development > listening post
Medicine man
Mark Arnoldy, CEO of Possible, attempts to connect the dots between Qatar, healthcare in rural Nepal, and the thousands of its citizens who come here for work. By Ayswarya Murthy
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Bringing primary healthcare to some of the most remote villages in Western Nepal.
I
n November last year, Mark Arnoldy brought down to Qatar for three weeks a small portion of his New York-based team. They had rented out a quaint little office space in 7ayak Hub and Arnoldy was helping out by giving its young residents a crash course on the importance of an organisational structure. That’s how we first heard of Possible, an American NGO that was working towards making primary healthcare accessible to those living in the most remote regions of Nepal. We were curious about the Qatar detour; Arnoldy says he flies through Doha about six times a year but this time it was different. Finally, several weeks after we first contacted him, Arnoldy talks to us from New York about his world and how it is about to collide with Qatar. Inception The story of Arnoldy in Nepal and Nyaya Health (Possible, as it was known before 2014) began with a potentially fatal allergic reaction during a countrywide shutdown.
An undergraduate on his first visit to Nepal, Arnoldy found himself in the throes of anaphylactic shock and no healthcare facility in sight. “Only a bottle of Benadryl stood between me and death,” he says matter-of-factly. In hindsight, it was the seminal moment, a “moment of obligation that unfolded over a number of years”. For the first time in his young life, the American from the Midwest knew what it was like to be in desperate need and have no access to healthcare. “I soon learnt that Nepal has some really troubling health indicators. Eighty percent of Nepal’s 30 million people live in rural areas, often hard to reach. Delivering healthcare to these people was extremely challenging but nothing much was being done,” he says. Arnoldy, now a Harvard graduate and a Fulbright Fellow, found himself returning to the country several times. In parallel, another story was unfolding. A Yale medical student and his Nepali documentary filmmaker wife were travelling to Western Nepal to investigate the rampant
"I soon learnt that Nepal has some really troubling health indicators. In the region we are working in, there wasn't a single healthcare provider for a quarter million people. That’s like there being not a single hospital for the entire Qatari population."
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development > listening post HIV there brought on by migration. They were going to meet a few people and get some comments but when they got there the reality of the situation completely overwhelmed them. “There was a crisis bigger than the HIV problem - there wasn’t any functional healthcare system whatsoever. Not a single healthcare provider for a quarter million people. That’s like there being not a single hospital for the entire Qatari population,” says Arnoldy, putting things in perspective. The Yale student, along with two of his friends, started Nyaya Health and soon after, Arnoldy joined the nascent organisation as its first full-time leader. And they had to start from scratch in one of the poorest nations in all of South Asia that was just coming out of a ten-year civil war. “It began out of moral compulsion more than
A majority of the Possible team is made up of Nepalis, local to the areas that it serves.
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"We want to find leaders within the contracting and construction industry here to work with us to raise the standards of how they interact with labourers and to build a financial reinvestment mechanism into their business model."
anything else; we couldn’t just turn away.” Six years hence, Arnoldy and the Possible team now have a rapidly expanding healthcare model, a sustainable partnership with the Nepali government, proof of tangible impact backed by hard data and, most importantly, an opportunity to demonstrate the adaptability of this kind of system in other poor, remote corners of the world. Their work now, he says, is at a unique stage. “It’s an exciting time.” From the ground up From the very beginning, Arnoldy says, their model required a public-private partnership. “Our work started in a humble way; we renovated and opened a clinic in what was previously the village’s grain shed. But even then we held out till we were sure that the government was invested in a meaningful way; we didn’t want to build a private parallel healthcare system.We wanted the government to participate with funding and infrastructure while we worked on operations and service delivery. And it evolved a lot from there on. We now operate a complete healthcare system based on a hub-and-spoke model. We run a hospital surrounded by a network of 13 clinics, followed by a tier of 164 women community health workers, delivering healthcare within the government’s existing infrastructure and getting paid based on performance.” Possible continues to work towards results better aligned with Nepal’s national healthcare goal (“the right to health is enshrined in their constitution”) while successfully moving away from a fee-for-service model that doesn’t work for the poorest patient. The community health workers are quite easily the backbone of their operations. Already part of a government network of volunteers, these workers are continually trained by Possible to deliver preventative care, education and, most importantly, referral and follow-up care. They are the connectors of the healthcare system who can be approached by any of the villagers for immediate consultation. Today, Possible is able to provide basic healthcare in the region it operates in for less than $4 (QR13) per person annually. “It’s this low for a variety of reasons. One, we are delivering pretty basic, primary care at this stage, so there is not much sophisticated technology involved. Two, we are trying to make it community driven, keep patients out of hospital and treat them at the lowest tier of care that is closest to their home. Third, our very incentive is to not provide excess care. In a lot of health-
The hospital run by Possible in Western Nepal.
Community health workers undergoing training.
care systems around the world, the incentive is to provide more care than is needed, prescribe more medicines than is needed, more tests than is needed. And finally, the dollar goes much further in Nepal,” he says. But Arnoldy’s goal is to deliver a comprehensive national system of health that spends at least about $20-25 per capita. Though Arnoldy is excited by the possibilities of this model, aware of its relevance in many other places in the world where the poor are forced to rely on either the purely government or the fee-for-service private sector, his focus now is on scaling up their operations in Nepal. “Immediately we want to move from our current size to two hospitals, 72 clinics and over 900
community health workers over the next two and a half years. That’s going to be instructive of where we go next,” he says. Qatar connection It was inevitable that his extensive work in Nepal would eventually bring him to Qatar – and not just in transit. “We recognised that there is a growing interdependent relationship between Qatar and Nepal. Everyone is aware of Nepali migrant labour that is involved in the building of Qatar. Through this mechanism we have an opportunity to build the country where these workers are coming from. We wanted to work connecting with government and private sector healthcare entities, individuals and leaders
interested in this endeavour,” he says. Even going by his short time here, Arnoldy says he is optimistic about “the opportunity to build transformative partnerships”. They have got the ball rolling almost immediately. At the World Innovation on Health Summit this month, Arnoldy and his work will be presented to the global delegates. In addition to trying to rope in the support of organisations like Qatar Airways, Possible will also propose partnerships with Qatar Foundation and their Education Above All programme to “jointly deliver on education and healthcare results to transform the rural areas of Nepal”. But perhaps the most ambitious of Arnoldy’s plans in Qatar is his attempt to try and engage the private sector. “We want to find leaders within the contracting and construction industry to work with us to raise the standards of how they interact with labourers and to build a financial reinvestment mechanism into their business model. Imagine if, for every employee, a small amount is invested back into their country’s healthcare system. We want to pioneer this. There is tremendous opportunity for everything concerning labour to turn from being a sour spot to a solution,” he says. “It just needs the right kind of leadership.” QATAR TODAY > FEBRUARY 2015 > 29