Health Facility Cost of Cesarean Delivery at a Rural District Hospital in Rwanda Using Time-Driven Activity-Based Costing
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.
KeywordsObstetrics Cost of surgery Africa TDABC Out of pocket pay Hospital stay
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.
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.
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