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Act as if

Posted by Duncan Maru

I wrote the following email last August to our Country Director, Gregory Karelas, and Executive Director, Mark Arnoldy, who had both recently taken the helm of Nyaya Health.   It was at a challenging moment of transition, and one that brought much frustration and self-doubt.   I asked Greg and Mark that I could share them now, since the themes I touched upon continue to be of relevance to our work and team dynamics.  As we go about trying to do the impossible, as “impossibilists” (thanks to Adam Braun of Pencils of Promise for that word), we confront frequent failure, our own weaknesses and vulnerabilities, and many uncertainties.  In these journeys together, we as leaders must accompany each other to translate failure into reflective evolution, and to accompany each other again to do the same when faced with the next failure.  Yes, I will admit that the “act as if” reference does indeed come from Ben Affleck’s classic lecture in the movie “Boiler Room.”  The letter below is unedited, including my grammatical mistakes and misspelling of the word “promissory” (that reference, of course, is from Dr. Martin Luther King, Jr).

“So as you transition in your first few weeks on the job, I wanted to ask you to reflect on acting as if.  I’m sending this along to you because I’ve seen in talking with both of you how Nyaya has already forced upon a sense of skepticism, a feeling of being part of a losing battle.  I think that is wrong, and I’m asking you, as the new leaders, to correct that.  I’m not asking you to overnight change your deep-routed skepticism of this work, or to hide your fears and insecurities.  But as leaders of Nyaya, as those to whom we look for guidance and ingenuity and boldness, I am asking you to act as if. Act as if Achham is a world of possibilities rather than one of death, nihilism, and incompetence.  Act as if the citizens of Achham can control their own destinies.  Act as if you are facilitators towards achieving these possibilities.  Act as if optimism is not a dirty word, but rather it is one grounded in the realities and hopes of individuals who are sick and their families.  For skepticism in what is possible quickly becomes defeatism, and defeatism, while an option perhaps for us, is not a viable option for those we serve.   Act as if our work addresses some of the fundamental challenges of our generation.  Act as if we can recruit the smartest people to meet these challenges, and that the most well-financed and hard-nosed donors will be inspired by our work. As leaders, you will need to believe that Nyaya has immense possibilities.  Rather than having all this “cultural baggage” or “broken structures”, Nyaya has a remarkable substrate upon which to build a dynamic organization.  We have the talent, the connections, the vision, the values—now we need you as our leaders to help us realize our potential.  What do I see two years from now?  I see a Nyaya that looks fundamentally different from where we stand today, though one that emerges from this period of growth sharing the same values as we always have:


    •  clean, tiled, structurally sound buildings at Bayalpata
    • surgeries and blood transfusions taking place
    • more dignified medical management of pain
    • ongoing QI initiatives
    • monthly data streams and effective research infrastructure


    • Operationalize our support of health posts through staff trainings, referral systems, and the CHW program


    • CHW network to cover entirety of Achham


    • start of work in Bajura, via support of a new government hospital there


    • $1 million per year in funding sources
    • a professionalized board
    • an effective volunteer network
    • online collaborative resources and publications that advance global health delivery

Act as if all of these things (or more importantly, whatever it is that you are looking to accomplish) are not only possible but are our obligation. Ever since we started spending time in Achham, we’ve been writing promisory notes and its high time for the citizens of the Far West to cash in.  Sometimes we get too caught up in being right.  It’s a defense mechanism really.  In Achham, if you choose skepticism and defeatism, you will always prove yourself right.  Nyaya has become very good at saying amongst ourselves what cannot be done.  Achham has gotten us down.  But we wouldn’t have opened a hospital if we had that mentality from the beginning.  Our only chance at survival as an organization is optimism.  Optimism is not a dirty word, whatever Nyaya may sometimes lead us to believe.  That optimism needs to be grounded in the realities our patients face and the realities of working in Achham, and it needs to be coupled with hard-nosed management strategies, with ongoing evaluations driven by data, and with a determination to never give up.   You two did not join Nyaya to fight the good fight but lose.  You’re in it for victory, and not just small victories, but big ones.”


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.

Dear Readers,

Mountains have become a metaphor for the challenges inherent in the work we do.
Surprisingly, that is not because we work in Nepal. Instead, it is credited to Mountains Beyond Mountains, Pulitzer Prize-winning author Tracy Kidder’s moving account of Dr. Paul Farmer’s quest to bring quality health care to the poor around the world.
We write with excitement today to share that Nepal’s mountains will soon become more than a metaphor for Dr. Farmer, as our Nyaya Health team welcomes him to Nepal for the first time.

Dr. Paul Farmer will join our team in Far-Western Nepal later this week.

This is an extraordinary honor and privilege, as Dr. Farmer and Partners In Health — a medical nonprofit he co-founded — have accompanied and advised our team for many years. Partners In Health’s bold efforts to offer a preferential option for the poor have been instrumental in shaping our own growth and trajectory.

For further reflection on the importance of Dr. Farmer’s trip to Nepal, visit the Nepali Times article re-posted on our blog here.

We also want you to experience and contribute to this trip alongside us, by following our live updates on Twitter using the hashtag #paulfarmer, and by sharing your thoughts and questions on our Facebook page.

Dr. Farmer’s visit will help us do as he recently advised graduates of Northwestern University: counter failures of imagination and harness the power of partnerships to improve the health of the poor.

That is a prescription desperately needed in Nepal, where the mountains are as mighty as any.

Please share this exciting news with your friends by forwarding this email.

Thank you,
The Nyaya Health Team

Posted by Mark Arnoldy

As a 22-year old, I distinctly recall rumbling along Route Nationale #3, Haiti’s unpaved and unattended central vein, toward the town of Cange. While crawling up a dusty incline past the dam that spawned Lac Peligre on my right, a nervous anticipation set in.

Those nerves were not of the sort one might attribute to popularized descriptions of Haiti. Instead, they originated from the knowledge that just ahead rested what had been described to me in Port-au-Prince as “Dr. Paul Farmer’s castle.”

What was it about that hailed castle that created such nervous anticipation?

Like thousands of young students across the world, I had found a special resonance in the story of Dr. Farmer, told by Pulitzer-Prize winning author Tracy Kidder in Mountains Beyond Mountains. Never before had a narrative so powerfully captured the essence of a growing movement of young global health advocates unwilling to let the poor around the world die unnoticed of preventable disease, or what Haitians appropriately term “stupid deaths.”

So it was much to my delight that our tire was popped rather serendipitously outside Cange, leading me into the home of

Partners in Health (PIH) in central Haiti for a brief tour. Though I wasn’t a patient, the facilities at Cange still acted exactly as intended—as an antidote to despair (to steal a beautiful phrase from PIH); there was a quality about the place that seemed attainable for the communities I had come to know in rural Nepal.

That attainability haunted me as I left Haiti for Nepal. I knew of the staggering need for strong rural health systems here, especially in the battered and neglected Far-Western region, yet I wasn’t sure how to replicate what I had seen in Cange. I didn’t know how, that is, until I met Dr. Farmer’s former students who were rebuilding the health system in partnership with the government and community in Achham District through Nyaya Health. I suppose no one should have been surprised that students of Dr. Farmer had rooted themselves in a community that lacked a single doctor for over 250,000 people as recently as 2006. Nyaya Health’s presence in Far-Western Nepal, a forgotten fold of the earth nearly 9,000 miles from Haiti, is a testament to just how far PIH’s moral reverberations truly extend.

Bayalpata Hospital

This week, Dr. Farmer himself will visit Nepal and Achham for the first time, 29 years after his work in Cange began. He comes with nearly all the accolades one could imagine, including a MacArthur “genius award”, a Harvard University professorship, and a post as Deputy UN Special Envoy for Haiti under President Clinton.

But, most importantly, Dr. Farmer will undoubtedly come with his characteristic commitment and pragmatism to understand and serve the poor, which is why all of us involved in developing rural health care systems can welcome his arrival as a bright contrast to the tragic ties of disease and privation which have bound Haiti and Nepal together in recent times.

When Dr. Farmer soon rumbles around a turn on Madhya Pahaadi Rajmaarga and arrives at Bayalpata Hospital in Achham District, his visit will accompany an opportunity to do as he recently advised graduates of Northwestern University to do: counter failures of imagination and harness the power of partnerships to improve the health of the poor.

That is a prescription desperately needed in Nepal, where the mountains are as mighty as any.

Mark Arnoldy is the Executive Director of Nyaya Health.

Posted by Bibhusan Basnet

It is for a reason that we admit patients for inpatient treatment.  As doctors, we admit them and order medications and treatment, but the inpatient department (IPD) is mostly run by nursing staff.  Normally, doctors are just there for the regular rounds and the emergency calls.  Due to the large number of patients in the outpatient department (OPD), spending time with patients in the IPD must be wedged in between breaks and holidays.  So, one fine Saturday morning, I decided to spend some quality time with my patients there.

The patient from bed number 1 has started to smile these days.  I remembered that she was admitted at the OPD with a diagnosis

A mother’s lullaby as the sun sleeps at Bayalpata

of severe depression.  She used to be in the corner, shy, timid. She denied everything including the oral fluoxetine, the best medication we could supply in Achham.  She never even talked to her cute 6 year old daughter, and was gloomy all the time.  Yes, surprisingly she has improved, in just 10 days at the hospital.  Her order for intravenous (IV) fluids has been stopped now and she is smiling!  Someone whispered that she was talking to her daughter now and she takes her drugs without hesitation.  I just wanted to peek through the door and try to note her smile and capture it.  We had even discussed electroconvulsive therapy (ECT) for her treatment, but now she’s improving!  “Yes yes” I said to myself; I felt happy to see her smile.

I was sharing my happiness with the nursing staffs when the lady in bed number 3 caught my attention.  I wanted to talk to her and went near her bed.  Her bed is near the window and the sun is always by its side there.  She was from Bajhura, a 12 hour walking distance from Bayalpata.  She said that her son is returning home to meet her since she is ill.  She came to us 3 days ago with a swollen leg.  She gave a history of a foreign body insertion on her right foot a month ago, and we drained 50-60 mL of pus from her foot in the emergency room.  She felt better after the procedure, but even yesterday there was around 10 mL of additional pus, which had invaded below her superficial fascia.  She told me that the pain and redness had improved, but I am praying that she improves more.  I just added metronidazole  to the cloxacillin injections on Friday and I assured her that she will have her dressing changes increased to two times per day.  Her youngest son has been helping her these days to move to the lawn outside the IPD, where she likes to go during the evenings to see the sun sleep at Bayalpata.

I noticed that the patients have been good friends to each other.  It felt so good when I saw my patients feeling at home here.

The evening sun brings respite to the patients after the scorching heat of the day

The mom with a one year old son, who was being treated for pneumonia, was talking with a huge smile to the old man near her bed.  He had been on a continuous supply of oxygen via nasal cannula for a few days.  I could see that with the new procurements, we now had two additional oxygen concentrators and few more nebulizer machines.  Dhansara Sister (our nursing staff) told me that the work has been much easier with these new procurements, including 4 hourly nebulizations for the old man.

At tea time I offered tea to the staff there.  We ordered 4 cups of tea and some biscuits from our nearby tea shop and had time for some chit chat.  Life is good inside the IPD, they told me.  When a patient is admitted for just a couple of days, they are able to share lots of feelings with the patient before they leave.  Time flies inside the IPD, they said.  My wrist watch struck 5 p.m.  Then I saw a few patients making their way to the lawn outside.  It was a wonderful day to spend inside the IPD.  It helped me know my patients better and it felt good.  Just as I thought to myself that I should do this more often, and on other days too, I saw the old lady with the swollen leg move towards the lawn.  I followed her to the lawn outside to watch the sun sleeping at its best.


Dr. Bibhusan Basnet , MBBS graduated from B.P Koirala Institute of Health Sciences,Nepal. He has a special interest in Emergency Medicine and Psychiatry and is currently the Medical Director for Nyaya Health.

Posted by Ryan Schwarz

My plane landed in Kathmandu this morning – my first day back in the country after a stint too long away (as a resident physician in the USA now, finding time away from work can be challenging). Coincidentally, today is also the 3rd anniversary of Nyaya’s collaboration with the Nepali Ministry of Health, overseeing Bayalpata Hospital.

On April 20th, 2009, I was sitting in the Sanfe Bagar Medical Center with Nyaya’s first lab technician, Santosh Shrestha, when we heard the news – our team in Kathmandu had signed a 5-year contract with the Minisitry of Health and Population to renovate and open the non-functioning Bayalpata Hospital (BH). Our team was excited – there was an energy in the clinic that day that rejuvenated our clinical staff as they saw the final patients of the day. And there was also a great anticipation of what would come next, after all, we were a very young organization – we had only opened our first health center one year earlier, and now we were going to open a hospital. Exciting, greatly needed in the region, and an enormous challenge.

The government’s contract gave us 2 months to open the hospital (or theoretically they would not provide the promised funding), and we made it; barely. On June 21st, 2009, Bayalpata Hospital formally re-opened and began seeing patients. Today, three years on, BH sees over 35,000 patients each year. We’ve written elsewhere on this blog of the tremendous work and dedication that have gone into building our programs at BH and in surrounding communities. Next week, with some very important guests (keep an eye on the blog for more news), we will celebrate this anniversary in good Achhami style. As I look forward to more time in Achham with Nyaya’s team at BH, perhaps more than the successes of the road thus far, the challenges remaining ahead are ever-present. We’ll write more on the blog in the coming weeks about some of these challenges as we have ongoing discussions and upcoming meetings about our next big steps.

For today, in a tribute to 3 years, and a commitment to many more ahead, I leave you with a slideshow of some of the not frequently seen photos of the beginnings of BH. Happy Anniversary, and thank you to everyone for the incredible support that has brought BH to where it is today:


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

Posted by Jason Andrews and Sanjay Basu

For the last several years, we’ve heard that privatizing public health systems in poor countries would be the best way to build more sustainable, efficient and effective healthcare systems. Large multinational firms and the World Bank have put out several reports advocating for the poorest countries to privatize.

Privatization proponents argue that the private sector is already delivering the lion’s share of services in most poor countries. Those arguing for greater reliance on public systems, by contrast, have contended that public-sector medical care is more equitable to the poor.

We recently evaluated the evidence for these claims, reviewing studies comparing public and private healthcare delivery in low- and middle- income countries. The full study was released yesterday in the peer-reviewed journal PLoS Medicine.

 We evaluated studies in both the published literature and those released by private organizations and international agencies, categorizing their findings into six themes that have been used by the World Health Organization (WHO) to assess health system effectiveness: 1) accountability and responsiveness; 2) quality; 3) patient outcomes; 4) accountability, transparency, and regulation; 5) fairness and equity; and 6) efficiency.

We found that the data do not support the idea that private providers are more efficient (in economical terms); rather, the private sector was associated with higher drug costs, weak regulation, and perverse incentives for unnecessary testing and treatment. We also found poorer adherence to evidence-based care for conditions like tuberculosis and sexually transmitted diseases among private providers.

However, private providers were often preferred to public providers due to timeliness and hospitality towards patients. Transparency and accountability was poor for public and private systems, and the availability of more data would be helpful in facilitating further comparison.

A view from Nepal

In 2007, the Interim Constitution of Nepal explicitly endorsed health care as a basic right, laying the foundation for the Ministry of Health and Population’s (MoHP) revised health policies. Later that year, the government declared all health services at public health posts and sub health posts to be free of charge to all.

In 2009, free health care was extended to primary health centers (the level above health posts), 40 essential medicines were declared free of charge at district hospitals, and health care related to deliveries was made free at all public institutions. Within the first two years, outpatient care visits by the very poor increased by 97% .

However, increased stockouts of medications were seen in the setting of rising health care use. The public system is likely underfinanced to meet this demand. In 2009, the entire free medicines budget amounted to approximately $0.39 per capita. As of 2010, only 33% of Nepal’s total health expenditure was from public funds, approximately 8% higher than two decades ago.

The 2011 Demographic and Health Survey (DHS) for Nepal underscored the reliance of the poor on public health systems. Among women delivering children in health facilities, 84% of the poorest quintile used government services and 10% used the private sector. By contrast, 64% of the wealthiest quintile used government services and 29% used the private sector. However, as the poor are significantly less likely to deliver in any facility (13.5% versus 79% for the richest quintile) despite free services, much work remains to be done beyond the policy level.

The DHS survey also asked where children with fever or cough were taken for health care. Among those seeking care, the proportion seeking care in public institutions was identical between the poorest and richest quintile in 2006 (29.9% for each). In 2011, the poorest quintile had increasing use of the public sector (46.9%) while the richest quintile had decreasing use (13.6%). When pharmacies are not considered health care providers, 78% of the poorest quintile used public services, compared with 21% of the richest quintile.

Despite considerable success towards achieving the Millennium Development Goals, Nepal continues to have disparities and deficiencies in its healthcare delivery. The Government of Nepal appears committed to investing in its public health care system via the free care policy, but whether it can adequately finance it while delivering on quality, equity, responsiveness and accountability remains an important question.

Broader implications

In the broader scope of the debate about private versus public sector care in poor countries, we often assume that markets will bring more efficiency and less corruption. This would be true, except for the data we have on healthcare showing how different it is from other goods. The Nobel-winning economist Kenneth Arrow explained in the 1970s that markets are often not the best way of letting consumers get good healthcare because of information asymmetry—that is, it’s very hard for consumers to actually tell if what they’re getting is good healthcare. Furthermore, the prices of healthcare aren’t competitively set like the price of bread—consumers are often not in a position to shop around, but must take what they can get in the context of urgency and often poverty .

A lot of the faith in the market for healthcare has derived from Ricardo’s theory of comparative advantage, which tells us that competitive specialization will lead to more efficiency and better outcomes for everyone (the basis of modern free trade theory). Yet Ricardo’s model makes several assumptions that aren’t true of modern healthcare markets : including that resources are fixed and can’t be lost (unlike the brain drain on doctors) and that markets are perfectly competitive and can’t be manipulated such that consumers will have perfect information (they know the drug they’re being prescribed is the best one for them, or that the test they’re getting is necessary and the risks outweigh the benefits) and producers will not be capable of wheeling-and-dealing amongst themselves. A look at the modern sector of healthcare delivery in poor countries, which is filled with informal drug shops and quack doctors, gives an altogether different reality in contrast to this theory.

That does not mean that the public sector is doing well. Rather, we found in our recent review that the public sector is full of challenging inadequacies, particularly in timeliness of patient care and overall hospitable treatment of patients. But we also found a phenomenon of “competitive dynamics” between public and private sectors that often kept the public sector from improving – that the private sector would be built-up by public funds through subsidies or other tax-based supports, and then draw away the richest consumers, preventing them from cross-subsidizing the poorer hospitals; public funding would then also decrease toward the public sector, essentially forcing the poor to go to an underfunded public facility or informal drug sellers on the street. A two-tiered system would be built and reinforced. Much of this competitive dynamics is now being observed in South Asian countries like India, where glass-and-metal private hospitals tower above slums.

These issues bring to mind questions of how to better produce equitable financing for the healthcare of the poor in developing countries, not allowing the wealthy to create their own system for themselves, but participating in meaningful redistribution of wealth. Nations like India, Rwanda and Ghana have started to put forth proposals that engage with this problem, and we look forward to seeing how well they can improve their delivery of healthcare to the poor in this setting.


Jason Andrews, MD, SM, DTM&H and Sanjay Basu, MD, PhD are Co-founders of Nyaya Health.

Posted by Lindsey Youngquist

In Achham, most people collect their water from a community Dhunge Dhara (stone water tap). Women often walk for hours each day hauling jugs of water up terraced hills. This water is used for drinking and washing, but large livestock such as buffaloes and cows consume the largest quantities. This patient is drinking from the Bayalpata Hospital Dhara after her appointment.


Lindsey Youngquist is a Rotary Ambassadorial Scholar studying Community Health in Nepal.  She recently volunteered at Bayalpata Hospital in Achham. 

Posted by Duncan Maru

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

I had dozed off, I think, when the jeep pulled over.  The door opened and our young patient and her mother got into the back.  It was pitch black, where the new moon had ceded the night stage completely to the stars.  Suddenly, mayhem seemed to break loose.  The child’s father, afflicted with a developmental disorder rendering him severely intellectually disabled, was crying and trying to enter the jeep.  An uncle was drunk and saying that we were stealing his niece for her organs.  Several other men had gathered around.  The child’s mother sat steadfast in her seat.  Agya calmly explained again that we were going to see the cardiologist in Kathmandu.  Ultimately, the men stepped away and we began our long, winding journey through the darkened hills.

Achham has taught me that accompaniment is both a philosophy of leadership and a way of life.  I had heard our colleagues and mentors at Partners In Health use the term, but have only begun to realize its power through the guiding hand of Achham and its people.  Accompaniment is the commitment to be present with patients and family members in the midst of suffering and injustice and stupid, unnecessary deaths.  It is the commitment to be present with our staff and volunteers as we make mistake after mistake, as we fail and fail and fail, and then as we learn and evolve and fail again.  It’s an undying belief in our vision and an unwavering hope in health and justice.  I have seen Achham break the spirits of many of us, where the lesson we take away from the deaths and the bandhs (strikes), the expired medicines and faulty equipment, is one of defeatism and nihilism, retreat and paralysis.  In Achham, learning accompaniment is not merely an act of compassion or good leadership, but one of necessity, of survival.  And ultimately, those acts of accompaniment are what draw us back to Achham time and again.

So it was with Agya Poudel, a young woman raised in Kathmandu who joined us last year after seeing Achham several years before, towards the tail end of the civil war.  She had recently received a Masters degree from a prominent German university and was compelled to put her education, experience, and passion to work in the Far West.  The subsequent year would bring huge, intense, personal challenges.  She weathered a staff crisis that brought her personal threats.  Being the only leader of a community health department that, within Nyaya, only receives a tiny fraction of our operating budget, yet is charged with delivering some of our most impactful and far-reaching initiatives.  Many of our objectives were not met; our follow-up program, community malnutrition initiatives, and expansion, were all delayed or incompletely met.  That is the nature of the work; we aim, we experiment, we fail, and then we evolve.  Throughout these struggles, the Agya I witnessed was someone with a gentle and accompanying presence for the families we serve.  Despite her life and world as an educated woman from Kathmandu being gulfs away—politically, economically, socially, culturally, linguistically—in so many ways from life in Achham, she listened and accompanied.  It was in those moments of human connection, like when she sat by our patient’s strong mother and helped her bring her daughter to get evaluated for cardiac surgery, that Agya provided such inspiration and impact.

Community Health Department members Agya and Ashma leading a discussion with Nyaya’s network of Female Community Health Volunteers (FCHVs)

Accompaniment is about identifying each other’s strengths and bringing them to bear for health and justice.  Agya demonstrated this with the child and her mother.  The mother had been married at the age of seven, is illiterate, and lives in dire poverty with her four children.  Yet she shares that most powerful force of hope in her daughter’s future.  Her daughter is attending school and will get a cardiac surgery to repair her damaged mitral valve.  Agya saw and appreciated this strength and supported it at a time of intense fear and doubt and danger.

She is moving on now, but her impact and spirit will persist, and she will bring the lessons and struggles, the failures and evolutions that she has learned from Achham, to all her future endeavors.  And, like all of us, she will one day return to these powerful hills.


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.

Posted by Lindsey Youngquist

This grandmother sat patiently in the waiting area as her microbiology tests were being processed. Bayalpata Hospital has a catchment area of 250,000 people and is set up to offer a wide breadth of tests, operations, and medications to serve the health needs of people of different ages, livelihoods, and economic levels. These patients, even when weak from illness, often walk days to reach Bayalpata Hospital.


Lindsey Youngquist is a Rotary Ambassadorial Scholar studying Community Health in Nepal.  She recently volunteered at Bayalpata Hospital in Achham. 

Posted by Ashma Baruwal

 [The following post was adapted from the community health report for the month of Baisakh, which spans from the middle of April to the middle of May on a Gregorian calendar.]

 This month, program development included the design of a family health program, menstrual hygiene workshop, and a high school health education program.  The family health program includes weekly household visits, and will begin in the next week in Ridikot.  The menstrual hygiene workshops and health education classes will be conducted on a monthly basis in schools in the Bayalpata catchment area starting next week.

Bayalpata’s community health worker (CHW) program has been extended to the village development committees (VDCs) of Nauathana and Gajra, increasing the hospital’s catchment areas to a total of 9 VDCs.  The CHW training program this month included a workshop on dental hygiene, conducted by Medical Director Dr. Bibhusan Basnet, as well as trainings on household treatment and care of burns, diarrheal care, and basic sanitation and hygiene.

The highlight of the month was a community-wide teaching at the Bayalpata Bazaar on May 12th.  This event was the first of its kind to be conducted by the hospital.  Outreach efforts included education on general nutrition, hand-washing techniques, menstrual hygiene, and fortified flour (lito). A skit on chhaupadi (isolated menstruation), which was well-received by the community.  Similar outreach programs are planned to occur approximately every three months as we move forward.


Ashma Baruwal is a MPH graduate from Chulalongkorn University,Thailand. She is currently the Associate Director of Community Health for Nyaya Health.

Posted by Chhitij Bashyal

 With my old laptop and hefty community health worker (CHW) log books, I still remember basking in the sun on our Sanfe Clinic roof back in 2008.  While digging through the weekly reports of our community health workers, even the thought of refining data collection and analysis process so to inform program improvement seemed full of both practical and technical challenges.  Envisioning an organization in which operations are driven by continual, iterative monitoring and evaluation, reinforced by the “transparency until it hurts” principle, our teams in Achham and our volunteers in the US Data Team have put in countless amounts of time and brain power over the years to overcome difficulties with innovative and simple solutions.  We certainly have come a long way in not only improving the data collection mechanisms of our clinical staff in the hospital and community health workers in the field, but also in making sure that data tells an actionable story.  After all, collection of data is irrelevant (and even counterproductive) if hundreds of data points from thousands of patients are not presented in a digestible form to be analyzed and used in program planning and improvement.  Data must come alive.  With this goal, in this blog, we are excited to showcase the latest development in data visualization and analysis techniques and other ideas that we have in the pipeline.


To make the data from our clinic and community health programs available in an aggregated form in our wiki, we have developed two specific platforms for easier data analysis and visualization.  First is the interactive data visualization platform for a more rigorous analysis and comparison of data.  Second is the picture-based platform that allows for easy visualization of data.  Below we present the tools in detail.


  • Interactive Data Visualization Platform:

We have developed an interactive data analysis platform for our Achham and US based-technical teams.  This publicly available platform allows our technical teams to monitor clinical and community health indicators (which are collected and reported monthly), and to conduct time-series, cross-tabulation, and spatial (geographical) analyses.  The platform uses StatPlanet, an open-source application that was developed with funding from the World Bank for non-commercial and not-for-profit use.  One of the key advantages of the tool is the ease with which data can be updated and presented using simple pre-configured Excel files.


  •  Graphs View:

We have also developed a platform that presents a slideshow of key graphs for our partners and donors who are mostly interested in key figures.  The graphs are generated automatically using an Excel macro, and are presented using Picasa album slideshow in our Wiki.


 In addition to making data accessible to our technical teams, international partners, and supporters, we are also formulating a mechanism to build local capacity for our staff to interpret and publicize the fruits of their hard work to our patients.  In our pipeline are two pilots: [a] showcasing our data on the TV located in the patient waiting area, and [b] displaying graphs, printed from the “Graphs View” platform (described above) on the staff room data board.  We will continue to make data analysis and interpretation a critical component of staff meetings.


Chhitij Bashyal is a graduate of the MPA in Development Practice from Columbia University. He is a volunteer for Nyaya Health.



Posted by Lindsey Youngquist

Children are often very self-sufficient while their parents are working in the fields. This leads to older siblings taking incredible responsibility for younger ones, and has the potential to create strong bonds between brothers and sisters. However, the prevalence of unattended children also leads to common injuries that we see at Bayalpata Hospital. One of the most common of these is falling from the steep hillsides or from trees while collecting fruit or playing.


Lindsey Youngquist is a Rotary Ambassadorial Scholar studying Community Health in Nepal.  She recently volunteered at Bayalpata Hospital in Achham.

Posted by Dan Schwarz

This past week, Nyaya had the opportunity to attend Partners In Health’s (PIH) first annual Community Health Worker (CHW) Summit in Boston. More than 30 CHW program leaders from more than 20 countries/programs attended, including representatives from Tiyatien Health (Liberia), Project Muso (Mali), Zanmi Lasante (Haiti), Inshuti Mu Buzima (Rwanda), Abwenzi Pa Za Umoyo (Malawi), Companeros de Salud (Mexico), Socios en Salud (Peru), and PACT (Dorchester, Massachusetts).  Spanning more than three days, the agenda included sessions on CHW recruitment, training, management and supervision, monitoring and evaluation, and retention.  It also addressed related topics such as the implementation of mobile health applications and research strategies to improve CHW programs.

With regards to Nyaya’s own CHW program, we had the opportunity to present our program to the other attendants, highlighting our progress and challenges to date, as we approach the notable milestone of our 24th month of program implementation. A robust discussion of interim program evaluations and re-evaluations ensued, highlighting other programs’ challenges in the early identification of “vision drift,” and the importance of periodically re-assessing a program’s progress as measured by the program’s stated goals. This discussion is particularly salient as Nyaya begins a complete CHW program audit and review during the summer of 2012, with the hopes of ensuring that we stay true to the our patients’ needs while also maintaining and expanding our program accordingly.

With gratitude to PIH and to all of our partners from around the world, we look forward to much more robust network collaborations in the future, such that we may learn from the lessons of those who have come before us, and humbly offer our own lessons learnt to those who are struggling for their own communities alongside us.

CHW program leaders representing more than 20 countries came together in Boston this past week for the first annual PIH CHW Summit.


Dan Schwarz is a member of the Board of Directors and a medical student at Brown University School of Medicine.  He completed his MPH at the Harvard School of Public Health.

Creating Smiles

Posted by Bibhusan Basnet

It was Saturday morning and, as planned with Agya and Ashma, we set out for the meeting with the Female Community Health

Dr .Bibhusan Basnet (our medical director)Left, Agya Poudyal(second to left) Community Health Director with the FCHVs during the Dental Hygiene orientation programme with the FCHVs

Volunteers (FCHVs) in our catchment Village Development Committee (VDC), Janalikot.  We planned to give a dental hygiene orientation program for the FCHVs and I was excited.  We printed materials on tooth brushing techniques and I was planning to teach them about the “modified bass method” to brush our teeth.  Since we didn’t have any tooth model at hand, at first it was challenging for us to demonstrate the recommended method of brushing technique.  But we had a better model!  There couldn’t have been a better model than our own set of natural teeth.  All we needed now was a toothbrush to show them how it is done.

I set off with my friends to Janalikot.  I was prepared to walk, but the bus ride that saved us from the heat, was like free double

cheese topping on a pizza.  The ride saved me from exhaustion and the girls from suntans.  Before we headed to the actual meeting, Community Health Worker Leader (CHWL) Ganga Luhar received us for lunch in her home.  We then walked up the hill to meet the FCHVs for one of their regular gatherings on Saturday.

Ashma Baruwal,our Assiatant Community Health Director(left); Agya Poudyal,our Community Health Director(second to left),with the FCHVs demonstrating the brushing techniques to the FCHVs.

The group of women gathered every Saturday in the local VDC office to talk about the diseases and patients they had met during the week.  They seemed to be eagerly waiting for us.  Agya was a known face and Ashma and I were excited to be introduced.  Agya introduced us and the conversation began.

I was talking to the FCHVs in a group for the first time.  The ladies were welcoming and the experience couldn’t have been better.  One of them seemed a little too elderly to work and I asked her age.  She told me that she was 60 and that she had already been working as a health worker for seventeen years.  Although I felt that it was time for her to retire, I was well aware that under her belt she had important skills that only came with experience.  Their work seemed to have empowered them in every sense of the word.  All that I had read about them and heard of them was exactly what I was seeing in real life.

As the meeting started, we talked about our hospital follow-up system.  This was the best opportunity to strengthen our ties by addressing the loopholes in the system.  The follow-up system is vital for referring our patients to the hospital for checkups, and also for looking after the patients who go back to their communities after treatment at the hospital.

The real show began when we gathered some of their ideas about dental hygiene.  I then tried to emphasize the importance of

Agya Poudyal (Left) ,our Community Health Director demonstrating the brushing techniques with the help of a poster to the FCHVs

brushing teeth daily in a proper way.  I explained the need to brush away the germs from gingival pockets between the gum and the teeth, getting the right toothpaste with fluoride, and the proper method of stroking.  They listened with patience and interest to what I was saying.  Then we asked them to share this knowledge in the community.

We were done with the lesson but they were still around the VDC office, eagerly waiting for the polio vaccine to arrive.  Since it was the national polio immunization day, they waited with hungry stomachs without any complaints to take the vaccines to the children in the community.  I was impressed by their passion to work.

Going to the community was not just a learning experience for them but also a wonderful learning experience for me.  Simple efforts on their side were making significant differences in the community.  It is amazing how the FCHVs help create smiles and spread happiness.


Dr. Bibhusan Basnet , MBBS graduated from B.P Koirala Institute of Health Sciences,Nepal. He has a special interest in Emergency Medicine and Psychiatry and is currently the Medical Director for Nyaya Health.

Posted by Mark Arnoldy

One is not like the others. The staff housing facility on the far left is one of only two buildings on the entire Bayalpata Hospital campus that remain in original condition (as built ~30 years before). With expansion of Bayalpata staff from 35 to more than 52 over the last 8 months, the need to renovate the remaining two staff housing facilities has become an organizational priority.



Mark Arnoldy is the Executive Director of Nyaya Health.