Cost of curative pediatric services in a public sector setting
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《美国医学杂志》
1 Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
2 Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi, India
Abstract
Objective: To estimate the cost of ambulatory (out-patient) and in-patient pediatric health services for the year 1999 provided by All India Institute of Medical Sciences (AIIMS) at all the three levels-primary, secondary and tertiary level. Methods: The costing module developed by Children's Vaccines Initiative (CVI) was used. This rapid assessment tool focuses on collection of data at macro level by using key informants like doctors, nursing staff, accountant, store keeper, engineer etc. Cost per beneficiary was estimated separately for in-patients and out-patients and was calculated by dividing the total cost of the services by the number of beneficaries for the year 1999. For the out-patient, the beneficiaries were the total out-patient attendees and for the in-patient, it was the total pediatric admissions multiplied by mean duration of stay in days. Results: The cost per out-patient visit was INR.20.2 (US$0.44@1US$=INR.46) at primary level, higher than INR14.5 (US$ 0.31) at the secondary level, while at tertiary level it was INR 33.8 (US$ 0.73). At the primary and secondary level, non-physician cost was more than the physician cost, and for tertiary level, physician cost was much higher than the other costs. There were no in-patient services at primary level. The cost of in-patient services at secondary level was estimated as INR 419.30 (US$ 9.1) per patient per day with a bed occupancy rate of 60%. Two-fifths of the cost was due to nursing and other supportive staff and one fifth due to the doctor costs and overhead costs. The unit cost of INR 928 (US$ 20.2) per patient per day incurred at AIIMS with a bed occupancy rate of 100% was almost twice that of secondary level. In contrast to the secondary level, almost half the total costs at tertiary level was due to the doctors costs. Conclusions: Effective use of resources at lower level of care especially ambulatory care at primary level and inpatient care at secondary level can result in much higher savings for the system and also, the society. These would need to be appropriately strengthened.
Keywords: Pediatric services; Cost; Health services; Efficiency utilisation; Hospitals
Information on cost of health services in developing countries including India is scarce. Such information can potentially be used for planning of health services. A cost analysis of the existing health care system also helps in identify inefficiencies of the system. The need for information on costs assumes greater importance, as Government of India is now considering implementing user fees for health care services.[1] Information on costs of health services usually comes from budgetary statements. Actual costs of various components of health care delivery system are often not available in developing countries like India.This is because budgetary provisions cover only the recurrent expenditures like salary and drugs but do not reflect the investments already done in the form of infrastructure and equipments. We have estimated the cost of ambulatory (out-patient) and in-patient pediatric health services at all the three levels-primary, secondary and tertiary in a public sector setting in North India.
Material and methods
Study Setting
The All India Institute of Medical Sciences (AIIMS) is a premier academic institution and tertiary hostipal in the country. However, through its outreach services in Ballabgarh, it provides health care at the other two levels as well. The primary level constitutes of two primary health centres in villages, Chhainsa and Dayalpur, covering a total population of about 75000. The secondary level care is provided by the Civil Hospital, Ballabgarh. Both these levels are part of the Comprehensive Rural Health Services Project at Ballabgarh (CRHSP) in district Faridabad, Haryana state. CRHSP is a collaborative project between AIIMS and the State Government of Haryana. These three levels of care also serve the purpose of training to all levels of workers from the birth attendants to the Superspecialists. The present study deals only with the cost of provision of pediatric care. Only the costs incurred on the curative pediatric care services have been dealt with. At the primary level, all out-patients including children are seen by a general physician in the same room, at the other two levels a special pediatric out-patient clinic is run dialy by trained pediatricians.
The Primary Health Centre are run by doctors who are postgraduates in Community Medicine and provide out-patient care. Emergency services are available but no regular in-patient services are available. Civil hospital Ballabgarh is a 50 bedded hospital jointly run by the State Government of Haryana and AIIMS. Specialists in disciplines of medicine, pediatrics, obstetrics and gynecology, surgery, anesthesia and ophthalmology are posted here by rotation. Two faculty members of Community Medicine from AIIMS are posted at Ballabgarh for management of CRHSP project including running the hospital.
Costing Methodology
Study instrument: The costing module developed by Children's Vaccines Initiative (CVI) as part of the study was used to determine the cost of vaccine preventable diseases.[2] The protocol had six modules, each of which covered the methodological aspects related to costing of different aspects of health care. The module that dealt with the costing of health facility was used. It was a rapid assessment tool and focused on collection of data at macro level by using key informants (important people from various departments like doctors, nursing staff, financebudget, store, engineering unit etc). The reference year for the costing was 1999. The providers viewpoint was adopted for the study.
The Overhead costs were distributed in proportion to their share in the hospital. For example, at the Civil Hospital, Ballabgarh 18% of all ward admissions were pediatric admissions. Therefore, it was assumed that 18% of all the shared resources in the ward (i.e. nurses time, other staffs time, electricity and other overhead costs etc.) were incurred in pediatric care. Thus, the total resources utilized at Ballabgarh were multiplied by 0.18 to get the cost attributable to pediatric patients. For general administrative costs, a step down approach was used. This means that first, the proportion of time devoted by administration to the ward was identified. Subsequently, this was multiplied by 0.18 to apportion the cost to pediatric department.
The capital cost of construction of the building was as per the civil engineering norms for such a building, whose size was measured. [At 1999 level, it was Rs. 250 per square feet for primary and secondary level and Rs. 600 per square feet for tertiary level]. The life of building was assumed to be 20 years as recommended in the protocol and a discount rate of 3% was considered to calculated annual equivalent cost of the building. The major equipments used for pediatric patients were also identified and costed based on their useful life in years and discount rate of 3%. For the shared equipments, the proportion of pediatric admissions to the total admission was taken as the multiplication factor as discribed above in the overhead costs.
Personnel costs: This was based on the full emoluments that the person received including all the allowances in one year. For non-doctor staff, the total number of various categories of staff present in each cost unit (Out-patient, In-patient, Opearation Theatre, Emergency etc.) was listed with their total annual emoluments based on their salary slip including all allowances. For doctors,their total salary was apportioned to out-patient and in-patient services based on the proportion of their time devoted in each unit. This was estimated by interviewing different categories of doctors.
While for the primary and secondary level, primary data was collected, for the tertiary level most of the information were derived from existing available information estimated on similar basis.[3],[4]
Cost per beneficiary was calculated by dividing the total cost of the services by the number of beneficiaries in the year 1999. For the out-patient, the beneficiaries were the total out-patient attendees and for the in-patient, it was the total pediatric admissions multiplied by mean duration of stay in days. Costs incurred on patients attending emergency/casualty and pediatric speciality clinics at AIIMS were not included.
Results
Cost of pediatric outpatient services
Total Costs: The cost of pediatric out-patient services at all the three levels is shown in table1. the costs have been classified as doctor costs and other costs. Other costs includes capital costs, overhead costs and other staff costs. In 1999, the total annual cost of running pediatric out-patient services at primary level was about Rs. 190,000 compared to double that amount at the secondary level. At tertiary level, the cost was much higher at Rs.3,170,000. This cost does not take into account the population served.
Unit Costs: When this was included, it was seen that the number of patients seen in the OPD rose steeply from a low 9,396 at primary level to 28,147 at secondary to 93,852 at tertiary level. The cost per out-patient visit was lowest at the secondary level (Rs 14.5) and highest (Rs.33.8) at the tertiary level. While for the primary and, secondary level, other costs were more than the doctors cost, for tertiary level doctors cost was much higher than the other costs.
Cost of Pediatric In-patient Services
Total Costs: At primary level, there were no in-patient services. The total annual cost of running the eight bedded pediatric in-patient services at secondary level was estimated to be approximately Rs. 730,000. Two fifths of the cost were due to nursing and other supportive staff and one fifth due to the doctor costs and overhead costs each. At tertiary level, the total annual cost of the sixty bedded pediatric ward at AIIMS was Rs. 20.8 million. In contrast to the secondary level, almost half the total cost at AIIMS was due to the doctors costs.
Unit Costs: The Ballabgarh hospital with eight pediatric beds had a total of 530 pediatric admissions with mean hospital duration of stay at 3.3 days in the year 1999. The bed occupancy rate for pediatric patients was 59.9%. The unit cost was estimated by dividing the total cost by the occupied bed days per year. This was estimated to be Rs. 419.30 per patient per day. If the bed occupancy was not taken into account, we estimated the cost per bed per day was INR 251. The total pediatric admissions at AIIMS in the year 1999 was 4233 with a mean durition of stay of 5.3 days. The bed occupancy rate was almost 100%. This gave the unit cost of Rs. 928 per patient per day at AIIMS. table2
Discussion
The present study, for the first time in the country, provides a comprehensive estimate of the costs at all the three levels of health care in a public sector setting. The costs are from the provider perspective but do not include drug or other consumable costs, supplied free to the patient by the provider. It should be noted that the study centers may not be entirely representative of such centers in the country. This could be both at the input level as well as at the output level. For example, while at the PHC, the number of doctors were more (because of posting of trainee interns and postgraduates), some clerical and technical staff positions were vacant. Similarly, at secondary level, the pediatrician was always assisted by junior doctors for provision of care whereas in the "routine" setting, she/he often works alone. Even at tertiary level, being attached to a medical school meant that there were more personnel including doctors than any other hospital of similar standing. In the Indian context, however, public sector tertiary level hospitals are almost always linked to a medical school. The hospitals selected for this study might also be utlised better than the corresponding state run hospitals. Therefore, it is difficult to hazard a guess on the direction of the bias these might have caused in the estimates.
At AIIMS, almost 50% of the total in-patient cost was due to doctor's salaries, whereas, for the secondary level it was only one-fifth. Salaries constituted 58% of the total in-patient cost at secondary level, compared to 67% at the tertiary level. As the doctors costs appears to be the main driver of the total cost, the method of its estimation is very important. We did face problems in apportioning time of the doctors, especially faculty members, to various activities. Faculty members are involved in clinical service, teaching, administration and research activities. They often have a flexible system of working and apportioning costs become difficult. We had estimated that 50% of faculty's time is spent in the ward for in-patient care. This assumes that most of the research activities are conducted outside the "office hours". However, even minor changes in this assumption could affect the cost estimates.
Goldar et at estimated the cost of a 400-bedded hospital in Delhi using budget allocation and utilization data[5] Captial costs were not included. The cost per bed per day was estimated at INR 171.60 (US$ 3.7) compared to the corresponding present estimate of INR 251 (US$ 5.4). The estimate by Goldar is not comparable to our estimate as, they belong to different years, different level of hospitals (this hospital would be somewhere between the Ballabgarh hospital and AIIMS hospital in its level of services) and use different methodology. In a study on cost of district hospital, costs in Malawi, Mills et al reported that the cost of per in-patient per day in children's ward varied between US$ 1.75 to US$ 5.0 for the years 1987-1988 among the six hospitals studied.[6] The outpatient cost was between US$ 0.4 to US$ 1.1. In the present study, the cost of these services at secondary level was US$ 0.31 for out-patient visit and US$ 9.1 per in-patient per day. However, comparison of costs across countries is difficult as the nature of services being provided at a similar level may be different.
The authors found that the cost of out-patient care in primary level was higher than that at secondary level. While the input at secondary level was doubled, the output was three times higher. Thus a more efficient use of the resource was being done at the secondary level. The authors also saw that while the bed occupancy rate at the secondary level was 60%, at tertiary level it was 100%. If we could increase the bed occupancy level at the secondary level, it brings down the cost from INR 419 (US$ 9.1) to INR 251(US$ 5.4) per bed per day. There were no in-patient services at the primary level. Many of the common pediatric morbidities like diarrohea, respiratory infections can, in fact, be managed at primary level. Thus, if we strengthen the system so that most patients are managed at primary and secondary level, it could result in major resource savings. As the level of services increases from primary to tertiary, their distance from the beneficiaries also increase. Therefore, better utilization of peripheral levels of services also results in reduction in the indirect costs of treatment. Thus there is a need to address the issue of underutilization of peripheral services by first identifying the reasons for them like accessibility, quality of care etc. The present study thus confirms the general notion of health planners about the underutilization of public services at lower levels and also helps to arrive at the cost of this underutilization to the system. These estimates also provide a reference point for comparison with the charges levied in the private sector. However, it should be remembered that in private sector the hotel or the non-technical costs (like; room service, air-conditioning etc.) could be higher. These estimates also provide a basis for useful discussion on the subsidy in health care. More information is needed on cost of health services from different types of hospitals in the public sectors to arrive at a good estimate of cost of public health services in the country
Acknowledgement
This paper is based on work undertaken as a part of Children's Vaccine Initiative (CVI) and international clinincal Epidemiology Network (INCLEN) sponsored study "Determination of the costs associated with vaccine preventable illnesses" vide reference 18-181-548,HQ/99/428977. India was one of the three centres, the other two being, Philippines and Mexico. The protocol used for the study was developed in consultation with all the participating teams.
References
1. Planning Commission. Ninth Five year plan-1997-2002. Vol ii-Thematic issues and sectoral programmes, Government of India, New Delhi, 1998.
2. World Health Organization. Review of treatment cost protocol studies. Geneva WHO, 2001, WHO/V&B/01.22.
3. Sharma Y. A study of cost analysis for in patient services at AIIMS hospital, New Delhi. Thesis submitted for Master of Hospital Administration at All India Institute of Medical Sciences , New Delhi, January 1998.
4. Jain S. Economic Evaluation management strategies for extra-hepatic portal hypertension in childhood: Efficiency of endoscopic sclerotherapy verus Porto-systemic shunt surgery. Thesis submitted to National Board of Examination for the degree of Diplomate National Board-Pediatrics. New Delhi, Aprill 2000.
5. Goldar K, Agarwal AK. Unit costing of important cost centres in a general hispital in Delhi. Health and Population-Perspectives and Issues 1995; 18(3): 120-125.
6. Mills AJ, Kapalamula J, Chisimbi S. The cost of the district hospital: a case study in Malawi. Bulletin of World Health Organization 1993; 71(3/4); 329-340.(Krishnan Anand, Arora Nar)
2 Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi, India
Abstract
Objective: To estimate the cost of ambulatory (out-patient) and in-patient pediatric health services for the year 1999 provided by All India Institute of Medical Sciences (AIIMS) at all the three levels-primary, secondary and tertiary level. Methods: The costing module developed by Children's Vaccines Initiative (CVI) was used. This rapid assessment tool focuses on collection of data at macro level by using key informants like doctors, nursing staff, accountant, store keeper, engineer etc. Cost per beneficiary was estimated separately for in-patients and out-patients and was calculated by dividing the total cost of the services by the number of beneficaries for the year 1999. For the out-patient, the beneficiaries were the total out-patient attendees and for the in-patient, it was the total pediatric admissions multiplied by mean duration of stay in days. Results: The cost per out-patient visit was INR.20.2 (US$0.44@1US$=INR.46) at primary level, higher than INR14.5 (US$ 0.31) at the secondary level, while at tertiary level it was INR 33.8 (US$ 0.73). At the primary and secondary level, non-physician cost was more than the physician cost, and for tertiary level, physician cost was much higher than the other costs. There were no in-patient services at primary level. The cost of in-patient services at secondary level was estimated as INR 419.30 (US$ 9.1) per patient per day with a bed occupancy rate of 60%. Two-fifths of the cost was due to nursing and other supportive staff and one fifth due to the doctor costs and overhead costs. The unit cost of INR 928 (US$ 20.2) per patient per day incurred at AIIMS with a bed occupancy rate of 100% was almost twice that of secondary level. In contrast to the secondary level, almost half the total costs at tertiary level was due to the doctors costs. Conclusions: Effective use of resources at lower level of care especially ambulatory care at primary level and inpatient care at secondary level can result in much higher savings for the system and also, the society. These would need to be appropriately strengthened.
Keywords: Pediatric services; Cost; Health services; Efficiency utilisation; Hospitals
Information on cost of health services in developing countries including India is scarce. Such information can potentially be used for planning of health services. A cost analysis of the existing health care system also helps in identify inefficiencies of the system. The need for information on costs assumes greater importance, as Government of India is now considering implementing user fees for health care services.[1] Information on costs of health services usually comes from budgetary statements. Actual costs of various components of health care delivery system are often not available in developing countries like India.This is because budgetary provisions cover only the recurrent expenditures like salary and drugs but do not reflect the investments already done in the form of infrastructure and equipments. We have estimated the cost of ambulatory (out-patient) and in-patient pediatric health services at all the three levels-primary, secondary and tertiary in a public sector setting in North India.
Material and methods
Study Setting
The All India Institute of Medical Sciences (AIIMS) is a premier academic institution and tertiary hostipal in the country. However, through its outreach services in Ballabgarh, it provides health care at the other two levels as well. The primary level constitutes of two primary health centres in villages, Chhainsa and Dayalpur, covering a total population of about 75000. The secondary level care is provided by the Civil Hospital, Ballabgarh. Both these levels are part of the Comprehensive Rural Health Services Project at Ballabgarh (CRHSP) in district Faridabad, Haryana state. CRHSP is a collaborative project between AIIMS and the State Government of Haryana. These three levels of care also serve the purpose of training to all levels of workers from the birth attendants to the Superspecialists. The present study deals only with the cost of provision of pediatric care. Only the costs incurred on the curative pediatric care services have been dealt with. At the primary level, all out-patients including children are seen by a general physician in the same room, at the other two levels a special pediatric out-patient clinic is run dialy by trained pediatricians.
The Primary Health Centre are run by doctors who are postgraduates in Community Medicine and provide out-patient care. Emergency services are available but no regular in-patient services are available. Civil hospital Ballabgarh is a 50 bedded hospital jointly run by the State Government of Haryana and AIIMS. Specialists in disciplines of medicine, pediatrics, obstetrics and gynecology, surgery, anesthesia and ophthalmology are posted here by rotation. Two faculty members of Community Medicine from AIIMS are posted at Ballabgarh for management of CRHSP project including running the hospital.
Costing Methodology
Study instrument: The costing module developed by Children's Vaccines Initiative (CVI) as part of the study was used to determine the cost of vaccine preventable diseases.[2] The protocol had six modules, each of which covered the methodological aspects related to costing of different aspects of health care. The module that dealt with the costing of health facility was used. It was a rapid assessment tool and focused on collection of data at macro level by using key informants (important people from various departments like doctors, nursing staff, financebudget, store, engineering unit etc). The reference year for the costing was 1999. The providers viewpoint was adopted for the study.
The Overhead costs were distributed in proportion to their share in the hospital. For example, at the Civil Hospital, Ballabgarh 18% of all ward admissions were pediatric admissions. Therefore, it was assumed that 18% of all the shared resources in the ward (i.e. nurses time, other staffs time, electricity and other overhead costs etc.) were incurred in pediatric care. Thus, the total resources utilized at Ballabgarh were multiplied by 0.18 to get the cost attributable to pediatric patients. For general administrative costs, a step down approach was used. This means that first, the proportion of time devoted by administration to the ward was identified. Subsequently, this was multiplied by 0.18 to apportion the cost to pediatric department.
The capital cost of construction of the building was as per the civil engineering norms for such a building, whose size was measured. [At 1999 level, it was Rs. 250 per square feet for primary and secondary level and Rs. 600 per square feet for tertiary level]. The life of building was assumed to be 20 years as recommended in the protocol and a discount rate of 3% was considered to calculated annual equivalent cost of the building. The major equipments used for pediatric patients were also identified and costed based on their useful life in years and discount rate of 3%. For the shared equipments, the proportion of pediatric admissions to the total admission was taken as the multiplication factor as discribed above in the overhead costs.
Personnel costs: This was based on the full emoluments that the person received including all the allowances in one year. For non-doctor staff, the total number of various categories of staff present in each cost unit (Out-patient, In-patient, Opearation Theatre, Emergency etc.) was listed with their total annual emoluments based on their salary slip including all allowances. For doctors,their total salary was apportioned to out-patient and in-patient services based on the proportion of their time devoted in each unit. This was estimated by interviewing different categories of doctors.
While for the primary and secondary level, primary data was collected, for the tertiary level most of the information were derived from existing available information estimated on similar basis.[3],[4]
Cost per beneficiary was calculated by dividing the total cost of the services by the number of beneficiaries in the year 1999. For the out-patient, the beneficiaries were the total out-patient attendees and for the in-patient, it was the total pediatric admissions multiplied by mean duration of stay in days. Costs incurred on patients attending emergency/casualty and pediatric speciality clinics at AIIMS were not included.
Results
Cost of pediatric outpatient services
Total Costs: The cost of pediatric out-patient services at all the three levels is shown in table1. the costs have been classified as doctor costs and other costs. Other costs includes capital costs, overhead costs and other staff costs. In 1999, the total annual cost of running pediatric out-patient services at primary level was about Rs. 190,000 compared to double that amount at the secondary level. At tertiary level, the cost was much higher at Rs.3,170,000. This cost does not take into account the population served.
Unit Costs: When this was included, it was seen that the number of patients seen in the OPD rose steeply from a low 9,396 at primary level to 28,147 at secondary to 93,852 at tertiary level. The cost per out-patient visit was lowest at the secondary level (Rs 14.5) and highest (Rs.33.8) at the tertiary level. While for the primary and, secondary level, other costs were more than the doctors cost, for tertiary level doctors cost was much higher than the other costs.
Cost of Pediatric In-patient Services
Total Costs: At primary level, there were no in-patient services. The total annual cost of running the eight bedded pediatric in-patient services at secondary level was estimated to be approximately Rs. 730,000. Two fifths of the cost were due to nursing and other supportive staff and one fifth due to the doctor costs and overhead costs each. At tertiary level, the total annual cost of the sixty bedded pediatric ward at AIIMS was Rs. 20.8 million. In contrast to the secondary level, almost half the total cost at AIIMS was due to the doctors costs.
Unit Costs: The Ballabgarh hospital with eight pediatric beds had a total of 530 pediatric admissions with mean hospital duration of stay at 3.3 days in the year 1999. The bed occupancy rate for pediatric patients was 59.9%. The unit cost was estimated by dividing the total cost by the occupied bed days per year. This was estimated to be Rs. 419.30 per patient per day. If the bed occupancy was not taken into account, we estimated the cost per bed per day was INR 251. The total pediatric admissions at AIIMS in the year 1999 was 4233 with a mean durition of stay of 5.3 days. The bed occupancy rate was almost 100%. This gave the unit cost of Rs. 928 per patient per day at AIIMS. table2
Discussion
The present study, for the first time in the country, provides a comprehensive estimate of the costs at all the three levels of health care in a public sector setting. The costs are from the provider perspective but do not include drug or other consumable costs, supplied free to the patient by the provider. It should be noted that the study centers may not be entirely representative of such centers in the country. This could be both at the input level as well as at the output level. For example, while at the PHC, the number of doctors were more (because of posting of trainee interns and postgraduates), some clerical and technical staff positions were vacant. Similarly, at secondary level, the pediatrician was always assisted by junior doctors for provision of care whereas in the "routine" setting, she/he often works alone. Even at tertiary level, being attached to a medical school meant that there were more personnel including doctors than any other hospital of similar standing. In the Indian context, however, public sector tertiary level hospitals are almost always linked to a medical school. The hospitals selected for this study might also be utlised better than the corresponding state run hospitals. Therefore, it is difficult to hazard a guess on the direction of the bias these might have caused in the estimates.
At AIIMS, almost 50% of the total in-patient cost was due to doctor's salaries, whereas, for the secondary level it was only one-fifth. Salaries constituted 58% of the total in-patient cost at secondary level, compared to 67% at the tertiary level. As the doctors costs appears to be the main driver of the total cost, the method of its estimation is very important. We did face problems in apportioning time of the doctors, especially faculty members, to various activities. Faculty members are involved in clinical service, teaching, administration and research activities. They often have a flexible system of working and apportioning costs become difficult. We had estimated that 50% of faculty's time is spent in the ward for in-patient care. This assumes that most of the research activities are conducted outside the "office hours". However, even minor changes in this assumption could affect the cost estimates.
Goldar et at estimated the cost of a 400-bedded hospital in Delhi using budget allocation and utilization data[5] Captial costs were not included. The cost per bed per day was estimated at INR 171.60 (US$ 3.7) compared to the corresponding present estimate of INR 251 (US$ 5.4). The estimate by Goldar is not comparable to our estimate as, they belong to different years, different level of hospitals (this hospital would be somewhere between the Ballabgarh hospital and AIIMS hospital in its level of services) and use different methodology. In a study on cost of district hospital, costs in Malawi, Mills et al reported that the cost of per in-patient per day in children's ward varied between US$ 1.75 to US$ 5.0 for the years 1987-1988 among the six hospitals studied.[6] The outpatient cost was between US$ 0.4 to US$ 1.1. In the present study, the cost of these services at secondary level was US$ 0.31 for out-patient visit and US$ 9.1 per in-patient per day. However, comparison of costs across countries is difficult as the nature of services being provided at a similar level may be different.
The authors found that the cost of out-patient care in primary level was higher than that at secondary level. While the input at secondary level was doubled, the output was three times higher. Thus a more efficient use of the resource was being done at the secondary level. The authors also saw that while the bed occupancy rate at the secondary level was 60%, at tertiary level it was 100%. If we could increase the bed occupancy level at the secondary level, it brings down the cost from INR 419 (US$ 9.1) to INR 251(US$ 5.4) per bed per day. There were no in-patient services at the primary level. Many of the common pediatric morbidities like diarrohea, respiratory infections can, in fact, be managed at primary level. Thus, if we strengthen the system so that most patients are managed at primary and secondary level, it could result in major resource savings. As the level of services increases from primary to tertiary, their distance from the beneficiaries also increase. Therefore, better utilization of peripheral levels of services also results in reduction in the indirect costs of treatment. Thus there is a need to address the issue of underutilization of peripheral services by first identifying the reasons for them like accessibility, quality of care etc. The present study thus confirms the general notion of health planners about the underutilization of public services at lower levels and also helps to arrive at the cost of this underutilization to the system. These estimates also provide a reference point for comparison with the charges levied in the private sector. However, it should be remembered that in private sector the hotel or the non-technical costs (like; room service, air-conditioning etc.) could be higher. These estimates also provide a basis for useful discussion on the subsidy in health care. More information is needed on cost of health services from different types of hospitals in the public sectors to arrive at a good estimate of cost of public health services in the country
Acknowledgement
This paper is based on work undertaken as a part of Children's Vaccine Initiative (CVI) and international clinincal Epidemiology Network (INCLEN) sponsored study "Determination of the costs associated with vaccine preventable illnesses" vide reference 18-181-548,HQ/99/428977. India was one of the three centres, the other two being, Philippines and Mexico. The protocol used for the study was developed in consultation with all the participating teams.
References
1. Planning Commission. Ninth Five year plan-1997-2002. Vol ii-Thematic issues and sectoral programmes, Government of India, New Delhi, 1998.
2. World Health Organization. Review of treatment cost protocol studies. Geneva WHO, 2001, WHO/V&B/01.22.
3. Sharma Y. A study of cost analysis for in patient services at AIIMS hospital, New Delhi. Thesis submitted for Master of Hospital Administration at All India Institute of Medical Sciences , New Delhi, January 1998.
4. Jain S. Economic Evaluation management strategies for extra-hepatic portal hypertension in childhood: Efficiency of endoscopic sclerotherapy verus Porto-systemic shunt surgery. Thesis submitted to National Board of Examination for the degree of Diplomate National Board-Pediatrics. New Delhi, Aprill 2000.
5. Goldar K, Agarwal AK. Unit costing of important cost centres in a general hispital in Delhi. Health and Population-Perspectives and Issues 1995; 18(3): 120-125.
6. Mills AJ, Kapalamula J, Chisimbi S. The cost of the district hospital: a case study in Malawi. Bulletin of World Health Organization 1993; 71(3/4); 329-340.(Krishnan Anand, Arora Nar)