World Journal of Surgery

, Volume 43, Issue 1, pp 52–59 | Cite as

Challenges of Costing a Surgical Procedure in a Lower–Middle-Income Country

  • Chanil EkanayakeEmail author
  • Arunasalam Pathmeswaran
  • Sanjeewa Kularatna
  • Rasika Herath
  • Prasantha Wijesinghe
Original Scientific Report



It is vital to enquire into cost of health care to ensure that maximum value for money is obtained with available resources; however, there is a dearth of information on cost of health care in lower–middle-income countries (LMICs). Our aim was to develop a reproducible costing method for three routes of hysterectomy in benign uterine conditions: total abdominal (TAH), non-descent vaginal (NDVH) and total laparoscopic hysterectomy (TLH).


A societal perspective with a micro-costing approach was applied to find out direct and indirect costs. A total of 147 patients were recruited from a district general hospital (Mannar) and a tertiary care hospital (Ragama). Costs incurred from preoperative period to convalescence included direct costs of labour, equipment, investigations, medications and utilities, and indirect costs of out-of-pocket expenses, productivity losses, carer costs and travelling. Time-driven activity-based costing was used for labour, and top-down micro-costing was used for utilities.


The total cost [(interquartile range), number] of TAH was USD 339 [(308–397), n = 24] versus USD 338 [(312–422), n = 25], NDVH was USD 315 [(316–541), n = 23] versus USD 357 [(282–739), n = 26] and TLH was USD 393 [(338–446), n = 24] versus USD 429 [(390–504), n = 25] at Mannar and Ragama, respectively. The direct cost of TAH, NDVH and TLH was similar between the two centres, whilst indirect cost was related to the setting rather than the route of hysterectomy.


The costing method used in this study overcomes logistical difficulties in a LMIC and can serve as a guide for clinicians and policy makers in similar settings.

Trial registration

The study was registered in the Sri Lanka clinical trials registry (SLCTR/2016/020) and the International Clinical Trials Registry Platform (U1111-1194-8422) on 26 July 2016.



We are grateful to the Regional Director of Health Services-Mannar; Director, District General Hospital-Mannar; Director, North Colombo Teaching Hospital, Ragama. We acknowledge the contribution of the study participants and the staff of the two respective units. A special note of appreciation goes to the research assistants, Dr. Rienzie Pieris and Dr. Lakshika Liyanage.


This work was supported by the National Research Council Grant 16-086 from National Research Council of Sri Lanka.

Compliance with ethical standards

Conflict of interest


Ethics approval and consent to participate

Ethics approval was obtained from the ethics review committee of the Faculty of Medicine, University of Kelaniya (P/12/01/2016). All participants provided informed written consent to participate.

Supplementary material

268_2018_4773_MOESM1_ESM.docx (16 kb)
Supplementary material 1 (DOCX 15 kb)
268_2018_4773_MOESM2_ESM.docx (29 kb)
Supplementary material 2 (DOCX 29 kb)
268_2018_4773_MOESM3_ESM.docx (27 kb)
Supplementary material 3 (DOCX 27 kb)


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Copyright information

© Société Internationale de Chirurgie 2018

Authors and Affiliations

  • Chanil Ekanayake
    • 1
    Email author
  • Arunasalam Pathmeswaran
    • 2
  • Sanjeewa Kularatna
    • 3
  • Rasika Herath
    • 4
  • Prasantha Wijesinghe
    • 4
  1. 1.District General HospitalMannarSri Lanka
  2. 2.Department of Public Health, Faculty of MedicineUniversity of KelaniyaKelaniyaSri Lanka
  3. 3.Australian Centre for Health Services Innovation, School of Public Health and Social ServicesQueensland University of TechnologyBrisbaneAustralia
  4. 4.Department of Obstetrics and Gynaecology, Faculty of MedicineUniversity of KelaniyaKelaniyaSri Lanka

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