Danielle Flaysakier, M.D., M.P.H., had returned to her home in July, one month after completing her MPH degree. Within a few weeks after reporting to the Undersecretary of the Ministry of Health, she had been given her first assignment, as Director of a clinic in Nosral, a large village some 300 kilometers south of the capital. According to the Under- secretary, her assignment was quite specific: Clinique Nosral had been spending more than the average allotment for a clinic its size, and she was to reduce these “cost overruns.” Moreover, circumstances permitting, she was to prepare a report describing her activities so that directors of other clinics experiencing cost problems could take similar actions.
BACKGROUND
Dr. Flaysakier’s country had identified health care as an important area of activity for the 2000s. Accordingly, the country had begun an extensive development effort centered on the provision of primary care throughout its full geographic area. A network of clinics had been designed in such a way that no individual in the country would be more than a one-day trip away. Since most travel was on foot, and the country was geographically quite large, an extensive clinic network had been necessary.
By 2002, using World Bank financing, many clinics had been built and most of them had been staffed. For the larger clinics the staff consisted of a full time physician (who also served as clinic director), several full time nurse practitioners (the number depending on the population to be served), and, generally, a full time clerical person who maintained the clinic’s records for both patients and supplies. Because of physician shortages, the smaller clinics were staffed with only nurse practitioners and part-time clerical persons. Patients needing treatment by a physician either had to be referred to a larger clinic or await a biweekly visit of a rotating physician.
The clinic in Nosral was one of the country’s largest. The surrounding area was richer agriculturally than much of the rest of the country, and hence the population was relatively large. In addition to Dr. Flaysakier, there were four nurse practitioners and a full-time records clerk.
CLINICAL SERVICES
As with most clinics in the country, Clinique Nosral delivered a variety of services. By far, its most significant activity was curative care. Curative visits were classified as either “major” or “minor.” A “major” visit was one which would occupy a fair amount of the physician’s time, such as an acute illness. A “minor” visit generally would require only a nurse practitioner; minor visits also included family planning counseling.
Another important activity of the clinic was immunization. Children were immunized against smallpox, diphtheria, pertussis, tetanus, tuberculosis, measles, and poliomyelitis. All immunizations were given by a nurse practitioner.
A third type of activity was nutrition counseling. This too was performed by a nurse practitioner, and frequently included oral re-hydration therapy. In general this activity was integrated into the well-baby clinic.
Although, when scheduling problems arose, there was some overlap of activities, the intent was to have one nurse practitioner assigned to each type of activity. An organization chart is . . . .
Assignment
- Calculate the figures for the “actual” and “variance” columns in Exhibit 4. What are the reasons for the variance in medical expenses? Please be as specific as possible in your explanation, using data from the case to support your conclusions.
- What is the nature of the staffing problem? What should Dr. Flaysakier do about it?