Assessing the cost of laparotomy at a rural district hospital in Rwanda using time-driven activity-based costing.

"Disclosure : The authors declare no conflict of interest."

"The authors acknowledge Partners In Health/Inshuti Mu Buzima for support of this work. This study was developed under the Partners In Health/Inshuti Mu Buzima Intermediate Operational Research Training Program, developed and facilitated by B.H.‐G. and J.O. R.R., B.H.‐G., T.N., J.O. and Y.L. provided direct mentorship to this paper as part of this training. The authors also acknowledge the contributions of G. Umugiraneza, B. Ramadhan, A. Bayingana and N. Nyirahabimana for data collection, and R. McBain and M. Browning for providing assistance on the TDABC methodology. All data collection and training costs were covered by a Harvard Global Health Initiative Burke Global Health Fellowship grant. Some training facilitators and mentors are from the Rwanda Human Resources for Health faculty, based in Rwanda or the USA, and funded with support from the Government of Rwanda, the Global Fund to Fight AIDS, Tuberculosis and Malaria, and the US Centers for Disease Control and Prevention. Limitations of this study include relying on certain assumptions for the calculation of costs, although these were minimized and, where possible, based on local data or interviews. Recall bias at interview was reduced by performing follow‐up interviews with other staff members and by prioritizing chart data where available. The study included only patients who were admitted to the district hospitals, and therefore patients with an acute abdominal condition who never presented to care and those transferred to tertiary hospitals without admission at the district hospital were not captured. It is plausible that if laparotomy were to become more available at these facilities, the number of patients presenting for care would increase. In addition, the cost data covered only patient admission to discharge; thus information on prehospital costs as well as the cost of follow‐up after laparotomy should be assessed in the future. A measure of cost‐effectiveness is needed to inform planning further. As the district hospitals in this study were supported by a non‐governmental organization and laparotomy costing data were available from only one hospital, generalizability to other district hospitals in Rwanda or in the region may be limited. However, surgical care practice for other procedures is similar between this district hospital and others in Rwanda. In addition, the unit costs for personnel, medicines and supplies used here are the same as those in other district hospitals in Rwanda, because the management of all of these is under the Ministry of Health."