Development and application of tools to cost the delivery of environmental health services in healthcare facilities: a financial analysis in urban Malawi.

BACKGROUND: Environmental health services (EHS) in healthcare facilities (HCFs) are critical for providing a safe, functional healthcare environment, but little is known about their costs. Poor understanding of costs impedes progress towards universal access of EHS in HCFs. We developed frameworks of essential expenses required to provide EHS and conducted an ex-post financial analysis of EHS in a network of medical research and training facilities in Lilongwe, Malawi, serving an estimated 42,000 patients annually through seven outpatient buildings. METHODS: 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 EHS and annual operations and maintenance. RESULTS: 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). DISCUSSION: 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 were incomplete primarily because administrative records did not record sufficient detail to disaggregate and attribute expenses. CONCLUSIONS: 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.

Occurrence of Lead and Other Toxic Metals Derived from Drinking-Water Systems in Three West African Countries.

BACKGROUND: Exposure to toxic metals (TMs) such as lead can cause lifelong neurodevelopmental impairment and other adverse outcomes. TMs enter drinking water from human activity, geogenic contamination, and corrosion of water system components. Several studies report TM contamination in piped systems and private wells in high-income countries (HICs). However, few robust studies report on TM contamination in low- and middle-income countries (LMICs). OBJECTIVES: We characterized the occurrence and investigated sources of TM contamination in 261 rural water systems in three West African LMICs to inform prevention and management. METHODS: Water samples were collected from 261 community water systems (handpumps and public taps) across rural Ghana, Mali, and Niger. Scrapings were collected from accessible components of a subset of these systems using a drill with acid-washed diamond-tipped bits. Samples were analyzed by inductively coupled plasma (ICP) mass spectrometry or ICP optical emission spectroscopy. RESULTS: Of the TMs studied, lead most frequently occurred at levels of concern in sampled water system components and water samples. Lead mass fractions exceeded International Plumbing Code (IPC) recommended limits (0.25% wt/wt) for components in 82% (107/130) of systems tested; brass components proved most problematic, with 72% (26/36) exceeding IPC limits. Presence of a brass component in a water system increased expected lead concentrations in drinking-water samples by 3.8 times. Overall, lead exceeded World Health Organization (WHO) guideline values in 9% (24/261) of drinking-water samples across countries; these results are broadly comparable to results observed in many HICs. Results did not vary significantly by geography or system type. DISCUSSION: Ensuring use of lead-free (<0.25%) components in new water systems and progressively remediating existing systems could reduce drinking-water lead exposures and improve health outcomes for millions. However, reflexive decommissioning of existing systems may deprive users of sufficient water for health or drive them to riskier sources. Because supply chains for many water system components are global, TM monitoring, prevention, and management may be warranted in other LMICs beyond the study area as well. https://doi.org/10.1289/EHP7804.

Sources of and Solutions to Toxic Metal and Metalloid Contamination in Small Rural Drinking Water Systems: A Rapid Review.

Exposure to toxic metals and metalloids (TMs) such as arsenic and lead at levels of concern is associated with lifelong adverse health consequences. As exposure to TMs from paint, leaded gasoline, canned foods, and other consumer products has decreased in recent decades, the relative contribution of drinking water to environmental TM exposure and associated disease burdens has increased. We conducted a rapid review from June to September 2019 to synthesize information on the sources of TM contamination in small rural drinking water systems and solutions to TM contamination from these sources, with an emphasis on actionable evidence applicable to small rural drinking water systems worldwide. We reviewed publications from five databases (ProQuest, PubMed, Web of Science, Embase, and Global Health Library) as well as grey literature from expert groups including WHO, IWA, and others; findings from 61 eligible review publications were synthesized. Identified sources of TMs in included studies were natural occurrence (geogenic), catchment pollution, and corrosion of water distribution system materials. The review found general support for preventive over corrective actions. This review informs a useful planning and management framework for preventing and mitigating TM exposure from drinking water based on water supply characteristics, identified contamination sources, and other context-specific variables.

Budgeting for Environmental Health Services in Healthcare Facilities: A Ten-Step Model for Planning and Costing.

Environmental health services (EHS) in healthcare facilities (HCFs) are critical for safe care provision, yet their availability in low- and middle-income countries is low. A poor understanding of costs hinders progress towards adequate provision. Methods are inconsistent and poorly documented in costing literature, suggesting opportunities to improve evidence. The goal of this research was to develop a model to guide budgeting for EHS in HCFs. Based on 47 studies selected through a systematic review, 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.

Geographical inequalities in drinking water in the Solomon Islands.

Sustainable Development Goal 6.1 seeks to "by 2030, achieve universal and equitable access to safe and affordable drinking water", which is challenging particularly in Small Island Developing States (SIDS) and Pacific Island Countries (PIC). We report drinking water sources and services in the Solomon Islands and examine geographical inequalities. Based on two quantitative baseline datasets of n = 1,598 rural and n = 1,068 urban households, we analyzed different drinking water variables (source type, collection time, amount, use, perceived quality, storage, treatment) and a composite index, drinking water service level. We stratified data by urban and rural areas and by province, mapped, and contextualized them. There are substantive rural-urban drinking water inequalities in the Solomon Islands. Overall, urban households are more likely to: use improved drinking water sources, need less time to collect water, collect more water, store their water more safely, treat water prior to consumption, perceive their water quality as better and have an at least basic drinking water service than rural households. There are also provincial and center-periphery inequalities in drinking water access, with more centrally located provinces using piped water supplies and more distant and remote provinces using rainwater and surface water as their primary source. There are also inter-national inequalities. Out of all PICs, the Solomon Islands have among the lowest access to basic drinking water services: 92% of urban and 55% of rural households. Of all SIDS, PICs are least serviced. This study shows that drinking water inequality is a critical issue, and highlights that all identified dimensions of inequality - rural-urban, provincial, center-periphery and inter-national - need to be explicitly recognized and addressed and included in pro-equity monitoring, policy and programming efforts by the Solomon Islands Government and stakeholders to reduce inequalities as per the Agenda 2030.