The proportion of total district expenditure for management activities during the 2008/09 financial year, including the management of district hospitals, was 5.6%. This proportion is the highest over the past four years the lowest being 4.7% in 2006/07.
Figure 1, Percentage of district health services expenditure on management, by district, 2008/09, shows the variation in the proportion of total expenditure on management2 country-wide. Metsweding (GP) spends nearly one-third (32.2%) of its budget on management - almost six-times the national average - and this despite not having a district hospital. Clearly, this is disproportionate to the total expenditure in the district and, without a district hospital, a value of less than the provincial average of 9.6% would be expected. At the other end of the scale, eThekwini (KZN) spent 0.8% of its budget on management. These wide variations call for investigation by district and provincial management.
Wide provincial variations were evident, ranging from 9.6% in Gauteng to 1.9% in KwaZulu-Natal - a five-fold difference. Additionally, within some provinces there were wide variations between districts. For example, in the Eastern Cape the highest proportion spent on management was 16.5% in Cacadu while the lowest proportion spent was 2.9% in Nelson Mandela Bay Metro. In Limpopo the proportion spent ranged from 10.2% in Greater Sekhukhune to 3% in Mopani.
In other provinces, notably North West and Mpumalanga, there was little inter-district variation and this pattern has been maintained for a number of years as is clearly shown in Figure 4, Annual trends in the percentage of district health services expenditure on management, 2005/06 - 2008/09. In Limpopo there has been a steady (and large) increase in the proportion spent on management from 4.7% in 2005/06 to 7.4% in 2008/09. On the other hand all the districts in the Free State show a steady decline from 7.6% in 2005/06 to 2.2% in 2008/09.
Figure 4 also shows that most districts have had relatively stable patterns of expenditure over the past four years. This stability does not, however, apply to all districts and many districts in Gauteng have had wide fluctuations. Other districts that have had wide variations include Ukhahlamba (EC), Thabo Mofutsanyane (FS), Sisonke (KZN) and JT Gaetsewe (NC).
Improved management and leadership have been identified as the critical issue facing the health sector in South Africa. Therefore, these intra-district, inter-district, and inter-provincial fluctuations and variations require analysis and explanation by managers at district, provincial and national levels. The scope of work of the district management teams (DMTs) should be, essentially, the same in all the districts and both fluctuation and variation should, as a result, be minimal.
Figure 2, Percentage of district health services expenditure on management, by metro district, 2008/09, illustrates that the average metro expenditure is consistent with the average for South Africa. The three Gauteng metros have been characterised by wide fluctuations from 2007/08 to 2008/09 whilst the pattern in the remaining three metros during this period has been fairly consistent.
As can be seen from Figure 3, Percentage of district health services expenditure on management, by ISRDP district, 2008/09, the average for the rural development districts was almost identical to the average for the country. The proportion spent on management in the KwaZulu-Natal districts has, however, been consistently low whilst in the Eastern Cape it has been consistently high.
Figure 1: Percentage of district health services expenditure on management, by district, 2008/09.
Figure 2: Percentage of district health services expenditure on management, by metro district, 2008/09.
Figure 3: Percentage of district health services expenditure on management, by ISRDP district, 2008/09.
Figure 4: Annual trends in the percentage of district health services expenditure on management, 2005/06 - 2008/09.
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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1. District management is sub-programme 2.1 of the Treasury basic accounting system (BAS).
2. District management expenditure generally includes: salaries travel equipment and goods and services for the district and sub-district offices. Accounting practices between provinces appear to vary. In a number of cases it seems that salaries for health facilities are included under district management, as appears to be the case for expenditure on certain of the district health programmes.