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Costing Delivery of Environmental Health Services in Healthcare Facilities

Water Institute has been leading Health Care Facilities research including a project that assessed the costs of environmental health services (EHS) (e.g., water, sanitation, hygiene waste management, cleaning, laundry) in healthcare facilities (HCFs) and developed practical tools to assist facility managers with budgeting and costing. There were four primary deliverables: (1) a systematic review on costs of EHS in HCFs, (2) a model to describe key steps to budget for EHS delivery in HCFs, (3) field data collection on costs of EHS delivery in a network of seven HCFs in Lilongwe, Malawi, and (4) a data collection toolkit to support costing EHS in HCFs.

Systematic review on costs of EHS in HCFs

We conducted the first systematic review to evaluate the costs of establishing, operating, and maintaining EHS in HCFs in low- and middle-income countries (LMICs). We systematically searched for studies costing water, sanitation, hygiene, cleaning, waste management, personal protective equipment, vector control, laundry, and lighting in LMICs. Our search yielded 36 studies that reported costs for 51 EHS. There were 3 studies that reported costs for water, 3 for sanitation, 4 for hygiene, 13 for waste management, 16 for cleaning, 2 for personal protective equipment, 10 for laundry, and none for lighting or vector control. Quality of evidence was low. Reported costs were rarely representative of the total costs of EHS provision. Unit costs were infrequently reported. This review identifies opportunities to improve costing research through efforts to categorize and disaggregate EHS costs, greater dissemination of existing unpublished data, improvements to indicators to monitor EHS demand and quality necessary to contextualize costs, and development of frameworks to define EHS needs and essential inputs to guide future costing.

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Model to support budgeting for EHS in HCFs

Based on 47 studies selected through a systematic review (deliverable 1 above), we identified discrete budgeting steps, developed codes to define each step, and ordered steps into a model. We identified good practices based on a review of additional selected guidelines for costing EHS and HCFs. Our model comprises ten steps in three phases: planning, data collection, and synthesis. Costing-stakeholders define the costing purpose, relevant EHS, and cost scope; assess the EHS delivery context; develop a costing plan; and identify data sources (planning). Stakeholders then execute their costing plan and evaluate the data quality (data collection). Finally, stakeholders calculate costs and disseminate findings (synthesis). We present three hypothetical costing examples and discuss good practices, including using costing frameworks, selecting appropriate indicators to measure the quantity and quality of EHS, and iterating planning and data collection to select appropriate costing approaches and identify data gaps.

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Field data collection on costs of EHS in HCFs

We estimated the cost of providing the following EHS: water, sanitation, hygiene, personal protective equipment use at the point of care, waste management, cleaning, laundry, and vector control. We developed frameworks of essential outputs and inputs for each EHS through review of international guidelines and standards, which we used to identify expenses required for EHS delivery and evaluate the completeness of costs data in our case study. For costing, we use a mixed-methods approach, applying qualitative interviews to understand facility context and review of electronic records to determine costs. We calculated initial costs to establish services and annual operations and maintenance. Available records contained little information on the upfront, capital costs associated with establishing EHS. Annual operations and maintenance totaled USD 220,427 for all EHS across all facilities (USD 5.21 per patient encounter), although costs of many essential inputs were missing from records. Annual operations and maintenance costs were highest for cleaning (USD 69,372) and waste management (USD 46,752).

Missing expenses suggests that documented costs are substantial underestimates. Costs to establish services were missing predominantly because purchases pre-dated electronic records. Annual operations and maintenance costs are incomplete primarily because administrative records did not record sufficient detail to disaggregate and attribute expenses. Electronic health information systems have potential to support efficient data collection. However, we found that existing records systems were decentralized and poorly suited to identify EHS costs. Our research suggests a need to better code and disaggregate EHS expenses to properly leverage records for costing. Frameworks developed in this study are a potential tool to develop more accurate estimates of the cost of providing EHS in HCFs.

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Data collection toolkit

We developed a toolkit to guide the following steps of costing EHS in HCFs: defining costing goals, developing and executing a data collection plan, calculating costs, and disseminating findings, based on our budgeting model (deliverable 2 above). The costing toolkit is divided into eight step-by-step modules with instructions, fillable worksheets, and guidance for effective data collection. It is designed for use by diverse stakeholders involved in funding, implementation, and management of EHS in HCFs and can be used by stakeholders with no prior costing experience. We also developed guidance for good practices for costing, including pilot testing data collection tools and iterating the data collection process, involving diverse stakeholders, considering long-term costs, and disaggregating environmental costs in records to facilitate future costing.

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Current activities:

Water Institute is developing a research strategy for WaSH in healthcare facilities. This research strategy is designed to highlight gaps in the current evidence base to prioritize investment and inform effective, sustainable service delivery. To inform this research agenda, the Water Institute has engaged stakeholders in research, policy, and practice through meetings and workshops at the UNC Water and Health conference to identify unanswered questions and priority research areas.

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