal (GoN) paired with an open-access operations model. Unlike charity models that create parallel systems and pull resources away from the public sector, NH’s PPP bolsters the public system, ensuring sustainability. Public sector strengthening involves 4 primary practical components: 1) hiring, training, and retaining local staff 2) lobbying for and receiving direct financial investment from the GoN for health services 3) strategically aligning programs with the GoN’s existing physical health infrastructure at 3 tiers: hospitals, health clinics, and community health workers and 4) building local accountability and ownership structures. In parallel, NH has pioneered an open-source operations model, the only in Nepal, to force a new standard of transparency, accountability and efficiency into the public system and provide organizations a platform to replicate the clinical, managerial, financial, and technological systems that are effective in resource-poor environments. NH uses an online wiki as a low-cost, scalable and transparent tool to achieve this ‘opening’ of the health system. Our wiki includes transparent data on operations, clinical outcomes, finances, and organizational management protocols. This innovative model of health delivery that pairs public sector strengthening with public sector ‘opening’ aims to overcome the many systems-level problems plaguing the global health field while at the same time providing high-quality care for our patients.
Impact: How does it Work

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

NH employs an all-Nepali staff to implement hospital- and community-based care for over 266,000 people. Bayalpata Hospital (BH), in western Nepal, is a free 25-bed hospital with inpatient/outpatient wards, 24-hour emergency, obstetric and lab services, a pharmacy, and ambulance referral. In 2011, BH will open a surgical ward, eliminating the costly, and often deadly, delays required by travel to other hospitals. For preventive, community-based health, NH runs an innovative program to leverage the Government of Nepal’s (GoN) Community Health Workers (CHW) program. Currently, 73 CHWs provide health education, ensure treatment adherence, and make referral services in addition to being a vital surveillance and communication bridge between BH and over 17,000 people in the community. Partnering with this Nepal-based care delivery team is a team of volunteers from around the world that is building an open-access operations model via Nyaya Health’s website, wiki, blog and through popular and academic press while also bringing funding and resources to bear for the organization’s growth.
About You
Organization:
Nyaya Health
About You
First Name

Mark

Last Name

Arnoldy

About Your Organization
Organization Name

Nyaya Health

Organization Phone

(617) 539-6203

Organization Address

666 Dorchester Ave, South Boston

Organization Country

, MA, Suffolk County

Country where this project is creating social impact

, XX

How long has your organization been operating?

1‐5 years

The information you provide here will be used to fill in any parts of your profile that have been left blank, such as interests, organization information, and website. No contact information will be made public. Please uncheck here if you do not want this to happen..

Innovation
What stage is your project in?

Operating for 1‐5 years

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.

Social Impact
Please describe how your project has been successful and how that success is measured

NH creates impact in 3 domains: 1) health system development, 2) disease reduction, and 3) model dissemination. Health system development is assessed by GoN investment in health infrastructure, number of patients, and staff retention (example metrics: sustain 10 million rupee / year hospital investment, retain 80% Achhami staff). To assess disease reduction, targets exist for disease-specific programs for HIV, TB, malnutrition, etc. (example metric: for maternal mortality, 800/100,000 mothers died in birth in 2005; by 2015 NH aims to lower to 50/100,000). A key function of the FCHV program is to achieve 100% follow-up for 7 disease-specific programs. All data is tracked via a rigorous, open-source data program, which ensures services address drivers of disease and that social return on investment is calculated transparently by linking to open financial data. Lastly, NH evaluates model dissemination by tracking visits to our wiki, publications using our data, and qualitative feedback from partners. NH has treated over 65,000 patients since opening the clinic in 2008, and in 2010, the organization was able to treat 21,797 patients for a total organizational budget of $166,000.The organization currently employs 38 Nepalis full-time at our hospital (over 80% are from far-western Nepal) and provides weekly financial incentives to 73 additional community health workers in Achham.

How many people have been impacted by your project?

More than 10,000

How many people could be impacted by your project in the next three years?

More than 10,000

Winning entries present a strong plan for how they will achieve growth. Identify your six-month milestone for growing your impact

- Finalize construction of surgical operating theater
- Double size of CHW program
- Operationalize public-private partnership with health clinics
- Raise $250,000
- Double number of wiki users

Task 1

Utilize partnership with Dhulikhel Hospital and Harvard's Center for Surgery and Public Health to construct operating theater.

Task 2

Diversify funding streams, build an expanded Board of Directors through the new, full-time Executive Director, and form new partnerships with the Nepali diaspora, foundations and corporate sector.

Task 3

Clarifying Nyaya's models of public sector strengthening and open-access via the creation of a new website that makes information on our wiki more accessible and integrated as part of our main site.

Identify your 12-month impact milestone

- Run a surgical operating theater in Achham
- Triple size of CHW program
- Implement health clinic PPP at 2 new facilities
- Increase annual funding capacity to $500,000
- Quadruple wiki users

Task 1

Continued plan, do, study, act cycles in partnership with Center for Surgery and Public Health on surgical implementation to refine staffing needs, funding projections, and procurement strategies.

Task 2

Access large-scale popular press outlets to publicize our model after the re-invention of website and wiki integration.

Task 3

Effectively lobby for a three-fold increase in government funding to Nyaya's programs for the budget released in July 2012 through Nyaya's newly created Nepal-based Board of Advisors.

How will your project evolve over the next three years?

Our immediate goal over the next 3 years is to continue to invest in healthcare in Achham specifically across the 3 tiers of current public health infrastructure (hospitals, health clinics and community health workers). While the next year will be spent refining our model of public-private partnership and building a more accessible platform of replicability through our open-access initiatives, years 2 and 3 will focus on rapidly expanding access through further partnerships at the health clinic and community health levels. By the end of 3 years, we plan to be partnered with 6 total institutions at the health clinic level and we expect our CHW program to be adopted in all of Achham's 75 districts.

Sustainability
What barriers might hinder the success of your project and how do you plan to overcome them?

Water. Electricity. Corruption. Supply chains. Staff retention. These are the fundamental external challenges we face in Nepal as entrepreneurs in the field of health systems delivery. We have a vision for free, public-sector, transparent health services, but achieving this vision requires logistics innovations and persistence. To date, we’ve proven successful at overcoming some of these challenges by increasing community ownership of our water pipeline, installing a solar grid on our campus, and pioneering new staff satisfaction initiatives. By establishing and documenting sound management strategies in both Nepal and the U.S., we can continue to overcome these challenges, and we can disseminate our efforts to our colleagues. Internal obstacles include the myopia that can result of being a primarily clinician-run organization. We have brought on new non-clinical leadership to address this issue, and our staff members are venturing out into the communities we serve, asking tough questions and gaining valuable feedback. Our development strategy must also scale rapidly if we are to truly deliver justice in health. Thus, we are dramatically expanding our development initiatives with the introduction of Mark in the Executive Director position. He will create and guide a new corps of volunteer team members focused on development to test several new fundraising models, maximize the support of our advisors, and recruit new, more diverse, and highly-networked board members.

Tell us about your partnerships

Partners in Health (PIH):
As an official PIH Partner Project, NH belongs to a reputed network of organizations in the field of global health delivery that are sharing technical expertise, best practices, and resources.

Ministry of Health and Population, Government of Nepal (MOHP):
Since 2009, Nyaya has been a formal partner with the MOHP and operates via a Public-Private Partnership in order to strengthen the public health sector. The MOHP has guaranteed NH $175,000 USD for investment in health infrastructure over a 5-year period.

The Center for Surgery and Public Health at Harvard (CSPH):
The CSPH has partnered with NH to provide technical support and design/installation oversight for surgical scale-up in addition to collaborating on operational research, focusing on implementation of surgical services in resource poor settings.

Explain your selections

NH’s fundraising operates in 2 domains – within and outside of Nepal – and targets 4 strategies: i) individual giving, ii) foundations, iii) large grants and iv) government funding. Outside of Nepal, NH aims to expand its individual supporter network and is working with its Board to identify other foundation opportunities. We have also begun exploring large grants for scientific research through such venues as the NIH. Within Nepal we will target philanthropists, as well as increase our applications to bi/multi-lateral agencies for health-related grant monies. Finally, we have a contract with the government that supplies ~25% of our funding which we aim to triple in the next year.

How do you plan to strengthen your project in the next three years?

We are already familiar with many of these actors mentioned above and plan to create more human and financial capital via continued marketing and social networking, an expanded familiarity in the Nepali diaspora, increased publications in both lay and academic press outlets, and further participation in advocacy initiatives to enhance NH’s brand.

NH will rely on funds from within and outside Nepal, from individuals, grants, foundations and the government. We aim to significantly increase our government funding (from 3 million to 10 million rupees) to invest in health infrastructure and enhance accountability and sustainability of the public health sector. We also aim to increase our proportion of funding from partners within Nepal. Finally, NH may engage in innovative revenue-generating activities, but will maintain a no user fee policy*.

*Special note:
We do not charge fees to patients at the time that they seek care because of the significant negative impact of user fees on healthcare utilization in extremely impoverished areas. Research in the economics and development fields has consistently shown that such fees act as a barrier to patients accessing healthcare and ultimately have a deleterious effect on population health. Eventually, users may pay through some form of community-based health insurance or other local community financing schemes. Even in these community financing mechanisms, however, medical services would be free at the point-of-care to the patient, and services overall would be subsidized by the government.

Challenges
Which barriers to health and well-being does your innovation address?
Please select up to three in order of relevancy to your project.

PRIMARY

Lack of physical access to care/lack of facilities

SECONDARY

Limited human capital (trained physicians, nurses, etc.)

TERTIARY

Lack of affordable care

Please describe how your innovation specifically tackles the barriers listed above.

Nyaya provides free-care, maintains a policy of hiring and training local staff (>80% currently), and is expanding access through all 3 tiers of the government's health infrastructure (hospital, health clinics, community health workers) to counter the extreme geographical and infrastructural barriers to pure, hospital-based care in Nepal's far-western hills.

How are you growing the impact of your organization or initiative?
Please select up to three potential pathways in order of relevancy to you.

PRIMARY

SECONDARY

Influenced other organizations and institutions through the spread of best practices

TERTIARY

Leveraged technology

Please describe which of your growth activities are current or planned for the immediate future.

Growth within Achham District is the explicit aim of the next 3 years, and continued growth throughout far-western Nepal will take place thereafter. This will be complemented by heavy investment in ensuring that we produce a platform of replicability that is both pragmatic and accessible through our wiki and other components of the open-access operations model.

Do you collaborate with any of the following: (Check all that apply)

Government, Technology providers, NGOs/Nonprofits, For profit companies, Academia/universities.

If yes, how have these collaborations helped your innovation to succeed?

Innovative, easy-to-use technologies form the backbone of an open and transparent operations model. Building programs through government health infrastructure lends ability to scale. And for profit companies, nonprofits, and university partnerships each provide funding, human resources, and technical capacity.

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