Healthcare Technology Management (HTM) guide 6 How to Manage Finances How to Manage the Finances of Your Healthcare Technology Management Teams

‘HOW TO MANAGE’ SERIES

FOR HEALTHCARE TECHNOLOGY

Guide 6
How to Manage the Finances

of Your Healthcare Technology
Management Teams

Management Procedures for
Health Facilities and District Authorities

TALCTALC

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Dedicated to baby Nathan and Trevor, for their patience and help.

Published by TALC, PO Box 49, St. Albans, Hertfordshire, AL1 5TX, UK
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Copyright © 2005 Ziken International

Ziken International (Consultants) Ltd,
Causeway House, 46 Malling Street, Lewes, East Sussex, BN7 2RH, UK
Tel: [phone], fax: [phone], email: [e-mail],
website: www.ziken.co.uk

‘How to Manage’ Series for Healthcare Technology

Guide 1: How to Organize a System of Healthcare Technology Management

Guide 2: How to Plan and Budget for your Healthcare Technology

Guide 3: How to Procure and Commission your Healthcare Technology

Guide 4: How to Operate your Healthcare Technology Effectively and Safely

Guide 5: How to Organize the Maintenance of your Healthcare Technology

Guide 6:How to Manage the Finances of your Healthcare Technology

Management Teams

Keywords: healthcare technology, management procedures,

health service administration, district health services, developing countries,

financial management, maintenance team, equipment

Any parts of this publication, including the illustrations, may be copied, reproduced, or adapted to
meet local needs, without permission, provided that the parts reproduced are distributed free or at
cost – not for profit. For any reproduction with commercial ends, permission must first be obtained
from the publisher. The publisher would appreciate being sent a copy of materials in which text or
illustrations have been used.

This document is an output from a project funded by the UK government’s Department for
International Development (DFID) for the benefit of developing countries. The views expressed
are not necessarily those of DFID.

ISBN: 0-9549467-5-8

All rights reserved

A catalogue record is available from the British Library

Design and layout by Jules Stock (email: [e-mail]

Illustrations and charts by David Woodroffe (email: [e-mail])

Edited by Sarah Townsend Editorial (email: [e-mail],
website: www.sarahtownsendeditorial.co.uk)

‘How to Manage’ Series for Healthcare Technology

Guide 6

How to Manage the Finances

of Your Healthcare Technology

Management Teams

by:

Willi Kawohl

Financial Management Consultant, FAKT, Stuttgart, Germany

Caroline Temple-Bird

Healthcare Technology Management Consultant,

Ziken International Consultants Ltd, Lewes, UK

Andreas Lenel

Health Economist Consultant, FAKT, Stuttgart, Germany

Manjit Kaur

Development Officer, ECHO International Health Services, Coulsdon, UK

Series Editor

Caroline Temple-Bird

Healthcare Technology Management Consultant,

Ziken International Consultants Ltd, Lewes, UK

CONTENTS

Section Page

Foreword i

Preface i

Acknowledgements iii

Abbreviations v

List of Boxes and Figures vii

1. Introduction 1

1.1 Introduction to the Series of Guides 1

1.2 Introduction to this Specific Guide 9

2. Framework Requirements 15

2.1 Framework Requirements for Quality Health Services 16

2.2 Background Conditions Specific to this Guide 25

3. What is Financial Management? 29

3.1 The Financial Management Cycle – an Overview of this Guide 30

3.2 Planning and Review Processes in this Guide 32

4. How to Set Operational Targets and Plans 35

4.1 Operational Targets 36

4.2 Purpose of an Operational Plan 37

4.3 Choosing Planned Activities to Meet Operational Targets 38

4.4 Improving your Operational Planning 39

5. How to Prepare an Operational Budget 41

5.1 Budgeting Process 42

5.2 Budget Format 43

5.3 Operational Income 46

5.4 Operational Expenditure 56

5.5 Example of an Operational Budget 57

5.6 Capital Budget 59

Contents

6. How to Set up an Activity-based Accounting System 61

6.1 HTM and Accounting Activities 61

6.2 Accounting Cycle 62

6.3 Accounting System 63

6.4 Chart of Accounts 65

7. How to Use Financial Monitoring Tools 67

7.1 Monitoring Variances 67

7.2 Performance Ratios 70

8. How to Use Financial Reports 75

8.1 Profit and Loss Account 75

8.2 Balance Sheet 78

9. How to Make Financial Decisions and Take Action 83

9.1 Financial Analysis and Decision-making 83

9.2 Action Planning 86

9.3 Monitoring Progress 90

Annexes 93

1. Glossary 93

2. Reference Materials and Contacts 107

3. Financial Fitness Test 113

4. Resources Required to Run Training Courses 117

5. Chart of Accounts 118

6. Source Material/Bibliography 121

Contents

Foreword

This Series of Guides is the output from a project funded by the UK government’s
Department for International Development (DFID) for the benefit of developing
countries. The output is the result of an international collaboration that
brought together:

◆ researchers from Ziken International and ECHO International Health Services in

the UK, and FAKT in Germany

◆ an advisory group from WHO, PAHO, GTZ, the Swiss Tropical Institute, and the

Medical Research Council of South Africa

◆ reviewers from many countries in the developing world

in order to identify best practice in the field of healthcare technology management.

The views expressed are not necessarily those of DFID or the other
organizations involved.

Garth Singleton

Manager, Ziken International Consultants Ltd, Lewes, UK

Preface

The provision of equitable, quality and efficient healthcare requires an extraordinary
array of properly balanced and managed resource inputs. Physical resources such as
fixed assets and consumables, often described as healthcare technology, are among
the principal types of those inputs. Technology is the platform on which the delivery
of healthcare rests, and the basis for provision of all health interventions. Technology
generation, acquisition and utilization require massive investment, and related
decisions must be made carefully to ensure the best match between the supply of
technology and health system needs, the appropriate balance between capital and
recurrent costs, and the capacity to manage technology throughout its life.

Healthcare technology has become an increasingly visible policy issue, and healthcare
technology management (HTM) strategies have repeatedly come under the spotlight
in recent years. While the need for improved HTM practice has long been recognized
and addressed at numerous international forums, health facilities in many countries
are still burdened with many problems, including non-functioning medical equipment
as a result of factors such as inadequate planning, inappropriate procurement, poorly
organized and managed healthcare technical services, and a shortage of skilled
personnel. The situation is similar for other health system physical assets such as
buildings, plant and machinery, furniture and fixtures, communication and information
systems, catering and laundry equipment, waste disposal, and vehicles.

Foreword

i

Preface (continued)

The (mis-)management of physical assets impacts on the quality, efficiency and
sustainability of health services at all levels, be it in a tertiary hospital setting with
sophisticated life-support equipment, or at the primary healthcare level where simple
equipment is needed for effective diagnosis and safe treatment of patients. What is
vital – at all levels and at all times – is a critical mass of affordable, appropriate, and
properly functioning equipment used and applied correctly by competent personnel,
with minimal risk to their patients and to themselves. Clear policy, technical
guidance, and practical tools are needed for effective and efficient management of
healthcare technology for it to impact on priority health problems and the health
system's capacity to adequately respond to health needs and expectations.

This Series of Guides aims to promote better management of healthcare technology
and to provide practical advice on all aspects of its acquisition and utilization, as well
as on the organization and financing of healthcare technical services that can deliver
effective HTM.

The Guides – individually and collectively – have been written in a way that makes
them generally applicable, at all levels of health service delivery, for all types of
healthcare provider organizations and encompassing the roles of health workers and
all relevant support personnel.

It is hoped that these Guides will be widely used in collaboration with all appropriate
stakeholders and as part of broader HTM capacity-building initiatives being
developed, promoted and implemented by WHO and its partners, and will therefore
contribute to the growing body of evidence-based HTM best practice.

The sponsors, authors and reviewers of this Series of Guides are to be congratulated
for what is a comprehensive and timely addition to the global HTM toolkit.

Andrei Issakov, Coordinator, Health Technology and Facilities Planning and
Management, World Health Organization, Geneva, Switzerland

Mladen Poluta, Director, UCT/WHO HTM Programme, University of Cape
Town, South Africa

Preface

ii

Acknowledgements

This Guide was written:

◆ with specialist support from:

Ike Osakwe (Chartered Accountant), Managing Director, GRID Consultancy,
Lagos, Nigeria

◆ with assistance from an Advisory Group of:

Hans Halbwachs, Healthcare Technology Management, Deutsche Gesellschaft
für Technische Zusammenarbeit (GTZ-GmbH), Eschborn, Germany

Peter Heimann, Director, WHO Collaborating Centre for Essential Health
Technologies, Medical Research Council of South Africa, Tygerberg, South Africa

Antonio Hernandez, Regional Advisor, Health Services Engineering and
Maintenance, PAHO/WHO, Washington DC, USA

Andrei Issakov, Coordinator, Health Technology and Facilities Planning and
Management, Department of Health System Policies and Operations, WHO,
Geneva, Switzerland

Yunkap Kwankam, Scientist, Department of Health Service Provision, WHO,
Geneva, Switzerland

Martin Raab, Biomedical Engineer, Swiss Centre for International Health of the
Swiss Tropical Institute, Basle, Switzerland

Gerald Verollet, WHO Technical Officer, Medical Devices, Blood Safety and
Clinical Technology (BCT) Department, WHO, Geneva, Switzerland

Reinhold Werlein, Biomedical Engineer, Swiss Centre for International Health of
the Swiss Tropical Institute, Basle, Switzerland

◆ reviewed by:

Kwasi Addai-Donkoh, MOH Regional Health Services Administrator, Ashanti
Region, Kumasi, Ghana

Dr. P. Asman, Head of the Bio-engineering Unit, Ministry of Health, Accra, Ghana

Narayan Baral, Administration Officer, Himalaya NGO Eye Hospital,
Pokhara, Nepal

Tsibu J. Bbuku, Medical Equipment Specialist, Central Board of Health,
Lusaka, Zambia

Juliette Cook, Biomedical Engineer, Advisor to Ministries of Health of
Mozambique, and Vanuatu

Acknowledgements

iii

Peter Cook, Biomedical Engineer, ECHO International Health Services,
Coulsdon, UK

Engineer Freedom Dellosa, Chief of Hospital Equipment Maintenance Service
Division, Region 9 – Mindanao Peninsula, Department of Health,
Zambonga City, Philippines

Pieter de Ruijter, Consultant, HEART Consultancy, Renkum, The Netherlands

Andreas Flotzinger, Electronic Engineer, German Development Service support
to Himalaya Eye Hospital, Pokhara, Nepal

Roland Fritz, HCTS Coordinator, Christian Social Services Commission, Dar es
Salaam, Tanzania

Andrew Gammie, Project Director, International Nepal Fellowship, Pokhara, Nepal

Elias Luhana, Head of Bio-Medical Engineering, University Teaching Hospital,
Lusaka, Zambia

Yohana Mkwizu, Regional Health Care Technical Service Coordinator, GTZ
District Health Support Project, Tanga Region, Tanzania

Sulaiman Shahabuddin, Director, Patient Services, Aga Khan Foundation Private
Hospital, Nairobi, Kenya

Zeenat Sulaiman, Director Projects and Administration, Aga Khan Foundation
Private Hospital, Nairobi, Kenya

Birgit Thiede, Physical Assets Management (PAM) Advisor, Ministry of Health,
Phnom Penh, Cambodia

◆ using source material:

as described in Annex 5: Source Material/Bibliography

◆ with financial assistance from:

the Knowledge and Research Programme on Disability and Healthcare
Technology, DFID, government of the United Kingdom

◆ with administrative support from:

all the staff at Ziken International Consultants Ltd, UK, especially Garth
Singleton, Rob Parsons, and Lou Korda, as well as Thomas Rebohle from
FAKT, Germany

Acknowledgements

iv

Abbreviations

a/c or acc. account

AHA American Hospital Association

b/f or b/fwd balance brought forward

CD-Rom compact disc – read only memory

c/f or c/fwd balance carried forward

CSSD central sterile supplies department

FOB free-on-board

HTM healthcare technology management

HTMS healthcare technology management service

HTMWG healthcare technology management working group

GAAP generally accepted accounting principles

GTZ Deutsche Gesellschaft für Technische Zusammenarbeit

(German government technical aid agency)

IAASB International Auditing and Assurance Standards Board

IASCF International Accounting Standards Committee Foundation

IAS international accounting standards

ICU intensive care unit

ISA international standards on auditing

ISO International Organization for Standardization

MOF Ministry of Finance

MOH Ministry of Health

MU money unit

NGO non-governmental organization

P&L profit and loss account

PPM planned preventive maintenance

SMART specific, measurable, achievable, relevant, time-bound (targets)

US $ United States dollars

WHO World Health Organization

Abbreviations

v

List of Boxes and Figures

Page

Box 1 Categories of items described as ‘healthcare technology’ 2

Box 2: Benefits of healthcare technology management (HTM) 4

Box 3: The collective responsibility for financial management 13

Box 4: Summary of issues in Section 2 on framework requirements 27

Box 5: Summary of procedures in Section 3 on financial management 34

Box 6: A checklist for improving your operational planning 39

Box 7: Summary of procedures in Section 4 on operational planning 40

Box 8: Example of a standard operational budget format for your

HTM service 45

Box 9: Example of productive and non-productive time 50

Box 10: AHA’s discussion of productivity levels in the USA 51

Box 11: How to determine chargeable hours for an HTM Team member 53

Box 12: How to calculate the service charges for an HTM Team 53

Box 13: How to estimate transport charges for a four-wheel drive vehicle

per km for a period of five years 55

Box 14: Example of an operational budget 58

Box 15: Example of a capital budget 59

Box 16: Summary of procedures in Section 5 on budgeting 60

Box 17: Summary of procedures in Section 6 on accounting 66

Box 18: Example of a variance report for an operational budget 69

Box 19: Example of a variance report for a capital budget 68

Box 20: Example of using key ratios to measure performance 71

Box 21: Example of monitoring productivity to measure performance 72

Box 22: Example of financial ratios for analyzing income and expenditure 73

Box 23: Summary of procedures in Section 7 on financial monitoring 74

Box 24: Basic layout for a profit and loss account 76

Box 25: Example of a profit and loss account (at the end of a period of time) 76

Box 26: Example of a depreciation schedule 79

Box 27: Basic layout for a balance sheet 80

Box 28: Example of a balance sheet 81

Box 29: Summary of procedures in Section 8 on financial reporting 82

Box 30: Outline of the problem-solving/decision-making process 85

Box 31: Different responsibilities for financial decision-making

and taking action 84

Box 32: Example of how to measure a goal 88

List of boxes and figures

vi

List of Boxes and Figures

Box 33: Summary of procedures in Section 9 on financial

decision-making, action planning, and monitoring progress 92

Box 34: WHO’s definition of the technology management hierarchy

(Annex 1) 100

Box 35: Resources required when running training courses yourselves

(Annex 4) 117

Figure 1: The place of HTM in the health system 2

Figure 2: The relationship between the Guides in this Series 6

Figure 3: The structure of Guide 6 12

Figure 4: The healthcare technology management cycle 18

Figure 5: Sample organizational chart for the HTM Service 23

Figure 6: The financial management cycle – an overview of this Guide 30

Figure 7: Planning and review cycle 33

Figure 8: Stages in the budgeting process 42

Figure 9: The difference between profit and cost centres 46

Figure 10: Matching HTM and accounting activities 62

Figure 11: The accounting cycle 62

Figure 12: The seven steps of the accounting system 63

List of boxes and figures

vii

1. INTRODUCTION

Why is This Important?

This introduction explains the importance of healthcare technology
management (HTM) and its place in the health system.

It also describes:

◆ the purpose of the Series of Guides and this Guide in particular

◆ the people the Guides are aimed at

◆ the names and labels commonly used in HTM, in this Series.

The Series of Guides is introduced in Section 1.1, and this particular Guide on
financial management is introduced in Section 1.2.

1.1 INTRODUCTION TO THE SERIES OF GUIDES

Healthcare Technology Management’s Place in the Health System

All health service providers want to get the most out of their investments. To enable
them to do so, they need to actively manage health service assets, ensuring that they
are used efficiently and optimally. All management takes place in the context of your
health system’s policies and finances. If these are favourable, the management of
health service assets can be effective and efficient, and this will lead to improvements
in the quality and quantity of healthcare delivered, without an increase in costs.

The health service’s most valuable assets which must be managed are its human
resources, physical assets, and other resources such as supplies. Physical assets such
as facilities and healthcare technology are the greatest capital expenditure in any
health sector. Thus it makes financial sense to manage these valuable resources, and
to ensure that healthcare technology:

◆ is selected appropriately

◆ is used correctly and to maximum capacity

◆ lasts as long as possible.

Such effective and appropriate management of healthcare technology will contribute
to improved efficiency within the health sector. This will result in improved and
increased health outcomes, and a more sustainable health service. This is the goal of
healthcare technology management – the subject of this Series of Guides.

1 Introduction

1

What Do We Mean By Healthcare Technology ?

The World Health Organization (WHO) uses the broader term ‘health technology’,
which it defines as including:

‘devices, drugs, medical and surgical procedures – and the knowledge associated
with these – used in the prevention, diagnosis and treatment of disease as well as
in rehabilitation, and the organizational and supportive systems within which care
is provided’

(Source: Kwankam, Y, et al, 2001, ‘Health care technology policy framework’, WHO Regional Publications,

Eastern Mediterranean Series 24: Health care technology management, No. 1)

However, the phrase ‘healthcare technology’ used in this Series of Guides only
refers to the physical pieces of hardware in the WHO definition that need to be
maintained. Drugs and pharmaceuticals are usually covered by separate policy
initiatives, frameworks, and colleagues in another department.

Therefore, we use the term healthcare technology to refer to the various equipment
and technologies found within health facilities, as shown in Box 1.

BOX 1: Categories of Equipment and Technologies described as ‘Healthcare Technology’

medical equipment walking aids health facility furniture

communication equipment training equipment office equipment

office furniture fixtures built into the building plant for cooling, heating, etc

service supply installations equipment-specific supplies fire-fighting equipment

workshop equipment fabric of the building vehicles

laundry and kitchen equipment waste treatment plant energy sources

For examples of these different categories, see the Glossary in Annex 1.

Figure 1: The Place of Healthcare Technology Management in the Health System

1.1 Introduction to this series of guides

2

Health

System

Policies

Health Sector Organization

and Management

Human Resources

Funds

Healthcare Technology

Consumable Supplies

Facilities

Healthy

Population

Health

Service

Provision

Often, different types of equipment and technologies are the responsibility of
different organizations. For example, in the government sector, different ministries
may be involved, such as Health, Works, and Supplies; and in the non-government
sector, different agencies may be involved, such as Health, and Logistics.

The range of healthcare technology which falls under the responsibility of the health
service provider varies from country to country and organization to organization.
Therefore each country’s definition of healthcare technology will vary depending on
the range of equipment and technology types that they actually manage.

For simplicity, we often use the term ‘equipment’ in place of the longer
phrase ‘healthcare technology’ throughout this Series of Guides.

What is Healthcare Technology Management?

First of all, healthcare hechnology management (HTM) involves the organization
and coordination of all of the following activities, which ensure the successful
management of physical pieces of hardware:

◆ Gathering reliable information about your equipment.

◆ Planning your technology needs and allocating sufficient funds for them.

◆ Purchasing suitable models and installing them effectively.

◆ Providing sufficient resources for their use.

◆ Operating them effectively and safely.

◆ Maintaining and repairing the equipment.

◆ Decommissioning, disposing, and replacing unsafe and obsolete items.

◆ Ensuring staff have the right skills to get the best use out of your equipment.

This will require you to have broad skills in the management of a number of
areas, including:

◆ technical problems

◆ finances

◆ purchasing procedures

◆ stores supply and control

◆ workshops

◆ staff development.

1.1 Introduction to this series of guides

3

However, you also need skills to manage the place of healthcare technology in the
health system. Therefore, HTM means managing how healthcare technology should
interact and balance with your:

◆ medical and surgical procedures

◆ support services

◆ consumable supplies, and

◆ facilities

so that the complex whole enables you to provide the health services required.

Thus HTM is a field that requires the involvement of staff from many disciplines
– technical, clinical, financial, administrative, etc. It is not just the job of managers, it
is the responsibility of all members of staff who deal with healthcare technology.

This Series of Guides provides advice on a wide range of management procedures,
which you can use as tools to help you in your daily work. For further clarification of
the range of activities involved in HTM and common terms used, refer to the
WHO’s definition of the technology management hierarchy in Annex 1.

Box 2 highlights some of the benefits of HTM.

BOX 2: Benefits of Healthcare Technology Management (HTM)

◆ Health facilities can deliver a full service, unimpeded by non-functioning healthcare technology.

◆ Equipment is properly utilized, maintained, and safeguarded.

◆ Staff make maximum use of equipment, by following written procedures and good practice.

◆ Health service providers are given comprehensive, timely, and reliable information on:

- the functional status of the equipment

- the performance of the maintenance services

- the operational skills and practice of equipment-user departments

- the skills and practice of staff responsible for various equipment-related activities in a range of
departments including finance, purchasing, stores, and human resources .

◆ Staff control the huge financial investment in equipment, and this can lead to a more effective and

efficient healthcare service.

1.1 Introduction to this series of guides

4

Purpose of the Series of Guides

The titles in this Series are designed to contribute to improved healthcare
technology management in the health sectors of developing countries, although they
may also be relevant to emerging economies, and other types of country. The Series
is designed for any health sector, whether it is run by:

◆ government (such as the Ministry of Health or Defence)

◆ a non-governmental organization (NGO) (such as a charitable or

not-for-profit agency)

◆ a faith organization (such as a mission)

◆ a corporation (for example, an employer such as a mine, who may subsidise

the healthcare)

◆ a private company (such as a health insurance company or for-profit agency).

This Series aims to improve healthcare technology at a daily operational level, as well
as to provide practical resource materials for equipment users, maintainers, health
service managers, and external support agencies.

To manage your technology effectively, you will need suitable and effective procedures
in place for all activities which impact on the technology. Your health service provider
organization should already have developed a policy document setting out the
principles for managing your stock of healthcare technology (Annex 2 provides a
number of resources available to help with this). The next step is to develop written
organizational procedures, in line with the strategies laid out in the policy, which
staff will follow on a daily basis.

The titles in this Series provide a straightforward and practical approach to
healthcare technology management procedures:

Guide 1 covers the framework in which Healthcare Technology Management
(HTM) can take place. It also provides information on how to organize a network of
HTM Teams throughout your health service provider organization.

Guides 2–5 are resource materials which will help health staff with the daily
management of healthcare technology. They cover the chain of activities involved in
managing healthcare technology – from planning and budgeting to procurement,
daily operation and safety, and maintenance management.

Guide 6 looks at how to ensure your HTM Teams carry out their work in an
economical way, by giving advice on financial management.

How the Guides are coordinated is set out in Figure 2.

1.1 Introduction to this series of guides

5

Figure 2: The Relationship Between the Guides in This Series

Who are These Guides Aimed at?

These Guides are aimed at people who work for, or assist, health service provider
organizations in developing countries. Though targeted primarily at those working in
health facilities or within the decentralized health authorities, many of the principles
also apply to staff in other organizations (such as those managing health equipment in
the Ministry of Works, private maintenance workshops, and head offices).

Depending on the country and organization, some daily tasks will be undertaken by
end users while others may be carried out by higher level personnel, such as central
level managers. For this reason, the Guides cover a range of tasks for different types of
staff, including:

◆ equipment users (all types)

◆ maintenance staff

◆ managers

◆ administrative and support staff

◆ policy-makers

◆ external support agency personnel.

1.1 Introduction to this series of guides

6

Framework/structure

Organizing a network of

HTM Teams (Guide 1)

Procurem

g and

Plannin

budgeting

(Guide 2)

Chain of activities

Maintenance

management

(Guide 5)

in the equipment

life cycle

commissionin

(Guide 3)

Daily operation

ent and

and safety

(Guide 4)

g

Ensuring efficiency

Financial management of HTM Teams (Guide 6)

They also describe activities at different operational levels, including:

◆ the health facility level

◆ the zonal administration level (such as district, regional, diocesan)

◆ the central/national level

◆ by external support agencies.

Many activities require a multi-disciplinary approach, therefore it is important to form
mixed teams which include representatives from the planning, financial, clinical,
technical, and logistical areas. Allocation of responsibilities will depend upon a
number of factors, including:

◆ your health service provider

◆ the size of the organization

◆ the number of decentralized levels of authority

◆ the size of your health facility

◆ your level of autonomy.

The names and titles given to the people and teams involved will vary depending on
the type of health service provider you work with.

For the sake of simplicity, we have used a variety of labels to describe
different types of staff and teams involved in HTM.

This Series describes how to introduce healthcare technology management into your
organization. The term Healthcare Technology Management Service (HTMS) is
used to describe the delivery structure required to manage equipment within the
health system. This encompasses all levels of the health service, from the central
level, through the regions/districts, to facility level.

There should be a referral network of workshops where maintenance staff with
technical skills are based. However, equipment management should also take place
where there are no workshops by involving general health facility staff. These groups
of people we call the HTM Team, and we suggest that you have a team at every level
whether a workshop exists or not. Throughout this Series, we have called the person
who leads that team the HTM Manager.

At every level, there should also be a committee which regularly considers all
equipment-related matters, and ensures decisions are made that are appropriate to
the health system as a whole. We have used the term HTM Working Group
(HTMWG) for this committee, which will advise the Health Management Teams on
all equipment issues.

1.1 Introduction to this series of guides

7

Due to its role, the HTMWG must be multi-disciplinary. Depending on the
operational level of the HTMWG, its members could include the following:

◆ Head of medical/clinical services.

◆ Head of support services.

◆ Purchasing and supplies officer.

◆ Finance officer.

◆ Representatives from both medical equipment and plant maintenance.

◆ Representatives of equipment users from a variety of areas (medical/clinical,

nursing, paramedical, support services, etc).

◆ Co-opted members (if specific equipment areas are discussed or specific interest

or need is shown).

The HTM Working Group prepares the annual plans for equipment purchases,
rehabilitation, and funding, and prioritizes expenditure across the facility/district as a
whole (see Guide 2 on planning and budgeting). It may have various sub-groups to
help consider specific aspects of equipment management, such as pricing,
commissioning, safety, etc.

How to Use These Guides

Each Guide has been designed to stand alone, and has been aimed at different types
of readers depending on its content (Section 1.2). However, since some elements
are shared between them, you may need to refer to the other Guides from time to
time. Also, if you own the full Series (a set of six Guides) you will find that some
sections of the text are repeated.

We appreciate that different countries use different terms. For example, a purchasing
officer in one country may be a supplies manager in another; some countries use
working groups, while others call them standing committees; and essential service
packages may be called basic healthcare packages elsewhere. For the purpose of
these Guides it has been necessary to pick one set of terms and define them. You can
then modify them for your own situation.

The terms used throughout the text are outlined, with examples, in the
Glossary in Annex 1.

We appreciate that you may find it hard to pursue the ideas introduced in these
Guides. Depending on your socio-economic circumstances, you may face many
frustrations on the road to achieving effective healthcare technology management.
We recognize that not all of the suggested procedures can be undertaken in all
environments. Therefore we recommend that you take a step-by-step approach,
rather than trying to achieve everything at once (Section 2).

1.1 Introduction to this series of guides

8

These Guides have been developed to offer advice and recommendations only,
therefore you may wish to adapt them to meet the needs of your particular situation.
For example, you can choose to focus on those management procedures which best
suit your position, the size of your organization, and your level of autonomy.

For more information about reference materials and contacts for healthcare
technology management, see Annex 2.

1.2 INTRODUCTION TO THIS SPECIFIC GUIDE

The Importance of Financial Management

The ability to use financial resources effectively and efficiently is one of the greatest
challenges facing health service providers all over the world.

It is the goal of healthcare technology management (HTM) to ensure that all the
equipment belonging to health service providers is properly managed, utilized,
maintained, and safeguarded. Financial investment in equipment also has to be
protected, in order to avoid a situation where income is lost because equipment
cannot be used. Guide 2 of this Series covers the planning and budgeting necessary
to purchase equipment for the health service and to keep it running throughout its
life. This Guide, however, covers the planning and budgeting necessary to ensure
that HTM Teams can carry out their work (their operations), and, if possible, run the
operation as a business.

In order to do this, you will need a clear understanding of financial responsibility and
financial accountability. This will enable you to use money in the best possible way,
to provide a quality service to your patients while fulfilling the objectives of the
health service provider.

Financial responsibility means paying staff and creditors on time, keeping

proper records of money going in and out of the
facility, and avoiding obligations that the health
service provider cannot fulfil.

Financial accountability means being able to account for the money received

and spent, to central bodies such as a Ministry of
Health, Diocesan Health Authority, Board of Trustees,
and external support agencies.

The gap between the financial needs of healthcare technology management services
(HTMS) and the financial resources available is widening at an alarming rate. HTM
Teams and, in particular, their managers at all levels are responsible and accountable
for the management of the financial resources needed for operating an effective and
efficient HTM system.

1.2 Introduction to this specific guide

9

Who is This Guide Aimed at?

This Guide introduces practical financial management tools and techniques. It is
primarily aimed at:

◆ HTM Managers

◆ Finance Officers

working for any type of health service provider.

However, it will also be useful for:

◆ members of HTM Teams and HTM Working Groups (HTMWG)

◆ section heads

◆ Health Management Teams.

We also believe it will be useful for staff responsible for healthcare technology
management who are working for:

◆ public maintenance/service support organizations

◆ private maintenance/service support companies.

All such staff should have a good understanding of how to use financial management
tools in their common effort to establish and operate a successful HTM Service.

What Topics are Covered?

This Guide concentrates primarily upon effective financial management of
HTM activities by HTM Teams, within the overall healthcare technology
management framework.

In all the Guides, it is recognised that, alongside repair and maintenance, technical
staff are also responsible for a wide range of other equipment management activities
including:

◆ planning equipment services

◆ managing stock

◆ providing technical advice for procurement

◆ plant operation

◆ training users

◆ developing technical cost estimates and budget forecasts.

Recommendations and procedures for all these tasks are provided in Guides 1 to 5
of this Series.

1.2 Introduction to this specific guide

10

Most health service providers managed by Ministry of Health or faith organizations
have established HTM Teams. These may be based at facility, district and regional
level and usually operate as cost centres. Common problems of these cost centres are:

◆ HTM Teams form only a small part of a larger organizational structure and have

very little autonomy in their operations.

◆ HTM Teams often have no clear targets or operational plan and, as a result, there

are no indicators by which to measure their results.

There is a generally accepted view that maintenance just costs money. Private sector
companies, however, are proving that HTM Teams can be successfully operated as
profit centres.

With this in mind, this Guide presents a profit centre approach for the HTM
Service. However, the financial management tools and techniques introduced in
Sections 3 to 9 can be applied to HTM Teams operating for all types of health
service providers. This Guide aims to:

◆ Clarify the subject for those organizations already running as profit centres and

established for full cost recovery – such as private and some NGO health facilities.

◆ Help those organizations already attempting partial cost-recovery (moving from

cost centres towards profit centres) – such as some NGO health facilities, and faith
and government health facilities that have some degree of financial autonomy.

◆ Encourage those organizations currently running as cost centres – such as faith and

government health facilities that are not financially autonomous – to manage their
resources more effectively and efficiently, and even to consider starting cost recovery.

Additional useful reference materials and contacts are given in Annex 2.

1.2 Introduction to this specific guide

11

1.2 Introduction to this specific guide

12

How is This Guide Structured?

The structure of Guide 6 highlights the different activities required for the financial
management of HTM work, as shown in Figure 3.

Figure 3: The Structure of Guide 6

Who Does What in Financial Management?

Since effectiveness and efficiency are goals for all health services, financial
management is a collective responsibility. Therefore many people have a role to play,
as shown in Box 3.

Introducing the Series, and this particular GuideSection 1

Section 2

Section 3

Section 4

Section 5

Understanding the central framework for HTM, and
background conditions specific to this Guide

Understanding the logical sequence of activities in
the financial management cycle, and the planning
and review processes involved

Setting operational targets and preparing
operational plans

Following a budgeting process to obtain realistic
operational budgets

Accounting for HTM servicesSection 6

Monitoring the operational budgetSection 7

Section 8

Section 9

Reporting financial results

Making decisions, taking action, and reviewing
progress

13

Section 1 summary

HTM Managers
(at all levels of
the HTMS)

HTM Teams

Health Service
Providers

Health
Management Teams
(at all levels), and
their HTMWG

Finance Officers

Accountants

Customers (such
as health facilities)

Government Bodies

◆ are key to a successful financial management system for the HTM Service

◆ develop annual action plans for the financial management cycle of the HTM

Service (Sections 3 and 9)

◆ plan what maintenance, repair, training, and range of consultancy services can be

supplied to customers, according to the skills available (see Guides 1, 4 and 5)

◆ plan the adequate supply and stock levels of spare parts and maintenance

materials (and possibly equipment accessories and consumables – see Guide 4)

◆ undertake financial monitoring of the HTM Teams (Section 7)

◆ monitor progress against targets for performance (Sections 7 and 9)

◆ make sound financial decisions (Section 9)

◆ set their own operational targets and make operational plans (Section 4)

◆ develop their own operational and capital budgets (Section 5)

◆ undertake maintenance, repair, training, and consultancy work for customers

◆ formally account for their use of resources (Section 6)

◆ keep a comprehensive equipment and maintenance record system (see Guide 5)

◆ produce financial reports (Section 8)

◆ decide whether the HTM Service will run as a profit or cost centre and what

degree of cost recovery will be required (Section 5)

◆ ensure that financial management is an integral part of healthcare technology

management (Section 3)

◆ provide sufficient resources for the operations of the HTM Service (Section 5),

and for all HTM activities (see Guide 2)

◆ decide on corrective action in response to financial reporting (Sections 8 and 9)

◆ liaise with and oversee the HTM Service

◆ allow HTM Teams to service clients at other sites

◆ set goals for health facilities which will provide a guide for the target-setting of

the HTM Teams (Sections 4 and 9)

◆ provide suitable space for workshop facilities (see Guide 5)

◆ agree on the budget format for the HTM Team (Section 5)

◆ agree on the accounting system for the HTM Team (Section 6)

◆ analyse the outcome from financial reporting (Section 8)

◆ understand the financial management requirements for HTM Teams (Section 3)

◆ provide HTM Teams with advice on the financial procedures, transactions, and

paperwork used by the health service provider

◆ help with the budgeting process (Section 5)

◆ help establish the accounting system (Section 6)

◆ are consulted and offer advice on setting up a suitable accounting system for the

HTM Service (Section 6)

◆ are consulted and offer advice on the outcome of financial reports (Section 8)

◆ settle bills and pay for HTM services promptly

◆ provide the legal and policy framework for healthcare technology management

(Section 2)

◆ provide the legal and policy framework for financial management (Section 2)

Working Together

BOX 3: The Collective Responsibility for Financial Management

14

2 Framework requirements

15

2. FRAMEWORK REQUIREMENTS

Why is This Important?

In order to deliver quality health services, it is essential to undertake effective
healthcare technology management (HTM).

There are various framework requirements to help you do this. These include
legislation, regulations, standards, and policies.

These framework requirements create the boundary conditions within which
you undertake healthcare technology management. They include central or
national guiding principles, policy issues, and high-level assumptions that can
impede or assist you in your work.

It is very difficult to function effectively if these framework requirements do not
exist, and you should lobby your organization to develop them.

Depending on how autonomous your health facilities are, you may be able to
develop these framework requirements at facility, region/district, or central level.

In most industrialized countries, laws, regulations, policies and guidelines form an
indispensable part of health service management. For many developing countries,
however, these regulatory procedures have yet to be developed.

Guide 1 provides a fuller analysis of how to develop these instruments, and shows that
effective healthcare technology management (HTM) is essential in order to deliver
quality health services. Section 2.1 summarizes these points and offers advice on:

◆ the regulatory role of government

◆ establishing standards for your health system

◆ policy issues for HTM

◆ the importance of introducing an HTM Service

◆ managing change.

Section 2.2 goes on to discuss the background conditions specific to this Guide, and
provides advice on:

◆ authorities responsible for guidance on financial management

◆ central laws, regulations, standards, principles, and policies for

financial management.

16

2.1 FRAMEWORK REQUIREMENTS FOR QUALITY
HEALTH SERVICES

Regulatory Role of Government

The World Health Organization (WHO) identifies four distinct functions for
health systems:

◆ The provision of health services.

◆ The financing of health services.

◆ The creation of health resources (investment in facilities, equipment, and training).

◆ The stewardship of health services (regulation and enforcement).

Health service provision and financing, as well as resource creation may be taken on by
both the government and private sector. Thus, there are various options for organizing
health systems:

◆ Mainly public.

◆ Mainly private for-profit (for example, run by a commercial organization), and

private not-for-profit (for example, run by faith organizations, NGOs).

◆ A mixture of government and private organizations.

However in all these systems, the government is solely responsible for the regulation
of health services. The reason for this is that the government has a duty to ensure
the quality of healthcare delivered in order to protect the safety of the population.
These regulations may then be enforced directly by government bodies or they may
be enforced by publicly funded bodies, such as professional associations, which apply
government sanctioned regulations.

Most governments would agree that the protection of health and the guarantee of
safety of health services is vital. However, in many countries this regulatory function is
underdeveloped, with weak legal and regulatory frameworks.

To regulate health services, the government should:

◆ adopt suitable quality standards for all aspects of health services, including

acceptable international or national standards for healthcare technology, drugs,
and supplies in order to ensure their efficacy, quality and safety

◆ establish systems to ensure standards are met, so that the bodies enforcing

regulations have legal sanctions they can use if standards are infringed

◆ establish wide-ranging policies covering all aspects of the utilization,

effectiveness, and safety of healthcare technology, drugs, and supplies

◆ establish systems to ensure these policies can be implemented.

For health services, the Ministry of Health is the body most likely to develop these
government regulations. Other health service providers need to be guided by
government laws, and should look to the Ministry of Health for guidance or follow
their direction if required to do so by law or regulation.

2 Framework requirements for quality health services

17

2.1 Framework requirements for quality health services

Establishing Standards for your Health System

The government should agree on which quality standards have to be met by the
health services in general. They will cover areas such as:

◆ procedures and training

◆ construction of facilities

◆ healthcare technology, drugs, and supplies

◆ safety

◆ the environment

◆ quality management.

Since drawing up these standards can be both time consuming and expensive,
governments may often choose to adopt acceptable international standards (such as
ISO), rather than develop their own. However, they must be suitable and applicable
to your country situation and fit in with your country’s vision for health services.

The adoption of suitable international or national standards for healthcare technology
is of particular relevance to this Guide. Such standards would cover areas such as:

◆ manufacturing practices

◆ performance and safety

◆ operation and maintenance procedures

◆ environmental issues (such as disposal).

These are important since countries can suffer if they acquire sub-standard and
unsafe equipment. Again, in the majority of cases ministries of health would save
money and time by adopting internationally recognized standards. For more
information on introducing internationally recognized standards into your
procurement procedures, refer to Guide 3.

It is not enough simply to establish these standards; they also need to be adhered to.
For this reason, you should establish a national supervisory body that has the power
to ensure that health service providers comply with the standards in force. To be
effective, such an enforcement agency must be allocated sufficient financial and
personnel resources. It should also be linked or networked with corresponding
international bodies.

Much healthcare technology in developing countries is received through foreign aid
and donations, but such products do not always meet international standards.
Therefore, your country will need to negotiate with external support agencies. The
best way to do this is to develop regulations for donors that supply equipment (see
Annex 2, and Guide 3 on procurement and commissioning).

Standard

a required or agreed level

of quality or attainment

set by a recognized authority,

used as a measure,

norm, or model

18

The legal system plays an important role in enforcing such standards, by ensuring
that any infringements can be effectively prosecuted. It is therefore essential that
the legal system is allocated sufficient financial and human resources to enforce
claims against any institution operating equipment that does not meet the
prescribed standards.

Developing Policies for Health Services

Every country needs to establish wide-ranging policies covering all aspects of health
services. National health policies are usually developed by the Ministry of Health. If
these policies are linked to regulations, then other health service providers must also
follow them. Each health service provider can expand them internally, and must
establish systems to ensure they are implemented.

One key framework requirement for this Series of Guides is that your health service
provider should have started work on a Healthcare Technology Policy (for guidance
on this process, see Annex 2). Such a policy usually addresses all the healthcare
technology management (HTM) activities involved in the life-cycle of equipment,
as shown in Figure 4.

Figure 4: The Healthcare Technology Management Cycle

2.1 Framework requirements for quality health services

Planning and
Assessment

Decommissioning
and Disposal

Maintenance
and Repair

Operation
and Safety

• Create
awareness

• Monitor
and
evaluate

Budgeting and
Financing

Technology Assessment
and Selection

Procurement
and Logistics

Training and Skill
Development

Installation and
Commissioning

19

2.1 Framework requirements for quality health services

Here we will consider just four issues that provide key background conditions:

◆ a vision for health services

◆ standardization

◆ the provision of maintenance; and

◆ finances.

A Vision for Health Services

Every health service provider needs a realistic vision of the service it can offer. This
should include a clear understanding of its role in relation to other health service
providers in the national health service. Only when this vision is known can the
health service provider decide what healthcare technology is needed, and prioritise
the actions required to develop its stock of equipment.

It is unhelpful if lots of individual health facilities pull in different directions, with
no coordinated plan for the health service as a whole. The central authority of each
health service provider should be responsible for considering what sort of healthcare
should be offered at each level of their health service. Preferably they will collaborate
with the Ministry of Health, or follow their guidance if regulated to do so.

If there is no health service plan, there is no framework on which to base decisions.
Guide 2 provides further information on developing a vision and planning your
healthcare technology stock.

Standardization of Healthcare Technology

Introducing an element of standardization for
healthcare technology will help you to limit the wide
variety of makes and models of equipment found in
your stock. By concentrating on a smaller range for
each equipment type, your technical, procedural, and
training skills will increase and your costs and
logistical requirements will decrease (see Guide 1).

It is easier to achieve standardization if equipment is

planned and ordered on a country-wide, district-wide
or health service provider basis. It is therefore important to combine forces with other
facilities or health service providers, and it may be wise to follow standardization
strategies of the Ministry of Health. It is important that these standardization efforts
do not just apply to products purchased by health facilities, but also to donations.

Standardization

(also known as rationalization,

normalization, and harmonization)

– the process of reducing the

range of makes and models of

equipment available in your stock,

by purchasing particular named

makes and models.

20

Standardizing your healthcare technology may be difficult for a number of reasons.
Your country and local businesses may have their own trade practices and interests.
National donors may have tied-aid practices, while the procurement procedures of
international funding agencies, health service institutions, and individuals may act
against your standardization strategies (see Guide 3).

You may need to hold discussions with organizations such as the Ministry of Industry
and/or Trade, the chambers of commerce or specific business associations, as well as
external support agencies. However, it is well worth persevering, as standardization
offers many benefits, both in terms of cost and efficiency.

Provision of Maintenance

Proper maintenance is essential to ensure that the equipment you have purchased
continues to meet the standards required throughout its entire working life.

Undertaking maintenance belongs to the service provision function of health
systems, and could therefore, in principle, be carried out by the government, the
private sector, or by a mixture of the two.

It is useful to organize the maintenance system along similar lines to the health
service provision already existing in your country. For instance, if the health sector is
predominantly run by the government, it is probably simplest to let the government
run the maintenance organization as well. In contrast, if private organizations run the
health services, it makes little sense for the maintenance activities to be carried out
by a government body. In the majority of cases, a mixed system is most likely.

However, the government may wish to take a regulatory role and establish regulations
that guarantee that healthcare technology performs effectively, accurately, and
safely. The rules established are valid for all health service providers, irrespective
of their type of organization.

Specific maintenance requirements would not need to be prescribed by the regulatory
body. Instead, it is up to individual health service providers to decide how these will
be provided. However, the nature and the complexity of some maintenance services
often call for partnerships between the public and private health service providers.
Partnerships may also exist between health service providers and private sector
sources of maintenance support. For more details, refer to Guide 1.

To provide maintenance services, you will normally need to establish good links
between maintenance workshops. This will create a network that supports the needs
of all your health facilities. Maintenance is, of course, only one of many HTM
activities that need to be carried out. However, the fact that maintenance workshops
usually already exist in most countries serves as a useful starting point for establishing
a physical HTM Service across your health service provider organization and across
your country. For more details on how to organize an HTMS, refer to Guide 1.

2.1 Framework requirements for quality health services

21

2.1 Framework requirements for quality health services

Finances

To ensure that healthcare technology is utilized effectively and safely throughout its
life, your health service provider will need to plan and allocate adequate capital and
recurrent budgets. See Guide 2 for more advice on this.

In a government-organized system these funds have to be provided by government
budgets, while private systems or mixed systems must generate the required funds
from their customers, or from benefactors and donors.

Depending on your health service provider and country, your HTM Service may be
able to generate income by charging for services provided. Whether this income can be
used to further improve the HTM Service depends on the policies of the responsible
financing authority (such as the treasury or central finance office). Section 8.1 provides
advice on this.

The Importance of Introducing a Healthcare Technology
Management Service

We have established the importance of:

◆ adopting standards for healthcare technology

◆ developing healthcare technology policies

◆ establishing systems to ensure the policy is implemented.

All these aims could be achieved if each health service provider practised healthcare
technology management (HTM) as part of the everyday life of their health service.
The best way to do this is to have an HTM Service incorporated into each health
service provider organization.

Box 2 (Section 1.1) shows that HTM provides a wide range of benefits. Guide 1
attempts to express this in terms of the sorts of savings that can be made if HTM is
effectively carried out. Taking maintenance as an example, we can see that it not
only has a positive impact on the safety and effectiveness of healthcare technology,
but also has two important economic benefits:

◆ it increases the life-span of the equipment

◆ it enhances the demand for health services, since demand for services is crucially

dependent upon the availability of functioning healthcare technology.

Healthcare technology that is out of order quickly leads to a decline in demand,
which will in turn reduce the income and quality of services provided by the health
facility. You will lose clients if, for example, it becomes known that malfunctioning
of sterilization equipment may endanger the health of the patients. Similarly,
patients will avoid visiting health facilities that do not possess functioning
diagnostic equipment.

22

Thus the justification for introducing an HTM Service is that it will benefit you
economically and clinically, by ensuring that healthcare technology continues to
meet the standards required throughout its working lifetime.

The activities of an HTM Service belong to the service provision function of health
systems. However, the government may wish to take a regulatory role and establish
regulations that guarantee that HTM occurs. To achieve this, it will be necessary
to have:

◆ a government body to provide regulations which will ensure the continued

performance and safety of healthcare technology throughout its life

◆ a control mechanism to check that all health service providers pursue these

healthcare technology management activities effectively

◆ legal or other sanctions that are enforceable if the rules are infringed.

The government body responsible for providing regulations could be the central
level of the national HTM Service. Each health service provider could then develop
its own HTM Service. It should involve a network of teams and committees that
enable HTM to be practised in all facilities. In order to establish an effective HTM
Service, you will need to provide sufficient inputs, such as finance, staff, workshops,
equipment, and materials. Only in this way will you get the outputs and benefits that
you require. For details of how to develop such an HTM Service, see Guide 1.

The organizational chart for the HTM Service will vary depending on the size of your
country and your health service provider organization, and whether you are just
starting out. However, Figure 5 provides an example of the relationship between
HTM Teams and HTM Working Groups (Section 1.1) that we envisage.

How to Manage Change

The regulatory requirements presented in this Section may appear somewhat
idealistic, compared to the reality in many health systems. However, the aim is not
to highlight the deficiencies of existing systems, but to provide a blueprint for a
functioning healthcare technology management system. Hopefully, this will enable
you to get the right framework conditions in place, and thus improve the effectiveness
and the safety of your health service.

We are not recommending that your health service provider:

◆ throw out all their current HTM strategies and start again

◆ make sudden and sweeping changes that are likely to fail if they are over ambitious.

Rather it is better to take a step-by-step approach, introducing changes gradually, with
a careful review process. To implement an HTM system with all the complexities
described in this Series of Guides will take several years, and to try to achieve
everything at once could be disastrous. However for healthcare technology
management to improve, it is important to act.

2.1 Framework requirements for quality health services

23

2.1 Framework requirements for quality health services

Figure 5: Sample Organizational Chart for the HTM Service

health

manage-

HTM

Working

HTM

Team

ment

team

technical

assistance

Group

Workshop

support

technical

health

manage-

HTM

Working

HTM

Team

ment

team

technical

assistance

Group

Workshop

support

technical

health

manage-

HTM

Working

HTM

Team

ment

team

technical

assistance

Group

Workshop

support

technical

health

manage-

HTM

Working

HTM

Team

ment

team

technical

assistance

Group

Central level

Zonal level

– large

Facility level

– small

24

It is possible to write down all the correct procedures and yet still fail to improve the
performance of staff. To ensure that your HTM procedures are effective, it is important
for there to be good managers who can find ways to motivate staff (Section 9). Simply
ordering staff to implement new procedures usually does not work. It is much better to
discuss and develop the procedures with the staff who will implement them. This could
take the form of discussion, working groups or training workshops. People who are
involved in developing ideas about their own work methods are more likely to:

◆ understand the objectives

◆ understand the reasons why processes are necessary

◆ be encouraged to change their way of working

◆ be more interested in making changes which result in improvement

◆ see that the aim of the HTM procedures is to improve their delivery of healthcare.

We recognize that many readers will face difficulties such as staff shortages, poor
finances, lack of materials, a lack of influence and time, and possibly even corruption.
Introducing new rules and procedures into a system or institution that has no real
work ethic, or which possibly employs dishonest workers, will not have any
significant effect.

Therefore, strategies may be required to bring about cultural and behavioural change.
For example:

◆ When materials are short, instead of focussing upon breakages and loss, place more

emphasis upon the importance of staff working hard and putting in the hours.

◆ Favour good managers who are seen to be present and doing what they preach.

◆ Encourage an atmosphere where staff are praised for good work, rather than a

culture of judgement and criticism.

Introducing rules and administrative procedures alone will not be sufficient to bring
about cultural change. You will also need to find ways of increasing performance and
productivity, and acknowledging/rewarding good behaviour is essential. For example:

◆ It is better to break a tool while actively undertaking maintenance, rather than

breaking nothing but never doing any work.

◆ It is better to break a rule in an emergency (such as withdrawing stocks from

stores), rather than stick to the rules and risk the possible death of a patient.

Annex 2 has some examples of useful reference materials. To bring about such
changes, you will require skills in:

◆ managing change

◆ staff motivation

◆ effective communication

◆ encouragement

◆ supportive training with demonstrations.

2.1 Framework requirements for quality health services

25

2.2 Background conditions specific to this guide

All parties involved in the network of HTM Teams and HTM Working Groups need
to participate in developing the HTM Service. This will encourage a sense of
ownership of the Service and its responsibilities, and will lead to greater acceptance
and motivation among staff. If you are short of skilled staff (such as technicians,
managers, planners or policy-makers), you may need to obtain specialist support to
assist with some of these tasks.

2.2 BACKGROUND CONDITIONS SPECIFIC TO
THIS GUIDE

Your country and health service provider may have existing principles and conditions
that can affect or inform aspects of financial management. These are described here.

Responsible Financial Management Authorities

If you work for a health service provider organization, you will need to conform to any
regulations and guidelines concerning financial management produced by the central
financing body of your health service provider. For example:

◆ The Ministry of Finance (MOF) sets national policy, financial regulations, and tax

regulations. It provides rules and guidance in documents such as financial
planning manuals and purchasing manuals. Government health facilities must
conform to these rules, and so must health facilities of other service providers
(such as faith organizations) if they receive government funds.

◆ The national taxation authority (which also falls under the MOF) implements

national tax policy and regulations. Health facilities of non-governmental and
private organizations must file their accounts to this body, according to these rules.

◆ The Offices of the Auditor General and, in some countries, the Accountant

General, independently monitor the use of public funds.

◆ The central level of your health service provider will decide if the HTM Service can

charge for its activities, can make a profit, and whether the profit can be used to
improve the HTM Service or must be returned to the treasury/finance department.

Guiding Principles

International standards, government laws, tax regulations, donor regulations, and
accounting principles and policies will affect and inform certain aspects of your
financial management, as follows:

Government law

In most countries, the drawing up of accounts is ruled by national legal
requirements. These laws are the overall national framework for producing and
presenting accounts.

Tax regulations

The national taxation authority has considerable influence on financial transactions
and financial statements.

International accounting standards (IAS)

These are internationally recognized accounting standards that must be followed.
They are promoted by the IASCF (International Accounting Standards Committee
Foundation), serve as accounting models for individual countries, and may be
adopted through countries’ domestic laws or domestic accounting codes of practice.

Generally accepted accounting principles (GAAP)

These are guidelines created by the accounting profession. There are also country­specific GAAP regarding certain financial transactions.

Accounting policies

Within the framework of strict legal requirements and GAAP, health service providers
are free to choose how they will treat certain financial transactions. However, you will
need to conform to any policies, regulations and guidelines provided by central
management bodies.

International standards on auditing (ISAs)

These are internationally recognized standards for auditing. Auditors operate as a
check on organizations, by carrying out independent inspections of accounts,
accounting records, procedures, and financial statements. All sectors may at some
time be audited. The IAASB (International Auditing and Assurance Standards
Board) encourages the use of its ISAs globally, to improve the uniformity of practice
by professional accountants throughout the world.

Donor requirements

Your financial policy and regulations will also depend, to some degree, on who is
funding the work of the HTM Service. If funding is provided by international
donors, they will usually insist on their own requirements for financial accountability
and reporting formats.

Box 4 contains a summary of the issues covered in this Section.

26

2.2 Background conditions specific to this guide

27

Section 2 summary

Government

Ministry of Health

All Health Service
Providers in
general

◆ actively regulates health services whether they are delivered by public providers,

private providers, or a mixture of the two

◆ develops checking systems and legal sanctions for infringement of health regulations

◆ adopts suitable standards for quality health services, in general

◆ specifically for healthcare technology, adopts standards for:

- design, development, and manufacturing

- performance and safety

- use and training

- waste disposal

◆ develops donor regulations to ensure all equipment received through foreign aid

and donations also comply with the standards

◆ establishes public or quasi-public supervisory bodies to enforce regulations

and standards

◆ develops national policies for health services

◆ specifically develops a Healthcare Technology Policy to cover all healthcare

technology management activities including:

- a vision

- an element of standardization

- the provision of maintenance

- provision of finances for all HTM activities

- the organizational structure for an HTM Service

◆ regulates on these issues (if required)

◆ develops an HTM Service made up of a network of teams and working groups

◆ uses the central level of the HTMS as the national regulatory body, if necessary,

and to ensure that HTM policies are implemented

◆ provides sufficient inputs to ensure the HTMS is effective

◆ uses strategies to manage the changes involved carefully, so that they can

be successful

◆ conform to regulations and guidelines provided by government

◆ conform to the standards set by government

◆ follow the policies of the Ministry of Health if regulated to do so

◆ develop their own internal Healthcare Technology Policy and expand strategies

◆ develop their own HTM Service made up of a network of teams and working

groups, with sufficient inputs to ensure it is effective, in order to ensure that

HTM policies are implemented

◆ follow MOH regulations on the HTMS if regulated to do so

◆ implement strategies to develop skills in managing change, staff motivation,

effective communication, encouragement, and supportive training with

demonstrations

◆ introduce rules and procedures using discussion, working groups, training

workshops, etc with the staff that will implement them

◆ include all parties involved in the network of HTM teams and working groups in

the development of the HTMS

◆ introduce changes to HTM step-by-step, with a careful review process

Quality Health Services

BOX 4: Summary of Issues in Section 2 on Framework Requirements

Continued overleaf

28

Section 2 summary

Government

Accountant
General and
Auditor General

International
Donors

Health Service
Providers

All HTM staff and
managers

◆ establishes national policies, laws, and regulations on financial transactions and

tax for government facilities and any others receiving government funds,

according to international standards

◆ uses the national taxation authority to implement national tax policy and

regulations for all sectors that file accounts

◆ establishes policies, laws, and regulations that form the overall national

framework for registration of HTM Services, and their presentation of accounts.

◆ monitor the use of public funds

◆ provide their special requirements for financial reporting and accountability

◆ commonly apply International Accounting Standards and International Standards

on Auditing

◆ abide by government laws, donor requirements and GAAP or IAS

◆ must also design their own policies for financial transactions

◆ provide central guidance to their health sector on financial policies and transactions

◆ decide whether the HTM Service can charge for its activities, can make a profit,

and whether the profit can be used to improve the HTM Service further

◆ conform to regulations and guidelines provided by relevant bodies on:

- financial management

- financial planning

- purchasing

- accounting

- taxation

- auditing

- financial reporting

Financial Management

BOX 4: Summary of Issues in Section 2 on Framework Requirements (continued)

29

3 What is financial management?

3. WHAT IS FINANCIAL MANAGEMENT?

Why is This Important?

Financial Management is an essential part of healthcare technology
management (HTM). It is built into every aspect of the work of the HTM
Service, from setting operational targets to planning, implementing,
reporting, and decision-making.

Financial management skills such as planning, budgeting and monitoring,
are essential in order to make well-informed decisions in a rapidly changing
environment. This is one element of quality management – an important goal
for managers.

The HTM Service needs to be able to manage the finances for the HTM activities
that it is responsible for. Its aim is to be efficient and productive, and to make good
use of resources, therefore being an effective and successful organization. It may
also try to generate income to cover some of its costs.

In this Section, the subject of financial management is explored by studying the
financial management cycle (Section 3.1). Each stage of this cycle is then covered in
detail by a further Section of the Guide. Thus, this Section provides an overview of
the financial management process described in the Guide.

To manage activities well requires a cycle of planning and reviewing your actions.
Section 3.2 explains how two planning and review cycles are incorporated into
this Guide

Tip

•

In this Guide, reference is made to two plans – an operational plan and an action plan –
both of which are annual plans:

- The term ‘operational’ refers only to the technical work (operations) of the HTM

Team. Thus, the operational plan covers the engineering activities that the teams
carry out for customers.

- The HTM Teams also undertake other activities covered by the financial

management cycle (such as budgeting, accounting and report-writing). The action
plan, therefore, is overarching, refers to goals made for all such activities, and
includes reviewing and updating the operational plan.

30

3.1 FINANCIAL MANAGEMENT CYCLE
– AN OVERVIEW OF THIS GUIDE

HTM Teams need to set operational targets for their work, and decide what budgets
are required to achieve these. They need to account for the use of the money,
monitor whether the money was well spent, and be able to report on their financial
situation. The HTM Team needs to review how well it is carrying out all these tasks,
and to evaluate whether the targets of the HTM Service have been fulfilled or
whether changes are required.

This process of financial decision-making consists of a logical sequence of activities,
and is illustrated by the Financial Management Cycle shown in Figure 6.

Figure 6: Financial Management Cycle – an Overview of this Guide

3.1 Financial management cycle

This Guide covers each of these steps as follows:

Step 1: Setting Operational Targets and Preparing an Operational Plan

The HTM Team begins by setting targets for its operations for the coming year.
These are determined, to a large extent, by the goals of the health facility and HTM
Working Group. The HTM Team prepares an operational plan, which will then be
integrated into the overall plan for the Healthcare Technology Management Service
(see Guide 2 on planning and budgeting).

Decision-

making and

taking action

Reporting

(communicating results

and recommending actions)

Operational

targets

and plans

Budgeting

(determining

resources needed)

Accounting,

recording & processing

financial transactions

Monitoring

variances and

performance

Section 4 of this Guide gives details of how to prepare an operational plan for HTM
Teams.

Tip

•

Setting operational targets/plans and budgeting (Step 2, below) are, in fact, linked in
a cycle. You cannot usually establish a plan by itself. Instead, you need to think about
the financial implications.

Step 2: Budgeting

The budget translates the operational plan into monetary terms. The HTM Team
considers the financial resources required to implement the operational plan. They
consider the costs of their planned equipment management activities and decide
what financial resources are required. The budget is the key financial planning tool
of the HTM Team.

Section 5 describes budgeting in greater detail.

Tip

•

Throughout this Guide financial transactions are described in ‘money units’ (MU)
rather than in any one particular currency.

Step 3: Accounting

Accounting provides managers, decision-makers, donors, and creditors with financial
statements that reflect the financial results of the HTM Team’s work. The team can
then use this information to gauge whether their resources have been administered
efficiently and productively. It is therefore a very important management tool. One key
aim of every accounting system is to provide financial data for planning and decision­making. Another is to provide a record of expenditure, in order to ensure propriety.

Section 6 shows you how to set up an accounting system.

Step 4: Financial Monitoring

By monitoring progress, HTM Managers at all levels of the HTMS, can make
constructive adjustments for the future. The accounting system, together with the
operational budget, enables them to monitor and control the work of their team and
to decide whether their financial resources are being well spent.

Section 7 demonstrates how to analyze the variances (differences) revealed by
comparing actual and budgeted results. It also introduces ratios for measuring
managerial and economic performance.

3.1 Financial management cycle

31

Step 5: Financial Reporting

Financial reports provide an invaluable insight into the operational performance of
HTM Teams.

Section 8 explains the key financial statements that HTM Teams need to produce,
and how to read them.

Step 6: Decision-making and Taking Action

HTM Teams may prepare sensible operational plans and budgets, keep detailed
accounts, and carry out monitoring and reporting. However, none of these activities
will be effective unless the teams have the power and ability to make decisions and
take action.

Section 9 provides an overview of how to make sound financial decisions and take action.

Tip

•

Use the financial fitness text in Annex 3 to test the financial fitness of your HTM Team.

3.2 PLANNING AND REVIEW PROCESSES IN
THIS GUIDE

Managing your activities involves a cycle of actions. You need to monitor your
performance, and set yourself goals so that you can improve. Then you monitor your
progress, revise your goals, and review your progress again. This continuous cycle of
planning and review is shown in Figure 7.

The planning and review activities are interlinked, but it is necessary to start the
discussion at some point in the cycle. In this Guide:

◆ the planning process (setting goals) is covered first

◆ followed by the review process (monitoring progress).

3.2 Planning and review processes in this guide

32

Country Experience

HTM Teams of faith organizations in western and eastern Africa have successfully implemented

financial management systems as illustrated by the financial management cycle.

3.2 Planning and review processes in this guide

33

Figure 7: Planning and Review Cycle

The financial management cycle (Section 3.1) contains two planning and review cycles:

◆ First of all, the financial management cycle contains a smaller planning and review

cycle, specifically covering the operations which the HTM Teams carry out for
customers. The operational goals and plans are made in Steps 1 and 2 (Sections
4 and 5), while financial monitoring takes place in Step 4 (Section 7).

◆ However, the overall financial management cycle is, itself, an example of a larger

planning and review cycle. All the financial management activities, including
budgeting, accounting, and reporting, are established and carried out in Steps 1 to 5
(Sections 4 to 8). Progress is then reviewed in Step 6 (Section 9), and action
plans are made to improve the next year’s financial management activities.

The planning process and the plans themselves should be clear and straightforward,
to assist participation and produce goals that can be understood and used by all staff.
Staff who are involved in setting goals and preparing plans are more likely to be
committed to carrying them out. Therefore, the planning process should involve
representatives of all different types of staff in the:

◆ HTM Team

◆ HTM Working Group

◆ Finance Office

◆ Health Management Team.

At the end of the year, it is essential to review and carefully analyze the results
achieved on all goals, before starting to develop action plans for the following year.
This step is the most important: to review results on a regular basis with the people

who are doing the work.

action

Set/Revise

Goals

Performance/Progress

feedback

Monitor

Section 3 summary

34

BOX 5: Summary of Procedures in Section 3 on Financial Management

The main outcome of the planning and review process is that you are able to
evaluate your performance. This is important for ensuring the quality of your work
(quality assurance), which is an essential component of quality management.

Aims of Quality Management

◆ client satisfaction

◆ cost efficiency

◆ compliance to laws

We recommend that quality management is introduced into the health management
systems of all the decentralized levels of the health service. This will create a frame of
mind for all staff that is favourable to the challenges connected with the many new
reforms and management tasks they face (such as those described in this Guide).
Important elements of quality management are:

◆ a management team approach

◆ supervision and evaluation

◆ participative leadership

◆ methods for encouraging staff

◆ individual responsibility and initiative

◆ control measures such as performance measurements and impact analysis

◆ community participation.

Box 5 contains a summary of the issues covered in this Section.

HTM Managers,

HTM Teams,

HTM Working

Groups, and

Health

Management

Teams at all

levels of the

health service

◆ ensure that financial management is an integral part of healthcare

technology management

◆ develop their financial management skills so that they can manage the finances

for HTM activities effectively

◆ undertake financial decision-making by following the sequence of activities

within the financial management cycle (Figure 6), and the procedures set out in

this Guide

◆ ensure they understand the difference between the operational plan and the

overall action plan for HTM Teams

◆ carry out cycles of planning and review with the people doing the work, in order

to manage their activities and improve performance

◆ try to introduce quality management into their decentralized level of the health

service, in order to help staff face the new challenges of financial management

and cost recovery.

Financial Management

4 How to set operational targets and plans

35

4. HOW TO SET OPERATIONAL TARGETS
AND PLANS

Why is This Important?

Every HTM Team needs to set goals for the future, in order to make informed
planning decisions. Goals can be set for all HTM activities, and the other
Guides in this Series describe goals for many different aspects of HTM.

This Section looks at the targets (annual goals) that the HTM Teams set for their
operations (work carried out for customers). An operational plan can show how
planned HTM activities over the coming year will lead to the agreed operational
targets being achieved.

This will serve as a guideline and reference for HTM Teams and will contribute
to well-informed and prompt decision-making.

There are three types of goals:

◆ Targets (annual actions that you can do with existing resources).

◆ Recommendations to others (actions that require external or additional inputs).

◆ Longer-term objectives (actions that require more time).

Section 9.2 discusses these goals in detail for action planning purposes, as well as
ways of using indicators to measure progress.

In this Section, we only look at the targets (annual goals) required for the operations
of the HTM Teams, and the work required to accomplish them. This is achieved
through discussing:

◆ operational targets (Section 4.1)

◆ the purpose of an operational plan (Section 4.2)

◆ choosing planned activities to meet operational targets (Section 4.3)

◆ improving your operational planning (Section 4.4).

Tip

•

Setting operational targets/plans and budgeting (Section 5) are, in fact, linked in a
cycle. You cannot usually establish a plan by itself; you need to think about the
financial implications. In government facilities, plans are based on the funds
available. Thus, there is a compromise between what one would like to do and what
one can afford to do.

4.1 OPERATIONAL TARGETS

Operational targets set out the annual goals you hope to achieve using existing
resources. Good targets follow the ‘SMART’ target-setting process:

Specific state what should be done and who will do it

Measurable easy to measure, or easy to decide that the target has been achieved

or if progress is being made

Achievable possible to carry out with existing staff, equipment and money

Relevant cover a priority problem or improvement

Time-bound state when the activity should be completed by.

Operational targets for HTM Teams only refer to the engineering activities
(operations) carried out for customers. They may concentrate on financial targets,
such as strategies that generate income (cover costs) for the HTM Team if that is
allowed. Goals for the other activities in the financial management cycle are covered
in Section 9.

4.1 Operational targets

36

B

Health service provider A Health service provider

A

possible technical support

technical

support

A

A

B

B

Examples of operational targets for an HTM Team might be:

Target 1: Reduce the financial contribution from international donors to 20,000

money units (MU).

Target 2: Introduce consultancy services to all health facilities for planned

preventive maintenance.

Target 3: Extend repair services to two new health facilities.

Target 4: Conduct training courses at all health facilities for the planned

preventive maintenance of autoclaves.

4.2 PURPOSE OF AN OPERATIONAL PLAN

Having set your targets, you then develop an operational plan containing activities
that ensure you achieve those targets. In order to make the operational plan a useful
tool, you should consider the following points:

◆ Your operational plan should be compiled jointly by staff from the HTM Team,

Health Management Team, and HTM Working Group at your level of the
health service.

◆ It should fit into the overall plan of operations for the HTM Service as a whole,

and be suitable for your level within that service.

◆ It should encourage openness, participation, and shared responsibilities among all

staff working within the HTM Service.

◆ The operational plan should illustrate how equipment management forms a part of

the overall plan for the health service at your health facility/health authority level.

◆ It should reflect the needs of your customers (health facilities, health authorities,

etc), but be appropriate to the skills and resources you have available.

◆ The document should inform and stimulate all staff working within the HTM system.

◆ It should provide the starting point for monitoring the operations of the HTM

Team, their evaluation, performance review, and other forms of assessment.

The operational plan is drawn up annually, and will be reviewed under the process of
annual action planning (setting and monitoring goals, covered in Section 9). This
will determine whether or not it needs to be changed.

4.2 Purpose of an operational plan

37

4.3 Choosing planned activities to meet operational targets

38

4.3 CHOOSING PLANNED ACTIVITIES TO MEET
OPERATIONAL TARGETS

It is important that you choose suitable activities for your operational plan. These
must ensure that you meet your operational targets, must be appropriate and
realistic for the workload, skills, and motivation of your HTM Team, and must also
be actions that you have the authority to undertake. This will vary depending on your
country, health service provider, and level.

Using the examples of operational targets from Section 4.1, here are some possible
planned activities which would achieve those targets:

For target 1: Reduce the financial contribution from international donors to

20,000 money units (MU).

Planned activities:

◆ Increase commission on sales of spare parts

and equipment from 10% to 20%, resulting
in extra income of MU 5,000.

◆ Increase operational income from maintenance

and repairs by MU 6,000, from consultancy by
MU 6,000, and from training by MU 3,000

For target 2: Introduce consultancy services to all health facilities for planned

preventive maintenance.

Planned activities:

◆ The engineer will provide 200 chargeable hours of

consultancy services per year.

◆ Each technician will provide 75 chargeable hours of

consultancy services per year.

For target 3: Extend repair services to two new health facilities.

Planned activities: ◆ Raise the productivity level by 5% from

55% to 60% for two technicians and the
engineer. Thus the productivity gain per
person will lead to 92 chargeable hours
per year for repair services.

4.4 Improving your operational planning

39

For target 4: Conduct training courses at all health facilities for the planned

preventive maintenance of autoclaves.

Planned activities: ◆ Increase the number of training courses

from four to six courses per year.

◆ One new trainer to be selected and trained

by the engineer.

You will need to monitor these targets and activities to see if progress is being made
or whether they have been achieved. Section 7 discusses financial monitoring tools
that you can use, and Section 9 looks at the use of indicators for measuring progress.

4.4 IMPROVING YOUR OPERATIONAL PLANNING

Good operational planning takes practise. There are several issues to consider if you
wish to improve your ability to set operational targets and make operational plans. Box 6
provides a checklist that HTM Teams can use to improve their operational planning.

BOX 6: A Checklist for Improving your Operational Planning

When making plans for the HTM Team:

◆ Did you consider any relevant policies, regulations, and national laws that provide a framework within

which you should operate, or which could affect your plans (Section 2)?

◆ Did you review and learn from past experience before making a new plan?

◆ Did you consider the goals of your health service provider before setting your targets?

◆ Did you clearly define your operational targets?

◆ Did you propose planned operational activities, expected results, and desired impacts that are in line with

your operational targets?

◆ Is your operational plan suited to the needs of your customers (health facilities, health authorities, etc)?

◆ Is your operational plan suitable for your level within the organizational structure of the HTM Service

(in other words, is it suited to your place within the decision-making process, the division of labour, shared
responsibilities, etc)?

◆ Is your operational plan suited to the level of financing available?

◆ Did you agree on tools and indicators for financial monitoring and performance assessment

(Sections 7 and 9)?

Tip

•

For more advice on how to analyze problems, decide on solutions, and plan actions
see Section 9.1.

Once you have successfully defined your operational plan, it will become a guideline
and reference for the HTM Team. It can then contribute to well-informed and
prompt decision-making about the work to be carried out for customers.

Section 4 summary

40

Box 7 contains a summary of the issues covered in this Section.

BOX 7: Summary of Procedures in Section 4 on Operational Planning

Health Service
Provider

HTM Managers

HTM Teams

Operational Planning

◆ plans and budgets for the HTM Service

◆ appoints a range of multi-disciplinary staff to form HTM Teams and HTM

Working Groups

◆ clearly defines the goals of the health service

◆ sets service-wide goals for healthcare technology management (HTM) activities

◆ plan which types of maintenance and repair work can be carried out by

the in-house teams and when to use external contracts (see Guide 5 on
maintenance management)

◆ plan which types of consultancy services (other HTM activities such as

installation, training, inventory-keeping, safety testing) can be carried out by the
in-house teams and when to use external contracts

◆ review past experiences and advise HTM Teams on their proposed targets and plans

◆ ensure the HTM Team’s operational plan fits into the plans for the HTM

Service as a whole

◆ prepare their operational targets and plan (as described in this Section)

◆ use tools and indicators for financial monitoring and performance assessment

(Sections 7 and 9)

◆ use strategies to improve their operational planning abilities (Box 6)

5 How to prepare an operational budget

41

5. HOW TO PREPARE AN OPERATIONAL
BUDGET

Why is This Important?

Budgets help HTM Managers, HTM Teams, and Health Management Teams to
achieve their targets.

Budgets also illustrate financial responsibilities to central bodies, donors, and
the owner (health service provider).

Budgeting creates a financial framework within which HTM Managers and
HTM Teams can work.

The operational budget refers to the planned engineering activities (operations)
that the HTM Team carries out for its customers. In other words it allocates funds
against the activities in the operational plan (Section 4). It is a recurrent budget –
all capital needs are contained in a separate capital budget.

The quality and usefulness of an operational budget for healthcare technology
management depends to a large degree upon the professional skills and experience
of the people who prepare it.

Some might argue that budgeting takes a lot of time, increases paperwork, and
contributes to inflexible working practices. However, experience shows that the
time and effort invested in preparing a realistic budget pays off during the course of
the year. An operational budget that is realistic and effective benefits the HTM
Service and your HTM Team in the following ways:

◆ The financial planning process takes place in a transparent and systematic way.

◆ Operational budgets provide the basis for monitoring and control.

◆ Budgets issue a challenge to HTM Managers and their teams to achieve

operational and professional goals.

◆ Budgets help to improve communications between all the people involved in

healthcare technology management, and this ensures better coordination of
activities in the HTM Service.

In this Section, we look at:

◆ the budgeting process (Section 5.1)

◆ how to create a standardized budget format (Section 5.2)

◆ how to define your operational income (Section 5.3)

◆ how to define your operational expenditure (Section 5.4)

◆ an example of an operational budget (Section 5.5)

◆ how to define your capital budget (Section 5.6).

5.1 BUDGETING PROCESS

Preparing a budget involves setting operational targets and planning your HTM
activities as accurately as possible. It is important to follow a series of stages in the
process of budgeting, as shown in Figure 8. This will ensure your budget figures are
consistent, realistic and accurate.

Figure 8: Stages in the Budgeting Process

5.1 Budgeting process

42

Stage 1

Stage 2

Stage 3

Reviewing operational results for the previous year

Working out income and expenditure headings

Estimating expenditure and income

Stage 4

Stage 5

Presenting first draft to others for feedback

Calculating surplus/deficit

Stage 6

Finalising operational budget

The following procedures are involved at each stage:

Stage 1: Start by reviewing the operational results of the previous year. The

lessons learned should be used for operating more effectively in the
future. Section 8 explains how to use financial statements as a tool for
equipment management.

Stage 2: Work out where your income is likely to come from, so that you can

create income headings. Use your operational plan to work out what
your expenditure headings should be. Section 5.2 describes a
standardized budget format for income and expenditure.

Stage 3: Estimating your operational income and expenditure for the coming

year can be difficult. However, if you have a realistic operational plan
showing the different types of HTM activities to be carried out by the
HTM Teams, you should be able to arrive at a reasonable estimate.
Sections 5.3 and 5.4 provide details and examples.

Stage 4: At this stage, the budget tells you whether you are likely to be able to

raise the money you need to implement your operational plan. If not,
you may need to re-think some of the operational targets and plans and
re-budget. Section 5.5 provides an example of an operational budget,
and Section 5.6 provides an example of a capital budget.

Stage 5: While the process of budgeting may be delegated to specific staff

members or committees, everyone involved in HTM should
understand how the budget is drawn up, why it is important, and how it
is monitored. After their feedback, it may be necessary to look again at
certain operational activities and to re-budget.

Stage 6: The operational budget should be finalized at least three months before

the start of the financial year it refers to. A finalized budget is not one
that is finished but one that is ready for use. Successful preparation of
the operational budget depends to a very large extent on how well you
have linked the budget to your operational targets and plans, and how
well the budgeting process is tailored to your organizational needs.

5.2 BUDGET FORMAT

To coordinate and integrate the budgets of the HTM Service within the health
system you should use a standard budget format. This will allow you to link it to
other budgets. It also prepares a common ground for discussions over budget content
and specific budget items.

5.2 Budget format

43

Box 8 provides a useful example of a standard budget format for your HTM Service,
and instructions on how to use it. It is called an operational budget because it is based
on only the engineering activities (operations) of the HTM Team. However, budgets
should always show the full picture (in other words, the total income and expenditure),
and, therefore, the budget format also contains entries for other ‘non-operational’
incomes and expenditures.

The budget format shown in Box 8 is only intended as a guide. You will need to
create your own, tailor-made budget format to suit your specific circumstances. A
good budget format should always be simple, consistent with the format of other
relevant HTM documents, logically organized and easy to understand, with very few
instructions required.

An example of an operational budget is provided in Section 5.5, with sample figures
and explanations taken from Sections 5.3 and 5.4.

Further details on how your health service provider can plan and budget for
equipment and a wide range of HTM activities (such as equipment procurement,
installation, operation, and rehabilitation) are contained within Guide 2 of this
Series, which deals with planning and budgeting.

5.2 Budget format

44

BOX 8: Example of a Standard Operational Budget Format for the HTM Service

Budget element Money unit (MU)

1. Operational Income

1.1 Training courses for equipment users

1.2 Maintenance, repairs, and calibration services to health facilities

1.3 Consultancy services for planned preventive maintenance, installation,

commissioning, safety, etc

1.4 Transport charges

1.5 Sales of spare parts and equipment

1.6 Commission on all sales of spare parts and equipment

1.7 Total Operational Income (sum of 1.1 to 1.6)

2. Operational Expenditure

2.1 Direct operational expenditure (related to jobs, thus variable costs):

2.1.1 Salaries and wages for technical staff (engineers, technicians, artisans, etc)

2.1.2 Staff training

2.1.3 Specific materials, supplies, spare parts per job (these costs are passed on to the

customer and charged to them later – see line entries 1.5 and 1.6)

2.1.4 Sub-total direct operational expenditure (sum of 2.1.1 to 2.1.3)

2.2 Indirect operational expenditure (overheads, thus fixed costs):

2.2.1 Salaries and wages for support staff (secretary, cleaner, driver, etc)

2.2.2 Travel and transportation

2.2.3 Office supplies

2.2.4 Rent of offices, workshop floor space

2.2.5 Vehicle insurance premiums

2.2.6 General materials and supplies

2.2.7 Depreciation of assets

2.2.8 Sub-total indirect operational expenditure (sum of 2.2.1 to 2.2.7)

2.3 Total Operational Expenditure = direct plus indirect expenditure
(sum of 2.1.4 and 2.2.8)

3. Operational Surplus or Deficit = income minus expenditure (1.7 - 2.3)

4. Other (Non-operational) Income

(such as donor contributions and government subsidies)

5. Other (Non-operational) Expenditure

(for example, interest paid, donations made)

6. Total Surplus or Deficit (= 3 + 4 - 5)

5.2 Budget format

45

5.3 OPERATIONAL INCOME

HTM services can be operated either as cost centres or as profit centres. The main
differences between these two approaches are shown in Figure 9.

Private HTM Teams and many NGO and faith teams operate as profit centres.
However, most government HTM Teams operate as cost centres (see Guide 2
on planning and budgeting).

Figure 9: The Difference Between Profit and Cost Centres

5.3 Operational income

46

Did you know?

◆ A cost centre is a unit within a health service provider organization that is only responsible for

keeping track of costs.

◆ A profit centre is a unit responsible for both generating income and for the expenditure incurred.

Experience in West Africa

In a West African country, the HTM Service of a faith organization has operated

successfully as a profit centre since 1996. Most of the faith organizations in the western

African region are in the process of reorganizing their HTM Services as profit centres.

In contrast, most government HTM Services in African countries operate as cost centres.

Objectives for financial
management

Objectives for HTM

Priorities

Staff involved

Budget method

Basis for budgeting

Budget lines/items

Criteria

To be a commercial organization,
generate income, undertake full
cost recovery, make a profit, use
some profit to improve and develop
the service offered if allowed.

Moving towards being a commercial
organization, undertake partial or no
cost recovery, use any surplus
subject to rules of the organization
(for example, in government, the
surplus returns to the treasury).

Clearly expressed Not stated

Priorities are set and resources
allocated

Not decided or expressed

Multi-disciplinary teams/groups Technician, manager, and

representative of central body

Operational targets

Operational plan

Financial resources needed to
achieve operational results

Financial resources available

Operational plan

Desirable operational results

Operational plan based on planned
activities

Last year's budget plus/minus a
certain percentage or sum

Few items, fixedRange of items, flexibility

Profit Centre Cost Centre

The income for an HTM Team can come from:

◆ government subsidy, donor grants, and health service provider support

◆ money the team generates itself.

As the latter type of income is new for many HTM Teams, we will now explain it in
more detail.

The basic concept of a profit centre is based on this simple formula:

operational income - operational expenditure = profit (surplus)

Of course, if you subtract total expenditure from total income you will also get an
indication of profit. But we are interested in the ‘operational’ profit or loss, as it is a
more important result of the operations of the HTM Team.

There are, therefore, three options for increasing profit, as follows:

◆ Decreasing the operational expenditure by being more efficient.

◆ Increasing the operational income by carrying out more tasks for customers.

◆ Increasing the operational income by charging more.

In order to start planning your budget, you will need to begin by estimating your
operational income. This is the income HTM Teams can generate from their own
engineering activities (operations). It is easier if you divide it up into types of
income, for example:

a. training courses

b. maintenance, repairs, calibration

c. consultancy services

d. transport charges

e. sale of spare parts, materials, and equipment

f. commission

g. other (non-operational).

This will not only make budgeting easier, it will also help you to communicate more
effectively with other staff and provide a good starting point for monitoring your
operational income.

Depending on your health service provider and country, your HTM Service may be
able to generate income by charging for services provided. Whether this income can
be used to improve the HTM Service further depends on the policies of the
responsible financing authority (treasury, central finance office, donor agency, etc).
Section 8 provides some advice on this.

Now we look at each type of income and show how to produce an accurate estimate
of your operational income, paying special attention to service charges and
transport charges.

5.3 Operational income

47

a. Income from Training Courses

This is fairly easy to estimate because all financial information should be readily
available. The income from training courses should cover all expenditures required for
running the training programme (such as equipment, materials, travel and subsistence,
fees, accommodation, room hire) plus a reasonable surplus. For more information on
planning training see Guide 2 on planning and budgeting, and for the resources
required to run training courses see Annex 4.

b. Income from Maintenance Services

The most effective way to calculate income from maintenance services is to look at
service charges per hour for technicians/engineers.

The advantages of this method are:

◆ it allows a comparison between internal and external maintenance services

◆ it is a good yardstick to determine effectiveness and efficiency of HTM Teams

◆ it provides a basis for pricing of services such as training, maintenance, repairs,

and consultancy.

5.3 Operational income

48

To calculate service charges per hour you need to know how many hours of time your
maintenance staff are available for work (known as chargeable hours), and what their
productivity levels are (how many of those hours are used for HTM activities). We
look at each of these interlinked issues in turn.

Productivity analysis of engineers and technicians

Often employees/workers do not like to discuss or calculate their productivity, but it is
an important tool if you are trying to calculate the service charge to set for your work.

The productivity level of an employee/worker can be calculated using the
following equation:

Productivity (%) = time worked x 100

time available

where:

◆ time worked equals only all the hours charged to work orders (for scheduled

maintenance, repairs, and other engineering activities) and not the hours spent on
tasks not linked to a work order

◆ time available equals total time paid, minus vacation, public holidays, and sick leave.

Thus if the total available hours for an employee/worker was 2,000 hours, and the
time worked was 1,000 then:

Productivity = 1,000 x 100 = 50%

2,000

As this productivity level relates only to time charged to work orders, it is a reflection of
the time spent directly on activities that could generate income. This figure provides
key information about the relationship between ‘productive’ time and time available.
When discussing productivity, it is usual to talk of ‘productive’ and ‘non-productive’
time. Although it may not sound like it, it is important to realize that non-productive
time is as valuable as productive time, and is different to unproductive time as follows:

◆ Productive time is time spent on engineering activities that produce an output

which can be charged to the customer, or reflects completed work orders
(sometimes known as direct labour)

◆ Non-productive time is time spent on administrative activities which, although

essential, do not produce an output that can be charged to customers, and are not
listed on work orders (sometimes known as indirect labour).

◆ Unproductive time is time that is wasted.

5.3 Operational income

49

5.3 Operational income

50

Box 9 provides some definitions and examples of productive and non-productive
tasks/time.

BOX 9: Example of Productive and Non-Productive Time

(Adapted from the American Hospital Association (AHA) and Bauld references – see Annex 6)

Productive time or direct labour Non-productive time or indirect labour

Tasks or services provided to a client

where the deliverable product is

information, advice, a serviced device,

or a patient service.

Chargeable:

These tasks or services can be

considered chargeable tasks, whether

or not an actual transfer of funds

occurs between departments

For example:

Attending to operator errors

Design services

Documentation of productive activities

Emergency call-outs

Equipment modification

Hazard reporting

In-service training

Inspection of incoming equipment

Installation and commissioning

Necessary travel time

Ordering spare parts, materials, consumables, etc

Planned preventive maintenance (PPM)

Performance checks

Pre-acquisition planning

Product evaluation

Repairs

Safety inspections

Service contract management

Site preparation

Technical consultation

Time that is paid, but not expected to result in

any work of benefit to clients, but is for necessary

administrative and overhead-type functions.

For example:

Administrative meetings

Break time

Budgeting

Calibration of test equipment

Committee meetings

Conventions/seminars

Documentation of non-productive activities

Employee activities

Keeping up with the field/reading journals

Maintenance of inventory

Maintenance of technical library

Meeting sales personnel

Public holidays

Record-keeping

Sick leave

Stock control

Supervision

Training of own team

Vacation

5.3 Operational income

51

Care must be taken when considering what is a reasonable level of productivity for
your circumstances.

Box 10 shows the American Hospital Association’s breakdown of productivity levels
for medical equipment management departments in hospitals in the United States.
We are not suggesting that the actual figures are valid anywhere else, but what is
interesting is their analysis of the difference between the figures, and their views on
why productivity may fall.

BOX 10: AHA’s Discussion of Productivity Levels in the United States of America

On the basis of historical data, the following breakdowns can be made for productivity levels:

Productivity levels of more than 85% = Questionable

75–85% = Excellent

60–74% = Acceptable

55–59% = Borderline

less than 55% = Unacceptable

Productivity of more than 85 per cent is questionable because it is difficult to achieve this without either

unpaid overtime, improper documentation of time worked, or an increasing level of recalls or repairs.

Experience has shown that a team that accounts for its work by individual job and sustains a real level of

productivity of more than 85% for three to six months is headed for a rash of recalls and complaints.

Productivity of less than 55 per cent is unacceptable (in the USA) because it indicates productive time

per person of less than 4.5 hours per day. This workload would be insufficient to justify a member of staff full

time unless the sources of outside service are a considerable distance away.

Lower-than-expected productivity generally indicates special problems requiring management attention.

These problems include:

◆ Lengthy periods spent waiting to gain access to equipment. This problem requires some discussion with

department heads to effect a mutually acceptable solution.

◆ Long periods of time spent tracking down equipment that has been relocated.

◆ Use of biomedical technicians to perform clerical functions that could easily be handled by a less

skilled individual.

◆ Use of inefficient test forms, requiring personnel to spend much more time than is necessary filling

out overly-detailed service reports.

◆ Inefficient maintenance practices, such as taking equipment back to the workshop for maintenance that

could be done in the user department, or routinely returning to the workshop between work orders.

There is no doubt that an efficient, well-managed internal maintenance programme can provide most health

facilities with some cost savings and other additional benefits. The challenge is in maintaining the consistently

high level of management oversight needed to keep the programme running in an optimum fashion.

5.3 Operational income

52

When you consider productivity levels for your HTM Service, you need to look at
typical productivity levels in your country, and for similar types of work. Then you
can determine a productivity level that is suited to your conditions and is attainable.
Productivity levels will be affected by:

◆ culture

◆ climate

◆ work practices

◆ constraints such as shortages of spare parts, distances to travel, and lack of tools

◆ levels of morale

◆ motivation

◆ management

etc.

Chargeable hours

Once you know your productivity level, you can calculate your chargeable hours.
These are the hours that staff are available for work that can be charged to customers.

Box 11 contains an example of how to calculate the chargeable hours for an engineer
or technician, and shows how this may change depending on their productivity levels.

Tip

•

Deficits are usually shown in brackets in financial statements.

Service charges per hour

Once you know your chargeable hours, you can calculate the service charge per hour
to set.

Box 12 provides an example of how to calculate your service charges per hour so that
you can make a profit.

Experience from East Africa

In one East African country, an HTM Team calculated their productivity level at 40 per

cent and were very disappointed with this result. But then they looked at productivity

levels in the private engineering sector of their country and found those to be only 50 per

cent. So, in the context of national constraints, their existing productivity was not too bad.

They also had a reasonable goal to aim for to improve their situation.

BOX 11: How to Determine Chargeable Hours for an HTM Team Member

Calculation with example figures Hours per year

paid hours per engineer/technician
(40 hours per week x 52 weeks) 2,080

minus paid public holidays

(8 hours x 12 days) (96)

minus paid vacation

(8 hours x 15 days) (120)

minus paid absence/leave

(8 hours x 4 days) (32)

Available hours 100% 1,832

Chargeable hours if your productivity level is 60% 1,100

Chargeable hours if your productivity level is 55% 1,007

BOX 12: How to Calculate the Service Charges for an HTM Team

Steps with sample figures Money unit (MU)

1. Determine your chargeable hours (Box 11 shows how to calculate this figure,

and provides the example figures assuming a productivity level of 60%)

One engineer chargeable hours 1,100

Two technicians chargeable hours 2,200

Total chargeable hours 3,300

2. Determine your operational expenditure (Section 5.4 explains the terms direct

and indirect operational expenditure, and Section 5.5 provides the figures from its example of an
operational budget)

direct operational expenditure 74,300

indirect operational expenditure 29,000

Total operational expenditure 103,300

minus costs passed on to the customer for materials, supplies, spare parts (42,300)

Net operational expenditure (expenditure net of the cost for materials) 61,000

3. Determine your service charges per hour

Service charges per hour are calculated using the following equation:

net operational expenditure =61,000

=

18.48 MU/hour

chargeable hours 3,300

4. Determine the service charge you will set for clients

A service charge of 18.48 MU/hour on average for each maintainer is required to cover net
operational expenditure.

Thus, in order to generate a profit of 10% the average hourly rate for each HTM Team member should be
set at 20.30 MU/hour.

5.3 Operational income

53

5.3 Operational income

54

c. Income from Consultancy Services

As well as maintenance and training, HTM Teams can offer consultancy services to
health facilities for activities, such as:

◆ advice on procurement

◆ site preparation

◆ installation and commissioning

◆ safety testing

◆ calibration of equipment

◆ purchase and stock control of equipment

spare parts, consumables, and accessories

◆ establishing and regularly updating an equipment inventory.

The income from these services is also calculated by looking at the service charges per
hour for technicians/engineers, as discussed for maintenance services in point b, above.

d. Income from Transport Charges

Transport charges must be estimated very carefully in order to recover expenditures
for vehicles through income from transport charges. Box 13 shows how to calculate
transport charges.

Experience from East Africa

In one East African country, the HTM Team of a faith organization had to raise service

charges (per technician/hour) by 360 per cent in order to compensate for the decrease

in donor contributions. By selling consultancy services to health facilities of other health

service providers, the HTM Team have been able to reduce the service charges for

health facilities of faith organizations.

5.3 Operational income

55

BOX 13: How to Estimate Transport Charges for a Four-Wheel Drive Vehicle per km

for a Period of Five Years

Calculation with sample figures

Money unit

(MU)

Purchase price including import tax 50,000

Insurance (500 MU x 5 years) 2,500

Fuel (20,000 km x 5 years x 10 litres/100km x 1.00 MU) 10,000

Tyres (one set per year x 5 years x 1,200 MU) 6,000

Repairs and maintenance (2,000 MU per year x 5 years) 10,000

Road licence and government tax (200 MU x 5 years) 1,000

Contingencies 4,000

Total vehicle costs for five years covering 100,000km overall 83,500

minus estimated retail value after five years (18,000)

Net vehicle costs for five years covering 100,000km overall 65,500

Thus, transport charges per km 0.655

e. Income from Sales of Spare Parts, Materials and Equipment

You can estimate your expected income from the sale of spare parts, materials, and
equipment by analyzing recent history, and cooperating with health service providers
in the planning of their equipment stock (see Guide 2 on planning and budgeting).

This income from sales balances out the expenditure you incurred purchasing spare
parts, materials, and equipment on behalf of your client (see costs passed on/charged to
customers under direct expenditure in the operational budget example in Section 5.5).

f. Income from Commission

It is usual to take a commission on sales (discussed in point e, above) to cover
the administrative cost of purchasing, storing, and issuing the item sold. This
commission will be a percentage (usually between 10% and 20%) of the sale value
and will depend on the organization, sector, and country.

g. Income from Other Sources

This item is for non-operational income such as government subsidies, donor grants,
earned interest, etc.

5.4 Operational expenditure

56

5.4 OPERATIONAL EXPENDITURE

It tends to be the case that operational income is often overestimated, while
operational expenditure is underestimated. Operational expenditure is the money
spent by the HTM Teams while undertaking their engineering activities (operations).

In order to make accurate forecasts of expenditure, it is advisable to differentiate
between:
a. direct operational expenditure

b. indirect operational expenditure

c. other (non-operational) expenditure.

a. Direct Operational Expenditure

This type of expenditure can be related to a specific technical service job provided by
technical staff. It is sometimes also referred to as variable costs or shared costs because
the expenditure varies with the quantity or level of services provided to customers.

There are three typical direct operational expenditures. The first two:

◆ salaries and additional benefits and allowances of technical staff (engineers,

technicians, artisans, etc), and

◆ training and meetings of technical staff,

have to be included in the total of direct operational expenditure used for calculating
service charges per hour (Section 5.3).

The third:

◆ specific materials, spare parts, and supplies for each job

are passed on to the customer and are charged to them later, thus they are not
included in the total direct costs used for calculating the service charge per hour
(Section 5.3).

5.4 Operational expenditure

57

b. Indirect Operational Expenditure

This type of expenditure is often referred to as overheads or fixed costs, and does
not fluctuate with the quantity or level of services provided to customers.

Typical indirect operational expenditures are:

◆ salaries, wages, and benefits for support staff (accountant, secretary, office

clerks, etc)

◆ travel and transportation

◆ communication

◆ office supplies

◆ rent for offices, workshops

◆ vehicle insurance premiums

◆ depreciation of assets (Section 8.2)

◆ general materials and supplies.

Only those expenditures of relevance to your HTM Team should be included in the
total of indirect operational expenditure used for calculating the service charge per
hour (Section 5.3).

c. Other Expenditure

This item is for non-operational expenditure such as interest paid on loans,
donations made, etc.

Section 5.5 provides an illustration of these operational expenditures.

5.5 EXAMPLE OF AN OPERATIONAL BUDGET

Box 14 provides an example of an operational budget with sample figures. As shown
in Section 5.2, your operational budget is made up of operational income and
operational expenditure (see Box 8). Thus, Box 14 uses the operational income
elements discussed in Section 5.3, and the operational expenditure elements
discussed in Section 5.4. The example is based on the sample operational targets
and planned activities in Section 4, and the sample figures are based on the
examples in Section 5.3.

5.5 Example of an operational budget

58

BOX 14: Example of an Operational Budget

Budget element Money unit (MU)

Operational Income

Training courses for equipment users (6 training courses per year x 1,000 MU) 6,000

Maintenance and repairs

Chargeable hours per technician/year x MU/hour (1,025 hours x 2 technicians x 20.30 MU/hour)
Chargeable hours per engineer/year x MU/hour (900 hours x 1 engineer x 20.30 MU/hour) 59,885

Consultancy

For advisory services provided to health facilities:
Chargeable hours per technician/year x MU/hour (75 hours x 2 technicians x 20.30 MU/hour)
Chargeable hours per engineer/year x MU/hour (200 hours x 1 engineer x 20.30 MU/hour) 7,105

Transport charges

(11,750km x 0.65 MU/km) 7,637

Sales of spare parts, materials and equipment 42,300

Commission 20% commission on all sales of spare parts and equipment

(20% of estimated total sales amounting to MU 42,300) 8,460

Total Operational Income 131,387

Operational Expenditure

Direct operational expenditure:

Salaries and wages for technical staff 28,000

Training costs 4,000

Materials, supplies, spare parts

(these pass-through costs are charged to customers later) 42,300

Sub-total direct operational expenditure 74,300

Indirect operational expenditure:

Salaries and wages for support staff 8,000

Travel and transportation 1,000

Office supplies 1,000

Communication 3,000

Rent of offices and workshops 2,000

Vehicle insurance premiums ,500

Depreciation 10,000

Materials and supplies 3,500

Sub-total indirect operational expenditure 29,000

Total Operational Expenditure 103,300

Operational Surplus or Deficit

(total operational income – total operational expenditure) 28,087

Other (Non-operational) Income

(donor contributions, government subsidies, etc.) 20,000

Other (Non-operational) Expenditure

(interest paid, donations made, etc.) (400)

TOTAL Surplus or Deficit

(operational surplus or deficit + non-operational income – non-operational expenditure) 47,687

5.6 Capital budget

59

5.6 CAPITAL BUDGET

Planned expenditure on capital items such as buildings, equipment, and vehicles
used by the HTM Team should not be included in the operational budget but are set
out in a separate capital budget. Box 15 contains an example of a capital budget.

BOX 15: Example of a Capital Budget

Budget element with sample figures Money unit (MU)

Purchase costs

Office equipment 2,000

Workshop equipment 8,000

Four-wheel drive vehicle 50,000

Total purchase costs 60,000

Financing

Loan from bank 34,000

Loan from donor 26,000

Total funding required 60,000

Though capital budgets and operational budgets are expressed separately, in practice
the two are interlinked. For example, if you buy a new vehicle (under your capital
budget), this will bring the benefits of increased transport capacity and efficiency,
and this should be reflected in your operational income. However, it will also bring
with it certain costs, such as depreciation and expenditure on petrol, insurance and
maintenance. This should be reflected in your operational expenditure.

Section 5 summary

60

For more information on capital budgeting for HTM activities as a whole, see Guide 2
on planning and budgeting.

Box 16 contains a summary of the issues covered in this Section.

BOX 16: Summary of Procedures in Section 5 on Budgeting

Health Service

Provider

Health Management

Teams

HTM Managers

Budgeting

◆ plans and budgets for the HTM Service in order to provide it with

sufficient resources

◆ reviews draft capital budget prepared by the HTM Team

◆ agree on a budget format for the HTM Service and link it to other budgets in the

healthcare system

◆ make recommendations on capital budgets

◆ discuss drafts of budgets and finalize the operational budget

◆ determine the productivity level and service charges per hour

◆ set limits for expenditure items

◆ set targets for different types of income

◆ gather information and estimate figures for operational income and expenditure,

and summarize them in an agreed budget format

◆ prepare capital budget proposals

6 How to set up an activity based accounting system

61

6. HOW TO SET UP AN ACTIVITY BASED
ACCOUNTING SYSTEM

Why is This Important?

The main objective of every accounting system is to provide financial data for
planning, monitoring, reporting and decision-making.

Accounting provides HTM Teams, HTM Managers, Health Management
Teams, health service providers, donors and creditors with financial
statements that reflect the true results of HTM activities. It is therefore a very
important management tool.

Managers in the HTMS need to understand enough about
accounting procedures to ensure their financial management
is based on accurate and relevant accounting information.

A good knowledge of accounting will enable you to monitor
whether money is being well spent, and can help you to

achieve your operational targets.

In this Section, we look at:

◆ HTM and accounting activities (Section 6.1)

◆ the accounting cycle (Section 6.2)

◆ the accounting system (Section 6.3)

◆ a chart of accounts (Section 6.4).

6.1 HTM AND ACCOUNTING ACTIVITIES

To be useful to the HTM Service, an accounting system must be tailor-made. This
way, you can ensure that it will generate the reliable information you need to make
effective decisions. HTM Managers should work with a chartered accountant to
develop such a system, to ensure healthcare technology management activities and
accounting activities are well matched. Figure 10 illustrates how this could be done.

Did you know?

Accounting is an essential part of

financial management.

6.2 Accounting cycle

62

Figure 10: Matching HTM and Accounting Activities

6.2 ACCOUNTING CYCLE

Once you have matched HTM and accounting activities, you will need to agree on
an accounting cycle to produce financial statements. Figure 11 shows the four basic
stages of the accounting cycle. The duration of the accounting cycle depends on your
financial reporting periods, for example, half-yearly and annual financial statements.

Figure 11: The Accounting Cycle

HTM Activities

Day to day operations

Daily activity reports and

work request/job forms (see Guide 5)

Activity register/equipment files

(see Guide 5)

Activity status reports

Accounting Activities

Day to day financial transactions

Official receipts and payments

Systematic and chronological recording of

transactions in books of accounts

Financial reports

Stages Remarks

Inflow and outflow of funds

Documentation of financial
transactions

Accounting system

Preparation of financial
statement

This refers to cash and non-cash
financial transactions

This refers to accounting forms to
be used for financial transactions

This refers to the books of accounts
to be maintained and kept

This refers to the type and format of
financial reports (Section 8)

6.3 ACCOUNTING SYSTEM

The purpose of the accounting system is to record, classify, and summarize financial
transactions in date order (chronologically) and in accordance with the chart of
accounts (Section 6.4). A series of steps are involved in recording transactions in books
of account, in a systematic and chronological way. These steps are shown in Figure 12.

Figure 12: The Seven Steps of the Accounting System

The activities involved in these steps are:

Step 1: Preparation

Primary evidence or source documents of transactions are gathered together.

Step 2: Journalization

Transactions are entered in a journal according to the date they occurred, as evidenced
by the corresponding vouchers or official receipts. These should be recorded in date
order (chronologically). At the end of the month, totals and balances are recorded. A
journal is an account book that is used to record amounts transferred from one ledger
account to another ledger account, together with explanations for the transfers.

63

6.3 Accounting system

1

2

3

4

5

6

Preparing the trial balance

Preparing the financial statements

Preparation

Journalization

Posting to the ledger

Adjusting the books

7

Closing the books

6.3 Accounting system

64

Step 3: Posting to the Ledger

A ledger is an account book used for recording financial transactions with a separate
page for each account. Totals from the journals are transferred (or ‘posted’) to the
proper account in the ledger. Each entry in the ledger is given a reference, showing
the source page in the journal from which it came. A similar reference entry is made
in the journal, showing the destination page in the ledger to which the transfer has
been made.

Step 4: Preparing the Trial Balance

The trial balance is the list of all the accounts in the ledger, together with the correct
balance for each account. It will show that the debit entries in the ledger will balance
with the credit entries.

Step 5: Adjusting the Books

Additional journal entries might have to be made to correct the balances of some of
the accounts. This may be necessary in order to present the results of operations and
the financial condition of the business in a more fair and more accurate manner.

Step 6: Preparing the Financial Statements

From the adjusted trial balance, first the profit and loss account is prepared, then the
balance sheet. Section 8 describes how to read these financial statements.

Step 7: Closing the Books

The accounts are closed at the end of the financial year, and any unspent monies are
moved as follows:

◆ Where donor-funded projects show a fund balance, this is moved to the

appropriate ‘fund account’ (according to the donor’s regulations).

◆ Where businesses show an operational profit, this is moved to ‘retained earnings’.

◆ In the case of government funds, any unspent balance is returned to the treasury.

The balance sheet will reflect this situation and show the state of the finances at the
start of the next financial year, and a new income and expenditure account is started.

6.4 Chart of accounts

65

6.4 CHART OF ACCOUNTS

The record of your expenditures (your accounts) should be arranged in a logical order
and listed in a Chart of Accounts: this will simplify the bookkeeping and preparation
of financial statements.

There are two systems of bookkeeping:

◆ Single entry bookkeeping – this shows inflow and outflow of cash and the cash

balance. Each transaction is recorded only once.

◆ Double entry bookkeeping – each transaction is recorded twice. One entry

shows where the money came from and another entry shows where it went. For
example, where salaries are paid in cash, this affects two accounts in the chart of
accounts. The money comes from the cash account and goes to the salaries
account.

In some countries, the law provides a chart of accounts that every business must use.
In addition, donor-funded HTM Services may be required to follow a chart of
accounts set up by the donors. However, local laws take precedence and it is usually
possible to adapt the legal chart of accounts to the requirements of both donors and
the HTM Service.

An example of a chart of accounts for recording the financial transactions of an HTM
Service is given in Annex 5.

Chartered accountants, auditors, and management consultants in your country can
help you to organize a chart of accounts tailored to your specific requirements.

Country Experience

In many West and East African countries, HTM Services which have changed their

operating approach from cost to profit centre have created a tailor-made chart of

accounts as part of their new financial management system.

Box 17 contains a summary of the issues covered in this Section.

Section 6 summary

66

BOX 17: Summary of Procedures in Section 6 on Accounting

Health Service

Provider

Health Management

Teams

HTM Managers

Accounting

◆ provides the charts of accounts used by the health facilities for reference

◆ provides accounting principles, methods, and policies for the HTM Team.

◆ make sure the chart of accounts for HTM activities fits into the chart of

accounts for the health service provider (Ministry of Health, diocese, private

business, etc).

◆ help accountants to match HTM activities with the account headings in the

chart of accounts

◆ agree with accountants on the duration of an accounting cycle leading to financial

reports.

7 How to use financial monitoring tools

67

7. HOW TO USE FINANCIAL
MONITORING TOOLS

Why is This Important?

Through monitoring the operational budget regularly, managers are able to
learn from experience, and to anticipate and estimate future events, thus
avoiding a negative result later on.

Financial monitoring tools, such as variance analysis and performance ratios,
should form an integral part of healthcare technology management. These
provide reliable management information, which will enable the HTM Manager
and the HTM Team to take corrective and preventive action, where necessary.

As discussed in Section 3.2, the planning and review cycle for managing activities
requires you to monitor progress against your operational plan and its associated
operational budget. This Section looks at suitable financial monitoring tools for
doing this.

There will always be differences between your budgeted and actual operational
figures. To take corrective action for the future, you need to monitor, understand and
analyze all differences. Differences between actual operational results and the
operational budget are known as variances.

In this Section, we look at two financial monitoring tools:

◆ monitoring variances (Section 7.1)

◆ performance ratios (Section 7.2).

7.1 MONITORING VARIANCES

To carry out effective monitoring, you should establish a regular
monitoring procedure and prioritize those variances that will be
most useful to you. In this Section, we examine how the budget,
together with actual figures taken from accounting books, can be
used to prepare a variance report.

Variance

the difference found when a

comparison is made between

actual results and budgeted

plans. The variance may be

favourable or adverse to the

interests of the organization.

7.1 Monitoring variances

68

Variances are either positive or negative:

Positive variances are favourable variances. For example, actual income is

higher than budgeted income, or actual expenditure is
lower than budgeted expenditure.

Negative variances are unfavourable variances. For example, actual income is

lower than budgeted income, or actual expenditure is
higher than budgeted expenditure. Negative variances are
usually shown in brackets within financial statements.

Box 18 provides an example of a variance report for an operational budget. It uses
budget figures taken from the example in Section 5.5, and sample actual figures.

Box 19 provides an example of a variance report for a capital budget. It uses budget
figures taken from the example in Section 5.6, and sample actual figures.

To ensure that variance reports are meaningful, they should include analysis of the
problems, and suggestions for avoiding them in the future.

First of all, the HTM Manager and his/her team should assess the implications of
each variance by asking the following questions:

◆ Is it a positive or a negative variance?

◆ Does it affect just one budget item, or a combination of budget items?

◆ Is it within or outside the normal range?

◆ Is the variance due to a new cause or a permanent problem?

◆ Does the variance affect only your HTM Team, or does it affect the HTM Service

as a whole, and/or your customers?

BOX 19: Example of a Variance Report for a Capital Budget

Budget Actual Variance Variance Remarks

Money units (MU) (MU) (MU) %

Purchase Costs

Office equipment 2,000 2,380 (2,380) (19.0) unfavourable

Workshop equipment 8,000 6,416 1,584 19.8 favourable

4WD vehicle 50,000 46,450 3,550 7.1 favourable

Total Purchase Costs 60,000 55,246 4,754 7.9 favourable

Financing

Loan from bank 34,000 30,000 4,000 11.8 favourable

Loan from donor 26,000 26,000 0 0 -

Total Funds Available 60,000 56,000 4,000 6.7 favourable

7.1 Monitoring variances

69

BOX 18: Example of a Variance Report for an Operational Budget

Budget Actual Variance Variance Remarks

Money units (MU) (MU) (MU) %

Operational Income

Training 6,000 4,237 (1,763) (29.4) unfavourable

Maintenance and repairs 59,885 50,303 (9,582) (16.0) unfavourable

Consultancy 7,105 6,252 (853) (12.0) unfavourable

Transport charges 7,637 9,045 1,408 18.4 favourable

Sales of spare parts, materials and

equipment (passed on/charged to

the customer) 42,300 34,840 (7,460) (17.6) unfavourable

Commission 8,460 6,968 (1,492) (17.6) unfavourable

Total Operational Income 131,387 111,645 (19,742) (14.8) unfavourable

Operational Expenditure

Direct operational expenditure:

Salaries and wages (technical) 28,000 30,800 (2,800) (10.0) unfavourable

Staff training 4,000 4,000 0 0 -

Materials, supplies and spare parts

(passed on/charged to the customer) 42,300 34,840 7,460 17.6 favourable

Sub-total direct operational expenditure 74,300 69,640 4,660 6.3 favourable

Indirect operational expenditure:

Salaries and wages (support) 8,000 8,800 (800) (10.0) unfavourable

Travel and transportation 3,000 3,486 (486) (48.6) unfavourable

Office supplies 1,000 1,214 (214) (21.4) unfavourable

Communication 1,000 2,412 (1,412) (141.2) unfavourable

Rent of offices and workshops 2,000 28,000 (800) (20.0) unfavourable

Vehicle insurance premiums 500 586 (86) (17.2) unfavourable

Materials and supplies 3,500 2,917 583 16.7 favourable

Depreciation 10,000 11,049 (1,049) (10.2) unfavourable

Sub-total indirect operational expenditure 29,000 33,264 (4,264) (14.7) unfavourable

Total Operational Expenditure 103,300 102,904 396 0.4 indirect +

direct =

favourable

Operational Surplus or Deficit 28,087 8,741 19,346 (68.9) total income

minus total

expenditure =

unfavourable

Other (Non-operational) Income

such as donor grants 20,000 20,000 0 0 -

Other (Non-operational)
Expenditure such as interest paid (400) (400) 0 0 -

Total Surplus or Deficit 47,687 28,341 (19,346) (40.02) unfavourable

7.2 Performance ratios

70

Secondly, recommend actions to decision-makers by asking the following questions:

◆ Why is there a variance?

◆ What should we do about it?

◆ Who needs to take action?

◆ When do they need to act?

◆ How should they act?

Variance reports like this should be prepared on a regular basis (for example,
quarterly, half-yearly or yearly). Monitoring your operational and capital budgets both
regularly and systematically will help you to identify trends and take timely
corrective and preventive action where necessary. In this way, you can avoid financial
constraints and negative operational results.

7.2 PERFORMANCE RATIOS

Performance ratios can be a useful management tool. In order to
use ratios effectively, you will need to ensure that they are
designed to:

◆ fit your system of healthcare technology management

◆ make comparisons year on year

◆ make comparisons with other HTM Teams

◆ reveal trends in the development of direct and indirect operational expenditure

◆ identify trends in the development of different types of income

◆ measure productivity gains/losses.

As well as looking at performance ratios based on accounting information, you should
also take into account any non-monetary benefits, such as any increase in the
availability and reliability of equipment.

Your ratios should be both specific and appropriate to your HTM Service, though you
may be able to benefit from using common business ratios for operating performance.

All HTM Services use money as a raw material. Depending on your type of health
service provider, you may have to pay for this raw material in the form of interest to the
bank, dividends to the owner/shareholder, or repayments on loans. HTM Services
carrying out partial cost recovery may have to earn sufficient money to make these
payments, while those operating as profit centres definitely have to. Payment can only
come from the operating surplus. To generate an operating surplus, the assets
and owners’/shareholders’ fund have to be used efficiently.

Performance ratio

a short and precise

indicator of operational

performance which shows

important inter-relationships.

71

There are two key ratios to measure the performance of an HTM Service operating
as a profit centre (Section 5.3):

◆ Return on total assets (ROTA) measures the operating efficiency of HTM

Services, and is expressed as a percentage.

◆ Return on equity (ROE) measures the return on the owners’/shareholders’ fund

(equity) invested in an HTM Service, and is expressed as a percentage.

Box 20 uses sample figures to provide an example of the way in which these key
ratios are used.

BOX 20: Example of Using Key Ratios to Measure Performance

1. Let’s assume the following situation for an HTM Service:

Operational surplus = MU 8,741

Total assets = MU 136,741

Owners’ fund = MU 50,000

Interest payable = MU 2,000

Tax payable = MU 0

2. Then calculate one performance ratio, the return on total assets, as follows:

ROTA = Operational surplus x 100% = 8,741 x 100% = 6.39%

Total assets 136,741

3. Then calculate the second performance ratio, the return on equity, as follows:

ROE = Operational result minus interest payable to lenders and tax payable to tax authorities x 100%

Equity (owners’/shareholders’ fund)

= 8,741 - 2,000 x 100% = 13.48%

50,000

4. Conclusion:

ROE of 13.48% is a very high rate of return for the owners’/shareholders’ investment.

ROTA of 6.39% is a good return for total assets, indicating an efficient use of assets.

These are very good results. This will enable the HTM Service to grow and to attract new funds for the

expansion of HTM activities.

Another important indicator for your operational performance is gains or losses in
productivity. Box 21 provides an example of how to monitor productivity and the
impact of your findings. It uses planned figures from the example in Section 5.3,
and sample actual figures.

7.2 Performance ratios

7.2 Performance ratios

72

BOX 21: Example of Monitoring Productivity to Measure Performance

1. Let’s assume the following situation for an HTM Service, and calculate the variances:

Productivity previous year: 55%

This year: Planned Actual Variance

Productivity 60% 50.6% (9.4%)

Chargeable hours 3,300 2,785 (515 hours)

Operational income 66,990 56,555 (10,435 MU)

Direct and indirect operational expenditure 103,300 102,904 396 MU

Costs passed on to customers 42,300 34,840 (7,460 MU)

2. Conclusion:

There is a loss in productivity of 4.4% as compared to the previous year’s productivity of 55%.

Actual productivity is 9.4% below the set productivity target of 60%.

A total of 515 available working hours were not turned into operational income, resulting in lost operational
income of MU 10,435.

3. Impact:

To see the effect of the loss in productivity, we compare the planned service charges per hour (which we
hoped would cover operational expenditure) with the actual service costs incurred.

Based on planning assumptions (Section 5.3), the following service charge per hour was used:

Service charge per hour = Net operational expenditure

Chargeable hours

= Planned direct + indirect expenditure minus costs passed on to customers

Planned chargeable hours

= 103,300 - 42,300 = 61,000 = 18.48 MU/hour

3,300 3,300

However, the actual service costs per hour incurred were:

Actual service costs per hour = Actual direct + indirect expenditure minus costs passed on to customers

Actual chargeable hours

= 102,904 - 34,840 = 68,064 = 24.44 MU/hour

2,785 2,785

Thus, service charges of 18.48 for the HTM Team were greatly underestimated.

The lower then expected productivity and higher net operational expenditure (expenditure net of the costs
for materials) are the main reasons for this disappointing result.

The service charge used should have been at least 24.44 MU/hour.

Various financial ratios can be useful for analyzing the operational income and
expenditure for the current year. You may compare these ratios with those for
previous years to establish a trend in the development of income and expenditure.
Box 22 provides some examples of useful financial ratios.

BOX 22: Examples of Useful Financial Ratios for Analyzing Income and Expenditure

1. Indirect operational expenditure in comparison with total operational expenditure

Indirect operational expenditure x 100%

Total operational expenditure

Example of results (using sample figures only):

2000 2001 2002 2003

21.6% 27.7% 31.3% 38.1%

Conclusion: indirect expenditure (also known as overheads or general expenditure) is rising. This is a
negative trend. The management didn’t set a limit for indirect operational expenditure as compared to total
operational expenditure.

2. Service charges in comparison with total operational income

Total of service charges for maintenance and consultancy x 100%

Total operational income

Example of results (using sample figures only):

2000 2001 2002 2003

87.6% 84.7% 79.2% 62.0%

Conclusion: this decreasing percentage implies an increase in income without a proportionate increase in
service charges. This means that you are making more efficient use of your resources and/or taking on more
jobs. Thus, this trend indicates a successful introduction of new services to customers, providing a greater
proportion of your income.

3. Operational surplus (profit) in comparison with total operational income

Operational surplus (profit) x 100%

Total operational income

Example of results (using sample figures only):

2000 2001 2002 2003

19.2% 18.4% 16.8% 7.6%

Conclusion: the diminishing operational surplus (profit) is an alarming trend. It means your operational
expenditure must be increasing more than your operational income.

Performance ratios and indicators are used for monitoring and as tools for control.
You should select and design the ones that you feel best support your effort to
maintain steady, ongoing control of the work of the HTM Service.

73

7.2 Performance ratios

Country Experience

In East and West African countries, those HTM Services of faith organizations that have

adopted a profit centre approach have successfully used variances to monitor budgets,

and performance ratios to improve their level of efficiency.

Section 7 summary

74

Box 23 contains a summary of the issues covered in this Section.

BOX 23: Summary of Procedures in Section 7 on Financial Monitoring

Health Service

Provider

Health Management

Teams

HTM Managers

Financial Monitoring

◆ introduces key performance ratios for HTM Teams.

◆ develop further performance ratios tailor-made to the requirements of the HTM

Service and HTM Teams

◆ analyze and explain variances and make recommendations to decision-makers.

◆ monitor progress with the operational plan and budget by:

- preparing variance reports

- calculating performance ratios.

8. HOW TO USE FINANCIAL REPORTS

Why is This Important?

There are strict national legal requirements set by government agencies, and
guidelines set by national and international accounting associations, for the
drawing up of financial statements.

Financial statements are useful, as they provide you with a clear indication of
your financial situation. Typical financial statements include balance sheets
and profit and loss accounts.

Additional internal financial reports, such as variance reports and performance
reports, are also necessary to make well-informed financial decisions (Section 7).

In order to use financial statements for decision-making, you will need to understand
how to read two important financial ‘tools’. Thus in this Section, we look at:

◆ the profit and loss account, which shows where you have been in financial terms

(Section 8.1)

◆ the balance sheet, which shows where you are now in financial terms (Section 8.2).

The profit and loss account has to be prepared first, since its result (profit or loss) is
recorded in the balance sheet.

8.1 PROFIT AND LOSS ACCOUNT

The profit and loss account is also sometimes referred to as an income and
expenditure account or as an operating results statement. The profit and loss
account monitors income and expenditure over a period of time. The time intervals
can be a week, a month, an accounting period, or a year. The profit and loss account
shows the financial result of your activities over that period.

The profit and loss account can be divided into three components:

◆ income

◆ expenditure

◆ profit or loss.

Box 24 shows the basic layout for a profit and loss account. Deficits are usually
shown in brackets in financial statements.

8 How to use financial reports

75

8.1 Profit and loss account

76

BOX 24: Basic Layout for a Profit and Loss Account

Operational income 100,000 Operational expenditure 80,000

Loss - Profit 20,000

The profit and loss account shows the result of your operations, and illustrates how
successful you were at managing your resources – in other words, if you succeeded in
making a profit, or made a loss.

Box 25 provides an example of a profit and loss account, using (actual) figures from
the example in Section 7 (see Box 18).

BOX 25: Example of a Profit and Loss Account (at the End of a Period of Time)

Operational Income (MU) Operational Expenditure (MU)

Training 4,237 Direct operational expenditure:

Maintenance and repairs 50,303 Salaries and wages (technical) 30,800

Consultancy 6,252 Staff training 4,000

Sales of spare parts, materials and Materials, supplies and parts

equipment (charged to the customer) 34,840 (passed on to the customer) 34,840

Commission 6,968 Sub-total 69,640

Transport charges 9,045 Indirect operational expenditure:

Salaries and wages (support) 8,800

Travel and transportation 3,486

Office supplies 1,214

Communication 2,412

Rent of offices and workshop floor space 2,800

Vehicle insurance premiums ,586

Materials and supplies 2,917

Depreciation 11,049

Sub-total 33,264

Total Operational Income 111,645 Total Operational Expenditure 102,904

Loss - Operational profit

(income – expenditure) 8,741

As explained in Section 5.3, you can work out your profit by subtracting your
expenditure from your income. There are a number of ways of doing this:

77

8.1 Profit and loss account

1. If you take your operational income (the money you generated from your HTM
activities charged to customers) and subtract only your direct operational
expenditure (the money spent undertaking those HTM activities for customers),
you obtain what is known as your gross profit. This is used as an important
measurement of your operational performance, and can be compared to figures
from previous periods.

In the example in Box 25, the gross profit would be 111,645 - 69,640 = 42,005 MU

2. If you take your operational income (the money you generated from your HTM
activities charged to customers) and subtract both your direct operational
expenditure (the money spent undertaking those HTM activities) and your
indirect operational expenditure (overhead costs), you obtain what is known as
your operational profit. This can be compared to figures from previous periods.

In the example in Box 25, the operational profit = 8,741 MU

3. The operational profit can also be used to calculate your profit margin
(expressed as a percentage) and this can be compared to those of other providers
of HTM Services. It is calculated using the following formula:

Profit margin = Operational profit x 100%

Operational income

In the example in Box 25, the profit margin would be 8,741 = 7.8%

111,645

4. You will also get an indication of profit if you subtract your total expenditure
from your total income. This would include your non-operational expenditure
(such as interest paid) and non-operational income (such as government
subsidies) – see Sections 5.3 and 5.4. But it is usual to concentrate on the
‘operational’ profit or loss instead, as this is a more important result of the
operations of the HTM Team.

Tip

•

Any donor funds which have not been utilized during the financial reporting period
should be treated as liabilities (something you owe) and not seen as surplus or profit
– see the example of a balance sheet in Box 28 (Section 8.2).

Whether profit can be used to improve the HTM Service further, depends on the
policies and decisions of the owners of the assets. Retained profits (surplus from the
previous year) may be used to acquire new assets or to expand the capacities of the
HTM Service, depending on the rules of your health service provider. For example,
this is the case if the health service provider is a private organization, or a
government or faith organization that has started to undertake cost recovery.

8.2 BALANCE SHEET

The balance sheet is like a snapshot of the HTM business – it shows the financial
picture of an enterprise at a particular moment in time (a date). You can prepare a
balance sheet whenever you like, in order to monitor the financial status of your
enterprise. It can be useful to prepare a balance sheet at fixed intervals (such as
monthly, quarterly, or annually) for this purpose.

Before you can complete the balance sheet, you need to know the depreciated value
of your fixed assets (buildings, vehicles, tools, equipment etc). We will look at this
calculation first, then at the preparation of the balance sheet.

Calculating the Depreciated Value of Assets

Depreciation of assets (such as vehicles or office and workshop equipment) allows
for a reduction in the value of an asset to take into account its wear and tear. In the
case of private organizations, these calculations are done for tax purposes as there is a
benefit in showing the reduced value of assets. Ideally, organizations should set aside
the amount by which an asset is reduced in value, into a fund that will finance the
replacement of the asset (see Guide 2 on planning and budgeting).

Box 26 provides an example of the calculations required for depreciating assets.
Depreciation periods vary depending on the expected lifespan of the equipment.
The example uses a depreciation period of five years, thus there would be an annual
depreciation of 20% of the value of the equipment. The table shows how to calculate
depreciation for the first and the second years. You continue to make the calculations
in this way in each subsequent year until the item is written off (condemned at the
end of its life).

8.2 Balance sheet

78

Country Experience

In many East and West African countries, the HTM Services of faith organizations

successfully manage to generate an operational surplus (profit). In most cases, owners

and donors allow this to be retained in order to improve the HTMS.

8.2 Balance sheet

79

BOX 26: Example of a Depreciation Schedule

Preparing the Balance Sheet

The balance sheet compares your current resources (your assets) with what you owe
(your liabilities).

Assets can be split into two types: fixed assets and current assets.

Fixed assets show how much the owner (provider) of an HTM Service has

invested in buildings, vehicles, tools and equipment. Only the
depreciated value of the assets (a reduced amount that
reflects wear and tear every year) is used in the balance sheet.

Depreciation

(20% of

purchase cost)

(MU)

Value after

depreciation
(purchase cost
– depreciation)

(MU)

Depreciation

(20% of value

after first

year’s

depreciation)

(MU)

Value after
depreciation
(value at end

of first year

– depreciation)

(MU)

Subsequent

years

Continue
these
calculations
in the same
way each
year

First yearItem Purchase

cost (MU)

Second year

Vehicle 46,450 9,290 37,160 7,432 29,728

Office
equipment 2,380 476 1,904 380 1,524

Workshop
equipment 6,416 1,283 5,133 1,026 4,107

Total 55,246 11,049 44,197 8,838 35,359

Assets Liabilities

Fixed assets (depreciated value) 60,000 Owners’ fund 100,000

Retained profits 20,000

Current assets 80,000 Current and long-term liabilities 20,000

Total assets 140,000 Total liabilities and funds 140,000

Current assets are cash, the contents of bank accounts, monies owed by

customers for unpaid services already provided (debtors),
as well as non-cash items that can be converted into cash
within a period of 12 months (such as stocks of materials).

Liabilities can be sub-divided into current and long-term liabilities, as well as funds
invested in the business.

Current liabilities are the amounts owed by the HTM Service for goods or

services that have been received but not yet paid for,
overdraft costs on bank accounts, and the balance of any
donor funds received but not yet used.

Long-term liabilities are amounts owed by the HTM Service for more than 12

months, such as loans from banks or donors.

Invested funds If you subtract your liabilities from your assets you are left

with an amount which is made up of:

◆ the initial capital investment in the enterprise by the

owners (the owners’ fund), and

◆ any previous profits retained in the enterprise (the

retained profit).

For accounting purposes, these are also classed as liabilities
in the balance sheet.

Box 27 shows the basic layout of a balance sheet with four components. The balance
sheet will always balance. The result from the profit and loss account (Section 8.1)
is recorded in the balance sheet. If it was a profit it appears under ‘retained profits’;
if it is a loss it appears as a reduction in the ‘owners’ fund’.

BOX 27: Basic Layout of a Balance Sheet

8.2 Balance sheet

80

8.2 Balance sheet

81

Your use of such a balance sheet will vary depending on your type of health
service provider:

◆ This type of balance sheet is used in the private and non-governmental sectors,

and will be used by HTM Teams run as profit centres.

◆ Government facilities (run as cost centres) do not have owners’ funds. Any

retained profit would be called surplus from the previous year, and is usually
returned to the treasury. Instead, government facilities balance their budgets
(see Guide 2 on planning and budgeting), by identifying their likely income and
trying not to let their expenditure exceed it. They don’t normally know the exact
value of all their fixed assets, but they do have an idea of their liabilities.
Governments don’t normally use depreciation in their financial system. Instead,
they should budget to replace their fixed assets (see Guide 2). Governments
don’t have to submit accounts for tax purposes either.

◆ The facilities of faith organizations and government facilities with a degree of

autonomy will fall somewhere in between and should be moving from the
balancing budgets situation towards this full type of balance sheet.

Box 28 provides an example of a balance sheet, based on (actual) figures from the
example in Section 7 (see Box 19).

BOX 28: Example of a Balance Sheet

Fixed assets Money units Owners’ fund (MU)

(depreciated values – see Box 27) (MU)

Vehicle 37,160 Issued shares 50,000

Office equipment 1,904 Retained profits 8,741

Workshop equipment 5,133

Sub-total fixed assets 44,197 Sub-total owners' fund 58,741

Current assets (MU) Liabilities (MU)

Bank 48,304 Loan from bank 30,000

Cash ,961 Loan from donor 26,000

Materials/supplies 41,479 Donor fund balance 20,000

Accounts receivable 1,800 Accounts payable 2,000

Sub-total current assets 92,544 Sub-total liabilities 78,000

Total assets 136,741 Total liabilities and funds 136,741

Box 29 contains a summary of the issues covered in this Section.

Section 8 summary

82

BOX 29: Summary of Procedures in Section 8 on Financial Reporting

HTM Managers

Health Management

Teams

Health Service

Provider

Financial Reporting

◆ discuss the profit and loss account and the balance sheet with accountants

and auditors

◆ analyze financial statements and prepare conclusions and recommendations to

central bodies for decision-making

◆ prepare internal financial reports such as variance and performance reports

(Section 7)

◆ studies financial reports and recommendations from the HTM Teams and

gives feedback

9 How to make financial decisions and take action

83

9. HOW TO MAKE FINANCIAL DECISIONS
AND TAKE ACTION

Why is This Important?

No matter how well you prepare your operational plan and budget, or keep
your accounts and monitor and report results, without the power and ability to
make decisions and take action you will be unable to manage the finances of
your HTM Service effectively.

You need to review your financial management activities so that you can
analyze the results, make decisions, and plan your actions for the following
year. Such evaluation helps you to ensure the quality of your work.

This last step in the financial management cycle (Section 3.1) involves:

◆ analyzing financial data and making financial decisions (Section 9.1)

◆ taking action for the following year (Section 9.2)

◆ monitoring progress with financial management activities (Section 9.3).

As discussed in Section 3.2, all staff involved in the financial management of HTM
activities should be involved in this planning and review process.

9.1 FINANCIAL ANALYSIS AND DECISION-MAKING

The key to making sound financial decisions is to carefully analyze your financial
data and financial management tools. Such analysis enables you to discover:

◆ where you have been successful

◆ where you have failed to achieve your aims

◆ what problems are constraining you

◆ what strategies have improved your performance.

Thus, the first step is to analyze the following:

◆ Variance reports and performance indicators and ratios (Sections 7.1 and 7.2).

◆ Financial results – profit and loss (Section 8.1).

◆ Financial statements – balance sheet (Section 8.2).

◆ The appropriateness of the operational targets set (Section 4.1).

9.1 Financial analysis and decision-making

84

The second step is to identify any problems and find solutions. Make sure that
everyone involved participates in this process as it will help them to learn and will
provide better solutions.

It is very important to define your problem clearly before trying to take decisions on
its resolution. Box 30 provides some strategies for doing this, using the example
from Section 7.1.

Different people are responsible for taking decisions on different aspects of the
financial system. Box 31 shows the suggested division of responsibilities.

BOX 31: Different Responsibilities for Financial Decision-Making and Taking Action

Health Service Provider makes financial decisions and takes action on:

◆ capital investments

◆ financial targets

◆ targets for operational income

◆ limits for expenditure items

HTM Teams make financial decisions and take action on:

◆ operational budget

◆ budget variances

◆ performance indicators

◆ service charges per hour

◆ chargeable hours

◆ productivity level

◆ plan of action

HTM Managers make financial decisions and take action on:

◆ all daily financial transactions within the framework of the approved

operational budget

◆ contracts with sub-contractors

Other strategies for improving your ability to make financial decisions are:

◆ to develop the financial skills of your staff to implement the activities in this

Guide (see all Sections, examples, and Annex 3)

◆ to make changes at your own pace and avoid obligations in the financial

management cycle which cannot be fulfilled (Section 3).

Once you have made a sound financial decision based on analysis of financial data
and a good problem-solving technique, it is time to:

◆ make sure everyone involved is informed about the decision and agrees with it

(see end-of-Section summary boxes), and

◆ prepare an action plan which everyone involved is committed to (Section 9.2).

Problem definition process

1. Recognition

Discuss and document
individual views, proven facts,
and relevant symptoms, until
everyone involved accepts that
there is a problem

2. Label

Clearly document both sides of
the conflict you want to resolve

3. Analysis

Find and agree on the single
most fundamental source of the
problem

Solution decision-making
process

4. Options

List all alternative strategies
that have the slightest chance
of resolving the problem and
correcting its root cause

5. Evaluation

Choose the best solution on
your list by objectively
evaluating the strategies
available

6. Action plan

Organize systematically the
tasks, timing, staff, and
resources required to
implement the decision in
the real world

Example

Analysis of financial
data highlights a problem

Some believe that the
overheads are too high,
others that the income is
too low

On studying the actual
incomes received, many
are found to have negative
variances, but one shows
the greatest money loss.

Example

Look at all the issues that
impact on maintenance
and repair services

Some of the solutions are
difficult for you to
implement, such as
getting clients to pay their
bills. But one solution
offers benefits in a
number of ways.

See Section 9.2 for the
action planning process

Result

Agreement that an
issue needs to be
resolved

An agreed
statement of the
problem

Unanimous
identification of
the root cause
which needs
correcting

Result

A complete list of
possible solutions

A firm joint
decision on the
chosen solution

A complete step­by-step plan to
translate the
decision into
reality

Example

The enterprise is making a loss

The negative variance on
income is much greater than
that on overheads, thus the
problem is too little income.

Much less money was raised
from maintenance and repair
services than expected.

Example

◆ Staff become more productive.

◆ Service charges are raised.

◆ Numbers of clients increase.

◆ Clients ask for more

maintenance support.

◆ Clients pay their bills.

◆ Staff with improved technical

skills can offer more support.

Improve technical skills of staff
so that additional types of
support can be offered to
clients, thus increasing the
take up of maintenance and
repair services and improving
client satisfaction.

◆ Send senior staff on various

short courses.

◆ Provide on-the-job training for

junior staff.

◆ Renew contact with old clients

and approach new clients.

◆ Demonstrate the improved

maintenance and repair
services available.

◆ Broaden the range of

maintenance and repair
services offered by the team.

85

9.1 Financial analysis and decision-making

BOX 30: Outline of the Problem-Solving/Decision-Making Process

9.2 Action planning

86

9.2 ACTION PLANNING

Purpose

It is necessary for each HTM Team to have goals and plans which set out their
priority activities. The goals and plans (such as those from Section 9.1) must be
clearly defined so that they guide the work of:

◆ the HTM Team

◆ the HTM Service

◆ the health facility

◆ the health service as a whole.

Good management benefits from an Annual Action Plan that has clear, specific goals
for the important activities of the HTM Team. Thus, an action planning process
should be undertaken once a year, as standard practice. This is an opportunity for
the teams to agree the range of activities (initiatives and changes) they want to
implement, because they believe the activities will improve:

◆ their working environment

◆ their performance

◆ the service they provide.

Other Guides in this Series cover the action plans for other aspects of HTM
activities, and the service-wide annual action planning process.

Here, the goals and plans will enable HTM Teams and managers to monitor their
own performance as well as their progress with the financial management cycle.

Setting Goals

Three types of goals are required – targets, recommendations, and longer­term objectives:

i. Targets

Targets guide the work of the HTM Team and HTM Working Group during the
following year. They help to improve services and make sure that the most
important work gets done. Targets are one of the best tools for judging progress
and work performance. We suggest that each department/group should have
between five and 10 targets, all of which should follow the ‘SMART’ target­setting process described in Section 4.1.

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9.2 Action planning

The annual action planning process should focus on improvements and changes
that staff can carry out themselves, and that can be achieved with existing staff,
equipment, facilities and other resources.

It will be clearer if targets are written down using the following headings, which
can be used when the final plans are produced:

Target By whom How to measure How to achieve Timetable

Actions agreed,
listed in order
of priority

ii. Recommendations

You will discover that some important problems cannot be overcome or
improvements achieved unless extra supplies, staff, or funds are provided, or unless
assistance is obtained from outside. In such cases, recommendations are required.
These should be:

Specifically addressed: to the person, official, department, organization, etc that

is able to carry out the recommendation.

Reasonable: there is no point in asking for the impossible, such as

10 times more staff.

Essential: there should be no easy way for the HTM Team to

achieve the same results on their own.

For example, there are boundaries and limitations to what the HTM Team can
achieve in the annual action planning process. The need for major investments in
equipment should be discussed through activities such as the equipment
development planning process (see Guide 2 on planning and budgeting). Similarly,
ongoing shortages of staff or money should be addressed to higher authorities who
can influence such issues.

iii. Longer-term objectives

You will also discover some problems that cannot be solved in one year. Maybe they
need large amounts of money, longer preparation, or plenty of time to achieve. Or
maybe it is simply not possible to do everything at once. In such cases, longer-term
objectives are required which will be carried forward to the next year, or for
implementation later on.

Names of persons
who will be
responsible

How progress will
be determined (see
indicators below)

Resources
required

Time-frame for
start and
completion

9.2 Action planning

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How to Measure the Goals

Each goal must be easily measured, so that you can see if it has been achieved or if
progress is being made:

◆ You need a way of determining if you are moving towards your goal – this is called

an indicator. There will always be several possible indicators for each goal, and
more than one way of measuring them.

◆ You need to know where you are starting from, in other words, what the situation

is now – this is called the baseline data. The data chosen must be relevant to
the indicator.

Box 32 provides an example of different ways of measuring a goal using indicators
and baseline data.

BOX 32: Example of How to Measure a Goal

Goal: Let’s improve our maintenance and repair skills

An indicator: Increase the number of on-the-job

maintenance training courses for
HTM Team members

One way of measuring this:

Calculation required:

Percentage of HTM staff who have received on-the-job maintenance training

= Number of HTM Team members received on-the-job maintenance training x 100 %

Total number of HTM Team members requiring training

Baseline data: Eight members of the HTM Team require on-the-job maintenance training, but in

January only two were found to have attended a course.
Therefore your baseline data is 25%.
Your aim is to improve this situation and increase this percentage.

Alternative way of measuring this:

Baseline data: In a study of the current situation you find that you only ran on-the-job maintenance

training courses once in the last year, and you plan to start running them every quarter.

Calculation required:

Percentage of on-the-job maintenance training courses implemented

= Number of on-the-job maintenance training courses carried out in a time period x 100 %

Number of training courses that should have been done in that time period

After 12 months you find that, in fact, you only managed to run three out of the four courses planned,
that is, 75% of your target.