1

Cost of care at public hospitals

in Sri Lanka

2

This is a study on efficiency and equity at public

hospitals in Sri Lanka

• To estimate the cost of treatment/ provision of eight disease/service at three public hospital (Efficiency?)

• To estimate the direct household cost of receiving care for each of those diseases/services (Equity?)

3

What are those diseases/services?

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

malnutrition)

4

What is our conceptual framework?

Efficiency is normally considered as the provision of a given service at the minimum cost

Equity is normally considered as the treatment of equal needs (or patients) equally irrespective of their socio-economic background

5

How and from where we collected the necessary

data?1. Reports and records of the three hospitals

2. Discussions with service providers

3. A survey amongst service receivers

Instrument used:

Guidelines

Checklist

Questionnaire for service receivers

6

What are those hospitals?

• Anurahapura GH

• Nuwara Eliya GH

• Hambantota BH

7

What are the variables on which data were collected?

1. All types of inputs related to the provision of care for each disease/service at operational level

2. Cost of all inputs of (1) above for each disease/service

3. Direct cost of receiving care for each disease/service by the household of patient

8

How did we analyse our data?

For the provision of care we have looked at operational cost rather than opportunity cost

For household cost we looked at only direct cost rather than social cost excluding indirect cost

9

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.

(Please note this is a repetition of the presentation on responsiveness as the same sample was used for both studies)

10

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

11

Source of energy for cooking

Source 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

Electicity & 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

12

Efficiency

13

Ante natal care

Item HM Anu NE

Manpower 147.59 189.54 97.17

Investigations 63.41 32.05 195.47

Assets/equipment 13.77 3.43 20.63

Drugs 41.45 63.14 50.39

Overheads 26.62 28.82 36.37

Average cost  292.85 316.97 400.02

14

Diabetes

  HM Anu NE

Item Average Average Average

Manpower 19.41 39.78 26.88

Investigations 16.29 12.11 40.43

Assets/equipment 1.49 0.55 4.70

Drugs 42.77 32.04 55.31

Overheads 8.00 8.45 12.73

Average Cost 87.96 92.94 140.06

15

Hypertension

  HM Anu NE

Item Average Average Average

Manpower 26.07 47.34 11.42

Investigations 12.10 6.67 6.90

Assets/equipment 1.15 0.44 2.03

Drugs 37.53 6.30 37.70

Overheads 7.69 6.07 5.80

Average Cost 84.54 66.82 63.85

16

Heart ailments

  HM Anu NE

Item Average Average Average

Manpower 18.87 23.02 20.33

Investigations 15.75 12.36 17.12

Assets/equipment 1.60 1.75 3.69

Drugs 17.48 36.87 33.36

Overheads 5.37 7.40 7.45

Average Cost 59.06 81.40 81.95

17

Obstetric care (inward)

  HM Anu NE

Item Item Average Average

Manpower 1061.97 1196.37 1619.69

Investigations 260.12 12.63 407.91

Assets/equipment 112.61 239.30 100.41

Supplies 243.77 428.08 455.43

Diet 298.20 220.29 329.47

Drugs 41.57 35.16 72.91

Overheads 201.82 213.18 298.58

Average Cost 2220.06 2345.01 3284.41

18

OPD

  HM Anu NE

Item Average Average Average

Manpower 58.12 87.57 54.12

Investigations 5.69 11.79 7.82

Assets/equipment 0.34 2.64 0.37

Supplies 3.45 6.25 10.81

Drugs 42.18 47.93 55.80

Overheads 10.98 15.62 19.34

Average Cost 120.75 171.80 148.25

19

Paediatric care (INP)Item HM   Anu   NE  

Item Per Pnt. Per day Per Pnt. Per day Per Pnt. Per day

Manpower 1144.82 323.99 2026.61 837.03 3101.49 1280.98

Investigations 131.46 37.20 50.63 20.91 198.55 82.00

Assets/eqpmnt. 53.29 15.08 76.52 31.61 76.57 31.62

Supplies 39.58 11.20 250.70 103.54 263.97 109.02

Drugs 311.86 88.26 902.72 372.84 199.35 82.33

Diets 333.00 94.24 306.34 126.52 457.37 188.90

Overheads 201.40 57.00 361.35 149.25 429.73 177.49

Average Cost 2215.40 626.97 3974.88 1641.71 4727.02 1952.36

20

Cost of receiving services

Type of cost OPD   Med. InvestigationsAnte natal

care

  Rs. % Rs. % Rs. %

Travel 78 20.8 92 16.7 148 9.3

Drugs 174 46.4 221 40.1 310 19.4

Investigations 47 12.7 124 22.5 312 19.5

Food 0 0.1 6 1.1 168 10.5

Private med. care 48 12.8 41 7.4 217 13.6

Rituals 24 6.4 56 10.1 357 22.4

Other 3 0.8 12 2.1 82 5.2

Total 374 100.0 550 100.0 1,594 100.0

% from monthly            

individual income 10.6   14.1   27.8  

% from monthly            

household income 3.4   4.9   10.9  

21

Cost of receiving services

Type of cost Hypertension Diabetes   Heart ailments

  Rs. % Rs. % Rs. %

Travel 115 13.0 126 17.1 87 8.8

Drugs 375 42.3 309 41.9 387 39.1

Investigations 164 18.5 173 23.5 328 33.1

Food 102 11.5 29 4.0 24 2.5

Private med. care 78 8.8 61 8.2 107 10.8

Rituals 50 5.6 39 5.3 53 5.4

Other 3 0.4 0 0.0 4 0.5

Total 887 100.0 737 100.0 991 100.0

% from monthly            

Individual income 25.9   22.3   26.1  

% from monthly            

household income 9.0   7.3   8.1  

22

Cost of receiving services

Type of cost Obstetric care Paediatric inp care

  Rs. % Rs. %

Travel 297 17.4 211 21.1

Drugs 221 12.9 414 41.5

Investigations 228 13.3 91 9.2

Food 259 15.2 51 5.1

Private med. care 170 10.0 99 9.9

Rituals 534 31.3 133 13.3

Total 1,708 100.0 999 100.0

% from monthly        

individual income 41.6   33.2  

% from monthly        

household income 12.5   10.9  

23

Average cost per patient

Type of costCost per patient  

  Rs. %

Travel 142 14.6

Drugs 301 31.0

Investigations 183 18.8

Food 78 8.1

Private med.care 102 10.5

Rituals 153 15.7

Other 13 1.4

Total 973 100.0

% from monthly    

individual income 25.4  

% from monthly    

household income 8.2  

24

Suggestions for further consideration

For the patients with chronic illnesses, a mechanism has to be devised to conduct clinics at peripheral stations, using the human resources available at the leading hospitals located in the centre of the district/province, on regular basis for reducing the travel cost and time cost borne by patients in remote areas and also to provide care for the patients who are unaffordable to reach city centres. To ascertain the successful operation and sustainability of these clinics, it is essential to introduce a method of incentives for those who conduct such clinics.

25

Cont.

For this purpose, assistance could be sought from the private sector as well as the NGOs. These clinics have to be conducted with the objective of avoiding frivolous users by way of setting up of a patient card system or patients’ clubs system.

Possible consequences:• New technology could be introduced to the

periphery through these clinics• Effect on minimizing referrals to the centre from the

periphery • Could lead to reduce cost of care at the hospitals in

city centres

26

2. Effective mechanism has to be devised to avoid drug shortages at public hospitals. Drug shortages have resulted in imposing an additional burden on unaffordable patients in purchasing prescribed drugs. Further, it leads to reduce the quality of care received by the patients when they are not in a position to purchase prescribed drugs.

27

3. Some measures need to be introduced to provide an opportunity for patients to get all the necessary medical investigations conducted within the hospital premises rather than directing them to private laboratories. This will lead to reduce the cost of service receivers as well as to improve quality of care as a large proportion of patents are not in a position to bear the cost of private medical investigations.

28

4. It is essential to undertake necessary measures to achieve the objectives of free health care services by way of providing hospital care to the patients free of charge in practice as well. This issue has become so aggravated: almost 8% of household income is spent in seeking care for a single patient from a public hospital during a period of one month. Therefore, measures have to be devised to minimize the cost borne by the patients for drugs, investigations, travel and even for food during hospital stay as the majority of them belong to the poorest stratum of the society.

29

Thank you