The gentleman sitting in my office believed he was helping us, or so I like to think. He was from the Nepal Red Cross Society (NRCS), visiting our hospital to discuss the NRCS’s criteria for Blood Banking Center approval –an approval necessary to begin any type of blood transfusion or storage services in Nepal.
His soliloquy on the advantages of hospital user-fees was unoriginal. Yet he delivered it with a passion, the likes of which I had rarely seen before. He waxed poetic about how Nyaya Health’s free-healthcare model was unsustainable, about how patients who paid for service would appreciate their care more than others, and how charging women for blood transfusion services—mid-child delivery and in need of an emergency C-section—could be the perfect opportunity for Bayalpata Hospital to begin a new and surely advantageous user-fee model.
After forty five minutes of our guest’s reflections, I politely intervened. I had noticed that three of our staff members—all of whom held high ranking posts and were in some way related to the conversation—began to support our guest’s idea with enthusiastic nods and comments like “Gregory, we really need to think about charging patients if this hospital is going to be sustainable.” I listened. And I waited for the conversation to end. But it didn’t. So I gave our guest a rather pointed ten minute monologue driven by the following three ideas:
- Nyaya Health is committed to serving the poorest of the poor.
- Nyaya Health plans to stay in Achham permanently.
- Neither Bayalpata Hospital nor I would tolerate someone coming into our home and telling us how to manage it.
The meeting ended shortly thereafter. Our guest and I agreed to continue the conversation in a formal meeting with community representatives the next week. With community buy-in, we both felt we could determine how to proceed with our proposed partnership. And we left with a handshake before our guest went to our hospital’s Outpatient Department to request a user-fee free medical examination.
As our guest left and I began a recap discussion with staffs present, I realized that the NRCS’s favorite word seemed to quickly become our own. “Sustainable”. How could an organization of any sort ever hope to survive if it did not charge for service? “It was simply not sustainable.” The gentleman from the NRCS seemed to believe it. Some of our staffs seemed to believe it. Perhaps even more than some. This was hardly the first time that I’d heard this logic. But it was the first time that I’d witnessed someone actually try to enforce it.
The community meeting was the following Wednesday. Our Administration fulfilled its promise of organizing the event, delivering invitations to local leaders and reserving the requisite tea and biscuits that all meeting attendees typically expect at such gatherings in Achham. Our two guests from the NRCS were hardly strangers, and arrived in high spirits. The lankier gentleman was the one described above. His burly counterpart was the Regional Manager, whom I had met on several prior occasions. We shook hands and walked into the room together, taking seats on opposite ends of our circle of plastic chairs.
After our meeting’s thirty members had completed their introductions, the NRCS began with its opening comments. Our burly guest began with descriptions of the purpose of this meeting, the necessity of NRCS approval before any blood banking could begin at Bayalpata Hospital and the importance of the community in developing those services through blood donations and general awareness. Then it came. Despite my neophyte Nepali skills, I heard the word again. “Sustainable.”
Why was everyone obsessed with this word? And perhaps more importantly, why was everyone so sure that our Hospital was in peril without charging less than $4 per blood transfusion? My questions were rhetorical and to myself. So I stayed quiet and continued listening. The Regional Manager continued for close to an hour, growing more confident with every dramatic pause he took. Then he stopped. He took a seat. And it was our turn.
My response was simple. It began with the first two points recounted above. It found its stride with “…and Nyaya Health is committed to working twice as hard to make sure that its patients never have to pay for service.” And it ended on “…thus it seems that there are really only three things that need to happen before Bayalpata Hospital can begin providing blood banking services : 1. The community must support the idea; 2. Nyaya Health must commit to covering all service costs; 3.The NRCS must approve it. It appears numbers 1 and 2 have been completed…”The crowd gave that faint but genuine applause I’d come to hear at so many of these events. And we knew we had sealed the deal.
The burlier of our two guests quickly walked over to me and requested in my ear that we finalize these discussions in my office. I agreed under the condition that his organization promise to grant our Hospital blood banking status in front of the community members present. And he did.
Is Nyaya Health’s model of free healthcare sustainable? To me our organization has flourished on the sleeplessness, brilliance, commitment and shameless funding requests of an international team of heroes. For an organization as young as we are, we have grown in leaps and bounds. In less than six years we have expanded from free blood pressure screenings in the local bazaar to a District-level hospital, whose staff of 54 will treat over 30,000 patients this year and provide community health outreach to nine districts. Our most recent board meeting confirmed that our budget for the next fiscal year will have to raise close to $1 million to cover in-country costs alone. And we still have our eyes on growth.
So is it sustainable? Or is Nyaya Health approaching its Icarus moment? How long can we beat our chests with the battlecry of “no user-fees” and “serving the world’s poorest” without any income to fuel them? If the most recent financial crisis has taught the non-profit industry anything, it’s that most donors view charity as akin to luxury good spending and will, understandably, close their wallets when a dollar in Nepal might also be put toward a harrowing mortgage payment.
The truth is that I don’t know the answer. There are times when I believe with every ounce of my being that we must continue to provide free health care, name brand medicines, x-rays, lab and community health services among others; that our efforts defy the “impossible” and will someday change healthcare across Nepal. But there are also times when I wonder “How in the world can we keep this up?” How in the world will we be able to raise $1 million next year? And will that even be enough? I’d lie if I said these questions and their myriad derivatives didn’t keep me awake on a regular basis. But I’d also lie if I said that I thought we should change our model; or at least before we have to.
It’s true that there may come a day when Nyaya Health must ask its patients for money. Perhaps that day will come in the form of a community health insurance model, or asking patients to purchase medicines, but not treatment. Perhaps it will never come at all.
But for as long as Nyaya is still driven by the sleeplessness, brilliance, dedication and shameless funding requests of its international heroes; for as long as Nyaya is able to recruit international heroes like the ones it has to date—ones of like mind and arguably nonsensical commitment to the ideal of justice through healthcare–for as long as Nyaya can afford to repeat figures like $1 million per annum with a straight face and glimmer of excitement, it should hold on. There is no question in my mind that every board member, visitor to Achham, or witness to the abject health that is this place would agree. We are committed to serving the poorest of the poor. We are committed to working extra hard to ensure healthcare for every last person here that needs it. Because, in Achham, we all need care. We need the efforts that have come to define Nyaya Health. And we need hope.
So we do what we do until we can’t do it anymore.
And that is sustainable.
Gregory Karelas is the Country Director of Nyaya Health. He graduated with an MSc in Medical Anthropology from Oxford University.