HEALTH SYSTEM COSTS OF UNSAFE ABORTION
IN RWANDA
INTERVIEWER MANUAL
REVISED 25 FEBRUARY 2012
For Interviews at All Facility Levels
_____________________________________________________________________________
GUTTMACHER INSTITUTE
AND
SCHOOL OF PUBLIC HEALTH, NATIONAL UNIVERSITY OF RWANDA
_____________________________________________________________________________
Interviewer Manual: Health-System Costs
The purpose of this manual is to give the interviewer detailed guidance in the
interview process. The manual is divided into two sections: general
considerations and question-specific instructions.
NB: (1) Change “septecemie” to “sepsis” everywhere; (2) a note is
repeated on page 4 and page 5 of the manual in French.
1. General Considerations for the Interviewing Process
1.1. Nature and Goals of the Study
The main goal of the study is to estimate the costs to the Rwandan health care
system of treating complications arising out of unsafe abortions. Estimation of
health system costs will be achieved through the process to be described in
this manual.
This is a 2-year research project designed to generate evidence needed to
drive policy and program reform that will address the economic and social
consequences of unsafe abortion, thereby improving maternal health in
Rwanda. The data collection process is likely to take one month.
1.2 The Survey Sample and Respondents
Knowledgeable health personnel at around 40 health facilities will be
interviewed using two data-collection instruments: Questionnaires A and B.
Questionnaire A comes in four versions:
 Questionnaire A1 – for respondents at the central level
 Questionnaire A2 – for respondents at regional hospitals
 Questionnaire A3 – for respondents at district hospitals and private
polyclinics and clinics
 Questionnaire A4 – for respondents at health centers
Questionnaire A collects data on personnel costs, overhead costs, and capital
costs associated with the provision of post-abortion care. Questionnaire B
collects data on the drugs, supplies and materials used in the provision of
treatment for specific post-abortion complications.
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A purposive sample of 39 facilities from all over the country has been selected
by the local project team. These facilities include 5 regional hospitals, 11
district hospitals and 23 health centers.a The selection criteria are based on
region, facility type and facility ownership (public, private, faith-based).
Questionnaire A1, for the central level, will primarily be aimed at the Ministry
of Health.
You, the interviewer, may have to interview several staff at a particular facility
in order to complete the two questionnaires. The larger the facility, the
greater the chance that you will interview more than one person.
 For the central level, typically in the ministry of health or equivalent,
respondents may include: the director of Reproductive Health Services,
the director of the Planning Division and the director of the Statistical
Division of the MOH.
 For regional hospitals, the head of the reproductive health services (or
the head of the maternity ward) and the head of administration may be
interviewed. An anesthetist, the in-charge of the operating theater, the
in-charge of the laboratory are other personnel that will probably be
interviewed to fill in specific parts of the questionnaires.
 For district hospitals, the respondent may be the district medical
officer.
 For health centers, the medical officer assigned to the center may be
interviewed.
 For all facilities, you may have to interview the head of the laboratory
and the pharmacist for certain items.
Since the goal of the health-system-cost survey is to collect expert opinions,
the staff member interviewed at a particular facility should be the highest
ranking person who is well versed in the facility’s treatment of cases of postabortion complications. If that person then tells you that another staff
member may be better able to answer certain questions, then you should
follow his/her advice and interview that person later.
The PACCM uses the generic terms “regional hospital”, “district hospital” and “health center”.
In the particular case of Rwanda, “regional hospital” refers to national and referral hospitals,
“district hospital” refers to district hospitals and private polyclinics and “health center” refers
to health centers and private clinics.
a
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Be aware, however, that primary respondents may try to pass you along to a
junior staff member. Try to avoid this—emphasize that the survey is meant to
collect expert opinion, not “data” as such (which are likely old, incomplete,
and inaccurate) and therefore you want to interview that person in his/her
capacity as an expert.
Experience from a Ugandan study: A similar study has recently been carried out
in Uganda. Interviewers found that at larger facilities, up to six staff were
interviewed. For example, the head of the laboratory was interviewed for
information on lab tests, the nurse in charge of the operating theater was
interviewed for inputs used in treating lacerations and perforations, etc.
1.3. Consent to be Interviewed
The information collected in this survey does not involve the gathering of any
personal data on patients at the facilities sampled or on any providers of health
services. Moreover, as the following section makes clear, the information to be
collected is not “hard” data but merely opinion-type data. Thus, ethical
considerations about confidentiality of the data and risks/harm to the respondents if
the data were to be divulged do not apply to this study.
Before beginning an interview with any facility staff member, the interviewer should
clearly inform the respondent that no personal information about him/her or about
any patient of the facility will be collected in the interview and thus that there are no
risks involved in consenting to be interviewed. On the contrary, to the extent that the
results of the study lead to a more optimum use of resources in the health sector,
he/she, along with the rest of the public, will benefit from more efficient use of
resources. Before an interview begins the respondent must have agreed to and
signed the consent form (see Annex 1).
1.4. The Type of Data to be Collected
It cannot be emphasized too strongly that the type of data that this survey will
collect is expert opinion. Respondents should give you their best estimate,
their considered opinion, their best guess to (almost) all of the questions in
both questionnaires. Except for a few questions—which are clearly indicated
in the questionnaires—you do not want the respondent to formulate his/her
response by reaching for some document, statistical table or other document,
or by reaching for the phone to ask some other official to look up some data.
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You want the respondent to give his/her opinion as a knowledgeable expert in
the field of post-abortion care.
Why does this survey want to avoid “hard data”? There are several reasons:
 The “data”, if found, will most likely not exactly answer the question
posed.
 The “data” will likely be incomplete or based on a biased set of inputs
into their information system.
 The “data” may well be old and
out-of-date.
The most important concept
 We already know from
that interviewers must
experience that most of the
remember is that they are to
questions we want answered do
collect expert opinions. The
not have data systematically and
interviewers must
accurately collected by any
internalize this concept and
information system.
 We do not need “data” that
must be ready to explain it
apparently are very precise
to respondents, repeatedly if
since our results do not demand
necessary.
high precision. Moreover, while
such data may appear precise,
they may well be very inaccurate for the reasons listed above.
Instead, we want experts to give their expert opinions. This type of approach
is generally known as the “Delphi method” and is an accepted form of
gathering hard-to-collect data. The underlying assumption of this method is
that, while individual expert estimates may be inaccurate, the average of
several experts is likely to give an estimate that is close to reality. This method
is appropriate when the results that one is looking for do not have to be very
precise. Since the results of this study are meant to be used by policy makers,
not by day-to-day managers, we do not need the cost estimates to be very
precise. The Delphi method can produce useful results at a low cost.
A note on ranges: If a respondent replies with a range (e.g., “20-30%”) rather
than an exact number (e.g., “80%”), write down the range as stated. The range
can be converted into an exact number later, during the data-coding process.b
For example, if the response was “20-30%”, “25%” should be entered during the data-entry
process.
b
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1.5. Definition of post-abortion complications
The study focuses on five post-abortion complications:
Sepsis. Sepsis refers to a serious infection resulting from the abortion. It
should be accompanied by fever (temperature > 37.3 degrees Celsius) and can
range from endometritis up to the condition known as septicemia, a
generalized infection that is life is threatening.
Shock. Shock refers to hypovolemic shock, a serious condition in which the
volume of blood in the body falls to such a low level (due to hemorrhaging)
that the body goes into shock and normal functions are shut down.
Incomplete Abortion. Incomplete abortion refers to a post-abortion
condition in which part of the fetus (or “product of conception”) remains
inside the uterus. This can lead to a very serious condition if not attended to.
Cervical/Vaginal Laceration. This is a laceration or other mechanical injury
to the cervix and/or vagina which occurred at the time of an unsafe induced
abortion. It includes burns caused by caustic chemical substances.
Uterine Laceration/Perforation. This condition refers to mechanical
damage to the uterus. Perforation refers to an opening made between the
uterus and the peritoneum (the lower body cavity containing the intestines).
Included here are other types of perforation such as perforation of the bowel
and of the peritoneum. Treatments such as laparotomies and hysterectomies
should be included here.
1.6. Don’t know (DK), no answer (NA) and blank
With a very few exceptions, the response “don’t know” is not allowed in either
Questionnaire A or B.c As mentioned, if after several attempts to prompt a
The questions in Questionnaire A where a “don’t know response is allowed are: A002, A102,
A202 and A302;
c
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response, a respondent still refuses to give an answer, the interviewer may
enter “NA” for No Answer. No question is ever to be left blank, except where it
has correctly been skipped.
2. Question-by-Question Instructions
2.1. Questionnaire A – Personnel, Capital, and
Overhead Costs
The four versions of Questionnaire A (i.e., Questionnaires A1, A2, A3, and A4)
are basically the same, varying only slightly because of differences between
type of facility. The instructions in this section apply to all four versions, but
for readability reference is actually made only to Questionnaire A2 (for
respondents at Regional Hospitals). In this questionnaire the question
numbers are all in the “one hundreds” (e.g., A104 or P114). The question
numbering for the four versions are as follows:
 Questionnaire A1: Sections 1.0, 2.0, 3.0; question numbers from 001 099
 Questionnaire A2: Sections 1.1, 2.1, 3.1; question numbers from 101 199
 Questionnaire A3: Sections 1.2, 2.2, 3.2; question numbers from 201 299
 Questionnaire A4: Sections 1.3, 2.3, 3.3; question numbers from 301 399.
Thus, the instruction for, say, question A104 applies equally to A004, A104,
A204 or A304. If a question is different from one level of facility to another,
facility-specific instructions will be noted in what follows.d
Identification of Facility
Note that questionnaire A1, for central-level respondents, is somewhat different in structure
from the other questionnaires because the questions are mostly aimed at finding information
about the three levels of facility that actually supply services, the central level being solely
administrative. The topics of the questions, however, are the same as the other versions of the
questionnaire.
d
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The name of the facility, the date of the interview and the name of the
interviewer should be written in the questionnaire before the interview
begins, or immediately after the interview has been completed.
Respondents’ Identification
You may have to interview more than one
expert in the facility, especially in larger
hospitals. There may be three or more
repondents, (e.g., head of reproductive
health department, chief of
administration, head of laboratory). In
smaller facilities, one expert may be able
to answer all questions (e.g., chief medical
officer). Write down the name,
designation and phone number of each
respondent.
Section 1: Abortion
Complications
DO NOT ACCEPT “DON’T
KNOW” AS AN ANSWER
Remember always that this
is a survey of expert opinion.
Logically, “don’t know” is
impossible since everyone
should have opinions. If,
after repeated attempts, a
respondent refuses to
answer, mark “NA” as the
response (No Answer).
A101. Does this [facility] maintain
statistics on the number of women who come to the hospital with postabortion complications? (See also A001, A201, A301)
The possible responses are either “Yes” or “No”. (If “No”, skip to A104.)
A102. What were the number of women who come to this [facility] with
post-abortion complications in the last year for which statistics are
available? (See also A002, A202, A302)
This is one of the very few questions where we want to get statistical data if
they exist. If the respondent answered “Yes” to A101 but then cannot find the
report or statistical table with the required data, proceed on the assumption
that the data do not exist and skip to A104. In this case, enter “DK” (don’t
know) for this question.
A103. What is the year referred to in A102? (See also A003, A203, A303)
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Write down the year to which the number of women given in A102 refers. If
the data is more than three years old, the response to A104 will be preferred
to A103 in the data analysis phase of the research.
A104. Give your best estimate of the number of women who came to this
[facility] during all of last year with post-abortion complications. (See also
A004, A204, A304)
Remember, you are now asking for an expert opinion, so inform the
respondent, if necessary, that his/her best estimate is all that is needed. Ask
this question even if the respondent has given answers to A102 and A103. The
respondent may say that the A102 response is also his/her best estimate, but
if the year referred to (A103) is a few years old, point that out to the
respondent and try to elicit his/her estimation of the current number of
women requesting PAC.
Before asking A105, you should make the following introduction: “It is
important for this study to get the best possible estimates of the distribution of
serious post-abortion complications. The next question asks you to think of 100
women presenting at this hospital with serious post-abortion complications.”
A105. Think about 100 women treated in this [facility] last year for postabortion complications. Of these 100 women, how many were treated for
each of the following:
a. Incomplete abortion
b. Sepsis
c. Shock
d. Cervical/vaginal lacerations
e. Uterine laceration/perforation (See also A005, A205,
A305)
This is a very important question, so it is important that the respondent
understand it very clearly. First of all, the interviewer should be thinking only
about women being treated for one or multiple post-abortion complication(s),
not all female patients treated.
Secondly, it is better to ask this question sequentially, that is, ask first how
many, out of 100, get treated for incomplete abortion (usually by vacuum
aspiration or by dilation and curettage); then ask how many get treated for
sepsis; and so on. Note that the sum of numbers in A105 (a. to e.) may well
add up to more than 100 since one woman may be treated for two or even
three complications. Record these five responses in the column with the
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heading “1st Answer”. Then repeat the responses just given by the respondent
and ask if the respondent would like to reconsider his/her five estimates.
Write these revised responses in the column “2nd Answer”, even if they are the
same. (The reason for this procedure is that respondents may initially give
five responses that add up to under 100—which should not happen since
virtually all PAC patients will have at least one of these five complications.)
A106. There are several other post-abortion complications that may
occur rarely (e.g., peritonitis, renal failure, etc.). Out of 1000
complications, how many would consist of these rare complications, i.e.,
complications not listed in A105? (See also A006, A206, A306)
Again, the respondent is asked for his/her expert opinion. The answer given
may be less than one woman. Do not accept an answer such as “very few”:
insist on a numerical estimate (e.g., “less than 1”; or “1 in 200”), then convert
it to per 1000 (e.g., “1 in 200” should be written as “5 per 1000).
A107. Treatment of a post-abortion complication sometimes fails to cure
the patient who must be retreated. For 100 cases of each of the following
five complications, how many need to be readmitted for further
treatment? (See also A007, A207, A307)
A woman with a post-abortion complication may be treated and released by a
health facility but then return because she has not been cured. The facility will
then have to treat the patient a second time. Question A107 requests an
estimate of how often this occurs for each of the five major complications,
considering 100 women who are treated for the complication. The answers,
therefore, must range between “0” (never) and “100” (always).
Section 2: Cost of Personnel
INCOMPLETE ABORTION
For the next two questions, ask the respondent to think (hypothetically) about
10 women admitted to this [facility] for incomplete abortion. They should
think in terms of women with just this one complication, even if some patients
will normally present at the facility with multiple complications.
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P101. How many women, out of 10 women admitted with incomplete
abortions, are seen by each type of [facility] worker listed below? (See also
P201, P301)
You should sequentially read from the table the names of the categories of
worker at the facility. Enter a zero (“0”, not “N/A”) if the respondent says that
particular type of worker never attends to women with incomplete abortions.
For each type of worker where “0” is the answer in P101, skip P102. As an
example, if you write down “5” beside “Nurse” (line d.), it means that the
respondent estimates that 5 out of every 10 cases of incomplete abortion are
attended to by a nurse or nurses.
P102. On average, how many minutes does each type of worker spend
with a woman admitted with incomplete abortion during the whole
course of treatment? (See also P202, P302)
Be sure not to ask this question for those worker categories that the
respondent has stated in P101 never attend incomplete abortion cases. The
number of minutes estimated should be for the whole treatment period, from
when the woman arrives at the facility until when she is discharged. It should
include all the time that a health worker spends directly on treating the
patient—which includes both time spent in the presence of the patient and
time spent away from the patient but engaged in an activity directly related to
treating that patient (e.g., filling out the patient’s chart; preparing the patient’s
medicine).
It should include the total time spent by all workers if each category of
personnel. For example, if in a particular facility three nurses normally attend
a post-abortion patient, then the response should be the total (average) time
spent by all three nurses. If nurses of different levels are all involved in the
treatment, the respondent should estimate the minutes spent by each level.
SEPSIS
Sepsis is a serious condition marked by localized or generalized infection.
Questions P103 and P104 (See also P203, P303 and P204, P304) are identical to
P101 and P102, except they ask about women admitted to the facility with
sepsis. Therefore, please refer to the instructions for P101 and P102 above.
SHOCK
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Shock is a serious condition in which the patient’s volume of blood has
reached a dangerously low level (in volume) due to hemorrhaging. Questions
P105 and P106 (See also P205, P305 and P206, P306) are identical to P101 and
P102, except they ask about women admitted to the facility with shock.
Therefore, please refer to the instructions for P101 and P102 above.
CERVICAL/VAGINAL LACERATIONS
Cervical and vaginal lacerations are serious conditions in which genital area is
physically injured usually due to the use of sharp objects or corrosive
chemicals. Questions P107 and P108 (See also P207, P307 and P208, P308) are
identical to P101 and P102, except they ask about women admitted to the
facility with such injuries. Therefore, please refer to the instructions for P101
and P102 above.
Even if a facility, such as a health center, has no operating theater needed for
the full treatment of lacerations, questions about this complication should still
be asked in order to capture the costs of any partial treatment that may be
given—e.g. pain management—before the patient is referred to a higher-level
facility.
UTERINE LACERATION/PERFORATION
Uterine laceration or perforation is serious condition in which the uterus is
physically damaged by mechanical or chemical agents. Since the cause is
generally the same, also include in this condition perforation of the bowel and
the peritoneum. Questions P109 and P110 (See also P209, P309 and P210, P310)
are identical to P101 and P102, except they ask about women admitted to the
facility with such injuries. Therefore, please refer to the instructions for P101
and P102 above.
Even if a facility, such as a health center, has no operating theater needed for
the full treatment of perforations, questions about this complication should
still be asked in order to capture the costs of any partial treatment that may be
given—e.g. pain management—before the patient is referred to a higher-level
facility.
P111. Besides attending to patients, [facility] workers have other
duties. Estimate the number of work hours per week that each type of
worker spends in these activities. (Examples: filling forms, attending
meetings, training, etc.) (See also P201, P301)
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The respondent should estimate, for each category of worker, the amount of
time spent in duties not directly related to treating patients (all patients, not
just those with post-abortion complications). Idle time should also be included
here. If a cadre spends normal working time in his/her private consult office,
this time should also be included. Press the respondent to estimate the
number of hours, not percentages.
The next set of questions refers to the cost of hospitalization.
Hospitalization is defined here as a patient who occupies a bed in the facility
for at least one night (even if the facility uses some other definition). Likewise,
“admission” signifies a stay of one night or more, even if not formally
“admitted”. Note that these questions may not apply to health centers. If the
facility is not equipped for overnight stays of patients, you should make a note
of this in the questionnaire and write “NA” in the boxes of all questions
pertaining to hospitalization (P112-P120).
P112. How many women, out of 10 women admitted with incomplete
abortion, need to be hospitalized? (See also P212, P312)
You are asking the respondent for his/her expert opinion, based on
experience, of the proportion of women with incomplete abortion who need
to be hospitalized because of that condition. Post-abortion cases may present
with multiple conditions, but the respondent must think only of incomplete
abortion when answering this question, in isolation from any other health
condition the patient may also have.
If the respondent answers that women are never hospitalized just for
incomplete abortion, you should write “0” (zero) in the box.
P113. How many women, out of 10 women admitted with sepsis, need to
be hospitalized? (See also P213, P313)
See question P112.
P114. How many women, out of 10 women admitted with shock, need to
be hospitalized? (See also P214, P314)
See question P112.
P115. How many women, out of 10 women admitted with
cervical/vaginal lacerations, need to be hospitalized? (See also P215, P315)
See question P112.
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P116. How many women, out of 10 women admitted with uterine
laceration/perforation, need to be hospitalized? (See also P216, P316)
See question P112.
P117. Thinking only about women who are hospitalized, estimate the
average number of nights of hospitalization for each of the following
complications:
a. Incomplete abortion
b. Sepsis
c. Shock
d. Cervical/vaginal lacerations
e. Uterine laceration/perforation (See also A217, A317)
Question P117 depends on the responses to questions P112-P116. If the
respondent estimated that women were never hospitalized for a particular
complication, then P117 should be recorded as “0” (zero). (Hint: the condition
least likely to need hospitalization is probably incomplete abortion.)
This question also asks the respondent to think of each condition or
complication in isolation—e.g., “If a woman’s only condition was [name of
complication] and was hospitalized, on average for how many days would she
be hospitalized?”
We define hospitalization here to be a stay of one or more nights in a bed in a
hospital or other facility.
P118. Do patients pay part of the fee for hospitalization? (See also P218,
P318)
This question is straightforward. If the response is “No”, then skip to question
P120.
P119. Do patients pay a fee for hospitalization? If so, how much do they
pay per day for hospitalization (in Rwanda francs)? (See also P219, P319)
This question is straightforward. If, however, there happen to be different
rates charged under different circumstances, ask the respondent to give
his/her best estimate of an overall average. E.g., if half of all hospitalized
patients are charged 2,000 Francs per day and half are charged 1,000 Francs,
the best estimate would be 1,500 Francs per day.
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P120. Do out-patients pay extra for special items or services? (See also
P220, P320)
Out-patients are those who are treated without hospitalization. In the case of
Rwanda, items that may be included here are drugs, supplies, laboratory tests
and x-rays. Do not include co-payments. If the response is “No”, then skip to
Section 3.
P121. If so, how much do they pay per visit (in Rwanda francs)? (See also
P221, P321)
If there happen to be different rates charged under different circumstances,
ask the respondent to give his/her best estimate of an overall average. E.g., if
half of all out-patients are charged 500 Francs per day and half are charged
900 Francs, the best estimate would be 700 Francs per day. Do not include
here any other special fees (e.g., a laboratory fee), only a fee paid by all outpatients.
P122. Do in-patients pay extra for special items or services? (See also
P222, P322)
In-patients are those who are treated after being hospitalized. In the case of
Rwanda, items that may be included here are meals, drugs, supplies,
laboratory tests and x-rays. Do not include co-payments. If the response is
“No”, then skip to Section 3.
P123. If so, how much do they pay per visit (in Rwanda francs)? (See also
P223, P323)
See question P121.
Section 3: Capital and Overhead Expenses
Data on capital and overhead costs are difficult to obtain, yet they are
significant components of the overall cost of care. Again, it is important to
remind the respondents that we are seeking their best estimates, their expert
opinions and that these are better—even if they are guesstimates—than no
answer at all.
K001. How many regional hospitals are in the health system?
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This question appears only in Questionnaire A1. Exceptionally, K001 should be
answered from official statistics if possible. If it is not possible, enter the
respondent’s best estimate. Consider only regional hospitals that are actually
in operation.
K002. How many district hospitals are in the health system?
This question appears only in Questionnaire A1. Exceptionally, K002 should be
answered from official statistics if possible. If it is not possible, enter the
respondent’s best estimate. Consider only district hospitals that are actually in
operation.
K003. How many health centers are in the health system?
This question appears only in Questionnaire A1. Exceptionally, K003 should be
answered from official statistics if possible. If it is not possible, enter the
respondent’s best estimates. Consider only health centers that are actually in
operation.
K004. Estimate the average total number of cases per year for each type
of facility.
This number represents the total number of cases (male and female, child and
adult) that are treated by a health facility in one year (the most recent 12
months).
K005. Estimate the percentage of cases that are related to maternal and
newborn health (MNH) for each type of facility.
This number represents the total number of cases relating to maternal and
newborn health (but not child health) that are treated by a health facility in
one year (the most recent 12 months).
N.B.: QUESTIONS K006 AND K007 HAVE BEEN DROPPED FROM
QUESTIONNAIRE A1. THE QUESTION NUMBERING, HOWEVER, HAS NOT
BEEN CHANGED TO AVOID POSSIBLE EDITING ERRORS.
K019. The Government supports the training of medical personnel
(doctors, nurses, health technicians) through various subsidies. Estimate
the annual value (in Rwandan francs) of the following: incomplete
abortion, sepsis, shock, lacerations and perforations.
Question K019 tries to get at public investment in human capital (trained,
skilled health providers). Investments in education that individuals or their
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households make should not be counted. Government subsidies should be for
operational expenses of the training institution, not for capital improvements.
K101. Estimate the average total number of cases per year in your
[facility]. (See also K004, K201, K301)
A “case” is defined as a patient (male or female) in a facility where service or a
referral is provided. One treatment to a patient may require one or more
visits.
Note that the total number of “cases” may be kept in different registers: the
antenatal and maternal register, the immunization register and the outpatient department register. Remind the respondent of this and make sure
that his/her estimate includes cases of all three types.
K102. Estimate the percentage of cases that are related to maternal and
newborn health in your [facility]. (See also K005, K202, K302)
The respondent is asked to estimate the percentage of all cases (male as well
as female cases) that are related to maternal or newborn health. “Newborn”
generally refers to the first week of life.
K103. Now think only of women who present at your regional hospital
with post-abortion complications. Estimate the following referral rates
(i.e., the percent of your regional hospital’s PAC patients (cases) who
come from district hospitals by referral): (See also K008, K203, K303)
For example, suppose K103 is estimated to be 20% by the respondent. This
would mean that 20% of all women with post-abortion complications who
present at the regional hospital for treatment were referred from district
hospitals. Note that this question varies by type of facility—thus
questionnaires A2, A3 and A4 differ for this question, but the instructions apply
to all variations.
The next set of questions refers to capital costs. It is difficult to obtain
precise figures for these items, so you should ask the respondent, as an expert,
to give his/her best estimate for each cost. All costs should be given in
Rwanda francs. The officer in charge of building maintenance may be best able
to answer these questions.
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K104. Estimate the cost of constructing and fully equipping this [facility].
(See also K009, K011, K013; K204, K304)
Equipment includes office furniture, vehicles, special machines, sterilization
equipment, laboratory equipment, OR equipment, X-ray machines, sonograph
equipment, etc. We expect only a rough estimate of this cost.
If the premises are rented, write the monthly cost of rent in the margin and
make a note on the questionnaire. Then, the respondent should still be asked
to estimate the cost of fully equipping the facility.e
Note that in Questionnaire A1, this question is broken down into three
questions, one for each level of facility.
K105. Estimate the average lifetime (years of useful service) of this
[facility]. (See also K010, K012, K014; K205, K305)
Again, only an approximate estimate can be expected from the respondent
here. You can prompt by asking how long other similar facilities have been
used before being replaced or refurbished. If there are government guidelines
about the service lifetime of this type of facility, and if the respondent believes
that they are actually being followed, use the official figure.
Note that in Questionnaire A1, this question is broken down into three
questions, one for each level of facility.
Providers’ Salaries. The next two questions ask about average monthly
salaries for workers in the facility. Estimate salaries for the average worker in
each job category according to your experience. When estimating salaries,
include benefits such as pension contributions, insurance contributions. Other
forms of compensation such as hardship pay, etc. should be included, but do
not include annual leave. Estimates should be of gross salaries, that is, salaries
before any deductions are made (e.g., for taxes, health insurance, pension
contribution, etc.).
K106. Estimate the average monthly gross salary of each category of
medical personnel (in Rwanda francs). (See also K017, K206, K306)
Calculating salaries can be complicated. We need estimates that reflect the
normal (average) monthly amounts paid to the various worker categories in
e
If the facility is rented, special instructions will apply to this datum at the time of data entry.
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Interviewer Manual: Health-System Costs
the facility. Respondents may be more willing to give such estimates, as they
will not reveal the actual salary of any worker in particular. Write “NA” in the
appropriate box for worker categories not present in the facility.
When estimating salaries include benefits such as pension contributions,
insurance contributions, housing subsidies, food subsidies, “responsibility
allowance” (e.g., nurses in private hospitals can be qualified to do a simple
Cesarean operation), and duty allowance. Do not include annual leave.
If the facility employs expatriate professionals who are paid at an
international salary level, they should be excluded from the respondent’s
estimations.
Note that in the case of the central level (Questionnaire A1) the question
(K017) refers to each of the three lower levels of facility.
Experience from a Ugandan study: A
similar study recently carried out in
In general, we are collecting Uganda found that some respondents
estimates of on-the-ground
would not answer salary questions for
reality, not what the
categories of workers not found in
their facilities. For example, at a
standard or ideal should be.
health center where no anesthetist is
on staff, a respondent may not venture
to offer an opinion about an anesthetist’s average salary. If, after repeated
attempts to solicit a reply, a respondent refuses to answer, mark “NA” as the
answer (no answer).
K107. What is considered the normal number of hours that a full-time
worker works in one year at your [facility]? (See also K018, K207, K307)
For example, if the work norm is 40 hours per week and 48 weeks per year,
then the number of hours worked per year for full-time employees is: 40 x 48
= 1920 hours. (The personnel office may have this datum readily available.)
Ask if there are a number of statutory holidays and other “personal” days. If
so, these should be deducted from the total. Do not deduct sick days.
K108. With regard to the treatment of incomplete abortion, how often is
manual vacuum aspiration (MVA) used? Out of 10 treatments of
incomplete abortion, in how many are MVA used in your hospital? (See
also K208, K308)
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Since MVA is an increasingly important method for treating incomplete
abortion in Rwanda, question K108 asks the respondent to estimate how
many times MVA is used out of 10 cases of incomplete abortion. The range is
“0” (never used) to “10” (always used).
K109. The MVA kit may be sterilized and reused. How many times does
your hospital reuse MVA kits before discarding them? (See also K209, K309)
The norm for reuse of MVA kits is 50 uses. However, record whatever answer
the respondent gives. Do not prompt.
The next set of questions asks about overhead costs. These costs are
general expenses of this regional hospital that are essential for it to function
and supply all of its services. The responses should be the respondent’s best
estimates. Remind him/her again, that you realize that such data are difficult
to find, so you are seeking his/her expert opinion or estimate. The facility’s
accountant may be best placed to answer these questions.
K150. How many of each type of worker are actually employed at your
[facility]? (See also K050, K052, K054; K250, K350)
Ask the respondent to answer in terms of “full-time equivalents” over a one
year reference period. E.g., if a certain worker works half-time, “0.5” should be
entered. Write “0” in the appropriate box for worker categories not present in
the facility.
Collect estimates of numbers of workers actually employed, not the number of
posts that are sanctioned or budgeted. In general, we are collecting estimates
of on-the-ground reality, not what the standard or ideal should be.
Probe for other workers in the facility not listed in the questionnaire and
write down their designation in the boxes marked “Other”. Continue adding
worker categories outside the table if necessary.
Note that in Questionnaire A1, this question is broken down into three
questions, one for each level of facility.
K151. What is the average monthly salary for each type of worker—fulltime, include benefits but not annual leave? (in Rwanda francs) (See also
K051, K053, K055; K251, K351)
Refer to question K106 for instructions on salary information.
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Note that in Questionnaire A1, this question is broken down into three
questions, one for each level of facility.
K152. In cases where cleaning and/or security are out-sourced
(contracts with private security or cleaning companies) in the regional
hospital, how much is paid monthly for these services? (See also K252, K352)
Questions K150 and K151 have entries for “guards” and “cleaners”. These are
regular employees of the facility. However, facilities may have no such
personnel on staff, instead contracting security and cleaning services from
private companies. If a service is not contracted out, enter “0” as the monthly
amount for that service.
If K152a is answered (that is, security is out-sourced), then K150a and K151a
must be zero (that is, no guards can be employed). If K152b is answered (that
is, cleaning is out-sourced), then K150b and K151b must be zero (that is, no
cleaners can be employed).
K153. Estimate the annual cost of each category of overhead expense at
your [facility]. (Rwanda francs) (See also K056, K057, K058; K253, K353)
The respondent’s best estimates are what are required here. Some
respondents may have a tendency to start looking for old receipts or
expenditure reports. Since precise amounts are not needed you should steer
the respondent away from doing so by emphasizing that we do not need exact
figures. Otherwise, the length of the interview may be unduly prolonged.
Note that in Questionnaire A1, this question is broken down into three
questions, one for each level of facility.
2.2. Questionnaire B – Costs of Drugs, Supplies,
Materials
Questionnaire B is an instrument for collecting detailed information on the
physical inputs used in treating five post-abortion complications. It is a long
questionnaire—you may need two sessions with the respondent to fill it out
completely. Do not let fatigue to lower the quality of the responses. If you note
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Interviewer Manual: Health-System Costs
that the respondent is getting tired (or bored), politely suggest that the
interview could be suspended for a coffee/tea break and resumed in an hour
or two.
The respondent must be the medical practitioner in the facility with the most
experience in the treatment of PAC patients.
This questionnaire was developed from experiences in several countries. It’s
origin is the World Health Organization’s Mother and Baby Package. For that
reason, it tries to be inclusive, listing many variations of drugs, not all which
will be used in the facility you are surveying. Thus, for many rows (inputs)
you will be filling in zeros—meaning that that input is not used in that facility
for that treatment. It is very important that ALL boxes be filled in, either with
zeros or with numbers. DO NOT LEAVE ANY BOXES BLANK.
Again, it is very important to inform the respondent at the beginning of the
interview that you want his/her expert opinions and best estimates. For
example, patients with the same complication may receive different doses of
the same drug depending on the severity of the symptoms. The respondent,
based on years of experience, should give an average estimate of the amount
of the drug the average case will be given. If the respondent is unable or
unwilling to give a point estimate (one, single number), then write down the
range he/she states. Try to avoid range-type answers as far as possible, as it
will make the data coding process longer and slower.
Experience from a Ugandan study: A similar study recently carried out in
Uganda found that some respondents preferred to give dosage amounts based
on a patient’s body weight. For example, a response might be “60 milligrams of
drug X per 75 kilograms of body weight”. In such cases the interviewer should
write down the answer as given. Later that day, after interviews are finished for
the day, the interviewer—while reviewing the questionnaires filled out during
the day—should calculate the proper answer. In this study we use 50
kilograms as the average body weight. Answers should be calculated
according this standard.
Example 1: The respondent answers “60 milligrams of drug X per 75 kilograms
of body weight is administered on average (over the course of the whole
treatment)”. The calculated answer should be “40 milligrams of drug X”, since 60
x (50 / 75) = 40.
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Interviewer Manual: Health-System Costs
Example 2: The respondent answers “250 milligrams of drug Y per 100
kilograms of body weight is administered on average (over the course of the
whole treatment)”. The calculated answer should be “125 milligrams of drug Y”,
since 250 x (50 /100) = 125.
Specific Interviewer Instructions
1. Data must be entered for each input into columns D, E, G and H. It is not
acceptable to leave any cells blank--such questionnaires are considered to be
incomplete.
2. Many inputs will not be used in a particular facility. These inputs must still be
coded with zeros in columns D, E, G and H. Blank cells are not allowed.
Columns D and E
3. Columns D and E are to be filled in with percentages. Therefore, each cell in
these columns must be filled in with a percentage from 0% to 100%. No other
values are acceptable and blank cells are not allowed.
4. Each answer in column D must be considered in terms of outpatients only
(NOT all patients). For example, if "75%" is entered, it means that 75 percent of
all outpatients with a particular complication (shock, sepsis, etc.) receive the
input.
5. Each answer in column E must be considered in terms of inpatients only
(NOT all patients). For example, if "85%" is entered, it means that 85 percent of
all inpatients with a particular complication (shock, sepsis, etc.) receive the
input.
Columns G and H
6. Columns G and H are to be filled in with numbers. The numbers signify the
number of basic units (basic units are shown in column F) that are
administered during the whole course of treatment for that particular
complication (shock, sepsis, etc.). Ranges are not allowed, only one number
should be entered per cell. E.g., "30-40" is not acceptable; the interviewee must
be asked to give his/her best point estimate (e.g., "35").
7. Each answer in column G must be considered in terms of outpatients only
(NOT of all patients). For example, if "800" is entered, it means that outpatients
with a particular complication (shock, sepsis, etc.) on average receive 800 basic
units of the input.
8. Each answer in column H must be considered in terms of inpatients only
(NOT of all patients). For example, if "1200" is entered, it means that inpatients
with a particular complication (shock, sepsis, etc.) on average receive 1200
basic units of the input.
9. The data entered in columns G and H often need to be calculated. The data
should always represent the number of basic units given over the entire course
of treatment. The following examples should be studied:
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Interviewer Manual: Health-System Costs
● If 4 tablets containing 200 mcg of a medicine are given each day for 3
days, then "2400" should be entered [4 x 3 x 200 mcg = 2400 mcg].
● If 2.5 grams of a medicine is given in total and the basic unit (shown in
column F) is "mg", then "2500" should be entered [1 g = 1000 mg].
● If 4.5 liters of a medicine (in liquid or gaseous form) are given in the
course of treatment and the basic unit (shown in column F) is "ml", then
"4,500" should be entered [1 liter = 1000 ml].
● If a medicine is in solution, the proper calculation may be complicated.
If a solution contains 3 mg / ml and 50 ml are administered in total, then
"150" should be entered, if the basic unit (shown in column F) is "mg"
[since 50 ml of the solution contain 3 x 50 = 150 mg of the drug].
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Annex 1: The Consent Form
My name is _________________________ working with the School of Public Health, National
University of Rwanda, and the Ministry of Health. The School of Public Health, in
collaboration with the Ministry of Health, is conducting a national study to assess
abortion care. We would like to ask for your cooperation in getting a better picture of
the situation in Rwanda. This research will provide information about the
reproductive health care system in Rwanda, which will contribute to the
improvement of women’s health here.
You were selected to respond to this questionnaire because of your position at this
health facility. Your responses in this study will be completely confidential and will
be used for research purposes only. No reference will be made to individual
responses to this survey of health-care establishments. We will combine your
responses with those from representatives of other health-care establishments to
give a general picture of the practice of abortion care in Rwanda.
To benefit from your extensive experience, may I request that you kindly provide
your best estimates to these questions? Responding to the questionnaire will take
approximately 45 minutes. Your responses to this questionnaire will be completely
confidential and will be used for purposes of this research project only.
Do I have your permission to proceed with the interview? _____Yes
______No
Thank you.
If you have any questions about this survey or the study please call Dr. Francine
Birungi, School of Public Health, National University of Rwanda. Dr. Birungi may be
reached at +0250 648 650 or by email at birufrance@yahoo.fr.
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