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.

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.

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.

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.

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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