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

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.

FIGURE 1.

Preliminary Health Care Outcomes of Pilot CHW Program in Nepal, Compared to National and Global Targets^a Abbreviations: CHW, community health worker. ^a Data published previously and reproduced here in parallel to Sustainable Development Goal and Nepal Health Sector Strategy targets.

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.

Cost Per Capita of the CHW Pilot Program in Nepal, by Village, N=24 Abbreviations: CHW, community health worker.

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.

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.

Costs by Functional Type of Expenditure in a CHW Pilot Program in Nepal Abbreviations: CHW, community health worker.

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.