The Unit and Scale-Up Cost of Postabortion Care in Tanzania

Figures & Tables

TABLE 1.

Number of Postabortion Cases Estimated by Facility Type by Complication and Hospitalization Status During Data Collection, June–September 2017

	Type of Complication and Hospitalization Status
	Incomplete Abortion		Shock		Sepsis		Laceration		Uterine Perforation		All Complications		Total
Facility Type	H	OP	H	OP	H	OP	H	OP	H	OP	H	OP	H	OP
Regional hospital	1,881	286	228	20	216	7	11	7	18	4	2,354	324	88%	12%
District hospital	940	859	114	1	129	0	21	95	16	3	1,220	958	56%	44%
Health center	296	695	89	2	82	20	41	12	10	6	518	735	41%	59%
Dispensary	NA	206	NA	0	NA	21	NA	0	NA	0	NA	227	0%	100%
Total	3,117	2,046	431	23	427	48	73	114	44	13	4,092	2,244	65%	35%
%	60%	40%	95%	5%	90%	10%	39%	61%	77%	23%	65%	35%

TABLE 2.

Average Time Spent on Each Type of Postabortion Complication by Health Worker Category

	Time Spent (minutes) per Complication
Health Worker	Incomplete Abortion	Shock	Sepsis	Laceration	Uterine Perforation	All Complications
Obstetrician/gynecologist	11.3	190.0	47.5	41.3	130.0	26.1
Anesthesiologist	0.0	0.0	3.3	7.5	20.0	9.7
Anesthetist	11.3	16.7	13.3	35.0	102.5	42.7
Anesthetist assistant	10.0	15.0	10.0	30.0	100.0	38.0
Doctor/medical officer	30.0	133.8	96.3	53.8	120.0	42.6
Assistant medical officer	26.3	10.0	3.3	3.8	5.0	23.2
Clinical officer	30.6	2.5	24.0	3.8	5.0	28.5
Registered nurse/principal enrolled nurse	23.6	94.0	123.5	66.3	25.8	39.3
Enrolled nurse (nurse midwife)	101.5	41.3	39.2	66.3	31.3	51.6
Medical attendant	25.3	20.0	55.3	20.0	86.7	24.1
Laboratory technician	22.5	12.6	16.4	13.8	35.0	19.0
Laboratory assistant	10.0	38.8	26.7	10.0	10.0	12.4
Sonographer	14.5	31.3	10.8	5.0	102.0	12.4
Pharmacist	11.3	13.3	22.5	18.8	75.0	7.7
Drug dispenser	8.8	23.3	6.3	13.8	26.3	8.4

TABLE 3.

Distribution of Personnel Costs of Postabortion Care per Health Worker and Complication Type

	% of Total Personnel Costs per Complication Type
Health Worker	Incomplete Abortion	Shock	Sepsis	Laceration	Uterine Perforation	All Complications
Obstetrician/gynecologist	3.6	58.4	14.8	16.7	13.4	9.4
Anesthesiologist	0.0	0.0	0.0	0.0	0.0	0.0
Anesthetist	2.5	0.6	3.0	4.6	5.7	2.1
Anesthetist assistant	2.5	1.0	2.3	5.2	3.8	1.7
Doctor/medical officer	15.1	6.5	17.4	14.7	7.2	14.8
Assistant medical officer	4.7	2.2	2.8	3.1	4.3	4.7
Clinical officer	0.8	0.6	1.8	2.0	2.1	0.8
Registered nurse/principal enrolled nurse	9.7	3.8	12.4	8.3	5.7	9.2
Enrolled nurse (nurse midwife)	42.8	21.9	29.7	39.0	33.7	41.0
Medical attendant	7.4	1.6	4.1	3.6	3.2	5.7
Laboratory technician	3.1	0.6	4.1	0.6	3.0	3.0
Laboratory assistant	1.8	0.3	0.8	0.6	2.6	1.6
Sonographer	2.6	2.1	1.9	0.0	9.5	2.7
Pharmacist	2.3	0.2	4.5	1.1	5.3	2.4
Drug dispenser	1.2	0.1	0.4	0.4	0.4	1.0
Total for all workers	100.0	100.0	100.0	100.0	100.0	100.0

TABLE 4.

Average Costs of Direct Inputs for Personnel, Medicines and Supplies, and Hospitalization for PAC Provision by Type of Complication (US$ in 2016)

	Type of Complication
	Incomplete Abortion	Shock	Sepsis	Laceration	Uterine Perforation	All Complications
Average cost of personnel used in PAC treatment
Primary care^a	10.01	54.85	12.48	22.83	17.01	13.42
District hospital	7.51	10.39	18.44	9.27	11.16	8.43
Regional hospital	25.94	44.21	25.21	29.46	115.64	28.33
Overall	15.85	37.14	20.07	15.06	53.13	18.01
Average cost of medicines and supplies used in PAC treatment
Primary care	9.25	0.89	22.18	44.38	21.92	11.21
District hospital	15.82	9.89	122.76	54.61	0	23.77
Regional hospital	20.40	29.49	22.56	10.06	131.67	22.26
Overall	16.22	18.79	49.67	47.42	56.97	20.20
Average cost of hospitalization for PAC treatment
Primary care	0.80	5.16	3.51	3.17	10.50	1.41
District hospital	1.66	7.35	10.06	1.36	7.68	2.50
Regional hospital	8.08	6.88	10.08	6.70	10.91	8.15
Overall	4.16	6.65	8.37	2.39	8.02	4.63
Total (by complication)	36.23	62.58	78.11	64.87	118.02	42.84

TABLE 5.

Unit and Total Health System Cost of Postabortion Care at 31 Sites in Tanzania

Cost Category by Complication Type	Costs by Health Care Level (US$)
Cost Category by Complication Type	Regional Hospital (n=2,678)	District Hospital (n=2,178)	Lower-Level Sites^a (n=1,480)	All Facilities (N=6,336)	% by Category
Personnel, total
Incomplete abortion	56,218.53	13,507.28	12,133.12	81,858.93
Sepsis	5,621.06	2,378.18	1,534.56	9,533.80
Shock	10,963.72	1,194.84	4,704.29	16,862.86
Lacerations	530.22	1,075.32	1,210.18	2,815.72
Uterine perforation	2,544.13	211.96	272.25	3,028.35
Total	75,877.66	18,367.59	12,133.12	114,099.66	25%
Medicines and supplies, total
Incomplete abortion	44,201.42	28,458.45	11,071.97	83 ,731.84
Sepsis	5,030.30	15,836.12	2,728.23	23,594.65
Shock	7,312.56	1,136.79	80.83	8,530.19
Lacerations	181.12	6,334.45	2,351.98	8,867.55
Uterine perforation	2,896.66	0	350.77	3,247.42
Total	59,622.05	51,765.81	16,583.78	127,971.65	28%
Hospitalization, total
Incomplete abortion	17,516.65	2,990.67	958.03	21,465.35
Sepsis	2,248.37	1,297.29	431.74	3,977.39
Shock	1,706.13	844.94	469.88	3,020.95
Lacerations	120.59	157.61	168.01	446.21
Uterine perforation	239.97	146.00	70.9	456.86
Total	21,831.70	5,436.51	2,098.56	29,366.76	6%
Capital costs, total	84,304.07	604.18	301.21	85,209.47	18%
Indirect costs, total	89,287.79	12,901.78	3,099.08	105,288.66	23%
Medical costs, total	157,331.41	75,569.91	38,536.75	271,438.07	59%
Nonmedical costs, total	173,591.87	13,505.96	3,400.30	190,498.13	41%
Overall total	331,143.53	89,145.83	41,937.04	461,936.20	100%
Total per case (N=6,336)	123.65	40.93	28.34	72.91

TABLE 6.

Total Average Out-of-Pocket Costs for Postabortion Care by Place of Residence (US$2016)

Out-of-Pocket Costs	Urban	Rural	All
Travel cost	3.59	6.64	4.69 (20.43%)
Hospitalization	5.59	0	3.58 (15.58%)
Food	3.93	3.09	3.63 (15.81%)
Medicines	5.82	3.03	4.89 (21.30%)
Laboratory tests	4.89	1.16	3.65 (15.90%)
Other^a	3.12	1.90	2.52 (10.98%)
Total out-of-pocket costs	26.94	15.82	22.96 (100.00%)

↵a Includes hospital registration fees, paying for miscellaneous drugs and supplies (e.g. gloves, Panadol), bed covers, and sheets for ultrasound.

TABLE 7.

Central, Minimum, and Maximum Estimates Used in Sensitivity Analysis

Parameters	Estimates	Minimum	Maximum
% Distribution of complication
Incomplete abortion	81.5	72.5	100
Sepsis	7.4	3.9	11
Shock	7	4.5	11
Laceration	2.9	1	5
Uterine perforation	1	0.5	2
Personnel
Total work hours for postabortion care per year	1,920	1,720	2,400
Salaries/allowances	—	10% lower	25% higher
Hospitalization	—	20% lower	20% higher
Capital costs (% of direct medical costs)	31	23	100
Indirect costs (% of direct medical costs)	39	31	100

TABLE 8.

Sensitivity Analysis for Cost to the Health System for PAC per Case (US$)

Overall Cost	Minimum	Reported	Maximum
Direct medical costs
Incomplete abortion	153,506.21	187,057.72	256,336.13
Sepsis	18,367.74	37,104.48	57,619.47
Shock	17,092.98	28,413.55	42,851.40
Lacerations	3,735.90	12,132.92	22,003.43
Perforations	3,221.23	6,729.37	13,750.38
All complications	195,924.05	271,438.04	392,560.18
Medical cost per PAC case	30.92	42.84	61.96
Direct nonmedical costs
Capital costs	63,497.21	85,209.47	271,438.04
Indirect costs	83,573.62	105,288.66	271,438.04
Total annual overhead (capital and indirect costs)	147,070.83	190,498.13	542,876.08
Nonmedical cost per PAC case	23.21	30.07	85.68
Overall cost per PAC case	54.13	72.91	147.64