COMMUNITY HEALTH STUDIES VOLUME VIII, NUMBER 2. 1984

THE DEVELOPMENT OF A PROGRAM CLASSIFICATION OF HEALTH SERVICES FOR THE

YEARS SOUTH AUSTRALIAN HEALTH COMMISSION - REFLECTIONS ON THE FIRST THREE

John Cooper and Craig Bennett

South Australian Health Commission*

Abstract Over the past three years, Program-

Performance Budgeting (PPB) has been promoted in South Australia as an alternative means of reporting on Government expenditures to the State Parliament. Very detailed financial, manpower and descriptive data has been compiled on programs and presented and debated in Parliament as an adjunct to the traditional line estimates of the State budget. Within this f ramework, the South Australian Health Commission has been required to develop a program classification of State Government- funded health services.’ In this paper,* the development of this classification is summarized, its usefulness assessed and its longer-term future discussed.

Introduction Budget allocations for Government agencies

are traditionally framed as a list of single line estimates covering items such as wages, salaries and equipment. There is, typically, no statement about what is intended to be achieved by the appropriations, nor concern about what was actually achieved by the expenditures made in the previous period. Appropriations for a given financial year are often determined by merely adjusting the previous year’s allocation to allow for inflation or some real growth.

Considerable effort has been expended in South Australia over the recent past in developing a system of Program-Performance Budgeting (PPB) as a possible means of overcoming some of the shortcomings of this approach. PPB, in the South Australian context, has been described as:

* Unless otherwise stated, the viewsand opinions expressed in this paper d o not necessarily reflect policies of the South Australian Health Commission.

COOPER & BENNETT 200

‘a plan which relates input resources (for example, money, manpower and plant) t o expected output results (service volumes, performance indicators or measures) using a classification scheme which groups similar endeavours.’3

High hopes for this approach were expressed by the Tonkin Liberal administration (September, 1979 - November, 1982). For example, in a speech to the Royal Australian Institute of Public Administration on 20th August, 1980, Premier Tonkin said:

‘...we see programmme and performance budgeting as dealing with both the need for Parliament to be better informed and the need for the public sector to be more effectively managed ... I t allows Ministers and Cabinet to allocate resources more effectively t o Government activities and it allows the efficiency of Government activity to be measured more effectively than can be done at present ... The Government is determined to proceed and reap the significant benefits which are to be achieved from the programme approach.’

From the Tonkin administration’s viewpoint, therefore, PPB would allow the results achieved by Government expenditure to be related to the resources committed. Its main requirements were for the Government agencies to define their objectives, list the functions they were performing in attempting to achieve these objectives and identify the financial and manpower resources that were involved. A similar approach was recommended by the recent Wilenski Review of N.S. W. Government Administration4 and has been ga in ing s t a t u r e a n d credence i n Commonwealth Treasury circles5 and amongst other State Governments.6

Yet this approach has had a n unhappy history since it was first developed as a defence application

COMMUNJTY HEALTH STUDIES

known as Planning Programming Budgeting Systems (PPBS) in the United States in the early sixties. An original aim of PPBS was to identify common missions or purposes served by a variety of different organisations, classically the common military missions of different elements within naval, air and land-based military forces. Later in the sixties, it evolved into an overall budgetary system, widely adopted by U.S. Government agencies. Its shortcomings in this area have, nevertheless, been well documented,’ with one critic even likening it to the ‘simultaneous equation of society in the sky’g.

In South Australia, PPB has not yet evolved into a complete budgeting system in which allocations can be made, and then expenditures reported, on a program b a s k 9 In addition, the current Bannon Labor administration has a much more restrained attitude towards PPB than its predecessor. In presenting his Government’s 1983- 84 Budget, for example, Premier Bannon said that:

’while undue emphasis has been given in the past to program-performance budgeting as the panacea for all management and financial problems, it can nevertheless be a n effective management aid, particularly in the area of resource management.’’O

What follows, therefore, is a description of the development of a classification schema designed to present information about State Government- funded services (and in particular health services) in a way that can easily be understood by Parliamentarians and provide a framework for priority-setting and other policy considerations.

The Government’s Framework To assist Government agencies and advise the

Government on the implementation of PPB in South Australia, a PPB Team, comprising seconded public servants, was set yp in the Treasury Department in late 1980. Consultants from a private firm, P.A. Australia, provided technical advice and assistance in co-ordinating the introduction of PPB in the various Government d e p a r t m e n t s a n d s t a t u t o r y authorities. A guidelines document was prepared jointly by P.A. Australia and the PPB Team and was tabled in Parliament by Premier Tonkin on 9th June, 1981.

The basic framework for program planning and analysis of State Government activities under PPB is the program structure. The program structure presents a hierarchical grouping of

COOPER & BENNETT 20 1

endeavours linked by common objectives, starting at the level of a broad policy area, and successively disaggregated down to the level of a specific activity. In South Australia, a six level hierarchy has been identified for the program structure. These six levels are: policy areas; program sectors; programs; sub-programs; components and activities. I I

Three types of support services have also been identified. These are program support services (to be costed to the programs), agency-wide support services (intra-agency support services costed to individual programs) and government-wide support services (inter-agency support services costed to the agencies).

A total of thirteen policy areas have been developed, namely: health; education; welfare services; sport, recreation and culture; health, education, welfare, sport, recreation and culture not elsewhere covered (n.e.c.); protection of persons, their rights and property; community amenities; assistance to local government n.e.c.; natural resources; economic development; information and other servics to the public n.e.c.; government management and administration; government-wide support services.

The last two policy areas d o not involve the direct provision of services to the public but, in general, support the other eleven policy areas.

As developed in South Australia over the past three years, PPB has been promoted as a means of making budgetary processes generate analytical material in order to assist the internal allocation of resources and assess the results of such allocations. At a Parliamentary level, the Tonkin Government set up two Budget Estimates Committees, in which Ministers could be questioned and required to justify their proposed levels of expenditure. These Budget Estimates Committees remain under the Bannon Government, as does the requirement to present annual budget estimates in both a program and line form.

The South Australian Health Commission’s Response

The South Australian Health Commission (SAHC) was required to develop a classification of S ta te Government-funded health services consistent with these overall criteria. Considerable emphasis was also given to devising a schema that would be useful for health policy priority-setting and planning purposes, as well as consistent with the development of activity, cost and performance measures.I2 Such a move towards an output-based financial system had also been recommended by

COMMUNITY HEALTH STUDIES

the 1980 Report of the Commission of Inquiry into the Efficiency and Administration of Hospitals (the Jamison Report).”

A number of program structures developed in America were considered.14 Classifications developed by the Federal Department of Health, Education and Welfare (1980) and the Californian Department of Health and Welfare (1979-80) were analysed as examples of schemas constructed from organizational entities and from legislative or f u n d i n g p r o g r a m s . T h e c o m p r e h e n s i v e classification of all health and welfare services contained in the second edition of the United Way of America Services Identification System

(UWASIS 11, 1976) was also analysed as a way of identifying similar services provided by different organisations and under various funding arrangements. 15

However, it was decided early on that if it was to meet its principal objectives, the classification would have to be uncoupled entirely from organizational requirements. Such requirements are dictated mainly by inputs rather than by the purposes or outputs of activities. Organisations tend to be built around the aggregation of like resources and skills, as well as being influenced by institutional inertia and historical accidents as to the legislative base, timing of the introduction of

TABLE I

Programs of Care

Department of Health and Social Security

Primary Care General Medical Services General Dental Services General Ophthalmic Services Pharmaceutical Services Health Centres Prevention Family Planning

General and Acute Hospital and Maternity Services Acute Inpatient and Outpatient Ambulances Miscellaneous Hospital Obstetric Inpatient and Outpatient Midwives

Services Mainly for Elderly and Physically Handicapped Geriatric Inpatient and Outpatient Non-Psychiatric Daypatient Home Nursing Chiropody Residential Care Home Help Meals Day Care Aids, Adaptations, Phones, et cetera Services for the Disabled

Services for the Mentally Handicapped Mental Handicap Inpatient and Outpatient Residential Care Day Care

Services for the Mentally Ill Mental Illness Inpatient and Outpatient Psychiatric Daypatient Residential Care Day Care Special Hospitals

Services Mainly for Children Clinics Health Visiting School Health Welfare Food Residential Care Boarding Out Day Nurseries Central Grants and Youth Treatment Centres

Other Services Social Work Additional Social Services Training Other Local Authority Services Miscellaneous Centrally-Financed Services

Source: Department of Health and Social Security: Consultative Document: Priorities for Health and Personal Social Services in England London H.M.S.O., 1976, 82.

COOPER & BENNETT 202 COMMUNITY HEALTH STUDIES

services and the like. While the UWASIS I1 classification worked well in terms of identifying common types of service, regardless of organizational or funding arrangements, it did not seem particularly useful for priority-setting. It did not relate service systems to the purposes of those services or to the populations they were intended to serve, except a t the very highest level in terms of abstract goals, such as optimal health. This goal- oriented approach did not seem particularly helpful, since a choice between achieving optimal health and achieving optimal provision of basic material needs, two of the goals of UWASIS 11, did not seem very meaningful.16

In comparison, the Programs of Care developed in 1976 by the Department of Health and Social Security in the United Kingdom did seem useful for policy and priority-setting tasks.” As can be seen from Table I. this classification is deliberately intended to separately identify and highlight groups of services - for the mentally handicapped, for the mentally ill and mainly for children et cetera - already identified as having priority. The choice between the priority to be accorded t o the population of mentally handicapped people and the population of the elderly and physically handicapped can, for example, be seen to be useful.

It is also possible to bring information to bear on such a choice, in terms of the size and severity of

problems among these groups. The client or target population approach to classification also has advantages in terms of the ultimate development of measures of activity and performance, since service activity can be related to the characteristics of client populations within the schema. The target population approach also allows better for the development of indicators of need and effectiveness at the macro level.

A major problem with this kind of classification is, however, that of generic services. This problem arises with most services, but particularly with acute services. The British approach overcomes this partially by the use of the formulation ‘mainly for’, identifying only the principal general target group of a service and acknowledging that the precision with which national or regional agencies can expect to carry through their priorities is limited.

So, for example, if within the British schema priority was to be given to health visiting as a part of priority for services mainly for children and that also happened to benefit other family members, well and good. The British classification, however, entirely avoids the problem of the main generic services, particularly acute services, by simply identifying them as such rather than in realtion to any particular population group.

In South Australia, we were required to develop a classification to a much greater level of

TABLE I1

PROGRAM SECTOR PROGRAM

1. Co-ordination and Planning for Health Services 1 .

2. 3.

2. Delivery of Health Services 4. 5. 6.

7.

8. 9.

Health System Co-ordination Policy Development and Service Planning Financial Planning and Co-ordination

Services Mainly for the Aged and Physically Disabled Services Mainly for the Intellectually Disabled Services Mainly for Adults with Mental and Behavioural Disorders Services Mainly for Mothers, Children and Adolescents Services Mainly for Aboriginals Services Mainly for those with Physical Illnesses or Disabilities not elsewhere included

3. Preventive and Enabling Services 10. Services for the Protection, Promotion and Improvement of Public Health

1 1. Enabling Services.l8 ~~ ~~

Source: Health. S.A.H.C., September, 1983.

Program Estimates 1983-84: volume 11, Book VI, Detailed Program Information for Minister of

COOPER & BENNETT 203 COMMUNITY HEALTH STUDIES

detail than these British programs of care. In essence our approach was to base the higher levels of our program structure on the British schema. At the lower levels, we used a similar approach to UWASIS 11, by identifying common types of service, without regard to their organisation or location. We therefore sought to carry through one of the original aims of PPBS, the identification of the common ‘missions’ served by different organisations and different services.

The format adopted by the S.A. Health Commission for presentation of its 1983-84 Program Estimates was as follows:

In itself, this format represented a considerable simplication of the classification schema developed in 1981 and 1982 and used to present the S.A. Health Commission’s 1982-83 Program Estimates to Parliament in October, 1982. A total of nine program sectors and thirty one programs were used on that occasion, with the classification not even having been fully developed.19 The move towards a simpler schema followed a review of the information requirements of the 1982-83 format consequent on the change in Government in South Australia in November, 1982 and the development of a schema along similar lines by the New South Wales Department of Hea1th.m

Sub-programs, components and activities, in accordance with the Government’s overall definitions and criteria, have now been developed for all these eleven programs. Detailed financial, manpower and descriptive material below the sub- program level has not yet been required.

As far as possible, the program sector entitled ‘delivery of health services’ comprises programs that relate to services provided to broadly defined target groups, such as the intellectually disabled.21 These programs are then typically disaggregated into sub-programs on the basis of functional criteria such as age, dependency levels or the identification of problems. For example, the relevant sub-programs for the program ‘services mainly for the intellectually disabled‘ are ‘services mainly for adults’, ‘services mainly for school-age children’, ‘services mainly for pre-school children’ and ‘general services to all age groups’. Above the sub-program level, the service delivery schema is therefore user-oriented: it relates to the population groups served and reflects the programs of care developed by the Department of Health and Social Security in England. Below the sub-program level, however, the schema is supplier-oriented: it related to the types of

COOPER & BENNETT 204

services provided and reflects the UWASIS I1 approach developed in America. For example, the activities identified within the program ‘services mainly for the intellectually disabled’ are typically discrete service units provided in different settings.

The Applicability of the Schema The program classification developed by the

S.A. Health Commission over the past three years has proved useful for priority-setting, policy and planning purposes. Priorities have been expressed when explicit decisions about whether to increase, maintain or decrease budget allocations to the eleven programs (and the associated support services) have been made. Initiatives within, or cost savings from, these programs have then been specified.

S.A. Health Commission Gross Payments for 1982-83 are shown by program (Table 111) and line (Table IV) to highlight the parameters within which these overall priority decisions have been made. Relative allocations to the geographically- based Sectors of the S.A. Health Commission have also been important considerations in the setting of these overall priorities.22

The descriptive material that has had to be compiled on each of these eleven programs has been of invaluable assistance for planning purposes. For example, descriptions of the needs being addressed, the broad objectives being pursued, the delivery mechanisms being used to provide services, the relevant issues and trends as well as details of any achievements in the previous financial year and any initiatives in the current financial year have been required for each program. This has focussed attention on both gaps in service provision and deficiencies in demographic, activity and evaluative data.

Describing health care services ina way which‘ fdentifies common purposes and common types of services, irrespective of organisational or funding arrangements, has been a challenge. It has also been an educative process for those involved. Detailed information on services provided across organisational entities and funding programs has had to be collected, documented and understood. Most importantly, it has required a change in thinking and a change in attitude. Health care services have come to be thought of as being directed towards improving the health status of identifiable groups of people rather than as the ‘busy work’ of enormous and impersonal institutions. The framework that this approach provides for the longer-term development of more meaningful measures of activity and performance is of fundamental importance.

COMMUNITY HEALTH STUDIES

TABLE 111

South Australian Health Commission 1982-83 Cross Payments

By Program

PROGRAM SOOO’S %

I . Health System Co-ordination 2. Policy Development and Service Planning 3. Financial Planning and Co-ordination 4. Services Mainly for the Aged and

5. Services Mainly for the Intellectually

6. Services Mainly for Adults with Mental

7. Services Mainly for Mothers, Children

8. Services Mainly for Aboriginals 9. Services Mainly for those with Physical

Illnesses or Disabilities not elsewhere included 10. Services for the Protection, Promotion

and Improvement of Public Health I 1. Enabling Services Support Services24

Physically Disabled

Disabled

and Behavioural Disorders

and Adolescents

I ,20 I .5 1,262.9

597.9

66,246.7

23,959.2

34,9 16.0

87,872.8 2,128.0

278,016.82)

6,384.3 21.1 17.2 8,792.9

0.2 0.2 0. I

12.4

4.5

6.6

16.5 0.4

52.2

I .2 4.0 1.7

TOTAL 532,496.2 100.0

Source: Program 4: and 62.

Volume 11, Book V1, Detailed Program Information for Minister of Health: op cir. 9-12

TABLE IV

South Australian Health Commission 1982-83 Gross Payments

By Line

LINE SOOO’S %

I . 2. 3. 4. 5.

6. 7.

8. 9. 10.

Office of the Minister SAHC - Central Office Public Health Services Recognised Hospitals Mental Health and Intellectually

Nursing Homes Community Health Services (including Dental Health Services but excluding the Adelaide Dental Hospital) Aboriginal Health Services Grants to Health Agencies Special Benefit Schemes

Disabled Services

(Pensioner Denture and South Australian Suectacles Schemes)

286.9 10,573.8 3,876.0

390,601.6

54,649. I 6,913.1

33,782.7 2,141.6

27,465.0

2.206.4

0. I 2.0 0.7

73.4

10.3 1.3

6.3 0.4 5.2

0.4

TOTAL 532,496.2 100. I (rndg.1

Source: Minister of Health and South Australian Health Commission: Drimures, S.A.H.C.. September, 1983 Statement I(c) 3.

Informution Supporring rhe 1983-84

COOPER & BENNETT 205 COMMUNITY HEALTH STUDIES

Problems with the Schema The main problem with the S.A. Health

Commission’s program classification of health services has been that of generic services. Services are not usually organised to address particular problems or objectives and this is most obvious in relation to acute services.

As discussed above, the British Programs of Care attempted to overcome this problem by using the formulation ‘mainly for’. The British classification, however, entirely avoids the problem of the main generic services, particularly acute services, by simply identifying them as such (that is general and acute hospital and maternity services) rather than in relation to any particular population group. In comparison, we have attempted to overcome this problem by identifying them as ‘services mainly for those with physical illnesses or disabilities not elsewhere included’.

As can be seen from Table 111, this program accounted for 52.2% of total S.A. Health Commission Gross Payments in 1982-83.25 Yet this approach has some advantage, in that a t least it is possible to relate the services to information about the incidence of physical illness and disability generally, vis a vis mental illness or intellectual disability. Initially, we sought to take this approach down to the sub-program level, consistent with the remainder of the classification, by identifying specialities with disease groups (for example, amalgamations of Internat ional Classification of Disease groupings). However, this proved unsuccessful. It highlighted single system specialities of relatively minor importance, such as ENT and Ophthamology, while the bulk of illness remained the undifferentiated target of primary care, general medicine and general surgery.

Acute services are the classic illustration of the problems with a target population approach. In effect, all illness is the target of primary care and all physical illness, with the exception of diseases of the sense organs and, to a lesserextent, the nervous system, is the target of the main general specialities. Internal medicine, and medical units, are not organised to address the problems of specific population groups or pathological conditions, but are organised on the basis of common skills and a common body of knowledge, which serves a diverse range of objectives and clients.

After wrestling with this problem for some time, we abandoned all attempts at a population- based classification below the program level and reverted to a sub-program classification that only

COOPER & BENNETT 206

distinguished between primary care and various types of secondary services.26 This is more meaningful descriptively and more useful for planning purposes, but it is not necessarily particularly useful for priority-setting. Beyond a general ideological commitment to primary care, which is common, the appropriate distribution of resources between primary and secondary services is a matter on which there can be many opinions, but not a matter to which this classification will bring much information to illuminate.

A second important problem has been to limit the information requirements of this schema. The South Australian Government laid down as a principle that in the longer-term, program budgeting would become the vehicle for the preparation of financial estimates and reporting to Parliament. Consequently, any schema developed had to be capable of aggregating costs in convent iona l a c c o u n t i n g te rms . Having deliberately chosen not t o organise the classification around organisational entities, this schema could not then be particularly useful for management control purposes, where budgets and costs had been developed on an organisational basis, since it is organisations in the end that have to be managed.

In order to limit information requirements to something that was practicable, as well as to meet accounting requirements, we decided that a t the lowest level the classification would be built up from those cost centres that had been identified for management accounting purposes. Essentially this required a common set of cost centres which could be ‘rolled up’ in one way, to institutions, for management purposes and ‘rolled up’ a second way, on a program basis, for planning and priority- setting purposes. Within the hospital sector, clinical units have been used as the appropriate cost centres.

Accounting requirements have major implications for this type of classification, since a t the lowest level it must be built up from organisational units. In addition, there are other trade-offs and constraints involved. F o r descriptive purposes, usage of health services could be much more accurately presented using statistical estimates. For example, statistically one might be able to show that a very large proportion of general acute services are in fact utilised by the aged and might therefore be thought of as services mainly for the aged. The type of program classification of health services described above will not, however, demonstrate this, since the services are not specifically for the aged and are not accounted for as such. Therefore, if such a

COMMUNITY HEALTH STUDIES

statistical approach were used, the resultant c lass i f icat ion might be more powerfu l descriptively, but it would probably have substantially less potential for action. There would be no direct linkage at any level between the framework for descriptive and priority-setting purposes and the organisational framework within which decisions had to be made.

The Future In summary, it must be stressed that while the

program classification of health services developed by the S.A. Health Commission over the past three years has many uses, it will be some time before it is able to report on a conventional accounting basis against all levels (that is, as an output of a n accoiinting system) and has a system of performance monitoring developed.27

Notwithstanding the importance of the schema for current priority-setting, policy and planning purposes, it is in meeting these longer- term requirements that its success or otherwise will ultimately be judged.

The development of activities, cost and other performance measures within this framework

opens up exciting new possibilities. Possible types of performance indicators include workload indicators, indicators of efficiency, indicators of effectiveness and performance targets. However, this task needs to be approached with a good deal of caution. Indicators of performance in the health field are difficult to define and although they can often provide quantitative data about the amount and trend of activities, they need not necessarily indicate anything a b o u t the quality of performance. Moreover, some programs lend themselves more readily to measurement than others. As a result, it could well prove easier to justify the continuation of programs such as these in preference to those for which meaningful indicators are more difficult to define.

The classification schema described above incorporates many compromises and some of the initial theoretical objectives have not been achievable. But given its current usefulness and future possibilities, is it really only worth one cheer, as Peter Self has argued -all right, but only worth half as much enthusiasm as democracy.28 However, it could well be the case that the longer- term cheers for this type of approach could be more substantial than the short-term cheers.

References

T h e development of t h e p r o g r a m classification of health services described in this paper has involved the time and effort of a number of officers of the South Australian Health Commission over the past three years. We have been greatly assisted by their enthusiasm and ideas as well as by their constructive criticism of earlier versions of the classification. In this regard, we are particularly indebted to Dr David Filby, Mr Bob Exelby and Mr Bronte Treloar. This paper draws substantially on two earlier papers - namely:

Classification of Health Services for Programme-Performance Budgeting A paper presented at the 1982 Australasian Conference of ANZSERCH/APHA in Christchurch, New Zealand, May, 1982; and Bennett C and Filby D. Programmes, Prayers and Promises: Towards a More

Australian Health Commission. A paper presented at the 1982 Health Economists' Group Conference in Canberra, August, 1982.

3.

Cooper J and Bennett C. A Programme 4.

Rational Budgetary Process for the South 5.

COOPER & BENNETT 207

The latter paper was subsequently published in Tatchell P M ed. Economics and Health 1982: Proceedings , o f the Fourth A u s t r a l i a n C o n f e r e n c e of Heal th Economists. Health Economics Research Unit, Australian National University 1983 (Technical Paper No 7), 31-56. P.A. Australia and the South Australian Government's P P B Team. Program- Performance Budgeting for the South Australian Government: Purposes and Direction. Adelaide: S. A. Government Publisher, June 1981. Review of New South Wales Government Administration (Chairman: Professor P. Wilenski). Directions for Change: An Interim Report (November, 1977); Towards Regionalization. Access and Community Participation (February, 1980); a n d Unfinished Agenda: A Further Report (May, 1982) Commonwealth Department of Finance. P o s t - B u d g e t D o c u m e n t : Program Presentation of Appropriations and OutIays - Departmental Estimates 1983-84. Canberra A.G.P.S., August 1983.

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6. For example, this approach has been introduced in both Victoria and Tasmania of late.

7. For example: Straussman JD. The Limits of Technocratic Politics. Transaction Books 1980; Knight KW and Wiltshire KW. Formulating Government Budgets: As- pects of Australian and North American Experience. Brisbane, University of Queensland Press, 1977; Wildavsky A. Speaking Truth to Power: 7%e Art and Craft of Policy Analysis. Little, Brown and Company 1979; and 7%e Politics of the Budgetary Process: Third Edition Little Brown and Company, 1979.

8. Wildavsky A: Speaking Truth to Power. 32.

9. Nevertheless, in the 1983-84 State Budget, seven departments presented their formal detailed estimates in a program form. The departments were those of the Public Service Board, Public and Consumer Affairs, Treasury, State Development, Attorney-General’s, the Corporate Affairs Commission and Auditor-General’s.

10. Financial Statement of the Premier and Treasurer (the Hon. J.C. Bannon, MP): Delivered on 1st September, 1983 on the Second Reading of the Appropriation Bill (No. 2), 1983 South Australian Government Printer 56-57.

I I . Guidelines provided by the PPB Team for interpreting the various levels of this program structure have proved to be largely tautological. For example, program sectors have been defined as ‘major areas of endeavour comprising a number of related programs’, while programs have been defined as ‘groupings of several related sub- programs which contr ibute t o the achievement of Government policy/ objec- tive(s)’. In comparison, activities have been defined as those operational tasks producing a distinct output. From the South Australian Health Commission’s viewpoint, cost centres have since been interpreted as those areas from which activities are performed and against which financial information can be collated. This ensured that cost centres would become the minimum discrete units in the classification schema as well as uniform between institutions, wholly contained within programs and capable of having services charged back to them.

COOPER & BENNETT 208

12. Other considerations related t o the specification of objectives and purposes and the development of a schema capable, a t least in principle of being reported against in c o n v e n t i o n a l a c c o u n t i n g t e r m s . Compatability with existing and proposed management accounting systems was also given priority.

13. Report of the Commission of Inquiry into the Efficiency and Administration of Hospitals (Chairman: Mr J.H. Jamison, 1980) Volume I, Recommendation 78: 15.

14. See Cooper J and Bennett C: op cit. 8-12. 15. ibid 8-12. 16. United Way of America: U W A S I S

11: Second Edition of the United Way of America Services Identification System: A Taxonomy of Social Goals and Human Service Programs, (November, 1976).

17. Department of Health and Social Security. Consultative Document: Priorities for Health and Personal Social Services in England. London H.M.S.O., 1976.

18. Treated separately from this classification were the following Intra-Agency Support Services - the Minister and Minister’s O f f i c e , E x e c u t i v e M a n a g e m e n t , Professional and Technical Support and Administrative and Clerical Support.

19. See Bennett C and Filby D: op cit 23-24. 20. New S o u t h Wales D e p a r t m e n t of

Health: Programme Budgeting: Pro- posed Programme Structure December 1982 This particular structure identified three program sectors and twenty six programs.

21. The other two program sectors d o not relate to services provided to identifiable target groups. They relate to co-ordination and planning functions, the provision of services for the benefit of all and to the infra- structure of the health system.

op cit. 7-14. The Regional Resource Allocation Model (RRAM), developed within the SAHC over the past three years as an adjunct to the PPB exercise, attempts to ensure. that the allocation of funds for health services reflects Sector-based indicators of relative need. The indicators of relative need used in the model include the age, sex and health s ta tus characteristics of the Sector populations, the provision of health services within the Sectors and the inter-Sector patient flows.

22. See Bennett C and Filby D:

COMMUNITY HEALTH STUDIES

23. This figure has been adjusted upwards by $204,000 to take account of an allocation of $181,500 to the Frozen Food Factory and $22,500 to the Hindmarch Memorial Community Hospital Inc.

24. To ensure comparability with Table IV, the Minister’s salary has been excluded from ‘Support Services’.

25. Nevertheless , even th i s is no t a s concentrated as the distribution, by line, of total S.A. Health Commission Gross Payments in 1982-83. As can be seen from Table IV, recognised hospitals accounted for 73.4% of total S.A. Health Commission Gross Payments in that year.

26. The relevant sub-programs for this program are ‘primary care services’, ‘general medical and surgical secondary services’, ‘secondary services in medical specialities’ and ‘secondary services in surgical specialities’. Medical specialities and sub-specialities are defined to include renal, haemodialysis, haematology, oncology, T.B., gastro- enterology, neurology, endocrinology/ meta -bolic, cardiology, radiotherapy, thoracic medicine, dermatology, rheumatology and infectious diseases clinics. Surgical specialities and sub-specialities a r defined to

i n c l u d e c a r d i o - t h o r a c i c s u r g e r y , ophthalmology, gynaecology, otorhinoO l a r y n g o l o g y , u r o l o g y , v a s c u l a r , neurosurgery, plastic surgery, oral surgery and burns clinics.

27. These two issues are inextricably linked. For example, in his 1983-84 Financial Statement, Premier Bannon said that:

‘the devleopment of (a new) Treasury Accounting System is a n essential pre- requisite to the effective operation of programme-performance budgeting. That technique will be effective fully only when resource information a b o u t programs is provided through the formal a c c o u n t i n g sys tems of agencies’ Financial Statement of the Premier and Treasurer delivered on 1st September, 1983 op. cit 56.

28. Peter Self: One Cheer for Program Budgeting, Royal Australian Institute of Public Adminis t ra t ion: New Series Number I (S.A. Regional Goup, November, 1981). Self was referring to E.M. Forster’s Two Cheers for Democracy, which implies that democracy is alright but not worth too much enthusiasm.

COOPER & BENNETT 209 COMMUNITY HEALTH STUDIES