Challenges in the Era of Globalization - iaabd

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Proceedings of the 12th Annual Conference © 2011 IAABD Table 2 says that, in all three hospitals, fixed costs exceeded variable costs substantially - more than twice as much at the mission and district hospitals and more than 13 times as much in the case of the referral hospital. The implication of our finding for all hospitals is that a reduction in the number of patients attended to without an adjustment in the structure of hospital costs will lead to technical inefficiency, Fuchs (1993), Roberts et al. (1999) and Wamukuo and Ntulela (2002). Our findings for the mission and district hospitals are lower than the 84% reported by Roberts et al. and Wamukuo and Ntulela. In all cases, the entire labour cost, Personal Emoluments, is virtually fixed and does not depend on the number of patients attended to. In addition, it is the biggest contributor to total costs, more than 50% in all cases. Thus, it would appear that, this is the first place to look to, to re-align resource allocations. The next item with a huge fixed cost component is Item 2: Total Administrative Costs. 97% of this item is fixed cost in the mission hospital; 98% in the district hospital and 89% in the referral hospital. Given the composition of this item – depreciation of equipment, equipment maintenance, travel and transport and utilities, it would appear that hospitals have little room to operate to reduce the proportion of fixed costs. Thus once again, all hospitals are vulnerable to a drop in the number of patients. On the other hand, fixed costs make up a smaller proportion of Item 3: Total Services Cost, 10% at both the mission and district hospitals and 40% at the referral hospital. Thus, this item is the one that is most directly tied to patient use of hospital services, and hospitals suffer least here if patient numbers fall. For further insight, we recall the Ghana Health Service (2009) report which speaks to “Inadequate resources for in-service training, fellowship and other management and leadership training.” The sub-item training and conferences under Item 3 captures expenditures on the item in question. While it is entirely a fixed cost, it makes up only 1% of total costs at each hospital. Training and conference attendance helps practitioners horn their skills and competences for better performance and are necessary. Fixed and variable costs at intermediate and direct patient-care centres In Table 3, we present the proportions of fixed and variable costs of each intermediate and direct patientcare center at each of the three hospitals. In all cases, fixed costs dominate variable costs. The dominance is least in the OPD. As calculated, the proportion of fixed costs at the OPD is influenced heavily by the sub-item Drug Consumables (drugs/medication issued to patients), which is entirely a variable cost, and an overwhelming number of hospital patients are outpatients. It is also influenced by the fact that the typical out-patient clinic uses few equipment, the main cost being doctors and nurses salaries. Primary Health Care (PHC) and Pharmacy are among cost centers with the highest fixed costs. While many outpatients report to the PHC unit for mother and child care, family planning, etc, not much of their variable costs are reflected here because, in general, they operate under the district and regional health directorates and receive drugs and other supplies directly from them. These are not reflected in hospital accounts. In the case of Pharmacies, there is no drug component, a variable cost. However, we note that on the whole, the cost of running Pharmacies is low, 2.5%, 11% and 8% at the at the mission, district and referral hospitals respectively. One also notes that, when cost centers within a hospital are ranked by the percentage of fixed costs, there are differences in the ranks attained by many centers from one hospital to another. For example, Radiology is higher than OPD only at the mission hospital, but ranks highest at the district and referral hospitals, while Children and Maternity wards rank very high at the mission hospital, but not as high at the district or referral hospitals. This observation lends support to the observation by Steinbrook (1996) and Woolhandler and Himmelstein (1997) that individual hospitals vary in the relationship between fixed and variable costs. 406
Conclusions and Implications Challenges in the Era of Globalization Edited by Emmanuel Obuah To position them to have a better handle on staff costs, it is recommended that hospitals (under the Ghana Health Service) consider restructuring contracts with hospital staff such that all staff costs are not fixed costs. As a policy, government can begin discussions with the Ghana Medical Association to move doctors off hospital payrolls and have them set up their own private consulting offices to attend to outpatients. Doctors will then bill the NHIS per patient. Beyond hospitals, the benefits of this more flexible contracting arrangement should please the NHIS. A similar conversation can be started with the Ghana Nurses and Mid-wives Council. If this is adopted, the NHIS would pay less during periods of low patient numbers. In fact, that does not have to be the end of the matter. Consider the case of one hospital that must pay an on-call laboratory technician specifically for performing tests at night as and when the need arises, versus another that hires a full-time in-house salaried technician at night. The cost of the technician in the first hospital is entirely variable, while the cost at the second is fixed. Depending on individual hospital situation the ideal cost saving strategies may be an on-call technician, or a full-time technician. Thus, the approach suggested here may not apply to doctors and nurses only. Table 3: Proportions of fixed and variable costs at intermediate and patient-care centers. Mission District Referral Fixed Variable Fixed Variable Fixed Variable Adult Medical/Surgical (Female) 79% 21% 77% 23% 83% 17% Adult Medical/Surgical (Male) 81% 19% 75% 25% 82% 18% Children's Ward 89% 11% 79% 21% 84% 16% Maternity/O&G 88% 12% 84% 16% 81% 19% OPD 53% 47% 40% 60% 54% 46% THEATRE 86% 14% 92% 8% 96% 4% Primary Health Care 97% 3% 88% 12% 94% 6% PHARMACY 92% 8% 87% 13% 94% 6% LABORATORY 78% 22% 89% 11% 84% 16% RADIOLOGY 69% 31% 92% 8% 97% 3% Accident/Emergency (OPD & Ward) 94% 6% Our findings further suggest that on a cost center basis fixed costs should be reduced at the Children and Maternity wards and the Theatre at the mission hospital; Laboratory and Radiology units of the district hospital; and the Theatre and Radiology units of the referral hospital. References Aboagye, AQQ., DEGBOE, ANK and OBUOBI, AAD. (2010a). “Estimating the Cost of Healthcare Delivery in Three Hospitals in Southern Ghana.” Ghana Medical Journal, volume 44(3), 83-92. Aboagye, AQQ and Degboe, ANK. (2010b). “Cost Analysis and Efficiency of sub-District Health Facilities in Two Districts in Ghana,” International Journal of Health Planning and Management. Published online in Wiley InterScience (www.interscience.wiley.com) DOI: 10.1002/hpm.1047 Fuchs VR. (1993). “No Pain, no Gain: Perspectives on Cost Containment,” N Engl J Med. 269, 631-633. Kwame, Ametor, “National Health Insurance Levy to Increase,” Radio discussion held on 18 Nov, 2010 http://www.xfmnewscenter.com/news/news.php?cat=General&title=NATIONAL+HEALTH+INSURAN CE+LEVY+TO+INCREASE%3F++ Roberts RR, Frutos PW, Ciavarella GG, Mensah EK, Kampe LM, Straus HE, Joseph G, and Rydman RJ. 407
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Table of Contents Challenges in the
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Lennart Bangens, Goteborg, Sweden C
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Local Steering Committee Jacob Musi
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Abstract Challenges in the Era of G
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Abstract Determinants of Bank Lendi
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Empirical Results Challenges in the
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Table 3 Determinants of Competitive
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Research Findings Challenges in the
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Abstract: Study on Africa Governmen
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Abstract Challenges of Oil Revenue
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Conclusion Challenges in the Era of
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37. Provision of sound education fo
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Variable Coefficient Std. Error t-S
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Abstract The Changing Requirements
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The Model, Data and Variable Defini
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Abstract Gender, poverty and sustai
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Source: Field survey, 2010 Table 3:
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Discussion and Conclusion Challenge
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Abstract What does Globalization me
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Banks in Ghana Challenges in the Er
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References: Challenges in the Era o
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The study seeks to: • examine typ
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Relationship Commitment Total 1264.
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Conclusion Dissatisfied 6 3.4 3.6 7
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