Globe Med Presentation, Dan Schwarz, March 2010


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This presentation was delivered as one of the "Partnerships in Global Health Equity" workshops at the 2009 GlobeMed Summit ( on March 6th, 2010.

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  • Animate slide so maps show up together, then circles appear kathmandu, everest, achham~450k/ 275 miles (as crow flies) KTM to Achham(do NOT discuss)geography has played an important role in historic socio-politics with the recent civil conflict$65k to climb Everest
  • Ultimately, our goal is to reduce maternal mortality at a population level.  This is expressed commonly as the Maternal Mortality Ratio (MMR), which is a public health outcomes measure that describes the risk of pregnancy in a population.  Its units are deaths per 100,000 live births.  The current best estimate of MMR in Achham is 800.  This is 200x higher than the MMR of 4 in many communities in the United States.   The most precise data on MMR are taken from facilities data.  These, however, are typically not very accurrate since they grossly underestimate MMR in areas such as Achham where only a small number of pregancies actually take place in medical facilities.  In Achham, for example, the number is 0.5%, or 1 in 200.    Greater details regarding the methodology for our mortality assessments are provided on our Mortality Data page.
  • Stress the “success” of being approached by the gov’t for collaboration – this slide should really just be “a few months after opening the clinic, we were approached by the government and local community, and offered to join in a public-private partnership to re-open the Bayalpata HospitalBridge to next slide where meat of the discussion is (with text bullets)
  • Stress the importance of our philosophy in how we approach our work
  • After discussing importance of transitioning to Bayalpata, this should be a quick overview of basic services
  • This slide is an outline of the aspects of Mission #2 Developing a Scalable Model we will now discuss.
  • Background:Historic lack of transparency and collaboration between non-profits, especially in health field2008 Global Accountability Report revealed that many non-profits scored even worse than for-profit multinational corporations on accountability metrics1Implications: Lack of transparency decreases accountability and results in missed opportunities for collaborationParticularly in the health sector, collaboration is needed to develop best practicesTransparency can facilitate accountability and collaboration in health delivery
  • Globe Med Presentation, Dan Schwarz, March 2010

    1. 1. The challenges of transparency, accountability, and collaboration in global health<br />Dan SchwarzExecutive Director | Nyaya Health<br /><br />
    2. 2. Outline of Presentation<br />Nyaya Health Overview<br />Developing a scalable model for health care delivery<br />1<br />
    3. 3. Nyaya Health: Who We Are<br />Mission: <br />To expand healthcare capacity in rural Nepal<br />To develop a scalable model of healthcare delivery in resource-poor settings throughout the world<br /><ul><li>501(c)(3) organization founded in 2006
    4. 4. Public-private partnership with Nepali Ministry of Health & Population (2009)
    5. 5. Managed by a volunteer Board of Directors and 26 full-time employed Nepali staff
    6. 6. Over 99% of all funds used directly in Nepal</li></ul>2<br />
    7. 7. Where We Work: Nepal – Achham District, Far Western Region<br />
    8. 8. Where We Work<br />250,000<br />population of Achham<br />0<br />number of allopathic doctors in Achham before Nyaya<br />10+<br />hours in bus to reach the nearest airport and operating room<br />14<br />hours in bus to reach the nearest intensive care unit<br />6% & 54%<br />Female and male literacy rates, respectively<br />1 in 125<br />deliveries results in the mother’s death<br />64<br />number of stillborns for every 1,000 live births<br />50%<br />of men migrate to India for work; over 7% return with HIV<br />99.5%<br />of babies are born in homes and cattle sheds<br />50¢<br />average daily per capita income in Achham<br />60%<br />60%<br />of children are chronically malnourished<br />4<br />
    9. 9. Achham District, Far Western Region, Nepal<br />
    10. 10. History: Sanfe Bagar Primary Health Center<br />6<br />
    11. 11. History: Sanfe Bagar Primary Health Center<br />Opened for service April 6, 2008<br />Served over 17,000 patients between April ’08 and May ‘09<br />Services included:<br />Outpatient department<br />24 hour emergency services<br />Maternity suite with 24 hour-obstetric services<br />Diagnostic laboratory<br />Pharmacy<br />23 all-Nepali staff<br />All services completely free<br />
    12. 12. History: Transition to Bayalpata Hospital<br />8<br />
    13. 13. History: Transition to Bayalpata Hospital<br />Goal: infrastructure development, capacity building, not care provision<br />Goal: to collaborate with the government in the development of pro-poor, rural health care development<br />Government contract for 5 years signed June 2009 – June 2014<br />Ministry of Health & Population to take over Bayalpata Hospital in 2014<br />
    14. 14. Current Services: Bayalpata Hospital<br /><ul><li>Services include (all free):
    15. 15. Inpatient & Outpatient services
    16. 16. 24-hour emergency and obstetric services
    17. 17. Laboratory & Pharmacy
    18. 18. Community Health Workers (CHWs)
    19. 19. Clean water supply for surrounding communities
    20. 20. 2010-2011 Expansion:
    21. 21. Surgical suite
    22. 22. X-Ray Services
    23. 23. Expanded CHW network
    24. 24. Solar energy</li></li></ul><li>Outline: Developing a scalable model of health care delivery<br />Background: accountability, transparency and collaboration<br />Health sector approaches to collaboration<br />Nyaya’s Approach<br />Case example: Tiyatien Health<br />Challenges<br />
    25. 25. Background: Importance of transparency, accountability, collaboration<br />Questions:<br />What are best practices for health care delivery in resource-poor settings?<br />How can NGO’s ensure accountability to stakeholders in global health delivery?<br />Background:<br />Historic lack of transparency and collaboration between NGO’s, especially in health <br />2008 Global Accountability Report (One World Trust) revealed that many non-profits scored even worse than for-profit multinational corporations<br />Implications: <br />Lack of transparency decreases accountability and misses opportunities for collaboration<br />Particularly in health sector, collaboration is needed to develop best practices<br />Transparency, accountability and collaboration can aid the development of a scalable model for health delivery<br />
    26. 26. Attributes of a scalable model of healthcare delivery<br />Transparency<br />Collaboration<br />Accountability<br />
    27. 27. Take-home message<br /> A lack of transparency not only reduces the accountability of individual programs, it also misses an opportunity to advance global health delivery by establishing best practices in the field and collaboration between partners in these efforts to create best practices.<br />
    28. 28. Nyaya’s Approach to transparency, accountability, & collaboration<br /><ul><li>Data-driven health care delivery
    29. 29. Clinical, financial and managerial
    30. 30. Open-access data fostering:
    31. 31. inter-team communication, and
    32. 32. collaboration with global health delivery community
    33. 33. Fully transparency aimed at accountability to stakeholders
    34. 34. Patients, public sector, partner org’s</li></li></ul><li>Nyaya Health: Wiki<br /><ul><li>Wiki is a searchable repository of:
    35. 35. Management policies
    36. 36. Financial data
    37. 37. Clinical protocols
    38. 38. De-identified clinical data
    39. 39. All pages viewable to the public
    40. 40. A forum to share lessons-learned from Achham with organizations in similar settings around the world
    41. 41. Opportunity for critical feedback and collaboration</li></ul><br />
    42. 42. Nyaya Health: Inter-team communication<br />Intra-team communication<br /><ul><li>Nyaya is a collaboration between Nyaya Health INGO (USA) and Nyaya Health Nepal (Nepal)
    43. 43. Fluid communication is critical to a collaborative model
    44. 44. Nyaya uses low-bandwidth, user-friendly, open-access, free technologies to communicate and facilitate work among team members</li></ul>Gmail Archive<br />Google Docs<br />EverNote<br />
    45. 45. Challenges and barriers to effective communication<br /> Two locales & two teams<br />Discontinuous communication<br />Details of day-to-day life lacking<br /> Context for decision-making lacking<br />Uncomfortable tensions:<br />Micro-management vs. “hands-off” approach<br />Empowerment vs. “letting go” of control<br />Deferral to local authority<br />…An imperfect system<br />
    46. 46. Communication challenges<br />Nyaya is a collaboration between Nyaya Health INGO (USA) and Nyaya Health Nepal (Nepal)<br />Fluid communication to facilitate inter-team collaboration is critical to model<br />Nyaya uses low-bandwidth, user-friendly, open-access technologies to communicate among team members<br />
    47. 47. Current approaches to collaboration in health delivery<br /><ul><li>Recent initiatives have utilized online communities to enhance collaboration among global health practitioners
    48. 48. Initiatives aimed at enhancing collaboration to facilitate development of sector-wide best practices</li></li></ul><li>Building a scalable model: Tiyatien Health<br />
    49. 49. Collaboration with partner organizations: Tiyatien Health<br />Case Study in Collaboration: Tiyatien Health<br /><ul><li>TH: similar organization in Liberia
    50. 50. TH and NH face similar challenges in effective health delivery practices
    51. 51. Via transparent operations and inter-team collaboration, TH and NH have been able to enhance work in both Liberia and Nepal
    52. 52. Successful collaborations including:
    53. 53. Financial accounting protocols
    54. 54. Pharmacy and inventory management
    55. 55. Fundraising strategies</li></li></ul><li>Limitations of model<br />Such tools do not replace local, community-level transparency and accountability structures, especially in resource-poor settings<br />Need for CABs, CHWs, partnerships w/ regional stakeholders<br />Model is not accessible to our patients and staff due to poverty and illiteracy<br />Model requires internet technologies, not available in many settings<br />High amount of start-up and maintenance capital ($)<br />M&E dependent on epidemiological and data management experience<br />Difficult skill set to recruit in many settings<br />“Evidence-based medicine” is a pedagogical culture not shared by all health care systems/practitioners<br />Need for education, training and incentives for staff<br />
    56. 56. Thank You… Questions?<br />24<br />