DHER REPORT – ANALYSIS AND INTERPRETATION



DHER GUIDELINES

- PART 2

WORD REPORT

APRIL 2012

Compiled by Tracey Hattingh, KZN DoH

Table of Contents

1 INTRODUCTION 3

1.1 THE PURPOSE OF THE DHER 4

1.2 PROCESS OF THE DHER – add to 4

2 INTERPRETATION AND ANALYSIS 7

2.1 DATA QUALITY 7

2.2 CORE DHIS DATA ELEMENTS 9

2.3 LINKING OF INDICATORS 10

3 DHER REPORT – WORD DOCUMENT 20

3.1 LAYOUT OF DHER WORD REPORT 20

3.2 FORMATING OF DHER WORD REPORT 22

3.3 DHER WORD TEMPLATE / REPORT 22

ACKNOWLEDGEMENTS 23

SUMMARY 23

INTRODUCTION 23

PRIMARY HEALTH CARE 24

HIV / AIDS 32

ENVIRONMENTAL HEALTH 32

HOSPITALS (DISTRICT & TB) 33

DISTRICT ALLOCATION AND USE OF RESOURCES IN PROGRAMME 2 34

DISCUSSION: SUMMARY OF RECOMMENDATIONS 34

4 ALIGNMENT OF DHER & DHP 35

4.1 TRANSLATION OF CHALLENGES BETWEEN DOCUMENTS 35

4.2 RELATIONSHIP BETWEEN DHP & DHER 39

5 ACKNOWLEDGEMENTS 40

INTRODUCTION

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

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

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

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

□ Programme 1-Administration

□ Programme 2-District Health Services

□ 2.1 District Management Expenditure

□ 2.2 PHC Expenditure

□ 2.3 CHC Expenditure

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

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

□ 2.6 HIV / AIDS

□ 2.7 Nutrition

□ 2.8 Environmental Health

□ 2.9 District Hospital Expenditure

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

□ Programme 3-Emergency Health Services

□ Programme 4-Provincial Hospital Services

□ Programme 5-Central Hospital Services

□ Programme 6-Health Sciences Training

□ Programme 7-Health Care Support Services

□ Programme 8-Health Facilities

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

1 THE PURPOSE OF THE DHER

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

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

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

• Cost drivers can be identified and reviewed.

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

• Can improve overall management of District.

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

• Accountability of District Management.

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

2 PROCESS OF THE DHER

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

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

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

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

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

Figure 1: DHER Process Flow

[pic]

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

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

Figure

2: DHER Process Flow

[pic]

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

Figure 2: Diagram of the 3 Sources of Information

[pic]

INTERPRETATION AND ANALYSIS

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

1 DATA QUALITY

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

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

ILLUSTRATED EXAMPLE: BUDGET ALLOCATED / PDE

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

Scenario 1: Incomplete data

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

Table 1: Data received 20th May 2011

| |Apr |May |Jun |

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

| | | | |

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

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

| | | | |

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

| | | |headcount. |

| |Utilisation Rate | |There is definite link between the PHC headcount and the utilisation rate. This can be carried forward into target setting and projections. |

| | | |If the utilisation rate is to be increased to 2.4, then the population data can be used to project the PHC headcount, and vice versa. |

| |PHC Budget Allocated | |If the cost per headcount is low and over-expenditure has occurred when reviewed against the budget, it could mean that clinics and CHC’s are |

| | | |under-funded. |

| | | |If the cost per headcount is high and over-expenditure has occurred when reviewed against the budget, it could mean that there is a need for |

| | | |more stringent efficiency measures. The comparison should ideally take place over a 3 year period to identify if there has been a spike in |

| | | |expenditure and if this is due to an increased utilisation rate or poor management. |

| |OPD Headcount | |If there is a decrease in PHC headcount, look for an increase in OPD headcount as patients sometimes prefer to be seen at hospital level due |

| | | |to quick referrals to doctors, perceived better service etc. However it stands to reason that as services start to improve at PHC level, the |

| | | |PHC headcounts should increase, so the Non-referred OPD headcount should decrease. |

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

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

|Utilisation Rate |Ambulatory Ratio |OPD Headcount |There is a correlation between the utilisation rate, the Ambulatory Ratio and OPD Headcount as if the PHC system is working, the utilisation |

| | | |rate will be high, the ambulatory ratio should be low, as should the OPD Headcount not referred. |

| | | | |

| | | |Investigate: If the utilisation rate is low, the ambulatory ratio is high (above 1.5) and the OPD headcount is high, this indicates that the |

| | | |PHC system is not functioning correctly. |

| |R / Capita |- |This compares the utilisation of the services against the cost per person (capita) to render those services. Therefore if the utilisation |

| | | |rate is high, there will be more visits to the clinic and therefore the cost per capita should be higher than districts with lower |

| | | |utilisations but similar PHC expenditure. |

| | | | |

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

| | | |investigated. |

| |R / PHC visit |Budget Allocated |To determine if the budget allocated is / was sufficient. For demonstration purposes, following data utilised:- |

| | |budget for PHC |utilisation rate is 3.5, |

| | | |population is 50 000, |

| | | |cost per PHC visit is R 100 |

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

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

| |Cost per uninsured |Allocated budget for|To determine if the budget allocated was / is sufficient. For demonstration purposes the following data has been used;- |

| | |PHC |R 150 cost per uninsured |

| | | |Population is 50 000 |

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

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

| | | |population is accessing health services at clinic level or at hospital level. If the population is by-passing clinics, further |

| | | |investigation is required to identify the root cause i.e. poor staff attitudes to patients, poor accessibility of services, opening times |

| | | |limited etc. |

|Ratio of ambulatory | | |If the ambulatory ratio is high (i.e. ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download