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How much do health services cost?
Findings from three districts
Annual Health Forum
BMICH
9th-10th February 2007
Dr. Ravi P. Rannan-EliyaInstitute for Health Policy
http://www.ihp.lk/
Outline
Study TOR & Goals Approach & Scope Methods Problems encountered Results Implications
Policy Future monitoring
Mandate and HPRA TOR
Original TOR: To measure public and private sector unit costs in
three districts Colombo, Badulla, Matale By levels of facilities
Modified TOR: To measure unit costs in public sector by levels of
institutions, and unit prices in combined private sector
General Approach & Scope
Public sector Cost survey of government health facilities Three districts only
Private sector National surveys of private sector hospitals,
laboratories and doctors All districts
Public Facility Cost Survey
Design of MoH-IHP Public Facility Cost Survey 2006 Based on previous Sri Lanka Public Facility Surveys (1992,
1997) to minimize development costs and maximize reliability by learning from previous experience
General method Stratified sample survey in the three districts Field investigators used to collect data on activities and
expenditures in each facility, supplemented by: Central MoH/Treasury data for MoH hospital expenditures Regional drug stores data for medical supplies Provincial/district office records for salaries/overtime
Analysis of data using statistical software
MOH-IHP PFS Sampling
Sample = 81 (Colombo - 30, Badulla - 28, Matale - 23)
69 hospitals/dispensaries, 12 MOOH units Response rates - 100% overall, >90% for most data
Total Sampled Total Sampled Total SampledTeaching 11 10 0 0 0 0Provincial 0 0 1 1 0 0District General 0 0 0 0 1 1Base 3 2 3 3 2 2District 2 2 12 6 3 2PU 5 3 1 1 3 3Rural 1 1 16 7 11 6Other (eg.Police& Prison) 2 1 0 0 0 0CD&MH 0 0 2 2 1 1CD 34 7 18 4 13 4MOOH 14 4 15 4 11 4
Colombo Badulla Matale
MOH-IHP PFS Data Collection Service activities
Questionnaire used to collect data on service outputs in 2005: Inpatients, outpatients, operations, X-rays, lab tests, etc. Supplemented by IMMR returns where available Dependent on responses from key informants
Time allocations of staff Questionnaire used to collect estimated time allocations of key staff groups
Doctors, nurses, labourers, attendants, lab staff Expenditures
Budgetary totals obtained from hospital directors Salary budgets re-estimated using staffing numbers where responses not
reliable Overtime and other data collected from district and provincial offices Medical supplies based on MSD data, and sample survey of drugs dispensed
in each facility Treasury data used for line ministry hospitals
MOH-IHP PFS Problems Non-line ministry facilities generally not responsible for
budgets, so usually lack reliable information on actual budgetary expenditures Salary expenditures data not easily accessed at low level facilities Needed to supplement using other data sources
Drug expenditures not responsibility of facilities Budget held by MoH MSD, estimates prepared by PDoHs MSD computerised inventory system only tracks supplies to
regional drug stores. Further distribution to facilities not computerised, and no easily accessible data on actual drug expenditures by facility
Reliability of IMMR returns in question in many facilities
Private sector price surveys
Surveys conducted of private hospitals, private laboratories, private ambulance companies
Survey of prices of private doctors found not to be feasible owing to reluctance of doctors to cooperate or provide accurate data
Response rates for private hospitals and laboratories high, but not for other surveys
Survey problems Private hospital respondents often did not understand or keep
track of “average length of stay” or average bed occupancy Inconsistencies between revenue and activity data suggested
reporting errors with many hospitals Non-responses and identified data errors handled using
imputation techniques
Findings
How do unit costs vary at different levels?
How do unit costs vary by district?How do private sector prices compare?
Bed-day costs by facility type
MOH-IHP Public Facility Survey 2006
685
544640
791664
943
1,968
1,427
-
500
1,000
1,500
2,000
2,500
RuralHospital
PeripheralUnit
DistrictHosp
District-Base Hosp
District-Gen Hosp
ProvincialHosp
TeachingHosp
SpecialisedHosp
Admission costs by facility type
MOH-IHP Public Facility Survey 2006
1,5451,076 1,324
2,349 2,380
4,564
8,099
11,922
-
2,000
4,000
6,000
8,000
10,000
12,000
14,000
Rural H
ospita
l
Perip
heral
Unit
Distri
ct H
osp
Distri
ct-B
ase
Hosp
Distri
ct-G
en H
osp
Provi
ncial
Hosp
Teac
hing H
osp
Specia
lised
Hosp
Outpatient costs by facility type
MOH-IHP Public Facility Survey 2006
6877
53 57 61
99
69
185
202
268
-
50
100
150
200
250
300
Centraldispensary
CDMH RuralHospital
PeripheralUnit
DistrictHosp
District-Base Hosp
District-Gen Hosp
ProvincialHosp
TeachingHosp
SpecialisedHosp
Chest X-ray costs by facility type
MOH-IHP Public Facility Survey 2006
130
183
131
174189
268
-
50
100
150
200
250
300
District Hosp District-BaseHosp
District-GenHosp
Provincial Hosp Teaching Hosp SpecialisedHosp
Admission costs by district
MOH-IHP Public Facility Survey 2006
1,3521,172
2,268
1,343
1,672
2,510
1,234
867
1,445
2,380
*
*
-
1,000
2,000
3,000
4,000
5,000
Rural Hospitals Periperal Units District Hospitals District Base/GeneralHosps
Badulla Colombo Matale* Sample size = 1
Outpatient costs by district
MOH-IHP Public Facility Survey 2006
55
71
48
110
69
43
727778
34
71
84
69
*
*
-
10
20
30
40
50
60
70
80
90
100
110
120
Central dispensary Rural Hospitals Periperal Units District Hospitals DistrictBase/General
HospsBadulla Colombo Matale
* Sample size = 1
*Private sector = Rs 200-300
Medical officer overtime costs by district (Rs per month)
MOH-IHP Public Facility Survey 2006
6,933
9,351
7,700
8,819
4,530
6,712
5,413 5,616
8,020
7,193
4,568
-
1,000
2,000
3,000
4,000
5,000
6,000
7,000
8,000
9,000
10,000
Centraldispensary
Rural Hospitals Periperal Units DistrictHospitals
DistrictBase/General
Hosps
Teaching Hosp SpecialisedHospitals
Colombo Matale
1,322 1,0712,1212,302
40,977
-
5,000
10,000
15,000
20,000
25,000
30,000
35,000
40,000
45,000
Badulla Matale Colombo
Public Private
Public-Private Comparison:Admission costs, small hospitals
Bed size < 70
MOH-IHP Public Facility Survey 2006
1,730 1,679
8,966
49,930
-
5,000
10,000
15,000
20,000
25,000
30,000
35,000
40,000
45,000
50,000
55,000
Badulla Matale Colombo
Public Private
Public-Private Comparison:Admission costs, large hospitals
Bed size > 70
MOH-IHP Public Facility Survey 2006
44
815
65
-5
13
2428
170
118
613
90
--
20
40
60
80
100
120
140
160
180
Dis
tric
tH
osp
ital
s
Dis
tric
tB
ase
Ho
spit
als
Pro
vin
cial
Ho
spit
als
Pri
vate
Ho
spit
als
Dia
gn
ost
icF
acili
ties
Dis
tric
tH
osp
ital
s
Dis
tric
tB
ase
Ho
spit
als
Teac
hin
gH
osp
ital
s
Sp
ecia
list
Ho
spit
als
Pri
vate
Ho
spit
als
Dia
gn
ost
icF
acili
ties
Dis
tric
tH
osp
ital
s
Dis
tric
tB
ase
Ho
spit
als
Pri
vate
Ho
spit
als
Dia
gn
ost
icF
acili
ties
MOH MOH MOH PRIVATEPRIVATE MOH MOH MOH MOH PRIVATEPRIVATE MOH MOH PRIVATEPRIVATE
Badulla Colombo Matale
* Public sector costs include only salary costs
Public-Private Comparison:WBC/DC Costs
Public-Private Comparison:Chest X-ray Costs
-
201
174 175
- -
148
189
268
304
243
130 131
- --
50
100
150
200
250
300
350
Dis
tric
tH
osp
ital
s
Dis
tric
tB
ase
Ho
spit
als
Pro
vin
cial
Ho
spit
als
Pri
vate
Ho
spit
als
Dia
gn
ost
icF
acili
ties
Dis
tric
tH
osp
ital
s
Dis
tric
tB
ase
Ho
spit
als
Teac
hin
gH
osp
ital
s
Sp
ecia
list
Ho
spit
als
Pri
vate
Ho
spit
als
Dia
gn
ost
icF
acili
ties
Dis
tric
tH
osp
ital
s
Dis
tric
tB
ase
Ho
spit
als
Pri
vate
Ho
spit
als
Dia
gn
ost
icF
acili
ties
MOH MOH MOH PRIVATEPRIVATE MOH MOH MOH MOH PRIVATEPRIVATE MOH MOH PRIVATEPRIVATE
Badulla Colombo Matale
* Public sector costs include salary costs + supplies only
Key Findings (1)
Variation in unit costs between districts is not great Significant variation in unit costs between individual
facilities, but largest variation is between levels of facility
Unit costs in public sector increase uniformly in all districts by level of hospital
Costs increase by level with longer admissions, greater levels of service provision, more complex case loads
Unit costs by themselves do not indicate inefficiencies. Must also look at case complexity, services provided, location and demand profile, etc.
Key Findings (2)
Public sector costs generally the same or lower than in private sector Need to consider purpose of exercise: If concern is
contracting-out, then overhead costs should be excluded Admission costs in private sector significantly higher than in
public sector No compelling evidence that contracting routine clinical
services out will produce significant cost savings - opposite might be true
Actual overtime costs appear to be significantly less than implicit liabilities Variation in overtime costs may be due to many factors,
including availability of overtime budget
Issues What is purpose of exercise?
Need to clarify in order to interpret data Unit costs may be useful at facility level, not at district BUT … unit costs alone are not good measure for assessing facility
efficiency or performance, see UK NHS experience Feasibility
Measurement difficult owing to lack of routine financial data at level of institutions - need for surveys
Short term priority should be improving information system Use of IHP-MOH PFS 2006 data
Survey is potentially valuable data source for examining determinants of facility efficiency in combination with other information Further analysis should be done by IHP/MOH Results should be fed back to individual facilities