The mission of Nyaya Health is to fight injustice in health.  Such injustice results in widely disparate health outcomes, which are unacceptable in this modern era of ample (but isolated) wealth, effective medical interventions, and advanced communication technology.  Health injustices are fundamentally a result of poverty, structural violence, and systematic exclusion and marginalization of certain populations.  Schools, water and sanitation systems, roads, telecommunications, agriculture, gender and caste social structures, geopolitical arrangements, all determine quite literally who lives and who dies. Modern biomedicine cannot alone rectify health injustice.  While Nyaya Health's initial focus and expertise lies in healthcare delivery, to achieve justice in health we must take a broader approach. 

 

To address the acute health needs of a district whose healthcare infrastructure has been ravaged by war, poverty, and government neglect, we have established a regional health program.  From this base, we will treat life-threatening diseases and learn together with community members how to best combat health injustice.  The front-line agents will be our community health workers, who will serve both as healthcare providers and as social advocates for change in their communities.  The long-term vision is to work with communities in Achham to democratically mobilize their citizenry to advocate for social justice in health and to fight power structures that bolster inequalities, whether those powers be at local, national, or international levels.  As outlined below, it is likely that the next five years will be focussed largely on health sector interventions.  By ten years, we hope to address health injustice at a larger level, through a multi-sector approach.

 

The below ten-year timeline provides an overview of where Nyaya might go with our efforts.  There is little way to predict where we will be in one year, given that our work is driven by on-the-ground realities and community members' goals and expectations.  Still, to be effective, we do need a long-term vision, one that will evolve as our work progresses.  The specific numbers provided are estimates that force us to think quantitatively about our scope and impact.  

 

This vision is driven by our four core objectives:

• Facilitating resource distribution to resource-denied areas
• Fostering grassroots collective action to fight injustice in health
• Involving the central government in pro-poor health infrastructure
• Achieving transparency and collaboration in global health delivery

 

Strategic Priorities Where is Nyaya on January 1, 2009? Scope: Activities: Goals Accomplished: Where will Nyaya be on January 1, 2010? Scope: Activities: Goals: Where will we be on January 1, 2012? Scope: Activities: Goals: Where will we be on January 1, 2014? Scope: Activities: Goals: Where will we be on January 1, 2019? Scope: Activities: Outcomes: Key questions Can we envision working outside Achham in the next ten years? The main capacity and focus of Nyaya Health has been health infrastructure development. Would it be better for Nyaya to focus its comparative advantage/particular expertise on healthcare, rather than enter into other areas impacting health justice?  Citizens may demand health services generally, but how to determine which specific programs to implement?

 

Strategic Priorities

This area is used by team members to provide a broad overview of what Nyaya organizationally needs to focus on over the the six-month period starting May 1, 2010, with targets by December 15, 2010.  Overall, we need to accomplish two primary objectives: 

1) greater attention to clinical effectiveness and outcomes monitoring (ie. through protocols and data)

2) rigorous follow-up of patients after they leave the hospital (as in our previous discussions re: follow up of TB and ART patients, f/u of inpatients and others leaving the hospital with treatable acute illnesses) 

The following programs are organized hierarchically in order of priority.  See individual program pages for operational details:

1.  Hospital management practices (staff and volunteer recruitment, long-term sustainability, training of leaders and managers

2.  CHW program

3.  Maternal Mortality program

4.  ART program

5.  TB  program

6.  PMTCT program

7.  Malnutrition program

8.  Improved accounting practices

9.  X-Ray deployment

10.  Health users committees and accountability boards

11.  Comprehensive case review program 

 

Where is Nyaya on January 1, 2009?

Scope:

We have set up a primary health center treating some of the more immediate needs of the dispersed and isolated populations of Achham and Bajura.  We conduct deliveries, treat acute conditions, and manage primary care problems.  We have improved our clinical protocols and begun to implement programs in evidence-based medicine.  We have four community health workers who are trained to follow-up patients in a few of the villages near our center.

Activities:

We operate a primary health center which served over 15,000 patients in our first eight months.

We run a CHW program to perform village-level outreach.

We have established the basic infrastructure for an electronic database.

Goals Accomplished:

1. Renovated and outfitted the primary health center.
2. Hired 1 MBBS, 5 midwives, 3 HAs, 2 lab techs to operate the center.
3. Expanded our fundraising base (receipts as of jan 1: $129,632 from among over 250 individual donors; this does not include approximately $189,000 worth of promised funding support from individuals and grants to be used for 2009).
4. Deployed ultrasound and QBC technologies.
5. Created basic workings of a data program for rapid input, analysis, and publishing on the wiki.
6. Expanded our cadre of volunteers (totalling 75 who have contributed in some capacity and who took part in the recent capital campaign).
7. Established the internet infrastructure for our dynamic, open-access content aimed at achieving greater transparency and collaboration in global health delivery. 

 

Where will Nyaya be on January 1, 2010?

Scope:

Our primary impact will remain in the health sector.  We will have expanded outpatient, delivery, inpatient, and surgical services.  We will be working to improve community ownership over the healthcare services and our overall community outreach strategies to reach the most marginalized populations.  The advances that we lay in community outreach and local oversight and management over health services will lay the groundwork for eventual, broader initiatives beyond the health sector. 

Activities:

Providing direct health services at Bayalpata hospital, a formerly abandoned government facility that the Ministry of Health is providing to us.

Providing community outreach through community health workers.  These community health workers will begin to serve as broader social justice advocates in their communities.

Continuing to publish our model through data, blog posts, and wiki pages provided in an open-access format on the web. 

Goals:

1. To have a functioning hospital with 6 inpatient beds, one surgical unit, a high-functioning referral laboratory complete with blood transfusion capacity, digital x-ray services, and a midwife-run delivery suite. This will be staffed by one MBBS physician and one general practitioner/family practitioner, at least ten nurse midwives, six health assistants, a nurse anesthetist, two staff nurses, and three lab technicians, in addition to severa supporting staff members. 
2. To be managing an effective community-based program aimed at detecting and treating pediatric severe acute malnutrition.
3. To be introducing a system to train providers in safe abortion and deploy safe abortion services.
4. To have reviewed our obstetric services to determine how to achieve the AMDD goals for emergency and comprehensive obstetrical services.
5. To have conducted a survey on the extent of gender-based violence and begun to address domestic violence in some capacity.
6. To have 20 CHWs who are trained effectively in follow-up of primary care patients, identification and engagement of pregnant women, screening and treatment of severe acute malnutrition among children, and providing adherence support to patients suffering from diabetes, tuberculosis, emphysema, and HIV/AIDS. 
7. To have created some form of community accountability boards for oversight of hospital operations.
8. To have an honest, open, and well-documented comprehensive mortality weekly staff report looking into the social, biological, and systemic causes of at least 50% of all the deaths that occur in the catchment area covered by our CHWs.  These deaths include those that occur in the community and at the clinic, since we are all collectively responsible.
9. To have a plan for an effecient mortality surveillance system to continually monitor deaths in the catchment area.
10. To have effectively lobbied Nepal Telecom to create a CDMA tower making mobile communication accessible to the bulk of the villages in which we work.
11. To have a solid data monitoring program that remains up-to-date and accurate month-to-month and is published to the wiki.  For key diseases such as HIV, h. pylori, TB, diabetes, COPD, abscess, malnutrition, and pneumonia, we will have solid outcomes measures assessing the effectiveness of our programs.  The data for the most part is recorded on paper by staff and then entered into the database by a data manager, but we will strive to test a preliminary electronic medical records system based on either OpenMRS, the PatientOS draft system we have programmed to date, or a similar system.  We will also have completed a pilot study of training select CHWs on electronic data collection tools, such as PDAs.
12. To have formulated research priorities, in line with the mission of Nyaya, to facilitate the investigation of healthcare delivery in resource-deprived areas, and to begin publishing our data and lessons-learned in an effort to a) solicit feedback/peer-review of our programs, and b) to broaden the impact of our evidence-based approach.
13. To have conducted 400 deliveries attended by a trained medical professional.  This would represent nearly 1/5 of all 2100 annual deliveries in a catchment area of 60,000 people closest to our clinic.  Approximately 8 (2%) of these deliveries would be by cesarean section.  50% of the pregnancies among women in areas covered by our CHWs would be conducted at our facility.
14. To have 40 volunteer members who are meaningfully engaged in the organization long-term.
15. To have established/codified an intra-organizational framework for overarching administration, planning and implementation of on-going, and developing Nyaya programs. Key tasks will be the ongoing evaluation, assessment and revision of job descriptions for both board members and volunteers, as laid out in 2008, as the 2009 calendar year progresses.
16. To have annual receipts totalling $250,000, from among at least 750 individual donors. 
17. To have expanded the readership of our internet sites, generating 500 page views per day on our blog, 2500 page views per day on our main site, and 800 page views per day on our wiki.
18. To begin planning for community projects that impact health but are outside the scope of conventional health care services: clean water projects, sanitation, education, etc.

 

Where will we be on January 1, 2012?

Scope:

The center of our activites will continue to be the Bayalpata Hospital, which by this time will be a high-functioning facility capable of delivering evidence-based, high-quality healthcare.  Our community health workers will be capable providers and advocates who mobilize their local villages to fight health injustice.  Our community management and accountability boards will have broad-based representation and will be knowledgeable and effective advocates for driving improvements in clinical services.  We will have begun to address community-level public health prevention through health-oriented community projects. 

Activities:

Providing direct health services at Bayalpata hospital.

Providing community outreach and advocacy through community health workers.

Continuing to publish our model through the web.

Participating in grassroots advocacy campaigns.

Conducting small-scale community-based interventions to address water-borne disease and indoor air pollution.

Goals:

1. To have expanded the hospital to include 20 inpatient beds, along with dental, eye care, and mental health services.  Additional staff will include at least one more MBBS physicians, three health assistants, and four staff nurses.   
2. To have expanded the CHW network to 100 health workers to cover 85% of a 60,000 population immediate catchment area.
3. To have equipped at least 30 of these CHWs with basic telemedicine applications via CDMA-enabled handheld devices.
4. To conduct 1200 deliveries annually attended by a trained medical professional.
5. To achieve no deaths among children from severe acute malnutrition in our our immediate catchment area.
6. To have a systematic method of tracking safe abortion services.
7. To deploy the complete AMDD emergency obstetrics approach including comprehensive monitoring.
8. To have a fully operational mortality surveillance system for the catchment area.
9. To have been part of at least one successful grassroots effort to lobby the government for improved public services in at least one sustained and effective campaign (could be in transportation, communications, health, education).
10. To be operating some project aimed at the prevention of emphysema/COPD in 60% of the communities where CHWs operate, aimed at addressing the root causes of indoor air pollution.
11. To be operating some water and sanitation projects aimed at prevention of water-borne diseases in 30% of the communities where CHWs operate.
12. To have implemented an effective strategy against domestic violence.
13. To have implemented a few true electronic medical record applications (for inpatient and surgical) that are used by the physician, pharmacist, and some health assistants. 
14. To have received at least 5 million NRs annual investment in the Bayalpata hospital from the Ministry of Health.
15. To have improved integration with surrounding government sub/health posts in areas where CHWs operate such that 1) all posts in the villages covered by our CHWs are regularly staffed with government-supplied medicines; 2) the staff at these posts are undertaking trainings with Nyaya staff and referring patients
16. To have worked with the community accountability boards on at least one substantial hospital quality improvement project.
17. To expand our contributions to the research community with the publication of lessons-learned and best practices in healthcare implementation, as well as associated programs designed to address structural issues facing those communities we work with (e.g. roll-out of a stove construction program to address air quality).
18. To have 100 volunteer members who are meaningfully engaged in the organization long-term
19. To have annual receipts totalling $400,000 from among at least 5000 individual donors.
20. To be generating 1500 page views per day on our blog, 9000 page views per day on our main site, and 4000 page views per day on our wiki.
21. To have begun community development projects in the area of clean water and sanitation

 

Where will we be on January 1, 2014?

Scope:

Bayalpata Hospital will be a center for education, community public health activities, and social activism.  Our data-driven, patient-centered healthcare delivery model will be mature and functioning at a high level.  Our development initiatives will extend beyond the traditional scope of biomedicine but be still restricted largely to the health sector. 

Activities:

Providing direct health services at Bayalpata hospital and three additional satellite clinics.

Providing community outreach, direct patient care, and advocacy through community health workers.

Participating in grassroots advocacy campaigns.

Conducting community-based interventions to address water-borne disease, indoor air pollution, and domestic violence.

Continuing to publish our model through the web.

Goals:

1. To have expanded to 120 CHWs, all of whom will be equipped with basic telemedicine applications.
2. To conduct 2500 deliveries annually attended by a trained medical professional, including 80% of those deliveries within the immediate catchment area.
3. To have been part of at least three successful grassroots advocacy campaigns that delivered tangible results.
4. To have established a fully functioning, comprehensive electronic medical record that is operable in real-time by all staff, including midwives and CHWs.
5. To have achieved sufficient community-level advocacy for the improvement sub/healthposts that there is sufficient pressure from communities and support from government to bar sub/health post staff from working in the private sector and neglecting their public function.
6. To have reduced the discrepancy between our highest paid and lowest paid full-time employees to no greater than eight times.  This will require sufficiently improved the work environment, living standards, and educational opportunities of our physicians to be able to recruit physicians at salaries more in proportion to their role on an integrated healthcare team.
7. To have made a clinically significant impact on rates of domestic violence, unsafe abortion, and maternal deaths.
8. To have run a successfull grassroots campaign to improve government health services that ensures: 1) staffing of a full-time general practice physician with surgical skills at the district hospital; 2)
9. To have hired at least one full-time female physician.
10. To have 120 volunteer members who are meaningfully engaged in the organization long-term
11. To have annual receipts totalling $1,000,000 from among at least 12,000 individual donors.
12. To be generating 5,000 page views per day on our blog, 12,000 page views per day on our main site, and 11,000 page views per day on our wiki.

 

Where will we be on January 1, 2019?

Scope:

We will be taking a broad-based development approach to addressing health injustice.  We will continue to deliver some clinical services, driven largely by the needs not met by government programs.  This may include ongoing hospital or primary care work in Bayalpata, other parts of Achham, or Bajura. We will be transitioning those programs to government financing and management for which local community members have sufficient power to continue to ensure continued delivery high quality clinical care.  We will be working on other community development programs that build off our healthcare-focussed community outreach and mobilization.  These will include microfinance, education, water, agricultural, and environmental interventions.

Activities:

Operating community, primary care, and hospital services.

Working with a large cadre of grassroots health workers and advocates.

Managing multi-sector community development programs. 

Continuing to innovate in public, web-based access to protocols, programs, and data.

Outcomes:

1. To have successfully transitioned management and financing of the Bayalpata hospital to the Ministry of Health.
2. To be addressing chronic food insecurity and agricultural productivity. 
3. To have reduced maternal mortality in the district to less than 30 per 100,000 pregnancies.  
4. To have reduced infant mortality in the district to less than 15 per 1000 live births. 
5. To have achieved better than 95% adherence rates among at least 80% of chronic care patients including HIV, tuberculosis, diabetes, emphysema, congestive heart failure, and asthma.
6. To have reduced domestic violence by 80%.
7. To have achieved tuberculosis case detection and cure rates exceeding the current consensus, based on the technologies available at that time and set by justice-oriented, aggressive TB control scientists. 
8. To have participated in a grassroots movement that now is capable of achieving 70% of the average level of direct government investment in public infrastructure and programs as that of the districts in the Bagmati Zone (the zone including the seat of government in Kathmandu).
9. To have annual receipts totalling $5,000,000 from among at least 20,000 individual donors.

 

Key questions

Can we envision working outside Achham in the next ten years?

Addressing healthcare inequalities anywhere in Nepal would certainly be within our mission.  However, the needs of Achham are so vast and the complexities of development so great that the most likely scenario would be that Nyaya stays focussed in Achham.  Our group is more likely to choose to establish deep, long-term roots in the community and take a broad-based, multi-sector approach to health equity than we would be to spread ourselves out over multiple different locales.  Even as now many patients come from the Bajura district, we would likely expand regionally through outreach to surrounding districts. Our broader impact in global health delivery will come from public dissemination of our data, protocols, and experiences. 

 

 

The main capacity and focus of Nyaya Health has been health infrastructure development. Would it be better for Nyaya to focus its comparative advantage/particular expertise on healthcare, rather than enter into other areas impacting health justice? 

Since Nyaya was founded originally by a group of people expert in some degree in healthcare, it is not surprising that our first effort to combat health injustice in Achham was to build a clinic.  It also, importantly, was identified as a major need in the region, seeing as there was not a single physician in Achham when we started our operations there.  The roots of health injustice, however, extend deeply throughout society. We should not be constrained by the biomedical model.  The classical metaphor is that it is better to build fences at the top of the cliff rather than run an ambulance service at the bottom.  

 

Emphysema (COPD) is a classic example.  Even at the high level of functioning that our hospital will be at, and even with continued medical advances that we will work to get our patients access to, emphysema is unlikely to have a cure or highly effective medical treatment.  Emphysema, however, is clearly preventable through decreasing smoking and indoor air pollution.  These mandate social, economic, and engineering interventions that include developing smoke-free indoor cooking alternatives.  Chronic malnutrition is another example, in which while we can and must treat the medical complications of malnutrition and provide food as therapy to the malnourished, food security can only be effectively addressed through initiatives aimed at agricultural and economic development.  Organizationally, we will need to learn, grow, and develop the technical and human resource capacity to take a broader, multi-sectoral, non-exclusively-biomedical approach to addressing injustices in health.

 

In order to achieve this mission of targeting the non-health causes of the many inequities faced by the people of Achham, we should also actively recruit those who are experts in these varied fields.  While well-rounded health professionals are aware of the social, economic, and cultural influences that affect such inequities, Nyaya would also benefit from those who are from outside the health field.  For example, we should aim to actively incorporate approach into our organization engineers, economists, anthropologists, and others who believe strongly in our mission.

 

Citizens may demand health services generally, but how to determine which specific programs to implement? 

Three main factors should drive health service expansion.  The first is community-level participation and demand.  The second is epidemiological data arising from community-based surveys and clinical care.  The third is what interventions are available for the particular diseases in question, summarized by the number-needed-to-treat.  This number represents the potential effectiveness of an intervention, and should drive decision-making as to which programs to roll out.