Scaling what works: from local success to broader impact
Student observations on Nyaya Health’s model for delivering care in rural Nepal

In late 2010, a small team of MIT students took a look at the organization from the outside and, as a course assignment, prepared an executive summary aimed at its board of directors. This article presents their overview and assessment of the organization, and their thoughts on challenges and opportunities. Keep in mind that this a class assignment drawing largely on publicly-available materials and in some cases direct, though limited, interaction with the organization. We share the student’s work in the hopes that others will build on it in keeping with the creative commons license.

By Molly Bodell, Pompa Debroy, Sophie Cain Miller, & Evvie Nanni

About Nyaya Health

Nyaya Health is a non-governmental health care organization that operates in a poor rural region of Nepal called Achham. It is founded on the belief that every individual has the right to excellent health care. Nyaya’s two-pronged mission is to provide free community-based health care, and to create a scalable and exportable model for health delivery in places that have been affected by poverty. Nyaya delivers several health services in the Achham region including: inpatient and outpatient services, pre-natal care and ambulance services.  Nyaya operates in one location in the Achham Valley – the government-owned Bayalpata Hospital.  Here they run a community health worker (CHW) program that utilizes community health workers who are hired and trained by the Nepali government.

Nyaya faces several challenges in delivery care in Achham.  These challenges include: difficult mountainous geography, a history of civil war, poverty and the government’s unreliability in delivering care.  Prior to Nyaya’s arrival, the region suffered from very poor health indicators, including an HIV/AIDS epidemic. The maternal mortality ratio in Achham was 740 per 100,000 live births, compared to a ratio of 240 per 100,000 live births in Nepal overall. Prior to Nyaya Health’s intervention, no health care staff existed in the region and the closest operating room was 10 hours by bus.

Given this challenging environment, Nyaya has implemented a variety of creative solutions integrating lessons learned from successful organizations, such as Partners in Health. As a result, Nyaya is able to deliver a very effective and scalable mix of healthcare solutions to the Achham Valley .  Nyaya places a high value on equity, including the provision of free care, as well as transparency and accountability. Nyaya operates under a 5-year Memorandum of Understanding with the Nepali government, in which the government owns the physical hospital facility, and contributes 12%-38% to Nyaya’s annual budget.  The remaining portion of Nyaya’s budget comes from a combination of private donations and scholarship grants from US students.  At this time Nyaya Health does not earn any revenue.

Nyaya’s leadership, including its Board, is US-based and serves primarily on a volunteer basis. Nyaya recently hired the organization’s first US-based, paid Executive Director. Nyaya employs 25-28 staff providing healthcare on the ground, 82% of which are Nepli.  Nyaya also leverages innovative information technology to accomplish their mission. In addition to developing a sophisticated and unprecedented supply chain for pharmaceuticals, they also collect patient data and document hospital protocols. All of the organization’s operational documentation is open-source and can be accessed using their online wiki.

Accounting for success

Through the organization’s unique organizational and care delivery model, Nyaya is able to offer a distinct value proposition to 4 key audiences.  First, they provide free comprehensive health care to individuals living in the Achham region.  This is the population that is served by traditional NGOs.  Nyaya goes beyond this population, serving the Nepali health system, the global health community and donors.  The Nepali health system can use Nyaya’s model for other facilities.  The global health community can look to Nyaya for information and templates, as well as their advanced use of IT in a rural setting.  Finally, donors find a tremendous amount of information available through their online wiki, by which they can monitor and measure Nyaya’s success and use of funding.

Nyaya is able to effectively serve all of these audiences through their dual mission and innovative use of technology. The success of the organization in achieving both of sides of its mission lies in a the reinforcing feedback loop between the quality of care it is able to achieve in the direct delivery of care to its patients and the quality of information it provides on its wiki. It is easy to understand that as the quality of care delivered in Achham increases, the quality of the information available on the wiki will also increase in quality and thus the value to the global health community will grow.  The less obvious part of the feedback loop is that as the quality of information made available on the wiki increases, the number of users will increase and thus the feedback that Nyaya receives will also increase.  This feedback from the global health community will help to validate or invalidate Nyaya’s operational infrastructure and care delivery model, which will further increase its ability to deliver quality care to the population it serves in the Achham Valley.  This reinforcing feedback loop is unique to Nyaya Health and will continue to grow in importance for the organizations as it scales.

Despite this success of Nyaya’s model, the organization currently faces three key challenges:

• Growth: How can Nyaya scale up to meet demand?  What is the appropriate scope of services to offer?
• Replicability: How can Nyaya ensure that their model is replicable for other global health organizations?
• Sustainability: How can Nyaya ensure consistent and sustainable funding?

Looking ahead: Student thoughts

There are several ways that Nyaya can confront these challenges to become a pioneering and successful global health delivery organization serving the Achham population, as well as becoming a frontrunner in disseminating information and developing standards and best practices for this community.  The following recommendations address the specific challenges that are outlined above:

• Concentrateon operating Bayalpata Hospital as the gold standard (keeping scale small in the short-term) while increasing their scope of services to include preventive and post-clinic care.
• Work to strengthen the available resources for model replicability by building awareness of their online resources, creating more robust input loops from the local and global communities, and streamlining the sources that are currently available.
• Create a sustainable revenue stream that monetizes services and remains aligned with Nyaya’s mission and strong set of organization values, including free care.  Options include packaging and selling their IT services consulting for or training other global health organizations.

As a young organization, Nyaya Health is positioned for large impact in Achham and the global health community in general. Facing such a series of challenges is not unique to an organization of this size or success. The question is whether Nyaya can overcome these obstacles using the unique technologies they employ and come out as a sustainable and replicable model for global health delivery worldwide.

Download the accompanying student presentation on Naya Health (pdf).

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