rwanda health service costing - msh · 2020. 1. 3. · 2. costing tools the most efficient way to...

REPUBLIC OF RWANDA

MINISTRY OF HEALTH

October 2011

RWANDA HEALTH SERVICE COSTING

HOSPITAL ANALYSIS

Rwanda Hospital Costing Analysis 30 October 2011

This study was made possible through the support for the Integrated Health System Strengthening Project funded by the U.S. Agency for International Development (USAID), under the terms of Contract GHS-I-00-07-00006-00, Task Order GHS-I-06-07-00006.

Abstract

The Rwandan Ministry of Health, in collaboration with the USAID-funded Integrated Health Systems Strengthening Project (IHSSP), carried out a study to determine the costs of providing hospital services. The results of the costing were intended for use in re-designing insurance reimbursement mechanisms and levels. The results can also be used for other purposes, such as resource allocation, budgeting and comparisons of efficiency.

The figures were derived from the actual services and expenditures at a sample of 4 well-performing district hospitals and from one referral hospital (CHUK). A step-down process was used to estimate the bed-day and outpatient cost costs and various allocation factors were used. These figures were combined with standard activity-based costs to develop a small number of diagnosis-related group costs.

Based on the average of the four district hospitals, the model used 243 beds of which 152 were occupied and it had 55,547 bed days and 23,535 outpatient visits. The total cost was RWF 667 million. The average cost per bed day ranged from RWF 5,710 in the Nutrition Rehabilitation Unit to RWF 13,118 in the Gynecology and Maternity Unit. The referral hospital had much higher bed day costs, ranging from RWF 21,442 in the Internal Medicine Unit to RWF 82,327 in the Obstetrics and Gynecology Unit (which includes Theatre costs).

The DRG direct costs were based on standard treatment procedures and resource needs developed by a group of experts. The DRG indirect costs were taken from the step-down analyses. The total DRG costs also varied considerably. At a district hospital, for example, a case of acute diarrhea cost RWF 15,221, based on an ALOS of 5 days. On the other hand, an abdominal emergency due to peritonitis or occlusion cost RWF 219,848 based on 15 days in hospital and a surgical intervention. A case of severe pediatric malaria was between these figures, with a cost of RWF 115,928.

Significant challenges were encountered in data collection. It was hard to obtain accurate data on the numbers of services provided, on staffing, and on some ancillary department services, and it was not possible to collect any data on the use and distribution of drugs and medical supplies since the recording systems are weak. It will be important to improve the quality of the data used so that the exercise will be easier and the results will be more accurate. The models can be updated and adapted by the MOH in accordance with their needs and people from the MOH and the School of Public Health have been trained to use and teach the models.

Recommended Citation

This report may be reproduced if credit is given to the USAID’s Integrated Health System Strengthening Project led by Management Sciences for Health. Please use the following citation:

Collins, D., J.L. Mukunzi, Z. Jarrah, C. Ndizaye, P. Kayobotsi, C. Mukantwali, B. Nzeyimana, and M. Cros. Rwanda Health Service Costing: Hospital Analysis. October, 2011. Management Sciences for Health. Submitted to USAID by the Integrated Health System Strengthening Project. Information shown in the Annexes may not be quoted or reproduced separate from the rest of the document without the written permission of the Rwandan Ministry of Health or Management Sciences for Health.

Key Words

Rwanda, hospital, cost, diagnosis-related groups.


Disclaimer

The authors’ views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development, the United States Government or the Government of Rwanda.


ACKNOWLEDGMENTS

This Costing Exercise represents a collaborative effort between the Government of Rwanda and the United States

Agency for International Development (USAID). It was conducted for the Ministry of Health with the support of the

USAID funded Integrated Health System Strengthening Project.

Under the costing steering committee led by the Honorable Minister of Health, Dr Agnes Binagwaho, this analysis

was produced by David Collins, Management Sciences for Health; Jean Louis Mukunzi, Ministry of Health; Zina

Jarrah, Management Sciences for Health; Cedric Ndizeye, Integrated Health System strengthening Project/ MSH;

Pascal Kayobotsi, Integrated Health System strengthening Project/ MSH; Christine Mukantwali Integrated Health

System strengthening Project/ MSH; Bonaventure Nzeyimana, Ministry of Health; Marion Cros, Management

Sciences for Health.

This exercise would not have been finalized without the usual support of all the stakeholders who are involved in the

health system strengthening in Rwanda.


Table of Contents Executive Summary ................................................................................................................................. 6

1. Introduction .................................................................................................................................... 7

2. Costing tools .................................................................................................................................... 7

3. Methodology ................................................................................................................................... 8

4. Results ........................................................................................................................................... 12

5. Conclusions and recommendations ............................................................................................... 20

Annexes ................................................................................................................................................ 22

Annex 1: District Hospital Internal Medicine DRG and priority case costs in 2009 (RWF) .................... 23

Annex 2: District Hospital Pediatric DRG and priority case costs in 2009 (RWF) .................................. 24

Annex 3. District Hospital Obstetrics and Gynecology DRG and priority case costs in 2009 (RWF) ...... 25

Annex 4: District Hospital Surgical DRG and priority case costs for 2009 (RWF) .................................. 26

Annex 5: Referral Hospital Internal Medicine DRG and priority case costs in 2009 (RWF) ................... 27

Annex 6: Referral Hospital Pediatric DRG and priority case costs in 2009 (RWF) ................................. 28

Annex 7: Referral Hospital Obstetrics and Gynecology DRG and priority case costs in 2009 (RWF) ..... 29

Annex 8: Referral Hospital Surgical DRG costs in 2009 (RWF) ............................................................. 30

Annex 9: Referral Hospital Surgical non-DRG priority case costs in 2009 (RWF) (Part 1) ..................... 31

Annex 9: Referral Hospital Surgical non-DRG priority case costs in 2009 (RWF) (Part 2) ..................... 32

Annex 10. References ........................................................................................................................ 33


Executive Summary

The Rwandan Ministry of Health (MOH), in collaboration with the USAID-funded Integrated Health Systems Strengthening Project (IHSSP), has undertaken a costing exercise to determine the costs of providing the Paquet Minimum d'Activités (PMA) and the Paquet Complémentaire d’Activités (PCA). The results of the costing are intended for use in re-designing insurance reimbursement mechanisms and levels. The costing can also be used for other purposes, such as resource allocation, budgeting and comparisons of efficiency.

The goal was to determine the actual cost of services at the health center (including community services), district hospital, and referral hospital levels. At the health centre level the objective was to estimate the cost of each service included in the PMA. At the hospital levels, the objective was to estimate the cost of each case treated and then to group them into Diagnosis Related Groups (DRGs). The classification of cases was based on the World Health Organization (WHO) codes and norms and standards for Rwanda as identified by the MOH.

This report covers the estimation of hospital bed-day and outpatient visit costs and DRG costs. A separate report was prepared for health centre costs.

The figures used in the study were derived from the actual services and expenditures at a sample of 4 well-performing district hospitals and from one referral hospital (CHUK). A step-down process was used to estimate the bed-day and outpatient cost costs and various allocation factors were used. The four district hospitals varied significantly in terms of numbers of beds and patients, service mix, staffing levels and total expenditures. The average cost per inpatient day also varied across the hospitals but not enough to invalidate the use of the figures to estimate the national averages.

Based on the average of the four district hospitals, the model had 243 beds of which 152 were occupied and it had 55,547 bed days and 23,535 outpatient visits. The total cost was RWF 667 million. The average cost per bed day ranged from RWF 5,710 in the Nutrition Rehabilitation Unit to RWF 13,118 in the Gynecology and Maternity Unit. The referral hospital had much higher bed day costs, ranging from RWF 21,442 in the Internal Medicine Unit to RWF 82,327 in the Obstetrics and Gynecology Unit (which includes Theatre costs).

The DRG direct costs were based on standard treatment procedures and resource needs developed by a group of experts. The DRG indirect costs were taken from the step-down analyses. The total DRG costs also varied considerably. At a district hospital, for example, a case of acute diarrhea cost RWF 15,221, based on an ALOS of 5 days. On the other hand, an abdominal emergency due to peritonitis or occlusion cost RWF 219,848 based on 15 days in hospital and a surgical intervention. A case of severe pediatric malaria was between, with a cost of RWF 115,928.

Significant challenges were encountered in data collection. In particular, it was hard to obtain accurate data on the numbers of services provided, on staffing, and on some ancillary department services. Importantly, it was not possible to collect any data on the use and distribution of drugs and medical supplies since the recording systems are weak. It will be important to improve the quality of the data used so that the exercise will be easier and the results will be more accurate. The models can be updated and adapted by the MOH in accordance with their needs and people from the MOH and the School of Public Health have been trained to use and teach the models.


1. Introduction

The Ministry of Health in Rwanda (MOH), in collaboration with the USAID-funded Integrated Health Systems Strengthening Project (IHSSP), has undertaken a costing exercise to determine the costs of providing the Paquet Minimum d'Activités (PMA) and the Paquet Complémentaire d’Activités (PCA). The results of the costing are intended for use in re-designing insurance reimbursement mechanisms and levels but can also be used for other purposes, such as resource allocation, budgeting and comparisons of efficiency.

The goal was to determine the actual cost of services at the health centre (including community services), district hospital, and referral hospital levels. At the health centre level the objective was to estimate the cost of each service included in the PMA. At the hospital level, the objective was to estimate the cost of each case treated and then to group them into Diagnosis Related Groups (DRGs). The classification of cases was based on WHO codes and norms and standards for Rwanda as identified by the MOH.

This report presents the results of the analysis of bed-day and outpatient visit costs at the hospital level and the results of the DRG cost analysis. It covers both district and referral hospitals.

2. Costing tools

The most efficient way to calculate health service costs is using computerized costing tools. The use of computer tools allows costs to be re-calculated quickly when new activities are added or procedures or prices change. Tools should be open source and should be built in a spreadsheet program that people are familiar with, such as MS Excel. Tools should allow the user to have an understanding of where the data goes and how calculations are made; they should be simple to use and modify and training needs should be minimal. In addition, tools should not be require so much memory that they are difficult to run or to transfer by e-mail.

From time to time the MOH will need to update resource prices, add new activities, and change resource types and mixes to reflect changes in procedures. Minimal training should be required to use the tools, and once this has been given, the tools should not require external technical assistance every time they are used.

The normal way to estimate the actual costs of hospital services is using a step-down model1. After a review of available tools and the above criteria it was decided that an existing spreadsheet tool (HOSPICAL) should be modified for Rwandan use. A separate spreadsheet tool was developed for costing DRGs. When developing the methodology and the tools we have attempted to make them easy to understand, use and modify and not dependent on information that data that is difficult or time-consuming to obtain. In addition, we have tried to keep them small enough so they can be downloadable and shared by e-mail.

1 This methodology is described in Designing and Implementing Health Care Provider Payment Systems: How-To Manuals; Edited by John C. Langenbrunner, Cheryl Cashin, and Sheila O’Dougherty. World Bank/USAID, 2009.


3. Methodology

Hospital bed-day and visit costs

The methodology used for calculating bed-day outpatient visit costs and was similar to one used previously in a previous study (Beaston Blaakman, 2008)2 and the results of the two studies are compared later in this document. That 2008 study did not produce detailed DRG costs for inpatient cases.

A small sample of hospitals was selected for the development of average district hospital bed-day and outpatient visit costs. An initial sample of 3 well-performing district hospitals was selected in conjunction with the MOH: Nyamata, Kibogora and Kibagabaga. An additional hospital, Ngarama, was selected as a hospital that was considered not well-performing so that costs could be compared. At the request of the MOH, Rwinkmwavu and Ruhengeri District Hospitals were later added to the sample. However, during the data collection process difficulties were encountered in collecting data from some hospitals and the final sample was Nyamata, Kibogora, Kibagabaga and Ruhengeri.

Centre Hospitalier Universitaire de Kigali (CHUK) and (Centre Hospitalier Universitaire de Butare) CHUB were selected by the MOH as referral-level hospitals. It was considered that a small sample was appropriate initially to see how difficult it would be to collect data and to see how much variations in data existed. As it proved to be quite difficult we did not expand the sample.

During the data collection process for (CHUB) we discovered that the service data are not included in the national HMIS system and that complete records and/or reports are not produced by the hospital. It was, therefore, decided to omit this hospital from the sample and costs were not calculated.

The hospital bed day and visit costs were based on actual expenditures from the sample of hospitals. We also obtained original budget requests so that we could estimate any possible underfunding that might represent a gap between the actual and standard (needed) costs.

Only recurrent hospital costs were included because the purpose of the study was to produce costs that can be used to set reimbursement rates, and it is unlikely that capital costs would be included in these calculations because they are generally funded from government capital budgets or donations. In addition, capital costs (e.g. construction, renovation, and major equipment) vary across facilities and over years and it is difficult and time-consuming to calculate depreciation. We also excluded the costs of supervision and support of district activities since they do not relate to the costs of hospital services.

Before describing the steps it is useful to deal with some definitions:

• General Departments: Departments such as administration and maintenance, that provide services to all ancillary and clinical departments.

• Ancillary Departments: Departments that support the clinical functions, such a laboratory, radiology, physiotherapy, and operating theatre.

• Clinical Departments: Departments that provide clinical services, such as Internal Medicine and Pediatrics. • Allocation Factors: The factors used to allocate the costs from one department to another, for example, the

cost of administrative services to the Internal Medicine Department. • Unit cost per bed day: The average cost of having one patient for one day in an inpatient department. • Unit cost per visit: The average cost of one outpatient visit to a hospital.

2 2006 Rwanda Health Centre and Hospital Cost Study. Twubukane Decentralization and Health Project.


Step-Down Process

The step-down methodology entails identifying the direct costs for each cost centre (department), allocating indirect costs across those departments, and assigning the costs of ancillary departments to clinical departments. Direct costs are those that can be identified with a specific department, for example, the cost of X-ray film which is only used in the radiology department. Indirect costs are those that cannot be identified with one specific department and have to be allocated across several departments. Where the costs and services of an ancillary department can be identified directly with a particular clinical department they assigned to that department. The final clinical department costs are then used to calculate a cost per bed day and per outpatient service. For inpatient services, the cost per bed day is then multiplied by the expected length of stay for selected cases or case groups to arrive at a cost per case type or group. The detailed steps used for Rwanda were as follows:

1. Identify the general, ancillary and clinical departments that will serve as cost centres. The clinical departments are the same as those identified during the DRG selection process.

2. Obtain the total expenditures of the hospital, broken down by resource type (e.g., staff, drugs) and the income by source. Include donor-funded resources and donated goods and services.

3. Remove expenditures that do not relate to hospital services (e.g. district supervision). 4. Remove capital and other non-recurrent expenditures. 5. Identify the number of each type of staff employed and their remuneration (e.g. salary, allowances, bonuses

etc.) and related employer costs (e.g. social security, health insurance). 6. Identify the distribution of staff across departments. If staff members are shared across departments

estimate the time distribution. 7. Compare the numbers of staff with the MOH norms. 8. Compare actual expenditures with requested budget funding to determine if the facility might be

underfunded. 9. Assign the direct expenditures to each department, including staffing. 10. Allocate the accumulated costs of the general departments (e.g., administration and maintenance) to the

ancillary and clinical departments. 11. Allocate the total “loaded” cost of each ancillary department to each clinical departments based on the

ancillary services used. 12. Divide the total cost for each inpatient clinical department by the number of bed days to arrive at the average

cost per bed day for that department. Divide the cost of the outpatient department by the number of visits to get the average cost per visit. Multiply the average cost per bed day by the ALOS to get the average cost per hospital inpatient stay.

13. Reconcile the final unit costs with the total expenditure of the hospital.

The allocation factors used were as follows:

1. Staff costs were allocated in proportion with the monthly salaries and related costs for the staff working in each cost centre.

2. Administration and maintenance costs were allocated to the other cost centres in proportion to staff costs. 3. Transport costs were allocated on the basis of staff and other direct costs. 4. Social service costs were allocated on the basis of numbers of discharges and outpatient visits. 5. Clinical management costs which were allocated on the basis of clinical staff numbers. 6. Patient food and laundry costs were allocated on the basis of bed days.


7. The central stores costs were allocated using proportions from Rwinkmwavu, which was the only district hospital that kept records of issues.

8. The distribution pharmacy costs were allocated on the basis of outpatient visits and inpatient bed-days. 9. The laboratory, radiology and physical therapy costs were allocated using proportions derived from

hospital registers. In cases where they were not recorded we used proportions from another district hospital. 10. The operating heater costs were allocated based on HMIS reports of quantities of services performed. 11. Emergency care costs were allocated on the basis of inpatient admissions.

After the data had been entered in the model the data and results were presented to hospital staff in a validation workshop and, in some cases, the hospitals provided corrected and additional information which was used to update the figures.

DRG Costing

The purpose of selecting Diagnosis Related Groups (DRGs) was to develop costs which may be used in the future as a basis for reimbursing facilities by DRG3. It was recognized that it would not be feasible to cost all the different case types in a short space of time, due partly to limitations in data availability (e.g. absence of computerized patient records in most hospitals). It is also recognized that it would not be wise to try to implement a wide range of DRG prices initially. The aim was, therefore, to select cases that would make between 20 and 30 DRGs.

Definitions

Before describing the steps it is useful to deal with some definitions. The term “case” is used here to cover a clinic case based on a diagnosis. Reimbursement can be for a single type of case or for a group of cases. A case group is defined as “a group of hospital cases that have similar clinical characteristics and resource intensities”4. A case group is the same as a diagnosis related group, since the determination of a case type is based on a diagnosis.

A standard costing methodology was used for the DRG costing since it was not practical to observe and record all the resources actually used for all the DRG cases. Expert groups of Rwandan doctors were chosen by the MOH to select the cases for the DRGs and to determine the types and quantities of resources that are needed to diagnose and treat each case (to be used for the standard costing of the cases).

DRG Steps

Creating DRGs has been described as “a process that is both art and science” where some groupings may rely on statistical analysis, others may rely on expert judgment and many may rely on both.5 For Rwanda, the following methodology was used to select the DRGs for costing.

1. The first step was to identify the types of case treated in Rwanda at the different levels (health centre, district hospital, referral hospital). The World Health Organization International Classification of Diseases (ICD) 10 classification was used as the basis for this.

2. The ICD 10 has 22 Chapters which are broken out into 69 Sub-Groups. These 69 Sub-Groups are further broken out into 1,269 blocks (Level 2 Sub-Groups). Each block is then broken out still further into sub-

3 The Rwandan MOH decided that it is more likely to implement a case-based payment system and not a procedure-based payment system. The costing was therefore based on case types (using DRGs) and not on procedures. The Australian Condensed Classification of Health Interventions was not used as it classifies procedure and interventions (for use instead of ICD 10 classifications where simpler payment mechanisms are desirable). 4 Langenbrunner et al, 2009 5 Langenbrunner et al. 2009.


blocks which represent the most specific case types and is the lowest level of detail. There are around 14,000 of these sub-blocks in total.

3. Of the 22 chapters, 19 were selected by the expert group as relevant for Rwanda6. The expert group then went through each chapter and classified each block according to several criteria: (1) if the type of case is treated in Rwanda, and, if so, at what level; and (2) if the type of case is high priority because it is frequently provided, is likely to have a high cost and/or has a high impact on mortality or morbidity. The expert group did not go down to the level of the sub-blocks.

4. Within the 19 selected chapters, a total of 1,248 blocks were deemed to be provided in Rwanda at one or more levels of care (referral hospital, district hospital or health centre). These 1,248 blocks fall within 69 Sub-Groups. Of these 1,248 blocks, 192 were selected from 67 sub-groups as high priority for costing in the current exercise, 268 were selected for costing in 2011/12 and the remaining 788 were left for the future.

5. At the health centre, all the services provided in the Minimum Package of Services were costed and the selected list of case types was checked against the MPA.

6. Hospital outpatient services were grouped by department and costed on a per visit basis. 7. The list of 192 Level 2 Sub-Groups were reviewed for errors and were compared with the District Hospital

Health Information System7 (DHHIS) reporting categories8. Level 2 Sub-Groups that were not in the DHHIS were be bundled into case groups or were removed from the list for costing in this current exercise.

8. The grouping of cases into DRGs was based on the clinical and economic homogeneity of the case types. Each DRG only contain cases that are similar anatomically and belong to one group of diseases. Each DRG also only contains cases which, on average, have a similar resource intensity and cost for the range of diagnostic and treatment services needed to completely diagnose and treat the case. The resource intensity was estimated using the standard cost developed for each case.9

9. The indirect costs of each case were determined from the bed-day and visit costing exercises. 10. Consideration was not currently being given to breaking down the DRGs by sex and or age for services that

are not sex or age-specific (e.g. Pediatric and Maternity services) due to the added complexity. 11. Cases that were not included in the DRGs were costed using the Average Length of Stay (ALOS) and

average cost per bed-day. 12. The standard costs can be adjusted to actual by applying a factor representing the gap between the

requested budget and actual expenditures. This adjustment was not yet made in the calculation of the figures shown in this report.

13. The bed-day costs shown in this report are based on 2009 expenditures and the DRG standard costs are based on 2009 resource prices. The costs can be adjusted easily in the model since a place for an inflation factor was included in the model.

6 The other 3 chapters cover external causes of mortality and morbidity, factors influencing health status and codes for special purposes. 7 The same categories are reported for Referral Hospitals. 8 It was agreed in the meeting with the Costing Steering Committee that the DRGs used for the costing exercise must match the HIS categories and will be the same that would be used in the billing system and in patient records. 9 Each DRG should contain enough hospital cases to produce stable aggregated estimates of cost per case in repeated samples.


Data collection

The costing started in 2010 and it was agreed that the costs would be calculated for calendar year 2009, which was the last complete financial year.

Service data were initially collected from the national HMIS. However, an analysis of those reports showed that there were gaps (both missing months, which were adjusted for, and missing data types). There were also instances where data in different sections of the reports should agree but did not. It was, therefore, necessary to collect lot of additional service data at the hospitals. In addition, ancillary department data were generally insufficient to allow for the accurate allocation of those costs across departments. None of the four district hospitals had complete records that showed the cost of drugs and medical supplies issued to the clinical departments and records of drugs issued to patients were not computerized and not stored in a way that could easily be analyzed. And in many cases, the registers for laboratory, radiology and physical therapy did not show for which departments the services were provided. Although we requested and received information on donated goods and services received by the hospitals it is likely that it was not always complete since records are not routinely kept.

Limitations

There are several limitations in the methodology that should be noted. These are the following:

1. The cost of drugs reflects the expenditure made in the year and not the cost of drugs issued. There can be significant differences in these figures due to factors such as large purchases near the year-end that are not issued during the year and stock losses.

2. We were unable to obtain cost estimates for each different kind of laboratory test and for blood (which was handled by the laboratory) and we, therefore, used an average cost for all tests. The same was true for radiology and other imaging examinations, and also for physical therapy.

3. The numbers and allocation of staff and related costs were based on the payroll records for a sample month during the year. Since staffing and salaries change during the course of the year, the allocation of the total staffing expenditures was, therefore, approximate.

4. Results

Hospital Services

When the costs were calculated for Rwinkmwavu hospital and compared with the other sampled hospitals it was found that staff levels were much higher at Rwinkmwavu. This would distort the averages significantly and those hospital costs were, therefore, left out of the calculations. The district hospitals used in calculating the average costs were, therefore, Nyamata, Kibogora, Kibagabaga and Ruhengeri.

The 4 hospitals differed significantly in size, both in terms of total beds (from 143 at Nyamata to 383 beds at Ruhengeri) and average occupied beds (106 at Kibogora to 231 beds at Ruhengeri) (Table 1). As was noted previously, Ruhengeri is more of a provincial hospital and is likely to be designated as such in the future. The


hospitals also varied in terms of numbers of services provided, ranging from 38,865 bed days and 12,371 outpatient visits at Kibogora to 80,392 bed days and 32,437 outpatient visits at Ruhengeri. Total costs also varied, ranging from RWF 514 million at Kibogora to RWF 810 million at Ruhengeri. ALOS rates are also shown in the table but this figure cannot be used for accurate comparisons across hospitals because the mix of services is different at each one.

Table 1: Comparison of beds, visits and total costs across 4 district hospitals, 2009

Hospital Total Beds

Occupied Beds BOR

IP Bed Days

Discharges ALOS Per Discharge OP Visits

Total Cost (RWF)

Kibagabaga

203 121 60% 44,236

10,186

4.3 26,940 524,874,035

Kibogora

233 106 46%

38,865

6,460

6.0 12,371 514,016,989

Nyamata

143 135 94%

54,764

6,785

7.2 22,391 692,183,804

Ruhengeri

383 231 60%

80,392

17,854

4.7 32,437 810,879,731 Source: National HMIS

The variations in the mix of services are shown in Tables 2, 3, 4 and 5. In some cases these were significant. At Nyamata Hospital, for example, the greatest number of bed days was in Internal Medicine (16,128), whereas at Kibogora the greatest number was in Surgery (12,071). Bed occupancy rates differed within each hospital and in some cases were quite low10. The ALOS also differed across the hospitals for each department; for example the rate for Internal Medicine ranged from 4.7 days at Ruhengeri to 9.7 days at Nyamata. Based on these variations it is rational that the resources needed and related costs would have been different.

Table 2: Nyamata Hospital services 2009

Clinical Department Total Beds Occupied Beds BOR IP Bed Days

ALOS per Discharge Op Visits

Ambulatory care - - 0% - - 22,391

Internal medicine 50 41 80% 16,128 9.7 -

Gynecology and maternity 34 33 99% 13,195 4.8 -

Surgery 25 29 119% 12,851 11.8 -

Pediatrics 24 29 119% 11,434 6.0 -

Nutrition Rehab - - 0% - - -

Mental health 10 3 29% 1,156 11.3 -

Total 143 135 94% 54,764 7.2 22,391 Source: National HMIS

10 A recommended target rate taking into account infection control and cost-efficiency is 85%.


Table 3: Kibogora Hospital services 2009






Surgery 68 33 48% 12,071 9.8 -

Pediatrics 64 22 35% 8,079 5.2 -

Nutrition Rehab 17 10 58% 3,597 18.2 -

Mental health - - 0% - - -


Table 4: Kibagabaga Hospital services 2009






Surgery 34 31 93% 11,466 23.5 -

Pediatrics 31 25 82% 9,092 4.6 -

Nutrition Rehab 29 4 12% 1,332 14.2 -



Table 5: Ruhengeri Hospital services 2009






Surgery 111 75 68% 27,343 14.8 -

Pediatrics 70 46 66% 16,896 5.5 -

Nutrition Rehab 18 14 75% 4,957 18.9 -



The equivalent figures for CHUK are shown in Table 6. There are a few specialty beds that are not shown in the table.


Table 6: CHUK services 2009

Clinical Department Total Beds

Occupied Beds

BOR IP Bed Days

ALOS per Discharge

OP Visits

Private outpatient (Clinique) 14,938

Polyclinique 54,562

Private wards 30 25 82% 8,987 6.3

Internal medicine (including Prisoners) 104 82 79% 30,086 12.9 Gynecology/Obstetrics (including Theatre) 51 34 67% 12,401 3.6

Surgery (including Neuro Surgery) 103 103 100% 37,758 22.1

Pediatrics (including Neonatology) 111 79 71% 28,723 9.9 Source: CHUK reports

Hospital Unit Costs

The total average cost per outpatient visit and bed day for each department at the 4 district hospitals is shown in Table 7. The table shows the numbers of inpatient bed-days and outpatient visits, the total hospital costs and the average cost per bed-bay or visit. Total hospital costs varied from RWF 514 million at Kibogora to RWF 810 million at Ruhengeri.

Differences in hospital expenditures are normal, of course, since the 4 hospitals are of varying sizes. So what is most important is to compare the total cost with the services that the hospital produces. This cannot be done by comparing the average cost of a service across the whole hospital because the mix of services varies from one hospital to another. The most accurate way and feasible way of comparing the costs is using department averages. The results of this can also be seen in Table 7. Again, the figures show differences across the 4 hospitals. For example the average cost of a bed-day in Internal Medicine ranged from RWF 6,996 at Nyamata to RWF 11,033 at Kibagabaga. These differences are due to different overall expenditure levels and the distribution of resources and their costs across the departments. The averages of the service and cost figures are shown in the next section.

Staffing is the key cost driver in the hospital costing and was a major reason for differences across the hospitals. It is recommended that the staffing patterns in the sampled hospitals be compared with the MOH staffing norms to see what differences exist.

CHUK was the only referral hospital for which we could collect data and so the average figures in the RH cost model are the same figures as in the CHUK model. Those figures are shown in the next section.11

11 Unfortunately, we had not been able to hold a validation meeting with CHUK managers and they have not reviewed the data shown here.


Table 7: Comparison of costs per bed day across the 4 district hospitals for 2009 (RWF)

Hospital Clinical Department IP Bed Days

OP Visits Total Costs Average Cost per Visit/ Bed Day

Nyamata Ambulatory care - 22,391 190,511,943 8,508

Nyamata Internal medicine 16,128 - 112,826,861 6,996

Nyamata Gynecology and maternity 13,195 - 172,500,979 13,074

Nyamata Surgery 12,851 - 117,601,736 9,151

Nyamata Pediatrics 11,434 - 97,325,457 8,512

Nyamata Nutrition Rehab - - - -

Nyamata Mental health 1,156 - 1,416,829 1,225

Nyamata Total 54,764 22,391 692,183,804 -

Kibogora Ambulatory care - 12,371 117,709,098 9,515

Kibogora Internal medicine 8,627 - 78,702,860 9,123

Kibogora Gynecology and maternity 6,492 - 95,900,203 14,772

Kibogora Surgery 12,071 - 129,693,462 10,745

Kibogora Pediatrics 8,079 - 71,922,590 8,903

Kibogora Nutrition Rehab 3,597 - 16,864,445 4,688

Kibogora Mental health - - - -

Kibogora Total 38,865 12,371 514,016,989 -

Kibagabaga Ambulatory care - 26,940 114,584,539 4,253

Kibagabaga Internal medicine 7,440 - 82,086,123 11,033

Kibagabaga Gynecology and maternity 13,789 - 164,883,112 11,958

Kibagabaga Surgery 11,466 - 78,335,923 6,832

Kibagabaga Pediatrics 9,092 - 80,541,885 8,859

Kibagabaga Nutrition Rehab 1,332 - 4,442,453 3,335

Kibagabaga Mental health - - - -

Kibagabaga Total 44,236 26,940 524,874,035 19,483

Ruhengeri Ambulatory care - 32,437 91,183,650 2,811

Ruhengeri Internal medicine 13,817 - 143,030,862 10,352

Ruhengeri Gynecology and maternity 17,378 - 194,026,279 11,165

Ruhengeri Surgery 27,343 - 212,917,321 7,787

Ruhengeri Pediatrics 16,896 - 130,055,501 7,697

Ruhengeri Nutrition Rehab 4,957 - 15,866,037 3,201

Ruhengeri Mental health - - 10,299,599 -

Ruhengeri Total 80,392 32,437 810,879,731 -


Hospital Cost Model

A separate Rwandan model for hospital costing was developed and was populated with average figures for the district hospitals and with the figures for CHUK. A section for the DRG costing was also developed and draws partly on figures in the hospital costing model.

The assumptions for the District Hospital model are shown in Table 8. These represent the average numbers of services provided across the 4 sampled hospitals. It should be noted that three of the four sampled were under-utilized as measured by their bed occupancy rates and the national model is, therefore, that of an under-utilized hospital with 63% bed occupancy. The desired bed occupancy rate of a general hospital from an efficiency and infection control perspective is generally thought to be 85%. If the hospital had higher occupancy rates, the unit cost of services would be lower since the indirect costs, such as administration, would be shared across more services.


Table 8: District Hospital model service assumptions

Clinical Department OP Visits IP Bed Days

ALOS per Discharge

Total beds

Occupied Beds

BOR

Ambulatory care 23,535

- -

- - -

Internal medicine -

11,503 6.37

59 32 54%

Gynecology and maternity -

12,713 3.34

52 35 67%

Surgery -

15,933 13.95

60 44 73%

Pediatrics -

11,375 5.47

48 31 65%

Nutrition Rehab -

2,472 17.84

16 7 42%

Mental health -

289 -

3 1 29%

Total 23,535 55,547 243 152 63%

The costs shown in the national district hospital model, which also represent the average of the 4 sampled hospitals, are shown in Table 9. The average cost per outpatient visit was RWF 5.149 and the cost of an inpatient bed day ranged from RWF 5,710 for Nutrition Rehabilitation to RWF 13,118 for Obstetrics and Gynecology.12 13 Based on these average bed-day costs and the average length of stay figures the average cost of a stay was RWF 61,152 in the Internal Medicine Department and RWF 131,420 in Surgical Department.

We compared these figures with the costs estimated by the study done in 2008 (Beeston Blackman), which used 2006 data14. In that study the average cost of an inpatient bed day was as follows: Internal Medicine RWF 8,195, Pediatrics RWF 9,693, OB/GYN RWF 6,150 and Surgery RWF 6,082. In this study the figures for Internal Medicine (RWF 9,598), Pediatrics (RWF 8,510) and Surgery (RWF 9,419) are slightly higher. This is not surprising given that resource prices must have increased over the 3 years, especially for drugs and medical supplies). The cost of an OB/GYN bed day was, however, much higher in this study (RWF 13,118), which is worth further investigation. The average cost of a general outpatient visit in the 2008 study was not shown in the report but most of the visits cost between RWF 4,000 and RWF 6,000, which can be compared with the average cost of a visit in this study which was RWF 5,149.

12 These figures should be reviewed when the costs are updated because a bed day in a Surgery Department should probably have a significantly higher cost than a bed day in Internal Medicine due to the use of the operating theatre. 13 Average bed-day costs can be converted into an average cost per discharge for each case type by multiplying them by the average length of stay or by a standard length of stay. 14 These figures are not strictly comparable because the 2008 study included depreciation and did not state what proportion of the costs that represented so we could not adjust those costs.


Table 9: District Hospital model costs for 2009 (RWF)

Clinical Department Total Costs OP Visits IP Bed Days Average Cost per Visit/ Bed Day

ALOS Average Cost per

Discharge Ambulatory Care 121,182,410 23,535 - 5,149 - NA

Internal Medicine 110,408,390 - 11,503 9,598 6.37 61,152

Gynecology and Maternity

166,774,531 - 12,713 13,118 3.34 43,750

Surgery 150,062,627 - 15,933 9,419 13.95 131,420

Pediatrics 96,807,543 - 11,375 8,510 5.47 46,513

Nutrition Rehab 14,113,153 - 2,472 5,710 17.84 101,855

The costs shown in the national referral hospital model are from CHUK only since we could not get sufficient data from CHUB for this study. CHUK is a teaching hospital and it was, therefore, necessary to consider the impact of teaching activities on patient service costs. In discussion with senior CHUK staff it determined that additional cost of teaching was not significant and were probably balanced by the additional “free’ human resource support for patient services. It was, therefore, agreed that these costs would be ignored.

CHUK inpatient bed day costs are higher than those at the district hospitals, which is understandable since referral hospital services should be more specialized. However, the average cost of a public outpatient visit is less than at a district hospital which may require additional research15. The highest cost service appears to have been Obstetrics and Gynecology (RWF 82,327 per bed day), as it was at the district hospitals, and this was significantly higher than the cost of other services. It should be noted that staffing levels are the main cost driver in most cases and getting accurate departmental staffing figures has been a difficulty throughout this exercise, partly because some staff share their time between outpatient and inpatient services. Based on the average bed-day costs and the average length of stay figures the average cost of a stay was RWF 277,350 in the Internal Medicine Department and RWF 795,066 in Surgical Department.

15 The outpatient costs are referral hospital should be higher than at a district hospital because the services should be more advanced, resulting in more of a doctor’s time, more advanced tests and more expensive drugs, although to some degree this can be offset by economies of scale. However, it is understood that some of CHUK services are actually the same level as provided at the district hospitals, which should not result in higher costs.


Table 10: Referral Hospital model costs for 2009 (RWF)

DRG costs

The DRG and case costs are shown in the DRG model and the total cost for each one is shown in Annexes 1 through 8. The DRGs are the priority cases that could be grouped. The individual cases shown in the lists were selected by the expert groups as priorities but the groups decided that they should not be grouped. As an example, Annex 1 shows the DRG and case costs for a district hospital Internal Medicine department. DRG 1 is comprised of two case types – “Diarrhea, acute, non-bloody” and “Acute diarrhea, bacterial (salmonella, shigella)”. The average length of stay should be 5 days for both case types according to the expert group. The SIS description is show for each case. The weight of each case types used for combining the two cases into DRGs, depending on how many of each case type is seen in a year. The loaded cost per service comprises the direct costs for staff, supplies and drugs plus ancillary costs and indirect costs. The two costs for Cases 1 and 2 were RWF 15,141 and RWF 15,341 and these were weighted and combined into the one DRG cost of RWF 15,221.

These are the standard costs based on the services that should be provided. Actual costs may be higher if more services are provided, such as additional tests.

5. Conclusions and recommendations

The purpose of the costing exercise was to estimate the cost of a small number of DRGs that comprise groups of high priority cases. Since the exercise involves carrying out a complete costing of all hospital services, we were also able to estimate the costs of other cases treated at the hospitals. The types of costs produced are as follows:

• A separate cost for each DRG which comprises a group of prioritized inpatient cases. • A separate cost for each prioritized inpatient case that was not grouped into a DRG. • An average cost per inpatient bed-day or discharge for cases that were not priorities for this study. • An average cost per outpatient visit.

Department Total costs OP visits IP bed days

Average cost per visit/ bed ALOS

Average cost per discharge

Private Outpatient (Clinique) 91,150,087 14,938 - 6,102 NA NAPublic Outpatients (Polyclinique) 229,007,760 54,562 - 4,197 NA NAPrivate Ward 237,318,489 - 8,987 26,407 6.3 165,494 Internal Medecine (Inc Prison Ward) 645,116,077 - 30,086 21,442 12.9 277,350 OB/GYN (Inc Theater) 1,020,942,890 - 12,401 82,327 3.6 294,985 Surgery (Inc Neuro Surgery & speciality beds) 1,357,972,067 - 37,758 35,965 22.1 795,066 Pediatrics (inc Neonatology) 772,620,629 - 28,723 26,899 9.9 266,054 O.R.L 48,241,928 - 1,931 24,983 9.4 234,184 Ophtalmologie 25,246,044 - 1,041 24,252 8.9 215,778 Stomatologie 78,506,766 - 1,247 62,957 7.8 490,667 Dermatologie 29,898,352 - 618 48,379 77.3 3,737,294


There are several factors that should be taken into account when using these costs. Firstly, costs reflect the actual expenditures made in 2009 and the cost of certain elements, such as drugs, has undoubtedly increased since then. Secondly, the sampled hospitals have indicated that these 2009 expenditures did not always reflect the resources that they need to provide good quality services since they generally did not receive the budgeted funds that they requested. Thirdly, the actual data are from a small sample of hospitals and it was not always possible to obtain accurate data from those hospitals.

An important part of this exercise was the development of district hospital and referral hospital costing models. For the purpose of this costing the models were populated with the data collected during the exercise and these data can be updated by the MOH as and when needed. Blank versions of the models were also produced and were used in capacity building. These blank versions can be used to estimate the costs of other hospitals and the results can be used for better planning and budgeting and for comparing efficiency. Senior members of the MOH and the School of Public Health have been trained to use and teach the models. And the MOH plans to train all district managers to cost the district hospitals and health centres and the MOH and SPH trainers already held an initial training course.

The hospital costs produced as a result of this exercise can already be used for setting reimbursement rates. The MOH has, however, recognized that this type of costing should be improved, repeated and updated on a regular basis since it will become an important element of its planning and management tools. In that context we have a number of recommendations which are as follows:

• The staffing figures used in the models should be compared with the MOH’s staffing norms • Individual costs should be developed for each type of laboratory test and imaging examination. • Individual costs should be developed for each type of hospital outpatient service. • The DRG costs should be reconciled with the total district hospital department costs and checked again

against the costs in the 2008 Beeston Blackman study. • The models should be run with the 2010 figures and comparisons made of the figures across the two years.


Annexes

Annex 1: District Hospital Internal Medicine DRG and priority case costs in 2009 (RWF)

1 Acute diarrhea, amebiosis 5 Diarrhée aigue non sanglante 60% 15,141

2Acute diarrhea, bacterial (salmonella, shigella)

5 Diarrhée aigue non sanglante 40% 15,341

DRG2 3 Malaria, severe Malaria, severe 7 Paludisme grave 100% 101,194 101,194

DRG3 4 Malaria, simpleMalaria, simple with troubles digestifs mineurs

2Paludisme simple avec troubles digestifs mineurs

100% 27,186 27,186

5 TB, pulmonary, BK- 15 Tuberculose pulmonaire BK- 69% 79,870

6 TB, pulmonary, BK+ 15 Tuberculose pulmonaire BK+ 31% 79,870

SECOND GROUP - Cases included in the "priority list" / Standard Treatment Guidelines, but not selected in the DRGs.DRC 7 Metabolic disorders Diabetes mellitus with acute complications 10 Diabète 55,117 DRC 8 Metabolic disorders Diabetic foot 14 Diabète 174,907 DRC 9 Opportunistic Infections - HIV/AIDS Chronic diarrhea 10 Infections opportunistes , Diarrhées chroniques 50,401 DRC 10 Opportunistic Infections - HIV/AIDS Pneumopathy, Pneumocyctis jiroveci 21 Infections opportunistes, Pneumopathies 181,375 DRC 11 Opportunistic Infections - HIV/AIDS Pneumopathy, pulmonary TB 21 Infections opportunistes, Pneumopathies 144,345 DRC 12 Opportunistic Infections - HIV/AIDS Pneumopathy, bacterial pneumonia 21 Infections opportunistes, Pneumopathies 60,054 DRC 13 Opportunistic Infections - HIV/AIDS Encephalitis 14 Infections opportunistes, Encéphalites 69,187 DRC 14 Opportunistic Infections - HIV/AIDS Cryptococcal meningitis 14 Infections opportunistes, Méningite à cryptocoques 114,091 DRC 15 Opportunistic Infections - HIV/AIDS Dermatological disease, Kaposi 10 Infections opportunistes, Affections dermatologiques 103,268 DRC 16 Opportunistic Infections - HIV/AIDS Dermatological disease, Herpes Zoster 10 Infections opportunistes, Affections dermatologiques 57,135 DRC 17 Opportunistic Infections - HIV/AIDS Cerebral toxoplasmosis 21 Infections opportunistes, Encéphalites 228,952

79,870

TOTAL LOADED COST PER SERVICE

DRG COST

DRG1 Diarrhea, acute, non-bloody

DRG4 Tuberculosis

Category

FIRST GROUP - DRG - Cases included in the "priority list" / Standard Treatment Guidelines, and selected for the DRGs

SIS (Description)# ICD-10 SubGroup (1) ICD-10 SubGroup (2) ALOSWeight

(DRG Only)

15,221


Annex 2: District Hospital Pediatric DRG and priority case costs in 2009 (RWF)

1 Amoebic dysentery 3Diarrhée sanglante, dont Dysenterie Amibienne (<15)

75% 39,462

2 Bacillary dysentery, shigellosis 3Diarrhée sanglante, Dysenterie Bacillaire (<15)

25% 40,981

3 Severe malaria, neurological 7Paludisme grave, Forme Neurogical (<15)

75% 134,696

4 Severe malaria, severe anemia 5 Paludisme grave (<15) 20% 59,623

5 Severe malaria, other 5Paludisme Grave, Autres formes (<15)

5% 59,623

DRG3 6 Malaria, simple Simple malaria, with minor digestive troubles 3Paludisme Simple avec trouble digestif mineure (<15)

100% 50,739 50,739

7 TB, pulmonary, BK- 15Tuberculose pulmonaire BK- , (<15)

75% 52,406

8 TB, pulmonary, BK+ 15Tuberculose pulmonaire BK+ , (<15)

25% 52,406

DRG5 9 Respiratory Infections Pneumonia 5Infection Respiratoire aiguë, (<15)

100% 34,390 34,390

2ND GROUP - Cases included in the "priority list" / STG, but NOT SELECTED for the DRGs.DRC 10 Bacterial meningitis, non-TB Bacterial meningitis, non-TB 10 Méningite (<15) 32,997 DRC 11 Diarrhea, acute, non-bloody Diarrhea, acute, non-bloody, with dehydration 0 Diarrhée aigue non sanglante, avec Déshydratation (<15) 40,400 DRC 12 Epilepsy Epilepsy 5 32,856 DRC 13 Hemato-oncological disorders Tropical splenomegaly 7 Paludisme grave, autres formes (<15) 24,925 DRC 14 Malnutrition Malnutrition, Protéino-Caloric 0 Paludisme Grave, Autres formes (<15) 89,976 DRC 15 Malnutrition Malnutrition, Protéino-Calorique : Kwashiorkor 0 Paludisme Simple avec trouble digestif mineure (<15) 86,936 DRC 16 Malnutrition Malnutrition, Protéino-Calorique : Marasme 0 Paludisme Simple (<15) 89,976 DRC 17 Malnutrition Malnutrition, Protéino-Calorique : Marasmic Kwashiorkor 0 Malnutrition Protéino-Calorique, (<15) 89,976 DRC 18 Metabolic disorders Diabetes mellitus with acute complications 7 Malnutrition Protéino-Calorique, Kwashiorkor (<15) 53,156 DRC 19 Neonatal Complications Neonatal infection 7 Malnutrition Protéino-Calorique, Marasme (<15) 87,347 DRC 20 Neonatal Complications Prematurity 7 Malnutrition Protéino-Calorique, Kwashiorkor marasmique (<15) 91,603 DRC 21 Neonatal Complications Neonatal jaundice 10 Diabete (<15) 130,038 DRC 22 Neonatal Complications Neonatal asphyxia 14 Anomalies congénitales ? 171,525 DRC 23 Neonatal Complications Neonatal tetanus 21 Prématurité 221,597 DRC 24 Opportunistic Infections - HIV/AIDS Chronic diarrhea 10 Epilepsie (<15) 44,500 DRC 25 Opportunistic Infections - HIV/AIDS Long term fever 14 Troubles neurologiques (<15) 61,039 DRC 26 Opportunistic Infections - HIV/AIDS Pneumopathy, Pneumocyctis jiroveci 21 Troubles neurologiques (<15) 76,376 DRC 27 Opportunistic Infections - HIV/AIDS Pneumopathy, pulmonary TB 21 Infections opportunistes , Diarrhées chroniques (<15) 165,027 DRC 28 Opportunistic Infections - HIV/AIDS Pneumopathy, bacterial pneumonia 21 Infections opportunistes, Fièvre prolongée (<15) 72,302 DRC 29 Opportunistic Infections - HIV/AIDS Encephalitis 21 Infections opportunistes, Pneumopathies (<15) 113,974 DRC 30 Opportunistic Infections - HIV/AIDS Cryptococcal meningitis 15 Infections opportunistes, Pneumopathies (<15) 87,750 DRC 31 Opportunistic Infections - HIV/AIDS Dermatological disease, Kaposi 7 Infections opportunistes, Pneumopathies (<15) 110,992 DRC 32 Opportunistic Infections - HIV/AIDS Cerebral toxoplasmosis 21 Infections opportunistes, Méningite à cryptocoques (<15) 103,681 DRC 33 Opportunistic Infections - HIV/AIDS Oropharyngeal candidiasis 10 Infections opportunistes, Affections dermatologiques, (<15) 37,612 DRC 34 Opportunistic Infections - HIV/AIDS Suppurative otitis media 7 Infections opportunistes, Affections dermatologiques, (<15) 28,717 DRC 35 Poisoning (Intoxication chimique) Organophosphorus 3 Infections opportunistes, Encéphalites (<15) 40,540 DRC 36 Poisoning (Intoxication chimique) Organochlorine 3 Infections opportunistes, Affections dermatologiques, (<15) 38,119 DRC 37 Poisoning (Intoxication chimique) Petrol 3 Infections opportunistes (<15) 37,771 DRC 38 Renal Disease Nephrotic syndrome 7 Affections rénales, Syndrome néphrotique, (<15) 52,498 DRC 39 Renal Disease Nephrotic syndrome (acute glomerulonephritis 7 Affections rénales, Syndrome néphrotique, (<15) 52,884 DRC 40 Renal Disease Urinary infection 5 Affections rénales, Syndrome néphrotique, (<15) 38,996 DRC 41 Respiratory Infections Laryngitis 5 Affections rénales, Syndrome néphrotique, (<15) 67,529 DRC 42 Respiratory Infections Pneumonia 5 Affections rénales, (<15) 41,148 DRC 43 Respiratory Infections Pleural effusion 14 Affections de l’appareil urinaire, (<15) 80,203 DRC 44 Respiratory Infections Bronchiolitis / asthma 5 Infection Respiratoire aiguë, (<15) 82,966 DRC 45 Tuberculosis TB, extrapulmonary, ganglionnaire 10 Affections cutanées, (<15) 65,546 DRC 46 Tuberculosis TB, extrapulmonary, meningee 14 Affections cutanées, (<15) 207,240 DRC 47 Tuberculosis TB, extrapulmonary, osseuse 10 Affections cutanées, (<15) 65,112 DRC 48 Tuberculosis TB, pulmonary, BK- 10 Tuberculose extra pulmonaire, (<15) 91,684 DRC 49 Tuberculosis TB, pulmonary, BK+ 21 Tuberculose extra pulmonaire, (<15) 120,428 DRC 50 Joint Disorders Rheumatic fever (RAA) 10 Tuberculose pulmonaire BK+ , (<15) 63,766 DRC 51 Joint Disorders Septic arthritis 21 Autres maladies de l’appareil urinaire (<15) 132,639


DRG COST

FIRST GROUP - DRG - Cases included in the "priority list" / STG, and SELECTED FOR the DRGs

Pulmonary TuberculosisDRG4

DRG1 Diarrhea, acute, bloody

Malaria, severeDRG2

39,842

115,928

52,406

Category SIS (2009 Totals)# ICD-10 SubGroup (2) ALOS SIS (Description)ICD-10 SubGroup (1) Weight (DRG Only)


Annex 3. District Hospital Obstetrics and Gynecology DRG and priority case costs in 2009 (RWF)

DRG1 1 Abortion Spontaneous abortion 2Affections obstétricales, Avortements

100% 21,101 21,101

DRG2 2 Delivery Eutocic delivery 2 Accouchement 100% 39,720 39,720 DRG3 3 Cesarean Section Cesarean Section 5 Cesarienne 100% 88,984 88,984

DRG4 4 Uterine Rupture Uterine rupture 7Complications liées a l'accouchement, Rupture utérine

100% 91,978 91,978

SECOND GROUP - Cases included in the "priority list"/ STG, but NOTE SELECTED for the DRGs.DRC 2 Abortion Medical abortion 2 Affections obstétricales, Avortements 16,216 DRC 3 Abortion Abortion complications 3 Affections obstétricales, Avortements 86,374 DRC 9 Ectopic Pregnancy Ectopic pregnancy 3 Affections obstétricales, Grossesses ectopiques 72,687 DRC 10 Ectopic Pregnancy Molar pregnancy 3 Affections obstétricales, Grossesses ectopiques ? 68,637 DRC 14 Malignant neoplasm Cervical cancer 10 Tumeurs malignes, Col utérin 158,450 DRC 15 Malignant neoplasm Breast cancer 10 Tumeurs malignes, Sein 179,244 DRC 16 Malignant neoplasm Endometrial cancer 10 Tumeurs malignes, Autres Tumeurs malignes 102,805 DRC 17 Malignant neoplasm Ovarian tumor or cyst of the ovary 10 Tumeurs malignes, Autres Tumeurs malignes 100,001 DRC 18 Malignant neoplasm Myoma 10 Tumeurs malignes, Col utérin 100,001 DRC 19 Multiple Delivery Cesarean Section 7 Accouchement Dystociques, Cesarienne 99,592 DRC 20 Obstetric Complications Abruptio placentae HRP 5 Complications Liees a l'Accouchement, Rétention Placentaire ? 85,039 DRC 21 Obstetric Complications Premature rupture of membranes 2 Complications Liees a l'Accouchement? 39,312 DRC 22 Placenta praevia Placenta praevia 5 Menace d’Accouchement Prématuré, Placenta previa 85,622 DRC 23 Postpartum Complications Puerperal infection 7 Complications du post partum, Infection puerpérale 95,327 DRC 24 Postpartum Complications Fistula vesico vaginal (or rectal) 15 Complications du post partum, Fistule vésico vaginale (ou rectale) 124,106 DRC 25 Postpartum Complications Post partum hemorrhage 2 Complications du post partum, Hémorragie 2,480,133 DRC 26 Postpartum Complications Tearing of the cervix 2 Complications liées a l'accouchement, Déchirure du Col 34,479 DRC 27 Postpartum Complications Uterine atony 0 Complications liées a l'accouchement, Rupture utérine 43,614 DRC 28 Postpartum Complications Placental retention 1 Complications liées a l'accouchement, Rétention Placentaire 7,005 DRC 29 Postpartum Complications Vulvo-perineal tear 0 Complications liées a l'accouchement, Déchirure périnéale 19,663 DRC 30 Pre-eclampsia Pre-eclampsie legere et moyenne 0 Cause de Cesarienne, Pré-éclampsie 51,679 DRC 31 Pre-eclampsia Pre-eclampsie severe 7 Cause de Cesarienne, Pré-éclampsie 173,360 DRC 32 Premature Labor Premature labor (eutocic delivery) 0 Menace d’Accouchement Prématuré ? 44,053 DRC 33 Premature Labor Cesarean Section 7 Accouchement Dystociques, Cesarienne 97,810 DRC 36 Uterine Rupture Uterine rupture 7 Complications liées a l'accouchement, Rupture utérine 84,809

FIRST GROUP - Cases included in the "priority list" / STG and SELECTED for the DRGs

ALOS# ICD-10 SubGroup (1) ICD-10 SubGroup (2)Category SIS (2009 Totals)SIS (Description)Weight

(DRG only)


DRG COST


Annex 4: District Hospital Surgical DRG and priority case costs for 2009 (RWF)

DRG 1 1 Osteo-articular Trauma Open fractures, treated orthopedically 10 Fractures ouvertes 100% 160,367 160,367

DRG 2 2 Osteo-articular Trauma Closed fractures, treated orthopedically 3 Fractures fermées 100% 134,623 134,623

3 Peritonitis 15 Péritonite non TBC 50% 253,226

4 Occlusion 15 Occlusion intestinale 50% 186,471 SECOND GROUP - Cases included in the "priority list" / Standard Treatment Guidelines, but not selected for the DRGs.DRC 5a Abdominal Emergency, Non-Traumatic Acute Appendicitis 5 Appendicite 135,784 DRC 5b Abdominal Emergency, Non-Traumatic Appendicular patron 10 Appendicite 119,032 DRC 6 Abdominal Trauma Abdominal Trauma, Open 10 Laparotomie or Traumatisme 181,954 DRC 7 Abdominal Trauma Abdominal Trauma, Close 17 Autres traumatismes fermés 220,437 DRC 8 Amputation Dislocation of Hip 21 Amputations 339,556 DRC 9 Amputation Dislocation of extremities, toes, fingers 1 Amputations 184,098 DRC 10 Amputation Amputation of limbs, upper and lower 10 Amputations 273,500 DRC 12 Anus Hemmorhoids 3 Affections de l' appareil Urinaire 72,830 DRC 13 Anus Polyps 2 Affections de l’appareil urinaire 57,406 DRC 14 Anus Fistula 5 Fistule vésico vaginale (ou rectale) 83,951 DRC 15 Anus Fissure 3 Affections de l’appareil urinaire 66,659 DRC 21 Burn Burn, second degree 15 Brûlures 307,059 DRC 22 Burn Burn, Third degree 30 Brûlures 365,706 DRC 23 Burn Skin grafts 14 Brûlures 235,004 DRC 24 Burn Plasty of post burn contractures 14 Brûlures 256,910 DRC 32 Head Trauma Head Trauma, Intermediate 7 Traumatismes crâniens 119,498 DRC 33 Head Trauma Head Trauma, minor 2 Traumatismes crâniens 24,335 DRC 43 Osteo-articular Trauma Open fractures, treated surgically 20 Fractures fermées 504,354 DRC 44 Osteo-articular Trauma Closed fractures, treated surgically 2 Fractures fermées 345,576 DRC 45 Osteo-articular Trauma Dislocations, treated surgically 21 Autres affections ostéo-articulaires ? 237,888 DRC 46 Osteo-articular Trauma Dislocations, treated orthopedically 12 Autres affections ostéo-articulaires ? 176,419 DRC 47 Osteo-articular Trauma Rupture of tendons 7 Autres affections ostéo-articulaires ? 226,220 DRC 48 Osteomyelitis Arthritis and acute osteomyelitis 21 Ostéites et Ostéomyélite 352,166 DRC 49 Osteomyelitis Chronic osteomyelitis 30 Ostéites et Ostéomyélite 417,782 DRC 65 Pediatrics Neuroblastoma 7 Tumeurs malignes, Autres Tumeurs malignes, (<15) 139,388 DRC 66 Pediatrics Hernias, umbilical and inguinal 4 Hernies, (<15) 58,629 DRC 92 Pediatrics Benign tumors and bone cysts 5 Anomalies congénitales, (<15) 96,619 DRC 94 Pediatrics Shoulder Instability 1 Anomalies congénitales, (<15) 128,860 DRC 95 Pelvic Trauma Pelvic Trauma, Stable 2 Traumatisme, Autres traumatismes fermés ? 154,491 DRC 98 Soft Tissue Infections Abcess, superficial 1 Fractures fermées ? 30,463 DRC 99 Soft Tissue Infections Abcess, deep 7 Fractures fermées ? 155,702 DRC 100 Spinal Trauma Contusion 2 Fractures ouvertes 257,350 DRC 125 Urological Hydrocele 3 Affections de l’appareil urinaire 68,647 DRC 126 Urologicol Varicocele 3 Affections de l’appareil urinaire 72,368 DRC 130 Wall Hernia Umbilical Hernia 3 Hernies 71,480 DRC 131 Wall Hernia Hernia of the white line 3 Hernies 71,480 DRC 132 Wall Hernia Scrotal inguinal hernia 3 Hernies 71,480 DRC 133 Wall Hernia Incisional hernias 3 Hernies 71,480

DRG COST

TOTAL LOADED

COST PER SERVICE

DRG 3 Abdominal Emergency, Non-Traumatic


Category ICD-10 SubGroup (1) ICD-10 SubGroup (2)

219,848

# ALOS SIS (Description) Weighting (DRG only)


Annex 5: Referral Hospital Internal Medicine DRG and priority case costs in 2009 (RWF)

1 Acute diarrhea, amebiosis 3Diarrhée aigue non

sanglante60% 58,643

2Acute diarrhea, bacterial (salmonella,

shigella)5

Diarrhée aigue non sanglante

40% 59,363

DRG2 3 Malaria, simple Malaria, simple with minor digestive troubles 2Paludisme grave

avec troubles digestifs mineurs

100% 73,981 73,981

4 Malaria, severe Malaria, severe 7 Paludisme grave 95% 147,048 5 Opportunistic Infections - HIV/AIDS Severe malaria, all forms 7 Paludisme grave 5% 147,048

6 Tuberculosis TB, pulmonary, BK- 15Tuberculose

pulmonaire BK-39% 130,546

7 Tuberculosis TB, pulmonary, BK+ 15Tuberculose

pulmonaire BK+61% 130,416

DRG5 8 Tuberculosis TB, extrapulmonary 21Tuberculose extra

pulmonaire100% 187,751 187,751

DRC 9 Hemato-oncological disorders Tropical splenomegaly 8 N/A 90,208 DRC 10 Hemato-oncological disorders Leukemia 30 Tumeurs malignes, Autres Tumeurs malignes 326,580 DRC 11 Hemato-oncological disorders Hodgkin's Lymphoma 30 Tumeurs malignes, Autres Tumeurs malignes 326,580 DRC 12 Hemato-oncological disorders Non-Hodgkin's Lymphoma 30 Tumeurs malignes, Autres Tumeurs malignes 326,580 DRC 13 Hemato-oncological disorders Burkitt's Lymphoma 30 Tumeurs malignes, Autres Tumeurs malignes 326,580 DRC 14 Metabolic disorders Diabetes mellitus with acute complications 7 Diabète 98,973 DRC 15 Metabolic disorders Diabetic foot 30 Diabète 212,382 DRC 16 Metabolic disorders Thyrotoxicosis 7 N/A 55,892 DRC 17 Opportunistic Infections - HIV/AIDS Chronic diarrhea 7 Infections opportunistes , Diarrhées chroniques 89,080 DRC 18 Opportunistic Infections - HIV/AIDS Pneumopathy, Pneumocyctis jiroveci 14 Infections opportunistes, Pneumopathies 227,189 DRC 19 Opportunistic Infections - HIV/AIDS Pneumopathy, pulmonary TB 15 Infections opportunistes, Pneumopathies 192,646 DRC 20 Opportunistic Infections - HIV/AIDS Pneumopathy, bacterial pneumonia 7 Infections opportunistes, Pneumopathies 113,675 DRC 21 Opportunistic Infections - HIV/AIDS Encephalitis 21 Infections opportunistes, Encéphalites 129,689 DRC 22 Opportunistic Infections - HIV/AIDS Cryptococcal meningitis 15 Infections opportunistes, Méningite à cryptocoques 166,052 DRC 23 Opportunistic Infections - HIV/AIDS Dermatological disease, Kaposi 7 Infections opportunistes, Affections dermatologiques 142,384 DRC 24 Opportunistic Infections - HIV/AIDS Dermatological disease, Herpes Zoster 5 Infections opportunistes, Affections dermatologiques 92,984 DRC 25 Opportunistic Infections - HIV/AIDS Cerebral toxoplasmosis 14 Infections opportunistes, Encéphalites 279,838


DRG COST


SECOND GROUP - Cases included in the "priority list" / Standard Treatment Guidelines, but not selected in the DRGs.

Category Weight (DRG only)SIS (Description)# ICD-10 SubGroup (1) ICD-10 SubGroup (2) ALOS

Diarrhea, acute, non-bloodyDRG1

DRG3

DRG4

58,931

147,048

130,467


Annex 6: Referral Hospital Pediatric DRG and priority case costs in 2009 (RWF)

1 Amoebic dysentery 3 Diarrhée sanglante, dont Dysenterie Amibienne (<15) 75% 91,491

2 Bacillary dysentery / shigellosis 3 Diarrhée sanglante, Dysenterie Bacillaire (<15) 25% 101,059

3 Severe malaria, neurological 7 Paludisme grave, Forme Neurogical (<15) 75% 191,109

4 Severe malaria, severe anemia 7 Paludisme grave (<15) 20% 113,975 5 Severe malaria, other 5 Paludisme grave (<15) 5% 184,700

DRG3 6 Malaria, simple Simple malaria, with TDM 3 Paludisme simple avec TDM (<15) 100% 104,710 104,710

7 TB, pulmonary, BK- 15 Tuberculose pulmonaire BK-, (<15) 75% 119,184

8 TB, pulmonary, BK+ 15 Tuberculose pulmonaire BK+ , (<15) 25% 119,184

9 TB, extrapulmonary, ganglionnaire 10 Tuberculose extra pulmonaire, (<15) 33% 139,440

10 TB, extrapulmonary, meningee 14 Tuberculose extra pulmonaire, (<15) 33% 284,776

11 TB, extrapulmonary, osseuse 10 Tuberculose extra pulmonaire, (<15) 33% 139,440 DRG6 12 Respiratory Infections Pneumonia 5 Infection Respiratoire aiguë, (<15) 100% 146,896 146,896

DRC 13 Bacterial meningitis, non-TB Bacterial meningitis, non-TB 10 Méningite (<15) 99,443 DRC 14 Cardiac decompensation Congential cardiopathies (CIV, CAV, PDA, CIA) 7 Cardiopathies (<15) 109,146 DRC 15 Cardiac decompensation Acquired cardiopathies (rhumatismales, cardiomyopathies) 7 Cardiopathies (<15) 109,146 DRC 16 Cardiac decompensation Tetralogy of Fallot 7 Cardiopathies (<15) ? 112,174 DRC 17 Cardiac decompensation Arterial hypertension 7 Hypertension artérielle (<15) 105,974 DRC 18 Diarrhea, acute, non-bloody Diarrhea, acute, non-bloody, with dehydration 0 Diarrhée aigue non sanglante, avec Déshydratation (<15) 107,812 DRC 19 Epilepsy Epilepsy 5 ? 85,184 DRC 20 Hemato-oncological disorders Anemia 14 ? 116,007 DRC 21 Hemato-oncological disorders Tropical splenomegaly 7 Paludisme grave, autres formes (<15) 70,568 DRC 22 Hemato-oncological disorders Leukemia 21 Tumeurs malignes, Autres Tumeurs malignes (<15) 106,127 DRC 23 Hemato-oncological disorders Hodgkin's Lymphoma 21 Tumeurs malignes, Autres Tumeurs malignes (<15) 106,127 DRC 24 Hemato-oncological disorders Non-Hodgkin's Lymphoma 21 Tumeurs malignes, Autres Tumeurs malignes? 106,127 DRC 25 Hemato-oncological disorders Burkitt's Lymphoma 21 Tumeurs malignes, Autres Tumeurs malignes (<15) 106,127 DRC 26 Hemato-oncological disorders Nephroblastoma 30 Tumeurs malignes, Autres Tumeurs malignes (<15) 128,987 DRC 27 Malnutrition Malnutrition, Protéino-Caloric 0 Paludisme Grave, Autres formes (<15) 143,769 DRC 28 Malnutrition Malnutrition, Protéino-Calorique : Kwashiorkor 0 Paludisme Simple avec trouble digestif mineure (<15) 143,769 DRC 29 Malnutrition Malnutrition, Protéino-Calorique : Marasme 0 Paludisme Simple (<15) 143,769 DRC 30 Malnutrition Malnutrition, Protéino-Calorique : Marasmic Kwashiorkor 0 Malnutrition Protéino-Calorique, (<15) 143,769 DRC 31 Metabolic disorders Diabetes mellitus with acute complications 7 Malnutrition Protéino-Calorique, Kwashiorkor (<15) 113,322 DRC 32 Neonatal Complications Neonatal infection 7 Malnutrition Protéino-Calorique, Marasme (<15) 129,496 DRC 33 Neonatal Complications Prematurity 7 Malnutrition Protéino-Calorique, Kwashiorkor marasmique (<15) 132,573 DRC 34 Neonatal Complications Neonatal jaundice 10 Diabete (<15) 198,747 DRC 35 Neonatal Complications Neonatal asphyxia 14 Anomalies congénitales ? 218,322 DRC 36 Neonatal Complications Neonatal tetanus 21 Prématurité 277,643 DRC 37 Opportunistic Infections - HIV/AIDS Chronic diarrhea 10 Epilepsie (<15) 86,172 DRC 38 Opportunistic Infections - HIV/AIDS Long term fever 14 Troubles neurologiques (<15) 102,318 DRC 39 Opportunistic Infections - HIV/AIDS Pneumopathy, Pneumocyctis jiroveci 21 Troubles neurologiques (<15) 118,200 DRC 40 Opportunistic Infections - HIV/AIDS Pneumopathy, pulmonary TB 21 Infections opportunistes , Diarrhées chroniques (<15) 200,897 DRC 41 Opportunistic Infections - HIV/AIDS Pneumopathy, bacterial pneumonia 21 Infections opportunistes, Fièvre prolongée (<15) 115,675 DRC 42 Opportunistic Infections - HIV/AIDS Encephalitis 21 Infections opportunistes, Pneumopathies (<15) 183,468 DRC 43 Opportunistic Infections - HIV/AIDS Cryptococcal meningitis 15 Infections opportunistes, Pneumopathies (<15) 154,840 DRC 44 Opportunistic Infections - HIV/AIDS Dermatological disease, Kaposi 7 Infections opportunistes, Pneumopathies (<15) 158,498 DRC 45 Opportunistic Infections - HIV/AIDS Dermatological disease, Herpes Zoster 7 Infections opportunistes, Encéphalites (<15) 107,370 DRC 46 Opportunistic Infections - HIV/AIDS Cerebral toxoplasmosis 21 Infections opportunistes, Méningite à cryptocoques (<15) 173,866 DRC 47 Opportunistic Infections - HIV/AIDS Oropharyngeal candidiasis 10 Infections opportunistes, Affections dermatologiques, (<15) 79,305 DRC 48 Opportunistic Infections - HIV/AIDS Suppurative otitis media 7 Infections opportunistes, Affections dermatologiques, (<15) 69,294 DRC 49 Poisoning (Intoxication chimique) Organophosphorus 3 Infections opportunistes, Encéphalites (<15) 91,071 DRC 50 Poisoning (Intoxication chimique) Organochlorine 3 Infections opportunistes, Affections dermatologiques, (<15) 88,097 DRC 51 Poisoning (Intoxication chimique) Petrol 3 Infections opportunistes (<15) 87,772 DRC 52 Renal Disease Nephrotic syndrome 7 123,647 DRC 53 Renal Disease Nephrotic syndrome (acute glomerulonephritis) 7 123,665 DRC 54 Renal Disease Renal insufficiency 14 161,769 DRC 55 Renal Disease Urinary infection 5 Affections rénales, Syndrome néphrotique, (<15) 90,746 DRC 56 Respiratory Infections Laryngitis 5 Affections rénales, Syndrome néphrotique, (<15) 111,903 DRC 57 Respiratory Infections Pleural effusion 14 Affections de l’appareil urinaire, (<15) 131,370 DRC 58 Respiratory Infections Bronchiolitis / asthma 5 Infection Respiratoire aiguë, (<15) 133,947 DRC 59 Joint Disorders Juvenile Rheumatoid Arthritis 14 Tuberculose pulmonaire BK-, (<15) 153,536 DRC 60 Joint Disorders Rheumatic fever (RAA) 10 Tuberculose pulmonaire BK+ , (<15) 136,384 DRC 61 Joint Disorders Septic arthritis 21 Autres maladies de l’appareil urinaire (<15) 156,358


DRG COST CategoryWeight (DRG only)

# ICD-10 SubGroup (2) ALOS SIS (Description)ICD-10 SubGroup (1)



93,883

175,362

119,184

186,007

DRG4 Tuberculosis

DRG5 Tuberculosis

DRG1 Diarrhea, acute, bloody

Malaria, severeDRG2


Annex 7: Referral Hospital Obstetrics and Gynecology DRG and priority case costs in 2009 (RWF)


1 Spontaneous abortion 2 Affections obstétricales, Avortements 50% 63,768

2 Medical abortion 2 Affections obstétricales, Avortements 50% 63,768

3 Eutocic delivery 2 Accouchement Eutociques 50% 79,148

4 Dystocic Pregnancy, Instrumental 2 Accouchement Dystociques 50% 78,971

DRG3 5 Delivery Dystocic Pregnancy, Cesarean 3 Accouchement Dystociques, Cesarienne 100% 129,045 129,045

DRG4 6 Ectopic Pregnancy Ectopic pregnancy 3 Affections obstétricales, Grossesses ectopiques 100% 134,668 134,668

DRG5 7 Uterine Rupture Uterine rupture 5 Complications liées a l'accouchement, Rupture utérine 100% 135,232 135,232

SECOND GROUP - Cases included in the "priority list" / Standard Treatment Guidelines, but not selected in the DRGs.DRC 8 Abortion Abortion complications 3 Affections obstétricales, Avortements 111,071 DRC 9 Ectopic Pregnancy Molar pregnancy 3 Affections obstétricales, Grossesses ectopiques ? 111,799 DRC 10 Malignant neoplasm Cervical cancer 10 Tumeurs malignes, Col utérin 223,616 DRC 11 Malignant neoplasm Breast cancer 10 Tumeurs malignes, Sein 243,153 DRC 12 Malignant neoplasm Endometrial cancer 10 Tumeurs malignes, Autres Tumeurs malignes 181,054 DRC 13 Malignant neoplasm Ovarian tumor or cyst of the ovary 10 Tumeurs malignes, Autres Tumeurs malignes 172,982 DRC 14 Malignant neoplasm Myoma 10 Tumeurs malignes, Col utérin 172,982 DRC 15 Multiple Delivery Cesarean Section 7 Accouchement Dystociques, Cesarienne 139,023 DRC 16 Obstetric Complications Abruptio placentae HRP 5 Complications Liees a l'Accouchement, Rétention Placentaire ? 120,164 DRC 17 Obstetric Complications Premature rupture of membranes 2 Complications Liees a l'Accouchement? 79,457 DRC 18 Placenta praevia Placenta praevia 5 Menace d’Accouchement Prématuré, Placenta previa 120,732 DRC 19 Postpartum Complications Puerperal infection 7 Complications du post partum, Infection puerpérale 133,113 DRC 20 Postpartum Complications Fistula vesico vaginal (or rectal) 15 Complications du post partum, Fistule vésico vaginale (ou rectale) 161,352 DRC 21 Postpartum Complications Post partum hemorrhage 2 Complications du post partum, Hémorragie 2,189,645 DRC 22 Postpartum Complications Tearing of the cervix 2 Complications liées a l'accouchement, Déchirure du Col 69,312 DRC 23 Postpartum Complications Uterine atony 0 Complications liées a l'accouchement, Rupture utérine 91,834 DRC 24 Postpartum Complications Placental retention 1 Complications liées a l'accouchement, Rétention Placentaire 46,968 DRC 25 Postpartum Complications Vulvo-perineal tear 0 Complications liées a l'accouchement, Déchirure périnéale 51,296 DRC 26 Pre-eclampsia Pre-eclampsie legere et moyenne 0 Cause de Cesarienne, Pré-éclampsie 123,902 DRC 27 Pre-eclampsia Pre-eclampsie severe 7 Cause de Cesarienne, Pré-éclampsie 239,172 DRC 28 Premature Labor Premature labor (eutocic delivery) 0 Menace d’Accouchement Prématuré ? 96,897 DRC 29 Premature Labor Cesarean Section 7 Accouchement Dystociques, Cesarienne 148,386

TOTAL LOADED

COST PER SERVICE

DRG COSTALOS# ICD-10 SubGroup (1) ICD-10 SubGroup (2)CategoryWeight

(DRG only)SIS (Description)

Abortion

Delivery

63,768

79,060

DRG1

DRG2


Annex 8: Referral Hospital Surgical DRG costs in 2009 (RWF)


1 Open fractures, treated surgically, articulaires15 Fractures ouvertes 25% 195,743

2 Open fractures, treated surgically, diaphysaires15 Fractures ouvertes 75% 181,727

3 Open fractures, treated orthopedically, articulaires5 Fractures ouvertes 25% 108,387

4 Open fractures, treated orthopedically, diaphysaires5 Fractures ouvertes 75% 95,615

5Closed fractures, treated surgically, articulaires 5 Fractures fermées 25% 156,273

6 Closed fractures, treated surgically, diaphysaires 5 Fractures fermées 75% 134,555

7Closed fractures, treated orthopedically, articulaires 1 Fractures fermées 25% 93,481

8Closed fractures, treated orthopedically, diaphysaires 1 Fractures fermées 75% 80,125

9 Peritonitis 8 Péritonite non TBC 42% 253,197 10 Occlusion 8 Occlusion intestinale 28% 260,996 11 Abdominal trauma, open 8 Laparotomie or Traumatisme 15% 262,489 12 Abdominal trauma, closed 8 Autres traumatismes fermés 15% 293,811

TOTAL LOADED

COST PER SERVICE

DRG COSTCategoryWeight

(DRG only)SIS (Description)ICD-10 SubGroup (1)# ICD-10 SubGroup (2) ALOS

DRG1

DRG2

DRG3

DRG4

DRG5

Abdominal Trauma

185,231

98,808

139,984

83,464

262,867

Osteo-articular Trauma



Osteo-articular TraumaAbdominal Emergency,

Non-Traumatic


Annex 9: Referral Hospital Surgical non-DRG priority case costs in 2009 (RWF) (Part 1)


DRC3b

Abdominal Emergency, Non-Traumatic Acute appendicitis 5 Appendicite 198,326

DRC4b

Abdominal Emergency, Non-Traumatic Appendicular plastron 10 Appendicite 179,697

DRC5b

Abdominal Emergency, Non-Traumatic Acute cholecystitis 10 N/A 179,697

DRC 8b Amputation Dislocation of hip 21 Amputations 449,220 DRC 9b Amputation Dislocation of extremities, fingers and toes 1 Amputations 287,797 DRC 10b Amputation Amputation of limbs, upper and lower 10 Amputations 380,233 DRC 12b Anus Hemmorhoids 3 Affections de l’appareil urinaire 116,255 DRC 13c Anus Polyps 2 Affections de l’appareil urinaire 99,768 DRC 14 Anus Fistula 5 Fistule vésico vaginale (ou rectale) 129,127 DRC 15 Anus Fissure 3 Affections de l’appareil urinaire 111,859 DRC 16 Biliary Tract Cholelithiasis 5 Affection Renale or Gastrite? 145,851 DRC 17 Biliary Tract Choledocholithiasis 14 Affection Renale or Gastrite? 205,197 DRC 18 Biliary Tract Cholangiocarcinoma 14 Affection Renale or Gastrite? 238,898 DRC 19 Biliary Tract Hepatocellular 14 Affection Renale or Gastrite? 238,887 DRC 20 Breast Malignant tumor, breast 7 Tumeurs malignes, sein 5,350,102 DRC 21 Burn Burn, second degree 15 Brûlures 384,809 DRC 22 Burn Burn, third degree 30 Brûlures 449,876 DRC 23 Burn Skin grafts 14 Brûlures 311,471 DRC 24 Burn Plasty of post burn contractures 14 Brûlures 334,972 DRC 25 Colon and Intestine Intestinal, tumor 7 Tumeurs malignes, Autres Tumeurs malignes 167,963 DRC 26 Colon and Intestine Intestinal, mesentheric tumor 7 Tumeurs malignes, Autres Tumeurs malignes 167,963 DRC 27 Colon and Intestine Colon, tumor 7 Tumeurs malignes, Autres Tumeurs malignes 167,963 DRC 28 Colon and Intestine Colon, dolicocolon 7 Gastrite ? 167,963 DRC 29 Colon and Intestine Colon, diverticulosis and polyps 7 Gastrite? 167,963 DRC 30 Colon and Intestine Rectum, tumor 10 Tumeurs malignes, Autres Tumeurs malignes 230,005 DRC 31 Head Trauma Head trauma, major 30 Traumatismes crâniens 521,796 DRC 32 Head Trauma Head trauma, intermediate 7 Traumatismes crâniens 148,467 DRC 33 Head Trauma Head trauma, minor 2 Traumatismes crâniens 61,469 DRC 45 Osteo-articular Trauma Dislocations, treated surgically 21 Autres affections ostéo-articulaires ? 309,357 DRC 46 Osteo-articular Trauma Dislocations, treated orthopedically 12 Autres affections ostéo-articulaires ? 241,657 DRC 47 Osteo-articular Trauma Rupture of tendons 7 Autres affections ostéo-articulaires ? 297,872 DRC 48 Osteomyelitis Arthritis and acute osteomyelitis 21 Ostéites et Ostéomyélite 369,545 DRC 49 Osteomyelitis Chronic osteomyelitis 21 Ostéites et Ostéomyélite 493,205

DRC50

PancreasTumors of the head of the pancreas / Ampulomes perivateriens 21 Tumeurs malignes, Autres Tumeurs malignes 368,361

DRC 51 Pancreas Tumors of the body and tail of the pancreas 10 Tumeurs malignes, Autres Tumeurs malignes 258,976 DRC 52 Pancreas Pseudocysts 7 Gastrites ? 179,085 DRC 53 Pediatric Hydrocephaly 5 Anomalies congénitales, (<15) 155,044 DRC 54 Pediatric Spina bifida 5 Anomalies congénitales, (<15) 155,135 DRC 55 Pediatric Omphalocele/ Laparoschisis 7 Anomalies congénitales, (<15) 152,097 DRC 56 Pediatric Intestinal Atresia 7 Anomalies congénitales, (<15) 155,278 DRC 57 Pediatric Hirshprung 7 Anomalies congénitales, (<15) 194,850 DRC 58 Pediatric Anal-rectal perforation 7 Laparotomie ? 194,301 DRC 59 Pediatric Hypertrophic pyloric stenosis 2 N/A 104,960 DRC 60 Pediatric Cleft lip and palate 5 Anomalies congénitales, (<15) 144,799 DRC 61 Pediatric Hypospadias 7 Anomalies congénitales, (<15) 129,261 DRC 62 Pediatric Epispadias 7 Anomalies congénitales, (<15) 112,027 DRC 64 Pediatric Nephroblastoma 7 Tumeurs malignes, Autres Tumeurs malignes, (<15) 214,840 DRC 65 Pediatric Neuroblastoma 7 Tumeurs malignes, Autres Tumeurs malignes, (<15) 177,482 DRC 66 Pediatric Hernias, umbilical and inguinal 1 Hernies, (<15) 101,121 DRC 67 Pediatric Testicular Ectopia 1 Anomalies congénitales, (<15) 101,121


Category Weight (DRG only)SIS (Description)ICD-10 SubGroup (1)# ICD-10 SubGroup (2) ALOS


Annex 9: Referral Hospital Surgical non-DRG priority case costs in 2009 (RWF) (Part 2)


DRC68

Pediatric Dysplasia and congenital dislocation of the hip 21 Anomalies congénitales, (<15) 274,215 DRC 69 Pediatric Coxavara and coxavalga 7 Anomalies congénitales, (<15) 142,897 DRC 70 Pediatric Flexion contracture of the hip and adductus 10 Anomalies congénitales, (<15) 138,412 DRC 71 Pediatric Upper femoral malrotation 7 Anomalies congénitales, (<15) 127,100 DRC 72 Pediatric Slipped capital femoral epiphysis 7 Anomalies congénitales, (<15) 127,100 DRC 73 Pediatric Congenital curvatures and pseudarthrosis 10 Anomalies congénitales, (<15) 153,348 DRC 74 Pediatric Knee varus and valgus knee 7 Anomalies congénitales, (<15) 136,229 DRC 75 Pediatric Instability of the patella 10 Anomalies congénitales, (<15) 137,420 DRC 76 Pediatric Meniscal Abnormalities 10 Anomalies congénitales, (<15) 137,420 DRC 77 Pediatric Talipes equinovarus 14 Anomalies congénitales, (<15) 192,419 DRC 78 Pediatric Neurological feet 10 Anomalies congénitales, (<15) 146,247 DRC 79 Pediatric Hallux valgus 2 Anomalies congénitales, (<15) 88,076 DRC 80 Pediatric Patella alta 7 Anomalies congénitales, (<15) 100,064 DRC 81 Pediatric arthroglypose 21 Anomalies congénitales, (<15) 170,649 DRC 82 Pediatric Coalition and synostosis of the tarsus 14 Anomalies congénitales, (<15) 169,493 DRC 83 Pediatric Gehrig's disease 14 Anomalies congénitales, (<15) 178,285 DRC 84 Pediatric Congenital convex and flat feet 14 Anomalies congénitales, (<15) 166,966 DRC 85 Pediatric Varus rear foot 7 Anomalies congénitales, (<15) 111,344 DRC 86 Pediatric Defaux axis of the forefoot 10 Anomalies congénitales, (<15) 139,674 DRC 87 Pediatric Malformations of fingers and toes 1 Anomalies congénitales, (<15) 84,294 DRC 88 Pediatric Osteoarthritis and osteochondritis dissection 10 Anomalies congénitales, (<15) 144,057 DRC 89 Pediatric Rupture of the cruciate ligaments of the knee 10 Anomalies congénitales, (<15) 154,417 DRC 90 Pediatric Inequality of length of lower limbs 7 Anomalies congénitales, (<15) 140,591 DRC 91 Pediatric Partial agenesis of the long bones 7 Anomalies congénitales, (<15) 140,543 DRC 92 Pediatric Benign tumors and bone cysts 5 Anomalies congénitales, (<15) 118,561 DRC 93 Pediatric Benign soft tissue tumors 5 Anomalies congénitales, (<15) 118,561 DRC 94 Pediatric Shoulder instability 7 Anomalies congénitales, (<15) 140,937 DRC 95 Pelvic Trauma Pelvic trauma, stable 2 Traumatisme, Autres traumatismes fermés ? 226,560 DRC 96 Pelvic Trauma Pelvic trauma, unstable 15 Traumatisme, Autres traumatismes fermés ? 332,829 DRC 97 Sequelae of arthritis Sequelae of arthritis, arthroscopic arthrodesis 10 Autres affections ostéo-articulaires 426,888 DRC 98 Soft Tissue Infections Abcess, superficial 1 Fractures fermées ? 76,255 DRC 99 Soft Tissue Infections Abcess, deep 7 Fractures fermées ? 203,481 DRC 100 Spinal Trauma Contusion 2 Fractures ouvertes 354,701 DRC 101 Spinal Trauma Fractures/dislocations, stable 7 Fractures ouvertes 382,530 DRC 102 Spinal Trauma Fractures/dislocations, unstable 28 Fractures ouvertes 553,817 DRC 103 Spinal Trauma Lumbar stenosis / disc hernias / Spondylolisthesis 28 Hernies 553,817 DRC 104 Stomach Tumor, stomach 7 Tumeurs malignes, Autres Tumeurs malignes 195,625 DRC 105 Stomach Pyloric stenosis 7 Gastrites ? 167,435 DRC 106 Stomach Perforated Peptic ulcer 5 Ulcère Gastro-Duodénal 154,261 DRC 107 Thoracic Trauma Thoracic trauma, open 7 Traumatisme, Autres traumatismes fermés 380,171 DRC 108 Thoracic Trauma Thoracic trauma, closed 44 Traumatisme, Autres traumatismes fermés 496,268 DRC 109 Thyroid disorder Goiter 5 Hernies 167,131 DRC 110 Thyroid disorder Thyroid cancer 5 Tumeurs malignes, Autres Tumeurs malignes 184,039 DRC 111 Thyroid disorder Thyrotoxicosis 10 Thyroïdectomie? 186,216

DRC112

Thyroid disorderAchalasie de l'oesophage/ Hernie hiatale/ Beance du cardia 0 Hernies? 301,798

DRC 113 Thyroid disorder Tumors of the esophagus 0 Tumeurs malignes, Autres Tumeurs malignes 180,224

DRC114

Thyroid disorderThoracic empyema / lung tumor / mediastinal tumors 0 Tumeurs malignes, Autres Tumeurs malignes 378,492

DRC 115 Urological Tumeurs du rein 7 Tumeurs malignes, Autres Tumeurs malignes 161,572 DRC 116 Urological Syndrome de la jonction pyelo-calicielle 7 Affections de l’appareil urinaire 161,541

DRC117

Urological Hydronephrose, Lithiase ureterale/ Stenose ureterale 7 Affections de l’appareil urinaire 178,378 DRC 118 Urological Rupture ureterale/ Ligature ureterale 14 Affections de l’appareil urinaire 204,686 DRC 119 Urological Rupture de la vessie 7 Affections de l’appareil urinaire 160,501 DRC 120 Urological Cancer de la vessie 21 Tumeurs malignes, Autres Tumeurs malignes 285,623 DRC 121 Urological Lithiase vesicale 7 Affections de l’appareil urinaire 150,975 DRC 122 Urological Rupture/ Stenose uretrale 10 Affections de l’appareil urinaire 162,322 DRC 123 Urological Cancer du penis 2 Tumeurs malignes, Autres Tumeurs malignes 162,009 DRC 124 Urological Cancer des testicules 7 Tumeurs malignes, Autres Tumeurs malignes 162,009 DRC 125 Urological Hydrocele 1 Affections de l’appareil urinaire 115,768 DRC 126 Urological Varicocele 2 Affections de l’appareil urinaire 119,529 DRC 127 Urological Priapisme 10 Affections de l’appareil urinaire 182,479 DRC 128 Urological Adenome de la prostate 14 Affections de l’appareil urinaire 192,882 DRC 129 Urological Adenocarcinome de la prostate 14 Affections de l’appareil urinaire 204,954 DRC 130 Wall Hernia Umbilical hernia 2 Hernies 115,246 DRC 131 Wall Hernia Hernia of the white line 2 Hernies 115,085 DRC 132 Wall Hernia Scrotal inguinal hernia 2 Hernies 115,103 DRC 133 Wall Hernia Incisional hernias 2 Hernies 115,096


Category Weight (DRG only)SIS (Description)ICD-10 SubGroup (1)# ICD-10 SubGroup (2) ALOS


Annex 10. References

1. Rwanda Interim Demographic and Health Survey, 2007-2008. Preliminary Report. Ministry of Health, Kigali, Rwanda. Measure DHS, ICF Macro, Calverton, Maryland, USA. April 2009.

2. 2006 Rwanda Health Centre and Hospital Cost Study. Beaston Blaakman, 2008 3. CORE Plus - CORE Plus. A description of the tool can be found at

http://erc.msh.org/mainpage.cfm?file=5.11.htm&module=toolkit&language=English 4. Suriname: Study on Health Needs and Determinants. Elizabeth Lewis, December 2003. Inter-

American Development Bank Support for Health Sector Reform in Suriname. Management Sciences for Health.

5. Technical Trip Report: Haiti. Elizabeth Lewis and Christele Joseph-Pressat. June 2007. Management Sciences for Health.

6. Contracting for health services: effects of utilization and quality on the costs of the Basic Package of Health Services in Afghanistan. Omid Abeli and William Newbrander. Bulletin of the World Health Organization, 2008; 86: 920-28.

7. A Cost Analysis of Primary Health Care Services in Benoni, May 2003. David Collins and Elizabeth Lewis. The EQUITY Project, Management Sciences for Health.

8. Designing and Implementing Health Care Provider Payment Systems: How-To Manuals; Edited by John C. Langenbrunner, Cheryl Cashin, and Sheila O’Dougherty. World Bank/USAID, 2009.

rwanda health service costing - msh · 2020. 1. 3. · 2. costing tools the most efficient way to...

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