Developing a health system: The case of Nyaya Health in rural Nepal

[Editor’s Note: This two-part entry features a narrative and photo essay by Dan Schwarz. The entire photo series and Dan’s bio may be found below.]

Founded on an unwillingness to accept the grave inequities and double standards that are tolerated every day within the world, Nyaya Health, a small NGO in rural Nepal, operates with a mission of health equity and social justice. Nyaya — which means “justice” in Nepali — founded much of their work upon the model of Partners In Health, taking a rights-based, community-based approach to health care delivery. This post tells the story of Nyaya’s work in Bayalpata, and lessons learned in developing a health system in rural Nepal.

The district of Achham in Nepal suffers from some of the highest rates of poverty and maternal mortality in all of South Asia. Before Nyaya Health opened its first clinic, there was not a single allopathic doctor in the area; perhaps not surprisingly, 1 out of every 125 deliveries results in the mother’s death, with less than 0.5% of deliveries occurring in a health facility. Achham’s remoteness also means that, in a country that boasts one of the world’s most famous trekking and tourism industries, 95% of the households are without electricity and only 45% of people have access to safe drinking water.

In 2008, following a civil war, Nyaya Health opened the first primary health center in the region. Shortly after opening the clinic, the community requested that Nyaya take over administration of Bayalpata Hospital.

Bayalpata Hospital, built in 1976, was designed to be the first hospital in the Achham district of rural western Nepal. In a bureaucratic entanglement of political conflicts, the funding and equipment for the hospital were sent to a more powerful constituency in the district. The people of Achham came together as a community, protesting this injustice; the military opened fire on them as they surrounded the facility, killing several and wounding and imprisoning many more. The hospital remained empty, its walls rotting and decaying with time.

In an effort to bolster the public sector health system, Nyaya partnered with the Nepali Ministry of Health and Population (MOHP) to begin rebuilding.

As Nyaya began to rebuild the dilapidated hospital, broad, system-level infrastructure development was a clear priority. Having sat dormant for over 20 years, Bayalpata Hospital was a shell of a health care facility. With crumbling walls, not a single piece of medical equipment, only a scant few chairs and cabinets, faulty electricity and running water, and staff quarters that were too damaged to be repaired, the hospital required extensive renovation. Complicating this process was the fact that the dirt road leading to the hospital was of incredibly poor quality and often impassable, making transportation of supplies extremely difficult.

In 2009, Nyaya re-opened Bayalpata Hospital. Striving to empower the Nepali public sector, Nyaya prioritized the hiring of an all-Nepali staff. This however, in an area as remote and impoverished as Achham, proved challenging as well: brain drain, both internal (to metropolitan areas such as Kathmandu) and external (to the USA and Europe), pulls the most well-trained from the region, leading to a dearth of qualified personnel. Nevertheless, Nyaya continually works to hire locally, thereby improving the area’s own capacity and development.

Upon opening the hospital in June, 2009, Nyaya had restored two clinical buildings, a staff kitchen, and two of the staff quarters. In addition to outpatient and maternal health services, Bayalpata Hospital became home to the first emergency room in the region, as well as the first inpatient ward. While radiological services were initially limited to ultrasound, an X-ray facility is currently being built, and plans to scale-up comprehensive surgical services are being developed. All services are offered completely free of charge, 24 hours a day, 7 days a week.

Nyaya believes fundamentally in health care as a human right, and accordingly, is working toward the development of not only a hospital, but an entire community-based health system. While still nascent in its work, Nyaya aims to expand its community programs over time, recognizing that only wide-ranging infrastructure development will affect population-level health change. By working toward a goal of full accountability and integration with the public sector in particular, Nyaya aims to walk in solidarity with both the people of Achham and with the local and national governments, strengthening Nepali capacity broadly while prioritizing the most marginalized populations and ensuring health equity for all.

For more information on Nyaya Health, please visit and

Dan Schwarz is currently an MD/MPH student at the Alpert School of Medicine, Brown University and the Harvard School of Public Health. He serves as the Executive Director for Nyaya Health and works for Partners In Health, as well.