Restructuring of Nursing Education in KwaZulu-Natal :

Restructuring of Nursing Education in KwaZulu-Natal : Financial Implications of Rationalising Nursing Education Campuses Researched by: Department of Community Health, Medical School, University of Natal - R Rustomjee, AKM Hoque, JT Wamukuo, and CC Jinabhai AND Department of Economics, University of Durban-Westville - P Brijlal Funded and Published by the Health Systems Trust 401 Maritime House Salmon Grove Victoria Embankment Durban 4001, South Africa Tel: +27 31 307 2954 Fax: +27 31 304 0775 Email: hst@healthlink.org.za Website: http://www.hst.org.za ISBN No. 1-919743-44-8 August 1999 Printed and designed by The Press Gang Durban Tel (031) 307 3240

Acknowledgements Health Systems Trust, in particular Mrs N Makhanya, for facilitating this study. Nursing Directorate of KwaZulu-Natal for their assistance: Dr LL Nkonzo-Mthembu, Director of Nursing, Department of Health, KZN Mrs L Ruiters, Deputy Director of Nursing, Department of Health, KZN Mrs VG Mkhize, Deputy Director of Nursing, Department of Health, KZN Department of Health, KZN, for nurse education expenditure records. Mrs S Skweyiya, Deputy Director General, Department of Health, KZN. The Heads of the various campuses and schools for assisting with data and other information. Fatima Suleman - editing the report.

Contents Introduction 1 Historical Background 1 Current Position 3 Results 6 Unit Costs 6 Expenditure Analysis 7 Distribution of Nurses 7 Limitations presented by data availability 9 Consideration for future planning 11 Conclusion and Recommendations 12

INTRODUCTION The Nursing Directorate and the Ministry of Health in KwaZulu-Natal proposed restructuring the nursing education infrastructure from its present system of three colleges with nine campuses and seventeen schools to one of the following options for its eight regions: One college with five-campus with a combination of regions; One college with three campuses with one combination of regions- Scenario 1; another combination of regions - Scenario 2; The principal aim of this project was to determine which of the alternatives proposed by the Nursing Directorate Task Team was most cost effective. HISTORICAL BACKGROUND The international trends indicate that there is a large public sector commitment to nursing education. In South Africa, about 96% of all nurses are employed in the public sector. It is important at this initial stage to present a brief historical perspective and the need for restructuring nursing education in South Africa in general, and in KwaZulu-Natal (KZN) in particular. Up to 1994 South African public policy was influenced by the apartheid policies of the previous government. The society was separated along racial and ethnic lines and all public services were provided within the constraints of this segregation policy. As part of the new government s Reconstruction and Development Policy (RDP) the principles of democracy, non-racialism, equity and redress were stressed. The restructuring of provision and delivery of Health Services was one of the principal areas of focus in this process. The new system of delivery favoured the District Health System (DHS) with the main thrust being Primary Health Care Services. It is critical that nurse education, and the supply of nurses forms an integral part of this transformation process. 1

The current situation is a legacy from a fragmented history of providing separate nursing education colleges and schools. Aspects such as the sites of college campuses, student selection, and health care service delivery were based on racial grounds. This resulted in the concentration of educational resources in the metropolitan areas and in the duplication of nursing education programmes. Rural areas were marginalised to the extent that nursing education in these areas had fewer resources. During this transition period, different health policies and health service delivery systems had to be reviewed. Core values such as accessibility, equity and availability needed to be considered. In addition, in order to streamline the health sector through the process of rationalisation, the provision of nursing education needs to be considered in light of future epidemiological and demographic needs and demands facing the health sector. The cost of nursing education in KwaZulu-Natal, as in the rest of South Africa, is borne by the health sector, although there are indications that are moves to place it under the National Department of Education, like all other tertiary or higher education. With this background, the restructuring process was viewed in KwaZulu-Natal. It should not end with the identification of the most cost effective college structure but rather, the first step to analysing the total nursing future requirements of the province. 2

CURRENT POSITION Map of KwaZulu-Natal with the different Regions: Ingwavuma Pongola Paulpietersburg Ubombo Utrecht Ngotshe Newcastle Vryheid Nongoma Dannhauser Hlabisa Glencoe Nqutu Mahlabathini Dundee Babanango Kliprivier Mtonjaneni Lower Umfolozi Msinga Nkandla Bergville Weenen Kranskop Mtunzini Eshowe Estcourt Umvoti Mooirivier Mapumulo New Hanover Lower Lions River Tugela Legend Impendle Ndwedwe Pietermaritzburg Inanda Region A (6) Underberg Camperdown Pinetown Polela Durban Region B (10) Richmond Chatsworth Region C (6) Umbumbulu Umlazi Ixopo Region D (6) Umzimkulu Mount Currie Umzinto Region E (3) Region F (7) Alfred Port Shepstone Region G (6) 0 35 70 Region H (8) Kilometers 3

Table 1: Existing Structure of Colleges and College Campuses: Colleges Natal College Ngwelezana Edendale of Nursing Campuses King Edward VIII (F) Ngwelezana (H) Edendale (B) Addington (F) Benedictine (D) Prince Mshiyeni (F) R K Khan (F) Charles Johnson (G) Greys (B) Northdale (B) University Natal Zululand UNISA No. of Students 1 422 530 544 Per Capita Expenditure (R) 40 902 (39.2%) 26 488 (25.4%) 36 893 (35.38%) Source: Department oh Health 1997 4

Table 2: Distribution of Expenditure in Schools by Region: Region No. of Students Schools Per Capita Expenditure A 0 Iris Marwick 127,639 B 60 St. Appolinaris 38,955 *Emmaus C 0 D 98 Ceza 36,918 Nkonjeni 36,618 Bethseda 24,386 E 271 Manguzi 22,929 Mosveld 6,022 Mselini 18,159 F 84 Osindisweni 39,644 Montebelo 25,400 Madadeni 38,663 G 235 Church of Scotland 28,348 *Newcastle Hlabisa 3,694 H 255 Mbongolwana 18,555 Nkandla 21,640 * information not available There are three nursing colleges (Natal College of Nursing (NCN); Ngwelezana College; Edendale College) with nine college campuses (see Table 1). The college campuses, in addition to the enrolled and Bridging courses, provide the four year course, one year Midwifery and Post Basic Courses in various specialised fields. 5

There are 17 nursing schools which are mainly distributed in rural areas. The nursing schools offer training to enrolled nurses, bridging programmes to enrolled nurses and professional nursing courses. Additional courses include one-year diploma courses in midwifery, primary health care and psychiatry. RESULTS Unit Costs The unit costs varied considerably between colleges ranging from under R20 000.00 to over R120 000.00. The overall regional averages ranged from R33 006.00 and R41 114.00, when taking the number of students and posts available as the denominators respectively. Regional and institutional differences were compared with respect to population size and projected norms. In the five-campus model, projected costs range from R85 191 767 to R157 723 631 for the different permutations. This suggests that the combination of King Edward, Edendale, Charles Johnson, Ngwelezana and Benedictine as administration centres for the five regions would be most efficient and that of Addington, Greys & Northdale, Charles Johnson, Ngwelezana and Benedictine the least efficient. In the second option (3 campuses scenario I), the range is from R79 236 389 (for King Edward, Charles Johnson and Benedictine) to R185 605 952 (for Addington, Charles Johnson and Ngwelezana). The final alternative (3 campuses scenario II), has the lowest set of total cost. The combination of King Edward, Edendale and Charles Johnson gives a low of R70 306 971 and that of Addington, Greys & Northdale and Ngwelezana a high of R162 266 771. 6

Expenditure Analysis Student expenditure i.e. student salaries and allowances, contributed the largest overall cost item (70.5%). Other component costs included tutor costs i.e. tutor salaries, allowances and benefits (24.9%) and administration costs inclusive of the Natal College of Nurses (NCN) component (4.6%). This breakdown in expenditure remained consistent across regions and institutions. On analysis of expenditure in relation to population size: Regions A and C with 8.09% and 6.66% of total population respectively, have no resources allocated for nursing education. Region B has a population of 1 202 404 (14.29%), and 29.84% of the total expenditure in nursing education is incurred in this region. In the other regions expenditure approximates the proportion of the population in that region. Distribution of Nurses Application of the national and international norms (inclusive of all nursing categories) to population figures for (see Table) shows that the number of nurses employed in 1997 was almost the same as the number required per 10 000 people in the province. Using the international norm all regions show a positive variance, i.e. surpluses with only region C having a negative variance of shortage. Using the National norm regions F, A and C have shortages or negative variances. While this indicated that the numbers trained seemed to be all right, the breakdown of the various categories of nursing staff required needs to be examined. This information was not available, thus no comment can be made. There is also a need to be cautious about numbers trained and the demand for nurses, as various factors could lead to changes in the number of nurses in the public sector of the province. What is being emphasised here is that there is a need for continuous monitoring of nurse education in KZN. 7

Table 3: Nurses per Region (for all categories) Vs Requirement per both International and National norms Nurses Required Regional Variance Region Population 1 22.7 Norm 2 29.1 Norm Actual No. 22.7 Norm 29.1 Norm B 1 202 404 2 729 3 499 4 743 2 014 1 244 D 639 413 1 451 1 861 1 943 492 82 F 3 412 437 7 746 9 930 9 206 1 460-724 G 719 665 1 634 2 094 3 098 1 464 1 004 E & H 1 201 124 2 727 3 495 3 544 817 49 A 681 283 1 547 1 983 1 666 119-317 C 560 694 1 273 1 632 1 040-233 -592 TOTAL 8 417 020 19 107 24 494 25 240 6 133 746 1 International norm = 22.7 nurses per 10 000 of the population 2 National norm = 29.1 nurses per 10 000 of the population The analysis does however indicate there is scope for redistribution of the nurses trained province-wide especially when one looks at the distribution of nurses compared to both national and international norms; 22.7 and 29.1 nurses per 10,000 population respectively. Though there are regional inequalities, the figures do not give a true picture, as they don t show the actual composition of the nursing staff, which is critical in assessing efficiency. If a comparison is made of these requirements with the number of posts then it can be determined if there is excess capacity for other purposes. If the number of posts exceeds the nursing requirements then the nursing authorities can concentrate on in-service training and re-orientation according to the needs of the DHS and PHC objectives of the new policy. 8

LIMITATIONS PRESENTED BY DATA AVAILABILITY Data were collected by means of a questionnaire and compared and verified with the Total Expenditure Report (X112). Only in the one instance did the information from the two sources correspond. Variations could not be easily explained. Four institutions did not have financial information independent of the total hospital expenditure. Two institutions did not submit expenditure reports and were therefore excluded from the initial analysis of existing costs. As a result of the restructuring process the KZN Department of Health is busy establishing various criteria for nurse education and have as yet not established firmly the norms to establish the number of nurses required. The Centre for Health Policy and the HST published population norms for nursing requirements. These were used in the study. Average per capita and per post costs were calculated per institution and per region. At the institution level there was no information on the proportion of costs involved in training the different categories of students. The proportionate cost of training the various categories of students and upgrading of registered nurses could not be obtained. The unit costs depend on factors such size, sophistication of service, quality of service and case mix. Therefore, the desegregation of unit costs by speciality was necessary to indicate the extent to which different specialities can give rise to differences in the unit costs. However, data could not be disaggregated for this purpose. The estimates of unit costs differ as teaching institutions differ in-terms of quality, case mix and, therefore, any conclusions on efficiency should be treated with caution where the unit costs vary by large amounts. The difference in unit costs maybe so great, that lack of quality of 9

data may not account for all the variation. For example, the intensity in which a facility is used most certainly influences strongly the unit costs, and given that capital costs don t vary proportionately with output, the higher the output, the greater the scope for economies of scale and thus the lower the unit costs. The scope for reducing the costs by raising the output will however be limited by capacity. In the absence of proper breakdown of the various categories of nurses produced by the colleges and given the data available the use of unit costs to determine cost of nurse education under the various scenarios was the best approach available. These unit costs did give to some extent the relative cost of the different colleges. These could be used as a sign of efficiency. The different colleges gave different average costs and though data on quality of output was not available, one can only speculate on the striking differences. The criteria used in making the different combinations of campuses was based on a number of assumptions. Firstly, the colleges were grouped in the respective groups as proposed. Secondly, one campus in each group was taken in turn as the administration centre with the assumption that the unit costs for the particular group will be pegged to the unit costs of that campus. The average cost (unit cost) for the group was then multiplied by the number of students in the group to give the total cost projected for that group. Another assumption was that the same number of students would continue to be trained as before. The total costs for all the groups (for each possible combination) were the added up to give the various provincial totals on the far right of each table (appendices). The ultimate purpose was to identify the most efficient combination among the lot. 10

CONSIDERATION FOR FUTURE PLANNING In addition to the above other points for future planning should include: Costs of in-service training and upgrading of existing nursing staff; Identification of the costs of training different categories of nursing staff; All budgeting and expenditure records should be based on a system of cost centres to make disaggregation of revenues and expenditures easier and complete; A database should be developed to record all information with respect to nurse education; All policies should be reviewed regularly (preferably annually) and adjustments made on an ongoing basis; For successful planning projections must be made for the short and long term based on reliable data; Appropriate and efficient administrative, managerial and other related skills must be developed for proper and successful implementation and assessment of policies; A system of monitoring and evaluating nursing education in the province must be developed to feed into the policy review system; There has to be clear co-ordination of nurse education efforts between the Departments of Health and Education in all respects and at all levels; and There must be an integrated and co-ordinated effort for policy planning and implementation between the health system for the country, education of health professionals, health services delivery, financing of health and financial controls, public works. Some of the above may require further research and action. They should be identified and followed up. Other issues, mostly of a qualitative nature, that should be considered: 11

to gain some insight into equitable distribution of resources. to examine the urban bias of existing programmes to see whether rationalisation through mergers could eliminate duplication of programmes to look into the integration of nursing programmes in order to develop and improve the academic programmes through integration of the various institutions and pooling resources. to examine and comment on the specific training needs in the Public Sector. to look at nursing education in the light of changing health services delivery policies. to consider the issue of short and long term requirements of nursing. CONCLUSION AND RECOMMENDATIONS If one takes into account the actual number of nurses trained under the present system (in 1997): The five-campus model would have cost R115 million The three campus, scenario 1 would have cost R121m The three campus, scenario 2, would have cost R117m. Clearly, given the size of the province and the running costs, the five-campus model is preferred. The administration of the college could be based on the NCN model for the province. Consider the scenario with the expenditures at 1997 prices: Under the existing circumstances the one college three campus models are not suitable for this vast province. 12

With the one college with five-campus scenario, there are major differences. It is proposed that an existing campus is chosen as an administrative centre and the other institutions, including the existing schools, are then attached to this administrative centre in each region. Once this is done then the details of the type of training should be considered: Regions A and C have no nurse education infrastructure. Given the population size of these regions it is agreed that they be combined with larger regions as pin the task team s proposal i.e. A with F and C with G. An important factor to consider is the expenditure on the student nurses. At present this amounts for about 70% of the total; expenditure. If methods are not found to rationalise this cost then there will be very small savings in terms of the other cost centres viz., Administration and Tutor Cost. The analysis was limited by the accounting system where the separation of hospital and college costs especially for shared costs was not possible. Generally if the total costs are flawed, so will the unit costs. Minor changes could be introduced to facilitate easier prediction of unit costs (cost centre approach) for planning and management purposes. It is generally useful to isolate the unit costs by type of output so that different forms of output can be assigned their appropriate costs. Otherwise lumping all output together (e.g. all nurses trained irrespective of category) assumes that equal costs can be assigned (allocated) to each output. The variation in costs per student requires some comment for example, the Iris Marwick/ Townhill had extremely high cost per student, which was about thrice the provincial average. Although a few nurses are trained here, which can contribute to the high unit costs, it is clear that other factors must be contributing to this rather huge difference. One factor, apart from the possibility of discrepancies in the data, could be that the category of nurses trained, but further analysis is required. Other institutions 13

like King Edward VIII, Greys and Edendale had high number of students enrolled and this led to their respective unit cost comparing more favourable with the provincial averages. Further, it must be noted that capital costs (buildings and equipment) and provision and updating of libraries were not considered. To help in identify more clearly the efficiencies in use of resources, two issues arise: There is a need for database at the hospitals to assist in monitoring and policy analysis purposes There is need for data to be available in a more desegregated manner for easier calculation of unit costs for the smallest cost centres possible. 14

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