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Global Health: Science and Practice

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ORIGINAL ARTICLE
Open Access

Costing Analysis of a Pilot Community Health Worker Program in Rural Nepal

Prajwol Nepal, Ryan Schwarz, David Citrin, Aradhana Thapa, Bibhav Acharya, Yubraj Acharya, Anu Aryal, Aaron Baum, Ved Bhandari, Laxman Bhatt, Dipak Bhattarai, Nandini Choudhury, Binod Dangal, Meghnath Dhimal, Santosh Kumar Dhungana, Bikash Gauchan, Scott Halliday, SP Kalaunee, Lal Bahadur Kunwar, Duncan Maru, Isha Nirola, Rashmi Paudel, Anant Raut, Hari Jung Rayamazi, Sabitri Sapkota, Dan Schwarz, Poshan Thapa, Pratistha Thapa, Aparna Tiwari, Roshani Tuitui, Eric Walter and Sheela Maru
Global Health: Science and Practice June 2020, 8(2):239-255; https://doi.org/10.9745/GHSP-D-19-00393
Prajwol Nepal
aPossible, New York, NY, USA.
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Ryan Schwarz
aPossible, New York, NY, USA.
bBrigham and Women’s Hospital, Department of Medicine, Division of Global Health Equity, Boston, MA, USA.
cHarvard Medical School, Department of Medicine, Boston, MA, USA.
dMassachusetts General Hospital, Department of Medicine, Division of General Internal Medicine, Boston, MA, USA.
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  • For correspondence: ryan@possiblehealth.org
David Citrin
aPossible, New York, NY, USA.
eUniversity of Washington, Department of Global Health, Seattle, WA, USA.
fUniversity of Washington, Department of Anthropology, Seattle, WA, USA.
gUniversity of Washington, Henry M. Jackson School of International Studies, Seattle, WA, USA.
hIcahn School of Medicine at Mount Sinai, Arnhold Institute for Global Health, New York, NY, USA.
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Aradhana Thapa
iNyaya Health Nepal, Kathmandu, Nepal.
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Bibhav Acharya
aPossible, New York, NY, USA.
jUniversity of California, San Francisco, Department of Psychiatry, San Francisco, CA, USA.
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Yubraj Acharya
kPennsylvania State University, College of Health and Human Development, Department of Health Policy and Administration, University Park, PA, USA.
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Anu Aryal
iNyaya Health Nepal, Kathmandu, Nepal.
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Aaron Baum
hIcahn School of Medicine at Mount Sinai, Arnhold Institute for Global Health, New York, NY, USA.
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Ved Bhandari
iNyaya Health Nepal, Kathmandu, Nepal.
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Laxman Bhatt
iNyaya Health Nepal, Kathmandu, Nepal.
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Dipak Bhattarai
iNyaya Health Nepal, Kathmandu, Nepal.
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Nandini Choudhury
aPossible, New York, NY, USA.
hIcahn School of Medicine at Mount Sinai, Arnhold Institute for Global Health, New York, NY, USA.
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Binod Dangal
iNyaya Health Nepal, Kathmandu, Nepal.
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Meghnath Dhimal
lNepal Health Research Council, Kathmandu, Nepal.
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Santosh Kumar Dhungana
iNyaya Health Nepal, Kathmandu, Nepal.
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Bikash Gauchan
iNyaya Health Nepal, Kathmandu, Nepal.
mUniversity of California, San Francisco, Health Equity Action Leadership Initiative, San Francisco, CA, USA.
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Scott Halliday
aPossible, New York, NY, USA.
eUniversity of Washington, Department of Global Health, Seattle, WA, USA.
fUniversity of Washington, Department of Anthropology, Seattle, WA, USA.
gUniversity of Washington, Henry M. Jackson School of International Studies, Seattle, WA, USA.
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SP Kalaunee
iNyaya Health Nepal, Kathmandu, Nepal.
nEastern University, College of Leadership and Development, St. Davids, PA, USA.
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Lal Bahadur Kunwar
iNyaya Health Nepal, Kathmandu, Nepal.
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Duncan Maru
aPossible, New York, NY, USA.
hIcahn School of Medicine at Mount Sinai, Arnhold Institute for Global Health, New York, NY, USA.
oIcahn School of Medicine at Mount Sinai, Department of Health Systems Design and Global Health, New York, NY, USA.
pIcahn School of Medicine at Mount Sinai, Department of Internal Medicine, New York, NY, USA.
qIcahn School of Medicine at Mount Sinai, Department of Pediatrics, New York, NY, USA.
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Isha Nirola
aPossible, New York, NY, USA.
rHarvard T.H. Chan School of Public Health, Boston, MA, USA.
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Rashmi Paudel
iNyaya Health Nepal, Kathmandu, Nepal.
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Anant Raut
aPossible, New York, NY, USA.
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Hari Jung Rayamazi
iNyaya Health Nepal, Kathmandu, Nepal.
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Sabitri Sapkota
iNyaya Health Nepal, Kathmandu, Nepal.
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Dan Schwarz
aPossible, New York, NY, USA.
bBrigham and Women’s Hospital, Department of Medicine, Division of Global Health Equity, Boston, MA, USA.
cHarvard Medical School, Department of Medicine, Boston, MA, USA.
sBeth Israel Deaconess Medical Center, Department of Medicine, Boston, MA, USA.
tAriadne Labs, Harvard T.H. Chan School of Public Health and Brigham and Women’s Hospital, Boston, MA, USA.
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Poshan Thapa
uUniversity of New South Wales, School of Public Health and Community Medicine, Sydney, NSW, Australia.
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Pratistha Thapa
iNyaya Health Nepal, Kathmandu, Nepal.
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Aparna Tiwari
iNyaya Health Nepal, Kathmandu, Nepal.
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Roshani Tuitui
vNursing and Social Security Division, Dept of Health Services, Kathmandu, Nepal.
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Eric Walter
wUniversity of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA.
xUniversity of Pennsylvania, The Wharton School, Healthcare Management Department, Philadelphia, PA, USA.
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Sheela Maru
aPossible, New York, NY, USA.
hIcahn School of Medicine at Mount Sinai, Arnhold Institute for Global Health, New York, NY, USA.
oIcahn School of Medicine at Mount Sinai, Department of Health Systems Design and Global Health, New York, NY, USA.
yIcahn School of Medicine at Mount Sinai, Department of Obstetrics, Gynecology and Reproductive Science, New York, NY, USA.
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Key Findings

  • The average per capita annual cost of a pilot community health worker (CHW) program in rural Nepal is US$3.05.

  • Personnel costs, the largest cost driver, contribute 74% of the total implementation costs and are affected by the number of households covered, population distribution, geographical terrain, and supervision structure.

Key Implications

  • Policy makers should consider further expansion and improvement of community health systems to make progress toward achieving universal health coverage and the health-related Sustainable Development Goals.

  • Policy makers may benefit from considering alternative implementation scenarios that explore 3 challenges with CHWs: payment amount, supervision structure, and integration of new cadres into local primary health care systems.

ABSTRACT

Community health workers (CHWs) are essential to primary health care systems and are a cost-effective strategy to achieve the Sustainable Development Goals (SDGs). Nepal is strongly committed to universal health coverage and the SDGs. In 2017, the Nepal Ministry of Health and Population partnered with the nongovernmental organization Nyaya Health Nepal to pilot a program aligned with the 2018 World Health Organization guidelines for CHWs. The program includes CHWs who: (1) receive regular financial compensation; (2) meet a minimum education level; (3) are well supervised; (4) are continuously trained; (5) are integrated into local primary health care systems; (6) use mobile health tools; (7) have consistent supply chain; (8) live in the communities they serve; and (9) provide service without point-of-care user fees. The pilot model has previously demonstrated improved institutional birth rate, antenatal care completion, and postpartum contraception utilization. Here, we performed a retrospective costing analysis from July 16, 2017 to July 15, 2018, in a catchment area population of 60,000. The average per capita annual cost is US$3.05 (range: US$1.94 to US$4.70 across 24 villages) of which 74% is personnel cost. Service delivery and administrative costs and per beneficiary costs for all services are also described. To address the current discourse among Nepali policy makers at the local and federal levels, we also present 3 alternative implementation scenarios that policy makers may consider. Given the Government of Nepal’s commitment to increase health care spending (US$51.00 per capita) to 7.0% of the 2030 gross domestic product, paired with recent health care systems decentralization leading to expanded fiscal space in municipalities, this CHW program provides a feasible opportunity to make progress toward achieving universal health coverage and the health-related SDGs. This costing analysis offers insights and practical considerations for policy makers and locally elected officials for deploying a CHW cadre as a mechanism to achieve the SDG targets.

  • Received: November 10, 2019.
  • Accepted: May 19, 2020.
  • Published: June 30, 2020.
  • © Nepal et al.

This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International License (CC BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. To view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/. When linking to this article, please use the following permanent link: https://doi.org/10.9745/GHSP-D-19-00393

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Global Health: Science and Practice: 8 (2)
Global Health: Science and Practice
Vol. 8, No. 2
June 30, 2020
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Costing Analysis of a Pilot Community Health Worker Program in Rural Nepal
Prajwol Nepal, Ryan Schwarz, David Citrin, Aradhana Thapa, Bibhav Acharya, Yubraj Acharya, Anu Aryal, Aaron Baum, Ved Bhandari, Laxman Bhatt, Dipak Bhattarai, Nandini Choudhury, Binod Dangal, Meghnath Dhimal, Santosh Kumar Dhungana, Bikash Gauchan, Scott Halliday, SP Kalaunee, Lal Bahadur Kunwar, Duncan Maru, Isha Nirola, Rashmi Paudel, Anant Raut, Hari Jung Rayamazi, Sabitri Sapkota, Dan Schwarz, Poshan Thapa, Pratistha Thapa, Aparna Tiwari, Roshani Tuitui, Eric Walter, Sheela Maru
Global Health: Science and Practice Jun 2020, 8 (2) 239-255; DOI: 10.9745/GHSP-D-19-00393

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Costing Analysis of a Pilot Community Health Worker Program in Rural Nepal
Prajwol Nepal, Ryan Schwarz, David Citrin, Aradhana Thapa, Bibhav Acharya, Yubraj Acharya, Anu Aryal, Aaron Baum, Ved Bhandari, Laxman Bhatt, Dipak Bhattarai, Nandini Choudhury, Binod Dangal, Meghnath Dhimal, Santosh Kumar Dhungana, Bikash Gauchan, Scott Halliday, SP Kalaunee, Lal Bahadur Kunwar, Duncan Maru, Isha Nirola, Rashmi Paudel, Anant Raut, Hari Jung Rayamazi, Sabitri Sapkota, Dan Schwarz, Poshan Thapa, Pratistha Thapa, Aparna Tiwari, Roshani Tuitui, Eric Walter, Sheela Maru
Global Health: Science and Practice Jun 2020, 8 (2) 239-255; DOI: 10.9745/GHSP-D-19-00393
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