Rwanda Health Service Costing: Hospital Analysis
The Rwandan Ministry of Health, in collaboration with the USAID-funded Integrated Health Systems Strengthening Project (IHSSP), carried out a study to determine the costs of providing hospital services. The results of the costing were intended for use in re-designing insurance reimbursement mechanisms and levels. The results can also be used for other purposes, such as resource allocation, budgeting and comparisons of efficiency.
The figures were derived from the actual services and expenditures at a sample of 4 well-performing district hospitals and from one referral hospital (CHUK). A step-down process was used to estimate the bed-day and outpatient cost costs and various allocation factors were used. These figures were combined with standard activity- based costs to develop a small number of diagnosis-related group costs.
Based on the average of the four district hospitals, the model used 243 beds of which 152 were occupied and it had 55,547 bed days and 23,535 outpatient visits. The total cost was RWF 667 million. The average cost per bed day ranged from RWF 5,710 in the Nutrition Rehabilitation Unit to RWF 13,118 in the Gynecology and Maternity Unit. The referral hospital had much higher bed day costs, ranging from RWF 21,442 in the Internal Medicine Unit to RWF 82,327 in the Obstetrics and Gynecology Unit (which includes Theatre costs).
The DRG direct costs were based on standard treatment procedures and resource needs developed by a group of experts. The DRG indirect costs were taken from the step-down analyses. The total DRG costs also varied considerably. At a district hospital, for example, a case of acute diarrhea cost RWF 15,221, based on an ALOS of 5 days. On the other hand, an abdominal emergency due to peritonitis or occlusion cost RWF 219,848 based on 15 days in hospital and a surgical intervention. A case of severe pediatric malaria was between these figures, with a cost of RWF 115,928.
Significant challenges were encountered in data collection. It was hard to obtain accurate data on the numbers of services provided, on staffing, and on some ancillary department services, and it was not possible to collect any data on the use and distribution of drugs and medical supplies since the recording systems are weak. It will be important to improve the quality of the data used so that the exercise will be easier and the results will be more accurate. The models can be updated and adapted by the MOH in accordance with their needs and people from the MOH and the School of Public Health have been trained to use and teach the models.