This page outlines Nyaya's vision and ongoing efforts toward becoming more transparent and accountable to the community it serves.

 Community Accountability Structures 

Vision

Accountability to community members is central to creating an effective and responsive health system.  Even the most well-intentioned government- or non-profit-operated health services will fail ultimately to meet core moral, social justice, and public health objectives without strong avenues for community-level oversight.  Nyaya Health therefore is developing community accountability structures that provide the following:

• avenues for lodging complaints and feedback on the quality of clinical services Nyaya provides
• venues at which to discuss Nyaya's priorities in service improvements and expansion
• mechanisms for addressing medical malpractice committed by Nyaya, government, or private providers
• up-to-date data from our clinical services in an understandable and open format to community members 
• strategies to engage the most marginalized community members (particularly, women, dalits, impoverished, illiterate, individuals with chronic conditions or disabilities)

Furthermore, these structures can serve to catalyze processes by which commmunity members become organized, mobilized, and effective at demanding justice, and effectiveness out of the health system.

Citizen Meetings: at the Hospital

Approach

In this approach, Community Health Workers recruit individuals from their communities and bring them to Nyaya Health facilities to discuss their concerns or suggestions about our clinical services.  The benefit of this is that CHWs are employees of Nyaya Health, know Nyaya Health's services, and are well-known in their communities locally.  By training them to identify particularly the more marginalized elements of their own micro-societies, we help to capacitate them as agents of social change.  Having the meetings take place at our clinical facilities facilitates interactions with other staff members. 

Protocol

Citizen recruitment 

1)  Request that the CHWs each bring two guests each. In the initial phases, the meetings are of this nature so we get a general sense of the common issues. Eventually, we should quickly move toward a meeting focusing on only one part of the community so we avoid groupthink and can identify challenges unique to a community.

2)  Create a log for all meetings. Note gender, caste and literacy status of all invited members. Better to pass a sign up sheet and note who will ask CHWs for helping writing their names rather than singling out folks with questions like: "who cannot read or write?" and also determine dalit status from last name and not by direct questioning. 

Setting the Agenda

The moderator, a Nyaya staff member will follow a basic procedure.

1) Moderator introduces him/herself and the rest of the Nyaya team members present.  Be open, welcoming, and gracious to all for coming.

2)  When soliciting list of issues, write the name of the person who raised the point next to every issue. If certain members are not participating, ask them what they may want to share or (if guest very shy) ask CHW to initiate a discussion with the guest.

3) The typical process as issues are put forth is:  

a) allow/facilitate ellaboration of thr problem

b) allow for one of the CHWs to respond

c) community members and CHW engage in discussion (moderator ensures neither side is shut out)

d) moderator advises and notes any shared resolution, conclusions, as well as what Nyaya do about this

e) reach a logical conclusion, but do not make promises on things that Nyaya can do, especially if it comes to tasks that require new resources (e.g. community members said they wanted X-ray services)

4) In concluding the meeting, advise community members that the next time they hear these issues in the community, they should respond in the way we just discussed and ask others to come to Nyaya during these meetings to raise their concerns because we will listen. It's much better to have this information go out into the community through the guests than by our CHWs because the latter are perceived to have a conflict of interest since they are paid by Nyaya so of course they would ask community members to go to the hospital for delivery etc.

Documentation and Follow-up

1)  The final notes should be discussed with the internal management board and should be used to A) inform further CHW trainings (e.g. focus on mutual respect and communication skills rather than purely didactic approaches that can make the CHWs arrogant and further disconnected from the community members); B) provide a context for the data that we use to decide which programs to invest in next; C) for those changes that can happen immediately, make rapid policy changes within the hospital (e.g. certain schedules are hurting or confusing our patients).

2) The internal management board will make recommendations for each of the issues raised and email the notes and recommendations to the team list. Team will discuss and collectively decide on how to follow through with the suggestions. Depending on the recommendation (some may be enacted immediately, some will require applying for grants, developing programs etc), the decisions made by the Board will be communicated to the CHWs who will speak with the community members.

3)  Given the nature of the meetings and our interest in revolving members, we will not be able to provide direct follow-up but will capitalize on the closely-knit networks in the community where information travels fairly quickly if you can tap the key members.

Frequency of Meetings

The frequency of meetings will have to be determined based on the extent of the issues and the timeframe of their resolution. We should avoid increased frequency if we have not addressed most of the issues raised in the last meetings. e.g. the first meeting yielded a lot of concerns (about 60%) that were related to low provider:patient ratio. It would have made sense to call for another meeting after we had implemented triage and added an HA. Be cautious to avoid giving a sense that these meetings are token exercises in "participation" where we do not really care about any of the issues raised.

Challenges

• CHWs need to be trained to seek out the more marginalized segments and not just the elite or their own friends/family members.
• There are current limits to the reach of the CHWs, and most communities in fact do not have one
• Establishing mechanisms for follow-up after the meeting. 

Citizen Meetings: in the Community

Approach

In this approach, one or more of Nyaya's core clinical staff visit villages and lead planned or ad-hoc discussions about health and justice.   The benefits of this approach are that the discussions take place on the "homefield" of citizens, where they may feel more empowered to address their concerns.  These meetings also can facilitate broader discussions about community health at a local, village level.

Protocol

Meeting Leadership

Ideally, the meeting would be conducted by a CHW from the village.  Since most villages will not have a CHW, we need to establish a midwife or roaming CHW who would conduct these.  The person conducting the meeting should be a woman from Achham.  Additionally, there should be an accompanying Nyaya leader who can provide feedback and assistance.  This person also would preferably be a woman, but in any case the person should be cognizant that their role is to help with documentation and feedback and that s/he should ensure that the meeting moderator  is perceived as the leader. For example, in the beginning of training the moderator may look to the other Nyaya leader as if to ask, "is this the right thing to say"; it is best for the Nyaya leader to play as low a profile as possible and just focus on documentation and feedback.   

Citizen Recruitment

To keep the number of participants small enough (< 20) to have a meaningful discussion, unannounced meetings will work. Time of the day and location will bias your recruitment. Most women work in the fields during the day so you are more likely to meet men (including those with government jobs), older women who may not be working because of weaknesses and children. Early mornings (before 8) are a good time to meet folks before they go off to work. Conduct meetings at the "border" between communities of "higher" and "lower" castes. If you feel like attendance is skewed with only one caste, attempt to bring members from the other community. If that fails, hold another meeting in the second community. CHWs or any other meeting leader should be comfortable mediating such meetings by being sensitive to both communities. Ensure that we are not seen as favoring one group over the other just because of caste, and focus on hearing from the most marginalized and the most diverse groups.

Discussions

These meetings are more challenging to manage than the in-hospital meetings. From the outset, the moderator should be established as a leader and should make sure the discussion stays focused on the agenda, which is learning the community's feedback on Nyaya's work. The other leader from Nyaya escorting the moderator will scribe all comments and let the moderator respond to the concerns. As always, silencing those who may be saying "negative" (e.g. the hospital is useless) or "irrational" (e.g. I needed an injection and the doctor refused to give it me) is not helpful. Focus on continuing the dialog and not ending it. Nyaya leader will conitue to maintain a low profile and only intervene if the CHW may be either being silenced/humiliated/treated unfiarly by the community members or vice versa.

Documentation and Follow-up

1)  Write down the location and date of the meeting on the top. The final notes should be read out loud by the CHW and get everyone's approval to ensure completeness. The notes will be discussed with the internal management board and should be used to A) inform further CHW trainings (e.g. focus on mutual respect and communication skills rather than purely didactic approaches that can make the CHWs arrogant and further disconnected from the community members); B) provide a context for the data that we use to decide which programs to invest in next; C) for those changes that can happen immediately, make rapid policy changes within the hospital (e.g. certain schedules are hurting or confusing our patients).

2) The internal management board will make recommendations for each of the issues raised and email the notes and recommendations to the team list. Team will discuss and collectively decide on how to follow through with the suggestions. Depending on the recommendation (some may be enacted immediately, some will require applying for grants, developing programs etc), the decisions made by the Board will be communicated to the CHWs who will speak with the community members.

3) After the decisions have been made, travel back to the same meeting site and discuss the decisions and changes, reminding the community members that their feedback has helped to improve our services and they should continue to be vocal about their dissatisfactions, not only with Nyaya but with other organizations and the work of the local Government bodies.

Frequency of Meetings

The frequency of meetings will have to be determined based on the extent of the issues and the timeframe of their resolution. We should avoid increased frequency if we have not addressed most of the issues raised in the last meetings. e.g. the first meeting yielded a lot of concerns (about 60%) that were related to low provider:patient ratio. It would have made sense to call for another meeting after we had implemented triage and added an HA. Be cautious to avoid giving a sense that these meetings are token exercises in "participation" where we do not really care about any of the issues raised.

Next Steps 

Shefali and Chhitij to observe one of these meetings together, and then discuss and revise the protocol and documentation aspect.  Then they will decide how to protocolize further.

Medical Malpractice Investigations Program 

Strategy

A key component of health justice is investigating and taking some degree of legal or economic action when a citizen is harmed by a health provider, be it a government employee, a private practitioner, or Nyaya's own staff.  For the most part, Nyaya would seek to engage and work with other human rights, legal advocacy, or health justice organizations who work in the area rather than undertaking the investigations ourselves.  

Protocol

Note: since Nyaya is a young organization still developing our community base, we are still developing how we might be able to do this.  Presently, we do not yet have the solid, multi-sector community-level support required to undertake a full-fledged program.  Still, we need to have a vision for the small, tangible steps we can take in this direction.  

Press Releases

For cases of complication that are referred to the hospital after being subject to malpractice from other health providers, we aspire to provide press releases. These releases will avoid implicating an individual and will present a case to disseminate information on the general state of malpractice and lack of legitimate services in Achham.

Engaging justice/human rights NGO

To the extent possible, we should engage justice and rights organizations on health injustices or malpractice that occur in Achham.  

Community-level Data Access and Empowerment 

Approach

Dissemination of accurate, up-to-date, and accessible data at a community level can lead to a more informed and empowered citizenry who can then advocate for better services.  One randomized controlled trial in Uganda, for example, demonstrated a 33 percent reduction in child mortality after one year following the start of a community-based monitoring project in which citizens were provided with aggregate service delivery and health outcomes indicators.  The idea is that the availability of data at a community level can increase utilization of healthcare and can empower citizens to push for better services, from the government and from Nyaya Health.  Achieving this in practice is predicated upon an up-to-date, easily aggregated database.  Once this is established, we then have to put a considerable amount of time and effort in identifying appropriate data points that the community desires; forums for their dissemination; further education on the meaning of these data; and strategies that can translate the data-knowledge into action.  If done in a meaningful way, this can be a critical component of ensuring that both Nyaya Health and the government are accountable to the citizens covered by our health services.  

See DataManagement page for more details about the data collection and analysis aspects of this.

Next steps: 

Immediate/Pilot

-identify core areas of Nyaya's data that can community members ought to know

-identify mechanisms to present those data (

Subsequently:

-identify members in the community who could serve as data liasons 

-start collecting similar data on the government

-organize members to utilize the government and nyaya for better/expanded services

Long-term:

-data liasons should collect and analyze the data independently from Nyaya Health and the government, and should rather demand excellent clinical and data practices from both groups.  Achieving true independence/oversight is going to be a massive challenge.  

Citizen Advisory Boards

Approach

With the opening of our new hospital, we will be creating advisory board for local leaders as per the agreement with MoHP.  It is important to manage this board diplomatically to avoid political conflicts while enabling it to function as some form of representative auditing/accountability structure.    This board should serve primarily in an audit/review capacity. 

Protocol

Selection of Members

The selection process should be open and transparent and require some form of formal application.  This will avoid the look of favoritism.  Care should be taken to ensure that all major political parties are represented, and that none have a signicantly larger presence than the others.  

Operation of the Board

The board should be a review/audit board than a planning board.  This is important to avoid political infighting about expenditures and programming.   No compensation should be provided to any of the members.

User Advisory Boards

We currently do not utilize advisory boards as part of our accountability strategy. 

There are several challenges to creating a users advisory board with membership exclusively to marginalized members:

1. Proper representation: how do we ensure that the most marginalized are well-represented? "Letting communities decide" may result in finding people who are usually well-connected with the elite in the communities. Electoral process, in addition to logistical challenges, can result in the same problem

2. Changing needs and empowerment: Our responsibility is to create an environment in which those who have been denied agency for all of their lives can speak out against our work. We may work with the same community members for a long time and thus make them more empowered but the trade-off is being unable to reach out to more members and thus failing to respond to changing needs of the community.

For these reasons we have decided, at least for now, not to have a user board with permanent membership and instead utilize the community meetings to achieve the objectives that a permanent user board would otherwise achieve.

References 

Empowering Women: Participatory Approaches in Women's Health and Development Projects  Manderson L,  Mark T. Health Care Women Int. 1997 Jan-Feb;18(1):17-30 

• Reviews 16 women's health projects implemented by Australian NGOs in Africa, China, SE Asia, the Pacific and South America. Gender issues are taken into account in nearly all projects. However, resoultions vary: facilitation of women's control over resources and their participation in community decision making; assistance to women in design and delivery of services; improvement of literacy to enhance women's access to knowledge, administration and ownership of projects by women and training of outreach workers.   
• Article emphasizes the importance of listening to women and talking with women at local and community levels abt perceived and real health care needs via focus groups and participatory discussions; assessment of women's needs prior to implementation and thorough planning and flexibility within program also important. 
• Article details two case studies in China (pig and poultry husbandry courses) and Indonesia (literacy training project) that ultimately raised the status of women involved with the project. 
• Conflicts Encountered by projects: (i) CHWs and traditional birth attendants working at primary health care level lacked support from their own communities; (ii) Social, cultural and political factors continue to limit women's full participation in project activities and their access to services. Common assumption that women's workload is decreased with program interventions does not always hold true because workload sometimes increases through  involvement in  income-generating activities and new patterns of work; (iii) Involvement of women in income-generating activities such as agriculture and business, traditionally male domains can result in men feeling disempowered,excluded and resentful. Men's support can be critical both directly and practically. Village governments and administrations typically rests with men, and their support becomes essential. 

 Primary health care, community participation and community-financing:experiences of two middle hill villages in Nepal

Sepheri A, Pettigrew J. Health Policy Plan.1996 Mar;11(1):93-100 

• Article draws on the experience of two middle hill villages of Western Nepal. Compares and contrasts the scope and extent of community participation in the delivery of primary health care in a community run and financed health post  (Ghandruk Community Health Center established in 1987 by a local NGO) versus state run and financed health post (Sikles health post, estd 1950s by the Indian Govt).
• Study concludes that community-financing did not appear to widen the scope or extent of participation of the community. Moreover, questions the applicability of a participatory approach to development in rural Nepal from a cross-cultural perspective.
• Also indicates the existence of socioeconomic and cultural hierarchies in the villages combined with male domination of the health committees that prevent health committees from representing the needs of the entire community.