CDC Central Clinic Debundscha NOV 2021

MONTHLY BALANCE SHEET

Incomes lines FCFA %

A0 Balance B/F from Petty cash Or cash in hand 54,312 9%
A1 User fees (Fee for services, Consultations fees, Ultra sounds, etc.) 6,500 1%
A2 Laboratory fees - 0%
B Sales from pharmacy plus obstetric Kits 34,275 6%
C PBF subsidies (effectively paid during the month) 500,000 84%
D Mutual health/insurance reimbursement - 0%
E Salaries from government (Government health facilities) 1 0%
F Credit card (Government health facilities) - 0%
G Other Income generating activities-(mortuary fees, etc.) - 0%
H Fund withdrawn from treasury during the month - 0%
I Funds withdrawn from savings-bank, etc. - 0%
J Other income generating activities, specify Canteen - 0%
K HIV User fees - 0%
L TOTAL FOR THE MONTH 595,088 100%
M1 Brought forward from savings ( treasury and banks) 510,653 86%
M2 Unsold stock of medication/reagents/X-ray (for current month) 568,485 96%
N TOTAL INCOME PLUS SAVINGS 1,674,226 281%

EXPENDITURES FCFA %
STAFF SALARIES 35%
O Basic fixed salaries for civil servants 1 0%
P Basic fixed salaries for non civil servant (Including CNPS) - 0%
Q Envelop for performance bonus + Quota part (L-U1) ToSanje 209,501 100% ?
R Sub-Total 1 209,501 100%
RUNNING COST 9%
S Office costs 11,560 22%
T Cleaning cost (Hygiene and sanitation expenses) 3,000 6%
U Transport costs 20,000 38% ?
V Mission allowances - 0%
W Social marketing (Outreach, home visit, media, campaigns, etc.) 9,500 18% ?
X Telephone bills 3,099 6%
Y Utility expenses (water+kerosine+light+gaz+taxes) 1,000 2% ?
Z Others ( specify) NID, Bank charges and other taxes 1,431 3%
A1 Referal/counter referal charges/Community Health Workers - 0%
B1 Training and information (capacity building) - 0%
C1 Meetings 3,500 7%
D1 Sub-Total 2 53,090 100%
Drugs and medical equipment 20%
E1 Medicine and Drugs 2,000 2%
F1 Medical equipment 12,000 10%
G1 Laboratory and other reagents - 0%
H1 Others (specify) 105,000 88%
I1 Sub-Total 3 119,000 100%
INVESTMENT 0%
J1 Infrastructure rehabilitation - #DIV/0!
K1 Equipments - #DIV/0!
L1 Maintenance - #DIV/0!
M1 Under contract services (e.g: Security, Canteen, etc.) - #DIV/0!
N1 Solidarity funds - #DIV/0!
O1 Return on investment - #DIV/0!
O2 Others (specify) - #DIV/0!
P1 Sub-Total 4 - #DIV/0!
SAVINGS 36%
Q1 Bank account - 0%
R1 Treasury - 0%
S1 Petty cash or cash in hand 213,497 100%
T1 Sub- total 5 213,497 100%
U1 TOTAL EXPENDITURES FOR THE MONTH 595,088 100%

V1 Total points gained by staff for performance bonus 4,171

Index for the month

= Envelop for performance bonus/Total points gained by 53

W1 staff for performance bonus/100 (Q/V1)

X1 Staff salary ( fixed + bonuses) = O+P+Q 209,501

Analysis of cost effectiveness of human resources X1/U1

Y1
Indicator of cost effectiveness of human resources 54% No more than 60%

Z1 Average running cost ( D1+I1+R) for the last six months 507,059 42.84412662037

of cost effectiveness of bank reserve (T1+M1+M2)/(D1+I1+R)*30) 40

Ideal = > 90 days; less than 60 days = danger; less than 30 jours = Very dangerous

Internal revenue = (A0+A1+A2+B+D+G+H+I+J)/L*100 29%

B2
rightful cost recovery :40-60%

Social marketing expenses/Community relay = (W/U1)*100 2%

C2
Rightful (=between 5-10%)

Procurement of essential drugs (E1/U1)*100 0%

D2
Rightful (=between 15-25%)

Chief of health centre /director of the hospital date:…………………………

signature

Name
 Internal revenue

7% rightful cost recovery :40-60%

Social marketing expenses/Community relay

2% Rigthful (=between 5-10%)

Procurement of essential drugs

0% Rigthful (=between 15-25%)
 GUIDELINES FOR FILLING THE INCOME AND EXPENDITURE STATEMENT FOR HEALTH FACILITIES IN THE FOUR HEALTH DISTRICTS FOR
THE PBF PROJECT

The indice tool has as one of its objectives to provide a summary snapshot of the income and expenditure statements of the health facility in a holistic and
intergrated manner. It should be noted that the index tool has been modified to include three components: 1.)the income and expenditure(Balance) sheet,
2.)staff performance evaluation using objective criteria 3.) monthly participatory management meeting (where financial and staff evaluation and other
feedbacks are shared and discussed).
Recently, some modifications have been done on the income and expenditure statement. The following table will give a comprehensive method of filling in the
income and expenditure statement otherwise known as the balance sheet with emphasis on how these figures are generated from the source documents.
Cell
Ref
ITEM ON THE DESCRIPTION OF ITEM ON INCOME
SOURCE DOCUMENT
Code BALANCE SHEET EXPENDITURE STATEMENT

All balances from petty cash or cash in hand

A0 Balance B/F available at the facility or inherited from the
The source document for information is the end of month cash count certificate, it
from Petty cash Or preious month. As long as the resources were
cash in hand can also be the available balance of an updated cash journal or book.
transferred from the last month it is is captured
here.
A0
This comprises payments from Consultation fees,
Source documents for these transactions should be obtained from receipts and also
User fees A1 bed fees, surgical fees to the health facility for the
captured in the cashbook as income.
A1 services rendered to them.

This has to do with fees recovered from laboratory

Cost recovery The source document for this transaction is the receipt and or cash book in the
test, and other anciliary examinations( x-ray, ultra
(Laboratory) facility at the end of the month.
A2 sound, etc).
Cost recovery (Sales This Income is derived from pharmacy sales of
from the Receipts and the pharmacy cash book or hospital cashbook are used as justification
medicines, other pharmaceuticals, surgical,
Pharmacy including for this entry.
Kits) obstritic, delivery kits, etc
B
All PBF subsidies that has effectively been
received by the health facility( through bank A bank statement for the said month is needed as a source document to verify or
PBF subsidies
transfer or cash payment) for the month have to be collect this figure.
C captured here.
 Mutual heallth/
Health insurance In case of any re-imbursements effected by the The source document for such a transaction is a clearly documented receipt of
and other mutual health/Associations or insurance effective payment from the health insurance organization. The cash book or bank
prepayment organization from a health insurance or prepayment journal. If bank payment was done, the bank statement for the month cam equally be
schemes re- schemes it has to be captured here. a reference.
imbursement
D
This space should contain only the amount paid
Salaries from the This can be obtained from staff payslips, personnel file and other updated payroll
as salaries from the government for civil servants,
Government information sheets available.
E state agents and "contractuelle".

Credit cards(State All funds effectively received from the treasury in The cash book(cash), the signed invoice and delivery notefrom the supplying firm
Running credits) cash or Kind (goods supplied through a contractor). attesting the value effectively received.
F
Income generating
All other income generating activities provided by Receipts for mortuary , canteen , etc income for the month and all of these can be
activities (mortuary,
etc) the health facility, e.g Mortuary, etc summed and captured in the income section of the cash book of the HF.
G
Income withdrawn
from the For public facilities, income withdrawn from the Justification of withdrawal either through the treasury receipt or withdrawal slip.
government health facility account at the treasury And updated treasury journal
H treasury

Withdrawal from
For both private and public facilities, justification of this transaction is through a
saving bank Any withdrawal from the bank during the month
accounts bank statement, bank withdrawal slip and the health facility bank/ cash book.
I
Sales from
particular unit Sales from facility runned canteen, restaurant, Specialized units should have a cashbook and receipts that captures sales of their
(physio therapy, medical records,Physiotherapy gadgets, products or services which when summed gives the figure to be inputted in this unit.
J eye, dental, etc)

Any contribution received from an external source

Contribution from which does not include PBF subsidy but may
other donor/AID include EPI, NTD, Council subventions for various A receipt , cash book or bank statement to serve as a justification for this entry.
agencies purposes, or other subsidy for both private and
K public facilities

Summation of all income received in the refernce

Total for the Month Addition of entries in A0 up to K.
L month.
 Balance brought This constitutes current or existing balance as
foward from A bank statement or balance of savings reported on the treasury ledger or account
reported in the bank or treasury journals or
savings (bank + on the last day of each month acts as a source document for this item.
treasury accounts) statements on the last day of the reference month
M
Total incomefor the
month Plus bank This figure represent the Total for the month and
AddCell (L + M)
and treasury the total balance for both treasury and banks.
N Savings
EXPENDITURES
Personnel fixed This figure should be the same as salaries from the
basic salary from Government under the income section of this Justification for this activity is from the treasury and expenditure on the cashbook.
O the government balance sheet.

Non civil servant

personnel basic All workers who are not employed by the
This figure is generated from the individual payslips
fixed salary paid government are captured here.
P out

This is the amount that is shared amongst staff as

motivation. It is the amount determined from the
surplus or profit. Part of it is saved in the bank or
Performance bonus treasury for further investments in the health
for personnel facility. Normally, staff performance bonuses
should not be above 50% of the total profits or
surplus. This is the last item to be filled on the
balance sheet. This include quota par
Q
The amount to be saved or shared as staff performance bonuses is arrived at in a
participatory manner where the entire staff or their representatives sit down and take
an informed decision for the best interest of the facility and the staff. Performance
bonuses are shared based on the establishment of measurable performance indicators
for each role and person. The total amount of what is effectively paid to each staff
is what is registered here. Source document: bonus payent scheme.

For example, source documents for office costs, telephone bills, and utility
expenses can be gotten from receipts on payments of these services. Transport costs
Sub Total Running This is a summation for all the running cost can be backed by a local transport form where employees sign transportation to
cost for the month incurred for the month . carry out local errans or services. For social marketing, expenses incurred for
outreach activities like vaccination, bed nets, campaigns can be justified with
receipts documenting purchase of equipments or services hired if any.
D1
 Subtotal Purchase Comprised of the medicines and drugs, medical
Medicines and drugs, medical equipments or other medical expenditures should
of drugs and eqipments and other surgical or medical expenses
medical equipment incurred during the month have receipts and also be captured in the expenditure section of the cashbook
I1
this is a summation of investment expenses like
Subtotal Investment All expenses for items like equipments, infrastructure should have receipts that
infrastructure and rehabiltation, office equipments
expenses justify them and should also be captured in the cashbook as an expenditure
P1 etc
Amount saved during the month. This amount can
Bank account be collected from from the deposite slip or bank Bank deposite slip or Bank statement for the month usually reveal this information,
Q1 statement

Treasury Amount deposited in the treasury during the month The treasury deposite slip.
R1

Cash count certificate duely dated and Signed by atleast two persons who verified
Petty cash or cash The amount available or unspent cash available in
and record the cash on the last working day of the month. The verified cash
in hand the office.
available is what is entered here.
S1

Unsold stock of The value of the unsold stock of medications, kits Stock cards and stock management soft ware can provide this information. The
medication/reagents and reagents already purchased by the facility. unsold quantity is multiplied by the purchase or buying price to have this value.
S2
All savings made to the bank, treasury and petty
Sub total savings
cash for the month should have bank or treasury All savings made to the bank, treasury and petty cash for the month should have
(bank+ treasury+
petit cash balance) statements and receipts to justify such bank or treasury statements and receipts to justify such transactions.
T1 transactions.
Average running
Collect this from the income /expenditure(balance sheet) of th previous 3 or 6
cost ( D1+I1+R) for
Z1 the last six months months.Add all and devide by 3 or 6 to have the averages
MOH/PBF: HEALTH FACILITY…………………….…………. MONTH...................Year......
DISTRICT: ......................MONTHLY BALANCE SHEET
Incomes lines
Code FCFA % (eg. A/L)
A0 Balance B/F from Petty cash Or cash in hand
A1 User fees (fee for services,consultation fees,ultra sounds, etc)
A2 Cost recovery 1 (Laboratory fees )
B Cost recovery 2 (Total Sales from pharmacy plus obstetric kits )
C PBF subsidies
D Mutual health/insurance reimbursement
E Salaries from government
F Credit card
G Income generating activities-IGA- (mortuary fees, etc)
H Fund withdrawn from treasury
I Withdrawal from savings-bank-
J Sales from particular unit (physiotherapy, eyes-dental-etc.) specify
K Contribution from other aid agencies( EPI, NTD, councils, etc)
L TOTAL FOR THE MONTH
M1 Brought forward from savings ( treasury and banks accounts)
M2 Unsold stock of medication/reagents
N TOTAL INCOME PLUS BANK AND TRREASURY SAVINGS.

EXPENDITURES FCFA % (eg. O/R) % (eg.

R/U1)
STAFF SALARIES
O Basic fixed salaries for civil servants
P Basic fixed salaries for non civil servants (Including CNPS)
Q Envelop for performance bonus including Quota part (L-U1)
R Sub-Total 1
RUNNING COST % (eg. S/D1)
S Office costs
T Hygiene and sanitation expenses
U Transport costs
V Mission allowances-
W Social marketing (Outreach, home visit, media, campaigns, etc.)
X Telephon bills
Y Utility expenses (Water+kerosine+electricity+gaz bills)
Z Others ( specify) Bank charges and other taxes
A1 Expenses for community health workers/ referal activities
B1 Training aand capacity building
C1 Meetings
D1 Sub-Total 2
Drugs and medical equipment
E1 Medicines and drugs
F1 Medical equipment
G1 Lab and other reagents
H1 Others (specify)
I1 Sub-Total 3
INVESTMENT
J1 Infrastructure and rehabilitation
K1 Equipments
L1 Maintenance
M1 Out sourcing & Contractual expenses (e.g security, canteen, etc)
N1 Solidarity funds
O1 Others ( specify) Bank charges and other taxes
P1 Sub-Total 4
SAVINGS
Q1 Bank account
R1 Treasury
S1 Petty cash or cash in hand
T1 Sub-Total 5 -
U1 TOTAL EXPENDITURES

V1 Total points gained by staff for performance bonus

Index for the month
W1 = Envelop for performance bonus / Total points gained by staff for performance bonus / 100 (Q/V1)

X1 Staff salary ( fixed + bonuses)= O+P+Q

Analysis of cost effectiveness of human resources X1/U1

Y1 Indicator of cost effectiveness of human resources
No more than 60%

Z1 Average running cost ( D1+I1+R) for the last six months -

Indicator of cost effectiveness of bank reserve (T1+M)/(D1+I1+R) *30) Days

A2
Ideal = > 90 days; less than 60 days = danger; less than 30 jours = Very dangerous

Internal revenue = (A0+A1+A2+B+D+G+H+I+J)/L*100

B2
rightful cost recovery :40-60%

Social marketing expenses/Community relay = (W/U1)*100

C2
Rightful (=between 5-10%)

Procurement of essential drugs (E1/U1)*100

D2
Rightful (=between 15-25%)

Chief of health centre /director of the hospital date:…………………………

signature

Name
 1.       HEALTH FACILITY PERSONNEL MONTHLY PERFORMANCE EVALUATION AND BONUS PAYMENT SUMMARY SHEET
Name of Health facility………………………………………………………………………………………………
District health service…………………………………………………………………………………………………
TOTAL AMOUNT TO BE SHARED…………………………………………………Total points Gained……………………………………Month………………………………………………YEAR………………..
Departmental Individual staff Total points
Basic Category/ Seniority Responsibility Overtime
Performance evaluation score per staff

(Using Quality (using Job

(+ 1 for (Max of 30 evaluation and descriptions,
each year and Min 05 ( Plus +0.5 Quantity monthly staff
salary Indices (Max 500)
in service). Pts) pts/H) production evaluation and
Name of the scores official reports) Amount Telephone
staff Job title received per Number Signature
staff
10 Pts =100 public (Max 200
service Indices. (Max 30) Absence/ Points) (Max 110)

10Pts = 1Category lateness

(Minus -
(Max 120pts)
0.75pts/H)
(Max 10 Pts)

TOTAL
1.       HEAD OF DEPARTMENTS: Individual performance score for departmental heads shall be the average score of all individual staff performances in their departments + departmental perf
2.       DIRECTORS: Individual performance score for Directors or head of facilities shall be the average score of all head of departments performances in their departments + average of all de
3.       Formula for bonus sharing = TOTAL Individual points per staff / Total points gained by all staff X the total amount to be shared.
4.       Please attach a copy of your personnel performance evaluation committee report, departmental performance scores, time sheet and individual staff evaluation criteria ( from the H
 departments + departmental performance score + his/her (indices/category + seniority + Responsibility scores).
eir departments + average of all departmental performance score + his/her (indices/category + seniority + Responsibility scores).
aff evaluation criteria ( from the Head to the least staff of the health facility). ( Name , signature and seal of HF)