(Eriksen et al, 2003). In one hospital in Rwanda, Sutherland et al (2019) found that the mean length of stay of 25.5 days for patients with HAI but not AMR compared with 21.9 days for those without HAI. Hence, an HAI increased ALOS by 3.6 days. In Ghana, the ALOS was 3 days longer between the HAI (non-AMR) group and the control group (Otieku et al, 2023). In a meta-analysis of cost impacts of HAIs, Karagiannidou et al (2020) present studies from 3 African countries. In Kenya, HAIs led to additional attributable length of stay of 10.1 days (Aiken et al, 2011); in South Africa, 9 days (Dramowski et al, 2016); and Algeria, 9.2 days (Atif et al, 2008).

By aggregating estimates provided in Manoukian et al (2018) from the different methods and drawing on the anecdotal evidence from Africa, a conservative estimate is that non-resistant HAI leads to an average excess length of stay of at least 5 days. This compares with an overall ALOS in government facilities in Kenya is 3.4 days in 2021/2, and in Uganda the ALOS is 4 days 2019/20.

AMR will lead to an even longer length of stay than with the HAI treatable with first line drugs. The available literature is mainly from developed countries. A systematic review conducted by Serra-Burriel et al (2020) of multi-drug resistant HAIs found 20 studies (19 OECD countries and China) with an average of 27% increase in hospital length of stay. Several studies in used in the meta-analysis of Manoukian et al (2018) compared patients with resistant versus nonresistant infections. Butler et al (2010) used 3 different statistical techniques to compare excess length of stay from vancomycin-resistant versus Vancomycin-susceptible enterococci. Their analysis revealed different results: for group comparison ALOS was 4.6 days more for resistant strains, while for the matching methods it was 1.3 days and for regression it was 1.1 days. Other studies found patients with resistant bacteria stayed 5 days longer (Riu et al, 2016), 1.2 days longer (de Kraker et al, 2011), 7.4 days longer (Barnett et al, 2013), and 7.2 days longer (Stewardson et al, 2013). Stewardson et al (2016) found 3.4 days longer for patients with third-generation cephalosporin resistant Enterobacteriaceae, and 1.8 days for patients with methicillin-resistant Staphylococcus aureus. In one hospital in Rwanda, Sutherland et al (2019) found that that AMR lead to 14.5 excess days of hospital stay compared with HAI without AMR. In Ghana, the ALOS was 4.9 days longer between the AMR group and the HAI group (Otieku et al, 2023).

Drawing on these studies, a conservative estimate is that AMR leads to an average excess length of stay of at least 5 days over and above the 5 excess days for the HAI.

# 7. Additional recovery time

Time lost from productive activities will be a minimum of the extra time spent in a healthcare facility due to the HAI. For patients that have had HAI, especially those with AMR, the time away from productive activities will be greater than the additional time they spent in hospital. It is assumed that an additional 2 days is required, both for the patient and the caregiver.

# 8. Value of time lost

This study takes a societal perspective and includes the loss in productive value for working adults and the opportunity cost of time for children and non-working adults. For working adults, the value is conservatively approximated by using the value-added per worker in agriculture, forestry and fishing (World Bank statistics, using 2021 values for most countries). The opportunity cost of time for children and non-working adults is approximated using 30% 36