1. 1 Cost of care at public hospitals in Sri Lanka

2. 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. 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. 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. 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. 6 What are those hospitals? Anurahapura GH Nuwara Eliya GH Hambantota BH

7. 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. 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. 9 Our results First 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. 10 Average daily income per household member (US $) Disease/serviceA'puraN'EliyaH'totaTotal OPD 1.41.10.91.1 Hypertension 1.11.21.01.1 Diabetes 1.31.10.81.1 Heart ailments 1.61.1 1.2 Med. investigations 1.51.11.21.3 Obstetric care 1.81.30.91.3 Ante natal care 2.51.61.31.8 Paediatric care 1.20.9 1.0 Total 1.51.11.01.2

11. 11 Source of energy for cooking SourceA'puraN'EliyaH'totaTotal Electricity1.5 0.61.2 Gas15.416.94.412.1 Electricity & gas5.41.20.02.2 Electicity & other0.6 0.90.7 Gas & other0.61.80.00.8 Sub total23.522.25.917.1 Kerosene0.93.41.21.8 Firewood55.153.881.763.8 Firewood & kerosene0.64.60.61.9 Firewood & gas19.916.010.615.5 Sub total76.577.894.182.9 Total100.0

12. 12 Efficiency

13. 13 Ante natal care ItemHMAnuNE Manpower147.59189.5497.17 Investigations63.4132.05195.47 Assets/equipment13.773.4320.63 Drugs41.4563.1450.39 Overheads26.6228.8236.37 Average cost 292.85316.97400.02

14. 14 Diabetes HMAnuNE ItemAverage Manpower19.4139.7826.88 Investigations16.2912.1140.43 Assets/equipment1.490.554.70 Drugs42.7732.0455.31 Overheads8.008.4512.73 Average Cost87.9692.94140.06

15. 15 Hypertension HMAnuNE ItemAverage Manpower26.0747.3411.42 Investigations12.106.676.90 Assets/equipment1.150.442.03 Drugs37.536.3037.70 Overheads7.696.075.80 Average Cost84.5466.8263.85

16. 16 Heart ailments HMAnuNE ItemAverage Manpower18.8723.0220.33 Investigations15.7512.3617.12 Assets/equipment1.601.753.69 Drugs17.4836.8733.36 Overheads5.377.407.45 Average Cost59.0681.4081.95

17. 17 Obstetric care (inward) HMAnuNE Item Average Manpower1061.971196.371619.69 Investigations260.1212.63407.91 Assets/equipment112.61239.30100.41 Supplies243.77428.08455.43 Diet298.20220.29329.47 Drugs41.5735.1672.91 Overheads201.82213.18298.58 Average Cost2220.062345.013284.41

18. 18 OPD HMAnuNE ItemAverage Manpower58.1287.5754.12 Investigations5.6911.797.82 Assets/equipment0.342.640.37 Supplies3.456.2510.81 Drugs42.1847.9355.80 Overheads10.9815.6219.34 Average Cost120.75171.80148.25

19. 19 Paediatric care (INP) ItemHM Anu NE ItemPer Pnt.Per dayPer Pnt.Per dayPer Pnt.Per day Manpower1144.82323.992026.61837.033101.491280.98 Investigations131.4637.2050.6320.91198.5582.00 Assets/eqpmnt.53.2915.0876.5231.6176.5731.62 Supplies39.5811.20250.70103.54263.97109.02 Drugs311.8688.26902.72372.84199.3582.33 Diets333.0094.24306.34126.52457.37188.90 Overheads201.4057.00361.35149.25429.73177.49 Average Cost2215.40626.973974.881641.714727.021952.36

20. 20 Cost of receiving services Type of costOPD Med. Investigations Ante natal care Rs.% % % Travel7820.89216.71489.3 Drugs17446.422140.131019.4 Investigations4712.712422.531219.5 Food00.161.116810.5 Private med. care4812.8417.421713.6 Rituals246.45610.135722.4 Other30.8122.1825.2 Total374100.0550100.01,594100.0 % from monthly individual income 10.6 14.1 27.8 % from monthly household income 3.4 4.9 10.9

21. 21 Cost of receiving services Type of costHypertensionDiabetes Heart ailments Rs.% % % Travel11513.012617.1878.8 Drugs37542.330941.938739.1 Investigations16418.517323.532833.1 Food10211.5294.0242.5 Private med. care788.8618.210710.8 Rituals505.6395.3535.4 Other30.400.040.5 Total887100.0737100.0991100.0 % from monthly Individual income25.9 22.3 26.1 % from monthly household income 9.0 7.3 8.1

22. 22 Cost of receiving services Type of cost Obstetric care Paediatric inp care Rs.% % Travel29717.421121.1 Drugs22112.941441.5 Investigations22813.3919.2 Food25915.2515.1 Private med. care17010.0999.9 Rituals53431.313313.3 Total1,708100.0999100.0 % from monthly individual income41.6 33.2 % from monthly household income12.5 10.9

23. 23 Average cost per patient Type of cost Cost per patient Rs.% Travel14214.6 Drugs30131.0 Investigations18318.8 Food788.1 Private med.care10210.5 Rituals15315.7 Other131.4 Total973100.0 % from monthly individual income25.4 % from monthly household income8.2

24. 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. 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. 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. 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. 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. 29 Thank you