This indicator measures the average cost of a patient visit to a primary care facility. In practice it is the average cost to the health service of a patient visit to a community health centre, clinic, satellite clinic or mobile clinic (but excluding district hospitals) - and which average cost includes the cost of managing the district1. This indicator's value is calculated by dividing the total cost of running all these facilities for a year in a particular district by the total headcount of visits to these facilities for the same year.
Districts vary considerably in their population numbers and their geographic size and, as a result, the number of facilities in each district also varies. The number of facilities ranges from less than 20 in the smallest districts to more than 300 in the largest.
It is important to remember that the rough cost of one patient visit provides an average that smoothes-out individual cost variations and does not take into account the patient case-mix found in practice. For example, it takes much longer and requires greater resources to perform a delivery, which counts as one visit, than it takes to administer daily medication to a tuberculosis patient. It also costs much more to see a patient after hours, when there is a low volume of patients, than it costs to see a patient during &ldquonormal&rdquo working hours.
When all these factors are lumped together in a district it is useful to have as a benchmark the average district cost per visit, so that districts can compare themselves with each other. In this way they can see how efficient they have been at running their primary care services for a particular year. Where a DHER (District Health Expenditure Review) has been conducted (as should be the case) an average cost per visit is calculated for each facility, making intra-district comparison possible.
This indicator is thus a means of creating a benchmark of efficiency regarding the delivery of primary care outside of district hospitals.
Figure 1, Non-hospital PHC expenditure per visit, by district, 2008/09, shows that the average cost of a single visit to a primary care facility in South Africa was R127.60 but that there was a wide range of values. Metsweding (GP) is an outlier district with an extremely high average cost of R222.80, followed by City of Johannesburg (GP) with an average cost of R175.00 per visit. At the low end of the spectrum is Siyanda (NC) with an average cost of R70.10 per patient visit, along with five other districts at under R100 per visit. Although inter-district differences are to be expected, differences as great as these require investigation. It is also necessary to establish the threshold at which diminishing cost per visit values no longer reflect enhanced efficiency but rather that the clients are being short changed.
Figure 1 also shows the wide intra-provincial ranges with large differences between districts in the same province. The reasons for these wide differences must be established and explained by district and provincial managers.
Figure 2, Non-hospital PHC expenditure per visit, by metro, 2008/09, illustrates that the metro average cost per visit of R133.60 is close to the South African average. This average, however, masks the virtual two-fold difference of the average cost per visit of R93.80 in Nelson Mandela Bay Metro (EC) and R175.00 in City of Johannesburg (GP). Understanding the reasons for this wide difference would be extremely useful to all managers.
Figure 3, Non-hospital PHC expenditure per visit, by ISRDP district, 2008/09, shows the rural picture with an average cost per visit of R 128.70, which cost is virtually identical to the national average. There is consistency in the average costs in the four KwaZulu-Natal districts. Three of the four Eastern Cape districts have costs well above the average, while together the four display a wide intra-provincial range. There is also a wide range in costs between the extremes - Thabo Mofutsanyane (FS) with an average cost per visit of R94.50 and Ukhahlamba (EC) with an average cost of R 166.80.
The trends over the past four years, 2005/06 to 2008/09 (together with values for 2001/02), based on 2008/09 Rand values2 are shown in Figure 4, Trends of non-hospital PHC expenditure per visit by province and district. The overall picture clearly shows the intra-provincial differences between districts within some provinces &ndash differences that should be explained by the DHERs. Figure 4 also shows that in some provinces, e.g. KwaZulu-Natal, the data are remarkably stable and consistent.
Figure 1:
Figure 2:
Figure 3:
Figure 4:
References:
- See explanation in Chapter 1, Input Indicators, for information on what is included and omitted when discussing district expenditure.
- Expenditure for previous years (2005/06 2007/08) has been adjusted for inflation. All figures are thus presented in real 2008/09 prices.
Resources:
The indicators in these sections are calculated from the Basic Accounting System (BAS) data obtained from National Treasury, North West Province's financial data, National Treasury data on Local Government expenditure, the current DHIS mid-2008 population estimates and the 3-year rolling average of medical aid coverage calculated using the General Household survey data 2005-2007.
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