Document Type: Original Article

Authors

Department of Accounting, Shiraz University, Shiraz, Iran

Abstract

Introduction: Given the importance of the education system in the health sector and the necessity to calculate the cost in this sector, this study aimed to calculate the cost of education for health students in Shiraz Medical School, using activity-based costing (ABC).
Methods: This study was conducted in Shiraz University of Medical Sciences in 2015-2016, considering the cost structure of the education department. The data required for the present 
research study was gathered from accrual accounting system, payroll system, educational deputy system called SAMA, list of paid salaries, information received from medical school such as exact position of individuals and course credits assigned to teachers, interviews conducted at the university headquarter in order to determine the appropriate indicators for allocating the costs, and interviewing clinical and non-clinical teachers to calculate the cost of training in these fields.
Results: The findings indicated that the cost of training in general accounted for 70% of the total cost of student education. PhD in Medical Ethics, Assistant of Radiotherapy and Ph.D. in Pharmacology turned out to posit the highest cost for each student respectively, while MPH, Master of Medical Engineering, and Master of Electronic Medicine Education had the lowest cost for each student, respectively. The cost in all fields is more than the per capita cost of student education paid to the university.
Conclusion: Authorities should focus on controlling and reducing the cost of training, which is the main component of the costs. Factors such as the number of students in each field, degree, and
type of field are effective in the costs of education. Hence, in order to allocate the budget more equitably, costs of education for each field calculated by ABC should be based on allocating the funds
to the university.

Keywords

Introduction

The health sector throughout the world is under a lot of pressure to improve its services, control costs, and manage its budget. Thus, in response to chronic financial constraints, management accounting tools and costing systems are utilized ( 1 ). University officials have also recognized the importance of management techniques for the management of universities and have noticed the growing need for an efficient accounting system for calculating the cost due to the reduction in available financial resources ( 2 ). Therefore, the issue of student and course costs has been the focus of attention both in research and practice ( 3 ).

Due to superiority of activity-based costing (ABC) over traditional cost accounting (TCA) system in decision-making ( 4 - 6 ) and subsequently ABC's significant impact on performance improvement as well as its benefits for budgeting levels, financial decision-making and strategic decision-making ( 7 , 8 ), the number of organizations implementing ABC is growing ( 9 ). Krishnan ( 10 ), among others, also indicates that ABC helps educational institutions improve their performance by accurately calculating the cost per student and by identifying nonvalue-added activities. Therefore, ABC can be utilized as a powerful tool to solve various university management problems in educational affairs. Much research has been conducted on the calculation of ABC in universities ( 11 - 14 ). These studies reveal how ABC is applied and what benefits it could have for universities ( 15 ). ABC allows university administrators to understand the factors influencing teaching in general and each course in particular, and this understanding is important in the decision-making process. For example, a university can increase its productivity by reconsidering its activities with a new and sensitive view of costs ( 16 ). It is worth noting that the full implementation of the ABC model depends on the understanding of all people working at the university about the benefits of this model, as well as a change in their view towards the cost management ( 17 ).

Some previous studies also have calculated the student costs using the ABC method in Iran ( 18 - 26 ). However, no research has so far been conducted in Iran regarding the calculation of the cost of clinical disciplines. The present study has provided some important advantages and strengths compared to previous research studies. This study is the first attempt to provide a model in this field. In addition, previous research has ignored the costs incurred to support the colleges by the University of Medical Sciences headquarters. Besides, since the information required to allocate to all faculties is considered in the present study, allocating headquarter costs to faculties will be attempted more accurately. Also, previous research studies failed to make a distinction between the salaries of professors as faculty members and their receipts as their activity in hospitals, and duty units with or without job positions have ignored the calculation of the cost allocated for salaries of professors.

Therefore, despite the benefits of ABC and its applications in many countries, the importance of adopting the ABC system in the health sector, especially in the clinical sector, has not yet been well recognized in Iran. Therefore, the cost of education in this section has not been determined accurately. As a result, university management in the health sector is struggling with the following issues: What are the cost patterns? What is the real cost of a student in clinical and non-clinical courses? How much tuition and budget is needed to effectively and efficiently manage these sectors? And how can management cope with the rising costs of health care and improve university performance? The aim of this study was to respond to the preceding enquiries. The ultimate goal of this article is to implement the ABC system in medical school, which includes both clinical and non-clinical courses, in order to reduce the difference between the practice and theory of using costing systems.

Methods

The present study is a quantitative research which falls within the category of applied-developmental research in terms of research type and direction, and is considered as a survey with regard to research method. All fields of Shiraz Medical School constituted the statistical population of this study. The implementation of ABC varies in different areas such as education, services, trade, and manufacturing, and requires specific features in each area ( 27 ). According to the five steps provided for the implementation of ABC in universities by Amizawati et al. ( 28 ) and considering the cost structure of the education department in Shiraz Medical School, this study employed ABC system in order to benefit from its advantages using the information of the 2015-2016 academic year.

Step 1: Identifying resources

Figure 1 shows the general structure of Fars University of Medical Sciences as well as general overview of the schools and the groups and fields of each school. Information on the costs incurred in faculties and headquarter (except for the cost of salaries and benefits) was gathered from the "accrual system", information on salaries and benefits of the faculty members and the staff of both the headquarter and the faculty itself from the "salary system", information on the tuition fees paid from "Forms of tuition fees" paid by Educational deputy, and information on expenses incurred for research matters such as books, articles, etc. from "Research Deputy Documents". Also, educational information such as the number of courses taught by each teacher, number of students in each class, type of each course including degree, field, being theoretical or practical was collected from the educational deputy system called ‘SAMA’.

Figure 1. Overview of the Structure of the Health Sector

Step 2: Identifying resource drivers

At the headquarter level, the expenses of Vice Chancellery for Health, Treatment, and Food & Drug Affairs, which provide most of their services to the health sector, have been eliminated. Due to the fact that no research has ever been conducted in Iran to allocate headquarter costs to subsidiary units in order to calculate the cost in the health sector, appropriate drivers to allocate the costs incurred in the headquarter to subsidiary units (like hospitals, faculties, etc.) were determined based on the information received from the interviews with the experts in different Vice Chancelleries: 1. “Education” and “Cultural and Students Affairs” Vice Chancelleries: Allocation to faculties based on the number of students in each faculty; 2. “Research and Technology” Vice Chancellery: Allocation to faculties based on the number of students (50%) and the number of faculty members (50%) of each faculty; and 3. “Chancellery” and “Development & Resource Management Affairs” Vice Chancellery: Allocation to all subordinate units (including hospitals, faculties, etc.) based on unit credits (40%), number of units (20%), and number of staff (40%). The preceding indicators are shown in Table 1.

Vice Chancelleries Units Cost Drivers
Education Faculties The number of students
Cultural and Students Affairs
Research and Technology Faculties The number of students (50%)
The number of Faculty Members (50%)
Chancellery All Subordinate Units Unit Credits (40%)
Development & Resource Management Affairs Number of Units (20%)
Number of Staff (40%)
Table 1. Drivers to Allocate the Costs Incurred in the Headquarter

School expenses during the academic year are represented in Table 2. As shown in Table 2, at the college level, most of the expenses (about 81% of total expenses for medical school) incurred in the education department are related to the salaries paid to the faculty members and the staff, and it is not cost-effective to pursue other expenses due to the low importance of the amount. Therefore, in the present study, all expenses incurred in faculty except salaries (such as water and electricity expenses) were considered together.

Account title Amount(Rials)* Percentage of total Expenses
Salaries and Benefits
Salaries of Teachers 599,182,690,870 49.47160%
Salaries of Medical Assistants 224,591,965,137 18.54347%
Tuition fee 14,602,292,994 1.20564%
Staff Salaries 141,286,750,535 11.66536%
Total Salaries and Benefits 979,663,699,536 80.88607%
Other Expenses
Use of goods and services:    
Mission and staff transfer costs 2,005,440,181 0.16558%
Transportation and communication costs 362,285,538 0.02991%
The cost of maintaining and repairing other assets 2,451,970,555 0.20245%
The cost of maintaining and repairing office equipment 2,135,723,410 0.17634%
Printing, buying magazines and press 231,036,100 0.01908%
Imaging and advertising 9,135,000 0.00075%
Ceremonies 3,037,552,967 0.25080%
Bank charges 895,250 0.00007%
Water, electricity and fuel 2,008,847,600 0.16586%
Consumable materials and supplies 17,895,471,321 1.47754%
Educational and Research Expenses 561,281,148 0.04634%
Fee for performing contract services 6,588,174,132 0.54395%
Social welfare:    
Welfare benefits for government employees 688,113,975 0.05681%
Student welfare assistance 160,303,668,574 13.23549%
Other Social Welfare Expenses 46,685,000 0.00385%
Other Expenses:    
Other Expenses 2,388,885,322 0.19724%
Group Sending aids 3,247,653,247 0.26814%
Depreciation Expenses of Assets:    
Depreciation Expenses of Building 17,154,274,968 1.41635%
Depreciation Expenses of Installations 94,649,493 0.00781%
Depreciation Expenses of equipment and machinery 6,911,783,669 0.57067%
Depreciation Expenses of Technical tools and equipment 9,741,345 0.00080%
Depreciation Expenses of 35,592,530 0.00294%
Depreciation Expenses of 3,331,849,697 0.27509%
Depreciation Expenses of 552,334 0.00005%
Other Expenses 231,501,263,351 19.11393%
Total Expenses 1,211,164,962,886  
In order to convert the amount of this column to dollars, each amount could be divided by 35000, the approximate average exchange rate dominated at that time.
Table 2. School Expenses During the Academic Year

In order to accurately track the cost of salaries, the position of all individuals was precisely determined, and the cost of salaries of all employees and the payment of faculty members relevant to their job positions was allocated to the relevant position. Considering duty units with or without job positions, we separated the tuition fees of the professors with job positions at the academia. Therefore, the cost share related to the professor's position was separated from the cost share related to the teaching of each professor and was allocated to the relevant position and the number of courses taught, respectively.

Step 3: Identifying activities

According to the four cost levels in the ABC system set out by Cooper and Kaplan ( 29 ), the course credit was defined as a "Unit" and the costs were classified as follows: UL: “Course credit cost level” like tuition fees for teaching the relevant course, BL: “Department cost level” such as the head of department's salary for their position in the department and the department secretary's fee; PL: “School cost level” such as expenses incurred in the faculty except salaries, which include water and electricity expenses and salaries of people who are related to all students. These people working in the faculties include the dean, vice-chancellor of the faculty, etc. Therefore, this cost level also includes expenses such as the salary received by the dean of the faculty for his/her position, the fee for the dean’s secretary, and the fee for the security guards of the faculty; FL: “Headquarter cost level” such as expenses incurred in “Chancellery” and “Education”, “Cultural and Students Affairs”, “Research and Technology”, and “Development & Resource Management Affairs” Vice Chancelleries (as determined in step 2).

Step 4: Identifying activity drivers

The headquarter cost level and the faculty cost level are allocated in proportion to the number of students in the faculty, and the department cost level is allocated in proportion to the number of students in the respective department. For determining the tuition fees for each course, first the tuition fee for each class is determined and then the tuition fee for each student is calculated based on the number of students in each class.

Step 5: Calculating the cost of the products

The overhead cost was calculated from the total share of each student from the costs of headquarters, faculty vice chancelleries, faculty department, and other faculty expenses. Then, given that these costs are calculated for one academic year, the total overhead cost is calculated by considering the length of each field, as presented in Table 3.

Group Code Degree Field Each Student's Share of the Costs of Overhead Cost for a Year(OC) Overhead Cost Considering the Length of Each Fields(TOC)
Headquarter (HC) School's Sallaries (SC) School's Other Costs (AC)
Amount % Amount % Amount %
General Practitioner 12104 General General Practitioner 81,292,296 45% 22,821,206 13% 74,701,924 42% 178,815,426 1,251,707,979
Anatomy 12585 Master Anatomy 81,292,296 28% 135,981,328 47% 74,701,924 26% 291,975,548 583,951,095
Anatomy 12586 Ph.D. Anatomy 81,292,296 28% 135,981,328 47% 74,701,924 26% 291,975,548 1,313,889,965
Medical Ethics 12356 Ph.D. Medical Ethics 81,292,296 9% 779,158,516 83% 74,701,924 8% 935,152,736 4,208,187,312
Biostatistics 12545 Master Biostatistics 81,292,296 31% 109,652,623 41% 74,701,924 28% 265,646,843 531,293,685
Biostatistics 12566 Ph.D. Biostatistics 81,292,296 31% 109,652,623 41% 74,701,924 28% 265,646,843 1,195,410,792
Parasitology and Mycology 12595 Master Parasitology 81,292,296 30% 112,444,730 42% 74,701,924 28% 268,438,950 536,877,900
Parasitology and Mycology 12075 Master Mycology 81,292,296 30% 112,444,730 42% 74,701,924 28% 268,438,950 536,877,900
Parasitology and Mycology 12596 Ph.D. Parasitology 81,292,296 30% 112,444,730 42% 74,701,924 28% 268,438,950 1,207,975,275
Immunology 12155 Master Immunology 81,292,296 25% 167,046,151 52% 74,701,924 23% 323,040,371 646,080,742
Immunology 12156 Ph.D. Immunology 81,292,296 25% 167,046,151 52% 74,701,924 23% 323,040,371 1,453,681,670
Bacteriology-Virology 12135 Master Microbiology 81,292,296 26% 162,145,296 51% 74,701,924 23% 318,139,516 636,279,032
Bacteriology-Virology 12097 Master Virology 81,292,296 26% 162,145,296 51% 74,701,924 23% 318,139,516 636,279,032
Bacteriology-Virology 12136 Ph.D. Bacteriology 81,292,296 26% 162,145,296 51% 74,701,924 23% 318,139,516 1,431,627,821
Clinical Biochemistry 12165 Master Clinical Biochemistry 81,292,296 27% 140,362,240 47% 74,701,924 25% 296,356,460 592,712,920
Clinical Biochemistry 12166 Ph.D. Clinical Biochemistry 81,292,296 27% 140,362,240 47% 74,701,924 25% 296,356,460 1,333,604,070
Medical-genetics 12565 Master Medical-genetics 81,292,296 11% 587,900,200 79% 74,701,924 10% 743,894,420 1,487,788,840
Pharmacology 12201 Ph.D. Pharmacology 81,292,296 14% 406,905,327 72% 74,701,924 13% 562,899,547 2,533,047,960
Medical Physic and Engineering 12055 Master Medical Physic 81,292,296 33% 89,514,649 36% 74,701,924 30% 245,508,869 491,017,737
Medical Physic and Engineering 12065 Master Medical Engineering 81,292,296 33% 89,514,649 36% 74,701,924 30% 245,508,869 491,017,737
Physiology 12175 Master Physiology 81,292,296 26% 161,985,322 51% 74,701,924 23% 317,979,542 635,959,083
Physiology 12176 Ph.D. Physiology 81,292,296 26% 161,985,322 51% 74,701,924 23% 317,979,542 1,430,907,937
MPH 12018 MPH MD-MPH 81,292,296 43% 31,795,112 17% 74,701,924 40% 187,789,332 375,578,664
Pathology 12227 Assistant Pathology 81,292,296 45% 22,821,206 13% 74,701,924 42% 178,815,426 715,261,702
Urology 12124 Assistant Urology 81,292,296 44% 30,463,695 16% 74,701,924 40% 186,457,915 745,831,659
Urology 129011 Fellowship Endourology 81,292,296 44% 30,463,695 16% 74,701,924 40% 186,457,915 279,686,872
Urology 12113 Fellowship Uro-Oncology 81,292,296 44% 30,463,695 16% 74,701,924 40% 186,457,915 279,686,872
Neurology 12697 Assistant Neurology 81,292,296 40% 48,811,376 24% 74,701,924 36% 204,805,596 819,222,385
Anesthesiology 12117 Master Circulatory Technology 81,292,296 43% 34,800,986 18% 74,701,924 39% 190,795,206 381,590,412
Anesthesiology 12217 Assistant Anesthesiology 81,292,296 44% 28,751,166 16% 74,701,924 40% 184,745,386 738,981,545
Anesthesiology 129511 Fellowship Abdominal Organ Transplantation Anesthesia 81,292,296 44% 28,751,166 16% 74,701,924 40% 184,745,386 277,118,080
Anesthesiology 12412 Subspecialty ICU 81,292,296 43% 34,342,154 18% 74,701,924 39% 190,336,374 380,672,748
Anesthesiology 129411 Fellowship Cardiac Anesthesia 81,292,296 44% 28,751,166 16% 74,701,924 40% 184,745,386 277,118,080
Radiotherapy 12667 Assistant Radiotherapy 81,292,296 38% 57,195,152 27% 74,701,924 35% 213,189,372 852,757,488
Social Medicine 12237 Assistant Social Medicine 81,292,296 36% 68,822,630 31% 74,701,924 33% 224,816,850 674,450,549
Nuclear Medicine 12211 Assistant Nuclear Medicine 81,292,296 37% 65,488,327 30% 74,701,924 34% 221,482,547 885,930,188
Dermatology 12247 Assistant Dermatology 81,292,296 42% 39,392,437 20% 74,701,924 38% 195,386,657 781,546,628
Surgery 12267 Assistant General Surgery 81,292,296 40% 47,608,066 23% 74,701,924 37% 203,602,286 814,409,142
Surgery 12105 Subspecialty Plastic Surgery, Reconstructive, Burns 81,292,296 39% 53,199,053 25% 74,701,924 36% 209,193,273 627,579,820
Surgery 12312 Subspecialty Vascular Surgery 81,292,296 39% 53,199,053 25% 74,701,924 36% 209,193,273 522,983,183
Surgery 129611 Fellowship Colorectal Surgery 81,292,296 40% 47,608,066 23% 74,701,924 37% 203,602,286 305,403,428
Surgery 12204 Fellowship Liver Transplantation 81,292,296 40% 47,608,066 23% 74,701,924 37% 203,602,286 407,204,571
Surgery 12828 Subspecialty Pediatric Surgery 81,292,296 39% 53,199,053 25% 74,701,924 36% 209,193,273 627,579,820
Surgery 12083 Fellowship Laparoscopy 81,292,296 40% 47,608,066 23% 74,701,924 37% 203,602,286 305,403,428
Surgery 12053 Fellowship CancerSurgery 81,292,296 40% 47,608,066 23% 74,701,924 37% 203,602,286 305,403,428
Neurosurgery 12337 Assistant Neurosurgery 81,292,296 36% 67,819,825 30% 74,701,924 33% 223,814,044 1,119,070,222
Neurosurgery 12128 Fellowship Spine Surgery 81,292,296 36% 67,819,825 30% 74,701,924 33% 223,814,044 895,256,178
Ophthalmology 12277 Assistant Ophthalmology 81,292,296 43% 33,733,530 18% 74,701,924 39% 189,727,750 758,911,001
Ophthalmology 129111 Fellowship Eye pathology 81,292,296 43% 33,733,530 18% 74,701,924 39% 189,727,750 284,591,625
Ophthalmology 12153 Fellowship Cornea and External Eye Diseases 81,292,296 43% 33,733,530 18% 74,701,924 39% 189,727,750 284,591,625
Ophthalmology 12073 Fellowship Pediatric Ophthalmology and Eye Aberrations 81,292,296 43% 33,733,530 18% 74,701,924 39% 189,727,750 284,591,625
Ophthalmology 12127 Fellowship Retina 81,292,296 43% 33,733,530 18% 74,701,924 39% 189,727,750 284,591,625
Internal-Medicine 12287 Assistant Internal Diseases 81,292,296 44% 29,227,261 16% 74,701,924 40% 185,221,481 740,885,923
Internal-Medicine 12126 Assistant Internal-Cardiology 81,292,296 44% 29,227,261 16% 74,701,924 40% 185,221,481 740,885,923
Internal-Medicine 12768 Subspecialty Endocrine and Metabolism Glands 81,292,296 43% 34,818,249 18% 74,701,924 39% 190,812,468 381,624,937
Internal-Medicine 12948 Subspecialty Adult Blood and Cancer 81,292,296 43% 34,818,249 18% 74,701,924 39% 190,812,468 572,437,405
Internal-Medicine 12212 Subspecialty Adult Digestive and Liver 81,292,296 43% 34,818,249 18% 74,701,924 39% 190,812,468 381,624,937
Internal-Medicine 12968 Subspecialty Nephrology (Adult Kidney) 81,292,296 43% 34,818,249 18% 74,701,924 39% 190,812,468 381,624,937
Internal-Medicine 12738 Subspecialty Lung Diseases 81,292,296 43% 34,818,249 18% 74,701,924 39% 190,812,468 381,624,937
Internal-Medicine 12748 Subspecialty Rheumatology 81,292,296 43% 34,818,249 18% 74,701,924 39% 190,812,468 381,624,937
Radiology 12867 Assistant Radiology 81,292,296 45% 22,847,900 13% 74,701,924 42% 178,842,120 715,368,480
Radiology 12023 Fellowship Interventional Radiology 81,292,296 45% 22,847,900 13% 74,701,924 42% 178,842,120 178,842,120
Psychiatry 12307 Assistant Psychiatry 81,292,296 36% 70,106,500 31% 74,701,924 33% 226,100,720 904,402,878
Obstetrics & Gynecology 12317 Assistant Obstetrics & Gynecology 81,292,296 42% 36,438,879 19% 74,701,924 39% 192,433,099 769,732,395
Obstetrics & Gynecology 12033 Fellowship Perinatology 81,292,296 42% 36,438,879 19% 74,701,924 39% 192,433,099 288,649,648
Obstetrics & Gynecology 128911 Fellowship Women's Oncology 81,292,296 42% 36,438,879 19% 74,701,924 39% 192,433,099 288,649,648
Obstetrics & Gynecology 129811 Fellowship IVF 81,292,296 42% 36,438,879 19% 74,701,924 39% 192,433,099 288,649,648
Obstetrics & Gynecology 12043 Fellowship Laparoscopy 81,292,296 42% 36,438,879 19% 74,701,924 39% 192,433,099 288,649,648
Emergency Medicine 12111 Assistant Emergency Medicine 81,292,296 42% 37,987,641 20% 74,701,924 39% 193,981,861 581,945,584
Traditional Medicine 12186 Ph.D. Traditional Medicine 81,292,296 24% 189,414,419 55% 74,701,924 22% 345,408,639 1,554,338,877
Physical Medicine & Rehabilitation 12257 Assistant Physical Medicine & Rehabilitation 81,292,296 39% 50,144,914 24% 74,701,924 36% 206,139,134 618,417,401
Cardiology 12657 Assistant Cardiology Diseases 81,292,296 42% 38,210,197 20% 74,701,924 38% 194,204,417 776,817,668
Pediatrics 12197 Assistant Pediatric Diseases 81,292,296 42% 36,215,780 19% 74,701,924 39% 192,210,000 768,840,000
Pediatrics 12978 Subspecialty Pediatric Cancer and Blood 81,292,296 41% 41,806,768 21% 74,701,924 38% 197,800,988 593,402,963
Pediatrics 12838 Subspecialty Children Digestive 81,292,296 41% 41,806,768 21% 74,701,924 38% 197,800,988 395,601,976
Pediatrics 12798 Subspecialty Children Infectious 81,292,296 41% 41,806,768 21% 74,701,924 38% 197,800,988 395,601,976
Pediatrics 12778 Subspecialty Pediatric Cardiology 81,292,296 41% 41,806,768 21% 74,701,924 38% 197,800,988 593,402,963
Pediatrics 12198 Subspecialty Neonatal Medicine 81,292,296 41% 41,806,768 21% 74,701,924 38% 197,800,988 395,601,976
Pediatrics 12788 Subspecialty Clinical Immunology and Allergy 81,292,296 41% 41,806,768 21% 74,701,924 38% 197,800,988 593,402,963
Pediatrics 12205 Fellowship PICU 81,292,296 42% 36,215,780 19% 74,701,924 39% 192,210,000 288,315,000
Pediatrics 12123 Fellowship Children Cardiology Intervention 81,292,296 42% 36,215,780 19% 74,701,924 39% 192,210,000 288,315,000
Pediatrics 12112 Subspecialty Endocrine and Metabolism Glands of Children 81,292,296 41% 41,806,768 21% 74,701,924 38% 197,800,988 395,601,976
ENT 12327 Assistant ENT 81,292,296 38% 55,936,905 26% 74,701,924 35% 211,931,125 847,724,500
MedicalEducation 12385 Master Electronic Medicine Education 81,292,296 44% 28,871,025 16% 74,701,924 40% 184,865,245 369,730,490
Family Doctor 12311 Assistant Family Doctor 81,292,296 36% 72,922,595 32% 74,701,924 33% 228,916,815 515,062,835
Orthopedics 12125 Assistant Orthopedics 81,292,296 45% 22,821,206 13% 74,701,924 42% 178,815,426 715,261,702
Orthopedics 12093 Fellowship Spine Surgery 81,292,296 45% 22,821,206 13% 74,701,924 42% 178,815,426 268,223,138
Orthopedics 12163 Fellowship Pediatric Orthopedics 81,292,296 45% 22,821,206 13% 74,701,924 42% 178,815,426 268,223,138
Cardiology 12143 Fellowship Adult Cardiology Intervention 81,292,296 45% 22,821,206 13% 74,701,924 42% 178,815,426 268,223,138
Cardiology 12658 Subspecialty Cardiology Diseases 81,292,296 44% 28,412,193 15% 74,701,924 41% 184,406,413 737,625,653
*In order to convert the amount of this column to dollars, each amount could be divided by 35000, the approximate average exchange rate dominated at that time.
Table 3. Cost of Overhead (Figures in Rials)*

To calculate each student's share of the costs of teaching non-clinical courses, the following were conducted: 1. Determining the cost of teaching each course credit by a professor: “The tuition fee and benefits paid to a teacher for teaching” (includes the tuition fee of the faculty member minus payment for job position, added by tuition fee) divided by “the number of credits taught by each professor during the school year”, taking into account the coefficient of the degree, theoretical or practical, the type of course, the number of professors in each class. 2. Determining the cost of each student in each classroom: “The cost of teaching each class” (the cost of tuition fee paid to a specific teacher for a single course credit multiplied by the number of credits equivalent to the corresponding class taught by the same professor) divided by “the number of students in that class”. 3. Determining the cost of each course: The average cost per student for each course in different classes. 4. Determining the cost of education in each field: According to the syllabus of each field, the cost of courses that were taught in the academic year 2015-2016 was considered, and an estimate of the training cost of practical and theoretical credits for the whole field was studied.

Unlike non-clinical courses, clinical courses do not have a course credit and some do not have even a course code. Due to the fact that some teachers teach in both clinical and non-clinical fields, first the share of non-clinical courses was calculated according to the duty units of each professor as well as the number of credits taught in non-clinical courses. The rest of the professor's salaries were allocated to teaching clinical courses. Then, the clinical groups and subgroups and their corresponding professors were identified. The rotation of each clinical field was precisely determined. After carefully examining how to teach clinical courses and after interviewing the experts of these courses, it was concluded that the amount of service provided to students, in addition to their routine, depends on the duration of attendance in the department, the number of students and their degree. In addition, given that the courses that require the operating room differed from those that do not, clinical professors believed that these disciplines should be considered separately. Finally, “the duration of attendance in the department (per month) * number of students” was considered as a criterion to measure the extent to which each student use and benefit from a professor's training of each main group and subgroup. In addition, since the university degree is also an effective factor in the use of professor training, it was determined (through a survey of clinical teachers) that the fields requiring an operating room be allocated teacher training of approximately 30%, 40% and 30%, and fields that do not require an operating room 26%, 33% and 41%, respectively, for general medicine, assistant and subspecialty or fellowship. Figure 2 indicates an overview of the model of the cost of student education.

Figure 2. Model of the Cost of Student Education

The present study is the result of a doctoral dissertation conducted at Shiraz University, but the code of ethics is not common in the Ministry of Science, Research and Technology, and despite full observance of ethics in this research, it does not have a code of ethics.

Results

The results of calculating the cost of students in all fields of Shiraz Medical School are presented in Table 4. In order to help in analysis and management, the average cost at different degrees has separately been presented to show the cost of training and the overhead, as well as the share of each in the total costs in percentage. Also, to help better compare the amount of the costs with each other, the rankings of each component of the cost are presented relative to all fields. In Table 5, the average cost values are presented separately for different degrees as well as the total average for all degrees. This Table also demonstrates the average of components and total costs by clinical and non-clinical disciplines.

Group Code Degree Field Overhead Cost Training Cost Total Cost
Amount Rank % Amount Rank % Amount Rank
General Practitioner 12104 General General Practitioner 1,251,707,979 10 40% 1,865,267,270 27 60% 3,116,975,249 11
Anatomy 12585 Master Anatomy 583,951,095 46 53% 515,131,564 80 47% 1,099,082,660 77
Anatomy 12586 Ph.D. Anatomy 1,313,889,965 9 45% 1,576,524,662 38 55% 2,890,414,626 18
Medical Ethics 12356 Ph.D. Medical Ethics 4,208,187,312 1 50% 4,171,214,201 4 50% 8,379,401,513 1
Biostatistics 12545 Master Biostatistics 531,293,685 51 59% 363,208,689 87 41% 894,502,374 86
Biostatistics 12566 Ph.D. Biostatistics 1,195,410,792 12 56% 930,389,889 66 44% 2,125,800,682 42
Parasitology and Mycology 12595 Master Parasitology 536,877,900 49 53% 483,655,862 83 47% 1,020,533,761 82
Parasitology and Mycology 12075 Master Mycology 536,877,900 50 60% 357,939,577 88 40% 894,817,477 85
Parasitology and Mycology 12596 Ph.D. Parasitology 1,207,975,275 11 45% 1,447,895,607 42 55% 2,655,870,882 20
Immunology 12155 Master Immunology 646,080,742 35 40% 964,687,629 64 60% 1,610,768,371 61
Immunology 12156 Ph.D. Immunology 1,453,681,670 5 55% 1,174,017,281 54 45% 2,627,698,951 21
Bacteriology-Virology 12135 Master Microbiology 636,279,032 37 57% 475,575,941 84 43% 1,111,854,972 75
Bacteriology-Virology 12097 Master Virology 636,279,032 36 45% 780,221,144 71 55% 1,416,500,176 67
Bacteriology-Virology 12136 Ph.D. Bacteriology 1,431,627,821 6 49% 1,474,723,838 40 51% 2,906,351,659 17
Clinical Biochemistry 12165 Master Clinical Biochemistry 592,712,920 45 46% 703,892,844 77 54% 1,296,605,764 71
Clinical Biochemistry 12166 Ph.D. Clinical Biochemistry 1,333,604,070 8 51% 1,276,396,071 49 49% 2,610,000,141 22
Medical-genetics 12565 Master Medical-genetics 1,487,788,840 4 64% 847,625,495 68 36% 2,335,414,335 33
Pharmacology 12201 Ph.D. Pharmacology 2,533,047,960 2 41% 3,685,759,992 5 59% 6,218,807,952 3
Medical Physic and Engineering 12055 Master Medical Physic 491,017,737 54 50% 494,202,144 82 50% 985,219,881 83
Medical Physic and Engineering 12065 Master Medical Engineering 491,017,737 55 68% 228,425,474 90 32% 719,443,211 89
Physiology 12175 Master Physiology 635,959,083 38 58% 458,306,421 85 42% 1,094,265,504 78
Physiology 12176 Ph.D. Physiology 1,430,907,937 7 46% 1,681,712,060 33 54% 3,112,619,998 12
MPH 12018 MPH MD-MPH 375,578,664 68 53% 332,720,863 89 47% 708,299,527 90
Pathology 12227 Assistant Pathology 715,261,702 32 21% 2,734,006,338 9 79% 3,449,268,040 9
Urology 12124 Assistant Urology 745,831,659 26 43% 1,005,418,909 63 57% 1,751,250,568 57
Urology 129011 Fellowship Endourology 279,686,872 83 11% 2,264,904,971 14 89% 2,544,591,843 25
Urology 12113 Fellowship Uro-Oncology 279,686,872 84 12% 2,150,010,430 16 88% 2,429,697,303 30
Neurology 12697 Assistant Neurology 819,222,385 19 30% 1,912,979,362 23 70% 2,732,201,747 19
Anesthesiology 12117 Master Circulatory Technology 381,590,412 66 31% 849,293,195 67 69% 1,230,883,607 74
Anesthesiology 12217 Assistant Anesthesiology 738,981,545 29 37% 1,273,964,067 51 63% 2,012,945,613 49
Anesthesiology 129511 Fellowship Abdominal Organ Transplantation Anesthesia 277,118,080 86 19% 1,147,209,631 58 81% 1,424,327,710 66
Anesthesiology 12412 Subspecialty ICU 380,672,748 67 21% 1,472,433,556 41 79% 1,853,106,304 55
Anesthesiology 129411 Fellowship Cardiac Anesthesia 277,118,080 85 5% 5,185,809,243 3 95% 5,462,927,322 5
Radiotherapy 12667 Assistant Radiotherapy 852,757,488 17 13% 5,778,924,683 1 87% 6,631,682,170 2
Social Medicine 12237 Assistant Social Medicine 674,450,549 34 48% 739,240,103 75 52% 1,413,690,653 68
Nuclear Medicine 12211 Assistant Nuclear Medicine 885,930,188 16 22% 3,079,910,766 8 78% 3,965,840,954 7
Dermatology 12247 Assistant Dermatology 781,546,628 21 36% 1,392,987,935 45 64% 2,174,534,563 39
Surgery 12267 Assistant General Surgery 814,409,142 20 14% 5,197,856,322 2 86% 6,012,265,464 4
Surgery 12105 Subspecialty Plastic Surgery, Reconstructive, Burns 627,579,820 40 47% 707,381,906 76 53% 1,334,961,726 70
Surgery 12312 Subspecialty Vascular Surgery 522,983,183 52 21% 1,973,466,962 21 79% 2,496,450,146 28
Surgery 129611 Fellowship Colorectal Surgery 305,403,428 70 21% 1,167,124,056 55 79% 1,472,527,485 65
Surgery 12204 Fellowship Liver Transplantation 407,204,571 56 43% 539,228,176 79 57% 946,432,747 84
Surgery 12828 Subspecialty Pediatric Surgery 627,579,820 39 25% 1,927,390,219 22 75% 2,554,970,039 24
Surgery 12083 Fellowship Laparoscopy 305,403,428 71 28% 798,822,159 70 72% 1,104,225,588 76
Surgery 12053 Fellowship Cancer Surgery 305,403,428 72 35% 556,658,057 78 65% 862,061,486 87
Neurosurgery 12337 Assistant Neurosurgery 1,119,070,222 13 44% 1,422,416,293 44 56% 2,541,486,516 26
Neurosurgery 12128 Fellowship Spine Surgery 895,256,178 15 30% 2,073,368,899 18 70% 2,968,625,077 16
Ophthalmology 12277 Assistant Ophthalmology 758,911,001 25 40% 1,148,537,442 56 60% 1,907,448,443 52
Ophthalmology 129111 Fellowship Eye pathology 284,591,625 81 18% 1,323,210,874 47 82% 1,607,802,500 62
Ophthalmology 12153 Fellowship Cornea and External Eye Diseases 284,591,625 79 12% 2,041,166,630 19 88% 2,325,758,255 34
Ophthalmology 12073 Fellowship Pediatric Ophthalmology and Eye Aberrations 284,591,625 80 12% 2,016,021,814 20 88% 2,300,613,439 35
Ophthalmology 12127 Fellowship Retina 284,591,625 82 27% 768,754,594 74 73% 1,053,346,219 80
Internal-Medicine 12287 Assistant Internal Diseases 740,885,923 27 37% 1,248,769,119 52 63% 1,989,655,042 50
Internal-Medicine 12126 Assistant Internal-Cardiology 740,885,923 28 40% 1,105,216,196 59 60% 1,846,102,119 56
Internal-Medicine 12768 Subspecialty Endocrine and Metabolism Glands 381,624,937 63 17% 1,905,407,675 24 83% 2,287,032,611 36
Internal-Medicine 12948 Subspecialty Adult Blood and Cancer 572,437,405 48 23% 1,897,086,277 25 77% 2,469,523,683 29
Internal-Medicine 12212 Subspecialty Adult Digestive and Liver 381,624,937 64 19% 1,652,935,380 35 81% 2,034,560,317 48
Internal-Medicine 12968 Subspecialty Nephrology (Adult Kidney) 381,624,937 62 15% 2,211,420,120 15 85% 2,593,045,057 23
Internal-Medicine 12738 Subspecialty Lung Diseases 381,624,937 61 10% 3,533,055,816 6 90% 3,914,680,753 8
Internal-Medicine 12748 Subspecialty Rheumatology 381,624,937 65 23% 1,274,216,265 50 77% 1,655,841,201 60
Radiology 12867 Assistant Radiology 715,368,480 31 48% 775,183,226 73 52% 1,490,551,706 64
Radiology 12023 Fellowship Interventional Radiology 178,842,120 90 14% 1,073,274,159 62 86% 1,252,116,279 72
Psychiatry 12307 Assistant Psychiatry 904,402,878 14 36% 1,599,880,090 36 64% 2,504,282,968 27
Obstetrics & Gynecology 12317 Assistant Obstetrics & Gynecology 769,732,395 23 37% 1,335,932,581 46 63% 2,105,664,976 44
Obstetrics & Gynecology 12033 Fellowship Perinatology 288,649,648 73 12% 2,087,578,167 17 88% 2,376,227,815 31
Obstetrics & Gynecology 128911 Fellowship Women's Oncology 288,649,648 74 13% 1,871,056,677 26 87% 2,159,706,326 40
Obstetrics & Gynecology 129811 Fellowship IVF 288,649,648 75 21% 1,077,015,442 61 79% 1,365,665,090 69
Obstetrics & Gynecology 12043 Fellowship Laparoscopy 288,649,648 76 23% 960,608,560 65 77% 1,249,258,208 73
Emergency Medicine 12111 Assistant Emergency Medicine 581,945,584 47 53% 511,028,109 81 47% 1,092,973,694 79
Traditional Medicine 12186 Ph.D. Traditional Medicine 1,554,338,877 3 66% 798,914,788 69 34% 2,353,253,665 32
Physical Medicine & Rehabilitation 12257 Assistant Physical Medicine & Rehabilitation 618,417,401 41 36% 1,096,723,833 60 64% 1,715,141,235 59
Cardiology 12657 Assistant Cardiology Diseases 776,817,668 22 34% 1,478,455,379 39 66% 2,255,273,047 37
Pediatrics 12197 Assistant Pediatric Diseases 768,840,000 24 24% 2,487,909,076 12 76% 3,256,749,077 10
Pediatrics 12978 Subspecialty Pediatric Cancer and Blood 593,402,963 44 20% 2,447,557,485 13 80% 3,040,960,449 15
Pediatrics 12838 Subspecialty Children Digestive 395,601,976 58 19% 1,717,735,552 31 81% 2,113,337,527 43
Pediatrics 12798 Subspecialty Children Infectious 395,601,976 57 19% 1,740,636,660 29 81% 2,136,238,636 41
Pediatrics 12778 Subspecialty Pediatric Cardiology 593,402,963 43 19% 2,496,432,297 11 81% 3,089,835,260 14
Pediatrics 12198 Subspecialty Neonatal Medicine 395,601,976 59 19% 1,684,632,329 32 81% 2,080,234,304 46
Pediatrics 12788 Subspecialty Clinical Immunology and Allergy 593,402,963 42 19% 2,497,503,535 10 81% 3,090,906,499 13
Pediatrics 12205 Fellowship PICU 288,315,000 78 18% 1,296,748,470 48 82% 1,585,063,470 63
Pediatrics 12123 Fellowship Children Cardiology Intervention 288,315,000 77 17% 1,436,454,786 43 83% 1,724,769,786 58
Pediatrics 12112 Subspecialty Endocrine and Metabolism Glands of Children 395,601,976 60 19% 1,672,441,312 34 81% 2,068,043,288 47
ENT 12327 Assistant ENT 847,724,500 18 21% 3,186,742,563 7 79% 4,034,467,062 6
Medical Education 12385 Master Electronic Medicine Education 369,730,490 69 46% 440,742,151 86 54% 810,472,641 88
Family Doctor 12311 Assistant Family Doctor 515,062,835 53 23% 1,738,930,930 30 77% 2,253,993,765 38
Orthopedics 12125 Assistant Orthopedics 715,261,702 33 37% 1,207,283,641 53 63% 1,922,545,343 51
Orthopedics 12093 Fellowship Spine Surgery 268,223,138 87 13% 1,817,102,826 28 87% 2,085,325,964 45
Orthopedics 12163 Fellowship Pediatric Orthopedics 268,223,138 89 26% 776,473,897 72 74% 1,044,697,036 81
Cardiology 12143 Fellowship Adult Cardiology Intervention 268,223,138 88 14% 1,596,933,326 37 86% 1,865,156,464 54
Cardiology 12658 Subspecialty Cardiology Diseases 737,625,653 30 39% 1,148,493,873 57 61% 1,886,119,526 53
*In order to convert the amount of this column to dollars, each amount could be divided by 35000, the approximate average exchange rate dominated at that time.
Table 4. The Total Cost of Student Education (Figures in Rials)*
Degree ClinicalorNon-Clinical Number The Average ofOverhead Cost The Average ofTraining Cost The Average ofTotal Cost Estimated Budget for Each Degree
Amount Rank % Amount Rank % Amount Rank BudgetAmount Budget Difference with Cost
MPH Non-Clinical 1 375,578,664 6 53% 332,720,863 7 47% 708,299,527 7 193,018,600 -515,280,927
Master Non-Clinical 14 611,246,900 4 52% 568,779,152 6 48% 1,180,026,053 6 238,093,300 -941,932,753
Ph.D. Non-Clinical 10 1,766,267,168 1 49% 1,821,754,839 4 51% 3,588,022,007 1 702,038,700 -2,885,983,307
General Practitioner Clinical 1 1,251,707,979 2 40% 1,865,267,270 3 60% 3,116,975,249 2 1,092,060,200 -2,024,915,049
Assistant Clinical 23 765,292,078 3 29% 1,889,491,172 1 71% 2,654,783,251 3 736,734,789 -1,918,048,461
Fellowship Clinical 23 312,408,155 7 17% 1,566,327,645 5 83% 1,878,735,801 5 308,885,974 -1,569,849,827
Subspecialty Clinical 18 485,534,450 5 20% 1,886,679,290 2 80% 2,372,213,740 4 474,691,883 -1,897,521,857
All Degrees 90 681,934,893 30% 1,575,805,608 70% 2,257,740,501
Non-Clinical Field 25 1,063,828,278 50% 1,060,527,095 50% 2,124,355,373
Clinical Field 65 535,052,822 23% 1,773,989,651 77% 2,309,042,473
*In order to convert the amount of this column to dollars, each amount could be divided by 35000, the approximate average exchange rate dominated at that time.
Table 5. Descriptive Statistics for Component of Education Cost (Rials figures)*

Discussion

The results of Table 4 show that the PhD in Medical Ethics, assistant of Radiotherapy and Ph.D. in Pharmacology turned out to have the highest cost for each student respectively, while MPH, Master of Medical Engineering, and Master of Electronic Medicine Education had the lowest cost for each student, respectively. In addition, assistant of Radiotherapy, assistant of General Surgery, Fellowship of Cardiac Anesthesia, respectively, demonstrated the highest, but Master of Medical Engineering, MPH, and Master of Mycology, respectively, had the lowest tuition fees per student. Furthermore, in terms of overhead prices, Ph.D. in Medical Ethics, Ph.D. in pharmacology, and Ph.D. in Traditional Medicine, respectively, had the highest cost of overhead, and fellowships of Interventional Radiology, Spine Surgery, Pediatric Orthopedics, and Adult Cardiology Intervention had the lowest overhead costs, respectively.

Table 5 shows the average cost at different degrees, separated into the average cost of education and overhead. In addition, according to the cost ranking, it is observed that the PhD., General Practitioner and Assistant had the highest costs, respectively. It seems that the most important reason for the higher cost of these degrees is the higher cost of overhead. According to the overhead ranking, it can be seen that these degrees have the highest amounts of overhead compared to other degrees. The main reason for the higher overhead amounts in these degrees is that they take longer than other degrees. As explained in the method section of this study, the final overhead cost is calculated for one academic year and is determined by the length of the course. Because the longer a student spends time at the university, the more ancillary services he or she will receive.

However, in general, the cost of training accounts for 70% of the total cost of student education, and the importance of paying attention to the cost of education is also highlighted. The share of the cost of education in the total cost of education for students in the degrees of fellowship (83%), subspecialty (80%), and assistant (71%) were higher than average. Factors such as the small number of students in these degrees compared to other degrees; the use of professors with higher academic degrees, which consequently costs more; and the use of equivalent credits in graduate programs can be among the factors influencing the higher cost of education. So far, no research study has been conducted on calculation of the cost of education in the field of clinical disciplines. Therefore, we compared the results of the present study with those of the research conducted in other fields.

Similar to the results of the present study, the findings of Rajabi ( 20 ), Abbasi ( 21 ), Rezaei ( 26 ) and Rahimniya et al. ( 30 ) show that the number of students in each field is a factor affecting the cost of students and increasing the number of students reduces the cost of education of each student. Also, similar to the results of the present study, Rajabi ( 20 ), Haghdoost and et al. ( 23 ), Ghasempour et al. ( 25 ) revealed that in higher educational levels, the costs of students increase.

In addition, Table 5 compares the budget paid by the government per student to study at each level with the cost of student education. As you see, the cost in all fields is more than the per capita cost of student education paid to the university. This result is consistent with those of Rezaei ( 26 ), Rahimniya et al. ( 30 ), and Kojuri et al.’s ( 31 ) studies. It is necessary to allocate the funds according to the type of university in the country, be more careful in allocating the funds, and determine the share based on per capita student costs; all universities and educational institutions operating in the education system should not be considered the same ( 31 ).

One of the limitations of the present study is the lack of access to information regarding the expenses incurred in the Ministry of Health and Medical Education. In addition, accounting information was recorded in the school by traditional cost systems and lacked a complete information about the ABC activities. This deficiency made it difficult to distinguish between information on expenses, except for salary information that was obtained directly from the payroll system. Nevertheless, every effort was made to ensure that the validity and reliability of this research are maintained as much as possible.

Conclusion

The most important achievement and importance of the present study is to provide a model for calculating the cost of student education in the health sector using the ABC method. The significance of this study is that we can provide important and empirical evidence regarding the cost of medical school courses at different degrees in the largest medical universities in the country and compare them. In addition, it illustrated the steps on how to implement ABC in the health sector in order to demonstrate the usefulness of the ABC system and reduce the gap between theory and practice. This information can be used by health managers and decision makers to make the most of the budget, save money, and improve productivity.

As the results in Table 5 show, for non-clinical disciplines, on the average, the costs of training and the costs of overhead are equal, and each makes up half of the total costs. It seems that the reason is that the duration of these courses is long; as a result, the overhead costs in these courses have increased. On the other hand, these disciplines are less specialized and the salaries and benefits of its professors are less than clinical disciplines; therefore, the cost of training in these disciplines is lower than clinical disciplines. These two cases led to equalization of the costs of training and the costs of overhead in these disciplines.

For clinical fields, the costs of training is 77% and those of overhead is 23% of the total costs. In these fields, due to the fact that the length of the fields is shorter than non-clinical fields, the overhead costs is the average less than non-clinical fields. On the other hand, because the amount of tuition fees for professors in these fields is higher, the cost of training is higher than non-clinical fields. Therefore, in order to reduce the cost of students’ education, it is suggested that clinical officials should pay more attention to the efficiency of curriculum planning.

In general, 70% of the total costs of the education is the costs of student training and 30% of it belongs to the overhead costs. Based on the findings of the present study, it seems that the authorities should focus on controlling and reducing the costs of training, which is the main component of the costs. The results show that the more specialized the field, the higher the costs of education because it needs to be taught by professors with higher expertise and consequently higher salaries. Therefore, in these fields, the need for special attention of officials to the educational planning of students becomes more and more clear. In addition, given that non-faculty professors are paid less than faculty members, it is recommended that non-faculty professors should be used to reduce the costs of education for less sensitive and less specialized courses, provided that the quality of education is maintained.

It is also suggested that officials should pay attention to the costs of overhead. Because the main purpose of the students’ education is training, and the overhead costs provide less added value than the costs of training. On the other hand, reducing the costs of training, given the factors such as salaries and benefits of faculty members, the number of students in each field, etc. is hardly possible; hence, the importance of attempts to reduce the overhead costs becomes more apparent. In this regard, it is suggested that the officials of the headquarters and the medical school should determine the optimal number of manpower required for each department and review the arrangement of the staff by employing human resource management methods such as job measurement and timing.

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