A Model of Health
In Nepal, a US-based nonprofit is partnering with the national government to deliver full-service medical care in remote areas.
In 2013, Ratan Kunwar was stirring a pot of lentils to feed her family for dinner when she knocked over the pot. It fell onto her arms, chest, and abdomen. Her skin was scalded and raw. Kunwar, a 28-year-old mother of two sons—a baby and a three-year-old—lives in the Nepali village of Mastamandu. After the accident, she was turned away from one hospital because she couldn’t afford treatment, and she assumed that she would endure her injuries forever. Her arm itched and burned. At night, the pain kept her awake. She had trouble farming, cooking food, and washing clothes for her family. She couldn’t comb her own hair. She was unable to hold her baby.
Three months after the injury, Kunwar arrived at a hospital run by a nonprofit organization called Possible. The organization posted Kunwar’s story on an affiliated crowdfunding site, and before long people from around the world had contributed enough to pay for her skin-graft surgery. Since the surgery, every aspect of Kunwar’s life has improved. Most important, she can now hold her infant son in her arms. “That’s a classic example of why taking a comprehensive approach to health care matters, because conditions as simple as a burn or fracture can destroy people’s lives,” says Mark Arnoldy, cofounder and CEO of Possible.
Kunwar is one of more than 173,000 patients whom Possible (formerly Nyaya Health) has helped treat since 2008. That year, a trio of friends from the Yale School of Medicine—Jason Andrews, Sanjay Basu, and Duncan Maru—along with local clinicians, started providing care out of a grain shed in the Achham district of Nepal. At that time, the people of Achham lived a 36-hour bus ride away from a major health care center.
Today, Possible operates a sophisticated health care delivery system that functions on top of the Nepali government’s existing infrastructure. The organization follows a hub-and-spoke model: It runs a hospital and a network of clinics, and it supports them by managing a team of community health workers. It treats patients who suffer from a variety of maladies, and it treats them free of charge. In addition, Possible has built a referral program for patients with complex care needs. “It’s a model that’s neither private sector nor public sector, but a combination of the two,” says Arnoldy. Unlike some efforts to deliver health care in developing countries, moreover, the Possible model doesn’t have a limited scope. “It’s not just for certain conditions, like HIV or maternal health,” Arnoldy notes. It is, he says, “a health care system [like] we would expect to have here in the United States.”
Hub and Spoke
Bayalpata Hospital serves as Possible’s hub for clinical care and organizational operations. The Nepali government built the hospital in 1979 and then abandoned it for 30 years. Possible refurbished the crumbling buildings and took over management of the facility in 2009, and since then providers there have treated more than 44,000 patients. Kunwar delivered her second baby at Bayalpata.
Nepal offers an opportune setting in which to build a delivery model based on combining public and private resources. The Nepali constitution includes a provision that guarantees free health care for patients who live in poverty. Each of Nepal’s 75 districts has its own public hospital, more than 13,000 government-run clinics dot the country’s rural landscape, and the government maintains a network of 50,000 women who act as community health volunteers. Yet the Ministry of Health and Population spends only about half its budget each year. That’s because of gaps in the “absorptive capacity of the government’s health care system,” says Maru, who serves as chief programs officer of Possible. “There’s a real interest in public-private partnerships on the part of politicians and the funders in the Ministry of Health.”
Maru and other members of the Possible team have worked with those officials to create the Possible delivery framework. Amit Aryal, a technical expert for the Ministry of Health and Population, praises the comprehensiveness of that framework. “In my mind, [Possible is] really taking health care to the people and not waiting for them to come to the hospital,” says Aryal.
Accessing health care can be nearly impossible for people in Nepal who live far from cities. The average Nepali pregnant woman, for example, will walk more than four hours to deliver her baby in a hospital. To help remedy that situation, Possible has transformed six underperforming government clinics into high-quality birthing centers. “If we’re going to solve the access problem, we need to get that [local clinic] tier of the health care system working at a very high level of performance,” Arnoldy says.
To improve primary and preventive care, Possible is strengthening the government-managed cadre of community health volunteers. That effort involves training volunteers to encourage patients to visit Possible facilities for follow-up care. It also involves training volunteers to keep records of all pregnancies and illnesses. In addition, Possible has developed a network of paid community health workers who track health information and provide services at the household level. It’s “the health care system’s responsibility to reach out and to make sure [that patients] continue to be engaged in the system and are getting the care they need,” Maru says.
The value of the hub-and-spoke model is especially evident when it comes to treating conditions such as neonatal jaundice. Trained health workers who operate in clinics and out in villages are able to screen infants for that disease. “With [the Possible] model, fewer infants will fall through the cracks,” says Garrett Spiegel, a product manager at D-Rev, a company that partners with Possible to provide phototherapy and jaundice management at Bayalpata Hospital. Instead, he explains, properly diagnosed infants are “brought in to the health center before the jaundice progresses to a level where their brain is permanently damaged.”
Possible holds itself to a high standard of care and applies rigorous evaluation to its operations. “The way we measure our success has changed, as the scale of operation has grown,” says Arnoldy. Epidemiologists from the Division of Global Health Equity (DGHE) at Brigham and Women’s Hospital in Boston work with Possible to track a variety of performance indicators: the number of days that surgical services are available to patients, the percentage of chronic-disease cases that community health workers treat, and so forth. (Maru is a faculty researcher at DGHE.)
Cost control is another goal that Possible leaders take seriously. Their long-term aim is to limit per-patient expenditures to less than $50 per year, and so far they have kept that figure to less than $20. By comparison, annual per capita health care spending in the United States comes to about $8,000.
Change and Challenge
In early 2014, Arnoldy led the organization through a rebranding initiative that resulted in a new website, a new logo, and a new name. The original name—Nyaya Health—was hard to spell, hard to pronounce, and hard to promote. Over time, the Nyaya brand had also become more and more restrictive. “For us, this is about way more than the name, look, feel, and colors,” says Arnoldy. “Our team thought we had a shrinking window of opportunity to communicate why we exist and how our health care model works. We had to make a move before we got too big and [the old name] became too cemented into the identity of the organization.”
To continue growing under its own identity, Possible has sought revenue from a broad range of sources. At this stage, the organization receives most of its funding from donors such as the Good Works Institute, Greatergood.org, and Rotary International. But Arnoldy foresees a time when the Nepali government might become its largest funder. In 2013, the government invested cash and in-kind contributions worth $270,000, up from $110,000 in 2011. (That year, Possible had annual revenues of about $1.25 million.) Along with land, infrastructure, and other forms of in-kind support, the government has provided a large supply of pharmaceuticals to Possible through the public-sector supply chain. “We have a quickly growing relationship on that front that makes us believe that this is very much possible to do on a large scale,” says Arnoldy.
In partnership with the crowdfunding sites Watsi.org and Kangu.org, Possible has also created an online medical referral network. “Before this model, we had to turn patients away,” says Arnoldy. Now when patients come to Bayalpata Hospital or to a clinic with complex care needs, Possible can tell their story on the Web, and anyone with Internet access can then help fund their care with a donation of $10 or more. In December 2013, Possible received a Sappi Ideas That Matter Award valued at $43,000, and with that money it launched CrowdFundHealth.org—a site that integrates the Possible referral network with the Watsi and Kangu sites. (In its first 14 weeks, CrowdFund Health raised enough money to provide $112,000 worth of treatments to 120 patients.)
Today, the most challenging aspect of Arnoldy’s job involves retaining qualified providers who will work in less-than-hospitable rural areas. Despite offering comfortable staff housing, high salaries, and a supportive management culture, leaders at Possible face environmental and social barriers that hinder long-term retention of senior staff members. “And we don’t expect that [problem] to go away anytime soon,” Arnoldy says.
Another challenge stems from the organization’s reliance on government funding. A new group of Nepali political leaders could easily take that funding away. “We can’t completely eliminate that risk, the same way we can’t eliminate the risk that a large-scale philanthropic funder might do that someday,” Arnoldy says. “We’ve tried to mitigate that risk—not by being too big to fail, but by being too influential to fail.”