Dear Partners,

The completion of the fourth quarter of FY19 gives us a moment to reflect on the progress and lessons of a decade of work in Nepal.

So much has changed politically in the country since 2008, which has required us to consider what it means to build enduring, scalable public health systems amidst a country in transition.

I summarize a few reflections that shape our work going forward:

We have witnessed that the sickest and most marginalized patients need quality care at clinics and hospitals, and Community Health Workers (CHWs) are only effective if their care is coordinated with inpatient and surgical care.
Reducing preventable death and disability requires inputs in technology, supervision, management, supply chain and practice across a local health system, including care in community settings, clinics, and hospitals.
The time for a new model of care in low-resource settings is now. In Nepal, the government’s reaffirmed commitment to Universal Health Coverage in its recent Public Health Acts, its historic payment mechanism via the National Health Insurance, the restructuring of the health system under municipal governments together provide a historic opportunity to expand care for the most vulnerable populations.
Our call to action is: to build, test and scale an integrated approach, so that the most underserved populations can access timely, coordinated, quality care that is their human right.
Success will mean demonstrating impact at the local (municipal) level and translating that impact into adoption and replication of our model across Nepal. We hope that this model will be relevant to advancing care in other low-resource settings globally.

In the stories below, we share progress on our journey. Thank you as ever for believing that everyone deserves quality care, without financial burden.

With hope,

Duncan Maru, MD, PHD
CEO, Possible

Municipal Integrated Care: Localizing Healthcare for Underserved Communities

In 2017, Nepal began its historic transition from a central to a decentralized federal government structure. Now local government units (municipalities), who have visibility into the challenges faced by their constituents can decide how to allocate their healthcare budgets.
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Possible’s role is to support municipalities to identify gaps in healthcare delivery, implement evidence-based strategies as well as our own innovations (such as NepalEHR) to fill those gaps, strengthen the health system and capacitate it to deliver consistent, quality and integrated care within their communities.

Photo: Nurses enter patient data in NepalEHR.

In February 2018, we signed our first agreement with Chaurpati municipality in Achham to strengthen the municipal health system at the community-level as well as facility-level; we subsequently launched services at Chaurmandu Primary Health Center (PHC) in the municipality.
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In the six months since, Possible has worked to develop Chaurpati municipality as the pilot site for the design and implementation of our integrated care model, including the establishment of optimized care delivery, management, logistics and digital systems at the PHC, and a paid, technology-enabled community health workforce.

Photo: Discussion on Community Healthcare expansion with team leads.

Our plan for FY20 is to work with the municipality to include CHWs in the healthcare budget and determine the digital tools and other support that can be absorbed by health posts so that they serve as a cohesive part of the municipal health system.
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As we analyze the data in partnership with the municipality, we hope to better address the primary drivers of morbidity and mortality at a localized level, and build a model that can be scaled.

Photo: Community Health Worker uses smart phone to guide decision-making and care.

A Win for Community Health: Integration into Municipal Healthcare Budget

‍ In late July of this year, Possible launched a new partnership with Ramaroshan Rural Municipality in Achham to deploy a network of paid and trained CHWs serving a population of approximately 30,000. With this addition, we are further expanding our community health program which currently includes 120 CHWs serving a population of over 230,000 across nine municipalities.

Our partnership with Ramaroshan represents a milestone on our journey towards sustainability - it marks the first time that a municipality has committed to underwriting the cost of CHWs. Until now, Possible has had to take on the full cost of the community health personnel.

Community Health Worker advises a pregnant woman on nutrition, in advance of delivery.

With decentralization of government healthcare resources and greater local control, Possible now has a unique opportunity to demonstrate that our community health program can be incorporated into, and financed within, the public healthcare system.

Ramaroshan municipality will train seven local women with a higher secondary education to become CHWs and provide home-based care in line with Possible’s approach to community healthcare delivery. In turn, Possible will hire Community Health Nurses to provide technical support and mentorship to the CHWs.

Photo: Community Health Worker counsels new mom about family planning options.

We hope that Ramaroshan can serve as an exemplar for municipality-owned community healthcare delivery and help advance a national policy around the accreditation and certification of CHWs. We are also hopeful that we can work with more municipalities to take the next step: optimizing the continuum of care delivery from the facility to the community so that mothers and infants, in particular, receive quality care.

We have begun to see promising and consistent results from this cadre, especially around reproductive, maternal, newborn and child health indicators. In coming months, Possible will launch our joint feasibility study with the municipality to refine the design of the community health program.

Photo: Community Health Workers participate in a group training around menstrual health.

Two Years Since National Health Insurance Act: Lessons Learned

As Nepal marks two years since the historic passage of the National Health Insurance Act in 2017, Possible is continuing to identify what insurance means for expanding healthcare access to underserved communities. Our digital platform, NepalEHR, is critical to realizing the potential of health insurance.

Out-of-pocket (OOP) healthcare expenditures at the point-of-care remain a significant financial burden worldwide. Globally, around 150 million people experience healthcare-related financial catastrophe annually, many of who are forced to choose between care and food. In Nepal, OOP payments comprise an estimated 48% of the total expenditure on healthcare nationally, which is exacerbated in rural areas.

Photo: Nyaya Health Nepal Executive Director discusses how healthcare causes burden on families.

One hindrance to realizing the full potential of Nepal’s health insurance scheme: there are currently no government-wide digital systems to facilitate the efficient and accurate processing of claims.

At the center of Possible’s systems design and evaluation efforts are the interrelated mandates around equitable access, affordability of healthcare services, and social protection for the most vulnerable populations.

Photo: NepalEHR aims to solve for access, affordability, and coordination of care across location and condition.

To evaluate the effectiveness of the integrated claims module, we will measure and visualize: Insurance claims; # of claims submitted each month, disaggregated by condition; Claims processing; % of submitted claims correctly processed; Claims reimbursement; % of correctly processed claims successfully reimbursed.

To evaluate financial protection among our catchment population, we will measure and visualize, via our community-based mobile health data platform: Reach; % of catchment area population enrolled in the national health insurance system; Protection; out of pocket expenditures as a proportion (%) of total household; expenditure on health (at baseline and one-year follow-up);Enrollee experience; assessed via grounded ethnographic methods, including participant observation and key informant interviews.

Photo: We measure insurance enrollment across our catchment via a community-based mobile health data platform.

With NepalEHR, we have the ability to track patient, supply, laboratory, radiology, and pharmacy data seamlessly. We have also integrated NepalEHR with District Health Information Software (DHIS), an open source software platform for reporting representing the first known integration of the two platforms to-date; we are in the process of integrating our mobile tool (CommCare) with NepalEHR.

Photo: Lab technician accesses x-ray, using patient record in NepalEHR.

Possible has begun accepting health insurance from patients and processing claims for reimbursement. We are hopeful of the role that integrated digital platforms can play in mapping, measuring, and reducing OOP expenditures on health, and resultant medical debt, and ultimately reducing the financial burden on families who need care the most.

Photo: Insurance offers a path to ensuring healthcare for those who need it the most.

Quarterly Impact Report

Municipal Integrated Care: Localizing Healthcare for Underserved Communities

A Win for Community Health: Integration into Municipal Healthcare Budget

Two Years Since National Health Insurance Act: Lessons Learned

POSSIBLE IN THE GLOBAL DIALOGUE

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