Re-Aligning Revenue With Care

David Citrin and Pritpal S Tamber

April 21, 2015

An interview of David Citrin of Possible on how they're trying to create an approach to health in Nepal that doesn't just replicate the unsustainable systems in high-income countries

There is much talk of the unsustainability of today’s health care systems and yet often this dialogue assumes the system is of primary importance – rather than the people the system was created to serve. The Nepal-based NGO, Possible, is asking itself how it creates a durable health care system, one that responds to the needs of the community, questions the ‘more is better’ mentality, and ultimately realigns revenue with care. I was lucky enough to meet David Citrin, Possible’s Director of Impact, and asked him about their approach but we started with ‘intentional acts of de-medicalization’.

Pritpal S Tamber: Hi David. We’ll get to Possible in a minute but I want to start with a fascinating insight you shared with me earlier – people selling their drugs for food? Tell us about that.

David Citrin: My experiences in Nepal begin in 2001 as a student studying abroad. I became a medical voluntourist helping NGOs deliver so-called ‘health camps’, essentially short term medical care provided for specific communities, for anywhere from a day to a week. What I noticed was that people were gathering up as many medicines as they could. Some was for family and friends who could not get to the camp, either because they were too ill or because they were unable to leave their jobs in the fields. However, some was being sold to local pharmacies to raise money for food. I found these observations extremely telling and instructive. It made me see the perils of ephemeral health care in settings of unmet need. It also made me see what I now describe as ‘intentional acts of de-medicalization’ – taking what is provided by health care and finding ways to exchange it for what is really needed. It ignited my interest in the social lives of medicines, which informed my subsequent research

PST: There’s so much we can learn about the realities of health versus health care right there. So what’s Possible?

DC: Possible is a health care company comprised of two entities: a U.S. based 501c3 non-profit entity and a Nepal-based non governmental organisation (NGO) that partners with the Nepali government to deliver high-quality, low cost health care in the district of Achham. When we say low cost we’re referring to our expenditures as opposed to cost to patients; all of our services are free and we deliver them for around US$20 per capita. Together with the Ministry, we are working to expand our work to the entire district, which includes 75 health care facilities serving a population of roughly 260,000 people. Our organization is currently made up of 291 people, 98% of which are Nepali: 8 full-time 501c3 staff, 119 full-time NGO employees, and 164 community health workers (CHWs), known in Nepal as Female Community Health Volunteers.

PST: So what’s the model, what’s the underlying ethos of what you’re trying to do?

DC: It’s an integrative care model built within the government’s existing infrastructure. It’s made up of a cadre of CHWs, a network of local clinics, and a hospital, which is a center of excellence for clinical care and medical education. It’s a hub and spoke model, with the hospital as the hub and the clinics encircling it. The CHWs move between homes providing referral and follow-up services, prioritizing maternal and neonatal child health and chronic disease management. They are Nepal’s renowned frontline health care workers borne out of the ‘barefoot doctor’ movement. There are currently around 50,000 of them in the country and they initially started as a way to increase access to, and acceptability of, family planning services and maternal and child health. As well as provide care, we strengthen the clinics by providing power, technology, mentorship, and training for clinic staff, and coordination with CHWs.

PST: So the model relies quite heavily on volunteers; how do you keep them engaged if they’re only volunteering?

DC: Well, we actually compensate our CHWs and, while they are not full-time employees of Possible, they work closely with our team of Community Health Worker Leaders. We encounter regular resistance from government and external donor partners who believe compensating is not a financially sustainable model, or that these women have pride in their volunteer status. We feel these justifications are rooted in romantic notions of poverty and patriarchy, and that the resistance is rote, almost rehearsed. Paying the country’s entire cadre of 50,000 CHWs would cost around US$25m per year — proverbial peanuts to the government and donors combined — and our experience also shows these women feel more proud to be a paid cadre of the health care workforce with opportunities for increased technical capacity and professional growth. It’s not hard to imagine.

PST: That’s interesting. So there’s a tension between what Possible thinks is the way to go about things and what the donors think.

DC: Right. I think there is always a slight tension between donor priorities and what is feasible, acceptable, and ultimately helps to meet people where they are in terms of their health care needs and aspirations – compensation for CHWs is just one example of this.

PST: So this is integrated care through a distributed infrastructure that includes local people as workers, even if they’re called volunteers. How does having local people directly involved change things?

DC: We regularly find that CHWs and other government health care workers are the ones coming up with the ideas, insights, and innovations that drive the design and re-design of our interventions. For example, after several months of meetings and focus group discussions between our team and government providers, we were able to redesign our group antenatal care intervention to be more convenient both for the women receiving the care and for the staff. We’ve decided to operationalize this approach by creating a Community Advisory Board (CAB) to provide independent advice and critical feedback on our programs, service delivery, and interventions, as well as the research methods we used to study these programs. The CAB will provide guidance on the relevance, acceptability, and, ultimately, the scalability of our model. We wanted to formalise this because oftentimes people take the processes of collaboration and local democracy for granted; health care is no exception.

PST: That’s awesome. So are you starting to flex your operations to what the community thinks is right for its people?

DC: We just recently finalized the composition of our CAB, and held the first meeting in mid February. Our CAB is comprised of leaders and stakeholders from multiple sectors of the district, including health, education, journalism, social service, business, NGO federations, and marginalized groups, such as the local Women’s Rights Forum and the Dalit Welfare Association (the so-called ‘untouchable caste’). While the first meeting was a success, in truth we have just begun the journey of engagement that seeks to actualize the experiences and knowledge of community members, not just be a head nod or a community ‘rubber stamp’. The CAB intends to be about putting our ears to the ground.

PST: Wait, they sound like local bureaucrats not local people…

DC: Yes, we could have walked into communities and tried to designate or select representatives ourselves, but the reality is we need to respect existing systems, institutions, and committees that represent constituencies in Achham. This isn’t always as satisfactory as we want. For instance, a primary focus of our organization is to empower women by drawing on their experiences and knowledge to design health care systems that meet the needs of the communities. To that end we set a CAB policy that stated we would have 50% or more women sitting on the board, but this proved to be more challenging than we imagined. At the end of the day, we were able to get 5 of 12 women representatives on the initial board; it’s a pragmatic start that we hope to improve upon moving forward. 

PST: Sounds like two big challenges: getting donors to think beyond their rote responses and engaging with local people in a way that respects local politics.

DC: Yes, definitely. We have a solid eight years of relationship building to draw from, though, and have come to recognize that our work is only possible by listening to and working closely with the communities where we’re based. Ultimately, we feel that our approach aligns with national priorities and values. We want to create a health care organization that is durable as opposed to just sustainable. Sustainability implies a commitment to donors or to ensuring an organization or program exists in perpetuity; it does not speak to the aspirations of those seeking to access health care. Durability is about creating a delivery model that is responsive to the needs of communities where we work, and avoids the pitfalls and failures of the ‘more is better’ and fee-for-service models. Possible’s durable health care model puts solving for poor people in complex settings at the center of our system design, and it places clinicians in front of patients with the incentive to provide high quality care without excess. Durability is about realigning revenue with care.

PST: Fascinating stuff. Well good luck with all of these challenges; come back and tell us what solutions you come up with, especially in getting donors to see things in ways more aligned with what the local community wants.

DC: Thank you for giving me this opportunity. I was inspired by the articulated mission of the Creating Health Collaborative, as it truly aligns with our value proposition at Possible: namely that transforming health care involves understanding that it is an intervention at the end of the spectrum of the social determinants of health, and that health is ultimately fostered through providing access to the material and non-material resources that promote and sustain health. These include hope, dignity, respect, and aspirations for improved health and livelihoods. And, while we cannot directly provide these as a non-profit health care company, per se, they continue to animate our attempt to create a durable health care model.

PST: Thanks. People are going to think I paid you to say that, but thanks.

It’s seems to me that so much of what drives David are those early experiences of watching people sell their drugs to buy food. Such a visceral example of the mismatch between what is provided versus what people want can only make you question the very system you’re part of. But his experiences of donors also illustrate how we remain locked within our current systems. While David calls their assumptions ‘patriarchal’, I can’t help wondering whether ‘prejudicial’ would be more precise. People often talk about how hard it can be to shake your underlying assumptions (prejudices) but perhaps, like David, we just need to observe the world around us. It seems to me we often ignore the ‘intentional acts of de-medicalization’ that could be instructive, if not transformative, to the future of health.

Pritpal S Tamber

I’m a doctor who trained as a medical editor and publisher and now researches and consults on the link between community power and health equity. My interest in community power started when I was the Physician Editor of TEDMED and is explained in My Perspective. I also work as a freelance medical editor and publisher for organisations that want to write high-quality articles and a strategy for their publishing and promotion. Find out more on my About page.

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