Posted by Duncan Maru, MD, PHD
We have spoken before about the lack of transparency and accountability among those working in the fields of global health and global development. This is a systemic problem at multiple levels: the disempowerment of the so-called “beneficiaries” of global health and development projects; persistent memes of colonialism and racism that dog development workers and organizations; and a disconnect between donors and recipients. It is this latter problem that concerns me in this post, as I reflect upon the recent exciting news that the America Nepal Medical Foundation has again decided, for the third straight year, to financially support the work of Nyaya Health.
Nyaya’s relationship with ANMF dates back nearly three years: ANMF provided Nyaya with some of its initial seed capital that was used to build the Sanfe clinic. Looking back at our initial grant proposal to ANMF, one number has always stuck in my mind: 1461 deliveries of babies. In writing the grant proposal to ANMF, we had estimated that number based on our honest, best, though limited, understanding of the demographics of Achham. The actual number of deliveries we would perform in our first year? 47. That’s a far cry from our target.
ANMF board members could have looked strictly at those numbers and decided that we had not met our targets. I think, however, they had the insight to see that, while we had not met that particular numerical target, we had achieved other impressive objectives. Namely, we had started the first physician-run medical services in this war-torn rural district, and had assembled an all-Nepali staff of midwives, health assistants, and community health workers. Perhaps most importantly, we had demonstrated talent and promise in our abilities and desires to work with the government on innovative approaches to rural healthcare delivery.
Now, three years into our relationship, ANMF can and should expect more from us. As a more mature organization, with two years of support from ANMF, it is Nyaya’s duty to become more responsible with our funding, and more accountable to our donors in each proposal we write, and each program we implement. Indeed, ANMF had extensive discussions about this internally as they were trying to assess how they should allocate their 2010 funding. They pushed us to be more specific. This, we believe, is an excellent example of a responsible approach to funding: how can donors take a flexible, open, but firm, approach to grantees? There is no simple resolution; protocols can be in place, performance targets can be mandated, but it comes down to a basic fiduciary understanding between the two parties which includes accountability and open dialogue throughout the process.
Ultimately, Nyaya Health has a monumental task ahead to meet the very ideals of transparency and accountability that we have laid out in our PLoS Medicine paper and on our wiki. Our data program, a pillar of monitoring and evaluation, remains extremely challenging to implement. We have suffered large gaps over months owing to personnel shortages and electricity outages. We have struggled to inculcate an organizational culture in which staff and volunteers value data, and all believe in the centrality of data integrity.
Our proposal to ANMF this year had these ideas in mind. It was led by Nyaya volunteer Chintan Maru. Chintan had recently returned from Achham, and had concerns about the large disconnect between Nyaya’s aspirations and our abilities to implement them. As a new volunteer to the organization, he was often confused by whether topics discussed in Nyaya’s reports or on our wiki were realities or simply aspirations for the future.
As we discussed what programs we should apply to ANMF for 2010 funding, we reflected on our ability to carry through with what we wrote about in our proposal. We ultimately submitted a piece to ANMF entitled “Human Resource Development for Clinical Effectiveness and Accountability at Bayalpata Hospital”. The programs under this proposal included: Comprehensive Case Review (CCR); the Community Health Worker (CHW) program; and Health User Committees (HUC). These were selected because they represent key organizational priorities and because they are within Nyaya’s capacity to implement in the next year.
We greatly appreciate ANMF’s continued support, and in particular their diligence in pressing us to think critically about the programs we propose for funding. We look forward to continuing to dialogue with ANMF to bridge the gaps between donor’s expectations, our own aspirations, and the realities and challenges that we confront daily working in Achham.
I provide our proposals to ANMF over the last three years for reference:
