Martilord Ifeanyichi - Department for Health Evidence, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
Henk Broekhuizen - Department for Health Evidence, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
Adinan Juma - East, Central and Southern Africa Health Community, Arusha, Tanzania
Kondo Chilonga - Department of Surgery, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
Edward Kataika - East, Central and Southern Africa Health Community, Arusha, Tanzania
Jakub Gajewski - Institute of Global Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
Ruairi Brugha - Department of Epidemiology and Public Health Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
Leon Bijlmakers - Department for Health Evidence, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands

Background Access to surgical care is poor in Tanzania. The country is at the implementation stage of its first National Surgical, Obstetric, and Anesthesia Plan (NSOAP; ۲۰۱۸-۲۰۲۵) aiming to scale up surgery. This study aimed to calculate the costs of providing surgical care at the district and regional hospitals.Methods Two district hospitals (DHs) and the regional referral hospital (RH) in Arusha region were selected. All the staff, buildings, equipment, and medical and non-medical supplies deployed in running the hospitals over a ۱۲ month period were identified and quantified from interviews and hospital records. Using a combination of step-down costing (SDC) and activity-based costing (ABC), all costs attributed to surgeries were established and then distributed over the individual types of surgeries. These costs were delineated into pre-operative, intra-operative, and post-operative components.  ResultsThe total annual costs of running the clinical cost centres ranged from ۵۶۷k at Oltrumet DH to ۳۴۵۳k at Mt Meru RH. The total costs of surgeries ranged from ۷۹k to ۸۱۳k; amounting to ۱۲%-۲۲% of the total costs of running the hospitals. At least ۷۰% of the costs were salaries. Unit costs and relative shares of capital costs were generally higher at the DHs. Two-thirds of all the procedures incurred at least ۶۰% of their costs in the theatre. Open reduction and internal fixation (ORIF) performed at the regional hospital was cheaper (۶۱۸) than surgical debridement (plus conservative treatment) due to prolonged post-operative inpatient care associated with the latter (۱۱۷۷), but was performed infrequently due mostly to unavailability of implants.Conclusion Lower unit costs and shares of capital costs at the RH reflect an advantage of economies of scale and scope at the RH, and a possible underutilization of capacity at the DHs. Greater efficiencies make a case for concentration and scale-up of surgical services at the RHs, but there is a stronger case for scaling up district-level surgeries, not only for equitable access to services, but also to drive down unit costs there, and free up RH resources for more complex cases such as ORIF.

Global Surgery, Tanzania, District Hospital, Surgical Costs, Economies of Scale