10 years of

2018 Annual Impact Report

Our story begins in far west Nepal, months after the ending of the 10-year civil war, with an abandoned hospital and a community in urgent need of quality healthcare. It was also a time when community health models, based in social justice, equity, and government partnerships, were gaining momentum. From the beginning, our approach was “intersectoral"; health equity meant tackling the local burden of disease, which included chronic diseases, alcoholism, and severe malnutrition, in addition to improving reproductive, maternal and child health. We also knew that transforming health outcomes could not be accomplished through a silver bullet; we envisioned integrated care delivery, from hospital to home. We remain committed to these roots.

Dear friends,

Thank you for supporting Possible over the past decade! Your confidence has inspired us to expand healthcare in some of the most underserved communities in the world.

Many of you have visited Nepal and have seen the stunning Himalayan foothills of the Far West— the winding rivers, the brilliant mustard flowers, the fantastic green of rice, the deep pine forests. This breathtaking landscape, however, also makes access to timely care particularly challenging.

We started comprehensive primary services in Achham in 2008. At the time, all we had was an invitation from the Government of Nepal to operate a facility that was unused and in disrepair. With local Achhami leaders, we committed to building health systems that secured quality healthcare for populations that until then did not have access to basic services.

We were told it would be difficult to manage logistics, find talent, and coordinate transportation in a place so remote that getting there from Kathmandu took over 30 hours by car. But you stood by us, knowing that if we solved for patients most in need, we could get closer to making healthcare work for all.

Like the terrain of Far West Nepal with dizzying peaks interspersed with deep chasms, our journey has been one of extremes. On one hand, there has been an urgency to meet the needs of pregnant women, children with bone fractures, the elderly, and others for whom transportation and costs stood in the way of life-saving treatments. Yet at the same time, we have considered the long arc of nyaya (justice) and are building institutions that can meet both current gaps and needs unforeseen. It is at that intersection, of service delivery and systems change, that we have worked.

We have achieved much in these ten years. Bayalpata is now under the new democratic Federal system, formally a Provincial Hospital, that serves the community healthcare, outpatient, inpatient, and surgical needs of patients from Achham and beyond.

Bayalpata’s catchment area has seen a notable reduction in under-two mortality - and, equally important, we have developed a system that reliably, affordably, and accurately captures pediatric mortality at both a household and population level.

When the devastating earthquakes of 2015 forced us to consider our role in rebuilding health systems that were decimated, you were with us as we committed to Dolakha, not just for the short-term, but for the long-haul. We have brought lessons from Achham to Dolakha and Dolakha back to Achham with your support.

Today, the 350+ staff across the two provinces annually deliver home-to-hospital integrated care for over 200,000 individuals, and attend to over 150,000 hospital visits. We continue to partner with municipal, provincial, and federal institutions to improve our services and identify scalable solutions, with government adoption as the endgame.

We know our path forward is long and we will stumble along the way. We hope for your continued partnership as we advance integrated care delivery systems in Nepal that can be beacons for health systems globally.

We have made this progress because of your support. Thank you.

Duncan Maru
Possible, CEO

S.P. Kalaunee
Nyaya Health Nepal, Executive Director

Possible, a US-based non-profit, and Nyaya Health Nepal, a Nepal-based NGO, have partnered over the last decade to provide quality, accessible care to underserved communities in Nepal.

Advancing Universal Healthcare in Public Sector Delivery Systems


Apply implementation research, quasi-experimental, experimental, and mixed methods to study evidence generated by our care delivery efforts.


Shape the financing environment by advancing principles of population health, value-based healthcare, and social protection for universal healthcare.


Train new cadres of healthcare workers, utilizing hospital infrastructure and staff.


Encourage government adoption of electronic health record, chronic care models, and public investment and professionalization of community health workers.


Design and test ideas that fill gaps in public health systems.


Deliver and coordinate care via government hospitals and community health workers.


Diversify revenue through insurance, municipal, provincial, and federal grants, research and philanthropy.


Iterate our care delivery system through data feedback loops and integrated electronic health record.

10 Years of Innovation & Learning

In 2007, we opened Sanfebagar Primary Clinic, at a time when Bayalpata Hospital, the closest primary care provider, had been abandoned. It was also a time when Nepal experienced a highly fragmented provider landscape, exacerbated by historic disinvestment and civil war. We recruited healthcare staff who worked in the closest town, 10 hours by road, and had roots in Achham. Staff who both knew the community, and were committed to the region, were the best hopes for retention and sustainability.

Patients often walk for hours or even days for illnesses that could have been prevented or managed at home. In 2008, we started comprehensive primary care services in Achham that coordinated care across conditions and access points. We leveraged the existing frontline health worker infrastructure and added technology, supervision, and a meaningful living wage, to introduce a cadre of professionalized community health workers (CHWs) to leapfrog our efforts.

We saw too many families sell livestock, sacrifice schooling, or go into debt to pay for healthcare. We knew that quality healthcare did not have to financially burden communities. We committed to care integration, digitization, longitudinal care, and financial protection as our call to action.

At Charikot Hospital, a government facility where Possible started work after the 2015 earthquakes, we perform 150 to 200 orthopedic procedures per month, a common occurrence in hilly regions. Too many people, children especially, die or are disfigured owing to treatable injuries. We attempted a referral program with urban hospitals 14 hours away, but the costs and travel was taxing on patients. So we developed our own safe surgery program based on three principles: task-share with local generalist physicians and mid-level providers; utilize the hospital as a place of training; and provide longitudinal care via CHWs.

Read about a patient who came in for a bone fracture.

In far west Nepal, the nearest psychiatrist is 30 hours away by road. Like other chronic health conditions, mental illness requires timely follow up and medical adherence. We have piloted an integrated mental healthcare program that includes primary care providers, on-site psycho-social counselors (PSC) and a remote psychiatrist, with the additional support of CHWs who do home visits. With our mental health protocol, 52% of our patients with depression demonstrated a clinical response over a 24-month period.

Read more about our integrated mental health program

The story of Possible is an organization committed to place, access, and public partnership with the end goal of improving population health outcomes of the region. Just as Bayalpata Hospital was reopened after an uprising and a public demand that everyone, regardless of income or geography, deserved quality healthcare, we continue to engage the community and government in all major decision-making.

10 Years of Community Health

Building a clinic, alone, could not improve healthcare in a hilly region with minimal transportation; CHWs were needed. We advertised for female health workers. Two men arrived, claiming it was discriminatory to hire women only. We asked: Imagine you are the CHW visiting a new mother. How would you ask about vaginal bleeding? One of the men said, “Those questions are better suited for women,” and left. We hired four female CHWs, who are employed with us to this day.

Over time, our CHW program has evolved into monitoring and managing reproductive, maternal and child health, and non-communicable diseases. Their work can be organized into three areas: 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.

CHWs are at the center of our integrated EHR. CHWs collect sensitive information about household economics, illness, and deaths in the family, that are integrated with facility-level data to support decisions about care. We leverage this experience to push for national adoption of a professionalized CHW model. And with our CHW Impact Coalition peers, we champion high-performing CHW design principles around the world.

Read how our professionalized Community Health Worker program works.

10 Years of Data & Technology

From the beginning, data and technology have been embedded into our work, with all staff, from frontline health workers to human resources, collecting and analyzing data. ‘Cultivating a culture of data’, however, did not come easily. We scoured for EHR models, but nearly all were optimized for billing rather than for learning. So we built our own.

In February 2015, we launched NepalEHR with our partner GIZ. By 2018, we successfully integrated the Government of Nepal’s District Health Information System (DHIS2) for data reporting with an OpenMRS-based NepalEHR platform our team developed, allowing for seamless and automatic reporting of facility data to the central government’s health database. This direct integration of OpenMRS and DHIS2 was the first of its kind anywhere in the world.

Read how this integration enables clinicians to scan for epidemics in real time.

This year, as a critical test of scale, we set out to determine if the NepalEHR could be implemented in government hospitals not managed by Possible. The implementation at a hospital in Nuwakot district helps us determine the feasibility of institutionalizing the EHR on a national scale. We realize that the impact of the NepalEHR is only as powerful as its users, and we are equally investing in the user experience.

Read how our team is scaling our EHR in public hospitals across Nepal.

Impact in Numbers

Receiving “Facility to Home”
Integrated Care Services

Reducing Under 2 Mortality

In Achham, the number of under 5 deaths, compared to the national under 5 mortality rate, is among the highest in the country. As a result, Possible has focused on monitoring deaths among children through the age of two years, noting the probability of a child dying is highest in the first year. We have observed a persistent decrease in the mortality rate of children under two years of age, from 36 in 2015, to 18 in 2016, to 12 in 2017 per 1,000 live births.

Read the impact of our Under 2 research

Improving Institutional Birth Rate

Possible’s professionalized CHWs currently deliver home-based care to over 200,000 people. We have seen measurable improvements in maternal and child health outcomes in the areas served by our CHWs. For example, institutional birth rate, a proxy for maternal health, increased from 30% to 95% between 2012 and 2017 in our catchment area in Achham.

Read about our approach to reducing maternal mortality

For a comprehensive review of our metrics and KPI definitions
username: impactreport
password: Possible1


August 1, 2017–July 31, 2018

Revenue by Type

Expenses by Investment

Statement of  Activities:
August 1, 2017 - July 31, 2018

Financial Sustainability Metrics

Meet the Supporters

“Beyond reducing fractures, beyond providing prenatal care and family planning, beyond vaccination and first aid, beyond primary care is a Pandora’s box of complex ailments. How can we promote global health equity without the tools of the trade? The fitting way to mark the third anniversary of the reopening of Bayalpata’s rebirth is to add essential instruments to the toolkit. We did this by cutting the ribbon on a new operating room and a laboratory.”

—Paul Farmer, MD
Partners in Health

Read more about Dr. Farmer’s visit to Nepal in 2012

"Each day people die of preventable and treatable diseases due to a lack of access to healthcare. Society can post and tweet about why it’s happening and what to do about it. Or we can engage, hand in hand, and go after it, one patient at a time. That is Possible."

—Jeff Kaplan
Partner, Deerfield Management

"Last Mile Health is honored to work alongside Possible in the movement to advance access for healthcare for everyone, everywhere. We are inspired by Possible's work in Nepal, and the potential for what's possible when we work together."

—Raj Panjabi
CEO, Last Mile Health

“We are thrilled to welcome Possible as a core partner to the Arnhold Institute for Global Health at Mount Sinai. I have closely watched the organization flourish and adapt over the past decade, and I deeply admire the team, the spirit, and the impact that it has achieved. We are looking forward to learning from Possible and supporting the team in achieving our deeply interlinked missions.”

—Prabhjot SIngh
Director of the Arnhold Institute for Global Health; Chair of the Department of Health System Design and Global Health, Mount Sinai Health System

“The health community has long struggled with realizing the promise of data integration to improve health outcomes. But Possible has proved that it is possible to make the right data available at the right time to inform patient care and improve population health outcomes.”

—Mary-Ann Etiebet, MD
Lead, Merck for Mothers

“Possible demonstrates indeed what is possible when you combine deep local knowledge with world-class talent and proven solutions. Possible has translated its evidence base of how to create better health outcomes at lower cost into an influential role advising national policy, which is a testament to their credibility. They offer a model of how social enterprises could partner with governments worldwide.”

—Katherine Milligan
Head of Schwab Foundation for Social Entrepreneurship

"Seeing Bayalpata Hospital's transformation from a padlocked dungeon on top of an inaccessible hill ten years ago to a thriving medical center of excellence in the far-West with free care, electronic medical records and training for mid-level practitioners makes me so proud, happy and most importantly, hopeful for rural Nepal and other similar corners of the globe."

—Ruma Rajbhandari
Brigham and Women's Hospital

“We were told that it would be impossible to hire clinicians to live and work full-time in Achham. How do you recruit and retain a hospital staff in one of the most historically marginalized parts of Nepal? We wanted to hire locally but the only hospital system in the area was 5 hours away. We spent months identifying clinicians of Achhami origin, essentially showing up at their workplace and telling them about a new non-profit clinic in Achham. Most  were eager to move closer to their family and community, while getting a fair salary and benefits. Ten years later, several of those original staff are still at Bayalpata Hospital.”

—Bibhav Acharya
Possible Co-Founder and Mental Health Advisor

"When I worked as a Community Health Nurse at Kamalbazar Hub, I had to walk 9 hours through thick forests, because there was no access of roads. It was not possible to return on the same day. I reached at my room late evening, without food. I got hungry, thirsty and tired. I saw wild animals or drunk men or rivers, where there was no bridge. This was the difficult part. I had also had opportunity to work with an ANC mom who had HIV and had been pregnant 13 times at age 42, and had experienced miscarriages. After 4 hours of prenatal counseling, she understood her complications and agreed to have a facility birth. She was grateful for a successful delivery, and I felt proud to support her."

—Sita Saud
Community Health Associate

"In mountainous parts of Nepal where quality healthcare is a far-fetched dream, Bayalpata Hospital serves the most underserved. By providing quality maternity care, child health, reproductive health, vaccination and general health services, Bayalpata Hospital presents a model of public and private partnership, something which can be replicated to address the enormous needs and challenges of the health sector in Nepal."

—Mohna Ansari
National Human Rights Commission of Nepal

"As healthcare systems are being built within low and middle income countries, there is a leapfrogging opportunity to build a data-driven ecosystem focused on patient-centered health outcomes. Possible is an example of how we moved directly to focusing on value in this continuum from volume to value. And to see this happening in the last mile is even more extraordinary."

—Muna Bhanji
Senior Vice President
The Global Market Access Group at MERCK

"NHN (Possible’s implementing partner in Nepal) is everything. It provided me and my family with a shelter, food and clothes. Without it I wouldn’t have the resources to educate my children in a good school. It provided a job to both of us, as husband and wife. Working here makes us feel very proud."

—Rambha Kumal, Health Aide, and Hiujal Kumal, Patient Navigator
Staff since 2008

Thank You

$1M and Above
Pineapple Fund
Tondo Foundation
$500,000 to $999,999
Deerfield Foundation
Nepal Ministry of Health & Population
UBS Optimus Foundation
$250,000 to $499,999
Manan Trust
Nick Simons Foundation
TATA Trust
$100,000 to $249,999
Alwaleed Bin Talal Foundations
Grand Challenge Canada
Mulago Foundation
Pfizer Foundation
Younger Family Fund
Harvard Medical School for
Global Health Delivery- Dubai
$50,000 to $99,999
Elmo Foundation
Horace W. Goldsmith Foundation
Justin Durand
Partners Healthcare
Planet Wheeler
$10,000 to $49,999
Albert J Kaneb
America Nepal Medical Foundation
Bhimeshwor Nagarpalika
Capital Group
District Health Office- Achham
District Health Office- Dolakha
Eswar Priyadarshan
GIZ- German Development
Corporation Office
Invesco Hong Kong
Joanne Kagle
Joel Wittenberg & Mary Ann Ek
John Bauman
Knut Skyberg & Borgny Ween
Latika & Rajiv Jain Foundation
National Philanthropic Trust
Nepal Government National Center for AIDS & STD Control
Nepal Government National
Tuberculosis Center
Neuman Foundation
Planned Parenthood League of Massachusetts
Robert Heine
Sall Family Foundation
Sandro Lazzarini
Sanfebagar Municipality
Small Improvements
The Ripple Foundation
The Rosebud Charitable Trust
Umed & Anand Maru
$1,000 to $9,999
Adam Butterworth
Anshuman Patwardhan
Barbara Kamholz
Baupost Group
Bridgit Burns
Bright Funds
Cathay Pacific
Dan Schwarz
Daniel Matlack
Daron Janzen
Dave Chokshi
District Development Committee Dolakha
Elizabeth Carls
Eng Fong Pang
Fidelity Charitable Gift Fund
First Dollar Foundation
Genentech Matching Funds
Giving Wings Foundation
Harvard University
Ilan Zechory
Jackie Bullis & Ryan Duffy
Jeffrey Schwarz
Jennifer T. Cook
Jessica Hawley
Josh Siegel & Meredith Martin
Julie Askew
Kangu, Inc.
Khushi Sharma
Leonard Wee
LiberatED Scholar
Marta Barlic
Matthew Busch
Matthew Isanuk
Meriden School Charitable
Muna Bhanji
Nancy Binder
National Public Health Laboratory
Nepal Government Epidemiology & Disease Control Division
Nepal Government Logistics
Management Division
Patrick McKee
Philanthropy Workshop
Plato Malozemoff Foundation
Pravin Kumar
Regional Medical Store, Dhangadhi
Ross Family Charitable Fund
Ryan Price
Ryan Schwarz
Schwab Charitable Fund
Sharad Jain
Simin Gul
Terhilda Garrido
The Herrnstein Family Foundation
The Mount Sinai School of Medicine
Tiwari Medicine Distributors
Wan-Ju Wu
$500 to $999
Amish Desai
Andrew Bunn
Ari  Johnson & Jessica Beckerman
British Nepal Medical Trust
Carol Wright
Cory Surdam
Dag Harald Hovind
Duke School of Medicine
Exelon Foundation
Ezra Furman
Fabrice Loudet
Hirotaka Torii
Indra Makhija
Isaac W Howley
Jack Lipszyc
Jason Jones
Jerry Grandage
Kevin Waite
Liz Hutton
Mathew Feldman
Matthew Murphy
Morris Prokop
Ondrej Sliva
Peter Bibler
Pew Charitable Trusts
Rachel Elizabeth Maley
Rob Tinworth
Sarah Hanck
Sarah Strongin
Save the Children
Smitha Mathew
Suzanne Loui

Please view on desktop for extensive overview of Possible's 2018 10-Year Annual Impact Report.

Muna Bhanji
Marta Bralic
Justin Durand
Terhilda Garrido
Jeff Kaplan
Pravin Kumar
Sandro Lazzarini
Duncan Maru, MD, PhD
Eswar Priyadarshan

Bibhav Acharya, MD
Bijay Acharya, MD
Jason Andrews, MD, SM
Mark Arnoldy
Amit Aryal, MPH
Birendra Bahadur Basnet
Sanjay Basu, MD, PHD
Kul Chandra Gautam
Paul Farmer, MD, PHD
Sheela Maru, MD, MPH
Isha Nirola, MPH
Prativa Pandey, MD
Ruma Rajbhandari, MD, MPH
Ryan Schwarz, MD, MBA
Dan Schwarz, MD, MPH
Prabhjot Singh, MD, PHD
Jhapat Thapa, MBBS
Wan-Ju Wu, MD

Arnhold Institute for Global Health at the Mount Sinai
School of Medicine
Ariadne Labs
Dhulikhel Hospital
Brigham and Women's Hospital Division of Global Health Equity
Harvard Medical School Center for Global Health - Dubai
University of California San Francisco Department of Psychiatry
University of Washington Nepal Studies Initiative
Innovations in Healthcare at Duke University
Nepal National Academy of Medical Sciences