Patient satisfaction
Overall, patient satisfaction regarding the quality of care was observed
to be high in this population. This trend was seen in patients of all
socioeconomic levels. One patient stated, “The ward staff and doctors
treated us nicely. They were kind even though they are very busy and
overworked”.
However, some patients who were in the lower socioeconomic quintiles
were less satisfied about the care they received. They perceived that
they were at a relative disadvantage and many used phrases such as
“although they treated him/her well” to mention a patient whom they
perceived to have been treated better than themselves by the staff.
“Some staff members were rude to us. They treated a patient who is
related to a hospital staff member very well and ignored me. I don’t get
medicines on time for the pain in my leg (pointing towards her knee
joints)”, said one patient who was not very satisfied with the quality
of care she received.
In general, patients in higher income quintiles were more satisfied
about the care they received. In one ward, a patient belonging to the
highest income quintile expressed his concern over the way the staff
treated other “poor, less connected patients”.
Discussion
In Sri Lanka, government funded public hospitals provide curative
services free of charge to all its citizens. These include out-patient
consultations, in-ward treatment, medicines, investigations, other
supportive services including linen and meals for in-patients. Sri Lanka
is listed as a country with a low out-of-pocket expenditure for health,
with less than 5% of households spending more than 10% of total
expenditure on health care. Catastrophic economic impacts of ill health
are minimal in Sri Lankans due to this system5. In an ideal
situation, a publicly funded health care system should minimize the
impact of ill health on individual households and reduce inequity in
health care.
This study revealed different situations in which out-of-pocket expenses
are incurred by patients and their households during a hospital
admission. The impact of these expenses was greater in individuals of
lower economic backgrounds. Those obtaining a daily wage or those whose
income depended on small-scale self-employment were affected by loss of
income due to hospitalization, sometimes severely disrupting the
functions of their households. However, loss of income was not a major
concern in individuals belonging to middle- and higher-income
categories. This seems to create an important inequity in the household
economic impact of ill health and hospitalization despite the
availability of state sponsored health care.
The findings of the study support previous observations that patients
with chronic diseases are more likely to encounter higher out-of-pocket
expenditures 8. Sri
Lanka is facing a rapidly rising epidemic of non-communicable diseases.
The relative inability of the state health care system to prevent
significant incapacitation of the household economy in patients with
chronic and multiple diseases may have a negative impact on the overall
acceptance of its health care system4. This needs to be
addressed by further discussion and improvement of economic security of
low-income groups. The National Insurance scheme is an example where
loss of income during hospitalization can be buffered by compensation.
Sri Lanka is a country with significant inequality in income
distribution and household expenditure9. However, due to the
structure of its public health system, Sri Lanka has minimal inequities
in health care utilization. Utilization of inpatient facilities is equal
across all economic quintiles. Outpatient facilities however, are
utilized more by the pro-poor patients, as a result of the rich
electively opting for private sector care10,11.
Public health sector in Sri Lanka is funded by a tax-based method3,11.
Hence every citizen contributes towards the funding of this service and
has an equal right for equitable services from the government health
sector. In this survey we demonstrate that other forms of inequity
beyond utilization of health care exist, especially with regards to
spending for health care, at patient level.
We observed inequities in expenses incurred, satisfaction, patient
management and possible clinical outcome across all quintiles based on
the individual’s household income. Wealthy patients were more likely to
receive requests for investigations from private laboratories and drugs
to be purchased from pharmacies. The poorer patients are given fewer
requests depending on their financial capabilities and were largely
unaware that they are receiving a “different” standard of care. This
“informal exemption” of the poor from out-of-pocket expenses has been
documented previously in Sri Lanka and Thailand5. Its impact on
clinical outcome, however, has not been studied. We observed that there
is significant inequity in patients being informed of their choices and
available options based on their economic status. Although this appears
to be an attempt to “safeguard” poorer patients from being unhappy
about their treatment, this cannot be justified from an ethical point of
view. Having a choice is one of the key principals of equity in health
care 12, and it is
necessary to take measures to change the current practices of the
doctors when handling such situations. In addition, a universal health
care plan should have horizontal equity where all patients are treated
equally 12. In this
perspective, it can be argued that the government should ideally
fund/cover direct costs incurred by the patient when it is inevitable.
The current evidence supports that patients belonging to low
socioeconomic groups are less satisfied with health services13. A health system
funded by the public should, however, attempt to minimize this. The
difference in satisfaction and examples provided by the patients in our
study further emphasize that not having a choice and the perception of
being treated unequally has contributed to this lack of satisfaction.
This evidence calls for an attitudinal change among health care workers,
including doctors and supportive staff.
Some expenses incurred by the patients cannot be justified in a
government-funded health care system. Examples noted were the requests
for investigations from private laboratories due to inaccurate reports
or delays in the in-house laboratory services, and the need for
bystanders to carry out patient-related work. These concerns need to be
addressed and corrected as an internal exercise. Since data collection
for this study, local authorities have implemented activities to improve
laboratory and service standards. Current hospital policy (implemented
after data collection for this study) has restricted medical staff on
ordering investigations and obtaining medicines or equipment from the
private sector for in-ward patients. Special permission from the
director of the hospital is now required before obtaining these services
or goods from the private sector after confirming that the good or
service requested is not available in the state sector.