A Network of Safety: Transforming A2C

Born and raised in one of the districts served by the organization he now leads, One Heart Worldwide (OHW), Surya Bhatta is passionate about improving the lives of society’s most vulnerable. With degrees in Public Health, Sociology and Healthcare Delivery and a decade of experience working in health development leadership roles supporting Nepal’s public health system to implement maternal and newborn health (MNH) interventions, Surya is a dynamic social entrepreneur championing the wellbeing of pregnant women and newborns in rural areas. Employed by OHW since its inception in Nepal, Surya has grown alongside the program from an entry-level Trainer to its Executive Director, giving him a thorough understanding of the MNH landscape in Nepal and its unique needs and solutions. During his tenure with OHW, he played a critical role in the program’s scale-up from 2 original pilot districts to the current 19 program districts in rural Nepal.

Remote, rural communities bear a devastating and disproportionate burden of preventable maternal and newborn mortality. Our project is transforming MNH across rural Nepal and catalyzing local government and communities to maintain improvements. Our model is grounded in deep respect for local culture and facilitates active local participation. We collaboratively identify, then address, the systemic disparities keeping +80% of pregnant women from accessing proper MNH care. We work in direct partnership with local governments and communities to strengthen their capacity to provide appropriate MNH services indefinitely. We train healthcare workers, upgrade public health facilities and ensure women are able to reach them. Humanity will be elevated when every pregnant woman and newborn has access to the care they need to survive and thrive during pregnancy and after childbirth. Our model is working in Nepal and can be adapted to any context with high incidence of maternal and newborn mortality.

Globally, over 300,000 pregnant women and 2.5 million newborns die each year from preventable causes related to pregnancy or childbirth. Low-resource settings bear the brunt of these deaths. In Nepal, 1,500 mothers and 12,000 newborns die from preventable causes related to pregnancy or childbirth annually. While the national mortality rates are comparable to other low-income countries, these rates are much higher in remote rural areas, revealing crippling inequities and underlining the need for improved system equity. In rural Nepal, most deaths occur due to shortages of appropriately trained health workers, lack of effective MNH service infrastructure, and poorly informed populations, all results of poorly allocated governmental resources. Rugged terrain, high altitudes, harsh winters, and heavy monsoon seasons isolate these underserved populations, further exacerbating gaps in Nepal’s basic infrastructure and healthcare delivery. As a result, fewer than 20% of rural women have access to quality care for pregnancy and delivery, resulting in significantly increased incidence of adverse obstetrical and neonatal outcomes. Unless concerted efforts are made, Nepal and similar countries will prevent the world from meeting SDG 3 targets on maternal and newborn mortality.

OHW strengthens local MNH infrastructure, ensuring high-quality MNH service delivery in rural Nepal. We train rural health workers, upgrade government facilities into functioning birthing centers that meet required quality standards, and train outreach workers to drive demand for MNH services. Our programs build a “Network of Safety” around mothers and newborns by establishing a self-sustaining continuum of care from the community to the referral hospital and from pregnancy to the postnatal period. We leverage time-bound philanthropic support with a proven exit-strategy: the government and local communities co-invest in, then fully maintain delivery of our intervention once outcomes goals are achieved post program completion, ensuring long-term impact sustainability. We actively engage local government members and community stakeholders throughout the process to ensure alignment with local priorities. We also drive local and national policy changes that prioritize MNH needs to unlock long-term budget allocations. As a result of our programs, we see more pregnant women accessing care and significant decreases in both maternal and newborn mortality. Investing alongside local governments and communities delivers a continuum of care that increases access to safe delivery options and encourages the adoption of culturally appropriate health behaviors.

OHW’s model saves the lives of pregnant women and babies. Our project aims to directly serve 500,000 vulnerable pregnant women and newborns every year, and indirectly impact a population of 10M in 36 underserved rural districts of Nepal. By improving healthcare facilities and providing specialized training to healthcare providers, we are ensuring that women can access the care they need closer to home. Improved training and mentoring empowers local providers to manage many common complications locally and efficiently recognize when hospital referrals  are  necessary. Providers benefit through increased confidence in their work and support networks, preventing the burnout so common in remote posts and resulting in improved quality of care for all. Our community outreach targets cultural gatekeepers, transforming these stakeholders from potential barriers preventing mothers from seeking care into informed and passionate advocates. By strengthening connections at each level, from the women and their neighbors, to their providers, and the formal healthcare system, we create a continuum of care that brings marginalized women’s needs to the attention of local healthcare providers, helping to close inequitable cultural and gender gaps.

Inequalities deepen when already marginalized groups are excluded from planning and implementing healthcare service delivery. OHW acts as an advocate for the needs of rural women in Nepal and drives the reallocation of existing government resources to ensure equitable access to care for all mothers and newborns, no matter where they live. This project gives a voice to those frequently forgotten within the larger system and improves equity in access to healthcare infrastructure. By empowering each community to maintain the improved systems, OHW is sustainably elevating underserved populations.

Our model was originally developed in Tibet in the late 1990s, after our founder met His Holiness, the Dalai Lama, whose own mother had given birth to 16 children, of whom only seven survived. In 2009, political unrest forced OHW to leave Tibet, and the Nepal program was launched. As OHW’s first Nepali employee, I immediately recognized the potential of the Network of Safety’s framework to create tremendous improvements for mothers and newborns in rural Nepal. Being born and raised in a rural village, I have an intrinsic understanding of the challenges rural women face during pregnancy. Over the following ten years, I led the tailoring of the model to the socio-cultural and political context of Nepal. Under my leadership, the model became a fully participatory process, working in direct partnership with local authorities and local communities with a system of local co-financing to build the capacity of local stakeholders to manage an equitable MNH system and develop a fully sustainable continuum of MNH care. I have also led the scale-up process of this improved model, from our two initial pilot districts and 300 annual pregnancies, to 19 districts and reaching over 205,000 pregnancies.

I was born and raised in a small rural village of Nepal, the youngest and third child of my parents. Wanting to help others led me to pursue a public health degree, which taught me a lot more about the issues and challenges that I had seen rural women face during pregnancy and childbirth. But reality really hit me the day I asked my mom about her birth experience and the birthing practices during her time. She shared a very disturbing incident that she went through while she was giving birth to my sister. My mother was married when she was 11 and had her first baby (my sister) when she was 16. Her placenta didn’t come out for a long time and my grandmother and other ladies hung a garden hoe on her placenta and she thought she was going to die. She was lucky, and eventually the placenta came out with some postpartum hemorrhage. She survived, but many women around her did not. Her story marked me profoundly, changing my path towards maternal and newborn health and guiding my work to adapt and implement the Network of Safety in Nepal.

My background in public health began in Nepal, where I completed my training before securing an MS graduate degree from Dartmouth. I spent the next decade working in global MNH, during which time I have held increasingly demanding roles within OHW, designing and leading crucial transformations resulting in lasting impacts on women and newborns. Under my in-country leadership and management, our program has grown from a pilot in five villages of one district, to 19 districts (out of 76 total in the country) over 10 years. My main responsibilities have included building government alliances and a national advocacy movement and maintaining relationships with all stakeholders, from government and community partners to donors. My experience sharing our learning and evidence with policy makers and directly delivering high quality health care to women and newborns in our program districts uniquely positions me to achieve OHW’s goal of significantly reducing maternal and newborn mortality in my country. Several of my initiatives have been acknowledged locally and internationally. The Government of Nepal (GoN) officially recognized us as one of the leading MNH organizations in the country and I have overseen the development of our partnership from the federal to municipal level. I have a deep understanding of the geopolitical complexity and cultural knowledge of the area we are serving as I myself come from that society. It is much easier to solve problems when you have a deep understanding of your own communities.

In 2015, several violent earthquakes struck Nepal. Two of our program districts (Sindhupalchok and Dhading) were among the most affected regions, with most of their healthcare infrastructure destroyed. This was a terrifying moment for Nepal. But I am proud to say that under my leadership, OHW was one of the first international organizations to respond to this crisis. When the GoN and other large humanitarian organizations failed to deliver the much needed basic reproductive health services in the aftermath of the earthquakes, we were able to step in and ensure that vulnerable communities had access to these essential services. We deployed fully equipped birthing tents with solar systems to ensure that pregnant women would still have access to a safe and clean environment to give birth. We continued our immediate relief efforts with reproductive health medical camps and radio messaging to ensure every woman who needed essential maternal and neonatal health services would be aware of the birthing tents. The work we accomplished in these two earthquake affected regions was a turning point for our organization. The GoN officially recognized us as one of the leading MNH organizations in the country and started to actively pursue our partnership.

In 2015 the Government of Nepal established federalism and promulgated a new constitution. This change introduced a new three-tiered government (municipality/local, provincial and federal) and changed our program implementation point of contact from the district level to the municipality level. For reference, there are now about 10 times more municipalities than there were districts, so we now have to develop and maintain partnerships with many more partners. However, under my leadership, OHW was able to turn this challenge into an unique opportunity by initiating a program cost-sharing component with the local municipalities. Under the new constitution, the local municipalities have planning and budgetary oversight over healthcare delivery. I started a technical assistance program where we train the new elected municipal authorities in healthcare planning and budgeting. Following this training, I have led the meetings with every local municipality to approach the issue of cost-sharing and, as a result, we have seen the cost-sharing component of our program increase significantly. Local municipalities now contribute 50% of facilities renovation costs. This community based initiative has been a game-changer for our organization and for the local communities who now feel even more integrated into our program.

We do not simply upgrade health facilities, or train medical professionals. We build a “Network of Safety” around mothers and newborns by establishing a holistic self-sustaining continuum of care in direct partnership with local government and community stakeholders. Working in partnership with rural communities, we ensure that mothers and newborns have access to appropriate care during pregnancy and delivery. At the frontlines of care where facilities are often run-down and where rural health providers often lack support and struggle with burnout, our programs inject renewed motivation. Our multi-faceted approach is uniquely designed to strengthen existing MNH systems by co-opting local support and developing solutions informed by the cultural practices and beliefs of those we serve. Few developmental efforts and government policies addressing MNH gaps in the past two decades have applied such an anthropological lens to the intricate relationship between health outcomes and the complex needs of a mother, her family, and her supporting structures. Rarely achieved by others, we also have a proven path to adoption by the government where in each district, our government partners first actively co-invest in our program, then fully fund and take over our program activities post program completion (after 6 years implementation). The result evident on the ground is remarkable; using skills transferred from their OHW partnership, municipality leaders, healthcare workers and community stakeholders demonstrate effective communication and proactive response to local MNH challenges, while maintaining fidelity to the Network of Safety model.

Our programs increase access to care for pregnant women and newborn infants in remote rural areas of Nepal. Our activities encompass three levels and are implemented in direct partnership with local government and stakeholders. At the community level, we train community outreach providers and local stakeholders and we implement social mobilization programs to enhance MNH access. At the health facility level, we upgrade the existing infrastructure, provide essential medical equipment and supplies, train healthcare providers and ensure subsequent quality of care provided. At the government level, we provide technical assistance in MNH planning and budgeting to the local municipalities and we advocate for MNH policy change with provincial and federal governments. At the community level, our immediate program outcomes are increased MNH awareness and increased demand for MNH services. At the facility level, we see enhanced capacity of MNH providers and improved quality of MNH services. At the government level, we see the integration of new evidence-based MNH interventions into service delivery and national programs. Our expected intermediate program impact (after 3 years of program implementation) is a 30% increase in MNH service access (as measured by delivery with a skilled birth attendant and institutional deliveries). Our expected long-term program impact (after 6 years of program implementation is a 50% reduction of both maternal and neonatal mortality. The full scope of our impact has been measured in our two completed pilot districts, Baglung and Dolpa, where the transformed MNH system serves 18,200 mothers and newborns yearly. Both districts now possess the necessary infrastructure to provide quality MNH services, and these programs are led exclusively by local governments. Rural communities, where child marriages were previously a regular occurrence, now advocate for delaying pregnancies. In 2019, an external survey led by the local research agency MITRA SAMAJ demonstrated that implementing the Network of Safety increased MNH service delivery by 265% in Baglung and 1400% in Dolpa. In both districts, maternal deaths were reduced by 89% and newborn deaths by 87%. These results prove our sustained impact on both MNH service delivery and mortality, far exceeding our original goals.

At the end of 2019, the OHW programs had reached a cumulative total of 410,000 mothers and newborn infants served. In 2020, we plan to serve 140,000 additional mothers and infants, bringing our cumulative total at the end of 2020 to 550,000 mothers and infants. In five years our goal is to serve 500,000 mothers and newborn yearly, bringing our total cumulative number of mothers and newborn served to 2.6M at the end of 2025.

Over the next five years, we plan to expand our reach to the 15 additional districts that we need to reach to complete our mandate to bring the Network of Safety to 36 underserved rural districts of Nepal. To this effect, we will continue our close partnership with the GoN and continue to strengthen the existing governmental MNH healthcare infrastructure. We are also planning to increase our focus on improving not only access to but also the quality of care offered at the health facilities level. We aim to have all of our upgraded health facilities maintain over 80% of their services quality standards and service providers core skills. We will continue our partnership municipalities and seek 50% of co-funding in all program activities beyond facility renovations (such as training and procurement of medical equipment and supplies). We will ensure that the impact of our program is maintained in completed districts by ensuring proper ownership from the local municipality government and communities. We will continue to integrate innovative global MNH research/best practices to improve our model and advocate MNH policy change at the central and provincial government to improve MNH service delivery and practice. Last but nor least, we aim to bring our learnings to support global prioritization for MNH care and amplify our impact in Nepal by using our results to take our model to scale in a new geographic location.

Funding: Several factors contribute to our challenges in raising consistent funding, largely around the time required before full impact is seen as well as the way our model does not fit most traditional funding structures. The very flexibility that enables our model to adapt to a wide range of needs and environments results in an unconventional approach that does not fit neatly within many donors. Those funding partners who do think outside the box however, often have difficulty with the length of time that mortality requires before long-term systemic change will occur.   

Potential delays in program implementation due to COVID: in the current context of the COVID19 pandemic, several of our activities are related to training that requires mass travel and gathering can pose challenges while maintaining appropriate social distancing. Our plan is to reduce the number of participants per session from the usual 20 to 10, which will increase the cost of training.

Funding: We have learned that our most successful partnerships are thought partnerships, which go beyond a grantor/grantee relationship and can help us maximize potential growth opportunities. We are fortunate to have several of those partnerships and are working with them closely to identify additional partners who are aligned with our core philosophy of collaborative systemic change. Additionally, we have engaged Dartmouth College to conduct an external evaluation of our impact and further demonstrate to funding agencies and individuals the efficacy of our approach, thus reassuring potential partners.     

Potential delays in program implementation due to COVID: Our plan is to reduce the number of participants if in-person training is required, though this may increase the cost of training. We are also exploring ways to shift applicable programs to be delivered virtually in areas where the telco/internet infrastructure is sufficiently developed.

OHW is committed to sustainable systemic change which is why our primary program partner will always be the Government. We integrate the GoN in each and every step of our program, from the design to the evaluation and financing. Our formal agreements with the central-level Nepali government (with the Ministry of Health and Population, and the Social Welfare Council) commit us to providing the initial investment costs for training, equipment, and supplies to improve the capacity of existing governmental maternal and neonatal health services in remote areas of Nepal. The responsibility to co-fund the renovation of birthing centers, support health providers, and provide essential life-saving equipment, and supplies rests with the municipality level government.Our municipal level partners sit at the center of our intervention, which focuses on developing their capacity to deliver an appropriate MNH system of care for their communities. Our Federal level partners are critical to our programs as they determine all nation-level healthcare priorities, allocate funding, and build the infrastructure for MNH service delivery. We align all programs in accordance with Nepal's national healthcare agenda. In addition, we also collaborate with other local and international groups when possible to avoid duplication of effort, but most apply a vertical model in operations and lack the comprehensive nature of our approach. Currently we are partnering with GIZ Nepal, Karuna Foundation, Dartmouth College, CARE Nepal, Rotary International and We Care Solar in different capacities, scope and locations.

OHW aims to transform MNH across 36 rural districts of Nepal, impacting 30% of all pregnancies in the country. Our goals are to increase access to MNH services by at least 30% and reduce maternal/newborn mortality by at least 50%. Over six years in each district, OHW strengthens existing public MNH infrastructure at the municipality level, ensuring high-quality MNH service delivery. We improve the skills and expertise of health workers at every level of the local system, upgrade public health facilities into functioning birthing centers that meet required quality standards, and train outreach workers to drive demand for MNH services. We support community-based groups helping mothers accessing appropriate information, and actively engage them as part of our continuum of care. Our model leverages time-bound philanthropic support with a proven exit-strategy: the government and local communities co-invest in, then fully maintain delivery of our intervention once outcomes goals are achieved post program completion, ensuring long-term impact sustainability. Preparing for this handover is central to our model: OHW actively engages local government members and community stakeholders  throughout the process to ensure alignment with local priorities, and we drive local and national policy changes that prioritize MNH needs to unlock long-term budget allocations.

Because OHW does not intend to support any program indefinitely, partnership with local government is a foundational component of how we operate, making our primary partnership always with the government itself. As OHW implements our model, the Network of Safety, the Nepali government continues to provide funding to the health facilities for staffing and supplies. Once OHW has completed its initial investment which is often too expensive for the government, the Nepali government provides follow-up with the trainees, equipment monitoring, and re-stocking of supplies. Our program model is specifically designed so that a one-time investment in capacity building results in a long-term systemic improvement in maternal and newborn care. Local buy-in, particularly to this extent is a nearly unheard-of achievement and a strong indicator that our program is not only desired by the communities but they consider it worth investing in. Post-program completion, each municipal government takes full ownership of OHW programs and associated costs. Preparing for this handover is central to our model: OHW works closely with local government members and community stakeholders throughout the process to ensure alignment with local priorities, and we drive local and national policy changes that prioritize MNH needs to unlock long-term budget allocations. By aligning with local priorities and building relevant knowledge within municipalities, we encourage communities to co-fund the program and ultimately prepare them for post-implementation ownership.

Our model leverages time-bound philanthropic support with local cost-shares, which requires us to raise funds to invest in the implementation of our intervention. The government is the largest funder of our intervention; first co-investing in, then fully maintaining delivery of our intervention once outcome goals are achieved post-program completion, ensuring long-term impact sustainability. Within the new healthcare system of Nepal, municipalities have full planning and budgeting authority for their communities. As of 2019, 100% of our municipality partners financially co-invested direct program costs with contributions up to 50%. Our philanthropic funding sources are predominantly social impact foundations. with several partners such as the Mulago Foundation and Jasmine Social Investments who have supported us from the beginning. Our top 5 funders for 2019 were: 

• Jasmine Social Investments (Grant): $300,000

• Mulago Foundation (Grant): $300,000

• Anonymous Foundation (Grant): $300,000

• Schooner Family Foundation (Grant): $265,000 over 3 years

• Planet Wheeler Foundation (Grant): $200,000

For some projects, we receive a combination of grant funding and in-kind funding. For example, Dartmouth College co-funded $55,000 towards OHW’s External Evaluation. The remaining balance was covered by the Vitol Foundation who provided a grant of $50,000, and $30,000 from several anonymous donors.

As of 2020, 75% of OHW’s revenue is secured through funding renewals and 85% of our revenue is unrestricted. OHW will need to raise approximately $24 million over the next 5 years to complete implementation of the Network of Safety in both our 19 existing districts and the remaining 15 districts identified by the Nepali Government in our contract. According to that timeline, we would launch our program in 3 new districts each year, while between 3 and 6 districts will complete the program each year and transition to full local program ownership. This translates to an annual budget of between $3.7 and $4.5 million, variant upon each district’s progress through the program as costs tend to be higher on the front-end and lower once transition occurs. Between 2021 and 2022, 5% of our budget has been secured. Our training programs are the backbone of our capacity building efforts. Grant funding would enable our team to ensure quality human resources for our program and to implement our program activities. Human resources to complete these activities are a key cost driver. Another key cost driver is Birthing Center upgrades. We expect to see the BC upgrades costs shift as more municipalities increase their cost-sharing, but it is currently difficult to anticipate the extent to which this will occur.

In 2020, OHW set a budget of $3.7m.