title: Rural health service planning: the need for a comprehensive approach to costing.
abstract: The precipitous closure of rural maternity services in industrialized countries over the past two decades is underscored in part by assumptions of efficiencies of scale leading to cost-effectiveness. However, there is scant evidence to support this and the costing evidence that exists lacks comprehensiveness. To clearly understand the cost-effectiveness of rural services we must take the broadest societal perspective to include not only health system costs, but also those costs incurred at the family and community levels. We must consider manifest costs (hard, easily quantifiable costs, both direct and indirect) and latent costs (understood as what is sacrificed or lost), and take into account cost shifting (reallocating costs to different parts of the system) and cost downloading (passing costs on to women and families). Further, we must compare the costs of having a rural maternity service to those incurred bynothaving a service, a comparison that is seldom made. This approach will require determining a methodological framework for weighing all costs, one which will likely involve attention to the rich descriptions of those experiencing loss.
authors.affiliation: University of British Columbia, Vancouver, British Columbia, Canada. jude.kornelsen@familymed.ubc.ca.
authors.forename: Jude A
authors.initials: JA
authors.lastname: Kornelsen
authors.affiliation: University of Sydney, Lismore, New South Wales, Australia. lesley.barclay@sydney.edu.au.
authors.forename: Lesley
authors.initials: L
authors.lastname: Barclay
authors.affiliation: University of British Columbia, Vancouver, British Columbia, Canada&#8232; 5950 University Boulevard Vancouver, British Columbia&#8232; CANADA V6T 1Z3. sgrzybow@mail.ubc.ca.
authors.forename: Stefan
authors.initials: S
authors.lastname: Grzybowski
authors.affiliation: Midwifery Research Institute, Mater Medical Research Institute, South Brisbane, Queensland, Australia; School of Nursing, Midwifery and Social Work, The University of Queensland, St Lucia, Queensland, Australia.
authors.forename: Yu
authors.initials: Y
authors.lastname: Gao
mesh_terms: D003362:Cost-Benefit Analysis; D003906:Developing Countries; D005193:Family Planning Services / Q000191:economics*; D005260:Female; D017048:Health Care Costs; D006285:Health Planning / Q000145:classification*; D006301:Health Services Needs and Demand; D006302:Health Services Research; D006801:Humans; D008427:Maternal Health Services / Q000191:economics*; D019035:Rural Health Services / Q000191:economics*
keywords: Australia/Pacific; Economics; Health Service reform; North America