Budgeting and Advocacy to Improve Water, Sanitation, and Hygiene in Health Care Facilities: A Case Study in Nepal

Laxman Kharal Chettry; Prakash Bohara; Ramesh C. Bohara; Ramhari Rijal; Sarad Khadha; Hari Subedi; Debesh Giri; Sarbesh Sharma; Upendra Dhungana; Matteus van der Valen; John Brogan; Darcy M. Anderson

doi:10.9745/GHSP-D-23-00491

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TABLE 1.

Characteristics of Health Care Facilities Included in the Study Sample, Thakurbaba Municipality, Nepal

Facility Name	Services Offered	Deliveries/Month, No.	Outpatient Visits/Month, No.
Neulapur Health Post	Outpatient, maternity, laboratory	25	1,418
Bagnaha Health Post	Outpatient, maternity, laboratory	8	666
Shivapur Health Post	Outpatient, maternity, laboratory	16	667
Thakurdwara Health Post	Outpatient, maternity, laboratory	24	297
Ranipur Basic Health Center	Outpatient	0	193
Bankatti Basic Health Center	Outpatient	0	328
Mohanpur Basic Health Center	Outpatient	0	425
Thakurdwara Basic Health Center	Outpatient	0	210

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TABLE 2.

Categories of WASH Expenses Included in Costing Study

Cost Category	Definition	Example Included Expenses
Capital hardware	Infrastructure or equipment purchases required to establish WASH services or implement changes to service delivery method that are not consumed during normal service operation.	Sanitation facilities (superstructure with squat pan/seats, pit/septic tank) Water source and pipe network
Capital software	Planning, procurement, and/or initial training costs associated with establishing new WASH services or implementing changes to WASH service delivery method.	Initial infection prevention and operations and maintenance trainings delivered upon establishing infrastructure
Maintenance	Expenses required to repair and maintain functionality of capital hardware, including labor costs required for these purposes.	Breakdown repairs (e.g., clogged pipes) Cleaning of toilets, patient care areas Supplies for water system testing (e.g., arsenic, residual chlorine)
Recurrent software	Necessary trainings, behavior change, and other nontangible produced to be delivered each year for the upkeeping of the established and other introduced practices.	Annual infection prevention training Annual WASH FIT meetings
Personnel	Labor costs associated with normal operation of a service, including staff benefits; labor costs for maintenance (e.g., plumbers and repair technicians that are outsourced) are included under maintenance.	WASH focal person Support staff
Consumables	Products and supplies that are consumed during normal operation.	Handwashing soap Cleaning detergents Cleaning tools (e.g., mops, brooms)
Support	Expenses required to strengthen WASH provision but that do not have direct service outputs.	Communication Capacity-building

Abbreviations: WASH, water, sanitation, hygiene, cleaning, and waste management; WASH FIT, Water and Sanitation for Health Facility Improvement Tool.

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TABLE 3.
Upfront Capital Investments Required to Install WASH Services, Thakurbaba Municipality, Nepal
Health Post Basic Health Center
Neulapur Bagnaha Shivapur Thakurdwara Ranipur Bankatti Mohanpur Thakurdwara
US$
Capital hardware 43893 38330 38347 15954 24629 10123 21379 21448
Capital software 368 368 460 1149 368 368 368 1149
Abbreviation: WASH, water, sanitation, hygiene, cleaning, and waste management.

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TABLE 4.

Annualized Costs for Capital Investments and Operations and Maintenance of WASH in Health Care Facilities in Thakurbaba Municipality, Nepal

	Health Post				Basic Health Center				All
	Neulapur	Bagnaha	Shivapur	Thakurdwara	Ranipur	Bankatti	Mohanpur	Thakurdwara	All
Annual outpatient visits, no.	17,016	8,004	3,558	7,992	2,315	3,937	5,104	2,525	50,451
Current annual expenditure, US$
Capital hardware^a	4341	3607	3723	1564	503	733	984	1170	16625
Capital software^a	0	0	0	117	0	0	0	117	234
Capital maintenance	1728	1498	2696	2018	845	1368	1516	1596	13265
Recurrent training	0	0	0	0	0	0	0	0	0
Consumables	1476	920	1616	1158	1048	670	808	922	8618
Personnel	0	0	0	0	747	0	0	0	747
Support	0	0	0	0	0	0	0	0	0
Additional annual investment needed to reach basic service, US$
Capital hardware^a	102	102	84	113	2470	274	1089	972	5206
Capital software^a	37	37	47	0	37	37	37	0	232
Capital maintenance	184	184	156	153	153	184	153	153	1320
Recurrent training	755	648	252	578	578	578	578	578	4545
Consumables	315	193	547	529	457	447	441	838	3767
Personnel	274	274	403	274	274	274	274	473	2520
Support	316	316	170	363	316	316	316	162	2275
Summary costs, US$
Total annual capital costs^b	4480	3746	3854	1794	3010	1044	2110	2259	22297
Total annual O&M costs^c	5047	4033	5841	4593	4417	3837	4086	4722	36576
Total annual cost for basic service	9527	7779	9695	6387	7427	4881	6196	6981	58873
Average cost per outpatient visit	0.56	0.97	2.72	0.80	3.21	1.24	1.21	2.76	1.68

Abbreviations: O&M, operations and maintenance; WASH, water, sanitation, hygiene, cleaning, and waste management.
↵a Capital hardware and capital software costs are annualized from the total upfront investment cost, using an interest rate of 0.08.
↵b Total annual capital costs include capital hardware and capital software.
↵c Total annual operations and maintenance costs include capital maintenance, recurrent training, consumables, personnel, and support.

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TABLE 5.

Total Annual Costs for Disaggregated by WASH Service, Thakurbaba Municipality, Nepal

	Health Post				Basic Health Center
	Neulapur	Bagnaha	Shivapur	Thakurdwara	Ranipur	Bankatti	Mohanpur	Thakurdwara
	US$
Water	1017	619	1068	781	654	527	577	680
Sanitation	2589	1413	1660	1197	1040	752	1123	932
Hygiene	226	146	375	45	253	220	296	67
Waste management	483	348	387	277	1069	160	121	100
Cleaning	2681	1788	3541	2324	1457	1582	1667	2225
Other^a	2532	3466	2664	1763	2955	1640	2412	2537

Abbreviation: WASH, water, sanitation, hygiene, cleaning, and waste management.
↵a Includes fencing and costs that were shared across multiple categories (e.g., infection prevention training, operations and maintenance training common to all infrastructure).