Budgeting and advocacy to improve water, sanitation, and hygiene in healthcare facilities: a case study in Nepal

Barriers to achieving and sustaining access to water, sanitation, hygiene, waste management (collectively, "WASH") in healthcare facilities include a supportive policy environment and adequate funding. While guidelines exist for assessing needs and making initial infrastructure improvements, there is little guidance on how to develop budgets and policies to sustain WASH services in the long-term. We conducted costing and advocacy activities in Thakurbaba municipality, Nepal, with the aim of developing a budget and operations and maintenance policy for WASH in healthcare facilities in partnership with the municipal government. Our objectives for this study are to (1) describe the process and methods used for costing and advocacy, (2) report the costs to achieve and maintain basic WASH services in the eight healthcare facilities of Thakurbaba municipality, and (3) report the outcomes of advocacy activities and policy development. We applied bottom-up costing to enumerate the resources necessary to achieve and maintain basic WASH services and their costs. The annual costs of WASH services ranged from USD 4,881 to 9,527 (including operations and maintenance and annualized capital investments). Cost findings were used to prepare annual budgets recommended to achieve and maintain basic access, which were presented to municipal government and incorporated into an operations and maintenance policy. To-date, the municipality has adopted the policy and established a recovery fund of USD 3,831 for repair and maintenance of infrastructure, and an additional USD 192 per facility for discretionary WASH spending. Advocacy at the national level for WASH in healthcare facilities is currently being championed by the municipality, and findings from this project are being used to inform development of a nationally costed plan for universal access. This study is intended to provide a roadmap for how cost data can be collected and applied to inform policy.