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Designing Community Health Systems for Integrated Care in Nepal

Community Health Workers (CHWs) play an important role in bringing high-quality health care services closer to the home, particularly in low- and middle-income countries like Nepal. For the last three-plus decades, the country’s Female Community Health Volunteers (FCHVs) have been doing just this, by acting as a touch point between families and the healthcare system. FCHVs have also been at the center of Nepal’s improvements in maternal and child health outcomes.

Building on this idea that systems of care should extend beyond clinics and hospitals, Possible employs full-time community healthcare workers who focus on integrated, longitudinal care for reproductive, maternal and child health, and non-communicable diseases. CHWs’ work primarily involves 1) active and passive identification of conditions in the community; 2) triage and referral care with facilities; and 3) community-based diagnosis, treatment, and counseling. Trained and regularly mentored CHWs are central to building adaptive systems of care that seek to ensure people are being followed-up in sickness and in health; put another way, the goal is to meet individuals and families where they are in terms of their health and healthcare needs.

CHWs must also be part of continuous data feedback loops, another central component of optimizing health systems. We have designed an integrated home-to-facility electronic health record platform that puts CHWs at the center of these efforts, which we describe in a recently published paper. CHWs are well positioned to collect community-level data prospectively as part of routine household visits, which ultimately might be a more “sensitive” approach to data collection and measuring health outcomes. Here, we mean ‘sensitive’ in both senses of the word: statistically capturing each household, as well as paying more attention to the inherent ethical dimensions that surround collecting such sensitive information about household economics, illness, and deaths in the family. Integrating these data with facility-level patient records can provide a more holistic view of healthcare access and health outcomes in the areas where we work.

To be sure, challenges remain. These include fostering better community and stakeholder engagement, data ownership, and other technological challenges inherent to working in remote places. Building adaptive healthcare systems requires that we continue to reflect on these core issues, iterating with our government partners along the way.

Nepal is creating new federal structures throughout the country, decentralizing both budgets and enabling increased decision-making power at the municipal level. This presents a tremendous opportunity for newly elected mayors and ward officials to support professionalized community health worker systems throughout the country. We look forward to continuing this collaborative work of building CHW-driven systems of integrated care.

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