PHN- 8707 PHN Technical Note 87-7 A SINULAI(I NIN TO SUPPORT MM PMIMI AND OW U&LIU SmYCES: A& Oporatioral lamal am Toeasioal Notts by Dow C skrmievsky aud Irit Zr 4a April 1987 Population, Health and Nutrition Department World Bank The World Bank does not accept responsibility for the views expressed herein which are those of the author(s) and should not be attributed to the World Bank or to its affiliated organizations. The findings, interpretations, and conclusions are the results of research supported by the Bank; they do not necessarily represent official policy of the Bank. The designations employed, the presentation of material, and any maps used in this document are solely for the convenience of the reader and do not imply the expression of any opinion whatsoever on the part of the World Bank or its affiliates concerning the legal status of any country, territory, city area, or of its authorities, or concerning the deliminations of its boundaries, or national affiliation. PHN Technical Note 87-7 A SIWLATION NODU. TO SUPPOR THE PUNNIN A 1 BUDGETING ULT SUICES; Az Operational Nammal and Technical Notes ABSTRACT The model described hero delineates the real and financial relationships, observed or assumed, making up a health care system. It comprises a complete accounting of the system, based to the largest extent possible on data about resource allocation, relationships among outputs and inputs, and among inputs and budgets. The model enables the user to study: - The budgetary and unit-cost implications of changes in input prices; e The potential effect on output, unit costs and budgets of alternative allocations of real resources; e The resources needed to meet particular health care objectives; 3 The effect on demand for service of user fees. While it takes advantage of available information on a particular health care system, the model can also serve as an indicator of data needs for policy making and planning. In the absence of complete information, the model is designed to view the implications of alternative assumptions about relationships and variables comprising the health care system. This document is complemented by two IBM-PC compatible diskettes which contain LOTUS 1-2-3 (Version 1.A) files constituting the model. This is a prototype model which is designed to illustrate its potential and point to data requirements for its application. The model needs to be adapted to a particular health care system. Comments, questions, and suggestions for the model's further development would be appreciated by the authors. Prepared by: Dov Chernichovsky and Irit Zmora Consultants to the World Bank April 1987 Acknowlledgmat To are indebted to Niss Iori Sailo for her assistauss. PREFACE This is one of two technical notes to-supplement the Department's. ongoing work on financing health care in developing countries, and assist policy making, planning and budgeting of health services. The first note, titled Health Finance Planninu Model, prov.des a procedure for projecting the recurront costs, training and personnel implications of a set of planned health projects. The emphasis in the first paper is on a comparison of the availability and use of resources over time. The second note, titled A Simulation Model to Sunport the Plannina and Budaetina of Health Services, provides a framework to assess, (a) the potential impact of alternative levels and allocations of resources on the output of medical services; (b) the resource requirements to meet particular levels of output, at a given time. The models are intended to be altered to meet specific situations and it is expected that as experience grows with their application the technical notes will be revised accordingly. A SIMULATION MODEL TO SUPPORT THE PLANNING AND BUDGETING OF HEALTH SERVICES: An Operational Manual and Technical Notes Table of Contents Page No. INTRODUCTION . . . . . . . . . . . . . . . ... . . . . . . . . . . I CHAPTER I . OPERATIONS OF THE MODEL AND ITS DATA NEEDS . . 4 . . . 4 I.1. OPERATIONS OF THE MODEL . . . . . . . . . . . . . . 4 1.1.1. Changes in Resources . . . . . . . . . . . 4 I.1.2. Changes in Demand and Need . . . . . . . . 6 I.2. DATA AND RESEARCH NEEDS . . . . . . . . . . . . . . 7 I.2.1. Data Needs . . . . . . . . . . . . . . . . 7 I.2.2. Research Needs. 8 CHAPTER II-: OPERATIONAL MANUAL . . ... . . . . . . . . . . . . . 9 II.1. INTRODUCTION. . . . . . . . . . . . . . . . . . . 9 II.2. CHANGES IN PRICES AND REAL RESOURCES. . . . . . . . 16 II.2.1. Wages. . . . . . . . . . . . . . . . . . . 17 II.2.2. Total-Labor. . . . . . . . . . . . . . . . 19 II.2.3. Labor. . . . . . . . . . . . . . . . . . . 20 -II.2.4. Capital. . . . . . . . . . . . . . . . . . 24 11.2.5. Investment . . . . . . . . . . . . . . . . 25 II.2.6. Depreciation . . . . . . . . . . . . . . . 26 1I.2.7. Exit . . . . . . . . . . . . . . . . . . . 27 II.2.8. Continue .28 II.3. OUTPUT DATA: Summary Tables on Resource Allocation, Budgets and Output of Services . . 30 I1.3.1. LABORI: Total Labor by Facility/Service. 32 II.3.2. LABOR2: Types of Labor by Services . . . . 34 11.3.3. LABOR3: Types of Labor by Facility . . . . 35 I1.3.4. CAPITALI: Capital by Type of Service . . . 36 11.3.5. CAPITAL2: Capital by Type by Facility. . . 37 I1.3.6. VISITS/PATIENT-Days by Services aid Facilities. . . . . . . . . . . . . 38 11.3.7. BUDGET Requirements by Services and Facilities (in Pulas) . . . . . . . . . 39 Page No. - tI.3.8. BUDGETI: Labor Cost by Services and Facilities. . . . . . . . . . . . 40 11.3.9. BUDGET2: Labor Cost by Type of Labor and by Service. . . . . . . . . . . . . 41 I1.3.10. BUDGET3: Labor Cost by Types of Labor and by Facilities . . . . . . . . 42 II.3.11. BUDGET4: Capital Costs by Service and by Facility . . . . . . . . ... . . 43 I1.3.12. BUDGET5: Capital Cost by Type of Capital and by Service. . . . . . . . . 44 II.3.13. BUDGET6: Capital Cost by Type of Capital and by Facility . . . . . . . . 45 II.3.14. EXIT . . . . . . . . . . . . . . . . . . . 46 II.4. ANCILLARY AND OTHER SUPPORT SERVICES. . . . . . . . 47 II.4.1. Changes in Data on Ancillary Services. . . 48 II.4.2. Ancillary Services - Results. . . . . . . 50 II.5. INPUT DATA: DEMAND OR NEED FOR SERVICES 11.6. INPUT-OUTPUT DATA: COMPARISON OF ACTUAL BUDGET WITH MODEL'S BUDGET . . . . . . . . 61 CHAPTER III THE DESIGN OF THE MODEL: TECHNICAL NOTES . . . . . . 63 11il. POPULATION, RESOURCES AND SERVICES. . . . . . . . . 63 III.1.1 Population and Services. . . . . . . . . . 63 III.1.2. Population and Resources . . . . . . . . . 65 III.1.3. Resources and Services . . . . . . . . . . 65 III.2. THE HEALTH CARE SYSTEM .66 III.2.1. Services and Facilities. . . . . . . . . . 66 1II.2.2. Output and Outcome Measures and Indicators. . . .67 III.2.3. Inputs and Resources: Labor, Capital and Support Services. . . . . . 68 IT1.2.4. Revenues from Services . . . . . . . .. 71 III.3. BASIC RELATIONSHIPS . . . . . . . . . . . . . . . . 71 111.3.1. Inputs and Outputs . . . . . . . . . . . . 1 IIT.3.2. Ambulatory and Preventive Services and Ancillary Services. . . . . . . . . 71 TII.3.3. Administration, Super-vision and On-the-Job Training . . . . . . . . . 75 111.3.4. Referrals. . . . . . . . . . . . . . . . . 75 A SIEULATION ODEL TO SUPPORT TME PLAMNU AND M BUD6rKNS OF H01AWL SURVICES: Am Operatiozml Mawwal and Technieal Notes INTIODUCTIOK Policy making, planning and budgeting for public health services where clear market signals are lacking, are complex activities; they involve numerous products or services, a complex multitude of inputs, and varying epidemiological and other population characteristics. All these variables are linked through relationships and parameters whose varying forms and values are at times unknown because of a lack of data. Yet, their manipulation by policy makers and planners is inevitable. The complexity of these activities stems to a substantial degree from the limited ability of policy makers and planners to have a quick view of the full consequences of alternative decisions they may make and of the sensitivity of the outcomes of particular decisions to varying assumptions about health care system relationships and parameters. For example, policy making and pursuant planning and budgeting are concerned with questions like the following: what if the availability of a particular resource (e.g., general practitioners) increases; what would bo the impact on the output of different services and the impact on health measures of alternative allocation decisions of given resources; what would be the derived need for other resources (e.g., ancillary services. drugs); what would be the budgetary consequences of those decisions. In short, what are the impact and full resource and unit cost implications of any particular decision? 2 Sensitivity questions then may follow: how sensitive are outcome measures to assumptions about the marginal productivity of general practitioners; to the ratios between any two inputs, e.g., physicians and nurses. A quick display of possible scenarios, outlined in terms of outputs and impact or budgetary and other resource implications, should substantially enhance the efficiency of policy making, planning and budgeting. Timely answers to planning and budgeting questions can give clear perceptions of alternatives, opportunity costs, actual costs and effective real and financial constraints. The model described here delineates the real and financial relationships, observed or assumed, making up a health care system. It comprises a complete accounting of the system and is based to the largest extent possible on available data and research. In the absence of data it is basod on assumptions which can be modified. The dynamics are introduced into the model by the user through changes in variables, parameters and relationships. The model aims to deal with the following: (a) The budgetary and hence unit-cost consequences of changes in input prices. (b) The potential consequences on output, unit costs and budgets of alternative allocations of existing or additional resources. (c) The resources neoded to meet particular health care objectives. (d) The consequences of alternative induced supply and demand responses, e.g., policy changes in wages of health practitioners and fees users pay for service. While the model takes advantage of information available on a particular health care system, it can also serve as an indicator of data and research needed 3 for structured policy making and planning. The model constantly poses questions about critical assumptions and changes in behavior and environment that will need to be answered with new data. At the same time the model is designed, in the absence of complete information, to view the implications of alternative assumptions about relationships and values. Hence the model is a second best. In the absence of full information and knowledge, it is believed to be superior to decisions based only on pure judgement which often suffer from a lack of tools for fast viewing of alternatives. This document comprises three parts. In the first introductory part, the operations of the model and its data and research needs are described. In the second part, an operational manual, the user is instructed on how to use the model. In the third part, the structure of the model and its analytic features are outlined. To avoid dealing with a 'black box', the reader is urged to go through the technical notes. This document is complemented by two IBM-PC compatible diskettes which contain LOTUS 1-2-3 (Version 1.A) files constituting the model. The user should install these diskettes on a hard disk and use Lotus 1-2-3 for operating the model.' This is a prototype model which is designed to illustrate its potential and point to data needs for its application. The model needs to be adopted to a particular health care system. Comments for the model's further development would be appreciated by the authors. 'Rudimentary knowledge of Lotus 1-2-3 is sufficient to operate the model. 4 CNRAPm I : OPATIONS OF THE YODEL AND m DATA NnDS I.1. OPUATIONS or D E MODEL The model is designed to answer policy, planning and budgeting questions through simulations with alternative situations and potential solutions. Policy making, planning and budgeting deal with two basic types of changes considered exogenous in this model: (a) Changes in resource availability or constraints for all or particular services. (b) Changes in 'needs' or health and medical care objectives. In the first instance, planning involves the allocation response to changes in resources given a policy objective function. In the second, it involves the response to changes in policy objectives given resource constraints. The two situations involve simulations with alternative planning or allocation solutions and their budgetary and output consequences. The model presented here is a short run model that provides for simulations with alternative decisions involving resource allocation. Two basic situations are considered (a) when overall real resources are given and (b) when particular or all or some resource constraints are relaxed. 1.1.1. ClasEes *i Resoarc-s In operating the model, the user can introduce three general types of changes for simulation purposes: changes in input prices, in real resources, and in financial resources. 5 Changes in Prices Changes in prices of primary inputs (labor and capital) and intermediate inputs (drugs, disposables and ancillary services) alter the unit cost of services in different facilities and have budgetary implications. Such changes may initiate a process of resource reallocation similar to those implied by a change in financial resources with a probable focus on the consequences of shifting away from inputs whose relative prices have increased. While changes in prices are treated by-and-large as exogenous to the systemB they can be made endogenous in ways suggested in section III.1.3. A planner may wish to simulate with the implications of various supply responses to changes, say, in wages of labor for their real resource and budgotary implications. Chanses in Real Resources A change in a real resource, e.g., the number of physicians available in the system, raises questions about alternative allocations, additional requirements of complementary resources and their full financial implications. The model is designed to answer the following questions with regard to a change in a particular real resource: (a) What would be the changes in the output of existing serviees of alternative allocation decisions? (b) What would be the changes in derived requirements for other intermediate outputs (drugs, x-rays, etc.) of each such allocation decision? (c) that would be the financial consequences of the changes described in questions (a) and (b)? By dealing with these, the model can assist in investment decisions; it can be helpful in assessing periodic (e.g. annual) output and operating cost of such decisions. This last point is important because in health services some 6 investment decisions are commonly made without regard to subsequent requirements in operational resources. Chanxes in Financial Resources A change in the availability of financial resources provides managers with the option to prooure the resources they desire.- Eventually, changes in financial resources lead to changes in real resources. With the aid of the model, planners and managers can view changes in output and cost of alternative procurement decisions and compare among them. 1.1.2. QMaros ii Demsad and No Planning is often initiated by perceptions about needs or demand for services. The policy maker or planner May wish to assess alternative designs and resource requirements implied by changing population size, characteristics and epidemiology. Output can be made a function of various population, epidemiological, socioeconomic and institutional parameters as suggested in relationship (2) in section III.1.1. below. The relationship between particular output and population size and characteristics can be established through sheer projection of size of population and through studies about utilization of, or demand for, services. The relationship between age distribution, epidemiology and use of services can be established through planning coefficients based on definition of need. Whether determined on the basis of demand or on the basis of need, once different desired or planned levels of output are determined, the model answers the following questions: (a) What are alternative services and delivery options to achieve particular- levels of output? 7 (b) What are the real and financial resource requirements to meet those levels under different alternatives? I.2. DATA AND RESUARC NEEDS The model comprises a complete accounting system of health care services in a particular environment; it is based to the largest extent possible on service data and information obtained through research. At the same time the model can also serve as an indicator of data and research needed for rational decision making. In fact, the model will be constantly posing questions about assumptions and changes in environment and behavior that should be answered by new data and research. 1.2.1. Data Needs Specific data needs relate to establishing a full accounting of the flow of resources in the system. These needs include: (a) Allocation of manpower by types, by types of service and facility. (b) Allocation of land, structures, and equipment by service and facility. (c) Consumption of drugs and other disposables by service and facility. (d) 'Levels' of administrative ancillary services used by service and facility. (e) Unit costs for each input including capital costs (interest and depreciation) for capital. (f) Levels of output, observed or assumed, per service and facility with given inputs of resources (a) and (b). (g) Levels of impact, observed or assumed, per levels of output.' zThese questions are not yet integrated in this model. 8 These data are useful in establishing the running costs of the system and any of its components, delineated by services and facilities, and the investment requirement for its expansion. Unit costs of services by facility, or of output, are established as well. 1.2.2. Researek Needs Research needs pertain to economic and other relationships underlying the model. These concern the following general issues: (a) The production functions of the system: the relationship between inputs and outputs and among inputs. (b) The long-run supply functions: the linkages, observed or assumed, between size of population and supply of resources, real and financial. (c) The short-run supply functions: the supply responso of inputs, labor in particular, to changes in their unit costs. (d) The demand functions: the demand response of the population to changes in socioeconomic conditions and institutional arrangements, e.g., fee for services. (e) The relationship between use of service and impact on morbidity, mortality and productive time lost because of illness. The data and research needs must be viewed in the right perspective with regard to this model. Better information will yield a better and more reliable model. At the same time the model is designed, in the absence of full information, to view quickly the implication of alternative assumptions about different parameters, relationships and values. CNAPElt II : OWEIRTICNL MANUAL II.1. INlmoDUCTI This chapter leads the user through the various computer files comprising the model. It explains at each step what the user is required to do and what is done by the model. The process starts with data the model needs. The user is asked to change data, if he or she wishes, or confirm the data given in the model as part of its initial design. These data may include unit costs of inputs, real resources and their allocation among different services and facilities, financial resources, and levels of services the system may wish to provide. There are some basic assumptions used by the model as to the types of services and facilities comprising the health care system, the types of resources used by it, and the relationship between output and these resources or inputs, and the relationship between the population it serves, resources, and services. These relationships are discussed in detail in Chapter III. Table II.1 lists the types of services and facilities used in this particular design which is in line with the health services of Botswana. Output of ambulatory services is in terms of "visits' or lcontacts. Output of. inpationt services in terms of *patient daysm (alternatively, one can assume 'cases'). The resources assused in the model are of two main types: Labor and capital. They are listed in table II.2 for the particular design here. The relationship between the resources and output in each operational unit or 'cell' in this table is established through a so called production function (see Section III.3). There are also other inputs, drugs, auxiliary and administrative services. Their levels 10 and costs are considered to be derived from levels of operations and ouput of.the health care system. Before guiding the reader in the operations of the model, its coMputor files are described below. PILd I. DATA The user uses this file for his or her input. Here the user is first introduced to the operations of the model and is asked to input data, or change existing data. These inputs can be as follows: TAGS: The types of labor assumed in our model are: Specialists, GPs, Registered nurses, enlisted nurses, FWEs and other personnel. The user can change average wages of each or all types of labor for budgetrary implicatlons. CAPITAL: (Invoat .t) The types of capital assumed are: i) rooms (buildings), ii) vehicles, iii) beds, and iv) equipment. The model assumes the same acquisition costs of capital for all facilities and services. The input dat& are average unit costs of each type of capital. DEPfRCIIMCE: For each type of capital, years of depreciation can be input into the model. The user can change assumptions regarding these numbers. The user may add-to this rate capital gains or losses for specific items. COST r CAPITAL: The interest rate used. The model assumes one interest rate for all types of capital. LABOR: Total number of workers of each type employed in the system. The user can change the numbers at his or her discretion depending on real or assumed availability of resoureces, for their impact on budget, output and unit costs of services. 11 DmISIC OF LAZO AONf SEUICES AND FACII.ITIU: The model enables the user to allocate total available labor by type among services and facilities through appropriate ratios. For example, one can assume 80% of the availbale specialists work in hospitals and 20% in supervision. Division between services is similar: for example, 20% of their time specialists might devote to surgery, and only 5% to psychiatry, etc. The division of labor of each type among services and facilities can be changed by the user to assess implications on (gains and losses) in output of different services, budgetary implications, and unit costs. PIZ III.* RESLTS Main summary file for supply or production side of the model. This file does not include information on administration costs or or requirements of ancillary services and drugs. These are handled in separate files. All the results are arranged in tables, usually with facilities on the horizontal axis and services on the vertical axis. The user is invited in this file to go over the summary tables, according to his choice, and then decide to print or transfer the summary tables to his own files etc. There are 13 summary tables, as follows: i. LABORl Total labor for each service and facility ii. LABOR2 Labor of each type within services iii. LABOR3 Labor of each type within facilities iv. CAPITALI Capital of each type by services v. CAPITAL2 Capital of each type by facilities vi. VISITS Visits and patient days by services and facilities 12 vii. BUDGET Total labor and capital budget by services and facilities3 viii. BUDGET1 Labor cost by services and facilities ix. BUDGET2 Labor cost by type of labor and service X. BUDGET3 Labor cost by type of labor and facility xi. BUDGET4 Capital cost by services and facilities xii. BUDGETS Capital cost by types of capital and services xiii. BUDGET6 Capital cost by types of capital and facility FILE IV. ANCIMALJ This file deals with resources and costs of resources of other than labor and capital, e.g. drugs, labtests, x-rays, administration and nbudget. It is based on relationships (7), (8) and (17) of chapetr III. This file concerns the derived demand in units for these services and their cost. It leads to a set of files summarizing the costs of these services. FILE V. DEKAND This file (not yet fully implemented for the user who is not familiar with Lotus 1-2-3) enables the user to set objectives or demand levels for different services based on epidemiological data etc. or set a fee through PRICES (file) as a means to 'regulate' demand, on the one hand, and wcreate' revenues on the other hand. The data from this file is later compared with data on output, VISITS, and costs in RESULT2 file. 3 Total budget - only labor and capital costs included, not administration and ancillary services. 13 This file uses data from DEMAND file and information on referrals (not yet changeable by user) to calculate total demand - direct and indirect. (The file is not yet fully implemented for users not familiar with LOTUS 1-2-3). PIuE VII. ESILT2 This last file incorporates the (-recurrent) financial resources available to the health care system, with resource requirements per different changes introduced earlier on the model. The model also uses other files, as working files of the model, or as intermediate files. The user is not required to know them, or to refer to them. Figure 1 describes the files in a flow-chart. 14 Table 11:1 Services-Facilities Matrix Health Health Supervisi Facilities Services Post Clinic Center Hospital Health-Te School Health Environmental Health Nutrition Health Education Family Planning Immunization Primary Health Care Maternal Health-Short Term (ST) Child Health (ST) Dental Health (ST) Other Short Term Maternity-Long Term (LT) General Long Term Child Health (LT) Medicine (LT) Surgery. Ophthalmology OtIxer LT Psychiatry Table 11:2 List of Labor amd Capital Inputs by Type LABOR CAPITAL ANCILLARY Specialists (SP) Buildings (Capl) Drugs General Practioners (GP) Vehicles (Cap2) Labtests Registered Nurses (RN) Beds (Cap3) X-Ray Enlisted Nurses (EN) Equipment (Cap4) Administration Family Welfare Workers (FWE) Others 1S ilmrze No. 1 PLO CUR CT OFlFu IN a D5. DATA RESULTS LABC-iRl -BE>LIEI\ \ LABOR2 B UD Gi ET 1I LABOROe: BLIDGlET27\ C:AFPITAL 1 BUD:§GET:3 CAFITAL2 .BUDGET4 VISITS 8LIDGET5 ,LID1L~ET~. ANCILL R(- -+ PgL48ND LABTES A Dr.MIN NBUIm-E -r' /2REFER RESiULT2 16 WDWa CU DU L Enter the LOTUS SYSTEM, and retrieve the file DATA by typing M/FRDATA0 and pressing the key. This file will lead you through the Various resources assumed by the model, and enable you to change the amounts as YOU wish in tho model. 11.2. CRAP*= IIN MRICES A1W REAL After a while you will see the following screen: AA1: 'The model enables you to see the effect of changes in some of the READY AA AB AC AD AE AF AG AH I The model enables you to see the-effect of changes in some of the 2 parameters of the model on results. At this stage, changes that c can be -put into the model are: 4 A. changes in wages (Wages) 5 B. changes.in cost of investment (Invest) - C. changes in years of depreciation (Deprec.) 7 D. changes in cost of capital (interest rate)(Capital) a E. changes in the division of types of labor between 9 facilities (Labor) 10 F. changes in total labor of one or all types (Total). 11 Choose the changes you are interested in: they will appear on a menu. 12 You will be required to do the changes, and then asked what output 13 tables interest you. 14 CA CS CC CD CE CF CG CH I 2 4 S 09-Sep-86 05:01 AM CMD We shall sow go with you through each of these possible changes in resources. If you press as indicated on the screen, you will see at the top of the screen the following MENU: 17 Waxes Total-labor Labor Kaiital Invest DeDreciation Continue Exit (Yes, we know you write Capital with a C, but the MENU works better if it is written with a K). This MENU includes the commands that will bring you to the various possible changes that are discussed below. 11.2.1. aa*s, Let us start with WAGES which is the first on the MENU list. If you typo ww (for WAGES) or just move the pointer to the place where WAGES is and press (RETURN>, you.will see.tho following screen: D4: U 900b READY A B C D 3 A.CHANGE IN WAGES 4 SPECIALIST 9000 5 GP 8000 6 REG.NURSE 6000 7 ENLI.NURSE 4000 8 FWE 1500 9 OTHER 3000 10) 11 12 13. 14 15 B. CHANGE IN INVESTMENT 16 CAPITALl/ROOMS 4000 AA AB AC AD AE AF AG AH 1t0 The numbers which appear on the screen are our own estimates. 101 You may change any of them. Go to the cell which yout want to change. 102 f'ut in your own number, and move on to the next cell you wish to 103 change. using the arrows. When you finished with the changes 104 09-Sep-86 05:01 AM CMD 18 The upper window of the screen gives you estimates of annual wages (in Pulas) for the different types of labor. The bottom includes a short explanation of what you are required to do. Assume, for example, that you want to change the wages of the enlisted nurses from 4000 to 6000. Move the pointer to the place where 4000 is written (using the down arrow key three times), type "6000", and press (RETURN>. The number in the cell changes to 6000, and the bottom window changes too, and asks yoU if you wish to make another change in this table. 106 Do youL wish to make some more changes in above table? 10.7 If yes: type 1 If not: type 0. and we shall return you to the menu. 109 to continue to make more changes. If you don't, type "0" and press , and you will be brought back to the MENU. If you wish to make more than one change at one time, just type the change in the correct cell, and without pressing , move to the next cell you wish to change by using the up and down arrows. Only by pressing the key will the model continue to ask you if you have finished with the changes, or wish to make more. 19 11.2.2. Tetal-Labor Lot us now go to the second item on the MENU: TOTAL-LABOR. To get there, either type IT* or move the pointer to "wOTAL-LABOR' and press . You will see the following screen: S42: U 30 READY A B C D 41 F. CHANGES IN TOTAL NUMBER OF LABOR 42 SPECIALIST 30 43 GP 50 44 REGIS.NURSE 120 45 ENLISTED NURSE 760 46 FWE 390 47 OTHER 90 48a 49 50 51 E2 -. 54 AA AB AC AD AE AF AG AH 100 The numbers which appear on the screen are our own estimates. 101 You may change any of them. Go to the cell which you want to change. 102 Put in your own number, and move on to the next cell you wish to l(Q3 change, using the arrows. When you finished with the changes 104 09-Sep-86 05:02 AM CMD The top window shows the number of personnel of each type of labor employed by the health care system. (Can be seen as FTEs, positions, etc.). For example. the total namber of specialists is 30, and that of registered nurses is 120 Again, you can make changes in the numbers written by moving the pointer to the cell you wish to change, and typing your own numbers there. After making each change you are asked (at the bottom window) whether you wish to make more changes, or return to the MENM (bottom window). If you wish to make more changes, type 11' 20 and press ; if you want to return to the MENU, type 10 and press . 11.2.3. Labor Let us now go on to the next item on the MENU by typing TL", or moving with the arrow to the right, to bring the pointer to the LABOR item and press . This item is a little more complicated than the first two, and to explain it we provide a screen which explains the meaning of division of labor between services and facilities. You will see the following screen: .^D44:,c, AD AE AF AG AH AI Ai A VI' 44 CHANGES IN DIVISION OF LABOR 45 Changes in division of labor: The model assumes each type labor 46 is divided in some proportion between the facilities and the services. 47 For example, one can assume specialists are divided Sl0% in hospitals and 48 20o. in supervision, - this is division between facilities. 49 50 Division between services is similar: for e.:ample, 20% of their time 51 Specialists might devote to surgery, and only 5% to psyciatry, etc. 52 You can choose your own division of labor of each type. 53 We shall first show you our division or labor beween facilities, and 54 enable you to make changes there. 55 56 -PRESS RETURN> 57 CA CB CC CD CE CF CG CH 1 4 s C)9-Sep-86 (:)5:0J Am CMID 21 After reading it, press and the following screen appears: F3: (PO) U Cp READY E F G H I J K L 1 E.CHANGES IN DIVISION OF LABOR BETWEEN FACILITIES: 2 HP CLINIC - HC HOSPITAL SUPERVISE TOTAL 3 SPECIALIS 0% 0% 1o% 80% 10% 100l. 4 GP C.% lO 20% 60% 10i 100% 5 REG.NURSE 0% 10% 20X 50% 20% 100% 6 ENLIS.NUR 0.% 3Z0% 20% 407. 10t% 10O 7 FWE 60% 4C)-. 07. 0X 0% lOC% 8 OTHER O% 101 l-)0% 50% 100.% 9 1o 11 12 1:3 14 AD AE AF AG AH Ai AJ AK 20 Make the changes you want in diVision of labor, by moving on the screen. 21 The screen might be too small to contain the whole table, and yoLu can 22 move also to the si-des of the screen, unseen at this momen. After you 23 made the changes, we shall move you on to change in division between 24. services. -::PRESS RETURN; 09-Sep-86 05: 04 AM CMD In this screen, the division of the different typos of labor between facilities is given in percentages. In our screen, for example, specialists work in hospitals 80% of their time and in supervision 20% of their time, enlisted nurses spend 40% of their time working in Health Posts, 20% in clinics, 20% in health centers, 10% in hospitals, and 10% in supervision. If you want to change this division of labor between facilities, move the pointer to the cell you wish to change by using the arrows, make the change, and move on with the arrows.4 4 The percentages havo to be written either as '40%', with the *%" sign, or as a decimal '0.4". 22 After pressing you are automatically moved to the next screen, which shows the actual division of labor between services. Be careful not to press before making all the changes you want (if this happens, however, you can go through the MENU and go-back to this screen again). Below is the screen of division of labor between services: N_:ti. 1 FEC Ii N O F' 0 R S 1 F. CHAiNGES IN DIVISION OF LABOR BETWEEN SERVICES SPEC. GP REG.NURSE EN.NURSE F.W.E. OTHER 7 Environmental health C) C) O 1 1 1 4 School health 0 1 1 1 1 1 5 Nutrition - C C 1 1 1 1 6 Health education C 1 1 1 5 1 7 Family planning 1 1 1 1 S 1 8 IrmMunization C) 1 1 1 0 9 Primary HC 0 5 5 10 1 10. Maternal (short term 1 '2Z 2 1 1 11 Child (short term) 1 2 3 2 1 12 Dental Health (s.t.) 2 t) 1 C) 2 1. Other short term 1 1 1 1 1 1 14 Maternitv (l.t.) 5 2 5 1 C 1 AA AB AC AD AE AF AG AH 100 The nutmbers which appear on the screen are our own estimates. 101 You may change any of them. Go to the cell which you want to change. 102 Put in YCLUr own number, and move on to the next cell vou wish to 10n change, utsing the arrows. When you,-Finished with the changes 10C)4 - "PRESS RETURN> 09-Sep-86 05:05 AM CMD Here the screen is not large enough to show you the whole table, but by using the arrows you can easily move outside the borders of the screen to the rights or to the bottom. The division of labor between services is not shown in pOrcentages, but in whole numbers, called units'. If you prefer to have the division of labor in percentages, you can of course write down your numbers in percentages. The units we use have no special meaning. You could use the actual numbers of personnel working in each service, or just some proportions - as is 23 used here. For example, we assumed there are 16 'units' of GPs divided betwe-en the services - 5 units in primary health care, 1 unit in immunization, etc. If you use different numbers, the TOTALs will change accordingly, and that is fine with the model. After making the changes - moving with the arrows again to make them - and pressing , you can still change your mind and make some more changes, or go back to the RNEU. This part concludes the changes for LABOR. We now move on to data required for CAPITAL resources. Remember, we have four types of capital in our model which we shall use in the model data regarding the cost of each type of capital, regarding the interest rate (or cost of capital) existing (or assumed), and regarding the depreciation years of each type of capital. 24 11.2.4. Capital At this stage of the model development the physical units of capital are sets and cannot be changed by the user. The user can only change the cost of capital.s Let us start with the simple one - move to KAPITAL and you see the following- screen: F>21: (P2 -U U.06 RE AD Y E F G H I J k 20 D. CHANGE IN INTERSET 21 CAPITAw 6. 0(% 24 2. 26 27 29 AA ASB ACA EA G A2H 100 The numbers which appear on the screen are our own estimates. 101 You may change any of them. Go to the cell which you want to change. 102 Put in your own number, and move on to the next c'ell you wish to 103 change, utsing the arr(ows. When you finished with the changes 104 _PRESS E 09-Sep 0 AS AC) AM CMD You have to accept or change only one number - that of cost of capital or interest rate, which you assume. We assumed 6% cost of capital - for all types of capital. If you agree, press , then type '0' and press and it will return you to the MENU. If not - make the change you want, press , and type 00" to return to the MENU. ' A model which enables the user to change capital inputs is available by request from the authors. 25 The next item on the MENU is INVEST. By typing I, or moving the pointer to INVEST and pressing you got the following screen: B16: U 4000 * READY A B C D 15 S. CHANGE IN INVESTMENT 16 CAPITAL1/ROOMS 4000 17 CAPITAL2/VEHICL 50001 18 CAPITAL3/BEDS 8000 19 CAPITAL4/EQUIPM 2000 20 21 2 2 23 24 2 5 26 27 2S AA AS AC AD AE AF AG AH lt0 The numbers which appear on the screen are our own estimates. 101 You may change any of them. Go to the cell which you want to change. 102 Fut in your own number, and move on to the next cell you wish to 10i: change, uising the arrows. When you *finished with the changes 104 PRESS RETURN": 09-Sep-6 o5K' 07 AM CMD The estimated nunbers are unit costs of basic capital units of inputs -- in Pula per unit (per room, or per vehicle, or per bed in hospital, or per basic equipment). Again, you can make the changes you want, or be satisfied with existing numbers, and return to the MENU. 26 11.2.6. Dboreoiatiom The last item which relates to data and changes is DEPRECIATION. Below is the screen you see, after typing 'DI or moving to DEPRECIATION on the MENU and pressing : DZ1: U EW203 100Q READY C D E F G 30 C.CHANGE IN DEPRECIATION TIME (YEARS) 31 CAPITAL1/ROOMS 0OO '2 CAPITAL2/VEHICLES 5 33 CAPITALZ/BEDS 50 34 CAPITAL4/EQUIPMENT 10 .5 76 37 :S9 4i 41 ER OF LABOR 42 4Z AA AB AC AD AE AF iAG iAH 100 The numbers which appear on the screen are our own estimates. 101 You may change any of them. Go to the cell which you want to change. 10x2 Put in your own number, and move on to the next cell you wish to 103 change, using the arrows. When you finished with the changes 104 'PRESS RETURN; 09-Sep-86 05:08 AM CMD The asubers are years of depreciation for each type of capital. Thus we assumed 50.years of depreciation for buildings (rooms), and 10 years for equipment, etc. Again, make the necessary changes you wish, and return to the MENU. 27 II.2.7. Exit The two last items on the IEN1 are: EXIT and CONTINUE. The EXIT item enables you to leave the model at each time and terminate the session. BE41 U I CMD READY BA B9 BC BD BE BF Fie BH I DO YOU WISH TO QUIT NOW? 2 To quit type 1 3 To continue with model type 0 4 1 5 6 7 8 9 10 11 12 i3 14 CA CB CC CD CE CF Ca CH I 2 3 4 5 If you wish to quit, but want to save the changes you have made so you don't have to aake then again, remember to save the file by typing: NIFSDATAO and press and type MrM (to replace the old file). 28 11.2.8. CoatiaO. If, after working hard and changing the data, etc., you wish to see the results of the model, type IC' (for CONTINUE) and let the model work for you. First you will see a screen which describes to you all the summary tables that the model can give you. '4A115: 'SUMMARY TABLES: - FED AA AB AC AD AE AF AG NH 115 SUMMARY TABLES: 116 There ex CA CB CC CD CE CF CG CH 1 4 -5 09-Sep-Sb 05;09 AM CMD 29 After reading this screen, press to move to the next screen, with another list of more swmary tables. AA13(: 'Budgets: there are seven budget summary tables READY AA ABI AC AD AE AF AG AH 130 Budgets: there are seven budget summary tables 131 1. Total budget for each service by facilities 172 2. Total labor cost by service by facility 1ZZ 3. Labor cost by type of labor by service 1Z4 4. Labor cost by type of labor by facility 135 5. Total capital cost by service by facility 136 6. Capital cost by type of capital by service 137 7. Capital cost by type of capital by facility 138 and read the next screen. AAl50: 'You can choose to see all these tables, or some of them. READY AA AB AC AD AE AF AG AH 150 You can choose to see all these tables, or some of them. 151 They will be saved by you in the files you will name. 152 Now the coputer will continue with the process - put in all the changes 153 You made, and do the proper computations. Once these are done you will 154 be asked what summary tables you would like to see. 155 156 BE PATIENT! 157 IT TAkES THE COMPUTER SOME TIME TO PUT IN ALL THE 158 CHANGES YOU MADE, AND TO DO ALL THE NECESSARY COMPUTATIONS! 159 PRESS RETURN:, 160 161 162 163 1 CA CB CC CD CE CF CG CH 1 4 09-Sep-86 05: 1t' AM CMD _- - - - _ _ _ _ _____ - -_ - - - - _ _ _ _ _ _ _ _ _ _ _________ - - _ - - _ ____ - - _ _ __ _ _ _ _ _ _ _ __ __ __ __ _ _ _ _ __ 30 Press again. Now the model starts working for you. As it is not a very simple model, and requires many calculations, it will take a while, with screens changing quickly from time to time, or telling you to wait patiently. As long as the WAIT sign continues to blink at the top right side of the screen, the model is still working. When it stops flashing WAIT and says CMD READY, you can continue to see the summary tables. 11.3. OWIPUT DAIA: Su-ary Tabies ou Rbso@re Allo.atiom, Budgets asd Output of Services All the s-mmary tables are located on a file called RESULTS. To remind you what summary tables the model has, we show you again on the screen below the list of tables, before you continue: DAl: 'All the summary tables are located in this file. CMD READM DA Ds DC DD DE DF DG I All the summary tables are located in this file. 2 To remind you there are the following summary files: ' 1.. LABORi Total labor for each service and facility 4 2. LABDR2 Labor a+ each type within services 5 3. LABOR3 Labor of each type within facilities 6 7 4. CAPITALl Capital of each type by services 8 5. CAPITAL2 Capital of each type by facilities 9 10 6. VISITS Visits and patient days by services and facilities 12 7. BUDGET Total budget by services and facilities 13 S. BUDGET1 Labor cost by services and facilities 14 9. BUDGET2 Labor cost by type of labor and service 15 lO.BUDGET3 Labor cost by type of labor and facility 16 11.BUDGET4 Capital cost by services and facilities 17 12.BUDGET5 Capital cost by types of capital and services 18 13.BUDGET6 Capital cost by types of capital and facility 19 `,PRESS RETURN> 20 31 After reading it, press to move to the next screen, which explains the special menu we use here: DA25: 'Using a special menu you can go through the summary tables, CMD MENU LABORL LABOR2 LABOR: CAPITiELl CAPITAL2 VISITS NEXT-MENU EXIT Total labor by service and facility DA DB DC DD DE DF DG 25 Using a special menu you can go through the summary tables, 26 and decide if you wish to save them in a separate file, or if you 27 wish to print them. You can see the first part of the menu now 28 at the top of the screen. The second line in the menu explains for 29 what table each name on the menu stands for. The first part of the menu 30 contains 5 summary tables, and the second part - to which you can get 31 by using the NEXT-MENU item of the menu, the remaining 7 summary tables. 32 As the items on the menu have similar names, it is best, in order to 33 move from item to item, to move the cursor to the item you wish to see. 4 -MOVE CURSOR TO CHOSEN ITEM AND PRESS RETURN> S 36 37 36 -9 44) 41 42 44 In the top window you can already see the MENU - the first part of it which includes the summry tables 1-6. Similar to the way you used the MENU in looking at the data and changing it. you will now be able to use it and to decide whether you wish to save the specific summary table or print it. After reading the message on the screen, decide what s3mmary table you want to see, move the pointer to the specific name on the MENU and press . We shall now go through the whole menu, and show you our snmmary table results. 32 11.3.1. LAUOEl: Total Labor by faciliftv/Srvioe As you are already at the first item, LABORi, all you have to do is press . A2: CMD EDIT SAVE THIS TABLE?(yes=l,no=0) A B C D E F G 1 LABOR SUMMARYL: TOTAL LABOR BY FACILITY/SERVICE 2 HP Clinic HC Hospital Supervise: 3 Environmental health 8.36 14.79 6.30 .13.04 5.17 4 School health - 8.36 15.23 7.17 15.44 5.83 5 Nutrition ' 8.36 15.01 6.73 14.13 5.61 1 6 Health education 41.79 37.51 7.17 15.44 5.83 : 7 Family planning 41.79 37.51 7.23 15.96 5.89 : 8 Immunization 16.71 20.35 6.72 14.09 3.58 1 9 Primary HC 83.57 101.75 33.16 69.61 19.26 10 Maternal (short term 8.36 24.65 14.39 31.14 9.91 it Child (short term) 8.36 24.65 14.39 31.14 9.91 12 Dental Health (s.t.) .00 9.67 6.88 15.44 7.55 13 Other short term 8.36 15.23 7.23 15.96 5.89 : 14 Maternity (l.t.) .00 10.74- 9.67 23.71 8.12 15 General long term .00 10.74 9.67 23.7i 8.12 ! 16 Child (ped. - l.t.) .00 10.74 9.67 23.71 8.12 : 17 Medicine (l.t.) .00 10.74 9.67 23.71 8.12 1 i8 Surgery .0 10.31 8.80 .21.11 7.68 19 Ophthalmology .0t 10.76 9.25 22.46 9.9Z 20 Other l.t. . .00 10.53 9.24 22.41 7.90 1 The summary table shows the total number of positions - of all types of labor by facility and by service. These are the Lij values of equation (5) in chapter III. In our example, there are 18.36 positions in Environmental Health in Health Posts, and 13.04 positions in Environmental Health in Hospitals. The total number of positions should be the total number of manpower employed in the Health Care system. The screen does not show you the whole table, as it is too large for the screen. We suggest that if you wish to see the whole table, you either print it, or save it on a separate file, and look at it later. (Another possibility is to exit the special menu, and move through the worksheet on your own -- if you know LOTUS 1-2-3 well enoughl). 33 In the top window (where the KENU used to be), you are asked SAVE THIS TABLE?(yes=l,no=O). If you decide to save this table in a separate file, type "1 and press , and the whole table (not just what you see on the screen) will be saved for you. You will see the following message on the top: SAVE FILE IS: LABOR1 So you know the name of the file in which this table is saved is LABOR1. After reading it (and maybe writing down the name of the file for later use), press . If you don't wish to save the table, answer M0N to the message asking you whether you wish to save the file, and got to the next message, which is: PRINT THIS TABLE?(yes=l,no=O) If you have a printer, and decide to print the table, type 1 and press (RETURN> and the whole table (not just what you see on the screen) will be printed for you. If you don't wish to print the table, type "0s and press . You are now back in the special MENU, so wo can move to the next item on it. 34 11.3.2. 1_ULG2: Types of Labor by S_erioes Move the pointer to LABOR2 and press to get to the second summary table - Types of Labor by Services. J2: CMD EDIT SAVE THIS TABLE?(yes=I,no=0) J K L m N 0 1 LABOR-SUMMARY2:TYPES OF LABOR BY SERVICES 2 SPEC GP RN EN FWE 3 Environmental health .00 .00 .00 29.23 13-.93- 4 School health .00 2.17 2.18 29.23 13.93 5 Nutrition .00 .00 2.18 29.23 13.93 6 Health education e.0 2.17 2.18 29.23 69.64 7 Family planning 0.65 2.17 2.18 29.23 69.64 8 Immunization .00 2.17 2.18 29.23 27.86 9 Primary HC .00 10.87 6.55 146.15 139.29 10 Maternal (short term 0.65 4.35 6.55 58.46 13.93 11 Child (short term) 0.85 4.35 6.55 5Q.46 13,93Z 12 Dental Health (s.t.) 1.30 .(0 .00 29.23 .0o 13 Other short term 0.65 2.17 2.18 29,23 13.93 14 Maternity (l.t.) 3.26 4.35 10.91 29.23 .0o 15 General long term 3.26 4.35 10.91 29.= .00 16 Child (ped. - l.t.) 3.26 4.35 10.91 29.23 .00 17 Medicine (l.t.) 3.26 4.35 10.91 29.23 .00(:) IS Surgery 3.26 C00 10.91 29. .00 19 Ophthalmology 3.26 .00 10.91 29.2Z (0 -O Otfher l.t. -. 26 '2.;17 10(.9rI29. .00 This table shows the positions, by services, of each type of labor. In our example, we have 2.17 General Practionners (GPs) in School Health, etc., and 10087 GPs in Primary Health, etc. The values are-the L1i in equation (5) in chapter III. On the top of the screen, you see again the messages asking whether you wish to save the table, or print it. If you save it, the name of the file in which the table was saved will also appear as a message (notice - it is not the same name as the file in which LABOR1 summary table was saved). 35 After responding with an "0 or 'l to the messages on the top, you find yourself again in our special MENU. 11.3.3. LAEOW: Tyesa of Labor by Facllitv Move the cursor to LABOR3 on the MENU, press , and you will see the third summary table: J27: LMD LDtY SAVE THIS TABLE?(yes=l,no=O) J K L M N 0 26 LABOR - SUMMARY3:TYPES OF LABOR BY FACILITY 27 SPEC GP RN EN FWE 28 Health Post .00 .00 .00 .00 234.00 29 Clinic .00 5.00 12.00 228.00 156.00 30 Health Center , 3.00 10.00 24.00 152.00 .00 31 Hospital 24.00 30.00 60.00 304.00 .00 32 Supervision 3.00 5.00 24.00 76.00 .00 33 ----- - -_-- - -- - - - -- - - -- - - - ---------------------- 34 Total 3O.0O 50.00 120.00 760.00 390.00 36 37 38 .39 4t) 41 42 43 44 45 This summary table shows positions, by facility, of the different types of labor (equal to LIj in equation (5), chapter III). For example, specialists can be found only in hospitals (24 positions) or in supervising positions (3 positions), while FIE work only in health posts (234 positions) and in clinics (156 positions). You can again save the table (in a new file), or print it, and then return to the MENU. 36 XX.3.4. CAPITALl: Ca-ital by TW,. of Service We now got to the capital summary tables. Below is the screen you see for the first capital summary table: T2: CMD EDIT SAVE THIS TABLE'(yes=I,no=0) T U V W X Y Z 1 CAPITAL - SUMMARYI: CAPITAL BY TYPE BY SERVICE * 2 CAPITALI CAPITAL2 CAPITAL3 CAPITAL4 : * Z Environmental health 45.07 6.60 .00 .00 * 4 School health 49.10 7.23 .O0 2.17 , * 5 Nutrition 47.04 6.93 .00 o° 1 * 6 Health education 104.82 14.19 .00 2.171 * 7 Family planning 105.44 14.28 .00 2.83 * S Immunization 59.66 8.13 .00 - 2.17 : * 9 Primary HC 297.72 40.83 .00 10.87 * 10 Maternal (short term 83.48 12.29 .00 5.00 1 * 11 Child (short term) 83.48 12.29 .00 5.00 * 12 Dental Health (s.t.) 3.5.76 5.89 .o0 1.30 * 13 Other short term 49.72 7.32 .00 2.83 1 * 14 Maternity (l.t.) 37.11 7e55 54.95 10.87 * 15 General long term 37.11 7.55 54.95 10.87 : * 16 Child (ped. - l.t.) 37.11 7.55 54.95 10.87 : * 17 Medicine (l.t.) 37.11 7.55 54.95 10.87 : * 18 Surgery _3.79 6.95 49.19 9.78 * 19 Ophthalmology 36.65 7.79 52.23 13.04 1 * 20 Other l.t. 35.45 7.25 52.07 8.70 1 * The summary table shows the units of capital, of each type, by service (or Kki ih equatiom (6). chapter III). In our example, CAPITAL3 (beds) does not exist in environmeatal health, or school health, but only in the long term services, while CAPITAL1 (rooms, or buildings) units exist in all services. You choose again if - you wish to save the file, or print it, and return to the MENU. 37 11.3.5. CAPITAL2: Calital by T-,u. by Facility Move the pointer to CAPITAL2 and press and you will see the following table: 121: W1ID EDIF SAVE THIS TABLE?(yes=l,no=0) - T U v w x Y Z 26 CAPITAL SUMMARY2: CAPITAL BY TYPE BY FACILITY * 27 CAPITALl CAPITAL2 CAPITAL3 CAPITAL4 * 28 HP 2:34. 00 29.25 - .00 .00 .* 29 CLINIC 367.85 51.25 23.41 5.00 * 30 HC 165.74 24.75 40.32. 16.10 * 31 HOSPITAL ' 425.64 55.63 387.25 78.78 * 32 SUPERVISION 76.50 38.25 .00 11.10 * 34 TOTAL 1269.74. 199.1.3 450.99 110.98 * 35 -- - - -- - - -- - - - -------------------------------- 36 37 * 39 * 40 41 * 42 43 44 45 This s-mmary table shows us the units of capital by facility, which are the values Kk; in equation (6), chapter III. We can see that no units of CAPITAL3 (beds) or CAPITAL4 (medical equipment) exist in Health Posts, and most units of CAPITAL3 (beds) are located in hospitals. You choose again whether to save the table, and/or print it, and return to the MENU. 38 II.3.6. VISIYSIPA§XnTU-Days by Services *d J a.ilitios The next item on the MENU is VISITS. After pressing you will see the following screen: AA26: (FO) CMD EDIT SAVE THIS TABLE?(yes=l,no=0) AA AB AC AD AE AF AG 25 VISITS/PATIENT-DAYS BY SERVICE AND FACILITY 26 HP CLINIC HC HOSPITAL SUPERVISE: 27 Environmental health 21,063 21,914 14,421 3,684 7,511 28 School health 21,o63 17,995 9,362 3,821 5,323 ' 29 Nutrition 21,063 209120 11,764 3,713 6,223 1 30 Health education 105,336 41,320 9,362 3,821 5,323 3.1 Family planning 105,336 41,320 8,773 3,664 4,946 32 Immunization 42,131 23,646 10,079 3,722 4,644 33 Primary HC 210,677 118,737 50,914 5,929 21,914 34 Maternal (short term 21,063. 33,144 17,95i 4,967 8,618 35 Child (short term) 21,063 33,144 17,95i 4,967 8,618 ' 36 Dental Health (s.t.) 100 70E8 4,001 4,078 9,141 37 Other short term 21,063 .17,995 8,773 - 3,664 4,946 38 Maternity (l.t.) 10 2,251 2,714 4,181 1,87.5 39 General long term 10 2,251 2,714 4,181 1,835 40 Child (ped. - l.t.) 10 2,251 2,714 4,181 1,8Z5 41 Medicine (1.t.) 10 2,251 2,714 4,181 1,835 42 Surgery 10 536 3,164 4,0)86 2,076 43 Ophthalmology 10 521 1,567 4,347 2,648 44 Other l.t. 10 2,387 2,777 3,973 1,888 This smmary table relates to the output of the health care system: with the resources assumed in tk. model, and the assumed production relationships. This product is the aunber of visits (in the ambulatory services) and patient-days (in the hospitals) that the system can produce (in chapter III, they appear as Vi. in equation (14)). In our example, the system produced about 21,063 visits in clinics, and only 3,684 visits in environmental health services in hospitals. After you decide whether to save the table or print it, return to the menu. 39 There are no more s-m-ary tables on this part of the menu, so you have to move to the second part by just typing ON* or moving the pointer to NEXT and pressing . You will now see the second part of the MENU. 11.3.7. Budget Retuireao.ts b_ Servioes amd Facilities (im Pulas) The first item is BUDGET: press (RETURN> and you see the following table: AJ26: (,O) CMD EDIT SAVE THIS TABLE7(yes=1,no=O) A3 AK: AL AM AN AO 25 BUDGET REQUIREMENTS BY SERVICES AND FACILITIES (in Pulas) 26 HP CLINIC HC HOSPITAL SUPERVISE 27 Environmental health 16,234 51.,329 27,521 56,591 20,848 28 School health 16,234 54,640 34,142 75,048 25,579 29 Nutrition - 16,234 52,735 30,332 6Z,619 23,669 3i) Health education 81,169 97,930 34,142 75,048 25,579 31 Family planning 81,169 97,930 34,778 80,141 26,217 32 Immunization 32,468 63,913 32,593 70,401 .7,783 33 Primary HC 162,338 318,302 158,890 342,594 91,066 34 Maternal (short term 16,234 98,313 70,182 157,570 46,820 35 Child (short term) 16,234 98,313 70,182 157,570 46,820 36 Dental Health (s.t.) 0 42,056 . 30,343 71,425 29,921 37 Other short term 16,234 54,640 34,778 80,141 26,217 38 Maternity (l.t.) 0 51,710 54,496 170,582 42,068 39 General long term 0 51,710 54,496 170,582 42,068 40 Child (ped. - l.t.) 0 51,710 54,496 170,582 42,068 41 Medicine (l.t.) 0 51,710 54,496 170,582 42,068 .42 Surgery 0 47,885 46,801 145,29Z3 38,3Z5 43 Ophthalmology 0 49,450 48,548 152,465 46,253 44 Other l.t. 0 49,798 50,596 157,520 40,158 This gives you the annual budgetary in Pula requirements for each service within osok faoility. Thus the budget requirement for onvironmental health in health posts is 16.234 pulas per year, and for primary health care in clinics, 318,302 pulas per year. The budget here includes only labor and capital costs, and not cost of disposables, materials or ancillary services. These are added to the budget later, 40 if the user chooses to. In the terms of Chapter III, the values which appear in the table are part of equation (9): TCij = CWij + CKi Save or print the table, if you wish, and return to the menu. You will always - return to the first menu, and to get to the second menu you have to type 'nM for Next-Menu (without ) and after it appears on the screen,, move the pointer to the item you want to retrieve and press . 11.3.8. BUDWI1: Labor Cost by Services sad Fasilities The second item on MENU2 is BUDGET1, and below is the table: AJ2: CMD EDIT SAVE THIS TABLE?(yes=l,no-O) AJ AK AL AM AN AO 1 BUDGET SUMMARYl: LABOR COST BY SERVICE/FACILITY 2 HP HC CLINIC HOSPITAL SUPERVISE 3 Environmental health 12,536 44,784 24,735 50,819 18,443 4 School health 12,536 47,832 30,831 67,800 22,800 5 Nutrition . 12,536 46,093 27,353 57,365 21,061 6 Health education 62,679 81,261 30,831 67,800 22,800 7 Family planning 62,679 81,261 31,418 72,495 23,387 a Immunization 25,072 54,840 29,481 63,750 16,050 9 Primary HC 125,357 272,929 143,519 309,707 81,762 10 Maternal (short term 12,536 87,267 63,517 142,790 42,054 11 Child (short term) 12,536 87,267 63,517 142,790 42,054 12 Dental Health (s.t.) 0 37,777 27,259 64,261 26,366 13 Other short term 12,536 47,832 31,418 72,495 23,387 14 Maternity (l.t.) 0 46,451 47,717 127,894 Z7,946 15 General long term 0 46,451 47,717 127,894 37,946 16 Child (ped. - l.t.) 0 46,451 47,717 127,894 37,946 17 Medicine (l.t.) 0 46,451 47,717 127,894 37,946 18 Surgery 0 42,973 40,760 107,025 34,468 19 Ophthalmology 0 44,323 42,110 111,075 41,218 20 Other l.t. 0 44,712 44,239 117,460 Z6,2t)7 This table shows the total cost of labor (in Pulas) by each service and facility (or CWij in equation (9), Chapter III). The first budget table shows the whole budget requirement (including labor and capital cost), while this table and the following three tables include only budgetary requirements for labor. Save or 41 print the file, move to the second half of the menu using NEXT, and get to the next item. 11.3.9. BJDGKr2: Labor Cost by Typo of Labor aDd by Service BUDGET2 brings you to the following table: AS2: CMD EDIT SAVE THIS TABLE?(yes=l,no=o) AS AT AU AV AW AX 1 BUDGET SUMMARY2: LABOR COST BY TYPE OF LABOR/SERVICE 2 SPEC BP RN EN FWE 3 Environmental health 0 0 0 116,923 20,893 4 School health 0 17,391 13,091 116,923 20,893 S Nutrition 0 0 13,091 116,923 20,893 6 Health education o 17,391 13,091 116,923 104,464 7 Family planning 5,870 17,391 13,091 116,923 104,464 8 Immunization 0 17,391 13,091 116,923 41,786 9 Primary HC -0 96,957 39,273 584,615 208,929 10 Maternal (short term 5,870 34,783 39,273 233,846 20,893 11 Child (short term) 5,870 34,783 39,273 233,846 20,893 12 Dental Health (s.t.) 11,739 0 0 116,923 0 -13 Other short term 5,870 17,391 13,091 116,923 20,893 14 Maternity (l.t.) 29,348 734,783 65,455 116,923 0 15 General long term 29,348 34,783 65,455 l1S,923 0 16 Child (ped. - l.t.) 29,348 34,783 65,455 116,923 C) 17 Medicine (l.t.) 29,348 34,783 65,455 116,923 0 18 Surgery 29,348 0 65,455 116,923 0 19 Ophthalmology 29,348 0 65,455 116,92Z u 20 Other l.t. 29,348 17,391 65,455 116,923 0 This table skows labor costs by type of labor, for each type of service. As no specialists work in environmental health (in our example), there are no costs on specialists in environmental health. Most of the cost of labor in environmental hoalth is the cost of enlisted nurses (116,923 pulas). etc. Savy or print the file, or move on, using NEXT to got to the following item on the second MENU. 42 11.3.10. BUD3633: Labor Cost by TYDs of Labor and by Fasilities The item BUDGET3 will show the following screen: AS26: (,O) Cit EDlt SAVE THIS TABLE?(yes=1,no=0) AS AT AU AV AW AX- - 25 BUDGET SUMMARY3:LABOR COST BY TYPE OF LABOR/FACILITY 26 SPEC GP RN EN FWE 27 HEALTH POST 2 2 1 1 351,000 28 CLINIC 2 40,000 72,000 912,000 234,000 29 HEALTH CENTER * 27,001 80,000 144,000 608,000 0 .0 HOSPITAL 216,001 240,000 360,000 1,216,000 0 31 SUPERVISION 27,001 40,000 144,000 304,000 0 32 … ________________--_____ 33 TOTAL 270,005 400,003 720,002 3,040,001 585,001- 34 35 36 37 38 :39 40 41 42 43 44 This summary table shows cost (in pulas) of labor by type of labor, for each facility. In our example: Costs of specialists in health posts is 2 (can be assumed tw b--0. the result of 1 is a result of rounding problems, etc.) Most of the cost (216.000 pulas) of specialists is in the hospitals, of course, and the rest in health centers and in supervision jobs. Again, decide if you wish to save or print the table, and move to the next item on the second menu. 43 11.3.11. BDuDGT4: Calital Costs by Service and by PEaility The first table of capital budgetary requirements shows capital cost for each typo of service and facility (CKiK in equation (9), chapter III). In our example, the following table will appear: BC2: (,0) CMD EDIT SAVE THIS TABLE?(yes=l,no=0) BC BD BE BF eG BH BI 1 BUDGET SUMMARY4: CAPITAL COST BY SERVICE/FACILITY 2 HP HC CLINIC HOSPITAL SUPERVISE! 3 Environmental health 3,698 6,545 2,786 5,771 2,406 ' 4 School health 3,698 6,807 3,311- 7,249 2,779 5 Nutrition 3,698 6,641 2,979 6,254 2,608 6 Health education 18,490 16,669 3,311 7,249 2,779 7 Family planning 18,490 16,669 .3,360 7,646 2,830 8 Immunization 7,396 9,073 3,112 6,651 1,733 9 Primary HC 36,980 45,373 15,371 32,888 9,304 10 Maternal (short term 3,698 11,(046 6,665 14,780 4,766 11 Child (short term) 3,698 11,046 6,665 14,780 4,766 12 Dental Health (s.t.) 0 4,279 3,085 7,164 3,554 13 Other short term 3,698 6,807 3,360 7,646 2,8zo 14 Maternity (l.t.) 0 5,259 6,780 42,688 4,122 15 General long term O 5,259 6,780 42,688 4,122 16 Child (ped. - l.t.) 0 5,259 6,780 42,688 4,122 17 Medicine (l.t.) 0 5,259 6,780 42,688 4,122 1B Surgery 0 4,913 6,040 38,268 Z,885 19 Ophthalmology 0 5,127 6,437 41,390 5,0.35 20 Other l.t. 0 5,086 6,358 40,061 3,951 Save or print the file, and, using NEXT, you will got to the next item. 44 11.3.12. BNDeErS: Caaital Cost bY T,e of Capital ad by Service The sumary table oaks like the following: BL2: (, 0)) x D SAVE THIS TABLE?(yes-l,no=0) BL BM BN BO BP BQ BR 1 BUDGET SUMMARY5: CAPITAL COST BY TYPE OF CAPITAL/SERVICE 2 CAPITALl CAPITAL2 CAPITAL3 CAPITAL4 1 TOTAL 23 Environmental health 12,620 8,5e5 0 0 1 21205.S1 4 School health 13,748 9,399 0 696 ' 23843.53 J Nutrition . 13,170 9,011 0 0 22181.06 6 Health educatio'n 29,348 1B,453 0 696 : 48497.10 7 Family planning 29,522 12,569 0 904 48995.83 8 Immunization 16,704 10,566 0 696 1 27965.07 9 Primary HC 83,363 53,075 0 3,478 1239916.15 10 Maternal (short term 23,375' 15,980 0 1,600 40955.69 11 Child (short term) 23,375 -15,980 0 1,600 ' 40955.69 12 Dental Health (s.t.) 10,012 7,652 cO 417 18081.77 13 Other short term 13,922 9,516 0 904 24342.26 14 Maternity (l.t.) 10,392 9,809 35,169 3,478 58848.61 15 General long term 10,,392 9,809 35,169 3,478 58848.61 16 Child (ped. - l.t.) 10,392 9,809 35,169 3,478 58848.61 17 Medicine (l.t.) 10,392 9,809 35,169 3,478 58848.61 18 Surgery 9,461 9,032 31,482 3,130 53105.40 19 Ophthalmology 10,261 10,129 33,426 4,174 57989.86 20 Other l.t. 9,926 9,421 33,326 2,783 55455.24 The table shows the cost of capital, for each type of capital, by service. Again,. as there *re so hospital beds in environmental health, there are no costs of CAPITAL3 (beds) in this type of service, while the larger part of CAPITAL1 (rooms or buildings) and CAPITAL2 (vehicles) is located in the ambulatory services. Save and/or print, and return to the second MENU. 45 I1.3.13. BUD6SI: Capital Cost by TMme of Capital and by Facility BUDGET6 summary table, in our example, looks like the following: BL26: (,0) CMD EDIT SAV TH1IS TABLE'Z-(y-i,i:z )-- BL BM BN BO BP BQ BR 25 BUDGET SUMMARY6: CAPITAL COST BY TYPE OF CAPITAL BY FACILITY 26 CAPITALI CAPITAL2 CAPITALZ CAPITAL4 TOTAL 27 HEALTH POST 65,520 38,025 O 0 103,546 28 CLINIC 102,999 66,625 14,985 1,600 186,210 29 HEALTH CENTER 46,408 32,175 25,805 5,451 109,540 30 HOSPITAL 119,179 72,313 247,841 25,210 1 464,543 31 SUPERVISION 21,420 49,725 0 3,S51 1 74,697 2 33 TOTAL 355,526 258,863 -288,632 35,513 938,535 34 35 .36 .37 38 39 40 41 42 43 44 This summary table shows capital costs, for each type of capital in each facility. In our example, capital costs in health posts comprise of costs of CAPITALI (roo-s or building) - 65,520 pulas, and CAPITAL2 (vehicles) -38,028 pulas. Save and/or print, and return to the second MENU using NEXT. 46 1.3.14r Another item on the menu (both parts of it) is EXIT, which enables you to exit either from the model, or continue to see somo other features of the model. If you move the pointer to EXIT and press , you will see the following screen: DA66: The model until now dealt only with direct resources in servicesCtD EDIT DA DB DC DD DE DF DG 66 The model utntil now dealt only with direct resources in services and 67 facilities. Further development of the model enables you to add ANCILLAR 68 services, DEMAND information, or some more summary tables which compare 69 actual budgets with budget requirements of this model. 70 ANCILLARY SERVIPES in the model are: drugs, lab-tests, x-rays and 71 administrative costs. If you wish to continue with these, type the word: 72 ANCILLAR 73 If you wish to continue to see the DEMAND side of the model - 74 type the word: DEMAND 75 76 If you wish to continue to see comparison of actual budget with 77 model budgetary requirements, type the word: 78 COMPARE 79 If you had enough for one day, and wish to quit, or wish to browse 80 through this file, tye the word: 81 EXIT 82 83 84 a5 The screen tells you how to got to ANCILLAR, DEXAND, COMPARE, etc. and that Ancillary services in the model are: drugs. lab-tests, x-rays and administrative costs. After reading the screen, the logical path, to continue with the model, would be to continue with ancillary services (unless you don't wish to include them in the model). Suppose you wish to do so, as instructed, type the word 'ANCILLAR", and you will see the flasher on the right side, asking you to wait (until the file with the ancillary services is retrieved). 47 11.4. ANCILLARY AND SUPPORT SUCES When it finishes flashing, you will see the following screen, which will- explain what appears in the ancillary services file. IRl: 'REMARKS: CMD READY IR IS IT IU IV 1 REMARKS: 2 This file calculates number of units of ancillary services and 3 of administrative costs. 4 Number of units of ancillary services are a function of Vijk (total 5 number of visits in each SF). - .' There are three types of ancillary services: DRUGS,LAB TESTS and XRAYS.R 7 Assumptions are made on NUMBER of each type of Anc.Serv. per Vii B Multiplying these (units per Vij) by Vij by Cost of Unit of Ancillary 9 gives total cost of each ancillary service, in SFij. The results 10 appear in DRUG, LABTEST,XRAY (named) matrixes. 11 Administration: We assume a proportion of cost per unit in each 12 facility (e.g. 15'S of costs i'n clinic, vs. 20-. in hbspit'al)', + 13 economies of scale (SIGMA =0.9 )(named). Results - in matrix 14 CADMIN (named) 15 Total budgetary requirments including: 16 Direct budget + ancillary services + administration cost 17 appear in TBUDGET is 19 20 48 11.4.1. CkaaEes ii Data om Aeillarv Services After reading the message, press (BETURN> as required, to get to the following- screen: IR22: 'We shall show you first the assumptions we have, regarding costsCMD READ' IR is IT IU IV 22 We shall show you first the assumptions we have, regarding costs 23 per unit of ancillary service, and regarding the number of units of 24 ancillary services used by each SFij. You can change these numbers 25 if you see fit,-and then the model will calcualte the total cost of 26 each ancillary service (and administration cost) and total budgetary 27 requirements - including these services. 28 .29 30 -<. PRESS RETURN> 32 34 35 -36 37 38 39 40 41 Again, after after reading press to see the following screen, which enables you to see the assumptions we had about prices of ancillary services (per unit), and onablos you to change these according to your own assumptions. 49 CKD EDIT BA BB BC BD BE BF 3 COST OF 1 DRUG UNIT: 1 4 COST OF 1 LABTEST: 3 5 COST OF 1 XRAY: 6 6 7 ADMINISTRATION COSTS: ASSUMPTIONS: 8 SIGMA (ECONOMIES/DISECONOMIES OF SCALE): 0.95 9 10 ADMINISTRATION COSTS AS % OF TOTAL COST, BY FACILITY: 11 12 FACILITY % OF TC 13 HP 10% 14 CLINIC 10% 15 HC 15% 16 HOSPITAL 20% 17 SUPERVISE 20% 18 19 IF YOU WISH TO MAKE ANY CHANGE, MAKE THE CHANGE, AND PRESS RETURN 20 21 22 CALC To make the changes, all you have to do is type your own number, and press (RETURN>. The model will move you to the next item to change on the screen. If you don't wish to change the numbers, just press return to move on from item to item. After going over the data on ancillary services and administration costs, press again (pointer will be on 20% of supervise), and the model will lead you so to the special manual snmming up the costs of ancillary services and of administration. The menu looks as follows: DRUG LABTEST XRAY ADMINISTRATION NBUDGET EXIT Remark: The user at this stage is not shown the number of units of ancillary services used at each service/facility, and cannot change the numbers assumed by us. This can be done, though, if the user is familiar enough with LOTUS 1-2-3o or done on request by the authors. II.4.2. Amcillary Services - Results As with the results of the first data file, you can see the results - in ter&s of costs of ancillary services, in the summary tables, you can save each summary table separately, and/or print it. The screen, being limited in its space, does, not always show the whole summary table, but by saving, or printing each tables, you get the whole summary table. As you are more experienced now with using the- model, we shall not go through each item on the menu, but just show you our summary tables, as they appear on the screen when using the menu: S1 The first item on the menu is DRUGs, and the table below will appear: J29: ' I LIT SAVE THIS TABLE?(yes=1,no=O) 3 K L M N 0- P 28 COST OF DRUGS - TOTAL 29 HP CLINIC HC HOSPITAL SUPERVISE! 30 Environmental health 0.00 0.00 0.00 0.00 0.00 I 31 School health 0,00 0.00 0.00 0.00 0.00 32 Nutrition 2095.08 1312.85 1610.93 352.53 540.77 33 Health education 0.00 0.00 0.00 0.00 0.00 34 Family planning 8494e18 4330.98 1466.79 484.62 563.67 7 35 Immunization 20950.81 12934.06 15551.69 4737.29 5074.69 36 Primary HC 172959.81 97730.78 78658.83 8263.65 22429.98 37 Maternal (short term 3133.63 2076.38 3123.98 494.19 1032.45 38 Child (short term) 62672.54 41527.58 62479.68 9883.71 20649.01 39 Dental Health (s.t.) 2s60.56 223.33 3421.00 2384.33 4245.30 40 Other short term 20950.81 13128.47 16109.32 3415.97 4897.50 41 Maternity (l.t.) 50.05 1481.28 4796.82 3Z00.61 2426.64 42 General long term 250.25 7406.38 23984.09 16503.07 12133.19 43 Child (ped. - l.t.) 500.51 14812.76 47968.-18 33006.15 24266.38 -44 Medicine (l.t.) 500.51 14812.76 47968.18 33006.15 24266.38 45 Surgery 250.25 1757.59 27350.19 17603.73 1tZ27.4z 46 Ophthalmology 250.25 1716.26 13345.79 19307.55 15952.77 47 Other l.t. -250.25 7406.38 23984.09 16503.07 12133.19 Moving to the next item on the menu, we got the LABTEST results: J54: CMD EDIT SAVE THIS TABLE?(yes=l,no=0) 3 1K L M N 0 P 53 COST OF LAB TESTS - TOTAL 54 HP CLINIC HC HOSPITAL SUPERVISE: 55 Environmental health C).OO 0 .0o 0O.oo 0.00 0. 00 56 School health 0.00 C). 00 0. tC)() O.00 C). 0) 57 Nutrition 0.00 0.00 0.00 0.OO 0 .00 58 ,Health education 0.0) C).00 0o.o o.o C.0 .C)) 59 Family planning ' 0.00 0.00 (:).00 14538. 63 :C 60 Immunization 0. 00 0.00 0. (:0O C). 00 O. (: 61 Primary HC 0.00 2931.92 2359.76 12Z95.47 6729.00 62 Maternal (short term 0.00 622.91 937.20 7412.78 Z097.35 63 Child (short term) O.00 622.91 937.20 7412.78 Z097.Z59 64 Dental Health (s.t.) 0.00 0.00 C).C0 C). 00 o. 0: 65 Other short term o.0o Z.93.85 483.28 1024.79 1469.24 66 Maternity (l.t.) 0.00 44.44 143.90 9901.84 3.639.96 67 General long term 0.00 222.19 719.52 49909.22 36z9.96 68 Child (ped. - l.t.) 0.o00 222.19 719.52 49509.22 3639.96 69 Medicine (l.t.) 0.O0 222.19 719.52 49509.22 3639.96 70 Surgery 0.00 0.00 0.00) 21124.47 0C). 1 71 Ophthalmology 0.00 O.00 0.00 23169.07 0).0:)0 72 Other.l.t. C0. 00 44.44 143.9C) 29705.53 3639.96 52 The next item is cost of I-RAYS, which brings you to the following summary table: 'J, -7 CMD EDIT SAVE THIS TABLE?(yes=l,no=0) J K L M N a P 78 COST OF X-RAY - TOTAL 79 HP CLINIC HC HOSPITAL SUPERVISE: 80 Environmental health 0.00 0.00 0. O. 00 0.. o.00 81 School health 0.00 0.00 C.00 0.00 0.00 82 Nutrition 0.-00 01.00 0.00 C).) 00 0.00 93 Health educatiob 0.00 0.00 0.00 .o00 0.00 84 Family planning 0.00 0.oo o.00 (.00 0.00 85 Immunization 0.00 0.00 0.00 0.00 o. oo: 86 Primary HC 0.00 0.00 0.00 4958.19 o.C10 87 Maternal (short term 0000 0.00 000 0.00 0.00C 88 Child (short term) 0.00 0.00 187.44 2965.11 0.O0 89 Dental Health (s.t.) 0.00 0.00 41.05 14305.99 0.00 90 Other short term 0.00 0.00 0.00 2049.58 0.00 91 Maternity (l.t.) 0.00 0.00 0.00 0.00 C) 00 92 General long term 0.00 0.00 28.78 3960.74 0.00 93 Child (ped. - l.t.) 0OnO 0w.O0 28.78 3960.74 0.00 94 Medicine (l.t.) 0.00 0.00 0.00 3960.74 0.00 95 Surgery 0.00 0.00 328.20 42248.94 0).0O 96 Ophthalmology 0.0o 0.00 160.15 2Z169.07 0.00 97 Other l.t. 0.00 0.00 0.00 3960.74 0.00 1 The next item is ADMINISTRATION, which shows the cost of administration, in the following table: J104: CMD EDIT SAVE THIS TABLE?(yes=l,no=0) J K L M N 0 P 103 TOTAL ADMIN.COST 104 105 ====== … … HP CLINIC HC HOSPITAL SUPERVISE: 106 Environmental health 600.22 1988.58 1566.92 5000.99 1765.20 107 School health 600.22 2116.83 194Z.88 6632.09 2165.75 108 Nutrition 600.22 2043. 03 1726.98 5622.07 - 2004.06 109 Health education 2609.03 33Z7.47 1943.88 6632.C)9 2165.75 11( Family planning 2609.0Z Z3.67.09 1998.78 6860.Z6 2210.59 111 Immunization 1200.42 2479.79 1862.24 6040.24 1515.25 112 Primary HC 4859.88 10088.7Z 7719.91 27803.07 6688.13 113 Maternal (short term 576.53 3.658.15 3739.80 13462.18 3716.02 114 Child (short term) 576.53 3638.15 3739.80 1-462.18 3716.0Z 2 115 Dental Health (s.t.) 0.oc) 2284.70 1882.07 6124.07 2421.62 116 Other short term 60o.22 2116.83 1980.13 7104.54 2241.es 117 Maternity (l.t.) 0.00 2491e78 3502.39 15174.17 3859.05 118 General long term 0.(0 2491.78 35C)2.39 15174.17 Z859.05 1i9 Child (ped. - l.t.) C).00 2491.78 3502.39 15174.17 3859.05 120 Medicine (l.t.) 0.00 2491.78 Z502.39 15174.17 Z359.05 121 Sutrgery 0.00 2664.45 2968.54 12841.3Z 3485.38 122 Ophthalmology 0.00 2758.06 3308.43 133l51.32 4128.45 - _ _ _ _ _ _ _ _ _ _ _ - - - - - - - - - -_ _ _ _ _ _ _ _ - -_ _ _ _ _ _ _ _ _ _ _ q - - -- - - - - - - - - -0 - - - - - - - - 53 This ends the summary tables of each of the ancillary tables, and the administrative costs. You can see another summary table which shows the total new budget required (according to the model) - including both the direct costs of each service/facility and the ancillary and administrative costs. In terms of .Chapter III, this table shows the values of TCij of equation (9). You get to the following table by moving the pointer to NBUDGET and pressing 55 56 57 58 59 60 61 Read what is on the screen and if you wish to continue and see the demand side of the model, type: NDEKANDW and, after waiting for a while, the model will lead you to the demand file. 55 11.5.0. INPUR DMlL: DIUD 0D NOLD PFO SfVICIS The demand side, at the moment, does not require the user to input any data of his own. The file includes our assumptions on demand of the population for services/facilities, and also our assumptions on the direct cost the population is requested to pay for the services. The user, though, can make changes in the demand data by using the regular lotus commands, and moving through the data files. Below is the screen you will see explaining the file: A11: 'This is the demand file, into which data on demand will be input, REhi, BA BB BC BD BE BF BeG BH i This is the demand file, into which data on demand will be input, 2 and it will also have a demand function which will be a function 3 of the price of the services. 4 At the moment this file includes some data on actual demand of 5 health services,in Botswana, based on HEALTH STATISTICS 1977. 6 Not using this data at the moment, a fictional demand matrix 7 was created, which the user can change, if he feels like it. 8 This demand data is used as input in calculating the total demand 9 (including referrals), and in comparing demand with supply results. o) 11 One more input in this file is PRICE PER SERVICE/FACILITY. 12 To see the DEMAND matrix type <:ALT-D>. 13 You can make changes in the data, if you see fit. 14 15 To see the PRICES for the services type 16 Again you can make any changes you want. - 17 18 Once you finished making the changes, type 19 20 After reading, press and MDI keys at the same time and you will get to the table which shows the demand assumption per service and facility. If you want 56 to change any of the nusbers, just move the pointer to the cell and make the change. The table looks as follows: ADI: 'DEMAND - DIRECT VIJ READY AD AE AF AG AH AI AJ 1 DEMAND - DIRECT VIJ 2 …HP CLINIC HC HOSPITAL SUPERVISE: 3 Environmental health 10 43500 500 30Z 400 4 Schoci health 1500 7400 150 100 140 5 Nutrition 200 5500 200 200 250 6 Health education 8o00 1300 200 25S:) 250 7 Family planning 800 13500 250 300 290 8 Immunization 400 2400 75 80 75 9 Primary HC 1800 43000 700 800 7(:10 i1 Maternal (short term .600 11400 80t)0 700 800) 11 Child (short term) 280 1t0)oo 700 700 770 12 Dental Health (s.t.) 5 0 0 2000 900 13 Other short term 430 6500 200 200 250 14 Maternity (l.t.) O 0 0 4000 160 15 General long term 0 Q 0 4000 160:) 16 Child (ped. - l.t.) O 0 -0 4500 17C) 17 Medicine (l.t.) O O 0 45(30 170 18 Surgery 0 0 0 2500 l0O 19 Ophthalmology O O 0 35Of) 130 20 Other l.t. C) 0 0 5000 170 The values given in.the table are the Vij values of equation (2) and (12) in chapter III. After making the changes (or leaving the table as is), you can move on to soe tke prices of services the visitors are requested to pay (using the terms of Chapter III these values are the Fij values of equation 12). According 57 to our assumptions, by pressing the and 'PI keys at the same time, you will see the following screen: AO28; 'PRICES - PER UNIT OF EACH SERVICE (in PULAS) EPAL-, AD AE AF AG AH Al AJ 28 PRICES - PER UNIT OF EACH SERVICE (in PULAS) 29 HP CLINIC HC HOSPITAL SUPERVISEI c)0 Environmental health 0 0 O 0 O1 31 School health 0 0 0 0 O( 32 Nutrition , O 0 0 0 33 Health education 0 0 0 0 0 34 Family planning 1 1 1 1 1 35 Immunization I I I j I 36 Primary HC 1 I I I 1 37 Maternal (short term I 1 1 1 1 38 Child (short term) 1 1 1 1 1 39 Dental Health (s.t.) 5 5 5 5 5 40 Other short term 1 1 1 1 1! 41 Maternity (l.t.)- 5 5 5 5 i 42 General long term 5 5 5 5 t 43 Child (ped. - l.t.) 5 5 5 5 5 - 44 Medicine (l.t.) 5 5 5 5 5 45 Surgery 5 5 5 5 5 46 Ophthalmology 5 5 5 5 5 47 Other l.t. 5 5 5 5 5 Again. you can make changes, by moving the cursor to the places you want to change. If you have finished making changes, press and 'El at the same time. After waiting for the model to do its work, the model moves you to a file showing the total visits to the service/facilities, based once on the supply side - as appeared in the first RESULTS file, and once on the demand side -- resulting from our assumptions on results. There are two TYPES of demand - direct demand for a service, and referral demand - resulting from referring the patients from one service to another. The assumption here is that referral is done by the medical personnel, thus it is not 58 actually a DEMAND by the patient himself. In this file we assume some referral relation between services (e.g. 10% of all visitors to long term maternity in a health center are referred to maternity in a hospital), and show the direct demand/supply, then the referrals, and then the total demand/supply. We also compare the demand and the supply. After waiting a while, the screen below explains some of it: IR IS IT I 1- . TI-iis file inaludes: . referreal furict i ns. 2. Tct.al visits/Fat.le-rt-t days baSed crt- Supp1y side 4 :3. dire:t visits/p'at;erit days based c-ri ef-mnad sidie 4. differe-rce between t:ctal sl.F Fl1y (c ,f visits/ - iFarit ta -. . arid tota l iernand . Tfhe referr-al fur:ticrn itn'illudes rny owrn estimates -,f :1l;. It. is a.sSrnC-:3 that re-ferrals are irintiated crnly by suF-F'1ir * :f S iStViCS. t_ !.'- * ' - .9 are- the sarne fctr the deiCrflmarnli anri supFly side. 10 T hc- *iirect. visits/ptds fot- supply sidpe arie calculatedt by: 11 Direc:tVij Tc'tatlVi j - £'irect.Vi, j*Si j 12 On th-fe diemand side, the data irFut int.o this file is dsirect lernmaro- 1 ' by patl. rit t. numb-ars should ciae input frcmn spe':i al demar,d fil,-, att. j- 14 mcmerit. they arre just "rar.-rn" numbers Wh ich I threw inp. 15 Total iij for the dernand side- is.: 1e. Tcotal Vij = Di re:t'Viij + Dir-ectVi j +5i j 17 If you finished re-adiri; (arid unrderstanld!) 1 S ['PRESS RETURN] 59 After pressing , the following screon will appear: IR23: 'The files appear in the toiiowing order: PLCAO IR IS IT IU 23 The files appear in the following order: 24 25 Total Vij - Supply Referrals - Supply Direct Vij - Supply 26 (Name: S.Tvij) (Name:S.Ref) (Name: S.Dvij) 27 28 Total v'ij - Demand Referrals-Demand Direct Vij - Demand 29 (Name:D.Tvij) (Name: D.Ref) (Name: S.Dvij) 30 31 Difference: Total Difference: Referal Difference:Direct 32 Supply-Demand Supply-Demand Supply-Demand 33 (Namei Dif.Tvij) (Name:Dif.Ref) . (Name:Dif.Dvij) Z4 35 To see the files , either use GOTO (F5) or move along the screen 36 starting at A1 (use HOME) 37 38 If you wish-to continue with, the model, type 39 40 41 42 CALC The screoo explains thle names of each of the files, and the way you can recall them on tkl sereen. 60 To continue with the model, press (ALT) and 0CM at the same time. The following screen will appear: IR70: 'If you wish to continue, and compare budget requirements accordiCMD POINT IR70.. IR70 IR IS IT IU 70 If you wish to continue, and compare budget requirements accordingto the 71 to the model, with data on actual budgets, type the word: 72 COMPARE 73 74 If you wish to quit for today, type the word: 75 EXIT 76 77 78 79 3 O 81 82 elZ a3 84 ,,5 86 87' 88 89 CALC 61 11.6.0. * WY-OU?UTr DAIA: CO4 ARI3SON OF ACTUAL DIKNET WITM muL'S BOX=G Again, you can decide either to EXIT from the model, or to move to the final summary file, which compares the budgetary requiresents according to the model, with those actually existing in your data. Suppose you want to see this file, then type the word 'COMPARE", ind after waiting for the model to work, you see the following screen: IAI: 'In this file we compare the actual budget, with the C1. REsifr IA IB IC ID IE IF IG IH 1 In this file we compare the actual budget, with the 2 budget requirements as reflected in the model. 3 This comparison appears under the name comp.serv 4 At the moment no data on actual budgets of government appear here. 5 6 7 9 12. 12 13 14 15 16 17 18 19 20 If you press and you will be out of the system. 63 C(Ar!UEt III TEE DESIGN OF THE MDEL: TECHNICAL NOTES The model comprises of three components: population, resources, and services. While interlinked, they can be handled as separate modules for different analytic purposes. The population (and epidemiology) component can be used for assessment of demand or need; services component, for supply and availability of resources. This chapter falls into two parts: firstly it interrelates the three components, and then delineates the health care system. 111.1. POFUlATIOP, XUSOMtCES AND SE'ICZS 111.1.1 Pomlatiom and Services Population is linked to the health care system through contacts which can take the form of visits to clinics, consultations, and patient-days for long term care. These. denoted by Vij per specified period, are defined and classified according to type of service or treatment (i), say immunization, and type of facility (j) providing that service, say health post or clinic, as shown in Table II.1. They are discussed in more detail in section III.2.2. Vii can be transformed into variables which take into account the population's epidemiology and behavior. Technically V's can be broken down or transformed into the following categories: (a) Visits or patient days by age and sex groups. (b) Types of diagnosis or treatment. (c) Impact measures: morbidity, mortality and working days lost due to illness. That is, if [Y] is a vector or matrix denoting any of the above, it can be related to any Vii: 64 IY]=tplVij (1) where [g] is a vector or matrix of coefficients transforming contacts into. clinical and epidemiological variables. An example could be the number of tuberculosis cases that are handled by a facility through the visits to this facility. This relationship can be based on actual observation or on the basis of a priori technical relationships. In the case of actual observatiom, categories (a) and (b) can be easily derived from service statistics. Category (c) is a matter of a relatively elaborate understanding of the relationship between contacts and treatments or output of health services and their impact and may not be readily available. In the case of proesmed toebnical relatioaskips, expression (1) can relate levels of services needed V ij for treating a population of a particular size and epidemiology LY ]. Hence, the relationship between population epidemiology and services can go either way depending on the nature of the analysis. -The relationship between population and services can be more complex than implied above. Use of services is not just a matter of their availability and perceived need by planners; it is also a matter of socioeconomic conditions and institutional arrangements involving economic access to service through fees, insurance, etc. An elaborate model would therefore consider a functional relationship that involves these conditions: Vij 5 g(epidemiology, socioeconomic conditions, institutional arrangements) (2) 65 This relationship, which can be incorporated in the model, is useful for - predicting utilization patterns under varying socioeconomic conditions and institutional arrangements, say a fee for service, provided appropriate data are available for any given size of population. III.1.2. Populations mad 3osoross Population is treated vis-a-vis resources in this model only as a source of at least part of the financial base for the health care system. Three sources of. finance linked to population can be incorporated in the model: taxes, insurance premiums, and fees. Depending on the nature of the system one or a combination of all three sources can be considered-. It is possible to design a tax module where revenues from taxes and the subsequent share going to health services are related to the population and its income profile and the tax structure. This exercise may be particulary useful. for systems which have earmarked revenues for health services. In a similar way actuarial tables can be incorporated in the model in the case of insurance. Fees, on the other hand, are directly reLated to service utilization as discussed in section 2.1.3. 111.1.3. tesuo.ers mad Ssrvicos Two types of resources are considered in the model: real and financial. Either of the two may be constraining the system in the short run from providing more services that it may wish at any moment of time. Real resources concern availability of personnel of different specialties, equipment and materials. Some of these may involve availability of the foreign exchange needed to import drugs and other goods and services. Availability can be defined in absolute or relative market terms. For example, if there are LL types 66 of labor or skills, one can consider absolute numbers available in a country or a region. That is, LL < LL (3) Alternatively, availability can be made a matter of prices or wages, e.g.: LL VL(W) (4) Tihis skill-specific (short run) supply function, either known or assumed, can be incorporated in the model. Similar supply functions for othir goods and services may be incorporated as well. At the initial stage the model will be concerned with absolute constraints whose removal is one of the major changes planners may wish to simulate with. The financial resources concern the budgetary constraint on the system that is made up of the allocation to health care from general revenues, premiums, fees and transfers from other sources as discussed below. 111.2 TIM NLT-H CURM SrSTI IXI.2.1. Services and Facilities Services or programs and the facilities through which they are delivered delineate the design of a health care system. The proposed model is structured accordingly. The system is envisioned as a matrix of n services or programs and m facilities (SFs) which provide them. Those can be further broken down by regions urban-rural etc. Such a matrix, tentatively outlined for health services in 67 Botswana, is illustrated in Table II.1.6 Each argument SiF. of the matrix stands for service Si delivered through facility Fj and is considered a basic operational unit or cell. In most instances particular services are given in more than one facility; for example, 'primary health care" is usually provided in all facilities. On the other hand, some services are associated with specific facilities. One such service would be 'surgery' which is usually associated with a particular hospital ward. This general construct is flexible; it allows for different kinds of aggregation or disaggregation by services and facilities, and provides for subordination of some services to others (e.g., ancillary services to ambulatory and preventive services) and for association among different types of services (e.g., referrals) as discussed in sections III.3.2 and III.3.4. These options depend on the particular health care system modeled, the assumptions about functional and behavioral relationships governing it, and the desired analysis. Each operational unit (StF;) comprises a few elements: (a) outputs (visits, patient-days, etc.), (b) inputs or resources, and (c) revenues. These are outlined in the following sections. 111.2.2. Ostvimt and Owteo Moasuares rad Indicators As outlined in section 2.1.1, visits, consultations and patient-days are conventional measures of output of medical services. They are delineated by V per specified time period. It is possible to associate with these measures support services, administration, supervision and training, and additional 4 We are indebted to M. Mills and V. Kumar for constructive discussions leading to this design. 68 intermediate outputs: drugs and output of ancillary services such as laboratory and x-ray facilities or clinics.7 At this stage of the work these measures are not related to the populations epidemiologic or socioeconomic characteristics, but only to the size of population. Unless assigned some subjective weights (n.j 'a reflecting some social preferences, Vi.'s are not additive; that is, output of different services cannot be added up unless they are standardized in some way, an option available to policymakerss. 111.2.3. Irhuts sad Resources: Labor, Ca-ital and Suport Servicos Several types of inputs and resources are considered: labor, capital (structures and equipment), disposables (drugs, etc.) and support and ancillary services (administration, supervision, labs, x-rays, etc.). These are defined and organized as follows: (a) Labor: there are nl skill categories of labor (physicians, nurses, family welfare workers, etc.) potentially allocated in activities in each cell. Each skill group is paid W1 periodically, so that the total wage bill in a cell is 7 Medical training and research are major activities of medical institutions, hospitals in particular. These activities are considered in the model insofar as they consume resources which can be allocated to other service activities. That is, at the outset, real and financial resources allocated to medicat training and research are withdrawn from other sources and, therefore, these resources do not flow through the model. S The model stops short of setting objective functions. By providing policymakers with alternative outcomes from which they need to choose, the model forces them to assign weights or preference to outcomes. 69 CWij = WL LLij (S) (b) Capital: land, structures and other equipment. There are n2 types of capital (buildings, beds, equipment of different types); each has a periodic rental rate (real or imputed) of RR. Total capital outlays' for a service by facility is n2 Cij = Rk XKki (6) R-1 (c) Drugs and other disposables: there are n3 types of drugs (possibly by categories) and other disposables, each with a unit cost of PD. During the month each SF is using drugs and disposables of a total value of - n3 CDj PdDdij (7) d=1 (d) Ancillary and Management Services: it is assumed that laboratory tests, x-rays, etc. are provided outside a particular facility only if prescribed or ordered through any of the SFs outlined above. In addition, general administration and supervision and training services are assigned to each SF. Consequently, if a particular SF uses n4 types of ancillary and management service A each at the price Px1 the total x ' In many instances operational capital costs are disregarded for most practical purposes. Instead, 'repair and maintenance' items are used. 70 cost of those services incurred by or through the unit is n4 CAlj = PEA. 0 (8) x=1 The current economic cost of running a service in a particular facility is thus TCij = Cij .+ CKij + CDij + CAij (9) The recurrent budget is a subset of (9); it would usually exclude CK+i because recurront budgets of health services rarely account for full capital costs. Clearly, the above can be aggregated vertically or horizontally depending an needs and data availability in the matrix delineated by Table 1. For *xample, there may be interest in computing horizontally the total costs of running family planning services within the health care system, across health posts and clinics, Similarly, the total costs of running a facility can be computed vertically. The highest levels of aggregation lead to resource constraints on the system. The budget constraint is B > (TCi) (10) i j- 71 The real resource constraint of any particular factor, when effective, is as -shown - in this example for labor of skill '1". Other resources are treated in a similar fashion.10 L > LL 1- > j lj(11) 111.2.4, Roeuoes from Sorvicos Fees may be associated with paxticular types of services and facilities. That is, f (>O)is the fee of service Vij. Total fees collected in the system, are: F f ijvi (12) ij - i j 111.3. BASIC KRLATIONSIIPS Several basic relationships determine the operations of the model. These concern the association between: (a) Inputs and outputs. (b) Primary services and ancillary services and other support services. (c) Different primary services (referrals). 111.3.1. Inputs and Outpats It is assumed that inputs and outputs in each SF or aggregates thereof are related through a linear and homogeneous production function that incorporates a 10 Financial and real resources allocated to research and medical training are excluded. 72 particular production technology. This technology concerns also the relationship between inputs themselves, notably the degree to which any two inputs are substitutes for each other. That is, for each Vij: V = f(L ....Lnl, Kl.-1 -Kn2) (13) Specifically, the Cobb-Douglas production function is considered at this stage of the model development because of its useful properties, a major one given below in relationship (15).11 That is, for each SF: y7~1 -IT i Lij ykij (14) Vij LnLLLij "k 'kij (4 The production function relates to the Nvaiue addedw of a given operation. It presumes marginal substitution between the various types of manpower and capital operating a particular SF. It does not assume substitution between various types of manpower and ancillary services such as laboratory services or even drugs. This approach, which can be easily modified, is adopted largely because, as described in section 2.3.2, disposables and ancillary and other support services are derived from the operation of SFs.13 11 A -production function' shows the relationship between inputs and output. Economic theory provides a variety of such function with different properties. There is no a priori reasoning to choose the function shown here. 11 As far as costs and production are concerned, ancillary services should be treated like any other services. 73 It should be noted that employing a production function approach does not preclude fixed proportions between inputs, e.g. physicians and nurses. It allows for a gain or loss in output, at the margin, even by changing just one of the inputs listed in the function. Again, these assumptions may be easily modified. Under the assumption of a Cobb-Douglas production function and a competitive market, the different p and i are the shares of particular output and costs.1' For example, W L -1 lij lij CL +4 CK (15) ii ij means that Pijl measure the relative contribution of manpower of type L1, e.g., nurses, to the total costs of running a particular SF, and their marginal product Pijl= Oiji x Vij/Llij (16) Indeed, as a first approximation of the relationship between inputs and outputs for Botswana, shares of inputs in costs are used as their shares in production. Consequently for small changes in ratios among factors, fixed coofficient. between ouputs and inputs (the approximated marginal pioductivity of each input in output) are assumed. There may be a problem in relating outputs to inputs that requires caution when establishing the coefficients of the production function. Ideally, one would like to use those technical coefficients which yield maximum output (Vii) for any 1 The user of the model should bear in mind that this assumptions may be unrealistic in different settings. 74 level and combination of inputs. A field observation may be misleading; services and facilities may be over- or under-utilized at any particular time. Consequently, coefficients based on these observations may be erroneous and misleading. Over-utilization may be a lesser problem than under-utilization. Under the assumption that the system is doing its best to meet demand or need, services rendered can be measured to establish the production function coefficients. Otherwise, coefficients established elsewhere, technical or 'targeted' coefficients, may be used. 111.3.2 Ambulatory and Prvoaetiv Services aad Ancillary Serviess Support or ancillary services can be treated in tbree ways: (a) As independent services in the FS matrix linked through referral coofficients to basic services. (b) Related to visits or some other measure of output. (c) Related to personnel who prescribe or order those services. The three may be the same under specific assumptions, depending on how these services are invoked. The proposed model is considering at this stage that the last two amount to the same under the assumed relationships between inputs and outputs. Each ancillary service Ax produces (during a specified period) Axij of service for output Vij, and Axij = axij Vij (16) where aij is the number of units of A. per unit Vij (Visits, PD, etc.). 75 For exampl0, given that only physicians L2 can order lab tests of any type and that fixed coefficionts relate output to physicians, there is a direct link between the two by substituting relationship (16) into (14). This would account for the number of tests of type A*ij incurred by an additional physician allocated to SFi. III.3.3. Ad iaistration. Siiervisiou ad On-the--Jd Tra1&ia1 All services need to be managed, implying administrative, supervisory and onu the-job training functions. In the model these functions are Nsubordinatedw to the front line services in the identical manner that ancillary services are treated. That is, various services are assigned administration, supervision and on-the-job training coefficients. *Outputs' (Ax) of these activities are not easy to define.. In the case of supervision and on-the-job training, the hours administered to each SF during a reforence period are measured. The cost or unit price of each such hour should account for all inputs associated with each activity. Output of administration, referring largely to overhead activities, is proposed to be measured in terms of cost; a unit of administration will have the cost of 1. Economies or diseconomies of scale may be considered under this rubric. These can be introduced by assigning the coefficients a in expression (16) another parameter so that aa will reflect economies for a < 1 than one and diseconomies for a > 1. 111.3.4. Referrals Most contacts with secondary services (specialists) and long term hospital care are initiated through primary care services. Patients can also be referred back from the former to the latter. 76 The referral system is treated in the proposed model through a set of coefficients interlinking in hierarchical fashion services of different facilities. That is, viol;~ SijjVj+J V (17) The coefficient Sij denotes either the relationship between a higher order SF and a lower order SF, or the reduced form relationship between services. Although theoretically a large and unmanageable number of referrals can be considered, in reality only a relatively few exist. Consequently, the Vij of any SF is made up of the direct number of contacts made by the population and the contacts initiated through other facilities.