Chamran Health Complex (CHC) is an integrated health center that provides primary health care for more than 57000 householders under the urban coverage area of Tabriz city. The administrative office manages the complex activities through 5 health facilities (HC1, HC2, HC3, HC4, and HC5) throughout the Akhmaghaye district to ensure fair access to healthcare. More than 83 services ranging from GP visits, vaccination, disease control and surveillance, dental care, and a limited sort of specialist visit were provided by the Complex. The Tabriz University of Medical Sciences proposed this project to produce evidence regarding the Complex's cost profile and economic performance as a first launched PPP program providing primary healthcare services.
The project was conducted in 4 steps. First, the team engaged with stakeholders to assess the ongoing data sources or patient records to determine which data collection method would provide the best-quality information. Data for service activities and process maps, time and workload, human and financial resources, equipment, and consumables were collected using paper-based forms or excel datasheets. To characterize the analysis unit, we categorized service departments into overhead, intermediate and final activity centers according to their role in service provision. The last activity center directly contacts patients to provide requested services. Intermediate activity center supports final activity centers during the care process; even it can provide intermediary services, for example, laboratory, radiology, cash, and bill wards. Overhead activity centers support intermediate and final activity centers; they are not in direct contact with patients while facilitating service provision. Second, the project team held several meetings at the activity centers and conducted face-to-face interviews with providers and staff to develop a logbook for each activity center. It included information about the staff time, equipment modality and cost, room dimensions, service modality, process map, time, and frequency of delivered services in the study year. Second, we measured cost items within activity centers by adopting a micro-costing approach which identifies resources at very detailed level. Data for cost items (staff, capital investment, consumables, and energy consumption) were collected from Accounting Information System. Utilization data were collected from the Iranian Integrated Health Record Portal (SIB: HTTPS://sib.tbzmed.ac.ir).
Where data was not available, we used expert opinion, direct observation, and log forms for recording needed data. During the third step the overhead costs were allocated by means of two different methods; Direct, and Step-down allocation (18). In direct allocation, the total costs of overhead and intermediate activity centers are directly allocated to the final activity centers, apart from their interactions. However, the step-down method allocates one overhead activity center’s cost, for example IT, to another overhead or intermediate activity center, for example HR or Laundry, which is then allocated to the final activity centers (19). Considering that, the unit cost which is calculated from previous steps reflects ongoing, but not standard practice arrangement, we hypothesized a standard scenario in which the current gap in staff and facilities assumed to be filled in accordance with the Iranian Ministry of Health standards for medical staff and organizational structure. Then, all the calculations were re-executed to determine the optimum unit costs (20). We used Purchasing Power Parity (PPP) 2015 to adjust unit costs in national currency and reported in international dollars (21). In the fourth step, the economic performance of five health centers was assessed through Data Envelopment Analysis. To estimate the technical efficiency, the input minimization approach with assumption of variable return to scale was adopted pursuing below linear programming.
In general, three types of efficiency can be distinguished from each other: First, technical efficiency: means that minimum resources are used to produce a particular product. The fundamental question in this type of efficiency is whether the health center's minimum personnel, tools, and equipment have been used to produce the output. Technical inefficiency can be caused by the lack or improper use of health center resources. Second, scale efficiency: faces planning issues regarding the number of resources and the size of the center. Third, managerial efficiency seeks to increase output with proper management and personnel effort (22). Also, Return to scale shows the rate of increase in production provided that all other resources are equally increased. Net technical efficiency (managerial efficiency) was assessed by dividing technical efficiency (in VRS state) to scale efficiency. The inputs used in the model were salary and wage, equipment expenses, building expenses, and covered population, while the outputs were the total time spent on service provision (23). Costing was performed in Microsoft Excel 2013, and efficiency analysis by Deap2.1.