Cost Projections for the Complementary Package of Activities - basics

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number of staff would fall to 49 and the total cost would go down to $207,731 but the cost perIDE would go up to $14.44 (because the fixed staff and operating costs are spread over fewerIDEs).The costs are sensitive to the staffing ratios used. For example, for CPA 1 hospitals we usednormative ratios of 1 MD/MA to 8 occupied beds, 1 nurse to 2.8 beds and 1 midwife to 7.5 beds(based on the CPA Guidelines). If we change the staffing ratios for the 60-bed CPA hospital inthe above table to 1 MD/MA to 16 occupied beds, 1 nurse for 5.6 beds and 1 midwife for 15beds, the total number of staff would be reduced from 60 to 45 and the budget from $260,830 to$234,292. However, this reduction is likely to affect quality of care. It should be noted that thereduction had limited effect on cost since the staffing numbers are fixed for most categories ofstaff.The study of HSP 2 costs estimated that inpatient admissions would increase from 2.07 per 100population in 2006 to 2.20 in 2007 and 2.99 in 2012 if the historical rate of growth continues,and to 2.26 in 2007 and 3.53 in 2012 if the rate of growth accelerates (Pearson 15 ). In the costsection of HSP 2 it is assumed that these increases in demand can be met to some degree bymaking better use of existing hospital capacity.This assumption seems reasonable since the BOR for all hospitals, excluding national hospitals,for 2007 was 68% and the ALOS was 7.4 days (both of which improved from 65% and 8.0 daysin 2006). The hospitals can, therefore, treat 22% more inpatients before reaching the level of85% and if the ALOS can be further lowered then even more can be treated. Since the ALOS atAng Roka, Kirivong and Kampong Cham are 4.6, 5.5 and 7.3 respectively, it should be feasibleto lower the overall average.Further increases in demand would have to be addressed through investments in infrastructureas per the Health Coverage Plan.15 Costing of Health Strategic Plan (2008 - 2015). Mark Pearson. Health System Strengthening Cambodia Project,USAID. 2008.20
9. COMPARISON OF NORMATIVE WITH ACTUAL COSTSIn 2007 Ang Roka Hospital had 26 staff and spent $175,231. As a 60-bed CPA 1 hospital, toprovide the number of services that it did on 2007 it should have had 59 staff and a budget ofaround $258,000. The hospital director recognized the shortage of staff and identified a needfor 14 additional persons, although according to the norm they needed 33 more. In terms of keystaff, according to the norms, Ang Roka should have had 7 doctors (Medical Doctors andMedical Assistants), 18 nurses and 7 midwives. The hospital actually had 6 doctors, 12 nursesand 1 midwife, and was, therefore, severely under-staffed in these areas (see Annex 6 for abreakdown of the actual staff by hospital). The hospital only carried out 149 deliveries andspontaneous abortions, which may be partly because of the shortage of midwives. Also it hadno dental staff, no pharmacist and no kinetic therapist. It should have a total of 16 employeesengaged in non-medical roles such as administration and maintenance, but only had 4.Prey Chor Hospital had 28 staff and spent $170,160. As a 70-bed CPA 1 hospital, to providethose numbers of services that it did in 2007 it should have had 54 staff and a budget of around$227,000. The hospital director recognized the staff shortage and estimated that they needed17 more staff, although the norms indicate that they needed 26 more. However, if it operated at85% and reduced its ALOS from 6.3 to 4.6 (the level at Ang Roka) it could have treated 4,721inpatients (almost twice as many as it did treat) and provided 5,000 outpatient services with 65staff and a budget of around $290,000. Based on the CPA Guidelines, Prey Chhor should havehad about 6 doctors, 16 nurses and 6 midwives for the services that it provided in 2007.However, it only had 5 doctors, 10 nurses and 3 midwives, fewer than the norm all cases. Itshould have had16 employees in non-medical roles but only had 8. The low utilization rate(61% BOR) may be partly due to the low staffing level, but even with the low utilization rate thehospital appears to have been understaffed.Kirivong Hospital had had 49 staff and spent $400,442. As an 80-bed CPA 2 hospital, for thenumber of services that it provided in 2007 it should have had 108 staff and a budget of around$476,000. Again, the hospital director recognized the shortage and estimated that they neededan additional 19 staff, although according to the norms they needed 59 more. However, if itoperated at maximum capacity of 85% BOR it should have only treated 4,513 inpatients andprovided 8,000 outpatient services with 89 staff and a budget of $374,337. Based on the CPAGuidelines, Kirivong should have had 15 doctors, 41 nurses and 13 midwives. In 2007 itactually had 7 doctors, 24 nurses and 5 midwives, and was thus seriously short of these keystaff. It should have had 23 non-medical staff but only had 8.Kampong Cham Hospital had 204 staff and spent $1,091,618. As a 260-bed CPA 3 hospital, toprovide the numbers of services that it did in 2007 it should have had 314 staff and a budget ofaround $1,414,000 16 . However, if it operated at maximum capacity of 85% BOR it should haveonly treated 11,050 inpatients which would have needed 262 staff and a budget of around$1,183,000. The hospital should have had 70 doctors, 140 nurses and 38 midwives but onlyhad 40 doctors, 102 nurses and 24 midwives. It should have had 39 non-medical staff but onlyhad 28.Using the norms, all four hospitals required many more staff and significant extra funding for theservices that they provided in 2007, and as a result it is likely that the quality of care may have16 The hospital director estimated that they needed an extra 15 staff.21
Page 1 and 2: COST PROJECTIONS FOR THECOMPLEMENTA
Page 3 and 4: Recommended CitationCollins, David,
Page 5 and 6: ACKNOWLEDGMENTSThis study is the re
Page 7 and 8: The normative cost per service can
Page 9 and 10: 1. BACKGROUNDThe Cambodian MOH, wit
Page 11 and 12: 3. METHODOLOGYThe main source docum
Page 13 and 14: NORMATIVE COST MODELSThe second ste
Page 15 and 16: 5. ACTUAL UTILIZATIONA summary of t
Page 17: A comparison of the ALOS across the
Page 20 and 21: increased to cover the increased pa
Page 22 and 23: needed 15 more than the 219 they ha
Page 24 and 25: CPA 1PreyChhorCPA 3KampongChamUS$CP
Page 26 and 27: the Guidelines for each hospital. W
Page 30 and 31: een less than optimal. If they had
Page 32 and 33: in the second child survival study
Page 34 and 35: 12. CONCLUSIONS AND RECOMMENDATIONS
Page 36 and 37: ANNEX 1: CPA SERVICES (COPIED FROM
Page 38 and 39: ANNEX 3: CPA 1 STAFFING STANDARDS F
Page 40 and 41: ANNEX 5: CPA 3 STAFFING STANDARDS F
Page 42 and 43: ANNEX 7: COST MODEL EXAMPLE FOR CPA
Page 44 and 45: ANNEX 9: COST MODEL EXAMPLE FOR SMA
Page 46 and 47: ANNEX 11: COST MODEL EXAMPLE FOR LA
Page 48 and 49: MOH costing task teamDr. Lim Yi Nat
Page 50: 15. Scaling Up for Better Health in

Cost Projections for the Complementary Package of Activities - basics

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