1. Nyaya five years on:Finding our role in the movement Mark Arnoldy, Executive Director&Ryan Schwarz, VP of US Operations

2. 2006 “…While I was staying there, I literally had 10 women a night knocking on my door asking for medical help for themselves or their children. All but one of their husbands had worked in India and half of them were widows at 25-40 years old. Among those that knew their [HIV] status, all were positive. There are no medical services available to them beyond the most basic primary care (and that is often geographically and financially inaccessible)… It was very difficult to talk with these women because there was nothing I could offer or recommend to them. The nearest facility providing HIV care (and doing so incredibly poorly) is a 12 hour bus-ride away… It's not just HIV that's a problem, of course. 95% of births (or more) take place in a home without a health worker present… Malnutrition is a major problem, with >60% of children in those two districts having moderate-to-severe malnutrition… One night I was sitting, having dinner in a room full of the women I had been providing my meager medical advice to and it struck me that they would almost all be dead within five years, given their symptomaticity and prospects for treatment. Since that moment, I’ve felt wholly compelled but completely adrift…” Jason Andrews, MD Nyaya Co-Founder 3/12/2006

3. Outline of Presentation Nyaya Health introduction Achham: 2006-2011 Nyaya: 2006-2011 Reflections on building the movement

5. Partners In Health (PIH) Partner Project

6. Nyaya Team:

7. 27 full-time employed Nepali staff + ~50 CHWs

8. 1 full-time US-based Executive Director

10. Nyaya Health: Mission and operations Goal: infrastructure development, capacity building, not only care provision Goal: collaborate with the government in development of pro-poor, rural health care Government partnership contract for 5 years June, 2009 – June, 2014

11. Achham: People ~270,000 people 99.6% Hindu 60% agricultural >80% of men migrate to India, and 35% of families rely on remittances from India 33% literate: 54% men, 14% of women <$1USD is daily per capita income

12. Achham: Infrastructure 2006: >90% of houses have did not have electricity 45% had access to clean water – 2.5x worse than national average Hydroelectric plant functioning <50% capacity Extremely limited landline telephone capacity, one cell phone tower Paved road ended in SanfeBagar Airport destroyed during war Hospital 5 hours, surgery 6 hours, ICU 14 hours

13. Achham: Progress and challenges, 2006-2011 Progress Continued Challenges 0 => 4 doctors & enhanced services Increased health spending per capita ($5) (USA = ~$6,956 in 2007) Road has been extended ~ 5 miles Further development post-war Landline phones a little more common, cell reception a bit better Other statistics difficult to predict due to lack of good data Lack of development relative to country Roads dismal and dangerous, no airport Continually limited electricity Still > 6 hours for surgery, >14h to ICU MMR: ?600-600? vs 251 Nepal avgvs 17 in USA (per 100,000) HIV burden ?highest? in country A long way to go…

14. Nyaya’s founding and the “all-volunteer” organization (AVO) Founded by students and residents Ability to leverage resources for resource-poor settings No high-paid NGO consultants; instead a “lean, nimble and innovative” volunteer model Full-time Nepali staff (locally hired when possible; >80%) “Part-time” volunteer USA staff – “All-volunteer organizational” model

15. Benefits & limitations of the AVO model PROS CONS Pragmatic “sexy” work vs “grunt” work “sin wave” model of reliability lack of centralized structure no accountability limited (no) expertise Weakness: HR = limiting factor Pragmatic no one else working in Achham no money to hire anyone harness student excitement for GH >99% funds to programs Philosophic volunteers > high-paid consultants Strength: innovative use of HR

16. Lessons-learned and transitioning to a professional organization HR outside of Achham became a limitation to expansion of our work in Achham (funding in particular) We lacked: Reliability in operations, capacity for opportunities, and funding Infrastructure to obtain enhanced advisory capacity – “we are supremely unqualified to do this work” Infrastructure to expand partnerships and enhance effectiveness We need to professionalize – providing healthcare for hundreds of thousands of people is not a part-time job AVO model

18. need for expanded networking, fundraising, partnership development

20. Reflections – finding our place in the movement Critical role for volunteers in the movement, and an equally critical role for us to recognize our limitations Students and activists can access resources our colleagues in resource-poor settings cannot As leaders of the movement we need to be cognizant of where we can add value – sometimes that is in the field, sometimes in the back-office Grassroots work relies on both advocates and implementers

21. We can do better for our patients.

22. …thoughts, questions, concerns, feedback?