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Dear friends and family,

I am honored to share that last week Nyaya Health became part of the 1% of organizations examined by GiveWell to be distinguished as a standout organization.  GiveWell, deemed “the gold standard for giving” by the Boston Globe, takes their evaluations seriously.  In fact, only 6 of the 750 organizations examined this year have earned this standing.Why has Nyaya Health stood out?For our ability to treat the poorest patients in Nepal, and for doing so with “unusual transparency.”

I love that description.  Because if you worked alongside our dedicated team of 25 international volunteers and 108 paid Nepali staff as I do, you would quickly learn that there is nothing “usual” about the work we do.  Our dual commitment to deliver health care to Nepal’s poorest and most marginalized, and to do so with a level of transparency that acts as a rebuke to the status quo, is driven by a fiery indignation.

Bayalpata Hospital, home of Nyaya Health’s operation in Achham District.

The origins of that indignation began five years ago, when three Yale medical students visited Achham District in Far-Western Nepal and bore witness to the horror of what happens when 260,000 people lack access to even a single allopathic physician.  The injustices they saw – of mothers dying of AIDS for lack of access to drugs, and of children wasting from malnourishment – created a moral mandate to rapidly expand a system of comprehensive and quality health care.But that sense of indignation did not end with those images.  It was unearthed time and time again as we were told that our vision was impossible.  We were told such a system could not be achieved because of the lack of infrastructure, the isolation, the immense poverty, the political turmoil, and for lack of precedent – no one had done it before.But we are not the type of team that bows to such barriers.

And that is why the indignant flame of 3 has turned into a powerful fire of 133.  Since 2008, 80,000 patients have been treated, and a system of community health has been built that covers 17,000 citizens while also providing dignified employment to 73 women.  This has all been done in partnership with the government and transparently via our organizational wiki, where all of our materials including outcomes data, internal documents, email correspondences, and even line-by-line expenses for both Nepal and the U.S. are freely available to the public.

I write today to confirm that between our office in Boston and hospital in Bayalpata, something very unusual is indeed being built.

And it is my hope this holiday season that you can help us ensure there will be nothing at all usual about how we grow and transform health care in rural Nepal by making an investment in the life-changing work we do.

With gratitude,
Mark Arnoldy
Executive Director

Posted by Jesse Brady

 

School girls adorned with marygold flowers during the celebration of Diwali. The literacy rate in Achham is 16% for the age group of 6-15 years old. Nyaya helps to promote literacy through health education programs, which are facilitated by the deployment of community health volunteers.

 

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Jesse Brady is the Blog Editor of Nyaya Health and is currently pursuing her MS in International Medicine at Montana State University.

 

Posted by Duncan Maru

Our Country Director and I had the honor of visiting Dhulikhel Hospital this week to meet with staff members and Administrative Director, Dr. Rajendra Koju.  Dhulikhel is a not-for-profit, non-governmental hospital that offers affordable prices to its patients and manifests a singular vision of high quality and equitable care in rural Nepal, representing much of what Nyaya Health aspires to.  Being sick is one of the most terrifying experiences in patients’ and families’ lives, and it is clear—from the professional staff, the beautifully tiled floors, the foliage—that Dhulikhel does their best to provide an environment that minimizes fear and maximizes compassion.  Dr. Koju expressed some of the principles that guide their work and their management practices:

-Start with community vision

-Transparency

-Recruit local talent

-Decentralized management with decreased hierarchy

-Leadership with a clear sense of mission and vision

-Take challenges as opportunities

-Foster an enjoyable workplace.

We signed a memorandum of understanding (MOU) with Dhulikhel that will enable us to partner in receiving training and technical assistance, especially for our surgical services.

 

Please see a slideshow of our visit:

 

Do pay a visit to their website: www.dhulikhelhospital.org and visit whenever you are in the Kathmandu area.  Dhulikhel represents the best of community-driven development and healthcare in Nepal.  

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Duncan Maru, MD, PhD is a co-founder and President 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.  

Posted by Dan Schwarz

Nyaya’s community health worker (CHW) program has grown extensively in its first 18 months. Covering an area of more than 20,000 people, throughout six of the area’s villages, Nyaya is now working with nearly 100 CHWs, who are all locally-employed women from the villages that they serve.

Recently, Nyaya has been working with its colleagues at Partners In Health, Tiyatien Health, and Project Muso, in an innovative new task force for CHW quality improvement. This task force includes CHWs from 14 different countries, all working within their communities to achieve better health for their people.

As part of this task force, each of the CHW programs has been rigorously evaluating its operations, in an attempt to develop cross-program best practices. In collaboration with some wonderful volunteers at Partners In Health, Nyaya has recently completed a flow-chart of its CHW program, to map out the mechanisms of care-provision, leadership, remuneration, and accountability. We share this flow-chart with our readers here, and look forward to continually improving our community health programs for the people of Achham.


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Dan Schwarz is the Chief Operating Officer of Nyaya Health and a member of the Board of Directors. He is a student at the Brown University School of Medicine and has recently completed his MPH at the Harvard School of Public Health.


Posted by Astha Ramaiya

Community health worker Kamala Koli carries out a mid upper arm circumference (MUAC) test on a child to measure malnutrition. The rate of global acute malnutrition in the district of Achham is 18%, one of the highest rates in Nepal and the entire continent. This picture shows a color scale on the MUAC measuring tape; the yellow-red color indicates acute malnutrition or wasting, which requires immediate medical attention. Bayalpata Hospital is currently one of two stabilizing centres in the area that are equipped to provide ready-to-use therapeutic foods to the mothers of malnourished children.

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Astha Ramaiya is the Blog Manager for Nyaya Health and a student pursuing her MSc Public Health at the London School of Hygiene and Tropical Medicine.

The Management Center highlighted Nyaya Health and its core values in the recent edition of “The Management Fix.”  Jerry Hauser , CEO of The Management Center, commends Nyaya’s core values of efficiency, results, and transparency, and references the introductory email sent to new Nyaya employees which features these values.

The article is available here.

Posted by Astha Ramaiya

Ranju Sharma, Nyaya's volunteer, holds an orientation meeting with the new Hattikot Community Health Workers (CHWs). CHWs and Female Community Health Volunteers (FCHVs) gather in the community each week to provide updates on community health status and the common diseases encountered in the field. The FCHV network has been very beneficial in reaching community members throughout the region. FCHVs are chosen by their communities, and their participation in local life enables them to build trust and to establish ongoing relationships with patients and families in the area.

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Astha Ramaiya is the Blog Manager for Nyaya Health and a student pursuing her MSc Public Health at the London School of Hygiene and Tropical Medicine.


Nyaya Health is honored to be a member of the Praxis Network, an organization dedicated to promoting the “rights to health, equity, and dignity for people living in poverty around the world.”  Today we are proud to announce the release of the Praxis Network Concept Paper.  Please read this document to learn about how Nyaya Health is working closely with numerous partners to advance the following collective mission:

 

“…To break down the barriers to collaboration in order to leverage each of our organizational strengths for greater impact within the communities we serve and beyond.  By raising our common belief in the universal rights to health, equity, and dignity above all else, we will galvanize a diverse movement of people to stand with us.”

 

The Concept Paper can be accessed by clicking on the image below.

It is our pleasure to share an update on what you, as members of the Nyaya Health community, have accomplished via the #nov4nyaya campaign over the last 16 days:

  • $3,740.80 has been raised.  This money will enable us to tile 348 square meters, which is 41% of all of our clinical facilities that need to be tiled.
  • 13 birthdays throughout the month have been dedicated to help raise this money.
  • 82 people have invested in this effort.
  • 250 new individuals have started to follow our work via TwitterFacebook, and Causes.

Despite this amazing progress, let us also remember that we have 14 days left to tile the remaining 59% of our facilities.  Here’s what you can do to help us get to that point:

  • Recruit more followers for our pages at  TwitterFacebook, and Causes.  We are offering $1 for every new follower (up to $1000).  That means we have the capacity for 750 new followers to help bring a safe, clean and dignified environment to our hospital.  Please help us find them!
  • More importantly, if you know someone with a late-November birthday and they are willing to dedicate it to #nov4nyaya, you can just email socialmedia@nyayahealth.org, and we will walk you through the very easy process.
  • Make an investment to transform our hospital directly here.

We are deeply grateful for your support, and are excited to continue working alongside you to transform our hospital during the remaining 14 days of the month!

Posted by Astha Ramaiya

Latika (on the right) is the daughter of two Nyaya members, and as a member of the Bayalpata family, she is a source of much joy among hospital staff. This photo shows her pasni celebration, or “first rice.” This event is a celebration of a child’s weaning, and transition to solid foods, and is held on an auspicious day between the age of 6 and 8 months.

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Astha Ramaiya is the Blog Manager for Nyaya Health and a student pursuing her MSc Public Health at the London School of Hygiene and Tropical Medicine

Stubbed Toe

Posted by Duncan Maru

 

[This poem was written by Duncan Maru, co-founder and President of Nyaya Health.]

 

You have come to me for a busted toe,

an accident, you say.

Dressed in your loose black shirt

with a large Christian cross on it,

grey sagging sweat pants.

Your face, round, youthful, inquisitive,

impresses me.

You speak respectfully, calmly.

I could be lulled into thinking

that the busted toe is all that ails you.

But then you rattle off your medication list

like state capitols.

This awakes me from my

“musculoskeletal chief complaint”

slumber where most problems resolve.

I now see in your chart where you have been,

raped, hit, punched, kicked, abandoned.

Etiology of your condition is not “mechanical trauma”

but predation,

neglect,

abuse.

While you were suffering a lifetime of abuse,

I was in medical school

learning about tendons

bones

muscles

molecules.

and now here’s your lifetime of chronic diseases: 

Metformin, amlodipine: for adult-type diabetes and hypertension

Risperidone: for psychosis

Celexa: for depression

Trazodone: for sleep

Truvada: for prophylaxis against a deadly virus since you were raped

again, this month.

How I wish I could prescribe better laws, better communities,

better protections, better families.

But back to the purpose of our 15-minute visit:

you stubbed your toe.

I don’t think it is broken but owing to clinical prediction rules

and perhaps my own cognitive and emotional needs

you need an X-Ray.

So I order that, and give you the usual advice for

mild musculoskeletal injuries.

You smile graciously and move on.

 

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Duncan Maru, MD, PhD is a co-founder and President 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.  

Nyaya’s Bayalpata Hospital and one of our partners, TEAM Hospital, in the nearby district of Dadeldhura, were featured in a new article on GHDonline .  The article discusses the development of health services in rural western Nepal, and specifically, the cooperation of GHDonline communities to improve communication between local healthcare implementers. You can read the article here.

Posted by Astha Ramaiya

Bayalpata Hospital serves a catchment area of 250,000 people in the Far West of Nepal. Many of our patients arrive by foot after a three or four hour walk, or are carried by family members and neighbors. In 2009, the Indian Embassy donated an ambulance which now allows transportation for patients who are unable to come to the hospital on their own. This ambulance has enabled Bayalpata staff to not only provide emergency transportation to Bayalpata Hospital, but also to ensure safe transport for those who are referred to larger district hospitals.

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Astha Ramaiya is the Blog Manager for Nyaya Health and a student pursuing her MSc Public Health at the London School of Hygiene and Tropical Medicine.


Posted by Agya Poudyal

 

[Below is  the Community Health Worker (CHW) update from Bayalpata Hospital for the month of Bhadra, as well as a story relating the experiences of CHWs in the field.]

 

1. Community Health Worker (CHW) Data for the Month of Bhadra:
Three new categories have been introduced in this month’s table: [1] new pregnancy, [2] new birth, and [3] death.

 

Click image to view data spreadsheet.

2. Program Development and Expansion:

Community Health Worker Ganga didi presenting during the Saturday teaching session in Janalikot.

We have planned to expand our CHW and Female Community Health Volunteer (FCHV) programs to the neighboring Village Development Committees (VDCs).  We have just started to contact the health-posts and are working on organizing the expansion process.  Ideally, we are hoping to expand to five VDCs.  More updates will be shared as we move ahead in this regard.

3. Activities:The German International Cooperation (GIZ) Documentary team, consisting of Centre for International Migration and Development (CIM) Coordinator Sushmita Malla and Dilbhushan Pathak, a leading documentary

Community Health Worker Pabitra didi on the way to Hattikot during the monsoon season.

 maker in Achham, were here last week to shoot a documentary.  They followed our CHW program for two days and shot in different locations in Bayalpata.  They also filmed the Friday CHW training session, and the community meeting on Saturday.  We are hoping that the film will be ready by the end of October.

 

 

[Below is also a story regarding the experiences of CHWs in the field.]

 
Acceptance of the Community Health Workers

During a recent meeting with the CHWs in Chandika, Dilbhushan dai from the GIZ documentary team thanked our FCHVs/CHWs for playing a major role in reducing the infant mortality index of Nepal.  The FCHVs/CHWs gave him a blank look at first—not because they didn’t understand what he was saying, but because it took time for his words to sink into their stomachs.  In a few seconds, I saw them smile like never before.  His words came as a surprise to them because rarely do people give the FCHVs words of acceptance for the work they have done, let alone voice their thanks.

Community Health Worker Leaders during their weekly Friday meeting in Teej.

Acknowledgment of a CHW’s work comes as real encouragement for dealing with the moments when she is turned away from homes.  It cheers her up for moments when she is told that she doesn’t know anything.  It gives her courage for the moments when she is mocked.  And for moments when her years of experience are not respected, a word of thanks is all it takes to give her confidence.

Appreciate a CHW and let her forget all the less-than-lukewarm receptions.  Thank her and let her forget the moments she was ignored.  Let her remember the times when she is called for a pregnant woman’s labor.  Remind her of the times when she is asked how many times a day a child should be given an oral rehydration solution.  Remind her how mothers come to ask for her opinion about which steps should be taken next for their children’s treatment.  A word of praise is all that it takes to remind her how important she is.

I am indifferent to people who underestimate the importance of the FCHVs.  But I very much care for the several “Dilbhushan dais” who remind them of how important they are.  Let the FCHVs feel dignified for what they are doing.  Let them forget being mocked, even if only for a day.  Let them be at ease.  Let them be encouraged more and corrected less.  Let them be thanked.  Let them feel accepted.

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Agya Poudyal is the Community Health Director at Bayalpata Hospital. She graduated with an MA in International Relations.

Posted by Astha Ramaiya

Infant who was prescribed four antibiotics from a private medical shop. Three of the antibiotics were from the same class (cephalosporins), leading to potential toxicities with no additional benefits. In rural Nepal, unlicensed practitioners--many with no formal medical training--offer medical services, thriving in areas where public health infrastructure is weak. Income is tied largely to profits on medicines sold, and the result is that many patients are sold unnecessary and sometimes harmful treatments. These perverse incentives underscore the importance of free, public medical services, such as those offered by Bayalpata Hospital.

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Astha Ramaiya is the Blog Manager for Nyaya Health and a student pursuing her MSc Public Health at the London School of Hygiene and Tropical Medicine.