An approach that is able to simultaneously develop community based health care and services, orient the people to understand the need for and to utilize such a system, and build capacity so that health care can be afforded, is the main solution to the failing health systems in most developing countries, including Nepal where health services remain in shambles.

Community based health care run by a not-for-profit organization can bring quality health services to rural areas of a developing country. However, it is essential to address health care not as an isolated entity but to integrate community development and capacity building into the system. Dhulikhel Hospital is a not-for-profit tertiary care center providing health services also at numerous outreach centers located in impoverished rural villages in Nepal. About four years ago we initiated a community development program targeting women for social support and to participate in a microfinance loan program. Recently we added a component in which health education and participation in a minimal-cost health insurance program has helped these women to get health care at the outreach center. This system has been extraordinarily successful thus far. We believe that this integrative approach is an excellent model that we would like to expand and offer as a model to other regions and nations.

Problem

Despite improvements in the economy since the end of a turbulent civil war, the health care infrastructure of Nepal remains in shambles. Three major problems exacerbate the problem: 1) access to health care is limited, especially in rural areas where governmental clinics are many miles apart and seldom staffed or equipped; 2) regardless of access, people do not seek care for treatment of even severe illnesses due to lack of education and mistrust of the system; and 3) even if people sought out health care, poverty prevents all but the elite from paying for it. An approach that is able to simultaneously develop health care and services, orient the people to understand the need for and to utilize such a system, and build capacity so that health care can be afforded, is desperately needed.

Solution

Community based health care run by a not-for-profit organization can bring quality health services to rural areas of a developing country. However, it is essential to address health care not as an isolated entity but to integrate community development and capacity building into the system. Dhulikhel Hospital is a not-for-profit tertiary care center providing health services also at numerous outreach centers located in impoverished rural villages in Nepal. About four years ago we initiated a community development program targeting women for social support and to participate in a microfinance loan program. Recently we added a component in which health education and participation in a minimal-cost health insurance program has helped these women to get health care at the outreach center. This system has been extraordinarily successful thus far. We believe that this integrative approach is an excellent model that we would like to evaluate and offer as a model to other regions and nations.

Example

Provision of health care in a rural community is the first step to building a comprehensive health system. Using institutional as well as collaborative partners and community, a simple yet up-to-date health clinic was constructed in Bahunepati, a rural village in Nepal. The second step was to organize the women of the village. Community meetings were held targeting 60 families at greatest need to discuss the goals of a microfinance program and to build trust. The women continued to meet to develop their projects and was provided the equivalent of $100 USD each, to be paid back in 3 years. The funding has been used for a variety of projects including purchase/raising of goats and pigs, candle-making, etc. Loans were disbursed only after the women were organized in groups and hence a structure for expanding the scope to include issues of health care became established. We provided training in multiple sessions on various health-related topics and introduced the concept of health insurance at these meetings. Each woman paid a premium of about 2 USD that would cover, for the woman and her children, a 24-hour health care provided by a physician and assistants, access to basic medicines and surgical procedures (limited under local anesthesia), and basic obstetric- gynecological care. Partnership with the government for free obstetric care and family planning made the cost of services for these almost negligible for the center. An assessment after six months revealed very encouraging findings in terms of appropriate health care utilization and financial viability of the program.

Marketplace

Thus far, we are the only ones to have such an approach to health care. We have developed this program in partnership with the government of Nepal and private individuals/organizations working in the community and thus have no competitors. Although there are a few private medical clinics in the area providing a very narrow range of medical services, they are at least three times more expensive than ours and the level of care is questionable. We work closely with them for timely referral of patients. The closest government health facility is about two hours walking distance and lacks regular man-power as well as medicines. However, as partners, we also get some items (e.g., family planning materials) free of cost from the government.