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“Transparent Until It Hurts”


Markets For Good is pleased to welcome Mark Arnoldy, Executive Director of Nyaya Health,  a complex operation in that it operates on the front lines of a few themes we’ve covered: beneficiary insights, open data, nonprofit decision-making, and this month’s theme, data privacy, among others. It was Mark’s own experience of getting sick and nearly dying in rural Nepal that sparked his work. Now seven years on and with a history of treating just over 100,000 patients, Nyaya uses an open wiki as a core managment tool to “deliver transparent, data-driven health care for Nepal’s rural poor.” I thank Mark for taking the time to share his experience via the intermittent email access he had available at the time.  After reading, let’s join the discussion in the comment section, especially if you are working in a similar data scenario or are doing related health work.

Eric J. Henderson, Markets For Good (Eric): How do you handle privacy in your open format, especially as a health organization dealing with sensitive information from citizens and the government?

Mark Arnoldy, Nyaya Health (Mark): At current scale, it’s surprisingly easy. Perhaps that’s because people don’t have interest in poaching or buying data for the world’s poorest people that live in forgotten folds of the Earth. Practically speaking, we code patients (we don’t use their full names or personal identifiers publicly without permission), protect our databases, and only publish data on our wiki or elsewhere in a de-identified fashion. That works when syncing with the government’s data systems because governments are primarily concerned with volume-based metrics. And data for large-scale volume-based metrics can remain de-identified.

Eric: “Data-driven” and “transparent” are now common language, while concrete examples will naturally lag behind. How do those two factors directly contribute to the mission of providing the tangible benefit of healthcare to rural Nepalese?

Mark: A key piece of our Cultural DNA is “be transparent until it hurts.” Transparency and data are two of the essential ingredients required to make great decisions. Without those two ingredients, we not only risk making bad decisions but we also fail to maximize our own learning. I view global health practitioners as never ending entrepreneurs; we are always working in environments of extreme uncertainty, and the way to be successful in uncertain environments is to maximize your learning. Without data, you cannot do that.

Eric: How does the information relationship work with the government and what have you both found the most beneficial – whether based on sharing knowlege via IT systems, providing previously unavailable information, collaborating on expertise, etc.?

Mark: We really bootstrapped this to begin with. We just found open-source software and “layered” it on top of the government’s current systems. For example, for our accounting, we used GnuCash to digitize our finances, trained local staff, and just built a internal protocol to get all of our financials posted to a public wiki. Now that we’ve grown, we’ve been undergoing a transition to Quickbooks. But the protocol will largely stay the same and we will continue to post our full transaction details openly. The same happens for clinical and public health data. All systems are purely paper-based in the health care sector in Nepal. But we built a Microsoft Access database that allows us to knuckle in data and get it in to a system in digital form. Funny enough, the local District Health Office won’t accept our emailed data outputs. So we still have to print it out and send it via a runner a couple hours by vehicle to the District Health Office. I use that example to show that things aren’t perfect and to push systems forward, you have to be willing to accept a bit of duplication for a certain period of time.

Eric: Thinking on your experience thus far and taking a wide view of health provision in the social sector, in general, what would you like to see (that we don’t have/aren’t doing now) with respect to how we could better use information to support our work?

Mark: What would be pioneering is to see an organization that can use open data to compel governments to structure major multi-million dollar, multi-year public private partnership agreements for rural health care delivery. We believe, and argue that history demonstrates, the most effective way to bring comprehensive health care to the world’s poorest is through public-private partnership models. Yet most of those models to date have focused on single, large-scale facilities that are often in urban or peri-urban locations.

We are interested in changing the game on how a public private partnership could work in “last mile” rural health care settings where the care that gets delivered at clinics and via community health workers is just as important, if not more important, than care provided at hospitals. So we want to see a large scale public private partnership where a government structures a performance-based financing that rewards private health care implementers (including nonprofit organizations like us) for changing health outcomes for a population. That moves us from models that reward only hospital-based behaviors to a model in which an organization would be rewarded for using the full spectrum of health care delivery (hospitals, clinics, and community health workers) to drive outcomes like increasing the number of women giving birth in safe health care facilities. But this can only happen with open data and a government committed third party structured to rigorous evaluate that data.

Many thanks, Mark.