Analisis de Costos

Users Guide for CORE Plus (Analysis of Cost and Revenue Plus) Tool Version 1
September 2007
Elizabeth Lewis Thomas McMennamin David Collins Management Sciences for Health
The tool is based on CORE, the Cost and Revenue Analysis Tool, developed by Management Sciences for Health (MSH) (www.msh.org). No part of this publication, including the related spreadsheet-based tool, may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopy, recording, or information storage and retrieval system, without prior permission of publisher. In any use of the publication or tool, credit must be given to MSH. The use of the spreadsheet-based tool requires a license for the appropriate software, such as Microsoft Excel, available under license from Microsoft Corporation. This tool is not a product of Microsoft Corporation and is not guaranteed by that company. CORE and CORE Plus were developed in part through support from the U.S. Agency for International Development (USAID), under various projects. Further modifications have been made with funding from MSH. The opinions expressed in this guide are those of the authors and do not necessarily reflect the views of USAID or Management Sciences for Health.
CORE Plus Users Guide
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Table of Contents
Overview......................................................................................................................................... 4 1. Introduction............................................................................................................................... 5 2. Description................................................................................................................................ 8 3. General tips ............................................................................................................................. 10 4. Step-by-step guidelines........................................................................................................... 11 4.1. Starting.........................................................................................................................11 4.2. Setting the assumptions................................................................................................12 4.3. Entering utilization data...............................................................................................16 4.4. Entering data on service staff.......................................................................................19 4.5. Calculating staff costs. .................................................................................................23 4.6. Calculating fixed and administrative staff costs. .........................................................24 4.7. Examining total facility costs.......................................................................................26 4.8. Examining total facility revenue..................................................................................27 4.9. Analyzing the results....................................................................................................28 4.10. Comparative reports.....................................................................................................34 5. Changing norms and prices..................................................................................................... 38 6. Comparing facilities................................................................................................................ 39 7. Cautions .................................................................................................................................. 40 ANNEX A: NORMS .................................................................................................................... 41 Table A-1: Clinic-level (Level A) service need norms............................................................42 Table A-2: Referral-level (Level B) service need norms.........................................................44 Table A-3: Standard minutes per clinic-level (Level A) service .............................................45 Table A-4: Standard minutes per referral-level (Level B) service ..........................................47 ANNEX B: FLOWCHARTS OF CALCULATION METHODS................................................ 48 B-1: Calculation of Services Needed.......................................................................................49 B-2: Calculation of Staffing Numbers .....................................................................................50 B-3: Calculation of Cost per Service .......................................................................................51 ANNEX C: UNDERSTANDING AND REVIEWING THE SERVICE PRACTICE WORKSHEETS...................................................................................................................... 52 ANNEX D: LIST OF DATA REQUIRED FOR A CORE PLUS ANALYSIS........................... 58
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Overview
This guide contains the following sections: 1. Introduction 2. Description 3. General tips 4. Step-by-step guidelines 5. Changing norms and prices 6. Comparing facilities 7. Cautions
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1.
Introduction
The purpose of the CORE Plus tool is to help managers and planners estimate the costs of individual services and packages of services under different scenarios. These cost estimates are based on certain norms, and the estimated costs can be compared to actual costs to see the variations between the two sets of figures. The tool is adapted from a previous cost and revenue analysis tool called CORE1, developed in 1998 and used in many countries. This version of the tool was adapted for costing priority health services (in the accompanying example, key reproductive health and child survival services). One major difference between CORE and CORE Plus is that this more recent version contains a new componenta population and epidemiological sectionto allow the user to estimate the expected numbers of services, depending on disease prevalence and incidence rates, the size of the facilitys catchment population, and so on. The purpose of the tool is to estimate the cost of each type of service in a facility that provides an integrated priority service package. Different countries and regions each have their own definitions of which services are included in a basic package of services; the illustrative spreadsheet that accompanies this Users Guide is based upon Haitis Priority Service Package (PSP), which focuses on reproductive health and child survival services.2 A standard costing approach has therefore been used, as is used in some hospitals3. In this approach, a standard unit cost is established for the variable costs of each service, and the total variable costs are then estimated by multiplying those unit costs by the numbers of services. Standard semi-variable or step-variable costs, such as nursing staff, are set to vary with major changes in the quantity of services provided. For example, if a nurse spends 30 minutes with each new client on a family planning visit, then the facility would need to hire an additional nurse for every 16 new family planning clients per day (assuming an eight-hour shift). Standard fixed costs, such as rent, are set to remain constant notwithstanding changes in service volumes. Total standard costs can be used for projecting funding needs; in addition, they can be compared with actual costs to determine efficiency. Capital costs are not included although it is possible to include depreciation. In CORE Plus, standard costs are based on normative4 costs. Rather than model the standard costs on current installed capacity in facilities, these costs are based instead on certain norms. For instance, the Service Practice Worksheets provide detail on which types of staff provide certain types of health services, as well as the drugs, supplies and lab tests that should be used for such cases. Thus, if we know the unit costs of each of these cost elements, we can determine the normative cost to treat each type of case. The Service Practice Worksheets included in CORE Plus specify staff times that have been developed by a small team of health care providers based on their experience. All treatment guidelines described in the Service Practice Worksheets are norms that were established for a specific application of the tool and do not represent
1 2
Available from Management Sciences for Health, Boston (www.msh.org). See Andr, Jean et al., Paquet de Services Prioritaires, Projet Hati Sant 2004, June 2000. 3 Herkimer, Jr., Allen G. Understanding Hospital Financial Management. 1986. Aspen Publishers Inc. 4 In this model, normative is taken to mean desirable, not average.
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international standards. The estimated types and quantities of drugs, supplies, and tests in the sample spreadsheet are based primarily on Ministry of Health treatment guidelines in Haiti. CORE Plus takes into account the fact that there may be regional differences in some of the costs. For example, personnel in more remote rural areas may receive bonus payments as an incentive for them to work in these more isolated areas. Similarly, the cost of drugs and supplies may be higher in more remote areas, simply because the extra cost of transporting the supplies must be included in the total cost. Some of the norms and standards used in CORE Plus are shown in the Annexes. The norms used to estimate the numbers of services needed at the clinic and referral levels are shown in Tables A-1 and A-2 of Annex A. In addition, the standard times used to determine direct salary costs are shown in Tables A-3 and A-4. The standard quantities and costs of other resources used in the tool, such as drugs and tests, are not shown here because of space limitations. The norms, standards, and prices should be reviewed and modified, where necessary, before using the tool. Again, these norms are not international standards, but rather norms developed by health care providers working in the context of country where the tool was recently utilized. The tool is a dynamic model built on spreadsheets, and can be used for community-based services, dispensaries (Disp.), health centers (HC), and hospital/referral level. A user can immediately see the impact of changing key variables, such as the number of services, on resource requirements and costs. Also a user can easily see the formulas used in the tool and can, if necessary, change them. The norms and standard costs used in the tool can easily be adjusted and can thus be updated regularly or modified for a particular region or province. This includes incidence and prevalence rates, service utilization rates, Service Practice Worksheets, salary levels, drug prices, and administration costs. Where new services are added, these can also be included. CORE Plus allows the user to compare a variety of standard costs. First, if the user knows the size of the catchment population and the prevalence or incidence rates of illness or conditions such as pregnancies, the tool will estimate the quantity of services needed, thus indicating the resources and funding required to provide priority health services to a specified population. Standard costs can also be estimated for the actual numbers of services provided, and compared with actual costs to indicate the level of efficiency. In addition, standard costs can be estimated for projected numbers of services, where the user wishes to see the cost impact of increasing or decreasing certain services. It should be noted that the version of the tool distributed with these guidelines reflects the direct costs of most of the curative ambulatory care services provided within the facilities, as well as defined community-based services. This version does not, however, provide estimates of total primary health care costs, since it covers only those services that are defined in the priority health services package. The tool has several uses for a planner or manager. It can be used to estimate:
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the cost of providing a particular package of services, such as a priority health services package, the cost of different service delivery models, such as community-based or facility-based, ideal staffing patterns for different numbers and mixes of services, efficiency levels of services currently provided, and estimated prices for contracting services in areas where services are not currently offered.
The remaining sections of this guide describe how to use CORE Plus. This is intended to be a simple introductory guide and does not cover all aspects of the tool in detail. It also provides basic, but not detailed, guidance on interpreting the results of the tool. Further assistance may be obtained from the authors, who may be contacted through Management Sciences for Health.
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2.
Description
CORE Plus is contained in a Microsoft Excel workbook, which is a collection of individual worksheets linked together. You have two separate Excel files; one is a blank template, and the other is a filled-in workbook that contains sample data for a fictitious health facility. Worksheet A: Assumptions is used to enter general information such as the population and working hours of the facility. Worksheet B: Need is used to enter and calculate the number of each service provided by the facility, based partly on the population data in worksheet A. Worksheet C: Service_Staffing is used to enter and calculate the number of staff, the proportion of time that they spend providing services, and the cost of each type of staff. Worksheet D: Staff_Costs is used to calculate and allocate staff costs, based on figures from worksheet C and the individual service practice worksheets. Worksheet E: Fixed_Costs is used to enter the cost of administrative staff and other costs, such as electricity. Worksheet F: Total_Costs is used to enter some special costs, to calculate variable costs based on figures from worksheet B and the individual service worksheets, and to aggregate costs from the worksheets D and E. Worksheet G: Revenue is used to enter information on fees charged (if any) for the services provided. The user can also enter information on waivers or exemptions. Worksheet H: Summary is used to present the costs in different ways based on figures from worksheet F. Worksheet I: Reports is used to present comparisons of key figures under different scenarios, drawing mainly on figures in worksheet H. Individual Service Practice Worksheets contain the standard quantities of resources used for each service, including the average time of each type of staff person, as well as the drugs, supplies, and lab tests used. Annex C provides an overview of the layout and rationale behind the service practice worksheets.
The diagram below shows how the different worksheets in the workbook are linked:
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Figure 1. Relationship of the worksheets in CORE Plus workbook
Cost elements:
A. Assumptions
B. Need
C. Service Staffing
D. Staff costs E. Fixed costs F. Total costs
I. Reports G. Revenue H. Summary

(comparing different scenarios)
Service practice worksheets

(Normative quantities for each service: staff time, drugs, supplies, and lab tests)
Key:
Input/ Data entry Output/ Results
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3.
General tips
Here are a few general tips to help you as you use the tool. If you are not very familiar with Excel, the following brief explanation of terms should help: Excel spreadsheets are comprised of rows and columns. The rows are labeled with numbersfor example, row 3 or row 124. The columns are labeled with lettersA, B, C, and so on. Each place where a row intersects with a column is called a cell, and each cell is referred to by its column letter and row number. So, for example, if the directions tell you to go to cell A4, you would find the cell in the first column, four rows from the top of the sheet. An Excel workbook can contain several worksheets. Each worksheet has a name, which can be seen on the worksheet tab at the bottom of your screen. The active worksheet is the one with its name highlighted. If you need to go to different worksheets within the same workbook, simply click with your mouse on the name of the worksheet tab that you want, and Excel will move the cursor to that worksheet. The cells used for entering data are shaded green (e.g., facility name, catchment population). The other parts of the workbooks that are not shaded green contain formulas or pre-set calculations. You should not erase or change cells in these parts of the tool. The Service Practice Worksheets and prices in the individual worksheets should be changed only at national or provincial levels (see Section 5). Each worksheet is protected to prevent formulas from being deleted or changed. You may still type in the areas shaded green, but if you try to change other cells you will see an error message. If you need to make changes to a worksheet, you will have to unprotect the worksheet first (from the Tools menu, choose Protection, and then Unprotect Sheet. After you have finished making your changes, choose Tools, Protection, Protect Sheet, and then click OK). We recommend that the head of each organization (or the national or provincial level, if being used in the public sector) protect the sheets with a password so that standards and formulas cannot be changed at lower levels. We have included comments in the tool to provide more detail when necessary. For example, comments are included to show where some of the prevalence or incidence rates were obtained. They also explain how certain calculations were done. If a cell contains a comment, you will see a small red triangle in the upper right-hand corner of the cell. The comment itself will not display automatically. If you would like to read the comment, move your mouse so it is on the cell that contains the comment, and the comment will pop up on your screen. Move the mouse off the cell to make the comment disappear again.
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4.
Step-by-step guidelines
4.1. STARTING
Note: Annex D provides a list of the data needed to conduct a CORE Plus analysis; you may wish to print Annex D and gather the required data before reading further. You should use the blank workbook, not the example workbook to enter data for your facility. As soon as you open the blank workbook file you should see a dialog box asking if you want to Enable Macros. You should click on the Enable Macros button. When the file opens you should click on File and then Save As and save the file with a new namepreferably the name of the facility and year so that you can recognize it in the future. This way the blank version of the file can be used for other facilities, or for future years at the same facility. When you open the file you should see the screen below (see Figure 2). You work through the workbook in the order of the pages, so you should start with the page labeled A_Assumptions, then move on to B_Need, and so on. You can see the names of the various worksheets on the different tabs near the bottom of the screen, and you can tell that A_Assumptions is the active page because its name is highlighted on the worksheet tab (all the other worksheet tab names are shaded gray).
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Figure 2. Starting screen (A_Assumptions) of CORE Plus
4.2.
SETTING THE ASSUMPTIONS.
Preliminary data: You will enter some preliminary data first. The data that you type will appear on each worksheet in the workbook, so that when you print your results you will always know which facility, time period, and currency were used for the calculations. Begin on the page titled A_Assumptions (the worksheet shown above). Enter the name of your facility in cell B1 (put the cursor in cell B1 and type the name of your facility). Type the period for which you have data in cell B3. For example, if you are looking at costs and utilization for the year 2006, enter the number 2006 in cell B3. If you are looking at quarterly data, you may type in something like Jan-Mar 2006 to indicate the time period. In cell B4, type in the currency you are using (e.g., francs or pesos).
Question A1: type of facility. Click on cell G8. You will see a small arrow appear at the right of the cell. This is a restricted cell, that is, you may fill it in only with a number of pre-set
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choices. Click on the arrow at the right of the cell and you will see a drop-down menu. Highlight the appropriate choice and hit the Enter key. Question A2: location of facility. Click on cell G10 and choose the location (primarily urban or rural area). Question A3: catchment population. Enter the facilitys clinic-level catchment population in cell G12. This is the catchment population for which you provide clinic-level (or first tier) services. If your facility also sees patients who are referred from other facilities (or from within your own facility), you will enter the referral catchment population in a subsequent step. For example, your facility might be part of a larger network of facilities, and the smaller ones refer their more serious cases to your facility. Thus, your referral catchment population would be larger than your clinic catchment population (i.e., the people who use your facility for basic services because your facility is the closest to them geographically).
Figure 3. Relationship of clinic- and referral-level catchment populations
Health clinic A catchment population
Health clinic B catchment population
Health clinic F catchment population
Health Center G catchment population (clinic-level services)
Health clinic C catchment population
Referral catchment population for Health Center G
Health clinic E catchment population
Health clinic D catchment population
Question A4: population distribution. Enter the population distribution (in percentages) for the different age groups in your catchment area in cells C16 through D21. The actual numbers will then be calculated automatically. If you do not have the distribution for your area, you can begin by using national or regional figures and then changing them when you have more accurate data. (The tool links to generic distribution figures, based on the location you chose in step A2, but you may overwrite the formulas with actual percentages if they are different.) Question A5: referrals. This question also has a pull-down menu choice. Click on cell G24, click on the drop-down arrow, and choose Yes or No by highlighting the correct response.
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Question A6: referral catchment population. If the answer to the previous question was No, this question is not applicable and will be shaded in gray. If the answer to question A5 was Yes, you will need to enter the referral catchment population of the facility here, in cell G27. The population figures for each age bracket will calculate automatically when you enter the total referral catchment population. Question A7: contraceptive prevalence rate. While most assumptions related to service utilization are on the second worksheet page, B_Need, this assumption is separated because it is used to calculate more than one rate on the B_Need page. Enter the contraceptive prevalence rate in your area, expressed as a percentage (e.g., 66%), in cell G38. Question A8: percentage of population served. In cell G40, enter the percentage of people in your catchment area who are served at your facility. If there are no other health services available in the area, and people seek care at your facility, you may enter 100%. If other facilities compete with yours, if many people go to traditional healers, or if some people do not seek care when ill, then you would enter an estimate that is less than 100%. Question A9: hours per day that the facility is open. Click on cell G42 to get a drop-down menu of choices. If your facility is open different hours on different days, you may take the average and enter it here. For example, if you are normally open Monday through Friday from 08:00 to 16:00 (eight hours per day), but you have extended hours until 18:00 on Mondays and Wednesdays, and until 17:00 on Thursdays, your average would be (10+8+10+9+8)/5, or nine hours per day. Question A10: days per week that the facility is open. Click on cell G44 and choose the appropriate response from the drop-down menu. Question A11: days per year that the facility is open. Enter the number of public holidays in cell G47, and then answer the Yes/No question directly below it in cell G48. If the facility is not open on public holidays, this number will be subtracted from the total number of days available. Question A12: available work days per staff person. Enter the average number of days that staff take leave (cell G52), need to use sick time (cell G53), and spend time in training (cell G54). The total of these numbers is subtracted from the number of days per year that the facility is open to get the average number of available work days per staff person. Question A13: staff turnover rate. Your facility may have low, medium, or high level of turnover, depending on many factors. For instance, you may have high turnover because your facility is located in a particularly remote area. Click on cell G57 and choose the estimated level of turnover for your facility. Question A14: average base salaries. Later in the data entry process, on the C_Service_staffing page, you will type in detailed data about actual staff at your facility. However, one of the features of this tool is that it will show you different scenarios so that you can compare different situations. For example, if your facility has never offered child survival services before, but you would like to start offering these services, you can determine estimated
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costs to do so, as well as estimated staffing need. This question asks you to enter average base salaries (before benefits are calculated) so that, even if you do not have a particular type of staff person currently, you can still get reasonable cost estimates for providing new and different services in the future. The figures should be entered in cells G61 through G73. (The types of staff named in this question are illustrative, based on staffing in a number of countries; the staff categories can be adapted to your own situation if need be.) Question A15: ratio of benefits to base salary. Enter in cell G75 the average ratio of benefits to base salary. For instance, if all staff receive an allowance to cover the cost of uniforms, meals, etc., figure out the percentage of these additional benefits to the base salary. Question A16: normative percentage of direct service time. In cell G77, enter the normative percentage of direct service time. That is, on average, how much time do clinical staff spend with clients or on client-related activities? For instance, a nurse may spend 80% of her time with clients, and the remainder of her time in administrative meetings. Question A17: transport cost on drugs purchased. If the base prices of the drugs need to be adjusted due to the additional cost of transporting them to your facility, enter that percentage here in cell G79. Question A18: transport cost on supplies purchased. If the base prices of the medical supplies need to be adjusted due to the additional cost of transporting them to your facility, enter that percentage here in cell G81. Question A19: average mark-up for drugs. If your facility sells the drugs for more than the purchase cost, enter the percentage mark-up here in cell G83 (e.g., if you charge patients 2% more than what your facility paid for the drugs, you would enter 2% in cell G83). Question A20: average mark-up for medical supplies. If your facility passes along the cost of medical supplies (e.g., syringes, sutures, and bandages) to patients, and the price charged is higher than the purchase cost, enter the percentage mark-up here in cell G85. Question A21: average mark-up for laboratory tests. If your facility passes along the cost of laboratory tests (e.g., HIV test or malaria smear) to patients, and the price charged is higher than the purchase cost, enter the percentage mark-up here in cell G87. Question A22: average mark-up for radiology services. If your facility charges a fee for radiology services, and that fee is higher than the cost, enter the percentage mark-up here in cell G89. Question A23: exchange rate for price conversions. If some of the normative prices (e.g., the unit costs of drugs) are in dollars or another currency, enter the exchange rate in cell G91. If all figures used are in the local currency, enter the number 1 in this cell. Question A24: scenario selection. The available scenarios are as follows:
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Scenario A: Actual Services and Actual Costs. This scenario reflects the actual services provided, based on the entries in row 21 of worksheet B_Need. It also reflects the actual expenditures made, for example the expenditure on drugs and supplies purchased. Scenario B: Actual Services and Normative Costs. This scenario reflects the actual services provided, as under Scenario A. But it substitutes the normative costs for the actual costs. Thus, it reflects the number of staff that should be employed according to the staff times used in the Service Practice Worksheets instead of the actual number of staff. The numbers of staff required are rounded to the next whole number on the assumption that part-time staff cannot be used (e.g., if 3.4 nurses are required, the figure is rounded up to 4). Similarly it reflects the quantities of drugs that should be used instead of the quantities of drugs purchased. Scenario C: Needed Services and Normative Costs. This scenario reflects the estimated numbers of services needed, based on the population, incidence and prevalence rates and expected service utilization rates (as shown in row 19 of worksheet B_Need). It also reflects the quantities of resources (staff, drugs etc.,) that should be used to provide the needed services. Scenario D: Projected Services and Normative Costs. This scenario reflects the projected numbers of services entered in row 20 of worksheet B_Need, where the user wishes to see the costs of services that are different from the actual services and the needed services. The normative costs are used to estimate the total costs. Scenario E: Projected Services and Ideal Staff. This scenario uses the same numbers of services as Scenario D, but estimates the staff costs based on an ideal number of staff. This shows the total staffing pattern and cost if one can employ part-time staff as needed. For example if the services require 3.4 professional nurses, the tool includes only the cost of those 3.4 nurses.
For now, you should choose Scenario A, until you have finished entering the service statistics and current data for your facility. Later, you will change this to see how the different scenarios affect number of visits, costs, and so on (see Section 4.9, which discusses how to analyze the results). Some of the figures shown on the worksheets depend on the current scenario (that is, the one that was last selected). To make it easier for you to remember which scenario has been selected, look at cell B5 of worksheets B_Need through H_Summary; the scenario name appears in that cell.
4.3.
ENTERING UTILIZATION DATA.
Now move on to the second sheet in the workbook, B_Need. See the sample screen below in Figure 4. To do this, simply click with your mouse on the worksheet tab near the bottom of your screen. The worksheet will become the active worksheet and the tab will be highlighted.
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Figure 4. The B_Need page of CORE Plus
Across the top of the worksheet, you will see the name of the facility and the time period that you filled in on the A_Assumptions page. These data appear on each sheet automatically for easy reference. In row 9, you will see a list of the services that have been defined as the priority service package, both at the clinic and referral level. (If you said on the first page that your health facility does not handle referral cases, the referral part of the worksheet will be shaded gray). Underneath row 9, the tool automatically calculates the estimated quantity of services. First, it automatically calculates the relevant population. For example, for prenatal care, the relevant population is comprised of women of reproductive age (age 15-49). The figures come from the population distribution entered on the A_Assumptions page. Next you will see the prevalence or incidence rate. If you have any questions about how the rate was determined, move your mouse over the cell to see the comment. These two numbers are multiplied together to give you the Total Quantity of Cases figure in row 13. Row 14 shows you the percentage of people expected to use services at your facilityagain, this figure is based on your answer to the question on the A_Assumptions page about the percentage of population served at your facility.
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Row 15 shows the result of the Total Quantity of Cases times the estimated percentage of people served at your facility. Rows 16 and 17 apply only to referral cases. Of the quantity of cases that you expect to see, what percentage will actually be referred after a primary care visit? The result appears in row 17. Row 18 contains norms set at the national, provincial, or district level for a reasonable number of services or visits per type of case. In our example, for prenatal care, the norm is three visits per pregnancy. Finally, the quantity of cases is multiplied by the quantity of services to get an estimate of the quantity of services needed; the figure is shown in row 19. The above calculations are shown visually in Flowchart B1 in Annex B. Actual services: Enter your own data in row 21, labeled Actual services. If your facility offers referral services but you do not have the data separated by clinic-level versus referral-level, enter your data in the green-shaded area in row 38 instead, and the services will be split automatically for you, based on the proportion of services needed as calculated above. (This is not an ideal solution, because your facility may have different referral patterns, but it will give you a rough idea of how the cases might be divided between the two levels.) Note that the total number of all services should be slightly more than the total number of visits to the facility (headcount), since some patients would have received more than one service when they visited the facility. Note for users who enter data in row 38 rather than row 21: After entering your service figures in row 38, go back to row 21 and enter a formula in cell C21: type the equal sign, followed by the cell reference C39. The formula will be: =C39 Copy this formula across to each green-shaded cell in row 21 (both for clinic-level and referral-level services). Projected services: If you would like to see the staffing and cost impact of adding new services, or significantly changing the quantity of services offered, you may enter those figures in row 20. For example, if you do not currently offer child survival services, but you want to see the effect of adding the child survival services described in the PSP, you can copy the figures on actual services from row 21 into row 20, and then copy the quantity of needed visits for child survival from row 19 into row 20. Then, when you run the scenarios, you can see the effects of adding this service. Adding and deleting services The services that comprise the Priority Service Package (PSP) are named in each column of the B_Need page of CORE Plus. It is possible that your facility offers additional services that are not included in the PSP. If this is the case, you may wish to add extra columns to the tool to show the full range of services provided. You will need to add columns to each worksheet page that shows a listing of the services, and you will have to develop Service Practice Worksheets for these other services.
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It is possible to include more services by adding more columns. However, it is better if this is done by a person with advanced spreadsheet skills, as great care must be taken with the copying of formulas to avoid errors. Deleting columns should also be avoided as this will also cause errors if not done properly. (If you do not offer certain services and do not want them to appear on a printout of your results, you can hide the columns instead.) If you do not wish to include a service you can use the Projected Services feature described above and put zero against that service.
4.4.
ENTERING DATA ON SERVICE STAFF
Now click on the third worksheet tab, C_Service_staffing. You will see a sheet like the one below in Figure 5. This sheet is used to enter and calculate figures for staff who provide services directly to patients. Questions C1, C2, C3, C4, and C5 are answered automatically from the information entered in worksheet A_Assumptions.
Figure 5. The C_Service_staffing page
For the following section, the Salary Costs Worksheet (rows 13-82), you fill in the names and positions of staff working at your facility.
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This section is divided into staff categories. That is, 13 staff categories have been defined in each of the Service Practice Worksheets. For lower-level facilities, based on these guidelines, you most likely will not have some categories of staff. The assumption is that lower-level facilities do not need staff such as a Pediatrician, Anesthesiologist, Radiologist, or General Practitioner. This is because patients coming for community-based or Dispensary services do not need to see these types of staff. However, if your facility is a Health Centre (HC) or Hospital, you would need staff working in these roles. For each type of staff category, you will need to fill in some data. Below is a description of each column on the C_Service_staffing page, and what data (if any) you need for each one. Some of the columns contain formulas; for these, you do not need to fill in data. The formulas are already part of the tool, and Excel will perform the calculations automatically when you enter data in other areas of the tool. Column B: Name (and position, if needed for easy reference). The first row of each block (e.g., cell B15) shows the category of job; this is linked from the A_Assumptions page. In the second and third rows of each block (additional rows can be added if necessary for a particular category of staff), enter the name of each staff person. Note that you should not include any volunteer or visiting staff who are not paid from the facility budget. Column C: Do you have this type of staff? This is a Yes/No question. Click in the cell and then click on the arrow to the right of the cell. Choose Yes or No. A message will appear, beginning in column E. It will either say OK or give you an error message. This is to help guide you with the data entry. For example, if you say that you have a Radiologist, but your facility does not handle referral cases, you will get an error message because the Service Practice Worksheets indicate that a Radiologists services are not used at the Dispensary or Health Centre level (i.e., the Radiologist handles only the more complicated cases at the referral level). Columns D and E: Ideal Number of Staff and Number of Staff (rounded up). These two columns calculate figures automatically, based on utilization data and the norms in the Service Practice Worksheets. Ideal Number of Staff refers to the number of staff per category that you would need if the Service Practice Worksheets were followed. This calculation assumes that you have flexibility in hiring; for example, if you only need someone half-time, you would be able to hire a person to work half-time. Number of Staff (rounded up) is calculated based on the assumption that you may not have hiring flexibility. For example, if you only need someone to work two hours per day, you still might need to hire someone full-time, due to hiring regulations. The method used to calculate the number of staff is shown in Flowchart B2 in Annex B. Column F: Actual Number of Staff. List the actual number of staff here. If you are listing staff individually by name, the number will usually be 1. However, if you have several staff working at the same level, you might want to list them together. For example, you might have five Professional Nurses who all have identical salaries and who spend all their time in a similar way, so you would list 5 under Actual Number of Staff. Do not list staff
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together unless they all work in the same area performing similar tasks, and unless they all earn the same salary. If their salaries are different, or they spend their time performing different tasks, list them separately. For example, of these five nurses, one may work primarily providing reproductive health care and another may work half-time providing pediatric care. You would list them separately under the appropriate categories. If a person works less than full-time, calculate the amount of time worked and enter it here instead of 1. For example, if a full-time person works eight hours per day, five days per week, and you have someone who works two hours per day, five days per week, this person works 2/8 of a full-time shift, or 1/4, or 0.25. You would enter 0.25 for Actual Number of Staff. Column G: Number of Staff for this Scenario. You do not need to fill in anything in this column; the tool will calculate it automatically for you, based upon which scenario you have chosen. Column H: Average Gross Salary (for FT). In this column, you fill in the base salary for the staff person, not including the benefits. If you have someone working less than full-time, you would fill in the salary for a full-time person; the tool will calculate the prorated salary for you. Column I: Average Salary including Benefits. This calculation is performed by the tool. It takes the base salary you have entered and adds the value of the benefits provided, to arrive at the total compensation package for the staff person. Note that the figure in the subtotal line is based on a full-time salary, so if the staff person works less than full-time, the figure will appear high. Adjustments for staff working less than full-time should appear in the next column. Column J: Total Annual Salary. This is a weighted average calculation of salary plus benefits for all staff working within a staff category type. You do not need to enter data here; the tool does the calculations automatically. Column K: Hours Worked per Year. Again, you do not need to fill in data here. The formula takes the number of staff and multiplies it by the number of hours that the facility is open per year (based on assumptions you entered on the A_Assumptions page). Column L: Average Salary per Hour. This is another automatic calculation. It is the total annual salary (column J) divided by the hours worked per year (column K). Column M: Direct Service Time (%). Enter a decimal to indicate how much time each staff person spends on direct service to clients. This is time in consultation, or time filling out a patients chart. It does not include participation on committees or administrative duties. For example, if someone spends 80% of his time on direct service to clients, you would enter 0.8 in the appropriate cell of the tool. Column N: Total Direct Service Time. This is another automatic calculation, based on direct service time and whether the person works full-time or not.
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Column O: Annual Direct Service Salary. This is an automatic calculation; it is the proportion of the salary that is allocated to direct service, based on the percentage of direct service time that you entered in column M. Column P: Total Direct Minutes Available. This is also an automatic calculation; it multiplies the hours worked per year by the direct service time percentage, and then multiplies the result by 60 to convert from hours to minutes. Figures are expressed in minutes because the times are listed in minutes in the Service Practice Worksheets, so that is the unit for calculations elsewhere in the tool as well. Column Q: Annual Admin. Salary. This is another automatic calculation. The Annual Direct Service Salary (Column O) is subtracted from the Total Annual Salary (Column J) to give the part of salary and benefits that are allocated to Administrative costs.
The method used to calculate direct, indirect, and administrative salary costs is shown in Flowchart B3 in Annex B. Following are some common questions and explanations. What if I get an error message when I say that I have a particular type of staff person? If the tool gives you an error message if you indicate that you have a particular type of staff, it is because of the personnel time norms set up in the standard treatment protocols. For example, if you enter data in the tool to show that your facility has an Obstetrician/Gynecologist, but your facility is not a hospital, you will get an error message. Is this specialist handling cases that could be seen by a professional nurse? If so, list the specialist under the category of professional nurse. On the other hand, if your facility does handle referral-level cases, then your data on the B_Need page should reflect that; you should list actual number of services provided at the referral level. What if my staff have multiple qualifications and serve in more than one type of staff category? CORE Plus will calculate staffing patterns for you, based upon the utilization data you entered and the times listed in the Service Practice Worksheets. It is possible that you will have staff people who work under more than one staff category. For example, a Professional Nurse has also been certified to treat pediatric patients, but you do not have a separate nurse assigned to that role exclusively. If this is the case, talk with the nurse and the supervisor to determine approximately how much time the nurse spends in each role, and enter the calculations accordingly. For example, a full-time Professional Nurse might spend 50% of her time in the Professional Nurse role, 30% of her time working in the community as a Community Health Nurse, and 20% of her time carrying out administrative activities. You would list the nurse twice on the staffing page: once under the Professional Nurse category, with Actual Number of Staff set to 0.6, (50% direct time and 10% administrative time) and once under the Community Health Nurse category, with Actual Number of Staff set to 0.4 (30% community work and 10% administrative work).
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In rows 85 through 88 at the bottom of this worksheet (row numbers may differ if you have added extra rows for staff categories above), the tool sums up the total direct minutes available for all staff that you have listed; the total direct service salaries; the total administrative salaries; and the total number of service staff full-time equivalents (FTEs) for the scenario that you have chosen. These totals are used in calculations elsewhere in the tool.
4.5.
CALCULATING STAFF COSTS.
Staff cost calculations take place on the sheet D_Staff_Costs. You do not need to enter any data on this sheet. A brief description appears below: As mentioned earlier, for each type of service defined in the package, there are Service Practice Worksheets. The number of minutes that each staff category spends with a client is referred to in the section D1 of D_Staff_Costs. In section D2, the total quantity of services is multiplied by the number of minutes for each service, to get the total estimated number of minutes spent per year by each type of staff. In section D3, the total minutes are multiplied by the average salary per minute (average salary per hour divided by 60 minutes per hour). This figure shows the estimated cost to provide the service staff time over the year. Section D4 calculates the indirect cost of staff providing patient care. In this case, indirect does not refer to administrative time. Rather, it measures the cost of staff inactivity. For instance, if a nurse was ready, willing, and available to see three patients per hour, but she saw only two patients per hour for scheduling or other reasons, the cost of the down time or slack time is figured in this section.
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Figure 6. The D_Staff_Costs page
4.6.
CALCULATING FIXED AND ADMINISTRATIVE STAFF COSTS.
Next, click on the fifth worksheet tab, E_Fixed_Costs. Here you will enter data on administrative staff costs and fixed costs such as electricity, water, cleaning, security, and so on. You will also enter the amounts spent on drugs, supplies, and tests (lab, x-ray). See Figure 7 below.
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Figure 7. The E_Fixed_Costs page
List administrative staff (that is, staff who do not provide any direct services, and who are not listed on the C_Service_Staffing page) in section E1. List the name and position in column C, the salary (including benefits) in column D, and the actual number of staff in column F. In section E2, fill in the other operating costs. Some categories are already listed; if you need others, you may add them. Type in the corresponding cost in column H. In section E3, fill in actual costs for x-rays, drugs, supplies, and lab tests. The tool calculates the difference between actual and expected costs, based on standard prices and treatment guidelines, and enters the figures in worksheet F_Total_Costs. This is done so that the actual expenditure is shown under Scenario A, instead of the normative expenditure. The total expenditure under Scenario A should then equal the total expenditure according to the financial system of your facility. In each case, the Variance column (column I) shows the difference between normative and actual cost. Column J, entitled Use in model, is just a reference for you so that you can see whether the particular scenario is making use of the normative or actual costs.
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4.7.
EXAMINING TOTAL FACILITY COSTS.
The sixth worksheet in the file, F_Total_Costs, shown below in Figure 8, is primarily to provide you with the results of the cost analysis, but there are a few areas where you might need to enter data in special cases.
Figure 8. The F_Total_Costs page
Any commission or fees based on individual services should be entered in row 12. A formula would have to be entered to link the commission to the relevant service data. Because so few of the types of cases require x-rays, and because these services are often contracted out, median unit costs for x-rays are not included in the Service Practice Worksheets. If you have unit costs for x-rays, you may enter them in the appropriate column of row 14. If you have special equipment for a particular service and you are depreciating it, enter that cost in the appropriate column of row 42. If your facility is responsible for contributing some funds toward regional or central office support costs, enter that amount in cell D51.
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4.8.
EXAMINING TOTAL FACILITY REVENUE.
Some facilities provide services free of charge, because they have outside financial support and they choose not to collect fees. Other facilities do charge fees. If you charge fees, you will need to fill in revenue data on the sheet G_Revenue. The facility data, names of services, and so on, are already filled in automatically; you need to enter only the information on fees charged for each type of service, as well as any waivers and exemptions. The tool then calculates automatically the net revenue per service. See Figure 9 below.
Figure 9. The G_Revenue page
In row 13, the quantity of services provided is automatically linked in from the B_Need page. In row 14, you should enter the figures for the fee charged (if any) for each service in the health services package provided at your facility. If you do not charge fees, you may enter zero (0) or leave the cell blank. In rows 28-30, the tool allocates additional revenue from pharmacy, radiology, and lab services. Many facilities do not track this revenue by service, and so the tool contains formulas to allocate total revenue for these ancillary services. o Enter the total pharmacy revenue (if tracked separately) in cell D28. o Enter the total radiology revenue (if tracked separately) in cell D29. o Enter the total laboratory revenue (if tracked separately) in cell D30.
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In rows 34-40, the tool makes adjustments to gross revenue to show the impact of waivers, discounts, and cash differences. o In row 34, enter the amount of waivers given for consultations. o In cell D35, enter the total amount of waivers given for pharmacy charges. o In cell D36, enter the total amount of waivers given for radiology service charges. o In cell D37, enter the total amount of waivers given for laboratory charges. o In row 38, enter the amount of discounts given. o In row 39, enter the amount of cash differences. The tool will automatically calculate the net revenue per service in row 43. You are now finished with data entry. The next step is to see if actual cost and revenue data were entered accurately. You must click on Scenario A before you do this to ensure that you are looking at the actual total cost figures. The total costs shown in column D, row 52 of worksheet F_Total_Costs should be the same as the total expenditure on the financial report from which you took the cost figures. You should compare the two figures and make sure that they agree. If you have taken any figures from other sources, for example regional office costs, they should be added to those shown on the financial report. You should also compare total revenue from the financial report with the calculated revenue on worksheet G_Revenue, cell D40 (total revenue less waivers, discounts, and cash differences). Once you have agreed the actual costs and revenue, save the workbook, and then study the results of your cost analysis.
4.9.
ANALYZING THE RESULTS.
Utilization analysis. CORE Plus provides many areas for analysis. Before you even begin to look at costs or revenue, you may have questions about the quantities of services. When you compare needed services (row 19 of the B_Need page) with actual services (row 21 of the same page), do any of the results surprise you?
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Figure 10. Comparing Needed and Actual Services
In the example above, the tool estimated that Buffalo Hill Health Centre should provide 2,123 prenatal services, based on the population, the expected rates for pregnancy, percentage of cases seen, and visits per pregnancy. However, during the year it recorded only 1,254 services. There could be many possible explanations, such as: Perhaps women came to the health centre for one or two visits instead of the expected three visits. More clients than expected went to another facility, or to a traditional healer. The catchment population may be smaller than the figure entered on the A_Assumptions page. If there is a large discrepancy between the quantity of cases you expected to see and the quantity you did actually see, this might be an area that warrants more study. Perhaps access is a problem, or perhaps the clients in your catchment area are not aware of all the different services that you offer. Or they cannot take time away from their work to make the journey to the health centre, because they will lose that days income if they do not go to work.
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Cost analysis. This is not an exhaustive discussion of cost analysis; rather, it offers some brief pointers and suggestions. Firstly, you should note that the figures shown on the F_Total_Costs worksheet depend on the current scenariothat is, the one that was last selected. Recall that the current scenario is shown in yellow on row 5. If you want to analyze actual services provided and actual costs incurred, make sure that you are using Scenario A. At the bottom of the F_ Total_Costs page, you will see a summary of total variable and fixed costs. The variable costs are those that change with the quantity of services offered, and in the tool are comprised of drugs, tests, and clinical supplies. The fixed costs do not change when service quantities change unless you need to hire more staff to take care of an increased level of patients. Other fixed costs include facility running costs. In the example below, the variable costs represent about 1% of total costs, while fixed costs represent about 99% of total costs. See Figure 11. This is an unusual pattern; in this example, the variable costs are extremely low because many of the drugs and supplies have been donated, and did not represent a cost to the facility. Note that negative numbers may appear in certain rows in this worksheet, and they will be carried through into the next worksheet, H_Summary. This should only happen when Scenario A is run. They will appear in rows 29 through 32 of F_Total_Costs if the actual expenditure in rows 47 through 51 of E_Fixed_Costs is more than the normative expenditure in those same rows. In this case the tool uses the normative costs to allocate the unit costs shown in rows 22 through 26 on the F_Total_Costs worksheet and then has to make negative adjustments in rows 29 through 32 to bring the total costs in line with the actual expenditure. The adjustments are spread proportionally across all the services that were charged with supplies. Similarly, where the normative time of any staff members comes to more than one full-time equivalent, or FTE, as shown in Column D of the C_Service_Staffing worksheet, the normative costs are shown in row 38 of the F_Total_Costs worksheet. In other words, the normative cost of the staff person comes to more than the actual expenditure. Negative adjustments are then made in row 39 to bring the total costs to match the actual expenditure. In this case, the adjustments are made only for those services that were charged with the time of that specific staff member.
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Figure 11. The lower part of F_Total_Costs worksheet, showing breakdown of costs
Here are some questions you might ask when you see your own results: If we are asked to control our costs, which area(s) can we control most easily? Is it possible to get better prices for drugs and supplies we procure? Are there ways we can reduce some of the fixed costs, such as by transferring staff to a busier facility, or cutting down on utility costs by turning off lights that are not needed? Revenue analysis. The revenue analysis page shows you a number of things: whether and how much you charge for services; the net revenue as compared to the gross revenue; and the amount of any waivers or exemptions that were given. Some organizations charge reduced or token fees for preventive and family planning services, because they want to encourage their clients to come to the health facility for those services. You can use the revenue page to answer the following types of questions: How does net revenue compare to gross revenue? Is the facility meeting its revenue target (if it has a target)? If fees are increased and quantity of services provided does not change, how will revenue be affected? You can carry out further analyses when you compare the costs and the revenue. For example, the summary page will show you the percentage of cost recovery that your facility has achieved. It will also show you which services cost the most to provide, either because they require
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significant staff time or expensive drugs and supplies. It will also show the results of any whatif analyses you have done. The summary page. First, recall that the figures shown on the H_Summary worksheet depend on the current scenariothat is, the one that was last selected. The current scenario is shown in yellow on row 5. If you want to see summary results for another scenario, go back to the A_Assumptions page and change the scenario there, in question A24. The page entitled H_Summary displays several things. A sample is shown below in Figure 12: First, in section H1 it shows the number of services from the B_Need page as a reference for studying the cost summary information. It also shows the numbers of services provided for each type of treatment as a percentage of the total number of services. Next, and also for reference, it shows the variable and fixed unit costs per service in section H2 so that you can see which services are more costly to provide. For example, you can see that an average prenatal consultation at the Health Centre level cost over 744 shillings, of which 434.01 shillings was variable costs (drugs, etc.) and 310.78 shillings was fixed costs (staff, etc.). You can also see that the direct staff cost of providing the service was 117.98 shillings, and the indirect staff cost was 25.63 shillings, indicating that there was some slack time and that there were too many staff for the number of patients seen.
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Figure 12. The H_Summary page
Section H3 shows the revenue per service (both the net revenue and the surplus or loss per service, as calculated on the G_Revenue page). Section H4 shows revenue and cost recovery for service categories, such as the reproductive health services as a group, and the child survival services as a group. It also shows cost recovery by facility level, so if your facility provides both primary care and referral services, the revenue and cost recovery can be calculated separately for each. Section H5 displays total facility costs and revenue. If you have both clinic and referral level services, it will give you a breakdown by each level. Figure 13 below shows the lower half of the H_Summary worksheet. In this example, the facility does not offer referral services, so the clinic level and facility totals are the same. We can see that salary costs are 95% of total facility costs, and drugs/supplies/tests are almost 1% of the total. (Recall that in this example, many of the drugs and supplies were donated.) The remaining costs are other fixed costs. Section H6 shows staff utilization for direct service delivery. Some of these results may surprise you. According to the example, the professional nurse category staff are spending about 79% of their available direct service time actually providing patient care, but the community health nurses are using slightly over 1% of their available direct service time. This indicates that staffing levels should be reviewed.
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Figure 13. The lower half of the H_Summary page
4.10.
COMPARATIVE REPORTS.
The worksheet tab I_Reports will show you the results of the different scenarios. To run the scenarios, simply click with your mouse on the gray buttons in row 6. For example, to run Scenario A, you put your mouse over the button labeled Run Scenario A and click on it. Do the same for scenarios B through E. Note that you must run each Scenario every time you want to see the results of changes in data entry, as these figures do not change automatically each time a change is made (unlike the other worksheets). A sample of the I_Reports worksheet is shown in Figure 14 below.
Clinic-level services The top section of the sheet shows the comparative results for clinic-level services (Level A). You can see that the catchment population stays the same, as does the estimated number of clients (rows 8-10). The differences begin to appear in row 13, Quantity of services provided. Since Scenario C represents the estimated total number of services needed by the population,
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based on disease prevalence or incidence rates and the rates of services per case, this figure is higher than any of the others. Some of the comparisons that can be made based on the example below are as follows: The average number of services provided per capita (for those with access to the facility) was actually 1.04, whereas the estimated number of services needed was 4.33. In other words, people are not using the services as much as they should. For scenarios D and E (projected services), the difference is that these latter scenarios include the introduction of child survival as well as reproductive health services, and thus show an increase in the number of services per capita to 1.12. Under Scenario B the total cost is 17.4 million shillings, which is higher than the actual cost of 14.1 million shillings. This is partly because the drugs, tests and clinical supplies are included at their normative costs instead of their actual costs (in this example, actual cost is lower because some of the drugs and tests, such as for treating HIV, are donated). Also, the number of staff is adjusted upwards in line with the staffing norms set in the tool. The number of services is the same under both scenarios.
Figure 14. The I_Reports page
Under Scenario C the total cost is 31.4 million shillings, much higher than the actual cost of 14.1 million shillings under Scenario A. This is to be expected, since the needed number of
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services is over four times the actual. The difference in cost is not as much as the difference in the number of services, as staff should be used more efficiently with increased volume of services, and the tool assumes that other fixed costs, such as electricity, would not increase. Under Scenario D the total cost is 17.7 million shillings. This is slightly more than the cost of Scenario B, reflecting the cost of adding child survival services. Under Scenario E the total cost is 17.0 million shillings. This is less than the total cost of 17.7 million shillings under Scenario D, even though the number of services is the same. This is because Scenario E calculates staff costs on the basis that staff can be hired for the exact amount of time needed. For example, if the services require 3.4 nurses, the cost is based on 3.4 nurses (rather than having to round up to full-time staffing when only parttime staffing might be needed in some categories of staff).
Referral-level services The middle section of the I_Reports sheet is similar to the above, but it shows summary results for referral-level services (if applicable). Since the example shown in Figure 14 above is for a clinic, there are no referral-level services. Combined statistics The bottom part of the sheet shows combined figures for the total facility, and then summarizes staff and facility use. In the example below, you can see that with an ideal staffing level, staff costs would be only 62% of total costs, compared with the actual of 95%. You can also see that the clinic would have to nearly double the number of staff seeing patientsfrom 58.5 to 100if it had to provide all of the needed services in the catchment area (compare Scenario AActual services with Scenario CNeeded services). Interestingly, under Projected Services (Scenarios D and E), the total number of staff is lower than with the actual staffing in Scenario A. This is most likely due to more efficient use of staff and a review of how staff are spending their time, as compared with the stated activities on the Service Practice Worksheets.
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Figure 15. Combined statistics (clinic- and referral-level) on the I_Reports page
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5.
Changing norms and prices
The norms used in the tool should be reviewed regularly and updated where necessary. They can be found in several places of CORE Plus, as described below. In some cases no norms were available, and best guesses were used. In such cases research should be carried out to develop proper norms. The norms should be changed only at national, provincial, or district levels (whichever level has the authority to determine service practices), since it is crucial that the same norms be used throughout an area for consistency and comparability. Care should be taken when changing norms, especially where costs may have been used in preparing service level agreements. The three types of norms used to determine the numbers of services needed appear in the B_Need worksheet. The relevant population figures are shown in row 11, and are derived through a formula that refers to a certain group of the population shown in the worksheet A_Assumptions. The incidence or prevalence rates are entered in row 12, and the comment attached to each cell describes the source of the figure used. The figure for the quantity of services per case is shown in each service column in row 18. These figures are linked in from the individual service practice worksheets and should be modified there if necessary. If your country, province, or district has administrative staffing norms, you may use them in the worksheet E_Fixed_Costs to determine how many administrative staff should be employed, as well as reasonable costs for recurrent expenditures such as electricity and fuel. For example, a norm might be that a facility needs one receptionist for every four or five clinical staff. Norms are also used to calculate salary differences among different regions of the country. If organizations routinely pay higher salaries to staff as an incentive for them to work in more remote locations, these are factored into the normative costs. Regional variations in cost are also considered when calculating drug and supply prices, based on the assumption that it costs more to transport these commodities to some of the more isolated areas. The remaining norms appear on the individual service practice worksheets, namely the type of person who should provide a service, the number of minutes required, and the quantities and types of tests, drugs, and clinical supplies. Standard costs of resources should be reviewed and updated annually, or more frequently if cost changes are large. These costs should be changed only at the national or provincial level, for consistency and comparability. Drug prices can be updated on the Drug_list worksheet; similarly, supply and lab test prices can be updated on the Supply_list and Lab_test_list worksheets, respectively. Standard fixed costs appear in column G on the E_Fixed_Costs worksheet, and standard variable costs appear on the individual service practice worksheets.
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6.
Comparing facilities
You may want to compare the results of several facilities or build up a picture of a network of facilities. In this case you must make sure to save the workbook for each facility in a separate file. You can then open a new workbook, which will be a summary workbook, and enter the key findings from each facility file into one worksheet. The best place to find the key findings is in the I_Reports worksheet. Set up your new workbook so that you have one column for each facility. This new worksheet can be linked directly to the facility workbooks and will update automatically if you open the facility workbooks before you open the summary workbook. To link a cell in the summary worksheet to a cell in a facility worksheet you should do the following. Put the cursor on the destination cell in the summary sheet Enter the equal sign (=) Go to the other file and worksheet, click on the source cell that contains the data you want to link, and press Enter.
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7.
Cautions
The CORE Plus tool was developed for facility- and community-based ambulatory care services. The modeling of other services is more complex and is simplistic in this version of the tool. The resource needs, especially staffing, and costs of facilities that provide these services should be analyzed and interpreted with caution. Keep in mind the following: Community-based care. It is difficult to set norms for numbers of visits by facility staff to communities, since the time taken will vary greatly according to the type of visit and the distance. The assumptions regarding need and time required that are used in the tool will need to be adjusted, depending on the geographic location and ease of community access for the facility. All of the assumptions for community-based care should be reviewed for accuracy. Inpatient care. The resource needs for looking after inpatients have not been included. In the case of maternity, for example, only the cost of the delivery has been included. Staffing norms would have to be included, as well as the cost of other resources such as patient food.
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ANNEX A: NORMS
Table A-1: Clinic-level (Level A) service need norms Table A-2: Referral-level (Level B) service need norms Table A-3: Standard minutes per clinic-level (Level A) service Table A-4: Standard minutes per referral-level (Level B) service
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TABLE A-1: CLINIC-LEVEL (LEVEL A) SERVICE NEED NORMS

Prevalence or Reference incidence (data rate source) 11.7 percent Quantity of services per case 3 1 1 1 6 1 1 1 5 2 1 1 1 2 1 3 1 1 1 6 1 1 1 2.4 1 1 1
SERVICE Dispensary (Disp.) : Prenatal consultation (Disp.) Delivery and post-partum (Disp.) Postnatal consultation (Disp.) Post-abortion care (Disp.) Family planning (Disp.) Responsible sexuality: Youth (Disp.) Responsible sexuality: Men (Disp.)
Target population
Women, 15-49 Women, 15-49 Women, 15-49 Women, 15-49 Women, 15-49 Youth, ages 15-24
Men 25 years and over Men and women STI / AIDS (Disp.) 15-59 Well-child visit/ monitoring (Disp.) Infants 0-11 months Acute respiratory infection/ ARI Children 0-4 years (Disp.) old Children 0-4 years Fever of unknown origin (Disp.) old Children 0-4 years Mild malnutrition (Disp.) old Children 0-4 years Mild diarrhea, dehydration (Disp.) old Children 0-4 years Pulmonary TB (Disp.) old Children 0-4 years Other illnesses (Disp.) old Health Centre (HC) : Prenatal consultation (HC) Women, 15-49 Delivery and post-partum (HC) Women, 15-49 Postnatal consultation (HC) Women, 15-49 Post-abortion care (HC) Women, 15-49 Family planning (HC) Women, 15-49 Responsible sexuality: Youth (HC) Youth, ages 15-24 Men 25 years and Responsible sexuality: Men (HC) over Men and women STI / AIDS (HC) 15-59 Well-child visit/ monitoring (HC) Infants 0-11 months Acute respiratory infection/ ARI Children 0-4 years (HC) old Children 0-4 years Severe fever (HC) old Children 0-4 years Severe malnutrition (HC) old
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SERVICE Persistent diarrhea, dehydration (HC) Pulmonary TB (HC) Other illnesses (HC) Community-based care : Prenatal consultation (Comm.) Delivery and post-partum (Comm.) Family planning (Comm.) Responsible sexuality: Youth (Comm.) Responsible sexuality: Men (Comm.) STI / AIDS (Comm.) Well-child visit/ monitoring (Comm.) Other illnesses (Comm.)
Target population Children 0-4 years old Children 0-4 years old Children 0-4 years old Women, 15-49 Women, 15-49 Women, 15-49 Youth, ages 15-24 Men 25 years and over Men and women 15-59 Children 0-4 years old Children 0-4 years old
Prevalence or Reference incidence (data rate source)
Quantity of services per case 1 1 1 3 1 6 1 1 1 2.4 1
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TABLE A-2: REFERRAL-LEVEL (LEVEL B) SERVICE NEED NORMS

Quantity of services per case 1 1 1 1 1 1 1 1
SERVICE
Target population
Prevalence or Reference incidence rate (data source)
Prenatal consultation/ high-risk Women, 15-49 (Hospital) Delivery and post-partum (Hospital) Women, 15-49 Post-abortion care (Hospital) Women, 15-49 Infants 0-11 Newborn/ complications (Hospital) months Infants 0-11 Neonatal conjunctivitis (Hospital) months Severe malnutrition with Children 0-4 complications (Hospital) years old Severe dehydration with Children 0-4 complications (Hospital) years old Other childhood illnesses with Children 0-4 complications (Hospital) years old
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TABLE A-3: STANDARD MINUTES PER CLINIC-LEVEL (LEVEL A) SERVICE Recall that these are weighted average times; for any given case, actual time might be more or less.
Traditional birth attendant
Community health nurse
Community health agent
Head nursing assistant
Community volunteer
General practitioner
Professional nurse
Nursing assistant
DIRECT TIME PER SERVICE (in minutes) Dispensary (Disp.) : Prenatal consultation (Disp.) Delivery and post-partum (Disp.) Postnatal consultation (Disp.) Post-abortion care (Disp.) Family planning (Disp.) Responsible sexuality: Youth (Disp.) Responsible sexuality: Men (Disp.) STI / AIDS (Disp.) Well-child visit/ monitoring (Disp.) Acute respiratory infection/ ARI (Disp.) Fever of unknown origin (Disp.) Mild malnutrition (Disp.) Mild diarrhea, dehydration (Disp.) Pulmonary TB (Disp.) Other illnesses (Disp.) Health Centre (HC) : Prenatal consultation (HC) Delivery and post-partum (HC) Postnatal consultation (HC) Post-abortion care (HC) Family planning (HC) Responsible sexuality: Youth (HC) Responsible sexuality: Men (HC) STI / AIDS (HC)
33.9 215.0 62.2 15.0 35.8 5.0 7.0 87.0 35.0 20.0 24.0 35.0 30.0 18.0 17.0 26.0 173.0 208.0 20.0 45.0 3.0 2.0 20.0 23.0 5.0 6.0 85.0 11.3 60.0 34.2 25.0 55.0 2.0 7.0
3.0 3.0 3.0 3.0 3.0 3.0 3.0 3.0 3.0 3.0 3.0 3.0 3.0 3.0 3.0 3.0 3.0 6.0 3.0 3.0 3.0 3.0 3.0
15.0
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Clerk
Community volunteer
Professional nurse
Nursing assistant
DIRECT TIME PER SERVICE (in minutes) Well-child visit/ monitoring (HC) Acute respiratory infection/ ARI (HC) Severe fever (HC) Severe malnutrition (HC) Persistent diarrhea, dehydration (HC) Pulmonary TB (HC) Other illnesses (HC) Community-based care : Prenatal consultation (Comm.) Delivery and post-partum (Comm.) Family planning (Comm.) Responsible sexuality: Youth (Comm.) Responsible sexuality: Men (Comm.) STI / AIDS (Comm.) Well-child visit/ monitoring (Comm.) Other illnesses (Comm.)
15.0 31.0 61.0 23.0 13.0 18.0 25.0
26.0 5.0 2.0 15.0 75.0 2.0 5.0 70.0 87.0 137.0 45.0 6.3 4.3 92.0 32.0 33.0
3.0 3.0 3.0 3.0 3.0 3.0 3.0
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Clerk
TABLE A-4: STANDARD MINUTES PER REFERRAL-LEVEL (LEVEL B) SERVICE
Obstetrician/Gynecologist
Community volunteer
Professional nurse
Nursing assistant
Anesthesiologist
Pediatrician
Radiologist
DIRECT TIME PER SERVICE (in minutes) Prenatal consultation/ high-risk (Hospital) Delivery and post-partum (Hospital) Post-abortion care (Hospital) Newborn/ complications (Hospital) Neonatal conjunctivitis (Hospital) Severe malnutrition with complications (Hospital) Severe dehydration with complications (Hospital) Other childhood illnesses with complications (Hospital)
50.0 228.0 15.0 110.0 48.0 13.0 23.0 33.0 23.0 20.0 10.0 2.0
3.0 3.0 3.0 3.0 3.0 3.0 3.0 3.0
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Clerk
ANNEX B: FLOWCHARTS OF CALCULATION METHODS

B-1: Calculation of Services Needed B-2: Calculation of Staffing Numbers B-3: Calculation of Cost per Service
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B-1: CALCULATION OF SERVICES NEEDED
Worksheet B_Need: Estimates of number of services needed
Total population % male/female and age groups
Multiply Number male/female and age Multiply Number of persons affected Multiply
Incidence and prevalence rates
% with access to facility
Number using facility
Number of services per treatment/case
Multiply Total number of services needed, by type of service
Key: Input or Output Process
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B-2: CALCULATION OF STAFFING NUMBERS
Worksheet C_Service_Staffing: Calculation of staffing numbers

Used in Scenarios B, C, D, or E
Total hours available Multiply
% service time by staff type
Service time available by staff type Total direct time needed by staff type Divide time needed by time available Total staff needed, in FTEs* by staff type Round up Total staff needed, in whole numbers by staff type
Used in Scenarios B, C, and D Used in Scenario E
Key: * Note: FTEs are full-time equivalents. Input or Output Process
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B-3: CALCULATION OF COST PER SERVICE
Worksheet D_Staff_Costs: Calculation of cost per service

% service time by staff type Total hours worked Quantity of each service Standard time per service per staff type Multiply Total direct time per staff type for each service Multiply Average hourly salary cost per staff type Total indirect cost per staff type Divide service salary by hours worked Total salary by staff type Multiply Total service salary by staff type Subtract total service salary cost from total salary cost
Total admin. salary cost
Subtract direct service salary from total service salary
Allocate in proportion to direct salary cost per staff type for each service
Total direct cost per staff type for each service Sum all staff types for each service Total direct cost per service Sum all services for each staff type Total direct cost per staff type Sum staff type totals Total direct costs Note: Salary figures include benefits.
Total indirect cost per staff type for each service Sum all services for each staff type Total indirect cost per staff type Sum staff type totals Total indirect costs Key: Input or Output Process Sum all staff types for each service Total indirect cost per service
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ANNEX C: UNDERSTANDING AND REVIEWING THE SERVICE PRACTICE WORKSHEETS

The service practice worksheets are the building blocks of the entire CORE Plus tool. The worksheets provided in the sample spreadsheet have been reviewed by Haitian health professionals in accordance with treatment guidelines set forth by the Ministry of Health. However, you should review them to see if any changes need to be made for your particular country, province, or area (e.g., iodine supplementation is not routinely prescribed for expectant mothers during prenatal visits, unless the health facility is in a part of the country where iodine deficiency is a problem). The service practice worksheets are divided into three sections. At the top right of each section, you will see a question that asks, Per case or per visit? Sometimes it is easier to specify the normal treatment guidelines for a visit (e.g., acute respiratory infection), while at other times it is easier to describe the treatment for a type of case (e.g., listing all of the required drugs to fully treat a case of TB over a six-month period). With these worksheets, you have the flexibility to do either, and if it makes sense, you can also choose differently for each section. For example, you might define staff time per visit and medicines needed per case. If you specify a treatment per case, the tool will calculate a per-visit cost by dividing the per-case treatment cost by the number of visits listed in cell Q3 of each service practice worksheet. The default number of visits in the blank template is one visit. This is not indicative of a standard protocol and should be modified in accordance with recommendations of health personnel familiar with the context in which the tool is applied. Please keep the following in mind when reviewing the service practice worksheets for appropriateness: In the example provided, the majority of drug costs, and some supply costs, are taken from the PROMESS Liste de Prix en Gros from August 2004. Obviously, the cost of drugs, supplies, and lab tests at your facility will differ. You need to review the master list of drugs, supplies, and lab tests to ensure that the costs shown are accurate for your situation. The list of medical supplies includes only disposable supplies that are consumed during a patient visit. Thus, while it may be necessary during a visit for a health professional to use a stethoscope, thermometer, etc., these items and larger pieces of medical equipment will not appear on the list of supplies. SECTION 1: SERVICE DELIVERY STAFF TIME In this first section, each activity involved in service provision is listedthat is, each interaction between the client and the service provider is described. In cell Q5, ensure that the proper choice is selected (either visit or case). If you need to change from one to the other, click on the cell and make your choice from the drop-down menu. In column B, each activity is listed. Review the activities to see if your own norms are similar or different, and make changes as necessary. In columns C through O, you will see an estimate of the number of minutes needed for this type of visit (or case). Again, the sample spreadsheet provided includes figures that have
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been reviewed by health professionals in Haiti. If you need to adjust the figures, please do so only in consultation with Ministry of Health staff at the national or provincial level (whichever administrative level has the responsibility and authority to define norms). Note that this section includes all activities, such as registering the client, taking the medical history, providing counseling, collecting any needed samples, or referring the client if necessary. - In some cases an average amount of time has been used. For instance, if 15% of women who come for prenatal visits will need special counseling or referral for complications, how much time has been allocated for this activity in the worksheet? It may take 10 minutes for this extra counseling, but we do not want to include 10 minutes for each and every visit on the service practice worksheet, because not every prenatal client needs this extra counseling. Thus, a weighted average has been used instead: 15% x 10 minutes = 1.5 minutes on average. For any given visit, the number of minutes may be under- or over-estimated. However, if we average all visits over the year, then the total time estimate will be close to the reality. The total minutes for each category of personnel are summed automatically and linked to the D_Staff_Costs worksheet of the tool.
SECTION 2: DRUGS AND MEDICAL SUPPLIES In cell Q245, ensure that the proper choice is selected (either visit or case). If you need to change from one to the other, click on the cell and make your choice from the drop-down menu. Drugs are listed first, then supplies. Note that although enriched milk is not a drug, it is included in the drug list rather than the supply list because it is given in cases of malnutrition, and the description of treatment (e.g., twice a day for 15 days) is similar to treatment guidelines for drugs. Here is an explanation of the different data needed, or the calculations done, in each column of this section of the worksheet. The first part of Section 2 shows the drugs used to treat the given illness or condition: - Drug, Protocol, Dosage, Unit: Click and choose from the drop-down menu to list the needed drug(s). These cells link to the master drug list, so you are restricted to only those drugs on the master list. You may see a drug name listed more than once. This is because a drug may come in different strengths, forms, etc. Ensure that the drug name, strength, and form are all correct (e.g., amoxicillin 250 mg tablet PO (per oral). - Number of times/day: Type in a number to indicate how many times a day the medication should be taken - Number of days/cycles: Type in a number to show how many days the treatment should continue (or how many cycles, in the case of family planning)
Row reference may be slightly different if extra rows were added in previous section.
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% of cases treated: For each drug listed in this section, enter a number between 1% and 100% (of all the clients who come for this type of visit, what percentage receive this particular drug?). If only a small percentage of clients have complications that result in an additional drug being prescribed, you can list the additional drug and then indicate that a small percentage of clients would receive it. Drug formulation: This is to double-check your choice in the first columnis the drug a tablet, syrup, injectable, etc.? It is not necessary to fill in this column, but it will help anyone who is verifying the worksheet for accuracy. Dosage: This may or may not be the same as the drug strength that you chose from the pulldown list. For example, the dose may be 400 mg, but you have only 200 mg tablets in stock. Thus, you would instruct the client to take two tablets instead of one to get the correct dosage. Units per dose: Here the worksheet should list the number of units needed to make up the correct dosage. In the example above, the number would be 2 (2 x 200 mg tablets = 400 mg dosage). In general, if the drug listed is a liquid (e.g., intra-muscular or syrup to be given orally), the number of milliliters should be listed here (because the drug list calculates the average cost per milliliter). If the drug is in tablet form, the number of tablets should be listed here. If the drug is a cycle of oral contraceptives, the unit will be the number of cycles prescribed per visit. If the drug is a pre-filled syringe with measured vaccine or injectable contraceptive, the unit will be 1 (one injection). Total units Based on the prior inputs, the tool calculates automatically the number of items for this type of drug (times per day x number of days x % of cases treated x units per dose). Unit cost The tool links in the unit cost automatically from the master drug list. Once the name of the drug is chosen from the pull-down list, the tool finds the corresponding cost and displays it here. Additional costs (x%) This figure is calculated automatically, based on the drugs unit cost and the extra transportation charge (if applicable) indicated on the A_Assumptions page. Weighted average cost per treatment This is the average cost of the drugs needed to treat this type of case. The tool calculates it automatically by multiplying (unit cost + additional cost) x total units. The total is then linked to the F_Total_Costs page. Comments Any explanatory notes or special circumstances should be noted here (e.g., for a pediatric case, you may see Dose is 50 mg per kilo of childs weight. Here we have used an average weight of 20 kilos for estimating total quantity of medicine needed).
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The second part of Section 2 shows the medical supplies used during a visit or course of treatment: - Medical supplies: Click and choose from the drop-down menu to list the needed supply or supplies. These cells link to the master supply list, so you are restricted to only those supplies on the master list. You may see a supply name listed more than once, but with slight variations. Take care when reviewing the worksheet to ensure that the list has the appropriate supply for the particular type of case. For instance, the list contains many different types of syringes (such as Syringe, 10 cc, with needle; Syringe, 5 cc, with needle; or Syringe, 5 cc, without needle). - Name of associated drugs (if IM or IV): Fill in this column only if the supply is a needle, syringe, or some other supply needed to administer one of the drugs listed in the first part of Section 2. - Quantity used: This column shows the quantity of the supply that is used during the treatment. It might be 1 (e.g., one syringe with needle) to give a vaccine, or it may be greater than 1 (you might need more than one pair of sterile latex gloves, depending upon the type of exam to be done). - Number of times used: This column shows the number of times the supply is needed. Usually it will be 1, but sometimes (e.g., in the case of ongoing treatment at the hospital level) the figure will be higher than 1. - Total quantity: The figure in this column is calculated automatically by multiplying the figures in the two previous columns (Quantity used x Number of times used). - % of cases treated: The percentage here shows whether the particular supply is used for all persons treated for a given condition or illness, or if the treatment applies only to a lower percentage of the clients. For instance, if women have three prenatal visits on average, then about 33% of women coming for a prenatal visit receive a Womans Health Card, on the assumption that the card is given only at the initial visit and not at the follow-up visits. - Supply unit: This column is used only rarely. It is for clarification if necessary. For instance, if a supply is distributed in large quantities (such as fixative spray for PAP test), the supply unit would be 1 can. - Dispensing unit: This column must always be filled in. The number will usually be 1. However, in the example above with the fixative spray, the dispensing unit would be some number less than 1. (The unit cost for the supply is the cost of the can, but one can could be used for many samples. If one can of fixative spray could be used for 25 Pap smear samples, then the dispensing unit is 1/25, or 0.04.)
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Total units: Based on the prior inputs, the tool calculates automatically the number of items for this type of supply (Total quantity x % of cases treated x Dispensing unit). Unit cost: The tool links in the unit cost automatically from the master supply list. Once the name of the supply is chosen from the pull-down list, the tool finds the corresponding cost and displays it here. Additional costs (x%): This figure is calculated automatically, based on the supplys unit cost and the extra transportation charge (if applicable) indicated on the A_Assumptions page. Weighted average cost of treatment: This is the average cost of the supplies needed to treat this type of case. The tool calculates it automatically by multiplying (unit cost + additional cost) x total units. The total is then linked to the F_Total_Costs page. Comments: Any explanatory notes or special circumstances should be noted here.
SECTION 3: LABORATORY TESTS In cell Q516, ensure that the proper choice is selected (either visit or case). If you need to change from one to the other, click on the cell and make your choice from the drop-down menu. - Laboratory test: Click and choose from the drop-down menu to select the needed lab test. These cells link to the master lab test list, so you are restricted to only those tests on the master list. - Quantity: This column shows the quantity of tests used during the treatment. It will usually be 1 (e.g., one Pap smear), but could be greater than 1 (e.g., a child hospitalized for a severe fever might have blood work done more than once to monitor his/her white cell count as treatment continues). - % of cases treated: The percentage here shows whether the particular test is used for all persons treated for a given condition or illness, or if the treatment applies only to a lower percentage of the clients. For instance, 100% of clients receiving treatment for a sexuallytransmitted infection might be tested for HIV, but only 5% of those clients would receive a second HIV test (in case the first test was positive). - Unit cost: The tool links in the unit cost automatically from the master lab test list. Once the name of the lab test is chosen from the pull-down list, the tool finds the corresponding cost and displays it here. - Weighted average cost of treatment: This is the average cost of the lab tests needed to treat this type of case. The tool calculates it automatically by multiplying (Quantity x % of cases treated x Unit cost). The total is then linked to the F_Total_Costs page.
6
Row reference may be slightly different if extra rows were added in either of the previous sections.
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Comments: Any explanatory notes or special circumstances should be noted here.
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ANNEX D: LIST OF DATA REQUIRED FOR A CORE PLUS ANALYSIS

This list outlines the types of data that you should compile in order to carry out a cost and revenue analysis. Note that if you wish to analyze only your actual utilization, costs, and revenue (Scenario A), you do NOT need to collect all of the data listed below. The data elements that are marked with an asterisk are used only for running comparative scenarios.
Each description below highlights the title of the worksheet in SMALL CAPS and the name of the worksheet tab in [bold and square brackets]. Worksheet A: ASSUMPTIONS [A_Assumptions] - The name of your facility - The period covered by the analysis (for example, the year 2006 or January-March 2006) - The currency used - Type of service delivery point (dispensary, health centre, community-based service delivery, or hospital) - Location of service delivery (capital city, other urban area, or rural area)* - Catchment population* - Population distribution by age groups* - Whether your facility sees referral cases or not (Yes or No)* - Catchment population for referral services, if applicable* - Contraceptive prevalence rate* - Percentage of the catchment population that seeks services at your facility* - Number of hours/day that the facility is open - Number of days/week that the facility is open - Number of days/year that the facility is open - Average number of working days available for each employee (total days open per year, less holiday, sick, and vacation time, as well as time spent in training) - Staff turnover rate (low, medium, or high)* - Average base salary for each category of staff* - Ratio: percentage of benefits to base salary - Normative percentage of direct service time* - Transport costs for medicines procured (as percentage of purchase cost) - Transport costs for supplies procured (as percentage of purchase cost) - Mark-up for drugs - Mark-up for supplies - Mark-up for lab tests - Mark-up for radiology services - Exchange rate used to convert drug and supply prices, if applicable - Choice of scenario: Scenario A: Actual services and actual costs Scenario B: Actual services and normative costs
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Scenario C: Needed services and normative costs Scenario D: Projected services and normative costs Scenario E: Projected services and ideal staffing Worksheet B: SERVICE NEEDS [B_Need] - Prevalence or incidence rate for each illness or type of case* - Actual number of services provided - Projected level of services (if you wish to add new services, or to see the impact of making significant changes in the quantity of services provided)* - Other servicesdescription and quantity provided (if your facility offers services beyond the priority service package) Worksheet C: DETERMINATION OF PERSONNEL CHARGES [C_Service_Staffing] - For each category of staff: Do you have this type of employee? (Yes or No) Name Actual number of employees (if you are not listing individual names, and if all employees thus grouped earn the same salary and allocate their time the same way) Base salary (gross) (for a full-time worker) Direct service time (percentage) Worksheet D: STAFF TIMES AND COSTS [D_Staff_Costs] All of the calculations on this worksheet draw from data on other worksheets; you do not need to enter any data here. Worksheet E: OTHER FIXED OPERATING COSTS AND ADJUSTMENTS TO ACTUAL DRUG/SUPPLY EXPENSES [E_Fixed_Costs] - List of support/administrative personnel (those who do not provide direct services and who are not listed on the C_Service_Staffing worksheet) Names and job titles/categories Salary and benefits Number of employees in each category - Other running costs of the facility - Actual cost/expenditure on drugs, supplies, radiology, and laboratory tests Worksheet F: TOTAL COSTS [F_Total_Costs] - The main function of this worksheet is to collect the cost information from the other worksheets and show the result of the cost analysis; however, in special cases, you may need to enter some data here also. If service providers are paid a commission, the percentage or amount of the commission per service provided Unit costs for radiology services Cost of special equipment needed for one particular service The total amount of funds needed to cover the running costs/support for a regional or central office (if your facility is expected to contribute to cover the cost of such an office)
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Worksheet G: REVENUE [G_Revenue] - The amount charged for each service in the service package (if applicable) - The price charged to patients for radiology services for each service (if applicable, and if you answered 0% to question A22 on the A_Assumptions page) - Actual revenue from ancillary services Total revenue from pharmacy services Total revenue from radiology services Total revenue from laboratory services - Total amount of waivers granted for outpatient consultation fees - Total amount of waivers granted for pharmacy services - Total amount of waivers granted for radiology services - Total amount of waivers granted for laboratory services - Total amount of discounts given - Total amount of cash differences Master lists for DRUGS, MEDICAL SUPPLIES and LABORATORY TESTS [Drug_list, Supply_List, and Lab_Test_List] - Unit cost for each drug (to verify that the cost is correct) - Unit cost for each medical supply (to verify that the cost is correct) - Unit cost for each laboratory test (to verify that the cost is correct)
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Analisis de Costos

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Users Guide for CORE Plus (Analysis of Cost and Revenue Plus) Tool Version 1

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Figure 1. Relationship of the worksheets in CORE Plus workbook

D. Staff costs E. Fixed costs F. Total costs

I. Reports G. Revenue H. Summary

Service practice worksheets

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Figure 2. Starting screen (A_Assumptions) of CORE Plus

SETTING THE ASSUMPTIONS.

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Health clinic A catchment population

Health clinic B catchment population

Health clinic F catchment population

Health Center G catchment population (clinic-level services)

Health clinic C catchment population

Referral catchment population for Health Center G

Health clinic E catchment population

Health clinic D catchment population

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ENTERING UTILIZATION DATA.

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Figure 4. The B_Need page of CORE Plus

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ENTERING DATA ON SERVICE STAFF

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CALCULATING STAFF COSTS.

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Figure 6. The D_Staff_Costs page

CALCULATING FIXED AND ADMINISTRATIVE STAFF COSTS.

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Figure 7. The E_Fixed_Costs page

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EXAMINING TOTAL FACILITY COSTS.

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EXAMINING TOTAL FACILITY REVENUE.

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ANALYZING THE RESULTS.

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Figure 10. Comparing Needed and Actual Services

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Figure 12. The H_Summary page

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Figure 13. The lower half of the H_Summary page

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Changing norms and prices

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