Step-by-step guideline for disease-specific costing studies in low- and middle-income countries: a mixed methodology

Figures & data

Fig. 1 Clinical pathways with relevant healthcare service activities and cost items for CVD prevention care.

Note: Each visit consists of different healthcare service activities (consultations, diagnostic tests, drugs). Each healthcare service activity consists of direct cost items and indirect cost items as listed in the figure. Traditional overheads include: security and housekeeping staff, information technology, building and equipment maintenance, fuel and electricity cost, training, medical non-CVD specific equipment, and general equipment. Context-specific overheads include: pharmacy staff, administration staff, general consumables (non-test specific).

Fig. 2 Methodology matrix and the level of accuracy at the identification and valuation of cost components.

Table 1 Illustrative example of parameter uncertainties, alternative assumptions, and sensitivity analyses

Assumption	Alternative assumption	Sensitivity analysis
Mark-up % similar for all services assuming linear relation between direct and indirect costs	CVD prevention patients might ‘consume’ less building and overhead costs because they are seen in an outpatient setting	Decrease building mark-up% and traditional overhead mark-up% by 20%
Pharmacy staff and administrative staff in indirect costs, assumes that time spent per patient is similar for all patients	CVD prevention patients might use more pharmacy resources: almost all patients on drugs and often complicated drug regimes. Similar consideration for record staff (searching for files of chronic patients)	Increase ‘context-specific’ overhead including records and pharmacy mark-up% by 20%
CVD consultation: doctor costs based on salary average medical staff	In this setting there is a lack of doctors. In private clinics, the medical director tends to run also patient clinics. In OOH, usually three doctors including the medical director attend to all patients	Use both medical director salary (1/3) and regular doctor salary (2/3) to value costs per minute for a doctor
Productive working hours based on contract hours	Certain staff such as doctors are overburdened and work many more hours per week	Increase productive work hours by 20%
Interest rate=16% (Central Bank)	Local interest rate in rural setting for entrepreneurs might be much higher (personal communication: can be up to 25%)	Vary by 20%
Building value: estimated to be 8% of building maintenance	No other data available	Vary building value mark-up by ±20%

CVD: cardiovascular disease; OOH: Ogo Oluwa Hospital.

Table 2 Methodologies, data requirements, and calculations to measure and value cost items for disease-specific costing

Cost component	Methodology	Data requirements	Calculations
Direct costs
Staff	Bottom-up micro-costing	Staff salary for staff involved in care for specific disease	1) Yearly staff salary/yearly productive work minutes=staff costs per minute
		Productive working hours staff	2) Minutes spent per patient with specific disease×
		Minutes spent per patient with specific disease	staff costs per minute
	Top-down micro-costing	Staff costs for specific disease	Total staff costs for specific disease/total number of
		Total number of activities (e.g. consultation for CVD prevention care)	patients with specific disease
Equipment	Bottom-up micro-costing	Equipment prices (purchasing value)	1) PMT^a=(equipment prices, life years, interest rates)
		Interest rate Life years Maintenance costs Total yearly equipment utilization all patients Utilization per patient with specific disease	2) (Annuity+ maintenance costs)/total yearly equipment utilization=equipment cost per test 3) Equipment cost per test×utilization per patient with specific disease
	Top-down micro-costing	Equipment prices Interest rate Life years Maintenance costs Total number of patients	1) PMT^a=(equipment prices, life years, interest rates) 2) (Annuity + maintenance cost)/total number of patients
Drugs and Consumables	Bottom-up micro-costing	Unit prices per drug/consumableUtilization per patient with specific disease	Unit prices per drug and consumable×utilization per patient with specific disease
	Top-down micro-costing	Total drug and consumable costs for specific disease	Total drug and consumable costs for specific disease/total number of patients with specific disease
		Total number of patients with specific disease
Indirect costs
Building and overhead	Mark-up	Total direct costs hospital Total indirect costs hospital	Total direct costs hospital/total indirect costs hospital
	Inpatient day	Total indirect costs hospital Total number of inpatient days	Total indirect costs hospital/total number of inpatient days

^aPMT is an annuity calculation function in Microsoft Excel.

Table 3 Examples of data collection tools

Data tool	Data collected
Staff activity
General information	Staff function, start time shift, end time shift
Regular daily activities:	For each activity:
Ward round, consultation, surgery, administrative tasks	Start time/end time, number of patients, patient category (e.g. disease based)
Extra activities:	For each activity:
Emergency consultations, emergency surgery, deliveries, ECG recording, ultrasound, other specify	Start time/end time, number of patients, patient category (e.g. disease based)
Monthly hospital expenditures
Staff	Staff salary per function
Drugs	Expenditures per drug category
Consumables	Expenditures for laboratory consumables, other consumables
Building maintenance	Monthly building maintenance expenditures
Equipment	Purchase and maintenance expenditures
Other overhead	Training, information technology, communication expenditures, stationery, fuel, and electricity