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.
Highlights
As the global community works to collectively realize our commitment to universal health coverage (UHC) and the Sustainable Development Goals (SDGs), robust community health care systems will be a critical foundation.[1]
Strong evidence suggests the cost-effectiveness of Community health worker (CHW) programs, with economic returns of up to 10:1.3 The World Health Organization (WHO) has recently endorsed them as a key mechanism to achieve UHC and SDG 3—ensure healthy lives and promote well-being for all at all ages—in the first global guidelines for CHW program design and implementation,[4] offering important guidance to policy makers and locally elected officials looking to improve progress toward SDG targets
The WHO guidelines,[4] and other recent recommendations[2,20] for design of effective CHW programs, offer helpful framing in these regards, highlighting that CHWs should: (1) receive regular financial compensation; (2) meet a minimum education level; (3) be well supervised; (4) be continuously trained; (5) be closely integrated into the local primary health care system; (6) use a mobile health tool; (7) have consistent supply chain; and (8) live in the communities they serve
Summary
As the global community works to collectively realize our commitment to universal health coverage (UHC) and the Sustainable Development Goals (SDGs), robust community health care systems will be a critical foundation.[1]. Nepal has made important gains in health outcomes, including a two-thirds decline in maternal mortality and halving rates of stunting between 1990 and 2015.5 Despite this, similar to many countries, Nepal is not presently on track to meet its SDG targets by 2030,6,7 with maternal mortality at 239 per 100,000 live births, under-5 mortality at per 1000 live births, and 38% of disability associated with noncommunicable diseases (NCDs) occurring before age years. Nepal has been a leader in community health care systems. The country has a long history of various CHW models, including both fulltime and part-time and paid and voluntary cadres, covering a range of programmatic outreach and service delivery foci
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