district health expenditure review - Health Systems Trust
district health expenditure review - Health Systems Trust
district health expenditure review - Health Systems Trust
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First Mt. Currie District <strong>Health</strong> Expenditure Report<br />
A project of ISDS, <strong>Health</strong> <strong>Systems</strong> <strong>Trust</strong>, and the <strong>Health</strong> Economics Unit, Department of Community<br />
<strong>Health</strong>, University of Cape Town<br />
Funded by the European Union via the National Department of <strong>Health</strong><br />
TABLE OF CONTENTS<br />
Section<br />
Pg<br />
TABLE OF CONTENTS ii<br />
LIST OF ILLUSTRATIONS iv<br />
ACKNOWLEDGEMENTS vi<br />
EXECUTIVE SUMMARY vii<br />
1. INTRODUCTION .............................................................1<br />
2. UNDERSTANDING SERVICES IN MOUNT CURRIE AS ONE OF THE EARLY<br />
STEPS IN THE EXPENDITURE REVIEW. .3<br />
3. OTHER BACKGROUND INFORMATION ....................................5<br />
3.1.The Population Growth Rate and Geographic Distribution .................................5<br />
3.2. The Population Age and Gender Distribution...............................................6<br />
3.3. Education and Income .....................................................................6<br />
3.4. The <strong>Health</strong> District’s Catchment Population ...............................................7<br />
4. INFORMATION, INDICATORS AND THE PROCESS OF DATA<br />
COLLECTION ..................................................................8<br />
4.1. The Information............................................................................8<br />
4.2. The Indicators..............................................................................8<br />
4.3. Data Collection and Compilation ...........................................................8<br />
4.4. Limitations of the Data Collected........................................................ 12<br />
5. RESULTS OF THE FIRST MT. CURRIE EXPENDITURE REVIEW 13<br />
5.1. Sources and Uses of Finances .......................................................... 16<br />
5.2. Percentage of total <strong>expenditure</strong> on different line items ............................... 17<br />
5.3. Workload Indicators...................................................................... 19<br />
5.4. Revenue Collected by the District Hospitals............................................. 19<br />
5.5. Expenditure Per Capita ................................................................... 20<br />
5.6. Hospitals in the District.................................................................. 22<br />
5.7. Clinics and District Surgeon Services .................................................... 24<br />
6. ANALYSIS................................................................... 26<br />
6.1. How Do Resources Compare Within Sub-Districts and Between Districts? (equity) .. 25<br />
6.2. Are Enough Resources Being Spent on Primary <strong>Health</strong> Care? (allocative efficiency) . 26<br />
6.3. Are PHC Resources and the Workload being shared fairly?<br />
(equity and technical efficiency) ...................................................... 27<br />
6.4 Are Hospitals Being Run Efficiently? (technical efficiency)............................. 27<br />
6.5 Will Fee Retention Make an Impact on District Finances? (sustainability).............. 28<br />
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7. LIMITATIONS OF THE STUDY AND THE WAY<br />
FORWARD................................................................... 29<br />
7.1. Limitations................................................................................ 29<br />
7.2. The Way Forward ........................................................................ 29<br />
8. REFERENCES ................................................................ 32<br />
Appendix A: Population Information and Workings ........................................... 33<br />
Appendix B: Expenditure, Activity and Staff Information .................................. 38<br />
Addendum 1: Data Presentation and Collection Issues........................................ 51<br />
Addendum 2: Indicators ....................................................................... 52<br />
Addendum 3: Cost Units....................................................................... 59<br />
Addendum 4: Reading the Hospital Cash Books ............................................... 61<br />
LIST OF TABLES<br />
Table 1: Overall population growth-rate ........................................................5<br />
Table 2: Rural/Urban and Sub-District Distribution of the Population .......................6<br />
Table 3: Age and Gender Distribution of the Population in Mt. Currie (1996) ................6<br />
Table 4: Annual Income Brackets in Mt. Currie (1996) ........................................7<br />
Table 5: District <strong>Health</strong> Account for Mt. Currie: showing<br />
the flow of <strong>expenditure</strong> (from sources to uses), Rands (1997/98)................. 15<br />
Table 6: Percentage Expenditure at Different Facilities/Services (1997/98)................ 16<br />
Table 7: Standard Line Item Expenditure by Sub-District Responsibility<br />
(excludes capital maintenance <strong>expenditure</strong>) (1997/98).............................. 17<br />
Table 8: District and Sub-<strong>district</strong> Line Item Expenditure, Rands (1997/98)................ 18<br />
Table 9: The Distribution of Primary <strong>Health</strong> Care Professional nurses in the<br />
Mt. Currie Sub-<strong>district</strong>s (1997/98)................................................. 19<br />
Table 10: Revenue Collected in the District (1997/98)...................................... 19<br />
Table 11: Total Expenditure in Mt. Currie and the <strong>Health</strong> Sub-<strong>district</strong>s,Rands(1997/98) 20<br />
Table 12: Expenditure per Capita, Rands (1997/98) ......................................... 21<br />
Table 13: Description of Hospitals in Mt Currie (1997/98) .................................. 22<br />
Table 14: Hospital Expenditure per PDE (1997/98) .......................................... 22<br />
Table 15: Inpatient Stay and Expenditure (1997/98) ........................................ 23<br />
Table 16: Out-patient Visits and Expenditure (1997/98) .................................... 23<br />
Table 17: Provincial Clinic Activity and Expenditure (1997/98).............................. 24<br />
Table 18: Municipal Clinic Activity and Expenditure (1997/98).............................. 24<br />
Table 19: Provincial Medicines Used at LA Clinics, Mt Currie 25<br />
Table 20: District Surgeon Activity and Expenditure (1997/98)............................. 25<br />
Table 21: Comparisons of Per Capita Expenditure ........................................... 26<br />
Table 22: Funding of Levels of Care ......................................................... 27<br />
Table 23: Visit Loads per Professional Nurse by Facility (1997/98)......................... 27<br />
Table 24: Funding of Levels of Care ......................................................... 28<br />
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LIST OF FIGURES<br />
Pg<br />
Figure 1: Overview of Appendices and Addenda ...............................................2<br />
Figure 2: <strong>Health</strong> Services in the Mount Currie <strong>Health</strong> District.................................4<br />
Figure 3: Classifications of the Information ...................................................8<br />
Figure 4: Sources of Expenditure Data and Methods of Estimation ......................... 11<br />
Figure 5(a): Tayler Bequest Hospital Responsibility ........................................... 17<br />
Figure 5(b): Usher Memorial Hospital Responsibility .......................................... 17<br />
Figure 6: Key Line Item Recurrent Expenditure in Mt. Currie (1997/98..................... 18<br />
Figure 7: Visits per PHC Professional Nurse per Sub-District................................ 27<br />
LIST OF BOXES<br />
Pg<br />
Box 1: Basic Steps of A District <strong>Health</strong> Expenditure Review ..................................1<br />
Box 2: Classifications of Different Types of Services .........................................9<br />
Box 3: Cost Centres for Mt. Currie........................................................... 13<br />
MAPS<br />
Map 1: KwaZulu-Natal<br />
Map 2: Mt. Currie <strong>Health</strong> District<br />
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ACKNOWLEDGEMENTS<br />
Thanks<br />
The people who assisted the authors in compiling this report need to thanked. These include all the members of<br />
the District Expenditure Review Task Team, as well as the helpful professionals in the <strong>health</strong> services, the<br />
municipalities and the provincial and regional head offices. Hopefully, this <strong>expenditure</strong> <strong>review</strong> has created a<br />
baseline dataset, which can augmented by the Mt. Currie District <strong>health</strong> team in the coming years.<br />
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EXECUTIVE SUMMARY<br />
Introduction<br />
This report documents the findings and conclusions of the first <strong>district</strong> <strong>expenditure</strong> <strong>review</strong> run for the Mt. Currie<br />
<strong>health</strong> <strong>district</strong>. The year under <strong>review</strong> is the government financial year, April 1997 to March 1998. Mt. Currie is a<br />
<strong>health</strong> <strong>district</strong> bordering on the Eastern Cape, in the southernmost part of the KwaZulu-Natal (KZN) province. Its<br />
close proximity to the Eastern Cape border, and the region’s geography, have meant that the main towns in the<br />
<strong>district</strong>, Kokstad and Matatiele, have for years acted as commercial centres for rural areas extending into the<br />
Eastern Cape, or what was formerly known as the Transkei. This fact, together with the history of the region’s<br />
administration, means that the <strong>health</strong> services in the <strong>district</strong> are well frequented by residents of the Eastern Cape.<br />
These cross-border flows made it essential to calculate the <strong>district</strong> catchment population, which was estimated at<br />
247 537 people in 1997/98.<br />
A full range of <strong>health</strong> services are rendered in the <strong>district</strong>, including primary <strong>health</strong> care services, environmental<br />
<strong>health</strong> services, <strong>district</strong> hospital level services and laboratory services. A number of <strong>health</strong> services to the <strong>district</strong> are<br />
still run directly by the province, or the regional office. In addition, as in many <strong>district</strong>s, there are two main public<br />
sector authorities running <strong>health</strong> services; namely local governments (municipalities) and the KZN provincial<br />
government. The two local authorities in the <strong>district</strong> are Matatiele and Kokstad.<br />
Study Methods<br />
The <strong>health</strong> services covered in the study included all <strong>health</strong> services rendered by the municipalities, the province,<br />
non-governmental organisations (NGOs) and the public work done by part-time <strong>district</strong> surgeons (also known as<br />
<strong>district</strong> medical officers). Services rendered by General Practitioners (GPs) to private patients were excluded from<br />
the scope of the <strong>review</strong>. The two <strong>district</strong> hospitals are Tayler Bequest (Matatiele) and E.G. & Usher Memorial (also<br />
referred to as Usher Memorial, in Kokstad). The third hospital in the <strong>district</strong> is the SANTA TB inpatient care facility in<br />
the town of Matatiele.<br />
The methods of investigation included primary data collection, from service records and information system reports;<br />
secondary data collection, from existing published materials (such as the KwaZulu-Natal (KZN) Informatics<br />
Bulletin); and interviews with various service providers in the <strong>health</strong> <strong>district</strong>.<br />
All data, except for the facility maps, were only obtained in the form of documents or system reports. All numerical<br />
data were entered onto Excel spreadsheets. The maps were obtained in electronic and hard copy format from the<br />
Geographical Information System (GIS) of the KZN (provincial) Department of <strong>Health</strong>. Data entered by one<br />
researcher were crosschecked by another researcher for accuracy. Accompanying this report is an electronic copy<br />
of the indicator tables, as well as the line item <strong>expenditure</strong> breakdown from the FMS X112 reports for the two<br />
hospital responsibilities in Matatiele and Kokstad, respectively.<br />
Two key groups of people influencing both the type of data collected and the methods used were the <strong>Health</strong><br />
Expenditure Review Task Team (HERTT), who were developing guidelines for running <strong>district</strong> <strong>expenditure</strong> <strong>review</strong>s,<br />
and the Mt. Currie District Expenditure Review Task Team (DERTT). Three of the authors were also involved in the<br />
HERTT. Both these groups generated lists of indicators and cost centres. In the end, the final <strong>review</strong> went further<br />
than the basic requirements of the HERTT team, except in supplying indicators using facility level catchment<br />
populations, which were not available from the Mt. Currie <strong>health</strong> services.<br />
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Results<br />
Total <strong>district</strong> <strong>expenditure</strong> for the year 1997/98 was R54, 056,359. About 5.6 % of this was capital <strong>expenditure</strong>. Total<br />
<strong>expenditure</strong> was divided between the two sub-<strong>district</strong>s as follows: R24, 505,013 in Matatiele (45 %), and<br />
R29,551,346 in Kokstad (55%). Using the <strong>district</strong> catchment population, whose calculation is described in<br />
Appendix A, these amounts translate into <strong>expenditure</strong> of R148 per capita in Matatiele, R362 per capita in Kokstad,<br />
and R218 per capita in the <strong>district</strong> as a whole.<br />
Most <strong>expenditure</strong> (80 %) in the <strong>district</strong> is under the control of the provincial <strong>health</strong> services, recorded under the<br />
hospital responsibility codes. About 10 % of <strong>expenditure</strong> in the <strong>district</strong> comes from a provincial subsidy, of which 85<br />
% goes from the Eastern Cape government to the Khotsong SANTA centre, with the remainder going to the two<br />
municipalities in the <strong>district</strong>. Of the remaining 10 % of <strong>district</strong> <strong>health</strong> <strong>expenditure</strong>, 6 % comes from the provincial<br />
regional budget and 4 % comes from NGO and Municipality own-revenue.<br />
About 81 % of <strong>district</strong> <strong>expenditure</strong> is on hospitals. About 10 % of <strong>expenditure</strong> is on mobile clinics, municipal fixed<br />
clinics and part-time <strong>district</strong> surgeon services to state patients. Of this amount, 7.7 % of <strong>expenditure</strong> is accounted<br />
for by mobile clinics, 2 % by municipal clinics and under 0.5 % by part-time <strong>district</strong> surgeons.<br />
Expenditure on personnel in Mt. Currie is at least 68 % of total recurrent <strong>expenditure</strong>. The actual figure is probably<br />
higher, as some <strong>expenditure</strong> classified on the FMS system under the standard line item, professional and special<br />
services, includes personnel <strong>expenditure</strong>. Personnel <strong>expenditure</strong> for laboratories was not separated out (and is<br />
quite difficult to do). Drugs and a small amount of consumables (only from municipalities, whose consumables<br />
could not be separated out) account for 11 % of <strong>expenditure</strong>, with the remaining 21 % containing other types of<br />
<strong>expenditure</strong>, a particularly large amount of which comes from other types of hospital inpatient <strong>expenditure</strong>.<br />
Analysis and Discussion<br />
Given that the indicators driving the <strong>expenditure</strong> <strong>review</strong> have been linked to various performance criteria, the study’s<br />
results are discussed with regard to the performance criteria of equity, allocative efficiency, technical efficiency and<br />
sustainability.<br />
1. Equity<br />
District <strong>expenditure</strong> per capita is R218. This <strong>expenditure</strong> is higher than shown in results from the Mt. Frere study<br />
performed in the previous year in a neighbouring <strong>district</strong> in the Eastern Cape (R155 – R163), but lower than<br />
<strong>expenditure</strong> of R249 in a <strong>district</strong> in Gauteng.<br />
Sub-<strong>district</strong> <strong>expenditure</strong> per capita in Matatiele (R148), is lower than <strong>expenditure</strong> per capita reported in the two<br />
other studies mentioned above. The discrepancy in <strong>expenditure</strong> per capita between the two sub-<strong>district</strong>s, namely<br />
Kokstad and Matatiele, is also far larger than between the sub-<strong>district</strong>s in the Mt. Frere study (which had a difference<br />
of R8, versus the difference of R214 here). While this illustrates the high inequity in the distribution of <strong>health</strong> finances<br />
between the Mt. Currie sub-<strong>district</strong>s, the actual figure for Matatiele is probably a little higher because <strong>expenditure</strong> on<br />
the cross-border population, which was included in the Matatiele sub-distirct population, did not take into account<br />
Eastern Cape <strong>expenditure</strong> on primary <strong>health</strong> care clinics.<br />
2. Allocative Efficiency<br />
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Primary <strong>health</strong> care <strong>expenditure</strong> per capita in the <strong>district</strong> is extremely low, and is estimated to be only R41 per<br />
person. This does not compare favourably with some estimates of R165 for the cost of a primary <strong>health</strong> care<br />
package. Admittedly, the estimate of R41 excludes laboratory tests, some provincially run programs and is biased<br />
downward due to the uncertainty surrounding the catchment population, but even with these adjustments, it is still<br />
likely to be lower than is adequate.<br />
Relative to two other studies <strong>review</strong>ed, the indicators communicate mixed signals about the weight given to primary<br />
<strong>health</strong> care services in overall <strong>district</strong> <strong>health</strong> <strong>expenditure</strong>. The Mt. Frere study showed <strong>expenditure</strong> on hospitals to<br />
be less than 70 %, while <strong>expenditure</strong> in Mt. Currie is recorded at about 80 %. On the other hand, hospital<br />
<strong>expenditure</strong> per capita is also lower in Mt. Currie (R173 – R157 = R16, or 10 % lower ), but certainly not as much as<br />
by the difference in primary <strong>health</strong> care <strong>expenditure</strong> per capita (300% lower ).<br />
3. Technical Efficiency<br />
Financial indicators of technical efficiency include hospital <strong>expenditure</strong> per patient day equivalent, inpatient<br />
<strong>expenditure</strong> per patient day, and <strong>expenditure</strong> per primary <strong>health</strong> care (or outpatient) visit.<br />
Inpatient day <strong>expenditure</strong> and patient day equivalent <strong>expenditure</strong> are higher in Usher Memorial hospital (Kokstad)<br />
than in Tayler Bequest (Matatiele). This is a function of the longer average length of stay and the low usage of<br />
casualty services in Tayler Bequest. Inpatient day <strong>expenditure</strong> is R198 in Tayler Bequest, compared with R351 in<br />
Usher Memorial, where there is less of a difference in patient day equivalent (PDE) <strong>expenditure</strong>: R241 in Matatiele<br />
and R342 in Kokstad. The difference for PDEs is only R101 versus R168 for inpatient day <strong>expenditure</strong>.<br />
When compared with two other studies, all <strong>expenditure</strong> indicators, for sub-<strong>district</strong>s and the averages, are higher for<br />
Mt. Currie, except for inpatient day <strong>expenditure</strong> in Tayler Bequest, which is lower than in the hospitals studied in Mt.<br />
Frere. This highlights the inefficient usage of beds in the hospital, due to transport problems experienced by<br />
patients from remote areas.<br />
In primary <strong>health</strong> care, <strong>expenditure</strong> per visit varies greatly between different service providers within the same sub<strong>district</strong>,<br />
and between sub-<strong>district</strong>s. The average number of daily visits per primary <strong>health</strong> care professional nurse in<br />
Kokstad is 29, versus 26 in Matatiele. However <strong>expenditure</strong> per primary <strong>health</strong> care visit is R31 in Kokstad versus<br />
R24 in Matatiele. Expenditure per visit is lowest at municipality clinics (R12 – R 15.80) even though their work has a<br />
high curative component, followed by part-time <strong>district</strong> surgeons (R19), then by mobile clinics (R36) and outpatient<br />
services (R37). Expenditure between providers between sub-<strong>district</strong>s varies mostly for municipal clinics (R 8 – R12<br />
in Matatiele versus R 21 in Kokstad) and outpatient/casualty services (R65 in Tayler Bequest versus R32 in Usher<br />
Memorial).<br />
4. Sustainability<br />
The only <strong>review</strong>ed information that related to the sustainability of hospitals was information on hospital fee<br />
collections. Information for other important issues for hospital sustainability, such as the ratio between capital and<br />
maintenance <strong>expenditure</strong>, was not <strong>review</strong>ed. Revenue collected by hospitals was only 3.6 % of <strong>expenditure</strong> in<br />
1997/98. While Taylor Bequest added 36 % to their debt from the beginning of the year, Usher Memorial managed<br />
to reduce their cumulative debt by 4 % by the end of the year. If hospital fee retention policies are introduced, Tayler<br />
Bequest Hospital will need to improve its billing system, or revise its fee policies in order to improve the efficiency of<br />
fee collection.<br />
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Another area of funding with implications for sustainability of services in the <strong>district</strong>, is the portion of funding used by<br />
and coming from local authorities. Local authorities contributed just under 5 % of total <strong>district</strong> <strong>expenditure</strong>, of which<br />
62 % was funded by their own revenue. About 90 % of this contribution from own-revenue comes from<br />
environmental <strong>health</strong> services. Therefore, the local authorities rely quite heavily on subsidies from the province to<br />
render personal primary <strong>health</strong> care services, whereas own revenue is used more to provide environmental <strong>health</strong><br />
services to the community.<br />
Recommendations<br />
1. Determine ways to decrease the length of stay at Tayler Bequest, focussing on addressing the transport<br />
needs of patients. Other transport needs might also exist between primary <strong>health</strong> care facilities and<br />
hospitals.<br />
2. Investigate drug usage at Tayler Bequest hospital, which appears rather low compared with usage at Usher<br />
Memorial. Either that, or it is recorded incorrectly.<br />
3. Assess the distribution of workload for primary <strong>health</strong> care. The nurses at the municipal clinic in Matatiele<br />
have the highest workload in the <strong>district</strong> (55 patients per nurse per day), followed by the outpatient<br />
department in Usher Memorial and the municipal clinic in Kokstad. While the services offered by the<br />
mobile clinics differ from facility based clinics, they need to be brought into a <strong>review</strong> of how the primary<br />
<strong>health</strong> care workload is distributed between nurses at different institutions. This sort of information will also<br />
be important for planning extra posts, which will require justification, and take some time to be approved.<br />
4. Improve the equity of distribution of resources between Kokstad and Matatiele sub-<strong>district</strong>s, with regard to<br />
hospital and primary <strong>health</strong> care <strong>expenditure</strong>. Kokstad sub-<strong>district</strong> currently has higher average per capita<br />
<strong>expenditure</strong> than Matatiele (R362 versus R148)<br />
5. For the 1998/99 Expenditure Review, the team should aim at doing the following, in order to improve upon<br />
this year’s <strong>review</strong>:<br />
♦<br />
♦<br />
♦<br />
♦<br />
♦<br />
♦<br />
Review and improve estimates of catchment population. Determine catchment populations for<br />
each facility and service.<br />
Collect certain important additional information that the this team did not have the time to collect<br />
for the 1996/97 <strong>review</strong>. In particular information on drugs paid for by the province, but used by the<br />
municipality and provincial vertical programmes, would be important.<br />
Collect more detailed information on which staff’s costs are on which responsibilities.<br />
Do cost allocations, in particular:<br />
♦ to allocate laboratory costs across all <strong>district</strong> services; and<br />
♦ to allocate provincially and regionally run primary <strong>health</strong> care services to the <strong>district</strong>.<br />
Assess the appropriateness of maintenance and capital <strong>expenditure</strong>, drawing up a capital and<br />
maintenance plan (if one does not already exist).<br />
Assess the improvement of the hospital billing systems.<br />
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MOUNT CURRIE DISTRICT EXPENDITURE REVIEW<br />
REPORT FOR THE YEAR APRIL 1997 TO MARCH 1998<br />
1. INTRODUCTION<br />
Mount Currie is a magisterial <strong>district</strong> in the province of KwaZulu-Natal. Map 1 shows the location of Mt. Currie with<br />
respect to the rest of the province. The boundaries of the <strong>health</strong> <strong>district</strong> coincide with those of the magisterial<br />
<strong>district</strong>. It falls within the Port-Shepstone <strong>health</strong> region, bordering on the Eastern Cape Province. As a result of its<br />
position, surrounded by the Eastern Cape and close to Lesotho, the <strong>district</strong>’s catchment population of about 247 537<br />
is far greater than the population of 42 310 recorded by the Census as residing in the <strong>district</strong>.<br />
The <strong>district</strong> <strong>health</strong> <strong>expenditure</strong> <strong>review</strong> in Mount Currie took place from February to August 1999. Before, and during<br />
this period, the <strong>Health</strong> Expenditure Review Task Team (HERTT), a body convened by the Initiative for Sub-District<br />
Support (ISDS) of the <strong>Health</strong> <strong>Systems</strong> <strong>Trust</strong> (HST ), were developing national <strong>district</strong> <strong>expenditure</strong> guidelines.<br />
Experiences from the Mount Currie <strong>expenditure</strong> <strong>review</strong> were fed back to the HERTT, and their developments also<br />
helped to shape the <strong>expenditure</strong> <strong>review</strong>.<br />
Other relevant processes occurring at the time of writing this report, which the reader should be aware of, is a<br />
National <strong>Health</strong> Accounts Project and the Data Dictionary Project. These projects are adding to the excellent work<br />
of the <strong>Health</strong> Information System Pilot Project (HISPP), completed last year, which developed a minimum set of<br />
largely non-financial, management information indicators. While the development of non-financial management<br />
indicators in the <strong>health</strong> sector is well underway, the development of financial management and equity indicators (i.e.<br />
indicators combining finance and output, activity or population information) needs further work. Thankfully, the NHA<br />
project and the work of teams piloting the <strong>district</strong> <strong>expenditure</strong> <strong>review</strong> guidelines will go some way to filling this gap in<br />
the months to come.<br />
Box 1 outlines the steps to be followed in a <strong>district</strong> <strong>health</strong> <strong>expenditure</strong> <strong>review</strong>, as recommended by the HERTT. The<br />
Mt. Currie researchers followed these steps, with the feedback from the <strong>district</strong> (step 6) adding substantively to the<br />
report. From here, it is up to the District Team to take forward this report’s findings in the ways suggested in steps 8<br />
and 9. The recommendations section will hopefully help them to complete these steps successfully.<br />
1. Process and participation:<br />
1.1. Orientate the <strong>district</strong> management team (DMT) and get the provincial level people involved.<br />
1.2. Identify key role players and establish a <strong>district</strong> <strong>expenditure</strong> <strong>review</strong> task team (DERTT).<br />
1.3. Identify what services there are in the <strong>district</strong> and who holds financial information about them. (If this is not known, this is the first part of the<br />
work that needs to be done before continuing.)<br />
1.4. Identify what indicators you will need, the relevant cost centres and what data you need to calculate the indicators.<br />
1.5. Data collection and compiling the information: Identify what information is required and where to get it.<br />
2. Organise the collection of information (who will collect what).<br />
2.1. Allocate tasks.<br />
2.2. Compile the information in tables.<br />
2.3. Check validity of the information.<br />
3. Finalise tables.<br />
4. Allocate costs to the cost centres, if needed.<br />
5. Analyse the results and make recommendations.<br />
6. Report back to the DMT.<br />
7. Revise and produce the final report. This report should highlight the next steps to be taken.<br />
8. The DMT studies the report and takes appropriate management decisions.<br />
9. The report is used as a basis for financial and service planning for the following financial years.<br />
<strong>Health</strong> Economics Unit and ISDS 1
First Mt. Currie District <strong>Health</strong> Expenditure Report<br />
Box 1: Basic Steps of A District <strong>Health</strong> Expenditure Review<br />
Source: Adapted from HERRT Draft District <strong>Health</strong> Expenditure Review Guidelines<br />
The steps in Box 1 also suggest an outline to follow when writing the report and this report is modelled accordingly,<br />
starting with itemising the <strong>health</strong> services offered in the <strong>health</strong> <strong>district</strong> boundary, and with determining where to find<br />
financial and non-financial information on them, in Section 2.<br />
The following section, Section 3, presents some additional background information on the population that is useful<br />
to people unacquainted with the area, as well as to the overall analysis of the <strong>health</strong> services <strong>expenditure</strong> and activity<br />
data.<br />
Section 4 briefly describes the indicators identified by the team, and the process of data collection.<br />
Section 5 presents a summation of the results for the <strong>district</strong>. For results on each of the cost units, see Addendum 3.<br />
Section 6 tries to bring into focus some of the more startling pictures emerging from the results.<br />
Section 7 suggests points to take forward for further investigation. As the <strong>district</strong> team will soon begin the 1998/99<br />
<strong>district</strong> <strong>health</strong> <strong>expenditure</strong> <strong>review</strong> (DHER), the final section, Section 7, includes some suggestions derived from<br />
experiences with conducting this <strong>expenditure</strong> <strong>review</strong>, for implementing the next <strong>district</strong> <strong>health</strong> <strong>expenditure</strong> <strong>review</strong> in<br />
Mt. Currie.<br />
Figure 1: Overview of Appendices and Addenda<br />
Main Report<br />
Appendices<br />
Addenda<br />
A. Catchment<br />
Population and<br />
Expenditure per<br />
capita Workings<br />
B. Activity, Staff and<br />
Expenditure<br />
Information<br />
1. Data<br />
presentation<br />
and collection<br />
issues<br />
2. Indicators<br />
(also on disc)<br />
3. Cost<br />
Units<br />
4. Reading<br />
the Hospital<br />
Cash Book<br />
<strong>Health</strong> Economics Unit and ISDS 2
First Mt. Currie District <strong>Health</strong> Expenditure Report<br />
2. UNDERSTANDING SERVICES IN MOUNT CURRIE AS ONE OF<br />
THE EARLY STEPS IN THE EXPENDITURE REVIEW<br />
The HERRT District Expenditure Review Guidelines, as represented by Box 1, in the introduction, identified the<br />
necessity for first understanding what services go into the <strong>district</strong>, before embarking upon the <strong>district</strong> <strong>expenditure</strong><br />
<strong>review</strong>. The information below briefly describes the <strong>health</strong> services in the <strong>district</strong>, and who holds financial<br />
information about these services.<br />
Mt Currie is made up of two <strong>health</strong> sub-<strong>district</strong>s: Kokstad and Matatiele. The services offered in each sub-<strong>district</strong><br />
are listed below in Figure 2. Both sub-<strong>district</strong>s have several types of services in common; they each have a <strong>district</strong><br />
hospital, a mobile clinic service, a <strong>district</strong> surgeon and a municipal clinic. Each sub-<strong>district</strong> also has it own<br />
municipality rendering environmental <strong>health</strong> services within its boundaries and the province (from the regional<br />
office) rendering services between municipal areas.<br />
Services found in one sub-<strong>district</strong> and not in another are: a mental <strong>health</strong> clinic, a laboratory and an oral <strong>health</strong><br />
service, which are only found in Kokstad. From the records we received on mental <strong>health</strong> services, the psychiatric<br />
clinic in Kokstad appears to offer some services in Matatiele, though fewer in number than in Kokstad. The<br />
Khotsong SANTA in-patient centre, or hospital, is located in Matatiele sub-<strong>district</strong>. Within the SANTA network of TB<br />
hospitals, it acts a regional referral centre for TB. According to a regional development report (Integrated Planning<br />
Services 1998), there are 7 private medical practitioner’s surgeries in Kokstad and 4 in Matatiele.<br />
No statistics were found on traditional medicine practices but given the rural location of the <strong>district</strong>, household<br />
surveys show that these services are likely to exist. A 1993 household survey 1 showed that 5 % of people consulting<br />
<strong>health</strong> services in rural KwaZulu-Natal consulted a traditional healer.<br />
Map 2, computed by the Geographic Information System (GIS) Unit at the provincial Department of <strong>Health</strong>, shows<br />
the location of the two major towns in the <strong>health</strong> <strong>district</strong>, as well as the number of physical structures clustered within<br />
each town. For presentation purposes, the places you see identified on the map are not shown in their exact<br />
physical location. Note, also, that the map only shows the physical buildings that offer <strong>health</strong> services and not the<br />
services themselves. This form of representation especially omits vertically funded services.<br />
1 The survey referred to was the 1993 South African Labour and Development Research Unit (SALDRU) Project for Statistics on Living<br />
Standards and Development.<br />
<strong>Health</strong> Economics Unit and ISDS 3
First Mt. Currie District <strong>Health</strong> Expenditure Report<br />
Figure 2: <strong>Health</strong> Services in the Mount Currie <strong>Health</strong> District<br />
Type of services Description Where <strong>expenditure</strong> information can<br />
be obtained<br />
Located in:<br />
Kokstad<br />
Sub-<br />
District<br />
Located in:<br />
Matatiele<br />
Sub-<br />
District<br />
(a) In-patient and outpatient<br />
services<br />
(b) Specialised Inpatient<br />
services<br />
(c) Primary <strong>health</strong> care<br />
services<br />
East Griqualand & Usher Memorial<br />
Hospital: authorised beds- 198, actual<br />
beds- 220<br />
Tayler Bequest Hospital: authorised beds –<br />
204<br />
Khotsong SANTA Centre – 250 beds<br />
(regional TB centre)<br />
Offered in the out-patient setting described<br />
above<br />
From FMS system in provincial<br />
head office (note 1)<br />
From FMS system in provincial<br />
head office<br />
From SANTA office at Khotsong<br />
From FMS system in provincial<br />
head office<br />
2 mobile clinic teams (note 1) From FMS system in provincial<br />
head office<br />
family planning fixed clinic in mobile clinic<br />
base complex<br />
From FMS system in provincial<br />
head office<br />
municipal fixed clinic From municipal offices X X<br />
X<br />
X<br />
X<br />
X<br />
X<br />
X<br />
X<br />
X<br />
X<br />
<strong>district</strong> surgeon practices: 1 in each sub<strong>district</strong><br />
From FMS system in provincial<br />
head office<br />
X<br />
X<br />
mental <strong>health</strong> fixed clinic: Kokstad Mental<br />
<strong>Health</strong> Clinic including management of clinic<br />
(with some services offered in Matatiele)<br />
From FMS system in provincial<br />
head office (cannot get separated<br />
<strong>expenditure</strong>)<br />
X<br />
(d) Community and<br />
programmatic Services<br />
(d) Environmental<br />
<strong>health</strong> services<br />
AIDS and AIDs awareness<br />
AIDS fund at province for workshops etc.<br />
Nutrition programme<br />
Other provincial <strong>health</strong> promotion activities<br />
Tuberculosis management at regional level<br />
School <strong>health</strong> teams<br />
Oral <strong>health</strong><br />
each municipality runs its own<br />
environmental <strong>health</strong> services<br />
from the regional office<br />
From regional office and provincial<br />
offices. Note that it is necessary to<br />
estimate <strong>expenditure</strong> on each of<br />
these programs as <strong>expenditure</strong> is<br />
not recorded separately in the<br />
system. See Addendum 1 for more<br />
on this.<br />
From municipal offices<br />
From FMS reports<br />
(e) Private practitioners 7 practices From practitioners themselves (if X<br />
the private sector is included in<br />
future <strong>review</strong>s)<br />
4 practices As above. X<br />
X<br />
X<br />
X<br />
X<br />
X<br />
X<br />
X<br />
X<br />
X<br />
X<br />
X<br />
X<br />
X<br />
X<br />
X<br />
(f) Support Services Ambulance garages From regional (Port Shepstone)<br />
office<br />
Laboratories<br />
From laboratory in EG & Usher<br />
Memorial Hospital/ also regional<br />
office FMS<br />
(g) Administration District Office From District Office: only since<br />
1998<br />
X<br />
X<br />
X<br />
X<br />
Note(1):<br />
Note (2):<br />
Mobile clinics and Transitional Local Council, or Municipality, clinics offer the following primary <strong>health</strong> care services:<br />
maternal and child <strong>health</strong> services; nutrition and growth monitoring; immunisations, family planning and ante-natal care; TB<br />
and psychiatric follow-up; minor ailments; and <strong>health</strong> education.<br />
Information on revenue from hospital services was obtained from the hospital monthly cashbook. For information on<br />
reading the cashbook, see Addendum 4.<br />
<strong>Health</strong> Economics Unit and ISDS 4
First Mt. Currie District <strong>Health</strong> Expenditure Report<br />
3. OTHER BACKGROUND INFORMATION<br />
3.1. The Population Growth Rate and Geographic Distribution<br />
According to the 1996 census the total population in Mt Currie is 44 875 and the number of households is 11 222.<br />
Of the 44 873, 42 310 reside in the <strong>district</strong>. The average household size is equal to the national average of 4.0<br />
people per household. In terms of residency, more than 94 % of the total <strong>district</strong> population usually live in KwaZulu-<br />
Natal. Working from available Census information, Table 1 shows the provincial growth rate for the <strong>district</strong>’s<br />
population at roughly 5-year intervals over the last fifteen years.<br />
Table 1: Overall population growth-rate<br />
Year Population % Population Growth Rate<br />
Total population (1980) 43 545<br />
Total population (1985) 34 973 -19.69<br />
Total population (1991) 41 562 18.84<br />
Total population (1995) 43 575 4.84<br />
Total population (1996) 44 875 2.98<br />
Source: Census data 1996<br />
According to the 1996 Census, the Mt. Currie population dropped by 19.69 % between the periods 1980 and 1985.<br />
There is no obvious explanation why this occurred, or whether the accuracy of the survey should be brought into<br />
question. Following this decline, a sharp growth of 18.84 percent occurred between the periods 1985 and 1991.<br />
The population growth rate was 4.84 % between the periods 1991 and 1995 and became 2.98 % between the<br />
periods 1995 and 1996. The final growth rate is large considering that it occurred in less than two years and when<br />
compared to the growth rate of the previous five-year period.<br />
Approximately 76.93 % of the <strong>district</strong>’s population live in the Kokstad Sub-District. The proportion of the <strong>district</strong>’s<br />
population living in non-urban areas is approximately 38.48 %.<br />
Table 2: Rural/Urban and Sub-District Distribution of the Population<br />
Population<br />
Matatiele Sub-<br />
District<br />
Kokstad Sub-<br />
District<br />
Mt. Currie<br />
District<br />
Urban Population 6 570 21 039 27 609<br />
Non-Urban Population 3 780 13 486 17 266<br />
Total Population 10 350 34 525 44 875<br />
Source: Census data 1996<br />
The percentage of people living in urban versus non-urban areas, especially in the Matatiele Sub-District, is<br />
factually accurate, but deceptive when translated into use of <strong>health</strong> services. As can be seen in Map 2, Matatiele is<br />
surrounded on several sides by land that falls under the Eastern Cape Provincial Government. This means that the<br />
<strong>Health</strong> Economics Unit and ISDS 5
First Mt. Currie District <strong>Health</strong> Expenditure Report<br />
actual number of people living in rural areas, which naturally use the town for commercial purposes, as well as the<br />
<strong>health</strong> services there, is far greater. In these cases, the estimation of catchment populations is extremely important<br />
(see Section 3.4).<br />
<strong>Health</strong> Economics Unit and ISDS 6
First Mt. Currie District <strong>Health</strong> Expenditure Report<br />
3.2. The Population Age and Gender Distribution<br />
According to the 1996 census, as shown in the age groups listed in Table 3 below, more than 50 percent of the<br />
population are below the age of 25. Between ages 26 and 40 years, lie 23.36 % of the total <strong>district</strong> population and<br />
between the ages 41 and 55 years, there are only 12.42 % of the total <strong>district</strong> population. By contrast, in the 0 to 5<br />
years group, which only spans five years, there is 13.88 % of the total <strong>district</strong> population. The very young age profile<br />
of the <strong>district</strong> is important information for <strong>health</strong> service planners.<br />
In terms of gender, there are more females (51.73%) than males (48.27%). In all age groups except “6” and<br />
“unspecified” years of age, it is notable that females always form more than 50 percent of the age group. While it is<br />
normal for there to be a higher proportion of females than males in a given human population, there is no obvious<br />
explanation for the reverse occurring in the two population groups mentioned. No statistical tests were done to<br />
assess whether this was caused by anything other than chance.<br />
Table 3: Age and Gender Distribution of the Population in Mt. Currie (1996)<br />
Age Groups (in<br />
years)<br />
Mt. Currie Population – weighted person and percentage<br />
Male % Female % Total % %<br />
(cumulative)<br />
0-5 3,048 14.07 3,180 13.70 6,228 13.88 13.88<br />
6 596 2.75 518 2.23 1,114 2.48 16.36<br />
7-10 1,945 8.98 1,949 8.40 3,894 8.68 25.04<br />
11-15 2,336 10.79 2,418 10.42 4,754 10.59 35.63<br />
16-20 2,130 9.84 2,319 9.99 4,449 9.90 45.53<br />
21-25 2,109 9.74 2,384 10.27 4,493 10.00 55.53<br />
26-40 5,114 23.61 5,370 23.13 10,484 23.36 78.89<br />
41-55 2,681 12.38 2,894 12.47 5,575 12.42 91.31<br />
56-65 892 4.12 1,116 4.81 2,008 4.47 95.78<br />
over 65 511 2.36 825 3.55 1,336 2.98 98.76<br />
unspecified 296 1.37 242 1.04 538 1.2 99.96<br />
Total 21,658 100.00 23,215 100.00 44,873 100.00<br />
Source: Census 1996<br />
3.3. Education and Income<br />
About 7 % of the <strong>district</strong>’s population have their matric (final year of schooling) even though about 55 % of people in<br />
the <strong>district</strong> are older than 20 years. This compares unfavourably with the provincial average of 14.74 %. More than<br />
72.73 % of the total <strong>district</strong> population have education equal to or less than grade eleven. Most of those who have<br />
tertiary education are those with diplomas followed by bachelor’s degrees. As indicated above very few of them have<br />
postgraduate degrees such as Honours, Masters and Doctoral degrees with percentages equal to no more than<br />
0.04 %.<br />
<strong>Health</strong> Economics Unit and ISDS 7
First Mt. Currie District <strong>Health</strong> Expenditure Report<br />
The pattern of employment reflects the below average education levels in the <strong>district</strong>. The unemployment rate<br />
amongst the adult population (people 16 years and older), as recorded in the 1996 Census, is 13.80%. About<br />
51.52% or people are recorded as employed and the remainder are not working or unspecified.<br />
Table 4 records the annual income of households in Mt. Currie. Given the estimate of 4 people per household,<br />
average annual consumption for 45 % of the households is R1,000 or less. This figure approximates the average<br />
annual per capita consumption estimated for the 2 nd poorest quintile of households in South Africa (McIntyre et al.<br />
1998).<br />
Table 4: Annual Income Brackets in Mt. Currie (1996)<br />
Income Bracket<br />
No.Households % Households % Households<br />
(cumulative)<br />
None 661 5.89 5.89<br />
R0-1400 1,931 17.21 23.10<br />
R2401-6000 2,501 22.29 45.39<br />
R6001-12000 1,191 10.61 56.00<br />
R12001-18000 840 7.49 63.49<br />
R18001-30000 687 6.12 69.61<br />
R30001-42000 368 3.28 72.89<br />
R42001-54000 308 2.74 75.63<br />
R54001-72000 294 2.62 78.25<br />
R72001-96000 251 2.24 80.49<br />
R96001-132000 221 1.97 82.46<br />
R132001-192000 106 0.94 83.40<br />
R192001-360000 67 0.60 84.00<br />
R360001 or more 19 0.17 84.17<br />
Unspecified 1,754 15.63 99.80<br />
NA 23 0.20 100.00<br />
Total 11,222 100.00<br />
Source: Census data 1996<br />
3.4. The <strong>Health</strong> District’s Catchment Population<br />
As mentioned above in Section 3.2, due to high rates of cross-border flows, it is not feasible to use the 1996 Census<br />
<strong>district</strong> population as the catchment population. The catchment population calculated in this study ranged between<br />
170 081 and 295 371. In discussion with the <strong>district</strong> team, they were satisfied with using the <strong>district</strong> catchment<br />
population estimate of 247 537, broken down as 165 975 in the Matatiele Sub-<strong>district</strong> and 81 562 in the Kokstad<br />
Sub-<strong>district</strong>. For more information on how this was calculated, see Appendix A.<br />
<strong>Health</strong> Economics Unit and ISDS 8
First Mt. Currie District <strong>Health</strong> Expenditure Report<br />
4. INFORMATION, INDICATORS AND THE PROCESS OF<br />
DATA COLLECTION<br />
4.1. The Information<br />
Many different types of information need to be collected for an <strong>expenditure</strong> <strong>review</strong>. One way to organise our thinking<br />
in the data collection process, was to categorise the information, as shown in Figure 3. The different types of<br />
information included population, services and financial information. Each of these types of information could be<br />
further categorised as shown below.<br />
Figure 3: Classifications of the Information<br />
POPULATION<br />
Needs and<br />
demographics of:<br />
• <strong>district</strong><br />
population<br />
• service<br />
catchment<br />
Finances Balance Need and Services<br />
FINANCES<br />
• <strong>expenditure</strong><br />
• revenue<br />
SERVICES<br />
• resource-related (e.g.<br />
number of beds, staff)<br />
• activity related (e.g.<br />
number of admissions,<br />
inpatient days)<br />
The population information describes <strong>health</strong> needs. Services information describes the application of medical<br />
resources and technology to meet those needs. Finances are what enable a balance to be struck between need<br />
and services. The financial information, when combined with need or services information, produces indicators<br />
that describe and measure the application of services to needs, both how efficient and how equitable the service<br />
provision is, relative to the population need, and relative to other ways resources could be used in the economy.<br />
4.2. The Indicators<br />
The Mt. Currie District Expenditure Review Task Team (DERTT) met near the beginning of the Expenditure Review<br />
to discuss which indicators would be most useful for monitoring equity, efficiency and financial sustainability in the<br />
<strong>district</strong>. The list developed by DERTT in March is recorded in Addendum 2, Figure 1. The final list of indicators<br />
developed for the <strong>district</strong> was based on this list developed by the DERTT, as well as the initial list of indicators<br />
developed by the national <strong>Health</strong> Expenditure Review Task Team (HERTT). Where it was possible to do so with<br />
extra information collected, the indicators requested by the <strong>district</strong> were calculated, in addition to the indicators<br />
recommended by HERTT. For the full list of indicators calculated, and their values, refer to Figure 3 of Addendum<br />
2.<br />
<strong>Health</strong> Economics Unit and ISDS 9
First Mt. Currie District <strong>Health</strong> Expenditure Report<br />
4.3. Data Collection and Compilation<br />
Most of the data collection occurred on three trips to KwaZulu-Natal. The first data collection trip to Mt. Currie<br />
included a two-day meeting where the researchers were introduced to the Mt. Currie District Expenditure Review<br />
Task Team and worked through the first few steps of the District <strong>Health</strong> Expenditure Review process (as described<br />
in Box 1, Section 1). Their activities included introducing members of the DERTT to what would be covered by the<br />
<strong>district</strong> <strong>expenditure</strong> <strong>review</strong>, working through exercises practising the interpretation of indicators, choosing relevant<br />
indicators and identifying sources of information. The remaining two-days were spent collecting information. One<br />
researcher made the second trip to KwaZulu-Natal, and collected information from the provincial head office over a<br />
period of two days. On the third and final trip , two researchers visited the KwaZulu-Natal <strong>health</strong> department head<br />
offices in Natalia and services in Mt. Currie, where they collected the outstanding service information. While the<br />
researchers were writing the report, they also kept in contact with the DERTT to ask them for clarification of data,<br />
where necessary.<br />
Box 2: Classifications of Different Types of Services<br />
♦<br />
♦<br />
♦<br />
♦<br />
Community services<br />
♦ emergency medical transport<br />
♦ municipal env. <strong>Health</strong><br />
♦ provincial env. <strong>Health</strong><br />
Clinics and <strong>district</strong> surgeon (<strong>district</strong> medical officer) services<br />
(also called personal <strong>health</strong> care services)<br />
♦ provincial mobiles<br />
♦ municipal clinics<br />
♦ <strong>district</strong> surgeons<br />
Hospital services<br />
♦ <strong>district</strong> hospital (provincial) auxiliary<br />
♦ <strong>district</strong> hospital (provincial) outpatients<br />
♦ <strong>district</strong> hospital (provincial) inpatients<br />
♦ SANTA inpatients<br />
District support services<br />
♦ laboratory<br />
Population information was collected from the 1996 census housed at the research unit (SALDRU) at the University<br />
of Cape Town. Maps were collected from the Geographic Information System (GIS) of the Provincial <strong>Health</strong><br />
Department of KwaZulu-Natal (KZN) and were drawn up by Shannon Hogan of the KZN GIS Unit.<br />
Service activity and resource-related information was obtained from a variety of sources. The most important<br />
information was collected from the following people and at the following places:<br />
♦ The <strong>Health</strong> Informatics Bulletin (KwaZulu-Natal Province 1998)<br />
♦ number of authorised beds<br />
♦ bed occupancy rates<br />
♦ length of stay<br />
♦ outpatient headcounts;<br />
<strong>Health</strong> Economics Unit and ISDS 10
First Mt. Currie District <strong>Health</strong> Expenditure Report<br />
♦<br />
♦<br />
♦<br />
♦<br />
♦<br />
♦<br />
♦<br />
♦<br />
♦<br />
♦<br />
♦<br />
Provincial <strong>Health</strong> Department, Natalia<br />
♦ PERSAL information: the number of provincial staff falling under the two hospital complex’s<br />
budgets - staff by category for each sub-<strong>district</strong><br />
♦ <strong>district</strong> surgeons (<strong>district</strong> medical officers): no. of scripts and no. of patients seen and breakdown<br />
of activities;<br />
Theatres nurses at both (provincial) <strong>district</strong> hospitals<br />
♦ number of theatre cases (major versus minor) – per month for 12 months<br />
♦ number of theatre hours – per month for 12 months;<br />
Outpatient admissions clerks at both <strong>district</strong> hospitals<br />
♦ number of inpatient admissions, by place of residence<br />
♦ number of outpatient headcounts (by place of origin, only for Matatiele);<br />
Chief nurse at Matatiele municipality (local authority) clinic (monthly patient statistics)<br />
♦ headcounts – per month for 12 months<br />
♦ number of clinic staff;<br />
Head office of Kokstad municipality<br />
♦ number of clinic staff<br />
♦ headcounts;<br />
Mobile clinic (Kokstad)<br />
♦ headcounts<br />
♦ kms travelled;<br />
Senior radiologist , X-ray Dept., Tayler Bequest Hospital (Matatiele)<br />
♦ number of X-rays, by in-patient and outpatient;<br />
SAIMR laboratory based at Usher Memorial (EG& Usher Mem) Hospital<br />
♦ number of tests<br />
♦ number of test units;<br />
Pharmacists at hospital pharmaceutical depot<br />
♦ number of prescriptions<br />
♦ number of items per script;<br />
Administration of each hospital<br />
♦ breakdown of staff at mobile clinic (mobile clinic complex) and<br />
♦ in outpatient departments; and<br />
Mental <strong>health</strong> clinic, Kokstad<br />
♦ number of staff<br />
♦ number of visit (headcounts) (obtained data for 7 months).<br />
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First Mt. Currie District <strong>Health</strong> Expenditure Report<br />
Financial information that related to hospital revenue was obtained from the hospital monthly cash book. For more<br />
information on the hospital cash books, see Addendum 4. Information on municipal clinic and environmental <strong>health</strong><br />
revenue was obtained from the municipality head offices.<br />
Figure 4 summarises the way in which <strong>expenditure</strong> data was collected for each of the different types of <strong>health</strong><br />
services in Mt. Currie, which were grouped as described in Box 2. While reading like instructions, the methods<br />
described in Figure 4 were the methods followed by the researchers. They are presented in this format so that they<br />
can also serve as an instruction sheet for future <strong>district</strong> <strong>expenditure</strong> <strong>review</strong>s.<br />
Once the non-financial and financial information was collected, the researchers compiled the information onto<br />
Excel spreadsheets. An electronic version of the indictors and some <strong>expenditure</strong> tables compiled from the FMS<br />
system reports, was handed to the DERTT on submission of this report.<br />
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First Mt. Currie District <strong>Health</strong> Expenditure Report<br />
Figure 4: Sources of Expenditure Data and Methods of Estimation<br />
Expenditure, by type of service<br />
Source of <strong>expenditure</strong> information and method of estimation<br />
Community services<br />
- emergency medical transport Source: From information compiled by Beth Engelbrecht from FMS on<br />
AEMS for region<br />
Method: Divide regional AEMS <strong>expenditure</strong> by 3 (three <strong>district</strong>s) and<br />
allocate according to populations (adjusted for cross-border flows) per sub<strong>district</strong><br />
- municipal env. <strong>Health</strong> Source: From municipal ledgers; Matatiele: Department 50, Section 40;<br />
Kokstad: “<strong>health</strong> services”<br />
Method: Take total <strong>expenditure</strong> for environmental <strong>health</strong>; for Kokstad, this<br />
includes an administrative <strong>expenditure</strong> line item of R8,000.00<br />
- provincial env. <strong>Health</strong> Source: From information compiled by Beth, extracted for Mt. Currie <strong>district</strong><br />
from regional budget<br />
Method: Divide Mt. Currie estimate in 2 (because <strong>expenditure</strong> represents<br />
services in 3 <strong>district</strong>s), then apportion between sub-<strong>district</strong>s according to the<br />
population, as was done for emergency medical services<br />
Clinics and <strong>district</strong> surgeon (<strong>district</strong> medical<br />
officer) services<br />
- provincial mobiles Source: From FMS report X112, for all responsibilities and programmes,<br />
down to level of minor item<br />
Method: Take total for clinics <strong>expenditure</strong> (capital and current); Note: this<br />
includes a fixed component, a fixed clinic based in the mobile clinic complex<br />
- municipal clinics Source: From municipal ledgers; Matatiele: Department 50, Section 42<br />
(“primary <strong>health</strong> care”); Kokstad: “clinic”; and from Report submitted by<br />
Kokstad TLC to the KZN province<br />
Method: Take total <strong>expenditure</strong> for clinic; for Kokstad, this includes an<br />
administrative <strong>expenditure</strong> line item (R5,000.00 for clinic)<br />
- <strong>district</strong> surgeons Source: From FMS system, provincial head office<br />
Method: Information on payments to <strong>district</strong> surgeons for units of service<br />
(includes medico-legal work), and for drugs (own and provided by state); add<br />
two together<br />
Hospital services<br />
- <strong>district</strong> hospital (provincial) auxiliary Source: From FMS system report, no. X112. There are two reports: one for<br />
East Griqualand and Usher Memorial; another for Tayler Bequest Hospital.<br />
The first <strong>expenditure</strong> breakdown in the report relates to auxiliary and support<br />
services<br />
Method: Take total <strong>expenditure</strong>. Included in the report for Kokstad’s<br />
<strong>expenditure</strong> statement under auxiliary services are laundry and management<br />
of buildings; for Matatiele, there are no laundry entries<br />
- <strong>district</strong> hospital (provincial) outpatients Source: From FMS system report, no. X112<br />
Method: Include all outpatient <strong>expenditure</strong><br />
- <strong>district</strong> hospital (provincial) inpatients Source: From FMS system report, no. X112<br />
Method: Include all inpatient <strong>expenditure</strong><br />
- SANTA inpatients Method: Received Income Statement from SANTA; include total<br />
<strong>expenditure</strong>, including 7.5 % administration fees paid to SANTA head office<br />
District support services<br />
- laboratory Source: From laboratory based at East Griqualand and Usher Memorial<br />
Hospital, Kokstad<br />
Method: Include all laboratory <strong>expenditure</strong> for the <strong>district</strong>. Divide equally<br />
between the sub-<strong>district</strong>s<br />
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First Mt. Currie District <strong>Health</strong> Expenditure Report<br />
4.4. Limitations of the Data Collected<br />
Problems experienced with data collection were evaluated using the following criteria, identified in the Department<br />
of <strong>Health</strong>’s District <strong>Health</strong> Information System Guidelines (Department of <strong>Health</strong>, February 1998), namely: face<br />
validity; inconsistencies; gaps; and calculations. A potential sources of error for all data recorded here was that data<br />
were inputted manually from physical records. To minimise errors in this work, work done by one researcher was<br />
checked by another researcher, using the original records.<br />
(a) Non-financial Information<br />
The greatest difficulty encountered with non-financial information was obtaining information on headcounts for<br />
primary <strong>health</strong> care services. The KZN Informatics Bulletin uses the term “attendances”, which were confirmed to<br />
describe cases, rather than headcounts. The Informatics Bulletin contained attendances information for<br />
provincially run mobile clinics and municipality clinics. The Informatics Department has compiled a new form,<br />
which will be used to collect headcount information from 1998/99 onwards.<br />
In order to obtain headcounts information, it was necessary to calculate these statistics from original clinic records.<br />
The instructions for calculating headcounts at clinics from clinic records, was described by the sister-in-charge at<br />
Matatiele municipal clinic as follows: add together the totals from child <strong>health</strong>, minor ailments and ante-natal care.<br />
Using this method, headcounts for the year 1997/98 were 61,677 in Matatiele municipal clinic rather than<br />
attendances of 82,055, as recorded in KZN Informatics Bulletin. This method was also used for the Kokstad<br />
municipal clinic records.<br />
Another problem noted with the primary <strong>health</strong> care records was that they contained numerous calculation errors. A<br />
further problem experienced with the documents used for service activity information were gaps for certain months.<br />
The municipality records had 1 month missing in the case of Matatiele and 2 months missing in the case of<br />
Kokstad. For the mobile clinics, no records were obtained for Matatiele mobile clinics, while information for 7<br />
months was obtained for Kokstad mobile clinics. Face validity of several records was also poor. For example, on<br />
some records the incorrect town name was filled in at the top of the page.<br />
What remains unclear after this <strong>expenditure</strong> <strong>review</strong>, is the inter-relationship between various types of primary <strong>health</strong><br />
care services. For example, on the psychiatric services records, there was mention of services given at the hospital<br />
and on mobile clinics. It is therefore unclear whether the workload reported on in this report reflects the actual<br />
situation, in particular for psychiatric services. Records obtained from the psychiatric clinic were difficult to interpret<br />
and seemed to be in need of improvement. On the other hand, the researchers did not spend much time at the<br />
clinic and perhaps more time there might have facilitated better understanding of these records.<br />
However, all records could be improved by standardising their data capture forms as much as possible, ensuring<br />
that there is a clear category for headcounts, easily understood by the nurses and anyone reading the form, and by<br />
ensuring that the calculations are correct (e.g., by getting someone else to cross-check the calculations).<br />
(b) Financial Information<br />
While there were fewer calculation problems with <strong>expenditure</strong> information from the FMS, a major problem was the<br />
fact that the data did not include breakdowns to clinics as cost centres. Once again, this problem should be<br />
remedied for the 1998/99 year, as separate responsibilities were recently created for clinics on the FMS system.<br />
<strong>Health</strong> Economics Unit and ISDS 14
First Mt. Currie District <strong>Health</strong> Expenditure Report<br />
Breakdowns of <strong>expenditure</strong> on vertical programs was also difficult to obtain, even from people running these<br />
programs. As the Mt. Currie services are not recorded separate in vertical programs, it is only possible to make<br />
estimates.<br />
One abnormally with the FMS reports was the inclusion of laundry services as a separate objective in the case of<br />
Tayler Bequest, but not for Usher Memorial. Of the non-provincial information, the greatest difficulty was trying to<br />
convert municipality clinic and NGO <strong>expenditure</strong> line items into FMS line items.<br />
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First Mt. Currie District <strong>Health</strong> Expenditure Report<br />
5. RESULTS OF THE FIRST MT. CURRIE EXPENDITURE REVIEW<br />
Two processes shaped the format of the results presented here. The first was the discussion the researchers had<br />
with the Mt. Currie <strong>district</strong> team, to find out which format would be most useful and readable for the team. In this<br />
discussion, the team indicated that they would like the indicators presented by cost centres. The second process,<br />
occurring simultaneously, was the development of the District Expenditure Review Guidelines by the <strong>Health</strong><br />
Expenditure Review Task Team (HERTT).<br />
While the feedback from the Mt. Currie discussion on a cost centre focus informed HERRT, HERTT was also<br />
receiving input from a variety of other sources. HERTT short-listed several indicators which they recommended as<br />
a minimum information set, and further proceeded to discuss these indicators in the light of an analytical framework<br />
which identified equity, allocative and technical efficiency and financial sustainability as the key criteria against<br />
which performance should be measured. The indicators listed in Addendum 2, Figure 3, conform to the HERTT<br />
guidelines for a basic <strong>district</strong> <strong>expenditure</strong> <strong>review</strong>, but they also include extra information, which was collected for Mt.<br />
Currie where it was available and feasible to do so. They are listed by cost-centre as requested by the DERTT.<br />
The Mt. Currie Team also suggested using the <strong>expenditure</strong> <strong>review</strong> to estimate a <strong>health</strong> budget for the <strong>district</strong>, and<br />
then making plans for the transfer of this budget from the provincial or regional government to the <strong>district</strong>. Estimating<br />
the <strong>district</strong>’s budget is complicated, and the <strong>district</strong> team will need to do more work to refine the information<br />
presented here but certainly these results make a start in this direction. Addendum 1 lists a number of services not<br />
costed in this <strong>review</strong>, which the team should <strong>review</strong> in the next <strong>expenditure</strong> <strong>review</strong>. Consequently, the greatest<br />
potential use of the information presented here is to highlight areas of inefficiency and inequity in service delivery.<br />
Using these markers, the team can hopefully improve the planning and monitoring of services delivered to the<br />
<strong>district</strong>.<br />
Bearing the criteria of equity, efficiency (allocative and technical) and financial sustainability in mind, this section<br />
presents the information for the whole Mt. Currie <strong>district</strong>. Box 3 shows the various cost centres and cost units<br />
identified by the DERTT. In order to keep the body of this report to a reasonable length, it was necessary to leave<br />
cost units 6 to 8 for discussion in Addendum 3. This section therefore covers cost centres 1 to 5 in detail.<br />
Box 3:<br />
Cost Centres for Mt. Currie<br />
Cost Centres<br />
1. The <strong>district</strong> as a whole: for which <strong>district</strong> indicators and sub-<strong>district</strong> indicators can be<br />
calculated;<br />
2. Hospitals as a whole<br />
3. Out-patient hospital services<br />
4. In-patient hospital services<br />
5. Clinics (mobile and fixed) and <strong>district</strong> surgeon services<br />
Cost Units<br />
1. Theatre services<br />
2. Radiology services (X-rays only)<br />
3. Laboratory services<br />
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First Mt. Currie District <strong>Health</strong> Expenditure Report<br />
Table 5: District <strong>Health</strong> Account for Mt. Currie: showing the flow of <strong>expenditure</strong> (from sources to uses) 2 , Rands (1997/98)<br />
Provincial - regional<br />
Provincial<br />
hospital<br />
responsibility<br />
Provincial<br />
subsidy<br />
Municipality own<br />
revenue<br />
NGO own revenue User fees Total<br />
Percentages to<br />
providers<br />
Community services 2,173,648 0 70,927 1,430,134 0 16,532 3,691,241 6.83%<br />
- emergency medical transport 2,086,522 0 0 0 0 0 2,086,522 3.86%<br />
- municipal env. <strong>Health</strong> 0 0 70,927 1,430,134 0 16,532 1,517,593 2.81%<br />
- provincial env. <strong>Health</strong> 87,126 0 0 0 0 0 87,126 0.16%<br />
Clinics and <strong>district</strong> surgeons 253,090 4,184,598 889,921 160,694 - 21,288 5,509,591 10.19%<br />
- provincial mobiles 0 4,184,598 0 0 0 0 4,184,598 7.74%<br />
- municipal clinics 0 0 889,921 160,694 0 21,288 1,071,903 1.98%<br />
- <strong>district</strong> surgeons 253,090 0 0 0 0 0 253,090 0.47%<br />
Hospital services 0 38,952,671 4,691,468 - 299,562 - 43,943,701 81.29%<br />
- <strong>district</strong> hospital (provincial) maintenance 0 421,977 0 0 0 0 421,977 0.78%<br />
- <strong>district</strong> hospital (provincial) administration 0 6,284,522 0 0 0 0 6,284,522 11.63%<br />
- <strong>district</strong> hospital (provincial) outpatients 0 2,221,733 0 0 0 0 2,221,733 4.11%<br />
- <strong>district</strong> hospital (provincial) inpatients 0 30,024,439 0 0 0 0 30,024,439 55.54%<br />
- SANTA inpatients 0 0 4,691,468 0 299,562 0 4,991,030 9.23%<br />
District technical support services 909,998 0 0 0 0 0 909,998 1.68%<br />
- laboratory 909,998 0 0 0 0 0 909,998 1.68%<br />
Adjustments from previous year (provincial) 0 1,828 0 0 0 0 1,784 0.00%<br />
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%<br />
Percentages from Sources 6.17% 79.80% 10.46% 2.94% 0.55% 0.07% 100.00%<br />
Source: various, see Section 4<br />
2 Ideally, a <strong>health</strong> account should show capital and recurrent <strong>expenditure</strong> separately. For this breakdown, by sub-<strong>district</strong>, see Appendix B, Table 3.<br />
<strong>Health</strong> Economics Unit and ISDS 15
First Mt. Currie District <strong>Health</strong> Expenditure Report<br />
5.1. Sources and Uses of Finances<br />
Table 5 shows the flow of funds from the various sources in the <strong>district</strong>, to different types of providers. The totals row<br />
shows a breakdown of finances from various sources, while the totals column shows a breakdown into <strong>expenditure</strong> on<br />
different types of providers.<br />
District <strong>health</strong> <strong>expenditure</strong> in Mt. Currie was approximately R54 million in the year 1997/98, with about 80 % of <strong>district</strong><br />
<strong>expenditure</strong> in the hands of the hospital system. Just less than 17 % of total <strong>district</strong> <strong>expenditure</strong> came directly from the<br />
province’s or region’s budget, rather than from the hospital budget. While municipal own-revenue only accounted for<br />
3 % of overall <strong>district</strong> <strong>health</strong> <strong>expenditure</strong>, it did play a significant role in environmental <strong>health</strong> <strong>expenditure</strong>, where it<br />
accounted for 89 % of total municipality and provincial <strong>expenditure</strong> on environmental <strong>health</strong>. The Eastern Cape<br />
Government funds most of SANTA’s <strong>expenditure</strong> (their contribution to <strong>expenditure</strong> in Mt. Currie), which is 9 % of total<br />
<strong>district</strong> <strong>expenditure</strong>.<br />
Table 6 shows the breakdown between <strong>expenditure</strong> on different types of services. The percentage of <strong>expenditure</strong> on<br />
personal primary <strong>health</strong> care services (i.e., clinic and <strong>district</strong> surgeon services) is only 10 % of total <strong>district</strong> <strong>expenditure</strong><br />
in Mt. Currie. Total primary <strong>health</strong> care <strong>expenditure</strong> (environmental <strong>health</strong>, ambulance, clinics and <strong>district</strong> surgeon<br />
services) was 17 % of <strong>expenditure</strong>. General inpatient services absorb about 56 % of total <strong>district</strong> <strong>expenditure</strong>.<br />
Tuberculosis inpatient facilities, which are funded by the Eastern Cape Provincial <strong>Health</strong> Department, absorbed 9 %<br />
of <strong>expenditure</strong>. If TB care is excluded, general inpatient hospital services absorb 61 %, and personal primary <strong>health</strong><br />
care (i.e., clinics and <strong>district</strong> surgeon services) absorb 11 % of the total of R 49,065,329.<br />
Table 6: Percentage Expenditure at Different Facilities/Services (1997/98)<br />
Matatiele Kokstad Total<br />
Community services 6.0% 7.5% 6.8%<br />
Clinics and <strong>district</strong> surgeon (medical officer) services 10.8% 9.7% 10.2%<br />
Hospital administration 11.1% 12.0% 11.6%<br />
Hospital maintenance 0.87% 0.70% 0.78%<br />
Hospital outpatient services 2.3% 5.6% 4.1%<br />
General inpatient services 56.9% 54.4% 55.5%<br />
TB inpatient services 10.2% 8.4% 9.2%<br />
Laboratory 1.9% 1.5% 1.7%<br />
Adjustments from previous year (provincial) 0.0% 0.0% 0.0%<br />
Total 3 100.0% 100.0% 100.0%<br />
Source: Table 5<br />
Hospital administration was recorded as a separate objective under each hospital responsibility in the FSM system.<br />
Some examples of <strong>expenditure</strong> included under “hospital administration” are salaries of clerical staff, postage,<br />
subsistence, travel allowances, post boxes, etc. This survey did not uncover which staff were located to which<br />
objectives and how it was defined, so its uncertain if the objective accurately reflects administration costs. Finance<br />
staff indicated that the exercise of allocating staff to the appropriate budgets was underway, but not yet fully completed,<br />
and would not have been in place in 1997/98. It is therefore possible, for example, that some staff who are only partly<br />
involved in administration are included under administration, and vice-versa. Therefore, the <strong>expenditure</strong> proportions<br />
presented in Table 6 need to be evaluated in this context.<br />
The only type of provider <strong>expenditure</strong> that varied substantially between sub-<strong>district</strong>s was <strong>expenditure</strong> on outpatient<br />
services. One reason for this might have been the misclassification of <strong>expenditure</strong> on medicines as there was no<br />
medicines line item under the outpatient objective in the FMS report. While the number of items dispensed to<br />
outpatients versus inpatients was known (14,174 to 7,735 (excluding take home drugs (TTOs) of 8,038)), with no price<br />
information, it was not possible to allocate medicine <strong>expenditure</strong> between the cost centres.<br />
3 Total comes to 100.02, 99.8 and 99.88%, respectively, due to rounding errors.<br />
<strong>Health</strong> Economics Unit and ISDS 16
First Mt. Currie District <strong>Health</strong> Expenditure Report<br />
5.2. Percentage of total <strong>expenditure</strong> on different line items<br />
(a) Standard Line Items<br />
Standard line item <strong>expenditure</strong> from the FMS system, are shown below in Table 7 and Figures 5a and 5b, for the<br />
hospital responsibility in each sub-<strong>district</strong>. The hospital responsibility includes all hospital <strong>expenditure</strong> and<br />
<strong>expenditure</strong> on mobile clinics (as shown in Table 5). The most striking aspect of the line item breakdown is the<br />
difference between the proportion of spending on stores and livestock in Tayler Bequest, versus Usher Memorial.<br />
Tayler Bequest reported only 16 % of <strong>expenditure</strong> in this category, versus 27 % in Usher Memorial. The<br />
categorisation of laundry <strong>expenditure</strong> might explain this to some extent. Normally, laundry <strong>expenditure</strong> is recorded<br />
under Stores and livestock under the inpatients objective, but for some reason, it has its own objective in the Tayler<br />
Bequest FMS report. Equipment and land and building <strong>expenditure</strong> is small in both areas, but smaller in Tayler<br />
Bequest. Personnel <strong>expenditure</strong> is a higher in Usher Memorial, but a higher proportion of <strong>expenditure</strong> is spent on<br />
personnel in Tayler Bequest.<br />
Table 7: Standard Line Item Expenditure by Sub-District Responsibility (excludes capital<br />
Expenditure categories<br />
maintenance <strong>expenditure</strong>) (1997/98)<br />
Matatiele: Tayler Bequest<br />
responsibility<br />
(R)<br />
Kokstad: Usher Mem.<br />
responsibility<br />
(R)<br />
Personnel <strong>expenditure</strong> 13,475,907 14,414,238<br />
Administrative <strong>expenditure</strong> 387,430 681,735<br />
Stores and livestock 2,909,151 5,979,639<br />
Equipment 485,808 20,725<br />
Land and buildings 61,020 37,267<br />
Professional and specialist services 332,524 453,614<br />
Miscellaneous <strong>expenditure</strong> 196,785 199,148<br />
Adjustments 44 1,784<br />
Laundry - own cost centre in Taylor Beq 612,857 -<br />
Total (added) 18,461,526 21,788,150<br />
Source: FMS report X112<br />
Figure 5(a): Tayler Bequest Hospital Responsibility Figure 5 (b): Usher Memorial Hospital Responsibility<br />
1.1% 3.3%<br />
1.8%<br />
3.0%<br />
15.8%<br />
Personnel <strong>expenditure</strong><br />
Administrative <strong>expenditure</strong><br />
Stores and livestock<br />
0.3%<br />
27.4%<br />
2.1%<br />
0.9%<br />
Personnel <strong>expenditure</strong><br />
Administrative<br />
<strong>expenditure</strong><br />
Stores and livestock<br />
2.1%<br />
73.0%<br />
Equipt and land and<br />
buildings<br />
Professional and special<br />
services<br />
Miscellaneous <strong>expenditure</strong><br />
Laundry<br />
3.1%<br />
66.2%<br />
Equipt and land and<br />
buildings<br />
Professional and special<br />
services<br />
Miscellaneous<br />
<strong>expenditure</strong><br />
Source: Table 7 Source: Table 7<br />
<strong>Health</strong> Economics Unit and ISDS 17
First Mt. Currie District <strong>Health</strong> Expenditure Report<br />
(b) Key District Expenditure Items<br />
The items presented in Table 8 and Figure 6 below are derived from a set of key items identified by the HERTT for<br />
<strong>district</strong> <strong>health</strong> <strong>expenditure</strong> <strong>review</strong>s. Since the development of this table, some changes have been made to the<br />
HERTT key items, but there was insufficient time to incorporate these changes in this report. The draft guidelines<br />
indicated that <strong>expenditure</strong> on drugs, vaccines and personnel, should be separated out, for all services, at very least. In<br />
addition to these categories, the following categories from the FMS, namely: other medical supplies, medical gas and<br />
equipment (recurrent), were also separated out. to see whether they would produce any interesting analyses.<br />
Municipal computer reports obtained, did not show a breakdown between drugs and consumables, and for this<br />
reason, their <strong>expenditure</strong> is reported on a separate line in Table 8.<br />
Table 8: District and Sub-<strong>district</strong> Line Item Expenditure, Rands (1997/98)<br />
Line Item Matatiele (Rands) Kokstad (Rands) Matatiele<br />
(%)<br />
Kokstad<br />
(%)<br />
Personnel 16,984,475 17,998,930 69.31% 60.91%<br />
Medicines and vaccines 858,015 2,213,652 3.50% 7.49%<br />
Med. 4 (LA clinics) and other medical consumables (all) 381,050 880,942 1.55% 2.98%<br />
Medical gas 185,667 414,426 0.76% 1.40%<br />
Equipment 504,128 22,554 2.06% 0.08%<br />
Other <strong>expenditure</strong> 4,490,973 6,094,831 18.33% 20.62%<br />
Capital <strong>expenditure</strong> 1,100,705 1,926,011 4.49% 6.52%<br />
Total 24,505,013 29,551,346 100.00% 100.00%<br />
Source: see Appendix B, Table 2<br />
It is interesting to analyse whether the key line item breakdown tells us anything different from the hospital responsibility<br />
standard line item breakdown. The main advantages of this format seem to be that it shows <strong>expenditure</strong> for the <strong>district</strong><br />
as a whole and that it separates out drugs. Drug <strong>expenditure</strong> is between 7.5 % and 10.5 % of total <strong>district</strong> <strong>expenditure</strong>.<br />
Personnel <strong>expenditure</strong> tells a similar story as before, for the whole sub-<strong>district</strong>. As a sub-<strong>district</strong>, Matatiele spends a<br />
higher proportion on personnel than Kokstad. The difference between proportions in Kokstad and Matatiele is even<br />
higher than in the standard line item comparison, indicating that the other services in the sub-<strong>district</strong> are reinforcing<br />
this trend.<br />
Figure 6: Key Line Item Recurrent Expenditure in Mt. Currie (1997/98)<br />
4 See section 5.7. for more information on medicines purchased by the province, for the LA clinics. These estimates were not<br />
included in the <strong>expenditure</strong> <strong>review</strong>.<br />
<strong>Health</strong> Economics Unit and ISDS 18
First Mt. Currie District <strong>Health</strong> Expenditure Report<br />
Personnel<br />
6%<br />
2%<br />
1%<br />
Medicines and vaccines<br />
1%<br />
Med. (LA clinics) and other<br />
20%<br />
medical consumables (all)<br />
Medical gas<br />
64%<br />
6%<br />
Equipment<br />
Other <strong>expenditure</strong><br />
Capital <strong>expenditure</strong><br />
Source: Table 7<br />
5.3. Workload Indicators<br />
Two indicators for workload <strong>review</strong>ed were professional primary <strong>health</strong> care nurses per 10 000 population and the<br />
number of visits per professional primary <strong>health</strong> care nurse. Table 9 shows both of these indicators for each of the<br />
sub-<strong>district</strong>s, and for the <strong>district</strong> as a whole. The overall number of nurses per population is almost half internationally<br />
accepted levels of 3 per 10,000 population. However, at a sub-<strong>district</strong> level, there is also an inequitable distribution of<br />
nurses. The number of nurses per 10 000 population in Matatiele is less than half of that in Kokstad, which would<br />
indicate a potentially much larger workload for staff in the Matatiele Sub-<strong>district</strong> than in Kokstad.<br />
Table 9:<br />
The Distribution of Primary <strong>Health</strong> Care Professional Nurses<br />
in the Mt. Currie Sub-<strong>district</strong>s (1997/98)<br />
Nurses per 10 000<br />
Population<br />
PHC Visits per<br />
Professional Nurse per<br />
Day (including hospital<br />
outpatients)<br />
Matatiele 1.33 25.67<br />
Kokstad 2.57 29.27<br />
Mt. Currie (average) 1.74 27.43<br />
Source: Appendix B and Addendum 2<br />
The number of primary <strong>health</strong> care visits per professional nurse per day also speaks, though less dramatically, of a<br />
higher workload for primary <strong>health</strong> care nurses in the Kokstad Sub-<strong>district</strong>. Overall, the number of visits per<br />
professional nurse per day is lower than internationally accepted levels of 35 visits per day. It is unclear why this<br />
should be the case, given that the primary <strong>health</strong> care nurses per 10 000 is lower higher than internationally accepted<br />
standards. One explanation is that the time required for travel between visiting points for mobile clinics reduces the<br />
number of visits they contribute to the total. Clinic visits per professional nurse should therefore be evaluated against<br />
an adjusted norm when including mobile clinic visits, or mobile visits should be weighted differently. A factor<br />
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First Mt. Currie District <strong>Health</strong> Expenditure Report<br />
complicating weighting mobile visits for Mt. Currie is that the data consolidated fixed clinic and visiting point visits, and<br />
it was not possible to separate the two.<br />
5.4. Revenue Collected by the District Hospitals<br />
Apart from sources of financing described in Table 5, Table 10 shows other funds which are collected by the <strong>district</strong><br />
and are currently passed on to the National Treasury. The main revenue recorded below comes from the following<br />
sources: fees from other government departments, workmen’s compensation victims, fees from medical scheme<br />
patients or private patients, fees from hospital patients and smaller miscellaneous fees from private vets (for X-rays) or<br />
doctors.<br />
Table 10: Revenue Collected in the District (Rands) (1997/98)<br />
Tayler Bequest Usher Memorial Mt. Currie Total<br />
Total Expenditure 24,505,013 29,551,346 54,056,359<br />
Total hospital fees collected in the year (including cash receipts<br />
from hospital patients (H1, H2 and H3) and accounts payable,<br />
paid by medical schemes and other patients with<br />
accounts,e.g.,correctional services, police)<br />
508,174 1,441,294 1,949,468<br />
Total hospital fees owing at the beginning of year 327,104 1,027,713 1,354,818<br />
Total hospital fees owing at end of year 444,287 984,487 1,428,774<br />
Percentage increase or decrease in amount owing + 36 % - 4 % + 5 %<br />
Source: Appendix B<br />
Fee revenue was R1,949,468, or 3. 6 % of <strong>district</strong> <strong>expenditure</strong> in 1997/98. Unpaid accounts showed a net increase of<br />
1 % over the year, but decreased in Kokstad by 11 % and increased in Matatiele by 11 %. Of the two hospitals, Usher<br />
Memorial, in the Kokstad sub-<strong>district</strong>, collects almost three times the amount in fee revenue than does Tayler Bequest<br />
Hospital. A breakdown of accounts owing at the end of the year show that 33.7 % of outstanding debt lay with medical<br />
scheme and other private patients; 27.9 % with workmens compensation patients and 25 % with statutory cases<br />
(police and prisons). The remainder was handed over to attorneys for collection.<br />
5.5. Expenditure Per Capita<br />
Total recurrent <strong>expenditure</strong> in the <strong>district</strong> was about R 51 million, 95 % of total <strong>district</strong> <strong>health</strong> <strong>expenditure</strong> in 1997/98.<br />
Recurrent <strong>expenditure</strong> as a proportion of total <strong>expenditure</strong> was 2 % higher in Matatiele than in Kokstad.<br />
Table 11: Total Expenditure in Mt. Currie and the <strong>Health</strong> Sub-<strong>district</strong>s, Rands (1997/98)<br />
Type of Expenditure Matatiele Kokstad Total Proportion of Total<br />
Expenditure<br />
Capital Expenditure 1,100,705 1,926,011 3,026,716 5.60%<br />
Recurrent Expenditure 23,404,308 27,625,335 51,029,643 94.40%<br />
Total Expenditure 24,505,013 29,551,346 54,056,359 100.00%<br />
Source: see Appendix B, Table 3<br />
Dividing <strong>expenditure</strong> by population gives <strong>expenditure</strong> per capita. Nevertheless, there are problems with this indicator.<br />
When catchment populations are not well defined, and where, as in the case of Mt. Currie, cross-border flows are<br />
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First Mt. Currie District <strong>Health</strong> Expenditure Report<br />
large, it is tricky to develop an accurate and meaningful indicator. In addition, the 1996 Census database, from which<br />
these estimations were derived, has not yet been cleaned. The reader must bear these limitations in mind when<br />
interpreting <strong>expenditure</strong> per capita.<br />
Table 12: Expenditure per Capita, Rands (1997/98)<br />
Capital Expenditure<br />
per capita<br />
Recurrent<br />
Expenditure per<br />
capita<br />
Total Expenditure<br />
per capita<br />
Matatiele R 7 R 141 R 148<br />
Kokstad R 24 R 339 R 362<br />
Mt. Currie District R 12 R 206 R 218<br />
Source: Appendix A, Table 3<br />
The indicator, <strong>expenditure</strong> per capita, can be calculated using several variations of <strong>expenditure</strong>, namely, recurrent<br />
<strong>expenditure</strong>, capital <strong>expenditure</strong> and total <strong>expenditure</strong>. Table 11, showed these three variants of <strong>expenditure</strong> for<br />
Matatiele, Kokstad and the whole Mt. Currie <strong>health</strong> <strong>district</strong>. Table 12 shows <strong>expenditure</strong> per capita, using capital,<br />
recurrent and total <strong>expenditure</strong>. Both recurrent and capital <strong>expenditure</strong> per capita are greater in Kokstad than in<br />
Matatiele. Total <strong>expenditure</strong> per capita is 2.5 times greater in Kokstad than in Matatiele Sub-<strong>district</strong>. This will be<br />
discussed further in the analysis section.<br />
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5.6. Hospitals in the District<br />
(a) Hospitals as a Group<br />
There are three hospitals in the Mt. Currie <strong>district</strong>. Their bed and staff complement are described in Table 13 below.<br />
Of these hospitals, only the Usher Memorial hospital sees more KwaZulu-Natal than Eastern Cape patients. About 95<br />
% of inpatients at the SANTA centre and at Tayler Bequest hospital are recorded as coming from the Eastern Cape.<br />
Table 13: Description of Hospitals in Mt Currie (1997/98)<br />
Hospitals Beds Staff Other<br />
Tayler Bequest (Matatiele) 200 255 no full-time doctors<br />
East Griqualand and Usher Memorial (Kokstad) 220 250 6 full-time doctors<br />
Khotsong SANTA Centre 250 73 Inpatients department only<br />
Source: see Appendix B<br />
Tayler Bequest hospital sees high numbers of Eastern Cape patients. This possibly accounts for the longer average<br />
hospital stay at Tayler Bequest, relative to Usher Memorial, as patients presenting at Tayler Bequest hospital are<br />
reported to stay longer because of transport problems.<br />
Expenditure per patient day equivalent (PDE) is 42 % higher in Usher Memorial than in Tayler Bequest Hospital. The<br />
recurrent <strong>expenditure</strong> per PDE differential is slightly less, at 38 %, because greater capital <strong>expenditure</strong> in Usher<br />
Memorial as a proportion of total <strong>expenditure</strong>. As SANTA is rendering a different type of inpatient service, its patient<br />
day equivalent rates are not comparable to those of the other two hospitals.<br />
Table 14: Hospital Expenditure per PDE (1997/98)<br />
Tayler Bequest Usher<br />
Memorial<br />
Total Provincial<br />
Hospitals<br />
SANTA –<br />
specialised TB<br />
Inpatient admissions 10,792 10,511 21,303 2,321<br />
Inpatient days per admission 6 4 5 31<br />
Hospital patient day equivalents 72,310 62,933 135,243 71,014<br />
Total hospital <strong>expenditure</strong> 17,436,017 21,516,654 38,952,671 4,991,030<br />
Expenditure per patient day equivalent R 241 R 342 R 288 R 70<br />
Recurrent hospital <strong>expenditure</strong> 16,374,445 19,688,805 36,063,250 4,991,030<br />
Recurrent <strong>expenditure</strong> per patient day equivalent R 226 R 313 R 267 R 70<br />
Personnel <strong>expenditure</strong> 12,429,648 12,808,982 25,238,630 2,858,114<br />
Personnel <strong>expenditure</strong> per in-patient day equivalent R 172 R 204 R 187 R 40<br />
Source: see Appendix A and B, Addendum 2<br />
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(b) Hospital Inpatient Services<br />
Expenditure per inpatient day paints a similar picture to total hospital <strong>expenditure</strong> per PDE (Table 15). The large<br />
difference between <strong>expenditure</strong> per inpatient day in Matatiele and Kokstad, could be explained by the long average<br />
length of stay of patients presenting at the Tayler Bequest Hospital. According to interviews with nurses in Tayler<br />
Bequest, there are a high number of patients travelling from rural areas and staying in the hospital beyond the<br />
necessary period of convalescence, which might be at the root of this difference. Ignoring the average length of stay,<br />
inpatient <strong>expenditure</strong> per patient is still higher in Kokstad than in Matatiele. Given the low per capita <strong>expenditure</strong> in the<br />
<strong>district</strong> as a whole, this is probably an indication that Tayler Bequest is under-resourced. Bed occupancy rates of 93<br />
% in Tayler Bequest also far exceed those in Usher Memorial (63 %) (Department of <strong>Health</strong> KwaZulu-Natal 1998).<br />
Table 15: Inpatient Stay and Expenditure (1997/98)<br />
Matatiele Kokstad Total Provincial<br />
Hospitals<br />
SANTA –<br />
specialised TB<br />
In-patient <strong>expenditure</strong> R 13,936,933 R 16,087,506 R 30,024,439 R 4,991,030<br />
In-patient days 67,254 45,848 113,102 71,014<br />
Number of in-patients 10,792 10,511 21,303 2,231<br />
In-patient <strong>expenditure</strong> per in-patient day R 207 R 351 R 265 R 70<br />
In-patient <strong>expenditure</strong> per in-patient R 1,291 R 1,531 R 1,409 R 2,237<br />
Recurrent in-patient <strong>expenditure</strong> per inpatient<br />
R13,921,180 R 15,802,123 R 29,723,303 R4,991,030<br />
day<br />
Recurrent in-patient <strong>expenditure</strong> per capita R 207 R 345 R 263 R 70<br />
Source: see Appendix A and B, Addendum 2<br />
(c)<br />
Hospital Out-patient Services<br />
Outpatient department <strong>expenditure</strong> per person treated in Matatiele is more than double the rate in Kokstad. However,<br />
both the service activity information, and the <strong>expenditure</strong> information raise questions as to the validity and meaning of<br />
these indicators. The first question is whether the data given on headcounts is correct. On the one extreme,<br />
professional nurses in Tayler Bequest casualty department see 8 people per day, while those in Usher Memorial<br />
outpatient department see 57 patients per day. If the total nursing complement (including staff nurses and nursing<br />
assistants) is taken as the denominator, then the rate drops but there is still a four-fold difference between the numbers<br />
seen in Tayler Bequest, versus Usher Memorial.<br />
Table 16: Out-patient Visits and Expenditure (1997/98)<br />
Matatiele Kokstad Total Provincial<br />
Hospitals<br />
Out-patient <strong>expenditure</strong> R 561,102 R 1,660,631 R 2,221,733<br />
Out-patient cases (different reasons for<br />
15,168 239,208 254,376<br />
attendance on the same day)<br />
Out-patient visits (head-count) 8,577 51,255 59,832<br />
Expenditure per visit R 65 R 32 R 37<br />
Expenditure per case R 37.00 R 6.94 R 8.73<br />
Personnel <strong>expenditure</strong> R 559,190 R 1,064,856 R 1,624,046<br />
Personnel <strong>expenditure</strong> as % of total 100% 64% 73%<br />
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First Mt. Currie District <strong>Health</strong> Expenditure Report<br />
Source: Appendix A and B, Addendum 2<br />
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While Tayler Bequest is reported to run more of a casualty service and therefore would see more serious patients than<br />
Usher Memorial, and the lower case to visit ratio in Tayler Bequest might, if fact, be indicating this, the number of<br />
patients seen is still very low. On the <strong>expenditure</strong> side, the data also raises several questions: the only item recorded in<br />
the Financial Management System for the Matatiele out-patient department is personnel <strong>expenditure</strong>. This indicates<br />
that something is happening in Matatiele, that is not fully explained by the <strong>expenditure</strong> indicators.<br />
5.7. Clinics and District Surgeon Services<br />
(a) Provincial mobile and fixed clinics<br />
Looking at mobile service <strong>expenditure</strong> between sub-<strong>district</strong>s shows that they spend comparable amounts per patient<br />
seen (Table 17), although staff represents a marginally higher proportion of <strong>expenditure</strong> per capita in Matatiele than in<br />
Kokstad. This indicator could be speaking to the problem of an undersupply of medicines in Matatiele, the point<br />
raised in the line item discussion in Section 5.2.<br />
Table 17: Provincial Clinic Activity and Expenditure (1997/98)<br />
Matatiele Kokstad Total<br />
Mobile complex <strong>expenditure</strong> R 2,087,038 R 2,097,560 R 4,184,598<br />
Visits - mobile teams 56,808 59,121 115,929<br />
Expenditure per patient 5 R 37 R 35 R 36<br />
Personnel <strong>expenditure</strong> R 1,647,441 R 1,605,257 R 3,252,698<br />
Personnel <strong>expenditure</strong> per visit R 29 R 27 R 28<br />
Personnel <strong>expenditure</strong> as percentage of total <strong>expenditure</strong> 79% 77% 78%<br />
Source: see Appendix A and B, Addendum 1<br />
(b) Local authority clinics<br />
Municipal <strong>expenditure</strong> per visit is very low, although the difference between municipalities is large. While one might<br />
expect facility visits to be cheaper than site visits made by mobile clinics, one would have expected comparability<br />
between municipal clinics.<br />
One possible reason for the large difference between municipality clinics might be that they see different types of<br />
cases. However, anecdotal evidence seems to suggest that Matatiele municipal clinic has a high workload. This<br />
might be explained by the fact that there is a smaller hospital outpatient department in Matatiele, with the result that<br />
many patients go to the clinic instead. In an interview, the chief nurse at the Matatiele municipal clinic indicated that<br />
they were extremely busy, saying that each nurse was currently seeing about 60 patients a day.<br />
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<br />
information for the different services. Expenditure per visit therefore includes visits to the fixed clinic (see Table 9).<br />
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First Mt. Currie District <strong>Health</strong> Expenditure Report<br />
Table 18: Municipal Clinic Activity and Expenditure 6 (1997/98)<br />
Matatiele Kokstad Total<br />
Expenditure R 470,293 R 601,610 R 1,071,903<br />
Cases 71,016 73,908 144,924<br />
Headcount 61,677 27,925 89,602<br />
Expenditure per headcount R 8 R 21 R 12<br />
Source: see Appendix A and B, Addendum 2<br />
Additional Data on LA Clinics<br />
Subsequent to the compilation of the main data set for this year’s <strong>district</strong> <strong>health</strong> <strong>review</strong>, some additional data was<br />
obtained for medicines purchased by the provinces, but used by the local authority clinics in Mt. Currie. Medicine<br />
<strong>expenditure</strong> by the two local authorities in 1997/98 is shown in the table below.<br />
Table 19: Provincial Medicines Used at LA Clinics, Mt Currie<br />
Kokstad Matatiele Total<br />
April 97 – March 98 R 137,499.76 R 264,391.28 R 401,891.04<br />
April 98 – March 99 R 296,940.18 R 274,818.54 R 571,758.72<br />
The implications of adding this <strong>expenditure</strong> to total municipal <strong>expenditure</strong> on primary <strong>health</strong> care would be to<br />
increase <strong>expenditure</strong> per head in Matatiele from R8 to R12.00. There would still be a substantial difference between<br />
the local authorities.<br />
Types of services run by the Mt. Currie local authorities are a mixture of curative and preventive services. Both clinics,<br />
but especially Matatiele LA clinic, see a lot of patients for minor ailments. Estimates by staff at Kokstad LA are that<br />
between 40 and 50 % of headcounts there are for minor ailments. Estimates are higher for Matatiele LA clinic. The<br />
Matatiele clinic does not see many TB patients (only about 100 – 150 patients per month).<br />
District surgeons<br />
The category, <strong>district</strong> surgeon <strong>expenditure</strong>, includes both medicines and <strong>district</strong> surgeon salaries. It is interesting to<br />
note that while fewer scripts are issued per patient in Matatiele (3.26) than in Kokstad (5.45), the number of items per<br />
patient is very similar, as is the cost per visit. It is difficult to judge whether the rate of <strong>expenditure</strong> per visit accurately<br />
reflects their efficiency because <strong>expenditure</strong> includes all <strong>expenditure</strong> on medico-legal services, some of which,<br />
especially the court appearances, would not involve seeing patients. However, on the other hand, their other duties,<br />
such as issuing sickness certificates, might counter-balance any bias from their non-personal services.<br />
Table 20: District Surgeon Activity and Expenditure (1997/98)<br />
Matatiele Kokstad Total Provincial Hospitals<br />
Expenditure 7 R 90,978 R 162,112 R 253,090<br />
Patients 4,493 8,735 13,228<br />
Expenditure per patient R 20 R 19 R 19<br />
Average no. items per patient 13 13 13<br />
6 Note that municipal <strong>expenditure</strong> was calculated on the basis of their financial year: July 1997 – June 1998.<br />
7 Includes all <strong>expenditure</strong> on <strong>district</strong> surgeon services, including drug/prescription costs as well as some medico-legal work that does not<br />
involve seeing patients.<br />
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First Mt. Currie District <strong>Health</strong> Expenditure Report<br />
Source: Appendix B records submitted by <strong>district</strong> surgeons to the provincial head office<br />
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6. ANALYSIS<br />
Limited analyses can be performed with indicators without “norms” or standards to which to compare them. By<br />
dividing the <strong>health</strong> <strong>district</strong> into two sub-<strong>district</strong>s, it is possible to make some comments on equity, but even these need<br />
to be compared with a greater array of other <strong>district</strong>s eventually. For this reason, this section includes information from<br />
other studies, in addition to comparing intra-<strong>district</strong> performance.<br />
6.1. How Do Resources Compare Within Sub-Districts and Between Districts?<br />
(equity)<br />
While it is very difficult to make conclusive deductions from the data when the catchment population has not been<br />
measured scientifically, it is possible to make one or two tentative comments on equity in the <strong>district</strong>. The studies<br />
documented in Table 20 for comparison purposes were both conducted fairly recently. The study by Daviaud was<br />
conducted in a <strong>district</strong> in Gauteng, while that by McCoy et al. was conducted in Mt. Frere in the Eastern Cape.<br />
Daviaud (1998) obtained an estimate of <strong>expenditure</strong> of R249 per capita in the <strong>district</strong> they <strong>review</strong>ed. Daviaud (1999)<br />
obtained an estimate of R226 in the South Peninsula <strong>district</strong> she <strong>review</strong>ed the following year. These are a little higher<br />
than average Mt. Currie <strong>district</strong> per capita <strong>expenditure</strong>, but R249 is 45 % lower than <strong>expenditure</strong> in the Kokstad sub<strong>district</strong>.<br />
McCoy (1998), whose study was conducted in the rural <strong>health</strong> <strong>district</strong> of Mt. Frere in the Eastern Cape,<br />
showed <strong>district</strong>s with lower <strong>expenditure</strong> per capita. These estimates have been adjusted for inflation 8 as the study was<br />
conducted a year earlier. They were R166 and R175 for the two sub-<strong>district</strong>s respectively. Personnel <strong>expenditure</strong> per<br />
capita in Mt. Currie is lower than that recorded in the Daviaud (1999) study of R189. This might be due to differing<br />
definitions. As mentioned in Section 5. personnel <strong>expenditure</strong> would be higher were it possible to extract personnel<br />
<strong>expenditure</strong> from other line items, such as professional and specialised services.<br />
Table 21: Comparisons of Per Capita Expenditure<br />
District <strong>expenditure</strong> per capita<br />
Study (see<br />
references in<br />
Sec.8)<br />
Year<br />
Study<br />
Estimate<br />
Mt. Currie<br />
Total <strong>expenditure</strong> per capita Daviaud et al. 1997/98 R249 R218<br />
Total <strong>expenditure</strong> per capita Daviaud 1997/98 R226 R218<br />
Per capita sub-<strong>district</strong> <strong>expenditure</strong> (2 McCoy et al. 1996/97 R155 R148<br />
sub-<strong>district</strong>s)<br />
R163 R362<br />
Personnel <strong>expenditure</strong> per capita Daviaud et al. 1997/98 R189 R141<br />
Source: Addendum 2<br />
In summary, intra-<strong>district</strong> equity seems worse in Mt. Currie than in Mt. Frere, where there was very little variance in<br />
<strong>expenditure</strong> per capita (R8.00). Overall, Matatiele emerges with the lowest sub-<strong>district</strong> <strong>expenditure</strong> per capita, lower<br />
than sub-<strong>district</strong>s in the Mt. Frere study.<br />
8 Using core inflation between January 1997 and January 1998, of 1.072 (Statistics South Africa, P0141).<br />
<strong>Health</strong> Economics Unit and ISDS 28
First Mt. Currie District <strong>Health</strong> Expenditure Report<br />
6.2. Are Enough Resources Being Spent on Primary <strong>Health</strong> Care? (allocative<br />
efficiency)<br />
Average <strong>district</strong> hospital <strong>expenditure</strong> per capita seems to compare well with hospital <strong>expenditure</strong> per capita recorded<br />
by Daviaud (1998), but the high proportion of total <strong>district</strong> <strong>health</strong> <strong>expenditure</strong> being spent on hospital services (80%)<br />
means that there is not likely to be sufficient remaining funds to finance primary <strong>health</strong> care appropriately. Also when<br />
compared with estimates from the McCoy (1998) study (67 %), hospital <strong>expenditure</strong> appears to consume too large a<br />
share of the total <strong>district</strong> <strong>expenditure</strong>.<br />
Table 22: Funding of Levels of Care<br />
Primary <strong>health</strong> care <strong>expenditure</strong><br />
Study (see<br />
references in<br />
Sec.8)<br />
Year<br />
Study<br />
Estimate<br />
Mt. Currie<br />
District Hospital Expenditure per capita Daviaud et al. 1997/98 R173.00 R157.00<br />
(District) Recurrent Hospital Expenditure as McCoy et al. 1996/97 67 % 78.33 % - 80.45 % 9<br />
Percentage of Recurrent Expenditure<br />
District Primary <strong>Health</strong> Care Expenditure per Daviaud et al. 1997/98 R76.00 R31 – R38 – R41 10<br />
capita (Including Management Expenditure )<br />
PHC Cost per Person per Year in Core Package Daviaud (1999) 1997/98 R165.00 R31 – R48 – R41<br />
Source: Addendum 2<br />
Note that the picture for Mt. Currie, with regard to <strong>district</strong> PHC <strong>expenditure</strong> per capita is skewed, as there are primary<br />
<strong>health</strong> care clinics across the border in the Eastern Cape, but Eastern Cape residents were included in the sub-<strong>district</strong><br />
catchment population, based on their utilization of inpatient facilities. Only more accurate catchment population<br />
estimates per facility would rectify this bias in the indicator.<br />
6.3. Are PHC Resources and the Workload being shared fairly? (equity and<br />
technical efficiency)<br />
The allocation of PHC workload seems to be unequally distributed when comparing the number of visits per<br />
professional nurse (or <strong>district</strong> medical officer). The extent to which this distribution can be justified by case-mix, is a<br />
point for the District Team to discuss. Table 22 and Figure 8 shows what appears to be an inequitable distribution of<br />
the workload, both between facilities and between sub-<strong>district</strong>s.<br />
Table 23: Visit Loads per Professional Nurse by Facility (1997/98)<br />
Matatiele<br />
Kokstad<br />
Municipal clinic 54.82 41.37<br />
Mobile clinics 21.04 18.77<br />
Outpatients/casualty 7.62 56.95<br />
9 The lower percentages excludes the specialised hospital, SANTA, while the higher percentage includes SANTA. SANTA, as a regional<br />
referral centre, is likely to serve a greater population than the <strong>district</strong> catchment population, but no assessment of their catchment population<br />
was made.<br />
10 The variance in <strong>expenditure</strong> per capita depends on whether outpatient <strong>expenditure</strong> is included (R38) and whether some of the<br />
regionally managed primary <strong>health</strong> care services are included (R41) (see Addendum 1 for data not obtained). The budget allocated to<br />
the <strong>district</strong> office for 1998/99 was not included nor were laboratory costs.<br />
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First Mt. Currie District <strong>Health</strong> Expenditure Report<br />
Source: Addendum 2<br />
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In Matatiele, visit loads are highest at the municipal clinic. In Kokstad, outpatient department visit loads are highest,<br />
followed closely by municipal clinics. Mobile clinic loads are higher in Matatiele than in Kokstad.<br />
Figure 7: Visits per PHC Professional Nurse per Sub-District<br />
Matatiele<br />
26<br />
Kokstad<br />
29<br />
- 10 20 30<br />
Visits per prof nurse<br />
Source: Table 9<br />
On average, visits per nurse are higher in Kokstad than in Matatiele. However, <strong>expenditure</strong> per PHC visit is also higher<br />
in Kokstad: R31 versus R24.<br />
6.4 Are Hospitals Being Run Efficiently? (technical efficiency)<br />
Given the large proportion of funds consumed by hospitals, one of the questions that needs to be answered is whether<br />
they are being run efficiently. A glance at the <strong>expenditure</strong> statistics from the Mt. Frere study, recorded in Table 23,<br />
would seem to indicate that <strong>expenditure</strong> per inpatient day equivalent is on the high side, and therefore hospitals might<br />
not be running efficiently. Average <strong>district</strong> hospital <strong>expenditure</strong> per inpatient day (excluding the TB hospital) of R263 is<br />
higher than R239 or R176 recorded in Mt. Frere (McCoy et al.). However, a much broader band of hospitals needs to<br />
be <strong>review</strong>ed to truly assess where these two hospitals stand.<br />
One factor contributing to the higher <strong>expenditure</strong> at Usher Memorial, relative to Tayler Bequest hospital, is usuage of<br />
the operating theatre for more complicated cases. The average duration of cases in theatre is similar: 10.04 minute in<br />
Tayler Bequest and 11.74 minutes in Usher Memorial. However, the ratio of minor to major cases is much higher in<br />
Tayler Bequest (6.07) relative to Usher Memorial (2.50). This means that Usher Memorial hospital theatre is<br />
undertaking a higher proportion of more serious operations than Tayler Bequest.<br />
Table 24: Funding of Levels of Care<br />
Hospital efficiency<br />
Study (see<br />
references in<br />
Sec.8)<br />
Year<br />
Study Estimate<br />
(s)<br />
Inpatient day cost (adjusted for<br />
inflation)<br />
McCoy et al. 1997/98 R239<br />
R176<br />
Bed Occupancy Monitor Study 1996 recommended<br />
70 –80 %<br />
Average length of stay Monitor Study 1996 recommended<br />
4 – 8 days<br />
Source: various studies (see References) and Addendum 2<br />
Mt. Currie<br />
Recurrent: R207 (M) - R345 (K) – R263 (T)<br />
Total: R207 (M) – R351(K) – R265(T)<br />
between 63 % (K) and 93 % (M)<br />
between 5 (K) and 7 (M) days<br />
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Table 23 also shows hospital bed occupancy to be higher than recommended in the Matatiele hospital, while being<br />
lower than recommended in the Kokstad hospital. High occupancy and long average length of stay in Tayler Bequest<br />
hospital, Matatiele, seems to support anecdotal reports that patients using this hospital have access problems<br />
(described in Section 5).<br />
In attempt to make a broader comparison of hospital efficiency with other hospitals, the indicator, <strong>expenditure</strong> per<br />
patient day equivalent (PDE), was drawn from the KZN <strong>Health</strong> Informatics Bulletin (KwaZulu-Natal 1998) for Mt Currie<br />
hospitals and other hospitals in KwaZulu-Natal. The Informatics Bulletin showed total <strong>expenditure</strong> per patient day<br />
equivalent to be R478 and R310 for Usher Memorial and Tayler Bequest hospitals respectively. However, in this<br />
<strong>expenditure</strong> <strong>review</strong>, <strong>expenditure</strong> per PDE, calculated by dividing the number of PDEs into total hospital <strong>expenditure</strong> 11 ,<br />
was equal to R241 for Tayler Bequest and R342 for Usher Memorial. The difference between the Informatics Bulletin<br />
estimates and these estimates might have arisen from the addition of administration charges of 15 % to hospital<br />
<strong>expenditure</strong>, which are included in the Informatics Bulletin estimates, but which were not included in this study’s<br />
estimation of total hospital <strong>expenditure</strong>. Another possible explanation is that the Informatics Bulletin estimates of<br />
hospital <strong>expenditure</strong> included <strong>expenditure</strong> on mobile clinic complexes, whereas they were excluded from the<br />
calculation of indicators in this <strong>review</strong>.<br />
Using the Infomatics Bulletin estimates, we find that within the Port Shepstone region, average <strong>expenditure</strong> per PDE is<br />
R314, which is the lowest in KwaZulu-Natal province. However, Usher Memorial <strong>expenditure</strong> per PDE is higher than<br />
averages for all other regions, and is the second highest in the Port Shepstone region (second to Assisi hospital).<br />
6.5. Will Fee Retention Make an Impact on District Finances? (sustainability)<br />
The impact that fees will have on <strong>district</strong> finances (should they be retained) will depend on how efficient fee collection<br />
services are, as well as what percentage of patients using public services can afford to pay. The three really large<br />
user-groups paying hospital fees are statutory patients (mostly from other government departments), workmen’s<br />
compensation cases (for both state and private enterprises) and individually liable groups (includes people above a<br />
minimum income level, R56,000.00 per annum, for a family in 1999/2000, and medical scheme members) [see<br />
Addendum 4].<br />
While some studies of user fees charged at hospitals in the former Cape Administration have shown fee revenue of 43<br />
% of recurrent <strong>expenditure</strong> in 1992/93 (Khosa & Thomas 1995), hospital fee revenue collected in a year in Mt. Currie<br />
only represents a much smaller proportion, 5 %, of recurrent hospital <strong>expenditure</strong>. In addition, in general, public<br />
sector hospital fee collection has decreased since 1992/93, due to the increased usage of private hospitals by<br />
medical scheme members. Nevertheless, while 5 % may seem small, it is R1,949,468, almost double the<br />
<strong>expenditure</strong> by municipality clinics in the Mt. Currie <strong>district</strong>, or, to take another example, roughly equal to capital<br />
<strong>expenditure</strong> in the Kokstad sub-<strong>district</strong> for the year 1997/98.<br />
Therefore, fee retention, if utilization were maintained at existing levels, could have a significant impact on <strong>district</strong><br />
finances. However, any optimism regarding the use of retained fees should be qualified by the following<br />
considerations:<br />
1. It is not possible to talk about fee collection without assessing the costs associated with collection. These costs<br />
increase with bad debt.<br />
11 Total hospital <strong>expenditure</strong> is comprised of the following objectives from the FMS report: <strong>district</strong> hospital auxiliary, <strong>district</strong> hospital<br />
administration, <strong>district</strong> hospital outpatients, <strong>district</strong> hospital inpatients. It included capital and recurrent <strong>expenditure</strong>.<br />
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2. While no estimates were made of fee collection costs, an interview with one of the hospital revenue clerks<br />
seemed to indicate that bad debts were on the decline, since the implementation of a system that directly bills<br />
medical schemes, rather than the patients. This improvement would not affect statutory patients or workmens<br />
compensation patients so there might still be room for improvement there.<br />
3. If fee retention at hospitals becomes policy, this might mean an effective reduction in <strong>expenditure</strong> allocated by the<br />
government, and would therefore reduce the net additional revenue earned.<br />
4. Fees might prevent some people from using <strong>health</strong> service, especially the very poor, or those people without<br />
medical schemes, but whose income is above the minimum level required to qualify as hospital patients (this<br />
argument is raised by the authors in Khosa & Thomas (1995).<br />
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7. LIMITATIONS OF THE STUDY AND THE WAY FORWARD<br />
7.1. Limitations<br />
The study has gone some way to highlighting general problems with regard to equity within the <strong>district</strong>, but these<br />
findings need to be tempered by the fact that we still have neither a good census estimate for the area, nor do we have<br />
a good enough estimate of cross-border flows. Furthermore, one needs to exercise caution when comparing average<br />
<strong>expenditure</strong> indicators with indicators from other <strong>district</strong>s, as the methods of estimating <strong>expenditure</strong> still needs to be<br />
standardised.<br />
One of the major limitations of using data in this study to analyse efficiency, especially at a primary <strong>health</strong> care level,<br />
was the lack of information on catchment populations. As this information is essential for proper management of the<br />
services, an attempt needs to be made to calculate these statistics for the next <strong>district</strong> <strong>expenditure</strong> <strong>review</strong>, if not before.<br />
While one of the aims of doing this <strong>district</strong> <strong>expenditure</strong> <strong>review</strong> was for the <strong>district</strong> to get an idea of what budget it could<br />
request from the province, this aim has only been moderately achieved. More detailed costing work will need to be<br />
done to draw up really specific cost centre budgets. In particular, these budgets will need to take better account of<br />
administration, management and other overhead costs, both within the <strong>district</strong> and at the regional level, which were<br />
not apportioned to the various cost centres in this exercise.<br />
7.2. The Way Forward<br />
This report compiles a vast array of information that can be used in helping to improve <strong>district</strong> management. The<br />
themes touched upon in the preceding section’s analysis has only brought some of the important issues to light. The<br />
picture painted in the preceding section was one of a <strong>district</strong> that does not have an exceptionally low amount of<br />
resources; however its resources could be more equitably and efficiently managed. With regard to equity, there is an<br />
unequal distribution of resources between sub-<strong>district</strong>s. With regard to efficiency, there are high rates of hospital<br />
consumption of <strong>health</strong> resources, which are affecting the amount of resources available for primary <strong>health</strong> care. Low<br />
investment in primary <strong>health</strong> care is also an inefficient means of allocating <strong>expenditure</strong>.<br />
(a) Points for Action<br />
The information and analyses presented in this report seem to suggest that the District Team should pay attention to<br />
the following issues:<br />
1. Determining catchment populations, in particular for individual facilities and services.<br />
In determining these statistics, it is necessary to know the following:<br />
♦ the population of neighbouring areas;<br />
♦ the size of cross-border flows; and<br />
♦ medical scheme membership in the <strong>district</strong>.<br />
2. Determining ways to decrease the length of stay at Tayler Bequest<br />
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Transport to and from the hospital, particularly in Matatiele, seems to be a major reason why their occupancy<br />
rates are so high, and there is high hospital <strong>expenditure</strong>, relative to primary <strong>health</strong> care <strong>expenditure</strong>.<br />
Is it possible to provide a cheaper inter-sectoral solution to this problem, instead of having the patients spend<br />
unnecessary time in the hospitals?<br />
3. Investigating drug usage<br />
The low rates of drug <strong>expenditure</strong> per capita, especially in Matatiele, suggest that there might be low<br />
availability of drugs to patients in that sub-<strong>district</strong>. This needs further investigation.<br />
4. Assessing the workload of primary <strong>health</strong> care<br />
There seems to be high rates of consultations per nurse per day at the municipal clinics (average, 50 ). The<br />
<strong>district</strong> management needs to assess how sustainable these work rates are (they could lead to a loss of staff,<br />
for example) and what impact they could have on the service when the various parts of the <strong>district</strong> <strong>health</strong><br />
system that are currently under different management, become integrated.<br />
Furthermore, the use of outpatient services in Kokstad needs to be assessed. It seems as though usage of<br />
outpatient services for primary <strong>health</strong> care needs could be high, due to the overload at the municipal clinics<br />
(41 visits per nurse per day), but shifting this patient load to the outpatients department is not an efficient<br />
solution, as costs per visit are relatively higher at the outpatients department: R32 per visit compared with<br />
municipality clinic visit <strong>expenditure</strong> of R 21 a visit.<br />
For primary <strong>health</strong> care services in the <strong>district</strong> as a whole, the Matatiele municipality clinic, with 55 patients<br />
per nurse per day, seems to the hardest hit, and their situation deserves immediate attention.<br />
Given, the high priority that the National Department of <strong>Health</strong> has given to primary <strong>health</strong> care service<br />
delivery, and the uneven distribution of workload across Mt. Currie primary <strong>health</strong> care services, it is important<br />
that the <strong>district</strong> team develop a plan for sharing this burden and using all primary <strong>health</strong> care workers in the<br />
<strong>district</strong> more appropriately.<br />
(b) The 1998/99 Expenditure Review<br />
Apart from collecting data for evaluating <strong>district</strong> performance, the purpose of this <strong>district</strong> <strong>expenditure</strong> <strong>review</strong> was also<br />
to build capacity in the <strong>district</strong> and this becomes an important part of the way forward for the District Team. In order to<br />
truly build a representative picture of the <strong>district</strong>, it is important to develop a time series of information. Therefore, the<br />
<strong>district</strong> should conduct an <strong>expenditure</strong> <strong>review</strong> for the year 1998/99 as soon as possible. The following points below<br />
are aimed at providing some guidelines for the next <strong>expenditure</strong> <strong>review</strong>:<br />
1. The team should collect certain important additional information that this team did not have the<br />
time to collect for the 1996/97 <strong>review</strong>. These data are:<br />
♦<br />
♦<br />
Information on drugs used, but not paid for by the municipal clinics. This information should be available<br />
from the drug depot records;<br />
Reports submitted to the provinces by the municipalities show <strong>expenditure</strong> and the subsidy from the<br />
provinces. This report was collected for one of the two municipalities in Mt. Currie. Information in this<br />
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First Mt. Currie District <strong>Health</strong> Expenditure Report<br />
♦<br />
♦<br />
♦<br />
report should be cross-checked with people at the municipality, however, and in particular, from the<br />
municipality financial system records;<br />
While headcount information was collected directly from the facilities, the 1997/98 collection of<br />
headcount data should be made easier by the KZN Informatics Department’s reports, which should be<br />
documenting headcount statistics;<br />
Information on regionally and provincially provided services need special attention. Much of this<br />
<strong>expenditure</strong> is on primary <strong>health</strong> care services, and it was estimated that the value of these services in<br />
1997/98 was about R800,000.00 (greater than the entire budget of a single municipal clinic) (adding this<br />
to <strong>district</strong> <strong>expenditure</strong> would increase total <strong>district</strong> <strong>expenditure</strong> to just under R55 million); and<br />
Capital <strong>expenditure</strong> in the <strong>district</strong> by any other departments (e.g., Public works, transport).<br />
2. Collect more detailed information on which staff’s costs are on which responsibilities<br />
Ideally, one would like to draw up a list of all the staff in the <strong>district</strong>, showing in which facility they work, as well as on<br />
which vertical programs they work, what percentage of their time is spent at different facilities or on different programs,<br />
the breakdown of that time between administration and patient contact, and where their salaries are charged. While<br />
this work will overlap with the work being done by the staff audit team, it might be a useful broadening of the scope of<br />
the staff audit.<br />
3. Do more cost allocations.<br />
Several cost allocations could be done in the next <strong>expenditure</strong> <strong>review</strong>, to get a more accurate picture of <strong>health</strong> care<br />
services in Mt. Currie. Some priority allocations are:<br />
♦<br />
♦<br />
to allocate laboratory costs across all <strong>district</strong> services, especially clinic services; and<br />
to allocate provincially and regionally run primary <strong>health</strong> care services to the <strong>district</strong>.<br />
Other lesser priorities, might be the following allocations:<br />
• to allocate management/administration costs across inpatients and outpatient services in hospitals;<br />
♦ to allocate management/administration costs across environmental <strong>health</strong> services and clinic services in<br />
municipalities;<br />
♦ to allocate provincial ambulance services according to services rendered to <strong>district</strong> and sub-<strong>district</strong>; and<br />
♦ to allocate provincially funded environmental <strong>health</strong> services to the <strong>district</strong> better.<br />
4. Assess the appropriateness of maintenance and capital <strong>expenditure</strong>. Draw up a capital and<br />
maintenance plan (if one does not already exist)<br />
Appendix B, Table 6, documents maintenance <strong>expenditure</strong>, as it appeared in the FMS report. No assessment was<br />
done of the linkage between, and sequencing of, capital and maintenance <strong>expenditure</strong>. It is important to model the<br />
impact that this could have on the <strong>district</strong> finances, especially on the hospital (with the replacement of out-dated<br />
equipment), in the future.<br />
5. Gain a better understanding of how user fee revenue is used in the municipalities and what factors<br />
affect the budget allocation to <strong>health</strong> services in the municipalities. Also, gauge the improvement of<br />
the hospital billing systems.<br />
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First Mt. Currie District <strong>Health</strong> Expenditure Report<br />
User fees will still be collected for environmental <strong>health</strong> services by municipalities in 1998/99. It would be useful to<br />
understand how these moneys are used when collected, and how these rates are set. Even more useful for future<br />
planning, would be to understand the budgeting process that the municipality goes through in allocating its <strong>health</strong><br />
budgets, the level of public involvement in this process, and what factors affect the process. Hospital patient fees<br />
revenue might become an important source of revenue to the <strong>district</strong> in the future given two developments. Firstly, if<br />
fee revenue generated by a facility can be retained by that facility, this might release more funds for primary <strong>health</strong> care<br />
in the future. Secondly, the development of the large C-max prison next to Kokstad might require the <strong>district</strong> to render<br />
<strong>health</strong> services on behalf of the Department of Correctional Services, who is already a large debtor of the hospitals. It<br />
would be worthwhile investigating how to improve the billing and collection of fees from this government department.<br />
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First Mt. Currie Expenditure Review Report<br />
8. REFERENCES<br />
Committee for Poverty and Inequality. “Poverty and Inequality in South Africa: Summary Report”. Report prepared for<br />
the Office of the Executive Deputy President and the Inter-Ministerial, Pretoria, 13 May 1998.<br />
Coburn J, Southall H and Collins D. “Equity Project: the Impact of a Public/Private Partnership Initiative on<br />
Uitenhage Provincial Hospital and Clinics”. A study commissioned by the Eastern Cape Department of <strong>Health</strong>.<br />
Management Sciences for <strong>Health</strong>, Bisho, August 1998.<br />
Daviaud E. and Cabral J. A District –Level Planning Tool for P.H.C. Services: combining utilisation-based and<br />
population-based approaches. Abbreviated manual version, an adaptation from the “Needs/Norms Package”,<br />
Confronting need and affordability: guidelines for primary <strong>health</strong> care services in South Africa by Rispel L. and<br />
Cabral J., Centre for <strong>Health</strong> Policy, Durban, September 1998.<br />
Daviaud E. Assessing Costs of PHC Services in an Urban District. Draft report for ISDS, August 1999.<br />
HERTT Draft District <strong>Health</strong> Expenditure Review Guidelines.<br />
Integrated Planning Services (1998). Sub-Region 5 Development Plan for the Indlovu Regional Council: Phase 1 –<br />
Perspectives Report. Pietermaritzburg: Integrated Planning Services.<br />
Khosa S & Thomas E (1995). “Free <strong>health</strong> care policies” in South African <strong>Health</strong> Review 1995. Durban: <strong>Health</strong><br />
<strong>Systems</strong> <strong>Trust</strong> and Henry J Kaiser Family Foundation.<br />
KwaZulu-Natal Province, Department of <strong>Health</strong>, <strong>Health</strong> Informatics Bulletin: Financial Year Report: April 1997 to<br />
March 1998. Prepared by the Sub-Directors – <strong>Health</strong> Informatics, Chief Directorate – Management Support<br />
Services, Pietermartizburg, August 1998.<br />
McCoy D., Thomas S., Makan B., and Chimfwembe D. (1998). “District Expenditure and Resource Allocation<br />
Reviews for Effective DHS Management: a <strong>review</strong> of <strong>expenditure</strong> and resource allocation in the Mount Frere <strong>Health</strong><br />
District”. ISDS Technical Report #8. <strong>Health</strong> Economics Unit, University of Cape Town, Cape Town and Initiative for<br />
Sub-District Support. Durban: The <strong>Health</strong> <strong>Systems</strong> <strong>Trust</strong>.<br />
McIntyre D., Bloom G., Doherty J. and Brijlal, P. (1995). <strong>Health</strong> Expenditure and Finance in South Africa. The<br />
<strong>Health</strong> <strong>Systems</strong> <strong>Trust</strong>, Durban and World Bank, Washington D.C.<br />
McIntyre D., Gilson L., Valentine N. and Soderlund N. (1998). Equity of <strong>Health</strong> Sector Revenue Generation and<br />
Allocation: A South African Case-Study. Report prepared for PHR, Abt. Associates. Cape Town: <strong>Health</strong> Economics<br />
Unit, University of Cape Town, and Centre for <strong>Health</strong> Policy, University of the Witwatersrand.<br />
Shepard D.S., Hodgkin D. and Anthony Y. Analysis of Hospital Costs: a manual for managers. Institute for <strong>Health</strong><br />
Policy, Brandeis University, Waltham and World <strong>Health</strong> Organisation, Geneva, May 7, 1999.<br />
Soderlund N., Schierhout G. and van den Heever, A. (1998). “Private <strong>Health</strong> Sector Care” in South African <strong>Health</strong><br />
Review 1998. Durban: The <strong>Health</strong> <strong>Systems</strong> <strong>Trust</strong>.<br />
<strong>Systems</strong>, Pretoria and The <strong>Health</strong> <strong>Systems</strong> <strong>Trust</strong>, Durban, February 1998.<br />
<strong>Health</strong> Economics Unit and ISDS 38
First Mt. Currie Expenditure Review Report<br />
The Department of <strong>Health</strong>. District <strong>Health</strong> Information System Guidelines. Directorates of the Department of<br />
<strong>Health</strong>: <strong>Health</strong> <strong>Systems</strong> Development, Legislation and Policy Co-ordination and National <strong>Health</strong> Information<br />
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APPENDICES<br />
Appendix A: Population Information and Workings<br />
The catchment populations for the Mt. Currie <strong>health</strong> sub-<strong>district</strong>s were estimated in two steps. Firstly, the population given for Mt. Currie<br />
as a whole had to be allocated between the two sub-<strong>district</strong>s (see Table 2). Secondly, the cross border flows from the Eastern Cape<br />
had to be estimated. This process is summarised in Table 1 below.<br />
Table 1: Estimating the Catchment Population<br />
1. Census Population estimate (1996) Matatiele Kokstad Mt. Currie District<br />
Census urban population 6570 21039 27609<br />
Census rural population 3780 13486 17266<br />
Total population 1996 10350 34525 44875<br />
2. Removing Medical Scheme Members from Population (1996)<br />
Population with medical scheme (13 % of urban, above (6570)) 854 2735 3589<br />
Population dependent on public services (10350 – 854) (a) 9496 31790 41286<br />
3. Adjust 2 from 1996 to 1998<br />
1997: multiply 1996 population 2 (a) by 2.98 % growth rate 9779 32737 42516<br />
1998: multiply 1997 population by 2.98 % growth rate 10070 33713 43783<br />
1997/98: take 3 quarters of 1997 and 1 quarter of 1998 (b) 9852 32981 42833<br />
4. Calculate Catchment Population residing in EC from Cross<br />
Border Inpatient Admission Rates of People from EC<br />
Inpatient admissions 12 10792 10511 21303<br />
- from KwaZulu-Natal 644 4244 4788<br />
- from Eastern Cape 10148 6267 16415<br />
KZN Inpatient admission as proportion of pop. (e.g., for Matatiele<br />
644 divided by 9852)<br />
Catchment population accounting for cross-border flows based on<br />
inpatient admission rates for KZN 13 : 6.5 %<br />
Catchment population accounting for cross-border flows based on<br />
inpatient admission rates for KZN 14 : 12.9 %<br />
5. Calculate Total Catchment Population (3 + 4)<br />
6.5 % 12.9 % 11.2 %<br />
156123 96415 252538<br />
78667 48581 124953<br />
5.1. Using 6.5 % admission rate (AR) 165975 129396 295371<br />
5.2. Using 12.9 % admission rate (AR) 88519 81562 170081<br />
5.3. Using 6.5 % for Matatiele and 12.9 % for Kokstad 165975 81562 247537<br />
12 The ratio of inpatient attendances, rather than outpatient attendances was used because there is no subsitute for inpatient services,<br />
whereas outpatient services could be subsituted with visiting the municipal clinics, for which we did not have complete information about<br />
cross-border flows.<br />
13 Assume all people coming from the Eastern Cape live in non-urban areas, otherwise medical scheme membership adjustments would<br />
be required again.<br />
14 Assume all people coming from the Eastern Cape live in non-urban areas, otherwise medical scheme membership adjustments would<br />
be required again.<br />
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Table 2: Provisional Results of the 1996 Census on Mt. Currie’s Population (1996)<br />
Mount Currie Polygrams (from 1996 Census)<br />
Matatiele<br />
Sub-<strong>district</strong><br />
Total<br />
Kokstad<br />
Sub <strong>district</strong><br />
Matatiele Sub<strong>district</strong><br />
Kokstad Urban 21039 21039<br />
Cederville Urban 1736 1736<br />
Matatiele Urban 4834 4834<br />
Total Urban 27609 21039 6570<br />
5120036 594 594<br />
5120037 704 704<br />
5120038 783 783<br />
5120039 823 823<br />
5120040 * 673 673<br />
5120041 * 597 597<br />
5120042 418 418<br />
5120043 993 993<br />
5120044 1116 1116<br />
5120045 0.5 496 248 248<br />
5120046 * 789 789<br />
5120047 1092 1092<br />
5120048 1157 1157<br />
5120049 590 590<br />
5120050 887 887<br />
5120051 381 381<br />
5120052 721 721<br />
5120053 677 677<br />
5120054 1032 1032<br />
5120055 0.5 437 218.5 218.5<br />
5120056 * 514 514<br />
5120057 * 741 741<br />
5120058 1051 1051<br />
5124001 * 0 0<br />
5124002 * 0 0<br />
Total Non-urban Mount Currie 17266 13485.5 3780.5<br />
Total Urban and Non-urban population 44875 34524.5 10351<br />
% Non-urban 38.48% 39.06% 36.52%<br />
Source: Statistics South Africa, July 1999<br />
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Table 3: Estimating Expenditure per Capita: census population versus catchment population<br />
Total Expenditure<br />
Census Population<br />
Estimates of Mt<br />
Currie Population<br />
Mt Currie Catchment<br />
Population (using<br />
estimate 5.3 from<br />
Table 1)<br />
Matatiele 10350 165975<br />
Expenditure per<br />
capita (using census<br />
pop.)<br />
Expenditure per capita<br />
(using catchment<br />
population))<br />
Capital 1,100,705 106 7<br />
Recurrent 23,404,308 2,261 141<br />
Total 24,505,013 2,368 148<br />
Kokstad 34525 81562<br />
Capital 1,926,011 56 24<br />
Recurrent 27,625,335 800 339<br />
Total 29,551,346 856 362<br />
Mt. Currie 44875 247537<br />
Capital 3,026,716 67 12<br />
Recurrent 51,029,643 1,137 206<br />
Total 54,056,359 1,205 218<br />
Table 4: Education Levels Achieved by the Mt. Currie Population<br />
Highest education level Mount Currie %<br />
No schooling 6,509 14.51<br />
Grade 0 49 0.11<br />
Grade 1 909 2.03<br />
2 1,157 2.58<br />
3 2,291 5.11<br />
4 3,009 6.71<br />
5 2,755 6.14<br />
6 2,983 6.65<br />
7 3,211 7.16<br />
8 3,261 7.27<br />
9 2,449 5.46<br />
10 2,592 5.78<br />
11 1,513 3.37<br />
Less than matric & cert/dip 693 1.54<br />
Matric only 3,145 7.01<br />
Matric& certificate 208 0.46<br />
Matric and Diploma 654 1.46<br />
Matric and Bachelors degree 195 0.43<br />
Matric and Bachelors degree and Diploma 19 0.04<br />
Matric and Bachelors degree and Honours 12 0.03<br />
Matric and Masters 19 0.04<br />
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Matric and Doctors degree 8 0.02<br />
Other qualification 332 0.74<br />
Unspecified 1,740 3.88<br />
NA 5,159 11.50<br />
Total 44,872 100.00<br />
Source: 1996 Census<br />
Table 5: Disability Rates in the Mt. Currie Population<br />
Disability<br />
MC total<br />
Urban:<br />
Cedarville<br />
Urban:<br />
Kokstad<br />
Urban:<br />
Matat<br />
Total urban<br />
MC<br />
Non-Urban:<br />
MC<br />
Sight 1258 47 647 175 869 389<br />
Hearing 484 34 259 34 327 157<br />
Physical 627 114 415 33 562 65<br />
Mental 176 17 106 16 139 37<br />
Multiple 141 0 83 25 108 33<br />
Type of disability not<br />
specified<br />
423 3 157 1 161 262<br />
Unspecified 273 15 96 77 188 85<br />
Total 3382 230 1763 361 2354 1028<br />
% 7.77% 14.83% 8.56% 8.31% 8.89% 6.04%<br />
No disability 40124 1321 18830 3982 24133 15991<br />
NA: institution (?) 1369 185 261 491 937 247<br />
TOTAL 44875 1736 20854 4834 27424 17266<br />
Source: 1996 Census<br />
The number of people with disabilities in Mt Currie is 7.77 %of the total <strong>district</strong> population. Most of these people are<br />
in urban areas. About 14.83 percent, 8.56 percent and 8.31 percent of people in urban areas of Cedarville, Kokstad<br />
and Matatiele respectively are disabled. Most of these disabilities have to do with problems relating to sight (more<br />
than a third of the total disabled persons in Mt Currie), followed by physical and hearing disabilities.<br />
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Appendix B: Expenditure, Activity and Staff Information<br />
Table 1: Non-Financial <strong>Health</strong> Services Information: Activity Information for the Various Cost Centres (1997/98)<br />
Matatiele<br />
Kokstad<br />
Services<br />
Visits/<br />
admissions<br />
Inpatient<br />
Days<br />
Available<br />
Beds<br />
No.<br />
Scripts<br />
No.<br />
Items<br />
Theatre<br />
Cases<br />
Hrs<br />
Visits/<br />
admissions<br />
Inpatient<br />
Days<br />
Available<br />
Beds<br />
No.<br />
Scripts<br />
No.<br />
Items<br />
Theatre<br />
cases<br />
Hrs<br />
Community services<br />
- emergency medical transport<br />
- municipal env. <strong>Health</strong><br />
- provincial env. <strong>Health</strong><br />
Clinics and personal services<br />
- provincial mobiles and family planning 56,808 59,121<br />
- psychiatric fixed clinic 6,142<br />
- municipal clinics 61,677 27,925<br />
- <strong>district</strong> surgeons 4,493 18,491 60,37<br />
1<br />
Hospital services<br />
8,735 47,564 116,41<br />
3<br />
- <strong>district</strong> hospital (provincial) auxiliary<br />
Laundry<br />
physical facility management<br />
- <strong>district</strong> hospital (provincial) administration<br />
- <strong>district</strong> hospital (provincial) outpatients 8,577 51,255<br />
- <strong>district</strong> hospital (provincial) inpatients 10,792 67,254 200 2,141 358 10,511 45,848 250 4,159 814<br />
- SANTA inpatients 2,321 71,014 220<br />
District technical support services<br />
- laboratory<br />
Adjustments from previous year (provincial)<br />
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Table 2 (a): Non-Financial <strong>Health</strong> Services Information: Personnel Distribution- Matatiele Sub-District (1997/98)<br />
Designation Mobile Teams Primary <strong>health</strong><br />
care<br />
Family<br />
planning<br />
Outpatient<br />
Department<br />
Inpatient<br />
Department and<br />
Management<br />
<strong>Health</strong> Economics Unit and ISDS 45<br />
Municipal<br />
Clinic<br />
Total clinic and<br />
hospital services<br />
SANTA (resource for both<br />
<strong>district</strong>s)<br />
Administrative Clerks 1 11 1 13<br />
Administration officer (senior) 1 1<br />
Artisan (a group) 0 0<br />
Artisan foreman 4 4<br />
Auxiliary services officer 4 2 6<br />
Chief professional nurse 34 34<br />
Cleaners 35 35<br />
Director nursing services 1 1<br />
Drivers 2 2<br />
Food services aid 7 7<br />
General foreman 0 0<br />
General worker (stores ass.) 1 1 2<br />
Groundsman 0 0<br />
Handyman 2 2<br />
Housekeeping supervisor 1 1<br />
Laundry services supervisors 0 0<br />
Linen supervisor 5 5<br />
Medical officer 1 1<br />
Medical superintendant 0 0<br />
Medical/Dental superintendant 0 0<br />
Nursing assistant 3 3 7 13 14<br />
Operator/senior operat. 9 9<br />
Professional nurse 3 9 4 2 4 22 5<br />
Seamstress 0 0<br />
Security guards 8 8<br />
Security officer 1 1<br />
Senior nursing assistant 29 29<br />
Senior professional nurse 1 16 1 18 4<br />
Senior radiographer 1 1<br />
Senior staff nurse 36 36<br />
Staff nurse 1 3 1 3 12 20 10<br />
Supervisor food services 4 4<br />
Telecom operators 0 0<br />
Tradesman aid 9 9
First Mt. Currie Expenditure Review Report<br />
Other (unclassified) 40<br />
Total 5 3 17 11 244 7 287 73<br />
Table 2 (b): Non-Financial <strong>Health</strong> Services Information: Personnel Distribution- Kokstad Sub-District (1997/98)<br />
Designation<br />
Mobile<br />
Teams<br />
Primary <strong>health</strong><br />
care<br />
Family<br />
planning<br />
Outpatient<br />
Department<br />
Inpatient Department<br />
and Management<br />
Municipal Clinic Psychiatric clinic Total clinic and<br />
hospital services<br />
Administrative Clerks 1 1 16 18<br />
Administration officer (senior) 1 1<br />
Artisan (a group) 2 2<br />
Artisan foreman 2 2<br />
Auxiliary services officer 6 3 9<br />
Chief professional nurse 29 1 30<br />
Cleaners 1 35 36<br />
Director nursing services 1 1<br />
Drivers 6 6<br />
Food services aid 5 5<br />
General foreman 1 1<br />
General worker (stores ass.) 3 1 4<br />
Groundsman 4 4<br />
Handyman 1 1<br />
Housekeeping supervisor 1 1<br />
Laundry services supervisors 3 3<br />
Linen supervisor 4 4<br />
Medical officer 2 2<br />
Medical superintendant 1 1<br />
Medical/Dental superintendant 1 1<br />
Nursing assistant 4 6 4 14<br />
Operator/senior operat. 5 5<br />
Professional nurse 3 5 6 4 6 2 1 27<br />
Seamstress 1 1<br />
Security guards 8 8<br />
Security officer 1 1<br />
Senior nursing assistant 1 28 29<br />
Senior professional nurse 18 1 19<br />
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Senior radiographer 1 1<br />
Senior staff nurse 23 23<br />
Staff nurse 1 2 1 3 9 16<br />
Supervisor food services 4 4<br />
Telecom operators 3 3<br />
Tradesman aid 4 4<br />
Other (unclassified)<br />
clinical<br />
psychologist visits<br />
for half day, 2<br />
times a year<br />
Total 5 9 17 14 236 3 3 289<br />
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Table 3: Recurrent and Capital District <strong>Health</strong> Expenditure for the Mt. Currie District (public and NGO services), Rands (1997/98)<br />
CAPITAL RECURRENT TOTAL TOTAL<br />
Matatiele Kokstad Matatiele Kokstad Matatiele Kokstad District<br />
Community services 31,466 98,162 1,438,663 2,122,950 1,470,129 2,221,112 3,691,241<br />
- emergency medical transport 31,466 79,544 683,614 1,291,898 715,080 1,371,442 2,086,522<br />
- municipal env. <strong>Health</strong> 18,618 725,165 773,810 725,165 792,428 1,517,593<br />
- provincial env. <strong>Health</strong> 29,884 57,242 29,884 57,242 87,126<br />
Clinics and <strong>district</strong> surgeons 7,667 - 2,640,642 2,861,282 2,648,309 2,861,282 5,509,591<br />
- provincial mobiles 2,087,038 2,097,560 2,087,038 2,097,560 4,184,598<br />
- municipal clinics 7,667 462,626 601,610 470,293 601,610 1,071,903<br />
- <strong>district</strong> surgeons 90,978 162,112 90,978 162,112 253,090<br />
Hospital services 1,061,572 1,827,849 18,869,960 22,184,320 19,931,532 24,012,169 43,943,701<br />
- <strong>district</strong> hospital (provincial) auxiliary 826,744 208,090 826,744 208,090 1,034,834<br />
maintenance (physical facility management) 213,886 208,090 - 213,886 208,090 421,976<br />
laundry (only shown separately for Matatiele) 612,858 - 612,858 612,858<br />
- <strong>district</strong> hospital (provincial) administration 831,932 1,334,376 1,892,163 2,226,051 2,724,095 3,560,427 6,284,522<br />
- <strong>district</strong> hospital (provincial) outpatients 561,102 1,660,631 561,102 1,660,631 2,221,733<br />
- <strong>district</strong> hospital (provincial) inpatients 15,754 285,383 13,308,322 15,802,123 13,324,076 16,087,506 29,411,582<br />
- SANTA inpatients 2,495,515 2,495,515 2,495,515 2,495,515 4,991,030<br />
District technical support services - - 454,999 454,999 454,999 454,999 909,998<br />
- laboratory 454,999 454,999 454,999 454,999 909,998<br />
Adjustments from previous year (provincial) 44 1,784 44 1,784 1,828<br />
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<br />
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Table 3 (a): Recurrent and Capital Expenditure on the Hospital Responsibility Budget: Tayler Bequest (Matatiele Sub-<strong>district</strong>), Rands (1997/98)<br />
Recurrent <strong>expenditure</strong><br />
Expenditure categories<br />
Matatiele<br />
clinics<br />
Hospital<br />
Administration<br />
Inpatients<br />
Department<br />
Outpatients<br />
Department<br />
Adjustments<br />
Personnel <strong>expenditure</strong><br />
1,647,441 1,705,836 9,563,439 559,190 13,475,907<br />
Administrative <strong>expenditure</strong><br />
100,166 79,726 205,625 1,912 387,430<br />
Stores and livestock<br />
246,475 1,833 2,660,844 2,909,151<br />
Equipment<br />
718 485,090 485,808<br />
Land and buildings<br />
61,020 61,020<br />
Professional and speculative services<br />
5,841 82,707 243,976 332,524<br />
Miscellaneous <strong>expenditure</strong><br />
25,376 22,061 149,348 196,785<br />
Adjustments 43.5<br />
44<br />
Laundry - own cost centre in Tayler Beq<br />
612,857 612,857<br />
Total<br />
2,087,038 1,892,163 13,308,322 561,102 44 18,461,526<br />
Capital <strong>expenditure</strong><br />
-<br />
Personnel <strong>expenditure</strong><br />
817,218 817,218<br />
Administrative <strong>expenditure</strong><br />
2,253 2,253<br />
Stores and livestock -<br />
Equipment<br />
- 15,754 15,754<br />
Land and buildings -<br />
Professional and speculative services -<br />
Miscellaneous <strong>expenditure</strong><br />
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Total<br />
12,461 12,461
First Mt. Currie Expenditure Review Report<br />
Adjustments -<br />
Total<br />
- 831,932 15,754 847,686<br />
TOTAL (current and capital) 2,087,038 2,724,095 13,324,076 561,102 44 19,309,212<br />
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Table 3 (b): Recurrent and Capital Expenditure on the Hospital Responsibility Budget: East-Griqualand & Usher Memorial (Kokstad Sub-<strong>district</strong>),<br />
Rands (1997/98)<br />
Recurrent <strong>expenditure</strong><br />
Expenditure categories Matatiele clinics Hospital Inpatients Outpatients Adjustments<br />
Total<br />
Administration Department Department<br />
Personnel <strong>expenditure</strong><br />
1,605,257 1,929,132 9,814,994 1,064,856 14,414,238<br />
Administrative <strong>expenditure</strong><br />
118,830 265,394 294,631 2,880 681,735<br />
Stores and livestock<br />
293,878 307 5,107,117 578,338 5,979,639<br />
Equipment<br />
2,421 18,304 20,725<br />
Land and buildings<br />
37,267 37,267<br />
Professional and speculative services<br />
15,892 808 436,915 453,614<br />
Miscellaneous <strong>expenditure</strong><br />
24,017 30,411 130,161 14,558 199,148<br />
Adjustments 1,784 1,784<br />
Laundry - own cost centre in Tayler Beq -<br />
Total 2,097,560<br />
Personnel <strong>expenditure</strong><br />
Capital <strong>expenditure</strong><br />
Administrative <strong>expenditure</strong><br />
Stores and livestock<br />
Equipment<br />
Land and buildings<br />
Professional and speculative services<br />
2,226,051<br />
- 1,311,189<br />
3,683 715<br />
15,802,123 1,660,631 1,784 21,788,150<br />
18,810<br />
265,858 -<br />
1,311,189<br />
4,398<br />
18,810<br />
265,858<br />
-<br />
-<br />
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Miscellaneous <strong>expenditure</strong><br />
19,504<br />
19,504<br />
Adjustments<br />
-<br />
Total -<br />
285,383 - 1,619,760<br />
1,334,376<br />
TOTAL (current and capital) 3,560,427 16,087,506 1,660,631 1,784 23,407,910<br />
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Table 3 (c): Recurrent and Capital Expenditure Proportions for Both Sub-Districts, % (1997/98)<br />
Expenditure categories<br />
Recurrent Expenditure<br />
Matatiele<br />
clinics<br />
Hospital<br />
Administratn<br />
Inpatients<br />
Department<br />
Outpatients<br />
Department<br />
Adjustments Total Kokstad<br />
clinics<br />
Hospital<br />
Administratn<br />
Inpatients<br />
Department<br />
Outpatients<br />
Department<br />
Adjustments<br />
Personnel <strong>expenditure</strong> 78.94% 90.15% 71.86% 99.66% 0.00% 72.99% 76.53% 86.66% 62.11% 64.12% 0.00% 66.16%<br />
Administrative <strong>expenditure</strong> 4.80% 4.21% 1.55% 0.34% 0.00% 2.10% 5.67% 11.92% 1.86% 0.17% 0.00% 3.13%<br />
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%<br />
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%<br />
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%<br />
Professional<br />
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%<br />
speculative services<br />
Miscellaneous <strong>expenditure</strong> 1.22% 1.17% 1.12% 0.00% 0.00% 1.07% 1.15% 1.37% 0.82% 0.88% 0.00% 0.91%<br />
Adjustments 0.00% 0.00% 0.00% 0.00% 100.00% 0.00% 0.00% 0.00% 0.01% 0.00% 0.01%<br />
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%<br />
in Tayler Beq<br />
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%<br />
Total ( inputed manually)<br />
Total<br />
Capital <strong>expenditure</strong><br />
Personnel <strong>expenditure</strong> 98.23% 0.00% 96.41% 98.26% 0.00% 80.95%<br />
Administrative <strong>expenditure</strong> 0.27% 0.00% 0.27% 0.28% 0.25% 0.27%<br />
Stores and livestock 0.00% 0.00% 0.00% 0.00% 6.59% 1.16%<br />
Equipment 0.00% 100.00% 1.86% 0.00% 93.16% 16.41%<br />
Land and buildings 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%<br />
Professional<br />
and<br />
0.00% 0.00% 0.00% 0.00% 0.00% 0.00%<br />
speculative services<br />
Miscellaneous <strong>expenditure</strong> 1.50% 0.00% 1.47% 1.46% 0.00% 1.20%<br />
Adjustments 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%<br />
Total (added) 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%<br />
Source: Table 3 (a) and 3 (b)<br />
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Table 4 (a): Sources of Funds to Types of Providers: Matatiele Sub-<strong>district</strong>, Rands (1997/98)<br />
Source of Fund (budget) Provincial -<br />
regional<br />
Provincial -<br />
hospital<br />
responsibility<br />
Provincial -<br />
subsidy<br />
Municipality -<br />
own revenue<br />
NGO - own<br />
revenue<br />
User Fees<br />
Community services 1,470,129<br />
- emergency medical transport 715,080 715,080<br />
- municipal env. <strong>Health</strong> 38,761 669,872 16,532 725,165<br />
- provincial env. <strong>Health</strong> 29,884 29,884<br />
Clinics and <strong>district</strong> surgeons 2,648,309<br />
- provincial mobiles 2,087,038 2,087,038<br />
- municipal clinics 449,921 20,372 470,293<br />
- <strong>district</strong> surgeons 90,978 90,978<br />
Hospital services 19,931,532<br />
- <strong>district</strong> hospital (provincial) auxiliary 826,744 826,744<br />
- <strong>district</strong> hospital (provincial)<br />
2,724,095 2,724,095<br />
administration<br />
- <strong>district</strong> hospital (provincial) outpatients 561,102 561,102<br />
- <strong>district</strong> hospital (provincial) inpatients 13,324,076 13,324,076<br />
- SANTA inpatients 2,345,734 15 149,781 2,495,515<br />
District technical support services 454,999<br />
- laboratory 454,999 454,999<br />
Adjustments from previous year<br />
44 44<br />
(provincial)<br />
Total from various sources 1,290,941 19,523,099 2,834,416 690,244 149,781 16,532 24,505,013<br />
Total<br />
15 This amount comes from the Eastern Cape Provincial <strong>Health</strong> Department, but about 99 % of SANTA patients are from the Eastern Cape.<br />
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Table 4(b): Sources of Funds to Types of Providers: Kokstad Sub-<strong>district</strong>, Rands (1997/98)<br />
Source of Fund (budget) Provincial -<br />
regional<br />
Provincial -<br />
hospital<br />
responsibility<br />
Provincial -<br />
subsidy<br />
Municipality -<br />
own revenue<br />
NGO - own<br />
revenue<br />
User Fees<br />
Community services 2,221,112<br />
- emergency medical transport 1,371,442 1,371,442<br />
- municipal env. <strong>Health</strong> 32,166 760,262 792,428<br />
- provincial env. <strong>Health</strong> 57,242 57,242<br />
Clinics and <strong>district</strong> surgeons 2,861,282<br />
- provincial mobiles 2,097,560 2,097,560<br />
- municipal clinics 440,000 140,322 21,288 601,610<br />
- <strong>district</strong> surgeons 162,112 162,112<br />
Hospital services 24,012,169<br />
- <strong>district</strong> hospital (provincial) auxiliary 208,090 208,090<br />
- <strong>district</strong> hospital (provincial)<br />
3,560,427 3,560,427<br />
administration<br />
- <strong>district</strong> hospital (provincial) outpatients 1,660,631 1,660,631<br />
- <strong>district</strong> hospital (provincial) inpatients 16,087,506 16,087,506<br />
- SANTA inpatients 2,345,734 16 149,781 2,495,515<br />
District technical support services 454,999<br />
- laboratory 454,999 454,999<br />
Adjustments from previous year<br />
1,784 1,784<br />
(provincial)<br />
Total from various sources 2,045,795 23,615,998 2,817,900 900,584 149,781 21,288 29,551,346<br />
Total<br />
16 This amount comes from the Eastern Cape Provincial <strong>Health</strong> Department, but about 99 % of SANTA patients are from the Eastern Cape.<br />
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Table 5 (a) :Uses of Funds: <strong>expenditure</strong> by major line item, Matatiele Sub-<strong>district</strong>, Rands (1997/98)<br />
RECURRENT EXPENDITURE CAPITAL TOTAL<br />
Source of Fund (budget) Personnel Medicines and Medicine and Medical gas Equipment Other<br />
vaccines other medical<br />
consumables<br />
Community services 1,470,129<br />
- emergency medical transport 419,037 22,883 14,302 10,009 217,383 31,466 715,080<br />
- municipal env. <strong>Health</strong> 631,544 93,621 725,165<br />
- provincial env. <strong>Health</strong> 27,100 825 1,959 29,884<br />
Clinics and personal services 2,648,309<br />
- provincial mobiles 1,647,441 223,786 7,520 718 207,573 2,087,038<br />
- municipal clinics 326,428 112,253 7,486 16,459 7,667 470,293<br />
- <strong>district</strong> surgeons 74,220 16,758 90,978<br />
Hospital services 19,931,532<br />
- <strong>district</strong> hospital (provincial) auxiliary 826,744<br />
laundry 601,183 11,675 612,858<br />
physical facility management 213,886 213,886<br />
- <strong>district</strong> hospital (provincial) administration 1,705,836 186,327 831,932 2,724,095<br />
- <strong>district</strong> hospital (provincial) outpatients 559,190 1,912 561,102<br />
- <strong>district</strong> hospital (provincial) inpatients 9,563,439 592,261 238,394 171,365 485,090 2,257,773 15,754 13,324,076<br />
- SANTA inpatients 1,429,057 25,210 1,041,248 2,495,515<br />
District technical support services 454,999<br />
- laboratory 454,999* 454,999<br />
Adjustments from previous year (provincial) 44 44<br />
Total from various sources 16,984,475 858,015 381,050 185,667 504,128 4,490,973 1,100,705 24,505,013<br />
* unallocated<br />
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Table 5 (b) : Uses of Funds: <strong>expenditure</strong> by major line item, Kokstad Sub-<strong>district</strong>, Rands (1997/98)<br />
RECURRENT EXPENDITURE CAPITAL TOTAL<br />
Source of Fund (budget) Personnel Medicines and Medicine and Medical gas Equipment Other<br />
vaccines other medical<br />
consumables<br />
Community services 2,221,112<br />
- emergency medical transport 803,665 43,886 26,743 417,604 79,544 1,371,442<br />
- municipal env. <strong>Health</strong> 683,132 13,526 77,152 18,618 792,428<br />
- provincial env. <strong>Health</strong> 51,907 1,563 3,772 57,242<br />
Clinics and personal services 2,861,282<br />
- provincial mobiles 1,605,257 293,214 2,421 196,668 2,097,560<br />
- municipal clinics 497,965 37,240 266 66,139 601,610<br />
- <strong>district</strong> surgeons 118,965 43,147 162,112<br />
Hospital services 24,012,169<br />
- <strong>district</strong> hospital (provincial) auxiliary 208,090<br />
physical facility management:<br />
207,890 207,890<br />
maintenance <strong>district</strong> hospitals<br />
physical facility management:<br />
200 200<br />
maintenance general hospitals<br />
- <strong>district</strong> hospital (provincial) administration 1,929,132 283 296,636 1,334,376 3,560,427<br />
- <strong>district</strong> hospital (provincial) outpatients 1,064,856 563,399 7,194 25,182 1,660,631<br />
- <strong>district</strong> hospital (provincial) inpatients 9,814,994 1,288,682 778,813 387,683 18,304 3,513,647 285,383 16,087,506<br />
- SANTA inpatients 1,429,057 25,210 1,041,248 2,495,515<br />
District technical support services 454,999<br />
- laboratory 454,999* 454,999<br />
Adjustments from previous year (provincial) 1,784 1,784<br />
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<br />
<strong>Health</strong> Economics Unit and ISDS 57
First Mt. Currie Expenditure Review Report<br />
Table 6: Recurrent and Capital Maintenance Expenditure<br />
MAINTENANCE EXPENDITURE OVERVIEW<br />
Matatiele maintenance <strong>expenditure</strong> reports<br />
Data capture data: 1999/08/21, from X112 report for Tayler Bequest Responsibility<br />
Maintenance - recurrent Codes Rands Maintenance - capital Codes Rands<br />
Clinics (curr) Physical facilities managment O2_425105<br />
Allowance maint personnel 0989 1,594 Maintenance of District Hosp. O3_425158<br />
Allowance - cap remuner 0809 6,372 Schedule A (cap) O4_425251 49,444<br />
Stores and Livestock: elec. material 336<br />
Professional and Spec Services<br />
Maintenance of buildings 3437 38,136<br />
Maintenance contracts 3530 10,972<br />
Physical facilities managment<br />
O2_425105<br />
Maintenance of District Hosp.<br />
O3_425158<br />
Schedule C (cap) O4_425270 164,443<br />
Stores and Livestock: elec. material<br />
Maintenance materials and parts 163,784<br />
Electronic material 420<br />
Professional and Spec Services<br />
Maintenance contracts 239<br />
Kokstad maintenance <strong>expenditure</strong> reports<br />
TOTAL 213,887<br />
Data capture data: 1999/08/21, from X112 report for East Griqualand and Usher Memorial Responsibility<br />
Maintenance - recurrent Codes Rands Maintenance - capital Codes Rands<br />
Clinics (curr) Physical facilities managment O2_425105<br />
Personnel<br />
Allowance maint personnel 0989 1,386 Maintenance of District Hosp. O3_425158<br />
Allowance - cap remuner 0809 4,766 Schedule A (cap) O4_425251 8,280<br />
In-pat (curr)<br />
Personnel<br />
Allowance maint personnel 0989 - Professional and Spec Services 8,280<br />
Allowance - cap remuner 0809 -<br />
Stores and Livestock<br />
Maint, materials and parts 2504 1,708 Maintenance contracts 3530 8,280<br />
Prof and Spec Services Physical facilities managment O2_425105<br />
Maintenance contracts 3530 962 Maintenance of District Hosp. O3_425158<br />
Schedule C (cap) O4_425270 199,610<br />
Stores and Livestock: elec. material<br />
Maintenance materials and parts 74,494<br />
Electronic material<br />
Professional and Spec Services 125,116<br />
Maintenance of building 109,128<br />
Maintenance contracts 15,988<br />
TOTAL: Maint of District Hosp 207,890<br />
Maintenance General Hospitals<br />
O3_423970<br />
Schedule A (cap)<br />
O4_424530<br />
Professional and Spec Services<br />
Maintenance contracts 0<br />
Maintenance General Hospitals<br />
O3_423970<br />
<strong>Health</strong> Economics Unit and ISDS 59
First Mt. Currie Expenditure Review Report<br />
Schedule C (cap) O4_424564 0<br />
Stores and Livestock 0<br />
Professional and Spec Services<br />
Maintenance of building 200<br />
Maintenance contracts 0<br />
TOTAL: Maint of Gen Hosp 200<br />
TOTAL 208,090<br />
<strong>Health</strong> Economics Unit and ISDS 60
Mt Currie Report, Addendum<br />
ADDENDA<br />
Addendum 1: Data Presentation and Collection Issues<br />
During data collection process, members of the <strong>district</strong> <strong>expenditure</strong> <strong>review</strong> team met with the District Management<br />
to discuss what types of data would be useful to the <strong>district</strong>, and how it would be best to present the data. The<br />
<strong>district</strong> gave the useful feedback, which was related to the HERTT team. They approved most of the initial set of<br />
indicators developed by the HERTT team, but really emphasised that it would be most useful to present the<br />
indicators according to cost centres. However, when writing the report, it was difficult to keep the length of the<br />
report down while at the same time compile a report by cost centre. The comprise reached was to place the more<br />
detailed cost centre information in the appendices.<br />
One of the most important pieces of information needed for assessing <strong>district</strong> performance is the catchment<br />
population of the <strong>district</strong> as a whole and of various services in the <strong>district</strong>. Several of the indicators developed by the<br />
team used information on a <strong>health</strong> service’s catchment population. It was on in the later stages of data collection<br />
that the Mount Currie team found that it was not an easy figure to obtain from the services.<br />
Data Left Out - to be Collected Next Time<br />
Figure 1<br />
ESTIMATES OF EXPENDITURE FOR SERVICES LEFT OUT OF DISTRICT EXPENDITURE<br />
REVIEW<br />
Recurrent Expenditure Year of estimate Rand<br />
AIDS and AIDs awareness (promotional materials) 1999/2000 125,000<br />
AIDS fund at province for workshops etc. 1999/2000 40,000<br />
Nutrition programme (2,000,000 whole Port Shep Region) 1998/1999 666,667<br />
Kokstad Mental <strong>Health</strong> Clinic (prov level)<br />
DATA GAP<br />
Management of Psych clinic recorded reg level 1997/98 1,161<br />
Other provincial <strong>health</strong> promotion activities (prov level)<br />
DATA GAP<br />
Tuberculosis management at regional level 1997/98 3,399<br />
School <strong>health</strong> teams (separate from nutrition prog?)<br />
NONE<br />
Oral <strong>health</strong> (possibly in primary <strong>health</strong> services budget?)<br />
NONE<br />
District office budget 1999/2000 282,000<br />
Drug <strong>expenditure</strong> at clinics – free from province, not properly<br />
captured?<br />
Total Recurrent Expenditure 1,118,227<br />
Expenditure left out as a % of 2.07%<br />
Capital Expenditure<br />
District office set-up costs plus running costs 1998 aug 575,635<br />
Works Department for capital works – none<br />
NONE<br />
<strong>Health</strong> Economics Unit and ISDS 61
Mt Currie Report, Addendum<br />
Addendum 2: Indicators<br />
Figure 1: List Developed by Mt. Currie DERTT at Meeting in March 1999<br />
DISTRICT<br />
Managed to Estimate<br />
Total <strong>expenditure</strong> per capita<br />
ü<br />
Line item % share<br />
ü<br />
Cost centre % share and AEMS, Flying dr. service<br />
% of <strong>district</strong> <strong>expenditure</strong> currently managed by <strong>district</strong>, and others<br />
Private clinical service contract <strong>expenditure</strong> % share<br />
Each provider’s % share of <strong>expenditure</strong><br />
ü<br />
% share of sources of funds for each provider ü<br />
Vehicle gap (actual/norm?)<br />
Utilization<br />
Down-time (veh days unavail/tot veh days)<br />
Ave. Number of items per script<br />
ü<br />
% share <strong>expenditure</strong> of each cost-centre and other exp.,not in cost-centres<br />
ü<br />
(AEMS, et.)<br />
No. visits for each service point in <strong>district</strong> and <strong>expenditure</strong> in 1 table<br />
ühalf (not in one table)<br />
FIXED CLINICS COST CENTRES<br />
ONLY FOR CLINICS AS A WHOLE:<br />
Cost per patient seen<br />
ü<br />
% share exp. of each line item ü<br />
Cost per patient per SLI<br />
ü<br />
Referral rate<br />
MOBILE CLINICS COST CENTRES<br />
Cost per patient seen<br />
% share exp.of each line item<br />
Cost per patient per SLI<br />
Visitation efficiency: no. scheduled /no. actual visits<br />
Ave frequency of visits per site<br />
Cost per km<br />
Utilization<br />
Downtime<br />
Referral rate<br />
HOSPITAL COST CENTRES<br />
Average length of stay<br />
ü<br />
Bed occupancy rate<br />
ü<br />
Cost per patient seen<br />
ü<br />
% share per line item ü<br />
(% share for each hospital) ü<br />
Cost per patient per standard line item<br />
ü<br />
<strong>Health</strong> Economics Unit and ISDS 62
Mt Currie Report, Addendum<br />
% total <strong>expenditure</strong> on different cost centres in each hospital ü<br />
Cost recovery (% of total cost of hospital/<strong>district</strong>)<br />
ü<br />
OUT-PATIENT HOSPITAL COST CENTRES<br />
Cost per patient<br />
ü<br />
% share line item ü<br />
Cost per patient per SLI<br />
ü<br />
% share line item (incl.drugs) ü half – info. not accurately<br />
recorded<br />
Cost per in-patient<br />
ü<br />
Nurse: patient ratio<br />
ü<br />
Dr: patient ratio<br />
IN-PATIENT HOSPITAL COST CENTRE<br />
Cost per in-patient day<br />
ü<br />
% share line item (SLI) ü<br />
Cost per patient per SLI<br />
ü<br />
% share each objective ü<br />
% share exp. Drugs on private patients ü<br />
Cost per meal per day<br />
Theatre cost per hour used<br />
ü estimate<br />
Nurse: patient ratio<br />
ü<br />
Nurse: bed ratio<br />
Dr: patient ratio<br />
COMMUNITY BASED SERVICES COST CENTRE<br />
% share of each type of comm. based service (School, Env. <strong>Health</strong>, etc.) ü<br />
Per capita <strong>expenditure</strong> on environmental <strong>health</strong><br />
ü<br />
Each share by SLI<br />
ü<br />
AEMS<br />
Cost per km<br />
Utilization<br />
% line item (and total cost)<br />
PHARMACY<br />
Average cost per script<br />
% share of total (and total cost of pharmacy)<br />
Ave. no. items/script<br />
X-RAYS<br />
% share in-pts, out-pts (and total cost X-ray dept)<br />
Cost per x-ray (and norm)<br />
No. x-rays processed/month divided by norm = optimum use indicator<br />
LABORATORY<br />
% share of <strong>expenditure</strong> for different cost centres<br />
Average cost per lab service unit per patient requiring service<br />
<strong>Health</strong> Economics Unit and ISDS 63<br />
ü<br />
ü<br />
ü estimate<br />
ü
Mt Currie Report, Addendum<br />
<strong>Health</strong> Economics Unit and ISDS 64
Mt Currie Report, Addendum<br />
Figure 2:<br />
List Developed by the National HERTT in June 1999, subsequently<br />
revised 17 (with associated aspects of <strong>district</strong> performance being<br />
measured)<br />
1. Expenditure per catchment population (CP) by facility (EQUITY)<br />
2. Per capita (CP) utilisation of services (using catchment populations) (EQUITY)<br />
3. Cost per “visit” per facility (hospitals - in-patient day; clinics - visit) (EFFICIENCY)<br />
4. Drug <strong>expenditure</strong> per “visit” by facility (EFFICIENCY)<br />
5. % of facility <strong>expenditure</strong> on human resources (EFFICIENCY)<br />
6. % of professional nurse <strong>expenditure</strong> by facility (EFFICIENCY)<br />
7. Nurse: visits ratio (EFFICIENCY)<br />
8. Average length of stay (EFFICIENCY)<br />
9. Bed occupancy rates (EFFICIENCY)<br />
10. Revenue collection as a % of total <strong>expenditure</strong> (EFFICIENCY)<br />
11. Peri-natal mortality (SERVICE GAPS)<br />
12. TB cure rate (Use disease profile if there is no info. on the above) (SERVICE GAPS)<br />
13. For municipal services: share of province in total <strong>district</strong> (SUSTAINABILITY)<br />
14. Table of funding by different sources (SUSTAINABILITY)<br />
17 See <strong>Health</strong> Expenditure Review Task Team Guidelines (1999)<br />
<strong>Health</strong> Economics Unit and ISDS 65
Mt Currie Report, Addendum<br />
Figure 3: Indicators and Data: Mt Currie 1997/98<br />
COST CENTRE Indicator Numerator Denominator Indicator Criteria<br />
Emergency Medical Services % of total <strong>district</strong> <strong>expenditure</strong> on emergency 2,086,522 54,056,359 3.86% allocative efficiency<br />
medical services<br />
Environmental <strong>Health</strong> Services % of total <strong>district</strong> <strong>expenditure</strong> on environmental 1,604,719 54,056,359 2.97% technical efficiency<br />
services<br />
Matatiele<br />
% of sub-<strong>district</strong> <strong>expenditure</strong> on environmental 755,049 24,505,013 3.08% allocative efficiency<br />
services<br />
Kokstad<br />
% of sub-<strong>district</strong> <strong>expenditure</strong> on environmental 849,670 29,551,346 2.88% allocative efficiency<br />
services<br />
Primary <strong>Health</strong> Care Services District primary <strong>health</strong> care services <strong>expenditure</strong> 7,731,324 247,537 R 31.23 equity/allocative efficiency<br />
per capita (<strong>district</strong> surgeons, mobiles, municipal<br />
clinics and outpatient services): Mt Currie<br />
District primary <strong>health</strong> care services <strong>expenditure</strong><br />
(including same as above) per capita: Matatiele<br />
3,209,411 165,975 R 19.34 equity/allocative efficiency<br />
District primary <strong>health</strong> care services <strong>expenditure</strong><br />
(including same as above) per capita: Kokstad<br />
4,521,913 81,562 R 55.44 equity/allocative efficiency<br />
District primary <strong>health</strong> care services including 9,336,043 247,537 R 37.72 equity/allocative efficiency<br />
environmental <strong>health</strong> (municipalities and province)<br />
<strong>expenditure</strong> per capita<br />
District primary <strong>health</strong> care services including 10,172,270 247,537 R 41.09 equity/allocative efficiency<br />
environmental <strong>health</strong> (municipalities and province)<br />
and other vertical programmes <strong>expenditure</strong> per<br />
capita<br />
District primary <strong>health</strong> care services <strong>expenditure</strong> 3,209,411 131,555 R 24.40 equity/allocative efficiency<br />
per visit (<strong>district</strong> surgeons, mobiles, municipal<br />
clinics and outpatient services): Matatiele<br />
District primary <strong>health</strong> care services <strong>expenditure</strong> 4,521,913 147,036 R 30.75 equity/allocative efficiency<br />
per visit (<strong>district</strong> surgeons, mobiles, municipal<br />
clinics and outpatient services): Kokstad<br />
District surgeons<br />
Total exp. (including <strong>expenditure</strong> on medical-legal 253,090 13,228 R 19.13 technical efficiency<br />
and other services, travel and revenue from ownmedicines<br />
use) per patient seen<br />
Number of items per script (including scripts issued 176,784 66,055<br />
technical efficiency<br />
from government medicines stock and own-stock)<br />
2.68<br />
Matatiele <strong>district</strong> surgeon Total <strong>expenditure</strong> per patient seen 90,978 4,493 R 20.25 technical efficiency<br />
Number of items per script 60,371 18,491<br />
technical efficiency<br />
3.26<br />
Number of scripts per patient 18,491 4,493<br />
technical efficiency<br />
4.12<br />
No. of items per patient 60,371 4,493<br />
technical efficiency<br />
13.44<br />
Kokstad <strong>district</strong> surgeon Total <strong>expenditure</strong> per patient seen 162,112 8,735 R 18.56 technical efficiency<br />
Number of items per script 116,413 47,564<br />
technical efficiency<br />
2.45<br />
Number of scripts per patient 47,564 8,735<br />
technical efficiency<br />
5.45<br />
No. of items per patient 116,413 8,735<br />
technical efficiency<br />
13.33<br />
Clinics - mobile complex Average total <strong>expenditure</strong> per visit 4,184,598 115,929 R 36.10 technical efficiency<br />
Expenditure on mobiles as a & of total <strong>district</strong> 4,184,598 54,056,359 7.74% allocative efficiency<br />
<strong>expenditure</strong><br />
Drug <strong>expenditure</strong> per visit 516,596 115,929 R 4.46 technical efficiency<br />
% <strong>expenditure</strong> on personnel 3,252,698 4,184,598 77.73% technical efficiency<br />
Personnel exp. per visit 3,252,698 115,929 R 28.06 technical efficiency<br />
Average number of visits per prof. nurse per day 115,929 26<br />
technical efficiency<br />
(225 working days a year )<br />
19.82<br />
Matatiele mobile (including a fixed Average total <strong>expenditure</strong> per visit 2,087,038 56,808 R 36.74 technical efficiency<br />
component)<br />
Drug <strong>expenditure</strong> per visit 223,786 56,808 R 3.94 technical efficiency<br />
<strong>Health</strong> Economics Unit and ISDS 67
Mt Currie Report, Addendum<br />
Kokstad mobile (including a fixed<br />
component)<br />
% <strong>expenditure</strong> on personnel 1,647,441 2,087,038 78.94% technical efficiency<br />
Personnel exp. per visit 1,647,441 56,808 R 29.00 technical efficiency<br />
Km travelled per patient served *missing kms 56,808 - technical efficiency<br />
Average number of visits per prof. nurse per day 56,808 12<br />
21.04<br />
technical efficiency<br />
Average total <strong>expenditure</strong> per visit 2,097,560 59,121 R 35.48 technical efficiency<br />
Average total <strong>expenditure</strong> per headcount 2,097,560 59,121 R 35.48 technical efficiency<br />
Drug <strong>expenditure</strong> per visit 293,073 59,121 R 4.96 technical efficiency<br />
% <strong>expenditure</strong> on staff 1,605,257 2,097,560 76.53% technical efficiency<br />
Personnel exp. per visit 1,605,257 59,121 R 27.15 technical efficiency<br />
Km travelled per patient served 148,677 40,549<br />
technical efficiency<br />
3.67<br />
Average number of visits per prof. nurse per day 59,121 14<br />
18.77<br />
technical efficiency<br />
<strong>Health</strong> Economics Unit and ISDS 68
Mt Currie Report, Addendum<br />
COST CENTRE Indicator Numerator Denominator Indicator Criteria<br />
Clinics - fixed: psychiatric Visits per professional nurse per day 6,142 2<br />
technical efficiency<br />
13.65<br />
Clinics - fixed: municipal Average total <strong>expenditure</strong> per visit 1,071,903 89,602 R 11.96 technical efficiency<br />
Drug <strong>expenditure</strong> per visit (includes consumables - 149,493 89,602 R 1.67 technical efficiency<br />
from information for prov. clinics, drug and vaccine<br />
<strong>expenditure</strong> accounted for 0.5 % to 3.5 % of<br />
<strong>expenditure</strong>)<br />
% <strong>expenditure</strong> on staff 824,393 953,991 86.42% technical efficiency<br />
Personnel exp. per case 778,518 89,602 R 8.69 technical efficiency<br />
Expenditure on municipal clinics as a % of total 1,071,903 54,056,359 1.98% allocative efficiency<br />
<strong>district</strong> <strong>expenditure</strong><br />
Average number of visits per prof. nurse per day 89,602 8 49.78 technical efficiency<br />
Matatiele municipal clinic Average total <strong>expenditure</strong> per visit 470,293 61,677 R 7.63 technical efficiency<br />
Drug <strong>expenditure</strong> per visit 112,253 61,677 R 1.82 technical efficiency<br />
% <strong>expenditure</strong> on staff 326,428 470,293 69.41% technical efficiency<br />
Personnel exp. per visit 326,428 61,677 R 5.29 technical efficiency<br />
Average number of visits per prof. nurse per day 61,677 5 54.82 technical efficiency<br />
Kokstad municipal clinic Average total <strong>expenditure</strong> per visit 601,610 27,925 R 21.54 technical efficiency<br />
Drug <strong>expenditure</strong> per visit 37,240 27,925 R 1.33 technical efficiency<br />
% <strong>expenditure</strong> on staff 497,965 601,610 82.77% technical efficiency<br />
Personnel exp. per visit 497,965 27,925 R 17.83 allocative efficiency<br />
Average number of visits per prof. nurse per day 27,925 3 41.37 technical efficiency<br />
Hospitals Excluding SANTA Hospital <strong>expenditure</strong> as % of <strong>district</strong> <strong>expenditure</strong> 38,952,671 54,056,359 72.06% allocative efficiency<br />
Hospital recurrent <strong>expenditure</strong> as a percentage of 36,063,250 38,952,671 92.58% allocative efficiency<br />
total hospital <strong>expenditure</strong><br />
Hospital capital <strong>expenditure</strong> as a percentage of total 2,889,421 38,952,671 7.42% allocative efficiency<br />
<strong>expenditure</strong><br />
Hospital recurrent <strong>expenditure</strong> as a percentage of 36,063,250 51,029,643 70.67% allocative efficiency<br />
total recurrent <strong>expenditure</strong><br />
Hospital administration <strong>expenditure</strong> as a percentage 6,284,522 38,952,671 16.13% allocative efficiency<br />
of total hospital <strong>expenditure</strong><br />
Hospital recurrent administration <strong>expenditure</strong> as a<br />
36,063,250 11.42% allocative efficiency<br />
percentage of total recurrent hospital <strong>expenditure</strong> 4,118,214<br />
Total hospital <strong>expenditure</strong> per patient day<br />
135,243 R 288.02<br />
equivalent (PDE): Mt Currie 38,952,671<br />
Recurrent hospital <strong>expenditure</strong> per PDE: Mt Currie<br />
135,243 R 266.66 allocative efficiency<br />
36,063,250<br />
Hospital personnel <strong>expenditure</strong> per PDE: Mt Currie<br />
135,243 R 186.62<br />
25,238,630<br />
Total hospital <strong>expenditure</strong> per PDE: Matatiele<br />
72,310 R 241.13 technical efficiency<br />
17,436,017<br />
Total hospital <strong>expenditure</strong> per PDE: Kokstad<br />
62,933 R 341.90 technical efficiency<br />
21,516,654<br />
Average recurrent hospital <strong>expenditure</strong> per PDE:<br />
72,310 R 226.45 technical efficiency<br />
Matatiele 16,374,445<br />
Average recurrent hospital <strong>expenditure</strong> per PDE:<br />
62,933 R 312.85 technical efficiency<br />
Kokstad 19,688,805<br />
Average hospital personnel <strong>expenditure</strong> per PDE:<br />
72,310 R 171.89 technical efficiency<br />
Tayler Beq. 12,429,648<br />
Average hospital personnel <strong>expenditure</strong> per PDE:<br />
62,933 R 203.53 technical efficiency<br />
Usher Mem. 12,808,982<br />
Total hospital <strong>expenditure</strong> per capita<br />
247,537 R 157.36 equity/technical efficiency<br />
38,952,671<br />
Recurrent hospital <strong>expenditure</strong> per capita<br />
247,537 R 145.69 equity/technical efficiency<br />
36,063,250<br />
Hospitals Including SANTA Provincial and SANTA hospital recurrent<br />
51,029,643 80.45% equity/technical efficiency<br />
<strong>expenditure</strong> as a percentage of total recurrent 41,054,280<br />
<strong>expenditure</strong><br />
<strong>Health</strong> Economics Unit and ISDS 69
Mt Currie Report, Addendum<br />
Hospital <strong>expenditure</strong> per capita<br />
Hospital <strong>expenditure</strong> as % of sub-<strong>district</strong><br />
<strong>expenditure</strong>: Matatiele<br />
Hospital <strong>expenditure</strong> as % of sub-<strong>district</strong><br />
<strong>expenditure</strong>: Kokstad<br />
247,537 R 177.52 equity/technical efficiency<br />
43,943,701<br />
19,931,532 24,505,013 81.34% allocative efficiency<br />
24,012,169 29,551,346 81.26% technical efficiency<br />
Out-patients (OP) Casualty/Outpatient <strong>expenditure</strong> per visit 2,221,733 59,832 R 37.13 technical efficiency<br />
Expenditure on OP as % total <strong>district</strong> and sub<strong>district</strong><br />
2,221,733 54,056,359 4.11% allocative efficiency<br />
<strong>expenditure</strong><br />
Outpatient visits per professional nurse (per day) 59,832 9 29.55 technical efficiency<br />
Hospital Casualty: Matatiele Casualty <strong>expenditure</strong> per visit 561,102 8,577 R 65.42 allocative efficiency<br />
Expenditure on personnel as % of total Casualty<br />
Dept Exp.<br />
559,190 561,102 99.66% technical efficiency<br />
<strong>Health</strong> Economics Unit and ISDS 70
Mt Currie Report, Addendum<br />
COST CENTRE Indicator Numerator Denominat Indicator<br />
Criteria<br />
or<br />
Expenditure on Casualty Dept. in Matatiele as % of 561,102 29,551,346 1.90% technical efficiency<br />
sub<strong>district</strong> exp<br />
Outpatient visits per professional nurse (per day) 8,577 5 7.62 technical efficiency<br />
Hospital OP: Kokstad Outpatient <strong>expenditure</strong> per visit 1,660,631 51,255 R 32.40 technical efficiency<br />
Expenditure on personnel as % of total OP Dept 1,064,855 1,660,631 64.12% technical efficiency<br />
Exp.<br />
Expenditure on OP in Kokstad as % of sub<strong>district</strong> 1,064,855 24,505,013 4.35% allocative efficiency<br />
exp<br />
Outpatient visits per professional nurse (per day) 51,255 4 56.95 technical efficiency<br />
Inpatients: provincial<br />
Expenditure per inpatient day 29,411,582 113,102 R 260.04 technical efficiency<br />
hospitals<br />
Drug (med and vacc.) <strong>expenditure</strong> as % total 1,880,941 29,411,582 6.40% technical efficiency<br />
inpatient department <strong>expenditure</strong><br />
Personnel exp. as % total hospital inpatient 19,378,433 29,411,582 65.89% technical efficiency<br />
<strong>expenditure</strong><br />
X-ray requirements as % hospital inpatient<br />
111,899 29,411,582 0.38% technical efficiency<br />
<strong>expenditure</strong><br />
Medical gas as % of hospital inpatient <strong>expenditure</strong> 559,048 29,411,582 1.90% technical efficiency<br />
Human Blood as % hospital inpatient <strong>expenditure</strong> 365,826 29,411,582 1.24% technical efficiency<br />
Other medical consumables as % hospital inpatient 990,325 29,411,582 3.37% technical efficiency<br />
<strong>expenditure</strong><br />
Recurrent inpatient <strong>expenditure</strong> per inpatient day 29,110,445 113,102 R 257.38 technical efficiency<br />
Hospital: inpatients - Matatiele Expenditure per inpatient day 13,324,076 67,254 R 198.12 technical efficiency<br />
Average duration of case in theatre 358 2,141 10.04 technical efficiency<br />
Ratio of minor cases to major cases 1,838 303 6.07 technical efficiency<br />
Drug exp. as a % of total inpatient department exp. 592,260 13,324,076 4.45% technical efficiency<br />
Personnel exp. as a % of total inpatient department 9,563,439 13,324,076 71.78% technical efficiency<br />
exp.<br />
Drug exp. per inpatient day 592,260 67,254 R 8.81 technical efficiency<br />
Laundry exp. as % of total inpatient department 612,858 13,324,076 4.60% technical efficiency<br />
exp.<br />
X-ray requirements as % hospital inpatient<br />
38,231 13,324,076 0.29% technical efficiency<br />
<strong>expenditure</strong><br />
Medical gas as % of hospital inpatient <strong>expenditure</strong> 171,365 13,324,076 1.29% technical efficiency<br />
Human Blood as % hospital inpatient <strong>expenditure</strong> 160,780 13,324,076 1.21% technical efficiency<br />
Other medical consumables as % hospital inpatient 238,394 13,324,076 1.79% technical efficiency<br />
<strong>expenditure</strong><br />
Recurrent inpatient <strong>expenditure</strong> per inpatient day 13,308,322 67,254 R 197.88 technical efficiency<br />
Hospital: inpatients - Kokstad Expenditure per inpatient day 16,087,506 45,848 R 350.89 technical efficiency<br />
Average duration of case in theatre (min) 814 4,159 11.74 technical efficiency<br />
Ratio of minor cases to major cases 3,243 1,298 2.50 technical efficiency<br />
Drug exp. as a % of total inpatient department exp. 1,288,681 16,087,506 8.01% technical efficiency<br />
Personnel exp. as a % of total inpatient department 9,814,994 16,087,506 61.01% technical efficiency<br />
exp.<br />
Drug exp. per inpatient day 1,288,681 45,848 28.11 technical efficiency<br />
X-ray requirements as % hospital inpatient<br />
73,668 16,087,506 0.46% technical efficiency<br />
<strong>expenditure</strong><br />
Medical gas as % of hospital inpatient <strong>expenditure</strong> 387,683 16,087,506 2.41% technical efficiency<br />
Human Blood as % hospital inpatient <strong>expenditure</strong> 205,046 16,087,506 1.27% technical efficiency<br />
Other medical consumables as % hospital inpatient 778,813 16,087,506 4.84% technical efficiency<br />
<strong>expenditure</strong><br />
Recurrent inpatient <strong>expenditure</strong> per inpatient day 15,802,123 45,848 R 344.66 technical efficiency<br />
Hospital: inpatients - SANTA Expenditure per inpatient day 4,991,029 71,014 R 70.28 technical efficiency<br />
Personnel exp. as % of total inpatient <strong>expenditure</strong> 2,858,113 4,991,029 57.27% technical efficiency<br />
Drug exp as % of total inpatient exp (drugs mostly<br />
freely provided by state)<br />
50,419 4,991,029 1.01% technical efficiency<br />
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District per capita <strong>expenditure</strong> estimates<br />
Drug exp per patient 50,419 2,321 R 21.72 technical efficiency<br />
Adjusted for cross-border flows Average total per capita <strong>expenditure</strong> 54,056,359 247,537 R 218.38 equity<br />
Average total per capita <strong>expenditure</strong>: Matatiele 24,505,013 165,975 R 147.64 equity<br />
Average total per capita <strong>expenditure</strong>: Kokstad 29,551,346 81,562 R 362.32 equity<br />
Excluding SANTA (because Average total per capita <strong>expenditure</strong> 49,065,329 247,537 R 198.21 equity<br />
SANTA funded by Eastern Cape<br />
and serving more 95 % Eastern<br />
Cape patients)<br />
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COST CENTRE Indicator Numerator Denominat Indicator<br />
Criteria<br />
or<br />
Average total per capita <strong>expenditure</strong>: Matatiele<br />
165,975 R 132.61 equity<br />
22,009,498<br />
Average total per capita <strong>expenditure</strong>: Kokstad<br />
81,562 R 331.72 equity<br />
27,055,831<br />
Using only Census estimates, Average total per capita <strong>expenditure</strong> 49,065,329 42,515 R 1,154.07 equity<br />
and 2.98 % per annum population<br />
growth rate (for comparison with<br />
per capita <strong>expenditure</strong> resulting<br />
from the use of the catchment<br />
population)<br />
Average total per capita <strong>expenditure</strong>: Matatiele<br />
8,605 R 2,557.76 equity<br />
22,009,498<br />
Average total per capita <strong>expenditure</strong>: Kokstad<br />
33,910 R 797.87 equity<br />
27,055,831<br />
Line item <strong>expenditure</strong> per capita<br />
Personnel <strong>expenditure</strong> per capita<br />
247,537 R 141.33 technical efficiency<br />
34,983,405<br />
Personnel <strong>expenditure</strong> per capita: Matat<br />
165,975 R 102.33 equity/technical efficiency<br />
16,984,475<br />
Personnel <strong>expenditure</strong> per capita: Kokstad<br />
81,562 R 220.68 equity/technical efficiency<br />
17,998,930<br />
Adjusted for cross-border flows Drug and medical supplies <strong>expenditure</strong> in <strong>district</strong> 4,333,659 247,537 R 17.51 equity<br />
per capita<br />
Drug and medical supplies <strong>expenditure</strong> in <strong>district</strong> 1,239,065 165,975 R 7.47 equity<br />
per capita: Matatiele<br />
Drug and medical supplies <strong>expenditure</strong> in <strong>district</strong> 3,094,594 81,562 R 37.94 equity<br />
per capita: Kokstad<br />
Revenue collection of, and debt owed to, hospitals<br />
Revenue collected as % of total <strong>district</strong> <strong>expenditure</strong> 1,949,468 54,056,359 3.61%<br />
Workload indicators<br />
Revenue collected as % of total recurrent hospital<br />
<strong>expenditure</strong><br />
Revenue collected as % of total recurrent <strong>district</strong><br />
<strong>expenditure</strong><br />
Revenue collected at Tayler Bequest as % tot hosp<br />
exp.<br />
Revenue collected at EG and Usher Mem. as % tot<br />
hosp exp.<br />
Collections in the year as a percentage of amounts<br />
owing, including cumulative debt from previous<br />
years: Tayler<br />
Collections in the year as a percentage of amounts<br />
owing, including cumulative debt from previous<br />
years: Usher Mem<br />
Change in debt outstanding (debt outstanding at the<br />
end of the year minus debt outstanding at the<br />
beginning of year, divided by debt outstanding at<br />
the beginning of the year):<br />
Change in debt outstanding : Tayler Bequest<br />
1,949,468 38,952,671 5.00% financial sustainability<br />
1,949,468 51,029,643 3.82% financial sustainability<br />
508,174 17,436,017 2.91% financial sustainability<br />
1,441,294 21,516,654 6.70% financial sustainability<br />
508,173.92<br />
1,441,294.00<br />
73,955.93<br />
952,461 53.35% financial sustainability<br />
2,425,781 59.42% financial sustainability<br />
1,354,818 5.46% financial sustainability<br />
327,104.44 35.82% financial sustainability<br />
117,182.54<br />
Change in debt outstanding: Usher Memberial - 1,027,713.45 -4.21% financial sustainability<br />
43,226.61<br />
PHC Professional nurses to 10 000 population<br />
workload<br />
43.00 247,537.00 1.74<br />
PHC Prof nurses to 10 000 population: Matat 22 165,975 1.33 workload<br />
PHC Prof nurses to 10 000 population: Kokstad 21 81,562<br />
2.57<br />
workload<br />
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PHC visits per prof nurses per day (excl<br />
psychiatry but including OP/casualty visits at<br />
hospitals)<br />
265,363 43<br />
27.43<br />
workload<br />
PHC visits per prof nurses per day (excl<br />
psychiatry) : Matat<br />
127,062 22<br />
25.67<br />
workload<br />
PHC visits per prof nurses per day (excl<br />
psychiatry) : Kokstad<br />
138,301 21<br />
29.27<br />
workload<br />
<strong>Health</strong> Economics Unit and ISDS 74
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Addendum 3: Cost Units<br />
1. Theatre Use<br />
While theatre <strong>expenditure</strong> was not estimated, activity information can generate some thought-provoking indicators<br />
for comparing the relative efficiencies of the two theatres in Mt. Currie. Average theatre times at Tayler Bequest,<br />
Matatiele, unadjusted for case mix, suggest that there is not much difference in their respective theatre efficiency.<br />
However, if the theatre time in Tayler Bequest were to be adjusted for the difference in the ratio of minor to major<br />
cases between Usher Memorial and Tayler Bequest theatres, the average theatre time should be 4.13 instead of<br />
10.75 minutes. This indicates that the efficiency of the theatre in Tayler Bequest hospital should be investigated<br />
further.<br />
Table 1: Theatre Usage (1997/98)<br />
Matatiele Kokstad Total<br />
Number of theatre hours 358.25 814.00 1172.25<br />
Number of theatre cases 2,141 4,541 6,682<br />
Average duration of theatre case (minutes) 10.75 10.03 10.52-<br />
Minor: major cases 2.50 6.07 3.17<br />
Source: hospital theatre books<br />
2. Radiography: X-rays only<br />
For every inpatient equivalent in Tayler Bequest hospital, fewer are receiving X-rays than in Usher Memorial. Each<br />
hospital had only one radiographer in 1997/98. The difference might be attributable to the longer length of stay at<br />
Tayler Bequest than at Usher Memorial. From the discussion of the workload with the radiographer at Tayler<br />
Bequest, it does not seem that the Tayler Bequest radiography department is being under-utilised, therefore the<br />
workload for the one radiologist at Kokstad might well be heavy indeed.<br />
Table 2: X-ray Activity at the Hospitals (1997/98)<br />
Matatiele Kokstad Total<br />
Radiography use: no. of patients x-rayed 8,257 10,565 18,822<br />
Hospital in-patient day equivalents 18 70,113 62,933 133,046<br />
Radiography use per inpatient day equivalent 0.12 0.17 0.14<br />
Radiography use: no. in-patients x-rayed 6,262 not available -<br />
18 Calculated by adding together inpatient days plus one third of outpatient admissions.<br />
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Radiography use: no. of out-patients x-rayed 1,995 not available -<br />
Radiography use: no. of SANTA patients x-rayed 693 N/A -<br />
Source: Hospital statistics sheet; ; senior hospital radiographer’s records<br />
An attempt was made to estimate x-ray activity <strong>expenditure</strong>, which when calculated was R249,000 for both<br />
hospitals, including the salary of one radiographer, and <strong>expenditure</strong> on items referred to as “x-ray requisites”. The<br />
salaries might well underestimate <strong>expenditure</strong> as salary scale midpoints were taken, in accordance with accepted<br />
costing methods used in other studies ( Shepard et al. 1998). Cost per x-ray was calculated using the estimates in<br />
Table 7. Costs per x-ray were higher at Kokstad (R13.50) than at Matatiele (R12.50). These results indicate either<br />
that Matatiele is under-funded or that Kokstad could be using their resources more efficiently.<br />
Table 3: Estimation of X-ray Department Expenditure, Rands (1997/98)<br />
Matatiele Kokstad Total<br />
Salary 64,959 64,959 129,918<br />
Salary plus Benefits 81,846 83,628 165,474<br />
Personnel costs for x-rays (83 % of time) 67,932 69,412 137,343<br />
X-ray requisites (inpatient) current 38,232 73,668 111,900<br />
TOTAL COSTS 106,164 143,080 249,244<br />
Source: FMS X112 reports for both hospital systems; salary grading system notes (mid-point salary scale values taken for a senior<br />
radiographer)<br />
3. Laboratory Use<br />
It was not possible to obtain separate laboratory costs for Matatiele and Kokstad, but is was possible to obtain<br />
separate cost and activity information for different types of tests according to whether they were microbiology ,<br />
chemical pathology or haematology tests. The averages for each of these types of test are fairly similar.<br />
Haematology tests are only marginally more expensive (7.22 per test) than microbiology (R7.08) and chemical<br />
pathology (R6.91) tests.<br />
Table 4: Laboratory Activity and Expenditure (1997/98)<br />
Microbiology<br />
Chemical<br />
Pathology<br />
Haematology<br />
Number of tests ordered 44,970 66,447 18,311 129,728<br />
Cost of tests R 318,445 R 459,338 R132,215 R909,998<br />
Average cost per test R 7.08 R 6.91 R 7.22 R 7.01<br />
Total<br />
Percentage of <strong>district</strong> laboratory <strong>expenditure</strong><br />
on different types of tests<br />
35 % 50 % 15 % 100 %<br />
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Another way of evaluating laboratory resource use is to calculate laboratory costs per capita. If the cost of all the<br />
tests are taken together, <strong>expenditure</strong> per capita works out at between R5.27 and R3.69 per capita. This type of<br />
indicator will be more useful when it can be compared with indicators for other <strong>district</strong>s.<br />
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Addendum 4: Reading the Hospital Cash Books<br />
The hospital’s revenue clerk keep two cash books, a daily one and a monthly one. The daily one records all<br />
revenue related transactions. The monthly one records only certain specific hospital related revenue, as will be<br />
described below.<br />
The monthly cash book<br />
Receipts are recorded in the following columns in the monthly cash book:<br />
WOR or WCA which stands for “Workmen’s Compensation”<br />
This refers to patients who were injured during the course of duty. This includes employees of state and private<br />
companies, who were injured while at work. In the area around Kokstad, examples of companies whose<br />
employees present at the hospital are the forestry companies. At least one of these state companies belong to the<br />
Eastern Cape. The bills are sent to the employer. The Workmen’s Compensation Commissioner is only billed<br />
directly in circumstances where the hospital has a certain report (name and content of report unknown).<br />
Stat, which stands for “Statutory” or Hospital Private<br />
This refers to patients who are employees of the South African Police Services (SAPS) or the Dept. of Correctional<br />
Services. The bills are sent directly to the medical scheme administrators, which is Medscheme in the case of<br />
Polmed, and Medihelp for Correctional Services. This category also includes prisoners or prisoners awaiting trial,<br />
who are treated. If the prisoners are awaiting trial, their bills are sent to SAPS. If the prisoners have been<br />
sentenced, their bills are sent to the Dept. of Correctional Services.<br />
I.L. which stands for Individual Liable<br />
This refers to patients whose income is either above the threshold minimum income, or patients who have medical<br />
aids. In 1999, the threshold minimum income for a family unit was R56,000.00 per annum and for a single person,<br />
the threshold minimum income was R34,00.00 per annum. Generally, the hospital sets up accounts for these<br />
patients, billing them later for care received.<br />
H/over which stands for Hand Over<br />
This refers to the cumulative debt, carried forward from the previous year. This debt may be written off several<br />
times a year.<br />
OP which stands for Outpatients<br />
This refers to payments made by patients who are categorised as hospital patients, rather than individual liable, or<br />
private patients. Hospital patients may fall into categories H1, H2 or H3. Hospital patients must pay cash. No<br />
accounts are opened for them, as a rule. However, in the past, accounts were occasionally opened. On<br />
admission, the hospital patient is charged a few Rand, a rate which is lower for H1 patients than H3 patients.<br />
Collections in this column also include charges for x-rays, laboratory tests, etc..<br />
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IP which stands for Inpatients<br />
This refers to payments made by hospital patients for inpatient services.<br />
AMB which stands for Ambulance Services<br />
This category is no longer in use. If an ambulance is used by a private individual, ambulance requisitions are sent<br />
to KZN head office in Durban. They will bill the medical aid or send the patient the account directly. There is no<br />
charge for hospital patients.<br />
VET X-RAY<br />
This includes payments from private vets for X-ray services.<br />
Surgappl.<br />
This covers surgical appliances used by private doctors. These doctors are billed via accounts for these<br />
appliances.<br />
The rows at the bottom of the page show the following:<br />
Cash collections<br />
This includes all cash payments received in the month (generally from the columns, IP, OP and AER).<br />
+Bfwd which stand for “ add brought forward”<br />
This includes all the unpaid accounts from the previous month, which are added to the total accounts and cash for<br />
the existing month.<br />
Less Receipts<br />
This deducts all receipts on accounts from the total balance of accounts outstanding (accounts receivable).<br />
Less ROA which stands for “reduction of accruals”<br />
This is used to reverse incorrect charges to the patients made by the hospitals.<br />
Less w/off<br />
This includes all those debts that have been written off. Note that in 1997/98, there were a number of debts written<br />
off as people gave incorrect addresses, or moved from their addresses, making it hard to track them down. Many of<br />
these patients normally reside outside the <strong>district</strong>, in the Eastern Cape.<br />
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Total<br />
The total includes all accounts receivable still on the hospital books from several prior years, as well as cash<br />
receipts for the month.<br />
The daily cash book<br />
The daily cash book contains two other categories: vote and other.<br />
Under the Vote category:<br />
the following are recorded:<br />
♦<br />
♦<br />
♦<br />
♦<br />
sale of government property,<br />
MMF claim forms,<br />
photocopies for MMF claim forms,<br />
condemned sales.<br />
Under the Other category:<br />
are the following types of expenses:<br />
♦<br />
♦<br />
♦<br />
♦<br />
board and lodging,<br />
uniforms,<br />
staff fines, and<br />
employee meals.<br />
For 1997/98 the daily cash book amounts in Usher Memorial Hospital were:<br />
Other:<br />
Vote:<br />
Total:<br />
R21,989.89<br />
R15,544.06.<br />
R37,533.95.<br />
<strong>Health</strong> Economics Unit and ISDS 81