Indian Journal of Public Health

: 2017  |  Volume : 61  |  Issue : 2  |  Page : 92--98

Cost analysis of a simulation-based training for health workforce in India

Gursimer Jeet1, Shankar Prinja2, Arun Kumar Aggarwal3,  
1 Research Scholar, School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh, India
2 Associate Professor, School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh, India
3 Professor, School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Correspondence Address:
Shankar Prinja
School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh


Background: Training of health-care workforce including doctors, staff nurses, and Auxiliary Nurse Midwives using simulation techniques for skill enhancement have been used in a variety of clinical settings to improve the quality of training. India adopted the skills laboratories model for capacity building of health workers in maternal and child health in Bihar state. Objective: Current economic evaluation was performed with the objective of assessing the financial and economic cost of implementing skills laboratories. Methods: Data on all resources spent for the development of skill laboratory and implementing training during financial year 2011 were collected from Patna district in Bihar state. We used standard methods to estimate the full financial and economic costs of implementing the skills laboratories from a health system perspective. Results: Overall cost of implementing 20 permanent and 10 mobile skills laboratory training in Bihar was Indian Rupee (INR) 8849895 from a financial perspective. The cost was nearly two times higher when using an economic perspective to account for opportunity cost of all resources used. The unit cost of training a participant using permanent and mobile laboratory was INR 6856 and INR 7474, respectively assuming an annual volume of 90 training. The optimum number of training which should be operated annually in a skills laboratory to make it most efficient is about 70–80 training per annum. Conclusions: Economic implications of skills laboratory organization should be borne while planning scale up in Bihar and other states. Further research on the effectiveness of two models of skill laboratory, that is, permanent and mobile and their cost is recommended.

How to cite this article:
Jeet G, Prinja S, Aggarwal AK. Cost analysis of a simulation-based training for health workforce in India.Indian J Public Health 2017;61:92-98

How to cite this URL:
Jeet G, Prinja S, Aggarwal AK. Cost analysis of a simulation-based training for health workforce in India. Indian J Public Health [serial online] 2017 [cited 2020 Oct 23 ];61:92-98
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Professional education recognizes that for a client-centered quality practice, competencies beyond purely fact-based knowledge, and technical skills are required.[1] Training of health care workforce including doctors, staff nurses, and Auxiliary Nurse Midwives using simulation techniques for skill enhancement have been used in a variety of clinical settings to improve the quality of training.[2]

In developed countries, patient simulators for clinical training of medical personnel have been used mostly in nursing schools for approximately 10 years.[3] In an extensive review of the literature on health-care education methods covering 100 studies, nine were found to have empirically examined the effectiveness of patient simulators.[4] The results of the review indicated that 75% of the effect sizes reported were sufficiently high to indicate favorable results in the use of the simulators.[4] Despite having shown good performance in clinical training, only one study was found to having reported the cost of establishing such laboratories which used a narrow financial perspective.[5] In a recent 2013 systematic review of the literature by Zendejas et al., it has been found that economic analysis in simulation-based medical education is infrequent and incomplete.[6]

The introduction of the concept of the skills laboratories (referred as laboratories henceforth) establishment is a relatively newer dimension toward quality improvement in Indian health-care delivery.[7] These laboratories offer skills-based learning to strengthen the capacity of health-care providers on the day-to-day practiced skills and knowledge's to ensure the quality of reproductive, maternal, neonatal, and child health services along with the timely provision of mentoring.[8] While skills laboratories have been used in developed countries primarily in undergraduate medical and nursing training, India has initiated the implementation of skills laboratories in Bihar state for capacity building of existing health workers in maternal and child health. Second, in view of special geographic and other operational concerns, a mobile skills laboratory concept is also being piloted which involves transport of entire laboratory equipment and personnel to different sites for training.

Lack of economic information on the cost of such training methodology can pose a challenge in planning and may delay the introduction of simulator-based education.[5] Moreover, since different agencies and states are trying to introduce skills laboratories for assessment and capacity building of health professionals, evidence related to cost is very crucial before scale up is attempted. We undertook this study to ascertain the financial and economic cost of implementing skills laboratories based training. Unit cost was estimated for both types of models, that is, permanent and mobile skills laboratories.

 Materials and Methods

Study setting and intervention

Skills laboratories were established on a pilot basis in Bihar, a state low on economic development and poor health indicators. Set up at an Auxiliary Nurse Midwife (ANM) school in a secondary care hospital, the laboratory was established to evaluate the skills of nurses and other medical professionals in the state. Apart from evaluation, nurses also got an opportunity to practice the skills needed to complete a thorough history and physical examination of the patients. The skill laboratories training as an intervention was implemented in response to need for performance evaluation of the workforce at peripheral health centers in the state. The idea of on job training was conceptualized to meet objectives of both evaluating the persons as well as to provide training to enhance skills. The intervention was implemented by State Health Department in collaboration with United Nations Children's Fund (UNICEF).

Planning of the intervention started from April 2011 and included start-up activities such as course design and master trainer training. UNICEF undertook the majority of activities during this phase. Full-time consultants were appointed by UNICEF to serve as master trainers for skill laboratories. The implementation phase of the intervention was accomplished in two modes. First, the permanent laboratory was established in Patna. Training were started for a batch of 20 persons including medical officers as well as auxiliary nurse midwives (ANMs). Initial 10 training were conducted by UNICEF. Later this was taken over by State Health Department. In addition to permanent skills laboratory, mobile training were started in Vaishali district followed by Purnia district. The later involved use of portable equipment and other infrastructure, which was transported along with trainers from one district to another for training.

Participants trained in first 5–6 initial batches took over the role of master trainers for subsequent training. UNICEF coordinators and consultants undertook field visits to monitor and provide supportive supervision to participants at their workplace. The establishment of skills laboratories is still in the process of evolution. Out of total 4282 doctors, ANMs and staff nurses that Bihar government wanted to evaluate before conceptualization of these laboratories, so far 600 have been trained. For the present study, skills laboratories have been studied during 1 year (2011) from the time of conceptualization until the completion of monitoring of participants trained in the initial 30 training. The intervention has been stratified in three phases, that is, planning and start-up phase, implementation phase, and the monitoring phase.

Costing methodology

We estimated full financial and economic costs of implementing the skills laboratory from a health system perspective.[9] Financial costs included all outlays made by the program to purchase goods and services, but do not include the costs of items for which the program does not have to pay. Alter natively, in economic costing, the cost was assigned to a good or service, in terms of opportunity cost, that is, the value of the most productive alternative use of the same resources. This perspective is broader than the financial cost framework as it includes all resources consumed in production of a service

The study followed a retrospective design, wherein financial costs were obtained from accounting system of both State Health Departments and UNICEF for 1 year period (April 2011–April 2012). Economic costs were calculated by valuing the opportunity cost of all the resources which were used for planning, implementing, and monitoring skills laboratories training. This included the financial costs (explicit) and the opportunity cost of implicit resources such as regular in-service personnel who spent time out of routine schedule on the training or resources drawn from other programs to implement skill laboratories.

Data were collected using bottom-up costing methods. Inputs were segregated into capital and recurrent costs. Capital inputs included buildings, equipment, furniture, and resources spent designing the course and training master trainers. The recurrent resources included resources spent on conducting permanent and mobile training, that is, staff salaries, consumables, refreshment, allowances, transportation of mobile laboratory equipment, electricity, laundry, overheads, etc. Costs were stratified by the phase of implementation, that is, planning, implementation and supportive supervision and by the agency which incurred cost. Based on unit costs for each skill laboratory, an annual estimate financial budget was prepared.

Human resources involved and their time allocation

A proforma for recording activities of staff members was developed. Staff members were interviewed to assess their activities, roles and responsibilities, daily numbers of hours devoted to skills laboratory-related work during different phases of the project. Person-months spent by different personnel involved were calculated by dividing daily work hours for skill laboratory-related tasks with total work hours in a day and multiplying with a number of months for which that particular phase lasted. Actual salaries of personnel specially employed for skills laboratory-related work or any honorarium amount paid to regular health system staff for skill laboratory-related work was included as part of the financial costs.

For estimating the economic cost of personnel, we attributed the time cost of all personnel involved in the skill laboratory-related work, either full-time or part-time. In a scenario analysis, we used “shadow prices” for the salary of the UNICEF staff as the actual salaries did not represent true opportunity cost of UNICEF staff time from a viewpoint of Government of Bihar.[9] The shadow prices used were the average salaries paid to consultants under contractual government service in the state.

Space utilization

All buildings used for skills laboratory were those belonging to the health department and thus had no financial costs. For estimating the economic cost of space, covered area used for skill laboratory-related work was multiplied with the prevailing market rental price for this space. For training halls which were used for other type of training besides skill laboratory, “proportion of person-days for which space was used for skills laboratory work” was used to apportion space cost for skills laboratory. Space costs were calculated separately for permanent as well as mobile laboratories.

Equipment costs

The equipment costs for the skills laboratory included the equipment costs to purchase the patient simulators and their associated support systems. Financial costs were calculated by using purchase price for each line item and attributing as the full amount to the year of purchase. For economic costing, the cost of equipment was annualized using standard assumptions regarding the life of the equipment [10] and discount rates.[11],[12] We used a discount rate of 3% for estimating annualized cost of capital resources.[13] In the case of equipment where no standard was being followed, expert opinion was sought. In a perfectly competitive market, the opportunity cost of input is its market price. These market prices for analysis could be based on the original purchase price (historical value) or the replacement price based on market surveys. A market survey was undertaken from random sample of vendors and the average market price was used for the cost analysis. While historical unit costs were known from records, these prices did not represent the opportunity cost of future resources spent for the purchase of capital items. For this reason, replacement prices were preferred over historical prices in our cost analysis.

Training costs

The cost for training was elicited under the heads of personnel, space, consumables, nonconsumables, refreshment, transportation charges and overheads such as electricity, generator hiring, and laundry. Time costs of the participants and resource persons were additional costs from an economic perspective. A detailed description of different data sources and assumptions for cost analysis is given in [Table 1].{Table 1}

Approval to undertake the research project was undertaken from Postgraduate Institute of Medical Education and Research, Chandigarh, India. Administrative approval of State Health Department, Bihar and Incharge of concerned health facilities was also taken.

Data analysis

Data were analyzed using MS-Excel (Microsoft Corporation, Redmond, WA, USA). The total cost of undertaking 20 training through permanent skills laboratory and 10 training through mobile skills laboratory methodology was computed.

The skills laboratories did not function for complete 1 year as initial months were spent in start-up activities. As the current dataset does not represent full capacity utilization for skill laboratory; hence, it does not allow for valid estimation of the unit participant training cost. Since fixed costs are annualized, the unit costs estimated from given set of data would be an over estimation. To correct this, we undertook a univariate sensitivity analysis by plotting the effect of increasing the number of training conducted on the unit cost of training. Based on the duration of a single training and consultation with stakeholders, we assumed that a single permanent or mobile laboratory could conduct about 90 training per year. Thus, we varied the per participant cost of training using permanent or mobile skill laboratory, by varying the number of training from 10 to 120 per year.


Overall cost of implementing 20 permanent skills laboratory and 10 mobile laboratory training in Bihar was Indian rupee (INR) 8849895 (USD 147722) from a financial perspective. The cost was 1.7 times higher when using an economic perspective (15046804, USD 251161) to account for opportunity cost of all resources used [Table 2].{Table 2}

Financial costs were contributed principally by equipment (38%) followed by training (24%), personnel (16%) and overheads (8%). From economic perspective, training costs constituted the major cost head. The largest components of economic costs were training costs (34%) followed by building (33%) and personnel costs (15%). In the scenario of using shadow prices for the salaries of UNICEF staff, the economic costs decrease to INR 13836804 (230964), but they still remain 1.56 times higher than the financial costs. UNICEF spending was twice more than Government spending. Nearly 84% of the total costs were incurred in implementation phase which included various training activities [Table 3].{Table 3}

Sensitivity analysis

To make the costs comparable, unit cost per training and unit cost per participant were individually calculated for using uni-variate sensitivity analysis by varying the number of training. Economic cost per participant remains higher than unit financial costs in both permanent as well as mobile laboratories except in the case of mobile laboratories at very low number of training. With the increase in number of training, cost per participant decreases gradually in unit financial costs for permanent as well as mobile laboratories, but the economic cost per participant showed a comparatively lower decrease. We found that the marginal decline in unit cost became almost negligible after 70–80 training; hence, the optimum number of training which should be operated annually in a skills laboratory to make it most efficient is about 70–80 training per annum.

Unit cost for skill laboratory

Assuming 90 training per year, the financial and economic cost of training a single participant using permanent simulation laboratory -based method is INR 6856 (USD 115) and INR 16479 (USD 277) [Figure 1] and [Figure 2]. Similarly, cost per participant with a mobile laboratory model was INR 7474 (USD 126) and INR 10959 (USD 184) using financial and economic perspective, respectively.{Figure 1}{Figure 2}


The results of this study present an example of a low-cost model of a simulation center in a developing country. The total economic costs calculated for establishment and maintenance of a skill laboratory were found to be 1.7 times of the financial costs involved. Fixed capital costs, that is, capital and equipment constituted the majority of costs, followed by recurrent training costs (24% in financial while 34% in economic costing). These results are in corroboration with those of Kurrek and Devitt in 1997,[5] who reported maximum expenditure on equipment purchase and salary support, in establishment and running of a simulation center. Perspective of analysis influences the results and its inference. For instance, capital costs, that is, buildings were mainly borne by Government of Bihar. While 61% of total costs were borne by Government using an economic perspective, its share fell to 32% under financial analysis due to noninclusion of capital costs for space. Higher UNICEF costs were attributable to higher start-up fixed costs.

During the period for which the skills laboratory were being evaluated, a total of 20 training at permanent and 10 training at the mobile skills laboratory had been conducted. However, the costs presented for permanent and mobile skills laboratory are not directly comparable as they are representing the actual costs incurred in relation to the volume of activities undertaken (e.g., the number of training).

The cost of training a single participant, with a volume of 90 training per year, was INR 6856 (USD 115) using the permanent laboratory and INR 7474 (USD 126) with the mobile laboratory. There is no other study from India which ascertains the cost of such a model of simulation-based learning. In a study from North India, cost per participant of a 5 days or 8 days training package of Integrated Management of Neonatal and Childhood Illness (IMNCI) was found to be INR 4,238 (USD 71) and INR 5,538 (USD 93). IMNCI which does not follow a simulation based learning provides a crude comparison of another form of training of health workers for child health-related issues. Costs related to traveling allowance, daily allowance, petrol/oil for field visit, accommodation for external facilitators, audio-visual aid rental, contingency and administrative charges were included in this study.[15] However, the study was limited as the initial start-up and implementation costs of the training were not included thus adopting a narrower financial perspective.

With an increase in number of training per skills laboratory established, the cost per participant decreased in a reverse-j shaped fashion. Similar results were reported by Berg et al.,[16] with a progressive decline in yearly cost per resident over time. However, the decline in cost became almost negligible after 70–80 training; hence, the skills laboratory would function at maximum cost-efficiency at 70 training per annum. We also found that the most efficient number of training per year per skill laboratory was in the range of 70–80.

Appropriate resource allocation decisions are possible only when all costs are explicitly reported. To ensure the total cost is captured properly, all constituent parts of a type of cost were included in this evaluation. Even costs for instructor's time, as well as indirect opportunity cost of removing clinical personnel from their routine jobs to undergo training have been accounted for in the economic perspective adopted for analysis. We also report the optimum number of training which a skill laboratory should operate in a year. No similar study has been reported from India which takes this point of view. To generate estimates of costs for planning purposes, shadow pricing for salaries of UNICEF staff was undertaken in a sub-analysis which is more representative of the opportunity cost of labor and hence can be used for operational planning.

We have reported only unit cost estimations for this evaluation, which is a limitation of the present study. A more useful analysis would have been cost-effectiveness analysis. However the project was in its infancy and is continually developing, valuation of the true benefits was challenging. There was no counterfactual during the study period where similar kind of training was given within health system. In view of this, we could not establish comparisons with similar models of training. However undertaking a full economic evaluation of simulator based skills laboratory training is recommended against counterfactual of no training and head-to-head comparison with traditional forms of classroom training. In our review, barring one study, we could not find any other study which has evaluated costs of training of health workers in India during the study.


Economic implications of skills laboratory organization should be borne while planning scale up in Bihar and other states.

Since the establishment of skills laboratories is a relatively new enterprise in India, the results of this study hold good significance. The average cost curves generated will be helpful to the managers to understand the types and behavior of the costs incurred in the production process and also the efficient levels for operation. Finally, the study also highlights the need to assess the effectiveness of the different models of skill laboratories to assess relative cost effectiveness.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


1Epstein RM, Hundert EM. Defining and assessing professional competence. JAMA 2002;287:226-35.
2Schädler D, Heinrichs W, Mönk S, Elke G, Zick G, Scholz J. Simulation training for German anesthesiologists – Case scenarios and training results. Anasthesiol Intensivmed Notfallmed Schmerzther 2008;43:474-7.
3Nehring WM, Lashley FR. Current use and opinions regarding human patient simulators in nursing education: An international survey. Nurs Educ Perspect 2004;25:244-8.
4Ravert P. An integrative review of computer-based simulation in the education process. Comput Inform Nurs 2002;20:203-8.
5Kurrek MM, Devitt JH. The cost for construction and operation of a simulation centre. Can J Anaesth 1997;44:1191-5.
6Zendejas B, Wang AT, Brydges R, Hamstra SJ, Cook DA. Cost: The missing outcome in simulation-based medical education research: A systematic review. Surgery 2013;153:160-76.
7Padmanaban P, Prasanth KS. District Skill Labs: An FFHI Initiative. New Delhi: National Health System and Resource Centre; 2011.
8UNICEF – Bihar. Skills Laboratory for MO/SN/ANM – Bihar Experiences. Bihar: UNICEF, Bihar; 2012.
9Drummond MF, Sculpher MJ, Torrance GW, Stoddart GL. Methods for the Economic Evaluation of Health Care Programmes. 3rd ed. New York: Oxford University Press; 2005.
10Rogowski J. Cost-effectiveness of care for very low birth weight infants. Pediatrics 1998;102 (1 Pt 1):35-43.
11Adam T, Manzi F, Kadundwa C, Schellenberg J, Mgalula L, de Savigny D, et al. Multi-Country Evaluation of the Integrated Management of Childhood Illnesses (IMCI). Analysis Report of the Costs of IMCI in Tanzania. Geneva: Department of Child and Adolescent Health and Development, World Health Organisation; 2004.
12Acharya A, Adam T, Baltussen R, Evans D, Hutubessy R, Murray C, editors. Making Choices in Health: WHO Guide to Cost-Effectiveness Analysis. Geneva: World Health Organization; 2003.
13Acharya A, Adam T, Baltussen R, Evans D, Hutubessy R, Murray CJ, et al., editors. Making Choices in Health: WHO Guide to Cost-Effectiveness Analysis. Geneva: World Health Organization; 2003.
14Arges GS, editor. Estimated Useful Lives of Depreciable Hospital Assets. 6th ed. Chicago: American Hospital Publishing Inc.; 1998.
15Kumar D, Aggarwal AK, Kumar R. The effect of interrupted 5-day training on Integrated Management of Neonatal and Childhood Illness on the knowledge and skills of primary health care workers. Health Policy Plan 2009;24:94-100.
16Berg DA, Milner RE, Fisher CA, Goldberg AJ, Dempsey DT, Grewal H. A cost-effective approach to establishing a surgical skills laboratory. Surgery 2007;142:712-21.