Re-engineering Healthcare

Mark Arnoldy is the executive director of Possible, a not-for-profit organization working to build healthcare systems in the remotest parts of Nepal. In 2009, the organization, formerly called Nyaya Health, took over the administration of the then abandoned Bayalpata Hospital (built in 1976) in Accham district. More than 173,000 patients benefitted from the hospital’s services till date.


Possible is not just a hospital, but is an organization dedicated to building a durable healthcare system through its hospital, clinics, community health workers and a referral network.

The idea is to provide healthcare services to the people patients as close as possible to their homes.
Arnoldy is an Aspen Ideas Festival Scholar, 2014, Rainer Arnhold Fellow, Cordes Fellow, and Bluhm/Helfand Social Innovation Fellow. He was also one of Forbes Magazine’s top 30 Under 30 Social Entrepreneurs.

Edited excerpts from our contributor and Department for International Development (DFID)Financial Sector Development Advisor
Prasanna KC’s conversation with Arnoldy.

Prasanna: So, what brought you to Nepal?

Mark: I’m here because I think a person’s birthplace should not determine the person’s ability to access healthcare. I first came to Nepal as a twenty-year-old. When I was here, I had a life threatening allergic reaction, and because there was a political strike in the country, I was in a situation where I didn’t have an access to healthcare. In a strange way that got me interested in making a commitment to the country. I guess this my twentieth….twenty-fifth trip to Nepal.

Prasanna: In a place such as Achham, where most people can’t pay for the transportation, do you think there is enough money to provide adequate health services?

Mark: In my perspective, access to healthcare is a fundamental platform for breaking the poverty cycle. Healthcare has to be there for people to grow and become economically productive. Data from around the world shows that spending on healthcare is actually detrimental to people’s ability to climb out of poverty in areas with per capita income on a par with places like Achham. So that’s why we are really big believers in the free healthcare model, when it comes to working in conditions of poverty like the ones in Achham.
Prasanna: What about the outreach? Would you like to expand your services?

Mark: The last time I checked, the average patient was walking two-and-a-half hours one way for care. Our average mother who is giving birth here is walking just under five hours. So I think we have a mandate to expand, and our team is ambitious. We view this (what we have done so far) as a tip of an iceberg, just the beginning of our work. I hope we have the privilege of working for the long term in the country, and we are trying to design a more feasible healthcare model.

Prasanna: In a way, you guys are also competing with the government hospital that takes two hours to reach on foot. I have heard that no one goes there anymore.

Mark: No that’s not true. Even at the District Health Office level we have a very supportive relationship. At the end of the day even if we sign a MoU with the Ministry of Health, all the work has to happen between us and the District Health Office.
This is the time in Nepal’s history when the government is looking for the best way to design the healthcare system. We are happy to be part of that experiment.

I was with a leading politician a month ago. His perspective was that the government had looked at what had happened to the education system here, and did not want the same to happen to healthcare. They (the government) spent around 20 percent of the GDP on education. Of the 80 percent students who go to government schools, 80 percent fail the SLC exams.
So they are spending a high percentage of the GDP on education but getting very poor results. They are trying not do the same in healthcare.

They are interested in other models of partnership which can make sure that the service delivery component of public sector- supported programs can be executed efficiently and effectively. And that’s part of the experiment we are a part of. It’s called public-private partnership. The government is playing the role as a funder and regulator but we are being enabled to do the service delivery. And what I know from government representatives is that, in theory, the government is interested in raising the percentage of GDP they spend on healthcare. It sees this as a priority. But it wants to make sure that the money is well utilized.

Prasanna: Can you briefly tell us about the financial model the hospital has adopted?

Mark: We say that this is more than a hospital. It is a necessary first step towards our broader healthcare model. Our healthcare model is the hub-and-spoke model. Under this model, our hospital has a network of health posts and sub-health posts. We also work with FCHV (female community health volunteers). We know that great healthcare doesn’t happen just at the hospital. An important part of it happens at the hospital, but you have to be engaged in the follow up care, especially when patients are coming from very far.

We have basically combined public sector funds from the government with philanthropic investment. We only work using existing government infrastructures.

So this (the hospital building we are using) was a thirty year-old government facility that we came into, and got the permission to operate and manage. Likewise, we are not building new clinics. We are figuring out a working model to work within the existing health posts and sub-health posts .At the FCHV-level, we have added a bit of performance-based financing and extra layer of management support to make sure that the women who have low level of education have additional support from people who have more experience in public health and healthcare.

That’s really the model. The Nepali healthcare system has a great design on paper but it has immense challenges when it comes to delivery of services.

And so we get approval from the government and figure out how to improve care delivery at various levels. And this hospital is obviously a big part of it. This (the hospital) is our hub and we have to have infrastructure such as this in rural Nepal to be able to attract good talent, and to manage complicated and integrated care needs.

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