A methodology for the calculation of health care costs and their recovery
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- Title
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A methodology for
the calculation of health
care costs and their
recovery
- extracted text
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"Macroeconomics,
Health and
Development" Series
WH0/IC0/MESD.2
Original: French
Distribution: Limited
«
V*
5
A methodology for
Number 2
the calculation of health
care costs and their
recovery
Guinea
*
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<
World Health Organization
Geneva, June 1995
04^1^
"Macroeconomics, Health and Development" Series, No. 2
Other titles in the "Macroeconomics, Health and Development" Series are:
No. 1:
Macroeconomic Evolution and the Health Sector: Guinea, Country
Paper - WHO/ICO/MESD.1
Community Health Cell
Library and Documentation Unit
BANGALORE
4
A methodology for
the calculation of health
care costs and their
recovery
Guy Carrin
Office of Intensified Cooperation
World Health Organization
Geneva
and
Kodjo Evlo
University of Benin
Lome, Togo
*
♦
?
■'loo
A
2J
I
This document is not issued to the general public, and all rights are reserved by the World
Health Organization (WHO). The document may not be reviewed, abstracted, quoted, reproduced or
translated, in part or in whole, without the prior written permission of WHO. No part of this
document may be stored in a retrieval system or transmitted in any form or by any means - elec
tronic, mechanical or other - without the prior written permission of WHO.
The views expressed in documents by named authors are solely the responsibility of those
authors.
Printed in 1995 by WHO
printed in Switzerland
CONTENTS
Page
ACKNOWLEDGEMENTS
6
EXECUTIVE SUMMARY
7
A.
B.
C.
D.
Introduction....................................
Objective of the Study .................
Methodology ..................................
Conclusions and Recommendations
Introduction
1.1
1.2
1.3
1.4
2.
9
9
10
11
12
Analysis of the Costs of Health Care Activities in Hospitals
12
Definition of costs ..................................................
Classification of costs..............................................
2.2.1 Recurrent costs and investment costs
2.2.2 Costs by activity .............................
12
13
13
16
2.1
2.2
3.
Institutional Background .
Objective of the Study . .
Methodology of the Study
Plan of the Study............
7
7
7
8
Methods of Cost Recovery
3.1
3.2
3.3
*
*
3.4
17
17
Criteria for the evaluation of cost recovery systems............
17
3.1.1 Economic efficiency......................................
18
3.1.2 Administrative efficiency...............................
19
3.1.3 Equity ............................................................
19
Overview of the different methods of fee setting.................
19
3.2.1 Itemized fees..................................................
21
3.2.2 Flat fees..........................................................
22
3.2.3 Health insurance (health cooperative systems)
Basic principles of the fee systems adopted
23
for cost recovery in Guinea..................................................
23
3.3.1 Itemized fees..........................................
23
3.3.1.1 The EPI/PHC/ED system ..............
24
3.3.1.2 N’Zerekore Hospital........................
24
3.3.2. Flat fees..........................................
25
Conclusion .............................................................................
Page
4.
Use of the Methodology to Analyse Costs at Two Health Facilities ... 26
4.1
4.2
4.3
5.
6.
. 26
. 27
. 28
. 28
. 28
. 28
29
29
30
30
31
31
32
32
32
32
33
The Influence of the Parameters on Costs
33
5.1
5.2
5.3
33
33
38
Introduction...................................................................
Simulations after partial variations of parameters . . . .
Simulations with simultaneous variation of parameters
Conclusions and Recommendations
6.1
6.2
2
Parameters...........................................................................
4.1.1 Macroeconomic parameters ..................................
4.1.2 Demographic parameters.......................................
4.1.3 Parameters relating to the health facility ............
4.1.4 Parameters relating to the financing of expenditure
The baseline scenario for the year 1991...........................
4.2.1 The costs of health care activities and
their financing at the Maneah Health Centre ....
4.2.1.1 Childbirth................................................
4.2.1.2 Treatment of uncomplicated malaria
in children ..............................................
4.2.1.3 Summary ................................................
4.2.2 The costs of hospitalization at the
Dalaba Hospital and their financing......................
Extension of analysis to subsequent years........................
4.3.1 Parameters...............................................................
4.3.2 Results for the year 1992 .......................................
4.3.2.1 Costs of activities and their financing
at the Maneah Health Centre.................
4.3.2.2 Costs of activities and their
financing at the Dalaba Hospital............
4.3.3 Results for the year 1993 .......................................
Analysis of the costs of health care......................
6.1.1 Development of the methodology for cost
calculation..................................................
6.1.2 Application of the methodology to other
health facilities...........................................
6.1.3 Study of the structure and variance of costs
Choice of modalities of financing and a system
of fees ...................................................................
6.2.1 Cost sharing ..............................................
6.2.2 Modalities of fee-setting ..........................
40
. 40
40
f
. 41
. 41
41
41
42
4
A
Page
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BIBLIOGRAPHY
44
******
>
Annexes:
4
Annex 1
Working tool for analysis of costs at
the Maneah Health Centre..............
Table Al
Table A2
Table A3
Table A4
Table A5
Table A6
Table A7
Table A8
Table A9
Table A10
Table All
Table A12
Table A13
Table A14
Table Al5
Table A16
Table A17
Table Al8
Table A19
Table A20
Table A21
Table Bl
Table B2
Table B3
Table Cl
Table C2
Table C3
Table Al
Table B2
Table B3
Table C2
Table C3
46
Year of operation 1991 .......................................................
47
Parameters relating to demand for care .............................
47
Parameters relating to the structure of costs ......................
47
Parameters relating to the evolution of prices...................
48
Parameters relating to contribution to the financing of care
48
General data for 1990 on the Maneah Health Centre ....
48
Epidemiological data on the Maneah Health Centre
for the baseline year 1990 ...................................................
49
Distribution of personnel by percentage of working time .
50
Distribution of personnel by hours per week......................
50
Monthly salaries and bonuses of personnel in (GF)..........
51
Distribution of annual salaries of personnel ......................
51
Distribution of annual bonuses of personnel......................
52
Total annual salaries and bonuses in GF ...........................
52
Cost and amortization of infrastructure in GF...................
52
Cost and amortization of medical equipment in GF..........
53
Distribution of medical equipment by activity...................
53
Amortization of medical equipment by activity.................
54
Annual expenditure excluding salaries in GF ...................
54
Annual expenditure of the health centre.............................
55
Distribution of working time by medical activity ............
55
Coefficients of indirect cost distribution for the calculation
of the cost of curative care............................................................................. 56
Cost of childbirth in GF ............................................................................... 57
Financing of the costs of childbirth...............................................................58
Financing required......................................................................................... 58
Costs of treating uncomplicated malaria in children (in GF)...................... 59
Financing of the costs of treating uncomplicated malaria in children ... 60
Financing required ......................................................................................... 60
Year of operation and type of simulation (1992)....................................... 61
Financing of the costs ofchildbirth................................................................61
Financing required......................................................................................... 61
Financing of the costs of treatinguncomplicated malaria in children ... 62
Financing required......................................................................................... 62
3
Page
Table Al
Table B2
Table B3
Table C2
Table C3
Annex 2
Year of operation and type of simulation (1993)....................................... 63
Financing of the costs of childbirth............................................................... 63
Financing required ......................................................................................... 63
Financing of the costs of treatinguncomplicated malaria in children ... 64
Financing required ......................................................................................... 64
Working tool for analysis of costs at the
Dalaba Prefectural Hospital...................
Table Al
Table A2
Table A3
Table A4
Table A5
Table A6
Table A7
Table A8
Table A9
Table A10
Table All
Table A12
Table A13
Table A14
Table A15
Table A16
Table A17
Table Al8
Table Bl
Table B2
Table B3
Table Al
Table B2
Table B3
Table Al
Table B2
Table B3
Year of operation and type of simulation (1991)...............
Parameters relating to demand for care .............................
Parameters relating to the structure of costs ......................
Parameters relating to the evolution of prices...................
Parameters relating to contribution to the financing of care
General data on the Dalaba hospital ..................................
Distribution of personnel by percentage of working time .
Distribution of personnel by hours of work per week . . . .
Monthly salaries and bonuses of personnel
by hours per week ...............................................................
Distribution of total monthly salaries by department . . . .
Distribution of total monthly bonuses by department . . . .
Monthly salaries and bonuses of personnel........................
Costs of infrastructure in GF ..............................................
Costs of rolling stock in GF................................................
Costs of technical equipment..............................................
Annual expenditure excluding salaries and amortization . .
Annual expenditure..............................................................
Distribution of hours of work..............................................
Costs of hospitalization in the surgery department............
Financing of costs of hospitalization in the
surgery department...............................................................
Financing required ...............................................................
Year of operation and type of simulation (1992)..............
Financing of costs of hospitalization in the
surgery department..............................................................
Financing required ...............................................................
Year of operation and type of simulation (1993)..............
Financing of costs of hospitalization in the
surgery department...............................................................
Financing required ..............................................................
4
65
66
66
66
67
67
67
68
69
71
72
74
76
76
76
77
83
83
84
85
86
86
87
87
87
88
88
88
4
4
4
Page
Annex 3
Figures
Figure 1
a
Figure 2
Figure 3
Figure 4
Figure 5
Figure 6
Figure 7
Figure 8
Figure 9
Figure 10
Figure 11
Figure 12
Figure 13
Figure 14
Figure 15
Figure 16
Figure 17
Figure 18
Figure 19
Figure 20
Figure 21
Figure 22
Figure 23
Figure 24
Cost of childbirth by rate of inflation at the
Maneah Health Centre............................................................
Financing required (childbirth) by rate of inflation
at the Maneah Health Centre ................................................
Cost of childbirth by demand at the Maneah Health Centre .
Financing required (childbirth) by demand at the
Maneah Health Centre............................................................
Cost of childbirth by exchange rate at the Maneah
Health Centre ........................................................................
Financing required (childbirth) by exchange rate at
the Maneah Health Centre.....................................................
Cost of treating uncomplicated malaria by rate of
inflation at the Maneah Health Centre.................................
Financing required (uncomplicated malaria) by rate of
inflation at the Maneah Health Centre...............................
Cost of treating uncomplicated malaria by demand
at the Maneah Health Centre ................................................
Financing required (uncomplicated malaria) by demand
at the Maneah Health Centre ................................................
Cost of treating uncomplicated malaria by exchange
rate at the Maneah Health Centre.........................................
Financing required (uncomplicated malaria) by exchange
rate at the Maneah Health Centre.........................................
Cost of hospitalization (surgery) by rate of inflation at
the Dalaba Hospital ..............................................................
Financing required (surgery) by rate of inflation at
the Dalaba Hospital ..............................................................
Cost of hospitalization (surgery) by demand at
the Dalaba Hospital ..............................................................
Financing required (surgery) by demand at the
Dalaba Hospital.....................................................................
Cost of hospitalization (surgery) by exchange rate
at the Dalaba Hospital............................................................
Financing required (surgery) by exchange rate
at the Dalaba Hospital............................................................
Cost of childbirth - Simultaneous change of
parameters at the Dalaba Hospital.........................................
Financing required for childbirth - Simultaneous
change of parameters at the Dalaba Hospital........................
Cost of treating uncomplicated malaria - Simultaneous
change of parameters at the Dalaba Hospital.....................
Financing required for uncomplicated malaria - Simultaneous
change of parameters at the Dalaba Hospital........................
Cost of hospitalization (surgery) - Simultaneous
change of parameters at the Dalaba Hospital........................
Financing required (surgery) - Simultaneous change
of parameters at the Dalaba Hospital....................................
89
89
90
90
91
91
92
92
93
93
94
94
95
95
96
96
97
97
98
98
99
99
100
100
5
ACKNOWLEDGEMENTS
We most sincerely thank the Minister of Public Health and Population, Dr
Madigbe Fofana, for the interest he has taken in this study. We should also like to
thank the Secretary-General, Dr Ousmane Bangoura, the National Director of Health,
Professor Mandy Kader Konde, and the Director of the Division of Hospital Medicine,
Dr Naby Daouda Camara, for their assistance during our visit to Guinea to carry out this
study.
Our thanks also go to our colleagues at the Ministry of Public Health and
Population, Dr Barry, Dr Diare, Dr Kone, Dr Sy Ila and Dr Tall for their collaboration
and assistance during this mission, to Dr Tambalou Sara and Dr Mamey Conte, the
Director and Deputy Director respectively of the Maneah Health Centre, and Dr Pepe
Dramou, the Director of the Dalaba Hospital, for their cooperation during our field
visits.
6
4
EXECUTIVE SUMMARY
1.
Introduction
The Government of Guinea is undertaking a reform of the state-run prefectural
and regional hospitals and the university teaching hospitals. In order to ensure that the
reform programme is financially viable, the Government has decided to establish a
system of cost recovery to help it to recover the recurrent costs other than salaries
incurred in the delivery of health care at these health facilities. The cost recovery
system to be adopted needs to take account of the socioeconomic constraints on the
population as well as the structure of costs. Above all, it must meet the specific criteria
(economic efficiency, equity and administrative efficiency) on which the quality and
relevance of a cost recovery system can be judged.
The Government’s immediate objective is to introduce a system of charges which
must be applied nationwide but may vary depending on the level of care. In order to
introduce charges for health care activities, it is not only necessary to know what they
cost but also to understand the effects the fee system used may have on the
Government’s declared objective of improving the health conditions of the population.
2.
Objective of the Study
This study has two objectives: (i) to develop a practical methodology for the
analysis of costs; (ii) to make a critical analysis of systems of cost recovery and an
overview of the cost recovery systems used by the national EPI/PHC/ED programme and
by different nongovernmental organizations.
The study concludes with
recommendations to the Government of Guinea on the development of a system of cost
recovery.
3.
I
Methodology
A model was constructed to calculate costs and identify the contribution of
different sources to the financing of the different types of costs incurred in the delivery
of health care at the health facilities in question. This model, developed using LOTUS
(r) software, is of a general nature and can be applied to any health facility. To test
the model in practice, the authors made field visits to the Maneah Health Centre, run by
the National EPI/PHC/ED Programme, and the prefectural hospital at Dalaba, run by the
Health Care Development Programme (PDSS), to collect data. Three activities were
analysed: childbirth and the treatment of uncomplicated malaria in children at the
Maneah Health Centre, and hospitalization in the surgery department at the Dalaba
Hospital. Simulations were made to assess the effects that certain macroeconomic,
demographic and health parameters may have on costs and on their structure and
financing.
7
4.
Conclusions and Recommendations
In view of the present condition of the public sector hospitals, the reform on
which the Government has now embarked is welcome and needs to be continued. But
the Government is well aware that hospital reform requires time and a great deal of
energy and financial resources.
A system of cost recovery that is to be fair and
effective as well as capable of nationwide implementation requires adequate knowledge
of the characteristics of the supply and demand for health services. The results of this
study constitute the first step in this direction.
4
We recommend that the methodology developed in this study should be used in
at least fifteen health centres and hospitals so as to enable deciders to arrive at results
that approximate to real conditions. Once it has a clear idea of costs and cost structure,
the Government will have some important elements to help it decide on a system of cost
recovery and to set charges.
4
8
J
§
1.
Introduction
1.1
I
Institutional Background
Guinea has adopted a policy of primary health care and is trying to
introduce a number of measures to help to improve access to health care for all
the country’s people.
In 1988, the National Programme, comprising the
expanded programme on immunization, primary health care and essential drugs
(EPI/PHC/ED), was set up on the basis of the principles of the Bamako Initiative
and with the assistance of donors. This programme, which initiated its activities
in a certain number of health centres in 1988, is now to some extent regarded as
successful, both in the provision of services and financially.
Meanwhile, the situation is deteriorating continuously in the public sector
hospitals in the prefectures and regions and at the university teaching hospitals.
This means that these hospitals are not able to ensure effective provision of the
referral and technical support services they are supposed to offer to the basic
health services. This is hampering the progress of primary health care and is
detrimental to the development of the health services in general.
To remedy this situation, the Government has decided to undertake
reforms in the hospitals at all three levels, the prefectural, regional and university
teaching hospitals. These reforms are based in essence on the recommendations
of the Seminar on National Hospital Policy that took place in Conakry from 28
to 30 April 1990. These reforms are supported technically and financially by
donors and can benefit from the experience of the National EPI/PHC/ED
Programme, the Health Care Development Programme (PDSS) and the projects
of certain nongovernmental organizations (NGOs) which run hospitals in
different regions of the country.
The problems of financing have not been overlooked in the reform
programme. In the brochure produced after the hospital policy seminar, the
Government not only stated its intention of introducing a cost recovery system
in the hospitals but also indicated the types of costs it wished to see recovered.
Thus it is now looking for an appropriate system of recovery that takes account
of the structure of costs in the health facilities in question, along with the
socioeconomic constraints of the population and political and administrative
constraints.
Together with constraints relating to the supply of services, the
socioeconomic, administrative and political constraints make it extremely
complex and difficult to define a national policy on charges for health services
in the hospitals. It is also essential that the charges that are introduced should
be dynamic in character, i.e. structured in such a way that they can be changed
as time goes on in the light of the evolution of certain socioeconomic parameters.
9
It is nevertheless true to say that the recovery of certain types of costs is
already possible in the public sector hospitals, for at least two reasons:
(i)
(ii)
the evident willingness of the population to pay, as seen from experience
with the National EPI/PHC/ED Programme and the projects of certain
NGOs.
Moreover, patients in the university hospitals are not only
paying the official charges, which are modest, but also pay the relatively
steep fees discreetly charged in parallel by the medical personnel;
4
the Government is strongly motivated to recover costs. It does not in
practice have many other options in its present financial situation. Not
only does the structural adjustment programme (SAP) it has adopted
impose budget restrictions and encourage privatization of anything that
can be privatized, but many of the donors who contribute to the sector
also stipulate the introduction of a system of cost recovery as one of their
conditions.
The issue is thus no longer to decide whether costs can be recovered but
to determine how to charge for services.
In order to set charges for services it is necessary to know what they cost.
Since the Government wishes to assume responsibility for certain specific
categories of costs, such as salaries, it is necessary to know the structure of the
costs of each service or department in detail in order to determine who should
or can pay what. Once the costs are known, the Government will then have to
choose the cost recovery system it considers appropriate and set the charges
needed to attain the objectives that have been determined.
1.2
Objective of the Study
This study has two objectives. First, the study sets out to develop a
practical methodology for the identification, calculation and analysis of the costs
of health care activities in the public sector health facilities. This methodology
is a tool that can be used by the Ministry of Public Health and Population to
elaborate a cost recovery strategy, and is flexible, general and capable of
application to all types of public sector hospitals.
Secondly, a review of methods of cost recovery has been undertaken. The
advantages and drawbacks of each method are analysed and recommendations are
made on the methods that are considered most appropriate for the country.
What is the role of this study in cost recovery strategy? As a rule, such
a strategy will comprise the following stages:
10
1
L
Analysis of the costs of health care
(i)
(ii)
(iii)
>
IL
Choice of modalities offinancing and a system offees
(i)
(ii)
(iii)
(iv)
(V)
in.
development of a method to calculate short- and medium-term
costs;
application of this method to a sample of health facilities;
study of the structure and variance of the costs of activities;
policy of cost sharing by the Government, the prefectures, donors
and households;
determination of the modalities of charging fees, in particular
whether fees should be of a national or regional character;
establishment of an administration for the management and
implementation of the cost recovery system;
development of tools of management;
how to introduce the cost recovery system: immediately
throughout the country or in certain pilot health facilities;
Evaluation of the cost recovery system
(i)
(ii)
evaluation of the system after it has been in operation for three
years;
adjustment of the modalities of financing and the fee system if
needed.
This study covers point (i) of the first stage and touches briefly on point
(ii) of the second stage. Obviously the points that have not been covered are
also important and need to be considered and decided upon at a later stage.
1.3
Methodology of the Study
A model was developed to serve as the analytical framework for this
study; calculations for this model can be made using the LOTUS software
programme. Costs have been classified in two categories, direct costs and
indirect or common costs.
Field visits were made to collect data and to test the model. Two health
facilities were visited: the Maneah Health Centre (EPI/PHC/ED) and the Dalaba
Prefectural Hospital (PDSS). These visits were not sufficient, however, to
obtain all the information that was needed. In some instances, estimations were
made after discussions with the national authorities, donors and experts in the
field. In other cases, extrapolations were made from the data at certain NGO
hospitals, in particular the hospital at N’Zerekore, co-managed by Medecins sans
Frontieres (MSF) Belgium, and the hospital at Koundara, co-managed by MSF
France.
11
1.4
Plan of the Study
The methodology is outlined in the next section. The basic principles
are described and concrete examples are given.
In section 3 the different
theoretical methods of cost recovery are reviewed and a succinct comparative
analysis is made of the methods currently in use in the country, notably those
used by the National EPI/PHC/ED Programme, MSF Belgium and MSF France,
and Entraide Medicale Internationale (EMI). In section 4, the methodology is
used to analyse the possibilities for cost recovery in health facilities. It is used
in particular to analyse the costs of certain services or activities, and can help to
determine the level of contribution to financing that should be made by the
different sources of funding in different scenarios and with different methods of
cost recovery.
2.
<
Analysis of the Costs of Health Care Activities in Hospitals
Health care activities, like any other socioeconomic activity, engender costs since
they consume human, financial and material resources. To facilitate analysis, costs
must be classified in certain categories. But it would first of all be useful to explain
the concept of costs.
2.1
Definition of Costs
The cost of goods or services is the value of the resources spent for the
acquisition of those goods or services, which may be expressed as a monetary or
non-monetary value. Conceptually, several definitions of the notion of cost are
possible; economists often distinguish between accounting cost and opportunity
or social cost. The latter definition is mostly usedTircost-benefit analysis of
projects. In the context of this study, it is preferable to use the first definition1.
The accounting cost of goods or services may be defined as the monetary
value of actual expenditure for the acquisition of those goods or services?
Example 1: if the stethoscope used by a technical health worker (THW) is
purchased at a market price of 15 000 GF, its accounting cost is effectively
15 000 GF. Example 2: if the salary of the hospital guard is 30 000 GF per
month, the employment of that guard therefore incurs an accounting cost of
30 000 GF per month for the hospital.
4
’ For a general overview of cost analysis, see A. Creese and D. Parker (1990).
12
2.2
Classification of Costs
2.2.1
Recurrent costs and investment costs
Expenditure by a health facility may be classified in two major
economic categories: recurrent expenses and investment expenses.
Recurrent expenses comprise expenditure on goods and services that do
not last for more than one year, while investment expenditure is for the
acquisition of goods and services that usually last for more than a year.
Recurrent costs comprise inter alia:
personnel costs;
the costs of maintaining infrastructure, technical equipment and
rolling stock;
the cost of drugs and consumables;
the cost of supervision;
the cost of tools of management;
the annual depreciation of infrastructure, equipment and rolling
stock.
Investment costs generally concern:
infrastructure;
major technical equipment;
rolling stock; and
(long-term) staff training.
Although they last for a long time, these types of equipment and
material facilities suffer continual wear and tear and any activity that
makes use of them contributes to this. As a result of this wear and tear,
the lifetime of this equipment is finite and it must then be renewed. It
is therefore necessary to determine the rate at which this wear occurs
annually, i.e. the rate of depreciation or amortization, in order to know
how much needs to be set aside annually to be able to ensure renewal.
To calculate the investment cost of an asset, the following need to be
known:
I
the lifetime of the asset;
the domestic rate of inflation if the asset has been purchased in
the national currency;
the interest rate at which the money saved annually is invested in
the bank;
the behaviour of the exchange rate between the national currency
and the currency of the country of origin and that country’s rate
of inflation if the asset has been imported.
13
Let us assume that an item of equipment produced locally and
purchased this year by a hospital costs Co Guinean francs and has a
lifetime of n years. If the inflation rate is i per year and remains
unchanged through the next n years, the value of the equipment at the
end of the nth year will be:
Cn = Co x (1 + i)n
(1).
By the end of the n111 year the hospital needs to have saved an amount
equivalent to Cn in order to be able to replace the equipment. The
hospital must not wait until the end of the n111 year to do this but should
spread the amount Cn (at the year n price) over the n years of the lifetime
of the equipment. This means that each year it should save an amount
Pi whose total over the n years should add up to Cn at the end of the n111
year. Thus:
Pj + P2 + ... + Pn.! + Pn
Cn
(2).
We know that the amount ?! saved at the end of the first year is invested
in the bank at an annual rate of interest r; it will thus be worth:
Pi (1 + 0
Pi (1 + r)2
at the end of the second year;
at the end of the third year;
Pi (1 + r)"-1
at the end of the n* year.
If the future cost Cn is to be distributed equally over the n years, the
amount P, to be saved by the end of each year i will give Cn/n at the end
of the n* year (if it is invested in the bank at interest rate r per year).
As the amount Pn saved at the end of the last year will not have
generated any interest, we shall thus have:
Pn = Q/n;
Pn.! = Cn/n(l+r);
Pn.2 = C„/n(l+r)2;
P2
Pi
(3)
= Cn/n(l+r)n*2;
= CVna+r)"-1 .
Example: annual amount to be set aside for amortization of a hospital
bed at the end of the first year.
Co = 100 000 GF;
14
i = 0.1;
n=10;
r = 0.1
*
This gives:
Ci©
Cio
Pi
= 100 000 x(l +0.1),°
= 259 374 GF
= 259 374/(10 x (1.1)9)
= 11 000 GF
If the equipment is imported, it is not the domestic rate of inflation but
the rate of depreciation of the national currency against the currency of
the country from which the equipment is imported and the inflation rate
in that country that determine the future value of the equipment in the
national currency.
If d is the rate of depreciation assumed to be constant for the n years of
the equipment’s lifetime, and if i* is the rate of inflation of the country
exporting the equipment, the value in local currency of the equipment at
the end of the n01 year will be:
Cn- = Co x (l+d)n (i+i*)n
(4)
and the amount to be set aside annually in national currency for
amortization of this equipment at the end of the year i will be:
= Cn./n(l+rr
(5)
Example: amortization of a refrigerator
Co = 600 000 GF;
d = 0.05;
i* = 0.05 ;
n = 15
If the other parameters remain the same as in the previous example, this
will give:
2 593 165 GF
C15*
= 600 000 x(1.05)15 x(1.05)15
Pi-
= 2 593 165/(15 x (1.1)14) = 45 524 GF
and
It should be noted that these results are based on the assumption that the
parameters will remain constant during the n years. Such an assumption
does not necessarily reflect reality and has merely been adopted to
simplify analysis and facilitate calculation.
15
2.2.2
Costs by activity
The total cost of the activities of a health facility is the sum of the
costs incurred by all the departments of the health facility. In order to
analyse the share of each department, service or activity in the total costs
of the health facility, a distinction must be made between direct and
indirect costs.
Direct costs
Direct costs may be defined in relation to a given activity, a
medical service or a hospital department. The direct costs of a medical
service are the costs relating to the provision of that service alone.
Example: the drugs consumed by a patient are a direct cost in the
treatment of that patient’s disease. The cost of radiology equipment is a
direct cost of the radiology department and has nothing to do with the
laboratory department, for instance. Direct costs are easy to identify and
relatively straightforward to calculate.
Indirect costs
Indirect costs are more difficult to identify. These are the costs
of goods and services used jointly for several activities or by several
departments of the health facility, and which cannot therefore be
attributed in their totality to one department, service or activity.
Example: the hospital guard does service for the entire hospital. His
employment therefore incurs a cost for the hospital as a whole. But this
common cost can be distributed between the different departments or
services on the basis of well-defined criteria:
(i)
It can be examined whether the guard’s services are used more by
some departments than others. For example, if the guard spends 50%
of his time keeping guard over the equipment of the surgery department,
then 50% of the cost of his service can be attributed to that department.
It can be decided to spread the common cost in question evenly
(ii)
between the different services.
For instance, if a hospital has five
technical departments, 20% of the common cost can be charged to each
of these departments.
The common cost can be distributed in proportion to the volume
(iii)
of activity of the departments. If it is determined that the volume of
activity of the surgery department represents 30% of the total work of all
the hospital’s technical departments, 30% of the common costs can be
charged to that department on this ground. But the problem is that the
concept of volume of activity may have several definitions.
A
16
1
department’s volume of activity may be defined in terms of:
the volume of work of the personnel;
the number of patients admitted by the department;
the size of the departments revenue from payments;
the amount of its direct costs;
other criteria.
In this study, the common costs have been distributed on the basis
of the volume of activity of the departments, this being defined in terms
of the volume of work of the personnel. The following categories of
costs have been recognized as indirect costs in this methodology:
all the costs relating to administrative services;
the cost of water, electricity and gas;
the cost of buildings and fixed installations;
the cost of rolling stock [except for the means of transport
reserved for specific activities (such as the moped reserved
for the advance immunization strategy at health centres)].
3.
Methods of Cost Recovery
3.1
Criteria for the evaluation of cost recovery systems
In this paper we propose three main criteria: economic efficiency,
administrative efficiency and equity.
3.1.1
Economic efficiency
Cost-effectiveness analysis is able to show the extent to which a
given system of financing is economically efficient.
One way of
applying this method of analysis to the study of a health project or
intervention is to try to minimize costs once the objective has been
determined. In an expanded programme of immunization (EPI), for
example, the number of children to be immunized must first be decided
so that the minimum cost of the project can then be determined. In the
case of a simple act of medical care, it will first be necessary to find the
least expensive method of treatment.
*
The aim is obviously to economise on the use of resources in
attaining the set objective. The savings thus achieved can then be used
for other interventions.
It is therefore clear that cost-effectiveness
analysis will need to look at possibilities for the substitution of inputs in
any intervention: it should be considered, for example, whether the
cheapest drugs should be used; whether the best combination of
categories of personnel has been found to minimize salary costs, etc.
17
3.1.2
Administrative efficiency
The administration of funds accruing from payments by patients,
international aid, etc., and the use of these funds must also be governed
by the rule of economic efficiency. This means that resources for
administration (personnel, equipment, etc.) must be used judiciously.
Following the rules of cost-effectiveness, the costs of administration must
therefore be minimized while the objective of producing adequate health
services must be still be achieved.
There are several factors that make for efficient administration.
Firstly, the manager of the system must be allowed a certain measure of
flexibility and freedom. Imposing too many restrictions may hamper the
efficiency of the system. For instance, strict rules on the distribution of
funds for expenditure on drugs can result in the rationing of drugs.
Secondly, another important factor for administrative efficiency is the
stability of sources of financing. For example, a system of fees per
episode of illness will only be effective if families are continuously able
to pay the charges. If they are not, it will be very difficult to keep the
chosen system of cost recovery going. Thirdly, the use of too many
management tools can add unreasonably to^administrative costs. The
number and types of management tools must be decided in the light of
whether they contribute to an adequate system of health care provision.
It should be noted that even the simplest systems of cost recovery that
cover only a limited population still require a certain amount of
administration. Even for a system confined to selling a limited range of
drugs, some competence in accounting and stock management is
indispensable.
The administrative implications of changing from one system to
another must also be taken into consideration. Suppose, for example,
that a flat rate system is to be adopted instead of itemized charging. It
is not certain whether the administrative costs will be any lower in this
case. It is true that accounting for revenue from payments will take less
administrative work, but the setting and monitoring of flat rate charges
may prove to be more difficult. In order to decide on a flat rate charge
for a simple consultation, for example, the manager will need a good
projection of the volume of consultations, the reasons for them and the
drugs prescribed. If the projections are bad, the rate may well fall short
of the average cost of consultations. A shortfall in revenue may then
arise and this could lead to rationing of drugs.
18
*
The introduction of a prepayment system will require a higher
level of administrative competence: (i) familiarity with actuarial principles
to be able to set premium levels: (ii) ability to manage sometimes
considerable volumes of capital (derived from premiums): (iii)
introduction of mechanisms for the collection of premiums.
3.1.3
Equity
A system of cost recovery is said to be equitable when patients
with similar needs for medical care are effectively able to obtain the same
treatment. The advantage of this definition of equity is that it is not too
difficult to monitor its application in practice. It is obvious that the
charges patients must pay influence the extent to which they seek care.
Indirect charges, such as the cost of transport may also affect the use of
services. It is essential to have a good knowledge of these effects if the
objective of equity is to be pursued.
In practice, it is not easy to incorporate the concept of equity into
cost recovery systems. Much of the population concerned is not always
prepared to accept a system that would from the outset impose a large
measure of solidarity between families.
The advantages and
disadvantages of this kind of solidarity need to be discussed with the
population before a method of financing that attempts to meet criteria of
equity is introduced.
Equity is often said to conflict with efficiency. It is important to
note that greater equity is often likely to be achieved at the price of
higher administrative costs? Suppose, for example, that it is wished to
make a system of itemized charges more equitable by exempting the
poorer part of the population from payment for care.
There will
inevitably be additional administrative costs because it will be necessary
to identify those who are poor and to monitor their poverty status at
regular intervals. Administrative costs are also likely to increase if
considerations of equity are incorporated into flat rate or prepayment
systems: exemptions from payment or the determination of special rates
or premiums for the poor will require extra monitoring and accountancy
work.? x
3.2
Overview of the different methods of fee setting
3.2.1
Itemized fees
We will start from the principle that the salaries of the personnel
employed at the health centres are paid by the Government. The costs
of drugs, incentive bonuses and other running costs must be financed
from other sources (families, the prefecture, donors, etc.). To simplify
19
the discussion, we shall assume that families will have to pay the charges
other than those financed by the State.
As explained above, establishing an itemized charging system at
a health centre means that the different types of diseases and the
treatment they require must first be identified. The cost of the drugs
needed to treat each type of illness (direct costs) and the overhead costs
(indirect costs) relating to treatment must then be determined. These
two types of costs (cost of drugs and overhead costs) will thus determine
the rate to be charged.
The itemized fee system is at present being used in the National
EPI/PHC Programme. It differs from the method described above in
that a "coefficient or multiplier" is applied to the cost of the drugs to
cover the other overhead costs. However, we would recommend that the
method of cost calculation set out in section 2 should be used to find the
costs and set the charges.
At the hospital level, the calculations needed to establish a fee
system by activity will be more complex. The different departments and
services of the hopitals must first be distinguished (e.g. general medicine,
surgery, maternity/obstetrics, radiology, dentistry, laboratory, pharmacy,
etc.). The different activities and/or interventions carried out by each
department must next be identified. For each intervention, the direct
costs (drugs, laboratory tests, radiology tests, etc.) and the indirect costs
(overheads relating to that particular intervention) must then be
determined. The fee system by activity is at present being used at the
hospital in N’Zerekore, where there are different charges for
consultations, hospital stay (depending on the length), surgical operations,
intensive care and drugs. It should be noted that the patients buy their
drugs from the hospital pharmacy when they attend outpatient
consultations or are admitted as inpatients (other than the drugs used in
surgical operations, intensive care and obstetric care).
This method of charging can be said to be economically efficient
if it enables costs to be kept to the minimum while still ensuring
provision of services of a certain quality. The questions to be asked will
mainly relate to whether the drugs that are cheapest are being used to the
best advantage and whether the current level of overhead costs is
justified. The use of prescribing guides at health centres and therapeutic
protocols in the hospitals may also help to keep cost increases down. It
is obvious that reducing costs to the minimum should result in lower
charges. As explained above, the level of charges must be carefully
controlled in order to encourage demand for health care.
20
*
With regard to administrative efficiency, it should be noted that
systems of itemized charging usually involve a considerable amount of
administrative work. Strict accounts of the revenue from the different
charges must be kept, in particular. The regular updating of the rates to
be charged also requires substantial administrative skills.
What degree of equity can be achieved with a system of itemized
charges? If charges are set to match the total costs of an activity, it is
to be expected that certain treatments or interventions will not be
accessible to certain strata of the population. In primary health care
these are mostly long-term types of treatment or treatment requiring
relatively expensive drugs. In hospitals intensive care and special types
of care would also be more expensive and less accessible to the
population.
It is always possible to depart from the "rate equals total cost" rule
in order to increase utilization of health care by the poor.
One
possibility would be internal subsidization of the types of care that ought
to be more widely consumed. The charges for these types of care should
be set below their actual cost in order to encourage greater demand from
families and the deficit resulting from these subsidies could be financed
by additional charges for other items of care.
3.2.2
Flat fees
The main difference between this and the previous method is that
certain categories of care are grouped together. The direct and indirect
costs of care in each category are then determined in order to calculate
a mean cost. At health centres, for example, consultations may be
divided into consultations for children and consultations by adults, so as
to calculate the cost of "children’s consultations" and the rate to be
charged for "adult consultations". In a hospital, activities can be grouped
by department. In the surgery department, for example, the direct costs
(drugs used, laboratory tests, radiology tests, etc.) and the indirect costs
of all surgical operations can be calculated. Once the costs are known,
the mean cost per surgical operation can be calculated.
I
Once again, it is important that the principle of cost-effectivness
should be respected. In terms of administrative efficiency, it must be
acknowledged that revenue accounting makes considerably less work than
in a system of itemized charging. But the flat rate system nevertheless
requires rigour in the calculation of the costs of different categories of
care and the setting of charges, as well as flexibility to permit the
periodic adjustment of charges. With regard to equity, it can be said that
this method enables financial risk to be better distributed among the
population.
In the case of surgical operations, the charge will be
21
identical for all operations. For some operations, the cost will exceed
the charge.
It is therefore clear that these operations will be more
accessible to the population than they would be under a system of
itemized charges.
In Guinea, flat rate charging systems are operated by the hospitals
that are co-managed by Medecins sans Frontieres (France) and by
Entraide Medicale Internationale.
3.2.3
Health insurance (health cooperative systems)
In the health insurance system, health care is basically financed by
advance or premium payment by the population. The premium may be
set for individuals or for families. In principle, the premium reflects the
average total cost (per person or per family) of the health care covered
by the insurance. In developing countries, health insurance is usually
organized by local mutual associations. These associations insure the
cost of the health care provided at specific health facilities (e.g. a health
centre, a hospital or health centres and hospitals forming part of an
integrated system of primary and referral care).
This system is cost-effective to the extent that efforts are made to
keep costs to the minimum while still offering adequate health care. In
mutual schemes in which patients only have to pay a premium, there is
definitely a risk of overconsumption of care by those who are insured.
This is because the patients no longer bear the true cost of the care they
consume.
This overconsumption and the resulting lack of cost
effectiveness can be attenuated if the collection of premiums is combined
with partial payment for the care received by the patient. This co
payment is generally only a fraction of the real costs, and is sometimes
known as the "ticket moderateur".
A mutual scheme is fairly complex to administer. First of all, the
level of the premium and of the "ticket moderateur" where applicable
must be set.
Determination of these parameters requires good
projections of the volume of the different categories of care and the
population covered.
Secondly, these premiums must effectively be
collected from the population and this demands considerable
administrative effort. Thirdly, the evolution of health care costs and
variations in the volume of care mean that premiums must be regularly
adjusted.
Health insurance measures up well to the criterion of equity. The
financial risks are spread among the population covered. Every insured
person or family pays the same premium in principle and same ’’ticket
moderateur" is then paid by the patient. In other words, the risk that a
22
family will have to pay a lot for medical care is diminished,
as a rule that access to care is increased.
It follows
One specific problem to which attention must be drawn is the
compulsory nature of health insurance.
This obligation to join is
necessary in order to distribute the risk to the greatest possible number
of people and improve access to care. If membership of a mutual
scheme is voluntary, the risks will be distributed among a relatively small
number of individuals. Let us suppose that some of the families at low
risk decide not to insure themselves. This would have the effect of
increasing the mean cost of the medical care insured by the mutual
association and thus raising the premium.
This increase is likely to
have an adverse effect on access to care. It may therefore be concluded
that voluntary participation goes against the objective of equity.
3.3
The basic principles of the fee systems adopted for cost recovery in
Guinea
3.3.1
Itemized fees
3.3.1.1 The EPI/PHC/ED system
In this system, which covers primary health care, charges have
been established for about thirty diseases or conditions. The principle
for the calculation of charges is as follows. First, the cost of treatment
is estimated (engendered by the purchase of drugs, medical supplies,
etc.); this cost is then multiplied by a mean factor of 2.5, known as the
"coefficient multiplicateur" [multiplier].
It should be noted that
different charges have been set for children and for adults for each
disease or condition. There are also rates for the "continuation" of
treatment. It should also be noted that none of these charges exceed
2000 GF. The revenue from these charges in principle covers the costs
of drugs and the other overhead costs (except salaries).
It has
nevertheless been found that some health centres have extreme difficulty
in financing all their costs (Waty, 1989; Waty and Brudon-Jacobowicz,
1990). These centres do not manage to produce sufficient revenue
because of their low level of activity.
With regard to cost-effectiveness, it should be noted in
particular that generic drugs that are affordable in price are used in the
EPI/PHC system, which enables the cost of drugs to be kept to the
minimum. Another important point is the fact that prescribing guides
are used at the health centres and this helps to keep down the volume
and hence the total cost of prescriptions. As far as administrative
efficiency is concerned, it will be noted that although only a limited
number of diseases are treated, there is a significant number of
management tools. It follows that the amount of time spent on
administrative tasks by the medical personnel is often considerable.
23
For the time being, however, no definitive judgement can be
made about the system as a whole as there is not sufficient information
on access to care and the equity of the system.
3.3.1.2 N’Zerekore hospital
The system of charges here is highly elaborate. There are
charges for all types of consultations (simple consultation, consultation
with referral, follow-up consultations). Patients admitted to hospital
pay a flat rate related to the length of their hospital stay. This flat rate
covers laundry, medical acts and medical care. Drugs, however, must
be bought by the patients at the hospital pharmacy. For intensive care,
the charge is based on the duration of hospitalization and the patient’s
age. In the surgery, maternity and ophthalmology departments, there
are charges for 33, 14 and 10 different acts respectively. The drugs
required in the course of interventions in these departments are included
in the charges. Then there are charges for three types of dental care
and 27 types of laboratory tests.
Most of these charges are higher than in other systems of cost
revovery in hospitals. One of the reasons is that the financial support
to the system from the NGO involved is very small. The charges have
also been calculated so as to include substantial incentive bonuses for
the staff.
The N’Zerekore system is characterized by a good cost
effectiveness ratio. The purchase of generic drugs at affordable prices
and the use of treatment protocols contribute substantially to this cost
effectiveness. With regard to administrative efficiency, we nevertheless
feel that the introduction of this fee system and the accountancy
involved in billing and collecting payment could require substantial
administrative resources. We do not have enough data on this question
to be able to judge whether or not the burden of administration is too
great.
For the same reason of lack of sufficient information it is
difficult to assess the degree of equity that is achieved.
3.3.2
Flat fees
A straightforward fee system is operated at the hospital in
Koundara, which co-managed by Entraide Medicale Internationale. Five
flat rate charges have been set for hospitalization in the different
departments. Charges have also been set for emergency cases, outpatient
consultations, laboratory tests and dental treatment. At the hospitals in
Kouroussa and Mandiana, which are co-managed by MSF (France), there
is only one flat rate charge for hospitalization with intervention. There
are three rates for hospitalization without intervention and two rates for
day care at the hospitals. The fee system at the hospitals that are part
of the health care development programme (PDSS) comprises seven flat
24
rate charges for care in the different departments of the hospital,
principle, drugs are included in these flat rate charges.
In
The level of charges is lower than those at the N’Zerekore
hospital. The main reason is that the NGOs (in the case of Kouroussa,
Mandiana and Koundara) and the PDSS (co-financed by the World Bank)
finance a substantial proportion of the overhead costs.
As these systems also use cheap generic drugs, the criterion of
cost-effectiveness is met. The administrative cost would also appear to
be lower than it would be with a system of itemized charges. However,
there are not sufficient data to permit any definitive judgement of the
degree of administrative efficiency and equity of these systems.
It can nevertheless be stated that these flat rate systems make for
a better distribution of risks among the population, and hence better
access to health care.
3.4
Conclusion
It is obvious that every country or community will have a different
conception of the system to be adopted for the recovery of costs. One country
or community may favour a system of itemized charges on account of its cost
effectiveness and not be so much concerned with access to care by the different
strata of the population. Another option would be a flat rate system if some
importance is attached to the distribution of financial risks among the different
patients, thus offering better chances of access to care to the poor. The health
insurance option may be chosen if importance is attached to equity and if there
is already the administrative capacity in existence.
It is too early to judge whether the cost recovery system at present in use
for primary health care needs to be substantially altered. If the results of the
socioeconomic survey (of November 1990) reveal problems of access to specific
types of treatment, it will obviously be necessary to make some adjustments to
the rates in question. But this will not necessarily mean switching to a flat rate
system (e.g. by type of consultation) if there is no clear evidence that this will
bring savings in administrative costs or guarantee better access.
t
In choosing an appropriate system for cost recovery in hospitals, it seems
to us that the adoption of a system of flat rates for each category of care fits
with the stated objectives of the Government of Guinea, which wants to promote
access to hospital care for the population. For the moment, the hospitals would
appear to have adequate administrative resources to manage a system of this
kind.
It should be noted, however, that this method will not significantly
increase demand for medical care if it is not cost-effective. It is therefore
essential to minimize the costs of the various inputs, such as drugs, vaccines,
25
medical supplies and other overhead costs, while still ensuring that adequate
services are provided. In principle, this rule could be applied to the inputs that
are directly financed by the State, such as the salaries of the personnel. In this
perspective, salaries paid to superfluous personnel or those with very little
productivity constitute a "loss" for the health system.
4.
Use of the Methodology to Analyse Costs at Two Health Facilities
The Maneah Health Centre and the Dalaba Prefectural Hospital
The methodolgy was used to calculate the costs of the health services and analyse
the possibilities for cost recovery at two health facilities at different levels, the Maneah
Health Centre and the Dalaba Prefectural Hospital. The cost calculations were based
on the data gathered in the course of field visits and information provided by the
national authorities, donors and NGOs, and on national macroeconomic and demographic
parameters. The results of these calculations were used to analyse the level of cost
recovery attained by these two health facilities and to assess the extent to which the
charges applied there are appropriate and effective.
4.1
Parameters
Although the costs of care depend in the first place on the costs of the
inputs used in the provision of these services, there are several macroeconomic,
health and demographic parameters that must be taken into account in the
calculation of these costs.
Cost analysis needs to be dynamic in nature. It is therefore necessary
that the analytical tool developed in this study should be able to be adjusted
where relevant to take account of the socioeconomic, demographic and health
changes that the country may experience. This will prevent the charges that are
ultimately set by the Government on the basis of the results of the study from
being too static and quickly becoming obsolete. It is for this reason that certain
macroeconomic parameters, such as the rate of inflation, the interest rate and the
rate of depreciation of the national currency, and certain sociodemographic
parameters play an important part in this study.
While the macroeconomic and demographic parameters are national in
scope, certain health parameters (such as the number of consultations per year,
the number of hospital admissions, etc.) relate to the volume of activity at the
health facility in question. In either case, the parameters are factors that are not
within the control of the health facility. When the parameters change, however,
the level and structure of costs will change as well. A whole range of scenarios
can therefore be contemplated by changing the parameters. The results of
analysis are sensitive to changes in the values of parameters. The quality of the
results of analysis thus reflects the quality of the data available in respect of
26
r
these parameters.
In order to facilitate calculation, most of the macroeconomic parameters
have been assumed to be constant for several years. The rate of inflation has
thus been taken as constant for twenty years, the entire lifetime of certain parts
of the health infrastructure.
4.1.1
Macroeconomic parameters
The economic parameters used have been estimated at the following
levels:
(i)
the domestic rate of inflation
In 1990, the predicted rate of inflation was 16%. Because of pressures
on the labour market, however, certain analysts consider that the true rate of
inflation for that year was more than 20% (Economist Intelligence Unit, 1990a,
1990b). It is this rate that we have adopted for the baseline scenario in this
study.
(H)
rate of inflation in the country of origin of imported products
This rate - 5% - is based on the mean of rates of inflation predicted (by
The Economist, 1990) for the year 1991 in 13 member states of the
Organization for Economic Cooperation and Development (OECD).
(Hi)
domestic interest rate
This rate is assumed to be equal to the domestic inflation assumed, i.e.
20%. This assumption is reasonable in view of the interest rates observed in
Conakry in November 1990 (on savings accounts, 14%; with notice of
withdrawal, 16%: at term, 21%).
(iv)
rate of depreciation of the national currency
The rate of depreciation in relation to the currency of the country of
origin of imported goods is estimated at 15%. It is assumed to be equal to the
difference between the domestic rate of inflation and the rate of inflation in the
countries of origin of imported goods, in accordance with the principle of
’’purchasing power partity’’ (PPP). This principle assumes at least that the
money and foreign exchange markets are functioning normally and freely and
are in balance. The PPP assumption has been adopted in spite of the fact that
the Guinean franc is overvalued. Even though it is rather difficult to accept in
the current economic conditions in which the foreign exchange market cannot
be said to be in a state of equilibrium, the PPP hypothesis is reasonable,
particularly in the long term as structural adjustment programmes aim at a
certain liberalization of the financial markets.
27
(V)
rate of salary increase
This is estimated at 15%. It has been assumed that the Government
will pursue a policy of salary indexation, setting the rate of salary increase at
75% of the domestic inflation rate.
(vi)
rate of increase in overhead costs
For the overhead costs to be paid in the national currency, the rate of
increase has been taken as equal to the domestic rate of inflation.
^A.2
Demographic parameters
ft)
rate of population growth
This rate has been estimated at 2.6%, in accordance with UNDP
forecasts (1990).
(H)
rate of increase in the demandfor health care
This rate has been assumed to be equal to the rate of natural population
growth, i.e. 2.6%. For the Maneah Health Centre, however, a zero increase in
the volume of health activities has been assumed for 1991 as this health centre
will be losing some of its patients - those who come from Coyah - to the newly
opened health centre at Coyah. Since demand for health services does not
depend only on the size of the population, the assumption that the rate of
increase in demand is equal to the rate of natural population growth may prove
to be inadequate. It can be complemented by information on all the factors that
affect demand: charges, purchasing power, distance and other costs, quality of
service, health conditions of the environment in which the population lives, etc.
4.1.3
Parameters relating to the health facility
See Annex 1
4.1.4
Parameters relating to the financing of expenditure
The salary costs of health personnel will be paid 100% by the
Government.
It has been assumed that donors will finance 50% of the
amortization costs of the infrastructure, rolling stock and technical equipment.
At the Dalaba Hospital, it should eb noted that the donor also pays the freight
and insurance charges as well as the logistic costs.
4.2
The baseline scenario for the year 1991
The detailed calculations are given in annex. They show us to what
extent the recurrent costs of health care activities are being recovered through the
charging systems in use at the two health facilities studied, the Maneah Health
Centre (Annex 1) and the Dalaba Hospital (Annex 2). As explained in section
28
r
3, there are cost recovery systems at both these health facilities, which are part
respectively of the National EPI/PHC/ED Programme and the PDSS.
The
charges applied in the two systems are different as the objectives pursued by
them are not exactly the same. Consequently, the results achieved by the two
systems are very different. At Maneah the present charges permit recovery of
all recurrent costs other than salaries and produce a certain margin of profit,
whereas the present PDSS charges result in substantial deficits at Dalaba
Hospital. But it is important to realise that even at Maneah, where the system
as a whole runs at a profit, some activities, such as the treatment of malaria, still
run at a loss, and that, unlike Maneah, there are also some health centres in the
EPI/PHC/ED system which are in deficit on account of their very low volume
of activity.
4.2.1
The costs of health care activities and their financing at the
Maneah Health Centre
The costs of two activities, childbirth and the treatment of malaria,
were studied at the Maneah Health Centre.
4.2.1.1 Childbirth
As shown in Table B2 (see Annex 1), the cost of childbirth
amounts to 1 067 Guinean francs and can be broken down as follows:
salaries: 415;
bonuses: 22;
drugs: 446;
logistics: 9;
amortization: 123;
other overhead costs: 51.
The objective of the cost recovery strategy is to cover the non
salary costs which amount to 652 GF. Under the EPI/PHC/ED system,
these costs must be recovered through the sale of drugs. The charge
for every drug is equal to the product of the cost price multiplied by a
coefficient. Here, since the cost of the drugs is 455 GF (including
logistic costs), to recover the exact amount of the recurrent non-salary
costs, i.e. 652 GF, a coefficient of 1.43 is needed, i.e. 652/455. With
the current charge of 1 000 GF per delivery (which corresponds to a
coefficient of 2.20), the centre makes a gross profit of 348 GF per
childbirth. If the assumption of the baseline scenario that the donors
will finance 50% of amortization costs is also taken into account, the
present charge will generate a gross profit margin of 410 GF per
childbirth for the centre.
29
4.2.1.2 Treatment of uncomplicated malaria in children
As shown in table C2, the cost of treating a child with
uncomplicated malaria amounts to 668 GF, with the following
breakdown:
salaries: 472;
bonuses: 25;
drugs: 15;
amortization: 96;
other overhead costs: 60.
As salaries are paid by the Government, a difference of 196 GF
remains to be covered by other sources of financing. Retaining the
assumption that donors will finance 50% of amortization costs plus
freight and insurance and logistic costs, the sum of 148 GF remains to
be financed, either by the local authorities or by households. But the
present charge is only 50 GF per course of treatment. So the health
centre faces a deficit of 98 Gf per case treated. In other words, if the
health centre wants to recover the recurrent non-salary costs of treating
children with uncomplicated malaria exclusively through itemized
charging, the charge needs to be:
196 GF if the donors and local government do not intervene;
148 GF if the donors finance 50% of the amortization costs.
4.2.1.3 Summary
Data on the costs to be recovered, the charges and the financing
required for these two activities are summarised in Table 4.1.
Table 4.1
Maneah Health Centre - Year 1991
Comparison of itemized fees and costs to be recovered
with (without) the contributions of donors
Cost to be
recovered
Current fee
Childbirth
590
(652)
1,000
1,000
-410
(-348
Uncomplicated malaria
in children
148
(196)
50
50
+98
(+146)
Activity
30
Financing
required
(-profit; + loss)
r
4.2.2
The costs of hospitalization at the Dalaba Hospital and their
financing
The activity studied here is hospitalization in the surgery department.
The costs of this activity are set out in Table B2 (Annex 2). For the year 1991,
these costs amounted to 86 029 Guinean francs, comprising 20 656 GF for
salaries, 19 046 GF paid by the central Government and 1610 GF paid by the
Prefecture. The costs to be recovered per hospital case amount to 65 373 GF.
As the present charge is 7 150 GF (including the cost of the patient’s personal
record of treatment (carnet de soins) which is 150 GF), an amount of 58 223 GF
is needed to finance each hospital case. Retaining the assumption that donors
will finance 50% of amortization costs, the final deficit per hospital case will
be 36 836 GF. These results are set out in Table 4.2.
Table 4.2
Dalaba Hospital - Year 1991
Comparison of itemized fees and costs to be recovered
with (without) the contributions of donors
4.3
Activity
Cost to be
recovered
Current fee
Financing
required
(-profit; + loss)
Hospitalization
for surgery
65,373
(43.986)
7,150
7,150
+58,223
(+36,836)
Extension of Analysis to subsequent years
Projections can be made for subsequent years on the basis of the
assumptions used for the parameters described in sub-section 4.1. In actual
practice, most of the elements that must be taken into account in the calculation
of costs - the quantities and prices of the goods and services consumed in the
activities in question, factors affecting demand, etc. - vary from year to year.
It is therefore essential to make the necessary adjustments to update costs so that
they accurately reflect the realities of each year. If charges are being set on the
basis of the actual costs of activities, this aspect of the problem must also be
taken properly into account.
From the standpoint of economic efficiency, the ideal solution would be
to adjust charges annually in line with the annual rate of cost increase. But
regular annual adjustment of charges might not be very well received by the
population which is not accustomed to this practice. More importantly, it would
be administratively costly to alter the charges every year. One solution would
be to set charges for a certain number of years, e.g. three years. This would
make it possible to adopt a charge corresponding to the costs in the third year or
He.' 1.00
31
f/<i) f
be to set charges for a certain number of years, e.g. three years. This would
make it possible to adopt a charge corresponding to the costs in the third year or
the mean level of costs over the three years.
4.3.1
Parameters
The main parameters used in the projections are the rate of
inflation, the annual rate of depreciation of the national currency, the
annual rate of growth in the demand for health care and the interest rate.
The volume of activity (number of consultations, hospitalizations, etc.)
is also of some importance in the calculation of mean costs.
Mean
variable costs may not always go down in line with the volume of
activity in a health facility, but mean fixed costs are inversely
proportional to the volume of activity. Hence it is possible that the
mean costs of care may decrease when the volume of activity rises.
4.3.2
Results for the year 1992
For 1992 we shall only present the tables summarising the costs
and the financing required.
4.3.2.1 Costs of activities and their financing at the Maneah Health
Centre
Childbirth
As shown in Table B2, projection of the cost of childbirth is
estimated at 1 258 Guinean francs in 1992. As the Government will
bear the cost of salaries which is estimated at 477 GF, a difference of
781 GF remains to be financed from other sources. If the present rate
of 1000 GF per delivery is maintained, the centre will make a gross
profit of 219 GF per childbirth. If the assumption that donors will
continue to finance 50% of amortization costs is also maintained, the
gross profit will amount to 293 GF. In 1992 the centre will thus make
an overall profit but the margin will be smaller than in 1991 as costs
will have risen between 1991 and 1992.
Treatment of children with uncomplicated malaria
As shown in Table C2, the cost of treating a child with
uncomplicated malaria will be 777 Guinean francs in 1992. If the
Government continues to pay the cost of salaries, which will be 542 GF,
and if the present charge of 50 GF per treatment is maintained, a deficit
of 185 GF will remain. If donors finance 50% of the amortization
costs, there will still be a net deficit of 127 GF per treatment. It is
obvious that this deficit will persist and that it will have increased by
29 GF as compared with 1991 because costs will have increased.
32
4.3.2.2 Costs of activities and their financing at the Dalaba
Hospital
At the Dalaba Hospital too, costs will evolve in accordance with
the same scenario as at the Maneah Health Centre. As shown in Table
B2, the cost of hospitalization in the surgery department is estimated at
99 991 Guinean francs for the year 1992. The financial deficit would
be 44 593 GF if the donors contributed to financing and 69 689 GF if
they did not intervene. The reasons for the increased net deficit that
would result are the same as in the case of the Maneah Health Centre.
4.3.3
Results for the year 1993
For 1993 we shall again present only the summary tables of costs and
financing required.
Costs will rise in 1993 in accordance with the same
scenario as described above. The results of the projections are presented in
tables B2 for childbirth at the Maneah Health Centre, C2 for the treatment of
uncomplicated malaria in children at the Maneah Health Centre, and B2 for
hospitalization in the surgery department of the Dalaba Hospital. The increase
in costs in 1993 as compared with 1992 has reduced the gross margin of profit
for childbirth at the Maneah Health Centre and increased the financial deficit for
the treatment of uncomplicated malaria in children at the Maneah Health Centre
and for hospitalization at the Dalaba Hospital.
5.
The Influence of the Parameters on Costs
5.1
Introduction
In the preceding section we set out the results of a baseline scenario. It
is important to note that there is only a certain level of probability that this
scenario will actually be realised. In practice, important parameters such as
inflation, the growth of demand for care and the exchange rate may be subject
to changes.
It therefore follows that deciders must have a minimum of
information on the effects that any changes in the parameters may have on the
volume and structure of the costs of health care. This information will facilitate
discussion of the distribution of future charges among the different partners
(Government, prefecture, households and donors).
5.2
Simulations after partial variations of parameters
The simulations that follow are partial in character. In each simulation,
one parameter only will be changed, the others being maintained at their baseline
scenario values:
33
(a)
variation in the rate of inflation
(i) 10%;
(ii) 30%
(b)
variation in the rate of growth in demand for health care
(i) 0.2%;
(ii) 4%
(c)
variation in the rate of depreciation of the national currency
(i) 10%;
(ii) 20%.
In a simulation, we look at the impact of variation of the parameter on
the total cost of the health service in question and its impact on the financing
required. Each simulation has been carried out in respect of the activities
studied at the Maneah Health Centre and the Dalaba Hospital. A comparison
is also made with the baseline scenario.
It can be seen from tables 5.1 to 5.3 and figures 1 to 18 in Annex 3 that
the costs and the financing required increase with the rate of inflation. A
margin of profit is achieved in the case of childbirth at the Maneah Health
Centre, but this almost completely disappears when the inflation rate is 30%.
The increase in the rate of growth of demand has a negative effect on unit costs.
Thus the financing required decreases as this rate rises. In the case of childbirth
the margin of profit is increased. The rate of depreciation of the national
currency also has a significant effect on the level of costs and the financing
required. Depreciation in excess of purchasing power parity (PPP) increases the
cost of care and financing required.
34
Table 5.1
Maneah Health Centre
Simulations of the cost of childbirtth
and the financing required (in GF 1991-1993)
Financing required
Cost of childbirth
Type of simulation
1991
1992
1993
1991
1992
1993
10%
1,056
1,135
1,219
-415
-361
-302
20%
1,067
1,240
1,443
-410
-297
-163
30%
1,077
1,347
1,689
-405
-233
- 10
0.2%
1,067
1,257
1,481
-410
-294
-54
2.6%
1,067
1,240
1,443
-410
-297
-163
4%
1,067
1,231
1,422
-410
-299
-168
10%
1,028
1,172
1,337
-429
-343
-243
15%
1,067
1,240
1,443
-410
-297
-163
20%
1,142
1,351
1,603
-372
-230
- 55
a) Variation in the
rate of inflation
b) Variation in the rate
of growth of demand
c) Variation in the rate
of depreciation of the
national currency
N.B.
The figures in bold type represent the baseline scenario.
35
Table 5.2
Maneah Health Centre
Simulations of the cost of treating uncomplicated malaria
in children and financing required (in GF 1991-1993)
Cost of malaria treatment
Type of simulation
1991
Financing required
1992
1993
1991
1992
1993
a) Variation in the
rate of inflation
10%
660
696
734
94
105
116
20%
668
758
859
98
123
151
30%
676
821
997
102
142
192
0.2%
668
774
900
98
127
160
2.6%
668
758
859
98
123
151
4%
668
748
837
98
121
147
10%
643
728
823
86
107
132
15%
668
758
859
98
123
151
20%
722
821
935
125
155
190
b) Variation in the rate
of growth of demand
c) Variation in the rate
of depreciation of the
national currency
N.B.
36
The figures in bold type represent the baseline scenario.
Table 53
Dalaba Hospital
Simulations of the cost of hospitalization
in the surgery department and financing required
(in GF 1991-1993)
Financing required
Cost of hospitalization
Type of simulation
1991
1992
1993
1991
1992
1993
10%
80,714
86,385
92,479
33,303
35,505
39,969
20%
86,029
99,991
116^86
36,836
44,593
53,736
30%
91,345
114,640
144,011
40,369
53,376
69.973
0.2%
87,713
103,924
123,179
37,577
46,343
56,837
2.6%
86,029
99,991
116,286
36,836
44,593
53,736
4%
85,083
87,822
112,553
36,420
43,628
52,057
10%
69,962
80,432
92,503
28,499
34,207
40,838
15%
86,029
99,991
116^86
36,836
44,593
53,736
20%
115,385
135,158
158,480
51,834
62,823
75,938
a) Variation in the
rate of inflation
b) Variation in the rate
of growth of demand
c) Variation in the rate
of depreciation of the
national currency
N.B.
The figures in bold type represent the baseline scenario.
37
53
Simulations with Simultaneous Variation of Parameters
It is obvious that it is also possible to vary the levels of the
different parameters simultaneously.
We have thus defined three
scenarios, as shown in Table 5.4.
Table 5.4
Scenarios with simultaneous variation of parameters
Rate of
inflation
Rate of growth
of demand
Rate of depreciation
of national currency
Optimistic scenario
10%
2.6%
5% (PPP)
Semi-optimistic scenario
20%
2.6%
15% (PPP)
Pessimistic scenario
20%
0.2%
20%
N.B.
The figures in bold type represent the baseline scenario.
Once again it must be remembered that there is only a certain degree of
probability that any of the scenarios described above will actually materialise.
The scenario ultimately adopted will depend on how the Ministry of Finance, the
Ministry of the Plan and the Ministry of Health and Population judge the
projections made for parameters such as the anticipated rate of inflation, the
anticipated rate of depreciation of the national currency and parameters relating to
the evolution of demand.
The results of the three scenarios are given in Table 5.5 and in figures 19
to 24 in Annex 3. They confirm that costs and financing requirements are
sensitive to changes in the values of parameters, as we have explained in section
4. More important still, these results underscore the need for adequate forecasting
of the socioeconomic environment for cost analysis.
38
Table 5.5
Simulations of costs and financing required
with simultaneous variation of parameters
(in GF 1991-1993)
Financing required
Cost
Type of simulation
1991
1992
1993
1991
1992
1993
Childbirth
a) Optimistic scenario
1,056
1,135
1,219
-415
-361
-302
b) Semi-optimistic
scenario
1,067
1,240
1,443
-410
-297
-163
c) Pessimistic scenario
1,142
1,370
1,646
-372
-227
-44
Uncomplicated malaria in children
a) Optimistic scenario
660
696
734
94
105
116
b) Semi-optimistic
scenario
668
758
859
98
123
151
c) Pessimistic scenario
722
841
979
125
160
201
Hospitalization for surgery
a) Optimistic scenario
80,714
86,385
92,479
33,303
36,505
39,939
b) Semi-optimistic
scenario
86,029
99,991
116,286
36,836
44,593
53,736
c) Pessimistic scenario
117,756
140,718
168,264
52,921
65,393
80,495
N.B.
The figures in bold type represent the baseline scenario.
39
6.
Conclusions and Recommendations
This study has enabled us to better understand the problems of financing
health care in Guinea.
The results of the study have led us to formulate
conclusions and recommendations on a certain number of stages to be followed in
establishing a strategy for cost recovery.
6.1
Analysis of the costs of health care
6.1.1
Development of the methodology for cost calculation
(i)
It was first of all necessary to obtain the most accurate data
possible on the different categories of costs observed in 1991. For
the moment, lacking sufficient data, we have had to make
assumptions about the size of the infrastructure and the costs of the
acquisition and amortization of the buildings at the Maneah Health
Centre and the Dalaba Hospital.
(ii)
With regard to the equipment at the Dalaba Hospital, we
have used the list of equipment proposed for prefectural hospitals
by the Ministry of Public Health and Population (1989). The
prices of the equipment are based on information from UNIPAC
(1990).
It remains to be seen whether this list of equipment
proposed in the context of the PDSS will actually be adopted.
(iii)
Although we have information on the total cost of the drugs
used at the Dalaba hospital, we have no reliable data on the cost of
the drugs prescribed in the different departments of the hospital.
In order to calculate the cost per case hospitalized in the surgery
department, we have assumed that the surgery department’s share
of overall drug costs is the same at the Dalaba Hospital as at the
hospital in Koundara. A more detailed system of accounting by
department is needed in order to be able to calculate charges per
episode of hospitalization.
(iv)
Detailed information on the volume of activity in each
hospital department are also needed to calculate the rates to be
charged in a system of itemized charging by activity. To calculate
the charge for appendectomy, for example, it will be necessary to
know the number of appendectomies carried out, as well as the
costs assumed directly by the patient, i.e. the cost of the drugs
prescribed and the medical materials used.
(v)
In section 5, we have mentioned the importance of being
well aware of the way in which macroeconomic parameters, such
as the domestic rate of inflation, the rate of inflation in the
40
countries from which equipment and drugs are imported, and the
rate of depreciation of the national currency are likely to evolve.
This information is needed in order to avoid underestimating future
costs to the extent possible. If they really wish to reduce this risk
to the minimum, deciders can use the most pessimistic scenario to
calculate costs and determine the structure of the financing of these
costs.
6.1.2
Application of the methodology to other health facilities
The calculations set out in this study are only part of the
first stage in the development of a system of cost recovery. These
calculations need to be repeated for other health centres and
prefectural hospitals. We recommend that about fifteen health
centres and hospitals should be studied in an exercise of this kind.
The sample chosen should be representative of the different levels
and sizes of health facilities and the different types of activities
carried within them. The results of the calculation of the cost of
activities at these different health facilities will provide us with
information on the variance of these costs among health facilities
of a similar level.
This information will be essential for the
establishment of a viable system of cost recovery and charges.
6.1.3
Study of the structure and variance of costs
This stage is necessary to ensure that differences between
health facilities and between regions are properly taken into
account. Such differences may arise for several reasons, including
efficiency in the provision of services and factors affecting demand
for care.
This variance needs to be known in order to know
whether a differential system of financing is reasonable.
6.2
Choice of modalities of financing and a system of fees
6.2.1
Cost sharing
The methodology proposed in this study will also enable
deciders to define a strategy for cost sharing. The readiness of
donors to contribute to the financing of care will obviously affect
the relative level of the charges that will have to be financed from
national sources.
Another important question is not just the
willingness but the ability of the Government and the prefectures
to co-finance activities. It is important to know, for example,
whether the contributions envisaged from the State are compatible
with the constraints on the Government’s budget. Another question
is whether the promised financing may run into problems of the
41
availability of foreign exchange2.
Finally, any decision by the Government defining the
contribution of households to the financing of costs may have
effects on the objective of equity and access to services.
6.2.2
Modalities of fee setting
(i)
In section 3 we have outlined the most important criteria for
the evaluation of a cost recovery system, in particular the criteria
of cost efficiency, equity and administrative efficiency. Economic
efficiency or minimization of the costs of care (given the quantity
and quality of services) will increase the purchasing power of
households and thereby stimulate access to care. Administrative
efficiency is another important criterion and means that a system
must be compatible with existing administrative capacities. If this
is not so, administration will absorb an excess of resources that
could be more effectively used elsewhere. The third criterion,
equity, requires that all patients with the same need should have the
same access to care.
We have observed that flat rate and
prepayment systems of charging go further towards meeting the
objective of equity than a system of itemized charges.
In the case of Guinea, a flat rate sytem would be the most
appropriate, especially for the health centres and prefectural
hospitals. This would be the system best able to satisfy all three
of these criteria. Substantial alteration of the method of cost
recovery used in the EPI/PHC system currently in force at many
health centres is not immediately needed. The results of the
socioeconomic survey carried out in November 1990 will give
deciders information on access to care and will provide food for
discussion of a possible revision of the system of cost recovery for
primary health care.
(ii)
As we have already pointed out in section 4, both the
quantities and prices of the goods and services consumed by health
activities and factors affecting demand fluctuate over time.
Regular updating of costs and charges is therefore necessary. But
regular annual adjustments would be costly, particularly in terms of
administrative efficiency. We therefore recommend that charges
should be set for a certain number of years, e.g. three years. It
would then be possible to adopt rates corresponding to the costs in
2 For a better understanding of the links between the public health sector and the rest of the economy,
see Camen and Carrin (1991).
42
the third year or to the mean level of costs over the three years.
(iii)
Socioeconomic conditions, the standard of living and access
to care may vary so widely between the different regions of the
country that the introduction of a nationwide fee system must be
contemplated with great caution. A national system could well run
counter to the objective of equity, with households in the least
economically developed regions having more difficulty with access
than those in the regions that are more well off. A system of
charges differentiated by region will then need to be considered.
A system of this kind can carry important implications that
must be pointed out here.
In practice, reduction of the rates
charged in some regions below the national level must be financed
by the system as a whole. In the first place, a review of the roles
of the Government, the prefectures and the donors in the financing
of care in the different regions will be necessary. Secondly, it will
also be necessary to know to what extent the prefectures and the
population of the more well off regions are able to contribute to the
financing of health care services in the deprived regions. The
establishment of an equalization fund might be considered, for
example. It should be noted that the method of cost calculation
proposed in this study includes the possibility of contributing an
amount equivalent to a certain percentage of a health facility’s
volume of activity to this fund.
43
BIBLIOGRAPHY
Camen, U. et Carrin. G. (1991), Guinea. Macroeconomic Evolution and the
health Sector, World Health Organization, Office of International
Cooperation.
Creese, A. et Parker, D., (eds.) Cost Analysis in Primary Health Care: A
Training Manual for Programme Managers (1990), WHO/SHS/NHP/90.5.
Ministere de la Sante Publique et de la Population (1989), Plan National
de Developpement Sanitaire {Propositions de Financement), Conakry.
Ministere de la Sante Publique et de la Population (1990), Journees de
Reflexion sur la Politique Hospitaliere, Conakry 28-30 Avril 1990.
PNUD (1990), Rapport Mondial sur le Developpement Humain 1990,
Economica, Paris.
The Economist (1990), Economic Forecasts, October 20, 1990.
UNIPAC (1990), UN Children’s Fund Supply Division - Price List.
Waty, M.-O (1989), Analyse du Systeme de Recouvrement des Couts,
Rapport d’une Mission, Mars, Programme National PEV/SSP/ME,
Republique de Guinee.
Waty, M.-O et Brudon-Jakobowicz, P. (1990), Rapport d’une Mission
OMS, Fevrier. Programme National PEV/SSP/ME, Republique de Guinee.
44
Annex 1
Working Tool for Analysis of the Costs of
Health Care and their Recovery in Guinea
Calculation of costs at the Maneah Health Centre
Table
Cell
Al
A2
A3
A4
A5
A51
A81
A101
A121
A141
A6
A7
A8
A161
A181
A241
A9
A10
All
A12
A13
A14
A15
A16
A17
A18
A19
A20
A21
A261
A281
A301
A321
A341
A361
A381
A401
A421
A441
A521
A541
A561
Bl
B2
B3
Cl
C2
A621
A701
A721
A741
A821
C3
A841
Year of operation and type of simulation
Parameters relating to demand for care
Parameters relating to the structure of costs
Parameters relating to the evolution of prices
Parameters relating to contribution to the financing
of care
General data on the health centre
Epidemiological data
Distribution of personnel by percentage of working
time
Distribution of personnel by hours per week
Monthly salaries and bonuses of personnel
Distribution of annual salaries of personnel
Distribution of annual bonuses of personnel
Total annual salaries and bonuses
Cost and amortization of infrastructure
Cost and amortization of medical equipment
Distribution of medical equipment by activity
Amortization of medical equipment by activity
Annual expenditure excluding salaries
Annual expenditure of the health centre
Distribution of working time by medical activity
Coefficients of indirect cost distribution for the
calculation of the cost of curative care
Costs of childbirth
Financing of the costs of childbirth
Financing required
Costs of treating uncomplicated malaria in children
Financing of the costs of treating uncomplicated
malaria in children
Financing required
45
Table Al
YEAR OF OPERATION AND TYPE OF SIMULATION
Year > 1991
Type of simulation > baseline simulation
Table A2
PARAMETERS RELATING TO DEMAND FOR CARE
rate of population
growth
2.6%
birth rate
4.6%
rate of increase in demand
for general care
0.0%
rate of increase
in childbirth
0.0%
rate of increase
in EPI activities
0.0%
Table A3
PARAMETERS RELATING TO THE STRUCTURE OF COSTS
freight/insurance rate
0.0%
logistic rate
2.0%
rate of contribution
to equalization fund
0.0%
46
Table A4
PARAMETERS RELATING TO THE EVOLUTION OF PRICES
rate of inflation
in countries of origin
of equipment and drugs
domestic rate of
inflation
5.0%
20.0%
interest rate
20.0%
rate of depreciation of
the national currency
15.0%
Table AS
15.0%
rate of increase in
overhead costs
(local origin)
20.0%
PARAMETERS RELATING TO CONTRIBUTION
TO THE FINANCING OF CARE
rate of participation
of donors to financing
of amortization
50.0%
rate of increase in
charges for households
0.0%
Table A6
rate of increase in
salaries and bonuses
GENERAL DATA ON THE MANEAH HEALTH CENTRE
consultations 1st contact
consultations follow-up
antenatal consultations (1st contact)
childbirths
immunizations
population of sub-prefecture
population at < 5 km from health
centre
No. observed
1990
No. anticipated
1991
9707
426
967
598
9707
426
967
598
Population
observed
1990
Population
anticipated
1991
9021
9256
6671
6844
47
Table A7
EPIDEMIOLOGICAL DATA ON THE MANEAH HEALTH CENTRE
Baseline year 1990
disease
<15 yrs
tetanus
polio
measles
whooping cough
diphtheria
suspected tb
uncomplic.
malaria
1173
pemic malaria
dracunculiasis
jaundice
vomiting
abdom pain
hernias
non-spec diarrhoea
diarrh + dehydr
spec diarrhoea
diarrh + dehydr
int helminth
headache
meningitis
chest pain
respir dis
respir inf ATB
oedemas
dyspnea
anaemia
malnutrition
gonorrhoea
urinary infects
gyn disorders
joint pain
eye disease
onchocerciasis
ear diseases
toothache
skin diseases
susp leprosy
wound/bum
fracture
other
Total
48
5238
>15 yrs
total
relative
%<15 yrs
frequency
%>15 yrs
767
1940
15.5%
10.1%
2320
7558
•*
Table A8
DISTRIBUTION OF PERSONNEL BY PERCENTAGE OF WORKING TIME
category
curative
consult.
MCH
minor
med. care
childbirth
adminis
tration
chief medical
officer
deputy emo
midwife
thw 1
thw 2
thw 3
thw 4
thw 5
thw 6
nurse
guard
45.0%
2.5%
Table A9
DISTRIBUTION OF PERSONNEL BY HOURS PER WEEK
category
curative
consult.
MCH
minor
med. care
childbirth
32
32
0
0
0
36
0
0
0
32
0
0
0
36
0
0
0
0
36
0
0
0
0
7
0
0
0
0
40
4
4
4
18
1
18
4
1
1
0
1
0
36
119
87
41
8
105
chief medical
officer
deputy emo
midwife
thw 1
thw 2
thw 3
thw 4
thw 5
thw 6
nurse
guard
total
80.0%
80.0%
20.0%
19.0%
1.0%
80.0%
17.5%
90.0%
90.0%
90.0%
45.0%
2.5%
10.0%
2.5%
2.5%
100.0%
10.0%
10.0%
10.0%
2.5%
0.0%
90.0%
adminis
tration
8
8
1
49
Table A10
MONTHLY SALARIES AND BONUSES OF PERSONNEL IN GF
category
monthly salary
monthly bonus
95240
91450
88655
62872
62872
62872
62872
7500
5000
5000
5000
51918
26250
5000
chief medical
officer
deputy emo
midwife
thw 1
thw 2
thw 3
thw 4
thw 5
thw 6
nurse
guard
Table All
DISTRIBUTION OF ANNUAL SALARIES OF PERSONNEL
category
curative
consult.
chief medical
officer
deputy emo
midwife
thw 1
thw 2
thw 3
thw 4
thw 5
thw 6
nurse
guard
914304
877920
MCH
minor
med. care
10974
851088
childbirth
186176
679018
679018
679018
adminis
tration
228576
208506
26597
754464
75446
75446
75446
280357
7875
280357
7875
62302
7875
7875
283500
2759474
1829312
749194
19405
1727982
I
1
50
Table A12
DISTRIBUTION OF ANNUAL BONUSES OF PERSONNEL
category
curative
consult.
chief medical
officer
deputy emo
midwife
thw 1
thw 2
thw 3
thw 4
thw 5
thw 6
nurse
guard
Table A13
72000
48000
minor
med. care
MCH
600
48000
childbirth
adminis
tration
18000
11400
1500
60000
10500
27000
27000
6000
147000
75600
6000
90900
10500
TOTAL ANNUAL SALARIES AND BONUSES IN GF
Salaries
Bonuses
7260012
330000
Total
7590012
Table A14
COST AND AMORTIZATION OF INFRASTRUCTURE IN GF
category
quantity
initial
lifetime
fut value
infrastr
amortiz
year 1
cost
nr2 building
share local
currency:
beds
office
furniture
150
150000
20
862595998
1350000
0.50
5
50000
10
1547934
30000
3
20000
10
371504
7200
864515437
1387200
>
total
_________
Oh-h'r-i51
SA nG
Table A15
COST AND AMORTIZATION OF MEDICAL EQUIPMENT IN GF
category
initial
cost
lifetime
fut value
equipment
amortization
year 1
refrigerator
moped
sphygmo
manometer
stethoscope
adult scales
thermometer
baby scales
delivery table
1000000
1200000
10
5
6191736
2985984
120000
288000
15000
10000
20000
2000
15000
263840
2
2
8
0.5
3
15
21600
14400
85996
2191
25920
4064989
9000
6000
3000
4800
6000
21107
457907
Table A16
DISTRIBUTION OF MEDICAL EQUIPMENT BY ACTIVITY
category
curative
consult.
refrigerator
moped
sphygmo
manometer
stethoscope
adult scales
thermometer
baby scales
delivery table
MCH
minor
med. care
childbirth
all
activs
1
1
2
4
4
1
1
2
1
2
1
1
1
1
1
1
*
52
»
Table A17
AMORTIZATION OF MEDICAL EQUIPMENT BY ACTIVITY IN GF
category
curative
consult.
refrigerator
moped
sphygmo
manometer
stethoscope
adult scales
thermometer
baby scales
delivery table
MCH
minor
med. care
childbirth
all
activs
9000
9000
6000
3000
4800
120000
288000
18000
24000
19200
6000
12000
6000
9600
4800
21107
10800
429600
30107
total
67200
Table A18
ANNUAL EXPENDITURE EXCLUDING SALARIES IN GF
Category:
essential drugs
freight/insurance logistics
management tools
fuel cold chain
advance activities
maintenance moped
bonuses
amortization fund
2355172
47103
544444
198000
26400
180000
330000
1845107
Other expenditure:
office supplies
maintenance materials
maintenance premises
packaging of small medical supplies
miscellaneous materials
repairs premises
transport bank payments
unforeseen
96200
56000
10000
84600
200000
300000
24000
200000
sub-total
special equalization fund
6497027
total
of which share of
other overhead costs
6497027
22800
970800
53
Table A19
A.
B.
C.
D.
ANNUAL EXPENDITURE OF THE HEALTH CENTRE
Expenditure excluding
equalization fund
13757039
Expenditure excluding
salaries
6497027
Expenditure for
essential drugs and
management tools
2946720
Multiplier coefficient
(B/C)
2.20
Table A20
«
DISTRIBUTION OF WORKING TIME BY MEDICAL ACTIVITY
medical activity
hours
%
curative consultations
119
46.6%
MCH
87
34.2%
minor medical care
41
16.1%
childbirth
8
3.1%
255
100%
total
54
Table A21
COEFFICIENTS OF INDIRECT COST DISTRIBUTION
FOR THE CALCULATION OF THE COST OF CURATIVE CARE
disease
tetanus
polio
measles
whooping cough
diphtheria
suspected th
uncomplic malaria
pemic malaria
dracunculiasis
jaundice
vomiting
abdom pain
hernias
non-spec diarrhoea
diarrh + dehydr
spec diarrhoea
diarrh + dehydr
int helminth
headache
meningitis
chest pain
respir dis
respir inf ATP
oedemas
dyspnea
anaemia
malnutrition
gonorrhoea
urinary infects
gyn disorders
joint pain
eye disease
onchocerciasis
ear diseases
toothache
skin diseases
susp leprosy
wound/bum
fracture
other
%<15 yrs
%>15 yrs
7.2%
4.7%
total
55
Table Bl
COSTS OF CHILDBIRTH IN GF
1. Drugs:
drug
aas
tetracycline ointment
ligature thread
razor blade
soap
dressing
ergometrine
unit
18.00
1.00
1.00
1.00
1.00
1.00
1.00
cost of drugs
GF/unit
cost
1.28
135.00
5.00
25.00
200.00
5.00
53.00
23.04
135.00
5.00
25.00
200.00
5.00
53.00
446.04
sub-total
freight/insurance
logistics
8.92
454.96
total drugs
2.
Annual direct remuneration:
3.
per childbirth
per childbirth
324
18
1727982
90900
3.1%
per childbirth
per childbirth
91
5
30107
per childbirth
50
1410000
3.1%
per childbirth
73
970800
3.1%
per childbirth
51
194050.50
10500.00
salaries
bonuses
Annual indirect remuneration:
salaries
bonuses
coefficient of distribution
4.
Annual direct amortization:
5.
Annual indirect amortization:
coefficient of distribution
6.
Other overhead costs:
coefficient of distribution
total cost per childbirth
total cost per childbirth excluding salaries
multiplier coefficient
56
1067
652
1.43
Table B2
FINANCING OF THE COSTS OF CHILDBIRTH
category
of costs
GF per
childbirth
salariea
bonuses
415
22
drugs
freight/insur
logistics
446
dir amortization
indir amortiz 73
50
Government
source of financing
Prefecture
households
donors
415
1000
9
25
37
other
overheads
51
total
1067
Table B3
FINANCING REQUIRED
1000
415
source of
financing
contribution
per childb in GF
Government
415
Prefecture
0
Households
1000
Donors
62
Total financing
1477
62
financing required in GF
per childbirth
total
-410
-396614
57
Table Cl
COSTS OF TREATING UNCOMPLICATED MALARIA IN CHILDREN IN
GF
Drugs:
drug
unit
cost of treatment
GF/unit
cost
aas
chloroquine
6.00
2.00
1.28
3.83
7.68
7.66
1.
15.34
sub-total
freight/insurance
logistics
0.31
total drugs
2.
Annual direct remuneration:
salaries
bonuses
relative frequency
3.
Annual direct amortization:
relative frequency
5.
Annual indirect amortiz:
coefficient of distribution
6.
per treatment
per treatment
365
19
1727982
90900
7.2%
per treatment
per treatment
107
6
67200
per treatment
9
per treatment
87
per treatment
60
2759474
147000
15.5%
Annual indirect renumeration:
salaries
bonuses
coefficient of distribution
4.
Other overhead costs:
coefficient of distribution
15.5%
1410000
7.2%
970800
7.2%
total cost per treatment
total cost per treatment excluding salaries
multiplier coefficient
58
15.65
668
196
13
»
Table C2
FINANCING OF THE COSTS OF TREATING UNCOMPLICATED MALARIA
IN CHILDREN
category
of costs
GF per
treatment
salariea
bonuses
472
25
drugs
freight/insur
logistics
15
dir amortization
indir amortiz
9
87
other
overheads
60
total
668
Table C3
FINANCING REQUIRED
Government
source of financing
Prefecture
households
donors
472
50
4
43
50
472
source of
financing
contribution
per treatment in GF
Government
472
Prefecture
0
Households
50
Donors
48
total financing
570
48
financing required in GF
per treatment
total
98
115488
59
Table Al
YEAR OF OPERATION AND TYPE OF SIMULATION
Year > 1992
Type of simulation
baseline simulation
Table B2
FINANCING OF THE COSTS OF CHILDBIRTH
category
of costs
GF per
childbirth
salariea
bonuses
465
25
drugs
freight/insur
logistics
535
dir amortization
indir amortiz
59
85
other
overheads
59
total
1240
Table B3
FINANCING REQUIRED
Government
donors
465
1000
11
29
43
0
465
source of
financing
contribution
per childb in GF
Government
465
Prefecture
0
Households
1000
Donors
72
total financing
1537
60
source of financing
Prefecture
households
1000
72
financing required in GF
per childbirth
total
- 297
-287555
Table C2
FINANCING OF THE COSTS OF TREATING UNCOMPLICATED MALARIA
IN CHILDREN
category
of costs
GF per
treatment
salariea
bonuses
529
28
529
drugs
freight/insur
logistics
18
50
dir amortization
indir amortiz
10
102
51
other
overheads
70
total
758
Table C3
Government
source of financing
Prefecture
households
donors
50
56
5
529
0
FINANCING REQUIRED
source of
financing
contribution
per treatment in GF
Government
529
Prefecture
0
households
50
Donors
56
total financing
635
financing required in GF
per treatment
total
123
147894
61
Table Al
YEAR OF OPERATION AND TYPE OF SIMULATION
Year
Type of simulation
1993
baseline simulation
Table B2
FINANCING OF THE COSTS OF CHILDBIRTH
category
of costs
GF per
childbirth
salariea
bonuses
521
28
drugs
freight/insur
logistics
642
dir amortization
indir amortiz
69
100
other
overheads
70
total
1443
Table B3
FINANCING REQUIRED
source of
financing
contribution
per childb in GF
Government
521
Prefecture
0
Households
1000
Donors
84
total
1606
62
Government
source of financing
Prefecture
households
donors
521
1000
13
34
50
521
0
84
1000
financing required in GF
per childbirth
total
- 163
-157452
Table C2
FINANCING OF THE COSTS OF TREATING UNCOMPLICATED
MALARIA IN CHILDREN
category
of costs
GF per
treatment
salariea
bonuses
593
31
593
drugs
freight/insur
logistics
22
50
dir amortization
indir amortiz
12
119
6
59
other
overheads
82
total
859
Table C3
Government
source of financing
Prefecture
households
0
593
50
donors
66
FINANCING REQUIRED
source of
financing
contribution
per treatment in GF
Government
593
Prefecture
0
Households
50
Donors
66
total financing
708
financing required in GF
per treatment
total
151
186959
63
Annex 2
Working tool for analysis of the costs of health care
and their recovery in Guinea
Calculation of costs at the Dalaba Prefectural Hospital
Table Cell
Al
A2
A3
A4
A5
A6
A7
A8
A9
A10
All
A12
A13
A14
A15
A16
A17
A18
A81
alOl
A121
A141
A161
A181
A201
A281
A361
A401
A481
A561
A581
A601
A621
A981
A1021
Al 041
Year of operation and type of simulation
Parameters relating to demand for care
Parameters relating to the structure of costs
Parameters relating to the evolution of prices
Parameters relating to contribution to the financing of care
General data on the Dalaba Hospital
Distribution of personnel by percentage of working time
Distribution of personnel by hours of work per week
Monthly salaries and bonuses of personnel
Distribution of total monthly salaries by department
Distribution of total monthly bonuses by department
Monthly salaries and bonuses of personnel
Costs of infrastructure
Costs of rolling stock
Costs of technical equipment
Annual expenditure excluding salaries and amortization
Annual expenditure
Distribution of hours of work
Calculation of the cost of hospitalization in the surgery department
Bl
B2
B3
64
A1061
Al 141
A1161
Costs of hospitalization in the surgery department
Financing of costs of hospitalization in the surgery department
Financing required
Table Al
YEAR OF OPERATION AND TYPE OF SIMULATION
Year > 1991
Type of simulation
Table A2
baseline simulation
PARAMETERS RELATING TO DEMAND FOR CARE
rate of population
growth
2.6%
birth rate
4.6%
rate of increase
in demand for
general care
2.6%
rate of increase
in hospitalization
2.6%
Table A3
PARAMETERS RELATING TO THE STRUCTURE OF COSTS
freight/insurance rate
25.0%
logistic rate
2.0%
rate of contribution
to equalization fund
0.0%
65
Table A4
PARAMETERS RELATING TO THE EVOLUTION OF PRICES
rate of inflation
in countries of origin
of equipment and drugs
5.0%
rate of increase in
salaries and bonuses
15.0%
domestic rate of
inflation
20.0%
rate of increase in overhead
costs (local origin)
20.0%
interest rate
20.0%
rate of depreciation of
the national currency
15.0%
exchange rate GF/$
October 1991
Table A5
680.00
PARAMETERS RELATING TO CONTRIBUTION
TO THE FINANCING OF CARE
rate of participation
of donors to financing
of amortization
50.0%
rate of increase in
charges for households
0.0%
Table A6
GENERAL DATA ON THE DALABA HOSPITAL
BASELINE YEAR > 1990
number of hospitalizations
actual
anticipated
1990
1991
general surgery
gynaecology/obstetrics
general medicine and paediatrics
total
66
218
339
273
224
348
280
830
852
Table A7
DISTRIBUTION OF PERSONNEL BY PERCENTAGE OF WORKING TIME
category
general
surgery
director
physician 2
physician 3
midwife 1
midwife 2
thw 1
thw 2
thw 3
thw 4
thw 5
thw 6
thw 7
orderly 1
orderly 2
orderly 3
nurse 1
nurse 2
health asst 1
health asst 2
pharmacist
biologist
lab technician
radiog technician
admin manager
driver
director
physician 2
physician 3
midwife 1
midwife 2
thw 1
thw 2
thw 3
thw 4
thw 5
thw 6
thw 7
orderly 1
orderly 2
orderly 3
nurse 1
nurse 2
health asst 1
health asst 2
pharmacist
biologist
lab technician
radiog technician
admin manager
driver
gen med
paediatric
gynaecoobstetric
labora
tory
dental
surgery
80%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
20%
100%
100%
100%
100%
67
Table A8
category
director
physician 2
physician 3
midwife 1
midwife 2
thw 1
thw 2
thw 3
thw 4
thw 5
thw 6
thw 7
orderly 1
orderly 2
orderly 3
nurse 1
nurse 2
health asst 1
health asst 2
pharmacist
biologist
lab technician
radiog technician
admin manager
driver
sub-total
68
DISTRIBUTION OF PERSONNEL BY HOURS PER WEEK
general
surgery
gynaecoobstetric
gen med
paediatric
dental
surgery
labora
tory
32
40
40
40
40
40
40
40
40
40
40
40
40
40
40
40
40
40
40
40
40
160
240
272
80
80
4
Table A8 (contd)
DISTRIBUTION OF PERSONNEL BY HOURS PER WEEK
category
pharmacy
director
physician 2
physician 3
midwife 1
midwife 2
thw 1
thw 2
thw 3
thw 4
thw 5
thw 6
thw 7
orderly 1
orderly 2
orderly 3
nurse 1
nurse 2
health asst 1
health asst 2
pharmacist
biologist
lab technician
radiog technician
admin manager
driver
sub-total
radiology
administration
8
40
40
40
40
40
128
69
Table A9
MONTHLY SALARIES AND BONUSES OF PERSONNEL
category
factor: 1
director
physician 2
physician 3
midwife 1
midwife 2
thw 1
thw 2
thw 3
thw 4
thw 5
thw 6
thw 7
orderly 1
orderly 2
orderly 3
nurse 1
nurse 2
health asst 1
health asst 2
pharmacist
biologist
lab technician
radiog technician
admin manager
driver
70
salary
1991
bonus
1991
salary
1991
bonus
1991
143903
113468
113389
92308
92158
69502
68809
71085
73164
73764
66880
91280
30000
30000
30000
66319
66319
104806
96939
108224
111839
86337
10000
5000
5000
5000
5000
5000
5000
5000
5000
5000
5000
5000
5000
5000
5000
5000
5000
5000
5000
7500
5000
5000
143903
113468
111389
92308
92158
99502
68809
71085
73164
73764
66880
91280
30000
30000
30000
66319
66319
104806
96939
108224
111839
86337
10000
5000
5000
5000
5000
5000
5000
5000
5000
5000
5000
5000
5000
5000
5000
5000
5000
5000
5000
7500
5000
5000
101535
48426
7500
5000
101535
48426
7500
5000
*
Table A10
DISTRIBUTION OF TOTAL MONTHLY SALARIES BY DEPARTMENT
category
general
surgery
director
113468
physician 2
physician 3
midwife 1
midwife 2
69502
thw 1
68809
thw 2
thw 3
thw 4
thw 5
thw 6
thw 7
30000
orderly 1
orderly 2
orderly 3
nurse 1
nurse 2
health asst 1
health asst 2
pharmacist
biologist
lab technician
radiog technician
admin manager
driver
sub-total
281779
gynaecoobstetric
gen med
paediatric
dental
surgery
labora
tory
115122
111389
92308
92158
71085
73164
73764
66880
91280
30000
30000
66319
66319
104806
96939
111839
86337
458493
534821
188219
198176
71
Table A10 (contd)
DISTRIBUTION OF TOTAL MONTHLY SALARIES BY DEPARTMENT
category
pharmacy
director
physician 2
physician 3
midwife 1
midwife 2
thw 1
thw 2
thw 3
thw 4
thw 5
thw 6
thw 7
orderly 1
orderly 2
orderly 3
nurse 1
nurse 2
health asst 1
health asst 2
pharmacist
biologist
lab technician
radiog technician
admin manager
driver
sub-total
radiology
administration
28781
108224
101535
48426
108224
1178742
X
.*
72
Table AH
DISTRIBUTION OF TOTAL MONTHLY BONUSES BY DEPARTMENT
category
general
surgery
director
5000
physician 2
physician 3
midwife 1
midwife 2
5000
thw 1
5000
thw 2
thw 3
thw 4
thw 5
thw 6
thw 7
5000
orderly 1
orderly 2
orderly 3
nurse 1
nurse 2
health asst 1
health asst 2
pharmacist
biologist
lab technician
radiog technician
admin manager
driver
sub-total
20000
gynaecoobstetric
gen med
paediatric
dental
surgery
labora
tory
8000
5000
5000
5000
5000
5000
5000
5000
5000
5000
5000
5000
5000
5000
5000
5000
5000
30000
38000
10000
10000
73
Table All (contd)
DISTRIBUTION OF TOTAL MONTHLY BONUSES BY DEPARTMENT
category
pharmacy
director
physician 2
physician 3
midwife 1
midwife 2
thw 1
thw 2
thw 3
thw 4
thw 5
thw 6
thw 7
orderly 1
orderly 2
orderly 3
nurse 1
nurse 2
health asst 1
health asst 2
pharmacist
biologist
lab technician
radiog technician
admin manager
driver
sub-total
74
radiology
administration
2000
7500
7500
5000
7500
14500
Table A12
MONTHLY SALARIES AND BONUSES OF PERSONNEL
salaries
1948454
bonuses
130000
total
Table A13
2078454
COST OF INFRASTRUCTURE IN GF
initial
unit cost
quantity
fut value
lifetime
annual
amortiz
year 1
building m2
local share: 0.50
150000
1200
69007667986
20
10800000
beds
100000
40
24766946
10
480000
category
office
furniture
5
11280000
6925534932
Table A14
COST OF ROLLING STOCK IN GF
category
initial
cost
ambulance
other
vehicle(s)
moped
lifetime
future value
annual amortiz
year 1
24000000
5
59719680
5760000
16000000
1200000
5
5
39813120
2985984
3840000
288000
102518784
9888000
41200000
75
Table A15
COSTS OF TECHNICAL EQUIPMENT
category
initial
cost US $
lifetime
quantity
annual amortiz
year 1
medical stethoscope
obstetrical stethoscope
scales
examination table
knee hammer
laryngeal mirror
set of nasal specula
set of ear specula
vaginal speculum
ophthalmoscope-otoscope
sphygmomanometer
tongue depressor
thermometer
pelvimeter
baby scales
gloves
5.10
8.31
31.45
388.20
4.95
2.96
23.40
23.40
8.20
136.00
36.60
2.30
1.00
8.79
151.80
0.83
5
15
15
15
15
15
15
15
15
15
5
15
1
15
15
1
2
2
1
1
2
2
3
3
3
1
1
4
5
1
1
200
1665
904
1711
21118
539
3222
3819
3819
1338
7398
5973
500
4080
478
8258
135456
sub-total
197378
1
10
10
100
100
500
500
5
5
20
20
5
5
2
2
21118
898
571
4080
3264
8160
8160
1425
1425
16320
2655
364
364
856
2753
Consultation Room
examination table
20 cc glass syringes
10 cc glass syringes
3 cc glass syringes
2.5 cc glass syringes
intramuscular needles
intravenous needles
dental forceps (front teeth)
dental forceps (back teeth)
ampoule files
Kocher forceps
curved scissors
crimping scissors
kidney dish
24 cm drum
388.20
0.11
0.07
0.05
0.04
0.02
0.02
5.24
5.24
1.00
2.44
1.34
1.34
7.87
25.30
15
1
1
1
1
1
1
15
15
1
15
15
15
15
15
Treatment Room - Injections and Immunization
table for minor surgery
kit for minor surgery
box of dressings
curved scissors
straight scissors
series of gloves Nos 6-8
instrument tray
instrument sterilizer
circumscr forceps
Kocher forceps
76
314.00
240.00
32.00
1.40
1.40
0.83
10.69
308.94
2.50
2.44
15
15
15
15
15
1
15
15
15
15
sub-total
72414
1
1
5
2
5
200
2
1
10
20
17082
13056
8704
152
381
135456
1163
16806
1360
2655
»
kidney dish
anatomical forceps
scalpel handle
scalpel blade
suture kit
kidney dish
7.89
2.50
1.42
0.30
42.00
7.87
15
15
15
1
15
15
Minor Surgery Ward
distillation kit
methylene blue powder
4-tube centrifuge
staining box for
microscope slides
staining dish for
30 slides
polyethylene funnel
polyethylene funnel, 200 ml
test tube, 100 ml
test tube, 25 ml
test tube, 500 ml
50 ml plastic bottle
10 ml dropper bottle
round-necked narrow cork
60 ml bottle
round-necked wide cork
60 ml bottle
urine test bottle
Giemsa powder 10 g
complete haemacytometer
complete haemoglobinometer
microscope oil, 25 ml
microscope slides
22 x 22 mm, box of 50
microscope slides, box of 72
alcohol lamp
lancets, box of 1000
binocular microscope (PZO)
timer, 60 min x 1 min
kit for urinary
albumin test
immersion lens for PZO
lens paper, packet of 50
forceps for blades
Kirkbride 125
stainless steel
125 mm forceps
urinary test set
rack for 6 test tubes
rack for Westergren
sedimentation kit
rack for test tubes
test tubes 100 x 13 mm
test tubes 150 x 25 mm
2
10
100
1000
2
5
858
1360
7725
244800
4570
2141
sub-total
458268
460.00
11.40
274.20
23.85
1.32
8.50
15
1
15
15
1
15
1
2
3
3
2
2
24480
18605
44749
3892
2154
925
0.46
0.46
1.36
4.70
10.00
0.50
2.40
5
5
1
1
1
5
1
5
5
10
10
5
50
50
375
375
11098
38352
40800
4080
97920
3.20
1
50
130560
3.30
0.10
0.50
10.53
5.30
1.45
1
1
I
15
15
I
50
5
2
2
2
2
134640
408
816
1146
577
2366
0.80
1.32
3.30
36.00
1810.00
20.40
1
1
15
1
15
5
10
20
3
5
1
2
6528
21542
539
146880
98464
6659
2.59
1
10
21134
0.31
1
5
1265
1.00
15
2
109
0.65
15
5
177
4.80
15
5
1306
0.21
0.23
1
1
50
50
8568
9384
77
test tubes 75 x 12 mm
centrifuge tubes
15 ml, graduated
centrifuge tubes
15 ml, non-graduated
heater
urine analysis kit
laboratory thermometer
vaccinostyles
electric centrifuge
haematoleucometer
glass funnel
bain-marie
incubator
precision balance
weights for
balance, series
balance for
centrifuge tubes
ordinary table
chair
0.25
1
50
10200
0.30
1
20
4896
0.28
13.10
1
15
50
2
11424
1425
14.41
1.00
225.00
10.53
0.05
5
1
15
15
1
4
2
1
2
5
9407
1632
12240
1146
204
577.52
652.11
15
15
1
1
31417
35475
94.23
15
1
5126
60.00
22.05
15
5
1
2
3264
7197
sub-total
1015925
Total Laboratory
adult scales, 140 kg
autoclavable poly
propylene bed pan
dressing dish, 1 litre
with stainless steel
cover
stainless steel 140 mm
Mayo straight
dissecting scissors
140 mm Braun curved
episiotomy scissors
vinyl 910 x 1920 mm
mattress cover
type 1, 280 mm Thomas
blunt uterine curette
type 3, 280 mm Thomas
blunt uterine curette
type 5, 280 mm Thomas
blunt uterine curette
type 1, 280 mm Sims
cutting uterine curette
type 3, 280 mm Sims
cutting uterine curette
type 5, 280 mm Sims
cutting uterine curette
complete Malmstrom
vacuum extractor
surgical gloves
height measuring
instrument, 2 m
78
30.85
15
3
5035
7.85
15
2
854
27.30
15
5
7426
1.39
15
5
378
1.39
15
5
378
5.00
5
20
16320
2.62
15
2
285
2.70
15
2
294
2.62
15
2
285
2.70
15
2
294
2.70
15
2
294
2.75
15
2
299
0.83
1
100
67728
8.52
5
5
6952
1.5 litre stainless
steel irrigator
obstetrical bed with
2-piece mattress
tape measure, 1.5 m
Collyer external
pelvimeter
Deler internal
pelvimeter
clinical infant
scales, 15.5 kg
stainless steel
300 mm Kelly
placenta forceps
300 mm graduated
Simpson uterine
sound
medium stainless steel
Graves bivalve
vaginal speculum
large stainless steel
Graves bivalve
vaginal speculum
Pinard fetal
stethoscope
stainless steel
instrument tray
3-section
examination table
520.00
1.00
15
1
1
10
28288
8160
6.07
15
2
660
8.79
15
2
956
116.50
15
3
19013
2.50
15
3
408
2.73
1
2
4455
3.36
15
5
914
3.48
15
5
947
8.31
15
6
2712
4.28
15
5
1164
314.00
15
2
34163
sub-total
208663
Total Obstetrics, MCH and FP
examination table
stool
delivery table
obstetrical
vacuum extractor
tape measure
mechanical aspirator
29 cm drum
fetal stethoscope
reanimation
apparatus
jar for forceps
hygienic bucket
pelvimeter
series of gloves
Nos 6-8
gynaecological box
suture kit
height measurer
sphygmomanometer
baby sheet
sheet for
deliveiy table
388.20
15
1
21118
1010.00
15
1
54944
560.00
1.00
47.40
23.87
8.31
15
15
15
15
1
1
1
2
2
30464
816
2579
2579
904
189.20
3.78
3.07
8.79
15
1
5
15
2
2
2
1
20585
6169
1002
478
0.83
480.00
42.00
8.52
36.60
1.00
1
15
15
15
5
1
200
2
2
2
2
3
135456
52224
4570
927
11946
2448
1.50
1
3
3672
79
sheet for bed
screen
enema kit
1.50
2.65
1.50
1
15
2
Delivery room
stainless steel
instrument box
stainless steel 144 mm
curved Mayo
dissecting scissors
stainless steel 144 mm
straight Mayo
dissecting scissors
nail brush
surgical gloves 6-1/2
surgical gloves 7
surgical gloves 7-1/2
scalpel blade No. 10
packet of 5
razor blades
packet of 5
sharpening stone
stainless steel 140 mm
straight
haemostatic forceps
stainless steel 140 mm
Kelly straight
haemostatic forceps
125 mm straight mosquito
haemostatic forceps
assortment of suture
needles, 6 of each type
stainless steel 125 mm
straight needle forceps
stainless steel 150 mm
straight needle
forceps
stainless steel 225 mm
straight swab forceps
280 mm Duplay retractor
stainless steel 200 mm
flat forceps
stainless steel
instrument tray
390x195x63 mm
scalpel handle
operating table
anaesthesia trolley
without drawers
revolving stool
cylindrical dressing drum
290 mm diameter
set of 6 stainless steel
Hank dilating bougies
3-piece metal razor
urinal
80
3
2
3
3762
288
1836
sub-total
358695
4.28
15
5
1164
0.87
15
5
237
1.04
0.51
0.83
0.85
0.87
15
5
1
1
1
5
5
100
100
100
283
416
67728
69360
70992
1.50
1
10
12240
0.16
12.00
1
5
20
1
2611
1958
1.69
15
6
552
1.47
15
6
480
1.28
1
5
5222
0.90
15
5
245
1.00
15
5
272
1.25
0.65
15
15
5
2
340
71
0.75
15
6
245
4.28
1.42
1100.00
15
15
15
5
3
2
1164
232
119680
85.58
60.19
15
15
4
4
18622
13097
27.20
15
5
7398
10.88
4.60
7.00
15
2
15
2
5
3
1184
9384
1142
all-purpose operating
table 0188100
EMO anaesthesia apparatus
for ether 01002001
pressure steam sterilizer
0156500
kerosene heater 174000.00
electric hot air
sterilizer 0164800
220 v. electric water
sterilizer 0166500
sterilizer drum 0107700
surgical instrument kit
9962000
instrument tray 0270000
instrument trolley
0187004
electric aspirating pump
scialytic lamp
8000.00
15
1
435200
2200.00
15
1
119680
6000.00
14.99
15
15
1
1
326400
815
700.00
15
1
38080
110.00
70.00
15
15
1
3
5984
11424
8000.00
10.60
15
15
3
3
1305600
1730
242.18
740.00
3060.00
15
15
15
1
i
i
13175
40256
166464
sub-total
2871128
1
1
3264000
380800
Radiology equipment
sub-total
3644800
TOTAL EQUIPMENT
including common equipment
(laboratory, radiology)
TOTAL
8827271
Total surgery
X-ray machine
developing equipment
60000.00
7000.00
15
15
4660725
81
Table A16
ANNUAL EXPENDITURE EXCLUDING SALARIES AND AMORTIZATION
category:
5171040
1292760
103421
295488
2829975
108000
8400000
988800
1836000
1560000
essential drugs
ffeight/insurance
logistics
office supplies
fuel
maintenance materials
maintenance of eqipment
maintenance and repair of vehicles
indemnities and benefits
bonuses
sub-total
22585484
TOTAL
22585484
21025484
equalization fund
Total excluding bonuses
Table A17
ANNUAL EXPENDITURE
Annual expenditure excluding
salaries, amortization and
equalization fund
Amortization:
infrastructure
rolling stock
technical equipment
22585484
11280000
9888000
8827271
sub-total
salary expenses
TOTAL (excluding equalization fund)
82
52580755
23381448
75962203
Table A18
DISTRIBUTION OF HOURS OF WORK
department:
hours
%
surgery
gynaecology/obstetrics
general medicine/paediatrics
dental surgery
160
240
272
80
21.3
31.9
36.2
10.6
sub-total
752
80
40
laboratory
pharmacy
radiology
administration
128
Total
1000
83
Table Bl
COSTS OF HOSPITALIZATION IN THE SURGERY DEPARTMENT
1. Drugs
drug
consumption of drugs
tablets/month
no. months
GF/tablet
cost
total consumption: 5171040
coefficient of
distribution:
0.43
9941
freight/insurance
logistics
2485
199
2. Health Record Book
2. Surgery Department
150
annual salaries
3381348.00
per hospitalization
15118
annual bonuses
240000.00
per hospitalization
1073
3. Intermediate services (administration,laboratory, pharmacy, radiology)
salaries
5821699
per hospitalization
5538
bonuses
384000
per hospitalization
365
coefficient of distribution
21.3%
4. Overhead costs
total
coefficient of distribution
14458263
21.3%
distributed costs
3076226
per hospitalization
13754
5. Direct amortization
2871128
per hospitalization
12837
per hospitalization
24570
6. Amortization of common equipment
total
coefficient of distribution
distributed costs
25828725
21.3%
5495473
OVERALL TOTAL PER HOSPITALIZATION
84
»>
86029
r
Table B2
FINANCING OF COSTS OF HOSPITALIZATION IN THE SURGERY DEPARTMENT
category
of costs
GF per
hospitaliz
salaries
bonuses
hlth record book
drugs
freight/insur
logistics
overhead costs
dir amortiz
common amortiz
total
Government
source of financing
Prefecture
households
20656
1438
150
9941
2485
199
13754
12837
24570
19046
1610
86029
19046
Table B3
FINANCING REQUIRED
source of
financing
contribution
per hospitalization
Government
19046
Prefecture
1610
households
7150
donors
21387
sub-total
49193
donors
150
7000
2485
199
6418
12265
1610
7150
21387
financing required
per hospitalization
total
36836
10056308
85
Table Al
YEAR OF OPERATION AND TYPE OF SIMULATION
Year
Type of simulation
1992
baseline simulation
Table B2
FINANCING OF COSTS OF HOSPITALIZATION IN THE SURGERY DEPARTMENT
category
of costs
GF per
hospitaliz
salaries
bonuses
hlth record book
drugs
freight/insur
logistics
overhead costs
dir amortiz
common amortiz
Government
source of financing
Prefecture
households
23152
1612
150
11930
2982
239
16176
15014
28737
21077
2075
total
99991
21077
Table B3
FINANCING REQUIRED
source of
financing
contribution
per hospitalization
150
7000
2982
239
7507
14368
Government
Prefecture
households
donors
21077
2075
7150
25096
sub-total
55398
86
donors
2075
7150
25096
financing required
per hospitalization
total
44593
12173928
Table Al
YEAR OF OPERATION AND TYPE OF SIMULATION
1993
Year
Type of simulation > baseline simulation
Table B?
FINANCING OF COSTS OF HOSPITALIZATION IN THE SURGERY DEPARTMENT
category
of costs
GF per
hospitaliz
salaries
bonuses
hlth record book
drugs
freight/insur
logistics
overhead costs
dir amortiz
common amortiz
25950
1870
150
14315
3579
286
19028
17560
33610
Government
source of financing
Prefecture
households
donors
2674
23276
150
7000
3579
286
8780
16805
23276
total
116286
Table B3
FINANCING REQUIRED
source of
financing
contribution
per hospitalization
Government
Prefecture
households
donors
23276
2674
7150
29450
sub-total
62550
29450
7150
2674
financing required
per hospitalization
total
537361
4669807
87
Annex 3
FIGURES
COST OF CHILDBIRTH BY RATE OF INFLATION
AT THE MANEAH HEALTH CENTRE
Figure 1
GF
2000
________________________ ___________________ "■
1500
------- 4-.. 1000
500
0
1991
1993
1992
Inflation 10%
Baseline scenario
'I' Inflation 30 %
FINANCING REQUIRED (CHILDBIRTH) BY RATE OF
INFLATION AT THE MANEAH HEALTH CENTRE
Figure 2
GF
0 —
-100
-200 “
..—r-------
-300
-400
-500 L_
Inflation 10%
88
1993
1992
1991
Baseline scenario
Inflation 30 %
COST OF CHILDBIRTH BY DEMAND AT
THE MANEAH HEALTH CENTRE
Figure 3
GF (Thousands)
1.5 --------------------
1.4 "
1.3 "
1.1 -
il—
1991
1993
1992
•• •
4” Baseline scenario
Demand growth 0.2%
Demand growth 4%
FINANCING REQUIRED (CHILDBIRTH) BY DEMAND AT
THE MANEAH HEALTH CENTRE
Figure 4
GF
o —
-100
-200
-300 -
.......
-500 L_
1991
1993
1992
Demand growth 0.2%
Baseline scenario
Demand growth 4%
89
COST OF CHILDBIRTH BY EXCHANGE RATE AT THE
MANEAH HEALTH CENTRE
Figure 5
r
GF (Thousands)
11
1993
1992
1991
*. Depreciation rate 10%
Baseline scenario
Depreciation rate 20%
FINANCING REQUIRED (CHILDBIRTH) BY EXCHANGE
RATE AT THE MANEAH HEALTH CENTRE
Figure 6
GF
0
-100
-200
.___
-300
-400_ r-'
-500
1991
Depreciation rate 10%
90
1993
1992
Baseline scenario
----- Depreciation rate 20%
Figure 7
COST OF TREATING UNCOMPLICATED MALARIA BY RATE OF
INFLATION AT THE MANEAH HEALTH CENTRE
GF
1200 F-
1000
$
800 -
600 ’
■400 "
200
I
o
Inflation 10%
Figure 8
1993
1992
1991
Baseline scenario
’Inflation 30 %
FINANCING REQUIRED (UNCOMPLICATED MALARIA) BY RATE OF
INFLATION AT THE MANEAH HEALTH CENTRE
GF
200 ----
ISO
........ .. ..........
ioo2^
so
0
1991
1993
1992
Inflation 10%
Baseline scenario
Inflation 30 %
91
COST OF TREATING UNCOMPLICATED MALARIA BY DEMAND
AT THE MANEAH HEALTH CENTRE
Figure 9
GF
950
900
850
800
750
700
650
600
1991
1992
Demand growth 0.2%
1993
Baseline scenario
Demand growth 4%
FINANCING REQUIRED (UNCOMPLICATED MALARIA) BY DEMAND
AT THE MANEAH HEALTH CENTRE
Figure 10
GF
200 ----
180
160
140
120
__
loo^r-—‘
t
80 u1991
1992
Demand growth 0.2%
Demand growth 4%
92
1993
Baseline scenario
COST OF TREATING UNCOMPLICATED MALARIA BY EXCHANGE
RATE AT THE MANEAH HEALTH CENTRE
Figure 11
GF
950 -----
900
850 "
...
800
750
“
700
“
_ +-""L-
650
i
600
1991
1993
1992
Depreciation rate 10%
--1; Baseline scenario
1 Depreciation rate 20%
FINANCING REQUIRED (UNCOMPLICATED MALARIA)
EXCHANGE RATE AT THE MANEAH HEALTH CENTRE
Figure 12
BY
GF
200 —
180
160 -
... .....
HO
100-
80 •—
1993
1992
1991
Depreciation rate 10%
----- Depreciation rate 20%
93
COST OF HOSPITALIZATION (SURGERY) BY RATE OF INFLATION AT
THE DALABA HOSPITAL
Figure 13
GF (Thousands)
145
125
........
105
sr*
85“ “
I
65
1991
1992
...... Inflation 10%
Baseline scenario
1993
4' Inflation 30 %
FINANCING REQUIRED (SURGERY) BY RATE OF INFLATION AT THE
DALABA HOSPITAL
Figure 14
GF (Thousands)
85
75
65
...
55
45 "
35 7.
25
1991
1993
1992
...... Inflation 10%
“I" Baseline scenario
4 Inflation 30 %
4
94
COST OF HOSPITALIZATION (SURGERY) BY DEMAND AT THE
DALABA HOSPITAL
Figure 15
GF (Thousands)
140
130
120
no
100
90
80
1991
1992
Demand growth 0.2%
*
1993
Baseline scenario
Demand growth 4%
FINANCING REQUIRED (SURGERY) BY DEMAND AT THE DALABA
HOSPITAL
Figure 16
GF (Thousands)
60 -------------------55 ~
50
45
40
35
30
1991
1993
1992
Demand growth 0.2%
•‘j-Baseline scenario
Demand growth 4%
c
95
COST OF HOSPITALIZATION (SURGERY) BY EXCHANGE RATE AT
THE DALABA HOSPITAL
Figure 17
i
GF (Thousands)
145
*
. ....... ........
125
—+—
105
85" “
65
1991
1993
1992
■- Depreciation rate 10%
^Baseline scenario
Depreciation rate 20%
FINANCING REQUIRED (SURGERY) BY EXCHANGE RATE AT THE
DALABA HOSPITAL
Figure 18
GF (Thousands)
85 --------------------
75
65
55
____ ______
■
X---------
45
35
i__
25
1991
1993
1992
*
*■■
96
Depreciation rate 10%
‘^Baseline scenario
Depreciation rate 20%
COST OF CHILDBIRTH - SIMULTANEIOUS CHANGE OF PARAMETERS
AT THE DALABA HOSPITAL
Figure 19
>
GF (Thousands)
4
12
1993
1992
1991
Semi-optimistic
Optimistic
Pessimistic
scenario
scenario
FINANCING REQUIRED FOR CHILDBIRTH - SIMULTANEOUS
CHANGE OF PARAMETERS AT THE DALABA HOSPITAL
Figure 20
GF
0
-100
-200 -
-300
----............
-400_
.....
-500
1991
1993
1992
4
Optimistic
Semi-optimistic
Pessimistic
scenario
scenario
scenario
4
97
COST OF TREATING UNCOMPLICATED MALARIA - SIMULTANEOUS
CHANGE OF PARAMETERS AT THE DALABA HOSPITAL
Figure 21
GF (Thousands)
I -------------------
»
0.9
•*
0.8
__ +0.6
1
05 u—
1991
1992
... ... Optimistic
scenario
1993
Pessimistic
scenario
------- JSemi-optimistic
scenario
FINANCING REQUIRED FOR UNCOMPLICATED MALARIA SIMULTANEOUS CHANGE OF PARAMETERS AT THE DALABA
HOSPITAL
Figure 22
GF
250 ----
200
................
ISO
: r----
:±
50
1991
1992
Optimistic
scenario
98
Semi-optimistic
scenario
1993
—*
Pessimistic
scenario
>
J
COST OF HOSPITALIZATION (SURGERY) - SIMULTANEOUS CHANGE
OF PARAMETERS AT THE DALABA HOSPITAL
Figure 23
GF (Thousands)
170
4
ISO
. ........
v
130
110
---------- +.--90
1
70
1992
1991
1993
Optimistic
i Semi-optimistic
scenario
1 scenario
* Pessimistic
scenario
FINANCING REQUIRED (SURGERY) - SIMULTANEOUS CHANGE OF
PARAMETERS AT THE DALABA HOSPITAL
Figure 24
GF (Thousands)
90 --------------------
80
70
60
50
4o::-------30 L1991
4
1993
1992
Optimistic
scenario
i Semi-optimistic
scenario
Pessimistic
scenario
4
99
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