Background
-
Inpatient day The estimated cost of a hospital bed-day reflects only the “hotel” component of the hospital cost—i.e. it excludes the cost of drugs and diagnostic tests but includes costs such as personnel, capital infrastructure and equipment, laboratory, maintenance and other operational costs of the hospital, as well as food costs. The intent is to produce a measure that covers those components that are assumed to be standardised across different diseases and treatments.
-
Outpatient visit Similarly, WHO-CHOICE outpatient costs include components not specific to the disease or treatment, but those largely assumed to be standardised across disease conditions for which the care is provided: namely personnel, capital infrastructure and equipment, laboratory, maintenance and other operational costs of the health facility. In recognition of the fact that costs for equipment, maintenance etc., may vary depending on the setting in which care is provided, inpatient and outpatient care costs are estimated for different types of providers and levels of the health system.
Methods
Data collection
Box 1 Definition of facility level and ownership/affiliation
Five levels of care were considered
-
Primary-level hospital: Have few specialities, mainly internal medicine, obstetrics-gynecology, paediatrics, general surgery or just general practitioners; limited laboratory services are available for general but not for specialized pathological analysis; bed size ranging from 30 to 200 beds; often referred to as district hospitals or first level referral.
-
Secondary-level hospital: Highly differentiated by function with five to ten clinical specialities; bed size ranging from 200 to 800 beds; often referred to as provincial hospital.
-
Tertiary-level hospital: Highly specialized staff and technical equipment, e.g. cardiology, ICU and specialized imaging units; clinical services are highly differentiated by function; might have teaching activities; bed size ranging from 300 to 1500 beds; often referred to as central, regional or tertiary level hospital.
Three categories for affiliation were considered
-
Public
-
Private
-
Not for profit private providers (i.e. faith-based, mission, or non-governmental organization).
Econometric analysis
-
A log-additive vector of input prices, and
-
An unknown function of:
-
A set of output indicators, and
-
A set of variables indicating the facility type.
-
-
The variable is a known determinant of unit cost,
-
Measurement data for the variable are readily available,
-
The variable performs well in regression models.
Model specification: inpatient care
Description | Mean | SE | |
---|---|---|---|
Ln cost per bed day | Natural log of cost per bed day in 2007 I$ | 181.59 | 241.21 |
Ln GDP per capita | Natural log of GDP per capita in 2007 I$ | 8788.86 | 3729.88 |
Ln occupancy rate | Natural log of bed occupancy rate | 0.23 | 0.33 |
Ln ALOS | Natural log of Average Length of Stay (ALOS) | 4.16 | 2.33 |
Ln admissions | Natural log of total inpatient admissions | 4700.00 | 7416.81 |
District | Dummy variable for level 3 facilitiesa (equivalent to district hospitals) | 0.80 | 0.40 |
Teaching | Dummy variable for level 5 facilities (teaching hospitals)a | 0.09 | 0 |
Public | Dummy variable for public hospitalsb | 0.58 | 1 |
Private | Dummy variable for private hospitalsb | 0.16 | 0 |
Brazil | Dummy variable for Brazil. Brazil = 1 | 0.58 | 1 |
Model specification: outpatient care
Description | Mean | SE | |
---|---|---|---|
Ln cost per visit | Natural log of cost per outpatient visit in 2007 I$ | 15.56 | 44.02 |
Ln GDP per capita | Natural log of GDP per capita in 2007 I$ | 7947.64 | 4618.50 |
Ln visits | Natural log of outpatient visits per facility | 62,924.53 | 118,929.70 |
Ln visits per provider | Natural log of visits per provider per day (nurses, general practitioners) | 5.71 | 10.90 |
Urban | Dummy variable for urban facility locationa | 0.21 | 0.41 |
Public | Dummy variable for public hospitalsb | 0.75 | 0.44 |
Private | Dummy variable for private hospitalsb | 0.12 | 0.32 |
Level 2 | Dummy variable for level 2 facilitiesc | 0.15 | 0.35 |
Level 3 | Dummy variable for level 3 facilitiesc | 0.25 | 0.43 |
Level 4 | Dummy variable for level 4 facilitiesc | 0.08 | 0.26 |
Colombia | Dummy variable for Colombia. Colombia = 1 | 0.10 | 0.30 |
Brazil | Dummy variable for Brazil. Brazil = 1 | 0.62 | 0.49 |
Brazil level 3 | Dummy variable for Brazil level 3 facilities | 0.18 | 0.39 |
Model-fit
Predicted values and uncertainty analysis
Inpatient care | Proxy for size | Proxy for capacity | Proxy for intensity of care provided |
---|---|---|---|
Total inpatient admissions per facility per year (p80) | Bed occupancy rate (p80) | Average length of stay, inpatient (p80) | |
Facility level 3 | 4971 | 0.756 | 7.14 |
Facility level 4 and 5 | 14,028 | 0.810 | 9.75 |
Outpatient care | Total outpatient visits per facility per year (p80) | Visits per provider per day (p80) |
---|---|---|
Facility level 1 | 67,656 | 8.96 |
Facility level 2 | 46,434 | 9.52 |
Facility level 3 | 93,739 | 3.22 |
Facility level 4 and 5a | 281,156 | 2.36 |
Additional variables | ||
Ownership is set to public provider; location is set to urban location for outpatient care |
Results
Descriptive statistics
Explanatory power
Regression coefficient | 95% confidence interval | |
---|---|---|
Ln GDP per capita | 1.192*** | [1.111, 1.272] |
Ln occupancy rate | − 0.0201** | [− 0.0340, − 0.00623] |
Ln ALOS | − 0.600*** | [− 0.649, − 0.550] |
Ln admissions | 0.0252* | [0.00471, 0.0457] |
District | − 0.204*** | [− 0.275, − 0.132] |
Teaching | 0.257*** | [0.163, 0.351] |
Public | − 0.144*** | [− 0.182, − 0.107] |
Private | 0.110*** | [0.0710, 0.148] |
Brazil | − 1.638*** | [− 1.694, − 1.583] |
Constant | − 4.277*** | [− 5.035, − 3.519] |
Observations | 3407 | |
R
2
| 0.760 | |
Adjusted R2 | 0.760 | |
F_stat | 1070.3 | |
Duan’s correction factor | 1.054 | |
Variance inflation factor | 1.721 |
Coefficient | 95% confidence interval | |
---|---|---|
Ln GDP per capita | 0.865*** | [0.826, 0.905] |
Ln visits | − 0.0142* | [− 0.0272, − 0.00119] |
Ln visits per provider | − 0.0412*** | [− 0.0578, − 0.0246] |
Urban | 0.352*** | [0.268, 0.435] |
Public | − 0.290*** | [− 0.330, − 0.249] |
Private | 0.0532* | [0.00479, 0.102] |
Level 2 | 0.208*** | [0.144, 0.271] |
Level 3 | 0.304*** | [0.213, 0.395] |
Level 4 | 0.348*** | [0.279, 0.417] |
Colombia | 0.628*** | [0.542, 0.713] |
Brazil | − 1.563*** | [− 1.656, − 1.470] |
Brazil level 3 | − 0.245*** | [− 0.337, − 0.153] |
Constant | − 4.534*** | [− 4.797, − 4.271] |
Observations | 9028 | |
R
2
| 0.658 | |
Adjusted R2 | 0.658 | |
F_stat | 1635.7 | |
Duan’s correction factor | 1.271 | |
Variance inflation factor | 3.209 |
Level and location of facilities
Size of facilities
Ownership
Capacity utilization
Country dummies
Comparison with earlier models
Validation
Country (ranked by GDP per capita) | GDP per capita (I$) | Hospital level | Cost per bed day (I$) | |||
---|---|---|---|---|---|---|
Mean | 95% uncertainty interval low | 95% uncertainty interval high | SD | |||
Mozambique | 894 | 3 | 6.97 | 2.74 | 15.29 | 3.15 |
4 | 7.46 | 2.81 | 15.58 | 3.37 | ||
5 | 9.76 | 3.56 | 21.80 | 4.62 | ||
Mali | 1215 | 3 | 10.17 | 4.05 | 21.49 | 4.72 |
4 | 10.78 | 4.21 | 22.94 | 4.99 | ||
5 | 14.40 | 5.45 | 30.34 | 6.59 | ||
Indonesia | 4298 | 3 | 46.61 | 19.03 | 102.61 | 21.68 |
4 | 48.61 | 19.83 | 102.41 | 20.87 | ||
5 | 62.97 | 23.33 | 139.86 | 28.97 | ||
Algeria | 8029 | 3 | 98.15 | 104.21 | 134.41 | 35.25 |
4 | 104.21 | 134.41 | 35.25 | 38.34 | ||
5 | 134.41 | 35.25 | 38.34 | 52.49 | ||
Ecuador | 8795 | 3 | 105.79 | 41.16 | 215.84 | 46.98 |
4 | 113.27 | 44.88 | 244.39 | 53.20 | ||
5 | 151.41 | 61.03 | 322.49 | 68.84 | ||
Brazil | 11,187 | 3 | 27.96 | 11.31 | 63.05 | 12.85 |
4 | 30.18 | 11.46 | 63.20 | 13.44 | ||
5 | 37.96 | 14.63 | 78.69 | 16.61 | ||
Romania | 14,815 | 3 | 202.22 | 79.57 | 439.38 | 93.24 |
4 | 210.68 | 88.23 | 466.93 | 96.38 | ||
5 | 272.20 | 104.03 | 577.31 | 123.74 | ||
Bahrain | 20,339 | 3 | 290.75 | 305.89 | 400.24 | 117.36 |
4 | 305.89 | 400.24 | 117.36 | 118.35 | ||
5 | 400.24 | 117.36 | 118.35 | 153.11 | ||
Russian Federation | 20,593 | 3 | 296.04 | 106.32 | 648.53 | 138.93 |
4 | 313.35 | 114.96 | 678.27 | 154.36 | ||
5 | 407.34 | 153.69 | 925.76 | 197.33 | ||
Greece | 27,545 | 3 | 437.22 | 162.5 | 943.81 | 209.06 |
4 | 441.67 | 174.11 | 960.97 | 196.38 | ||
5 | 569.30 | 226.01 | 1206.52 | 260.50 | ||
United Kingdom | 35,433 | 3 | 570.07 | 217.32 | 1265.39 | 267.32 |
4 | 612.29 | 218.78 | 1397.20 | 299.66 | ||
5 | 767.92 | 289.87 | 1664.19 | 367.70 | ||
Canada | 39,176 | 3 | 646.49 | 237.17 | 1461.88 | 299.35 |
4 | 680.16 | 266.49 | 1532.70 | 317.30 | ||
5 | 869.98 | 331.92 | 1869.47 | 403.22 | ||
United Arab Emirates | 42,180 | 3 | 719.15 | 272.51 | 1625.10 | 357.52 |
4 | 740.80 | 294.82 | 1629.96 | 338.45 | ||
5 | 952.57 | 381.38 | 2097.89 | 426.29 | ||
United States of America | 46,747 | 3 | 788.50 | 293.85 | 1700.93 | 381.24 |
4 | 834.13 | 318.51 | 1789.65 | 375.56 | ||
5 | 1093.51 | 415.16 | 2426.98 | 535.63 |
Country | GDP per capita (I$) | Facility level | Cost per outpatient visit | Cost per inpatient bed day | ||||||
---|---|---|---|---|---|---|---|---|---|---|
Mean (with standard drug % share)a | Mean (with lower drug % share)b | Mean (with standard drug % share)a | Mean (with lower drug % share)b | |||||||
2010 I$ | 2010 USD | 2010 I$ | 2010 USD | 2010 I$ | 2010 USD | 2010 I$ | 2010 USD | |||
Mozambique | 894 | 1 | 2.2 | 1.0 | 3.7 | 1.7 | ||||
– | 2 | 2.7 | 1.2 | 4.5 | 2.1 | |||||
– | 3 | 3.1 | 1.4 | 5.2 | 2.4 | 7.0 | 3.2 | 12.9 | 6.0 | |
– | 4 | 3.2 | 1.5 | 5.4 | 2.5 | 7.5 | 3.5 | 13.5 | 6.3 | |
– | 5 | 3.2 | 1.5 | 5.4 | 2.5 | 9.8 | 4.6 | 17.4 | 8.1 | |
Mali | 1215 | 1 | 4.0 | 1.5 | 6.8 | 2.6 | ||||
– | 2 | 4.8 | 1.9 | 8.2 | 3.2 | |||||
– | 3 | 5.6 | 2.2 | 9.5 | 3.7 | 10.2 | 3.9 | 18.6 | 7.2 | |
– | 4 | 5.7 | 2.2 | 9.7 | 3.7 | 10.8 | 4.2 | 19.3 | 7.5 | |
– | 5 | 5.8 | 2.2 | 9.9 | 3.8 | 14.4 | 5.6 | 25.0 | 9.7 | |
Indonesia | 4298 | 1 | 15.0 | 5.7 | 25.6 | 9.6 | ||||
– | 2 | 18.5 | 7.0 | 31.4 | 11.8 | |||||
– | 3 | 20.7 | 7.8 | 35.2 | 13.3 | 46.6 | 17.6 | 83.1 | 31.3 | |
– | 4 | 21.2 | 8.0 | 36.1 | 13.6 | 48.6 | 18.3 | 88.4 | 33.3 | |
– | 5 | 20.9 | 7.9 | 35.6 | 13.4 | 63.0 | 23.7 | 113.1 | 42.6 | |
Algeria | 8029 | 1 | 21.6 | 7.6 | 36.8 | 13.0 | ||||
– | 2 | 25.0 | 8.9 | 42.6 | 15.1 | |||||
– | 3 | 29.5 | 10.4 | 50.3 | 17.8 | 98.2 | 34.7 | 176.3 | 62.4 | |
– | 4 | 30.6 | 10.8 | 52.1 | 18.5 | 104.2 | 36.9 | 186.4 | 66.0 | |
– | 5 | 31.5 | 11.2 | 53.7 | 19.0 | 134.4 | 47.6 | 234.2 | 82.9 | |
Brazil | 8795 | 1 | 4.8 | 3.8 | 8.2 | 6.5 | ||||
– | 2 | 5.8 | 4.5 | 9.8 | 7.7 | |||||
– | 3 | 5.4 | 4.2 | 9.2 | 7.2 | 28.0 | 22.0 | 51.2 | 40.3 | |
– | 4 | 7.0 | 5.5 | 12.0 | 9.4 | 30.2 | 23.8 | 52.7 | 41.6 | |
– | 5 | 6.9 | 5.5 | 11.8 | 9.3 | 38.0 | 29.9 | 67.2 | 52.9 | |
Romania | 14,815 | 1 | 27.9 | 13.5 | 47.5 | 22.9 | ||||
– | 2 | 33.8 | 16.3 | 57.5 | 27.8 | |||||
– | 3 | 37.5 | 18.1 | 63.8 | 30.8 | 202.2 | 97.7 | 371.4 | 179.4 | |
– | 4 | 40.6 | 19.6 | 69.2 | 33.4 | 210.7 | 101.7 | 384.1 | 185.5 | |
– | 5 | 41.1 | 19.8 | 69.9 | 33.8 | 272.2 | 131.5 | 493.0 | 238.1 | |
Russian Federation | 20,593 | 1 | 31.9 | 16.6 | 54.3 | 28.3 | ||||
– | 2 | 38.8 | 20.2 | 66.0 | 34.4 | |||||
– | 3 | 42.4 | 22.1 | 72.3 | 37.6 | 296.0 | 154.2 | 537.4 | 279.9 | |
– | 4 | 46.2 | 24.1 | 78.7 | 41.0 | 313.4 | 163.2 | 561.3 | 292.3 | |
– | 5 | 47.3 | 24.7 | 80.6 | 42.0 | 407.3 | 212.1 | 741.0 | 385.9 | |
United Arab Emirates | 56,415 | 1 | 77.1 | 47.9 | 131.3 | 81.6 | ||||
– | 2 | 95.9 | 59.6 | 163.3 | 101.5 | |||||
– | 3 | 109.5 | 68.0 | 186.4 | 115.8 | 719.2 | 446.8 | 1275.1 | 792.2 | |
– | 4 | 108.8 | 67.6 | 185.2 | 115.1 | 740.8 | 460.2 | 1299.2 | 807.2 | |
– | 5 | 112.6 | 70.0 | 191.8 | 119.2 | 952.6 | 591.8 | 1726.3 | 1072.5 |