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Nyaya Health

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 [1]. 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 [2]. 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 [1], 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 [3], only 3% of women have skilled workers on hand during labour [4], as many as 60% of children are reportedly malnourished [3], and the HIV problem is growing, but poorly understood [5]. 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 [6]. Indeed a local survey commissioned by Nyaya health found that the median sum spent on medical services and travel was half the median income [6].

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 [7] 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.

NGO Accountability

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” [8]. The result is that “poor practice and inefficiency to go unchallenged” [9]. 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 [9]. 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.

Collaborative Technology

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 [10]. 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.

Conclusion

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.

References

[1] Open Architecture Challenge – Asia, http://www.openarchitecturenetwork.org/challenge/asia

[2] Like a Cumin Seed in an Elephant’s Mouth: July 29 - Getting There, http://meronyaya.blogspot.com/2007/07/july-29-getting-there.html

[3] Rural Health Equity Initiative in Far Western Nepal, http://nyayahealth.org/primary_care_model.html

[4] Nyaya Health Equity Initiative http://www.anmf.net/programs/projects/2006projects/06nh001/06nh001.doc

[5] Nyaya Health Prusoff Grant Application http://omega.med.yale.edu/~ds446/Nyaya/Grants/Prusoff/Prusoff%20Grant%20-%20JRA%2012-3-06.doc

[6] Health Services Assessment in Five Village Development Committee Areas Surrounding Sanfe Bagar, Achham, http://nyayahealth.pbwiki.com/f/HA_Achham.pdf

[7] The Challenge of Global Health , http://www.foreignaffairs.org/20070101faessay86103/laurie-garrett/the-challenge-of-global-health.html

[8] Measures of Success, Martin Brooke, http://www.guardian.co.uk/society/2007/nov/20/voluntarysector1

[9] The numbers game, Adam Sampson, http://www.guardian.co.uk/society/2007/nov/20/voluntarysector.comment

[10] Nyaya Health Wiki – Information Technology, http://nyayahealth.pbwiki.com/InformationTechnology

Posted in Public Health.

E-campaigning Will Lead to a Stronger Democracy

A modified version of this article was published in What Makes Us Sick, it is also available in pdf

National and international systems of governance are failing to fulfil their promises. The system, described as “representative democracy”, is intended to achieve rule by the people; the citizenry should direct government and hold it to account for its decisions. Unfortunately national governments increasingly flout their responsibilities, whilst international bodies from the UN to the WTO fail to offer the public representation at all. To exacerbate matters, citizens have become dangerously accepting of government policy. One indicator of this is declining turnout at elections –in the UK voter turnout between 1955 and 1992 was stable at 75%, but this fell to 58% in 2001[1]. As a result, many decisions are made in the interests of the powerful, rather than the people. In 2001 just 11% of the British public supported privatisation of public services[2], but the government carried them through anyway; it now has its sights on the NHS. The war in Iraq is another case where interests of powerful forces in both the US and UK seemed to dominate over public opinion. Meanwhile in the International arena the WTO, IMF and World Bank force countries with delicate economies to open their markets, and the people most affected are powerless to stop them.

One of the most compelling reasons for citizens’ incapacity to hold governments to account is that individuals find it difficult to know how to respond to these failings. Structured channels of feedback to the government are not immediately accessible, and they do not help form communities of understanding. Campaigns are in part a response to this failing. They help inform, connect, involve and mobilise individuals[3]. They form a deliberative channel of communication between the people and the government, and in doing so fill a void in the democratic structure. As campaigners, it is important that we understand and respect this role and our concomitant duty to run campaigns accessibly and democratically.

In order recognise how campaigns can help achieve these goals, it is important to understand the relationship between the campaign itself and its participants. How campaigns reach and influence people depends on how this target audience interacts and engages with those campaigns. The research project Participate[4] is an excellent resource for understanding the different modes of participation. The research project shows that different types of interaction indicate different levels of commitment and roles as a participator. The practices of listening and watching are at the bottom of a hierarchy of involvement, followed by giving money, providing information, “being there”, giving time and starting something new. The actions at the bottom of the hierarchy tend to be mass ones, involving large numbers of people – these are the happy bystanders. As you move up the structure you find increasingly more committed people who are willing to deal with more niche issues: starting with the reluctants, and moving through followers, evangelists and instigators. Key motivators for participants are a sense of belonging to a community and the idea of the cause, followed by (in no particular order) passion, altruism, reward and specific good. Important barriers meanwhile are apathy, cynicism and triviality – the sense that a contribution is too trivial to be a valuable contribution. A successful campaign will capture large numbers of people at the bottom of the hierarchy of involvement, and use the motivators to push people up the ladder.

Hierarchy of Involvement

Adapted from slide 60 -  Participate Online - User Motivation in Mass Participation

Understanding this participation model can help you ensure that your members contribute to the best of their ability. In order to allow campaigns to fill the democratic void in deliberative communication with government however, they need to find ways to increase the levels of participation by the happy bystanders, reluctants and followers. This has always been a difficulty for campaigners, but I believe the current wave of social innovation in the Internet is opening up exciting, dynamic and innovative solutions to the problem. The Internet creates the potential to open up a dialogue with a massive audience across economic and geographic borders. Never before has it been possible to speak freely to so many different people, whilst avoiding the constraints placed by funding bodies and censorship. Now modern “Web 2.0” sites are making it possible to build communities around this global conversation. Ricken Patel of the international online campaigning group Avaaz.org describes this as “the public square moving online”. The potential impact of this is massive, and the responses by economic powerhouses to global movements such as to the global environmental movement are indicative of this. Global public opinion, in Avaaz’s words, is “becoming the new superpower”.

So what is the evidence for all this potential? The Internet is replete with examples of organisations which have exploited modern communications to instigate and accelerate successful campaigns. The most exciting aspect of this is not that there is a large collection of resources to learn from, but that every day people are finding new applications of the technology. One of the pioneer campaigning websites, MoveOn.org, was founded after an email demanding American politics move on from the Clinton-Lewinsky affair was sent to 100 people, and reached 100,000 people within a week. Greenpeace’s greenmyapple.org incorporated unedited articles and imagery contributed by users in its successful campaign to get Apple to reduce the environmental impact of their products. The lightamillioncandles.com website was stunned to reach its target of lighting 1,000,000 online candles for the victims of child pornography in just 60 days. Avaaz.org is another impressive innovator, creating new convergence opportunities between online and offline spaces. Their recent live webcast of a talk by the new Foreign Minister David Milliband allowed them to open direct communications between their international membership and a member of the British Cabinet.

The greatest Internet opportunities however are still unknown. The World Wide Web is currently going through a minor revolution, with a battle going on over how best to build trusted, authoritative, accurate and dependable resources. The notion of crowdsourcing – the idea that contributions from a large community of committed people can produce better solutions than trained individuals – has had an incredible impact. The collaboratively built Wikipedia has not only proved that the concept cannot be ignored, it has also shifted the entire culture of the web: people are no longer browsers, but contributors. Nowhere has this new wave of user contributed content been more pronounced than in the Social Networking sites such as MySpace and Facebook – which is attempting to shift the platform for the web from individuals and companies to networks.

The challenge now is to exploit these new “Web 2.0” practices to achieve an equivalent browser-to-contributor-shift in our democratic practices. If we can do this, we can move from a representative democracy to a participative democracy. Now wouldn’t that be something?

References

[1] International IDEA Database, http://www.idea.int/vt/country_view.cfm?CountryCode=GB

[2] Private sector plan ‘more unpopular than poll tax’, Patrick Wintour, 12/07/ 2001, The Guardian

[3] Web Campaigning, Kirsten A. Foot and Steven M. Schneider, 2006

[4] Mass Participation Review, Participate Online, 2006, http://massparticipationreview.notlong.com

Posted in Democracy, ecampaigning.

Time Contours

Last year, for my University Master’s project, I completed a project which explored the potential of combining time with maps. The basic concept was to build dynamic maps, based on the user’s frame of reference, which would adapt to describe journey time to different locations on the map. The primary method I considered for implementing this was the isochrone - which is essentially a contour which traces a boundary beyond which you cannot cross in less than a given time period. For my implementation I focussed on their usage in describing the status of the London Underground network. See here for a detailed overview of the project, and here for the full project report.

7 Minute Isochrones from Oxford Circus

During the development of the project, a lot of discussion was sparked when Oskar Karlin released his Master’s project looking at isochrones on the Underground on the Internet. Tom Carden followed this up with an applet implementation using Processing, and then mySociety created an isochronal map for Britain as a whole. The flurry of activity proved that the concept has potential, and I expect a resurgence to appear as the GeoWeb continues to develop. I did look into the potential for improving my software, and taking it to either KaZoom (who do Transport For London’s web software), or one of the advertising agencies, but I haven’t been able to find the time the project would require. If people are interested in the code, then I may still be persuadable to Open Source it.

Working on the project led me to develop ideas further around the concept of relating points in space to the “cost” of travelling there. I think that there is potential to apply this concept to a much more complex set of variables than just time, such as the financial impact, or “value” to the user in reaching that location. I’m particularly interested in the application of this idea to relief situations, where decisions have to be made very quickly on limited knowledge. For example, after the Tsunami, information such as availability of transport and resources could be combined with risk and need to generate a heat map describing where best to set up camps and food distribution points. Implementations may be crude, but they could certainly help in describing the overall picture of a complex situation quickly to relief workers. In all likelihood this already exists, or at least I hope something like it does!

Posted in GIS. Tagged with , .