We in the development, global health delivery, and social justice businesses seek to change current conditions that produce poverty, injustice, and ill-health. On the one hand, our vision is often ambitious and over-sized for our levels of experience both as practitioners and visitors in communities that can remain unfamiliar even after many years. On the other hand, our implementation is more modest; for those of us who work to deliver healthcare services, we literally make our impact one patient at a time. That impact is tangible for our patients—if anyone argues that medical care is a “band-aid,” remind them that is probably not what they themselves experience when they or their family members fall ill—but its significance is more modest in the larger socioeconomic sense. So we work onwards, trying to facilitate dignity within the suffering around us, yet holding onto a larger vision. When does that vision become a dream forever deferred, and we become technocrats, having forgotten the underlying social and economic factors creating the problems we aim to solve technocratically? Alternatively when does that vision even matter?
For someone such as myself, primarily concerned with the technicalities of healthcare delivery, these concerns can occasionally feel like idle ruminations. But if every act is in essence political, particularly when you are working in resource-denied settings, then these questions do matter. The problems we face in getting the right drugs and diagnostics to our patients are fundamentally social, economic, and global. So, a global health delivery organization’s “theory of change” should address these problems to some extent. Ted Constan, COO of Partners in Health (PIH), reminded us of this in an insightful talk he delivered to our Global Health Equity Fellows orientation recently. He outlined PIH’s theory of change, and I found it instructive.
Their theory of change is focused on three actors—PIH, Brigham and Women’s Hospital, and Harvard Medical School, who work together to achieve four goals: Service, Training, Advocacy, and Research (STAR). The service is the mandate of PIH, and it is the grassroots core that makes the other elements possible. Training and research are both activities that Brigham, being an academic teaching hospital, and Harvard, being a biomedical education and research institute, are well-equipped to engage in. For advocacy, PIH is a grassroots organization with connections to local community organizations and organizers, to national politicians, businesses, and government officials. They have extensive ties within the international activist community with groups like Healthgap, ACT UP!, and Physicians for Human Rights. These activists can leverage PIH’s research and examples to build compelling policy and political arguments. We have seen this work with some impressive successes with HIV and TB.
Back to Nepal. Let’s face the fact of life of our patients: the Far West lacks surgical services. There is no infrastructure to house clinical services, or more precisely, clinical providers. That is the problem. My instinct, as is most of the Nyaya team’s is to ask the question: how do we fix that? Build an operating room. We can do that in alignment with a certain vision—free services provided in a government building and paid, at least partially, by the government. We can pursue this technocratically, through supplies chains management and quality improvement initiatives and staff trainings. But of course that is not all that is going on in the Far West with respect to why citizens are not getting the care they need. Supplies don’t come on time partly because of trucking syndicates that the government can’t seem to break. Doctors don’t stay long because there are no schools or opportunities for their families. Public infrastructure is lacking because of small national budgets of which even smaller amounts get apportioned to the politically-marginalized Far West. What can be done?
As it stands, we at Nyaya have not proved ourselves to achieve results in this realm of advocacy. We are too consumed with trying to get care for our patients, for good reason. Our patients in the immediate term cannot wait for large-scale political and economic transformation. While the lack of surgical services (or any public goods or services, for that matter) is fundamentally a political and economic problem, we approach it technically. In economically and politically powerful places, the technical problem of access has largely been solved; if Achham had power, they would have plenty of surgeons. Of course, in the (only slightly) longer-term, the people of Achham are literally dying awaiting such broader change. We do act with purpose: free services, building a government-owned structure, and working within the government’s existing community health worker network, but if the roots of the problem are political and economic marginalization, then we are ultimately missing the boat.
Nyaya has historically had a vision of direct service and local action that, through transparency and dissemination, could facilitate global change. Achieving that vision has been a challenge, though we have had successes. Currently, we are in the midst of refining that vision. Here is one draft attempt:
That is, the work that we do on the ground in Achham has a vision about delivering healthcare in resource-denied environments: working to achieve community-level ownership over the health system, collaborating with the government, collecting ongoing data to evaluate our impact, actively revising our systems through quality improvement. Subsequently, this work feeds into our broader work as a participant and leader in the global health equity movement, through collaborating directly with similar groups, through pushing the field to be more transparent, through global advocacy, and through scientific research. The impact of these parallel activities on each other runs in both directions: our local healthcare delivery directly impacts our contributions to global health equity, and victories in global health equity facilitate generating resources and ideas for our on-the-ground work. There is much work to be done…
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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.
