Introduction
Sri Lankan government provides universal health coverage through a
well-established public health care delivery system. The quality of
clinical care in the public sector, which cater to the health care needs
of the majority of Sri Lankans, is known to be comparable to that
provided in the private sector, which delivers health care services only
to a minority of the population1. In addition, there is
more public trust towards the government health system2. Health care in this
free public sector is universally accessible and provides unlimited
health care for all citizens. This may have aided Sri Lanka to achieve
better health care indices compared to other countries with a similar
socioeconomic status3-5.
Curative services in the public sector are provided through government
hospitals. There are several strata of hospitals based on physical and
human resources, ranging from primary care centers such as rural
hospitals to tertiary care centers with advanced facilities that are
located in major cities in association with medical schools. There is no
compulsory referral system, hence patients seek treatment from different
centers based on their preference3-5.
Sri Lankans who are treated in government hospitals should ideally
receive equal care across different hospitals. If absolute equity is
maintained patients of all socioeconomic levels should receive equal
care. It should be cost-free as the public health system is funded by
taxpayers and has been designed to eliminate costs to the consumer. In
this context, this study was planned to answer the following questions:
Is the government health care system completely cost-free? If not, what
are the costs borne by the patient? Is the current system equitable?
Methods
This study was carried out in the largest and most equipped tertiary
care center in the country, among patients with cirrhosis of liver who
were in-patients in two general medical wards, and referred to the
Gastroenterology and Hepatology Unit. Ethical clearance was obtained
from the institutional review board of the hospital.
Patients were selected from two medical wards and both patients and
their caregivers were interviewed by the principal investigator (IK).
Quota sampling was used to ensure equal participation of both genders
and to include participants belonging to all income quintiles according
to 2012 national data 6.
Sampling was done until data saturation was achieved. Selected patients
who consented to participate were first interviewed to obtain their
household income, occupation and disease status. This information was
used to stratify patients (table 1) into different sample groups.
Twelve medical doctors from the relevant wards were interviewed in order
to acquire their perception on the issues raised based on the interviews
with the patients and their caregivers. Their perspectives were also
sought to obtain possible solutions to the questions that were raised
during analysis.
During the interview, both guiding questions and open-ended questions
were used. All interviews were carried out by the principal
investigator. Interviews were done in the patient clerking room of the
respective wards to maintain privacy and confidentiality. The interviews
were tape recorded (with patients’ consent) and transcribed later and
these recordings and transcripts were stored securely. Coding was done
both manually and using NVivo version 10 qualitative analysis software
(QSR International). All transcripts and computer databases were
anonymously and securely stored.
Thematic framework method was used to analyze data7. The framework was
created and reviewed using emerging data to identify commonly occurring
themes. The themes were indexed in each transcript and later collated by
mapping under common themes.
Results