1. Scholarly Writing: Presentation Title “Costs of vaginal delivery and Caesarean section at a tertiary level public hospital in Islamabad, Pakistan Author : Attia Khan & Shakila Zaman Journal: BMC Pregnancy and Childbirth 2010, 10:2 Submitted to: Ms. Rabia Riaz Submitted by: Ms. Ruth K Alam Submitted by: Ms. Ruth K Alam MSc Nursing Student College of Nursing, JPMC, Karachi 23 rd August, 2010 1

2. Background Observed reduction maternal mortality rates was achieved by providing skilled care and of safe intervention. Observed reduction maternal mortality rates was achieved by providing skilled care and of safe intervention. In Pakistan maternal mortality ratio is 297/100,000. In Pakistan maternal mortality ratio is 297/100,000. The proportion of pregnant women received prenatal care from skilled health professional: The proportion of pregnant women received prenatal care from skilled health professional: 43%, 2001-2002 43%, 2001-2002 50%, 2004-2005 50%, 2004-2005 61%, 2006-2007 61%, 2006-2007 Rural 74% Urban 43% Home deliveries 2

3. Introduction 3

4. Introduction cont…. Green & Ali et all 2001 Cost & expenditure of health facilities/services needed rational decisions, application by decentralized budget India & Kenya 2005 Cost analysis was important element in decision on setting level of user fees Vietnamese & Argentine 2004 Measure efficiency & allocation of public funds as decentralization 4

5. Objective To estimate the average cost of SVD & CS at a tertiary level Government hospital: To estimate the average cost of SVD & CS at a tertiary level Government hospital: To highlight an insight to hidden and real costs To identify area where cost could be reduced and output or productivity (services) could be increased Cost to use resource tool for financial management in hospital 5

6. Methodology Design : Cross sectional Design : Cross sectional Provider (hospital) perspective & user (patient) perspective. Provider (hospital) perspective & user (patient) perspective. Setting : Large Government Maternity and Child Hospital (MCH). Setting : Large Government Maternity and Child Hospital (MCH). Participants : 133 Postpartum mothers(68 delivered SVD and Participants : 133 Postpartum mothers(68 delivered SVD and 65 delivered by CS). 65 delivered by CS). Sampling: Convenience sampling technique used for selection of Sampling: Convenience sampling technique used for selection of selection of interview from obstetric cases in general ward. selection of interview from obstetric cases in general ward. (all new admissions & all cases discharged 2-3 in 24 hrs) (all new admissions & all cases discharged 2-3 in 24 hrs) Sample size: Used Statistical formula to demonstrate Sample size: Used Statistical formula to demonstrate significant difference between SVD & CS groups significant difference between SVD & CS groups for comparing proportion; for comparing proportion; a 0,05(1.96) and confidence interval 95% a 0,05(1.96) and confidence interval 95% 6

7. Methodology cont…. Perspective Hospital Patient Hospital Patient - Approaches - Risk factors variable activity/top-down/bottom -up demographic/clinical/neonatal/economical activity/top-down/bottom -up demographic/clinical/neonatal/economical - Current cost - Cost factors shared/direct render/personnel total/direct & indirect/opportunity/intangible shared/direct render/personnel total/direct & indirect/opportunity/intangible - Capital cost average length of stay x cost/bed/per day average length of stay x cost/bed/per day 7

8. Results (Figure-1) Capital and Recurrent Costs (US$) 8

9. Results (Figure-2) Cost Factors (SVD vs. CS) 9

10. Result cont…. Result cost summery: (overview) Hospital side Hospital side One year statistics One year statistics Admission bed occupancy 80% all 90% 80% all 90% Average cost hospital stay Average cost hospital stay SVD/01day CS/04 days 40 US$(Rs.2688) 162 US$(Rs.10868) Current cost 84% Current cost 84% Capital cost 16% Personal cost 35% Patient’s side Patient’s side Average cost Average cost SVD CS SVD CS 79 US$(Rs.95278) 204 US$(Rs.12678 ) transportation drugs transportation drugs & drugs 27% hospital dues & drugs 27% hospital dues hospital fees 26% hospital fees 26% 10

11. Study limitation (by author) Can not include cost confounding factors related time activities (patient care, administrative work, personal time) because non availability of individual salary data. Can not include cost confounding factors related time activities (patient care, administrative work, personal time) because non availability of individual salary data. Shared services available but not accurate data on the number of maternity patient’s taking test & kind of test. Shared services available but not accurate data on the number of maternity patient’s taking test & kind of test. Inability to interview patients arriving at night for uncomplicated SVD & leaving hospital before morning round. Inability to interview patients arriving at night for uncomplicated SVD & leaving hospital before morning round. Cost of delivery not representative in rural/semi-urban setting. Cost of delivery not representative in rural/semi-urban setting. Intangible costs not measured because pain is difficult to asses. Intangible costs not measured because pain is difficult to asses. Authors declare no competing interest. Authors declare no competing interest. 11

12. Conclusion Despite 10,000 annual births, 90% bed occupancy & high turnover. Despite 10,000 annual births, 90% bed occupancy & high turnover. Costs of SVD & CS in public hospital are substantially high than other developing countries. Costs of SVD & CS in public hospital are substantially high than other developing countries. Costs of SVD & CS is far beyond the limits of three fourth of households in Pakistan. Costs of SVD & CS is far beyond the limits of three fourth of households in Pakistan. Health insurance tailored to be introduced to make maternal health care more affordable to poor and average households. Health insurance tailored to be introduced to make maternal health care more affordable to poor and average households. 12

13. Scholarly Writing: Presentation Title “ Unit costs of inpatient days in district “ Unit costs of inpatient days in district hospitals in South Africa” hospitals in South Africa” Author: Olukoga A Author: Olukoga A Journal : Singapore Med.J 2007:48 (2): Journal : Singapore Med.J 2007:48 (2): 143-147 143-147 13

14. Introduction Major consumers of health care resources at health care sector. Major consumers of health care resources at health care sector. Health planners have inadequate knowledge of cost of care. Health planners have inadequate knowledge of cost of care. Requires capital investments to employ highly trained staff. Requires capital investments to employ highly trained staff. 5%-10% of government expenditure, & 50%-80% of public sector health resources. 5%-10% of government expenditure, & 50%-80% of public sector health resources. Lack of data on the unit costs & total cost of running inpatient services. Lack of data on the unit costs & total cost of running inpatient services. Major public issue is the components of the total treatment costs & the evaluation of inpatient costs. Major public issue is the components of the total treatment costs & the evaluation of inpatient costs. 14

15. Methodology Design : Design : Not mentioned, but cost exercise carried out Not mentioned, but cost exercise carried out health care perspective. health care perspective. Setting : Setting : Five district hospitals (urban & rural) from four Five district hospitals (urban & rural) from four provinces in South Africa. provinces in South Africa. Sampling : Sampling : Purposive sampling (non-probability) from top- Purposive sampling (non-probability) from top- down & step- down allocation of overhead down & step- down allocation of overhead costs to the final costs centres. costs to the final costs centres. 15

16. Result Descriptive statistics = Patients admitted per year : 3.757---12.058 = Inpatient ranged : 30.600—78.996 = Bed occupancy : 39%---68% = Average length of stay : 3---8.8 days = Costs ranged : 65.29--212.03 USD wards: - Maternity highest unit cost 141.39 USD - Medical, 37.23---70.86 USD - Surgical 37.23---93.55 USD - Paediatric 38.37---139.60 USD 16

17. Conclusion The unit costs of inpatient days varied between The unit costs of inpatient days varied between the hospitals. the hospitals. Average unit costs for maternity patient was highest. Average unit costs for maternity patient was highest. It is important institution measures to improve the efficiency in provision of quality & effective healthcare services to their catchment population. It is important institution measures to improve the efficiency in provision of quality & effective healthcare services to their catchment population. 17

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