Dear partners,
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March 24th marked World Tuberculosis Day. I found myself thinking about a patient who I had met six years earlier.

We were in Sanfebagar, the settlement about 45 minutes by foot from Bayalpata Hospital, the government facility that serves as our base of operations in western Nepal. Bibek, a nine-year-old boy experienced severe weight loss and fatigue that was impeding his ability to go to school. An x-ray and ultrasound revealed fluid around his heart, which, epidemiologically, was almost certainly tuberculosis. He had slipped through the cracks of the local tuberculosis control system and was at substantial risk of death. The clinical team drained the fluid and arranged a tuberculosis course. Fortunately, he had a drug-sensitive strain. Several years later, I met him again as a gangly adolescent playing cricket at a nearby field.
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His story is paradigmatic to the challenge of local primary health systems, where patients often come to the hospital when it is too late. While frontline healthcare workers monitor children in their homes and may have detected his condition, they, working alone, lack the supportive systems to deploy evidence-based tools. We need strong systems to connect frontline workers across the continuum of care, from the facility to community, to prevent patients from suffering from treatable diseases, be they a pregnant woman, a child with malnutrition, an elder with emphysema, or an adolescent with tuberculosis.
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Since 2017, the government of Nepal has been transitioning to a more decentralized structure, where the health system will largely be owned and operated by the country’s new 750 municipalities. Possible is building health systems solutions within this municipal primary care model.

We have started to see success. In Quarter 2 of this year, we expanded our community health worker (CHW) coverage area to 200,000 people -- and are advocating with the municipality to have CHW costs included in local budgets. And we are starting to see our first patients within a municipality adjacent to Sanfebagar, Chaurpati, which will serve as an opportunity to test truly integrated primary care systems.
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Every day, we are reminded that building a sustainable health system is a decades-long effort. It is our collective charge to deepen this work, at the level of the grassroots and policy change. Thank you for walking with us on this journey.

With hope,

Duncan Maru, MD, PHD
CEO, Possible, on behalf of Possible’s global team

Photo: Group ANC discussion about menstruation as a normal, physiological response and the impacts of "chaupadi" or menstrual exclusion

Advancing Universal Healthcare in Municipal Primary Care Systems

Research

Apply implementation research, quasi-experimental, experimental, and mixed methods to study evidence generated by our care delivery efforts.

Disseminate

Shape the financing environment by advancing principles of population health, value-based healthcare, and social protection for universal healthcare.

Train

Train new cadres of healthcare workers, utilizing hospital infrastructure and staff.

Advocate

Encourage government adoption of electronic health record, chronic care models, and public investment and professionalization of community health workers.

Design

Design and test ideas that fill gaps in public health systems.

Deliver

Deliver and coordinate care via government hospitals and community health workers.

Sustain

Diversify revenue through insurance, municipal, provincial, and federal grants, research and philanthropy.

Iterate

Iterate our care delivery system through data feedback loops and integrated electronic health record.

Building Community Health Systems in the New Municipal Landscape

In 2017, Possible’s Community Health Worker program was approved to be a national pilot, with an explicit focus on improving reproductive, maternal and child health outcomes in Nepal.

However, this was not the beginning of Nepal’s interest in community healthcare. Nepal’s cadre of more than 50,000 female community health volunteers (FCHVs), established in 1988, has contributed substantially to the country’s incredible gains in maternal and child health outcomes over the past three decades. They are a testament to the potential of community health programs.

Photo: Community Health Worker Tara Thakulla leads a group ANC session.

Over the years, however, FCHVs have become overburdened with demands, and without regular support from professional clinicians, or a salary, FCHVs have struggled to meet the healthcare needs of the present population.

Possible’s experience operating two government-owned referral hospitals, where patients with serious health conditions are often the result of deferred or poor diagnosis, demonstrates a clear need for strong primary healthcare systems, particularly in rural areas. Community Health Workers (CHWs) form the core of such systems.

Recent political developments in Nepal resulting in the devolution of power to local government units –- the municipalities -- have opened a window of opportunity. Possible is taking advantage of this changing landscape.

Photo: Community Health Associate Sonu Khadha shares about the community health program expansion in Achham district, with municipal leaders and other stakeholders.

We are scheduled to complete a USAID-funded, joint Possible-Nepal Ministry of Health study within the next four months that looks at the impact of a professionalized community health worker cadre on maternal and child health outcomes. In alignment with many of the World Health Organization guidelines, our CHWs are locally hired, paid, continuously trained and supervised, and enabled with technology and data.

At the same time, we are working with municipalities in our two provinces to incorporate, support and ultimately finance the CHWs as part of their municipal primary healthcare systems. Successful implementation will pave the path for improved access to quality primary care in the most underserved regions across Nepal.

Photo: Sarita Basnet, age 28, delivered two children at home, with much difficulty. Now with Community Health Workers coming to her home, she feels better equipped to take care of herself and her family.

Impact in Numbers

200,000
Integrated Care Delivery Catchment Area

Monitoring Chronic Disease Control Rate

In Nepal, non-communicable diseases (NCDs) and injuries, in addition to deaths due to maternal, neonatal and nutritional factors, have surpassed communicable diseases as a leading cause of deaths.

We define and measure our KPI "Chronic Disease Control Rate" as the percentage of patients who have their disease under control. This is measured at the facility, when patients return to one of our hospitals for follow up visits.
Measuring chronic disease control at the facility-level, however, is complicated: many of the patients cannot make it to the facility for follow-up as recommended, because of in- and out-migration or the long-distance travel to the facility for follow-up appointments. In addition, adherence to a long-term medication regimen is challenging.
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Possible is working with the Ministry to enable NCD care and management to be delivered to our patients in the community, where they live. We will continue to report on the progress of these efforts.

IMPACT DASHBOARD

For a comprehensive review of
our metrics and KPI definitions
username: impactreport
password: Possible1

Quarterly Impact Report