Cost and Quality Indicators for Home Community-Based

Care Service delivered by NPOs in South Africa

Veni NaiduJean-Francois Aguilera

Peter NetshipaleStephen Dike

Connie KganakgaJohanna de Beer

Geoff Harris

BackgroundObjective of the Paper

MethodsFindings & Discussion

Recommendations

Background HCBC

• HCBC programs started to gain momentum since the early 90’s and most were in existence for the last 5 years.

• Provide primarily health and social services

• DSD audit identified almost 1,500 HCBC programs in SA in 2004

• Wide variations in type, content and cost of services

Background

• Numerous studies have examined the cost of HCBC services in Africa– There is evidence that HCBC cost is lower

than facility-based care

• Only few studies on quality evaluation of HCBC organizations

• Variety of services and costs between NPOs make it difficult any comparison

To contribute to the development of service delivery indicators for HCBC

services provided by NPOs

Purpose of Study

Development of Indicators

• Indicators were extracted from a survey done in 12 NPOs– in-depth interview of management and caregivers

[Naidu, 2006]

• Assumptions on levels of performance for each indicator were extracted from: – Naidu’s survey– experience from DOH– Distinction between rural and urban NPOs was applied

• Arbitrary ranges were applied to some indicators (e.g. +/- 20%)

Cost Indicators

• 2 main cost measures– Cost per contact hour– Cost per beneficiary

• Cost were defined using – The government-recommended HCBC caregiver rate

of R500– Estimated number of visits per day (rural and urban,

including travel and estimated contact time)– Estimated number of visits per beneficiary per week– No. of working days for caregivers

Indicators

• Quality Indicators– The total number of HCBC visits received by beneficiaries

– The total number of HCBC visits made by community caregivers

– Number of beneficiaries per community caregiver

– Use of HCBC kits and frequency of replenishment

– The percentage of community caregivers with 59-day HCBC

training

• Cost Indicators– Cost per contact hour

– Cost per beneficiary per annum

Indicators for Urban and Rural NPOs

Urban1 visit/week for each HCBC client (at least 1 hour contact time)

3-5 home visits per day(Annual 576-960 visits)

12-20 beneficiaries per caregiver

Rural1 visit/week for each HCBC client (at least 1 hour contact time)

2-3 home visits per day(Annual 384-576 visits)

8-12 beneficiaries per caregiver

Quality IndicatorsLow Acceptable High

Visits per beneficiary per annumUrban and Rural

<38 38-58 >58

Visits per caregiver per annum Urban

<576 576-960 >960

Visits per caregiver per annumRural

<384 384-576 >576

Beneficiaries per caregiverUrban

<12 12-20 >20

Beneficiaries per caregiver Rural

<8 8-12 >12

Other Quality Indicators

Low Acceptable High

Use of HCBC kits

Do not use HBC kits

Use kits but no regular replenishment

Use kits with regular replenishment

% of caregivers trained (59-day HCBC training)

<33% 33-66% >66%

Cost Indicators (ZAR)

Low Acceptable High

Direct cost per contact hour Urban

<6.25 6.25-10.42 >10.42

Direct cost per contact hour Rural

<10.42 10.42-15.63 >15.63

Direct cost per beneficiaryUrban

<300 300-500 >500

Direct cost per beneficiaryRural

<500 500-750 >750

Findings and Discussion

Findings Quality Indicators(N=12)

Low Acceptable High

Average No. of visits per beneficiary per annum

7 2 3

Average number of visits per caregiver per annum

4 6 2

Average No. of beneficiaries per caregiver

3 3 6

Use and replenishment of HBC kits

7 5 0

Training of community caregivers (59-day training)

5 1 6

Findings Cost IndicatorsN=12

Low Acceptable High

Direct cost per contact hour

1 7 4

Direct cost per beneficiary

6 3 3

Allocation of Points - Quality Indicators

Indicator Low Acceptable High

Visits per beneficiary per annum

0 1 0

Visits per caregiver per annum 0 1 0

Number of beneficiaries per caregiver

0 1 0

Regular replenishment of HBC kits

0 1 2

Training of carers 0 1 2

Maximum total points 7

Allocation of Points - Cost Indicators

Indicator Low Acceptable High

Direct cost per contact hour 0 1 0

Cost per beneficiary per annum 0 1 0

Maximum total points 2

Total Points

• Quality

0 71 6532 4

Unacceptable Acceptable

• Cost

0 21

Unacceptable Acceptable

Cost/Quality Matrix

1.

2.

3.

4.

Acceptable

Unacceptable

Qua

lity

NPO 11

NPO 1

NPO 1 NPO 2

NPO 7

NPO 3 NPO 4 NPO 5

NPO 12 NPO 8

NPO 2

NPO 6

NPO 9

NPO 10

Cost UnacceptableAcceptable

Conclusions

• Model developed is promising

• Allows an insight on cost-efficiency for funders

• Can trigger targeted action for targeted NPOs

Limitations

• Small sample size• Arbitrary ranges • Assumptions on performance levels based on

small number of NPOs• Important differences in terms of performance

between NPOs, making conclusions difficult• The tool only allows a broad estimate of

potential areas of underperformance– Additional evaluation on site is still necessary

Next step

• Model implementation on a larger sample size for fine-tuning

• Different assumptions of performance levels and ranges should be tested

• Different scales for allocations of points should also be tested

• Larger study planned at DOH