When one has no or limited funds… one needs ideas! Here are a few points that should be tackled, step by step to help you build up a safe, efficient and sustainable HCWM system.

Gather and analyse field information

Before any strategies are defined or budgets elaborated, it is indispensable to first get an as good as possible understanding of the current field situation: what are the main problems; what solutions/ systems already exist; what do (para)medical staff suggest to remediate identified deficiencies on a pragmatic, cost efficient and step by step basis.

The WHO Rapid Assessment Tool can be used to help avoid forgetting important questions/ issues during this initial phase.

Gathering available costing information both at HCF, administrative, transport and equipment supplier levels will be useful for subsequent calculations (see Excel spreadsheet for details).

For initial estimations, ideally try to gather data about total amounts of HCW produced. Annexes 5 and 6 of the WHO guidance manual for the preparation of national HCWM plans in sub-Saharan countries can be used to this effect.

Data on the number of HCFs, (para)medical staff and beds will also be necessary for subsequent budgeting estimations/ calculations.

Budgeting steps

Depending on the information available/ gathered, you can either start by carrying out an estimation of the total budget that will be necessary to maintain in the long run a comprehensive HCWM system at national level or proceed to a simplified system costing (see next page).

One important step that should be taken consists in the creation of a specific HCWM budget line at all levels of the accountancy from MoH to HCF. This move has the following advantages:

• It obliges everybody from the MoH to the HCF levels to think about, plan and budget HCWM actions. This participates in the awareness raising efforts;
• Having a certain amount of money allocated specifically to HCWM avoids there not being any funds left for this critical issue as often happens when there is no dedicated budget line;
• Potential HCWM donors will provide funds all the more willingly if they know that there are means of tracking how the funds will be spent.

Sources of funds

In most contexts, public funds are insufficient to pay for the initial capital investments. The two standard options are either to rely on:

1. Private funding;
2. Support from NGOs/ International Organisations either in the form of a loan or donation.

Private funding has the following advantages:

• No capital investments for the State and HCFs;
• Reduced recurrent costs linked to the expected greater efficiency of the private sector and scale effects;
• Expected reduced pollution (better performing equipment and necessity to comply with environmental regulations to be able to operate);
• Easier to monitor and sanction in case of legal non-conformity.

The main disadvantages are:

• The need to carry out regular inspections by well qualified staff to ensure compliance with the legislation. It is important to note that depending on the status of the regulatory framework regarding HCWM, this could be a source of problems (lack of legal instruments to control the system);
• Vulnerability in terms of dependency on a unique service provider if no alternatives/ competitors exist…

Financial support from NGOs or International Organisations will typically be most often limited to the country assessment phase, with support for some initial capital investments and training costs.

The HCWM strategy that will be elaborated following the assessment must take into account the resources (both human and financial) that can realistically expected to be made available not only in the short but also the medium/ long term. Acquiring sophisticated equipment that one then can't maintain isn't of much use…

Defining a realistic recurrent cost plan that shows you will be able to keep the system running in the long term isn't only necessary for sustainability reasons but is a convincing way of obtaining support from external donors for the initial capital investments.

The following page provides some basic costing estimation and calculation methods.