questionnaire: cost of unsafe...

HEALTH SYSTEM COSTS OF UNSAFE ABORTION IN RWANDA

INTERVIEWER MANUAL

REVISED 25 FEBRUARY 2012

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GUTTMACHER INSTITUTE AND

SCHOOL OF PUBLIC HEALTH, NATIONAL UNIVERSITY OF RWANDA

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For Interviews at All Facility Levels

Interviewer Manual: Health-System Costs

The purpose of this manual is to give the interviewer detailed guidance in the interview process. The manual is divided into two sections: general considerations and question-specific instructions.

NB: (1) Change “septecemie” to “sepsis” everywhere; (2) a note is repeated on page 4 and page 5 of the manual in French.

1. General Considerations for the Interviewing Process

1.1. Nature and Goals of the Study

The main goal of the study is to estimate the costs to the Rwandan health care system of treating complications arising out of unsafe abortions. Estimation of health system costs will be achieved through the process to be described in this manual.

This is a 2-year research project designed to generate evidence needed to drive policy and program reform that will address the economic and social consequences of unsafe abortion, thereby improving maternal health in Rwanda. The data collection process is likely to take one month.

1.2 The Survey Sample and Respondents

Knowledgeable health personnel at around 40 health facilities will be interviewed using two data-collection instruments: Questionnaires A and B. Questionnaire A comes in four versions:

Questionnaire A1 – for respondents at the central level Questionnaire A2 – for respondents at regional hospitals Questionnaire A3 – for respondents at district hospitals and private

polyclinics and clinics Questionnaire A4 – for respondents at health centers

Questionnaire A collects data on personnel costs, overhead costs, and capital costs associated with the provision of post-abortion care. Questionnaire B collects data on the drugs, supplies and materials used in the provision of treatment for specific post-abortion complications.

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A purposive sample of 39 facilities from all over the country has been selected by the local project team. These facilities include 5 regional hospitals, 11 district hospitals and 23 health centers.a The selection criteria are based on region, facility type and facility ownership (public, private, faith-based).

Questionnaire A1, for the central level, will primarily be aimed at the Ministry of Health.

You, the interviewer, may have to interview several staff at a particular facility in order to complete the two questionnaires. The larger the facility, the greater the chance that you will interview more than one person.

For the central level, typically in the ministry of health or equivalent, respondents may include: the director of Reproductive Health Services, the director of the Planning Division and the director of the Statistical Division of the MOH.

For regional hospitals, the head of the reproductive health services (or the head of the maternity ward) and the head of administration may be interviewed. An anesthetist, the in-charge of the operating theater, the in-charge of the laboratory are other personnel that will probably be interviewed to fill in specific parts of the questionnaires.

For district hospitals, the respondent may be the district medical officer.

For health centers, the medical officer assigned to the center may be interviewed.

For all facilities, you may have to interview the head of the laboratory and the pharmacist for certain items.

Since the goal of the health-system-cost survey is to collect expert opinions, the staff member interviewed at a particular facility should be the highest ranking person who is well versed in the facility’s treatment of cases of post-abortion complications. If that person then tells you that another staff member may be better able to answer certain questions, then you should follow his/her advice and interview that person later.

Be aware, however, that primary respondents may try to pass you along to a junior staff member. Try to avoid this—emphasize that the survey is meant to

a The PACCM uses the generic terms “regional hospital”, “district hospital” and “health center”. In the particular case of Rwanda, “regional hospital” refers to national and referral hospitals, “district hospital” refers to district hospitals and private polyclinics and “health center” refers to health centers and private clinics.

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collect expert opinion, not “data” as such (which are likely old, incomplete, and inaccurate) and therefore you want to interview that person in his/her capacity as an expert.

Experience from a Ugandan study: A similar study has recently been carried out in Uganda. Interviewers found that at larger facilities, up to six staff were interviewed. For example, the head of the laboratory was interviewed for information on lab tests, the nurse in charge of the operating theater was interviewed for inputs used in treating lacerations and perforations, etc.

1.3. Consent to be Interviewed

The information collected in this survey does not involve the gathering of any personal data on patients at the facilities sampled or on any providers of health services. Moreover, as the following section makes clear, the information to be collected is not “hard” data but merely opinion-type data. Thus, ethical considerations about confidentiality of the data and risks/harm to the respondents if the data were to be divulged do not apply to this study.

Before beginning an interview with any facility staff member, the interviewer should clearly inform the respondent that no personal information about him/her or about any patient of the facility will be collected in the interview and thus that there are no risks involved in consenting to be interviewed. On the contrary, to the extent that the results of the study lead to a more optimum use of resources in the health sector, he/she, along with the rest of the public, will benefit from more efficient use of resources. Before an interview begins the respondent must have agreed to and signed the consent form (see Annex 1).

1.4. The Type of Data to be Collected

It cannot be emphasized too strongly that the type of data that this survey will collect is expert opinion. Respondents should give you their best estimate, their considered opinion, their best guess to (almost) all of the questions in both questionnaires. Except for a few questions—which are clearly indicated in the questionnaires—you do not want the respondent to formulate his/her response by reaching for some document, statistical table or other document, or by reaching for the phone to ask some other official to look up some data. You want the respondent to give his/her opinion as a knowledgeable expert in the field of post-abortion care.

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Why does this survey want to avoid “hard data”? There are several reasons: The “data”, if found, will most likely not exactly answer the question

posed. The “data” will likely be incomplete or based on a biased set of inputs

into their information system. The “data” may well be old and out-of-date. We already know from

experience that most of the questions we want answered do not have data systematically and accurately collected by any information system.

We do not need “data” that apparently are very precise since our results do not demand high precision. Moreover, while such data may appear precise, they may well be very inaccurate for the reasons listed above.

Instead, we want experts to give their expert opinions. This type of approach is generally known as the “Delphi method” and is an accepted form of gathering hard-to-collect data. The underlying assumption of this method is that, while individual expert estimates may be inaccurate, the average of several experts is likely to give an estimate that is close to reality. This method is appropriate when the results that one is looking for do not have to be very precise. Since the results of this study are meant to be used by policy makers, not by day-to-day managers, we do not need the cost estimates to be very precise. The Delphi method can produce useful results at a low cost.

A note on ranges: If a respondent replies with a range (e.g., “20-30%”) rather than an exact number (e.g., “80%”), write down the range as stated. The range can be converted into an exact number later, during the data-coding process.b

b For example, if the response was “20-30%”, “25%” should be entered during the data-entry process.

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The most important concept that interviewers must

remember is that they are to collect expert opinions. The

interviewers must internalize this concept and

must be ready to explain it to respondents, repeatedly if

necessary.


1.5. Definition of post-abortion complications

The study focuses on five post-abortion complications:

Sepsis. Sepsis refers to a serious infection resulting from the abortion. It should be accompanied by fever (temperature > 37.3 degrees Celsius) and can range from endometritis up to the condition known as septicemia, a generalized infection that is life is threatening.

Shock. Shock refers to hypovolemic shock, a serious condition in which the volume of blood in the body falls to such a low level (due to hemorrhaging) that the body goes into shock and normal functions are shut down.

Incomplete Abortion. Incomplete abortion refers to a post-abortion condition in which part of the fetus (or “product of conception”) remains inside the uterus. This can lead to a very serious condition if not attended to.

Cervical/Vaginal Laceration. This is a laceration or other mechanical injury to the cervix and/or vagina which occurred at the time of an unsafe induced abortion. It includes burns caused by caustic chemical substances.

Uterine Laceration/Perforation. This condition refers to mechanical damage to the uterus. Perforation refers to an opening made between the uterus and the peritoneum (the lower body cavity containing the intestines). Included here are other types of perforation such as perforation of the bowel and of the peritoneum. Treatments such as laparotomies and hysterectomies should be included here.

1.6. Don’t know (DK), no answer (NA) and blank

With a very few exceptions, the response “don’t know” is not allowed in either Questionnaire A or B.c As mentioned, if after several attempts to prompt a response, a respondent still refuses to give an answer, the interviewer may enter “NA” for No Answer. No question is ever to be left blank, except where it has correctly been skipped.

c The questions in Questionnaire A where a “don’t know response is allowed are: A002, A102, A202 and A302;

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2. Question-by-Question Instructions

2.1. Questionnaire A – Personnel, Capital, and Overhead Costs

The four versions of Questionnaire A (i.e., Questionnaires A1, A2, A3, and A4) are basically the same, varying only slightly because of differences between type of facility. The instructions in this section apply to all four versions, but for readability reference is actually made only to Questionnaire A2 (for respondents at Regional Hospitals). In this questionnaire the question numbers are all in the “one hundreds” (e.g., A104 or P114). The question numbering for the four versions are as follows:

Questionnaire A1: Sections 1.0, 2.0, 3.0; question numbers from 001 - 099



Questionnaire A4: Sections 1.3, 2.3, 3.3; question numbers from 301 - 399.

Thus, the instruction for, say, question A104 applies equally to A004, A104, A204 or A304. If a question is different from one level of facility to another, facility-specific instructions will be noted in what follows.d

Identification of Facility

The name of the facility, the date of the interview and the name of the interviewer should be written in the questionnaire before the interview begins, or immediately after the interview has been completed.

d Note that questionnaire A1, for central-level respondents, is somewhat different in structure from the other questionnaires because the questions are mostly aimed at finding information about the three levels of facility that actually supply services, the central level being solely administrative. The topics of the questions, however, are the same as the other versions of the questionnaire.

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Respondents’ Identification

You may have to interview more than one expert in the facility, especially in larger hospitals. There may be three or more repondents, (e.g., head of reproductive health department, chief of administration, head of laboratory). In smaller facilities, one expert may be able to answer all questions (e.g., chief medical officer). Write down the name, designation and phone number of each respondent.

Section 1: Abortion Complications

A101. Does this [facility] maintain statistics on the number of women who come to the hospital with post-abortion complications? (See also A001,

A201, A301) The possible responses are either “Yes” or “No”. (If “No”, skip to A104.)

A102. What were the number of women who come to this [facility] with post-abortion complications in the last year for which statistics are available? (See also A002, A202, A302) This is one of the very few questions where we want to get statistical data if they exist. If the respondent answered “Yes” to A101 but then cannot find the report or statistical table with the required data, proceed on the assumption that the data do not exist and skip to A104. In this case, enter “DK” (don’t know) for this question.

A103. What is the year referred to in A102? (See also A003, A203, A303) Write down the year to which the number of women given in A102 refers. If the data is more than three years old, the response to A104 will be preferred to A103 in the data analysis phase of the research.

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DO NOT ACCEPT “DON’T KNOW” AS AN ANSWER

Remember always that this is a survey of expert opinion.

Logically, “don’t know” is impossible since everyone should have opinions. If,

after repeated attempts, a respondent refuses to

answer, mark “NA” as the response (No Answer).


A104. Give your best estimate of the number of women who came to this [facility] during all of last year with post-abortion complications. (See also A004, A204, A304)

Remember, you are now asking for an expert opinion, so inform the respondent, if necessary, that his/her best estimate is all that is needed. Ask this question even if the respondent has given answers to A102 and A103. The respondent may say that the A102 response is also his/her best estimate, but if the year referred to (A103) is a few years old, point that out to the respondent and try to elicit his/her estimation of the current number of women requesting PAC.

Before asking A105, you should make the following introduction: “It is important for this study to get the best possible estimates of the distribution of serious post-abortion complications. The next question asks you to think of 100 women presenting at this hospital with serious post-abortion complications.”

A105. Think about 100 women treated in this [ facility ] last year for post- abortion complications. Of these 100 women, how many were treated for each of the following:

a. Incomplete abortionb. Sepsisc. Shockd. Cervical/vaginal lacerationse. Uterine laceration/perforation (See also A005, A205,

A305)

This is a very important question, so it is important that the respondent understand it very clearly. First of all, the interviewer should be thinking only about women being treated for one or multiple post-abortion complication(s), not all female patients treated.

Secondly, it is better to ask this question sequentially, that is, ask first how many, out of 100, get treated for incomplete abortion (usually by vacuum aspiration or by dilation and curettage); then ask how many get treated for sepsis; and so on. Note that the sum of numbers in A105 (a. to e.) may well add up to more than 100 since one woman may be treated for two or even three complications. Record these five responses in the column with the heading “1st Answer”. Then repeat the responses just given by the respondent and ask if the respondent would like to reconsider his/her five estimates. Write these revised responses in the column “2nd Answer”, even if they are the same. (The reason for this procedure is that respondents may initially give

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five responses that add up to under 100—which should not happen since virtually all PAC patients will have at least one of these five complications.)

A106. There are several other post-abortion complications that may occur rarely (e.g., peritonitis, renal failure, etc.). Out of 1000 complications, how many would consist of these rare complications, i.e., complications not listed in A105? (See also A006, A206, A306) Again, the respondent is asked for his/her expert opinion. The answer given may be less than one woman. Do not accept an answer such as “very few”: insist on a numerical estimate (e.g., “less than 1”; or “1 in 200”), then convert it to per 1000 (e.g., “1 in 200” should be written as “5 per 1000).

A107. Treatment of a post-abortion complication sometimes fails to cure the patient who must be retreated. For 100 cases of each of the following five complications, how many need to be readmitted for further treatment? (See also A007, A207, A307)

A woman with a post-abortion complication may be treated and released by a health facility but then return because she has not been cured. The facility will then have to treat the patient a second time. Question A107 requests an estimate of how often this occurs for each of the five major complications, considering 100 women who are treated for the complication. The answers, therefore, must range between “0” (never) and “100” (always).

Section 2: Cost of Personnel

INCOMPLETE ABORTION For the next two questions, ask the respondent to think (hypothetically) about 10 women admitted to this [facility] for incomplete abortion. They should think in terms of women with just this one complication, even if some patients will normally present at the facility with multiple complications.

P101. How many women, out of 10 women admitted with incomplete abortions, are seen by each type of [facility] worker listed below? (See also

P201, P301) You should sequentially read from the table the names of the categories of worker at the facility. Enter a zero (“0”, not “N/A”) if the respondent says that

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particular type of worker never attends to women with incomplete abortions. For each type of worker where “0” is the answer in P101, skip P102. As an example, if you write down “5” beside “Nurse” (line d.), it means that the respondent estimates that 5 out of every 10 cases of incomplete abortion are attended to by a nurse or nurses.

P102. On average, how many minutes does each type of worker spend with a woman admitted with incomplete abortion during the whole course of treatment? (See also P202, P302)

Be sure not to ask this question for those worker categories that the respondent has stated in P101 never attend incomplete abortion cases. The number of minutes estimated should be for the whole treatment period, from when the woman arrives at the facility until when she is discharged. It should include all the time that a health worker spends directly on treating the patient—which includes both time spent in the presence of the patient and time spent away from the patient but engaged in an activity directly related to treating that patient (e.g., filling out the patient’s chart; preparing the patient’s medicine).

It should include the total time spent by all workers if each category of personnel. For example, if in a particular facility three nurses normally attend a post-abortion patient, then the response should be the total (average) time spent by all three nurses. If nurses of different levels are all involved in the treatment, the respondent should estimate the minutes spent by each level.

SEPSIS Sepsis is a serious condition marked by localized or generalized infection. Questions P103 and P104 (See also P203, P303 and P204, P304) are identical to P101 and P102, except they ask about women admitted to the facility with sepsis. Therefore, please refer to the instructions for P101 and P102 above.

SHOCK Shock is a serious condition in which the patient’s volume of blood has reached a dangerously low level (in volume) due to hemorrhaging. Questions P105 and P106 (See also P205, P305 and P206, P306) are identical to P101 and P102, except they ask about women admitted to the facility with shock. Therefore, please refer to the instructions for P101 and P102 above.

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CERVICAL/VAGINAL LACERATIONS Cervical and vaginal lacerations are serious conditions in which genital area is physically injured usually due to the use of sharp objects or corrosive chemicals. Questions P107 and P108 (See also P207, P307 and P208, P308) are identical to P101 and P102, except they ask about women admitted to the facility with such injuries. Therefore, please refer to the instructions for P101 and P102 above.

Even if a facility, such as a health center, has no operating theater needed for the full treatment of lacerations, questions about this complication should still be asked in order to capture the costs of any partial treatment that may be given—e.g. pain management—before the patient is referred to a higher-level facility.

UTERINE LACERATION/PERFORATION Uterine laceration or perforation is serious condition in which the uterus is physically damaged by mechanical or chemical agents. Since the cause is generally the same, also include in this condition perforation of the bowel and the peritoneum. Questions P109 and P110 (See also P209, P309 and P210, P310)

are identical to P101 and P102, except they ask about women admitted to the facility with such injuries. Therefore, please refer to the instructions for P101 and P102 above.

Even if a facility, such as a health center, has no operating theater needed for the full treatment of perforations, questions about this complication should still be asked in order to capture the costs of any partial treatment that may be given—e.g. pain management—before the patient is referred to a higher-level facility.

P111. Besides attending to patients, [facility] workers have other duties. Estimate the number of work hours per week that each type of worker spends in these activities. (Examples: filling forms, attending meetings, training, etc.) (See also P201, P301)

The respondent should estimate, for each category of worker, the amount of time spent in duties not directly related to treating patients (all patients, not just those with post-abortion complications). Idle time should also be included here. If a cadre spends normal working time in his/her private consult office, this time should also be included. Press the respondent to estimate the number of hours, not percentages.

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The next set of questions refers to the cost of hospitalization. Hospitalization is defined here as a patient who occupies a bed in the facility for at least one night (even if the facility uses some other definition). Likewise, “admission” signifies a stay of one night or more, even if not formally “admitted”. Note that these questions may not apply to health centers. If the facility is not equipped for overnight stays of patients, you should make a note of this in the questionnaire and write “NA” in the boxes of all questions pertaining to hospitalization (P112-P120).

P112. How many women, out of 10 women admitted with incomplete abortion, need to be hospitalized? (See also P212, P312)

You are asking the respondent for his/her expert opinion, based on experience, of the proportion of women with incomplete abortion who need to be hospitalized because of that condition. Post-abortion cases may present with multiple conditions, but the respondent must think only of incomplete abortion when answering this question, in isolation from any other health condition the patient may also have.

If the respondent answers that women are never hospitalized just for incomplete abortion, you should write “0” (zero) in the box.

P113. How many women, out of 10 women admitted with sepsis, need to be hospitalized? (See also P213, P313)

See question P112.

P114. How many women, out of 10 women admitted with shock, need to be hospitalized? (See also P214, P314)

See question P112.

P115. How many women, out of 10 women admitted with cervical/vaginal lacerations, need to be hospitalized? (See also P215, P315)

See question P112.

P116. How many women, out of 10 women admitted with uterine laceration/perforation, need to be hospitalized? (See also P216, P316)

See question P112.

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P117. Thinking only about women who are hospitalized, estimate the average number of nights of hospitalization for each of the following complications:

a. Incomplete abortionb. Sepsisc. Shockd. Cervical/vaginal lacerationse. Uterine laceration/perforation (See also A217, A317)

Question P117 depends on the responses to questions P112-P116. If the respondent estimated that women were never hospitalized for a particular complication, then P117 should be recorded as “0” (zero). (Hint: the condition least likely to need hospitalization is probably incomplete abortion.)

This question also asks the respondent to think of each condition or complication in isolation—e.g., “If a woman’s only condition was [name of complication] and was hospitalized, on average for how many days would she be hospitalized?”

We define hospitalization here to be a stay of one or more nights in a bed in a hospital or other facility.

P118. Do patients pay part of the fee for hospitalization? (See also P218, P318)

This question is straightforward. If the response is “No”, then skip to question P120.

P119. Do patients pay a fee for hospitalization? If so, how much do they pay per day for hospitalization (in Rwanda francs)? (See also P219, P319)

This question is straightforward. If, however, there happen to be different rates charged under different circumstances, ask the respondent to give his/her best estimate of an overall average. E.g., if half of all hospitalized patients are charged 2,000 Francs per day and half are charged 1,000 Francs, the best estimate would be 1,500 Francs per day.

P120. Do out-patients pay extra for special items or services? (See also P220, P320)

Out-patients are those who are treated without hospitalization. In the case of Rwanda, items that may be included here are drugs, supplies, laboratory tests

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and x-rays. Do not include co-payments. If the response is “No”, then skip to Section 3.

P121. If so, how much do they pay per visit (in Rwanda francs)? (See also

P221, P321) If there happen to be different rates charged under different circumstances, ask the respondent to give his/her best estimate of an overall average. E.g., if half of all out-patients are charged 500 Francs per day and half are charged 900 Francs, the best estimate would be 700 Francs per day. Do not include here any other special fees (e.g., a laboratory fee), only a fee paid by all out-patients.

P122. Do in-patients pay extra for special items or services? (See also P222, P322)

In-patients are those who are treated after being hospitalized. In the case of Rwanda, items that may be included here are meals, drugs, supplies, laboratory tests and x-rays. Do not include co-payments. If the response is “No”, then skip to Section 3.

P123. If so, how much do they pay per visit (in Rwanda francs)? (See also

P223, P323) See question P121.

Section 3: Capital and Overhead Expenses

Data on capital and overhead costs are difficult to obtain, yet they are significant components of the overall cost of care. Again, it is important to remind the respondents that we are seeking their best estimates, their expert opinions and that these are better—even if they are guesstimates—than no answer at all.

K001. How many regional hospitals are in the health system? This question appears only in Questionnaire A1. Exceptionally, K001 should be answered from official statistics if possible. If it is not possible, enter the respondent’s best estimate. Consider only regional hospitals that are actually in operation.

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K002. How many district hospitals are in the health system? This question appears only in Questionnaire A1. Exceptionally, K002 should be answered from official statistics if possible. If it is not possible, enter the respondent’s best estimate. Consider only district hospitals that are actually in operation.

K003. How many health centers are in the health system? This question appears only in Questionnaire A1. Exceptionally, K003 should be answered from official statistics if possible. If it is not possible, enter the respondent’s best estimates. Consider only health centers that are actually in operation.

K004. Estimate the average total number of cases per year for each type of facility. This number represents the total number of cases (male and female, child and adult) that are treated by a health facility in one year (the most recent 12 months).

K005. Estimate the percentage of cases that are related to maternal and newborn health (MNH) for each type of facility.This number represents the total number of cases relating to maternal and newborn health (but not child health) that are treated by a health facility in one year (the most recent 12 months).

N.B.: QUESTIONS K006 AND K007 HAVE BEEN DROPPED FROM QUESTIONNAIRE A1. THE QUESTION NUMBERING, HOWEVER, HAS NOT BEEN CHANGED TO AVOID POSSIBLE EDITING ERRORS.

K019. The Government supports the training of medical personnel (doctors, nurses, health technicians) through various subsidies. Estimate the annual value (in Rwandan francs) of the following: incomplete abortion, sepsis, shock, lacerations and perforations.Question K019 tries to get at public investment in human capital (trained, skilled health providers). Investments in education that individuals or their households make should not be counted. Government subsidies should be for operational expenses of the training institution, not for capital improvements.

K101. Estimate the average total number of cases per year in your [facility]. (See also K004, K201, K301)

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A “case” is defined as a patient (male or female) in a facility where service or a referral is provided. One treatment to a patient may require one or more visits.

Note that the total number of “cases” may be kept in different registers: the antenatal and maternal register, the immunization register and the out-patient department register. Remind the respondent of this and make sure that his/her estimate includes cases of all three types.

K102. Estimate the percentage of cases that are related to maternal and newborn health in your [facility]. (See also K005, K202, K302)

The respondent is asked to estimate the percentage of all cases (male as well as female cases) that are related to maternal or newborn health. “Newborn” generally refers to the first week of life.

K103. Now think only of women who present at your regional hospital with post-abortion complications. Estimate the following referral rates (i.e., the percent of your regional hospital’s PAC patients (cases) who come from district hospitals by referral): (See also K008, K203, K303)

For example, suppose K103 is estimated to be 20% by the respondent. This would mean that 20% of all women with post-abortion complications who present at the regional hospital for treatment were referred from district hospitals. Note that this question varies by type of facility—thus questionnaires A2, A3 and A4 differ for this question, but the instructions apply to all variations.

The next set of questions refers to capital costs. It is difficult to obtain precise figures for these items, so you should ask the respondent, as an expert, to give his/her best estimate for each cost. All costs should be given in Rwanda francs. The officer in charge of building maintenance may be best able to answer these questions.

K104. Estimate the cost of constructing and fully equipping this [facility]. (See also K009, K011, K013; K204, K304) Equipment includes office furniture, vehicles, special machines, sterilization equipment, laboratory equipment, OR equipment, X-ray machines, sonograph equipment, etc. We expect only a rough estimate of this cost.

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If the premises are rented, write the monthly cost of rent in the margin and make a note on the questionnaire. Then, the respondent should still be asked to estimate the cost of fully equipping the facility.e

Note that in Questionnaire A1, this question is broken down into three questions, one for each level of facility.

K105. Estimate the average lifetime (years of useful service) of this [facility]. (See also K010, K012, K014; K205, K305)

Again, only an approximate estimate can be expected from the respondent here. You can prompt by asking how long other similar facilities have been used before being replaced or refurbished. If there are government guidelines about the service lifetime of this type of facility, and if the respondent believes that they are actually being followed, use the official figure.


Providers’ Salaries. The next two questions ask about average monthly salaries for workers in the facility. Estimate salaries for the average worker in each job category according to your experience. When estimating salaries, include benefits such as pension contributions, insurance contributions. Other forms of compensation such as hardship pay, etc. should be included, but do not include annual leave. Estimates should be of gross salaries, that is, salaries before any deductions are made (e.g., for taxes, health insurance, pension contribution, etc.).

K106. Estimate the average monthly gross salary of each category of medical personnel (in Rwanda francs). (See also K017, K206, K306)

Calculating salaries can be complicated. We need estimates that reflect the normal (average) monthly amounts paid to the various worker categories in the facility. Respondents may be more willing to give such estimates, as they will not reveal the actual salary of any worker in particular. Write “NA” in the appropriate box for worker categories not present in the facility.

When estimating salaries include benefits such as pension contributions, insurance contributions, housing subsidies, food subsidies, “responsibility

e If the facility is rented, special instructions will apply to this datum at the time of data entry.

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allowance” (e.g., nurses in private hospitals can be qualified to do a simple Cesarean operation), and duty allowance. Do not include annual leave.

If the facility employs expatriate professionals who are paid at an international salary level, they should be excluded from the respondent’s estimations.

Note that in the case of the central level (Questionnaire A1) the question (K017) refers to each of the three lower levels of facility.

Experience from a Ugandan study: A similar study recently carried out in Uganda found that some respondents would not answer salary questions for categories of workers not found in their facilities. For example, at a health center where no anesthetist is on staff, a respondent may not venture to offer an opinion about an anesthetist’s average salary. If, after repeated attempts to solicit a reply, a respondent refuses to answer, mark “NA” as the answer (no

answer).

K107. What is considered the normal number of hours that a full-time worker works in one year at your [facility]? (See also K018, K207, K307)

For example, if the work norm is 40 hours per week and 48 weeks per year, then the number of hours worked per year for full-time employees is: 40 x 48 = 1920 hours. (The personnel office may have this datum readily available.) Ask if there are a number of statutory holidays and other “personal” days. If so, these should be deducted from the total. Do not deduct sick days.

K108. With regard to the treatment of incomplete abortion, how often is manual vacuum aspiration (MVA) used? Out of 10 treatments of incomplete abortion, in how many are MVA used in your hospital? (See also K208, K308)

Since MVA is an increasingly important method for treating incomplete abortion in Rwanda, question K108 asks the respondent to estimate how many times MVA is used out of 10 cases of incomplete abortion. The range is “0” (never used) to “10” (always used).

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In general, we are collecting estimates of on-the-ground

reality, not what the standard or ideal should be.


K109. The MVA kit may be sterilized and reused. How many times does your hospital reuse MVA kits before discarding them? (See also K209, K309)

The norm for reuse of MVA kits is 50 uses. However, record whatever answer the respondent gives. Do not prompt.

The next set of questions asks about overhead costs. These costs are general expenses of this regional hospital that are essential for it to function and supply all of its services. The responses should be the respondent’s best estimates. Remind him/her again, that you realize that such data are difficult to find, so you are seeking his/her expert opinion or estimate. The facility’s accountant may be best placed to answer these questions.

K150. How many of each type of worker are actually employed at your [facility]? (See also K050, K052, K054; K250, K350)

Ask the respondent to answer in terms of “full-time equivalents” over a one year reference period. E.g., if a certain worker works half-time, “0.5” should be entered. Write “0” in the appropriate box for worker categories not present in the facility.

Collect estimates of numbers of workers actually employed, not the number of posts that are sanctioned or budgeted. In general, we are collecting estimates of on-the-ground reality, not what the standard or ideal should be.

Probe for other workers in the facility not listed in the questionnaire and write down their designation in the boxes marked “Other”. Continue adding worker categories outside the table if necessary.


K151. What is the average monthly salary for each type of worker—full-time, include benefits but not annual leave? (in Rwanda francs) (See also K051, K053, K055; K251, K351)

Refer to question K106 for instructions on salary information.


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K152. In cases where cleaning and/or security are out-sourced (contracts with private security or cleaning companies) in the regional hospital, how much is paid monthly for these services? (See also K252, K352)

Questions K150 and K151 have entries for “guards” and “cleaners”. These are regular employees of the facility. However, facilities may have no such personnel on staff, instead contracting security and cleaning services from private companies. If a service is not contracted out, enter “0” as the monthly amount for that service.

If K152a is answered (that is, security is out-sourced), then K150a and K151a must be zero (that is, no guards can be employed). If K152b is answered (that is, cleaning is out-sourced), then K150b and K151b must be zero (that is, no cleaners can be employed).

K153. Estimate the annual cost of each category of overhead expense at your [facility]. (Rwanda francs) (See also K056, K057, K058; K253, K353)

The respondent’s best estimates are what are required here. Some respondents may have a tendency to start looking for old receipts or expenditure reports. Since precise amounts are not needed you should steer the respondent away from doing so by emphasizing that we do not need exact figures. Otherwise, the length of the interview may be unduly prolonged.


2.2. Questionnaire B – Costs of Drugs, Supplies, Materials

Questionnaire B is an instrument for collecting detailed information on the physical inputs used in treating five post-abortion complications. It is a long questionnaire—you may need two sessions with the respondent to fill it out completely. Do not let fatigue to lower the quality of the responses. If you note that the respondent is getting tired (or bored), politely suggest that the interview could be suspended for a coffee/tea break and resumed in an hour or two.

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The respondent must be the medical practitioner in the facility with the most experience in the treatment of PAC patients.

This questionnaire was developed from experiences in several countries. It’s origin is the World Health Organization’s Mother and Baby Package. For that reason, it tries to be inclusive, listing many variations of drugs, not all which will be used in the facility you are surveying. Thus, for many rows (inputs) you will be filling in zeros—meaning that that input is not used in that facility for that treatment. It is very important that ALL boxes be filled in, either with zeros or with numbers. DO NOT LEAVE ANY BOXES BLANK.

Again, it is very important to inform the respondent at the beginning of the interview that you want his/her expert opinions and best estimates. For example, patients with the same complication may receive different doses of the same drug depending on the severity of the symptoms. The respondent, based on years of experience, should give an average estimate of the amount of the drug the average case will be given. If the respondent is unable or unwilling to give a point estimate (one, single number), then write down the range he/she states. Try to avoid range-type answers as far as possible, as it will make the data coding process longer and slower.

Experience from a Ugandan study: A similar study recently carried out in Uganda found that some respondents preferred to give dosage amounts based on a patient’s body weight. For example, a response might be “60 milligrams of drug X per 75 kilograms of body weight”. In such cases the interviewer should write down the answer as given. Later that day, after interviews are finished for the day, the interviewer—while reviewing the questionnaires filled out during the day—should calculate the proper answer. In this study we use 50 kilograms as the average body weight. Answers should be calculated according this standard.

Example 1: The respondent answers “60 milligrams of drug X per 75 kilograms of body weight is administered on average (over the course of the whole treatment)”. The calculated answer should be “40 milligrams of drug X”, since 60 x (50 / 75) = 40.

Example 2: The respondent answers “250 milligrams of drug Y per 100 kilograms of body weight is administered on average (over the course of the whole treatment)”. The calculated answer should be “125 milligrams of drug Y”, since 250 x (50 /100) = 125.

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Specific Interviewer Instructions

1. Data must be entered for each input into columns D, E, G and H. It is not acceptable to leave any cells blank--such questionnaires are considered to be incomplete.

2. Many inputs will not be used in a particular facility. These inputs must still be coded with zeros in columns D, E, G and H. Blank cells are not allowed.

Columns D and E3. Columns D and E are to be filled in with percentages. Therefore, each cell in these columns must be filled in with a percentage from 0% to 100%. No other values are acceptable and blank cells are not allowed.

4. Each answer in column D must be considered in terms of outpatients only (NOT all patients). For example, if "75%" is entered, it means that 75 percent of all outpatients with a particular complication (shock, sepsis, etc.) receive the input.

5. Each answer in column E must be considered in terms of inpatients only (NOT all patients). For example, if "85%" is entered, it means that 85 percent of all inpatients with a particular complication (shock, sepsis, etc.) receive the input.

Columns G and H6. Columns G and H are to be filled in with numbers. The numbers signify the number of basic units (basic units are shown in column F) that are administered during the whole course of treatment for that particular complication (shock, sepsis, etc.). Ranges are not allowed, only one number should be entered per cell. E.g., "30-40" is not acceptable; the interviewee must be asked to give his/her best point estimate (e.g., "35").

7. Each answer in column G must be considered in terms of outpatients only (NOT of all patients). For example, if "800" is entered, it means that outpatients with a particular complication (shock, sepsis, etc.) on average receive 800 basic units of the input.

8. Each answer in column H must be considered in terms of inpatients only (NOT of all patients). For example, if "1200" is entered, it means that inpatients with a particular complication (shock, sepsis, etc.) on average receive 1200 basic units of the input.

9. The data entered in columns G and H often need to be calculated. The data should always represent the number of basic units given over the entire course of treatment. The following examples should be studied:

● If 4 tablets containing 200 mcg of a medicine are given each day for 3 days, then "2400" should be entered [4 x 3 x 200 mcg = 2400 mcg].● If 2.5 grams of a medicine is given in total and the basic unit (shown in column F) is "mg", then "2500" should be entered [1 g = 1000 mg].

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● If 4.5 liters of a medicine (in liquid or gaseous form) are given in the course of treatment and the basic unit (shown in column F) is "ml", then "4,500" should be entered [1 liter = 1000 ml].● If a medicine is in solution, the proper calculation may be complicated. If a solution contains 3 mg / ml and 50 ml are administered in total, then "150" should be entered, if the basic unit (shown in column F) is "mg" [since 50 ml of the solution contain 3 x 50 = 150 mg of the drug].

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Annex 1: The Consent Form

My name is _________________________ working with the School of Public Health, National University of Rwanda, and the Ministry of Health. The School of Public Health, in collaboration with the Ministry of Health, is conducting a national study to assess abortion care. We would like to ask for your cooperation in getting a better picture of the situation in Rwanda. This research will provide information about the reproductive health care system in Rwanda, which will contribute to the improvement of women’s health here.

You were selected to respond to this questionnaire because of your position at this health facility. Your responses in this study will be completely confidential and will be used for research purposes only. No reference will be made to individual responses to this survey of health-care establishments. We will combine your responses with those from representatives of other health-care establishments to give a general picture of the practice of abortion care in Rwanda.

To benefit from your extensive experience, may I request that you kindly provide your best estimates to these questions? Responding to the questionnaire will take approximately 45 minutes. Your responses to this questionnaire will be completely confidential and will be used for purposes of this research project only.

Do I have your permission to proceed with the interview? _____Yes ______No

Thank you.

If you have any questions about this survey or the study please call Dr. Francine Birungi, School of Public Health, National University of Rwanda. Dr. Birungi may be reached at +0250 648 650 or by email at [email protected].

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mailto:[email protected]

questionnaire: cost of unsafe...

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