3 Management Inpatients Nazia Peer
Transcript of 3 Management Inpatients Nazia Peer
35
Section A: Management Inpatients Indicator Comparisons by District
3 Management Inpatients Nazia Peer
Introduction
All of the following indicators are measures of efficiency, which is defined as “the allocation and use of resources in a manner that obtains the best health service outputs at the least cost”.a All of the indicators in this section are presented for district hospitals only, unless otherwise indicated.
3.1 Average length of stay
The average length of stay (ALOS) indicator measures how long, on average, each patient spends in a hospital, expressed as a number of days. The ALOS is calculated by using the patient days (number of inpatient days plus half of the total number of day patients seen) divided by the number of separations (discharges added together with transfer-out, deaths and day patients).
ALOS is regarded as an indicator of efficiency, since a shorter stay can reduce the cost per patient and allow more patients to be treated in a given period. Moreover, a shorter stay in hospital can also make provision for treatment to be shifted from expensive inpatient care to post-acute settings. However, very short ALOS could be more service-intensive and could incur more costs per episode or costs per day. It could also have adverse effects on health outcomes, might reduce the comfort and recovery of the patient, and may lead to a rising readmission rate.b A low ALOS may also indicate inadequate quality of care.
Too long a stay is also concerning, and could be as a result of many factors, including delayed patient diagnosis, treatment and overall management, the patient’s low socio-economic status, inadequate transport and poor referral systems. A persistently high ALOS should be investigated by managers, and processes of patient care, referral procedures and quality of service need to be evaluated.
In 2012/13, the South African average for ALOS was 4.2 days. Figure 1 shows the values of ALOS per district. Frances Baard (NC) had the shortest ALOS (1.1 days) followed by Xhariep (FS) (2.1 days). In contrast, both Uthungulu and iLembe districts in KwaZulu-Natal (KZN) had the longest ALOS (6.8 days), followed by Buffalo City (6.3 days) in the Eastern Cape (EC). What becomes clear is that there are provincial patterns (Map 1). All the districts in the Northern Cape and Free State, except for JT Gaetsewe (NC) (3.6 days) and Mangaung (FS) (3.9 days) respectively, have ALOS well below the national average. Apart from Amajuba with an ALOS at 3.0 days, 10 of the 11 KZN districts reported an ALOS higher than the national average. Six of the eight EC districts were above the national average. However, it is interesting to note that the ALOS is generally low in the vast, sparsely populated districts of the Northern Cape.
Four of the 11 NHI districts have an ALOS above the national average.
The annual trends are shown in Figure 4. The ALOS in Mangaung (FS) is clearly higher than all other provincial districts, while KZN’s districts show a clear reduction with each district having a unique pattern. EC districts also show an obvious decline; however, Buffalo City trends have fluctuated, as only 13% of patient separations in Buffalo City are in district hospitals.
a Mwase T. The Application of National Health Accounts to Hospital Efficiency Analyses in Eastern and Southern Africa. Working Paper. Bethesda, MD: The Partners for Health Reformplus Project, Abt Associates Inc.; August 2006.
b Organisation for Economic Co-operation and Development (OECD). Average length of stay in hospitals. In: OECD Health at a Glance: Europe 2012. Paris: OECD Publishing; November 2012.
Average length of stay (District Hospitals) by district, 2012/13
Days [Source: DHIS]
Uthungulu: DC28iLembe: DC29
Buffalo City: BUFUgu: DC21
Zululand: DC26Umzinyathi: DC24OR Tambo: DC15
A Nzo: DC44Amathole: DC12
Umkhanyakude: DC27Sisonke: DC43
Joe Gqabi: DC14Uthukela: DC23
uMgungundlovu: DC22Vhembe: DC34
C Hani: DC13Capricorn: DC35eThekwini: ETH
Nkangala: DC31Gr Sekhukhune: DC47
Waterberg: DC36RS Mompati: DC39
G Sibande: DC30Mopani: DC33
Ehlanzeni: DC32Mangaung: MAN
NM Molema: DC38West Rand: DC48
Cacadu: DC10N Mandela Bay: NMA
Johannesburg: JHBJT Gaetsewe: DC45
Cape Town: CPTBojanala: DC37
Fezile Dabi: DC20Sedibeng: DC42
Dr K Kaunda: DC40Central Karoo: DC5
Eden: DC4Amajuba: DC25Tshwane: TSH
Ekurhuleni: EKUCape Winelands: DC2
West Coast: DC1Siyanda: DC8
Overberg: DC3T Mofutsanyane: DC19
Lejweleputswa: DC18Pixley ka Seme: DC7
Namakwa: DC6Xhariep: DC16
Frances Baard: DC9
2 4 6
6.28
3.64
5.51
4.48
5.32
5.55
5.51
3.63
2.05
2.45
2.65
3.38
3.92
3.27
3.80
2.99
3.57
3.02
6.20
5.04
5.05
6.00
3.04
6.07
5.50
6.83
6.76
5.44
4.26
4.02
4.64
4.47
4.17
4.18
4.11
4.24
4.01
3.57
2.30
2.31
2.86
1.09
3.38
3.91
4.14
3.22
3.54
2.87
2.89
2.70
3.10
3.17
SA average
Target
ProvincesECFSGPKZNLPMPNCNWWC
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Section A: Management Inpatients Indicator Comparisons by District
Figure 1: Average length of stay (district hospitals) by district, 2012/13
Average length of stay (District Hospitals) by NHI district, 2012/13
Days
Umzinyathi: DC24
OR Tambo: DC15
uMgungundlovu: DC22
Vhembe: DC34
G Sibande: DC30
Dr K Kaunda: DC40
Eden: DC4
Amajuba: DC25
Tshwane: TSH
T Mofutsanyane: DC19
Pixley ka Seme: DC7
2 4 6
5.55
2.65
3.02
5.04
6.00
3.04
4.64
4.11
2.31
3.22
3.10
SA average ProvincesECFSGPKZNLPMPNCNWWC
DC6
DC7
DC8
DC10
DC5
DC36
DC39
DC1
DC16
DC13
DC19DC18
DC30
DC4
DC2
DC38
DC32
DC45
DC14
DC34
DC12
DC35
DC20
DC33
DC37
DC31
DC3
DC9
DC26
DC40
DC27
DC47
DC15
DC23
DC44
DC43
DC22
DC24
DC28
TSH
MAN
DC25
TSH
DC42
DC48 EKUJHB
Gauteng
LegendProvince
District
ALOS_DH_20121.1 - 2.4
2.5 - 3.4
3.5 - 4.3
4.4 - 5.3
5.4 - 6.8
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Section A: Management Inpatients Indicator Comparisons by District
Figure 2: Average length of stay (district hospitals) by NHI district, 2012/13
Map 1: Average length of stay (district hospitals) by district, 2012/13
0 1 1 2 2 3 3 4 4 5 5 6 6 7 7Indicator Value
EC N Mandela Bay: NMA
Cacadu: DC10
C Hani: DC13
Joe Gqabi: DC14
Amathole: DC12
A Nzo: DC44
OR Tambo: DC15
Buffalo City: BUF
FS Xhariep: DC16
Lejweleputswa: DC18
T Mofutsanyane: DC19
Fezile Dabi: DC20
Mangaung: MAN
GP Ekurhuleni: EKU
Tshwane: TSH
Sedibeng: DC42
Johannesburg: JHB
West Rand: DC48
KZN Amajuba: DC25
eThekwini: ETH
uMgungundlovu: DC22
Uthukela: DC23
Sisonke: DC43
Umkhanyakude: DC27
Umzinyathi: DC24
Zululand: DC26
Ugu: DC21
iLembe: DC29
Uthungulu: DC28
LP Mopani: DC33
Waterberg: DC36
Gr Sekhukhune: DC47
Capricorn: DC35
Vhembe: DC34
MP Ehlanzeni: DC32
G Sibande: DC30
Nkangala: DC31
NC Frances Baard: DC9
Namakwa: DC6
Pixley ka Seme: DC7
Siyanda: DC8
JT Gaetsewe: DC45
NW Dr K Kaunda: DC40
Bojanala: DC37
NM Molema: DC38
RS Mompati: DC39
WC Overberg: DC3
West Coast: DC1
Cape Winelands: DC2
Eden: DC4
Central Karoo: DC5
Cape Town: CPT
4.5
5.5
5.5
5.5
5.3
6.3
3.6
3.6 SA
: 4.2
3.9
2.7
2.4
3.4
2.1
..
3.8
3.3
3.6
3.0
3.0
5.5
6.8
6.8
4.3
3.0
5.0
6.0
5.4
6.2
5.1
6.1
4.5
4.6
4.0
4.2
4.2
4.0
4.2
4.1
2.9
2.3
2.3
3.6
1.1
3.9
3.4
3.2
4.1
3.5
2.9
2.9
2.7
3.2
3.1
22
2SD 2SD1SD 1SD
Average length of stay (District Hospitals) by district, grouped by province, showing standard deviations from average, 2012/13Prov
ECFSGPKZNLPMPNCNWWC
Units: DaysSource: DHIS
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Section A: Management Inpatients Indicator Comparisons by District
Figure 3: Average length of stay (district hospitals) by district, grouped by province, showing standard deviations from the average, 2012/13
Annual trends: Average length of stay (District Hospitals)
Day
s
2
4
6
8
10EC FS
●
● ● ● ●● ● ● ●
●●
GP
2
4
6
8
10KZN
●● ● ● ● ● ●
● ●●
●
LP MP
2
4
6
8
10
2002
/03
2003
/04
2004
/05
2005
/06
2006
/07
2007
/08
2008
/09
2009
/10
2010
/11
2011
/12
2012
/13
NC
2002
/03
2003
/04
2004
/05
2005
/06
2006
/07
2007
/08
2008
/09
2009
/10
2010
/11
2011
/12
2012
/13
NW20
02/0
320
03/0
420
04/0
520
05/0
620
06/0
720
07/0
820
08/0
920
09/1
020
10/1
120
11/1
220
12/1
3●
● ● ● ● ● ●
●● ● ●
WC
EC A NzoEC AmatholeEC Buffalo CityEC C HaniEC CacaduEC Joe GqabiEC N Mandela BayEC OR TamboFS Fezile DabiFS LejweleputswaFS MangaungFS T MofutsanyaneFS Xhariep
GP EkurhuleniGP JohannesburgGP SedibengGP TshwaneGP West RandKZN AmajubaKZN eThekwiniKZN iLembeKZN SisonkeKZN UguKZN uMgungundlovuKZN UmkhanyakudeKZN Umzinyathi
KZN UthukelaKZN UthunguluKZN ZululandLP CapricornLP Gr SekhukhuneLP MopaniLP VhembeLP WaterbergMP EhlanzeniMP G SibandeMP NkangalaNC Frances BaardNC JT Gaetsewe
NC NamakwaNC Pixley ka SemeNC SiyandaNW BojanalaNW Dr K KaundaNW NM MolemaNW RS MompatiWC Cape TownWC Cape WinelandsWC Central KarooWC EdenWC OverbergWC West Coast
●
●
●
39
Section A: Management Inpatients Indicator Comparisons by District
Figure 4: Annual trends: Average length of stay (district hospitals)
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Section A: Management Inpatients Indicator Comparisons by District
3.2 Inpatient bed utilisation rate
This indicator measures the occupancy of the beds available for use in district hospitals, and represents how efficiently a hospital uses its available capacity. This rate is expressed as a percentage and is calculated by dividing the number of inpatient days by the usable bed days. In a district which has more than one hospital, these data can mask inequities and conceal variations between the individual hospitals.
The SA average for bed inpatient utilisation rate (BUR) has been about 65% over the last five years, with a low of 64.7% in 2010/11 and a high of 68% in 2008/09. The 2012/13 BUR is 67.3% which is a minimal rise from 67.2% in 2011/12. The distribution of BUR by district is shown in Figure 5.
Nine districts – City of Cape Town (WC) (94.3%), Namakwa (NC) (87.9%), Ekurhuleni (GP) (87.1%), Siyanda (NC) (84.0%), West Coast (WC) (83.7%), Fezile Dabi (FS) (83.6%), Eden (WC) (82.6%), Mangaung (FS) (82.5%) and Bojanala (NW) (81.2%) – had BURs of over 80%. This was a clear increase from the previous year, when five districts had BURs of 80% or higher.
The highest BUR was 94.3% for the City of Cape Town (WC) and the lowest was Frances Baard District (NC) at 43.6%. The difference is more than two-fold. Sixteen districts had BURs lower than 60%, a deterioration from 2011/12 when there were 12 districts with BURs under 60%.
In the Western Cape, all the districts have BURs that are greater than the national average. The Northern Cape is of particular interest, as its districts show the most intra-provincial variation. Namakwa (87.9%) and Siyanda (84.0%) have the second and fourth highest BURs respectively, while Frances Baard (43.6%) and Pixley ka Seme (54.0%) are among the lowest. In Mpumalanga, all the districts had narrow intervals between each other, showing a uniform provincial picture.
In the North West Province, two districts, Mompati (55.8%) and NM Molema (47.6%) are among the 10 districts with the lowest BUR. It is of concern that both these districts have dropped from 2011/12.
Johannesburg Metropolitan District (GP) has a BUR of 53.0%, which is the fourth lowest nationally. Given that there is a drastic shortage of district-level beds in Johannesburg, this low BUR is difficult to understand.
There is a wide range in the BUR among the NHI districts, which probably highlights the differences among these districts across factors such as socio-economic status, geographic context, disease burden, management and resources.
Inpatient bed utilisation rate (District Hospitals) by district, 2012/13
Percentage [Source: DHIS]
Frances Baard: DC9NM Molema: DC38
Uthungulu: DC28Johannesburg: JHB
Amajuba: DC25Pixley ka Seme: DC7
T Mofutsanyane: DC19RS Mompati: DC39
Lejweleputswa: DC18Uthukela: DC23
Umzinyathi: DC24C Hani: DC13
OR Tambo: DC15JT Gaetsewe: DC45
Amathole: DC12Umkhanyakude: DC27
Sisonke: DC43Cacadu: DC10iLembe: DC29
Waterberg: DC36Zululand: DC26Tshwane: TSH
A Nzo: DC44West Rand: DC48
N Mandela Bay: NMASedibeng: DC42
Buffalo City: BUFJoe Gqabi: DC14G Sibande: DC30Capricorn: DC35Ehlanzeni: DC32
Xhariep: DC16Mopani: DC33
Nkangala: DC31uMgungundlovu: DC22
Central Karoo: DC5Ugu: DC21
Dr K Kaunda: DC40Gr Sekhukhune: DC47
eThekwini: ETHCape Winelands: DC2
Vhembe: DC34Overberg: DC3
Bojanala: DC37Mangaung: MAN
Eden: DC4Fezile Dabi: DC20West Coast: DC1
Siyanda: DC8Ekurhuleni: EKUNamakwa: DC6
Cape Town: CPT
20 40 60 80 100
68.2
62.6
59.5
59.2
68.5
59.4
66.2
67.1
70.2
55.9
54.3
83.6
82.5
67.9
66.7
87.1
53.0
66.2
74.6
73.5
56.4
57.7
53.5
66.0
59.8
52.3
63.9
60.9
76.5
70.8
78.5
69.4
64.8
75.0
69.3
70.8
70.0
59.5
87.9
54.0
84.0
43.6
81.2
47.6
55.8
74.7
94.3
83.7
78.4
78.7
82.6
73.6
SA average
Target
ProvincesECFSGPKZNLPMPNCNWWC
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Section A: Management Inpatients Indicator Comparisons by District
Figure 5: Inpatient bed utilisation rate (district hospitals) by district, 2012/13
Inpatient bed utilisation rate (District Hospitals) by NHI district, 2012/13
Percentage
Amajuba: DC25
Pixley ka Seme: DC7
T Mofutsanyane: DC19
Umzinyathi: DC24
OR Tambo: DC15
Tshwane: TSH
G Sibande: DC30
uMgungundlovu: DC22
Dr K Kaunda: DC40
Vhembe: DC34
Eden: DC4
20 40 60 80 100
59.4
54.3
66.2
73.5
57.7
53.5
78.5
69.3
54.0
74.7
82.6
SA average
ProvincesECFSGPKZNLPMPNCNWWC
DC6
DC7
DC8
DC10
DC5
DC36
DC39
DC1
DC16
DC13
DC19DC18
DC30
DC4
DC2
DC38
DC32
DC45
DC14
DC34
DC12
DC35
DC20
DC33
DC37
DC31
DC3
DC9
DC26
DC40
DC27
DC47
DC15
DC23
DC44
DC43
DC22
DC24
DC28
TSH
MAN
DC25
TSH
DC42
DC48 EKUJHB
Gauteng
LegendProvince
District
BUR_DH_201244 - 54
55 - 63
64 - 71
72 - 79
80 - 94
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Section A: Management Inpatients Indicator Comparisons by District
Figure 6: Inpatient bed utilisation rate (district hospitals) by NHI district, 2012/13
Map 2: Inpatient bed utilisation rate (district hospitals) by district, 2012/13
0 10 20 30 40 50 60 70 80 90 100Indicator Value
EC C Hani: DC13
OR Tambo: DC15
Amathole: DC12
Cacadu: DC10
A Nzo: DC44
N Mandela Bay: NMA
Buffalo City: BUF
Joe Gqabi: DC14
FS T Mofutsanyane: DC19
Lejweleputswa: DC18
Xhariep: DC16
Mangaung: MAN
Fezile Dabi: DC20
GP Johannesburg: JHB
Tshwane: TSH
West Rand: DC48
Sedibeng: DC42
Ekurhuleni: EKU
KZN Uthungulu: DC28
Amajuba: DC25
Uthukela: DC23
Umzinyathi: DC24
Umkhanyakude: DC27
Sisonke: DC43
iLembe: DC29
Zululand: DC26
uMgungundlovu: DC22
Ugu: DC21
eThekwini: ETH
LP Waterberg: DC36
Capricorn: DC35
Mopani: DC33
Gr Sekhukhune: DC47
Vhembe: DC34
MP G Sibande: DC30
Ehlanzeni: DC32
Nkangala: DC31
NC Frances Baard: DC9
Pixley ka Seme: DC7
JT Gaetsewe: DC45
Siyanda: DC8
Namakwa: DC6
NW NM Molema: DC38
RS Mompati: DC39
Dr K Kaunda: DC40
Bojanala: DC37
WC Central Karoo: DC5
Cape Winelands: DC2
Overberg: DC3
Eden: DC4
West Coast: DC1
Cape Town: CPT
59.5
68.5
62.6
59.4
59.2
66.2
68.2
67.1
SA
: 67.
3
82.5
55.9
54.3
83.6
70.2
55
.
67.9
66.7
53.0
66.2
87.11
53.5
73.5
76.5
59.8
60.9
63.9
52.3
57.7
74.6
66.0
56.4
55
5
.
78.5
64.8
70.8
75.0
69.4
77
70.8
69.3
70.0
59.5
87.9
43.6
54.0
84.0
33
.
00
55.8
74.7
47.6
81.2
55
78.7
83.7
94.3
73.6
82.6
78.4
77
77
2SD 2SD1SD 1SD
Inpatient bed utilisation rate (District Hospitals) by district, grouped by province, showing standard deviations from average, 2012/13Prov
ECFSGPKZNLPMPNCNWWC
Units: PercentageSource: DHIS
43
Section A: Management Inpatients Indicator Comparisons by District
Figure 7: Inpatient bed utilisation rate (district hospitals) by district, grouped by province, showing standard deviations from the average, 2012/13
Annual trends: Inpatient bed utilisation rate (District Hospitals)
Perc
enta
ge
40
60
80
EC FS
●
●● ●
● ●●
●
●
●●
GP
40
60
80
KZN
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●
●
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LP MP
40
60
80
2002
/03
2003
/04
2004
/05
2005
/06
2006
/07
2007
/08
2008
/09
2009
/10
2010
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2011
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2012
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NC
2002
/03
2003
/04
2004
/05
2005
/06
2006
/07
2007
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2008
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2009
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2010
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2011
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2012
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NW
2002
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2003
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2004
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2005
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2006
/07
2007
/08
2008
/09
2009
/10
2010
/11
2011
/12
2012
/13
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●
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WC
EC A NzoEC AmatholeEC Buffalo CityEC C HaniEC CacaduEC Joe GqabiEC N Mandela BayEC OR TamboFS Fezile DabiFS LejweleputswaFS MangaungFS T MofutsanyaneFS Xhariep
GP EkurhuleniGP JohannesburgGP SedibengGP TshwaneGP West RandKZN AmajubaKZN eThekwiniKZN iLembeKZN SisonkeKZN UguKZN uMgungundlovuKZN UmkhanyakudeKZN Umzinyathi
KZN UthukelaKZN UthunguluKZN ZululandLP CapricornLP Gr SekhukhuneLP MopaniLP VhembeLP WaterbergMP EhlanzeniMP G SibandeMP NkangalaNC Frances BaardNC JT Gaetsewe
NC NamakwaNC Pixley ka SemeNC SiyandaNW BojanalaNW Dr K KaundaNW NM MolemaNW RS MompatiWC Cape TownWC Cape WinelandsWC Central KarooWC EdenWC OverbergWC West Coast
●
●
●
44
Section A: Management Inpatients Indicator Comparisons by District
Figure 8: Annual trends: Inpatient bed utilisation rate (district hospitals)
45
Section A: Management Inpatients Indicator Comparisons by District
3.3 Expenditure per patient day equivalent
Hospitals consume a large proportion of the healthcare budget. A hospital bed is both a scarce and an expensive commodity in health care, and efficient bed management is known to bring about significant financial benefit to the hospital. Expenditure per patient day equivalent (PDE) is a composite indicator because it links financial data with service-related data from the hospital admissions and outpatients records. All values in this section are adjusted for the effects of inflation and are reported in real 2012/13 prices.
Expenditure per PDE reflects whether a particular hospital is being optimally managed. It measures and compares the inputs (total financial resources available to the hospital) with the outputs (volume of patients seen). It is important for managers to understand the breakdown of their costs and to ensure that they benchmark their hospitals against similar district hospitals in the province.
In 2012/13, the average expenditure per PDE in South Africa for all district hospitals was R1 823, which is higher than the 2011/12 value of R1 740. Figure 9 shows a wide range of expenditure per PDE across the 52 districts, from R2 573 in Nelson Mandela Bay (EC) to R1 020 in Siyanda (NC) – an almost three-fold difference. The second highest is Frances Baard (NC) at R2 504.
There have been very wide fluctuations in values in the Northern Cape over several years, as illustrated in Figure 12. The Eastern Cape also showed a large variance with Alfred Nzo (R1 586) and Chris Hani (R1 594) districts having the lowest expenditure per PDE, and Nelson Mandela Bay (R2 573) having the highest. Gauteng districts had high values on the whole, and the Western Cape (apart from the City of Cape Town) showed a low expenditure per PDE. KwaZulu-Natal and Mpumalanga have all their districts in the middle and low ranks of expenditure.
Figure 9 shows that there are wide intra-provincial variations in 2012/13 – and over the past four years – in the trends of expenditure per PDE. As most districts contain a number of district hospitals, these district variations conceal the much greater variations that exist between individual hospitals. To illustrate this point, in Uthungulu (KZN), the district average expenditure per PDE in 2012/13 was R1 791. Within the district there are six district hospitals, where expenditure per PDE varies in range from KwaMagwaza (R2 530), to Eshowe Hospital at R1 015 – a difference of over 100% between the lowest and highest expenditure per PDE by hospital. Similar and even greater differences between the expenditure per PDE values can be seen in most districts. These differences require investigation by hospital, district, provincial and national managers.
In terms of the NHI districts, six of the 11 are above the national average, as illustrated in Figure 10.
Expenditure per patient day equivalent (District Hospitals) by district, 2012/13
Rand (real 2012/13 prices) [Source: BAS, DHIS]
Siyanda: DC8West Coast: DC1
eThekwini: ETHCape Winelands: DC2
Eden: DC4Amajuba: DC25
Central Karoo: DC5Mangaung: MAN
Ugu: DC21G Sibande: DC30
A Nzo: DC44C Hani: DC13
T Mofutsanyane: DC19OR Tambo: DC15
Overberg: DC3Amathole: DC12Zululand: DC26Cacadu: DC10
Uthungulu: DC28Umkhanyakude: DC27
Ehlanzeni: DC32Sisonke: DC43
Bojanala: DC37iLembe: DC29
Cape Town: CPTUthukela: DC23
uMgungundlovu: DC22Umzinyathi: DC24Buffalo City: BUF
Namakwa: DC6Xhariep: DC16Vhembe: DC34
Joe Gqabi: DC14Nkangala: DC31
JT Gaetsewe: DC45Mopani: DC33
Fezile Dabi: DC20Dr K Kaunda: DC40RS Mompati: DC39
Pixley ka Seme: DC7Lejweleputswa: DC18
Tshwane: TSHGr Sekhukhune: DC47
Capricorn: DC35Ekurhuleni: EKU
Johannesburg: JHBWest Rand: DC48
Sedibeng: DC42Waterberg: DC36
NM Molema: DC38Frances Baard: DC9
N Mandela Bay: NMA
500 1000 1500 2000 2500
2504
1020
2016
1891
1463
2234
2147
1923
1586
1827
2321
1987
1389
2011
2425
1835
2346
2148
1905
1924
1824
1913
1561
1660
1836
1791
1815
1779
1428
1882
1857
1863
1548
1979
1382
1628
2035
1895
1645
1912
1594
1695
1790
1298
1857
1890
2174
1348
2198
1535
2573
2111
SA average
ProvincesECFSGPKZNLPMPNCNWWC
46
Section A: Management Inpatients Indicator Comparisons by District
Figure 9: Expenditure per patient day equivalent (district hospitals) by district, 2012/13
Expenditure per patient day equivalent (District Hospitals) by NHI district, 2012/13
Rand (real 2012/13 prices)
Eden: DC4
Amajuba: DC25
G Sibande: DC30
T Mofutsanyane: DC19
OR Tambo: DC15
uMgungundlovu: DC22
Umzinyathi: DC24
Vhembe: DC34
Dr K Kaunda: DC40
Pixley ka Seme: DC7
Tshwane: TSH
500 1000 1500 2000 2500
2016
1987
1389
1905
1561
1428
1882
1863
1628
1645
2111
SA average
ProvincesECFSGPKZNLPMPNCNWWC
DC6
DC7
DC8
DC10
DC5
DC36
DC39
DC1
DC16
DC13
DC19DC18
DC30
DC4
DC2
DC38
DC32
DC45
DC14
DC34
DC12
DC35
DC20
DC33
DC37
DC31
DC3
DC9
DC26
DC40
DC27
DC47
DC15
DC23
DC44
DC43
DC22
DC24
DC28
TSH
MAN
DC25
TSH
DC42
DC48 EKUJHB
Gauteng
LegendProvince
District
EXPPDE_DH_20121020 - 1428
1429 - 1695
1696 - 1987
1988 - 2234
2235 - 2573
47
Section A: Management Inpatients Indicator Comparisons by District
Figure 10: Expenditure per patient day equivalent (district hospitals) by NHI district, 2012/13
Map 3: Expenditure per patient day equivalent (district hospitals) by district, 2012/13
0 200 400 600 800 1,000 1,200 1,400 1,600 1,800 2,000 2,200 2,400 2,600 2,800Indicator Value
EC A Nzo: DC44
C Hani: DC13
OR Tambo: DC15
Amathole: DC12
Cacadu: DC10
Buffalo City: BUF
Joe Gqabi: DC14
N Mandela Bay: NMA
FS Mangaung: MAN
T Mofutsanyane: DC19
Xhariep: DC16
Fezile Dabi: DC20
Lejweleputswa: DC18
GP Tshwane: TSH
Ekurhuleni: EKU
Johannesburg: JHB
West Rand: DC48
Sedibeng: DC42
KZN eThekwini: ETH
Amajuba: DC25
Ugu: DC21
Zululand: DC26
Uthungulu: DC28
Umkhanyakude: DC27
Sisonke: DC43
iLembe: DC29
Uthukela: DC23
uMgungundlovu: DC22
Umzinyathi: DC24
LP Vhembe: DC34
Mopani: DC33
Gr Sekhukhune: DC47
Capricorn: DC35
Waterberg: DC36
MP G Sibande: DC30
Ehlanzeni: DC32
Nkangala: DC31
NC Siyanda: DC8
Namakwa: DC6
JT Gaetsewe: DC45
Pixley ka Seme: DC7
Frances Baard: DC9
NW Bojanala: DC37
Dr K Kaunda: DC40
RS Mompati: DC39
NM Molema: DC38
WC West Coast: DC1
Cape Winelands: DC2
Eden: DC4
Central Karoo: DC5
Overberg: DC3
Cape Town: CPT
1,593.8
1,644.9
2,572.9
1,911.7
1,585.6
1,695.2
1,790.2
1,890.1
SA
: 1,8
23.3
1,894.5
1,534.8
1,978.7
2,034.7
1,628.4
.
2,233.5
2,173.9
2,197.8
2,111.0
2,321.11
1
1,814.9
1,862.9
1,881.9
1,347.7
1,428.3
1,827.3
1,857.3
1,778.6
1,836.0
1,548.1
1,791.1
88
1,904.8
2,146.8
2,147.7
1,924.4
2,346.1.
22
22
1,560.7
1,912.6
1,824.1
1,922.9
1,019.7
1,891.0
2,504.4
2,016.111
1,987.3
2,010.6
2,424.6
1,835.1
4
66
1,462.6
1,389.0
1,660.0
1,298.4
1,382.1
1,857.1
4
00
1
2SD 2SD1SD 1SD
Expenditure per patient day equivalent (District Hospitals) by district, grouped by province, showing standard deviations from average, AllProv
ECFSGPKZNLPMPNCNWWC
Units: Rand (real 2012/13 prices)Source: BAS, DHIS
48
Section A: Management Inpatients Indicator Comparisons by District
Figure 11: Expenditure per patient day equivalent (district hospitals) by district, grouped by province, showing standard deviations from the average, 2012/13
Annual trends: Expenditure per patient day equivalent (District Hospitals)
Ran
d (re
al 2
012/
13 p
rices
)
500
1000
1500
2000
2500
3000EC FS
●
● ●
● ● ●
●●
●
GP
500
1000
1500
2000
2500
3000KZN
● ●
● ●
●●
●● ●
LP MP
500
1000
1500
2000
2500
3000
2004
/05
2005
/06
2006
/07
2007
/08
2008
/09
2009
/10
2010
/11
2011
/12
2012
/13
NC
2004
/05
2005
/06
2006
/07
2007
/08
2008
/09
2009
/10
2010
/11
2011
/12
2012
/13
NW20
04/0
520
05/0
620
06/0
720
07/0
820
08/0
920
09/1
020
10/1
120
11/1
220
12/1
3
● ●
●
●●
●
●
●●
WC
EC A NzoEC AmatholeEC Buffalo CityEC C HaniEC CacaduEC Joe GqabiEC N Mandela BayEC OR TamboFS Fezile DabiFS LejweleputswaFS MangaungFS T MofutsanyaneFS Xhariep
GP EkurhuleniGP JohannesburgGP SedibengGP TshwaneGP West RandKZN AmajubaKZN eThekwiniKZN iLembeKZN SisonkeKZN UguKZN uMgungundlovuKZN UmkhanyakudeKZN Umzinyathi
KZN UthukelaKZN UthunguluKZN ZululandLP CapricornLP Gr SekhukhuneLP MopaniLP VhembeLP WaterbergMP EhlanzeniMP G SibandeMP NkangalaNC Frances BaardNC JT Gaetsewe
NC NamakwaNC Pixley ka SemeNC SiyandaNW BojanalaNW Dr K KaundaNW NM MolemaNW RS MompatiWC Cape TownWC Cape WinelandsWC Central KarooWC EdenWC OverbergWC West Coast
●
●
●
49
Section A: Management Inpatients Indicator Comparisons by District
Figure 12: Annual trends: Expenditure per patient day equivalent (district hospitals), real 2012/13 prices
50
Section A: Management Inpatients Indicator Comparisons by District
3.4 Ratio ambulatory to inpatient days
This indicator is new in the profile of DHB reporting, and compares outpatient visits with inpatient days (including half of day patients). The indicator is calculated by dividing the total Outpatient Department (OPD) headcount (including emergencies) – as the numerator – by the sum of the total inpatient days plus 50% of the total day patients, which constitutes the denominator. A value greater than 1 would indicate that more outpatient and casualty patients are seen than are those who are admitted.
In an ideal setting, all patients coming to the OPD should be referred from a PHC facility. In some cases, hospitals even have clinics on their premises or very close by, known as gateway clinics, to provide a filtering service and prevent unreferred patients from arriving in the OPD. Therefore, a lower ratio is relatively better than a higher ratio.
The 2012/13 value for ratio of ambulatory to inpatient days was 1.3. This means that there are 1.3 times more OPD and casualty patients than there are patient days. The highest ratio (7.9) is Amajuba (KZN) which is a clear outlier and requires further investigation of the one hospital in the district. The lowest ratios were found in JT Gaetsewe (NC) 0.5 and Nelson Mandela Bay (EC) 0.6.
With this indicator there will be intra- and inter-provincial variation because district hospitals provide different levels of care. A ratio below 1 means that fewer clients were seen at the emergency unit/OPD clinics than were admitted into hospital. For example in the Cape Town Metro the larger district hospitals provide a significant quantum of level 2 services which impacts on inpatient days.
Ratio Ambulatory to Inpatient days (District Hospitals) by district, 2012/13
Number [Source: DHIS]
Amajuba: DC25T Mofutsanyane: DC19
G Sibande: DC30Ekurhuleni: EKUNkangala: DC31
uMgungundlovu: DC22Mopani: DC33iLembe: DC29
Waterberg: DC36Pixley ka Seme: DC7
Capricorn: DC35Bojanala: DC37eThekwini: ETH
Gr Sekhukhune: DC47Uthukela: DC23Tshwane: TSH
Uthungulu: DC28Ehlanzeni: DC32
Vhembe: DC34West Coast: DC1
Lejweleputswa: DC18Namakwa: DC6
Fezile Dabi: DC20Ugu: DC21
Johannesburg: JHBCape Winelands: DC2
Mangaung: MANCentral Karoo: DC5
Umkhanyakude: DC27Eden: DC4
Overberg: DC3A Nzo: DC44
Sisonke: DC43Umzinyathi: DC24
Zululand: DC26Buffalo City: BUFSedibeng: DC42
RS Mompati: DC39C Hani: DC13
Frances Baard: DC9Cape Town: CPT
Cacadu: DC10Joe Gqabi: DC14
NM Molema: DC38West Rand: DC48OR Tambo: DC15Amathole: DC12
Siyanda: DC8Dr K Kaunda: DC40
Xhariep: DC16N Mandela Bay: NMA
JT Gaetsewe: DC45
2 4 6 8
1.05
0.83
0.73
0.92
0.80
0.76
1.08
0.55
0.67
1.27
2.54
1.26
1.18
1.01
0.76
1.89
1.23
1.46
1.23
1.76
1.48
1.06
7.92
1.06
1.15
1.45
1.70
1.07
1.51
1.75
1.34
1.60
1.69
1.50
1.94
1.89
1.34
0.51
1.27
1.60
0.71
0.92
1.55
0.78
1.00
0.67
0.92
1.30
1.20
1.12
1.14
1.15
SA average
ProvincesECFSGPKZNLPMPNCNWWC
51
Section A: Management Inpatients Indicator Comparisons by District
Figure 13: Ratio ambulatory to inpatient days (district hospitals) by district, 2012/13
Ratio Ambulatory to Inpatient days (District Hospitals) by NHI district, 2012/13
Number
Amajuba: DC25
T Mofutsanyane: DC19
G Sibande: DC30
uMgungundlovu: DC22
Pixley ka Seme: DC7
Tshwane: TSH
Vhembe: DC34
Eden: DC4
Umzinyathi: DC24
OR Tambo: DC15
Dr K Kaunda: DC40
2 4 6 8
0.76
2.54
1.46
1.76
1.06
7.92
1.34
1.94
1.60
0.67
1.14SA average Provinces
ECFSGPKZNLPMPNCNWWC
DC6
DC7
DC8
DC10
DC5
DC36
DC39
DC1
DC16
DC13
DC19DC18
DC30
DC4
DC2
DC38
DC32
DC45
DC14
DC34
DC12
DC35
DC20
DC33
DC37
DC31
DC3
DC9
DC26
DC40
DC27
DC47
DC15
DC23
DC44
DC43
DC22
DC24
DC28
TSH
MAN
DC25
TSH
DC42
DC48 EKUJHB
Gauteng
LegendProvince
District
AMBOPD_DH_20120.5 - 0.8
0.9 - 1.2
1.3 - 1.6
1.7 - 2.5
2.6 - 7.9
52
Section A: Management Inpatients Indicator Comparisons by District
Figure 14: Ratio ambulatory to inpatient days (district hospitals) by NHI district, 2012/13
Map 4: Ratio ambulatory to inpatient days (district hospitals) by district, 2012/13
-1 -1 0 1 1 2 2 3 3 4 4 5 5 6 6 7 7 8 8 9Indicator Value
EC N Mandela Bay: NMA
Amathole: DC12
OR Tambo: DC15
Joe Gqabi: DC14
Cacadu: DC10
C Hani: DC13
Buffalo City: BUF
A Nzo: DC44
FS Xhariep: DC16
Mangaung: MAN
Fezile Dabi: DC20
Lejweleputswa: DC18
T Mofutsanyane: DC19
GP West Rand: DC48
Sedibeng: DC42
Johannesburg: JHB
Tshwane: TSH
Ekurhuleni: EKU
KZN Zululand: DC26
Umzinyathi: DC24
Sisonke: DC43
Umkhanyakude: DC27
Ugu: DC21
Uthungulu: DC28
Uthukela: DC23
eThekwini: ETH
iLembe: DC29
uMgungundlovu: DC22
Amajuba: DC25
LP Vhembe: DC34
Gr Sekhukhune: DC47
Capricorn: DC35
Waterberg: DC36
Mopani: DC33
MP Ehlanzeni: DC32
Nkangala: DC31
G Sibande: DC30
NC JT Gaetsewe: DC45
Siyanda: DC8
Frances Baard: DC9
Namakwa: DC6
Pixley ka Seme: DC7
NW Dr K Kaunda: DC40
NM Molema: DC38
RS Mompati: DC39
Bojanala: DC37
WC Cape Town: CPT
Overberg: DC3
Eden: DC4
Central Karoo: DC5
Cape Winelands: DC2
West Coast: DC1
0.8
0.8
0.8
0.9
0.7
0.6
1.1
1.1
SA
: 1.3
2.5
0.7
1.3
1.3
1.2
1.5
0.8
1.9
1.0
1.2
1.5
1.5
1.8
7.9
1.7
1.4
1.2
1.2
1.1
1.1
1.1
1.5
1.3
1.7
1.7
1.6
1.9
1.9
1.3
0.5
0.9
0.7
1.3
1.6
1.5
0.8
0.7
1.0
0.9
1.3
1.2
1.2
1.1
1.1
2SD 2SD1SD 1SD
Ratio Ambulatory to Inpatient days (District Hospitals) by district, grouped by province, showing standard deviations from average, 2012/13Prov
ECFSGPKZNLPMPNCNWWC
Units: NumberSource: DHIS
53
Section A: Management Inpatients Indicator Comparisons by District
Figure 15: Ratio ambulatory to inpatient days (district hospitals) by district, grouped by province, showing standard deviations from the average, 2012/13
Annual trends: Ratio Ambulatory to Inpatient days (District Hospitals)
Num
ber
0
2
4
6
8EC FS
● ●●
GP
0
2
4
6
8KZN
●●
●
LP MP
0
2
4
6
8
2010
/11
2011
/12
2012
/13
NC
2010
/11
2011
/12
2012
/13
NW20
10/1
1
2011
/12
2012
/13
●● ●
WC
EC A NzoEC AmatholeEC Buffalo CityEC C HaniEC CacaduEC Joe GqabiEC N Mandela BayEC OR TamboFS Fezile DabiFS LejweleputswaFS MangaungFS T MofutsanyaneFS Xhariep
GP EkurhuleniGP JohannesburgGP SedibengGP TshwaneGP West RandKZN AmajubaKZN eThekwiniKZN iLembeKZN SisonkeKZN UguKZN uMgungundlovuKZN UmkhanyakudeKZN Umzinyathi
KZN UthukelaKZN UthunguluKZN ZululandLP CapricornLP Gr SekhukhuneLP MopaniLP VhembeLP WaterbergMP EhlanzeniMP G SibandeMP NkangalaNC Frances BaardNC JT Gaetsewe
NC NamakwaNC Pixley ka SemeNC SiyandaNW BojanalaNW Dr K KaundaNW NM MolemaNW RS MompatiWC Cape TownWC Cape WinelandsWC Central KarooWC EdenWC OverbergWC West Coast
●
●
●
54
Section A: Management Inpatients Indicator Comparisons by District
Figure 16: Annual trends: Ratio ambulatory to inpatient days (district hospitals)
55
Section A: Management Inpatients Indicator Comparisons by District
3.5 OPD new client not referred rate
This indicator is new and refers to the proportion of new outpatient clients who enter a hospital without a referral letter. OPD new client not referred rate is a percentage of the new OPD cases that are not referred (numerator) divided by all new OPD cases (denominator). OPD follow-up and emergency clients are excluded from the denominator. OPD new client not referred rate monitors utilisation trends of clients’ by-passing PHC facilities. There is no target set for this indicator.
In 2012/13 the average OPD new client not referred rate was 64.1% (Figure 17). The highest was Frances Baard (NC) with 94.9% and the lowest was Dr K Kaunda (NW) with 6.1%. There are no distinct provincial patterns. However the Gauteng districts do not exceed 63.1% and the Limpopo districts in contrast do not drop below 61.2%. There are no values for the WC for OPD new client not referred rate.
There are substantial intra- and inter-provincial variations. High OPD new client not referred rate values could imply overburdened primary health care facilities or inadequately performing ones resulting in poor referral systems. Long queues and lack of faith in nursing staff could also motivate clients to attend hospital OPDs without consulting a primary health care facility first.
Four of the NHI districts have OPD new client not referred rate values greater than the average. This is important particularly because this indicator will highlight the effect of PHC re-engineering on OPD utilisation. If PHC improves, then this value should ideally decrease. This value will be closely monitored over the next few years and should provide key evidence as to how the re-engineering process is evolving.
OPD new client not referred rate (District Hospitals) by district, 2012/13
Percentage [Source: DHIS]
Frances Baard: DC9Waterberg: DC36
Mopani: DC33Pixley ka Seme: DC7
iLembe: DC29Gr Sekhukhune: DC47
C Hani: DC13Joe Gqabi: DC14Ehlanzeni: DC32Amathole: DC12
Fezile Dabi: DC20G Sibande: DC30Umzinyathi: DC24
Bojanala: DC37Cacadu: DC10Vhembe: DC34
Buffalo City: BUFWest Rand: DC48
A Nzo: DC44Ekurhuleni: EKUCapricorn: DC35Mangaung: MANUthungulu: DC28
Sisonke: DC43T Mofutsanyane: DC19
Zululand: DC26Namakwa: DC6
Lejweleputswa: DC18Siyanda: DC8
eThekwini: ETHUmkhanyakude: DC27
JT Gaetsewe: DC45Uthukela: DC23
OR Tambo: DC15Nkangala: DC31
Tshwane: TSHAmajuba: DC25
NM Molema: DC38Sedibeng: DC42
uMgungundlovu: DC22Xhariep: DC16
N Mandela Bay: NMAUgu: DC21
RS Mompati: DC39Dr K Kaunda: DC40
20 40 60 80 100
63.4
72.4
74.6
78.0
76.0
48.1
62.4
22.3
25.8
55.8
58.5
74.5
60.7
38.6
63.1
62.2
47.3
21.0
26.1
49.3
73.9
46.3
57.0
51.4
59.4
81.7
59.1
51.8
82.9
70.8
61.2
92.8
81.2
74.2
48.0
75.1
49.6
56.9
82.3
51.9
94.9
72.5
45.5
6.6
6.1
ProvincesECFSGPKZNLPMPNCNWWC
56
Section A: Management Inpatients Indicator Comparisons by District
Figure 17: OPD new client not referred rate (district hospitals) by district, 2012/13
OPD new client not referred rate (District Hospitals) by NHI district, 2012/13
Percentage
Pixley ka Seme: DC7
G Sibande: DC30
Umzinyathi: DC24
Vhembe: DC34
T Mofutsanyane: DC19
OR Tambo: DC15
Tshwane: TSH
Amajuba: DC25
uMgungundlovu: DC22
Dr K Kaunda: DC40
20 40 60 80 100
48.1
58.5
47.3
26.1
73.9
46.3
70.8
74.2
82.3
6.1
SA averageProvincesECFSGPKZNLPMPNCNWWC
DC6
DC7
DC8
DC10
DC5
DC36
DC39
DC1
DC16
DC13
DC19DC18
DC30
DC4
DC2
DC38
DC32
DC45
DC14
DC34
DC12
DC35
DC20
DC33
DC37
DC31
DC3
DC9
DC26
DC40
DC27
DC47
DC15
DC23
DC44
DC43
DC22
DC24
DC28
TSH
MAN
DC25
TSH
DC42
DC48 EKUJHB
Gauteng
LegendProvince
District
OPDNNREF_DH_20126 - 26
27 - 52
53 - 63
64 - 78
79 - 95
57
Section A: Management Inpatients Indicator Comparisons by District
Figure 18: OPD new client not referred rate (district hospitals) by NHI district, 2012/13
Map 5: OPD new client not referred rate (district hospitals) by district, 2012/13
0 10 20 30 40 50 60 70 80 90 100Indicator Value
EC N Mandela Bay: NMA
OR Tambo: DC15
A Nzo: DC44
Buffalo City: BUF
Cacadu: DC10
Amathole: DC12
Joe Gqabi: DC14
C Hani: DC13
FS Xhariep: DC16
Lejweleputswa: DC18
T Mofutsanyane: DC19
Mangaung: MAN
Fezile Dabi: DC20
GP Sedibeng: DC42
Tshwane: TSH
Ekurhuleni: EKU
West Rand: DC48
KZN Ugu: DC21
uMgungundlovu: DC22
Amajuba: DC25
Uthukela: DC23
Umkhanyakude: DC27
eThekwini: ETH
Zululand: DC26
Sisonke: DC43
Uthungulu: DC28
Umzinyathi: DC24
iLembe: DC29
LP Capricorn: DC35
Vhembe: DC34
Gr Sekhukhune: DC47
Mopani: DC33
Waterberg: DC36
MP Nkangala: DC31
G Sibande: DC30
Ehlanzeni: DC32
NC JT Gaetsewe: DC45
Siyanda: DC8
Namakwa: DC6
Pixley ka Seme: DC7
Frances Baard: DC9
NW Dr K Kaunda: DC40
RS Mompati: DC39
NM Molema: DC38
Bojanala: DC37
22.3
74.6
76.0
78.0
62.4
63.4
72.4
48.1
.
7
SA
: 64.
1
58.5
74.5
25.8
55.8
60.7
47.3
38.6
62.2
63.1
51.8
73.9
46.3
49.3
81.7
21.0
57.0
51.4
59.4
26.1
59.1
70.8
82.9
92.8
61.2
81.2
48.0
74.2
75.111
51.9
56.9
94.9
82.3
49.6
45.5
72.5
6.6
6.1
2SD 2SD1SD 1SD
OPD new client not referred rate (District Hospitals) by district, grouped by province, showing standard deviations from average, 2012/13Prov
ECFSGPKZNLPMPNCNW
Units: PercentageSource: DHIS
58
Section A: Management Inpatients Indicator Comparisons by District
Figure 19: OPD new client not referred rate (district hospitals) by district, grouped by province, showing standard deviations from the average, 2012/13
Annual trends: OPD new client not referred rate (District Hospitals)
Perc
enta
ge
20
40
60
80
100EC FS
●●
●
GP
20
40
60
80
100KZN LP
●
●●
MP
20
40
60
80
100
2010
/11
2011
/12
2012
/13
NC
2010
/11
2011
/12
2012
/13
NW
EC A NzoEC AmatholeEC Buffalo CityEC C HaniEC CacaduEC Joe GqabiEC N Mandela BayEC OR TamboFS Fezile DabiFS LejweleputswaFS MangaungFS T Mofutsanyane
FS XhariepGP EkurhuleniGP SedibengGP TshwaneGP West RandKZN AmajubaKZN eThekwiniKZN iLembeKZN SisonkeKZN UguKZN uMgungundlovuKZN Umkhanyakude
KZN UmzinyathiKZN UthukelaKZN UthunguluKZN ZululandLP CapricornLP Gr SekhukhuneLP MopaniLP VhembeLP WaterbergMP EhlanzeniMP G SibandeMP Nkangala
NC Frances BaardNC JT GaetseweNC NamakwaNC Pixley ka SemeNC SiyandaNW BojanalaNW Dr K KaundaNW NM MolemaNW RS Mompati
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59
Section A: Management Inpatients Indicator Comparisons by District
Figure 20: Annual trends: OPD new client not referred rate (district hospitals)