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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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Figures

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  • FIGURE 1.
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    FIGURE 1.

    Preliminary Health Care Outcomes of Pilot CHW Program in Nepal, Compared to National and Global Targetsa

    Abbreviations: CHW, community health worker.

    a Data published previously22 and reproduced here in parallel to Sustainable Development Goal and Nepal Health Sector Strategy targets.

  • FIGURE 2.
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    FIGURE 2.

    Program Design of Nepal Ministry of Health and Population, Family Welfare Division and Nyaya Health Nepal CHW Pilot Program

    Abbreviations: CHPA, community health program associate; CHN, community health nurse; CHW, community health worker.

  • FIGURE 3.
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    FIGURE 3.

    Cost Per Capita of the CHW Pilot Program in Nepal, by Village, N=24

    Abbreviations: CHW, community health worker.

  • FIGURE 4.
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    FIGURE 4.

    Distribution of Intermediate Cost Centers, Including Service Delivery and Administrative Functions, of Pilot CHW Program in Nepal, by Municipality

    Abbreviations: CHW, community health worker.

  • FIGURE 5.
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    FIGURE 5.

    Costs Per Capita and Per Beneficiary by Service Delivery of CHW Pilot Program in Nepal

    Abbreviations: CHW, community health worker; NCD, noncommunicable diseases.

  • FIGURE 6.
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    FIGURE 6.

    Costs by Functional Type of Expenditure in a CHW Pilot Program in Nepal

    Abbreviations: CHW, community health worker.

  • FIGURE 7.
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    FIGURE 7.

    Potential Advantages and Disadvantages and Additional Per Capita Cost of 3 Alternative CHW Program Implementation Scenarios, US$

    Abbreviations: CHW, community health worker, PHC, primary health care.

Tables

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    TABLE 1.

    Pilot CHW Program Design in Relation to WHO Guidelines

    WHO Recommended CHWProgram Attributes4CHW Pilot Program Descriptive CharacteristicsProgram Alignment WithWHO Recommendations
    Selection

    CHWs:

    • Have minimum education requirement of 10th level

    • Locally selected women who live in the community they serve

    ✓
    Training
    • Includes both preservice and continuous training

    • Training combines theory and practice based in community

    ✓
    Certification
    • Formal program certification is currently in process, pending government approval

    –
    Supportive supervision

    Supervisors conduct:

    • Regular in-person supervision including observation in community

    • Dedicated supervision, data-driven feedback, and performance review

    ✓
    Incentives
    • CHWs are salaried, full-time employees, at a rate competitive to local market conditions, paired with additional non-financial incentives

    ✓
    Career ladder
    • Pending further government certification/approval

    –
    CHW: population ratio
    • Ratio is based upon epidemiology, geography, topography, security, andworkload/expected responsibilities

    ✓
    Data collection/utilization
    • CHWs collect data via mHealth platform, use in monitoring and review with supervisors, use in service delivery improvements

    ✓
    Community integration
    • CHWs mobilize resources and promote health and social needs

    ✓
    Supply chain
    • CHWs have reliable and consistent supply of medicines and supplies closely linked to local primary health centers

    ✓
    • Abbreviations: CHW, community health worker; WHO, World Health Organization.

    • View popup
    TABLE 2.

    Description and Summary Statistics from Catchment Area of CHW Pilot Program, Including Sanfebagar and Kamalbazaar Municipalities

    SanfebagarKamalbazaarTotal
    Total population36,76623,73860,504
    Direct service beneficiaries10,8168,22219,038
    CHW: population ratio1:1,9351:2,1581:2,017
    Community health nurses: CHW ratio1:4.81:5.51:5
    Total costs (USD$)118,32766,177184,504
    Number of CHWs191130
    Number of CHNs426
    Number of CHPAs213
    Cost per capita (USD$)3.222.793.05
    • Abbreviations: CHN, community health nurse; CHPA, community health program associates; CHW, community health worker.

Additional Files

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      Supplement 3

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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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