I’ve recently started working with a few friends I know through EWB on a project submission for the Open Architecture Challenge. The OAC
is hosts competitions every year to contribute designs for various development related projects around the world. This year, there are three projects on: one in South America, one in Africa and one in Asia. We’re working on the project in Asia to design a telemedicine centre for a rural community in Western Nepal . The project is particularly interesting to me because it brings together a whole range of issues I’ve been discussing for some time. These include the impact of private healthcare, how NGOs should collaborate with government, horizontal vs vertical healthcare, NGO accountability, transparency of organisation, and exploitation of Information Technology to drive as well as support projects.
Background on Nyaya Health
The organisation behind the telemedicine centre is an NGO called Nyaya Health. Nyaya Health was set up by Jason Andrews, who travelled to Nepal to offer his services as a newly graduated medic from Yale University . After witnessing the lack of public healthcare provision, he was inspired to confront and respond to this with his Nepali partner. Their approach to doing this is direct and determined: to take on provision of primary healthcare for the Western Nepalese regions Doti and Acham, and to integrate the services they build back into the public health service over three years.
Doti and Acham are certainly in need of concerted action to provide health services. The areas have a combined population of 440,000 , but only one doctor. The only hospital was built twenty years ago, but never brought into service. TB, maternal healthcare, child health and HIV/AIDS are massive problems. TB stands at 316/100,000 , only 3% of women have skilled workers on hand during labour , as many as 60% of children are reportedly malnourished , and the HIV problem is growing, but poorly understood . The lack of healthcare means that 80-90% of healthcare is provided privately - which is crippling when the average houshold’s income is only $30 per month . Indeed a local survey commissioned by Nyaya health found that the median sum spent on medical services and travel was half the median income .
Relationship to States
Taking on board the primary healthcare for whole regions is a powerful approach, which immediately brings into question the relationship between state and charity. The idea of handing over such an essential national service to a small NGO is unnerving, even when there is very little to pass across. Shouldn’t healthcare be the ultimate responsibility of the state, rather than a foreign NGO? It almost certainly should, but even if the primary healthcare responsibility were not officially handed over, the problems of accountability would still remain. Instead, Nyaya Health is able to take advantage of what little infrastructure exists, and build it up in an integrated fashion. For example, Nyaya Health will be able to make use of the abandoned hospital in Batalbaya for its work. Furthermore, by engaging with the government and phasing the services back in over three years, the government has a stake in the project from the beginning. This helps counter the common problem where governments neglect the services that are provided by NGOs, which can lead to heavily disconnected healthcare infrastructure.
Vertical vs Horizontal Programmes
Poor integration between health services has other roots too. Over-investment in vertical rather than horizontal healthcare has meant that there are often large numbers of NGOs working in a region, with each only dealing with specific health problems. This trend has been driven in part by the increased availability of disease specific funding available through the Global Fund for HIV/AIDS, TB and Malaria. In The Challenge of Global Health  Laurie Garrett argues that by concentrating so heavily on these issues, the infrastructure necessary to improve public health is being neglected: “It takes states, health-care systems, and at least passable local infrastructure to improve public health in the developing world. And because decades of neglect there have rendered local hospitals, clinics, laboratories, medical schools, and health talent dangerously deficient, much of the cash now flooding the field is leaking away without result.” The Nyaya Health Equity Initiative appears to offer an excellent model for how aid can be used to help states concentrate on local infrastructure.
As mentioned above, taking responsibility for the primary healthcare for 440,000 people raises the problem of NGO accountability. Regulation of NGOs is almost non-existent, both nationally and internationally. In Britain, Martin Brooke points out that “Charities are one of the very few types of organisation - public and private - whose performance is not scrutinised” . The result is that “poor practice and inefficiency to go unchallenged” . A change to British legislation does come in this year which demands that charities should be “for the public good”, but Brooke insists this is not sufficient as it only allows regulation in terms of whether a charity is legitimate rather than a public benefit . It also completely fails to address international accountability of NGOs. Accountability should not be held primarily against the financial donors, or the notion of the “public good” back in Britain. Accountability should ultimately lie with the people a charity aims to serve, and those it has its greatest impact upon.
Nyaya Health are not held accountable by any independent body. They do however try to make their organisation transparent. Through a combined use of blog and wiki, it is possible to see many of their day to day decisions being made. Without such transparency, this article and much of the work we do on our OAC entry would not be possible. Public information includes current tasks, as well as their financial records.
In fact, I find the general approach to technology by Nyaya Health is encouraging. They are extremely careful to make sure that their use of technology is pragmatic and appropriate, and avoid being sidetracked by novel, but inappropriate uses of technology. For example, whilst getting funding for a telemedicine centre, they are content to use store-and-forward technologies such as email, rather than bare the cost of modern real-time video and audio . Furthermore, the use of a wiki to help manage the development of the project helps them learn about the potential of online collaboration, to obtain support from the community, and also offer back their own findings to others.
So, in conclusion, this is a fantastic case study for how to pragmatically deal with some of the most difficult issues facing the Third Sector, but also how to exploit modern technology. I hope that the Open Architecture Challenge provides Nyaya Health with valuable insights that help make their project a success.
 Open Architecture Challenge – Asia, http://www.openarchitecturenetwork.org/challenge/asia
 Like a Cumin Seed in an Elephant’s Mouth: July 29 - Getting There, http://meronyaya.blogspot.com/2007/07/july-29-getting-there.html
 Rural Health Equity Initiative in Far Western Nepal, http://nyayahealth.org/primary_care_model.html
 Nyaya Health Equity Initiative http://www.anmf.net/programs/projects/2006projects/06nh001/06nh001.doc
 Nyaya Health Prusoff Grant Application http://omega.med.yale.edu/~ds446/Nyaya/Grants/Prusoff/Prusoff%20Grant%20-%20JRA%2012-3-06.doc
 Health Services Assessment in Five Village Development Committee Areas Surrounding Sanfe Bagar, Achham, http://nyayahealth.pbwiki.com/f/HA_Achham.pdf
 The Challenge of Global Health , http://www.foreignaffairs.org/20070101faessay86103/laurie-garrett/the-challenge-of-global-health.html
 Measures of Success, Martin Brooke, http://www.guardian.co.uk/society/2007/nov/20/voluntarysector1
 The numbers game, Adam Sampson, http://www.guardian.co.uk/society/2007/nov/20/voluntarysector.comment
 Nyaya Health Wiki – Information Technology, http://nyayahealth.pbwiki.com/InformationTechnology