"I was given an injection and my wounds were stitched at Bayalpata, [the Possible] hospital. If I had been more severely injured and never fully recovered, it would have been a sad situation for my family and me. We are already struggling and there would be one less person earning for the family. Because I am well now, I can do a lot of work to support my family."
Dilu Dhami, 46, patient of Possible
Voices of NCDI Poverty narrative, April 2017
In Nepal, non-communicable diseases (NCDs) and injuries are now the leading causes of deaths, surpassing communicable diseases, maternal, neonatal deaths and nutritional diseases. In fact, over half of the country’s death and disability (DALYs) in 2015 was caused by NCDs. Smoking and wood-burning stoves are the main causes of chronic obstructive pulmonary disorder (COPD) in Accham, a district in far west Nepal, where Possible works. Treatment of heart disease, hypertension, and diabetes is causing incredible financial strain on families, especially in villages, where seeing a doctor is more difficult.
Possible has developed an integrated hospital-to-home healthcare model in Nepal that includes improved quality of care at government-owned facilities, home-based care delivered by trained community health workers (CHWs), and an Electronic Health Record (EHR) that integrates data from the different points of care to map disease, target care and continuously improve quality. Possible’s integrated healthcare model is designed for patient-centered, longitudinal care and as such is uniquely set up to address severe NCDs in the communities they serve.
The bottom line
Through its emphasis on longitudinal care and effective care coordination between the facility and community levels, Possible’s integrated hospital-to-home approach provides an effective model to tackle the NCD burden in the most underserved communities, where the need is the greatest.
- CHWs are instrumental in counseling around preventive behaviors to reduce NCDs. Possible has incorporated follow up of patients seen at facilities into the CHW’s package of services provided, recognizing the need for longitudinal care to improve NCD control among patients. Furthermore, CHWs, who best understand the conditions in the communities they hail from and serve, are an important bridge between the community and the health system. Currently, while CHWs provide follow-up care and counseling to NCD patients, Possible plans is to include active case finding of NCDs by CHWs in the near future.
- Integrated healthcare delivery is necessary to treat NCDs. A technology-enabled integrated care model that combines facility-based services with home-based care provided by CHWs is an effective way to address the problem of NCDs. It enables access for communities to timely care, reduction of catastrophic health conditions that require hospitalization and the provision of quality care in a cost-effective manner.
Local barriers to care
Currently, Possible implements its integrated healthcare model in two of the most remote and resource-poor districts in Nepal: Achham and Dolakha. In these districts, the per capita annual income is $536 and $922, respectively. Located in the far Western region of the country, Achham is very remote; citizens walk on average 2.5 hours to access care, some as long as 7-8 days. In Dolakha, a mountainous region in central Nepal, over 85% of healthcare facilities were damaged or destroyed by the 2015 earthquakes. These barriers, combined with high out-of-pocket costs at private facilities make our model of integrated community and facility-based care crucial to tackling challenges like NCDs.
- In both of the districts where Possible works, Possible utilizes the WHO’s Package of Essential Noncommunicable Disease Interventions (WHO PEN), a set of simple algorithms encompassing screening, diagnosis, and management of common, less severe NCDs like type 2 diabetes, hypertension, asthma, and COPD. At the same time, Possible has addressed gaps in WHO PEN by developing a “PEN-PLUS” approach to longitudinal care for more complex, severe NCDs, which has led to improvements in NCD follow-up rates from 46% to 59% from 2016 to 2017. This work includes:
- Trained CHWs who follow-up to ensure patients fully understand the implications of their diagnosis and are able to receive counseling for all aspects of their treatment plan (i.e. medications, lifestyle, etc.).
- Task sharing, including the training of health assistants to assess risk and offer counseling.
- Mental health screening and follow-up at health facilities and in the community.
- Motivational interviewing to improve medication adherence.
- Decision support tools and quality improvement through our integrated Electronic Health Record.
- Possible has successfully helped Nepal establish a Non Communicable Diseases and Injuries (NCDI) Commission in collaboration with Harvard Medical School, which aims to rethink global policies and to broaden the current NCD agenda in the interest of equity. Through this work, Possible leveraged Nepal’s success through this commission to help create a long-term, formalized NCD committee within the Nepali government.
As Possible gathers more data on the impact of the PEN-Plus package of services, their implementers anticipate seeing improvements in rates of NCD follow-up and control. As a next step, Possible is also enhancing its digital tools to allow for seamless integration across the facility and community points of care, which will allow for more streamlined follow-up of patients and better guide its CHWs in supporting treatment adherence for NCDs.
- Mishra SR, Neupane D, Bhandari PM, et al (Global Health 2015; 11: 32)
- The Nepal NCDI Poverty Commission
Duncan Maru, MD, PhD, is Co-Founder and CEO of Possible. In his role, Duncan oversees the vision and execution of our work in government partnerships, impact evaluation, and implementation science, to ensure that public sector strategy, policy change, high-quality service delivery, and research are integrated toward healthcare systems transformation. Duncan is a faculty member at Harvard Medical School and the Brigham and Women’s Division of Global Health Equity. He also practices part-time on the Complex Care Service at Boston Children’s Hospital. Duncan graduated from Harvard College, received his MD/PhD from Yale University, and completed the Harvard Combined Internal Medicine-Pediatrics Program and the Brigham and Women’s Global Health Equity Residency Program. Duncan’s work as a doctor and epidemiologist has generated over 40 peer-reviewed articles. In 2015, he was named a Schwab Foundation Social Entrepreneur of the Year.
SP Kalaunee, PhD, is the Executive Director of Possible. As Executive Director, SP Kalaunee works closely with the Ministry of Health and other ministries within the government of Nepal. He leads the partnership strategy with the government and nongovernment organizations within Nepal. SP served as the acting executive director of a Nepali nonprofit, and led the organization’s functions in health, education, and community development sectors. SP also worked as the principal of Somang Academy, a secondary school, and the board member of Kathmandu International Study Center, an international school in Kathmandu. His teaching has ranged from primary level to the university level in different schools including both part time and full time in Nepal, Vietnam, Finland, and USA. He received his M.A. (Sociology), B. Ed., and LL.B. from Tribhuvan University, Nepal, M. A. (English Literature), and B. A. from Kumaun University, India. SP completed his PhD in Organizational Leadership at Eastern University, where he is an adjunct faculty member at the School of Leadership and Development.