Feed on
Posts
Comments

Posted by Duncan Maru

As I’ve discussed in another thread, email forms a central aspect of the modern work life for many; as I cited in that post, in one study among British white-collar workers, a full 55 work-days per worker are spent on email.  So, there should be a way to ensure that the core organizational task of email communication is done in a transparent fashion.  The strategy we used here was the Nyaya Health mailarchive.   This is a google apps email account to which all emails to the domain @nyayahealth.org are stored.  We set this up initially (when you could count our volunteers on two hands) as a way to ensure that all our emails could be housed in one place and could be quickly reviewed for institutional memory purposes.  We provided all team members access to this as a point of transparency and efficiency; from our wiki:

“We feel that it is an important aspect of organizational efficiency, history, and transparency that our Nyaya-related emails are housed centrally in one location and open to all Nyaya team members.  The primary functions of having an open mail archive are:

1) internal transparency: our email communication, which constitutes a huge portion of how we work, are available for review by other team members as needed;

2) institutional memory: in the cases of transitions of team members, it is helpful to have an archive of previous correspondence on various subject matters or with various individuals

3) efficiency: this can cut-down on the need for forwarding or looking around for lost emails

4) reliability: in the cases in which anything unfortunately happens to a member (death, sickness, etc.), we need to be able to maintain all the hard work and efforts and contacts of that member.

5) team coherence: members are less likely to disobey basic rules of etiquette (e.g., not respecting others, not engaging in productive and non-judgment dialogue)”

 

This, I think, is a fairly unique idea: all email communication within the organization is open to everyone within the organization.  Another way that I’ve personally thought about this is as follows, which I wrote in an email to some of our leaders:  Security on the internet is so hideously poor such that there could easily come a time when all that we have ever emailed becomes fully available to the public, including donors and team members.  Whenever we write an email, we should keep this in mind, and write positively and respectfully.  We can of course write informally and tell jokes and be very critical of each other, our work, the government etc.  I don’t think that being respectful inhibits critical dialogue; rather if we are disrespectful then we’ve just closed avenues for honest and critical and reflective dialogue and the opportunity for honesty.  Furthermore, when we are in the mindset that what we write could be read by anyone, we are more likely to say, “maybe that will make a good blog or wiki entry or institutional memory document” rather than an email, email being a necessary crutch that should be minimized since it is such an inefficient mode of communication.  This is a supremely challenging goal, and one that I fail to achieve on so many occasions, but I had hoped that the mailarchive could help influence our organizational culture in a positive way. Unfortunately, this has not worked out as well as it could have, and the mailarchive facilitated just the opposite of respectful, honest, open dialogue.

 

We used the mailarchive successfully for nearly four years without much problem, then what happened?  Somewhere along the way there was a breakdown of trust between various members of our leadership team, and folks started using the mailarchive to identify he-said-she-said moments to confirm growing biases against each other.  This ultimately led to one particularly very bad decision that has taken us a few months to recover from and at significant monetary costs.  Our team recovered, and I believe our unity and ties as an organization is as strong as ever, but the dangers of the mailarchive was exposed.  I think these sorts of interpersonal conflicts are natural in any small organization, but the presence of an ongoing record of our communications, especially in email form that poses such challenges to interpretation, fueled the fire.  This, I will note, was despite clear guidelines on the wiki to not do precisely this:

“One thing that Nyaya members agree not to do:  read the email archive regularly.  The mail archive is a privilege and a pact between each other to.  The mail archive is simply not meant for that purpose; since the risk is real given human nature, the following points are worth noting, particularly for Nyaya team leaders/managers:

1) Do not “jump into” another conversation that you come across in the archive.  Doing that is like a boss snooping around the corner between two officemates in their cubicles.

2) Do not read the archive; other people are managing all the emails in the archive and it is wickedly inefficient to be reading those.  Though it is tempting to think one can be helpful in such situations, it is very unlikely to be productive and is going to feel intrusive and make one feel less inclined to using @nyaya emails.

3) People are entitled to having private threads without intrusion by managers, just as in the non-virtual organizations people have lunches, phone calls, cubicle chats, etc.  The flip side of this on the part of all team members is above, in the section on collaboration and efficiency: that most conversations should be focussed on wiki, team@, or other collaborative content.”

 

The point is, I think, that there comes a time where “information overload” is just not mentally healthy.  When we start interacting with each other as largely electronically constructed ideotypes rather than actual persons, our natural abilities to communicate break down.  I still feel strongly that, if a Givewell or a donor wants to read our mailarchive, we should give them the password, and that our members should write emails in a respectful and open way that allows for that.  But open access to too much information just led to too much conflict.

—————————

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.  This post is part of a series on the logistical challenges of achieving transparent operations


 

CHW Leader of Siddheswor Village Satya Sunar, talking to some kids in her village during one of her ward visits this week.

——————

Ranju Sharma is currently the Program Coordinator at Bayalpata Hospital. She recently completed her BSc at Mount Holyoke

Posted by Dan Schwarz

Bayalpata Hospital has been featured in a new article on Outline News, written by Nepali free-lance journalist Loksari Kunwar. You can view the article here. Nyaya Health would like to thank Loksari ji for her great reporting and for her continued commitment to the people of Achham.

—————–

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 from Harvard School of Public Health.

House visit

Posted by Duncan Maru

Recently, Dr. Bikash visited one of his patients with tuberculosis who did not make it to the hospital for his scheduled visit.  He needed adherence counseling, an HIV test, and sputum investigation.  Fortunately, he lives within an hour of the hospital.  After outpatient clinic, Dr. Bikash and I motorbiked and walked with our driver Dilidai to the gentleman’s house.  The first leg of the trip was via motorbike over the recently pitched road leading from the hospital to the Bayalpata bazaar.  The road had fundamentally improved since I had traversed it last; from dust and potholes and large boulders to pavement.   The journey from the hospital to the bazaar would have taken twice as long prior to the pitching of the road.  Shopkeepers and restaurant owners all greeted Dilidai and Dr. Bikash warmly.  We then turned off the bazaar strip and made our way down the mountain through the fields to the gentleman’s house.  Halfway through, Dr. Bikash remembered that we had forgotten the sputum containers.  Dilidai ran back up to the market to search for a replacement; he would catch up to us fifteen minutes later bearing a plastic bottle with a pink cap. We then proceeded to the patient’s house.  His house was filled with children, running, playing, beating rice, carrying littler ones.  Dilidai counted fifteen in all.  Dr. Bikash’s patient was seated on the third floor of his mud house.  Dr. Bikash asked him how things were going.  He described continued pain in his back, and that was the reason why he had not been able to make it to the hospital.  He was planning on taking two anti-tuberculosis pills (instead of the prescribed three) today and tomorrow so that he could stretch out the medicines until he would build up enough strength to come back on Sunday.  He was also concerned about bright red urine.  Dr. Bikash gently asked him to take his third dose of the anti-tuberculosis medicine, explained to him about the red coloring as a side effect of the medicines, and instructed him to come to the bazaar in two days where he would be picked up in the ambulance to stay at the hospital to help figure out a good pain regimen.  Finally, he provided him with Dilidai’s sputum collector; the patient already had collected one himself.  He would provide the third and final sputum sample at the hospital in two days.  Here, I provide some photographs of Dr. Bikash’s journey; out of respect for the patient’s confidentiality, I do not provide pictures of the patient, his family, or his house:

—————————

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.  This post is part of a series on the logistical challenges of achieving transparent operations.

 

Posted by Ryan Schwarz

On April 1st, The Nick Simons Foundation generously donated $25,000 to Nyaya and offered an additional matching donation of $75,000 more – the total donation, if Nyaya was able to raise $75,000 ourselves, would equal $175,000!

I write today to announce that with your support Nyaya has not only reached that goal, but done so in record time! While we had set what we thought was an overly ambitious deadline of July 1st, 2011, to raise the $75,000, with your commitment to this work we were able to raise the money in only 2 months!

Thank you – for all you do and all you have done. Through your dedication to this work we have literally changed the face of healthcare in one of the poorest regions in South Asia, and bring life-saving treatment to hundreds of patients every day. Over the next year these funds will help to bring the first surgical facility to the region, continue to build our community health worker and public health programs, and bolster the current services offered at Bayalpata Hospital.

Thank you, again, and we look forward to working with you more this year.

———————-

Ryan Schwarz, MD, MBA, is the Vice President of US Operations for Nyaya Health. He is currently a resident in the Harvard Brigham and Women’s/Children’s Hospital Medicine-Pediatrics Residency program

Posted by Duncan Maru

Since starting services at the Sanfe Clinic, Nyaya Health has been planning for the ultimate day when we would start surgical services.  Now, nearly two years into services at Bayalpata Hospital, we are making preparations to take that next step.  Concurrently, Nyaya Health has been developing the basic infrastructure necessary to conduct “implementation research” to help rigorously develop and disseminate our model.  Implementation research is the scientific study of the real-world deployment of healthcare services, and is necessary in bringing key public health interventions to scale.  We have decided to study the implementation process of surgical services at Bayalpata Hospital as our first major research endeavor.  We are doing this because there is an acute need: two billion people live in places like Achham, where there is less than one operating room for 100,000 people.  Yet never before has anyone undertaken to prospectively study the deployment of surgical services in a place such as ours.  So, we are endeavoring to study the process of scaling-up surgical services in Achham.  To do this, we are collaborating with our colleagues at the Center for Surgery and Public Health.  Trauma surgeon Selwyn Rogers and myself will be leading a team of researchers.  We recently have submitted an NIH grant for this purpose.

In this noon-conference at my residency program, I grapple with my colleagues about the challenges of research in a setting such as ours.  We discussed issues of unreliable electricity supplies, of staff familiarity with research protocols, and of not obstructing our service mission with the logistics of research.  We also discussed challenges particular to the NIH grant process and of identifying mentors for this kind of work.  I provide our readers with the slideset to give a sense of the talk:



—————————

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.  This post is part of a series on the logistical challenges of achieving transparent operations.

 

posted by Ryan Schwarz

Two months ago we announced the exciting $75,000 matching grant from the Nick Simons Foundation and set a goal of July 1st, 2011, to raise the full $75,000, generating a total of $150,000 for our patients in Achham. With a month to go we are on track to meet this goal, and with your help today, we can far exceed it!

As of this morning, we have raised $71,988 of the $75,000 goal, leaving only $3,012 to go. Given the enormous outpouring of support we’ve received, we’re asking you to help us reach our goal earlier than July 1st. We are setting a new goal of June 21st, 2011. Why this date? Because on June 21st, Bayalpata Hospital will turn 2 years old! Bayalpata is a symbol of our collective commitment to Achham, and of the immense collaboration that Achhamis, Nepalis, and people of a dozen countries around the world have helped to build. This year, please help us celebrate the 2-year anniversary with a commitment for an additional $150,000 for Achham!
So, how can you help? Today, right now, please, take no more than 5 minutes to share this link with 3 friends who don’t know about Nyaya’s work. Tell them why you’re excited about the movement for health equity in Nepal, and how you have contributed towards providing life saving services in Achham.  Use Facebook, Twitter, old-fashioned letter writing, or host a party and talk to your party-goers about this work. We’re so close, and hitting the $75,000 mark means doubling every dollar we’ve raised in the last two months and bringing new services to our patients in Achham.
As we approach our 2-year anniversary, we extend our thanks to all of you once again for the support you have provided, and hope you’ll take an extra 10 minutes today to push one step further down our path.

Dear Friends,

We write seeking your assistance in issuing an urgent call for trained physicians who are interested in serving in Liberia with Tiyatien Health. Founded by survivors of the Liberian civil war, Tiyatien Health is a young, growing organization providing community-based health care in rural southeastern Liberia since 2007.

We are asking for your help in spreading the word on the following two gaps that we need to fill as soon as possible:
- Interim Clinical Director – Volunteer position to serve 4-12 weeks in Liberia, responsible for providing clinical care in Tubman Hospital and supervising all of TH’s health services in and around Zwedru. Travel and living expenses will be covered. (Full description and how to apply)
Full-time Clinical Director - Full-time position to serve at least 12 months in Liberia, responsible for providing clinical care at Tubman Hospital, supervising and promoting excellence across all of TH’s program areas, and mentoring and training TH clinical and community-based teams in Zwedru. Annual compensation (including benefits) of $42,000 USD. (Full description and how to apply)
Thank you for considering our request and for your support and solidarity as we seek to rebuild health and hope in rural Liberia.
Visit Tiyatien Health or contact info(at)tiyatienhealth(dot)org for additional information or questions.

Posted by Duncan Maru

Access to organizational documents are a key aspect of transparency. Overall, Nyaya has done a solid job documenting what we do so that our staff, leadership team, and volunteers are able to access the “institutional memory” needed to get work done.  We’ve had a hodge-podge of a system in accomplishing this, in part because of very real technical limitations.  Again, from the beginning, we’ve had a system that was available to everyone in the organization and to a large extent the public at large, though the accessibility (in this case, navigability) remains limited.  The wiki has from the beginning been the centerpiece of our transparency initiative; it is supposed to allow for real-time public access to nearly all relevant organizational documents. Until recently, here was our system (again directly from our wiki):

We use several collaborative technologies that can be confusing at first as to their purpose.  Many members ask, “why do we need to have all these different technologies?

wiki: for publishing to the public and collaborating on projects among US-based team members.  it loads poorly in Nepal.

evernote: collaborative clinic manual.  this has online/offline options and tags for “chapters”.  slow internet is not a problem and thus this is used heavily by Achham team.

live sync: for sharing our ~1400 organizational files amongst our members.  neither wiki nor evernote has good file-sharing capabilities

google docs: primarily for collaborative spreadsheets.  foldershare does not have versioning.  also, google docs allows to easily publish data and analysis to the web/wiki

The uptake of these different technologies has been very poor.  While editing the wiki is literally a matter of logging in and starting to type, mentally it’s a challenge to write something in draft form on an organization’s site that anyone can stumble across.   Here’s the challenge, and our suggested solution, as we have summarized on the wiki on our section “promoting a wiki culture”:

“There is a perception that a wiki is somehow “high tech” or requires “tech saaviness” to use.  This is wholly incorrect, and the Wiki Manager, together with Nyaya leadership, needs to help dispel this myth.  The bottom-line is that if people can login to their email accounts and can edit a word document then they can use a wiki.  So establishing the wiki as a mode of how we do business is a purely cultural issue; the analogy is that it would have been unacceptable 8 years ago for any self-respecting organization to not mandate its members to use email. The wiki is just a fundamental and basic tool of the modern business world.  As an aside, there are a number of “high tech” applications– such as all those short-attention-span, slow-typing-on-mobile-devices applications like chat, text– that are in fact wholly inefficient and should be discouraged in an efficient organization.   See also our blog post on the subject.  The primary challenge in promoting a wiki culture is to get members out of their email inboxes.  This is no small challenge since the email inbox is one of our society’s primary addictions.  We should encourage our users to take a deep breath before they write a several paragraph email and think “Wait, I am about to spend thirty minutes on something that is going to go to a handful of people, who will then archive the email.  My ideas will be lost.  I should get out of crisis-mode and get into optimization mode.  Let me take an extra few minutes to organize my thoughts only slightly more and put them on the wiki instead, and send the link to my collaborators.” Now, sometimes we forget; if we come across an excellent email thread, we should be comfortable pasting the contents on the wiki.   Copy-paste however must be done with great care, as we caution our grant writers; the reason for “thinking in the wiki instead of your inbox” is so that you think in an organized, professional way which our email inboxes are not typically designed for. “

Nyaya has largely failed at implementing this culture, and our wiki remains largely aspirational, with a lot of outdated and disorganized content that most of our members do not feel comfortable editing.

The other technologies all had their challenges; live sync was difficult to download and had syncing issues, evernote was not intuitive for many people and didn’t have good public sharing options.  Ultimately, we came across dropbox, which pretty much solved a major problem for us: good offline access to collaborative documents with easy sync-ability between Achham and the US.  With this, we have been able to eliminate evernote and (mostly) google docs and focus only on dropbox and the wiki.

Today, our organizational dropbox account, containing over 4,500 files, from contracts to old grant applications to planning documents, can be browsed and downloaded by the public, is available on our wiki, and is shared across all our volunteers.  Every document that we edit or save on dropbox is almost instantaneously available to the rest of the world.  For privacy and security reasons, we do not have any volunteer or staff applications, patient data, staff contracts and correspondence, web login information, or banking login information.   Unlike the wiki, dropbox has had a rapid and effective uptake within our organization, I think because it is easily integrated within Nyaya members’ daily e-work-flow.  After all, dropbox items are merely word documents and pdf files in a folder on one’s computer, just like any of their personal folders.  The folder just happens to be shared for editing with all of Nyaya and for viewing with all of the world.

So, all this information is fairly compelling as far as being available to the public; if you’re a volunteer or a donor or supporter and have hundreds of hours to browse, you might get a sense of what we do.  But the information is not really accessible or navigable in a compelling way.   Currently, a working group lead by two Nyaya veterans (Shefali Oza and Astha KC) is working through this very problem.   It’s not easy, and made more complicated by the fact that ideally we would have one system, whereby all the dropbox files (mostly word documents) are perfectly linked and easily browsable on the wiki without any BW-intensive wiki uploading from Achham.  That unfortunately is a big technical task for which we have yet to find a good solution.

—————————

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.  This post is part of a series on the logistical challenges of achieving transparent operations.  


Posted by Ranju Sharma

Some Achhami women performing a local song and dance from called "Deuda" at a festival in a Temple nearby. Of the performers are a few of our CHWs and one of our CHW leaders

——————

Ranju Sharma is currently the Program Coordinator at Bayalpata Hospital. She recently completed her BSc at Mount Holyoke.

 

Posted by Duncan Maru

At the pharmacy with Raviman Kunwar

“Duita bihana ma, Duita sanjh ko, la”. In counseling patients on how to take their medicines, the Bayalpata Hospital pharmacist Raviman Kunwar has the cadence of a Kathmandu micro-bus helper calling out to passengers to get on board, or an auctioneer selling his wares.  At twenty-one years old, complete with stylish spiky hair, Adidas windbreaker, and a mischievous smile, he’s enjoying his first job since graduating from pharmacy school.  He makes it clear on the drawer on his desk who is in charge: “Raviman’s Drawer.  Keep Ur Hands Away”.  Despite having only recently graduated, he had impressed the Nyaya management team with his knowledge base and interpersonal style and he landed the job.

 

Ravimanji’s desk makes it clear who the boss is in the pharmacy

The Nyaya Health pharmacy is an impressive logistical operation.   Every day, some one hundred patients are provided some form of medicine from our formulary.  All of these medicines are dispensed free of cost to the patient.  The annual pharmaceutical cost to run Bayalpata Hospital is on the order of a quarter of the entire operating budget.  These medicines have all made the long journey, typically from India, to the south of Nepal, up through the mountains.  They are then processed at intake by Deepak Bista, the Data and Supply Assistant, for distribution to the pharmacy shelves.  Well, most of the medicines are on shelves; there remain a number of boxes for which we do not as of yet have the shelving space, a fact Raviman readily points out.  Raviman makes a record of these transactions via a register, which goes back to Deepakji for accounting purposes.

 

Shelves housing medicines. As can readily be seen by the boxes on the floor, we need to procure more shelves.

What does Raviman like about his job?  The counseling, the dispensing of interesting medicines, the patients he Is helping.  To me, watching him peer through a small barred window through which he dispenses medicines and providing counseling at a breakneck pace to an enormous queue of patients, a process improvement would be to give him more time.  He sees it differently; he takes as much time as he needs with every patient, regardless of how long the queue is.  The single most important change he advocates for is to establish a hospital pharmacy committee to oversee pharmaceutical purchasing.  This committee would consist of himself, the medical director, and the hospital administrator.  As it is, now he alone forms a sort of ad hoc committee.

 

The pharmacy register

My impression remains that, while Raviman does an excellent job, patients require a lot more counseling than we are currently providing.  Given most of our patients do not read, some pictorial system for dosing and side effects would be nice.  Within our current set-up, however, I do not have any solid ideas for instilling such changes.  For now, I do think that patients for the most part feel well-served by our fast-talking, good-humored pharmacist.

 


Posted by Duncan Maru

Much has been written and talked about with regards to the need for organizations, corporations, and governments to operate more transparently.  The non-profit sector is particularly problematic, as the Global Accountability Report has made clear.  Nyaya Health for our part has long held an organizational mandate of transparent operations.  Operationalizing transparency poses large practical challenges, and, while I do believe we have tackled them head-on and reflectively, Nyaya Health has been unable to overcome many of them.  Having the vision is important, but being able to enact that vision is what separates effective organizations from the rest.  Ultimately, once we have the vision and commitment to be transparent, the problem becomes a technical and managerial one.  Addressing these logistical details is the motivation behind the new Nyaya blog series on transparency.

I had the privilege of talking with new Nyaya volunteer Roger Wellington-Oguri on the phone about these issues recently.  The conversation was somewhat unexpected.  A PHD in computer science, he has joined our team to help redesign the website.  I am myself not particularly involved in redesigning the website; I have the aesthetic sense of a blind New York City subway rat.  What got me interested, however, in Roger’s work was his insight into the very process of how we use the web to communicate with each other and to the outside world.  I was intrigued when I saw a few emails from him that made it clear that he was not just interested in a cosmetic change to our web presence, but was interested in re-conceptualizing the very processes by which we use information technology.  I also was hoping to metaphysically catch some of his San Diego sunshine, currently living amidst the mounds of snow, ice, and dirt in Boston.  It was illuminating for me to talk through the issues of transparency from an individual with an eye for this sort of stuff and just coming into our organization as a relative “outsider”.

Later, I had the opportunity to talk with some of the analysts at an innovative organization called Givewell.  They evaluate charities and recommend a very small handful.  They take transparency  very seriously, and in fact make that a central component of their evaluations.  They have a large, prominent section of their website entitled “Mistakes”.  In fact, they publish their conversations with charities online, as they did with mine.  In discussing with them, I was reminded again by the how hard transparency really is.  Most of my answers involved were (disappointing for me, perhaps unfortunately revealing for them) very aspirational.  Yes, for three years we’ve been trying to get reliable data, but no we don’t have much to show for it; in fact at one point our data program had collapsed.  Yes, we publish our budget line-by-line online for the public but no we have a very hard time calculating cost-efficiency ratios. Good intentions are probably the single greatest impediment to doing well or giving well, and Nyaya’s history with respect to transparency in many areas has been marked by a failure to meet our good intentions.

Defining Transparency

But I’m getting ahead of myself.  This series is a reflection on transparency, and I should first define the problem. I’ll duly note that these definitions have arisen from a recent Nyaya conference call on transparency and other conversations, such as those with Roger. Transparency can be divided into three basic levels: availability (can someone find information about an organization?), accessibility (is this information in an understandable or analyzable format?), and usability (can knowledge and understanding of the information facilitate change within the organization?).   That latter point gets at accountability, and I don’t want to conflate the two, but I do think it is important to be clear that the ultimate goal of transparency is better operations, greater effectiveness.   There are four classes of actors for whom transparency matters: volunteers within our organization, our international donors and supporters, our paid staff in Achham, and local community members in Achham.  In my mind, the ultimate bottom line on transparency is the local community: do our patients and families understand the services we offer, the quality, the staff, the costs and risks, the decision-making processes?   Can our clients identify and advocate for fixing problems in the care we deliver?  The local aspect of transparency is a central one, an under-analyzed one, and one that is critical to that dangerous buzzword: sustainability.  Most of the international community’s focus on transparency has been at the donor level, for obvious reasons, and Nyaya’s successes thusfar have been at the international, rather than local, level.

Understanding the different actors for whom transparency matters is important because transparency is not so much a strategy as it is a culture, a way of organizational life.  If transparency is merely a matter of putting up our 990s or budget information or our outcomes stats, then I don’t think this achieves the primary objective of transparency: accountable operations done with integrity.  We can publish lots of reports on what we do, but that is only window-dressing if volunteers and staff do not go about their daily life knowing that their successes and failures are part of an open organizational process, one that hopefully will lead to self-improvement.  To take one example: we have a public-access wiki and a public-access institutional file cabinet that are both updated by our staff and volunteers and synchronized in real-time to the outside world.  As this is integrated into our work-flows, transparency becomes simply a part of life, and acting with integrity becomes less of a burden than just a way of systematically doing things.  I do not want to over-state the case (ultimately only our mothers and fathers and teachers are responsible for our individual integrity), but I do think that a culture of transparency can improve integrity at a systems-level.

We will return to these issues with specific examples over the coming weeks.  In this series, we will center the discussion around a series of challenges that Nyaya has encountered in our transparency initiatives.  Stay tuned for more; in the meantime do check out our wiki page on transparency, which provides an overview of some of the issues.

—————————

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.  This post is the first part of a series on the logistical challenges of achieving transparent operations.  


Hardwick Gazette has featured Dr. Mark Lichtestein and Cynthia West’s work in Nepal.

The article outlines the the author’s views on the Nepali language, culture and perception of health conditions amongst the population of Achham.

Posted by Dan Schwarz

Here at Bayalpata Hospital, we’ve recently had several visits from respected government and non-government officials / organizations who have questioned our policy of paying our community health workers (CHWs). In reflecting with them and in other conversations, I thought it might be appropriate to say a bit about our position on CHWs and where we stand in the world-wide CHW movement.

Background:
Historically, there have been many examples internationally of government and non-governmental volunteer CHW programs. These programs claim that, despite being desperately impoverished, (mostly) illiterate, and (mostly) agrarian women who have children, animals, and the fields to tend to, these women should be proud to serve their communities voluntarily and that if they are paid, it will detract from their sense of community or their value in the community. These programs also state that it is “economically unsustainable” to pay CHWs because there’s not enough money in health budgets.

In remote areas like Achham with scant health facilities and low health awareness, CHWs can have immense benefit.

Over the past 10-20 years however, a different movement has risen up. Our partners at PIH have been at the forefront of this movement (among others), claiming that these village women not only can be paid, but should be paid. This logic, which seems clear to us here in Achham, is nonetheless widely refuted throughout the world still to this day. The broad-picture arguments for paying CHWs include:

  • Human rights – All over the world people are paid for work; why should CHWs be any different? Isn’t it fair to pay all people for all types of work? Why should Ministers of health, doctors, nurses, other health workers, or expatriate INGO workers be paid, but CHWs should be volunteers?
  • Life demands – CHWs are, by virtue of the populations from which they are selected, profoundly impoverished. If there was any hope of having sustainable volunteer health systems throughout the world, selecting your volunteers from the poorest of the poor is unlikely to produce good retention, motivation, reliability, or accountability. Here in Achham for example, how can we expect a poor village woman to do house-calls for a diarrhea outbreak in early monsoon when her entire family is depending on her to be plowing the fields that day? Whereas volunteering might be feasible for a year or two with financially-stable college kids in the US or Europe, it is not likely to be sustainable to depend on women who literally do not have enough food to eat themselves.
  • Effectiveness — All over the world, everyone accepts that when people are rewarded appropriately for their work, given recognition and compensation, they tend to be more motivated. Not surprisingly, the same is true of CHWs.

From a programmatic perspective, the overwhelming demands on these women, including agricultural duties, household duties, and motherhood, make this work infeasible without some sort of compensation.

The literature has slowly, but increasingly, begun to support this. Studies are difficult to conduct, but what little has been studied has shown that incentives and recognition improve retention and effectiveness, and increasingly, many policy recommendations are shifting to supporting CHW salaries. USAID, for example, recently published its 2011 CHW Assessment and Improvement Matrix (AIM) Toolkit, which includes incentives (both financial and non-financial) as one of its 15 high-yield recommendations for CHW improvement. Others, including many transnational bodies such as the UN and WHO are saying the same things.

To read more about the literature and data on this topic, please see this recent piece written by Nyaya’s Co-Founder, Dr. Sanjay Basu, on his blog [EpiAnalysis].

Nyaya’s CHW program:
To clarify, our program was built on these principles. We believe firmly that

  1. Our CHWs deserve compensation for their work, and
  2. We are confident that compensation makes them more motivated and engaged in the work because of what they directly tell us themselves. I think it speaks volumes that, since starting the program 9 months ago, we have a mean attendance rate of greater than 99% at our CHW meetings for all VDCs in which we are working. Yet, our CHWs tell us directly that, without the money, they would not be as motivated to come because of their other pressing demands in their lives.

We have recently been criticized for this quite a bit. We have spent quite a lot of time clarifying our position, and the response tends to almost always include the “S” word (“sustainability”). To this common complaint, there is no answer that will assuage the conversant. Yet nonetheless, we try. Continuing to highlight the double-standards of the large salaries of officials and foreign development workers who are paid to “consult” or “design” programs in which CHWs work, and yet then asking them to be volunteers to enhance “community pride” is still controversial for many, but we feel strongly about this and will maintain our position, both through advocacy and implementation here in Achham (“show, don’t just tell”).

We believe firmly that CHWs should be paid. If everyone else in the world is paid for their work, CHWs must be paid as well.

In closing, I’d like to quote PIH Founder and Nyaya Board member, Dr. Paul Farmer. When asked “Which single intervention would do the most to improve the health of those living on less than $1 per day?”, his answer was simple: “Hire community health workers to serve them.”

———————————-

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 from Harvard School of Public Health.

Posted by Gregory Karelas

Please consider the following definition. Transformation: “a thorough or

Examination table before and after the paint

dramatic change in form or appearance.” (OED 2011, online) Now please look at the photos below. One is what one Bayalpata staff bathroom once looked like. One is what it now looks like. One is what a Bayalpata patient bed once looked like. One is what it now looks like. What’s the difference? Paint.

In a career some time ago, I worked as a superintendent for two apartment buildings in Brooklyn, NY with maintenance and repair responsibilities at two others. For those unfamiliar with NYC living, allow me to paint you a picture–pun intended. With their charm and beauty, New York apartments often rest upon outdated plumbing bound by generations of patchwork, labyrinithian electrical systems and heat that seems to never find the great middle road between sauna and icebox. As a result, my career development included years of calls from desperate tenants and a Pandora’s box of structural adjustments, fix-it jobs and general crowd control. With each came great lessons in mechanics, patience and persistence. But each also reinforced one great lesson that applies from the streets of Brooklyn to the mountains of Achham. “Paint heals.” That lesson has proven true time and time again, in countless circumstances, with countless people and towards solving countless problems. It has even become laughable to think of how simple and effective it is. But it is.



Bathroom windows before and after the paint

Yes, I’ll repeat it. “Paint heals.” It’s an elegant concept that many know, but often forget. “Paint heals.” Now don’t get me wrong, paint is not a cure-all tactic, and there is no science to its healing powers. If anything, I believe it follows a simple pattern of “look good, feel good” that may not be revelation worthy, but is nonetheless true. I believe that people want to be in a place that looks good, because it makes them feel good. Spaces that are clean, organized and well-kept give the impression that someone cares about them. Those spaces command respect from the people who occupy them and reassure the world that details matter.

Now, in thinking about a hospital, it only seems logical that such reassurances are not just beneficial but necessary. Similar to supering, hospitals are in the business of fixing distressed people’s problems and, at the very least, comforting them with the knowledge that all is being done to help them. The appearances of spaces like waiting rooms, bathrooms, hallways and even outdoor grounds affect patient care—and that’s not even broaching the obvious accompanying issues of infection control, sanitation standards or staff satisfaction(!). Who hasn’t spent three hours waiting for a doctor, felt disgusted by the condition of a bathroom somewhere or taken even five minutes to walk the hallways of a yet unexplored building, especially if spending the night. In fact, one might argue that a patient spends more time in those spaces than even receiving treatment. Thus, the conditions of those spaces matter. They tell patients that they are in good hands and would inspire trust. “If the hospital pays this much attention to their bathrooms, then its patient care must be exceptional.” Right?

So please look again at the photos below. The best part of the transformations you see below you—and I truly believe those photos illustrate transformations—is that they’re cheap and easy. Paint is generally easy to find, inexpensive and fun to apply. It can be done by one person or used as a team-building exercise. It can be done in the spaces between other tasks, or it can be done to music or as a weekend long activity. Regardless of how it’s done, it makes a difference. It transforms space in a way that even plumbing and wiring don’t, and can prove absolutely effective in a hospital context. Thus, I implore you, hospital administrators, staff, patients and individuals, “Paint thy walls.” I’m pretty sure you’ll be glad you did.

————-

Gregory Karelas is medical anthropologist and volunteer with Nyaya Health. He has worked in New York and as a consultant in Achham to further Nyaya’s efforts domestically and abroad.