You can’t improve what you don’t measure. Here’s how we measure our high-quality, low-cost healthcare model.
Scale of Impact
We’ve treated 313,356 patients since 2008, and volume nearly doubled over the last 2 years. Updated quarterly.
patients treated to date.
We employ 247 team members around the world, of which 92% are located in rural Nepal. Updated quarterly.
team members employed.
Nepal’s government is our largest partner, when cash and in-kind investments are combined. Updated yearly.
of cash & in-kind support from Nepali government.
Our cost per capita hasn’t exceeded $20. Updated yearly.
per capita price point.
Optimizing for Quality and Cost
$20 Price Point
We optimize the design of our healthcare system around both quality and cost.
Using cost as an indicator without quality metrics leads to over-optimizing for a low cost per capita and failing to deliver quality care.
Using only quality metrics as indicators without a strategic price point would lead to over-optimizing for quality and run away costs.
We balance a practical price point of $20 per capita with a set of six key performance indicators of quality to achieve optimal impact.
Key Performance Indicators
The six KPIs below were selected because they can be feasibly collected in rural impoverished areas and reflect the overall performance of our integrated healthcare model.
The KPIs represent the impact we are making for the entire population beyond any single tier (hospitals, clinics, community health workers or the referral network).
In addition to the overall KPIs, we openly publish results from individual tiers of the healthcare system in Quarterly Impact Reports.
Key Performance Indicators
The % of days when surgical services are fully available to patients.
The ratio of hospital service utilization of marginalized patients vs. general catchment population.
The % of women giving birth in a healthcare facility with a trained clinician.
The % of chronic disease cases successfully followed-up in our catchment area.
The frequency of healthcare service utilization among our catchment population.
The % of reproductive aged women who delivered in the past 2 years using contraceptive methods.
Our KPI Progress
In order to transform healthcare delivery systems, we pursue aggressive targets. We refactor as needed based on data analyses, global and national recommendations and guidelines, existing literature, and thorough input from our government partners.
View our metrics creation protocol and approach to target setting here. The charts below show our performance of these six KPIs over the last six quarters, and provide brief context for each.
Surgical Access Ratio is measured through a services checklist, including surgeon availability, anesthesia provider, surgical nursing staff, x-ray and ultrasound, surgical equipment, autoclave, water, and electricity. It measures an effective hospital system and the availability of a critical service at the district hospital level. We have been at 100% since we began measuring this KPI.
Institutional Birth Rate captures women’s perceptions of quality service delivery, and the healthcare system’s commitment to follow-up from antenatal care visits. The IBR is measured through data collection by Community Health Workers and is likely high compared to national averages because of our catchment area’s proximity to the hospital, and our Community Health Program’s strong focus on follow-up and birth planning.
Outpatient Utilization Rate offers a snapshot of essential primary care access. The drop in performance seen in Q2 represents a change in our data source, from collecting data at the clinic and hospital level, to measuring at our hospital hub. We aim to reincorporate outpatient visits once we scale our Electronic Health Record (EHR) to the primary clinic level.
Equity is at the heart of the struggle for access to healthcare. Here, a value of 1 suggests equal access to primary care at our hospital hub between low-caste and non-low caste patients. In the future, we hope to stratify this by socio-economic status, as caste does not ultimately determine a family’s wellbeing or access to high-quality healthcare.
Chronic Disease Follow-Up is a critical function of a healthcare system for patients. Our chronic disease follow-up rate increased from 27% to 50% in large part because of our Community Health Workers home visit program; more recent fluctuations represent a transition of our chronic disease registry to our EHR, through which we also measure chronic disease control rates.
Family Planning Uptake has been linked to lower rates of poverty and reduced maternal and child mortality. This KPI encompasses uptake methods of contraception including intrauterine devices and implants, condoms, and contraceptive pills. In Nepal, an estimated 41% of married women of reproductive age use some method of contraception. There are challenges to setting targets for contraceptive use; however, based on our original measurement and available regional data, we are in the process of refactoring the target.
Meet Our Medical Director Dr. Bikash
Meet Dr. Bikash, our Medical Director who has keen insight and an inspiring vision for how to strengthen our durable healthcare model.
“We keep adding additional services, like digital x-rays, dental work, and an electronic medical record. We keep improving. We are never the same. ”
You probably recognize this man above, who’s been involved with our team since 2010.
Dr. Bikash first heard about our work in 2008 while he was in medical school. Now he’s our Medical Director— and has keen insight and an inspiring vision for how we will take our teaching hospital to remarkable heights for our patients.
Bikash rejoined our team this summer after receiving his doctorate in General Practice and Emergency Medicine so he could advance his skillset and treat more complex cases at our hospital. We recently asked him how it felt to be back with the team and to hear more about the expansion.
So, how does it feel to be back?
It’s such a great feeling to be back at Possible! This is a place where I get so much job satisfaction. I love to be with each and every team member who is eager and enthusiastic to provide better and better services for our patients.
We used to be a very small team when I first joined in 2010. Now, we have a huge number of members (nearing 300) who all share the same dedication. We keep adding additional services, like digital x-rays, dental work, and an electronic medical record. We keep improving. We are never the same.
What is a typical day like for you?
My day is always busy. I start by attending the morning update meeting. Right after we conduct Continual Medical Education classes. Then, I do rounds starting from our Emergency to Inpatient Department. Afterwards I see our patients in our Outpatient Department. Often, I perform surgeries, like caesarian sections, hernia repairs, and appendicectomies.
What has been the most challenging moment for you at Possible? What about the most rewarding?
I think it would be the day when we performed an emergency hysterectomy. It was the most challenging moment, but later it became the most rewarding. She was dying on operation table, and we saved her life.
What excites you most about our hospital expansion?
I’m excited about leading our hospital expansion for so many reasons. Right now, we’re a fifteen bed hospital, and have to treat more patients by making beds on the floor and pushing benches together. That’s the challenging reality. But soon, we’ll not only be able to meet our current needs, but also the additional needs we foresee in the future—providing care to over 250,000 people in Achham District. Our unique Community Health Department will power that reach too by treating patients at their home and at nearby clinics.
Why are you a Possibilist?
“I’m a Possibilist” because I am providing quality health services beyond the imagination of many healthcare policy makers.
With your support as a Possibilist, we are making quality health services imaginable for both our team members like Dr. Bikash, and the hundreds of patients we serve each day.
When a Hospital Isn’t Enough
Why mothers need more than a hospital to bring their babies safely into the world.
“It wasn’t like this when I was born – I was born at home. But there are many difficulties with home births.”
+ Rupa, a new mother
In rural Nepal, pregnancy is referred to as a “gamble with death.”
There was a pregnant woman named Rupa who nearly lost that gamble. She, like so many other women, wanted to give birth in a safe healthcare facility near her home. She herself was born in her home, and her mother warned her of the dangers of home births.
Because of that, when she went into labor, she immediately journeyed to the nearest clinic. Yet, there was only one midwife there, and part way through her delivery, the nurse realized she didn’t feel comfortable proceeding alone because she suspected a complication with the delivery.
Because of that, Rupa called for an ambulance, and Possible’s ambulance driver came to pick up Rupa and bring her to the hospital. This 3-minute video shows what happened next.
Rupa’s story has a happy ending. And for many mothers who are fortunate enough be close to a hospital, that is the case. At Possible’s hospital hub in rural Nepal, the number of births taking place within the facility has grown 197% from 2010 to 2013.
But a hospital isn’t enough. What pregnant women really need, in a region with one of the highest maternal mortality rates in the world, is access to safe birthing centers closer to their homes and support throughout their pregnancies.
That’s why we are pioneering a new approach to put safe births at the center of our integrated healthcare model.
It’s also why the percentage of women delivering in health facilities is one of our six Key Performance Indicators.
We solve for the problems of pregnant mothers like Rupa by having female community health workers provide training and referral support in villages, working with local community governments to transform clinics into safe birthing centers, and linking clinics to a central hospital with ambulances for emergency deliveries.
This model is supported financially through a partnership with the Nepali government’s Safe Motherhood Program, where both pregnant mothers and Possible receive payments for attending prenatal care visits and delivering in a health facility.
It’s a model of safe births that works fully for pregnant women, not partially.
Meet Our Medical Director Dr. Binod Dangal
Dr. Binod joined our team shortly after we expanded our work in Dolakha District when the earthquakes struck Nepal. Hear his inspiring story.
Dr. Binod’s journey is a unique one. At a young age, a British teacher volunteering in his rural village recognized his potential, and sent him to study in Kathmandu. He quickly immersed himself into city life, living with classmates who “didn’t like when someone studied more than they should.”
Having never spoken English until moving to Kathmandu, Binod barely passed his first exams. But he pushed forward with grit, and graduated high school with impressive scores, especially in science. He went to China to complete his Bachelors in Medicine, where he finished top of his class.
He conducted his higher-level MD studies in Nepal, and then moved to Dolakha, a three hour jeep ride on bumpy roads from the rural village where he grew up. He jokes that by now he’s probably treated every person here. When he visits his home, patients approach him with their back problems, headaches, and fevers, and he draws out the stethoscope from his coat pocket without hesitation.
When the earthquake struck Nepal, many rural villages in and surrounding Dolakha District were destroyed. His own home turned to rubble, and many of his family members and neighbors passed away. After spending countless, extended shifts to respond to the immediate needs of earthquake victims, he joined our team.
After his journey to Kathmandu and abroad, Dr. Binod now leads Possible’s medical strategy in one of the worst-hit districts in Nepal, while also coming back close to home to deliver dignified care.