title: A time-driven activity-based costing model to improve health-care resource use in Mirebalais, Haiti.
abstract: BACKGROUND
  In resource-limited settings, efficiency is crucial to maximise resources available for patient care. Time driven activity-based costing (TDABC) estimates costs directly from clinical and administrative processes used in patient care, thereby providing valuable information for process improvements. TDABC is more accurate and simpler than traditional activity-based costing because it assigns resource costs to patients based on the amount of time clinical and staff resources are used in patient encounters. Other costing approaches use somewhat arbitrary allocations that provide little transparency into the actual clinical processes used to treat medical conditions. TDABC has been successfully applied in European and US health-care settings to facilitate process improvements and new reimbursement approaches, but it has not been used in resource-limited settings. We aimed to optimise TDABC for use in a resource-limited setting to provide accurate procedure and service costs, reliably predict financing needs, inform quality improvement initiatives, and maximise efficiency.
  
  
  METHODS
  A multidisciplinary team used TDABC to map clinical processes for obstetric care (vaginal and caesarean deliveries, from triage to post-partum discharge) and breast cancer care (diagnosis, chemotherapy, surgery, and support services, such as pharmacy, radiology, laboratory, and counselling) at Hôpital Universitaire de Mirebalais (HUM) in Haiti. The team estimated the direct costs of personnel, equipment, and facilities used in patient care based on the amount of time each of these resources was used. We calculated inpatient personnel costs by allocating provider costs per staffed bed, and assigned indirect costs (administration, facility maintenance and operations, education, procurement and warehouse, bloodbank, and morgue) to various subgroups of the patient population. This study was approved by the Partners in Health/Zanmi Lasante Research Committee.
  
  
  RESULTS
  The direct cost of an uncomplicated vaginal delivery at HUM was US$62 and the direct cost of a caesarean delivery was US$249. The direct costs of breast cancer care (including diagnostics, chemotherapy, and mastectomy) totalled US$1393. A mastectomy, including post-anaesthesia recovery and inpatient stay, totalled US$282 in direct costs. Indirect costs comprised 26-38% of total costs, and salaries were the largest percentage of total costs (51-72%).
  
  
  CONCLUSIONS
  Accurate costing of health services is vital for financial officers and funders. TDABC showed opportunities at HUM to optimise use of resources and reduce costs-for instance, by streamlining sterilisation procedures and redistributing certain tasks to improve teamwork. TDABC has also improved budget forecasting and informed financing decisions. HUM leadership recognised its value to improve health-care delivery and expand access in low-resource settings.
  
  
  BACKGROUND
  Boston Children's Hospital, Harvard Business School, and Partners in Health.
authors: Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA; Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, MA, USA; University of Miami Miller School of Medicine, Miami, FL, USA. Electronic address: mandigo@gmail.com.
authors: Morgan
authors: M
authors: Mandigo
authors: Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA; Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, MA, USA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
authors: Kathleen
authors: K
authors: O'Neill
authors: Value Measurement in Health Care Department, Harvard Business School, Boston, MA, USA.
authors: Bipin
authors: B
authors: Mistry
authors: Zanmi Lasante/Partners in Health, Mirebalais, Haiti.
authors: Bryan
authors: B
authors: Mundy
authors: Zanmi Lasante/Partners in Health, Mirebalais, Haiti.
authors: Christophe
authors: C
authors: Millien
authors: Zanmi Lasante/Partners in Health, Mirebalais, Haiti.
authors: Yolande
authors: Y
authors: Nazaire
authors: Zanmi Lasante/Partners in Health, Mirebalais, Haiti.
authors: Ruth
authors: R
authors: Damuse
authors: Partners in Health, Boston, MA, USA; Program in Health Systems Strengthening and Social Change, Harvard Medical School, Boston, MA, USA.
authors: Claire
authors: C
authors: Pierre
authors: Partners in Health, Boston, MA, USA.
authors: Jean Claude
authors: JC
authors: Mugunga
authors: Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA; Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, MA, USA.
authors: Rowan
authors: R
authors: Gillies
authors: Zanmi Lasante/Partners in Health, Mirebalais, Haiti.
authors: Franciscka
authors: F
authors: Lucien
authors: Value Measurement in Health Care Department, Harvard Business School, Boston, MA, USA.
authors: Karla
authors: K
authors: Bertrand
authors: Value Measurement in Health Care Department, Harvard Business School, Boston, MA, USA.
authors: Eva
authors: E
authors: Luo
authors: Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA; Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, MA, USA.
authors: Ainhoa
authors: A
authors: Costas
authors: Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA; Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, MA, USA; Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA.
authors: Sarah L M
authors: SL
authors: Greenberg
authors: Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA; Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, MA, USA.
authors: John G
authors: JG
authors: Meara
authors: Value Measurement in Health Care Department, Harvard Business School, Boston, MA, USA.
authors: Robert
authors: R
authors: Kaplan