Take the example of Nama, a 20 year-old female who walked two hours to Chaurmandu PHC. Nama previously traveled to the PHC, but found a doctor was rarely present. Now she is able to get a proper diagnosis, labs, and medicine to treat her stomach ailments, not a life-threatening condition, but one severe enough to disrupt her day to day working in the fields to provide for her family.
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There are many patients like Nama, who can be treated at PHCs, before minor conditions become acute.
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In addition to our partnership with the PHC, we have been leading community health efforts in the same municipality over the past two years, with meaningful impact on maternal and child health.
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After ten years of healthcare delivery in Achham district, where Chaurpati is located, we understand the inputs that will have the greatest impact on communities in this area. Furthermore, the partnership with the municipality enables local officials to have direct visibility and accountability into the health of its constituents.
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There are multiple things we consider in the design, including: inputs that will improve maternal and infant health, and a staffing structure and equipment that is appropriate within the existing public health system.
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Over the first six months of operations, we have observed the following:
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(1) There is a strong demand for services closer to home, evidenced by an average of 1,000 patient visits per month to the PHC.
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(2) Optimizing care in PHCs reduces the volume of non-emergency patients at nearby Bayalpata Hospital, for example for those seeking lab services, pharmacy, antenatal and postnatal care, x-rays and normal deliveries, family planning, and immunizations, who can access non-emergency care closer to home.
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(3) PHCs perform strongest, when there is close partnership and political will at the municipal level, evidenced by strong leadership by the Mayor. 
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(4) NepalEHR has been successfully rolled out in the PHC and is tracking outpatient visits, antenatal care, postnatal care, deliveries, safe abortion, and labs. All staff members are effectively using the EHR, despite low digital literacy when we launched this partnership.
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(5) Two years of developing community health systems in Chaurpati municipality has led to a deeper relationship with the local government, including public financing for an ultrasound machine, medicines, and labs to support maternal health.
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Ultimately, our goal is to develop a roadmap for delivering integrated care that can reach those most left behind.

Using NepalEHR, Possible is making progress toward incorporating insurance into the standard workflow at our facilities, from verifying patient enrollment to submitting and processing claims, to ensure social protection for the most vulnerable populations.
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“Insurance plays a crucial role in my family's health. Our family members can get health services up to $1,000 when we pay $35 to get enrolled in health insurance, with coverage for up to five members in the family. Patients who have National Health Insurance are able to avoid long waits at Possible facilities, in addition to accessing healthcare in other parts of the country. Personally, insurance has prevented financial burden for my family,” says Mukunda Rawal, Patient Navigator In-Charge, at Bayalpata Hospital.

The rise in C-sections affects low-, middle- and high-income countries, although the consequences of unnecessary C-sections may be different across settings and countries, depending on the human or financial resources available, and the capacity to perform C-sections safely.  
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The data show high rates of C-section in the world; in Nepal, the C-section rate often exceeds 20% in private hospitals. The WHO recommends a rate of 5-15%.
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“Private hospitals are too often incentivized by high out-of-pocket expenditures associated with surgery, and discourage vaginal birth after C-section, and in  cases like breech presentation, Oligohydramnious, etc,“ says Dr. Binod Dangal, Provincial Director at Charikot PHC.
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Charikot PHC, a government facility, with the highest catchment population among all municipalities in the district, has trained staff and an anesthesia assistant, to handle complicated births. 
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“We maintain our C-section rate between 5-15%. We promote and encourage collaborative midwifery obstetric care at the center. Our team is trained and prepared to perform C-sections at anytime. However, we encourage vaginal delivery when possible, in order to reduce the number of complications and encourage early recovery and discharge,” continues Dr. Binod.
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Shama, a 30 year-old woman presented at 40 weeks of gestation at Charikot PHC. This was her second pregnancy and her first in a facility. 
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 Shama’s childbirth experience with this delivery was vastly different from her first one.  Her pregnancy was detected early as a result of a CHW’s visit to her home, she completed the four recommended antenatal visits at a nearby health post, and the CHW referred her to the facility for delivery.
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Shama was able to get full pregnancy lab services and ultrasound, took folic acid supplements, iron and calcium during her first trimester, and tetanus vaccine at three and four months. She delivered a healthy seven pound baby boy vaginally, with no complications, and recovered quickly.
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At our daily continuing medical education (CME) sessions, we share clinical guidelines among health workers across the continuum of care. Our systems strengthening approach is geared toward codifying recommendations around c-sections, and other safe delivery practices, that are relevant to rural health settings.

Dhana’s story is common in Nepal, where one in 400 women die during childbirth.
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I had the skills to intervene at Dhana’s doorstep. I left my nursing job knowing that I could be more useful as a Community Healthcare Nurse.
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Now, my day starts at 5 AM with a torch light, a hike through steep hills, gushing monsoon rivers and often jungles– all this while carrying an ultrasound machine to detect a complicated pregnancy.
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Many women are keen to exercise their sexual and reproductive choices, but tools must be available. Women must have easy access to contraceptives.
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I worked with local politicians to ensure contraceptives are available in the nearest health posts.
At first, I was not taken seriously, but I persisted.
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I feel most proud of providing quality care and making a referral to a facility at a moment when the decision can be life-saving.
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Together, we have increased institutional birth rate from 76% to 96% over two years.
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I have found my calling. But it will take an integrated approach, from one on one prenatal counseling, to group antenatal sessions on breastfeeding and nutrition, to well-equipped and appropriately staffed facilities to make sure every mother and child has access to quality care, when they need it. 
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Aasha Bhatta is a key member of Possible’s Community Healthcare efforts.
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