title: Cost of installing and operating an electronic clinical decision support system for maternal health care: case of Tanzania rural primary health centres.
abstract: BACKGROUND
  Poor quality of care is among the causes of high maternal and newborn disease burden in Tanzania. Potential reason for poor quality of care is the existence of a "know-do gap" where by health workers do not perform to the best of their knowledge. An electronic clinical decision support system (CDSS) for maternal health care was piloted in six rural primary health centers of Tanzania to improve performance of health workers by facilitating adherence to World Health Organization (WHO) guidelines and ultimately improve quality of maternal health care. This study aimed at assessing the cost of installing and operating the system in the health centers.
  
  
  METHODS
  This retrospective study was conducted in Lindi, Tanzania. Costs incurred by the project were analyzed using Ingredients approach. These costs broadly included vehicle, computers, furniture, facility, CDSS software, transport, personnel, training, supplies and communication. These were grouped into installation and operation cost; recurrent and capital cost; and fixed and variable cost. We assessed the CDSS in terms of its financial and economic cost implications. We also conducted a sensitivity analysis on the estimations.
  
  
  RESULTS
  Total financial cost of CDSS intervention amounted to 185,927.78 USD. 77% of these costs were incurred in the installation phase and included all the activities in preparation for the actual operation of the system for client care. Generally, training made the largest share of costs (33% of total cost and more than half of the recurrent cost) followed by CDSS software- 32% of total cost. There was a difference of 31.4% between the economic and financial costs. 92.5% of economic costs were fixed costs consisting of inputs whose costs do not vary with the volume of activity within a given range. Economic cost per CDSS contact was 52.7 USD but sensitive to discount rate, asset useful life and input cost variations.
  
  
  CONCLUSIONS
  Our study presents financial and economic cost estimates of installing and operating an electronic CDSS for maternal health care in six rural health centres. From these findings one can understand exactly what goes into a similar investment and thus determine sorts of input modification needed to fit their context.
authors.affiliation: Behavioural Sciences Department, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania. sarongahappiness@yahoo.com.|Institute of Public Health, University of Heidelberg, Heidelberg, Germany. sarongahappiness@yahoo.com.
authors.forename: Happiness Pius
authors.initials: HP
authors.lastname: Saronga
authors.affiliation: Navrongo Health Research Centre, Navrongo, Ghana. madalaba@yahoo.com.|Institute of Public Health, University of Heidelberg, Heidelberg, Germany. madalaba@yahoo.com.
authors.forename: Maxwell Ayindenaba
authors.initials: MA
authors.lastname: Dalaba
authors.affiliation: Centre for Health Policy Studies, Zhejiang University, Hangzhou, China. donghj@zju.edu.cn.
authors.forename: Hengjin
authors.initials: H
authors.lastname: Dong
authors.affiliation: Behavioural Sciences Department, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania. mleshabari@gmail.com.
authors.forename: Melkizedeck
authors.initials: M
authors.lastname: Leshabari
authors.affiliation: Institute of Public Health, University of Heidelberg, Heidelberg, Germany. rainer.sauerborn@urz.uni-heidelberg.de.
authors.forename: Rainer
authors.initials: R
authors.lastname: Sauerborn
authors.affiliation: Behavioural Sciences Department, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania. sukums@gmail.com.|Institute of Public Health, University of Heidelberg, Heidelberg, Germany. sukums@gmail.com.
authors.forename: Felix
authors.initials: F
authors.lastname: Sukums
authors.affiliation: Institute of Public Health, University of Heidelberg, Heidelberg, Germany. Antje.Blank@med.uni-heidelberg.de.
authors.forename: Antje
authors.initials: A
authors.lastname: Blank
authors.affiliation: Institute of Public Health, University of Heidelberg, Heidelberg, Germany. Jens.Kaltschmidt@med.uni-heidelberg.de.
authors.forename: Jens
authors.initials: J
authors.lastname: Kaltschmidt
authors.affiliation: Institute of Public Health, University of Heidelberg, Heidelberg, Germany. svetla.loukanova@urz.uni-heidelberg.de.
authors.forename: Svetla
authors.initials: S
authors.lastname: Loukanova
mesh_terms: D000328:Adult; D020000:Decision Support Systems, Clinical / Q000191:economics*; D005260:Female; D006282:Health Personnel / Q000193:education*; D006801:Humans; D008427:Maternal Health Services / Q000191:economics* / Q000592:standards*; D008875:Middle Aged; D017410:Practice Guidelines as Topic; D011247:Pregnancy; D011320:Primary Health Care / Q000191:economics*; D012189:Retrospective Studies; D019035:Rural Health Services / Q000191:economics; D013636:Tanzania; D014944:World Health Organization