In September of 2011, Bayalpata Hospital in rural Achham, Nepal almost collapsed under the weight of its own staff discontent. The hospital, a government facility, had been largely abandoned until 2009 when our organization Nyaya Health endeavored to open it in partnership with local and national authorities. Since then the hospital had already seen over 75,000 patients and seemed to have broad community support. Yet over the course of that month, led primarily by our senior clinical staff members, a broad-based staff revolt happened, with threats of strikes, black armbands, verbal outbursts, some (not severe) forms of physical violence, blatant untruths published in national newspapers by our staff physician, aggressive, racist postings on Facebook, and angry, defiant letters to the Nyaya Health Board. It was, in short, a mental, organizational, managerial, and spiritual disaster. Ultimately, the crisis ended, though not without the departure of our three most senior clinicians—our medical director, our staff physician, and our nurse-in-charge—and not without significant loss of morale throughout Bayalpata staff and the Nyaya Health organization as a whole. What happened?
The purpose of this piece is to discuss the managerial and pragmatic aspects of the case, and how we have endeavored to work through the crisis. This type of crisis is all too common throughout the world, but all too little is discussed. We do not seek to get into the more broad spiritual/philosophical questions of the role and nature of international non-profits, non-local volunteers. That discussion is important enough, but it was largely irrelevant to us as leaders and managers trying to work through the crisis; we had already committed ourselves to Achham and went into the work knowing that these sorts of episodes would be part of the work. Our job has always been to stay put, stay reflective, stay committed, and stay pragmatic.
For some brief background, Bayalpata Hospital is supposed to operate as an independent entity via internal management structures, though staff are paid by the non-profit Nyaya Health Nepal (NHN, which itself is funded and technically supported by Nyaya Health International (NHI). All current staff are Nepali citizens, except for the Country Director. The Hospital has approximately 34 staff members, and provided comprehensive inpatient, outpatient, maternal, laboratory, and radiological services, though does not have an operating room. The operating budget is expanding, though this fiscal year will be approximately 250,000 dollars. NHI has been supporting direct clinical services in Achham since 2008, and Bayalpata Hospital is our only project. NHN, at this young juncture and given a history of corruption among non-profits in Nepal, is largely a legal mechanism, and though we would like it to be an autonomous entity with real leaders and decision-makers, it is not that yet.
We cannot pretend that the following is an accurate synopsis. History, particularly in times of emotional strain, is always a reconstruction. As we have written elsewhere, there is oftentimes a fog in resource-limited settings that makes management challenging. To protect identities and career reputations, I am not naming names. Briefly, the conflict arose, probably predictably, over staff salaries. That the initial spark was over salaries is not wholly surprising: most of our staff live in dire poverty, struggle to survive, to put food on the table, to educate their children. But at every weekly staff meeting salaries are discussed. The deeper context of this affair was that it happened during a period of leadership transition. The Country Director of Nyaya Health International had recently arrived in Nepal, and, while an experienced and effective manager, was neither Nepali, a speaker of the Nepali language, nor a physician. We had been unable to arrange for an effective executive assistant for him to serve as a translator. The Medical Director had recently transitioned to pursue additional graduate studies. This left our previous staff physician, who had served Bayalpata as an excellent clinician for the last year to step into the role of medical director, overseeing all the clinical staff, including a new staff physician we had just brought on. Both of them were extremely young and medical school does not prepare their future doctors for either the practical or leadership aspects of rural medicine. Around this time, staff began to express concerns about our procurement team who made a series of purchases for our inpatient unit, leaving significant wastage of money on equipment that was both overpriced and of poor quality. Many staff felt that this was frank corruption, and that the Country Director did not take enough steps to remediate or discipline.
So, a power struggle ensued. The new Staff Physician made several demands and made exceedingly unprofessional and at times racist comments in front of staff, directly to the country director, on Facebook, and to the NHI board. The Medical Director and nurse in charge followed suit, and the staff in general universally supported threats of a strike. Our Country Director attempted to mediate the situation, but was met with resistance. Threats, counterthreats, in both written and verbal form, ensued. The hospital was an extremely toxic and demoralized environment to work in. To our staff’s credit, services largely continued unabated. Throughout this process, the local government, most community members, and the police were all supportive of the Hospital and intervened in key moments to help keep it running. The other details are not too relevant here; suffice it to say, that after over four weeks of negotiations and counter-negotiations, the only solution was to have the three senior clinical members leave. This was a great loss organizationally and personally for all involved; the Medical Director and Nurse-in-Charge had served the Hospital with distinction for over a year, had given their hearts and souls to Achham, and now were forced to leave under the most unfortunate of circumstances. Achham, with all its suffering and isolation and poverty, has so often broken the spirits and psyches of our staff and volunteers. While they acted unprofessionally, they were broken by Achham, and Nyaya Health did not have the support or management structures to prevent that.
Subsequently, a community meeting was held, with local community members, government leadership, and Nyaya Health Nepal’s Kathmandu-based President. This meeting, together with the departure of the three primary leaders of the strike, calmed the situation. Now the challenge for NHI and Bayalpata Hospital was to identify what changes in our management structures could be put in place to prevent such occurrences in the future. In Table 1, we present the management failures on our parts, and what we are endeavoring to do as a result. Many of these failures were owing to our youth as an organization; it does take time to develop a community and leadership base. We hope that this table can serve as a point of departure for others to discuss the issues of managing at the margins—of learning how to be an effective employer in impoverished areas. We belief in working in communities that are marginalized, and who live at the margins of political power, the margins of health, the margins of the economy. Managing at these margins presents unique challenges. I should emphasize that when I say “management” it is not about me as a leader of an international non-profit managing a hospital from afar, but rather about us as as an organizationand a team developing effective management structures to deliver excellent healthcare.
Why does our somewhat rather parochial, he-said she-said drama matter to global health delivery? Most global health practitioners can relate that this is an all-to-common type of occurrence. The roots, or at least the correctable parts, of these problems, are poor management structures. Yet those very poor management structures are oftentimes not what donors, grantmakers, or the public health and scientific communities want to hear. The dirty secrets of management are not, on the face of them, particularly inspiring; rather they seem to confirm the “rat hole” of development aid. As a result, many of us in global health delivery oftentimes have to lead double lives, where we internally are self critical but externally have to put on an inspiring face. As advocates, we must identify what our supporters can relate to about our work, and “Saving lives” is a much more effective tagline than “Managing at the margins”. The truth is that we do, in fact, do both: we save lives but we also fail so much of the time to enact the right management structures that can bring out people’s strengths rather than amplify their weaknesses.
Duncan Maru, MD, PhD is a co-founder of Nyaya Health. He is currently a resident in the Internal Medicine – Pediatrics program and fellow in Global Health Equity at Brigham and Women’s Hospital and Children’s Hospital of Boston.