PROVIDER COST

The provider cost of CS was calculated for the four hospitals in the Bunia Health Zone from which cases were recruited: BM, CME, HGR and RW. Because Bunia Cité, a referral health centre, ceased to perform EMOC at an early stage of the study, it was not included in the costinganalyses.

The choice of methods reflected feasibility and the importance of precision within time and financial constraints. (82) The preferred method was bottom-up micro-costing. Because the study aimed to demonstrate the feasibility of cost-effectiveness analysis in a crisis environment, some estimates were based on gross costs (e.g. the staff salaries in HGR), or were obtained using a top-down approach (e.g. medicine).

Capital costs were itemized under the headings: buildings, vehicles, communications, furniture, equipment and linen. Recurrent costs were listed as: medicine and medical supplies, salaries, maintenance and land rent. Stationery, water, electricity and fuel were part of maintenance. To estimate the annual cost of performing CSs, a proportion of each listed

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cost was allocated to EMOC. For laundry use, the figure was doubled, to account for surgical procedures as well as bed linen.

Research team members made repeat visits to the participating referral structures to collect information from hospital administrators, logistics staff and managers. The number of deliveries was recorded from the maternity registers. The total numbers of CSs and major surgical interventions were taken monthly from theatre records. Figures for in-patient admissions were estimated by comparing data from various sources, including monthly internal reports and previous annual reports. It was assumed that the workload in each structure during the second half of 2008 would be similar to that recorded during the study period.

At CME, ultrasound was performed on all pregnant women attending antenatal care (ANC). The proportion of ultrasound cost for CSs was taken as the proportion of CSs among the maternity cases. At BM, an emergency hospital, there was no ANC consultation. CSs accounted for 5% of the inpatient beds occupancy (about 15 beds out of 300 available), but constituted 67% of major surgical cases, including complications of abortion. Most cases at BM did not necessitate ultrasound examination to establish the need for CS at the time of admission. Assuming some women receiving EMOC had been admitted to BM with pregnancy complications, the proportional CS-related use of ultrasound equipment was estimated at 10% of its total use.

BM had been constructed in 2005 to replace a field hospital mainly housed in tents since 2003. The surface of each ward was 178 m2 and contained 28 beds, leaving some additional “overflow space” for occasions when all beds were occupied. The ward space for one maternity bed, including corridors and a reception area was estimated to be 6 m2. The recommended bed space in Britain for acute patient wards was 104 square feet (=9.66 m2) in 1935. (83) A recent study found cubicle floor space ranging between 6.84m2 and 9.29 m2. (84) Since only basic sanitary facilities were available, no additional cost was added for toilets (pit latrines) and bathrooms (water taps). The cost of water was included under maintenance.

For the other hospitals, ward dimensions were either not known or difficult to apply. The spacious buildings of HGR were in disrepair and under-used, while the new CME hospital was still under construction. At RW, the building designated to be used as a maternity ward had been occupied by international peacekeeping forces for several years. The newly built

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BM hospital was used as a reference for the dimensions in the cost calculations of all four hospitals. Information on building cost was obtained from local construction companies. The replacement cost per square metre was set at 250 USD for a space with walls, a roof and a cement floor. For spaces with a tiled floor, the cost was set at 300 USD per square metre. Amortization factors used for capital expenditure were those proposed in the WHO manual “Cost Analysis in Primary Health Care: A Training Manual for Programme Managers.” (85) The amortization period for buildings was 20 years. To keep costs comparable, this period was applied to all building cost calculations, although BM was built to be used as a hospital for a limited period of time, and HGR had been constructed more than 50 years ago. Amortization time for vehicles was seven years and for communications equipment two years. For electricity generators, a period of five years was used, the same as for cooling equipment. Medical equipment was given a period of five years, and furniture a period of seven years. All other items were valued with an amortization period of two years.

Vehicles and communications equipment were imported. The replacement cost included freight and import taxes. The price of locally manufactured wooden furniture was obtained from MEDAIR, an international NGO involved in the rehabilitation of hospitals and health centres. Bed sheets and linen for the operating theatre were locally made from imported fabric. Imported blankets and stationery were available on the local market. The items procured locally were valued in USD, the preferred currency for transactions among traders in Bunia. Only BM provided separate costs for sheets and blankets. For the other hospitals, the cost estimated by CME for “bed covers” was used.

Since medicine, medical supplies and equipment were imported, international prices applied. The cost of equipment was taken from recent orders by international NGOs working in the area. Donated items were valued at replacement cost. To calculate the proportion of each cost attributable to CS, the workload of EMOC as a proportion of inpatients, maternity cases and major theatre procedures was assessed for each structure. Except for ultrasound scanning, the out-patient department was not included as a cost factor.

The cost of medicine and recurrent medical supplies was calculated from the 2006 UNFPA price list for reproductive health kit 11b of the Interagency Reproductive Health kits. (86) The supplies in the kit were intended to cover the needs of 105 patients, including 75 CSs. Because other emergency procedures, such as hysterectomy, were likely to require more inputs, the proportion of cost for CS-related inputs was estimated to be 60%. The cost of a

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full kit was 2905 USD. The approximate cost of renewable supplies for one CS, including 25% overheads and transport, was estimated to be 28.5 USD. The interagency RH kit does not include supplies for blood transfusion. The price charged for a transfusion at CME was 10 USD. Since CME had a cost-recovery policy, this amount was taken as a reasonable cost estimate. The proportion of women receiving a blood transfusion related to CS was derived from the proportion of cases in the study reporting transfusion, and from the laboratory records in the four hospitals. BM hospital had its own blood bank for transfusion, while other hospitals relied on relatives to donate blood in case of emergency. The blood bank in the central laboratory, adjacent to the HGR had been rehabilitated by the World Health Organization.

Except at BM, where in-patients received three meals daily, relatives were expected to provide food for patients. The cost of catering for patients was therefore only calculated for BM. A proportion of the capital cost of the kitchen building was added. The cost of feeding each CS patient three meals daily for five days was based on the amount provided and the cost of the staple food for each meal on the local market: maize flour for breakfast gruel, beans and rice for lunch and dinner. The cost of food items was verified by the manager of the UN restaurant in Bunia. The cost of vegetables as an accompaniment was considered negligible. The cost of fuel was included in the total maintenance cost of the hospital.

All salary figures were gross estimates. The costs of international travel and local living expenses such as housing for expatriate workers were not included. It was thought that such costs should be allocated to the organization, rather than to the health structure providing the service. The calculated cost of providing emergency obstetric care does not reflect the actual cost to international humanitarian organisations of setting up and running health services with personnel on short contracts and recruited overseas.

Salary scales were only available for BM and CME. Scales were based on professional grade and years of service. Individual monthly payments varied according to the time spent on duty, with supplementary amounts for night duty and emergency call-outs for maternity and theatre staff. Since the number of service years varied, average salaries in the cost analysis were based on an estimate of the number of years of experience. For maternity staff, the proportion of the salary allocated to EMOCS was the same as the proportion of maternity building space.

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For administrative staff, the proportion of admissions was used. The proportion was doubled for hygienists (cleaners) and general medical doctors, to reflect the additional time spent in the operating theatre.

As no individual salaries were available for HGR, an arbitrary proportion had to be allocated. The total amount of salaries paid was taken from the 2007 annual report and the same figure applied to 2008. Salaries at HGR were similar to those paid at CME. A higher proportion of maternity admissions received EMOC at CME, but fewer CSs took place in total, and CSs at CME constituted a lower proportion of major surgical interventions than at HGR. Attributing an overall proportion of 11% of salaries at HGR to EMOC resulted in a figure very similar to the estimated amount at CME.

The administrator at RW explained that staff members were paid in accordance with the monthly hospital income from patient charges. Average monthly salaries were based on the estimated monthly receipts of the hospital, using the quota applied to re-distribute this income among different grades of personnel.

2.2.6. USER COST

Direct user costs were taken from the interview questionnaire of cases and controls. Respondents were asked to estimate how much they would be paying for hospitalization, including anticipated costs. Information on indirect costs was limited. Interviewees were asked about the cost of transport to and from the hospital. An additional question on disposable income provided a level of comparison for healthcare related expenditure. All user costs were expressed in local currency. The official local exchange rate of the Congolese Franc (Franc Congolais, FC) against the US dollar at the start of the study was 500 FC for one USD. This value was used for conversion of results into dollars, allowing comparison between costs. By the end of the study, the exchange value of the FC had decreased by 10 percent.

Other indirect costs, such as the compensation of a caregiver (“garde-malade”), were taken from the focus group responses. Information related to the social cost of maternal death was used as an approximation of intangible cost. The focus groups also explored assumptions of potential EMOC users and their families regarding the direct cost of CS, and their willingness to pay considering the possibility of a loan.

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Population data and reference values for morbidity and mortality

Demographic information was obtained from the Directorate of Public Health and from the local office of the World Health Organization. Population estimates used the figures from the National Institute for Statistics, with the 1984 census as a baseline. The results from the National Demographic and Health Survey, conducted in 2007, were published in August 2008. (87) The DHS presented results of the direct sisterhood survey on maternal mortality by age group for the country. Neonatal and infant mortality figures were available by province.

Bunia was a sentinel site for the 2006 annual survey by the National Action Programme against AIDS (Programme National Multi-sectoriel de Lutte contre le SIDA, PNMLS). The estimated prevalence of HIV and syphilis among pregnant women was taken from a local report based on data from selected health structures in Bunia. (88)

2.3. ANALYSIS