COST, RESOURCE USE AND FINANCING OF DISTRICT HEALTH SERVICES: A STUDY OF OTJIWARONGO DISTRICT, NAMIBIA
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COST, RESOURCE USE AND FINANCING OF
DISTRICT HEALTH SERVICES: A STUDY OF
OTJIWARONGO DISTRICT, NAMIBIA - extracted text
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COST, RESOURCE USE AND FINANCING OF
DISTRICT HEALTH SERVICES: A STUDY OF
OTJIWARONGO DISTRICT, NAMIBIA
unicef
Bamako Initiative Technical Report Series
Number 22
USfiAFiY
V
/
COST, RESOURCE USE AND FINANCING OF
DISTRICT HEALTH SERVICES: A STUDY OF
OTJIWARONGO DISTRICT, NAMIBIA
Bamako Initiative Management Unit
UNICEF New York
Copyright (c) 1993
United Nations Children’s Fund
3 UN Plaza
New York, NY 10017
USA
December 1993
The purpose of the Bamako Initiative Technical Report Series is to highlight and discuss
main issues related to the Bamako Initiative, in order to facilitate the rapid exchange of
knowledge and perspectives among developing countries, UNICEF field offices, donor
countries, international development agencies and other Interested parties.
The content of this paper does not necessarily reflect the policies or the views of UNICEF.
The typescript has not been edited to official publication standards and UNICEF accepts
no responsibility for errors.
The designations employed in this publication and the presentation of material do not
imply on the part of the United Nations Children’s Fund the expression of any opinion
whatsoever concerning legal status of any country or territory, or of its authorities, or the
delimitations of its frontiers.
All correspondence should be addressed to:
Dr. Agostino Paganini
Manager
•
Bamako Initiative Management Unit, H-10F
UNICEF
3 UN Plaza
New York, NY 10017, USA
Phone:
Facsimile:
212-326-7384
212-326-7059
HE IDO
10.17
TABLE OF CONTENTS
Page Number
L
INTRODUCTION......................................................................................................... 1
H.
COST ANALYSIS......................................................................................................... 3
HL
EFFICIENCY ...............................................................................................................
9
IV.
RESOURCE ADEQUACY.........................................................................................
17
V.
FINANCING .............................................................................................................
22
VL
CONCLUSIONS.........................................................................................................
23
APPENDICES......................................................................................................................... 26
LIST OF TABLES
Page Number
1.
Average Cost by Activity.......................................................................................... 5
2.
Hospital Summary Statistics...................................................................................... 8
3.
Toted and Average Cost Otijwarongo Hospital....................................................... 9
4.
Breakdown of Total Costs by Activity ..................................................................... 9
5.
Utilization of Staff Time..........................................................................................
6.
Drug Use Indicators................................................................................................. 12
7.
Efficiency Indicators.................................................................................................
8.
Utilization of Staff Time, Otjiwarongo Hospital ................................................... 16
9.
Summary of Resource Requirements ....................................................................
Present and Expanded Levels of Utilization
ii
11
15
21
LIST OF FIGURES
Page Number
1.
Distribution of Total Cost by Input............................................................................ 4
2.
Distribution of Resources by Activity........................................................................ 4
Breakdown of Total Recurrent Costs
3.
Outpatients Consultations: Average cost vs. utilization ......................................... 6
4.
Antenatal Care: Average cost vs. utilization............................................................. 7
5.
Family Planning: Average cost vs. utilization........................................................... 7
6.
Cost per Outpatient Visit.........................................................................................
Relationship with Staff Workload
11
7.
Staff Level Adequacy:................................................................................................
Present Level of Utilization
18
8.
Staff Adequacy: ......................................................................................................... 19
Increased Level of Utilization
9.
Drug Adequacy:......................................................................................................... 20
Present Level of Utilization
iii
Cost, Resource Use and Financing of District Health Services
1
I. INTRODUCTION
The Cost, Resource Use and Financing Workshop was held from July 19 to 30,1993 in
Otjiwarongo, Namibia. During the course of these two weeks, officials from ministries of
Health and other government agencies, donor agencies, and independent research
institutions were brought together from 14 different anglophone African countries.
Participants were invited on the basis of their possession of a rare combination of skills in
both economics and public health.
This workshop constituted part of a broader programme of work being supported by the
Bamako Initiative Management Unit, UNICEF, the objectives of which are:
•
to strengthen national capacity in the analysis of costs, resource use and financing of
district health services, with a particular emphasis on considering issues of
sustainability;
°
to train national trainers who will adapt the Cost, Resource Use and Financing
methodology to their own country circumstances and train district health teams to
undertake similar studies;
•
to develop a network of national experts in health economics in order to reinforce
national and regional capacity, and to encourage the exchange of national expertise.
The focus of the workshop was on achieving the second of these objectives. Formal
presentation of conceptual materials and of the study methodology took place during the
first four days of the workshop. Discussions revolved around the five key modules of the
methodology:
•
defining the basic package of services to be offered in the clinics and the district
hospital;
•
determining basic resources required to deliver these services;
•
principles and practice of cost analysis;
•
assessing the adequacy of existing resources to provide these services, in light of the
requirements, as well as the efficiency with which these resources are used;
•
analyzing the present health financing system at district level and the potential for
mobilising additional resources.
The formal presentations of these different themes were significantly enriched by the
discussions and experiences of die workshop participants.
The second phase of the workshop was spent undertaking an actual case study in the
Cost, Resource Use and Financing of District Health Services
2
health facilities of Otjiwarongo district, using the study instrument prepared during the first
part of the workshop. Participants were divided into five teams, four of which spent two
days visiting clinics, whilst the fifth team spent the two available days costing the district
hospital.
The third and final phase of the study involved analyzing the information collected
during the fieldwork and discussing its implications for the management of the district
health system.
Analysis followed a sequence of steps:
•
first, total and average costs per activity were calculated;
•
second, resource adequacy was evaluated with respect to both present and expanded
service levels;
•
third, the current health care financing system at district level was analyzed;
•
fourth, the above results were interpreted with the view to identifying management
reforms which could be undertaken to strengthen the district health system.
Once the preliminary analysis was completed, the results of the study were presented
to file regional health authorities for their feedback. They were also summarized in a
presentation to the Minister of Health, the Hon. Dr. Nickey lyambo.
At the end of the workshop, participants were asked to outline an Action Plan for the
implementation of the methodology in their own countries. These action plans were to be
finalized with Ministry of Health officials and submitted to UNICEF national offices and
other donor agencies for support.
The present report summarizes the findings of the study conducted in Otjiwarongo
District.
Specific features of Otjiwarongo District
Since independence in 1990, the Ministry of Health of Namibia has made tremendous
advances in re-orienting their primarily curative, urban-based health services towards a
rural, primary health care oriented system.
A main feature of this study is that it represents a "snapshot” in time. Because the
environment is changing so rapidly, a study of this type may be misleading because it does
not explicitly allow reference to what existed before, or to the direction in which the system
is evolving. This was recognized by the study team, and consequently the particular value
of the study lies in its identification of potential areas for further study and analysis.
Originally this study was intended to look at both facilities and management structures
Cost, Resource Use and Financing of District Health Services
3
that is to take an integrated perspective and consider the cost of running a district
However, this analysis was impossible at present, since the structure of the District Health
Management Team is not yet in place, and their specific duties have not yet been
determined. There is a regional management and supervision structure, but responsibilities
are somewhat different so that it was not possible to determine the costs specific to the
district Because of this, the results presented in this report pertain to a facility-based rather
than a comprehensive notion of a health district.
II. COST ANALYSIS
Clinics
The "ingredients" approach was taken in calculating the total and average cost for the
clinics. Quantities of each input consumed over the period 1 June 1992 to 30 May 1993 were
estimated on the basis of interviews with regional authorities, facility staff and review of
health centre-level documentation. Drug and family planning commodity consumption, for
example, were estimated from order books and Health Information System reports,
respectively. Often these records were not available for the entire period studied, and
annual figures were extrapolated from whatever information was available. Once the total
quantity of each type of input was estimated, all were valued on a full-cost basis, including
donated inputs. The total cost of each input was then allocated across activities in order to
determine the total cost per activity. Average costs were calculated on the basis of
utilization levels as reported in the health information system, with facility-level reports for
the previous 12 months provided by the regional primary health care coordination office.
For outreach, home visits and school health it was felt to be difficult to calculate average
costs due to problems of defining the unit of output for these activities therefore only total
costs are reported for these activities.
The total recurrent cost of the seven health centres studied was estimated to be
Rl,658,372, or an average of R236,910 each. Of this, personnel costs amounted to 54%, drugs
15%, family planning supplies 12%, utilities 8% and vaccines 1% and "other" 2% (Figure 1).
The distribution of total cost across activities is shown in Figure 2.
Cost, Resource Use and Financing of District Health Services
Distribution of total cost by Input
Uffitm (7.7%)
FF comm (13.1%)
Ottw (2.0%)
VAfcto (6.1%)
Stationary (0.4%)
Drug> (15.2%)
Voociras (1.0%)
Figure 1
Distribution of resources by activity
Breakdown of total recurrent costs
OJ
0.45
0A
I
0.35
OJ
?0J5
o
02
0.1
0.05
0
Figure 2
4
Cost, Resource Use and Financing of District Health Services
Table 1:
5
Average Cost by Activity
Clinic
Outpatients
Antenatal
Family
Planning
Child Health
Coblenz
Okakarara
Okamatapati
Okondjatu
Orwetoveni
Otavi
Outjo
23
10.4
26.78
19.02
11.42
10.3
8.38
48
12.1
53.35
13.41
63.91
23.8
27.24
36
6
11.73
19.64
43.42
12.4
3.58
27
20.7
33.81
13 .73
9.96
15.8
8.79
Table 1 shows average cost per contact for the different activities. There is clearly a large
degree of variation in average costs between facilities. Outpatients care, for example, is
three times more expensive at Okamatapati clinic than at Outjo clinic. The level of variation
in average cost is even greater for antenatal care and family planning services.
Interpreting Average Costs
Outpatients:
As can be seen in Figure 3, average costs decrease with output until cost is
approximately R9 per visit, increasing thereafter. If the numbers are reasonably accurate,
or at least biased consistently as a result of consistent under-estimation of drug costs, we can
think of this as representing a classical "u-shaped" average cost curve. At low levels of
output, fixed costs (mostly staff costs in this case) are spread out over a relatively small
number of patients. The high fixed costs per unit lead to a high average cost Low
attendance levels in this case may be due to small catchment population or to insufficient
community mobilization, the presence of competing sources of care, poor relations between
the community and the clinic, or some other factor. At very high levels of output, the
average cost appears to begin to rise again. This may be due to higher costs of additional
units - that is, higher marginal cost This might occur, for example, if drug wastage
increases at higher levels of output, disproportionately higher numbers of support staff are
needed to maintain a larger facility, among other reasons. Case mix could have an influence
on average costs, and it is difficult to incorporate measures of case-mix into this type of cost
analysis. Facilities with higher numbers of TB cases, for example, would be likely to have
higher average costs because of the relatively higher costs of TB drugs.
Cost, Resource Use and Financing of District Health Services
6
OUTPATENTS CONSULTATIONS
OutpaHwrfi oorrtocti par yaor
(Thomaidi)
Figure 3
Family Harming and Antenatal Care
As in the case of outpatients, both family planning and antenatal care show an inverse
relationship between average cost and output, with the exception of Orwetoveni clinic.
Lower levels of personnel utilization may explain the high average cost per contact in these
high cost facilities. The way in which services are organized likely has an important effect
on levels of output and staff utilization. This can be seen, for example, in the case of
Okakarara Clinic, which offers integrated antenatal and delivery care, with the result that
the level of utilization of antenatal services was much higher there than at similar clinics.
In the case of family planning services, Orwetoveni clinic is clearly exceptional because of
the apparently extremely high consumption of family planning commodities. According to
the monthly reports, family planning commodities make up 33% of total costs at Orwetoveni
clinic, which is 90% of the costs of family planning activities and amounts to R39 per
woman. This seems extraordinarily high and should be further investigated to determine
whether the problem is in the reporting of contraceptive consumption or in contraceptive
use itself.
Cost, Resource Use and Financing of District Health Services
ANTENATAL CARE
Figure 4
FAMLY PLANNING
Figure 5
7
Cost, Resource Use and Financing of District Health Services
8
Child Health Activities
Like the preceding activities, the general relationship between the level of child health
activity output and average cost is downwards sloping. The larger variation around the line
may be due to the fact that attendance is highly variable for this activity, and that the
greatest part of the average cost of this activity is personnel. It was also felt that both the
costs and output of this activity may have been measured imprecisely.
All of these results should be considered to be indicative only, due to the difficulties
experienced in quantifying both the consumption of inputs and the level of output
However, the fact that, relatively speaking, the numbers are what we would expect, gives
some confidence that the biases are consistent.
Hospital
Otjiwarongo hospital has an effective bed capacity of 161 and provides mainly curative
services, although health education, immunization and family planning services are
provided at the facility. For the purposes of the study, the following cost centres were used:
•
•
•
•
•
•
•
outpatients including casualty
paediatric ward
surgical ward
maternity ward
medical wards
female wards
theatre
Summary output statistics by cost centre appear in Table 2.
Table 2: Hospital Summary Statistics
Broadly the same method was used to calculate total and average costs in the hospital
as was used for the clinics: total costs per input were determined, and these were
apportioned between cost centres on bases that varied with the particular input (patient
load, drug cost, staff allocation, occupancy rates, etc). Personnel costs include professional
and non-professional staff salaries as well as allowances. Drug costs were apportioned on
the basis of records of issues to wards, and interviews with key personnel when these
Cost, Resource Use and Financing of District Health Services
9
records were not available.
"Other costs" in this case consist of stationary, food for
inpatients, food for staff, supervision costs, in-service training, fuel, vehicle maintenance,
medical gases, cleaning materials, repairs, laundry, telephone, water and electricity, cylinder
hire, equipment maintenance, laboratory reagents and x-ray films.
The following table shows the breakdown of total and average cost by cost centre:
Table 3: Total and Average Cost: Otjiwarongo Hospital
CQflC
Category
Total
OPD
PAED
MAT
SURG
MED
Fec&ale
Theatre
Personnel
Drugs
Other
Total
Output
Unit cost
1983589
461145
885064
3329798
41662
79.92
269245
102509
112912
484666
3243
149.45
212510
34387
105712
352609
5580
63.19
222193
34387
107558
364138
5695
63.94
236263
53127
141104
430494
7584
56.76
275289
53127
174417
502833
5660
88.84
262702
34402
155354
452458
8472
53.41
505387
149206
88007
742600
1428
520.03
Notable here is the high cost of an outpatient visit compared with an inpatient day. As
will be discussed in the next sections, this is at least partly due to the low levels of staff
utilization in the OPD, as well as the high drug cost per visit for that department
The breakdown of total cost by input for each cost centre reveals that the proportion of
total cost accounted for by salaries is roughly constant, at between 55 and 65% of total cost
Drug cost is significantly higher as a proportion of total cost in theatre (33%) and in
outpatients (23%) than in other wards which vary from 6 to 13% (Table 4).
Table 4: Breakdown of Total Costs by Activity
(figures are percent of total cost)
Cost Centre
Personnel Cost
(%>
Drugs
(%)
Other
(%)
OPD
Paediatric
Surgical
Maternity
Medical
Female
Theatre
56
60
55
59
58
58
68
23
8
11
13
6
8
33
23
30
33
29
37
34
12
III. EFFICIENCY
Clinics
Three different approaches to the assessment of efficiency issues were taken in this
study. First, since differences in average costs reflect differences in the productivity with
which resources are used, these differences can be examined and efforts made to explain
Cost, Resource Use and Financing of District Health Services
10
them in terms of both the consumption of resources (the numerator) and the level of output
(the denominator). Second, efforts were made to consider specific areas of resource use
through the use of "key indicators". Since drugs and personnel were, ex ante, believed to
constitute the largest components of cost, information was collected for indicators in these
areas (average drug cost/contact, number of drugs prescribed per patient, and other
indicators of drug use, as well as utilization of staff time). The third approach was more
qualitative, relying on the experience and observation of the study participants during the
course of their field trips.
Average Cost Differences
As noted in the previous section, there are important differences in average costs across
facilities. To the extent that costs have been accurately estimated, or at least that the biases
are relatively consistent across facilities, differences in average cost can be attributed to
differences in the quantity of resources devoted to each activity (total cost as reflected in die
numerator) and/or differences in the level of output (production, measured in the
denominator). The strong relationship between average cost and output demonstrated for
outpatient care, antenatal care and family planning suggests that fixed cost factors are
important determinants of average cost, in other words, that decreasing fixed costs per unit
and hence decreasing average costs are associated with higher levels of output Given that
the quantity of fixed factors cannot generally be changed in the short-to-medium run, the
only way to reduce average costs and hence to increase efficiency is to increase the level of
output An increase in output without loss of quality of care would seem to be feasible in
the case of rural clinics in this district given the existing low level of staff utilization (this
will be discussed more in later sections). The main constraint to increasing output, however,
may be the sparseness of population settlements in many areas, and the consequent large
distances which must be travelled by those in need of health care. In cases where small
catchment populations mean high average costs, this may have to be accepted in the shortto-medium term as an unavoidable cost of increasing the accessibility of health services to
these populations.
Key Indicators
A second approach to assessing the efficiency of resource use is to look more closely at
specific areas which are known to be of particular interest Generally speaking these can fall
into two areas: looking at those inputs which make up particularly important shares of total
cost; and secondly, those inputs which have a significant impact on the efficiency with
which other resources are used. Since in most cases, personnel and drugs make up the
majority of total recurrent costs, it was decided to focus on these two areas and to use
efficiency indicators which would permit a closer look at these two inputs.
Efficiency of Staff Use
One approach to evaluating the efficiency of staff use is to consider how much of the
time available to see patients (under reasonable assumptions for administrative work,
statutory breaks and holidays, etc) is actually used for consultations. The details of the
Cost, Resource Use and Financing of District Health Services
11
method and assumptions used to estimate the percentage staff time utilization indicator
appear in Appendix X. The results are summarized in Table 5 which shows for each clinic
the proportion of available time used for consultations.
Table 5: Utilization of Staff Time
Clinic
% Utilization of Staff
Time
Coblenz
Okakarara
Okamatapati
Okondjatu
Orwetoveni
Otavi
Outjo
36
51
35
56
47
57
30
The effect of differences in staff time utilization levels on outpatient care average costs
can be seen in Figure 6. Generally low levels of staff utilization are associated with higher
average cost and vice versa.
Cost per outpatient visit:
Relationship with staff workload
Figure 6
Cost, Resource Use and Financing of District Health Services
12
In general it appears that workloads are quite low in relation to the availability of staff.
Care must be taken, however, in interpreting such figures as they have not been adjusted
to take account of staff mix issues: for the purposes of this analysis all trained staff receive
equal weight One suggestion which emerged from discussions with district management
team members, however, was that overall staff efficiency could be improved with a more
appropriate mix of staff. In particular, the need for a minimum of one professional nurse
in each clinic in order to be able to provide the complete package of services (especially
antenatal care) was emphasized.
Drug Use Indicators
Following the guidelines produced by WHO and the International Network for the
Rational Use of Drugs (INRUD) (WHO, 1993), an effort was made to collect clinic level
information about drug use practices. This was done by way of a random sample selected
from patient registers. The following indicators were compared for the different clinics:
•
•
•
average number of drugs prescribed per patient;
percentage of patients receiving injections;
percentage of patients receiving antibiotics.
In addition, where possible, the information necessary to calculate vaccine wastage rates
was also collected. Table 6 summarizes these results.
Table 6: Drug Use Indicators
Clinic
Coblenz
Okakarara
Okamatapati
Okondjatu
Orwetoveni
Otavi
Out jo
Average coet
of drugs per
consultation1
4.53
2.2
1.81
5.2
2.93
3.8
3.2
Average nuxaber
of drug#
prescribed per
patient
Percentage of
patients
receiving
infections
Percentage of
patients
receiving
antibiotics
Average
vaccine
wastage rate
2.5
2.7
1.95
3
2.53
2.3
n/a
1.6
6
38
19.4
15
16
n/a
39
26
5
40
36
54
n/a
55
53
86
66
88
79
74
1 Calculated as the total cost of drugs for the clinic divided by the number of consultations.
Although it is not possible to say what the "correct" or "appropriate" level of any of these
indicators is, it is possible to consider variation in the level of the indicators across facilities that is, we can take a relative rather than an "absolute" interpretation. For example, without
further information about case mix and, indeed, precise prescribing practices, it is not
possible to say what the drug cost per patient should be. A high average cost of drugs per
patient may be due to inappropriate prescription practices or to a case mix characterized by
relatively sicker patients requiring more drugs for appropriate treatment. At the other end
of the spectrum, we cannot tell whether a facility with a low drug cost per patient is under
prescribing or using drugs particularly rationally. What all of these indicators permit, then
Cost, Resource Use and Financing of District Health Services
13
is to identify ends of the spectrum, suggesting facilities in need of special attention. Of
particular note when looking at the results above are the differences in the level of average
cost of drugs per consultation (ranging from R1.8 to R5.2); the proportion of patients
receiving injections (1.6 to 38%); and the proportion of patients receiving antibiotics (5 to
54%). There is relatively less variation in the number of drugs prescribed per patient.
Unfortunately the data does not reveal clearly the relationship between the efficiency of
drug use and average cost, although in principle more efficient use of a variable input
(drugs) should be reflected in lower average costs. This may be due to the relatively small
proportion of drug costs in total costs which may, in turn, be due to errors in calculating
annual drug consumption.
In addition, although efforts were made to ensure that the selection of consultations from
patient registers was random, it should be noted that an absence of standardized protocols
for using the patient registers may mean that these results are biased. All facilities suffered
from a shortage of registers. In one facility, for example, it was clear that only patients that
were unusual (for example, from outside the immediate area, or cases likely to involve a
police investigation) were recorded in the register. This means that all of these results must
be assessed with caution.
Vaccine Wastage
Vaccine wastage is often a good indicator of particular problems in the efficiency of use
of this resource. Vaccine wastage rates (averaged across antigens) are fairly high in the
facilities visited, ranging from 53% to 88%. In a number of cases these rates were
extrapolated from a few months' data, and may be subject to bias. The feeling of the
workshop was that being such a small proportion of total costs, other areas of efficiency
warranted more urgent attention than vaccine use.
In light of the substantial amount of resources apparently being spent on family
planning commodities, a feature only discovered during the course of the study, it would
have been useful to devise a special indicator to enable a closer look at efficiency of use of
this resource. Commodity costs per couple year of protection, or annual cost by method,
calculated in a way which would incorporate utilization data so as to capture possible
wastage or other losses, would be one appropriate way to consider efficiency in this area.
Qualitative Observations
Based on the experience of the workshop participants a number of general comments
were made concerning efficiency issues in the clinics:
Generally, managerial systems appeared to be weak in the clinics: this was reflected in
the generally poor quality of the routine information produced by the health information
system (discussed more below); and poor quality of data from routine supply management
tools. An important feature here is that these systems were not designed to do the job being
demanded of them by this study. This is not meant to be criticism of the existing system.
Cost, Resource Use and Financing of District Health Services
14
but rather, a pointer to the needs for management strengthening if district health managers
are to be truly responsible for resource management.
The problems of data reliability have particular implications for the reliability of the
average cost estimates. At best, the problems of estimation of, for example, drug supply are
relatively constant across facilities and the overall sense if not die actual figures is reliable.
The study team felt that there was a particular need to consider the decentralization of
the health system. There appeared to be an imbalance in the quantity of resources available
to different areas. It was pointed out that the experience of other countries in the regions
indicates that "selective" decentralization is insufficient to allow for a meaningful control
over resources by district managers. Also, the need for capacity building was emphasized.
A particularly good example of this was in the use of the health information system. The
achievement of rapid data turnaround and the high levels of reporting are to be applauded.
However, it was clear in a number of facilities that the forms were not being filled out
properly and that more training and reinforcement of previous training is essential to ensure
that the data generated by the HIS is of a reasonable quality and hence useful in both
epidemiological and managerial monitoring.
Issues of file essential drugs policy and drug management were perceived to be central
to better use of existing resources. It was suggested that a more formal way of assessing
drug needs at clinic level should be put into place, for example, including a stock
management system and annual or semi-annual stock reconciliation. A standardized format
for stock-keeping, such as the one used for contraceptives and vaccines, would both
strengthen stock-keeping practices, and make monitoring of drug use practices much easier.
It was felt that considerable waste is generated by the purchase of non-generic drugs:
an essential drugs list for the clinic level is needed, and the accompanying treatment
protocol needs to be made more "accessible" to lower cadres. There was concern, for
example, that the language might be difficult for those not schooled in English to
understand; that the manual is somewhat bulky and formidable; that simple treatment flow
charts might provide a useful addition; and finally, that there is a need for training in the
use of the manual and in national rational drug prescription practices.
Finally, it was felt that personnel management practices could be strengthened in order
to improve the motivation of health workers. This might include considering:
•
•
•
•
hardship allowance for distant rural posts;
clarification of the organizational flowchart who is responsible to whom;
training in health information system use;
improvement of handing-over procedures when staff are moved (for example,
transfer of stock books, consultation registers, statistic summaries, etc).
There might be a role for a health personnel survey which could include:
determination of standard workloads for various cadres;
Cost, Resource Use and Financing of District Health Services
15
establishing more accurately whether staff are truly under-utilized;
asking staff how they would envisage increasing their utilization and productivity,
including additional training and skills.
Otjiwarongo Hospital
Evaluating efficiency of resource use at the level of the district/regional hospital is
somewhat more complicated than in the clinics. First, the range of tasks is more complex.
Second, there is no similar unit, producing the same type of output, with which the hospital
can be compared. This makes it impossible to use the cross-facility comparison of average
costs as a way of assessing productivity. What remains then, is to evaluate specific
efficiency indicators. In some cases, they can be assessed across wards, allowing for some
form of comparison.
Table 7 Efficiency Indicators
Ward
Paediatric
Maternity
Surgical
Medical
Female
Average
OPD
Theatre
1
2
3
4
Occupancy
Rate1
Average
Length of
Stay2
Beds Per
Nurse3
Drug Cost
Per Day4
36.4
82.1
82.9
75.6
58.0
62.9
5.3
4.6
6.9
72
6.6
6.1
8.4
5.8
6.6
4.2
3.8
4.0
62
2.7
4.10
7.01
8.30
5.27
31.61
104.48
Occupancy rate defined as: hospital days/(no. beds x 365) * 100
Length of stay = hospital days/admissions
Beds/nurse = no. beds/no. nurses
Drug cost/day = cost of drugs/hospital days
The above table summarizes some of the main efficiency indicators calculated. The
average occupancy rate varies from 36% in the paediatric ward to 83% in the surgical ward.
There is relative uniformity in length of stay across wards, with the lowest LOS in the
maternity ward and the highest in the medical ward. The number of beds per nurse varies
from 8.4 in the paediatric ward to 3.8 in the female ward. The level of workload, however,
is more a function of the degree to which the beds are occupied than the absolute number
of beds per nurse. Finally, although for inpatient services the level of variation in drug cost
per day is not of concern, the extremely high drug cost in the OPD is a source of worry.
Since we would on average expect admitted patients to be more ill than those being seen
in the OPD, this is clearly an area for additional investigation by the hospital and regional
authorities.
Cost, Resource Use and Financing of District Health Services
16
The analysis of drug costs was extended by a "rapid assessment" of the average cost of
one weeks' OPD records which shows that while the average cost of drugs per prescription
is R17, the average drug cost per OPD consultation for the year was R31. It was felt that
seasonal patterns of illness might explain part, but not all, of this discrepancy. Further
research into this question was encouraged.
Personnel Time Utilization
The assumptions made in calculating the percentage utilization of staff time for the
hospital appear in Appendix 2. As can be seen in the table below, there is substantial
under-utilization of personnel time, both at the level of nursing and physician staff.
Particular problems were apparent for doctors, and it is recommended that in the short term,
contracts be reviewed with regard to the number of sessions per month. The rate of
utilization of nursing time in the OPD is only 9.5%. This suggests that at the present
utilization rates there is a need to re-deploy nursing personnel to ensure more efficient use
of their time. With the present rate of utilization of nursing time elsewhere in the facility,
the potential for re-deployment within the hospital is limited. Any decision for deployment
to other sites in the region will need to be made after a comprehensive review of utilization
rates for the region as a whole. It should also be recalled that the hospital is in the process
of being upgraded to a regional hospital which will increase the level of inpatient use
substantially. For file OPD, future research may be needed to establish why utilization rates
are so low.
Table 8: Utilization of Staff Time, Otjiwarongo Hospital
Ward
Percent Utilization of Available Time
Inpatients
Outpatients
Doctors
43%
9.46%
31.1%
Other Qualitative Observations
Specific comments were made by the study team regarding drug use. It was noted that
the drug cost per OPD contact was excessively high. Preliminary analysis of the quantity
and type of drugs prescribed by nurses to OPD patients suggests that they prescribe to cover
all possibilities. In addition, a cursory observation of the drugs available in the Pharmacy
as well as discussions with the Pharmacist indicate that up to 90% of the drugs on die
shelves are "brand-name" or non-generic products. Given that brand-name drugs may cost
up to 5-10 times more than generic drugs, this represents a significant waste of resources.
The study team noted that the overall management and control of drugs was very poor
at all levels of the hospital. No proper stock control procedures were evident at the
pharmacy. Drugs were freely "lent” to the clinic when they were in short supply, but were
never replaced. In the absence of a proper stock system it is impossible to tell at any
Cost, Resource Use and Financing of District Health Services
17
moment in time what drug stocks are. There is no system to control leakages.
At the hospital level, similar problems were noted with regard to the health information
system as are discussed for the case of the clinics. It was felt that the health information
system is ineffective, and the quality of information produced poor. Interviews with senior
staff reveal that this information is not used as a management tool. More attention needs
to be paid to the quality of the data generated, as well as training in the use of routine data
in management.
IV. RESOURCE ADEQUACY
Clinics
In addition to quantifying the present availability of resources, the study aimed to
determine the adequacy of these resources with respect both to the current level of
operation, and to coverage targets which were fixed in consultation with district personnel.
It should be understood that these coverage targets are merely indicative, used for the
purpose of considering the resource implications of increased utilization, and not intended
to displace actual Ministry of Health policy. The targets adopted for the purpose of the
study were as follows:
Curative care:
EPI:
Family planning:
Antenatal care:
1 episode of illness per inhabitant per year
80% fully immunized
30% coverage
50% coverage
The approach taken in considering these adequacy issues is outlined in Appendix 1. It
involves establishing, for each of the main inputs, a "standard" against which to compare
the actual availability of resources.
Personnel
In assessing resource adequacy for personnel the standard workload approach was
taken. This requires estimating the average number of patients a nursing staff member can
be expected to see during a year, on the basis of an average consultation time, the number
of hours available for patient consultations in an average day allowing for administration,
tea breaks, etc, and the number of working days per year. This number is then compared
against the number of patients actually seen during a year to determine whether staffing
resources are in surplus or in deficit.
This method implicitly treats different types of nursing cadres as the same type of input
Although there was agreement that there is a need to refine this general method to take
into account issues of personnel mix, the method did suggest that there is generally a
surplus of personnel with respect to actual utilization levels. It was also found that the
region may be able to achieve the projected utilization levels with the current level of staff.
Cost, Resource Use and Financing of District Health Services
18
Figures 7 and 8 show the relationship between actual availability of staff needs for die
existing level of activity, and the expanded level of activity associated with the coverage
targets described above. As can be seen in Figure 7, each facility currently has sufficient or
surplus staff. Figure 8 shows that only Orwetoveni clinic would need additional personnel
under the assumptions of increased coverage, and this need could be met from within the
existing clinic resources within the district.
Figure 7
Cost, Resource Use and Financing of District Health Services
19
Figure 8
Drugs and Supplies
The time available for the study did not permit a comprehensive assessment of drug
requirements. A rapid assessment approach was taken, adopting Outjo as a "standard"
facility in which drug use practices are felt by regional managers to be relatively rational.
The drug cost per outpatient (total estimated drug costs/number of outpatient consultations)
at Outjo clinic was used to compare the availability of drugs at different facilities with this
"standard". At current levels of utilization, three clinics (Okakarara, Okamatapati and
Orwetoveni) presented a deficit and three (Coblenz, Okondjatu, and Otavi) presented a
surplus, with a net surplus for all clinics overall. At the projected increased levels of output,
the overall drug requirement will increase beyond present resource availability.
Cost, Resource Use and Financing of District Health Services
20
Figure 9
The limitations of this method are that it fails to take into account differences in case mix
which will have important implications for resource requirements at different facilities.
In addition, given that the current drugs policy does not insist on generic drug supply, it
is highly probable that considerable savings could be generated. This is true even for
facilities where drug prescription practices are relatively rational. Although it was not
possible to quantify the extent of the surplus that could be generated, this is clearly an area
for urgent policy attention.
Vaccines
Overall vaccine supplies appear to be adequate at both present utilization levels and at
the projected coverage rate of 80% full immunization. Current high levels of vaccine
wastage explain why such a large increase in coverage could be achieved within current
resource limits, since vaccine requirement estimates are made on the basis of (much lower)
WHO standard wastage rates. The real reasons for such high levels of wastage need to be
more fully investigated before the validity of this proposal can be tested.
Other Inputs
Other areas of resource need noted by the study teams were stationary, particularly
patient consultation registers and stationary requirements for an adequate drug management
team. There appeared to be sufficient supply of the stationary associated with the new
Health Information System.
Cost, Resource Use and Financing of District Health Services
21
Table 9: Summary of Resource Requirements - Present and Expanded Levels of Utilization
Input
Present Level of
Activity
Expanded Level of
Activity
Staff
Drugs
Vaccines
+ 285,300*
+ 6,571
+ 5,417
+152,1602
-182,804
- 7340
Total
+R297,288
-R37,984
1 This represents an excess of 15 nursing staff at an average cost of R19/320
2 This represents an excess of 8 nursing staff at an average cost of R19,020
The above summary table combines information about efficient resource use and
resource adequacy, insofar as the standards used to explore resource requirements make
some assumptions about efficiency. For example, the calculation of personnel requirements
is based on a "standard" number of consultations per nurse per year; drug needs are based
on consumption at Outjo clinic where it is felt that drug use practices are relatively rational;
and vaccine requirements are based upon WHO standard wastage rates. Implicit in the
adding of the surplus and deficit areas is the assumption that managers can costlessly
substitute across inputs. This is clearly not the case: managers cannot simply transform
salary resources into drugs or drugs into vaccines. This table thus shows an ideal case, with
a perfectly flexible management system. The questions that it raises for consideration at the
level of district management are the following:
•
How much flexibility do district managers have to substitute resources and make
transfers between budget items?
•
What is needed to increase the efficiency with which these resources are used?
•
What are the major constraints to these efficiency improvements, and at which levels
of the system do they occur?
The main lesson to be taken from this analysis is that existing resources can be made to
go considerably further towards fulfilling the health needs of the Namibian population. The
extent to which more efficient management can be achieved depends on the extent to which
managers possess the powers and authority to make timely and appropriate decisions.
Hospital
Because Otjiwarongo Hospital is currently undergoing a major change in role (from
district to regional referral hospital) and because of the short time available for this study,
with the exception of staffing levels it was not possible to consider issues of resource
adequacy. The main conclusions about the availability of staff at current levels of utilization
appear in the preceding section. More information than was available at the time of this
Cost, Resource Use and Financing of District Health Services
22
study would be needed to undertake a projection of future hospital utilization levels, and
the implications for staffing levels.
V. FINANCING
Clinics
At present there is a flat fee (R3.50) per visit for curative services, with a lower rate for
re-attendances and free services for follow-up patients with chronic illness. Information was
not available to evaluate the impact on utilization of health services of the current user fee
policy, particularly since there had recently been a change in the level of fee being charged
at the district hospital level.
It appears that people who cannot pay are not turned away, but that the exemption
system is largely ad hoc.
Fees collected are not retained at the facility, but revert to the Ministry of Finance.
Current user fee collections amount to 4.5% of total recurrent costs for three clinics (names)
and 17% for Okakarara. User fees collected as a proportion of estimated drug costs range
from 37 to 150% in three clinics. The possibility of decentralizing the retention and
management of all or part of the user fees to facility level was proposed, with the proviso
that additional training would be required to reinforce such financial decentralization.
Hospital
The main sources of financing of hospital services are user fees and central government
allocations. User fees are not retained at the hospital, but returned to Treasury. Vaccines
and volunteer staff are donated by UNICEF and the Cuban government respectively. The
magnitude of this donation is insignificant compared with the total hospital budget, and
hence no attempt was made to quantify this amount.
Table X: 1992/3 Hospital Financing
Government budget
User fees
R3 204 509 (97%)
R 110 892 (3%)
Total expenditure
R3 315 401
The following services are offered free:
immunization
antenatal care
well-baby clinic
family planning
TB treatment
Cost, Resource Use and Financing of District Health Services
23
For all other services, the following fee structure applies:
Outpatients department:
Public
Private
R 9.00
24.00
(Patients can decide whether they would like to be private or public)
Inpatients:
Public
Private
R 24 per day per stay
R 120 per day (general weird)
150 per day (private ward)
Taking a conservative approach and applying only the state tariffs to the number of patients
seen, the total revenue should have been:
Inpatients:
OPD:
R 144 384
29 187
Total
R 173 892
This can be compared with the actual amount received, of R110 892 to see that there was
a deficit of R62 679 (36%), suggesting that 36% of patients did not pay any user fees for their
visits. In addition to unclear criteria for exemption, it is also clear that most outpatients will
choose to be treated under the state fee schedule, since the quality of care is file same for
both.
Sustainability
Questions were raised as to whether the present high level of government support (97%
of operating expenses) can be sustained into the future. Currently, health accounts for 15%
of total government spending. Although this commitment to health services is to be
admired, it is clear that are a number of ways in which extra resources could be generated
fairly painlessly. This includes tightening up the system of user fee collection, including
ensuring that patients with medical aid schemes receive "private" care in both outpatients
and inpatients departments. Once all areas of increased efficiency have been explored,
efforts to mobilize additional resources can be sought
VI. CONCLUSIONS
In summary, the main conclusions of the study can be summarized in four parts:
information availability, efficiency issues, adequacy issues and management reform.
Cost, Resource Use and Financing of District Health Services
24
Information Availability
In many ways, the most revealing features of this study arise in what was not possible
to calculate or analyse, or what could only be calculated with significant margins of error,
rather than in what could itself be accurately assessed. This is particularly true of the cost
analysis itself, for which it is clear that inaccuracies are introduced into the calculations via
both the quantification of total quantities of inputs used, and the correct estimation of an
output measure. As already noted, this is not a judgement on the functioning of the system
as it was designed, since it was not intended to provide the information which was required
for average cost calculations. Rather, it points to the types of strengthening needed if
managers are to have access to the information needed to enable them to exercise more in
the way of meaningful resource management. The two most important areas for attention
are the health information system and the drug management system.
At both the clinic and hospital level it is clear that the HIS has now moved into the stage
where quality control is essential. This will likely mean stepped-up training at both the
facility and the district data processing unit level, which should focus on the correct filling
out of forms, and consistency checks at the processing stage. Training can then be
reinforced through regular supervision and rapid feedback of HIS information to facilities
level. Action in this area can take place at the district level, but may require additional
attention from the centre.
Efficiency Issues: Staff, Drugs
Even with the difficulties mentioned above regarding the accurate calculation of drug
consumption and output, it is clear that available resources can be used more efficiently,
freeing up resources for expanding activities. This is true for all of the major inputs (staff,
drugs). The main question to be addressed in this area is whether district managers will
have sufficient authority to make the required changes, or whether additional actions are
needed at higher levels. The drug procurement and management issue, for example, is one
which requires action at the centre, since changes to a generic-only procurement system
would require policy change.
Adequacy Issues
In the Namibian context the study was not primarily used to identify resource
requirements: facilities are relatively well-resourced. Rather, the more interesting
application of the methodology lay in the way in which efficiency and adequacy information
could be integrated to show where there are surpluses. The main additional requirements
noted by the study team are inputs that fall into the category of "little things that make the
system work" - such as stationary.
Reform of Management Structures
Given the rapid-assessment nature of this study and the fact that the health system is
in a state of rapid evolution, it was not possible to identify specific areas for management
Cost, Resource Use and Financing of District Health Services
25
reform. The study did, however, help to identify some of the ways in which cost analysis
can be used to explore issues of efficiency and resource adequacy in the district. Detailed
cost studies are time-consuming to undertake on a regular basis. One possibility for
consideration by the DHMT would be to include in the HIS some indicators oriented
towards "management information" (MIS) which would allow regular monitoring of key
efficiency issues.
Cost, Resource Use and Financing of District Health Services
APPENDIX 1:
SETTING STANDARDS AND A
ADEQUACY
26
MG ISSUES OF RESOURCE
Objective:
Determine availability of resources to provide the basic services.
Approach:
Compare present resource availability with some standard of
resource requirements
—>
resource gap
Steps: For each input assess:
•Present level of resources
•Requirements
- with respect to actual levels of activity
- with respect to coverage objectives
1. ESTIMATING DRUG REQUIREMENTS
•
The patient morbidity standard treatment method
■
■
•
The adjusted consumption method
■
■
■
•
number of episodes/health problem
Average standard treatment
Actual consumption at standard facilities
Adjust quantities for inappropriate consumption
Convert adjusted quantities per 1000 treatment
episodes
The "rapid - assessment" method
■
Use as a standard a facility perceived by district supervisor to have the
following:
rher i
- a regular supply of drugs with no major problems of stock-outs
- rational prescription practices
u ro ■ X'l i
Cost, Resource Use and Financing of District Health Services
■
27
Adjust total consumption for any stock-outs (by item)
total consumption
-------------------------------# days without stock-out
X
number of
opening days
■
Calculate the average cost of drugs per curative consultation
■
Use this figure to determine the requirements at the other facilities
= average cost/contact X number of consultations
Note: This method does not allow for differences in case mix between facilities.
2. ESTIMATING PERSONNEL REQUIREMENTS
Calculation of standard workload:
■
Determine the average consultation time across all activities provided at the
facility:
* where there are regular deliveries - 15 minutes could be considered as
"standard";
* in Namibia, where deliveries are rare and not part of the basic service
package, 10 minutes could be considered as standard.
■
Determine the number of working hours per day which are available for
consultations (allowing time for lunch breaks, administration, etc):
* in Namibia clinics are open from 8:00-1:00 and 2:00-5:00 (8 hours). Assume
that of these hours, 5 are available for consultations.
■
Calculate the number of consultations of all types which can be carried out by
one person during one day:
* 5 hours x 60 minutes -r 10 = 30.
■
Determine the number of working days per year, excluding annual leave, sick
leave and statutory holidays:
Eg. 4 weeks annual leave, 2 weeks sick leave and 15 days statutory holiday
Cost, Resource Use and Financing of District Health Services
28
leaves 220 working days per year.
■
Multiply the number of available working days by the number of
consultations possible per day to arrive at the number of potential
consultations per person per year:
* 220 X 30 = 6600 consultations per person per year.
Application to actual workload:
■
Determine the total number of consultations of all types in the last 12 months
(1st OPD visits + re-visits, EPI contacts, ANC contacts, FP contacts, ...).
■
Divide by the number of qualified staff to determine the average number of
contacts per staff member
■
Divide this number by the "standard" workload to determine the % utilisation
of staff time.
Application to potential workload given coverage objectives:
■
Determine the catchment population and target groups:
* eg. 10 000 people.
Target groups:
o # births : 5% = 500
o children < 1: 4% = 400
o children < 5:18% = 1800
o women
15-45: 20-22% = 2100
■
Considering current coverage levels determine coverage objectives for each
activity:
* eg. Curative consultations: suppose present coverage is 50% (5000 first
curative visits per year). A possible objective is 75% (7500 first curative visits
per year);
• eg. EPI: Suppose present coverage is 50%. A possible objective is 80% (320
fully vaccinated children per year);
* eg. ANC: suppose present coverage is 30%. A possible objective is 50% (250
women receive at least 3 ANC visits during pregnancy);
* eg. Deliveries. Suppose you want to add deliveries to the basic package
Cost:, Resource Use and Financing of District Health Services
29
offered at clinics. Present coverage is 0%. A possible objective is 20%. The
number of expected births is 500. A coverage level of 20% would mean 100
deliveries in the clinic.
■
Given these coverage objectives, determine the workload associated with these
activities:
* eg. Curative consultations. You will need to know the ratio of total visits
to first visits. Suppose the average number of visits per episode is 1.5. The
workload associated with 7500 first curative visits is 11250 visits;
* eg. EPL The total number of contacts required for each fully immunized
child is 5. The workload associated with 320 fully vaccinated children is 1600
contacts;
* eg. ANC. Each women should attend at least 3 ANC visits during
pregnancy. The workload associated with 250 women is 750 contacts;
* eg. Deliveries. The weighted consultation time of 10 minutes does not
include the time required for deliveries. One way of adjusting for this is to
use a "consultation equivalent". If the average time a nurse spends with a
mother during delivery is 120 minutes, this is equivalent to 12 consultations.
The workload associated with 100 deliveries is 1200 contacts.
■
Determine the total number of consultations associated with these coverage
objectives:
* eg. For this package of services, the total workload would be:
11250 + 1600 + 750 + 1200 = 14800.
■
Determine the number of staff required for this workload:
* eg. 14800 -e- 6600 = 224 (round up to 3) - you might want to re-consider your
objectives to ensure that third person is fully utilized.
■
Compare this staff requirement with the actual staffing level:
* eg. Suppose that the present staffing level is 1 nurse: 2 more will be needed
to provide the basic package at the coverage levels defined above;
* eg. Suppose another facility has 4 staff. Here, there is an excess of 1 person
with respect to the workload associated with the coverage objectives.
Note: It would be important here to explore the possibilities of transferring staff between
facilities in order to improve the use of currently available resources.
Cost, Resource Use and Financing of District Health Services
30
3. VACCINES
To estimate vaccine requirements, you need to consider the target population, the
coverage objective, the number of doses per antigen and expected wastage levels. In the
above example the target group was 400 children, the coverage objective 80% and the
number of children to be completely vaccinated was 320. With standard wastage levels of
100% for BCG and 50% for other antigens, the vaccine requirements would be:
Vaccine Requirements:
BCG
DPT
Polio
Measles
320 x 2 x 1
320 x 1.5 x 3
320 x 1.5 x 4
320 x 1.5 x 1
= 640 doses
= 1 440 doses
= 1 920 doses
= 420 doses
For tetanus toxoid vaccine, the number of doses required will depend on the target groups
and strategy. If we restrict the target group to those women who come for antenatal care
the number of doses required with a strategy of 2 doses during pregnancy would be:
250 x 1.5 x 2
=
750 doses
Cost, Resource Use and Financing of District Health Services
31
SETTING STANDARDS AND ASSESSING
T rm NATION AT OTJIWARCNGO HOSPITAL
PERSONNEL
APPENDIX 2:
Calculation of standard workload for hospital: Assumptions
1. Average consultation time:
OPD = 15 minutes (Nurse)
10 minutes (Doctor)
INP
= 20 minutes
2. Average working hours:
INP
= 8hrs - 0.5 (tea) - 2hrs(admin)
= 5.5 hours per day
3. Average working hours:
OPD = 8hrs - 0.5 (tea) - lhr(admin)
= 6.5 hours per day
4. Inpatients:
No. of contacts possible per day
= 5.5 x (60mn/20mn)
= 16.5
No. of working days per year
= 260(excl weekends) 49(leave) -13(public holidays)
- 10(avg. sick leave)= 188
No. of possible contacts per year, per person
= 16.5 x 188
= 3102
Actual contact per year per person= Total IPD days/Total Prof Staff
= 36991/28
= 1321
Rate of Utilisation
= INP days per staff/INP days per year *100
= 1321/3102 *100
= 43 %
H
■ IOO
Cost, Resource Use and Financing of District Health Services
5. Out Patients
No. of contacts possible per day
= 6.5 x 60/15
= 26
No. of possible contacts per year = 26 x 188
= 4888
Actual contact per person
= 3243/7 = 462
Rate of Utilisation
= 462/4888 * 100
= 9.46 %
6. Doctors (OPD)
Working Hours
Average contact time
= 22 per month
= 10 minutes
No. of possible contacts per mth per doctor
= 22 * 60/10
= 132 per month
Actual work Load (estimated on the basis of 15% of total OPD)
= 15% of 3243/12
= 41 per month
Rate of utilisation
= 41/132 ‘100
= 31.1%
Personnel: Actual v. Required
Required Personnel = Hospital days/STD work load
7. Required Staff by Ward
Paeds
= 5580/3102
=2
Maternity
= 5695/3102
=2
32
Cost, Resource Use and Financing of District Health Services
Medical
= 9660/3102
=4
Female
= 8472/3102
=3
OPD
= 3243/4888
=1
Doctors(OPD)
= 41/132
=1
33
OPD
PAEDS
MAT
Surgical
Medical
Female
Doctor
Actual
7
5
5
6
6
6
5
Required
1
2
2
3
4
3
1
Surplus
6
3
3
3
2
3
4
Result: 20 of 35 professional staff are surplus
Note: For theatre there is insufficient information to determine what the workload and what
the optimum staff requirements are.
Cost, Resource Use and Financing of District Health Services
APPENDIX 3:
LIST OF PARTICIPANTS
Gambia:
Mr. Paul J. Mendy
Ghana:
Mr. Fidelis G. Dakpallah
Mauritius:
Ms. Minakshi Dabee
Mr. L. Ramtohul
Mozambique:
Ms. A. J. Namburete Cumbi
Mr. Manuel Ndimande
Ministry of Health and Social Welfare
Planning Unit, Medical and Health Department
Banjul
The Gambia
Tele. No.: 25379
Ministry of Health
P.O. Box M44
Accra
Ghana
Tele. No.: 665421 ext 4233
Ministry of Economic Development and Planning
9th Floor Emmanuel Anquetil Building
Desforges Street
Port Louis
Mauritius
Tele. No.: 230. 201.1603
Ministry of Health
Emmanuel Anquetil Building
Desforges Street
Port Louis
Mauritius
Tele. No.: 230201.1491
Swiss Cooperation, MOH
C.P. 74 Maputo
Mozambique
Tele. No.: 258.1.421.034
Maputo Central Hospital
Agostinho Neto Avenue
P.O. Box 1164
Maputo
Mozambique
Tele. No.: 424.598
Fax No.: 421.109
34
Cost, Resource Use and Financing of District Health Services
Namibia:
Mr. Kenapeta J. Hikuama
Mupaine
Ministry of Health and Social Services
Private Bag 13198
Windhoek
Namibia
Tele. No.: 2032825
Ms. Agnes M Limbo
Ministry of Health and Social Services, Otjiwarongo
Private Bag 2612
Otjiwarongo
Namibia
Tele. No.: 0651.3017
Fax No.: 06512078
Ms. Utete Mupaine
National Planning Commission
P.O. Box 13356
Windhoek
Namibia
Tele. No.: 222549 ext 242
Fax No.: 226501
Ms. Kautoo Mutirua
Ministry of Health and Social Services
Private Bag 13198
Windhoek
Namibia
Tele. No.: 0612032333
Fax No.: 0612032334
Mr. Gerson Na ruseb
Ministry of Finance
Fiscus Building
John Meinert Street
Windhoek
Namibia
Tele. No.: 0612092815
Mr. Asser K. Ngula
Ministry of Health and Social Services, Otjiwarongo
P.O. Box 280
Omaruru
9000
Namibia
Tele. No.: 062232.37 or 186
35
Cost, Resource Use and Financing of District Health Services_______________ 36
Dr. David Uirab
Nigeria:
Mr. Duru Tobi
Sierra Leone:
Mr. Sahr M. Kondeh
Ministry of Health and Social Services
Private Bag 2612
Otjiwarongo
Namibia
Tele. No.: 0651.3138
Fax No.: 06512078
UNICEF, Lagos
UNICEF Country Office
11A Osborne Road, Ikoyi
Lagos
Nigeria
Tele. No.: 2690277-280
Fax No.: 23412690726
Ministry of Development and Economic Planning
c/o 6th Floor, Youyi Building
Freetown
Sierra Leone
Tele. No.: 32322241645
South Africa:
Dr. K. Naidoo
University of Natal Medical School
Department of Community Health
P.O. Box 17039
Congella, 4013
South Africa
Tele. No.: 0312504308
Mr. Sagie Pillay
Centre for Health and Social Studies, University of Natal
Medical School
P.O. Box 17120
Congella, 4013
South Africa
Tele. No.: 031251481
Fax No.: 031258840
Cost, Resource Use and Financing of District Health Services
Dr. Brigid Strachan
Sudan:
Mr. Muneef A.B.Babiker
Dr. Hassan M. Salih
Swaziland:
Mr. Robert Shongwe
Tanzania:
Mr. Maximillian K. K. Mapunda
37
Health Economics Unit, University of Cape Town
Medical School
Anzio Road
Observatory, 7924
Cape Town
South Africa
Tele. No.: 021.406.6911
University of Khartoum
Department of Economics
P.O. Box 321
Khartoum
Sudan
Tele. No.: 79291
Telex No.: 22738
Ministry of Planning and Investments
Director of Social Development Sector
P.O. Box 2092
Khartoum
Sudan
Ministry of Health
P.O. Box 5
Mbabane
Swaziland
Tele. No. 268.42431
Ministry of Health
P.O. Box 9083
Dar-Es-Salaam
Tanzania
Tele. No. 20261
Cost, Resource Use and Financing of District Health Services
Uganda:
Dr. Sam Okonzi
Ministry of Health
Health Planning Unit
P.O. Box 8, Entebbe
Uganda
Tele. No.: 042.23591/2
Fax No.: c/o 256.42.259146
Dr. Francis Oriokot
Ministry of Health
Mulago Hospital
Dept of Paediatrics & Child Health
P.O. Box 7051, Kampala
Uganda
Tele. No.: 256.41.531350
Dr. Angela Maria Wakhweya
Ministry of Health
P.O. Box 6756
Kampala
Uganda
Fax No.: c/o 256.41235160
Zambia:
Mr. Felix K. Chindele
Ministry of Health
Planning Department
P.O. Box 30205
Lusaka
Zambia
Tele. No.: 260.1228385
Fax. No.: 225785
Mr. Jolly Kamwanga
University of Zambia
Institute for African Studies
P.O. Box 30900
Lusaka
Zambia
Mr. Edward Kapwepwe
National Commission for Development Planning
P.O. Box 50268
Lusaka
Zambia
Tele. No.: 260.1250296
38
Cost, Resource Use and Financing of District Health Services
Ms. Sally Lake
UNICEF, Lusaka
P.O. Box 33610
Lusaka
Zambia
Tele. No.: 260.1.251472
Fax No.: 220370
Mr. Dominic Sylvester Phiri
Ministry of Health
P.O. Box 80945
Kabwe
Zambia
Tele. No.: 260.5.222488/9
Zimbabwe:
Mr. Leon Bijlmakers
Ms. Margaret Nyandoro
USA:
Ms. Kara Hanson
Mr. Abdelmajid Tibouti
UNICEF, Harare
P.O. Box 1250
Harare
Zimbabwe
Tele. No.: 263.4.703941
Fax No.: 263.4.731849
Ministry of Health and Child Welfare
P.M.D. P.O. Box 323
Mutare
Zimbabwe
Tele. No.: 60624
Dept, of Population and International Health
Harvard School of Public health
665 Huntington Ave.
Boston, MA 02115
Fax. No. 617.566.0365
UNICEF, NYHQ
Senior Advisor
Bamako Initiative Management Unit H-10F
3 United Nations Plaza
New York, New York
10017
Tele. No.: 212.326.7539
Fax No.: 212.326.7059
39
#
1
Title
Economic Crisis, Adjustment and the Bamako Initiative: Health Care Financing in the
Economic Context of Sub-Saharan Africa. [June 1990]
La crise dconomique, I'ajustement et Nnitiative de Bamako: Le financement des Soins de
Santd dans le contexte economique de TAfrique subsaharienne.
2
Towards a National PHC Policy: The Bamako Initiative Strategy in Mauritania:
1989 - Year of the Village Level.
Ministry of Health, Government of Mauritania and UNICEF Mauritania. [July 1990]
Vers une politique nationale des SSP: Strategic cf Implantation de Hnitiative de Bamako en
Mauritania. 1989: Fannie du niveau village
3
The Financing of Community Health Services in Sierra Leone: Initial Results of an
Operations Research Study.
Stephen J. Fabricant and Clifford IV. Kamara. [August 1990]
4
Baseline Survey for the Implementation of the Bamako Initiative in Ghana.
David Ofori-Adjei, Agnes B. Amoa and Sam Adjei. [December 1990]
5
Community Financing and District Health Strengthening in Zambia.
Sara Bennett and Manengu Musambo. [September 1990]
6
The Costs and Financing of PHC Activities in Botswana.
Sara Bennett and Innocent Modisaotsile. [April 1991]
7
Charging for Services in Non-Govemmental Health Facilities in Tanzania.
P.G.M. Mujinja and Richard Mabala. [September 1992]
Paiement des Services dans les structures sanitaires non-gouvemementales en Tanzanie.
P.G.M. Mujinja and Richard Mabala.
8
The Financing of Community Health Services in Sierra Leone: Seasonality, SocioEconomic Status, Gender and Location Factors Affecting Access to Services.
Stephen J. Fabricant and Clifford Kamara. [November 1991]
9
Community Cost-Sharing and Participation: A Review of the Issues.
David Parker and Rudolf Knippenberg. [December 1991]
Financement et Participation Communautaire: Un Examen de la Question.
it
Title
10
Knowledge, Attitude and Practice towards Health and Essential Drugs in Rural Nepal.
Anand K. Tamang, Dr. Shanta Basnet Dixit - Integrated Development Systems, Kathmandu.
[September 1992]
11
Les Unites Sanitaires de Base. Presentation des premiers resuttats du Programme National
de Soins de Sante Primaires en Republique Islamique de Mauritania.
Ministere de la Sante et des Affaires Sociales, Nouakchott. [September 1991]
12
Cost, Resource Use and financing: A Study of Monze District, Zambia.
Kara Hanson and Felix Chindele. [December 1992]
13
Les couts et I'utilisation des ressources dans les centres de santd de la province
de Muyinga, Burundi.
Kara Hanson and Ferdinand Nkunzimana. [December 1992]
14
Le financement des couts recurrents de la santd dans le cercle de Djenne au Mali.
Kafing Diarra et Dominique Robez-Masson. [December 1992]
15
Revitaliser FHopital de Premiere R6f6rence: Workshop on the Relevance of the Bamako
Initiative Principles for the Revitalization of the first Referral Level of Care (District/Local
Hospital), 26-28 August 1992.
UNICEF. [April 1993]
Revitalization of the first Referral Level of Care (District Hospital)
16
Cost, Resource Use and financing Methodology for Basic Health Services —
A Practical Manual.
Kara Hanson and Lucy Gilson. [April 1993]
17
Enquetes menages sur les recours aux soins et les depenses de sante —
Guide methodologique.
Yves-Antoine Fk>ri, Anne Juillet et Abdelmajid Tibouti. [September 1993]
18
Les comptes nationaux de la sant6 au Mali: 1988- 1991.
Seydou O. Coulibaly et Moussa Keita. [July 1993]
19
Quality of Health Care Provision in Africa through the Bamako Intiative:
Problems and Strategies.
IV. Van Lerberghe, V. Tellier, M. Van Dormael. [July 1993]
tfifiiiilM
__
#
Title
20
Gouts, utilisation des ressources et financement des services de sante de district - Etude de
cas: District d'Obala (Cameroun).
Participants au Seminaire-Atelier. [December 1993]
21
Report on the Joint WHO/UNICEF Study ■Quality of Selected Drugs at the Point of use in
Developing Countries, 1993".
Universities of Bradford, Oslo and Pavia, WHO, UNICEF. [December 1993]
22
Cost, Resource Use and Financing of District Health Services: A Study of Otjiwarongo
District, Namibia.
Costing Workshop Participants. [December 1993]
23
Emergency Health Kits Survey.
Patrizia Carievaro, UNICEF. [December 1993]
IVW&WEME1
Title
#
1
Kenya. Strengthening Primary Health Care through Community-Based Action:
The Bamako Initiative, 1990 - 1993.
[March 1990]
2
Sierra Leone. Improved Health, Nutrition and Sanitation through Community-Oriented
MCH/PCH Interventions: The Bamako Initiative, 1990- 1995.
[July 1990]
3
Benin. Strengthening Primary Health Care: The Bamako Initiative, 1991 - 1994.
[August 1990]
4
Cameroon. Programme pour la Survie et le Developpement des Enfants: L'lnitiative de
Bamako, 1991 - 1995
[March 1991]
5
Zambia. Strengthening of District Health Services: The Bamako Initiative,
1991 - 1995.
[March 1991]
6
Burundi. Renforcement des Soins de SantS Primaires: Adaptation de l'lnitiative
de Bamako, 1991 - 1993.
[March 1991]
7
Ghana. Strengthening of District Health Services: The Bamako Initiative,
1991 - 1995.
[April 1991]
8
Nigeria. Nigerian PHC Development under the Bamako Initiative Strategy,
1992 - 1995.
[July 1992]
9
Guinea. L'lnitiative de Bamako, 1991 - 1995.
[June 1991]
10
Sao Tome e Principe. Strengthening of Basic Health Senrices with Emphasis
on Maternal and Child Health Care: The Bamako Initiative, 1991 - 1995.
[July 1991]
11
Rwanda. L'lnitiative de Bamako, 1991 - 1994.
[August 1991]
12
Togo. L'lnitiative de Bamako, 1991 - 1994.
[July 1991]
I
#
Title
14
Equatorial Guinea. Strengthening of Basic Health Services with Emphasis on Maternal and
Child Health Care: The Bamako Initiative, 1991 - 1995.
[January 1992]
15
Guinea-Bissau. The Bamako Initiative in Guinea-Bissau, 1992 - 1994.
[May 1992]
16
Congo. [-'Initiative de Bamako au Congo, 1992 - 1996.
[September 1992]
17
Lesotho. The Bamako Initiative in Lesotho, 1992-1996.
[March 1993]
ll
Year
Title
1993
The Bamako Initiative Interim Progress Report — UNICEF Executive Board 1993
(English/French/Spanish)
1992
Experience to Date of Implementing The Bamako Initiative: A Review and Five Country
Case Studies. Department of Public Health & Policy, Health Policy Unit, London School
of Hygiene and Tropical Medicine. (English & French)
1992
Operational Research Related to Rational Use of Drugs. WHO-DAP/UNICEF (English)
1992
Progress Report and Recommendation on The Bamako Initiative presented to the
UNICEF Executive Board, 1992 session. (English & French)
1991
Progress Report and Recommendation on The Bamako Initiative presented to the
UNICEF Executive Board, 1991 session. (English & French)
1990
Progress Report presented to the UNICEF Executive Board. Revitalizing
Primary Health Care/Matemal and Child Health: The Bamako Initiative.
(English & French)
1990
Report of the Pan-African Conference on the Financing of Community Health Activities,
Volume I: Conference Report and Volume II: Annexes. (English & French)
1990
The Bamako Initiative: Reaching Health Goals through Strengthened Services Delivery.
(English)
1989
Recommendation to the Executive Board (E/ICEF/1989/P/L/26) and
Progress Report (E/1CEF/1989/L.3).
Year
Title
1989
Report on the International Study Conference on Community Financing in Primary
Healthcare. Freetown, Sierra Leone 23-30 September 1989. (English & French)
1988
Recommendation to the Executive Board (E/ICEF/1988/P/L/40).
- Media
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