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.