district health expenditure review - Health Systems Trust

First Mt. Currie District Health Expenditure Report 

A project of ISDS, Health Systems Trust, and the Health Economics Unit, Department of Community 

Health, University of Cape Town 

Funded by the European Union via the National Department of Health 

TABLE OF CONTENTS 

Section 

Pg 

TABLE OF CONTENTS ii 

LIST OF ILLUSTRATIONS iv 

ACKNOWLEDGEMENTS vi 

EXECUTIVE SUMMARY vii 

1. INTRODUCTION .............................................................1 

2. UNDERSTANDING SERVICES IN MOUNT CURRIE AS ONE OF THE EARLY 

STEPS IN THE EXPENDITURE REVIEW. .3 

3. OTHER BACKGROUND INFORMATION ....................................5 

3.1.The Population Growth Rate and Geographic Distribution .................................5 

3.2. The Population Age and Gender Distribution...............................................6 

3.3. Education and Income .....................................................................6 

3.4. The Health District’s Catchment Population ...............................................7 

4. INFORMATION, INDICATORS AND THE PROCESS OF DATA 

COLLECTION ..................................................................8 

4.1. The Information............................................................................8 

4.2. The Indicators..............................................................................8 

4.3. Data Collection and Compilation ...........................................................8 

4.4. Limitations of the Data Collected........................................................ 12 

5. RESULTS OF THE FIRST MT. CURRIE EXPENDITURE REVIEW 13 

5.1. Sources and Uses of Finances .......................................................... 16 

5.2. Percentage of total expenditure on different line items ............................... 17 

5.3. Workload Indicators...................................................................... 19 

5.4. Revenue Collected by the District Hospitals............................................. 19 

5.5. Expenditure Per Capita ................................................................... 20 

5.6. Hospitals in the District.................................................................. 22 

5.7. Clinics and District Surgeon Services .................................................... 24 

6. ANALYSIS................................................................... 26 

6.1. How Do Resources Compare Within Sub-Districts and Between Districts? (equity) .. 25 

6.2. Are Enough Resources Being Spent on Primary Health Care? (allocative efficiency) . 26 

6.3. Are PHC Resources and the Workload being shared fairly? 

(equity and technical efficiency) ...................................................... 27 

6.4 Are Hospitals Being Run Efficiently? (technical efficiency)............................. 27 

6.5 Will Fee Retention Make an Impact on District Finances? (sustainability).............. 28 

Health Economics Unit and ISDS 

ii


7. LIMITATIONS OF THE STUDY AND THE WAY 

FORWARD................................................................... 29 

7.1. Limitations................................................................................ 29 

7.2. The Way Forward ........................................................................ 29 

8. REFERENCES ................................................................ 32 

Appendix A: Population Information and Workings ........................................... 33 

Appendix B: Expenditure, Activity and Staff Information .................................. 38 

Addendum 1: Data Presentation and Collection Issues........................................ 51 

Addendum 2: Indicators ....................................................................... 52 

Addendum 3: Cost Units....................................................................... 59 

Addendum 4: Reading the Hospital Cash Books ............................................... 61 

LIST OF TABLES 

Table 1: Overall population growth-rate ........................................................5 

Table 2: Rural/Urban and Sub-District Distribution of the Population .......................6 

Table 3: Age and Gender Distribution of the Population in Mt. Currie (1996) ................6 

Table 4: Annual Income Brackets in Mt. Currie (1996) ........................................7 

Table 5: District Health Account for Mt. Currie: showing 

the flow of expenditure (from sources to uses), Rands (1997/98)................. 15 

Table 6: Percentage Expenditure at Different Facilities/Services (1997/98)................ 16 

Table 7: Standard Line Item Expenditure by Sub-District Responsibility 

(excludes capital maintenance expenditure) (1997/98).............................. 17 

Table 8: District and Sub-district Line Item Expenditure, Rands (1997/98)................ 18 

Table 9: The Distribution of Primary Health Care Professional nurses in the 

Mt. Currie Sub-districts (1997/98)................................................. 19 

Table 10: Revenue Collected in the District (1997/98)...................................... 19 

Table 11: Total Expenditure in Mt. Currie and the Health Sub-districts,Rands(1997/98) 20 

Table 12: Expenditure per Capita, Rands (1997/98) ......................................... 21 

Table 13: Description of Hospitals in Mt Currie (1997/98) .................................. 22 

Table 14: Hospital Expenditure per PDE (1997/98) .......................................... 22 

Table 15: Inpatient Stay and Expenditure (1997/98) ........................................ 23 

Table 16: Out-patient Visits and Expenditure (1997/98) .................................... 23 

Table 17: Provincial Clinic Activity and Expenditure (1997/98).............................. 24 

Table 18: Municipal Clinic Activity and Expenditure (1997/98).............................. 24 

Table 19: Provincial Medicines Used at LA Clinics, Mt Currie 25 

Table 20: District Surgeon Activity and Expenditure (1997/98)............................. 25 

Table 21: Comparisons of Per Capita Expenditure ........................................... 26 

Table 22: Funding of Levels of Care ......................................................... 27 

Table 23: Visit Loads per Professional Nurse by Facility (1997/98)......................... 27 

Table 24: Funding of Levels of Care ......................................................... 28 


iii


LIST OF FIGURES 

Pg 

Figure 1: Overview of Appendices and Addenda ...............................................2 

Figure 2: Health Services in the Mount Currie Health District.................................4 

Figure 3: Classifications of the Information ...................................................8 

Figure 4: Sources of Expenditure Data and Methods of Estimation ......................... 11 

Figure 5(a): Tayler Bequest Hospital Responsibility ........................................... 17 

Figure 5(b): Usher Memorial Hospital Responsibility .......................................... 17 

Figure 6: Key Line Item Recurrent Expenditure in Mt. Currie (1997/98..................... 18 

Figure 7: Visits per PHC Professional Nurse per Sub-District................................ 27 

LIST OF BOXES 

Pg 

Box 1: Basic Steps of A District Health Expenditure Review ..................................1 

Box 2: Classifications of Different Types of Services .........................................9 

Box 3: Cost Centres for Mt. Currie........................................................... 13 

MAPS 

Map 1: KwaZulu-Natal 

Map 2: Mt. Currie Health District 


iv


ACKNOWLEDGEMENTS 

Thanks 

The people who assisted the authors in compiling this report need to thanked. These include all the members of 

the District Expenditure Review Task Team, as well as the helpful professionals in the health services, the 

municipalities and the provincial and regional head offices. Hopefully, this expenditure review has created a 

baseline dataset, which can augmented by the Mt. Currie District health team in the coming years. 


v


EXECUTIVE SUMMARY 

Introduction 

This report documents the findings and conclusions of the first district expenditure review run for the Mt. Currie 

health district. The year under review is the government financial year, April 1997 to March 1998. Mt. Currie is a 

health district bordering on the Eastern Cape, in the southernmost part of the KwaZulu-Natal (KZN) province. Its 

close proximity to the Eastern Cape border, and the region’s geography, have meant that the main towns in the 

district, Kokstad and Matatiele, have for years acted as commercial centres for rural areas extending into the 

Eastern Cape, or what was formerly known as the Transkei. This fact, together with the history of the region’s 

administration, means that the health services in the district are well frequented by residents of the Eastern Cape. 

These cross-border flows made it essential to calculate the district catchment population, which was estimated at 

247 537 people in 1997/98. 

A full range of health services are rendered in the district, including primary health care services, environmental 

health services, district hospital level services and laboratory services. A number of health services to the district are 

still run directly by the province, or the regional office. In addition, as in many districts, there are two main public 

sector authorities running health services; namely local governments (municipalities) and the KZN provincial 

government. The two local authorities in the district are Matatiele and Kokstad. 

Study Methods 

The health services covered in the study included all health services rendered by the municipalities, the province, 

non-governmental organisations (NGOs) and the public work done by part-time district surgeons (also known as 

district medical officers). Services rendered by General Practitioners (GPs) to private patients were excluded from 

the scope of the review. The two district hospitals are Tayler Bequest (Matatiele) and E.G. & Usher Memorial (also 

referred to as Usher Memorial, in Kokstad). The third hospital in the district is the SANTA TB inpatient care facility in 

the town of Matatiele. 

The methods of investigation included primary data collection, from service records and information system reports; 

secondary data collection, from existing published materials (such as the KwaZulu-Natal (KZN) Informatics 

Bulletin); and interviews with various service providers in the health district. 

All data, except for the facility maps, were only obtained in the form of documents or system reports. All numerical 

data were entered onto Excel spreadsheets. The maps were obtained in electronic and hard copy format from the 

Geographical Information System (GIS) of the KZN (provincial) Department of Health. Data entered by one 

researcher were crosschecked by another researcher for accuracy. Accompanying this report is an electronic copy 

of the indicator tables, as well as the line item expenditure breakdown from the FMS X112 reports for the two 

hospital responsibilities in Matatiele and Kokstad, respectively. 

Two key groups of people influencing both the type of data collected and the methods used were the Health 

Expenditure Review Task Team (HERTT), who were developing guidelines for running district expenditure reviews, 

and the Mt. Currie District Expenditure Review Task Team (DERTT). Three of the authors were also involved in the 

HERTT. Both these groups generated lists of indicators and cost centres. In the end, the final review went further 

than the basic requirements of the HERTT team, except in supplying indicators using facility level catchment 

populations, which were not available from the Mt. Currie health services. 


vi


Results 

Total district expenditure for the year 1997/98 was R54, 056,359. About 5.6 % of this was capital expenditure. Total 

expenditure was divided between the two sub-districts as follows: R24, 505,013 in Matatiele (45 %), and 

R29,551,346 in Kokstad (55%). Using the district catchment population, whose calculation is described in 

Appendix A, these amounts translate into expenditure of R148 per capita in Matatiele, R362 per capita in Kokstad, 

and R218 per capita in the district as a whole. 

Most expenditure (80 %) in the district is under the control of the provincial health services, recorded under the 

hospital responsibility codes. About 10 % of expenditure in the district comes from a provincial subsidy, of which 85 

% goes from the Eastern Cape government to the Khotsong SANTA centre, with the remainder going to the two 

municipalities in the district. Of the remaining 10 % of district health expenditure, 6 % comes from the provincial 

regional budget and 4 % comes from NGO and Municipality own-revenue. 

About 81 % of district expenditure is on hospitals. About 10 % of expenditure is on mobile clinics, municipal fixed 

clinics and part-time district surgeon services to state patients. Of this amount, 7.7 % of expenditure is accounted 

for by mobile clinics, 2 % by municipal clinics and under 0.5 % by part-time district surgeons. 

Expenditure on personnel in Mt. Currie is at least 68 % of total recurrent expenditure. The actual figure is probably 

higher, as some expenditure classified on the FMS system under the standard line item, professional and special 

services, includes personnel expenditure. Personnel expenditure for laboratories was not separated out (and is 

quite difficult to do). Drugs and a small amount of consumables (only from municipalities, whose consumables 

could not be separated out) account for 11 % of expenditure, with the remaining 21 % containing other types of 

expenditure, a particularly large amount of which comes from other types of hospital inpatient expenditure. 

Analysis and Discussion 

Given that the indicators driving the expenditure review have been linked to various performance criteria, the study’s 

results are discussed with regard to the performance criteria of equity, allocative efficiency, technical efficiency and 

sustainability. 

1. Equity 

District expenditure per capita is R218. This expenditure is higher than shown in results from the Mt. Frere study 

performed in the previous year in a neighbouring district in the Eastern Cape (R155 – R163), but lower than 

expenditure of R249 in a district in Gauteng. 

Sub-district expenditure per capita in Matatiele (R148), is lower than expenditure per capita reported in the two 

other studies mentioned above. The discrepancy in expenditure per capita between the two sub-districts, namely 

Kokstad and Matatiele, is also far larger than between the sub-districts in the Mt. Frere study (which had a difference 

of R8, versus the difference of R214 here). While this illustrates the high inequity in the distribution of health finances 

between the Mt. Currie sub-districts, the actual figure for Matatiele is probably a little higher because expenditure on 

the cross-border population, which was included in the Matatiele sub-distirct population, did not take into account 

Eastern Cape expenditure on primary health care clinics. 

2. Allocative Efficiency 


vii


Primary health care expenditure per capita in the district is extremely low, and is estimated to be only R41 per 

person. This does not compare favourably with some estimates of R165 for the cost of a primary health care 

package. Admittedly, the estimate of R41 excludes laboratory tests, some provincially run programs and is biased 

downward due to the uncertainty surrounding the catchment population, but even with these adjustments, it is still 

likely to be lower than is adequate. 

Relative to two other studies reviewed, the indicators communicate mixed signals about the weight given to primary 

health care services in overall district health expenditure. The Mt. Frere study showed expenditure on hospitals to 

be less than 70 %, while expenditure in Mt. Currie is recorded at about 80 %. On the other hand, hospital 

expenditure per capita is also lower in Mt. Currie (R173 – R157 = R16, or 10 % lower ), but certainly not as much as 

by the difference in primary health care expenditure per capita (300% lower ). 

3. Technical Efficiency 

Financial indicators of technical efficiency include hospital expenditure per patient day equivalent, inpatient 

expenditure per patient day, and expenditure per primary health care (or outpatient) visit. 

Inpatient day expenditure and patient day equivalent expenditure are higher in Usher Memorial hospital (Kokstad) 

than in Tayler Bequest (Matatiele). This is a function of the longer average length of stay and the low usage of 

casualty services in Tayler Bequest. Inpatient day expenditure is R198 in Tayler Bequest, compared with R351 in 

Usher Memorial, where there is less of a difference in patient day equivalent (PDE) expenditure: R241 in Matatiele 

and R342 in Kokstad. The difference for PDEs is only R101 versus R168 for inpatient day expenditure. 

When compared with two other studies, all expenditure indicators, for sub-districts and the averages, are higher for 

Mt. Currie, except for inpatient day expenditure in Tayler Bequest, which is lower than in the hospitals studied in Mt. 

Frere. This highlights the inefficient usage of beds in the hospital, due to transport problems experienced by 

patients from remote areas. 

In primary health care, expenditure per visit varies greatly between different service providers within the same subdistrict, 

and between sub-districts. The average number of daily visits per primary health care professional nurse in 

Kokstad is 29, versus 26 in Matatiele. However expenditure per primary health care visit is R31 in Kokstad versus 

R24 in Matatiele. Expenditure per visit is lowest at municipality clinics (R12 – R 15.80) even though their work has a 

high curative component, followed by part-time district surgeons (R19), then by mobile clinics (R36) and outpatient 

services (R37). Expenditure between providers between sub-districts varies mostly for municipal clinics (R 8 – R12 

in Matatiele versus R 21 in Kokstad) and outpatient/casualty services (R65 in Tayler Bequest versus R32 in Usher 

Memorial). 

4. Sustainability 

The only reviewed information that related to the sustainability of hospitals was information on hospital fee 

collections. Information for other important issues for hospital sustainability, such as the ratio between capital and 

maintenance expenditure, was not reviewed. Revenue collected by hospitals was only 3.6 % of expenditure in 

1997/98. While Taylor Bequest added 36 % to their debt from the beginning of the year, Usher Memorial managed 

to reduce their cumulative debt by 4 % by the end of the year. If hospital fee retention policies are introduced, Tayler 

Bequest Hospital will need to improve its billing system, or revise its fee policies in order to improve the efficiency of 

fee collection. 


viii


Another area of funding with implications for sustainability of services in the district, is the portion of funding used by 

and coming from local authorities. Local authorities contributed just under 5 % of total district expenditure, of which 

62 % was funded by their own revenue. About 90 % of this contribution from own-revenue comes from 

environmental health services. Therefore, the local authorities rely quite heavily on subsidies from the province to 

render personal primary health care services, whereas own revenue is used more to provide environmental health 

services to the community. 

Recommendations 

1. Determine ways to decrease the length of stay at Tayler Bequest, focussing on addressing the transport 

needs of patients. Other transport needs might also exist between primary health care facilities and 

hospitals. 

2. Investigate drug usage at Tayler Bequest hospital, which appears rather low compared with usage at Usher 

Memorial. Either that, or it is recorded incorrectly. 

3. Assess the distribution of workload for primary health care. The nurses at the municipal clinic in Matatiele 

have the highest workload in the district (55 patients per nurse per day), followed by the outpatient 

department in Usher Memorial and the municipal clinic in Kokstad. While the services offered by the 

mobile clinics differ from facility based clinics, they need to be brought into a review of how the primary 

health care workload is distributed between nurses at different institutions. This sort of information will also 

be important for planning extra posts, which will require justification, and take some time to be approved. 

4. Improve the equity of distribution of resources between Kokstad and Matatiele sub-districts, with regard to 

hospital and primary health care expenditure. Kokstad sub-district currently has higher average per capita 

expenditure than Matatiele (R362 versus R148) 

5. For the 1998/99 Expenditure Review, the team should aim at doing the following, in order to improve upon 

this year’s review: 

♦ 

♦ 

♦ 

♦ 

♦ 

♦ 

Review and improve estimates of catchment population. Determine catchment populations for 

each facility and service. 

Collect certain important additional information that the this team did not have the time to collect 

for the 1996/97 review. In particular information on drugs paid for by the province, but used by the 

municipality and provincial vertical programmes, would be important. 

Collect more detailed information on which staff’s costs are on which responsibilities. 

Do cost allocations, in particular: 

♦ to allocate laboratory costs across all district services; and 

♦ to allocate provincially and regionally run primary health care services to the district. 

Assess the appropriateness of maintenance and capital expenditure, drawing up a capital and 

maintenance plan (if one does not already exist). 

Assess the improvement of the hospital billing systems. 


ix


MOUNT CURRIE DISTRICT EXPENDITURE REVIEW 

REPORT FOR THE YEAR APRIL 1997 TO MARCH 1998 

1. INTRODUCTION 

Mount Currie is a magisterial district in the province of KwaZulu-Natal. Map 1 shows the location of Mt. Currie with 

respect to the rest of the province. The boundaries of the health district coincide with those of the magisterial 

district. It falls within the Port-Shepstone health region, bordering on the Eastern Cape Province. As a result of its 

position, surrounded by the Eastern Cape and close to Lesotho, the district’s catchment population of about 247 537 

is far greater than the population of 42 310 recorded by the Census as residing in the district. 

The district health expenditure review in Mount Currie took place from February to August 1999. Before, and during 

this period, the Health Expenditure Review Task Team (HERTT), a body convened by the Initiative for Sub-District 

Support (ISDS) of the Health Systems Trust (HST ), were developing national district expenditure guidelines. 

Experiences from the Mount Currie expenditure review were fed back to the HERTT, and their developments also 

helped to shape the expenditure review. 

Other relevant processes occurring at the time of writing this report, which the reader should be aware of, is a 

National Health Accounts Project and the Data Dictionary Project. These projects are adding to the excellent work 

of the Health Information System Pilot Project (HISPP), completed last year, which developed a minimum set of 

largely non-financial, management information indicators. While the development of non-financial management 

indicators in the health sector is well underway, the development of financial management and equity indicators (i.e. 

indicators combining finance and output, activity or population information) needs further work. Thankfully, the NHA 

project and the work of teams piloting the district expenditure review guidelines will go some way to filling this gap in 

the months to come. 

Box 1 outlines the steps to be followed in a district health expenditure review, as recommended by the HERTT. The 

Mt. Currie researchers followed these steps, with the feedback from the district (step 6) adding substantively to the 

report. From here, it is up to the District Team to take forward this report’s findings in the ways suggested in steps 8 

and 9. The recommendations section will hopefully help them to complete these steps successfully. 

1. Process and participation: 

1.1. Orientate the district management team (DMT) and get the provincial level people involved. 

1.2. Identify key role players and establish a district expenditure review task team (DERTT). 

1.3. Identify what services there are in the district and who holds financial information about them. (If this is not known, this is the first part of the 

work that needs to be done before continuing.) 

1.4. Identify what indicators you will need, the relevant cost centres and what data you need to calculate the indicators. 

1.5. Data collection and compiling the information: Identify what information is required and where to get it. 

2. Organise the collection of information (who will collect what). 

2.1. Allocate tasks. 

2.2. Compile the information in tables. 

2.3. Check validity of the information. 

3. Finalise tables. 

4. Allocate costs to the cost centres, if needed. 

5. Analyse the results and make recommendations. 

6. Report back to the DMT. 

7. Revise and produce the final report. This report should highlight the next steps to be taken. 

8. The DMT studies the report and takes appropriate management decisions. 

9. The report is used as a basis for financial and service planning for the following financial years. 

Health Economics Unit and ISDS 1


Box 1: Basic Steps of A District Health Expenditure Review 

Source: Adapted from HERRT Draft District Health Expenditure Review Guidelines 

The steps in Box 1 also suggest an outline to follow when writing the report and this report is modelled accordingly, 

starting with itemising the health services offered in the health district boundary, and with determining where to find 

financial and non-financial information on them, in Section 2. 

The following section, Section 3, presents some additional background information on the population that is useful 

to people unacquainted with the area, as well as to the overall analysis of the health services expenditure and activity 

data. 

Section 4 briefly describes the indicators identified by the team, and the process of data collection. 

Section 5 presents a summation of the results for the district. For results on each of the cost units, see Addendum 3. 

Section 6 tries to bring into focus some of the more startling pictures emerging from the results. 

Section 7 suggests points to take forward for further investigation. As the district team will soon begin the 1998/99 

district health expenditure review (DHER), the final section, Section 7, includes some suggestions derived from 

experiences with conducting this expenditure review, for implementing the next district health expenditure review in 

Mt. Currie. 

Figure 1: Overview of Appendices and Addenda 

Main Report 

Appendices 

Addenda 

A. Catchment 

Population and 

Expenditure per 

capita Workings 

B. Activity, Staff and 

Expenditure 

Information 

1. Data 

presentation 

and collection 

issues 

2. Indicators 

(also on disc) 

3. Cost 

Units 

4. Reading 

the Hospital 

Cash Book 



2. UNDERSTANDING SERVICES IN MOUNT CURRIE AS ONE OF 

THE EARLY STEPS IN THE EXPENDITURE REVIEW 

The HERRT District Expenditure Review Guidelines, as represented by Box 1, in the introduction, identified the 

necessity for first understanding what services go into the district, before embarking upon the district expenditure 

review. The information below briefly describes the health services in the district, and who holds financial 

information about these services. 

Mt Currie is made up of two health sub-districts: Kokstad and Matatiele. The services offered in each sub-district 

are listed below in Figure 2. Both sub-districts have several types of services in common; they each have a district 

hospital, a mobile clinic service, a district surgeon and a municipal clinic. Each sub-district also has it own 

municipality rendering environmental health services within its boundaries and the province (from the regional 

office) rendering services between municipal areas. 

Services found in one sub-district and not in another are: a mental health clinic, a laboratory and an oral health 

service, which are only found in Kokstad. From the records we received on mental health services, the psychiatric 

clinic in Kokstad appears to offer some services in Matatiele, though fewer in number than in Kokstad. The 

Khotsong SANTA in-patient centre, or hospital, is located in Matatiele sub-district. Within the SANTA network of TB 

hospitals, it acts a regional referral centre for TB. According to a regional development report (Integrated Planning 

Services 1998), there are 7 private medical practitioner’s surgeries in Kokstad and 4 in Matatiele. 

No statistics were found on traditional medicine practices but given the rural location of the district, household 

surveys show that these services are likely to exist. A 1993 household survey 1 showed that 5 % of people consulting 

health services in rural KwaZulu-Natal consulted a traditional healer. 

Map 2, computed by the Geographic Information System (GIS) Unit at the provincial Department of Health, shows 

the location of the two major towns in the health district, as well as the number of physical structures clustered within 

each town. For presentation purposes, the places you see identified on the map are not shown in their exact 

physical location. Note, also, that the map only shows the physical buildings that offer health services and not the 

services themselves. This form of representation especially omits vertically funded services. 

1 The survey referred to was the 1993 South African Labour and Development Research Unit (SALDRU) Project for Statistics on Living 

Standards and Development. 



Figure 2: Health Services in the Mount Currie Health District 

Type of services Description Where expenditure information can 

be obtained 

Located in: 

Kokstad 

Sub- 

District 

Located in: 

Matatiele 

Sub- 

District 

(a) In-patient and outpatient 

services 

(b) Specialised Inpatient 

services 

(c) Primary health care 

services 

East Griqualand & Usher Memorial 

Hospital: authorised beds- 198, actual 

beds- 220 

Tayler Bequest Hospital: authorised beds – 

204 

Khotsong SANTA Centre – 250 beds 

(regional TB centre) 

Offered in the out-patient setting described 

above 

From FMS system in provincial 

head office (note 1) 


head office 

From SANTA office at Khotsong 


head office 

2 mobile clinic teams (note 1) From FMS system in provincial 

head office 

family planning fixed clinic in mobile clinic 

base complex 


head office 

municipal fixed clinic From municipal offices X X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

district surgeon practices: 1 in each subdistrict 


head office 

X 

X 

mental health fixed clinic: Kokstad Mental 

Health Clinic including management of clinic 

(with some services offered in Matatiele) 


head office (cannot get separated 

expenditure) 

X 

(d) Community and 

programmatic Services 

(d) Environmental 

health services 

AIDS and AIDs awareness 

AIDS fund at province for workshops etc. 

Nutrition programme 

Other provincial health promotion activities 

Tuberculosis management at regional level 

School health teams 

Oral health 

each municipality runs its own 

environmental health services 

from the regional office 

From regional office and provincial 

offices. Note that it is necessary to 

estimate expenditure on each of 

these programs as expenditure is 

not recorded separately in the 

system. See Addendum 1 for more 

on this. 

From municipal offices 

From FMS reports 

(e) Private practitioners 7 practices From practitioners themselves (if X 

the private sector is included in 

future reviews) 

4 practices As above. X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

(f) Support Services Ambulance garages From regional (Port Shepstone) 

office 

Laboratories 

From laboratory in EG & Usher 

Memorial Hospital/ also regional 

office FMS 

(g) Administration District Office From District Office: only since 

1998 

X 

X 

X 

X 

Note(1): 

Note (2): 

Mobile clinics and Transitional Local Council, or Municipality, clinics offer the following primary health care services: 

maternal and child health services; nutrition and growth monitoring; immunisations, family planning and ante-natal care; TB 

and psychiatric follow-up; minor ailments; and health education. 

Information on revenue from hospital services was obtained from the hospital monthly cashbook. For information on 

reading the cashbook, see Addendum 4. 



3. OTHER BACKGROUND INFORMATION 

3.1. The Population Growth Rate and Geographic Distribution 

According to the 1996 census the total population in Mt Currie is 44 875 and the number of households is 11 222. 

Of the 44 873, 42 310 reside in the district. The average household size is equal to the national average of 4.0 

people per household. In terms of residency, more than 94 % of the total district population usually live in KwaZulu- 

Natal. Working from available Census information, Table 1 shows the provincial growth rate for the district’s 

population at roughly 5-year intervals over the last fifteen years. 

Table 1: Overall population growth-rate 

Year Population % Population Growth Rate 

Total population (1980) 43 545 

Total population (1985) 34 973 -19.69 

Total population (1991) 41 562 18.84 



Source: Census data 1996 

According to the 1996 Census, the Mt. Currie population dropped by 19.69 % between the periods 1980 and 1985. 

There is no obvious explanation why this occurred, or whether the accuracy of the survey should be brought into 

question. Following this decline, a sharp growth of 18.84 percent occurred between the periods 1985 and 1991. 

The population growth rate was 4.84 % between the periods 1991 and 1995 and became 2.98 % between the 

periods 1995 and 1996. The final growth rate is large considering that it occurred in less than two years and when 

compared to the growth rate of the previous five-year period. 

Approximately 76.93 % of the district’s population live in the Kokstad Sub-District. The proportion of the district’s 

population living in non-urban areas is approximately 38.48 %. 

Table 2: Rural/Urban and Sub-District Distribution of the Population 

Population 

Matatiele Sub- 

District 

Kokstad Sub- 

District 

Mt. Currie 

District 

Urban Population 6 570 21 039 27 609 

Non-Urban Population 3 780 13 486 17 266 

Total Population 10 350 34 525 44 875 


The percentage of people living in urban versus non-urban areas, especially in the Matatiele Sub-District, is 

factually accurate, but deceptive when translated into use of health services. As can be seen in Map 2, Matatiele is 

surrounded on several sides by land that falls under the Eastern Cape Provincial Government. This means that the 



actual number of people living in rural areas, which naturally use the town for commercial purposes, as well as the 

health services there, is far greater. In these cases, the estimation of catchment populations is extremely important 

(see Section 3.4). 



3.2. The Population Age and Gender Distribution 

According to the 1996 census, as shown in the age groups listed in Table 3 below, more than 50 percent of the 

population are below the age of 25. Between ages 26 and 40 years, lie 23.36 % of the total district population and 

between the ages 41 and 55 years, there are only 12.42 % of the total district population. By contrast, in the 0 to 5 

years group, which only spans five years, there is 13.88 % of the total district population. The very young age profile 

of the district is important information for health service planners. 

In terms of gender, there are more females (51.73%) than males (48.27%). In all age groups except “6” and 

“unspecified” years of age, it is notable that females always form more than 50 percent of the age group. While it is 

normal for there to be a higher proportion of females than males in a given human population, there is no obvious 

explanation for the reverse occurring in the two population groups mentioned. No statistical tests were done to 

assess whether this was caused by anything other than chance. 

Table 3: Age and Gender Distribution of the Population in Mt. Currie (1996) 

Age Groups (in 

years) 

Mt. Currie Population – weighted person and percentage 

Male % Female % Total % % 

(cumulative) 

0-5 3,048 14.07 3,180 13.70 6,228 13.88 13.88 

6 596 2.75 518 2.23 1,114 2.48 16.36 

7-10 1,945 8.98 1,949 8.40 3,894 8.68 25.04 

11-15 2,336 10.79 2,418 10.42 4,754 10.59 35.63 

16-20 2,130 9.84 2,319 9.99 4,449 9.90 45.53 

21-25 2,109 9.74 2,384 10.27 4,493 10.00 55.53 

26-40 5,114 23.61 5,370 23.13 10,484 23.36 78.89 

41-55 2,681 12.38 2,894 12.47 5,575 12.42 91.31 

56-65 892 4.12 1,116 4.81 2,008 4.47 95.78 

over 65 511 2.36 825 3.55 1,336 2.98 98.76 

unspecified 296 1.37 242 1.04 538 1.2 99.96 

Total 21,658 100.00 23,215 100.00 44,873 100.00 

Source: Census 1996 

3.3. Education and Income 

About 7 % of the district’s population have their matric (final year of schooling) even though about 55 % of people in 

the district are older than 20 years. This compares unfavourably with the provincial average of 14.74 %. More than 

72.73 % of the total district population have education equal to or less than grade eleven. Most of those who have 

tertiary education are those with diplomas followed by bachelor’s degrees. As indicated above very few of them have 

postgraduate degrees such as Honours, Masters and Doctoral degrees with percentages equal to no more than 

0.04 %. 



The pattern of employment reflects the below average education levels in the district. The unemployment rate 

amongst the adult population (people 16 years and older), as recorded in the 1996 Census, is 13.80%. About 

51.52% or people are recorded as employed and the remainder are not working or unspecified. 

Table 4 records the annual income of households in Mt. Currie. Given the estimate of 4 people per household, 

average annual consumption for 45 % of the households is R1,000 or less. This figure approximates the average 

annual per capita consumption estimated for the 2 nd poorest quintile of households in South Africa (McIntyre et al. 

1998). 

Table 4: Annual Income Brackets in Mt. Currie (1996) 

Income Bracket 

No.Households % Households % Households 

(cumulative) 

None 661 5.89 5.89 

R0-1400 1,931 17.21 23.10 

R2401-6000 2,501 22.29 45.39 

R6001-12000 1,191 10.61 56.00 

R12001-18000 840 7.49 63.49 

R18001-30000 687 6.12 69.61 

R30001-42000 368 3.28 72.89 

R42001-54000 308 2.74 75.63 

R54001-72000 294 2.62 78.25 

R72001-96000 251 2.24 80.49 

R96001-132000 221 1.97 82.46 

R132001-192000 106 0.94 83.40 

R192001-360000 67 0.60 84.00 

R360001 or more 19 0.17 84.17 

Unspecified 1,754 15.63 99.80 

NA 23 0.20 100.00 

Total 11,222 100.00 


3.4. The Health District’s Catchment Population 

As mentioned above in Section 3.2, due to high rates of cross-border flows, it is not feasible to use the 1996 Census 

district population as the catchment population. The catchment population calculated in this study ranged between 

170 081 and 295 371. In discussion with the district team, they were satisfied with using the district catchment 

population estimate of 247 537, broken down as 165 975 in the Matatiele Sub-district and 81 562 in the Kokstad 

Sub-district. For more information on how this was calculated, see Appendix A. 



4. INFORMATION, INDICATORS AND THE PROCESS OF 

DATA COLLECTION 

4.1. The Information 

Many different types of information need to be collected for an expenditure review. One way to organise our thinking 

in the data collection process, was to categorise the information, as shown in Figure 3. The different types of 

information included population, services and financial information. Each of these types of information could be 

further categorised as shown below. 

Figure 3: Classifications of the Information 

POPULATION 

Needs and 

demographics of: 

• district 

population 

• service 

catchment 

Finances Balance Need and Services 

FINANCES 

• expenditure 

• revenue 

SERVICES 

• resource-related (e.g. 

number of beds, staff) 

• activity related (e.g. 

number of admissions, 

inpatient days) 

The population information describes health needs. Services information describes the application of medical 

resources and technology to meet those needs. Finances are what enable a balance to be struck between need 

and services. The financial information, when combined with need or services information, produces indicators 

that describe and measure the application of services to needs, both how efficient and how equitable the service 

provision is, relative to the population need, and relative to other ways resources could be used in the economy. 

4.2. The Indicators 

The Mt. Currie District Expenditure Review Task Team (DERTT) met near the beginning of the Expenditure Review 

to discuss which indicators would be most useful for monitoring equity, efficiency and financial sustainability in the 

district. The list developed by DERTT in March is recorded in Addendum 2, Figure 1. The final list of indicators 

developed for the district was based on this list developed by the DERTT, as well as the initial list of indicators 

developed by the national Health Expenditure Review Task Team (HERTT). Where it was possible to do so with 

extra information collected, the indicators requested by the district were calculated, in addition to the indicators 

recommended by HERTT. For the full list of indicators calculated, and their values, refer to Figure 3 of Addendum 

2. 



4.3. Data Collection and Compilation 

Most of the data collection occurred on three trips to KwaZulu-Natal. The first data collection trip to Mt. Currie 

included a two-day meeting where the researchers were introduced to the Mt. Currie District Expenditure Review 

Task Team and worked through the first few steps of the District Health Expenditure Review process (as described 

in Box 1, Section 1). Their activities included introducing members of the DERTT to what would be covered by the 

district expenditure review, working through exercises practising the interpretation of indicators, choosing relevant 

indicators and identifying sources of information. The remaining two-days were spent collecting information. One 

researcher made the second trip to KwaZulu-Natal, and collected information from the provincial head office over a 

period of two days. On the third and final trip , two researchers visited the KwaZulu-Natal health department head 

offices in Natalia and services in Mt. Currie, where they collected the outstanding service information. While the 

researchers were writing the report, they also kept in contact with the DERTT to ask them for clarification of data, 

where necessary. 

Box 2: Classifications of Different Types of Services 

♦ 

♦ 

♦ 

♦ 

Community services 

♦ emergency medical transport 

♦ municipal env. Health 

♦ provincial env. Health 

Clinics and district surgeon (district medical officer) services 

(also called personal health care services) 

♦ provincial mobiles 

♦ municipal clinics 

♦ district surgeons 

Hospital services 

♦ district hospital (provincial) auxiliary 

♦ district hospital (provincial) outpatients 

♦ district hospital (provincial) inpatients 

♦ SANTA inpatients 

District support services 

♦ laboratory 

Population information was collected from the 1996 census housed at the research unit (SALDRU) at the University 

of Cape Town. Maps were collected from the Geographic Information System (GIS) of the Provincial Health 

Department of KwaZulu-Natal (KZN) and were drawn up by Shannon Hogan of the KZN GIS Unit. 

Service activity and resource-related information was obtained from a variety of sources. The most important 

information was collected from the following people and at the following places: 

♦ The Health Informatics Bulletin (KwaZulu-Natal Province 1998) 

♦ number of authorised beds 

♦ bed occupancy rates 

♦ length of stay 

♦ outpatient headcounts; 



♦ 

♦ 

♦ 

♦ 

♦ 

♦ 

♦ 

♦ 

♦ 

♦ 

♦ 

Provincial Health Department, Natalia 

♦ PERSAL information: the number of provincial staff falling under the two hospital complex’s 

budgets - staff by category for each sub-district 

♦ district surgeons (district medical officers): no. of scripts and no. of patients seen and breakdown 

of activities; 

Theatres nurses at both (provincial) district hospitals 

♦ number of theatre cases (major versus minor) – per month for 12 months 

♦ number of theatre hours – per month for 12 months; 

Outpatient admissions clerks at both district hospitals 

♦ number of inpatient admissions, by place of residence 

♦ number of outpatient headcounts (by place of origin, only for Matatiele); 

Chief nurse at Matatiele municipality (local authority) clinic (monthly patient statistics) 

♦ headcounts – per month for 12 months 

♦ number of clinic staff; 

Head office of Kokstad municipality 

♦ number of clinic staff 

♦ headcounts; 

Mobile clinic (Kokstad) 

♦ headcounts 

♦ kms travelled; 

Senior radiologist , X-ray Dept., Tayler Bequest Hospital (Matatiele) 

♦ number of X-rays, by in-patient and outpatient; 

SAIMR laboratory based at Usher Memorial (EG& Usher Mem) Hospital 

♦ number of tests 

♦ number of test units; 

Pharmacists at hospital pharmaceutical depot 

♦ number of prescriptions 

♦ number of items per script; 

Administration of each hospital 

♦ breakdown of staff at mobile clinic (mobile clinic complex) and 

♦ in outpatient departments; and 

Mental health clinic, Kokstad 

♦ number of staff 

♦ number of visit (headcounts) (obtained data for 7 months). 



Financial information that related to hospital revenue was obtained from the hospital monthly cash book. For more 

information on the hospital cash books, see Addendum 4. Information on municipal clinic and environmental health 

revenue was obtained from the municipality head offices. 

Figure 4 summarises the way in which expenditure data was collected for each of the different types of health 

services in Mt. Currie, which were grouped as described in Box 2. While reading like instructions, the methods 

described in Figure 4 were the methods followed by the researchers. They are presented in this format so that they 

can also serve as an instruction sheet for future district expenditure reviews. 

Once the non-financial and financial information was collected, the researchers compiled the information onto 

Excel spreadsheets. An electronic version of the indictors and some expenditure tables compiled from the FMS 

system reports, was handed to the DERTT on submission of this report. 



Figure 4: Sources of Expenditure Data and Methods of Estimation 

Expenditure, by type of service 

Source of expenditure information and method of estimation 


- emergency medical transport Source: From information compiled by Beth Engelbrecht from FMS on 

AEMS for region 

Method: Divide regional AEMS expenditure by 3 (three districts) and 

allocate according to populations (adjusted for cross-border flows) per subdistrict 

- municipal env. Health Source: From municipal ledgers; Matatiele: Department 50, Section 40; 

Kokstad: “health services” 

Method: Take total expenditure for environmental health; for Kokstad, this 

includes an administrative expenditure line item of R8,000.00 

- provincial env. Health Source: From information compiled by Beth, extracted for Mt. Currie district 

from regional budget 

Method: Divide Mt. Currie estimate in 2 (because expenditure represents 

services in 3 districts), then apportion between sub-districts according to the 

population, as was done for emergency medical services 

Clinics and district surgeon (district medical 

officer) services 

- provincial mobiles Source: From FMS report X112, for all responsibilities and programmes, 

down to level of minor item 

Method: Take total for clinics expenditure (capital and current); Note: this 

includes a fixed component, a fixed clinic based in the mobile clinic complex 

- municipal clinics Source: From municipal ledgers; Matatiele: Department 50, Section 42 

(“primary health care”); Kokstad: “clinic”; and from Report submitted by 

Kokstad TLC to the KZN province 

Method: Take total expenditure for clinic; for Kokstad, this includes an 

administrative expenditure line item (R5,000.00 for clinic) 

- district surgeons Source: From FMS system, provincial head office 

Method: Information on payments to district surgeons for units of service 

(includes medico-legal work), and for drugs (own and provided by state); add 

two together 


- district hospital (provincial) auxiliary Source: From FMS system report, no. X112. There are two reports: one for 

East Griqualand and Usher Memorial; another for Tayler Bequest Hospital. 

The first expenditure breakdown in the report relates to auxiliary and support 

services 

Method: Take total expenditure. Included in the report for Kokstad’s 

expenditure statement under auxiliary services are laundry and management 

of buildings; for Matatiele, there are no laundry entries 

- district hospital (provincial) outpatients Source: From FMS system report, no. X112 

Method: Include all outpatient expenditure 

- district hospital (provincial) inpatients Source: From FMS system report, no. X112 

Method: Include all inpatient expenditure 

- SANTA inpatients Method: Received Income Statement from SANTA; include total 

expenditure, including 7.5 % administration fees paid to SANTA head office 

District support services 

- laboratory Source: From laboratory based at East Griqualand and Usher Memorial 

Hospital, Kokstad 

Method: Include all laboratory expenditure for the district. Divide equally 

between the sub-districts 



4.4. Limitations of the Data Collected 

Problems experienced with data collection were evaluated using the following criteria, identified in the Department 

of Health’s District Health Information System Guidelines (Department of Health, February 1998), namely: face 

validity; inconsistencies; gaps; and calculations. A potential sources of error for all data recorded here was that data 

were inputted manually from physical records. To minimise errors in this work, work done by one researcher was 

checked by another researcher, using the original records. 

(a) Non-financial Information 

The greatest difficulty encountered with non-financial information was obtaining information on headcounts for 

primary health care services. The KZN Informatics Bulletin uses the term “attendances”, which were confirmed to 

describe cases, rather than headcounts. The Informatics Bulletin contained attendances information for 

provincially run mobile clinics and municipality clinics. The Informatics Department has compiled a new form, 

which will be used to collect headcount information from 1998/99 onwards. 

In order to obtain headcounts information, it was necessary to calculate these statistics from original clinic records. 

The instructions for calculating headcounts at clinics from clinic records, was described by the sister-in-charge at 

Matatiele municipal clinic as follows: add together the totals from child health, minor ailments and ante-natal care. 

Using this method, headcounts for the year 1997/98 were 61,677 in Matatiele municipal clinic rather than 

attendances of 82,055, as recorded in KZN Informatics Bulletin. This method was also used for the Kokstad 

municipal clinic records. 

Another problem noted with the primary health care records was that they contained numerous calculation errors. A 

further problem experienced with the documents used for service activity information were gaps for certain months. 

The municipality records had 1 month missing in the case of Matatiele and 2 months missing in the case of 

Kokstad. For the mobile clinics, no records were obtained for Matatiele mobile clinics, while information for 7 

months was obtained for Kokstad mobile clinics. Face validity of several records was also poor. For example, on 

some records the incorrect town name was filled in at the top of the page. 

What remains unclear after this expenditure review, is the inter-relationship between various types of primary health 

care services. For example, on the psychiatric services records, there was mention of services given at the hospital 

and on mobile clinics. It is therefore unclear whether the workload reported on in this report reflects the actual 

situation, in particular for psychiatric services. Records obtained from the psychiatric clinic were difficult to interpret 

and seemed to be in need of improvement. On the other hand, the researchers did not spend much time at the 

clinic and perhaps more time there might have facilitated better understanding of these records. 

However, all records could be improved by standardising their data capture forms as much as possible, ensuring 

that there is a clear category for headcounts, easily understood by the nurses and anyone reading the form, and by 

ensuring that the calculations are correct (e.g., by getting someone else to cross-check the calculations). 

(b) Financial Information 

While there were fewer calculation problems with expenditure information from the FMS, a major problem was the 

fact that the data did not include breakdowns to clinics as cost centres. Once again, this problem should be 

remedied for the 1998/99 year, as separate responsibilities were recently created for clinics on the FMS system. 



Breakdowns of expenditure on vertical programs was also difficult to obtain, even from people running these 

programs. As the Mt. Currie services are not recorded separate in vertical programs, it is only possible to make 

estimates. 

One abnormally with the FMS reports was the inclusion of laundry services as a separate objective in the case of 

Tayler Bequest, but not for Usher Memorial. Of the non-provincial information, the greatest difficulty was trying to 

convert municipality clinic and NGO expenditure line items into FMS line items. 



5. RESULTS OF THE FIRST MT. CURRIE EXPENDITURE REVIEW 

Two processes shaped the format of the results presented here. The first was the discussion the researchers had 

with the Mt. Currie district team, to find out which format would be most useful and readable for the team. In this 

discussion, the team indicated that they would like the indicators presented by cost centres. The second process, 

occurring simultaneously, was the development of the District Expenditure Review Guidelines by the Health 

Expenditure Review Task Team (HERTT). 

While the feedback from the Mt. Currie discussion on a cost centre focus informed HERRT, HERTT was also 

receiving input from a variety of other sources. HERTT short-listed several indicators which they recommended as 

a minimum information set, and further proceeded to discuss these indicators in the light of an analytical framework 

which identified equity, allocative and technical efficiency and financial sustainability as the key criteria against 

which performance should be measured. The indicators listed in Addendum 2, Figure 3, conform to the HERTT 

guidelines for a basic district expenditure review, but they also include extra information, which was collected for Mt. 

Currie where it was available and feasible to do so. They are listed by cost-centre as requested by the DERTT. 

The Mt. Currie Team also suggested using the expenditure review to estimate a health budget for the district, and 

then making plans for the transfer of this budget from the provincial or regional government to the district. Estimating 

the district’s budget is complicated, and the district team will need to do more work to refine the information 

presented here but certainly these results make a start in this direction. Addendum 1 lists a number of services not 

costed in this review, which the team should review in the next expenditure review. Consequently, the greatest 

potential use of the information presented here is to highlight areas of inefficiency and inequity in service delivery. 

Using these markers, the team can hopefully improve the planning and monitoring of services delivered to the 

district. 

Bearing the criteria of equity, efficiency (allocative and technical) and financial sustainability in mind, this section 

presents the information for the whole Mt. Currie district. Box 3 shows the various cost centres and cost units 

identified by the DERTT. In order to keep the body of this report to a reasonable length, it was necessary to leave 

cost units 6 to 8 for discussion in Addendum 3. This section therefore covers cost centres 1 to 5 in detail. 

Box 3: 

Cost Centres for Mt. Currie 

Cost Centres 

1. The district as a whole: for which district indicators and sub-district indicators can be 

calculated; 

2. Hospitals as a whole 

3. Out-patient hospital services 

4. In-patient hospital services 

5. Clinics (mobile and fixed) and district surgeon services 

Cost Units 

1. Theatre services 

2. Radiology services (X-rays only) 

3. Laboratory services 



Table 5: District Health Account for Mt. Currie: showing the flow of expenditure (from sources to uses) 2 , Rands (1997/98) 

Provincial - regional 

Provincial 

hospital 

responsibility 

Provincial 

subsidy 

Municipality own 

revenue 

NGO own revenue User fees Total 

Percentages to 

providers 

Community services 2,173,648 0 70,927 1,430,134 0 16,532 3,691,241 6.83% 

- emergency medical transport 2,086,522 0 0 0 0 0 2,086,522 3.86% 

- municipal env. Health 0 0 70,927 1,430,134 0 16,532 1,517,593 2.81% 

- provincial env. Health 87,126 0 0 0 0 0 87,126 0.16% 

Clinics and district surgeons 253,090 4,184,598 889,921 160,694 - 21,288 5,509,591 10.19% 

- provincial mobiles 0 4,184,598 0 0 0 0 4,184,598 7.74% 

- municipal clinics 0 0 889,921 160,694 0 21,288 1,071,903 1.98% 

- district surgeons 253,090 0 0 0 0 0 253,090 0.47% 

Hospital services 0 38,952,671 4,691,468 - 299,562 - 43,943,701 81.29% 

- district hospital (provincial) maintenance 0 421,977 0 0 0 0 421,977 0.78% 

- district hospital (provincial) administration 0 6,284,522 0 0 0 0 6,284,522 11.63% 

- district hospital (provincial) outpatients 0 2,221,733 0 0 0 0 2,221,733 4.11% 

- district hospital (provincial) inpatients 0 30,024,439 0 0 0 0 30,024,439 55.54% 

- SANTA inpatients 0 0 4,691,468 0 299,562 0 4,991,030 9.23% 

District technical support services 909,998 0 0 0 0 0 909,998 1.68% 

- laboratory 909,998 0 0 0 0 0 909,998 1.68% 

Adjustments from previous year (provincial) 0 1,828 0 0 0 0 1,784 0.00% 

Total from various sources 3,336,736 43,139,097 5,652,316 1,590,828 299,562 37,820 54,056,359 100.00% 

Percentages from Sources 6.17% 79.80% 10.46% 2.94% 0.55% 0.07% 100.00% 

Source: various, see Section 4 

2 Ideally, a health account should show capital and recurrent expenditure separately. For this breakdown, by sub-district, see Appendix B, Table 3. 



5.1. Sources and Uses of Finances 

Table 5 shows the flow of funds from the various sources in the district, to different types of providers. The totals row 

shows a breakdown of finances from various sources, while the totals column shows a breakdown into expenditure on 

different types of providers. 

District health expenditure in Mt. Currie was approximately R54 million in the year 1997/98, with about 80 % of district 

expenditure in the hands of the hospital system. Just less than 17 % of total district expenditure came directly from the 

province’s or region’s budget, rather than from the hospital budget. While municipal own-revenue only accounted for 

3 % of overall district health expenditure, it did play a significant role in environmental health expenditure, where it 

accounted for 89 % of total municipality and provincial expenditure on environmental health. The Eastern Cape 

Government funds most of SANTA’s expenditure (their contribution to expenditure in Mt. Currie), which is 9 % of total 

district expenditure. 

Table 6 shows the breakdown between expenditure on different types of services. The percentage of expenditure on 

personal primary health care services (i.e., clinic and district surgeon services) is only 10 % of total district expenditure 

in Mt. Currie. Total primary health care expenditure (environmental health, ambulance, clinics and district surgeon 

services) was 17 % of expenditure. General inpatient services absorb about 56 % of total district expenditure. 

Tuberculosis inpatient facilities, which are funded by the Eastern Cape Provincial Health Department, absorbed 9 % 

of expenditure. If TB care is excluded, general inpatient hospital services absorb 61 %, and personal primary health 

care (i.e., clinics and district surgeon services) absorb 11 % of the total of R 49,065,329. 

Table 6: Percentage Expenditure at Different Facilities/Services (1997/98) 

Matatiele Kokstad Total 

Community services 6.0% 7.5% 6.8% 

Clinics and district surgeon (medical officer) services 10.8% 9.7% 10.2% 

Hospital administration 11.1% 12.0% 11.6% 

Hospital maintenance 0.87% 0.70% 0.78% 

Hospital outpatient services 2.3% 5.6% 4.1% 

General inpatient services 56.9% 54.4% 55.5% 

TB inpatient services 10.2% 8.4% 9.2% 

Laboratory 1.9% 1.5% 1.7% 

Adjustments from previous year (provincial) 0.0% 0.0% 0.0% 

Total 3 100.0% 100.0% 100.0% 

Source: Table 5 

Hospital administration was recorded as a separate objective under each hospital responsibility in the FSM system. 

Some examples of expenditure included under “hospital administration” are salaries of clerical staff, postage, 

subsistence, travel allowances, post boxes, etc. This survey did not uncover which staff were located to which 

objectives and how it was defined, so its uncertain if the objective accurately reflects administration costs. Finance 

staff indicated that the exercise of allocating staff to the appropriate budgets was underway, but not yet fully completed, 

and would not have been in place in 1997/98. It is therefore possible, for example, that some staff who are only partly 

involved in administration are included under administration, and vice-versa. Therefore, the expenditure proportions 

presented in Table 6 need to be evaluated in this context. 

The only type of provider expenditure that varied substantially between sub-districts was expenditure on outpatient 

services. One reason for this might have been the misclassification of expenditure on medicines as there was no 

medicines line item under the outpatient objective in the FMS report. While the number of items dispensed to 

outpatients versus inpatients was known (14,174 to 7,735 (excluding take home drugs (TTOs) of 8,038)), with no price 

information, it was not possible to allocate medicine expenditure between the cost centres. 

3 Total comes to 100.02, 99.8 and 99.88%, respectively, due to rounding errors. 



5.2. Percentage of total expenditure on different line items 

(a) Standard Line Items 

Standard line item expenditure from the FMS system, are shown below in Table 7 and Figures 5a and 5b, for the 

hospital responsibility in each sub-district. The hospital responsibility includes all hospital expenditure and 

expenditure on mobile clinics (as shown in Table 5). The most striking aspect of the line item breakdown is the 

difference between the proportion of spending on stores and livestock in Tayler Bequest, versus Usher Memorial. 

Tayler Bequest reported only 16 % of expenditure in this category, versus 27 % in Usher Memorial. The 

categorisation of laundry expenditure might explain this to some extent. Normally, laundry expenditure is recorded 

under Stores and livestock under the inpatients objective, but for some reason, it has its own objective in the Tayler 

Bequest FMS report. Equipment and land and building expenditure is small in both areas, but smaller in Tayler 

Bequest. Personnel expenditure is a higher in Usher Memorial, but a higher proportion of expenditure is spent on 

personnel in Tayler Bequest. 

Table 7: Standard Line Item Expenditure by Sub-District Responsibility (excludes capital 

Expenditure categories 

maintenance expenditure) (1997/98) 

Matatiele: Tayler Bequest 


(R) 

Kokstad: Usher Mem. 


(R) 

Personnel expenditure 13,475,907 14,414,238 

Administrative expenditure 387,430 681,735 

Stores and livestock 2,909,151 5,979,639 

Equipment 485,808 20,725 

Land and buildings 61,020 37,267 

Professional and specialist services 332,524 453,614 

Miscellaneous expenditure 196,785 199,148 

Adjustments 44 1,784 

Laundry - own cost centre in Taylor Beq 612,857 - 

Total (added) 18,461,526 21,788,150 

Source: FMS report X112 

Figure 5(a): Tayler Bequest Hospital Responsibility Figure 5 (b): Usher Memorial Hospital Responsibility 

1.1% 3.3% 

1.8% 

3.0% 

15.8% 

Personnel expenditure 

Administrative expenditure 

Stores and livestock 

0.3% 

27.4% 

2.1% 

0.9% 


Administrative 

expenditure 


2.1% 

73.0% 

Equipt and land and 

buildings 

Professional and special 

services 

Miscellaneous expenditure 

Laundry 

3.1% 

66.2% 

Equipt and land and 

buildings 

Professional and special 

services 

Miscellaneous 


Source: Table 7 Source: Table 7 



(b) Key District Expenditure Items 

The items presented in Table 8 and Figure 6 below are derived from a set of key items identified by the HERTT for 

district health expenditure reviews. Since the development of this table, some changes have been made to the 

HERTT key items, but there was insufficient time to incorporate these changes in this report. The draft guidelines 

indicated that expenditure on drugs, vaccines and personnel, should be separated out, for all services, at very least. In 

addition to these categories, the following categories from the FMS, namely: other medical supplies, medical gas and 

equipment (recurrent), were also separated out. to see whether they would produce any interesting analyses. 

Municipal computer reports obtained, did not show a breakdown between drugs and consumables, and for this 

reason, their expenditure is reported on a separate line in Table 8. 

Table 8: District and Sub-district Line Item Expenditure, Rands (1997/98) 

Line Item Matatiele (Rands) Kokstad (Rands) Matatiele 

(%) 

Kokstad 

(%) 

Personnel 16,984,475 17,998,930 69.31% 60.91% 

Medicines and vaccines 858,015 2,213,652 3.50% 7.49% 

Med. 4 (LA clinics) and other medical consumables (all) 381,050 880,942 1.55% 2.98% 

Medical gas 185,667 414,426 0.76% 1.40% 

Equipment 504,128 22,554 2.06% 0.08% 

Other expenditure 4,490,973 6,094,831 18.33% 20.62% 

Capital expenditure 1,100,705 1,926,011 4.49% 6.52% 

Total 24,505,013 29,551,346 100.00% 100.00% 

Source: see Appendix B, Table 2 

It is interesting to analyse whether the key line item breakdown tells us anything different from the hospital responsibility 

standard line item breakdown. The main advantages of this format seem to be that it shows expenditure for the district 

as a whole and that it separates out drugs. Drug expenditure is between 7.5 % and 10.5 % of total district expenditure. 

Personnel expenditure tells a similar story as before, for the whole sub-district. As a sub-district, Matatiele spends a 

higher proportion on personnel than Kokstad. The difference between proportions in Kokstad and Matatiele is even 

higher than in the standard line item comparison, indicating that the other services in the sub-district are reinforcing 

this trend. 

Figure 6: Key Line Item Recurrent Expenditure in Mt. Currie (1997/98) 

4 See section 5.7. for more information on medicines purchased by the province, for the LA clinics. These estimates were not 

included in the expenditure review. 



Personnel 

6% 

2% 

1% 

Medicines and vaccines 

1% 

Med. (LA clinics) and other 

20% 

medical consumables (all) 

Medical gas 

64% 

6% 

Equipment 

Other expenditure 

Capital expenditure 


5.3. Workload Indicators 

Two indicators for workload reviewed were professional primary health care nurses per 10 000 population and the 

number of visits per professional primary health care nurse. Table 9 shows both of these indicators for each of the 

sub-districts, and for the district as a whole. The overall number of nurses per population is almost half internationally 

accepted levels of 3 per 10,000 population. However, at a sub-district level, there is also an inequitable distribution of 

nurses. The number of nurses per 10 000 population in Matatiele is less than half of that in Kokstad, which would 

indicate a potentially much larger workload for staff in the Matatiele Sub-district than in Kokstad. 

Table 9: 

The Distribution of Primary Health Care Professional Nurses 

in the Mt. Currie Sub-districts (1997/98) 

Nurses per 10 000 

Population 

PHC Visits per 

Professional Nurse per 

Day (including hospital 

outpatients) 

Matatiele 1.33 25.67 

Kokstad 2.57 29.27 

Mt. Currie (average) 1.74 27.43 

Source: Appendix B and Addendum 2 

The number of primary health care visits per professional nurse per day also speaks, though less dramatically, of a 

higher workload for primary health care nurses in the Kokstad Sub-district. Overall, the number of visits per 

professional nurse per day is lower than internationally accepted levels of 35 visits per day. It is unclear why this 

should be the case, given that the primary health care nurses per 10 000 is lower higher than internationally accepted 

standards. One explanation is that the time required for travel between visiting points for mobile clinics reduces the 

number of visits they contribute to the total. Clinic visits per professional nurse should therefore be evaluated against 

an adjusted norm when including mobile clinic visits, or mobile visits should be weighted differently. A factor 



complicating weighting mobile visits for Mt. Currie is that the data consolidated fixed clinic and visiting point visits, and 

it was not possible to separate the two. 

5.4. Revenue Collected by the District Hospitals 

Apart from sources of financing described in Table 5, Table 10 shows other funds which are collected by the district 

and are currently passed on to the National Treasury. The main revenue recorded below comes from the following 

sources: fees from other government departments, workmen’s compensation victims, fees from medical scheme 

patients or private patients, fees from hospital patients and smaller miscellaneous fees from private vets (for X-rays) or 

doctors. 

Table 10: Revenue Collected in the District (Rands) (1997/98) 

Tayler Bequest Usher Memorial Mt. Currie Total 

Total Expenditure 24,505,013 29,551,346 54,056,359 

Total hospital fees collected in the year (including cash receipts 

from hospital patients (H1, H2 and H3) and accounts payable, 

paid by medical schemes and other patients with 

accounts,e.g.,correctional services, police) 

508,174 1,441,294 1,949,468 

Total hospital fees owing at the beginning of year 327,104 1,027,713 1,354,818 

Total hospital fees owing at end of year 444,287 984,487 1,428,774 

Percentage increase or decrease in amount owing + 36 % - 4 % + 5 % 

Source: Appendix B 

Fee revenue was R1,949,468, or 3. 6 % of district expenditure in 1997/98. Unpaid accounts showed a net increase of 

1 % over the year, but decreased in Kokstad by 11 % and increased in Matatiele by 11 %. Of the two hospitals, Usher 

Memorial, in the Kokstad sub-district, collects almost three times the amount in fee revenue than does Tayler Bequest 

Hospital. A breakdown of accounts owing at the end of the year show that 33.7 % of outstanding debt lay with medical 

scheme and other private patients; 27.9 % with workmens compensation patients and 25 % with statutory cases 

(police and prisons). The remainder was handed over to attorneys for collection. 

5.5. Expenditure Per Capita 

Total recurrent expenditure in the district was about R 51 million, 95 % of total district health expenditure in 1997/98. 

Recurrent expenditure as a proportion of total expenditure was 2 % higher in Matatiele than in Kokstad. 

Table 11: Total Expenditure in Mt. Currie and the Health Sub-districts, Rands (1997/98) 

Type of Expenditure Matatiele Kokstad Total Proportion of Total 

Expenditure 

Capital Expenditure 1,100,705 1,926,011 3,026,716 5.60% 

Recurrent Expenditure 23,404,308 27,625,335 51,029,643 94.40% 

Total Expenditure 24,505,013 29,551,346 54,056,359 100.00% 

Source: see Appendix B, Table 3 

Dividing expenditure by population gives expenditure per capita. Nevertheless, there are problems with this indicator. 

When catchment populations are not well defined, and where, as in the case of Mt. Currie, cross-border flows are 



large, it is tricky to develop an accurate and meaningful indicator. In addition, the 1996 Census database, from which 

these estimations were derived, has not yet been cleaned. The reader must bear these limitations in mind when 

interpreting expenditure per capita. 

Table 12: Expenditure per Capita, Rands (1997/98) 

Capital Expenditure 

per capita 

Recurrent 


capita 

Total Expenditure 

per capita 

Matatiele R 7 R 141 R 148 

Kokstad R 24 R 339 R 362 

Mt. Currie District R 12 R 206 R 218 

Source: Appendix A, Table 3 

The indicator, expenditure per capita, can be calculated using several variations of expenditure, namely, recurrent 

expenditure, capital expenditure and total expenditure. Table 11, showed these three variants of expenditure for 

Matatiele, Kokstad and the whole Mt. Currie health district. Table 12 shows expenditure per capita, using capital, 

recurrent and total expenditure. Both recurrent and capital expenditure per capita are greater in Kokstad than in 

Matatiele. Total expenditure per capita is 2.5 times greater in Kokstad than in Matatiele Sub-district. This will be 

discussed further in the analysis section. 



5.6. Hospitals in the District 

(a) Hospitals as a Group 

There are three hospitals in the Mt. Currie district. Their bed and staff complement are described in Table 13 below. 

Of these hospitals, only the Usher Memorial hospital sees more KwaZulu-Natal than Eastern Cape patients. About 95 

% of inpatients at the SANTA centre and at Tayler Bequest hospital are recorded as coming from the Eastern Cape. 

Table 13: Description of Hospitals in Mt Currie (1997/98) 

Hospitals Beds Staff Other 

Tayler Bequest (Matatiele) 200 255 no full-time doctors 

East Griqualand and Usher Memorial (Kokstad) 220 250 6 full-time doctors 

Khotsong SANTA Centre 250 73 Inpatients department only 

Source: see Appendix B 

Tayler Bequest hospital sees high numbers of Eastern Cape patients. This possibly accounts for the longer average 

hospital stay at Tayler Bequest, relative to Usher Memorial, as patients presenting at Tayler Bequest hospital are 

reported to stay longer because of transport problems. 

Expenditure per patient day equivalent (PDE) is 42 % higher in Usher Memorial than in Tayler Bequest Hospital. The 

recurrent expenditure per PDE differential is slightly less, at 38 %, because greater capital expenditure in Usher 

Memorial as a proportion of total expenditure. As SANTA is rendering a different type of inpatient service, its patient 

day equivalent rates are not comparable to those of the other two hospitals. 

Table 14: Hospital Expenditure per PDE (1997/98) 

Tayler Bequest Usher 

Memorial 

Total Provincial 

Hospitals 

SANTA – 

specialised TB 

Inpatient admissions 10,792 10,511 21,303 2,321 

Inpatient days per admission 6 4 5 31 

Hospital patient day equivalents 72,310 62,933 135,243 71,014 

Total hospital expenditure 17,436,017 21,516,654 38,952,671 4,991,030 

Expenditure per patient day equivalent R 241 R 342 R 288 R 70 

Recurrent hospital expenditure 16,374,445 19,688,805 36,063,250 4,991,030 

Recurrent expenditure per patient day equivalent R 226 R 313 R 267 R 70 

Personnel expenditure 12,429,648 12,808,982 25,238,630 2,858,114 

Personnel expenditure per in-patient day equivalent R 172 R 204 R 187 R 40 

Source: see Appendix A and B, Addendum 2 



(b) Hospital Inpatient Services 

Expenditure per inpatient day paints a similar picture to total hospital expenditure per PDE (Table 15). The large 

difference between expenditure per inpatient day in Matatiele and Kokstad, could be explained by the long average 

length of stay of patients presenting at the Tayler Bequest Hospital. According to interviews with nurses in Tayler 

Bequest, there are a high number of patients travelling from rural areas and staying in the hospital beyond the 

necessary period of convalescence, which might be at the root of this difference. Ignoring the average length of stay, 

inpatient expenditure per patient is still higher in Kokstad than in Matatiele. Given the low per capita expenditure in the 

district as a whole, this is probably an indication that Tayler Bequest is under-resourced. Bed occupancy rates of 93 

% in Tayler Bequest also far exceed those in Usher Memorial (63 %) (Department of Health KwaZulu-Natal 1998). 

Table 15: Inpatient Stay and Expenditure (1997/98) 

Matatiele Kokstad Total Provincial 

Hospitals 

SANTA – 

specialised TB 

In-patient expenditure R 13,936,933 R 16,087,506 R 30,024,439 R 4,991,030 

In-patient days 67,254 45,848 113,102 71,014 

Number of in-patients 10,792 10,511 21,303 2,231 

In-patient expenditure per in-patient day R 207 R 351 R 265 R 70 

In-patient expenditure per in-patient R 1,291 R 1,531 R 1,409 R 2,237 

Recurrent in-patient expenditure per inpatient 

R13,921,180 R 15,802,123 R 29,723,303 R4,991,030 

day 

Recurrent in-patient expenditure per capita R 207 R 345 R 263 R 70 


(c) 

Hospital Out-patient Services 

Outpatient department expenditure per person treated in Matatiele is more than double the rate in Kokstad. However, 

both the service activity information, and the expenditure information raise questions as to the validity and meaning of 

these indicators. The first question is whether the data given on headcounts is correct. On the one extreme, 

professional nurses in Tayler Bequest casualty department see 8 people per day, while those in Usher Memorial 

outpatient department see 57 patients per day. If the total nursing complement (including staff nurses and nursing 

assistants) is taken as the denominator, then the rate drops but there is still a four-fold difference between the numbers 

seen in Tayler Bequest, versus Usher Memorial. 

Table 16: Out-patient Visits and Expenditure (1997/98) 

Matatiele Kokstad Total Provincial 

Hospitals 

Out-patient expenditure R 561,102 R 1,660,631 R 2,221,733 

Out-patient cases (different reasons for 

15,168 239,208 254,376 

attendance on the same day) 

Out-patient visits (head-count) 8,577 51,255 59,832 

Expenditure per visit R 65 R 32 R 37 

Expenditure per case R 37.00 R 6.94 R 8.73 

Personnel expenditure R 559,190 R 1,064,856 R 1,624,046 

Personnel expenditure as % of total 100% 64% 73% 



Source: Appendix A and B, Addendum 2 



While Tayler Bequest is reported to run more of a casualty service and therefore would see more serious patients than 

Usher Memorial, and the lower case to visit ratio in Tayler Bequest might, if fact, be indicating this, the number of 

patients seen is still very low. On the expenditure side, the data also raises several questions: the only item recorded in 

the Financial Management System for the Matatiele out-patient department is personnel expenditure. This indicates 

that something is happening in Matatiele, that is not fully explained by the expenditure indicators. 

5.7. Clinics and District Surgeon Services 

(a) Provincial mobile and fixed clinics 

Looking at mobile service expenditure between sub-districts shows that they spend comparable amounts per patient 

seen (Table 17), although staff represents a marginally higher proportion of expenditure per capita in Matatiele than in 

Kokstad. This indicator could be speaking to the problem of an undersupply of medicines in Matatiele, the point 

raised in the line item discussion in Section 5.2. 

Table 17: Provincial Clinic Activity and Expenditure (1997/98) 


Mobile complex expenditure R 2,087,038 R 2,097,560 R 4,184,598 

Visits - mobile teams 56,808 59,121 115,929 

Expenditure per patient 5 R 37 R 35 R 36 

Personnel expenditure R 1,647,441 R 1,605,257 R 3,252,698 

Personnel expenditure per visit R 29 R 27 R 28 

Personnel expenditure as percentage of total expenditure 79% 77% 78% 


(b) Local authority clinics 

Municipal expenditure per visit is very low, although the difference between municipalities is large. While one might 

expect facility visits to be cheaper than site visits made by mobile clinics, one would have expected comparability 

between municipal clinics. 

One possible reason for the large difference between municipality clinics might be that they see different types of 

cases. However, anecdotal evidence seems to suggest that Matatiele municipal clinic has a high workload. This 

might be explained by the fact that there is a smaller hospital outpatient department in Matatiele, with the result that 

many patients go to the clinic instead. In an interview, the chief nurse at the Matatiele municipal clinic indicated that 

they were extremely busy, saying that each nurse was currently seeing about 60 patients a day. 

5 Although it was possible to separate the visits to the mobile clinics from visits to the fixed clinic, it was not possible to draft separate 

information for the different services. Expenditure per visit therefore includes visits to the fixed clinic (see Table 9). 



Table 18: Municipal Clinic Activity and Expenditure 6 (1997/98) 


Expenditure R 470,293 R 601,610 R 1,071,903 

Cases 71,016 73,908 144,924 

Headcount 61,677 27,925 89,602 

Expenditure per headcount R 8 R 21 R 12 


Additional Data on LA Clinics 

Subsequent to the compilation of the main data set for this year’s district health review, some additional data was 

obtained for medicines purchased by the provinces, but used by the local authority clinics in Mt. Currie. Medicine 

expenditure by the two local authorities in 1997/98 is shown in the table below. 

Table 19: Provincial Medicines Used at LA Clinics, Mt Currie 

Kokstad Matatiele Total 

April 97 – March 98 R 137,499.76 R 264,391.28 R 401,891.04 

April 98 – March 99 R 296,940.18 R 274,818.54 R 571,758.72 

The implications of adding this expenditure to total municipal expenditure on primary health care would be to 

increase expenditure per head in Matatiele from R8 to R12.00. There would still be a substantial difference between 

the local authorities. 

Types of services run by the Mt. Currie local authorities are a mixture of curative and preventive services. Both clinics, 

but especially Matatiele LA clinic, see a lot of patients for minor ailments. Estimates by staff at Kokstad LA are that 

between 40 and 50 % of headcounts there are for minor ailments. Estimates are higher for Matatiele LA clinic. The 

Matatiele clinic does not see many TB patients (only about 100 – 150 patients per month). 

District surgeons 

The category, district surgeon expenditure, includes both medicines and district surgeon salaries. It is interesting to 

note that while fewer scripts are issued per patient in Matatiele (3.26) than in Kokstad (5.45), the number of items per 

patient is very similar, as is the cost per visit. It is difficult to judge whether the rate of expenditure per visit accurately 

reflects their efficiency because expenditure includes all expenditure on medico-legal services, some of which, 

especially the court appearances, would not involve seeing patients. However, on the other hand, their other duties, 

such as issuing sickness certificates, might counter-balance any bias from their non-personal services. 

Table 20: District Surgeon Activity and Expenditure (1997/98) 

Matatiele Kokstad Total Provincial Hospitals 

Expenditure 7 R 90,978 R 162,112 R 253,090 

Patients 4,493 8,735 13,228 

Expenditure per patient R 20 R 19 R 19 

Average no. items per patient 13 13 13 

6 Note that municipal expenditure was calculated on the basis of their financial year: July 1997 – June 1998. 

7 Includes all expenditure on district surgeon services, including drug/prescription costs as well as some medico-legal work that does not 

involve seeing patients. 



Source: Appendix B records submitted by district surgeons to the provincial head office 



6. ANALYSIS 

Limited analyses can be performed with indicators without “norms” or standards to which to compare them. By 

dividing the health district into two sub-districts, it is possible to make some comments on equity, but even these need 

to be compared with a greater array of other districts eventually. For this reason, this section includes information from 

other studies, in addition to comparing intra-district performance. 

6.1. How Do Resources Compare Within Sub-Districts and Between Districts? 

(equity) 

While it is very difficult to make conclusive deductions from the data when the catchment population has not been 

measured scientifically, it is possible to make one or two tentative comments on equity in the district. The studies 

documented in Table 20 for comparison purposes were both conducted fairly recently. The study by Daviaud was 

conducted in a district in Gauteng, while that by McCoy et al. was conducted in Mt. Frere in the Eastern Cape. 

Daviaud (1998) obtained an estimate of expenditure of R249 per capita in the district they reviewed. Daviaud (1999) 

obtained an estimate of R226 in the South Peninsula district she reviewed the following year. These are a little higher 

than average Mt. Currie district per capita expenditure, but R249 is 45 % lower than expenditure in the Kokstad subdistrict. 

McCoy (1998), whose study was conducted in the rural health district of Mt. Frere in the Eastern Cape, 

showed districts with lower expenditure per capita. These estimates have been adjusted for inflation 8 as the study was 

conducted a year earlier. They were R166 and R175 for the two sub-districts respectively. Personnel expenditure per 

capita in Mt. Currie is lower than that recorded in the Daviaud (1999) study of R189. This might be due to differing 

definitions. As mentioned in Section 5. personnel expenditure would be higher were it possible to extract personnel 

expenditure from other line items, such as professional and specialised services. 

Table 21: Comparisons of Per Capita Expenditure 

District expenditure per capita 

Study (see 

references in 

Sec.8) 

Year 

Study 

Estimate 

Mt. Currie 

Total expenditure per capita Daviaud et al. 1997/98 R249 R218 

Total expenditure per capita Daviaud 1997/98 R226 R218 

Per capita sub-district expenditure (2 McCoy et al. 1996/97 R155 R148 

sub-districts) 

R163 R362 

Personnel expenditure per capita Daviaud et al. 1997/98 R189 R141 

Source: Addendum 2 

In summary, intra-district equity seems worse in Mt. Currie than in Mt. Frere, where there was very little variance in 

expenditure per capita (R8.00). Overall, Matatiele emerges with the lowest sub-district expenditure per capita, lower 

than sub-districts in the Mt. Frere study. 

8 Using core inflation between January 1997 and January 1998, of 1.072 (Statistics South Africa, P0141). 



6.2. Are Enough Resources Being Spent on Primary Health Care? (allocative 

efficiency) 

Average district hospital expenditure per capita seems to compare well with hospital expenditure per capita recorded 

by Daviaud (1998), but the high proportion of total district health expenditure being spent on hospital services (80%) 

means that there is not likely to be sufficient remaining funds to finance primary health care appropriately. Also when 

compared with estimates from the McCoy (1998) study (67 %), hospital expenditure appears to consume too large a 

share of the total district expenditure. 

Table 22: Funding of Levels of Care 

Primary health care expenditure 

Study (see 

references in 

Sec.8) 

Year 

Study 

Estimate 

Mt. Currie 

District Hospital Expenditure per capita Daviaud et al. 1997/98 R173.00 R157.00 

(District) Recurrent Hospital Expenditure as McCoy et al. 1996/97 67 % 78.33 % - 80.45 % 9 

Percentage of Recurrent Expenditure 

District Primary Health Care Expenditure per Daviaud et al. 1997/98 R76.00 R31 – R38 – R41 10 

capita (Including Management Expenditure ) 

PHC Cost per Person per Year in Core Package Daviaud (1999) 1997/98 R165.00 R31 – R48 – R41 


Note that the picture for Mt. Currie, with regard to district PHC expenditure per capita is skewed, as there are primary 

health care clinics across the border in the Eastern Cape, but Eastern Cape residents were included in the sub-district 

catchment population, based on their utilization of inpatient facilities. Only more accurate catchment population 

estimates per facility would rectify this bias in the indicator. 

6.3. Are PHC Resources and the Workload being shared fairly? (equity and 

technical efficiency) 

The allocation of PHC workload seems to be unequally distributed when comparing the number of visits per 

professional nurse (or district medical officer). The extent to which this distribution can be justified by case-mix, is a 

point for the District Team to discuss. Table 22 and Figure 8 shows what appears to be an inequitable distribution of 

the workload, both between facilities and between sub-districts. 

Table 23: Visit Loads per Professional Nurse by Facility (1997/98) 

Matatiele 

Kokstad 

Municipal clinic 54.82 41.37 

Mobile clinics 21.04 18.77 

Outpatients/casualty 7.62 56.95 

9 The lower percentages excludes the specialised hospital, SANTA, while the higher percentage includes SANTA. SANTA, as a regional 

referral centre, is likely to serve a greater population than the district catchment population, but no assessment of their catchment population 

was made. 

10 The variance in expenditure per capita depends on whether outpatient expenditure is included (R38) and whether some of the 

regionally managed primary health care services are included (R41) (see Addendum 1 for data not obtained). The budget allocated to 

the district office for 1998/99 was not included nor were laboratory costs. 






In Matatiele, visit loads are highest at the municipal clinic. In Kokstad, outpatient department visit loads are highest, 

followed closely by municipal clinics. Mobile clinic loads are higher in Matatiele than in Kokstad. 

Figure 7: Visits per PHC Professional Nurse per Sub-District 

Matatiele 

26 

Kokstad 

29 

- 10 20 30 

Visits per prof nurse 


On average, visits per nurse are higher in Kokstad than in Matatiele. However, expenditure per PHC visit is also higher 

in Kokstad: R31 versus R24. 

6.4 Are Hospitals Being Run Efficiently? (technical efficiency) 

Given the large proportion of funds consumed by hospitals, one of the questions that needs to be answered is whether 

they are being run efficiently. A glance at the expenditure statistics from the Mt. Frere study, recorded in Table 23, 

would seem to indicate that expenditure per inpatient day equivalent is on the high side, and therefore hospitals might 

not be running efficiently. Average district hospital expenditure per inpatient day (excluding the TB hospital) of R263 is 

higher than R239 or R176 recorded in Mt. Frere (McCoy et al.). However, a much broader band of hospitals needs to 

be reviewed to truly assess where these two hospitals stand. 

One factor contributing to the higher expenditure at Usher Memorial, relative to Tayler Bequest hospital, is usuage of 

the operating theatre for more complicated cases. The average duration of cases in theatre is similar: 10.04 minute in 

Tayler Bequest and 11.74 minutes in Usher Memorial. However, the ratio of minor to major cases is much higher in 

Tayler Bequest (6.07) relative to Usher Memorial (2.50). This means that Usher Memorial hospital theatre is 

undertaking a higher proportion of more serious operations than Tayler Bequest. 

Table 24: Funding of Levels of Care 

Hospital efficiency 

Study (see 

references in 

Sec.8) 

Year 

Study Estimate 

(s) 

Inpatient day cost (adjusted for 

inflation) 

McCoy et al. 1997/98 R239 

R176 

Bed Occupancy Monitor Study 1996 recommended 

70 –80 % 

Average length of stay Monitor Study 1996 recommended 

4 – 8 days 

Source: various studies (see References) and Addendum 2 

Mt. Currie 

Recurrent: R207 (M) - R345 (K) – R263 (T) 

Total: R207 (M) – R351(K) – R265(T) 

between 63 % (K) and 93 % (M) 

between 5 (K) and 7 (M) days 



Table 23 also shows hospital bed occupancy to be higher than recommended in the Matatiele hospital, while being 

lower than recommended in the Kokstad hospital. High occupancy and long average length of stay in Tayler Bequest 

hospital, Matatiele, seems to support anecdotal reports that patients using this hospital have access problems 

(described in Section 5). 

In attempt to make a broader comparison of hospital efficiency with other hospitals, the indicator, expenditure per 

patient day equivalent (PDE), was drawn from the KZN Health Informatics Bulletin (KwaZulu-Natal 1998) for Mt Currie 

hospitals and other hospitals in KwaZulu-Natal. The Informatics Bulletin showed total expenditure per patient day 

equivalent to be R478 and R310 for Usher Memorial and Tayler Bequest hospitals respectively. However, in this 

expenditure review, expenditure per PDE, calculated by dividing the number of PDEs into total hospital expenditure 11 , 

was equal to R241 for Tayler Bequest and R342 for Usher Memorial. The difference between the Informatics Bulletin 

estimates and these estimates might have arisen from the addition of administration charges of 15 % to hospital 

expenditure, which are included in the Informatics Bulletin estimates, but which were not included in this study’s 

estimation of total hospital expenditure. Another possible explanation is that the Informatics Bulletin estimates of 

hospital expenditure included expenditure on mobile clinic complexes, whereas they were excluded from the 

calculation of indicators in this review. 

Using the Infomatics Bulletin estimates, we find that within the Port Shepstone region, average expenditure per PDE is 

R314, which is the lowest in KwaZulu-Natal province. However, Usher Memorial expenditure per PDE is higher than 

averages for all other regions, and is the second highest in the Port Shepstone region (second to Assisi hospital). 

6.5. Will Fee Retention Make an Impact on District Finances? (sustainability) 

The impact that fees will have on district finances (should they be retained) will depend on how efficient fee collection 

services are, as well as what percentage of patients using public services can afford to pay. The three really large 

user-groups paying hospital fees are statutory patients (mostly from other government departments), workmen’s 

compensation cases (for both state and private enterprises) and individually liable groups (includes people above a 

minimum income level, R56,000.00 per annum, for a family in 1999/2000, and medical scheme members) [see 

Addendum 4]. 

While some studies of user fees charged at hospitals in the former Cape Administration have shown fee revenue of 43 

% of recurrent expenditure in 1992/93 (Khosa & Thomas 1995), hospital fee revenue collected in a year in Mt. Currie 

only represents a much smaller proportion, 5 %, of recurrent hospital expenditure. In addition, in general, public 

sector hospital fee collection has decreased since 1992/93, due to the increased usage of private hospitals by 

medical scheme members. Nevertheless, while 5 % may seem small, it is R1,949,468, almost double the 

expenditure by municipality clinics in the Mt. Currie district, or, to take another example, roughly equal to capital 

expenditure in the Kokstad sub-district for the year 1997/98. 

Therefore, fee retention, if utilization were maintained at existing levels, could have a significant impact on district 

finances. However, any optimism regarding the use of retained fees should be qualified by the following 

considerations: 

1. It is not possible to talk about fee collection without assessing the costs associated with collection. These costs 

increase with bad debt. 

11 Total hospital expenditure is comprised of the following objectives from the FMS report: district hospital auxiliary, district hospital 

administration, district hospital outpatients, district hospital inpatients. It included capital and recurrent expenditure. 



2. While no estimates were made of fee collection costs, an interview with one of the hospital revenue clerks 

seemed to indicate that bad debts were on the decline, since the implementation of a system that directly bills 

medical schemes, rather than the patients. This improvement would not affect statutory patients or workmens 

compensation patients so there might still be room for improvement there. 

3. If fee retention at hospitals becomes policy, this might mean an effective reduction in expenditure allocated by the 

government, and would therefore reduce the net additional revenue earned. 

4. Fees might prevent some people from using health service, especially the very poor, or those people without 

medical schemes, but whose income is above the minimum level required to qualify as hospital patients (this 

argument is raised by the authors in Khosa & Thomas (1995). 



7. LIMITATIONS OF THE STUDY AND THE WAY FORWARD 

7.1. Limitations 

The study has gone some way to highlighting general problems with regard to equity within the district, but these 

findings need to be tempered by the fact that we still have neither a good census estimate for the area, nor do we have 

a good enough estimate of cross-border flows. Furthermore, one needs to exercise caution when comparing average 

expenditure indicators with indicators from other districts, as the methods of estimating expenditure still needs to be 

standardised. 

One of the major limitations of using data in this study to analyse efficiency, especially at a primary health care level, 

was the lack of information on catchment populations. As this information is essential for proper management of the 

services, an attempt needs to be made to calculate these statistics for the next district expenditure review, if not before. 

While one of the aims of doing this district expenditure review was for the district to get an idea of what budget it could 

request from the province, this aim has only been moderately achieved. More detailed costing work will need to be 

done to draw up really specific cost centre budgets. In particular, these budgets will need to take better account of 

administration, management and other overhead costs, both within the district and at the regional level, which were 

not apportioned to the various cost centres in this exercise. 

7.2. The Way Forward 

This report compiles a vast array of information that can be used in helping to improve district management. The 

themes touched upon in the preceding section’s analysis has only brought some of the important issues to light. The 

picture painted in the preceding section was one of a district that does not have an exceptionally low amount of 

resources; however its resources could be more equitably and efficiently managed. With regard to equity, there is an 

unequal distribution of resources between sub-districts. With regard to efficiency, there are high rates of hospital 

consumption of health resources, which are affecting the amount of resources available for primary health care. Low 

investment in primary health care is also an inefficient means of allocating expenditure. 

(a) Points for Action 

The information and analyses presented in this report seem to suggest that the District Team should pay attention to 

the following issues: 

1. Determining catchment populations, in particular for individual facilities and services. 

In determining these statistics, it is necessary to know the following: 

♦ the population of neighbouring areas; 

♦ the size of cross-border flows; and 

♦ medical scheme membership in the district. 

2. Determining ways to decrease the length of stay at Tayler Bequest 



Transport to and from the hospital, particularly in Matatiele, seems to be a major reason why their occupancy 

rates are so high, and there is high hospital expenditure, relative to primary health care expenditure. 

Is it possible to provide a cheaper inter-sectoral solution to this problem, instead of having the patients spend 

unnecessary time in the hospitals? 

3. Investigating drug usage 

The low rates of drug expenditure per capita, especially in Matatiele, suggest that there might be low 

availability of drugs to patients in that sub-district. This needs further investigation. 

4. Assessing the workload of primary health care 

There seems to be high rates of consultations per nurse per day at the municipal clinics (average, 50 ). The 

district management needs to assess how sustainable these work rates are (they could lead to a loss of staff, 

for example) and what impact they could have on the service when the various parts of the district health 

system that are currently under different management, become integrated. 

Furthermore, the use of outpatient services in Kokstad needs to be assessed. It seems as though usage of 

outpatient services for primary health care needs could be high, due to the overload at the municipal clinics 

(41 visits per nurse per day), but shifting this patient load to the outpatients department is not an efficient 

solution, as costs per visit are relatively higher at the outpatients department: R32 per visit compared with 

municipality clinic visit expenditure of R 21 a visit. 

For primary health care services in the district as a whole, the Matatiele municipality clinic, with 55 patients 

per nurse per day, seems to the hardest hit, and their situation deserves immediate attention. 

Given, the high priority that the National Department of Health has given to primary health care service 

delivery, and the uneven distribution of workload across Mt. Currie primary health care services, it is important 

that the district team develop a plan for sharing this burden and using all primary health care workers in the 

district more appropriately. 

(b) The 1998/99 Expenditure Review 

Apart from collecting data for evaluating district performance, the purpose of this district expenditure review was also 

to build capacity in the district and this becomes an important part of the way forward for the District Team. In order to 

truly build a representative picture of the district, it is important to develop a time series of information. Therefore, the 

district should conduct an expenditure review for the year 1998/99 as soon as possible. The following points below 

are aimed at providing some guidelines for the next expenditure review: 

1. The team should collect certain important additional information that this team did not have the 

time to collect for the 1996/97 review. These data are: 

♦ 

♦ 

Information on drugs used, but not paid for by the municipal clinics. This information should be available 

from the drug depot records; 

Reports submitted to the provinces by the municipalities show expenditure and the subsidy from the 

provinces. This report was collected for one of the two municipalities in Mt. Currie. Information in this 



♦ 

♦ 

♦ 

report should be cross-checked with people at the municipality, however, and in particular, from the 

municipality financial system records; 

While headcount information was collected directly from the facilities, the 1997/98 collection of 

headcount data should be made easier by the KZN Informatics Department’s reports, which should be 

documenting headcount statistics; 

Information on regionally and provincially provided services need special attention. Much of this 

expenditure is on primary health care services, and it was estimated that the value of these services in 

1997/98 was about R800,000.00 (greater than the entire budget of a single municipal clinic) (adding this 

to district expenditure would increase total district expenditure to just under R55 million); and 

Capital expenditure in the district by any other departments (e.g., Public works, transport). 

2. Collect more detailed information on which staff’s costs are on which responsibilities 

Ideally, one would like to draw up a list of all the staff in the district, showing in which facility they work, as well as on 

which vertical programs they work, what percentage of their time is spent at different facilities or on different programs, 

the breakdown of that time between administration and patient contact, and where their salaries are charged. While 

this work will overlap with the work being done by the staff audit team, it might be a useful broadening of the scope of 

the staff audit. 

3. Do more cost allocations. 

Several cost allocations could be done in the next expenditure review, to get a more accurate picture of health care 

services in Mt. Currie. Some priority allocations are: 

♦ 

♦ 

to allocate laboratory costs across all district services, especially clinic services; and 

to allocate provincially and regionally run primary health care services to the district. 

Other lesser priorities, might be the following allocations: 

• to allocate management/administration costs across inpatients and outpatient services in hospitals; 

♦ to allocate management/administration costs across environmental health services and clinic services in 

municipalities; 

♦ to allocate provincial ambulance services according to services rendered to district and sub-district; and 

♦ to allocate provincially funded environmental health services to the district better. 

4. Assess the appropriateness of maintenance and capital expenditure. Draw up a capital and 

maintenance plan (if one does not already exist) 

Appendix B, Table 6, documents maintenance expenditure, as it appeared in the FMS report. No assessment was 

done of the linkage between, and sequencing of, capital and maintenance expenditure. It is important to model the 

impact that this could have on the district finances, especially on the hospital (with the replacement of out-dated 

equipment), in the future. 

5. Gain a better understanding of how user fee revenue is used in the municipalities and what factors 

affect the budget allocation to health services in the municipalities. Also, gauge the improvement of 

the hospital billing systems. 



User fees will still be collected for environmental health services by municipalities in 1998/99. It would be useful to 

understand how these moneys are used when collected, and how these rates are set. Even more useful for future 

planning, would be to understand the budgeting process that the municipality goes through in allocating its health 

budgets, the level of public involvement in this process, and what factors affect the process. Hospital patient fees 

revenue might become an important source of revenue to the district in the future given two developments. Firstly, if 

fee revenue generated by a facility can be retained by that facility, this might release more funds for primary health care 

in the future. Secondly, the development of the large C-max prison next to Kokstad might require the district to render 

health services on behalf of the Department of Correctional Services, who is already a large debtor of the hospitals. It 

would be worthwhile investigating how to improve the billing and collection of fees from this government department. 


First Mt. Currie Expenditure Review Report 

8. REFERENCES 

Committee for Poverty and Inequality. “Poverty and Inequality in South Africa: Summary Report”. Report prepared for 

the Office of the Executive Deputy President and the Inter-Ministerial, Pretoria, 13 May 1998. 

Coburn J, Southall H and Collins D. “Equity Project: the Impact of a Public/Private Partnership Initiative on 

Uitenhage Provincial Hospital and Clinics”. A study commissioned by the Eastern Cape Department of Health. 

Management Sciences for Health, Bisho, August 1998. 

Daviaud E. and Cabral J. A District –Level Planning Tool for P.H.C. Services: combining utilisation-based and 

population-based approaches. Abbreviated manual version, an adaptation from the “Needs/Norms Package”, 

Confronting need and affordability: guidelines for primary health care services in South Africa by Rispel L. and 

Cabral J., Centre for Health Policy, Durban, September 1998. 

Daviaud E. Assessing Costs of PHC Services in an Urban District. Draft report for ISDS, August 1999. 

HERTT Draft District Health Expenditure Review Guidelines. 

Integrated Planning Services (1998). Sub-Region 5 Development Plan for the Indlovu Regional Council: Phase 1 – 

Perspectives Report. Pietermaritzburg: Integrated Planning Services. 

Khosa S & Thomas E (1995). “Free health care policies” in South African Health Review 1995. Durban: Health 

Systems Trust and Henry J Kaiser Family Foundation. 

KwaZulu-Natal Province, Department of Health, Health Informatics Bulletin: Financial Year Report: April 1997 to 

March 1998. Prepared by the Sub-Directors – Health Informatics, Chief Directorate – Management Support 

Services, Pietermartizburg, August 1998. 

McCoy D., Thomas S., Makan B., and Chimfwembe D. (1998). “District Expenditure and Resource Allocation 

Reviews for Effective DHS Management: a review of expenditure and resource allocation in the Mount Frere Health 

District”. ISDS Technical Report #8. Health Economics Unit, University of Cape Town, Cape Town and Initiative for 

Sub-District Support. Durban: The Health Systems Trust. 

McIntyre D., Bloom G., Doherty J. and Brijlal, P. (1995). Health Expenditure and Finance in South Africa. The 

Health Systems Trust, Durban and World Bank, Washington D.C. 

McIntyre D., Gilson L., Valentine N. and Soderlund N. (1998). Equity of Health Sector Revenue Generation and 

Allocation: A South African Case-Study. Report prepared for PHR, Abt. Associates. Cape Town: Health Economics 

Unit, University of Cape Town, and Centre for Health Policy, University of the Witwatersrand. 

Shepard D.S., Hodgkin D. and Anthony Y. Analysis of Hospital Costs: a manual for managers. Institute for Health 

Policy, Brandeis University, Waltham and World Health Organisation, Geneva, May 7, 1999. 

Soderlund N., Schierhout G. and van den Heever, A. (1998). “Private Health Sector Care” in South African Health 

Review 1998. Durban: The Health Systems Trust. 

Systems, Pretoria and The Health Systems Trust, Durban, February 1998. 



The Department of Health. District Health Information System Guidelines. Directorates of the Department of 

Health: Health Systems Development, Legislation and Policy Co-ordination and National Health Information 



APPENDICES 

Appendix A: Population Information and Workings 

The catchment populations for the Mt. Currie health sub-districts were estimated in two steps. Firstly, the population given for Mt. Currie 

as a whole had to be allocated between the two sub-districts (see Table 2). Secondly, the cross border flows from the Eastern Cape 

had to be estimated. This process is summarised in Table 1 below. 

Table 1: Estimating the Catchment Population 

1. Census Population estimate (1996) Matatiele Kokstad Mt. Currie District 

Census urban population 6570 21039 27609 

Census rural population 3780 13486 17266 

Total population 1996 10350 34525 44875 

2. Removing Medical Scheme Members from Population (1996) 

Population with medical scheme (13 % of urban, above (6570)) 854 2735 3589 

Population dependent on public services (10350 – 854) (a) 9496 31790 41286 

3. Adjust 2 from 1996 to 1998 

1997: multiply 1996 population 2 (a) by 2.98 % growth rate 9779 32737 42516 

1998: multiply 1997 population by 2.98 % growth rate 10070 33713 43783 

1997/98: take 3 quarters of 1997 and 1 quarter of 1998 (b) 9852 32981 42833 

4. Calculate Catchment Population residing in EC from Cross 

Border Inpatient Admission Rates of People from EC 

Inpatient admissions 12 10792 10511 21303 

- from KwaZulu-Natal 644 4244 4788 

- from Eastern Cape 10148 6267 16415 

KZN Inpatient admission as proportion of pop. (e.g., for Matatiele 

644 divided by 9852) 

Catchment population accounting for cross-border flows based on 

inpatient admission rates for KZN 13 : 6.5 % 

Catchment population accounting for cross-border flows based on 

inpatient admission rates for KZN 14 : 12.9 % 

5. Calculate Total Catchment Population (3 + 4) 

6.5 % 12.9 % 11.2 % 

156123 96415 252538 

78667 48581 124953 

5.1. Using 6.5 % admission rate (AR) 165975 129396 295371 

5.2. Using 12.9 % admission rate (AR) 88519 81562 170081 

5.3. Using 6.5 % for Matatiele and 12.9 % for Kokstad 165975 81562 247537 

12 The ratio of inpatient attendances, rather than outpatient attendances was used because there is no subsitute for inpatient services, 

whereas outpatient services could be subsituted with visiting the municipal clinics, for which we did not have complete information about 

cross-border flows. 

13 Assume all people coming from the Eastern Cape live in non-urban areas, otherwise medical scheme membership adjustments would 

be required again. 

14 Assume all people coming from the Eastern Cape live in non-urban areas, otherwise medical scheme membership adjustments would 

be required again. 



Table 2: Provisional Results of the 1996 Census on Mt. Currie’s Population (1996) 

Mount Currie Polygrams (from 1996 Census) 

Matatiele 

Sub-district 

Total 

Kokstad 

Sub district 

Matatiele Subdistrict 

Kokstad Urban 21039 21039 

Cederville Urban 1736 1736 

Matatiele Urban 4834 4834 

Total Urban 27609 21039 6570 

5120036 594 594 

5120037 704 704 

5120038 783 783 

5120039 823 823 

5120040 * 673 673 

5120041 * 597 597 

5120042 418 418 

5120043 993 993 

5120044 1116 1116 

5120045 0.5 496 248 248 

5120046 * 789 789 

5120047 1092 1092 

5120048 1157 1157 

5120049 590 590 

5120050 887 887 

5120051 381 381 

5120052 721 721 

5120053 677 677 

5120054 1032 1032 

5120055 0.5 437 218.5 218.5 

5120056 * 514 514 

5120057 * 741 741 

5120058 1051 1051 

5124001 * 0 0 

5124002 * 0 0 

Total Non-urban Mount Currie 17266 13485.5 3780.5 

Total Urban and Non-urban population 44875 34524.5 10351 

% Non-urban 38.48% 39.06% 36.52% 

Source: Statistics South Africa, July 1999 



Table 3: Estimating Expenditure per Capita: census population versus catchment population 

Total Expenditure 

Census Population 

Estimates of Mt 

Currie Population 

Mt Currie Catchment 

Population (using 

estimate 5.3 from 

Table 1) 

Matatiele 10350 165975 


capita (using census 

pop.) 

Expenditure per capita 

(using catchment 

population)) 

Capital 1,100,705 106 7 

Recurrent 23,404,308 2,261 141 

Total 24,505,013 2,368 148 

Kokstad 34525 81562 

Capital 1,926,011 56 24 

Recurrent 27,625,335 800 339 

Total 29,551,346 856 362 

Mt. Currie 44875 247537 

Capital 3,026,716 67 12 

Recurrent 51,029,643 1,137 206 

Total 54,056,359 1,205 218 

Table 4: Education Levels Achieved by the Mt. Currie Population 

Highest education level Mount Currie % 

No schooling 6,509 14.51 

Grade 0 49 0.11 

Grade 1 909 2.03 

2 1,157 2.58 

3 2,291 5.11 

4 3,009 6.71 

5 2,755 6.14 

6 2,983 6.65 

7 3,211 7.16 

8 3,261 7.27 

9 2,449 5.46 

10 2,592 5.78 

11 1,513 3.37 

Less than matric & cert/dip 693 1.54 

Matric only 3,145 7.01 

Matric& certificate 208 0.46 

Matric and Diploma 654 1.46 

Matric and Bachelors degree 195 0.43 

Matric and Bachelors degree and Diploma 19 0.04 

Matric and Bachelors degree and Honours 12 0.03 

Matric and Masters 19 0.04 



Matric and Doctors degree 8 0.02 

Other qualification 332 0.74 

Unspecified 1,740 3.88 

NA 5,159 11.50 

Total 44,872 100.00 

Source: 1996 Census 

Table 5: Disability Rates in the Mt. Currie Population 

Disability 

MC total 

Urban: 

Cedarville 

Urban: 

Kokstad 

Urban: 

Matat 

Total urban 

MC 

Non-Urban: 

MC 

Sight 1258 47 647 175 869 389 

Hearing 484 34 259 34 327 157 

Physical 627 114 415 33 562 65 

Mental 176 17 106 16 139 37 

Multiple 141 0 83 25 108 33 

Type of disability not 

specified 

423 3 157 1 161 262 

Unspecified 273 15 96 77 188 85 

Total 3382 230 1763 361 2354 1028 

% 7.77% 14.83% 8.56% 8.31% 8.89% 6.04% 

No disability 40124 1321 18830 3982 24133 15991 

NA: institution (?) 1369 185 261 491 937 247 

TOTAL 44875 1736 20854 4834 27424 17266 

Source: 1996 Census 

The number of people with disabilities in Mt Currie is 7.77 %of the total district population. Most of these people are 

in urban areas. About 14.83 percent, 8.56 percent and 8.31 percent of people in urban areas of Cedarville, Kokstad 

and Matatiele respectively are disabled. Most of these disabilities have to do with problems relating to sight (more 

than a third of the total disabled persons in Mt Currie), followed by physical and hearing disabilities. 



Appendix B: Expenditure, Activity and Staff Information 

Table 1: Non-Financial Health Services Information: Activity Information for the Various Cost Centres (1997/98) 

Matatiele 

Kokstad 

Services 

Visits/ 

admissions 

Inpatient 

Days 

Available 

Beds 

No. 

Scripts 

No. 

Items 

Theatre 

Cases 

Hrs 

Visits/ 

admissions 

Inpatient 

Days 

Available 

Beds 

No. 

Scripts 

No. 

Items 

Theatre 

cases 

Hrs 


- emergency medical transport 

- municipal env. Health 

- provincial env. Health 

Clinics and personal services 

- provincial mobiles and family planning 56,808 59,121 

- psychiatric fixed clinic 6,142 

- municipal clinics 61,677 27,925 

- district surgeons 4,493 18,491 60,37 

1 


8,735 47,564 116,41 

3 

- district hospital (provincial) auxiliary 

Laundry 

physical facility management 

- district hospital (provincial) administration 

- district hospital (provincial) outpatients 8,577 51,255 

- district hospital (provincial) inpatients 10,792 67,254 200 2,141 358 10,511 45,848 250 4,159 814 

- SANTA inpatients 2,321 71,014 220 

District technical support services 

- laboratory 

Adjustments from previous year (provincial) 



Table 2 (a): Non-Financial Health Services Information: Personnel Distribution- Matatiele Sub-District (1997/98) 

Designation Mobile Teams Primary health 

care 

Family 

planning 

Outpatient 

Department 

Inpatient 

Department and 

Management 

Health Economics Unit and ISDS 45 

Municipal 

Clinic 

Total clinic and 

hospital services 

SANTA (resource for both 

districts) 

Administrative Clerks 1 11 1 13 

Administration officer (senior) 1 1 

Artisan (a group) 0 0 

Artisan foreman 4 4 

Auxiliary services officer 4 2 6 

Chief professional nurse 34 34 

Cleaners 35 35 

Director nursing services 1 1 

Drivers 2 2 

Food services aid 7 7 

General foreman 0 0 

General worker (stores ass.) 1 1 2 

Groundsman 0 0 

Handyman 2 2 

Housekeeping supervisor 1 1 

Laundry services supervisors 0 0 

Linen supervisor 5 5 

Medical officer 1 1 

Medical superintendant 0 0 

Medical/Dental superintendant 0 0 

Nursing assistant 3 3 7 13 14 

Operator/senior operat. 9 9 

Professional nurse 3 9 4 2 4 22 5 

Seamstress 0 0 

Security guards 8 8 

Security officer 1 1 

Senior nursing assistant 29 29 

Senior professional nurse 1 16 1 18 4 

Senior radiographer 1 1 

Senior staff nurse 36 36 

Staff nurse 1 3 1 3 12 20 10 

Supervisor food services 4 4 

Telecom operators 0 0 

Tradesman aid 9 9


Other (unclassified) 40 

Total 5 3 17 11 244 7 287 73 

Table 2 (b): Non-Financial Health Services Information: Personnel Distribution- Kokstad Sub-District (1997/98) 

Designation 

Mobile 

Teams 

Primary health 

care 

Family 

planning 

Outpatient 

Department 

Inpatient Department 

and Management 

Municipal Clinic Psychiatric clinic Total clinic and 

hospital services 

Administrative Clerks 1 1 16 18 

Administration officer (senior) 1 1 

Artisan (a group) 2 2 

Artisan foreman 2 2 

Auxiliary services officer 6 3 9 

Chief professional nurse 29 1 30 

Cleaners 1 35 36 

Director nursing services 1 1 

Drivers 6 6 

Food services aid 5 5 

General foreman 1 1 

General worker (stores ass.) 3 1 4 

Groundsman 4 4 

Handyman 1 1 

Housekeeping supervisor 1 1 

Laundry services supervisors 3 3 

Linen supervisor 4 4 

Medical officer 2 2 

Medical superintendant 1 1 

Medical/Dental superintendant 1 1 

Nursing assistant 4 6 4 14 

Operator/senior operat. 5 5 

Professional nurse 3 5 6 4 6 2 1 27 

Seamstress 1 1 

Security guards 8 8 

Security officer 1 1 

Senior nursing assistant 1 28 29 

Senior professional nurse 18 1 19 



Senior radiographer 1 1 

Senior staff nurse 23 23 

Staff nurse 1 2 1 3 9 16 

Supervisor food services 4 4 

Telecom operators 3 3 

Tradesman aid 4 4 

Other (unclassified) 

clinical 

psychologist visits 

for half day, 2 

times a year 

Total 5 9 17 14 236 3 3 289 



Table 3: Recurrent and Capital District Health Expenditure for the Mt. Currie District (public and NGO services), Rands (1997/98) 

CAPITAL RECURRENT TOTAL TOTAL 

Matatiele Kokstad Matatiele Kokstad Matatiele Kokstad District 

Community services 31,466 98,162 1,438,663 2,122,950 1,470,129 2,221,112 3,691,241 

- emergency medical transport 31,466 79,544 683,614 1,291,898 715,080 1,371,442 2,086,522 

- municipal env. Health 18,618 725,165 773,810 725,165 792,428 1,517,593 

- provincial env. Health 29,884 57,242 29,884 57,242 87,126 

Clinics and district surgeons 7,667 - 2,640,642 2,861,282 2,648,309 2,861,282 5,509,591 

- provincial mobiles 2,087,038 2,097,560 2,087,038 2,097,560 4,184,598 

- municipal clinics 7,667 462,626 601,610 470,293 601,610 1,071,903 

- district surgeons 90,978 162,112 90,978 162,112 253,090 

Hospital services 1,061,572 1,827,849 18,869,960 22,184,320 19,931,532 24,012,169 43,943,701 

- district hospital (provincial) auxiliary 826,744 208,090 826,744 208,090 1,034,834 

maintenance (physical facility management) 213,886 208,090 - 213,886 208,090 421,976 

laundry (only shown separately for Matatiele) 612,858 - 612,858 612,858 

- district hospital (provincial) administration 831,932 1,334,376 1,892,163 2,226,051 2,724,095 3,560,427 6,284,522 

- district hospital (provincial) outpatients 561,102 1,660,631 561,102 1,660,631 2,221,733 

- district hospital (provincial) inpatients 15,754 285,383 13,308,322 15,802,123 13,324,076 16,087,506 29,411,582 

- SANTA inpatients 2,495,515 2,495,515 2,495,515 2,495,515 4,991,030 

District technical support services - - 454,999 454,999 454,999 454,999 909,998 

- laboratory 454,999 454,999 454,999 454,999 909,998 

Adjustments from previous year (provincial) 44 1,784 44 1,784 1,828 

Total from various sources 1,100,705 1,926,011 23,404,308 27,625,335 24,505,013 29,551,346 54,056,359 



Table 3 (a): Recurrent and Capital Expenditure on the Hospital Responsibility Budget: Tayler Bequest (Matatiele Sub-district), Rands (1997/98) 

Recurrent expenditure 


Matatiele 

clinics 

Hospital 

Administration 

Inpatients 

Department 

Outpatients 

Department 

Adjustments 


1,647,441 1,705,836 9,563,439 559,190 13,475,907 


100,166 79,726 205,625 1,912 387,430 


246,475 1,833 2,660,844 2,909,151 

Equipment 

718 485,090 485,808 

Land and buildings 

61,020 61,020 

Professional and speculative services 

5,841 82,707 243,976 332,524 


25,376 22,061 149,348 196,785 

Adjustments 43.5 

44 

Laundry - own cost centre in Tayler Beq 

612,857 612,857 

Total 

2,087,038 1,892,163 13,308,322 561,102 44 18,461,526 


- 


817,218 817,218 


2,253 2,253 

Stores and livestock - 

Equipment 

- 15,754 15,754 

Land and buildings - 

Professional and speculative services - 



Total 

12,461 12,461


Adjustments - 

Total 

- 831,932 15,754 847,686 

TOTAL (current and capital) 2,087,038 2,724,095 13,324,076 561,102 44 19,309,212 



Table 3 (b): Recurrent and Capital Expenditure on the Hospital Responsibility Budget: East-Griqualand & Usher Memorial (Kokstad Sub-district), 

Rands (1997/98) 

Recurrent expenditure 

Expenditure categories Matatiele clinics Hospital Inpatients Outpatients Adjustments 

Total 

Administration Department Department 


1,605,257 1,929,132 9,814,994 1,064,856 14,414,238 


118,830 265,394 294,631 2,880 681,735 


293,878 307 5,107,117 578,338 5,979,639 

Equipment 

2,421 18,304 20,725 


37,267 37,267 


15,892 808 436,915 453,614 


24,017 30,411 130,161 14,558 199,148 

Adjustments 1,784 1,784 

Laundry - own cost centre in Tayler Beq - 

Total 2,097,560 





Equipment 



2,226,051 

- 1,311,189 

3,683 715 

15,802,123 1,660,631 1,784 21,788,150 

18,810 

265,858 - 

1,311,189 

4,398 

18,810 

265,858 

- 

- 




19,504 

19,504 

Adjustments 

- 

Total - 

285,383 - 1,619,760 

1,334,376 

TOTAL (current and capital) 3,560,427 16,087,506 1,660,631 1,784 23,407,910 



Table 3 (c): Recurrent and Capital Expenditure Proportions for Both Sub-Districts, % (1997/98) 


Recurrent Expenditure 

Matatiele 

clinics 

Hospital 

Administratn 

Inpatients 

Department 

Outpatients 

Department 

Adjustments Total Kokstad 

clinics 

Hospital 

Administratn 

Inpatients 

Department 

Outpatients 

Department 

Adjustments 

Personnel expenditure 78.94% 90.15% 71.86% 99.66% 0.00% 72.99% 76.53% 86.66% 62.11% 64.12% 0.00% 66.16% 

Administrative expenditure 4.80% 4.21% 1.55% 0.34% 0.00% 2.10% 5.67% 11.92% 1.86% 0.17% 0.00% 3.13% 

Stores and livestock 11.81% 0.10% 19.99% 0.00% 0.00% 15.76% 14.01% 0.01% 32.32% 34.83% 0.00% 27.44% 

Equipment 0.03% 0.00% 3.65% 0.00% 0.00% 2.63% 0.12% 0.00% 0.12% 0.00% 0.00% 0.10% 

Land and buildings 2.92% 0.00% 0.00% 0.00% 0.00% 0.33% 1.78% 0.00% 0.00% 0.00% 0.00% 0.17% 

Professional 

and 0.28% 4.37% 1.83% 0.00% 0.00% 1.80% 0.76% 0.04% 2.76% 0.00% 0.00% 2.08% 

speculative services 

Miscellaneous expenditure 1.22% 1.17% 1.12% 0.00% 0.00% 1.07% 1.15% 1.37% 0.82% 0.88% 0.00% 0.91% 

Adjustments 0.00% 0.00% 0.00% 0.00% 100.00% 0.00% 0.00% 0.00% 0.01% 0.00% 0.01% 

Laundry - own cost centre 0.00% 0.00% 4.61% 0.00% 0.00% 3.32% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 

in Tayler Beq 

Total (added) 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 

Total ( inputed manually) 

Total 


Personnel expenditure 98.23% 0.00% 96.41% 98.26% 0.00% 80.95% 

Administrative expenditure 0.27% 0.00% 0.27% 0.28% 0.25% 0.27% 

Stores and livestock 0.00% 0.00% 0.00% 0.00% 6.59% 1.16% 

Equipment 0.00% 100.00% 1.86% 0.00% 93.16% 16.41% 

Land and buildings 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 

Professional 

and 

0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 

speculative services 

Miscellaneous expenditure 1.50% 0.00% 1.47% 1.46% 0.00% 1.20% 

Adjustments 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 

Total (added) 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 

Source: Table 3 (a) and 3 (b) 



Table 4 (a): Sources of Funds to Types of Providers: Matatiele Sub-district, Rands (1997/98) 

Source of Fund (budget) Provincial - 

regional 

Provincial - 

hospital 


Provincial - 

subsidy 

Municipality - 

own revenue 

NGO - own 

revenue 

User Fees 

Community services 1,470,129 

- emergency medical transport 715,080 715,080 

- municipal env. Health 38,761 669,872 16,532 725,165 

- provincial env. Health 29,884 29,884 

Clinics and district surgeons 2,648,309 

- provincial mobiles 2,087,038 2,087,038 

- municipal clinics 449,921 20,372 470,293 

- district surgeons 90,978 90,978 

Hospital services 19,931,532 

- district hospital (provincial) auxiliary 826,744 826,744 

- district hospital (provincial) 

2,724,095 2,724,095 

administration 

- district hospital (provincial) outpatients 561,102 561,102 

- district hospital (provincial) inpatients 13,324,076 13,324,076 

- SANTA inpatients 2,345,734 15 149,781 2,495,515 

District technical support services 454,999 

- laboratory 454,999 454,999 

Adjustments from previous year 

44 44 

(provincial) 

Total from various sources 1,290,941 19,523,099 2,834,416 690,244 149,781 16,532 24,505,013 

Total 

15 This amount comes from the Eastern Cape Provincial Health Department, but about 99 % of SANTA patients are from the Eastern Cape. 



Table 4(b): Sources of Funds to Types of Providers: Kokstad Sub-district, Rands (1997/98) 

Source of Fund (budget) Provincial - 

regional 

Provincial - 

hospital 


Provincial - 

subsidy 

Municipality - 

own revenue 

NGO - own 

revenue 

User Fees 


- emergency medical transport 1,371,442 1,371,442 

- municipal env. Health 32,166 760,262 792,428 

- provincial env. Health 57,242 57,242 

Clinics and district surgeons 2,861,282 

- provincial mobiles 2,097,560 2,097,560 

- municipal clinics 440,000 140,322 21,288 601,610 

- district surgeons 162,112 162,112 


- district hospital (provincial) auxiliary 208,090 208,090 

- district hospital (provincial) 

3,560,427 3,560,427 

administration 

- district hospital (provincial) outpatients 1,660,631 1,660,631 

- district hospital (provincial) inpatients 16,087,506 16,087,506 

- SANTA inpatients 2,345,734 16 149,781 2,495,515 


- laboratory 454,999 454,999 

Adjustments from previous year 

1,784 1,784 

(provincial) 

Total from various sources 2,045,795 23,615,998 2,817,900 900,584 149,781 21,288 29,551,346 

Total 

16 This amount comes from the Eastern Cape Provincial Health Department, but about 99 % of SANTA patients are from the Eastern Cape. 



Table 5 (a) :Uses of Funds: expenditure by major line item, Matatiele Sub-district, Rands (1997/98) 

RECURRENT EXPENDITURE CAPITAL TOTAL 

Source of Fund (budget) Personnel Medicines and Medicine and Medical gas Equipment Other 

vaccines other medical 

consumables 


- emergency medical transport 419,037 22,883 14,302 10,009 217,383 31,466 715,080 

- municipal env. Health 631,544 93,621 725,165 

- provincial env. Health 27,100 825 1,959 29,884 

Clinics and personal services 2,648,309 

- provincial mobiles 1,647,441 223,786 7,520 718 207,573 2,087,038 

- municipal clinics 326,428 112,253 7,486 16,459 7,667 470,293 



- district hospital (provincial) auxiliary 826,744 

laundry 601,183 11,675 612,858 

physical facility management 213,886 213,886 

- district hospital (provincial) administration 1,705,836 186,327 831,932 2,724,095 

- district hospital (provincial) outpatients 559,190 1,912 561,102 

- district hospital (provincial) inpatients 9,563,439 592,261 238,394 171,365 485,090 2,257,773 15,754 13,324,076 

- SANTA inpatients 1,429,057 25,210 1,041,248 2,495,515 


- laboratory 454,999* 454,999 

Adjustments from previous year (provincial) 44 44 

Total from various sources 16,984,475 858,015 381,050 185,667 504,128 4,490,973 1,100,705 24,505,013 

* unallocated 



Table 5 (b) : Uses of Funds: expenditure by major line item, Kokstad Sub-district, Rands (1997/98) 

RECURRENT EXPENDITURE CAPITAL TOTAL 

Source of Fund (budget) Personnel Medicines and Medicine and Medical gas Equipment Other 

vaccines other medical 

consumables 


- emergency medical transport 803,665 43,886 26,743 417,604 79,544 1,371,442 

- municipal env. Health 683,132 13,526 77,152 18,618 792,428 

- provincial env. Health 51,907 1,563 3,772 57,242 

Clinics and personal services 2,861,282 

- provincial mobiles 1,605,257 293,214 2,421 196,668 2,097,560 

- municipal clinics 497,965 37,240 266 66,139 601,610 



- district hospital (provincial) auxiliary 208,090 

physical facility management: 

207,890 207,890 

maintenance district hospitals 

physical facility management: 

200 200 

maintenance general hospitals 

- district hospital (provincial) administration 1,929,132 283 296,636 1,334,376 3,560,427 

- district hospital (provincial) outpatients 1,064,856 563,399 7,194 25,182 1,660,631 

- district hospital (provincial) inpatients 9,814,994 1,288,682 778,813 387,683 18,304 3,513,647 285,383 16,087,506 

- SANTA inpatients 1,429,057 25,210 1,041,248 2,495,515 


- laboratory 454,999* 454,999 

Adjustments from previous year (provincial) 1,784 1,784 

Total from various sources 17,998,930 2,213,652 880,942 414,426 22,554 6,094,831 1,926,011 29,551,346 



Table 6: Recurrent and Capital Maintenance Expenditure 

MAINTENANCE EXPENDITURE OVERVIEW 

Matatiele maintenance expenditure reports 

Data capture data: 1999/08/21, from X112 report for Tayler Bequest Responsibility 

Maintenance - recurrent Codes Rands Maintenance - capital Codes Rands 

Clinics (curr) Physical facilities managment O2_425105 

Allowance maint personnel 0989 1,594 Maintenance of District Hosp. O3_425158 

Allowance - cap remuner 0809 6,372 Schedule A (cap) O4_425251 49,444 

Stores and Livestock: elec. material 336 

Professional and Spec Services 

Maintenance of buildings 3437 38,136 

Maintenance contracts 3530 10,972 

Physical facilities managment 

O2_425105 

Maintenance of District Hosp. 

O3_425158 

Schedule C (cap) O4_425270 164,443 

Stores and Livestock: elec. material 

Maintenance materials and parts 163,784 

Electronic material 420 


Maintenance contracts 239 

Kokstad maintenance expenditure reports 

TOTAL 213,887 

Data capture data: 1999/08/21, from X112 report for East Griqualand and Usher Memorial Responsibility 

Maintenance - recurrent Codes Rands Maintenance - capital Codes Rands 

Clinics (curr) Physical facilities managment O2_425105 

Personnel 

Allowance maint personnel 0989 1,386 Maintenance of District Hosp. O3_425158 

Allowance - cap remuner 0809 4,766 Schedule A (cap) O4_425251 8,280 

In-pat (curr) 

Personnel 

Allowance maint personnel 0989 - Professional and Spec Services 8,280 

Allowance - cap remuner 0809 - 

Stores and Livestock 

Maint, materials and parts 2504 1,708 Maintenance contracts 3530 8,280 

Prof and Spec Services Physical facilities managment O2_425105 

Maintenance contracts 3530 962 Maintenance of District Hosp. O3_425158 

Schedule C (cap) O4_425270 199,610 

Stores and Livestock: elec. material 

Maintenance materials and parts 74,494 

Electronic material 

Professional and Spec Services 125,116 

Maintenance of building 109,128 

Maintenance contracts 15,988 

TOTAL: Maint of District Hosp 207,890 

Maintenance General Hospitals 

O3_423970 

Schedule A (cap) 

O4_424530 



Maintenance General Hospitals 

O3_423970 



Schedule C (cap) O4_424564 0 

Stores and Livestock 0 


Maintenance of building 200 


TOTAL: Maint of Gen Hosp 200 

TOTAL 208,090 


Mt Currie Report, Addendum 

ADDENDA 

Addendum 1: Data Presentation and Collection Issues 

During data collection process, members of the district expenditure review team met with the District Management 

to discuss what types of data would be useful to the district, and how it would be best to present the data. The 

district gave the useful feedback, which was related to the HERTT team. They approved most of the initial set of 

indicators developed by the HERTT team, but really emphasised that it would be most useful to present the 

indicators according to cost centres. However, when writing the report, it was difficult to keep the length of the 

report down while at the same time compile a report by cost centre. The comprise reached was to place the more 

detailed cost centre information in the appendices. 

One of the most important pieces of information needed for assessing district performance is the catchment 

population of the district as a whole and of various services in the district. Several of the indicators developed by the 

team used information on a health service’s catchment population. It was on in the later stages of data collection 

that the Mount Currie team found that it was not an easy figure to obtain from the services. 

Data Left Out - to be Collected Next Time 

Figure 1 

ESTIMATES OF EXPENDITURE FOR SERVICES LEFT OUT OF DISTRICT EXPENDITURE 

REVIEW 

Recurrent Expenditure Year of estimate Rand 

AIDS and AIDs awareness (promotional materials) 1999/2000 125,000 

AIDS fund at province for workshops etc. 1999/2000 40,000 

Nutrition programme (2,000,000 whole Port Shep Region) 1998/1999 666,667 

Kokstad Mental Health Clinic (prov level) 

DATA GAP 

Management of Psych clinic recorded reg level 1997/98 1,161 

Other provincial health promotion activities (prov level) 

DATA GAP 

Tuberculosis management at regional level 1997/98 3,399 

School health teams (separate from nutrition prog?) 

NONE 

Oral health (possibly in primary health services budget?) 

NONE 

District office budget 1999/2000 282,000 

Drug expenditure at clinics – free from province, not properly 

captured? 

Total Recurrent Expenditure 1,118,227 

Expenditure left out as a % of 2.07% 

Capital Expenditure 

District office set-up costs plus running costs 1998 aug 575,635 

Works Department for capital works – none 

NONE 



Addendum 2: Indicators 

Figure 1: List Developed by Mt. Currie DERTT at Meeting in March 1999 

DISTRICT 

Managed to Estimate 

Total expenditure per capita 

ü 

Line item % share 

ü 

Cost centre % share and AEMS, Flying dr. service 

% of district expenditure currently managed by district, and others 

Private clinical service contract expenditure % share 

Each provider’s % share of expenditure 

ü 

% share of sources of funds for each provider ü 

Vehicle gap (actual/norm?) 

Utilization 

Down-time (veh days unavail/tot veh days) 

Ave. Number of items per script 

ü 

% share expenditure of each cost-centre and other exp.,not in cost-centres 

ü 

(AEMS, et.) 

No. visits for each service point in district and expenditure in 1 table 

ühalf (not in one table) 

FIXED CLINICS COST CENTRES 

ONLY FOR CLINICS AS A WHOLE: 

Cost per patient seen 

ü 

% share exp. of each line item ü 

Cost per patient per SLI 

ü 

Referral rate 

MOBILE CLINICS COST CENTRES 


% share exp.of each line item 


Visitation efficiency: no. scheduled /no. actual visits 

Ave frequency of visits per site 

Cost per km 

Utilization 

Downtime 

Referral rate 

HOSPITAL COST CENTRES 

Average length of stay 

ü 

Bed occupancy rate 

ü 


ü 

% share per line item ü 

(% share for each hospital) ü 

Cost per patient per standard line item 

ü 



% total expenditure on different cost centres in each hospital ü 

Cost recovery (% of total cost of hospital/district) 

ü 

OUT-PATIENT HOSPITAL COST CENTRES 

Cost per patient 

ü 

% share line item ü 


ü 

% share line item (incl.drugs) ü half – info. not accurately 

recorded 

Cost per in-patient 

ü 

Nurse: patient ratio 

ü 

Dr: patient ratio 

IN-PATIENT HOSPITAL COST CENTRE 

Cost per in-patient day 

ü 

% share line item (SLI) ü 


ü 

% share each objective ü 

% share exp. Drugs on private patients ü 

Cost per meal per day 

Theatre cost per hour used 

ü estimate 

Nurse: patient ratio 

ü 

Nurse: bed ratio 

Dr: patient ratio 

COMMUNITY BASED SERVICES COST CENTRE 

% share of each type of comm. based service (School, Env. Health, etc.) ü 

Per capita expenditure on environmental health 

ü 

Each share by SLI 

ü 

AEMS 

Cost per km 

Utilization 

% line item (and total cost) 

PHARMACY 

Average cost per script 

% share of total (and total cost of pharmacy) 

Ave. no. items/script 

X-RAYS 

% share in-pts, out-pts (and total cost X-ray dept) 

Cost per x-ray (and norm) 

No. x-rays processed/month divided by norm = optimum use indicator 

LABORATORY 

% share of expenditure for different cost centres 

Average cost per lab service unit per patient requiring service 


ü 

ü 

ü estimate 

ü




Figure 2: 

List Developed by the National HERTT in June 1999, subsequently 

revised 17 (with associated aspects of district performance being 

measured) 

1. Expenditure per catchment population (CP) by facility (EQUITY) 

2. Per capita (CP) utilisation of services (using catchment populations) (EQUITY) 

3. Cost per “visit” per facility (hospitals - in-patient day; clinics - visit) (EFFICIENCY) 

4. Drug expenditure per “visit” by facility (EFFICIENCY) 

5. % of facility expenditure on human resources (EFFICIENCY) 

6. % of professional nurse expenditure by facility (EFFICIENCY) 

7. Nurse: visits ratio (EFFICIENCY) 

8. Average length of stay (EFFICIENCY) 

9. Bed occupancy rates (EFFICIENCY) 

10. Revenue collection as a % of total expenditure (EFFICIENCY) 

11. Peri-natal mortality (SERVICE GAPS) 

12. TB cure rate (Use disease profile if there is no info. on the above) (SERVICE GAPS) 

13. For municipal services: share of province in total district (SUSTAINABILITY) 

14. Table of funding by different sources (SUSTAINABILITY) 

17 See Health Expenditure Review Task Team Guidelines (1999) 



Figure 3: Indicators and Data: Mt Currie 1997/98 

COST CENTRE Indicator Numerator Denominator Indicator Criteria 

Emergency Medical Services % of total district expenditure on emergency 2,086,522 54,056,359 3.86% allocative efficiency 

medical services 

Environmental Health Services % of total district expenditure on environmental 1,604,719 54,056,359 2.97% technical efficiency 

services 

Matatiele 

% of sub-district expenditure on environmental 755,049 24,505,013 3.08% allocative efficiency 

services 

Kokstad 

% of sub-district expenditure on environmental 849,670 29,551,346 2.88% allocative efficiency 

services 

Primary Health Care Services District primary health care services expenditure 7,731,324 247,537 R 31.23 equity/allocative efficiency 

per capita (district surgeons, mobiles, municipal 

clinics and outpatient services): Mt Currie 

District primary health care services expenditure 

(including same as above) per capita: Matatiele 

3,209,411 165,975 R 19.34 equity/allocative efficiency 

District primary health care services expenditure 

(including same as above) per capita: Kokstad 

4,521,913 81,562 R 55.44 equity/allocative efficiency 

District primary health care services including 9,336,043 247,537 R 37.72 equity/allocative efficiency 

environmental health (municipalities and province) 

expenditure per capita 

District primary health care services including 10,172,270 247,537 R 41.09 equity/allocative efficiency 

environmental health (municipalities and province) 

and other vertical programmes expenditure per 

capita 

District primary health care services expenditure 3,209,411 131,555 R 24.40 equity/allocative efficiency 

per visit (district surgeons, mobiles, municipal 

clinics and outpatient services): Matatiele 

District primary health care services expenditure 4,521,913 147,036 R 30.75 equity/allocative efficiency 

per visit (district surgeons, mobiles, municipal 

clinics and outpatient services): Kokstad 

District surgeons 

Total exp. (including expenditure on medical-legal 253,090 13,228 R 19.13 technical efficiency 

and other services, travel and revenue from ownmedicines 

use) per patient seen 

Number of items per script (including scripts issued 176,784 66,055 

technical efficiency 

from government medicines stock and own-stock) 

2.68 

Matatiele district surgeon Total expenditure per patient seen 90,978 4,493 R 20.25 technical efficiency 

Number of items per script 60,371 18,491 


3.26 

Number of scripts per patient 18,491 4,493 


4.12 

No. of items per patient 60,371 4,493 


13.44 

Kokstad district surgeon Total expenditure per patient seen 162,112 8,735 R 18.56 technical efficiency 

Number of items per script 116,413 47,564 


2.45 

Number of scripts per patient 47,564 8,735 


5.45 

No. of items per patient 116,413 8,735 


13.33 

Clinics - mobile complex Average total expenditure per visit 4,184,598 115,929 R 36.10 technical efficiency 

Expenditure on mobiles as a & of total district 4,184,598 54,056,359 7.74% allocative efficiency 


Drug expenditure per visit 516,596 115,929 R 4.46 technical efficiency 

% expenditure on personnel 3,252,698 4,184,598 77.73% technical efficiency 

Personnel exp. per visit 3,252,698 115,929 R 28.06 technical efficiency 

Average number of visits per prof. nurse per day 115,929 26 


(225 working days a year ) 

19.82 

Matatiele mobile (including a fixed Average total expenditure per visit 2,087,038 56,808 R 36.74 technical efficiency 

component) 




Kokstad mobile (including a fixed 

component) 

% expenditure on personnel 1,647,441 2,087,038 78.94% technical efficiency 


Km travelled per patient served *missing kms 56,808 - technical efficiency 


21.04 


Average total expenditure per visit 2,097,560 59,121 R 35.48 technical efficiency 

Average total expenditure per headcount 2,097,560 59,121 R 35.48 technical efficiency 


% expenditure on staff 1,605,257 2,097,560 76.53% technical efficiency 


Km travelled per patient served 148,677 40,549 


3.67 


18.77 




COST CENTRE Indicator Numerator Denominator Indicator Criteria 

Clinics - fixed: psychiatric Visits per professional nurse per day 6,142 2 


13.65 

Clinics - fixed: municipal Average total expenditure per visit 1,071,903 89,602 R 11.96 technical efficiency 

Drug expenditure per visit (includes consumables - 149,493 89,602 R 1.67 technical efficiency 

from information for prov. clinics, drug and vaccine 

expenditure accounted for 0.5 % to 3.5 % of 

expenditure) 

% expenditure on staff 824,393 953,991 86.42% technical efficiency 

Personnel exp. per case 778,518 89,602 R 8.69 technical efficiency 

Expenditure on municipal clinics as a % of total 1,071,903 54,056,359 1.98% allocative efficiency 

district expenditure 

Average number of visits per prof. nurse per day 89,602 8 49.78 technical efficiency 

Matatiele municipal clinic Average total expenditure per visit 470,293 61,677 R 7.63 technical efficiency 



Personnel exp. per visit 326,428 61,677 R 5.29 technical efficiency 


Kokstad municipal clinic Average total expenditure per visit 601,610 27,925 R 21.54 technical efficiency 



Personnel exp. per visit 497,965 27,925 R 17.83 allocative efficiency 


Hospitals Excluding SANTA Hospital expenditure as % of district expenditure 38,952,671 54,056,359 72.06% allocative efficiency 

Hospital recurrent expenditure as a percentage of 36,063,250 38,952,671 92.58% allocative efficiency 

total hospital expenditure 

Hospital capital expenditure as a percentage of total 2,889,421 38,952,671 7.42% allocative efficiency 


Hospital recurrent expenditure as a percentage of 36,063,250 51,029,643 70.67% allocative efficiency 

total recurrent expenditure 

Hospital administration expenditure as a percentage 6,284,522 38,952,671 16.13% allocative efficiency 

of total hospital expenditure 

Hospital recurrent administration expenditure as a 

36,063,250 11.42% allocative efficiency 

percentage of total recurrent hospital expenditure 4,118,214 

Total hospital expenditure per patient day 

135,243 R 288.02 

equivalent (PDE): Mt Currie 38,952,671 

Recurrent hospital expenditure per PDE: Mt Currie 

135,243 R 266.66 allocative efficiency 

36,063,250 

Hospital personnel expenditure per PDE: Mt Currie 

135,243 R 186.62 

25,238,630 

Total hospital expenditure per PDE: Matatiele 

72,310 R 241.13 technical efficiency 

17,436,017 

Total hospital expenditure per PDE: Kokstad 


21,516,654 

Average recurrent hospital expenditure per PDE: 


Matatiele 16,374,445 

Average recurrent hospital expenditure per PDE: 


Kokstad 19,688,805 

Average hospital personnel expenditure per PDE: 


Tayler Beq. 12,429,648 

Average hospital personnel expenditure per PDE: 


Usher Mem. 12,808,982 

Total hospital expenditure per capita 

247,537 R 157.36 equity/technical efficiency 

38,952,671 

Recurrent hospital expenditure per capita 


36,063,250 

Hospitals Including SANTA Provincial and SANTA hospital recurrent 

51,029,643 80.45% equity/technical efficiency 

expenditure as a percentage of total recurrent 41,054,280 




Hospital expenditure per capita 

Hospital expenditure as % of sub-district 

expenditure: Matatiele 

Hospital expenditure as % of sub-district 

expenditure: Kokstad 


43,943,701 

19,931,532 24,505,013 81.34% allocative efficiency 

24,012,169 29,551,346 81.26% technical efficiency 

Out-patients (OP) Casualty/Outpatient expenditure per visit 2,221,733 59,832 R 37.13 technical efficiency 

Expenditure on OP as % total district and subdistrict 

2,221,733 54,056,359 4.11% allocative efficiency 


Outpatient visits per professional nurse (per day) 59,832 9 29.55 technical efficiency 

Hospital Casualty: Matatiele Casualty expenditure per visit 561,102 8,577 R 65.42 allocative efficiency 

Expenditure on personnel as % of total Casualty 

Dept Exp. 

559,190 561,102 99.66% technical efficiency 



COST CENTRE Indicator Numerator Denominat Indicator 

Criteria 

or 

Expenditure on Casualty Dept. in Matatiele as % of 561,102 29,551,346 1.90% technical efficiency 

subdistrict exp 


Hospital OP: Kokstad Outpatient expenditure per visit 1,660,631 51,255 R 32.40 technical efficiency 

Expenditure on personnel as % of total OP Dept 1,064,855 1,660,631 64.12% technical efficiency 

Exp. 

Expenditure on OP in Kokstad as % of subdistrict 1,064,855 24,505,013 4.35% allocative efficiency 

exp 


Inpatients: provincial 

Expenditure per inpatient day 29,411,582 113,102 R 260.04 technical efficiency 

hospitals 

Drug (med and vacc.) expenditure as % total 1,880,941 29,411,582 6.40% technical efficiency 

inpatient department expenditure 

Personnel exp. as % total hospital inpatient 19,378,433 29,411,582 65.89% technical efficiency 


X-ray requirements as % hospital inpatient 

111,899 29,411,582 0.38% technical efficiency 


Medical gas as % of hospital inpatient expenditure 559,048 29,411,582 1.90% technical efficiency 

Human Blood as % hospital inpatient expenditure 365,826 29,411,582 1.24% technical efficiency 

Other medical consumables as % hospital inpatient 990,325 29,411,582 3.37% technical efficiency 


Recurrent inpatient expenditure per inpatient day 29,110,445 113,102 R 257.38 technical efficiency 

Hospital: inpatients - Matatiele Expenditure per inpatient day 13,324,076 67,254 R 198.12 technical efficiency 

Average duration of case in theatre 358 2,141 10.04 technical efficiency 

Ratio of minor cases to major cases 1,838 303 6.07 technical efficiency 

Drug exp. as a % of total inpatient department exp. 592,260 13,324,076 4.45% technical efficiency 

Personnel exp. as a % of total inpatient department 9,563,439 13,324,076 71.78% technical efficiency 

exp. 

Drug exp. per inpatient day 592,260 67,254 R 8.81 technical efficiency 

Laundry exp. as % of total inpatient department 612,858 13,324,076 4.60% technical efficiency 

exp. 









Hospital: inpatients - Kokstad Expenditure per inpatient day 16,087,506 45,848 R 350.89 technical efficiency 

Average duration of case in theatre (min) 814 4,159 11.74 technical efficiency 

Ratio of minor cases to major cases 3,243 1,298 2.50 technical efficiency 

Drug exp. as a % of total inpatient department exp. 1,288,681 16,087,506 8.01% technical efficiency 

Personnel exp. as a % of total inpatient department 9,814,994 16,087,506 61.01% technical efficiency 

exp. 

Drug exp. per inpatient day 1,288,681 45,848 28.11 technical efficiency 









Hospital: inpatients - SANTA Expenditure per inpatient day 4,991,029 71,014 R 70.28 technical efficiency 

Personnel exp. as % of total inpatient expenditure 2,858,113 4,991,029 57.27% technical efficiency 

Drug exp as % of total inpatient exp (drugs mostly 

freely provided by state) 




District per capita expenditure estimates 

Drug exp per patient 50,419 2,321 R 21.72 technical efficiency 

Adjusted for cross-border flows Average total per capita expenditure 54,056,359 247,537 R 218.38 equity 

Average total per capita expenditure: Matatiele 24,505,013 165,975 R 147.64 equity 

Average total per capita expenditure: Kokstad 29,551,346 81,562 R 362.32 equity 

Excluding SANTA (because Average total per capita expenditure 49,065,329 247,537 R 198.21 equity 

SANTA funded by Eastern Cape 

and serving more 95 % Eastern 

Cape patients) 



COST CENTRE Indicator Numerator Denominat Indicator 

Criteria 

or 

Average total per capita expenditure: Matatiele 

165,975 R 132.61 equity 

22,009,498 

Average total per capita expenditure: Kokstad 

81,562 R 331.72 equity 

27,055,831 

Using only Census estimates, Average total per capita expenditure 49,065,329 42,515 R 1,154.07 equity 

and 2.98 % per annum population 

growth rate (for comparison with 

per capita expenditure resulting 

from the use of the catchment 

population) 

Average total per capita expenditure: Matatiele 

8,605 R 2,557.76 equity 

22,009,498 

Average total per capita expenditure: Kokstad 

33,910 R 797.87 equity 

27,055,831 

Line item expenditure per capita 

Personnel expenditure per capita 


34,983,405 

Personnel expenditure per capita: Matat 


16,984,475 

Personnel expenditure per capita: Kokstad 


17,998,930 

Adjusted for cross-border flows Drug and medical supplies expenditure in district 4,333,659 247,537 R 17.51 equity 

per capita 

Drug and medical supplies expenditure in district 1,239,065 165,975 R 7.47 equity 

per capita: Matatiele 

Drug and medical supplies expenditure in district 3,094,594 81,562 R 37.94 equity 

per capita: Kokstad 

Revenue collection of, and debt owed to, hospitals 

Revenue collected as % of total district expenditure 1,949,468 54,056,359 3.61% 

Workload indicators 

Revenue collected as % of total recurrent hospital 


Revenue collected as % of total recurrent district 


Revenue collected at Tayler Bequest as % tot hosp 

exp. 

Revenue collected at EG and Usher Mem. as % tot 

hosp exp. 

Collections in the year as a percentage of amounts 

owing, including cumulative debt from previous 

years: Tayler 

Collections in the year as a percentage of amounts 

owing, including cumulative debt from previous 

years: Usher Mem 

Change in debt outstanding (debt outstanding at the 

end of the year minus debt outstanding at the 

beginning of year, divided by debt outstanding at 

the beginning of the year): 

Change in debt outstanding : Tayler Bequest 

1,949,468 38,952,671 5.00% financial sustainability 


508,174 17,436,017 2.91% financial sustainability 


508,173.92 

1,441,294.00 

73,955.93 

952,461 53.35% financial sustainability 

2,425,781 59.42% financial sustainability 

1,354,818 5.46% financial sustainability 

327,104.44 35.82% financial sustainability 

117,182.54 

Change in debt outstanding: Usher Memberial - 1,027,713.45 -4.21% financial sustainability 

43,226.61 

PHC Professional nurses to 10 000 population 

workload 

43.00 247,537.00 1.74 

PHC Prof nurses to 10 000 population: Matat 22 165,975 1.33 workload 

PHC Prof nurses to 10 000 population: Kokstad 21 81,562 

2.57 

workload 



PHC visits per prof nurses per day (excl 

psychiatry but including OP/casualty visits at 

hospitals) 

265,363 43 

27.43 

workload 


psychiatry) : Matat 

127,062 22 

25.67 

workload 


psychiatry) : Kokstad 

138,301 21 

29.27 

workload 



Addendum 3: Cost Units 

1. Theatre Use 

While theatre expenditure was not estimated, activity information can generate some thought-provoking indicators 

for comparing the relative efficiencies of the two theatres in Mt. Currie. Average theatre times at Tayler Bequest, 

Matatiele, unadjusted for case mix, suggest that there is not much difference in their respective theatre efficiency. 

However, if the theatre time in Tayler Bequest were to be adjusted for the difference in the ratio of minor to major 

cases between Usher Memorial and Tayler Bequest theatres, the average theatre time should be 4.13 instead of 

10.75 minutes. This indicates that the efficiency of the theatre in Tayler Bequest hospital should be investigated 

further. 

Table 1: Theatre Usage (1997/98) 


Number of theatre hours 358.25 814.00 1172.25 

Number of theatre cases 2,141 4,541 6,682 

Average duration of theatre case (minutes) 10.75 10.03 10.52- 

Minor: major cases 2.50 6.07 3.17 

Source: hospital theatre books 

2. Radiography: X-rays only 

For every inpatient equivalent in Tayler Bequest hospital, fewer are receiving X-rays than in Usher Memorial. Each 

hospital had only one radiographer in 1997/98. The difference might be attributable to the longer length of stay at 

Tayler Bequest than at Usher Memorial. From the discussion of the workload with the radiographer at Tayler 

Bequest, it does not seem that the Tayler Bequest radiography department is being under-utilised, therefore the 

workload for the one radiologist at Kokstad might well be heavy indeed. 

Table 2: X-ray Activity at the Hospitals (1997/98) 


Radiography use: no. of patients x-rayed 8,257 10,565 18,822 

Hospital in-patient day equivalents 18 70,113 62,933 133,046 

Radiography use per inpatient day equivalent 0.12 0.17 0.14 

Radiography use: no. in-patients x-rayed 6,262 not available - 

18 Calculated by adding together inpatient days plus one third of outpatient admissions. 



Radiography use: no. of out-patients x-rayed 1,995 not available - 

Radiography use: no. of SANTA patients x-rayed 693 N/A - 

Source: Hospital statistics sheet; ; senior hospital radiographer’s records 

An attempt was made to estimate x-ray activity expenditure, which when calculated was R249,000 for both 

hospitals, including the salary of one radiographer, and expenditure on items referred to as “x-ray requisites”. The 

salaries might well underestimate expenditure as salary scale midpoints were taken, in accordance with accepted 

costing methods used in other studies ( Shepard et al. 1998). Cost per x-ray was calculated using the estimates in 

Table 7. Costs per x-ray were higher at Kokstad (R13.50) than at Matatiele (R12.50). These results indicate either 

that Matatiele is under-funded or that Kokstad could be using their resources more efficiently. 

Table 3: Estimation of X-ray Department Expenditure, Rands (1997/98) 


Salary 64,959 64,959 129,918 

Salary plus Benefits 81,846 83,628 165,474 

Personnel costs for x-rays (83 % of time) 67,932 69,412 137,343 

X-ray requisites (inpatient) current 38,232 73,668 111,900 

TOTAL COSTS 106,164 143,080 249,244 

Source: FMS X112 reports for both hospital systems; salary grading system notes (mid-point salary scale values taken for a senior 

radiographer) 

3. Laboratory Use 

It was not possible to obtain separate laboratory costs for Matatiele and Kokstad, but is was possible to obtain 

separate cost and activity information for different types of tests according to whether they were microbiology , 

chemical pathology or haematology tests. The averages for each of these types of test are fairly similar. 

Haematology tests are only marginally more expensive (7.22 per test) than microbiology (R7.08) and chemical 

pathology (R6.91) tests. 

Table 4: Laboratory Activity and Expenditure (1997/98) 

Microbiology 

Chemical 

Pathology 

Haematology 

Number of tests ordered 44,970 66,447 18,311 129,728 

Cost of tests R 318,445 R 459,338 R132,215 R909,998 

Average cost per test R 7.08 R 6.91 R 7.22 R 7.01 

Total 

Percentage of district laboratory expenditure 

on different types of tests 

35 % 50 % 15 % 100 % 



Another way of evaluating laboratory resource use is to calculate laboratory costs per capita. If the cost of all the 

tests are taken together, expenditure per capita works out at between R5.27 and R3.69 per capita. This type of 

indicator will be more useful when it can be compared with indicators for other districts. 



Addendum 4: Reading the Hospital Cash Books 

The hospital’s revenue clerk keep two cash books, a daily one and a monthly one. The daily one records all 

revenue related transactions. The monthly one records only certain specific hospital related revenue, as will be 

described below. 

The monthly cash book 

Receipts are recorded in the following columns in the monthly cash book: 

WOR or WCA which stands for “Workmen’s Compensation” 

This refers to patients who were injured during the course of duty. This includes employees of state and private 

companies, who were injured while at work. In the area around Kokstad, examples of companies whose 

employees present at the hospital are the forestry companies. At least one of these state companies belong to the 

Eastern Cape. The bills are sent to the employer. The Workmen’s Compensation Commissioner is only billed 

directly in circumstances where the hospital has a certain report (name and content of report unknown). 

Stat, which stands for “Statutory” or Hospital Private 

This refers to patients who are employees of the South African Police Services (SAPS) or the Dept. of Correctional 

Services. The bills are sent directly to the medical scheme administrators, which is Medscheme in the case of 

Polmed, and Medihelp for Correctional Services. This category also includes prisoners or prisoners awaiting trial, 

who are treated. If the prisoners are awaiting trial, their bills are sent to SAPS. If the prisoners have been 

sentenced, their bills are sent to the Dept. of Correctional Services. 

I.L. which stands for Individual Liable 

This refers to patients whose income is either above the threshold minimum income, or patients who have medical 

aids. In 1999, the threshold minimum income for a family unit was R56,000.00 per annum and for a single person, 

the threshold minimum income was R34,00.00 per annum. Generally, the hospital sets up accounts for these 

patients, billing them later for care received. 

H/over which stands for Hand Over 

This refers to the cumulative debt, carried forward from the previous year. This debt may be written off several 

times a year. 

OP which stands for Outpatients 

This refers to payments made by patients who are categorised as hospital patients, rather than individual liable, or 

private patients. Hospital patients may fall into categories H1, H2 or H3. Hospital patients must pay cash. No 

accounts are opened for them, as a rule. However, in the past, accounts were occasionally opened. On 

admission, the hospital patient is charged a few Rand, a rate which is lower for H1 patients than H3 patients. 

Collections in this column also include charges for x-rays, laboratory tests, etc.. 





IP which stands for Inpatients 

This refers to payments made by hospital patients for inpatient services. 

AMB which stands for Ambulance Services 

This category is no longer in use. If an ambulance is used by a private individual, ambulance requisitions are sent 

to KZN head office in Durban. They will bill the medical aid or send the patient the account directly. There is no 

charge for hospital patients. 

VET X-RAY 

This includes payments from private vets for X-ray services. 

Surgappl. 

This covers surgical appliances used by private doctors. These doctors are billed via accounts for these 

appliances. 

The rows at the bottom of the page show the following: 

Cash collections 

This includes all cash payments received in the month (generally from the columns, IP, OP and AER). 

+Bfwd which stand for “ add brought forward” 

This includes all the unpaid accounts from the previous month, which are added to the total accounts and cash for 

the existing month. 

Less Receipts 

This deducts all receipts on accounts from the total balance of accounts outstanding (accounts receivable). 

Less ROA which stands for “reduction of accruals” 

This is used to reverse incorrect charges to the patients made by the hospitals. 

Less w/off 

This includes all those debts that have been written off. Note that in 1997/98, there were a number of debts written 

off as people gave incorrect addresses, or moved from their addresses, making it hard to track them down. Many of 

these patients normally reside outside the district, in the Eastern Cape. 



Total 

The total includes all accounts receivable still on the hospital books from several prior years, as well as cash 

receipts for the month. 

The daily cash book 

The daily cash book contains two other categories: vote and other. 

Under the Vote category: 

the following are recorded: 

♦ 

♦ 

♦ 

♦ 

sale of government property, 

MMF claim forms, 

photocopies for MMF claim forms, 

condemned sales. 

Under the Other category: 

are the following types of expenses: 

♦ 

♦ 

♦ 

♦ 

board and lodging, 

uniforms, 

staff fines, and 

employee meals. 

For 1997/98 the daily cash book amounts in Usher Memorial Hospital were: 

Other: 

Vote: 

Total: 

R21,989.89 

R15,544.06. 

R37,533.95.

district health expenditure review - Health Systems Trust

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