Re-aligning revenue with care

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Re-Aligning Revenue With CareBy PRITPAL S TAMBER

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There is much talk of the unsustainability of today’s health care systems and yet oftenthis dialogue assumes the system is of primary importance – rather than the people thesystem was created to serve. The Nepal-based NGO, Possible, is asking itself how itcreates 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 waslucky enough to meet David Citrin, Possible’s Director of Impact, and asked him abouttheir 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 afascinating insight you shared with me earlier – people selling their drugs for food? Tell usabout that.

David Citrin: My experiences in Nepal begin in 2001 as a student studying abroad. I

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became a medical voluntourist helping NGOs deliver so-called ‘health camps’, essentiallyshort term medical care provided for specific communities, for anywhere from a day to aweek. 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 weretoo ill or because they were unable to leave their jobs in the fields. However, some wasbeing sold to local pharmacies to raise money for food. I found these observationsextremely telling and instructive. It made me see the perils of ephemeral health care insettings 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 itfor what is really needed. It ignited my interest in the social lives of medicines, whichinformed my subsequent research.

PST: There’s so much we can learn about the realities of health versus health care rightthere. 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 withthe Nepali government to deliver high-quality, low cost health care in the district ofAchham. When we say low cost we’re referring to our expenditures as opposed to cost topatients; all of our services are free and we deliver them for around US$20 percapita. Together with the Ministry, we are working to expand our work to the entiredistrict, which includes 75 health care facilities serving a population of roughly 260,000people. Our organization is currently made up of 291 people, 98% of which are Nepali: 8full-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 acenter 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 homesproviding referral and follow-up services, prioritizing maternal and neonatal child healthand chronic disease management. They are Nepal’s renowned frontline health careworkers 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, andacceptability of, family planning services and maternal and child health. As well as providecare, we strengthen the clinics by providing power, technology, mentorship, and trainingfor clinic staff, and coordination with CHWs.

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

DC: Well, we actually compensate our CHWs and, while they are not full-time employeesof Possible, they work closely with our team of Community Health Worker Leaders. Weencounter regular resistance from government and external donor partners who believecompensating is not a financially sustainable model, or that these women have pride intheir volunteer status. We feel these justifications are rooted in romantic notions ofpoverty and patriarchy, and that the resistance is rote, almost rehearsed. Paying thecountry’s entire cadre of 50,000 CHWs would cost around US$25m per year — proverbialpeanuts to the government and donors combined — and our experience also shows thesewomen feel more proud to be a paid cadre of the health care workforce with opportunitiesfor 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 goabout things and what the donors think.

DC: Right. I think there is always a slight tension between donor priorities and what isfeasible, acceptable, and ultimately helps to meet people where they are in terms of theirhealth 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 localpeople as workers, even if they’re called volunteers. How does having local people directlyinvolved change things?

DC: We regularly find that CHWs and other government health care workers are the onescoming up with the ideas, insights, and innovations that drive the design and re-design ofour interventions. For example, after several months of meetings and focus groupdiscussions between our team and government providers, we were able to redesign ourgroup 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 aCommunity Advisory Board (CAB) to provide independent advice and critical feedback onour programs, service delivery, and interventions, as well as the research methods we usedto study these programs. The CAB will provide guidance on the relevance, acceptability,and, ultimately, the scalability of our model. We wanted to formalise this becauseoftentimes 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 communitythinks is right for its people?

DC: We just recently finalized the composition of our CAB, and held the first meeting inmid February. Our CAB is comprised of leaders and stakeholders from multiple sectors ofthe district, including health, education, journalism, social service, business, NGOfederations, and marginalized groups, such as the local Women’s Rights Forum and theDalit Welfare Association (the so-called ‘untouchable caste’). While the first meeting was asuccess, in truth we have just begun the journey of engagement that seeks to actualize theexperiences and knowledge of community members, not just be a head nod or acommunity ‘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 selectrepresentatives ourselves, but the reality is we need to respect existing systems,institutions, and committees that represent constituencies in Achham. This isn’t always assatisfactory as we want. For instance, a primary focus of our organization is to empowerwomen by drawing on their experiences and knowledge to design health care systems thatmeet the needs of the communities. To that end we set a CAB policy that stated we wouldhave 50% or more women sitting on the board, but this proved to be more challengingthan we imagined. At the end of the day, we were able to get 5 of 12 women representativeson 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 responsesand 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 andworking closely with the communities where we’re based. Ultimately, we feel that ourapproach aligns with national priorities and values. We want to create a health careorganization that is durable as opposed to just sustainable. Sustainability implies acommitment to donors or to ensuring an organization or program exists in perpetuity; itdoes not speak to the aspirations of those seeking to access health care. Durability is aboutcreating 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 atthe center of our system design, and it places clinicians in front of patients with theincentive to provide high quality care without excess. Durability is about realigningrevenue with care.

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

DC: Thank you for giving me this opportunity. I was inspired by the articulated mission ofthe 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 atthe end of the spectrum of the social determinants of health, and that health is ultimatelyfostered through providing access to the material and non-material resources thatpromote and sustain health. These include hope, dignity, respect, and aspirations forimproved 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 adurable 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 ofwatching people sell their drugs to buy food. Such a visceral example of the mismatchbetween what is provided versus what people want can only make you question the verysystem you’re part of. But his experiences of donors also illustrate how we remain lockedwithin our current systems. While David calls their assumptions ‘patriarchal’, I can’t help



wondering whether ‘prejudicial’ would be more precise. People often talk about howhard it can be to shake your underlying assumptions (prejudices) but perhaps, likeDavid, 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, tothe future of health.

This post was first published on pstamber.com.

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Pritpal S TamberPritpal S. Tamber (@pstamber) is an innovation consultant, the founder ofthe Creating Health Collaborative, and a public speaker. A physician bytraining, he has worked in academic publishing and clinical improvement,and his clients include established organizations like the NEJM Group,TEDMED, and WHO, as well as startups such as My Clinical Outcomes,Thicket, and Raremark.More posts by Author

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