FROM GRASSROOTS DELIVERY TO HEALTH SYSTEMS CHANGE

I recently returned from Nepal after another inspiring visit. I spent time with Rashmi Paudel, our Community Health Team Leader in Dolakha, a province to Nepal’s east. Rashmi has been challenging Community Health Workers to present cases where their clients have suffered—a stillbirth, a homebirth in a high-risk pregnancy, a late referral for childhood pneumonia—as an opportunity to learn.

Diving into community health system failures is as important as celebrating our successes.

During my Obstetrics and Gynecology training, I made similar presentations on clinical complications. While the presentations were hard, I learned to look beyond the obvious causes of complications, and prepare for hard questions from my audience. These presentations often resulted in systems changes in my hospital. Rashmi sees the same potential in this exercise with Community Health Workers.

Rashmi’s work exemplifies supportive supervision of Community Health Workers, a critical component of the newly released *WHO CHW Guidelines, to which our team contributed. As we head into the new year, we commit to bringing such lessons to bear on policy change, nationally within Nepal, and globally.

I also had the honor of welcoming a new leader—Dr. Sabitri Sapkota, a nurse and public health expert who has joined our team with more than a decade of experience in building evidence and shaping policy in the field of women’s health. One of Dr. Sabitri’s goals will be to lead our effort around community health system strengthening and leveraging results toward government investment and adoption, not an easy task.

The time is ripe. At the Astana convening in October of last year, Nepal made a commitment to building strong, equitable primary care systems.

Village by village, our frontline health workers are elevating the health status of Achham and Dolakha.They are generating the evidence necessary to shift healthcare policy and practice. And they are paving the way to universal healthcare.

Thank you for believing in this work.

Sheela Maru, MD, MPH

Technical Adviser, Reproductive, Maternal, Newborn, and Child Health

*WHO guideline on health policy and system support to optimize community health worker programmes. 2018. Available from: https://www.who.int/hrh/community/en/

Advancing Universal Healthcare in Public Sector Delivery 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.

Using Integrated Care Principals to Ensure People with Mental Illness Receive High-Quality Care

In Nepal, a country of thirty million people, there are a dismal one hundred psychiatrists and twelve psychologists. Furthermore, most mental health specialists are based in Kathmandu, a thirty hour car ride from Accham, in the far west, or an eight hour car ride from Dolakha, in the east, the two communities where we work. Nearly sixty percent of Nepal’s healthcare budget toward mental health goes to one hospital in the capital.

It is in this context that we share the story of a 16-year-old Nepali boy who went from being at the top of his class to mumbling to himself and destroying property. When we came across this patient, he had walked to our clinic after having his hands and legs tied in a fetal position for twenty four hours a day by his family who had limited ability to manage his condition. Ordinarily, in situations like these in rural Nepal, the family would have been referred to a specialist in Kathmandu or India, a trip that is costly and compromises the continuity of care, or seen by a doctor with little training in mental health. In this case, however, our Primary Care Physicians (PCPs) identified the teenager’s condition as psychosis, and with a team of healthcare workers, helped the family develop the tools to manage his condition.

Our Collaborative Care Model harnesses technology, training, and supervision, so thousands of patients can access high-quality mental health care. This approach engages a new cadre of non-specialist providers, psychosocial counselors.

The model works as follows: PCPs diagnose mental health conditions such as depression or chronic psychosis that otherwise go ignored or are treated with painkillers. PCPs refer patients to psychosocial counselors who conduct a 30 to 45 minute evaluation, and help finalize the diagnosis: someone who appears depressed may actually be recovering from trauma and has PTSD. Based on this evaluation, PCPs prescribe appropriate medications. The counselors invite the patients back to develop coping mechanisms. A consultant psychiatrist reviews cases and treatment plans with psychosocial counselors, via teleconferencing, and visits the facility once in three months for on-site trainings. Community Health Workers follow-up with home-based care. Quality of care is further maintained through guidelines-based treatment.

Our strategy is yielding results. Over half of the patients with moderate to severe depression from our catchment area between September 1, 2016, to August 31, 2018, demonstrated a substantial improvement in their clinical scores. These results are similar to what is seen in well-funded clinical studies conducted by world-class research universities in high-income countries.

Our collaborative care mental health model exemplifies the value of an integrated healthcare delivery system in an under-resourced setting such as rural Nepal. With our impact in Achham, in August 2017, we expanded our mental health services to our second hub in Dolakha, where we have been receiving similar reactions from the care providers and encouraging results from patients’ scores.

Watch this video to see the factors that contribute to mental health illnesses in rural areas of Nepal, and how our intervention is having an impact.

Credit: NCD Alliance production team Marty Logan, Sairica Rose, Srawan Shrestha

Impact in Numbers

200,000
Integrated Care Delivery Catchment Area

Reducing Under 2 Mortality

In Achham, the number of under 5 deaths, compared to the national under 5 mortality rate, is among the highest in the country. As a result, Possible has focused on monitoring deaths among children through the age of two years, noting the probability of a child dying is highest in the first year. We have observed a persistent decrease in the mortality rate of children under two years of age, from 36 in 2015, to 18 in 2016, to 12 in 2017 per 1,000 live births.

Read the impact of our Under 2 research

IMPACT DASHBOARD

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POSSIBLE IN THE GLOBAL DIALOGUE

See updates by and about Possible staff.

How do you transform primary care inputs to outcomes in Low- and Middle-Income Countries? See schematic developed by Possible Senior Adviser and Ariadne Labs Associate Director of Primary Health Care, Dan Schwarz

Learn how Possible is improving care for patients with mental illness in rural Nepal by implementing a teleconsultation model.

WHO Community Health Worker guidelines released, which support and underscore our approach

Listen to a Community Health Worker share the need for integrated care from hospital to home as an impactful way to reduce maternal and infant morbidity and mortality among underserved communities.

Quarterly Impact Report