Economic Costs of Providing District- and Regional-Level Surgeries in Tanzania

Document Type : Original Article

Authors

1 Department for Health Evidence, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands

2 East, Central and Southern Africa Health Community, Arusha, Tanzania

3 Department of Surgery, Kilimanjaro Christian Medical Centre, Moshi, Tanzania

4 Institute of Global Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland

5 Department of Epidemiology and Public Health Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland

Abstract

Background
Access to surgical care is poor in Tanzania. The country is at the implementation stage of its first National Surgical, Obstetric, and Anesthesia Plan (NSOAP; 2018-2025) aiming to scale up surgery. This study aimed to calculate the costs of providing surgical care at the district and regional hospitals.

 
Methods
Two district hospitals (DHs) and the regional referral hospital (RH) in Arusha region were selected. All the staff, buildings, equipment, and medical and non-medical supplies deployed in running the hospitals over a 12 month period were identified and quantified from interviews and hospital records. Using a combination of step-down costing (SDC) and activity-based costing (ABC), all costs attributed to surgeries were established and then distributed over the individual types of surgeries. These costs were delineated into pre-operative, intra-operative, and post-operative components.
 

Results
The total annual costs of running the clinical cost centres ranged from $567k at Oltrumet DH to $3453k at Mt Meru RH. The total costs of surgeries ranged from $79k to $813k; amounting to 12%-22% of the total costs of running the hospitals. At least 70% of the costs were salaries. Unit costs and relative shares of capital costs were generally higher at the DHs. Two-thirds of all the procedures incurred at least 60% of their costs in the theatre. Open reduction and internal fixation (ORIF) performed at the regional hospital was cheaper ($618) than surgical debridement (plus conservative treatment) due to prolonged post-operative inpatient care associated with the latter ($1177), but was performed infrequently due mostly to unavailability of implants.
 

Conclusion
Lower unit costs and shares of capital costs at the RH reflect an advantage of economies of scale and scope at the RH, and a possible underutilization of capacity at the DHs. Greater efficiencies make a case for concentration and scale-up of surgical services at the RHs, but there is a stronger case for scaling up district-level surgeries, not only for equitable access to services, but also to drive down unit costs there, and free up RH resources for more complex cases such as ORIF.

Keywords


  1. Alkire BC, Raykar NP, Shrime MG, et al. Global access to surgical care: a modelling study. Lancet Glob Health. 2015;3(6):e316-323. doi:10.1016/s2214-109x(15)70115-4
  2. Meara JG, Greenberg SL. Global surgery 2030: evidence and solutions for achieving health, welfare and economic development. Surgery. 2015;157(5):834-835. doi:10.1016/j.surg.2015.02.009
  3. Debas HT, Gosselin R, McCord C, Thind A. Surgery. In: Jamison DT, Breman JG, Measham AR, et al, eds. Disease Control Priorities in Developing Countries. Washington, DC: The World Bank Group; 2006.
  4. Bickler SN, Weiser TG, Kassebaum N, et al. Global burden of surgical conditions. In: Debas HT, Donkor P, Gawande A, Jamison DT, Kruk ME, Mock CN, eds. Essential Surgery: Disease Control Priorities. Washington, DC: The International Bank for Reconstruction and Development, The World Bank; 2015:19-40.
  5. Verguet S, Alkire BC, Bickler SW, et al. Timing and cost of scaling up surgical services in low-income and middle-income countries from 2012 to 2030: a modelling study. Lancet Glob Health. 2015;3 Suppl 2:S28-37. doi:10.1016/s2214-109x(15)70086-0
  6. Jumbam DT, Reddy CL, Roa L, Meara JG. How much does it cost to scale up surgical systems in low-income and middle-income countries? BMJ Glob Health. 2019;4(4):e001779. doi:10.1136/bmjgh-2019-001779
  7. Cornelissen D, Mwapasa G, Gajewski J, et al. The cost of providing district-level surgery in Malawi. World J Surg. 2018;42(1):46-53. doi:10.1007/s00268-017-4166-5
  8. Odhiambo J, Ruhumuriza J, Nkurunziza T, et al. Health facility cost of cesarean delivery at a rural district hospital in Rwanda using time-driven activity-based costing. Matern Child Health J. 2019;23(5):613-622. doi:10.1007/s10995-018-2674-z
  9. Ruhumuriza J, Odhiambo J, Riviello R, et al. Assessing the cost of laparotomy at a rural district hospital in Rwanda using time-driven activity-based costing. BJS Open. 2018;2(1):25-33. doi:10.1002/bjs5.35
  10. Falase B, Sanusi M, Majekodunmi A, Ajose I, Idowu A, Oke D. The cost of open heart surgery in Nigeria. Pan Afr Med J. 2013;14:61. doi:10.11604/pamj.2013.14.61.2162
  11. Warf BC, Alkire BC, Bhai S, et al. Costs and benefits of neurosurgical intervention for infant hydrocephalus in sub-Saharan Africa. J Neurosurg Pediatr. 2011;8(5):509-521. doi:10.3171/2011.8.peds11163
  12. Gallaher JR, Mjuweni S, Cairns BA, Charles AG. Burn care delivery in a sub-Saharan African unit: a cost analysis study. Int J Surg. 2015;19:116-120. doi:10.1016/j.ijsu.2015.05.015
  13. Löfgren J, Mulowooza J, Nordin P, Wladis A, Forsberg BC. Cost of surgery in a low-income setting in eastern Uganda. Surgery. 2015;157(6):983-991. doi:10.1016/j.surg.2015.01.026
  14. Kramer EJ, Shearer DW, Marseille E, et al. The cost of intramedullary nailing for femoral shaft fractures in Dar es Salaam, Tanzania. World J Surg. 2016;40(9):2098-2108. doi:10.1007/s00268-016-3496-z
  15. National Surgical, Obstetrics and Anaesthesia Plan (NSOAP) 2018-2025. Dodoma: Ministry of Health, Community Development, Gender, Elderly and Children (MOHCDGEC) of Tanzania; 2018.
  16. Gajewski J, Pittalis C, Lavy C, et al. Anesthesia capacity of district-level hospitals in Malawi, Tanzania, and Zambia: a mixed-methods study. Anesth Analg. 2020;130(4):845-853. doi:10.1213/ane.0000000000004363
  17. Pittalis C, Brugha R, Crispino G, et al. Evaluation of a surgical supervision model in three African countries-protocol for a prospective mixed-methods controlled pilot trial. Pilot Feasibility Stud. 2019;5:25. doi:10.1186/s40814-019-0409-6
  18. WHO. CostIt (Costing interventions templates) software. Geneva: World Health Organization https://www.who.int/choice/toolkit/cost_it/en/.
  19. Weiser TG, Regenbogen SE, Thompson KD, et al. An estimation of the global volume of surgery: a modelling strategy based on available data. Lancet. 2008;372(9633):139-144. doi:10.1016/s0140-6736(08)60878-8
  20. Shepard DS, Hodgkin D, Anthony YE. Analysis of Hospital Costs: A Manual for Managers. World Health Organization; 2000.
  21. MapDevelopers. Area Calculator.  https://www.mapdevelopers.com/.  Accessed November 12, 2018.
  22. Mogyorosy Z, Smith P. The Main Methodological Issues in Costing Health Care Services: A Literature Review. York: University of York, Centre for Health Economics; 2005.
  23. Kruk ME, Wladis A, Mbembati N, et al. Human resource and funding constraints for essential surgery in district hospitals in Africa: a retrospective cross-sectional survey. PLoS Med. 2010;7(3):e1000242. doi:10.1371/journal.pmed.1000242
  24. English M, Lanata CF, Ngugi I, Smith PC. District hospitals. In: Jamison DT, Breman JG, Measham AR, et al, eds. Disease Control Priorities in Developing Countries. Washington, DC: The World Bank Group; 2006.
  25. Lönnroth K. Medical expenditures: not the only source of financial hardship. Lancet Glob Health. 2020;8(3):e336. doi:10.1016/s2214-109x(20)30023-1
  26. Bijlmakers L, Wientjes M, Mwapasa G, et al. Out-of-pocket payments and catastrophic household expenditure to access essential surgery in Malawi-a cross-sectional patient survey. Ann Med Surg (Lond). 2019;43:85-90. doi:10.1016/j.amsu.2019.06.003
  27. Teni FS, Gebresillassie BM, Birru EM, et al. Costs incurred by outpatients at a university hospital in northwestern Ethiopia: a cross-sectional study. BMC Health Serv Res. 2018;18(1):842. doi:10.1186/s12913-018-3628-2
  28. Hensher M, Price M, Adomakoh S. Referral hospitals. In: Jamison DT, Breman JG, Measham AR, et al, eds. Disease Control Priorities in Developing Countries. Washington, DC: The World Bank Group; 2006.
  29. Kapologwe NA, Meara JG, Kengia JT, et al. Development and upgrading of public primary healthcare facilities with essential surgical services infrastructure: a strategy towards achieving universal health coverage in Tanzania. BMC Health Serv Res. 2020;20(1):218. doi:10.1186/s12913-020-5057-2
  30. Simba DO, Mbembati NA, Museru LM, Lema LE. Referral pattern of patients received at the national referral hospital: challenges in low income countries. East Afr J Public Health. 2008;5(1):6-9. doi:10.4314/eajph.v5i1.38969
  31. Bhorat H, Kanbur R, Stanwix B. Minimum wages in sub-Saharan Africa: a primer. World Bank Res Obs. 2017;32(1):21-74. doi:10.1093/wbro/lkw007
  32. Gajewski J, Dharamshi R, Strader M, et al. Who accesses surgery at district level in sub-Saharan Africa? evidence from Malawi and Zambia. Trop Med Int Health. 2017;22(12):1533-1541. doi:10.1111/tmi.12989
  33. Kouanda S, Coulibaly A, Ouedraogo A, Millogo T, Meda BI, Dumont A. Audit of cesarean delivery in Burkina Faso. Int J Gynaecol Obstet. 2014;125(3):214-218. doi:10.1016/j.ijgo.2013.11.010
  34. van Heemskerken P, Broekhuizen H, Gajewski J, Brugha R, Bijlmakers L. Barriers to surgery performed by non-physician clinicians in sub-Saharan Africa-a scoping review. Hum Resour Health. 2020;18(1):51. doi:10.1186/s12960-020-00490-y
  35. McCord C, Mbaruku G, Pereira C, Nzabuhakwa C, Bergstrom S. The quality of emergency obstetrical surgery by assistant medical officers in Tanzanian district hospitals. Health Aff (Millwood). 2009;28(5):w876-885. doi:10.1377/hlthaff.28.5.w876
  36. Beard JH, Oresanya LB, Akoko L, Mwanga A, Mkony CA, Dicker RA. Surgical task-shifting in a low-resource setting: outcomes after major surgery performed by nonphysician clinicians in Tanzania. World J Surg. 2014;38(6):1398-1404. doi:10.1007/s00268-013-2446-2
  37. Gajewski J, Conroy R, Bijlmakers L, et al. Quality of surgery in Malawi: comparison of patient-reported outcomes after hernia surgery between district and central hospitals. World J Surg. 2018;42(6):1610-1616. doi:10.1007/s00268-017-4385-9
  38. Tyson AF, Msiska N, Kiser M, et al. Delivery of operative pediatric surgical care by physicians and non-physician clinicians in Malawi. Int J Surg. 2014;12(5):509-515. doi:10.1016/j.ijsu.2014.02.009
  39. Clelland SJ, Chauhan P, Mandari FN. The epidemiology and management of tibia and fibula fractures at Kilimanjaro Christian Medical Centre (KCMC) in Northern Tanzania. Pan Afr Med J. 2016;25:51. doi:10.11604/pamj.2016.25.51.10612
  40. Ikem IC, Oginni LM, Bamgboye EA. Open fractures of the lower limb in Nigeria. Int Orthop. 2001;25(6):386-388. doi:10.1007/s002640100277
  41. Premkumar A, Massawe HH, Mshabaha DJ, Foran JR, Sheth NP. The burden of orthopaedic disease presenting to a referral hospital in northern Tanzania. Ann Glob Health. 2016;82(3):553-554.
  42. Opondo E, Wanzala P, Makokha A. Cost effectiveness of using surgery versus skeletal traction in management of femoral shaft fractures at Thika level 5 hospital, Kenya. Pan Afr Med J. 2013;15:42. doi:10.11604/pamj.2013.15.42.2451
  43. Reeves RB, Ballard RI, Hughes JL. Internal fixation versus traction and casting of adolescent femoral shaft fractures. J Pediatr Orthop. 1990;10(5):592-595. doi:10.1097/01241398-199009000-00004

Articles in Press, Corrected Proof
Available Online from 23 February 2021
  • Receive Date: 05 June 2020
  • Revise Date: 02 September 2020
  • Accept Date: 31 January 2021