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South Africa

Hospital Strategy Project

Module 1:

National Affordability Guidelines for Hospital Service Delivery

Part 1

June 1996

Monitor Company

Health Partners International

Centre for Health Policy

NALEDI

ABBREVIATIONS

COHSASA Council for Health Services Accreditation of Southern Africa

CSIR Council for Scientific and Industrial Research

CQI Continuous quality improvement

FMS Financial Management System

OPD Outpatients department

PERSAL Personnel and Administration Management System

PHC Primary health care

NHIS/SA National Health Information Systems/South Africa

ReHMIS Regional Health Management Information System

TB Tuberculosis

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EXECUTIVE SUMMARY

1. AIMS AND OVERALL APPROACH

The current situation regarding public sector hospitals in South Africa is untenable. Resources are concentrated in relatively few hospitals involved in providing sophisticated care, mainly to urban populations. Attention is now focused on re-orienting the health system towards primary health care and priority hospital services. This is a daunting task which holds many risks but which could yield many benefits.

The purpose of this module of the Hospital Strategy Project is to develop national affordability guidelines which can be used across the country to support the achievement of this task. Together with the strategies suggested in other modules (especially Module 2 on the reform of hospital management), recommendations reported here are designed to help transform the hospital sector into an equitable, appropriate and sustainable system which is able to meet the needs of ordinary South Africans.

The actual guidelines reported here, as well as recommendations regarding the further development of guidelines, are the result of the collective experience of the Hospital Strategy Project as well as extensive meetings and workshops with provincial and national managers. However, most of the recommendations still need to be taken through formal processes before they become official policy.

The recommendations which appear at the end of each section of the main report are summarised below under the section headings. More details on the issues and principles which underpin these recommendations are provided in each section. Each section is accompanied by detailed appendices which are useful resource documents for provinces wanting to act on any of the recommendations.

2. SUMMARY OF RECOMMENDATIONS

2.1 The development of national affordability guidelines

General recommendation

The process of developing and implementing national affordability guidelines should continue beyond the life of the Hospital Strategy Project.

Important next step

The Hospital Co-ordinating Committee of the Provincial Restructuring Committee should consider and amend the recommendations presented in this report.

Responsibility for acting on these recommendations should be allocated to departments, institutions and individuals.

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A time frame, or strategic plan, for implementing recommendations should be developed.

Follow-on actions

For the purpose of developing and implementing guidelines, funds or expertise required to supplement provincial and national resources should be identified.

2.2 Definitions


It is important to develop a common and consistent classification method for hospitals, and to clarify some of the concepts that are important in the classification process.

Important next step

Provinces should review the analyses performed on the 1994/95 ReHMIS database to see whether the use of the Hospital Strategy Project’s definitions has made the grouping of hospitals more representative.

Follow-on actions

A decision should be made by the Hospital Co-ordinating Committee on the final definitions for national use.

2.3 Restructuring the hospital sector

General recommendations

Provincial and national planners need to continue with detailed analysis and planning exercises which result in concrete strategies to re-structure hospital services according to national affordability guidelines.

Realistic and achievable timescales need to be developed for reform.

Lower levels of care should be developed before devolving services previously provided by higher levels.

Hospital management should be improved (see Module 2).

Change management techniques need to be employed during the transition, to promote support for reform by personnel and the public. In general, personnel management needs to be improved dramatically.

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Important next steps

Using the guidelines proposed by this module, comprehensive but relatively rapid provincial needs analyses should be performed. This would be the basis for developing a strategy for re-structuring the hospital sector.

Accurate and uniform estimations of expenditure by hospital, level-of-care and, at least in academic hospitals, by cost centre, should be developed.

The referral obligations of central hospitals to referring provinces should be concretised through developing a “map” of expected referrals.

Nationally applicable but flexible affordability guidelines, especially for human resources planning, should be developed.

Target expenditures that reflect a move towards equity within the context of the current capacity of different provinces should be established by province and level of care.

Follow-on actions

Using the national affordability guidelines, define clear missions for hospitals with specified catchment populations, level-of-care commitments and expenditure ceilings.

Once lower level services have been established, institute obligatory, comprehensive referral and discharge letters for all patients, and establish fines and/or loss of privileges and promotion opportunities for failure to comply.

Equal access to referral services should be guaranteed by instituting various mechanisms (such as purchaser/provider arrangements between different provinces and hospitals, or the designation of beds for specific provincial referrals).

A variety of incentives to improve capacity at all levels of the service should be established, including: the improvement of facility appearance and design; the development of widespread academic links; the provision of financial and other incentives in under-served areas (such as housing, continuing medical education, conferences and libraries); and the creation of credible career paths, especially in disadvantaged areas.

Clarify models of training in the hospital setting (that is, single academic hospitals versus more widely dispersed academic involvement in the health system), as well as training requirements.

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2.4 Indicators of the level of service provision


Agreement needs to be reached on what are the appropriate and affordable levels of service provision by level of care for the country as a whole. Although South Africa is falling behind other middle-income countries in its hospital service provision, initially there should be no increase in the number of beds.


While ReHMIS remains the main source of nation-wide, facility-based data which can be used for the estimation of indicators, all efforts should be made to ensure that the data is accurate and complete.

The planning of facilities, services, personnel and other requirements for service provision should proceed on the basis of encouraging equity through the use of the following bed per 1,000 population guidelines (for the public and private sectors):

Level III care: 0.3Level II care: 1Level I care: 2Chronic hospitals: 0.4All hospitals 3.7

Mindful of current private sector coverage, availability of resources, efficiency of hospital service delivery and public sector hospital beds in use (which the recent National Facilities Audit suggests is in the order of 2.7 beds per 1000 population), affordable bed to population ratios for the foreseeable future range between 2.2 and 2.8 beds per 1000 population.

2.5 Guidelines for Level I services


Nationally accepted guidelines for the design of new and upgraded district hospitals need to be developed. The guidelines must be based on models of the appropriate mode of delivery of Level I care.

Important next step

The guidelines proposed by the Hospital Strategy Project, and the design guidelines of the CSIR, need to be reviewed and amended.

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2.6 Guidelines for Level II services


Short-term planning for Level II services should make allowances for higher than normal case-loads for regional hospitals during the transition stage. Initially, staff ratios will probably have to exceed those expected in a stable referral system.


A credible career structure for doctors providing Level II services needs to be developed urgently. This should provide for adequate remuneration (especially for doctors working in rural areas) , job satisfaction and a promotion structure which is based on achievement rather than years of service alone.

A national “Level II therapeutics and technology assessment committee” should be set up to advise provinces and hospitals on the appropriate choice of pharmaceuticals and technology. This committee should prioritise the investigation of commonly used expensive treatments.

A national “purchasing list” should be developed to advise provinces on the purchasing of affordable and reliable equipment.

Follow-on actions

A formalised process of continuing education for Level II doctors needs to be developed, with the active involvement of academics based at central hospitals.

Systems for regional hospitals to access information should be developed (including electronic communication and hospital libraries). Electronic communication would also assist in consultation regarding individual patients and the dissemination of revised guidelines.

2.7 Guidelines for Level III services


The Level III profiles provided in this report are based on a series of broad assumptions and constitute the basis for discussion only.

Unique units that provide much of what presently constitutes level IV services (such as transplants) should be planned and funded separately on a national basis.

Support units in hospitals (e.g. ICUs, anaesthetics and radiology) and other services potentially using very high-tech equipment that is essential for Level III care but which are not particularly associated with a single Level III speciality, also require separate attention.

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ReHMIS should increasingly also collect data on the provision of services reflected by the subspecialists deployed in smaller divisions.

The IMDC should routinely monitor the number of specialists deployed in private and public practice.

The National DOH should, in consultation with the IMDC, determine the number of training posts required for each category of specialist and sub-specialist based on current deployment of specialists in the public and private sectors.

Follow-on actions

It is not feasible to provide a full range of level III services in all provinces in the forseeable future. A range of strategies needs to be developed to overcome current constraints and to formulate medium term plans for provision of level III services in all provinces.

2.8 Guidelines for planning human resources


In order to improve efficiency of hospital service delivery in South Africa, management structures and staff establishments of hospitals need to be revised considerably to facilitate decentralisation of management. Models developed for various types of hospitals can inform this process.

To improve equity of hospital service provision, staff establishments of hospitals need to be rationalised on a uniform basis using national affordability guidelines as a departure point.

Acceptable access to hospital services and adequate staffing levels of hospital services can only be maintained if considerable efficiency gains are achieved with fewer beds overall.

Explicit policy decisions are required on the following issues before appropriate and affordable staffing levels for hospitals can be determined:

The extent of the resource shift to PHC by 2001. If current projections of resource shifts to primary health care are to be realised by 2001 considerable rationalisation of the hospital sector is required.

The expansion of private sector. Continued expansion of the private sector hospital coverage will reduce requirements for public sector beds. Will the projected expansion of the private sector be controlled by new legislation?

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Strengthening of regional hospital services. Restructuring public hospital service delivery is largely dependant on strengthening regional hospital services. Inappropriate central hospital services can only be rationalised effectively if there is an adequate regional hospital service that can accommodate the service shift away from central hospitals.

Separation of levels of care in hospitals. Combining levels of care in regional and central hospitals is an expensive model of service delivery and undermines the integrity of the referral system with consequent overloading of higher level more expensive facilities. Considerable capital investment in hospitals to maintain an appropriate and affordable hospital estate is inevitable. Before any major investments are made in upgrading existing facilities and building new ones, a national policy on the appropriate hierarchy of service provision, separation of levels of care and referral system is required.

Decentralisation of management. Commitment to decentralisation of management will require more specialised management expertise, revised structures and staffing approaches to hospitals.

Minimum package of essential services. Policy decisions need to be made at national or provincial level regarding the appropriateness and affordability of essential clinical and support services that are staffed uniformly in district, regional and central hospitals.

Use of mid level health workers. A national policy on the use of mid level health workers (sub-professionals) to provide basic essential support services with in the context of level I hospital care is required.

Use of multi-purpose assistants in patient care units. The public service commission should be approached to create a new occupational class for a semi-skilled multipurpose worker that can perform several non nursing support tasks in patient care units including cleaning, making beds, lifting/restraining patients, serving food and transporting of messages, files, specimens, linen food specimens etc.


Provinces need to develop strategic plans for rationalisation and or development of their hospital services.

Strategies will need to be developed for managing the needs of personnel during this extensive restructuring phase.

A second model for central hospital service provision still needs to be developed that provides the full range of tertiary services usually provided in a hospital linked to a university.

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Follow-on actions

Professional boards and associations need to be consulted regarding the professional implications of proposed staffing ratios and the training and use of mid level health workers to provide basic essential support services with in the context of level I hospital care

A comprehensive strategy needs to be developed to improve productivity of hospital personnel.

Once right sizing of hospitals has taken place, the major efficiency gains that can be achieved by hospitals will be through transformation of hospital management support systems.

2.9 Essential performance indicators


A standard set of a limited number of indicators should be introduced into all public hospitals.


The Hospital Strategy Project’s document on indicators (Appendix X) should be sent to provinces for further consultation; and

Northern Province will pilot the system which should be introduced by August 1996.

Follow-on actions

Following implementation, Northern Province will present the system to NHIS/SA. A comprehensive implementation programme led by individual provinces may then follow.

Training in the usefulness and application of performance indicators should take place in each province.

The finalisation of definitions for indicators will be addressed by the NHIS/SA National Standards Committee.

The development of a simple software package to present the indicators in a user-friendly format should be considered.

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2.10 Improving the quality of care


It is important to introduce continuous quality improvement (CQI) programmes into public hospitals. This is not only for ethical reasons. These programmes will also improve management and efficiency.

Important next step

The performance of the CQI programmes recently introduced by COHSASA (the Council for Health Services Accreditation of Southern Africa) into several hospitals in North West should be evaluated.

Follow-on action

If the overall approach of COHSASA appears to be useful, minor problems in the content or process of its CQI programme should be adjusted through a process of consultation.

2.11 Clinical and referral guidelines


It is proposed that there be a nationally co-ordinated effort to formalise referral guidelines, to state explicitly what conditions should and should not be managed at each level of care, and to encourage the development of a prioritised set of clinical guidelines.

Important next step

It is proposed that a national guidelines co-ordinating body be established.

2.12 Planning facility development and maintenance


A comprehensive strategic plan for the development and maintenance of hospital facilities should be developed in conjunction with a plan for primary care facilities.


Following the completion of the national facilities audit, consensus on appropriate guidelines and prioritisation criteria for new and upgraded facilities needs to be developed.

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A policy regarding the licensing and regulation of private sector facilities needs to be developed (including a review of private facility regulations, which is already in progress).

Follow-on actions

Needs assessments should be performed on a provincial and national basis. Amongst other things, the development of existing or new academic hospitals should be resolved within the context of these plans.

Funding sources for future capital development need to be identified.

Once the process of facility planning is in progress, attention should be turned towards the other aspect of capital planning, namely the procurement and maintenance of equipment.

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SECTION 1:THE ROLE AND DEVELOPMENT OF NATIONAL

AFFORDABILITY GUIDELINES

1.1 INTRODUCTION

The reform of the public hospital sector cannot proceed in a rational and fair manner unless it is based on universally accepted guidelines which take into account a number of factors. These factors include: national and provincial health service priorities; services provided by the private sector; equity; efficiency; quality of care; and, importantly, prevailing resource constraints. Guidelines should relate to issues of need, access, input, process and output.

The following sections motivate for a number of different guidelines which fall into the categories listed above. Each section is accompanied by appendices which provide more detailed information. The relevant appendices are highlighted in a box at the beginning of each section. In some cases, relatively detailed guidelines are provided while, in others, broader guidelines suggest a process for developing more detailed guidelines.

1.2 PRINCIPLES GOVERNING NATIONAL AFFORDABILITY GUIDELINES

Guidelines should conform to national health care objectives.

Guidelines should be the product of an extensive consultation process.

Guidelines should be flexible so that they can be adjusted according to prevailing circumstances.

Guidelines should take cognisance of services provided by the private sector.

Relevant appendices

Appendix 1: Report on the first meeting of the working group on national affordability guidelines for hospital services, September 1995

Appendix 2: Planning hospital services: the role of national affordability guidelines

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1.3 BENEFITS OF NATIONAL AFFORDABILITY GUIDELINES

Guidelines make it possible to measure inequity in service provision between regions and communities.

Guidelines can be used to estimate the resources required to fill the inequity gap.

Guidelines promote the efficient use of resources.

Guidelines can be used to motivate for more money and competing with other departments for funds.

Guidelines are useful management tools and, in particular, can support the process of decentralisation of management (see Module 2).

1.4 RECOMMENDATIONS

1.4.1 General recommendation

The process of developing and implementing national affordability guidelines should continue beyond the life of the Hospital Strategy Project.

1.4.2 Important next steps

The Hospital Co-ordinating Committee of the Provincial Restructuring Committee should consider and amend the recommendations presented in the Executive Summary of this report.

Responsibility for acting on these recommendations should be allocated to departments, institutions and individuals.

A time frame, or strategic plan, for implementing recommendations should be developed.

1.4.3 Follow-on actions

For the purpose of developing and implementing guidelines, funds or expertise required to supplement provincial and national resources should be identified.

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SECTION 2:DEFINITIONS

2.1 INTRODUCTION

Several terminologies have been used in the past to describe hospitals and the care delivered within them. This sometimes leads to confusion and controversy, especially when data on hospitals (such as that in the Regional Health Management Information System (ReHMIS)) is used to compare categories and provinces. Below are described broad definitions for types of hospitals and levels of care which the Hospital Strategy Project considers to be practical and appropriate (of course, no definition is ever able to capture all the characteristics of any one institution). More technical definitions, which can be used to classify hospital data, appear in Appendix 3. The analysis of the 1994/95 ReHMIS database will make use of these latter definitions.

2.2 DEFINITIONS

2.2.1 The classification of hospitals

The Hospital Strategy Project suggests classifying hospitals as district, regional or central hospitals. These terms denote the position of an hospital in the referral chain. Both acute and chronic care may be delivered at these hospitals. District hospitals deliver mainly Level I care, regional hospitals mainly Level II care (but possibly also some Level I and Level III care), and central hospitals mainly Level III care (but possibly also some Level I and Level II care. The term “academic hospital” simply refers to a hospital linked to a Faculty of Health Sciences, and has no implications in terms of the sort of care provided at that hospital.

2.2.2 Levels of care

The care that is provided within hospitals can be categorised into levels which denote the sophistication or expense of the care (see Box 1). This allows hospitals of the same sort (such as regional hospitals) to be distinguished according to the proportion of care they deliver at each level.

Relevant appendices


Appendix 3: Defining hospitals by level of care: towards a consensus position

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National (or supra-regional) services are those referral services which are also provided by a hospital to populations outside its provincial boundaries. These services should only include Level IV services and some Level III services (other Level III services may eventually be provided in all provinces). However, the current situation of poor services in some provinces has resulted in widespread referral across provincial boundaries for secondary services.

Box 1: level of care definitions

Level I care is care delivered by general practitioners, medical officers or primary health care nurses in the absence of any specialist, other than a family medicine specialist. Primary care clinics and district hospitals operate at this level. Inside regional and central hospitals, Level I services include polyclinics, casualties, family medicine and sleepover wards, and paediatric rehydration units.

Level II care is patient care that requires the expertise of general specialist-led teams. This includes general surgery, orthopaedics, general medicine, paediatrics, obstetrics & gynaecology, psychiatry, radiology and anaesthetics.

Level III care is patient care that requires the expertise of a clinician working as a sub-specialist or in a rare speciality (for example, in surgery, the specialities of urology, neurosurgery, plastic surgery and cardiothoracic surgery).

Level IV care is provided by sub-specialities and includes services which are:~ very new;~ require scarce expertise;~ require highly expensive technology; and~ as a result, are found in only one or two centres in the country.

The difference between quaternary services and applied research is blurred. The definition of quaternary care allows that such care may change over time, as costs diminish or the interventions becomes more widespread. For example, renal haemodialysis would have been considered quaternary in the 1960s, while all nephrology units in South Africa would have this Level III facility today. Other techniques have moved with time from quaternary to secondary care (for example, ECGs) or even to primary care (urinalysis) over time. The distinction between ordinary tertiary and quaternary services is potentially a useful one, because it allows for the exclusion of expensive and unusual techniques that prevent the comparison of Level III services, and also allows for more focused budgeting.

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2.3 BENEFITS OF COMMON DEFINITIONS

Common definitions make it possible to group data in a way that reflects the true situation regarding hospital service provision in provinces so that appropriate comparisons can be made between hospitals;

Common definitions help to clarify the roles and functions of hospitals in the hierarchy of service provision;

Level-of-care definitions make it possible to classify beds and/or patients in a hospital to indicate the proportional care and expenditure for each level in the hospital.

2.4 RECOMMENDATIONS


It is important to develop a common and consistent classification method for hospitals and to clarify some of the concepts that are important in the classification process.

2.4.2 Important next step

Provinces should review the analyses performed on the 1994/95 ReHMIS database to see whether the use of the Hospital Strategy Project’s definitions has made the grouping of hospitals more representative.


A decision should be made by the Hospital Co-ordinating Committee on what should be the final definitions to adopt.

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SECTION 3:RESTRUCTURING THE HOSPITAL SECTOR

3.1 INTRODUCTION

The subject of this report is the development of national affordability guidelines which will enable the re-structuring of the hospital sector in an equitable and sustainable manner, and in support of national health objectives. The guidelines which follow in subsequent sections cannot be understood without some prior discussion of the main problems faced by the planners of reform, appropriate strategies for reform, and the place of guidelines with in these strategies. This section addresses these issues.

3.2 MAJOR CONSTRAINTS

The overriding problem is that hospitals do not serve current health priorities appropriately and efficiently.

There is an over-concentration of health care services in metropolitan areas and deprivation in rural areas.

There is a distorted referral system, with higher level hospitals over-burdened and lower level hospitals under-resourced.

Some hospitals are over-resourced in terms of personnel, while most are under-resourced. The planning of human resources is inconsistent and morale is poor.

In terms of the training of medical doctors, some Faculties have trained students for practice within high-tech environments that are not affordable throughout the country even though there is a shortage of generalists.

The number, quality and distribution of facilities impedes good service delivery.

Relevant appendices

Appendix 4: Priorities for restructuring referral hospitals in support of hospital reform

Appendix 5: A measuring tool to determine the personnel expenditure per unit output in complex hospitals

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The distorted supply of services is reflected in distorted expenditure patterns. Recent changes in financial allocation patterns are not well-reflected in changes in the distribution of personnel, drugs, supplies and equipment.

Having said this, there is little accurate and useful information on existing resource allocation patterns within and between hospitals, especially with regard to the expensive academic hospitals. Often the available data does not reflect the real situation in hospitals.

Hospitals are managed inefficiently (see the report of Module 2 of this project).

3.3 PRINCIPLES GOVERNING REFORM

The hospital sector should be re-structured into an efficient and equitable service, in which the needs of people are the first priority.

There should be effective referrals up and down the referral chain.

Expenditure patterns should reflect and support new priorities.

Personnel should be distributed equitably by level of care, and good staff should be retained and attracted.

Faculties should produce excellent graduates who are trained appropriately for South African realities, as well as more generalists and general specialists, and hospitals should be reimbursed properly for student training.

Wherever possible, facilities should be located where they are needed and designed appropriately. Facilities should be maintained.

Data that can be used for planning purposes should be collected uniformly.

Hospitals should be managed efficiently (see Module 2).

3.4 RECOMMENDATIONS

These recommendations attempt to place recommendations which follow in subsequent sections in context. Recommendations are not repeated here when they appear in subsequent sections.

3.3.1 General recommendations

Provincial and national planners need to continue with detailed analysis and planning exercises which result in concrete strategies to re-structure hospital services according to national affordability guidelines.

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Realistic and achievable time scales need to be developed for reform.

Lower levels of care should be developed before devolving services previously provided by higher levels.

Hospital management should be improved (see Module 2).

Change management techniques need to be employed during the transition to promote personnel and public support of reform measures. In general, personnel management needs to be improved dramatically.


Perform comprehensive but relatively rapid provincial needs analyses as the basis for developing a strategy for re-structuring the hospital sector.

Develop accurate and uniform estimations of expenditure by hospital, level-of-care and, at least in academic hospitals, cost centre (see Appendix 5).

Concretise the referral obligations of central hospitals to referring provinces through developing a “map” of expected referrals.

Develop nationally applicable but flexible affordability guidelines, especially for human resources planning (see the following sections).

Establish target expenditures by province and level-of-care that reflect a move towards equity within the context of the current capacity of different provinces.

Achieve consensus on special allocations for the high costs of service delivery in certain areas.


Using the national affordability guidelines, define clear missions for hospitals with specified catchment populations, level-of-care commitments and expenditure ceilings.

Once lower level services have been established, institute obligatory, comprehensive referral and discharge procedures for all patients, and establish fines and/or loss of privileges and promotion opportunities for failure to comply.

Equal access to referral services should be guaranteed by instituting various mechanisms (such as purchaser/provider arrangements between different provinces and hospitals, or the designation of beds for specific provincial referrals).

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A variety of incentives to improve capacity at all levels of the service should be established, including: the improvement of facility appearance and design; the development of widespread academic links; the provision of financial and other incentives in under-served areas (such as housing, continuing medical education, conferences and libraries); and the creation of credible career paths, especially in disadvantaged areas.

Clarify models of training in the hospital setting (that is, single academic hospitals versus more widely dispersed academic involvement in the health system), as well as training requirements.

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SECTION 4:INDICATORS OF THE LEVEL OF SERVICE PROVISION

4.1 INTRODUCTION

The appendices which are linked to this section define a few basic indicators of hospital service provision and utilisation, analyse South African data on these indicators (in particular, the 1994/95 ReHMIS database) and make comparisons with international experience. The appendices show that the current level of hospital service provision in South Africa has fallen behind both the norms laid down by the National Health Facilities Plan (1981) and the actual levels of service provision in other countries classified as middle-income.

The appendices also extrapolate guidelines for indicators which should be applied across the country when planning the distribution of health services: it is these guidelines which are reported here.

4.2 TYPES OF INDICATORS OF THE LEVEL OF SERVICE PROVISION

The main types of indicators which quantify the level of hospital services available in a country are:

beds per 1000 population;

health professionals per 1000 population;

staff per bed;

admission rate per 1000 population; and

admission rate per staff member.

These indicators can be expressed jointly for the public and private sectors, or separately.

Relevant appendices


Appendix 6: Use of indicators of hospital service provision, utilisation and efficiency

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Indicators which relate to the efficiency of services, and which are therefore more useful as management tools rather than for planning purposes, are summarised in Appendix 15 which discusses performance indicators. However, it should be remembered that indicators of provision, utilisation and efficiency are inter-linked and therefore need to be analysed together when planning the distribution of beds. For example, it is only apparent that a hospital has an excess of beds when it is realised that its occupancy rate is very low. For many analyses it is thus preferable to refer to patient day equivalents, rather than beds, as this provides a more precise summary of hospital activity. This indicator combines the number of inpatient days with the number of outpatient visits (see Appendix 14 on human resources planning).

4.3 BENEFITS OF INDICATORS OF SERVICE PROVISION

Indicators evaluate the equity of the distribution of existing services.

Indicators can be used to estimate affordable levels of resources (see, for example, Appendix 14 on human resources planning).

Indicators can be used to develop guidelines for the appropriate level of resources.

4.4 RECOMMENDATIONS


Agreement needs to be reached on what are the appropriate and affordable levels of service provision by level of care for the country as a whole. Although South Africa is falling behind other middle-income countries in its hospital service provision, initially there should be no increase in the number of beds.


While ReHMIS remains the main source of nation-wide, facility-based data which can be used for the estimation of indicators, all efforts should be made to ensure that the data is accurate and complete.

The planning of facilities, services, personnel and other requirements for service provision should proceed on the basis of encouraging equity through the use of the following bed per population guidelines (these have been calculated on the basis of the occupancy rates described in Appendix 15 on performance indicators):

Level III care: 0.3 beds per 1,000 populationLevel II care: 1 bed per 1,000 populationLevel I care: 2 beds per 1,000 populationChronic hospitals: 0.4 beds per 1,000 populationAll hospitals: 3.7 beds per 1,000 population

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It is important to note that these guidelines refer to total public and private beds. South Africa already has 4.0 beds per 1,000, but these beds are predominantly in the private sector and in urban settings.

As highlighted in Appendix 14, these levels are probably not affordable for the public sector. Mindful of the limitations of affordable staffing levels and the state’s restricted capacity to maintain the current hospital estate, it seems inevitable that the total public sector beds will have to be reduced to a level below 2.5 beds per 1000 population.

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SECTION 5:GUIDELINES FOR LEVEL I SERVICES

5.1 INTRODUCTION

Little attention has been paid to the development of appropriate district hospital services, this despite the fact that most of the referrals from primary health care services can be treated at this level. District hospitals are often the only accessible services for people living in rural areas.

The appendices associated with this section attempt to provide some indication of how new district hospitals could be planned, and how existing hospitals could be upgraded, in a rational manner. The guidelines are based on a hospital of 250 beds, as well as the assumption that adequate primary health care (PHC) services are also provided. The guidelines can be read in conjunction with Appendix 14 on human resources planning. The Council for Scientific and Industrial Research (CSIR) have also developed some design guidelines for hospitals.

This section simply highlights the topics which the main appendices address.

5.2 COMPONENTS OF DISTRICT HOSPITAL GUIDELINES

5.2.1 Guidelines for organisational characteristics of patient care (Appendix 8)

This appendix:

Relevant appendices


Appendix 3: Defining hospitals by level of care: towards a consensus positionAppendix 7: Introduction to guidelines for district hospitalsAppendix 8: Guidelines for organizational characteristics of patient care in a district

hospitalAppendix 9: Guidelines for site lay-out and inter-relation between various

departments of district hospitalsAppendix 10: Guidelines for health professional departments or services in a district

hospitalAppendix 11: Guidelines for support services in a district hospitalAppendix 14: Guidelines for human resources planning of hospital services

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identifies general organisational characteristics of inpatient and outpatient care in district hospitals.;

reviews the functions of a district hospital in terms of providing suitable medical, nursing and other professional care appropriate to the patient's condition on an outpatient or inpatient basis;

summarises the activities which normally take place in the outpatients department (OPD) and the wards in terms of patient activities, nursing, medical and paramedical activities, administration, supply and disposal, cleaning, visiting and teaching.

reviews key processes involved in patient care and hospital organisation; and

addresses key issues such as: the documentation of functions, activities and processes; the arrangement of spaces to suit nursing functions; the grouping of wards for staffing, supervision and control; progressive patient care; use of day spaces; and infection control.

5.2.2 Guidelines for site lay-out and interrelation between various departments (Appendix 9)

This appendix:

provides an overall perspective on the layout of a district hospital;

identifies important relationships between the various departments;

clarifies arrangements for external traffic and internal circulation;

addresses key issues such as: general site lay-out into seven primary zones; the consolidation of wards in smaller hospitals; the position of the TB ward, staff changing, the boiler house and the mortuary; and control of external traffic and internal circulation.

5.2.3 Guidelines on health professional departments and services (Appendix 10)

This appendix:

proposes guidelines for: the PHC department, OPD and casualty, dental department, eye department, theatre and the central sterilisation and supplies department, pharmacy, laboratory, X-ray department, rehabilitation department, general wards, maternity ward, paediatric ward, psychiatric ward, TB ward and mortuary;

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describes the functions, staffing requirements, potential workload, capacity, organisation, layout, location and space requirements of departments;

emphasises professional services that are either new or warrant particular attention, namely, the PHC department, eye department, rehabilitation department, psychiatric ward and high care wards/cubicles; and

addresses key issues such as: internal lay-out and space dimensioning (ie. open planning and the versatile use of space); economies of scale especially for medical support services; future need and potential to expand services and mechanical/electrical services (piped services, air conditioning etc.).

5.2.3 Guidelines for support services (Appendix 11)

This appendix:

proposes guidelines for: the administration block; a combined reception and admissions office; the kitchen; a staff cafeteria; the laundry; hospital stores; staff changing and rest rooms; grounds and security (including a services yard); transport facilities; staff accommodation; the maintenance department; and waste disposal and incineration;

emphasises key issues such as: services for staff (cafeteria, meetings, training, change and rest, accommodation); transport; centralisation of stores; maintenance and waste disposal and incineration.

emphasises support services that are either new or warrant particular attention, such as: the combined reception and admissions office; the staff cafeteria; a meeting/teaching room; staff changing and rest rooms; staff accommodation in flats and the maintenance department.

5.3 RECOMMENDATIONS


Nationally accepted guidelines for the design of new and upgraded district hospitals need to be developed. The guidelines must be based on models of the appropriate mode of delivery of Level I care.


The guidelines proposed by the Hospital Strategy Project, and the design guidelines of the CSIR, need to be reviewed and amended.

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SECTION 6:GUIDELINES FOR LEVEL II SERVICES

6.1 INTRODUCTION

In discussions around the reform of the referral system, Level III care is usually singled out for cut-backs, while Level I care is usually singled out for development. The role of Level II services in dealing with referred patients who would otherwise be sent to central hospitals is somewhat neglected, as is the problem of supporting regional hospitals in the provision of Level I care while district hospitals are being developed.

This section describes the main features of Level II services and highlights the essential strategies which are required to make them viable. The section should be read in conjunction with Appendix 12 which provides considerable detail on Level II services, and Appendix 14 which describes staff establishments and staffing levels for Level II services and pays more attention to staff categories other than doctors.

6.2 DEFINITIONS AND FUNCTIONS

Section 2 and Appendix 3 define Level II services in some detail. Here it is only necessary to repeat that a regional hospital contains all four of the core services of medicine, surgery, paediatrics, and obstetrics and gynaecology, as well as some other specialities and/or sub-specialities. Which sub-specialities are included should depend on the need for, and cost-effectiveness, of these services. The role of Level II services would be clarified by the development of clear, detailed clinical practice and referral guidelines (see Section 11).

The functions of the core specialities include:

the initial management of all presenting general and sub-speciality patients;

the provision of a consultative service to other departments within the hospital;

the appropriate onward referral of patients requiring Level III care or sub-speciality care not offered at the hospital; and

Relevant appendices

Appendix 3: Defining hospitals by level of care: towards a consensus positionAppendix 12: Level II care: structure and functionAppendix 14: Guidelines for human resources planning of hospital services

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the education of junior staff in the diagnosis and management of general conditions in the specialities.

Essential support services required for the functioning of the core specialities are:

a well-staffed anaesthetics department;

a CT scanner and radiologist;

an intensive care unit; and

a 24-hour laboratory and blood transfusion service.

6.3 RECOMMENDATIONS

6.3.1 General recommendations

Short-term planning for Level II services should make allowances for higher than normal case-loads for regional hospitals during the transition stage. Initially, staff ratios will probably have to exceed those expected in a stable referral system.


A credible career structure for doctors providing Level II services needs to be developed urgently. This should provide for adequate remuneration (especially for doctors working in rural areas) , job satisfaction and a promotion structure which is based on achievement rather than years of service alone.

A national “Level II therapeutics and technology assessment committee” should be set up to advise provinces and hospitals on the appropriate choice of pharmaceuticals and technology. This committee should prioritise the investigation of commonly used expensive treatments.

A national “purchasing list” should be developed to advise provinces on the purchasing of affordable and reliable equipment.


A formalised process of continuing education for Level II doctors needs to be developed, with the active involvement of academics based at central hospitals.

Systems for regional hospitals to access information should be developed (including electronic communication and hospital libraries). Electronic communication would also assist in consultation regarding individual patients and the dissemination of revised guidelines.

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SECTION 7:GUIDELINES FOR LEVEL III SERVICES

7.1 INTRODUCTION

Level III care is relevant because it facilitates research that effects mortality and quality of life outcomes, permits training and development of specific expertise, provides significant service output and results in more successful outcomes. However, this is all provided in South Africa at a price which is generally considered too high. Therefore, Level III care is likely to be subject to the most stringent budget cuts in future. The challenge inherent in the rationalisation of Level III services is to preserve these functions whilst dealing with the problem of the excessive cost of this sort of care.

7.2 DISCIPLINE BASED SERVICE PROFILES

Appendix 13 provides discipline-based profiles of all Level III specialities in the South African public sector. These include: Interim Medical and Dental Council (IMDC) registration data and estimates of specialists working with in the public and private sectors, ReHMIS data, projections from the Groote Schuur data and UK recommended ratios. In the light of this data the hospital strategy project has made recommendations (both nationally and provincially) on ratios of specialist to population, bed numbers and projected costs of specialist services at recommended levels. These recommendations are not intended to be definitive, but to provide the basis for informed discussion and modelling of central hospital services.

An indication of the national and provincial budgets for Level III services, overall and for each category is provided. Clearly, not every province will be able to provide all Level III divisions, but provision for access to these services in other provinces should be made through contractual arrangements.

7.3 RECOMMENDATIONS


The Level III profiles provided in this report are based on a series of broad assumptions and constitute the basis for discussion only.

Relevant appendicesAppendix 3: Defining hospitals by level of care: towards a consensus positionAppendix 13: Level III careAppendix 14: Guidelines for human resources planning of hospital services

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Unique units (e.g. liver transplant units) cannot be considered as ever constituting provincial Level III services and need to be dealt with separately.

Support units in hospitals (e.g. ICUs, anaesthetics and radiology) and other services potentially using very high-tech equipment that is essential for Level III care but which are not particularly associated with a single Level III speciality, also requires separate attention.



ReHMIS should increasingly also collect data on the provision of services reflected by the sub-specialists deployed in smaller divisions.

Clearly, some of Level III units would be too small to be viable in some provinces. A range of strategies to overcome these problems should be developed.

The IMDC should routinely monitor the number of specialists deployed in private and public practice

The National DOH should, in consultation with the IMDC, determine the number of training posts required for each category of specialist and sub-specialist based on current deployment of specialists in the public and private sectors.

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SECTION 8:GUIDELINES FOR HUMAN RESOURCES PLANNING

3. INTRODUCTION

The purpose of formulating national affordability guidelines for human resource planning is to facilitate the restructuring of an inefficient, fragmented, inequitable, hospital centric health service to an efficient, integrated, decentralised, equitable and comprehensive health care system which is supportive of primary health care.

Rationalisation of human resource utilisation in hospitals needs to take place with in the context of national policy on the development of the National Health System (NHS) and transformation of the public sector:

The draft national policy document “Towards a National Health System” provides a tentative policy framework for the process of restructuring the health sector aimed at unifying the fragmented health services into a comprehensive and integrated NHS, reducing disparities and inequities in health service delivery and increasing access to integrated services based on primary health care principles.

The white paper on the transformation of the public service focuses on the need for devolution and decentralisation of managerial responsibility and accountability with in the Public Service, together with the introduction of new and more participative organisational structures. The White Paper creates an opportunity for profound reform to public hospital management through its provisions for extensive decentralisation of management throughout the public sector.

The Hospital Strategy Project (HSP) has completed several pieces of work that are relevant to the future development of human resources in hospital services. Documents completed as part of module 1 that inform human resource planning include the review of indicators of hospital service provision, utilisation and efficiency and the development of

Relevant appendices

Appendix 3: Defining hospitals by level of care: towards a consensus positionAppendix 4: Priorities for restructuring referral hospitals in support of hospital reformAppendix 6: Use of indicators of hospital service provision, utilisation and efficiency Appendix 10: Guidelines for health professional departments or services in a district

hospitalAppendix 11: Guidelines for support services in a district hospital Appendix 12: Level II care: structure and functionAppendix 13: Level III careAppendix 14: Guidelines for human resources planning of hospital services

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guidelines on functions and service delivery for different types of hospitals and levels of care.

Module 2 on decentralised management has emphasised the need for transformation of hospital management in South Africa and proposed that:

Management structures should be revised to accommodate the complex, multi-speciality, multi-professional nature of hospitals and facilitate decentralised hospital management to reflect the need for general management in each hospital. And the creation of structures based on cost and responsibility centres where people in management positions take full responsibility for the quantity and quality of activity, staffing, supporting resources and associated financial matters.

Management capacity must be developed to overcome basic deficits in existing management and to meet the new needs under decentralised hospital management. Decentralised management will require specific capabilities for new functions which include: skilled administrative support for boards, accountants for financial management, human resources and labour relations manager, expert support in procurement and managing contractors, information management expertise, hospital engineering support.

Ensuring adequate management for hospitals will require extra financial resources. However, this should take place with in the context of cost saving that improved management can achieve.

4. KEY PRINCPLES OF HUMAN RESOURCES PLANNING FOR HOSPITALS

4.1 Comprehensive rationalisation of human resources for health

Decisions regarding size and composition of various offices and services/ facilities need to be informed by the functions and hierarchical relationships of all other functional components in the health care system. Staff establishment rationalisation of hospitals should therefore be undertaken with in the context of a comprehensive process of rationalisation of human resources for the entire health system.

4.2 Service access, affordability and quality

The availability and skills mix of health workers are major determinants of access to services and quality of services provided. Affordable staffing levels depend on requirements regarding access and quality of services. If access norms and affordability constraints are not negotiable then staffing levels must drop with consequent reduction in quality of care. On the other hand, should certain staffing levels be considered essential to maintain acceptable quality of care, then access to hospital services will inevitably drop.

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4.3 Revised management structures

Regional and central hospitals need a substantially revised management structure if they are to be managed more efficiently. This will require management structures that reflect the need for output orientated management with in the context of various service and support roles. Generally speaking this will result in the reorganisation of the hospital into: patient service departments (various groupings of wards and outpatient units), clinical support departments (radiology, pharmacy etc.), hospital wide support services (catering, maintenance etc.) and corporate management departments (human resources, finances etc.)

4.4 Strengthen senior management

Improved management of hospitals will require strong management skills by the chief executive officer (CEO) and additional senior management posts to handle new management functions including clinical management, financial management and accounting, engineering, labour relations and human resource management, public relations, quality assurance and operations management.

4.5 Cost and responsibility centres - Organised functional units

Organisational structures and staffing should facilitate decentralised management and optimal utilisation of staff. Therefore hospitals should be organised into functional units with clearly defined roles. Individual functional units (e.g. pharmacy) or groups of functional units (e.g. all general surgery wards or all outpatient services) should be organised and staffed in such a way that they can be managed as cost and responsibility centres. Each cost centre should have a focus of responsibility which may be either an individual or a team. Posts should be allocated to functional components where a service is rendered and not along professional lines or administrative procedures that are followed.

Management of cost centres in patients care services and clinical support services should be strengthened by establishing responsibility and cost centre management teams consisting of various combinations of senior/principal specialists, medical superintendents/chief medical officers, nursing service managers, senior clinical support personnel and administrative officers.

4.6 Strengthen essential clinical services

Certain clinical services need to be strengthened to improve quality, efficiency and access to appropriate hospital services. These include:

PHC and casualty services in all types of hospitals

radiological, laboratory and ICU services at regional hospitals

acute psychiatry services at all regional and central hospitals

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All regional hospitals and central hospitals should have an orthopaedic workshop, a clinical engineering service, a dietetics service, a hospital social work service in addition to other clinical services provided routinely.

Central hospitals should have an ophthalmology service, a urology service, an ENT service and a radiotherapy service. Additional level III services will depend on service provision modelling at provincial and national level.

4.7 Strengthen essential support services

The following support services should be established or strengthened to improve the quality, and efficiency of hospital services:

All regional hospitals and central hospitals should have an office of the CEO which incorporates public relations, internal audit and administration support.

All regional hospitals and central hospitals should have a labour relations service with dedicated expert staff that can facilitate improvement in labour relations skills of all managers in the hospital.

All regional hospitals and central hospitals should have finance service staffed with accountants.

Most hospitals (with the exception of very small district hospitals) should have 24 hour switchboard and admissions services run by dedicated staff.

All hospitals should have a dedicated maintenance service.

Most hospitals (with the exception of very small district hospitals where an after hours service is adequate) should have 24 hour security service that can at least guard the main entrance and patrol the terrain.

4.8 Use of mid level health workers

Greater use should be made of mid level health workers (sub-professionals) to provide essential support services rendered with in the context of level I hospital care including:

Health therapy assistants (radiography) that can take most routine X rays required for level I services.

Health therapy assistants (physiotherapy) that can perform most routine physiotherapy tasks required for level I services.

Health therapy assistants (occupational therapy) that can provide basic OT services required for level I care.

Specialised auxiliary services officers (pharmacist’s assistants) that can provide most routine pharmaceutical services required for level 1 care.

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4.9 Differentiation between levels of care provided in a single hospital

Individual hospitals may provide different levels of care in varying proportions. Staff workload ratios vary according to level of care and even with in level II and III care depending on the nature of the service. To accommodate these differences, patient care units need to be staffed according to the level of care. However, allocating staff by level of care does not imply that patients must necessarily be managed by level of care although there are definite advantages in doing so.

4.10 Differentiation between incremental and linear increases in staff allocations.

Incremental increases in staffing are necessitated by variation in size and complexity of the institution or services and affect supervisory and promotion posts as well as the range of posts. Incremental posts are allocated on the basis of policy issues that relate to the organisation and management of hospitals of various sizes and complexity and not in direct proportion to workload. The type of posts allocated on an incremental basis are either senior and mid-level management posts or the minimum posts required to render an essential service (e.g. casualty service). The number of posts allocated on an incremental basis should be kept at a minimum to reduce inefficient top heavy structures.

Linear increases in staff allocation are determined by workload. This applies to all the functional posts in the hospital (e.g. nurses, medical officers, clerks, cleaners). In larger hospitals it may be possible to allocate mid level managers and staff for essential services entirely on a linear basis where staff allocation is directly related to workload because economies of scale make it feasible.

4.11 Development of simple indicators of workload for planning human resource allocations

A few simple indicators of workload need to be developed to determine appropriate staffing levels in functional units. These can then be applied to an extensive list of staff allocated to a comprehensive range of functional units in each type of hospital. Indicators frequently used include: inpatients per staff category, outpatients per staff category, patient day equivalents (combination of inpatient day and outpatients also called patient unit) per staff category, operations per staff category etc. These indicators may be applied to any category of patient e.g. acute, chronic, level I or II, internal medicine inpatients, oncology outpatients etc.

4.12 Management support services

Staff establishment recommendations have been made on the assumption that hospitals will continue to be administered by the current financial management system, provisioning administrative system, personnel administrative system and pharmaceutical supply system. When new systems are introduced staffing can be revised accordingly.

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4.13 Post categories and occupational classes

The type of post and career structures that can be used in model staff establishments are dependant on the personnel administrative measures for specific occupational classes that are determined by the Public Service Commission. It is anticipated that the entire personnel administrative system will be revised over the next few years. Future changes in post categories can easily be accommodated if and when they occur by the Hrplan database because all posts incorporated in the system have a numerical key that can be manipulated accordingly.

4.14 Flexibility

Any approach to revising organisational structures and staff establishments needs to be flexible enough to accommodate the considerable variation in needs and possible responses. Staffing models should not be prescriptive but remain useful even if they are changed. Flexibility is required to accommodate variation in organisational structures, different post categories and mix of posts, variations in availability of staff, different staffing levels for patients receiving different levels of care and changes in management support systems.

5. DEVELOPMENT OF A DATABASE FOR MANIPULATION OF STAFF ESTABLISHMENTS AND ORGANISATIONAL STRUCTURES

A database called Hrplan (for Human Resources Planning) has been developed by the Hospital Strategy Project as a human resources strategic planning tool. The database can be used by institutional managers, district, regional, provincial and national health service managers and human resource planners to manipulate staff establishments and plan human resources for health. All data in the various components of Hrplan can be altered and updated. Components of Hrplan include:

All data linked to the ReHMIS database is potentially accessible to Hrplan.

A dictionary of posts containing the post name, PSC rank and class code and current salary scale of all posts currently on health staff establishments.

Workload variables including various categories of beds, outpatients per day, inpatients per day, patient day equivalents per day, operations per week, admissions per day and residents per day.

Model organisational structures for district, regional and central hospitals are created by organising functional components in various hierarchical arrangements

A staff complement is created for each functional unit or component by identifying the types of posts required to staff the component and identifying what workload variable the staff in a component should be based on.

A particular model that has been developed can be applied to any individual facility or groups of facilities by region, province or nationally to generate a recommended staff

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establishment for that facility or facilities. Furthermore, if the existing establishment has been incorporated into the database, several manipulations can be performed which will generate information regarding obsolete posts, vacant posts and surplus staff

6. DEVELOPMENT OF NATIONAL AFFORDABILITY GUIDELINES FOR STAFFING OF HOSPITALS

6.1 Model staff establishments

Mindful of the policy context, deficiencies of current staff establishments, principles of decentralised of management and human resource planning and guidelines for district hospitals and level II and level III care, model staff establishments have been created for 4 different sized district hospitals, 3 different sized regional hospitals and one central hospital.

Model functional units and appropriate staff categories and staffing ratios with in units were developed after reviewing existing organisational structures and staff establishments of a number of best practice sites as well as several hospital management reports and analyses by private consultants, government work study investigators and researchers.

The various models that have been created were staffed at two levels namely: a “minimum” level and a minimum plus 20% level. These two levels were developed to evaluate affordability constraints. It is sobering to note that the minimum levels in many categories of staffing in South Africa are considerably higher than current staffing levels in Botswana and Namibia. Interestingly, some disadvantaged provinces in South Africa have even questioned whether the minimum levels are affordable in their provinces.

6.2 Detailed staffing guidelines

Detailed staff establishments have been generated for a range of different sizes and types of hospitals including:

Models using the national averages of hospitals for a given type as default values. These models provide for separate staffing rates for acute and chronic care and separate staffing rates for different levels of acute care where appropriate.

Conceptual models using minimum sized institutions for a given type. Separate staffing rates for different care provided as in previous paragraph.

Conceptual models for specific size hospitals expressed in beds. Only acute care is included in workload variables to facilitate population based planning for acute care.

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6.3 Summary staffing guidelines

Staffing guidelines have also been developed that relate total staffing of different sized hospitals to total beds (corrected for minimum efficiency levels), total inpatients/day and total PDE/day. These guidelines can be used to perform rapid analysis of the level of staffing of a specific institution under consideration. Summary staffing guidelines are only available for district and regional hospitals.

7. COSTING OF STAFFING GUIDELINES AND MODELS OF HOSPITALS

7.1 Personnel costs of hospital models

The personnel costs of certain standard sized hospitals (expressed in terms service provision, utilisation and efficiency variables) are presented in tabular format. Key findings of this analysis include:

At minimum staffing levels district hospitals cost between R 105 and R111 per patient day equivalent (PDE) per day. A PDE or patient unit is a composite indicator of total workload that combines inpatient days and outpatients (where three outpatients are equivalent to one inpatient day).

Unit costs do not vary much between district hospitals which is probably due to the fact that there are four different management structures for district hospitals with in a reasonably small range of hospital size (38 to 250 bed) which reduces inappropriate overhead costs as the hospitals get smaller.

At minimum staffing levels regional hospitals cost between R149 and R 196 /PDE/day which represents a 42-77% increase over district hospitals. Unit costs of regional hospitals vary significantly due to the differences in levels of care as well as economies of scale of regional hospitals.

Level I care in a 250 bed district hospital costs R107 /PDE/day. By contrast, a 250 bed regional hospital that is staffed to render only level 1 inpatient care (with the exception of the ICU) costs R154 /PDE/day which is 44% more.

7.2 The implications providing level 1 care in regional hospitals

Level 1 care costs roughly 50% more when provided in a regional hospital as opposed to a district hospital. This is due to management and service overheads inherent in a regional hospital. The functional units that are most affected (with financial implications of more than R100000 per annum) are: the office of the CEO, theatre and CSSD, pharmacy, orthopaedic workshop, radiology, general outpatients, casualty, ICU, nursing management, human resources management, office administration, porter service, clinical workshops and building maintenance and grounds.

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Providing level I care at higher unit costs in regional hospitals on an extensive basis will increase the total cost of hospital care. Consequent pressure to reduce regional hospital costs will compromise their capacity to provide good quality level II care resulting inevitably in overloading of central hospitals to provide core level II services at level III costs. Furthermore, rendering level I care in urban areas from regional hospitals undermines the integrity of the referral system by suggesting to rural communities that district hospital care is inferior and is only offered to communities as a second rate alternative.

7.3 Affordability of staff establishments

7.3.1 Premises of modelling exercise

The cost implications of staffing public sector beds according to the recommended ratios were modelled. The basic premises of the modelling exercise were:

(a) To be realistic, future rather than current costs should be estimated. The year 2000/01 was chosen for this modelling exercise.

(b) In 2000/01, service provision in the public sector will be rendered efficiently. That is, staff establishments and staff complements will be adjusted according to the model described previously, and hospitals will experience an average occupancy rate of 80 percent and an average duration of stay of 7 days.

(c) There will continue to be sufficient beds in the private sector to provide equivalent (or better) care to those able to afford private care.

(d) Costs per bed reflect total hospital costs and are determined by dividing total hospital costs by total beds.

The starting point of the costing exercise were “ideal” total bed to population ratios based on international experience (as recommended by the HSP in Appendix 6). As Table 1 shows, the proportion of these beds which could be provided by the public sector was calculated first assuming that 20 percent of the total population will be served by the private sector and then assuming that this figure will rise to 30 percent. (The latter percentage could be applicable in the year 2000/01, following the introduction of more efficient and cheap services as a result of managed care.) The proportion of beds which would therefore have to be provided by the public sector was then calculated. It was assumed that all chronic beds would be provided in the public sector.

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Table 1: The calculation of bed to population ratios for different levels of coverage by the private sector

LEVEL OF CARE

IDEAL TOTAL BEDS PER 1,000 POPULATION

IDEAL PRIVATE SECTOR BEDS PER 1,000 POPULATION

IDEAL PUBLIC SECTOR BEDS PER 1,000 POPULATION

20% coverage

30% coverage

20% coverage

30% coverage

Level I 2.00 0.40 0.60 1.60 1.40Level II 1.00 0.20 0.30 0.80 0.70Level III 0.30 0.06 0.09 0.24 0.21Sub-total 3.30 0.66 0.99 2.64 2.31Chronic 0.40 0.00 0.00 0.40 0.40TOTAL 3.70 0.66 0.99 3.04 2.71

7.3.2 Projections of costs

The total cost (in 1996/97 prices) of providing this level of coverage by the public sector in 2000/01 were then modelled using minimum and optimum staffing levels as the basis for the estimation. The cost of providing chronic beds was not estimated as no information on the appropriate cost of servicing such beds is available.

The costs were compared with the projected budgets for each level of care in 2000/01. These projections include inpatient and outpatient care at each of the three levels of care but do not include the costs of Level IV care or of training doctors in the hospital setting i.e. the projections are consistent with the staffing model on which the costing exercise is based i.e. a service provision model.

Where the cost of providing public care according to the desired ratios was found to exceed projected budgets, the ratios were decreased until they became affordable. Table 2 summarises these affordable bed to population ratios.

Table 2: Affordable bed to population ratios for acute care in the public sector, 2000/01

LEVEL OF CARE AFFORDABLE ACUTE PUBLIC BEDS PER 1,000 TOTAL POPULATION

Minimum staffing level Optimum staffing levelLevel I 1.321 1.108Level II 0.661 0.554Level III 0.198 0.166Total 2.180 1.829Total as % of ideal public bed ratio (20% population served by private sector)

82.6% 69.3%

Total beds as % of ideal public bed ratio (30% population served by private sector)

94.4% 79.2%

Table 2 shows that the country will probably only be able to afford to provide 79 percent of the ideal acute public bed ratio if it wishes to staff beds at an optimum level, assuming that coverage by the private sector will rise to 30 percent in 2000/01. That is, the public

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sector will only be able to provide 1.8 acute beds per 1,000 as opposed to the ideal of 2.3 per 1,000. If this is not acceptable, there are a number of options which could be pursued. For example, it could be decided that an occupancy rate higher than 80 percent will be tolerated, or a shorter duration of stay would be achieved resulting in higher turnover of beds, or that less expensive categories of staff will be replace more expensive categories, or that the ratios for Level III care should be reduced. Also, other sources of funding, such as user fees, could be found to finance the gap between likely budgets and the likely cost of the ideal provision of beds.

7.4 Revised estimates of public sector bed requirements

The analysis of affordability of proposed staffing levels suggests that bed provision levels initially recommended by the project are unrealistic and that an overall reduction in public sector beds is inevitable. A review of bed requirements was undertaken based on public hospital admission rates, average length of stay (ALOS) and bed occupancy rates. Key findings are:

Bed requirements per 1000 population vary from 1.55 to 2.39 depending on admission rate, ALOS and bed occupancy.

An overall admission rate for hospital inpatient care of 80 per 1000 population reflects reasonably good access with in the current South African context and it is probably unrealistic to aim for a level any higher than this given national affordability constraints.

To reduce acute bed levels below 2, 39 beds/1000 population will require average occupancy rates of over 70-75% and average ALOS of less than 7-8 days (depending on level of care). Alternatively, a reduction in beds can be achieved by admission rates below 80 per 1000 population (with consequent reduction in access).

Bed levels in the range of 1.8 beds per 1000 population can only be achieved with considerable reduction in ALOS to 5-6 days and high occupancy rates if an admission rate of 80 per 1000 is to be maintained.

In conclusion, reduction of beds to levels where staffing is affordable will require considerable efficiency gains if access is not going to be compromised. Such efficiency gains can only be achieved if hospitals are appropriately staffed, suitably structured and optimally managed.

8. USEFULNESS OF GUIDELINES FOR HUMAN RESOURCE PLANNING AND THE HRPLAN DATABASE

8.1 Strategic planning of human resource

The staffing guidelines and the Hrplan database can be used for strategic planning of human resources for health for individual institutions and services at district, regional and provincial level. Hrplan has the capacity to accommodate all components of the national

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health system. The implications of new services or modification of existing services on staff numbers, staff mix and budget can be determined. Use of the Hrplan database as a strategic planning tool is however dependant on accurate information regarding current staffing and workload.

8.2 Staff establishment rationalisation

The process of rationalisation of human resources at Provincial level can be facilitated by Hrplan producing the following outputs:

(a) Generation of various model staff establishments based on type of institution and staffing requirements according to workload variables.

(b) Costing of alternative models providing detailed breakdown of costs of functional components, sections and divisions of the model hospital as well as costs per post category.

(c) Generation of staff establishments for specific institutions which can be modified according to local circumstances.

(d) Ready access to information on staff establishment and staff deployment according to post category, functional components, institutions or offices etc. that can be used on an ongoing basis for human resource planning and budget allocations.

8.3 Highlighting cost implications of inefficiencies

Staff guidelines and model establishments are developed on the assumption that services will be rendered with in certain parameters of efficiency. When model staff establishments for specific institutions need to be adjusted to accommodate local inefficiencies, the differences between the ideal establishment for a particular facility type and proposed or desired establishment represents the costs of the inefficiency. Some inefficiencies may be organisational, which can be corrected by improved management of human resources but others may be structural due to inappropriate facility design such as small uneconomical sized wards and duplication of services. The latter inefficiencies may require capital investment to correct. By identifying the cost implications of the inefficiency the additional recurrent cost can be weighed up against the capital costs of correcting them.

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9. RECOMMENDATIONS

9.1 Policy decisions on appropriate levels of hospital service provision

Explicit policy decisions are required on the following issues before appropriate and affordable staffing levels for hospitals can be determined:

(a) The extent of the resource shift to PHC by 2001. If current projections of resource shifts to primary health care are to be realised by 2001 considerable rationalisation of the hospital sector is required.

(b) The expansion of private sector. Continued expansion of the private sector hospital coverage will reduce requirements for public sector beds. Will the projected expansion of the private sector be controlled by new legislation?

(c) Strengthening of regional hospital services. Restructuring public hospital service delivery is largely dependant on strengthening regional hospital services. Inappropriate central hospital services can only be rationalised effectively if there is an adequate regional hospital service that can accommodate the service shift away from central hospitals.

(d) Separation of levels of care in hospitals. Combining levels of care in regional and central hospitals is an expensive model of service delivery and undermines the integrity of the referral system with consequent overloading of higher level more expensive facilities. Considerable capital investment in hospitals to maintain an appropriate and affordable hospital estate is inevitable. Before any major investments are made in upgrading existing facilities and building new ones, a national policy on the appropriate hierarchy of service provision, separation of levels of care and referral system is required.

(e) Decentralisation of management. Commitment to decentralisation of management will require more specialised management expertise, revised structures and staffing approaches to hospitals.

(f) Minimum package of essential services. Policy decisions need to be made at national or provincial level regarding the appropriateness and affordability of essential clinical and support services that are staffed uniformly in district, regional and central hospitals. These services include:

Essential clinical services such as casualty services, intensive care units, acute psychiatric inpatient services, CAT scanning and the use of mid-level health workers to provide essential pharmacy, radiological, physiotherapy and occupational therapy services at small district hospitals where direct supervision of professionals is usually not feasible or economical.

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Non-clinical services such as a 24 hour switchboard, 24 hour admission office, 24 hour security services, public relations and labour relations, internal audit and estate management.

(g) Use of mid level health workers. A national policy on the use of mid level health workers (sub-professionals) to provide basic essential support services with in the context of level I hospital care is required.

(h) Use of multi-purpose assistants in patient care units. The public service commission should be approached to create a new occupational class for a semi-skilled multipurpose worker that can perform several non nursing support tasks in patient care units including cleaning, making beds, lifting/restraining patients, serving food and transporting of messages, files, specimens, linen food specimens etc.

9.2 Important next steps

9.2.1 Provincial rationalisation exercises

Provinces have already embarked on hospital rationalisation exercises. These exercises have been driven largely by resource constraints with in provinces. In the absence of national affordability guidelines it has not been possible for provinces to apply uniform guidelines that would facilitate the process of rationalisation towards equity of provision with in the national context. The draft guidelines developed by this module provide a departure point for provinces to review their staffing norms with in the context of what is affordable nationally. This will result in two different scenarios. Well resourced provinces will be confronted with the full implications of restructuring the hospital services to achieve equity with in the next five years which will entail radical cuts “across the board”. Strategies will need to be developed for redeployment of staff and even retirement of surplus personnel. On the other hand, under resourced provinces will have a definite indication of the levels of provision that can be achieved over the next 5 years. They in turn need to develop strategies for expansion of services and deployment of new staff. Rationalisation of “better resourced” facilities in disadvantaged provinces may not be warranted with in the context of what is affordable nationally.

Clearly all provinces need to develop strategic plans for rationalisation and or development of their hospital services. These plans should be based on what the ultimate goal of an equitable, appropriate and affordable hospital service by the year 2001. Transitional management plans need to be formulated to ensure that this goal is achieved in a systematic and coherent manner with minimum disruption of the service.

9.2.2 Managing the needs of personnel

The extensive restructuring of referral hospitals will impact dramatically on personnel. Likewise, the way in which personnel react to change will impact dramatically on the success of reforms. It is thus essential to develop a comprehensive strategy for informing personnel of imminent changes, involving personnel in developing solutions problems faced by the system, managing the sense of insecurity and sometimes dissatisfaction

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amongst personnel in times of change, and retaining or recruiting staff in newly restructured services. Management will need to fully negotiate the transfer or cutting of posts, the relocation of staff, and voluntary retirement or retrenchment of staff with labour unions, personnel associations and individual employees.

9.2.3 Consultation with professional groups

Professional boards and associations need to be consulted regarding the professional implications of proposed staffing ratios and the training and use of mid level health workers to provide basic essential support services with in the context of level I hospital care.

9.2.4 Modelling for central hospitals and academic hospital complexes.

The central hospital model that have been developed in the Hrplan to date has been based largely on the model of the large regional hospital. This model provides level II and III care at a ratio of roughly 2 : 1 and level III is confined to between 4 and 8 of the more common (and less expensive) level III services. These hospitals were previously referred to as non academic tertiary hospitals. The cost per PDE in such a hospital is of the same order of a large regional hospital.

A second model for central hospital service provision still needs to be developed that provides the full range of tertiary services. This would be a service provision model for tertiary care that is usually linked to a university. Quaternary services should not be included in this model.

9.2.5 Transforming hospital management support systems

Once right sizing of hospitals has taken place, the major efficiency gains that can be achieved by hospitals will be through transformation of hospital management support systems. One of the important criteria for accessing the benefit of any new system will be the impact it has on staffing levels for support services.

9.2.6 Improvement in staff productivity

The traditional method of increasing output by increasing staffing levels is no longer affordable. A comprehensive strategy needs to be developed to improve productivity of hospital personnel. This will require inputs at national, provincial, regional, district and institutional level and must address a wide range of issues including: career mobility, job satisfaction, remuneration and other incentives improved labour relations, decentralised management, revised management systems, quality improvement programmes etc.

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SECTION 9:ESSENTIAL PERFORMANCE INDICATORS

9.1 INTRODUCTION

Relevant, timely and accurate information is required to run a large and complex organisation like a hospital. Performance indicators are management tools which summarise important data that a hospital produces. South African hospitals, in the majority of cases, do not adequately use information to inform their decision-making processes, although they habitually collect vast amounts of data. Furthermore, the hospital data is often not comparable between institutions. The analysis by the Hospital Strategy Project of the 1995/96 ReHMIS database suggest that there is considerable variation in the performance of South African hospitals (see Appendix 6).

Some of the reasons why hospital managers generally do not use information to its full potential are:

data is not manipulated into meaningful information;

if relevant data is produced, it is often presented statistically in a cumbersome format, which complicates interpretation;

even when information is available, is seldom routinely reviewed;

hospital managers often do not have the training to use such information;

as discussed in Module 2, hospital managers in South Africa do not have adequate authority to manage hospitals, as many of the key management functions are controlled at provincial level. This has resulted in the lack of a driving force to develop management information systems in hospitals.

9.2 PRINCIPLES FOR SUCCESSFUL PERFORMANCE INDICATORS

Indicators should be collected from readily available sources.

Relevant appendix

Appendix 6: Use of indicators of hospital service provision, utilisation and efficiency

Appendix 15: Hospital performance indicators

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Indicators should summarise essential data in the form of information.

Each indicator should have a clear purpose.

9.3 PROPOSED INDICATORS

The Hospital Strategy Project has developed a standard set of a limited number of hospital performance indicators in consultation with hospital managers, provincial representatives and representatives of NHIS/SA (National Health Information Systems/South Africa). These indicators have been chosen as a minimum requirement to monitor critical areas of a hospital performance (see Table 1).

Indicators are categorised into basic, additional and advanced indicators. Basic indicators are indicators that all hospitals should be able to produce, are essential to manage a hospital, and must be reviewed regularly. Additional indicators are indicators that provide a more detailed analysis of the hospital, using the data collected for basic indicators. These indicators should be produced only on request by a manager. Advanced indicators provide a comprehensive overview of the hospital. These require additional data to be collected and it is the choice of the individual hospital whether this data should be collected. Appendix 15 explains the definition and usefulness of each indicator, suggests the data source for the indicator, explains how the indicator should be calculated and suggests how often the indicator should be reported. It also suggests actions for a manager to consider if an indicator highlights a problem.

Table 1: Proposed standard set of indicators

INDICATOR INDICATOR LEVEL

REPORTING FREQUENCY

SUGGESTED NORM

1. Activity1.1 Inpatient days1.2 Inpatient admissions1.3 Outpatients - attendances

and head counts1.4 Emergency attendances1.5 Inpatients in hospital for

more than 8 days1.6 Waiting lists for outpatient

appointments

2. Efficiency 2.1 Average length of stay2.2. Bed occupancy rate2.3 Sickness and absence rate2.4 Theatre utilisation2.5 Staff turnover

BasicBasicBasic

BasicAdvanced

Advanced

BasicBasicBasicBasicAdvanced

MonthlyMonthlyMonthly

MonthlyMonthly

Quarterly

MonthlyMonthlyMonthlyQuarterlyQuarterly

N/AN/AN/A

N/AN/A

N/A

4-8 days 70 - 80 %5 - 10 %5 - 10 %N/A

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2.6 Admission rates per staff 3. Quality3.1 Complaints Received3.2 Post operative infection rate 3.3 Percentage of patients that

fail to attend clinics 3.4 Clinical Audit

4. Financial4.1 Expenditure 4.2 Cost per patient day4.3 Income

Advanced

BasicBasicAdvanced

Advanced

BasicBasicBasic

Quarterly

MonthlyQuarterlyQuarterly

Quarterly

MonthlyMonthlyMonthly

See indicator

N/AN/AN/A

N/A

N/AN/AN/A

9.4 BENEFITS OF PERFORMANCE INDICATORS

Indicators can be used by hospital managers to:

provide an overview of a hospital’s performance;

serve as a management tool to improve decision-making such as the allocation, and effective use, of resources, the identification of deficiencies and the prioritisation of needs; ans

set and monitor targets for the hospital.

Indicators can be used at a provincial level to:

monitor and compare performance of hospitals within the province;

assess equity of services offered both within the province and nationally;

aid the strategic planning process; and

assist in resource allocation.

9.5 THE COMPATABILITY OF THE INDICATORS WITH OTHER INITIATIVES

The proposed performance indicators are compatible with other initiatives relating to health information and are not meant to replace or supersede them. These initiatives are:

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NHIS/SA will be introduced in the next few years and will provide a comprehensive information system. The proposes indicators can be modified to accommodate new sources of data and can be incorporated into NHIS/SA. During the transitional period the performance indicators will produce a simple management tool based on existing data sources which will help to develop a culture that uses information to take decisions.

The Standards Committee of NHIS/SA has agreed to give priority to finalising definitions for the proposed indicators in the system.

The Council for Health Service Accreditation of Southern Africa (COHSASA) is currently introducing a continuous quality improvement programme into 10 public hospitals in North West (see Section 10). COHSASA has indicated that it is willing to develop an additional management module in its programme which will audit data to ensure that it is accurate, and evaluate the use of performance indicators as decision-making tools in hospitals.

Information systems currently in place in hospitals (such as the financial management system (FMS) and the personnel and administration management system (PERSAL)) will not be compromised, as the indicators developed will use the data that they produce.

9.6 RECOMMENDATIONS


It is proposed that a standard set of a limited number of indicators should be introduced into all public hospitals in South Africa.


Following a national consultative workshop, the following strategy for the implementation of performance indicators was proposed:

Appendix 15 should be sent to provinces for further consultation; and

Northern Province will pilot the system which should be introduced by August 1996.

9.6.3 Follow-up activities

In addition, the workshop proposed that:

Following a brief implementation time period, Northern Province will present the system to NHIS/SA. A comprehensive implementation programme led by individual provinces may then follow.

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Training in the usefulness and application of performance indicators should take place in each province. This, including the support of managers using the system, is the responsibility of each province.

The finalisation of definitions for indicators will be addressed by the NHIS/SA National Standards Committee.

The Hospital Strategy Project also proposes that a simple software package be developed to present the indicators in a user-friendly format (a draft specification for such a package has been included in Appendix 15).

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SECTION 10:IMPROVING THE QUALITY OF CARE

10.1 INTRODUCTION

Much of the planning for health sector reform in South Africa focuses on expanding the coverage and efficiency of services. Advances in the quality of care are often seen as by-products of equity and efficiency initiatives. However, for both ethical and practical reasons, quality of care improvement deserves its own strategy. Public health services are morally obliged to render the best possible care to patients within the prevailing resource constraints, regardless of race, income or geographic location. To ensure this, explicit decisions and processes are required to prioritise resource use, develop treatment protocols, train personnel and monitor the many aspects of patient care on a continuous basis. Far from being a luxury that can be afforded only by wealthy industrialised countries, a programme to manage continuous quality improvement within hospitals is fundamental to the fair and efficient management of scarce resources in developing countries.

A continuous quality improvement (CQI) programme is one which continuously measures and evaluates the quality of services delivered, identifies opportunities for improvement, and provides mechanisms to bring about and maintain improvements, all within the context of existing resource constraints. A CQI programme focuses on the entire process which results in the delivery of care and cuts across different disciplines, categories of health worker and types of service.

10.2 PRINCIPLES FOR A CQI PROGRAMME

A CQI programme should develop quality of care guidelines which are affordable within the national context and thus feasible to implement.

Quality of care guidelines should be agree upon at a national level in order to ensure equity, but should be sufficiently flexible to adapt to the peculiarities of local conditions.

CQI programmes should result in the empowerment of health workers and patients.

Relevant appendix

Appendix 16: Improving the quality of care in public hospitals

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10.3 COMPONENTS OF A CQI PROGRAMME

A CQI programme is made up of three consecutive components which should be applied in a cyclical fashion as the hospital develops.

10.3.1 The development of guidelines

National guidelines are developed through a process of comparing what is considered professionally optimal with what is realistically feasible, given prevailing resource constraints.

10.3.2 The development and implementation of assessment mechanisms

Hospital personnel develop relevant mechanisms for evaluating the degree to which their hospital conforms with national guidelines. The reasons for deficiencies are also identified. This self-evaluation can be supplemented with evaluations by external assessors.

10.3.3 The development and implementation of response mechanisms

Strategies for redressing deficiencies are developed within the context of resource constraints.

10.4 BENEFITS OF A CQI PROGRAMME

The successful implementation of guidelines results in facilities that comply with nationally agreed standards.

Facility staff are empowered and motivated through the process of self-evaluation and the implementation of improvements.

As the CQI programme examines the entire process of health care delivery, it is a powerful management tool.

The detailed information provided by a CQI supports planning at an institutional and provincial level.

The focus of a CQI on patient satisfaction means that community involvement in the design of services is promoted.

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10.5 THE WORK OF COHSASA

The Council for Health Service Accreditation for Southern Africa (COHSASA) has developed a CQI programme over the past years. The highly specific quality guidelines used by this programme were developed with the assistance of international and local experts and have been applied and tested in over forty hospitals in South Africa. COHSASA helps to introduce this programme into hospitals by using facilitators who work closely with hospital staff over 12 to 18 months. Hospital staff are trained to gather and analyse data collected before and after interventions to improve the quality of care. The interventions are designed by the hospital staff themselves after investigation of the reasons for poor quality care. The post-intervention status of the hospital is also assessed by an independent team of surveyors from COHSASA. At all stages detailed reports are made available to the hospital management. COHSASA provides its services to hospitals at cost, as it is a non-profit organisation. The introduction of the CQI programme is thus relatively inexpensive.

Although COHSASA’s quality guidelines were initially developed in private hospitals, they have since been adapted for application in the public sector which frequently confronts severe resource constraints. The CQI programe is currently being introduced into several hospitals in North West, the first province to consider developing a strategy for the improvement of the quality of care delivered by its hospitals on a wide scale.

10.6 RECOMMENDATIONS


Apart from resulting in better care for patients, CQI programmes contribute to better management in a variety of ways. Improving the quality of care can thus also results in greater efficiency in the delivery of care. It is thus important that South African hospitals examine options for improving the quality of care they provide.

Over the years COHSASA has developed a detailed CQI programme which it has tested and applied in many hospitals, both in the private and public sector. It appears likely that this programme represents the best option for developing a quality improvement strategy in public hospitals.


The performance of the CQI programmes recently introduced by COHSASA into several hospitals in North West must be evaluated. This could be done readily through a structured workshop which includes personnel from all the participating hospitals. Possibly the workshop could be supplemented by a series of in-depth interviews with some of the key personnel.

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10.6.3 Follow-up activities

If the overall approach of COHSASA appears to be useful, minor problems in the content or process of its CQI programme should be adjusted through a process of consultation.

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SECTION 11:CLINICAL AND REFERRAL GUIDELINES

11.1 INTRODUCTION

Clinical guidelines for the appropriate care of patients, and referral guidelines which indicate when patients should be transferred to higher levels of care, are important mechanisms for promoting the equitable and affordable use of resources to provide care of good quality. As such, they are another management tool for ensuring the smooth operation of a hospital, and relate closely to the quality of care guidelines discussed in Section 10.

In South Africa good quality guidelines on the appropriate and affordable management of many common conditions are scarce. Consequently, clinicians struggle to assess the standard of their care, resources are often wasted and many patients receive inadequate care. For managers, it is difficult to allocate resources without information on the costs and benefits of particular interventions. For planners, it is difficult to make comparisons between different institutions and regions.

The local development of clinical guidelines is hampered by a shortage of personnel with the considerable time and resources to engage in this relatively complex process. Guidelines often do not meet internationally acceptable standards in terms of the development process, it is rarely clear exactly which group of health care staff is being addressed by guidelines, and some recommendations are not affordable. There is little emphasis on the delineating precisely when patients should be referred and to what destination.

11.2 PRINCIPLES FOR DEVELOPING CLINICAL AND REFERRAL GUIDELINES

The process of developing guidelines should:

include collaboration with international and local experts;

involve academics in both the generation and dissemination of guidelines; and

Relevant appendix

Appendix 17: Clinical guidelines and referral routes

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ensure validation and trial of guideline recommendations;

ensure the active and universal dissemination of the guidelines in an effective way;

include guidelines into the training of health workers;

ensure ongoing audit of the efficacy of the process;

be consistent with health service objectives; and

be affordable.

11.3 COMPONENTS OF GUIDELINES

11.3.1 Clinical guidelines

The development of clinical guidelines follows certain internationally-defined steps:

the definition of objectives;

review of the literature;

the description of methods to analyse data and reach conclusions;

the listing of conclusions reached, together with the strength of the evidence for and against each conclusion; and

recommendations.

11.3.2 Referral guidelines

In general, the following need to be actively developed:

explicit and well-publicised referral guidelines, incorporating details on both when and where to refer;

quick, reliable, and efficient communication channels between referring and referral institutions; and

adequate and easily arranged transport so that logistics are rarely a consideration when deciding on referral.

standardised referral letters, electronic mail, and telephonic access to expedite communication in both directions between referring and referral centres.

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In particular, Level III and IV services, which act as gatekeepers for scarce resources, should:

publicise “entry criteria” for patients to gain access to these scarce resources;

develop funding mechanisms which ensure equity of access of care, especially for patients who live far from these services; and

establish and maintain communication channels with referring centres to the extent that all referring doctors are familiar with both the difficulties and the successes of the referral services, feel free to contact the services at any time, and are confident that they will be regularly updated on the progress of all patients they have referred.

11.4 BENEFITS OF CLINICAL AND REFERRAL GUIDELINES

The combination of an explicit referral system with clinical guidelines which incorporate information on costs and benefits will facilitate planning decisions. Without the detailed decision-making that this sort of detailed information makes possible, care is likely to remain inequitable and inefficient. Knowledge of what is appropriate care allows comparisons within and between provinces, facilitates estimation of the potential outcome of defined services, and allows auditing of the health system to optimise efficiency as well as the quality of care.



It is proposed that there be a nationally co-ordinated effort to formalise referral guidelines, to state explicitly what conditions should and should not be managed at each level of care, and to encourage the development of a prioritised set of clinical guidelines.


It is proposed that a national guidelines co-ordinating body be established. This body would have the responsibility of co-ordinating, delegating, prioritisation, communicating and reviewing guideline development activities. In the first instance its aim would be to address rapidly (and thus fairly crudely) the main problems associated with poor referral systems and the wastage of resources due to inappropriate treatment.

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SECTION 12:PLANNING FACILITY DEVELOPMENT AND MAINTENANCE

12.1 INTRODUCTION

Unlike the primary care sector, little attention was paid until recently to the number, size and state of facilities in the hospital sector. Beds are maldistributed geographically as well as in terms of level of care, while the quality of beds varies widely, depending on the physical state of the buildings in which they are housed. The servicing of beds in dilapidated buildings is very expensive as maintenance costs are high, and many buildings are designed poorly.

This state of affairs led the national Department of Health to commission the Council for Scientific and Industrial Research (CSIR) to perform a national audit of health facilities. Following the completion of the audit there is a need for more clarity on the guidelines which should be used to plan the upgrading and maintenance of facilities as well as the building of new facilities.

While Sections 5, 6 and 7 discussed the planning and design of individual institutions, this section discusses the planning of the distribution of facilities on a geographic basis.

12.2 PRINCIPLES OF A FACILITY DEVELOPMENT AND MAINTENANCE PLAN

There should be no, or only a minimal, increase in the overall number of public hospital beds in the next 10 years.

Access to facilities should be improved, especially for people in disadvantaged, rural areas

The focus should be on strengthening the district health system as opposed to higher levels of care.

Having said this, key facilities which support primary health care services should be developed in order to create a functional referral system.

Hospital staff, beds and technologies should be deployed in a manner consistent with acceptable productivity standards (see Appendices 6 and 15).

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Relevant appendices

Appendix 6: Use of indicators for hospital service provision, utilisation and efficiency.Appendix 18: Developing a capital investment and maintenance plan for hospitals: strategy and

issues.Appendix 9: Guidelines for site lay-out and inter-relation between various departments of a

district hospital.

Resources should be used optimally within existing resource constraints. This means that a balance between equity of access and achieving economies of scale needs to be found. Also, some of the irrational planning of the past needs to be accommodated, given the cost of building new facilities.

12.3 COMPONENTS OF A FACILITY DEVELOPMENT AND MAINTENANCE PLAN

The steps which make up the development of a strategic plan are summarised below (see also Appendix 18).

12.3.1 Preparatory phase

Policy decisions have to be made regarding:

what is the appropriate model for the delivery of services (in particular, as it impacts on the planning of facilities)?;

how will capital planning be integrated with service planning processes to reflect these service delivery models and priorities?

what will be the process by which national affordability guidelines for equity are developed?

what should be the policy regarding private hospitals, both in terms of their licensing as well as their design?

12.3.2 Step 1: the assessment of existing health facilities

A methodical analysis of the existing stock of facilities is a crucial first step in the development of a strategic plan. As already mentioned, a national audit of clinics and hospitals is already in progress

12.3.3 Step 2: the development of facility guidelines

In the interests of equity, nationally accepted guidelines should be used to decide when it is justifiable to provide a community with a new or upgraded facility. These guidelines should be affordable within a national context. Some preliminary guidelines for hospitals have been proposed by the Hospital Strategy Project. These guidelines focus on bed to population ratios (2,1

1, 0.2 and 0.4 beds per 1,000 population for district, regional, central and chronic hospitals respectively (see Appendix 6) (as well as the organisational layout of district hospitals (see Appendix 9). Some detailed design guidelines for hospital facilities have also been published by the CSIR.

12.3.4 Steps 3: a needs assessment

1 The ratio for district hospitals in urban areas can be lower given the fact that regional hosptials, which are generally located in these areas, provided extensive Level II services.

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An assessment of need is performed by comparing the existing stock with what is desired on the basis of facility guidelines and a number of other factors. These factors include the existence of geographical barriers (such as hills, rivers and railway lines) which make it difficult to access otherwise nearby facilities, the availability of important infrastructure (such as transport routes, water and sewerage systems, and an electricity supply), population projections, changing utilisation patterns (especially as a result of HIV/AIDS) and the general policy context of health services development which was referred to earlier.

12.3.5 Step 4: the development of a prioritised master plan

Given that health facilities, especially hospitals, are expensive and take a long time to build, a comprehensive plan for capital development includes the prioritisation of facilities according to explicit, rational and well-accepted criteria. Criteria could include technical criteria to assess buildings, mechanical and electrical infrastructure and equipment, and policy criteria to evaluate the importance of facilities in terms of equity and access, affordability and the extent to which they meet health goals.

A capital development master plan should indicate which facilities are going to be closed, down-graded, up-graded or simply maintained. It will also indicate which new facilities will be built and at which location. This information will be expressed within the relevant timeframe for implementing the plan.

12.3.6 Step 5: identification of the recurrent cost implications of capital development plans

Budgeting for capital expenditure often occurs in isolation from budgeting for the costs of personnel and other resources to operate the facility. In the past this has led to facilities being built and then being left idle. It is therefore essential that the services to be delivered by new facilities be planned in conjunction with the facilities themselves. A facility should not be constructed if there is no foreseeable mechanism for funding the services it is meant to provide.

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12.3.7 Step 6: financing the capital development plan

At present the capital expenditure components of provincial health budgets are really recurrent budgets intended for maintenance purposes. Budgets for the building of new facilities have usually been held by the Departments of Public Works. It is unlikely that these budgets will be able to fund the extensive rehabilitation of facilities which is required in South Africa. Possible new sources of funds are the RDP and donor funding.

12.3.8 Step 7: the co-ordination of facility development with other departments and contractors

In the planning, design and construction of new the Departments of Health and Public Works should operate as an efficient team, understanding one another’s constraints and objectives. Likewise, the relationship between these departments and the contractors responsible for the construction of the new facility should be a close one. This will avoid unnecessary delays in construction as well as the development of facilities which are not responsive to the needs of health care workers.

12.3.9 Step 8: the development of a strategic plan for maintenance

Maintenance has habitually been neglected in facilities across the country. This has led to the unnecessarily rapid decay of buildings and infrastructure, often beyond the point of salvage. Thus, it is as important to develop a maintenance plan as it is to develop a building plan. A maintenance plan should provide for the monitoring of existing capital stock, its timely repair and its eventual replacement, if necessary. It should also alert planners to changing priorities.

12.4 BENEFITS OF A FACILITIES DEVELOPMENT AND MAINTENANCE PLAN

A comprehensive plan ensures that inequities are redressed, limited resources are used efficiently, facilities support the delivery of appropriate services and the life-span of capital stock is lengthened.



A comprehensive strategic plan for the development and maintenance of hospital facilities should be developed in conjunction with a similar plan for primary care facilities.


Following the completion of the national facilities audit, consensus on appropriate guidelines and prioritisation criteria for new and upgraded facilities needs to be developed.

A policy regarding the licensing and regulation of private sector facilities needs to be developed (including a review of private facility regulations, which is already in progress).

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12.5.3 Follow-up actions

Needs assessments should be performed on a provincial and national basis. Amongst other things, the issue of the development of existing or new academic hospitals should be resolved within the context of these plans.

Funding sources for future capital development need to be identified.

Once the process of facility planning is in progress, attention should be turned towards the other aspect of capital planning, namely the procurement and maintenance of equipment.

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