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.

Qatar Today - - INSIDE THE ISSUE - By Ayswarya Murthy

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.

In 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."

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 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-

"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."

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.”

Bring­ing pri­mary health­care to some of the most re­mote vil­lages in

West­ern Nepal.

A ma­jor­ity of the Pos­si­ble team is made up of Nepalis, lo­cal to the ar­eas that it serves.

The hos­pi­tal run by Pos­si­ble in West­ern Nepal. Com­mu­nity health work­ers un­der­go­ing train­ing.

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