A Model of Health

November 5, 2014 Editor 0

By Corey Binns

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.”

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Categories: Social Innovation, South-South

Tags: Community health worker, Health economics, Health equity, Health informatics, Healthcare in Nepal, Nyaya Health