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Health Facility Cost of Cesarean Delivery at a Rural District Hospital in Rwanda Using Time-Driven Activity-Based Costing

  • Jackline OdhiamboEmail author
  • John Ruhumuriza
  • Theoneste Nkurunziza
  • Robert Riviello
  • Mark Shrime
  • Yihan Lin
  • Christian Rusangwa
  • Jack M. Omondi
  • Gabriel Toma
  • Alexandre Nyirimodoka
  • Tharcisse Mpunga
  • Bethany L. Hedt-Gauthier
Article

Abstract

Objective To determine the health facility cost of cesarean section at a rural district hospital in Rwanda. Methods Using time-driven activity-based costing, this study calculated capacity cost rates (cost per minute) for personnel, infrastructure and hospital indirect costs, and estimated the costs of medical consumables and medicines based on purchase prices, all for the pre-, intra- and post-operative periods. We estimated copay (10% of total cost) for women with community-based health insurance and conducted sensitivity analysis to estimate total cost range. Results The total cost of a cesarean delivery was US$339 including US$118 (35%) for intra-operative costs and US$221 (65%) for pre- and post-operative costs. Costs per category included US$46 (14%) for personnel, US$37 (11%) for infrastructure, US$109 (32%) for medicines, US$122 (36%) for medical consumables, and US$25 (7%) for hospital indirect costs. The estimated copay for women with community-based health insurance was US$34 and the total cost ranged from US$320 to US$380. Duration of hospital stay was the main marginal cost variable increasing overall cost by US$27 (8%). Conclusions for Practice The cost of cesarean delivery and the cost drivers (medicines and medical consumables) in our setting were similar to previous estimates in sub-Saharan Africa but higher than earlier average estimate in Rwanda. The estimated copay is potentially catastrophic for poor rural women. Investigation on the impact of true out of pocket costs on women’s health outcomes, and strategies for reducing duration of hospital stay while maintaining high quality care are recommended.

Keywords

Obstetrics Cost of surgery Africa TDABC Out of pocket pay Hospital stay 

Notes

Acknowledgements

We acknowledge Partners In Health/Inshuti Mu Buzima for the support of this work. We also acknowledge the contributions of Micaela Browning and Ryan McBain in costing methodology, Grace Umugiraneza, Bahati Ramadhan, Alice Bayingana and Naomi Nyirahabimana in data collection and Edison Nihiwacu in data cleaning. All data collection and training costs were covered by the Harvard Global Health Initiative Burke Global Health Fellowship grant.

Author Contributions

JO and JR led study design and protocol development. JO, JR and YL led data collection. JO led analysis and manuscript development. BHG supervised the research process. BHG, TN, RR and YL contributed to study design. BHG, TN, RR, MS, YL, JMO, TM, GT, AL and CR supported protocol development. All authors critically reviewed the first drafts of the manuscript, supported results interpretations and approved the final manuscript for publication.

Compliance with Ethical Standards

Conflict of interest

Authors declare that they have no conflict of interest.

Supplementary material

10995_2018_2674_MOESM1_ESM.docx (20 kb)
Supplementary material 1 (DOCX 19 KB)

References

  1. Alkire, B. C., Vincent, J. R., Burns, C. T., Metzler, I. S., Farmer, P. E., & Meara, J. G. (2012). Obstructed labor and caesarean delivery: The cost and benefit of surgical intervention. PLoS ONE, 7(4), e34595.  https://doi.org/10.1371/journal.pone.0034595.CrossRefPubMedPubMedCentralGoogle Scholar
  2. Ang, J., Chris, H., Caris, B., Lane, R. H. S., Cotton, M. H., Henry, J. A., … Cotton, M. H. (2015). Essential surgery: The way forward. World Journal of Surgery, 39(4), 822–832.  https://doi.org/10.1007/s00268-014-2937-9.CrossRefGoogle Scholar
  3. Arsenault, C., Fournier, P., Philibert, A., Sissoko, K., Coulibaly, A., & Tourigny, C. (2013). Emergency obstetric care in Mali: Catastrophic spending and its impoverishing effects on households. Bulletin of the World Health Organization, 91, 207–216.  https://doi.org/10.2471/BLT.12.108969.CrossRefPubMedPubMedCentralGoogle Scholar
  4. Berhan, Y., & Berhan, A. (2014). Causes of maternal mortality in Ethiopia: A significant decline in abortion related death. Ethiopian Journal of Health Sciences, 24, 15–28.CrossRefGoogle Scholar
  5. Boukhalfa, C., Abouchadi, S., Cunden, N., & Witter, S. (2016). The free delivery and caesarean policy in Morocco: How much do households still pay? Tropical Medicine & International Health, 21(2), 245–252.  https://doi.org/10.1111/tmi.12638.CrossRefGoogle Scholar
  6. Collins, D., Mukunzi, J., Jarrah, Z., Ndizaye, C., Kayobotsi, P., Mukantwali, C., … Cros, M. (2011). Rwanda health service costing: Hospital analysis. Management sciences for health, (October), 1–60. Retrieved from https://www.msh.org/sites/msh.org/files/rwanda_health_service_costing_-_hospital_analysis.pdf.
  7. Debas, H. T., Donkor, P., Gawande, A., Jamison, D. T., Kruk, M. E., & Mock, C. N. (2015). Essential surgery: Disease control priorities. (3rd edn, Vol. 1), Washington, DC: World Bank Group.CrossRefGoogle Scholar
  8. Deboutte, D., Dempsey, T. O., Mann, G., & Faragher, B. (2013). Cost-effectiveness of caesarean sections in a post-conflict environment: A case study of Bunia, Democratic Republic of the Congo. Disasters, 37(S1), S105–S120.CrossRefGoogle Scholar
  9. Decoster, C., & Kozyrskyj, A. (2000). Long-stay patients in Winnipeg acute care hospitals. Winnipeg: University of Manitoba.Google Scholar
  10. Dexter, F., & Lubarsky, D. A. (2004). Using length of stay data from a hospital to evaluate whether limiting elective surgery at the hospital is an inappropriate decision. Journal of Clinical Anesthesia, 16, 421–425.  https://doi.org/10.1016/j.jclinane.2003.11.003.CrossRefPubMedGoogle Scholar
  11. Galukande, M., von Schreeb, J., Wladis, A., Mbembati, N., de Miranda, H., Kruk, M. E., … Macfarlane, S. B. (2010). Essential surgery at the district hospital: A retrospective descriptive analysis in three African countries. PLoS Medicine, 7(3), e1000243.  https://doi.org/10.1371/journal.pmed.1000243.CrossRefPubMedPubMedCentralGoogle Scholar
  12. Harrison, M. S., & Goldenberg, R. L. (2016). Cesarean section in sub-Saharan Africa. BMC Maternal Health, Neonatology and Perinatology, 2(6), 1–10.  https://doi.org/10.1186/s40748-016-0033-x.CrossRefGoogle Scholar
  13. Joharifard, S., Rulisa, S., Niyonkuru, F., Weinhold, A., Sayinzoga, F., Wilkinson, J., … Thielman, N. M. (2012). Prevalence and predictors of giving birth in health facilities in Bugesera District, Rwanda. BMC Public Health, 12, 1049.  https://doi.org/10.1186/1471-2458-12-1049.CrossRefPubMedPubMedCentralGoogle Scholar
  14. Johnson, A., Gaughwin, B., Moore, N., & Crane, R. (2005). Long-stay views from the hospital bed: Patient perspectives of organisation of care and impact of hospitalisation. Australian Health Review, 29(2), 235–240.CrossRefGoogle Scholar
  15. Khan, K. S., Wojdyla, D., Say, L., Gülmezoglu, A. M., Van Look, P. F. A., Van Look, P. F. A., & Van Look, P. F. A. (2006). WHO analysis of causes of maternal death: A systematic review. The Lancet, 367(9516), 1066–1074.  https://doi.org/10.1016/S0140-6736(06)68397-9.CrossRefGoogle Scholar
  16. Khan, N. A., Quan, H., Bugar, J. M., Lemaire, J. B., Brant, R., & Ghali, W. A. (2006). Association of postoperative complications with hospital costs and length of stay in a tertiary care center. Journal of General Internal Medicine, 21, 177–180.  https://doi.org/10.1111/j.1525-1497.2006.00319.x.CrossRefPubMedPubMedCentralGoogle Scholar
  17. Kitui, J., Lewis, S., & Davey, G. (2013). Factors influencing place of delivery for women in Kenya: An analysis of the Kenya demographic and health survey, 2008/2009. BMC Pregnancy and Childbirth, 13, 40.  https://doi.org/10.1186/1471-2393-13-40.CrossRefPubMedPubMedCentralGoogle Scholar
  18. Löfgren, J., Mulowooza, J., Nordin, P., Wladis, A., & Forsberg, B. C. (2015). Cost of surgery in a low-income setting in eastern Uganda. Surgery, 157(6), 983–991.  https://doi.org/10.1016/j.surg.2015.01.026.CrossRefPubMedGoogle Scholar
  19. Mamun, A. A., Callaway, L. K., Callaghan, M. J. O., Williams, G. M., Najman, J. M., Alati, R., … Lawlor, D. A. (2011). Associations of maternal pre-pregnancy obesity and excess pregnancy weight gains with adverse pregnancy outcomes and length of hospital stay. BMC Pregnancy & Childbirth, 11(62), 1–9.Google Scholar
  20. McBain, R. K., Jerome, G., Warsh, J., Browning, M., Mistry, B., Faure, P. A. I., … Kaplan, R. (2016). Rethinking the cost of healthcare in low-resource settings: The value of time-driven activity-based costing. BMJ Global Health, 1(3), e000134.  https://doi.org/10.1136/bmjgh-2016-000134.CrossRefPubMedPubMedCentralGoogle Scholar
  21. Meara, J. G., Leather, A. J. M., Hagander, L., Alkire, B. C., Alonso, N., Ameh, E. A., … Yamey, G. (2016). Global Surgery 2030: Evidence and solutions for achieving health, welfare, and economic development. International Journal of Obstetric Anesthesia, 25, 75–78.  https://doi.org/10.1016/j.ijoa.2015.09.006.CrossRefPubMedGoogle Scholar
  22. Mock, C. N., Donkor, P., Gawande, A., Jamison, D. T., Kruk, M. E., & Debas, H. T. (2015). Essential surgery: Key messages from disease control priorities. The Lancet, 385(9983), 2209–2219.  https://doi.org/10.1016/S0140-6736(15)60091-5.CrossRefGoogle Scholar
  23. Muchemi, O. M., Gichogo, A. W., Mungai, J. G., & Roka, Z. G. (2016). Trends in health facility based maternal mortality in Central Region, Kenya: 2008–2012. Pan African Medical Journal, 23(259), 2–10.  https://doi.org/10.11604/pamj.2016.23.259.8262.CrossRefGoogle Scholar
  24. National Institute for Health and Care Excellence. (2011). Caesarean section: Clinical guideline. Retrieved from https://www.nice.org.uk/guidance/cg132/chapter/1-Guidance#procedural-aspects-of-cs.
  25. National Institute of Statistics of Rwanda, Ministry of Finance and Economic Planing, Ministry of Health, I. I. (2015). Rwanda demographic and health survey 2014-15: Final report.Google Scholar
  26. Nkurunziza, T., Toma, G., Odhiambo, J., Maine, R., Riviello, R., Gupta, N., … Hedt-Gauthier, B. L. (2016). Referral patterns and predictors of referral delays for patients with traumatic injuries in rural Rwanda. Surgery, 160(6), 1636–1644.  https://doi.org/10.1016/j.surg.2016.08.006.CrossRefPubMedGoogle Scholar
  27. Nyirahabimana, N., Ufashingabire, C. M., Lin, Y., Hedt-gauthier, B., Riviello, R., Odhiambo, J., … Nkurunziza, T. (2017). Maternal predictors of neonatal outcomes after emergency cesarean section: A retrospective study in three rural district hospitals in Rwanda. BMC Maternal Health, Neonatology and Perinatology.  https://doi.org/10.1186/s40748-017-0050-4.CrossRefGoogle Scholar
  28. Ogola, G. O., & Shafi, S. (2016). Cost of specific emergency general surgery diseases and factors associated with high-cost patients. The Journal of Trauma and Acute Care Surgery, 80(2), 265–271.  https://doi.org/10.1097/TA.0000000000000911.CrossRefPubMedGoogle Scholar
  29. Pearson, L., & Shoo, R. (2005). Availability and use of emergency obstetric services: Kenya, Rwanda, Southern Sudan, and Uganda. International Journal of Gynecology and Obstetrics, 88, 208–215.  https://doi.org/10.1016/j.ijgo.2004.09.027.CrossRefPubMedGoogle Scholar
  30. Petroze, R. T., Nzayisenga, A., Rusanganwa, V., Ntakiyiruta, G., & Calland, J. F. (2012). Comprehensive national analysis of emergency and essential surgical capacity in Rwanda. British Journal of Surgery, 99, 436–443.  https://doi.org/10.1002/bjs.7816.CrossRefPubMedGoogle Scholar
  31. Ravit, M., Philibert, A., Tourigny, C., Dumont, A., & Fournier, P. (2015). The Hidden costs of a free Caesarean Section Policy in West Africa (Kayes Region, Mali). Maternal and Child Health Journal, 19(8), 1734–1743.  https://doi.org/10.1007/s10995-015-1687-0.CrossRefPubMedPubMedCentralGoogle Scholar
  32. Republic of Rwanda, & Rwanda, N. I. of S. of. (2015). Fourth Population and housing census, Rwanda, 2012: Burera District Profile. Retrieved from http://statistics.gov.rw/sites/default/files/publications/3aeabafc-19fe-4cb1-b2a7-b1b5ecdd56f0/Burera_District_Profilel.pdf.
  33. Ruhumuriza, J., Odhiambo, J., Riviello, R., Lin, Y., Nkurunziza, T., Shrime, M., ... Hedt-Gauthier, B. (2018). Assessing the cost of laparotomy at a rural district hospital in Rwanda using time-driven activity-based costing. BJS Open, 2(1), 25–33.  https://doi.org/10.1002/bjs5.35.
  34. Schecter, W. P., & Adhikar, S. (2015). Global surgery and poverty. In H. T. Debas, P. Donkor, A. Gawande, D. T. Jamison, M. E. Kruk & C. N. Mock (Eds.), Essential surgery: Disease control priorities (3rd edn, pp. 353–360). Washington, DC: World Bank.CrossRefGoogle Scholar
  35. Smith, G. R., Ma, M., Hansen, L. O., Christensen, N., & O’Leary, K. J. (2016). Association of hospital admission service structure with early transfer to critical care, hospital readmission, and length of Stay. Journal of Hospital Medicine, 11(10), 669–674.  https://doi.org/10.1002/jhm.2592.CrossRefPubMedGoogle Scholar
  36. Thomas, S., Meadows, J., Mcqueen, K. A. K., Thomas, S., & Meadows, J. (2016). Access to Cesarean Section will reduce maternal mortality in low-income countries: A mathematical model. World Journal of Surgery, 40(7), 1537–1541.  https://doi.org/10.1007/s00268-016-3479-0.CrossRefPubMedGoogle Scholar
  37. Vonlanthen, R., Slankamenac, K., Breitenstein, S., Puhan, M. A., Muller, M. K., Hahnloser, D., … Clavien, P. (2011). The impact of complications on costs of major surgical procedures. Annals of Surgery, 254(6), 907–913.  https://doi.org/10.1097/SLA.0b013e31821d4a43.CrossRefPubMedGoogle Scholar
  38. Wardlaw, T., You, D., Hug, L., Amouzou, A., & Newby, H. (2014). UNICEF Report: Enormous progress in child survival but greater focus on newborns urgently needed. Reproductive Health, 11(82), 1–4.  https://doi.org/10.1186/1742-4755-11-82.CrossRefGoogle Scholar
  39. Weiser, T. G., Uribe-leitz, T., Fu, R., Jaramillo, J., Maurer, L., Esquivel, M. M., … Haynes, A. B. (2015). Variability in mortality after caesarean delivery, appendectomy, and groin hernia repair in low-income and middle-income countries: Implications for expanding. The Lancet, 385, S34.  https://doi.org/10.1016/S0140-6736(15)60829-7.CrossRefGoogle Scholar
  40. Witter, S., Dieng, T., Mbengue, D., Moreira, I., & De Brouwere, V. (2010). The national free delivery and caesarean policy in Senegal: Evaluating process and outcomes. Health Policy and Planning, 25(5), 384–392.  https://doi.org/10.1093/heapol/czq013.CrossRefPubMedGoogle Scholar
  41. World Bank Group, World Health Organization, UNICEF, UNFPA, & United Nations Population Division. (2015). Trends in maternal mortality: 1990 to 2015.Google Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  • Jackline Odhiambo
    • 1
    Email author
  • John Ruhumuriza
    • 2
  • Theoneste Nkurunziza
    • 2
  • Robert Riviello
    • 3
    • 4
    • 5
  • Mark Shrime
    • 4
    • 6
  • Yihan Lin
    • 4
  • Christian Rusangwa
    • 2
  • Jack M. Omondi
    • 2
    • 7
  • Gabriel Toma
    • 2
    • 4
  • Alexandre Nyirimodoka
    • 3
  • Tharcisse Mpunga
    • 7
  • Bethany L. Hedt-Gauthier
    • 2
    • 4
  1. 1.Partners In HealthBostonUSA
  2. 2.Partners In Health/Inshuti Mu BuzimaKigaliRwanda
  3. 3.College of Medicine and Health SciencesUniversity of RwandaKigaliRwanda
  4. 4.Department of Global Health and Social MedicineHarvard Medical SchoolBostonUSA
  5. 5.Center for Surgery and Public HealthBrigham and Women’s HospitalBostonUSA
  6. 6.Center for Global Surgery EvaluationMassachusetts Eye and Ear InfirmaryBostonUSA
  7. 7.Ministry of HealthKigaliRwanda

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