DHER REPORT – ANALYSIS AND INTERPRETATION€¦ · Web viewRefer to the Word Template where comments have been included. LAYOUT OF DHER WORD REPORT. Below is the layout of the

DHER GUIDELINES-PART 2

WORD REPORT

APRIL 2012

Compiled by Tracey Hattingh, KZN DoH

DHER REPORT – ANALYSIS AND INTERPRETATION

Table of Contents1 INTRODUCTION.....................................................................................................................................3

1.1 THE PURPOSE OF THE DHER..........................................................................................................4

1.2 PROCESS OF THE DHER – add to....................................................................................................4

2 INTERPRETATION AND ANALYSIS...........................................................................................................7

2.1 DATA QUALITY...............................................................................................................................7

2.2 CORE DHIS DATA ELEMENTS..........................................................................................................9

2.3 LINKING OF INDICATORS..............................................................................................................10

3 DHER REPORT – WORD DOCUMENT...................................................................................................20

3.1 LAYOUT OF DHER WORD REPORT................................................................................................20

3.2 FORMATING OF DHER WORD REPORT........................................................................................22

3.3 DHER WORD TEMPLATE / REPORT..............................................................................................22

ACKNOWLEDGEMENTS........................................................................................................................23

SUMMARY...........................................................................................................................................23

INTRODUCTION...................................................................................................................................23

PRIMARY HEALTH CARE.......................................................................................................................24

HIV / AIDS............................................................................................................................................32

ENVIRONMENTAL HEALTH...................................................................................................................32

HOSPITALS (DISTRICT & TB).................................................................................................................33

DISTRICT ALLOCATION AND USE OF RESOURCES IN PROGRAMME 2..................................................34

DISCUSSION: SUMMARY OF RECOMMENDATIONS............................................................................34

4 ALIGNMENT OF DHER & DHP...............................................................................................................35

4.1 TRANSLATION OF CHALLENGES BETWEEN DOCUMENTS............................................................35

4.2 RELATIONSHIP BETWEEN DHP & DHER........................................................................................39

5 ACKNOWLEDGEMENTS........................................................................................................................40

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1 INTRODUCTIONThe DHER paints the picture of how resources are allocated within districts and of financial performance related to pertinent criteria and indicators. Focuses on financial data and links this to other resources such as staff as well as to service delivery and population data.

The DHER Report is made up 3 main data sources, namely BAS, PERSAL and DHIS data. The blending of these three data sources in relation to each other will produce the DHER report which will give a ‘snapshot’ of the district at that point in time.

The District Health Expenditure Review (DHER) is an annual Expenditure Report submitted by each district reporting down to sub-district level for PHC and facility level for hospitals. Currently, the report is only required for Programme 2, 3 & 4, but it is hoped that in the future this will be expanded to include all service performance activities at a district level.

Below is an outline of the Programme and Sub-Programmes as per budget allocation. The programmes and sub-programmes relevant to the DHER are highlighted in red.

Programme 1-Administration

Programme 2-District Health Services

2.1 District Management Expenditure

2.2 PHC Expenditure

2.3 CHC Expenditure

2.4 Community Services (i.e. services delivered at the CHC / PHC)

2.5 Other Community Services (i.e. services delivered outside of PHC structure i.e. community care givers)

2.6 HIV / AIDS

2.7 Nutrition

2.8 Environmental Health

2.9 District Hospital Expenditure

2.10 Coroner / Forensic Services (not yet included as part of DHER)

Programme 3-Emergency Health Services

Programme 4-Provincial Hospital Services

Programme 5-Central Hospital Services

Programme 6-Health Sciences Training

Programme 7-Health Care Support Services

Programme 8-Health Facilities

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Community-based services are accounted for in terms of expenditure under sub-programme ‘2.5 Other Community Services Expenditure’.

1.1 THE PURPOSE OF THE DHERThe DHER is used as a justification for resources used within the district in terms of service delivery performance and forms part of the Budget Allocation Process. It is a situational analysis of the district in terms of allocated resources, including personnel, in relation to health outcomes. It ‘holds’ the district management team accountable for service delivery against expenditure at a district level.

Based on the analysis and interpretation of the data, it will assist the district in identifying challenges / backlogs in the system.

It can identify misallocated funds / staff so that systems can be amended.

Cost drivers can be identified and reviewed.

Can assist the Districts with short-term planning and linkages with the District Health Plans.

Can improve overall management of District.

Can improve service delivery performance at a ‘grass-root’s’ level.

Accountability of District Management.

Budget allocation – Under-resourced districts must have a higher % increase than the others. Planning of budgets cannot be made by adding the same percentage increase to all sub-districts.

1.2 PROCESS OF THE DHER

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NOTE:

The main focus of the DHER is Service Delivery In Relation To Expenditure

NOTE:

This guideline should be read in conjunction with:-

The DHER Guidelines – Part 1,

The DHER Excel Template and

The DHER Word Template.


The DHER process is made of 3 phases all combining to form the DHER Report.

1. Initially the raw data is entered into the DHER Excel Workbook which automatically calculates certain indicators.

2. Secondly, the data is interrogated and analysed within the context of the district. Operational challenges are noted in the matrix for resolving.

3. Thirdly, the interpretation of data is included in the DHER Word Report and a draft submitted to Province for comment.

4. Lastly, DHER Word Report is finalised. The DHER Excel Workbook and the DHER Word Report per district are submitted to NDoH as per the PFMA regulations. See diagram below.

Figure 1: DHER Process Flow

Workshops are facilitated by Province for the inputting of the raw data into the Excel Template and on the analysis and interrogation of data.

Below is a process map of the DHER showing the linkage between the DHER Excel Template and the DHER Word Report.

Figure

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DHER

Raw data = DHER Excel Template

Analysis + Interrogation =

Matrix

Interpretation = DHER Word

Report


2: DHER Process Flow

Province provides support to the Districts for the DHER process, however it remains the responsibility of the district to meet with and disseminate information to facility managers. This is an integral part of the Planning, Monitoring and Evaluation Process as feedback is essential.

Figure 3: Diagram of the 3 Sources of Information

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DHER Word Report finalised for submission

to PDoH

Workshop with Province to discuss challenges and review analysis

Submission of 1st Draft Word Report to PDoH for comment

Analysis and interpretation

of data by District DHER

Team

Inputting of data from Pivot

tables into DHER Excel Templates

Initial meeting with PDoH to provide BAS & PERSAL data

BAS

DHIS PER-SAL

DHER

2 INTERPRETATION AND ANALYSISThe interpretation and analysis of indicators is an important aspect of the DHER process and cannot be over-emphasised. Without the ability to analyse and interpret data, the DHER holds no value for the District / Province and becomes a compliance based exercise only. It is therefore essential that the District DHER Management Team understand this aspect of the DHER to ensure that the DHER Report is meaningful and appropriate for their district.

2.1 DATA QUALITYData quality has a HUGE impact on the analysis and interpretation. Future budget allocations, will take the DHER into consideration to identify where extra budget is required for resources and staff.

The integrity of data can be compromised by the completeness of the data. Incomplete data submitted by districts/ facilities can cause discrepancies in data but can also lead to incorrect conclusions being drawn and under-funding of resources. An example has been included to illustrate the impact that incomplete data has.

ILLUSTRATED EXAMPLE: BUDGET ALLOCATED / PDE

In the example below the budget allocation per PDE is explained in detail to emphasis the impact that incorrect / incomplete data has on the planning and budgeting process.

Scenario 1: Incomplete data

In Table 1 is reflected data received from a facility when data was closed off on the 20th May 2011. It is clearly evident that there is data missing for April, May, June, July, August and September for both Out-Patient Department (OPD) and Emergency Headcounts (EHC). No Day Patients (DP’s) are accepted at this institution.

Table 1: Data received 20th May 2011

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Total

IPD 2,535 3,269 2,057 2,071 1,613 2,098 2,096 1,948 2,264 2,555 2,128 2,272 26,906

DP 0 0 0 0 0 0 0 0 0 0 0 0 0

NOTE:

Check for data completeness when verifying data or investigating anomalies before interpretation and analysis.

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Total

OPD 0 0 0 0 0 0 2,697 2,477 2,621 2,810 2,179 2,730 15,514

EHC 0 0 0 0 0 0 205 230 279 227 154 133 1,228

IPD = In-Patient days OPD = Out Patient Department

DP = Day Patients EHC = Emergency Headcount

Equation 1: PDE Calculations using data from 20th May 2011

• PDE = (1/3 OPD) + (1/3 Emergency) + (1/2 DP’s) + IPD• PDE =(15,514 / 3) + (1,228 / 3) + (0 / 2) + 26,906• PDE = 5,171 + 409 + 0 + 26,906• PDE = 32,486• Cost / PDE = R1,200 x 32,486 PDE• Budget allocated = R 38,983,200

Scenario 2: Complete data

In the scenario below, it is clearly illustrated the difference that complete data makes from both an analysis and a budget point of view.

Table 2: Data received August 2011

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Ttl

IPD 1,727 1,823 2,070 2,408 1,902 1,599 1,670 1,493 1,477 1,422 1,191 1,306 20,088

DP 0 0 0 0 0 0 0 0 0 0 0 0 0

OPD 7,643 7,221 10,450 10,188 7,723 14,341 2,697 2,477 2,621 2,810 2,179 2,730 73,080

EHC 195 215 211 221 165 167 205 230 279 227 154 133 2,402

Cells highlighted indicate data change

IPD = In-Patient days OPD = Out Patient Department

DP = Day Patients EHC = Emergency Headcount

The entire data set for IPD has decreased from 26,906 in May 2011 to 20,088 in August 2011. The question remains why – was there a miscalculation at facility level. If the hospital originally had 26,906 in-patients where have these patients gone, have they been counted, what is the explanation?

Highlighted cells in OPD and EHC indicate data that was added after the 20 th May 2011 cut-off. OPD has increased by 57,566 – is this possible? The 57,566 patients were seen in the 1st 6 months of the year, with only 15,514 seen in the last 6 months? Why?

If the same calculation is redone using the new set of data, the result is as follows.

Equation 2: PDE Calculations using data from 20th May 2011

• PDE = (1/3 OPD) + (1/3 Emergency) + (1/2 DP’s) + IPD• PDE =(73,080 / 3) + (2,402 / 3) + (0 / 2) + 20,088• PDE = 24,360 + 801 + 0 + 20,088• PDE = 45,249• Cost / PDE = R1,200 x 45,249 PDE• Budget allocated = R 54,298,800

This is a difference of R 15,3 million per annum, that the facility will be UNDER-FUNDED due to data incompleteness.

Important data elements to review and verify on a monthly / institutional basis as it has a “knock-on” effect for the majority of indicators

PHC headcount

IPD

OPD

Emergency Headcounts

Separations

2.2 CORE DHIS DATA ELEMENTS In relation to the DHER report, a list of five core data elements have been identified. These 5 data elements need to be reviewed from a data management perspective to ensure the completeness and validity of the data as these data elements are utilized in many indicators throughout the DHER report.

The consequence of incorrect data will have a profound knock-on effect on the analysis and interpretation of data in the DHER and will impact on recommendations made. It is therefore essential that these core data elements are correct to ensure accurate analysis.

1. PHC Headcount

2. Total Separations

3. Total OPD Headcount

4. Day Patients

5. Total In-Patient Days

2.3 LINKING OF INDICATORSIn the development of these guidelines the linking of indicators has been discussed in various sections of the document including the section below and also in the section titled “DHER WORD TEMPLATE”. This is done for ease of referencing as the relationship between indicators is dependent on the expected outcome of the analysis. Therefore the same indicator could be repeated used in the analysis but within a different context (in relation to a different set of indicators).

An example would be the workload per PN. If this indictor is reviewed in relation to the Cost per PHC Headcount it would be from a Sustainability of Services perspective. However if this same indicator was compared between facilities, it would be from an Equity of Resources perspective. This same indicator, workload per PN, could be reviewed in conjunction with the National / Provincial norm and as such it would relate to the Efficiency (quality) of services.

The discussion on the linking of indicators has been placed within the context of the subject being discussed. In the chapter entitled “DHER WORD TEMPLATE” the linking of specific indicators for a specific outcome has also been included to act as a basis for the analysis of that narrative.

A broader discussion of the relationship between indicators appears in the table below and outlines some linkages between various indicators. This is not an all-inclusive list and is designed as a guide only.

Table 3: Linkages with Service Delivery (Activity) Indicators

Prime Indicator Link with other indicators

Further Links Rationale / Scenario

PHC Headcount Utilisation Rate Cost per Visit The theory or concept of “Scale of economies”1 states that the more patients you treat, the cheaper it should be to treat the patients.

Example: If cost per visit ↑high, utilisation should be ↓low with a comparatively ↓low PHC headcount.

Example: If cost per visit is ↓low, utilisation should be ↑high with a comparatively ↑ headcount.

Investigate: if cost per visit high, with high utilisation and high headcount or if cost per uninsured low, with low utilisation and low headcount.

Utilisation Rate There is definite link between the PHC headcount and the utilisation rate. This can be carried forward into target setting and projections. If the utilisation rate is to be increased to 2.4, then the population data can be used to project the PHC headcount, and vice versa.

PHC Budget Allocated

If the cost per headcount is low and over-expenditure has occurred when reviewed against the budget, it could mean that clinics and CHC’s are under-funded.

If the cost per headcount is high and over-expenditure has occurred when reviewed against the budget, it could mean that there is a need for more stringent efficiency measures. The comparison should ideally take place over a 3 year period to identify if there has been a spike in expenditure and if this is due to an increased utilisation rate or poor management.

OPD Headcount

If there is a decrease in PHC headcount, look for an increase in OPD headcount as patients sometimes prefer to be seen at hospital level due to quick referrals to doctors, perceived better service etc. However it stands to reason that as services start to improve at PHC level, the PHC headcounts should increase, so the Non-referred OPD headcount should decrease.

Investigate: Big increase in PHC headcount coupled with increase in OPD.

1 The term ‘Economy of Scales’ is used in the table above refers to the correlation between production (i.e. number of people treated) and expenditure (i.e. the cost to treat each patient). As production (i.e. the number of patients) increases so expenditure per unit (i.e. cost to treat each patient) decreases. Therefore clinics with a low headcount will have a higher cost per visit than a clinic with a high number of patients.



R / PHC If the R/PHC visit is high comparatively, it indicates that there has been high expenditure with low headcounts.

Utilisation Rate Ambulatory Ratio

OPD Headcount

There is a correlation between the utilisation rate, the Ambulatory Ratio and OPD Headcount as if the PHC system is working, the utilisation rate will be high, the ambulatory ratio should be low, as should the OPD Headcount not referred.

Investigate: If the utilisation rate is low, the ambulatory ratio is high (above 1.5) and the OPD headcount is high, this indicates that the PHC system is not functioning correctly.

R / Capita - This compares the utilisation of the services against the cost per person (capita) to render those services. Therefore if the utilisation rate is high, there will be more visits to the clinic and therefore the cost per capita should be higher than districts with lower utilisations but similar PHC expenditure.

Investigate: If the utilisation rate is comparatively high, but the cost per capita is low, the situation / data should be further investigated.

R / PHC visit Budget Allocated budget for PHC

To determine if the budget allocated is / was sufficient. For demonstration purposes, following data utilised:-

utilisation rate is 3.5,

population is 50 000,

cost per PHC visit is R 100

1st Calculation: 50 000 x 3.5 = 175 000 projected PHC headcount

2nd Calculation: 175 000 xR 100 = R 17,500,000 budget

Cost per uninsured

Allocated budget for PHC

To determine if the budget allocated was / is sufficient. For demonstration purposes the following data has been used;-

R 150 cost per uninsured

Population is 50 000

Calculation: R 150 x 50 000 = R 7,500,000

Ambulatory OPD If the ambulatory ratio is higher than 1.5, this needs to be reviewed in conjunction with the PHC utilisation rate to



Ratio Headcount identify if the population is accessing health services at clinic level or at hospital level. If the population is by-passing clinics, further investigation is required to identify the root cause i.e. poor staff attitudes to patients, poor accessibility of services, opening times limited etc.

Ratio of ambulatory

If the ambulatory ratio is high (i.e. <2) it means that the PHC system is not working. It should be less than 1 but in KZN less than 1.5 is about average. If higher, it needs to be reviewed, see indicator below.

R / PHC visit PHC Headcount

- Link between the PHC headcount and the R/ PHC Visit. If the Headcount is high then the cost per visit should be lower due to economy of scales.

% Drug Expenditure

HIV / TB Prevalence

Drug expenditure makes up a high % of the R / PHC visit review in relation to HIV / TB prevalence.

Example: If the drug expenditure % is high for the R / PHC visit in Umzinyathi, look at the number of MDR TB cases as TB expenditure is under programme 2 and the MDR programme is facilitated at community level.

% CoE - The proportion of the CoE for R / PHC visit reflects the sustainability of the workforce. A high CoE is unsustainable however; the CoE cost in rural areas should be higher when compared to urban areas due to rural allowance paid.

If a there are a high number of PHC doctors also allocated to PHC this would increase the CoE % proportion of the R / PHC visit.

% CoE Workload Review the cost of CoE per R / PHC visit in relation to the workload. If there is a high CoE % but a low workload further investigation is required. It could be that staff are not reflected on the FTE table but are being paid at clinic level. It could also indicate that staff are being paid at the clinic, which are not working at clinic level.

ALOS BUR - Correlation between the ALOS& BUR. Normally if the ALOS is high, the BUR is low and vice versa. This is because the BUR has the separations as a data element, therefore the more separations there are the shorter the ALOS, the higher BUR due to the increase in both separations and In-Patient Days.

Investigate: If both the ALOS and the BUR are high (or low) further investigations are required. It is recommended that this be done at ward level.

IPD - If the ALOS is high, with a high number of IP Days it means that the hospital BoD is more chronic / step-down than acute. Investigation: In this instance ward data per month should be reviewed to try and identify where the actual



challenge lies.

FTE Dr’s - There is a correlation between the ALOS, the number of doctors available for clinical rounds, and the competency of the doctors employed by the hospital.

Scenario 1: Generally, newly qualified doctors lack the confidence of the more experienced doctors when it comes to diagnosis and therefore keep the patients longer while over prescribing in medication, and running more tests than economically viable.

Scenario 2: If there is a shortage of doctors to do clinical rounds, the patients stay longer while waiting to see a doctor. A shortage of radiographers can also have an influence on the ALOS as patients stay longer while waiting for radiography services.

C/S FTE Dr’s The ALOS should increase if there is a higher C/S rate. The C/S rate could be affected by the competency and skills of the attending doctors. More inexperienced doctors tend to perform more c/s and/or refer to higher levels of care. Therefore the more community service doctors there are, the chances are likely of a higher c/s rate which will influence the ALOS as it takes a longer time to recuperate than natural births.

PDE BUR The higher the ALOS, the lower the PDE should be comparatively. If patients stay longer, then there should be a decrease in the PDE, especially if the BUR remains relatively stable.

Investigate: If the ALOS and PDE are both comparatively high, it would meant that although more people are being admitted and being seen to at OPD, that there has been a decrease in separations – this would need to be explored further.

BUR R / PDE - The increase between the BUR and the R/PDE is relative but not proportional. If the BUR increases substantially, the R/PDE will increase slightly (or maybe even decrease) due to economy of scales, it will not increase at the same rate as the BUR. The reverse is true, if there is a decline in BUR, the R/PDE could increase significantly. This is based on the principle that the cost per person is cheaper to treat 3,000 people than 1,000 people.

IPD - If the BUR increases, there should be a proportional increase in IPD’s.

Investigate: If there is not a proportional increase, verify data and drill down to ward level.

Ward Level - It is always a good idea to look at BUR at ward level as some wards are more inherently busier than others. The paediatric ward is normally quieter than the medical and surgical wards. The hospital management can then look



at alternatives and identify challenges.

IPD OPD - OPD should always be higher than IPD.

Investigation: If this is not the situation, further investigation is required to identify why more people are being admitted as it is not economically sustainable.

OPD IPD - The OPD should not be more than 1.5 times of the IPD if the referral system is working. High OPD and low IPD means referral system not working.

R / PDE CoE - The proportion of the CoE for R / PDE reflects the sustainability of the workforce. Cognizance should be taken of districts that qualify for rural allowance.

Drug Expenditure

Competency for Dr’s

There is a correlation between the R/PDE, the % Drug expenditure /PDE and competency of doctor’s available (FTE for Dr’s). In general community service doctors lack confidence in the ability and tend to over-prescribe medication. Drugs, as previously discussed, are cost-drivers therefore the more community service doctors employed by the hospital, the higher the drug expenditure might be which in turn will affect the R/PDE.

R/PHC visit Medical Supplies / Drug Supplies / Bloods / CoE

CoE, Bloods, Drugs and medical supplies are cost-drivers therefore if the R/PDE is high at hospital level refer to the % proportion of the cost drivers in relation to the R/PHC visit. The reason is that expenses for these cost drivers are often not journaled from the hospital expense to the clinic expenditure thus increasing the cost at hospital level and reducing the cost at PHC level. The incorrect linking of staff has a major effect on these two indicators.

Proportion of line item expenditure per PDE

- To allow for comparison between hospitals linking the line item to Staff (a known cost driver) and ultimately to the impact on activities and therefore directly to service delivery.

Example: If Mbongolwane spend 59% on CoE for Clinical staff with Eshowe spending 67% of their R/PDE for the same line item, it indicates that there is a disparity between the two hospitals. Further investigation in to the number (and grade) of doctors employed (cost driver) would reveal that Eshowe has more doctors per patient (660 per month per doctor) compared to Mbongolwane (1,137 per month per doctor). This impacts directly on the ALOS and the BUR of both hospitals.



High drug expenditure

No. of community service doctors.

- If there is high drug expenditure, review in conjunction with the number of community service doctors working in the facility / sub-district. The reason being that newly qualified doctors tend to prescribe more drugs and use more clinical supplies as they are not as confident in their abilities as more experienced doctors.

High CoE - - If there is a high CoE / PDE look at the level of staff on the staff establishment for that facility. Doctors and PN’s are cost drivers at PHC level therefore if a hospital has two clinical managers (who do not do daily rounds) it would mean an increase in cost but also a higher doctor workload and a higher ALOS as the doctors that are doing the daily rounds would need to make up the shortfall leading to a higher ALOS if workload is too high.

In-house security

Contracted Security

- When comparing security costs per facility / sub-district, always combine in-house security and contracted security costs to get a more accurate picture.

Also remember to keep in mind the current PDoH policy on security and the oustsourcing of security when discussing security issues.

Caesarian sections

ANC before 20 weeks

- If there is a high c/s rate, review in conjunction with the ANC before 20 weeks, the number of maternal deaths, the staff competencies (mid wifes etc), BBA (Births Before Arrival) and clinical governance.

Blood expenditure

Drug expenditure

With high c/s rates the blood expenditure and drugs per delivery should also be reviewed. The number of deliveries and the level of care provided at that facility should also be part of the analysis process, and include the HIV prevalence and the skills mix. Young green doctors tend to have a higher c/s rate which has higher cost implications.

BUR vs Beds / 1 000

The linking of the BUR with the number of beds / 1 000 will determine if the bed numbers allocated are sufficient and if they are being utilised.

NOTE:

In the above table linkages and rationale have been given. If further investigation is required, it is suggested that the data elements first be reviewed and verified to ensure data correctness before an investigation at ground level is instigated.

Finance indicators have been discussed separately as this a focus area of the DHER with specific reference to expenditure in relation to service delivery as there is commonality between PHC Expenditure and Hospital Expenditure in terms of the approach and comparisons utilised in the narrative.

Table 4: Analysis of Finance Indicators

Approach Comparison Rationale

PHC & CHC Expenditure

Actual expenditure per PHC line item

Intra-district within in same classification

This will allow any major mis-allocations to be identified, based on the DHERT’s knowledge of the facilities and expenditure within the facilities. This is the starting point to identify misallocations.

Example: If East Street CHC has an CoE less than Pholela CHC there is a challenge with allocation of CoE .

R/PHC visit - can also be done at a line item level

Intra-district across all classifications

Inter-district across all classifications

Allow for identification of cost drivers

Allows for evidence based motivation for increased budget

Example: Turton CHC has a CoE of R 50 per PHC visit but Gamalakhe has a CoE of R 100 per PHC visit. This coupled with the FTE comparison between the two CHC’s could be used as evidence based motivation for the appointment of additional staff.

Proportion of line item expenditure per Cost per PHC visit (line item expenditure as a % of total cost per PHC



Rural and urban facilities

Identification of cost drivers.

Comparison between the different facilities

Allows for evidence based motivation for increased budget per line item in comparison to other facilities

Comparison between different resourced facilities. Therefore it would be possible to compare an urban ‘well-resourced’ district hospital against a ‘poorly resourced’ district hospital in terms of which line items are

Approach Comparison Rationale

visit) cost drivers and their impact on service delivery.

Example: Drug expenditure between LG clinics and provincial clinics or between rural and urban clinics both in the same district.

Hospital Expenditure

Actual expenditure per line item

Intra-district within in same classification

This will allow any major mis-allocations to be identified, based on the DHERT’s knowledge of the facilities and expenditure within the facilities.

Example: Expenditure at Mbongolwane Hospital should be less than Eshowe Hospital for drugs.

R/PDE - can also be done at a line item level



Allow for identification of cost drivers

Allows for evidence based motivation for increased budget

Proportion of line item expenditure per R/ PDE (line item expenditure as a % of total cost per PDE)



Rural and urban facilities

Identification of cost drivers.

Comparison between the different facilities

Allows for evidence based motivation for increased budget per line item in comparison to other facilities

Comparison between different resourced facilities. Therefore it would be possible to compare an urban ‘well-resourced’ district hospital against a ‘poorly resourced’ district hospital in terms of which line items are cost drivers and their impact on service delivery.

Example: If Mbongolwane spend 59% on CoE for Clinical staff with Eshowe spending 67% of their R/PDE for the same line item, it indicates that there is a disparity between the two hospitals. Further investigation in to the number (and grade) of doctors employed (cost driver) would reveal that Eshowe has more doctors per patient (660 per month per doctor) compared to Mbongolwane (1,137 per month per doctor). This impacts directly on the ALOS and the BUR of both hospitals.

3 DHER REPORT – WORD DOCUMENTOnce the data has been inputted into the Excel Spreadsheets, and the data interpreted and analysed as per section 2 above, a brief outline of the analysis must be captured in the Report. This should outline the challenge experienced, and if possible, the root cause based on EVIDENCE from the Excel Spreadsheets and the District DHER Teams inherent knowledge of the district.

Recommendations should only be included in the recommendation box and should not be repeated in the text. Again, if necessary, explanations should be included with recommendations to ensure that all role players understand the context in which the recommendation was made.

Refer to the Word Template where comments have been included.

3.1 LAYOUT OF DHER WORD REPORT

Below is the layout of the DHER Word Report by headings and sub-headings so that the District DHER Management Team can gain an understanding of what is required from them when drafting the DHER Word Report.

SUMMARY

PHC Level

Hospital Services

District Overall

NOTE:

It is important in the DHER Word Report to compare and analysis core indicators against projected targets (refer DHP) as budget was allocated on the basis of the activities / strategies outlined in the DHP and on targets set for core indicators i.e. PHC headcount, BUR, PDE etc. This would be important specifically if budget had been allocated for an identified strategy that would have an impact on service delivery. An example would be if extra funding was provided for a sub-district / facility to run a media campaign to increase utilisation of PHC facilities within the surrounding area. The target set for the PHC headcount would have been increased to allow for the effect of the campaign on PHC headcounts and thus budget allocated would have been increased based on the projected increase in PHC headcount. It would therefore be important to ascertain if the projected target for PHC headcount was achieved. This would then justify the investment for the media campaign against the increase in actual headcount and thus the improvement in accessibility and utilisation of facilities. .

1. INTRODUCTION

1.1 Methodology

1.2 Provincial Overview

2. PRIMARY HEALTH CARE

2.1 Health Performance Indicators

2.2 Access

2.3 Equity PHC

2.4 Efficiency

2.5 Sustainability

3. HIV / AIDS

4. ENVIRONMENTAL HEALTH

5. DISTRICT HOSPITALS

4.1 Activity

5.2 Staffing

5.3 Finance

6. REGIONAL HOSPITALS

6.1 Activity

6.2 Staffing

6.3 Finance

7. TB HOSPITALS

7.1 Activity

7.2 Staffing

7.3 Finance

8. SPECIALISED PSYCHIATRIC HOSPITALS

8.1 Activity

8.2 Staffing

8.3 Finance

9. DISTRICT ALLOCATION AND USE OF RESOURCES IN PROGRAMME 2

10. DISCUSSION: SUMMARY OF RECOMMENDATIONS

ANNEXURE A: FINANCIAL TABLES

ANNEXURE B: DEFINTIONS OF THE DHER

ANNEXURE C: ABBREVIATIONS AND ACRONYMS

3.2 FORMATING OF DHER WORD REPORT Formatting should be consistent throughout the document and should NOT VARY depending on source of inputs. The cutting and pasting of documents should be done with understanding and sections inserted should be formatted to fit in with the rest of the documents format.

Common errors identified with regards to formatting:

Proof read document before submission for both content and formatting errors.

All narrative must be in Arial 12 with 1.15 spacing with 3pnts above and below text is prescribed for ease of reading.

Heading formatting should be consistent throughout the document

The formatting of expenditure should be rounded off to Rands only, no cents (no decimals places).

Ensure statements / sentences are complete and not left hanging

Numbers should all be in the same font and size in all tables

Where %’s are required, the numerator and denominator are required to place the % into context

Empty pages to be deleted

Narratives must be clear and understandable - no ambiguity

Strategies must be clear and concisely worded

Indicators should be cross-referenced throughout the document

Please make sure that the DHER is formatted in the same way that last year’s DHER’s were formatted by Head Office. There must be consistency in the formatting of the document.

3.3 DHER WORD TEMPLATE / REPORTBelow are guidelines on what content is required under which headings in the DHER Word Report. The layout of the Word Report is divided into 10 main parts starting with the Executive Summary and then PHC services and District Hospital Services. Regional, TB and Psychiatric Hospitals have also been included, however if this section is not relevant to your district, a note should be made that there are no TB hospitals located in the district and therefore it is not relevant. Do not delete the section.

Should a challenge be identified, there should be further investigations into the root cause of the challenge in order to provide an evidence-based explanation specifically with regard to low performance or over-expenditure.

ACKNOWLEDGEMENTSAll relevant mangers / components involved in the DHER process should be identified and acknowledged. Their designations and their component / unit should also be included so that the reader can identify which components were actively part of the DHER process and at what level district senior management was involved.

SUMMARYThe executive summary should summarise the ‘backbones’ of the report but should not ‘parrot’ the report. Issues identified in the summary can be further elaborated upon in the report itself with a reference indicating the page number where further information can be found.

The objectives of the DHER, the major challenges experienced and the relevant recommendations made by the District DHER Team should all be included as part of the executive summary, and then further unpacked in the main body of the document itself.

Under the summary there are sections for PHC Level including Community Based Health and Environmental Health, Hospital Services and the District overall.

INTRODUCTIONIn the introduction, contextual issues should be analysed and socio-economic challenges elaborated on to create an background understanding for the reader including employment and literacy rates indicated. . The population profile should take into consideration population growth rate, people insured vs uninsured. Disease profile and risk factors should be highlighted. Provincial and LG budget allocation trends explained. Health services in the health district indicated.

MethodologyMethodology on data collection and analysis should be prominent in this section and the review period must be clearly stipulated. Explanation of cost centres used in the report. . Data collection and compilation of process explained to ensure credibility. Methodologies used to overcome Data Challenges indicated.

NOTE:

Recommendations / solutions provided in the Recommendations Box must always match the identified challenge in the discussion above.

Technical capacity to conduct DHER review at district level i.e. are all relevant managers trained in DHER? Comparisons between sub-districts and facilities should be relevant and appropratit therefore the basis for the comparison should be outlined here. DHER findings should be compared to National Norms, standards and trends for each indicator.

It is important to discuss the quality of data i.e. was the data verified adequately at various stages, did all institutions submit relevant data. Mention should be made of comparisons that take place between different time periods and factors that could affect the data or comparison i.e. changes in bed numbers, change in package of service etc.

District OverviewEster to provide input.

PRIMARY HEALTH CAREPrimary Health Care is divided up into “4 pieces of a puzzle” based on the 4 main “pillars” of the DHER philosophy, namely:-

1. access,

2. equity,

3. efficiency and

4. sustainability

Each piece of the puzzle is interlinked to provide an overall picture. If one piece of the puzzle (pillar) is missing, this would impact significantly on the overall picture and diminish the ability to identify core challenges or develop appropriate recommendations.

Figure 4: Four (4) PHC Pieces of the Puzzle (Pillars of Service Delivery)

Recommendations should address gaps identified based on the analysis. PHC forms the cornerstone of community health services in KZN and as such this section should be as comprehensive and as complete as possible. An analysis and interpretation of data should appear under each heading, based on ‘evidence’ quoted form the DHER Excel Template. Further information on analysis of data can be access on page 9, section “CORE DHIS DATA ELEMENTS ”.

There are no clear norms for the skills mix at PHC facilities or district hospitals.

Health Performance Indicators Health performance indicators, as per Excel Template are discussed here in relation to the district and provincial targets against achievements. These health performance indicators give a snap-shot of the state of the health in the district and link with many other indicators in the DHER i.e. ANC before 20 weeks can be linked with caesarian section rates.

ACCESS

SUSTAINABILITY

EQUITY EFFICIENCY

AccessIdentify and discuss the various PHC services in each sub-district in terms of the number of facilities, the size of the facilities and the services rendered by the facilities i.e. 24 hrs, CHC’s. Under this heading all health services provided in the district should be identified including local government clinics, state-aided hospitals and private hospitals.

Link these PHC services to the population size and expenditure per sub-district per capita. This section is about the ease of which communities can access health services and utilizes these services including mobile services, health posts etc. Remember there is a direct correlation between PHC headcount and utilisation rate, if there is not, then there is a problem with the data quality and it would need to be investigated further.

It is expensive to render 24 hr services or ‘on-call’ services therefore where every possible, the number of patients / clients seen after hours should be noted so that the efficiency of the service can be compared with the cost of the service to interpret if the service is cost-effective or not and to justify the existence of the after-hour services. It might be more cost-effective to have one strategically placed 24 hr service rather than all facilities being 24 hrs. The challenges should be discussed in the DHER Word Report with the recommendations being carried over to the DHP.

Note: Total population to be used for NHI and planning purposes. Uninsured population to be used in retrospective comparisons between districts / sub-districts only.

Table 5: Access ‘Pillar / Piece of Puzzle’ of PHC Analysis

APPLICABLE INDICATORS COMPARISONS AND / OR ANALYSIS

RATIONALE

ACCESS

PHC Headcount per sub-district

Projected headcount per sub-district for the same time period (refer DHP)

The headcount should be compared against the projected headcount per sub-district to determine if the target was met and if not why – determine root cause for under-utilisation of facilities.

Population per PHC clinic Compared with Provincial Norm as per STP.

This should be compared against the Provincial norm with cognisance to the population density and the environment in which the facility operates i.e. rural / urban / peri-urban.

Population per CHC Clinic Same as above Same as above

Utilisation rate at PHC level Projected utilisation rate for the same time period (refer DHP).

By comparing the projected utilisation rate against the actual PHC utilisation rate the district can determine if they were successful in increasing their utilisation rate and by implication increasing accessibility

Equity PHCEquity is the equal distribution of resources from a financial and resource (HR, infrastructure etc) perspective in relation to the needs and demands of the population. When analyzing these indicators, the differences between the districts should be emphasized and comparisons between sub-districts / districts should be made between districts / sub-districts with similar profiles in terms of rural / urban orientation, population density. Therefore although the equity indicators would suggest that eThekwini is better resourced financially than other districts, based on the district profiles, it is not the necessary true due to the different migration patterns impacting on eThekwini which have not been documented and therefore not included into the equation. It is in these instances that the narrative would provide better insight into the situation.

When looking at equity, the workload between the different sub-districts / districts should also be compared as this has cost implications. Before reaching any radical conclusions that don’t concur with known facts at a facility / sub-district level, data should be verified to ensure accuracy before continuing grass-root investigations.

When comparing indicators which have population as a denominator from different time periods, cognisance should be taken of any major changes in that population, including changes of source data, change in demarcation areas etc, as this will impact on the analysis.

Below are some suggestions that could be used for analysis in this section:-

Comparison with previous year capita expenditure

Distribution of resources per sub-district

What is the burden of disease, if expenditure is high on pharmaceuticals

If FTE is high, what is clinical workload

Expenditure against headcount

Table 6: Equity ‘Pillar / Piece of the Puzzle” of PHC Analysis


RATIONALE

EQUITY

Expenditure per capita at PHC level

Compare with previous year’s figure

To determine if there has been an increase or decrease in expenditure per capita

Ratio of expenditure between PHC & Hospital

This will determine if there has been an increase in PHC expenditure and if so, to what extent it has it cost per capita.

Expenditure per capita per sub-districts

Same as Expenditure per capita at PHC Level

Same as above


RATIONALE

District Expenditure per Capita (this includes hospitals and district management structures)

Compare with previous year’s figure

To determine if there has been an increase or decrease in overall expenditure per capita.

Expenditure per capita at PHC Level

To determine how much of the Expenditure per capita can be attributed to PHC. This will determine

Expenditure per capita per facility

Compare with previous year’s figures

To determine the efficiency of the facility in relation to the catchment population. If the expenditure per capita is high but the expenditure per headcount is low, it might be due to cross-border population usage. In this instance it should be determined why this situation is occurring i.e. good placement of clinic, staff have good attitude etc with District Management looking at ways to ensure the over-utilisation of the clinic does not affect the quality of service negatively. The workload per PN should give an indication if the quality of service has been negatively affected due to the demand placed on the facility.

Utilisation Rate per facility

Workload per PN

Workload per PN / MO / Pharmacist

Compared against other facilities sub-districts within the district / province

This will determine equity of HR resources. If one facility has a high workload per PN and another facility within the same sub-district has a low workload per PN, additional resources i.e. budget for the employment of additional PN’s should be allocated based on the identified need.

Efficiency PHCUnder the sub-heading of efficiency, comparisons between the various costs, workload and skills mix per sub-district / facility should be analysed and interpreted within the context of the district / sub-district. Suggestions that could be utilized in the analysis of PHC data under the Efficiency heading are:-

Identification of major cost drivers i.e. drugs, staff etc

PERSAL Staff turnover (and correct linkages)

Impact of quality of service vs Warm Bodies

Skills level of staff in facilities (High referrals)

Chronic conditions that are often referred

Table 7: Efficiency ‘Pillar / Piece of the Puzzle’ for PHC Analysis


RATIONALE

EFFECIENCY (AND QUALITY)

Cost per PHC visit Between district / sub- This could indicate which facilities / sub-districts are


RATIONALE

district / facility more efficient in terms of budget utilisation. It can also be an indication of the efficiencies of management i.e. a poorly run facility would have a higher cost per PHC visit due to poor resource allocation etc.

A high cost per PHC visit could also be due to economy of scales which could be influenced by the location of the clinic etc. A poorly located clinic would have a lower PHC headcount thus increasing the Cost per PHC visit.

Compared with targets set (refer DHP) for the same time period.

The budget is allocated according to the PHC Headcount target determined in the DHP. Therefore expenditure and services have to be justified in terms of this allocation. An example would be if the Cost per PHC visit had been determined at R 120 per visit (DHP) against an actual value of R 100 per visit, there should be an explanation provided in the narrative as too why the services were not as cost effective as originally planned.

National / Provincial norms This would determine if the facility / sub-district / district was efficient in the rendering of services from a National / Provincial perspective.

Workload per PN / MO / doctors/ pharmacist etc.

Provincial / National norm When reviewing the workload, although cognisance should be taken of the Provincial / National norm, each facility / sub-district / district is different and experiences different challenges. It is important that these are reflected in the narrative. An example would be a high workload in one facility could be due to the strategic placement of the clinic while in another it could be due to the inability to attract staff. It is important to identify the root cause as this will determine the remedial action required.

Cost per staff line item per PHC visit i.e. staff, drugs, medical supplies etc.

Between PHC facilities / sub-districts / districts

The comparison between the cost per staff per PHC visit between the different facilities / sub-district would highlight in which facilities staffing is a major cost driver. If staffing expenditure is high, this indicator should be reviewed in relation to the workload per PN and within the context of the location of the clinic / sub-district. There should be a correlation between the cost of staff per PHC visit and the workload, if the workload is high the cost of staff per PHC visit should be comparatively lower. If there is no correlation, PERSAL linkages should be reviewed in relation to staff expenditure at a facility level to

Workload per PN


RATIONALE

ensure that only staff in that facility are paid from their budget.

Cost per drugs line item per PHC visit

Between PHC facilities / sub-districts / districts

If the drug expenditure per PHC visit is comparatively high, further investigations are warranted into:-

linkages with PPSD to ensure correct importing of expenditure against the correct cost centre.

the prescribing habits of the PN’s could also be reviewed as newly qualified PN’s tend to over prescribe if not mentored by a more experienced nurse.

The ordering process of drugs as dumping of drugs at a PHC level or stock-piling of drugs are two symptoms of management inefficiencies at the clinic / sub-district.

Referral rate to higher levels Referral policy and referral patterns currently in use

When analysing the referral rate it should also be done in conjunction with other core indicators and based on evidence, not ‘heresay’. If there is a high referral rate, this could be due to various factors at a PHC level including:

inefficiencies within the current system due to poor management or inadequate resources (HR, equipment or infrastructure). Relate to indicators of BUR, ALOS, Workload, skills mix, infrastructure

poor Referral Policy. Relate to the referral policy and referral patters

a change in the burden of disease pattern within that catchment population which could warrant further investigations into the feasibility of establishing a higher level of care accessible to that catchment population (an increase in PPT could also be considered). Relate to indicators that refer to the Burden of Disease.

BUR and ALOS of referring facility

Workload of PN’s and doctors of referring facility

Infrastructure of facility, no. of facilities, capacity of facilities etc.

Skills mix of doctors and nurses

Average length of stay Provincial norm From a PHC perspective, a long ALOS could be due various factors occurring at a PHC level which impacts on patients not being diagnosed or treated timeously and therefore patients presenting at a District Hospitals already very sick and requiring a longer hospital stay to stabiles and recuperate. If this indicator is comparatively high, it should be reviewed in conjunction with other indicators to form a body of evidence as part of the narrative. See indicators

Referral rate to higher levels

Medical Officer coverage at PHC level

HIV / AIDS and TB prevalence


RATIONALE

identified in previous column.

SustainabilityOn the basis of the analysis of the indictors, it should be determined if the under / over expenditure is due to poor management and inefficiency or if it is due to under / over allocation of funds.

Table 8: Sustainability ‘Pillar / Piece of the Puzzle’ for PHC Analysis


RATIONALE

SUSTAINABILITY

Ratio of expenditure vs budget

This will give an indication as to the sustainability of services within the district. As with all government institutions the funding envelope is limited. Therefore if there is a big different between expenditure and budget the district should prioritise programmes / activities to ensure the best return on their investment instead of trying to implement all services / programmes in all facilities. This prioritization should be detailed in the DHP after analysis of the DHER.

Main sources of funding Funding from Municipalities, NGO’s NPO’s etc.

Cognisance should be taken of the impact of NPO’s, NGO’s, state-aided facilities etc. It is importantly to firstly determine if these services have an impact on the provision of health services within the district, and if so to what extent. If it is determined that these services are essential to good health outcome indicators, provision must be made in budget allocations for the sustainability of these services.

Revenue generated as a proportion of expenditure

If this data is available it should be included in the analysis. Although the Health Department is state funded and therefore not a profit driven organization, as per the Revenue Collection guidelines, revenue should be collected where possible to ensure sustainability of services provided.

Total PHC expenditure per headcount

Total PHC budget per projected headcount for the same time period

This will give an indication if PHC services are under-funded. If the expenditure per PHC headcount is R 119 but the budget allocation for the same time period was based on R 90 per projected headcount, PHC services were under-funded. This should be taken into consideration when determining future


RATIONALE

budget allocations and reference to this should be made in the DHP.

PHC Actual headcount per facility / sub-district

PHC projected headcount per facility / sub-district (refer to DHP)

This should be done as the projected headcount target was used in the allocation of budget and therefore a lower actual PHC headcount will have an impact on expenditure trends.

HIV / AIDSHIV / AIDS is a major factor in the quadruple burden of disease that affects South Africa. The high prevalence rate in KZN, the rapidly increasing number of patients accessing ART and the correlation with MDR-TB all impact on the sustainability of this sub-programme.

It is imperative that this programme is costed accurately as this will assist the Budget Component in determining the budget required for the Medium Term Expenditure Framework to ensure the sustainability of this programme. Staffing and the cost of drugs are the two main cost drivers of this progamme.

Expenditure in relation to service delivery outcomes is an important aspect of this DHER Word Report narrative as it will justify the high expenditure related to this sub-programme.

ENVIRONMENTAL HEALTHEnvironmental Health Services within KZN are still being negotiated through the Office of the Premier as to where responsibility for these services rests.

It is however important to complete this worksheet and narrative to give a clearer picture on the expenditure and extent of services rendered by the Provincial Department of Health. When discussing services and expenditure, it should be services rendered at a district level by the District Office.

Staffing appears to be the major cost driver of this sub-programme when viewed at a provincial level. The Malaria Control Programme is an important component of this programme and should be expanded upon in Umkhanyakude’s DHER Word Report as it is a cost driver for that district and impacts on the malaria control provincially as cases are ‘exported’ to other districts in the province.

HOSPITALS (DISTRICT & TB)Challenges relating to service delivery, that are based on the DHER Excel Template should be included in this section, as should any change or deviation in service delivery that has an impact on expenditure. Explanations for outliers, on variances etc, should be discussed in this section.

It is important to compare the hospital indicators (activity, staffing and expenditure) against the provincial and national target / norms to allow for comparison with other facilities. It is understandable that in some instances, the district / facility will not attain the targets set due to reasons beyond management’s control, however these circumstances / situations should be explained to provide an insight for the reader.

ActivityThis relates to the activity for the year under review and indicators are often compared with the previous year and in relation to other hospitals.

For further information on analysis and interpretation of indicators, refer to the “CORE DHIS DATAELEMENTS ” on page 9.

Indicators often analysed under this heading are:-

Separations

IPD

OPD

PDE

BUR

ALOS

R / PDE

Remember that it is important to link service delivery with expenditure to ensure value for money.

StaffingUnder this heading, the FTE of the facility is reviewed in relation to CoE expenditure. Workload should also be reviewed especially between the different facilities to ensure equity. The competencies of doctors (and to some degree Professional Nurses) should also be discussed under this heading as this will have an impact on expenditure.

Example: If there are a number of community service doctors working at hospital with limited mentorship / supervision, drug expenditure could be high as newly qualified doctors lack confidence in their ability to diagnose and therefore tend to over-prescribe medication and analysis tests. Another

challenge identified with newly qualified doctors that have little senior guidance is the increase of caesarian sections which impacts the ALOS and has cost implications.

In the DHER Excel Template there are many HR tables in the Hospital worksheets that provide projected number of staff required based on the service delivery data inputted. Again this could be used as part of a comparative process for future staff requirements.

FinanceHere it is important to look at expenditure from the 3 different viewpoints in relation to service delivery. For further information on the analysis of finance indicators refer to “Linkages of Indicators” on page 9.

Therefore if there is an increase in drug expenditure this could be due to a variety of reasons including the quadruple burden of disease, inexperienced doctors, incorrect linkages between BAS & PPSD or poor prescribing habits of doctors whose skills and knowledge on drugs has not been updated. Link in to other indicators to ensure evidence-based reporting.

DISTRICT ALLOCATION AND USE OF RESOURCES IN PROGRAMME 2Given the link between PHC and District hospital services, this section summarises the indicators of distribution per level of care, and sustainability for PHC services and for the district/sub-district as a whole.

Under / over expenditure is discussed here in terms of sustainability and in relation to inflation etc. The affordability of district management is also included in this section i.e. % of expenditure for District Management.

Remember that this is in terms of Programme 2 only and not Programme 4.

DISCUSSION: SUMMARY OF RECOMMENDATIONSSummarise recommendations – do not repeat each recommendation individually i.e. all HR challenges can be grouped together etc.

Ensure that there is a ‘golden thread’ throughout the document for continuity and ease of reading.

4 ALIGNMENT OF DHER & DHPIn essence the DHP is used as a tool for budget allocation, therefore budget requested is based on the targets set in the DHP and the priorities / strategies identified for additional funding. The DHER actual data should be compared against the targets set in the DHP and reviewed in relation to service delivery indicators to determine if the investment in terms of expenditure improved service delivery.

Conversely, recommendations made by the District DHER Management Team based on challenges identified during the DHER process should be incorporated into the DHP as part of the situational analysis and form part of the basis for the priority focus areas and strategies developed.

Figure 5: Flow of Identified Challenges through the DHP and DHER documents

4.1 TRANSLATION OF CHALLENGES BETWEEN DOCUMENTS

Review of Matrix during Annual Report & DHER processes

District Operational Plan – Monitoring

of Performance Indicators

Facility Operational Plan – Monitoring

of supporting indicators

Strategy outlined in DHP Part B.

Indicator identified

Challenge outlined in DHP – Part A

DHER – challenge identified during

process.

Challenge in District Matrix for

translation into DHP

This section describes how challenges that are identified are translated between the DHP and DHER referring to the District Matrix below.

The table below is an example of a District Matrix that forms a referral document for all challenges identified via different processes, i.e. DHER, DHP, District Meetings etc. Challenges are recorded in the Matrix to ensure that they do not ‘slip between the cracks’ and are captured in either the DHP or the District Operational Plan for correction or amendment. This is especially useful when dealing with the DHER Excel Templates where operational issues are identified that need to be corrected.

Table 9: Example of a DHER Matrix

CHALLENGES ID IN DHER TEMPLATE

CHALLENGES / RECOMMEND-ATIONS ID IN DHER WORD DOCUMENT

RESPONSIBILITY COMMENTS

PROPOSED RECOMMENDATIONS

DATE RESOLVEDPDOH DISTRIC

T

DISTRICT

PHC / Clinics

1. District hospital data (in all three information systems) for the different levels to be separated out and costs allocated correctly.

Identified as part of the PDoH DHER Report

Hospitals

2. Data missing / inaccuracy in DHIS resulting in indicators being affected. Data management to review processes and systems, with the appointment of the new manager. Also to be form part of the workshop to be held in November 2011.


District Office

3. Data missing / inaccuracy in DHIS resulting in indicators being affected. Data management to


CHALLENGES ID IN DHER TEMPLATE

CHALLENGES / RECOMMEND-ATIONS ID IN DHER WORD DOCUMENT

RESPONSIBILITY COMMENTS

PROPOSED RECOMMENDATIONS

DATE RESOLVEDPDOH DISTRIC

T

review processes and systems, with the appointment of the new manager.

The Matrix allows for challenges to be identified in either the DHER or DHP and for these challenges to be transferred over to the following strategic document. It is envisaged that the challenges identified in the DHER process, should be carried over to the DHP, and vice versa. Operational challenges should form part of the Operational Plan for the District but with clear linkages to the strategic issues being mentioned in Part A of the DHP, and then broken down in Part B.

An example is described below on how to ensure that a there is a clear link between both the documents and the indicators at different levels.

DHER: In the DHER, a challenge was identified at district hospital level with data quality in all three systems. Therefore as DHIS, BAS & PERSAL all reflected incorrect data it was difficult to determine the exact root causes for high ALOS or BUR, to determine the cost for acute vs chronic patients or to do a cost analysis etc. For the purpose of this example, the specific challenge identified was that 12 hospital staff members are working at various clinics within the district but their salaries and related CoE expenditure is still reflected at the hospital.

Matrix: In the Matrix the exact wording for the above challenge appears as, “District Hospital data for the different levels to be separated out costs allocated correctly”.

DHP – Part A: In Part A of the DHP, the situational analysis, this challenge should be mentioned as there are cost implications and repercussions for correct analysis of data to determine root causes of issues. The statement should not be made in a negative context and should give the reader a clear indication on what the challenge is and what the impact that the challenge is on service delivery. This can be included in Part A as follows, “The data quality at district hospital level for all three information system is weak, leading to incorrect analysis and poor expenditure control impacting on service delivery at a grass roots level.”

DHP – Part B: In Part B of the DHP, the challenge could form part of the Data Quality Turn-Around Plan to improve data quality. As part of the Data Quality Turn-Around Plan, a strategy to improve data quality would be outlined with the broad strokes of who, what, when and where – no specifics should be included here. Only activities that are NOT routine in nature, that have cost implications and have a clear and concise indicator to monitor performance should be included. The activities discussed as part of the Turn-Around strategy could include monthly Data Information Meetings for Senior Management, quality

checking and verification of data by the DIO, HR to clean up PERSAL or the Finance Manager to provide training on the allocation of costs etc. Performance indicators could for the activities mentioned above could be, “Staff identified as incorrectly linked on Persal to be amended”. This would include all staff identified as incorrectly linked at all facilities in the District. Therefore in the district, 27 staff were identified with incorrect PERSAL linkages, this would form the denominator. The numerator would be the number of linkages rectified.

District Operational Plan: Indicators that appear in the Operational Plan should be clear, concise and operational in nature. There should be more indicators at this level, to give meaning to the performance indicators in Part B. Therefore it is here that the challenge identified in the DHER with regards to staff linkages and deployment of hospital staff to clinics should be unpacked i.e into input, output, outcome and performance indicators. The denominator and numerator for the performance indicator has already been identified in Part B, and should be monitored in relation to the input, output and outcome indicators.

Hospital Operational Plan: It is at this level that the actual operational activity for the correction of the challenge will appear ie. 12 staff identified by the DHER process as being deployed to clinics to be amended on PERSAL. This would be the denominator with the number of staff links corrected as the numerator. Again, more indicators should be monitored at this level to give meaning to the indicators in the District Operational Plan.

Figure 6: Indicator Pyramid

It is clear in the pyramid above that the hospital Operational Plan should monitor more indicators than the District Operational Plan in order to give meaning to the indicators monitored at this level. Only core performance indicators for challenges identified with correlating strategies / activities should be included in Part B of the DHP.

DHP

District Operational Plan

Hospital Operational Plan

An example could be long ALOS identified in the DHP, Part B. A strategy would be implemented by the district and monitored in the district Operational Plan i.e. chronic vs acute. This would be further broken down in the Hospital Operational Plan where the chronic vs acute would be monitored at a ward level. Therefore when it comes to commenting on the long ALOS, further information can be obtained from the Hospital Operational Plan to give meaning to the district value.

4.2 RELATIONSHIP BETWEEN DHP & DHER Below, the alignment between the DHER, DHP – Part A and Part B is represented in table format for ease of understanding. It indicates exactly which information / data should correlate between the DHER and Parts A & B of the DHP.

Table 10: Correlation between DHER and DHP for data

DHER DHP – Part A DHP – Part B

DHER Report – Table 11 Table A5 – PHC Headcount DHS1 & 2

DHER Report – Table 12 Table A6 – PHC Utilisation Rate DHS1 & 2

DHER Report – Table 28 Table A7 DHS4 & 5

Summary of PHC, Community Based Health, Hospitals and District Management

Challenges identified under correlating headings

Strategies / Activities to rectify challenge

The data that appears in the DHER should be verified and confirmed data. This same data should, in theory, be carried over to the DHP for that same time period. As discussed continuously at different levels, data quality is a challenge for the Department and therefore it is recommended that the following process be utilized when transferring the data from the DHER to the DHP.

Confirm the DHER data against the current DHIS data for the same time period.

Should the data be different in DHIS compared to the DHER, the data should be changed in the DHP table and a footnote made of the change in data and why the difference. The change in data should be indicated in all tables in both Part A & B.

Cross-reference the data in Part A with the same indicators in Part B. This would include targets that appear in the NSDA table against the same targets that appear in Part B.

5 ACKNOWLEDGEMENTSDistrict Health Expenditure Review Presentation by HST 17 May 2010

Feedback KZN DHER 2009/10 Provincial Overview – HST 7th July 2010

Excel Template for DHER 2011 – NDoH

Doing and Using the DHER – Presentation by HST May & June 2010

Guidelines for the DHER in SA published by HST 2nd edition print June 2011

DHP 2012/13 Template - NDoH

Mrs E. Snyman for the guidance on the analysis of indicators

DHER REPORT – ANALYSIS AND INTERPRETATION€¦ · Web viewRefer to the Word Template where comments have been included. LAYOUT OF DHER WORD REPORT. Below is the layout of the

Documents