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A study on responsiveness at public hospitals in

Sri Lanka

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Our questions ?

• How do clients receive services from public hospitals?

• What are the problems encountered by them?

• We have attempted to answer these questions with respect to eight diseases/services.

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What are they?

• Outdoor patient care • Hypertension• Diabetes • Heart ailments• Medical investigations• Obstetric care • Antenatal care• Paediatric hospital care (including

malnutrition)

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We have looked at two specific issues in making answers to

those two questions

What are they?

• Quality

• Equity

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What is our conceptual framework?

The study was undertaken within a Conceptual Framework developed on the basis of the WHO concept of RESPONSIVENESS: How the system performs relative to non-health aspects?

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From where we collected data?1. A household survey amongst service receivers selected from respective hospitals2. A survey amongst service providers

Instrument used: Questionnaire (WHO format for responsivness)

2. A series of in-depth interviews at household level with a set of service receivers selected from 1 above

Instrument used: Guidelines for in-depth Interviews

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What are those hospitals?

• Anurahapura GH

• Nuwara Eliya GH

• Hambantota BH

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What are the variables on which data were collected?

Quality of care:• Prompt attention• Dignity • Communication• Autonomy• Confidentiality• Choice • Basic amenities• Social support (for inpatients)

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Equity: equal needs treated equallyIn assessing equity we looked at two types of variables:1. Socio-economic background of service receivers

2. Whether there was any discrimination against by the health system due to:Social class AgeEthnicityReligionLanguagePolitical beliefsHealth statusLack of wealth / moneyLack of personal relationships with the health staff

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Our resultsFirst we have examined who are coming to public hospitals in seeking care?

We have assessed their socio-economic background with respect to several indictors and two of them are given below.

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Average daily income per household member (US $)

Disease/service A'pura N'Eliya H'tota Total

OPD 1.4 1.1 0.9 1.1

Hypertension 1.1 1.2 1.0 1.1

Diabetes 1.3 1.1 0.8 1.1

Heart ailments 1.6 1.1 1.1 1.2

Med. investigations 1.5 1.1 1.2 1.3

Obstetric care 1.8 1.3 0.9 1.3

Ante natal care 2.5 1.6 1.3 1.8

Paediatric care 1.2 0.9 0.9 1.0

Total 1.5 1.1 1.0 1.2

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Source of energy for cookingSource A'pura N'Eliya H'tota Total

Electricity 1.5 1.5 0.6 1.2

Gas 15.4 16.9 4.4 12.1

Electricity & gas 5.4 1.2 0.0 2.2

Electricity & other 0.6 0.6 0.9 0.7

Gas & other 0.6 1.8 0.0 0.8

Sub total 23.5 22.2 5.9 17.1

Kerosene 0.9 3.4 1.2 1.8

Firewood 55.1 53.8 81.7 63.8

Firewood & kerosene 0.6 4.6 0.6 1.9

Firewood & gas 19.9 16.0 10.6 15.5

Sub total 76.5 77.8 94.1 82.9

Total 100.0 100.0 100.0 100.0

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Quality

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Prompt attention

• Patients were highly dissatisfied, particularly, with respect to waiting time. No mechanism exists to provide any assistance or concessions to the patients from remote areas in attending clinics of the public hospitals in city centres.

• Lack of drugs and investigations outside lead to improper/incomplete treatment

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Dignity

• Except doctors, all the other staff members were found to be not complying with the principles of dignity in dealing with service receivers.

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Communication

• Communication with doctors was highly appreciated by service receivers.

• Other staff members do not seem to be maintaining any cordial relationship with service receivers unless otherwise they have any personal relationships with them.

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Autonomy

• The patients who belong to the poorest stratum of the society are indeed not much concerned about autonomy rather than obtaining virtually free public health care services at the best possible manner.

• What they really need is just receiving care

provided by the public hospitals for their illnesses rather than deciding on what would be the best method of treatment, particularly, due to unaffordability in seeking care from alternative sources.

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Confidentiality

• The diseases/services concerned for the study are not, in general, involved with any confidential issues.

• However, the general view of the patients was that even if they need to maintain confidentiality in seeking care, it is not possible due to the absence of providing those services personally within a highly crowded environment.

• Due to unaffordability, the main concern of the service receivers is just receiving the necessary services rather than paying any emphasis on ascertaining whether there is any accessibility to their personal information for others.

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Choice of care

• The choice of care is indeed an irrelevant factor for the majority of patients as the pubic hospitals are the only source of treatment for their needs: they are indeed not in a position to make a choice amongst all the other alternative service providers due to unaffordability, particularly, for inward care.

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Basic amenities

• Patients are highly dissatisfied with basic amenities provided at public hospitals.

• Inpatient care and particularly obstetric care have been rated as the most dissatisfied services.

• Lack of proper toilet facilities was highlighted by inpatients as well as outpatients.

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Social support for inpatients

• Extremely good at all hospitals

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Equity

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Discrimination against by the health system

Reason Yes No

Social class 0.3 99.7

Age 0.5 99.5

Ethnicity 2.8 97.2

Religion 0.3 99.7

Language 7.4 92.6

Political beliefs 0.1 99.9

Health status 0.5 99.5

Lack of wealth / money 1.6 98.4

Lack of personal relationships    

with the health staff 12.9 87.1

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Lack of personal relationships with the health staff

Discriminated  A'pura N'Eliya H'tota Total

Yes 20.5 1.5 16.4 12.9

No 79.5 98.5 83.6 87.1

Total 100.0 100.0 100.0 100.0

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Language barrier

Discriminated  A'pura N'Eliya H'tota Total

Yes 0.0 19.7 2.7 7.4

No 100.0 80.3 97.3 92.6

Total 100.0 100.0 100.0 100.0

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Two case studies

1. Sarojini’s experience in seeking obstetric care

2. Punchisingho’s experience in seeking care from the medical clinic for hypertension

Summaries are given below

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Sarojini’s voice

• Just after the operation I was given a single bed but from the following day I had to share it with two other patients. I was so uncomfortable and couldn’t move properly because when I tried to do so I couldn’t bare the pain. I was just lying on the bed with great difficulties and there was a small space left to me on the bed. Even before the delivery, I slept on the floor for two days. There is only one toilet for the patients at the ward and the others are locked.

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Cont..When my baby got wet no one was there to change the nappies. I had to wait until someone coming from home. Though the ward staff asked us to keep our personal hygiene they were not ready to help us to do so. Otherwise they should allow us to keep someone (relatives) for helping us in such situations. They scold us…But they treat very well for their known people…. At the time of taking my drugs I was asked to come to the nurse and collect them. In case we got late they shout at us. Even if you can’t walk up to the nurse’s table, you have to be there for drugs. In one particular occasion I had to go there with carrying the saline bottle that had hanged over my bed. …….I am not happy about the service that I received from the hospital. But what to do? Poor people like us have no other place to go. Sir, please tell them to treat poor people like us with dignity.

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Punchisingho’s voiceThe doctor writes in my book and a sheet what drugs should be given to me by the pharmacy and asks me to go to the dispensary and collect those drugs. The (Mahaththaya) officer in the dispensary delivers the drugs written in the book and asks me to buy the drugs written in the sheet from a (private) pharmacy….. I normally spend about Rs. 600 for those drugs……The doctor normally allows me to explain my ailments and listens to me. But the doctor examines us very quickly because there are many patients. There is a large number of patients at this hospital. It is around 600. Therefore there is no time for the doctors to talk with patients. So they just look at us and prescribe the drugs. They do not have a time to examine us properly. Once again I think that is due to the large number of patients. But the doctors never disregard (awulak danne ne) us. …… The staff members of the clinic are normally not there when we attend the clinic….. I am given drugs for four weeks. But for safety what I do is to go to the clinic after three weeks keeping the drugs for the next week with me. But don’t tell it to them. (What would happen if there is a strike?)

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Cont..Punchisingho further stated when we were leaving his house (not recorded but noted down) that why should I spend such a long time to get these few tablets (sochchama). I am indeed not affordable in purchasing those drugs prescribed by the doctor. My sun normally purchases those drugs. He is a poor fisherman. He is a father of two children and his elderly son tragically died in Tsunami at the age of 7. Sometime he borrows money from others to buy my drugs: otherwise we are forced to buy a lesser quantity of drugs depending on the availability of money.

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Suggestions for further consideration

1. Devise a method to change the behaviour of the hospital staff other than the doctors to provide their service to the service receivers in a polite manner by maintaining their dignity.

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2. Measures have to be introduced to reduce hardships encountered by the service receivers due to long waiting time at public hospitals. In introducing such measures it is essential to devise some methods to provide special concessions to the patients coming from remote areas.

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3. An effective mechanism has to be devised to avoid drug shortages at hospitals. Drug shortages have resulted in imposing an additional burden to the patients to purchase prescribed drugs. It could lead to reduce the quality of care received by the patients when they are not in a position to purchase the prescribed drugs.

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4.Related to the same issue, some measures need to be introduced to make patients satisfied by way of providing them with an opportunity to get all the necessary medical investigations conducted within the hospital rather than directing them to private laboratories.

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Thank you