Study of Quality of Care in Public and Private Sectors - IHP · Study of Quality of Care in Public...
Transcript of Study of Quality of Care in Public and Private Sectors - IHP · Study of Quality of Care in Public...
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Study of Quality of Care in Public and Private Sectors
Research Symposium Quality of Healthcare in Sri Lanka
Hosted by SLMA, CMASL and IHP
30 August 2013
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Study Organization
*Study Team – Isurujith K Liyanage, Janaki Jayanthan, Nilmini Wijemanne, Sanil
de Alwis, Sarasi Amarasinghe, Indika Siriwardana, Shanti Dalpatadu, Prasanna Cooray, R P Rannan-Eliya
Study Objective – To assess levels and differences in quality of care in public and
private medical sectors in Sri Lanka
Funding – World Bank contract to IHP, IHP Public Interest Research Fund
Grant PIRF-2012-03, IDRC Grant 106439-003
Ethical Review – Ethical review and clearance of study design and survey
instruments by IHP Ethical Review Committee (IHP ERC Approval Nos. 2012/006A, 2012/006B)
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Outline
• Study Organization • Background • Methodology • Findings • Conclusions
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Background - Importance of measuring quality - Background on Sri Lanka
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Why did we measure quality?
• How to optimise the contribution of the private sector within Sri
Lanka’s mixed health system? – Who they treat – Relative costs – Quality of care provided
• Research questions – Does clinical quality differ between the public and private sectors in
Sri Lanka – Does interpersonal quality differ between the public and private
sectors in Sri Lanka
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Concepts
What is quality? • “The degree to which health services for individuals and
populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.” – Institute of Medicine 1991
Dimensions of quality (Donabedian 1980) • Structure
– Whether providers have correct inputs, equipment, training, etc. • Process
– Whether good practices are followed • Outcomes
– Impact of medical services on patients, including health outcomes and patient satisfaction
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Measuring process quality
• No widely accepted approach • Methods differ
– Developing countries: • Single conditions • Little relevance to Sri Lanka (tuberculosis, HIV, malaria)
– Developed countries • Broader methods (range of conditions)
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Utilization of healthcare services CBSL CFS 2003/04
45%
55%
Outpatient
8
96%
4%
Inpatient
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Key indicators of hospitals in Colombo, Gampaha, Galle (2011)
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Sources: Management Development and Planning Unit (2011) and Institute for Health Policy (2013)
Category Hospitals Beds Admissions Inpatient spending per admission
n n n rupees
!"#$%&'()*+%,-$* ./ /01232 456'7%$$%)8 401/2.
!9%:-,;'()*+%,-$* 63 /1<2= 05/'7%$$%)8 231643
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Inpatient quality of care
Comparison between public and private sectors
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Methodology - Study design - Tracer indicators & inclusion criteria - Sampling
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Study design – inpatient care Overview
• Study object – Process quality, i.e., what providers actually do
• Approach – Retrospective review of inpatient medical records – Analysis of care using tracer conditions
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Inpatient tracer conditions
Criteria for selection • Conditions should be relatively frequent • Feasible quality indicators should exist with support in literature
• Should be representative of a range of conditions and patient populations
Tracer conditions (initial) 1. Acute Myocardial Infarction (AMI) (1% of discharges) 2. Acute Asthma (4% of discharges)
3. Childbirth (6% of discharges)
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Selecting quality indicators
• Identified possible quality indicators – Quality clearing houses – Quality assessment agencies – Studies: developed and developing countries – Clinical guidelines
• Review by panel of doctors
• Subsequent review of RAND quality assessment tool – Identification of additional tracer conditions and quality indicators – Choice of method to aggregate quality indicators
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Inpatient Quality Indicators 55 Quality Indicators
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Condition
Asthma (7)
AMI (15)
Childbirth (10)
Other (TIA, Dengue, COPD,
Heart Failure, Pneumonia)
Resource Intensity
Low (12)
Medium (33)
High (4)
Drug prescribing
All drug prescribing
(36)
DVT prophylaxis
(9)
Surgical antibiotics
(4)
Clinical area
Assessment and investigations (10)
Management (39)
Outcome (6)
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Inpatient quality indicators – examples
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Indicator Condition Clinical area Resource intensity
Drug prescribing
Neonatal APGAR score recorded
Childbirth Assessment / Investigations
Low -
Prophylactic antibiotics given during LSCS
Childbirth Management Medium All drug prescribing, surgical antibioitics
Live discharge, AMI AMI Outcome - -
AMI patient underwent PCI / stenting
AMI Management High -
Oxygen saturation measured in acute asthma
Acute asthma Assessment / Investigations
High -
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Sampling Distribution of sampled facilities
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Colombo Gampaha Galle Total
Large 2 1 1 4Intermediate 2 1 1 4Obstetric 1 0 1 2Paediatric 1 0 0 1Other specialist 0 0 0 0
Total 6 2 3 11
Large 3 1 0 4Intermediate / small 1 2 2 5Obstetric 1 0 0 1Paediatric 0 0 0 0Other specialist 0 0 0 0
Total 5 3 2 10
Sampled facilities
Public
Private
Hospital type
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Geographic distribution of sampled providers
Gampaha
Colombo
Galle
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Distribution of private hospitals, Sri Lanka 2012
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Data collection and processing
Patient sampling • Systematic sample of patient records from 2011 discharges • Supplementary samples of tracer conditions
Data collection • Data extraction and entry by pre-intern medical graduates using Apple
iPads. Drug name entry using pre-coded listing of brand and generic names.
Data analysis • Diagnoses coded to ICD-10 by physician. • All analysis using Stata 12.0.
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Data collection and processing Quality and satisfaction scores
Adapted method used by RAND quality study (McGlynn et al)
• Quality instance = each opportunity a patient could potentially receive recommended care
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Data collection and processing Quality scores
22
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Findings - Inpatient quality of care
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Characteristics of patient sample
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Average age, yearsMale sex, %
Discharge diagnosesAsthma, %AMI, %Childbirth, %
Characteristic Public Sector (n = 2,523)
Private Sector (n = 1,815)
36.8 37.0 1.047.9 47.8 1.0
1.0 1.2 0.70.6 0.7 0.86.9 6.2 0.9
Weighted, standardizedStandardized p value
Average length of stay, days 3.6 3.0 0.1
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63 68
89
69† 68
89
0
10
20
30
40
50
60
70
80
90
100
Asthma AMI Childbirth
Per
cent
age
of p
atie
nts
(%)
Quality by condition
Public Private
25 Condition Resource limitation Drug prescribing Clinical area
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26
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Condition Resource limitation Drug prescribing Clinical area
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94**
58*
10
81
48
31**
0
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Low Medium High
Per
cent
age
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Quality by resource limitation
Public Private
27 Condition Resource limitation Drug prescribing Clinical area
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68*
0
68*
60
1
58
0
10
20
30
40
50
60
70
80
Drug indicators (all) DVT prophylaxis Perioperative antibiotics
Per
cent
age
of p
atie
nts
(%)
Drug prescribing
Public Private
28 Condition Resource limitation Drug prescribing Clinical area
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Difference in scores by clinical area
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Quality scores by hospital size Is quality better in small/intermediate hospitals than large hospitals?
30
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Quality scores by hospital size and resource limitation
Difference in scores compared to large hospitals
31 Condition Resource limitation Drug prescribing Clinical area
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Conclusions
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Key findings
Public vs. private • Quality is fairly similar, although the public sector is slightly
better • Private sector performs better in indicators that are resource
intensive
• Smaller hospitals tend to do slightly better in both sectors in low resource intensity indicators
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Outpatient quality of care and patient satisfaction
Comparison between public and private sectors
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Study design - outpatient Overview
• Study objects: Process quality and Patient Perceptions
• Approach – Observation of patient consultations
• Analysis of care using tracer conditions
– Exit interview of patient • Patient satisfaction • Socioeconomic background and ethnicity
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Final conditions
• Common conditions from Sri Lanka Primary Care Survey, 2000 • Conditions with quality indicators used in other settings – India
study, RAND – Cough
– Diarrhoea
– URTI & tonsillitis
– Asthma
– Hypertension
– Diabetes
– Pregnancy
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Quality indicators 39 quality indicators
37
Condition Diarrhoea (7)
Cough (4)
Hypertension (7)
Diabetes (6)
Asthma (3)
Pregnancy (2)
Clinical Area
History (6)
Examination (7)
Investigations and Management (20)
Patient education (6)
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Outpatient quality indicators – examples
38
Condition Indicator Type
Diarrhoea Patient asked about fever HistoryCough Physician performed a physical examination ExaminationDiabetes Physician gave dietary advice EducationOther Patients 65 years or older given < 5 drugs Assessment and management
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Patient satisfaction
39
Patient satisfaction
Technical (2)
Interpersonal (6)
System (2)
Overall (1)
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Sampling Distribution of sampled facilities
40
Colombo Gampaha Galle Total
Large 1 1 1 3Intermediate 2 1 1 4Obstetric 1 0 1 2Paediatric 1 0 0 1Other specialist 0 0 0 0
Total 5 2 3 10
General practitioners 27 25 14 66
Public
Private
Hospital typeSampled facilities
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41
Geographic distribution of sampled providers
Gampaha
Colombo
Galle
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Data collection and processing
Patient sampling • Systematic sampling of patients waiting for consultation • All patients asked to give consent
Data collection and analysis • Patient symptoms and doctor diagnosis coded using ICPC
– In field where possible – Coding by physicians
42
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Findings - Outpatient quality of care
43
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Final sample
• Small number of refusals • No significant differences in age and sex in participants vs.
refusals
44
n % n %
Total number of patients approached 1,971 100.0 1,948 100.0
PartipicationParticipated 1,948 98.8 1,906 97.8 Refused 23 1.2 42 2.2
Patients approached for observation of consultation
(for PER)
Patients approached for exit survey of patient
satisifcation
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Patient characteristics after standardization
45
Average age, yearsMale sex, %
Socioeconomic statusLower third, %Middle third, %Upper third, %
Characteristic Public Sector (n = 1,027)
Private Sector (n = 944)
32.2 32.1 1.035.2 35.3 1.0
29.1 14.1 0.042.2 38.8 0.428.6 47.1 0.0
Weighted, standardizedStandardized p value
Conditions of interestDiarrhoea, %Cough, %Hypertension, %Diabetes, %Asthma, %Pregnancy, %URTI and Tonsilitis, %Other, %
Length of consultation, min
1.9 2.5 0.720.8 23.8 0.56.8 6.4 0.95.3 3.0 0.32.9 5.1 0.25.9 0.7 0.316.5 26.4 0.060.3 58.5 0.8
3.1 7.8 0.0
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78† 76†
68
34
59
49
31
59 66
72
55* 54 48
40
0
20
40
60
80
100
Diarrhoea Cough Hypertension Diabetes Asthma Pregnancy URTI and tonsilitis
Per
cent
age
of p
atie
nts
(%)
Quality by condition
Public Private
46 Condition Clinical Area Patient satisfaction
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Condition Clinical Area Patient satisfaction
Quality by clinical area
47
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48
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49
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Condition Clinical Area Patient satisfaction
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72
86**
72*
12
65 65 69
63 57**
65
0
20
40
60
80
100
History Examination Investigations and management
Education Overall
Per
cent
age
of p
atie
nts
(%)
Quality by clinical area
Public Private
50 Condition Clinical Area Patient satisfaction
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51
!"#$%#$&'%($)*+,-*./012
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Condition Clinical Area Patient satisfaction
Quality by clinical area
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98*
84 84
98 96 94** 95* 98
0
20
40
60
80
100
120
Technical Interpersonal System Overall satisfaction
Per
cent
age
of p
atie
nts
(%)
Patient satisfaction
Public Private
52 Condition Clinical Area Patient satisfaction
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53
• Comparison of public and private sectors – Socioeconomic status – Ethnicity
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Process quality by socioeconomic status Difference in scores compared to the poorest tertile
54
!"#$"%&#"'"($#)*+",-
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6"#$"&#"'"($#)4&+:/&)
Condition Clinical Area Patient satisfaction
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Patient satisfaction by socioeconomic status Difference in scores compared to the poorest tertile
55
!"#$"%&#"'"($#)*+",-
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)6"#$"&#"'"($#)4&+:/&)
Condition Clinical Area Patient satisfaction
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Process quality by ethnicity Difference in scores compared to Sinhala patients
56 Condition Clinical Area Patient satisfaction
!"#$%&%"' ()%$%&*)+,-.* /01)%&+2.&"3- /-%4*".+5.&"3-!"#$% &$'()*+
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Patient satisfaction by ethnicity Difference in scores compared to Sinhala patients
57 Condition Clinical Area Patient satisfaction
!"#$%&%"' ()%$%&*)+,-.* /01)%&+2.&"3- /-%4*".+5.&"3-!"#$% !&'()$'"%
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Conclusions
58
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Key findings Outpatient
Public vs. private • Overall quality, diagnosis and treatment is similar between the
two sectors
• Patients in the private sector receive more – Time from the physician – Education and advice (independent of time from physician)
• Patient satisfaction reflects this – Overall satisfaction & satisfaction with technical aspects similar – Satisfaction with interpersonal quality & systems quality better in
private sector
59
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Key findings
• Seems to be no large systematic differences between socioeconomic and ethnic groups
• Socioeconomic groups – Richer patients scoring less in examination, investigations and
management in public sector
• Ethnic groups – Tamil patients more satisfied with the public sector – Moor patients more satisfied with the private sector
60
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International comparisons
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International comparisons
• Limited • Sources of comparison
– Indian study (Das & Hammer, 2004) – US study – RAND Quality Assessment Tool – Australian study – RAND + others
62
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100 100 100
16
84
70
97
37 28
33
18 9
0
20
40
60
80
100
120
Asked about fever Asked about vomiting Asked about stool Given oral rehydration solution
Per
cent
age
of p
atie
nts
(%)
Outpatient process quality – diarrhoea Comparison with India
Public Private India (Das & Hammer, 2004)
63
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89
27
82 80
24
74
17
7
20
0
20
40
60
80
100
Asked about fever Asked about chest pain Asked about expectoration
Per
cent
age
of p
atie
nts
(%)
Outpatient process quality – cough Comparison with India
Public Private India (Das & Hammer, 2004)
64
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International comparisons Conclusions
Sri Lanka’s performance compared to: • India
– Sri Lanka performs better
• US – Sri Lanka performs similarly in inpatient and outpatient – caveat – we are mainly looking at indicators with low resource
intensity
• Australia – awaiting – Australia’s quality study results were similar to the US
65
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Concluding Thoughts
Research Symposium Quality of Healthcare in Sri Lanka
Hosted by SLMA, CMASL and IHP
30 July 2013
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Health outcomes – Sri Lanka comparative performance
20
Source: Unpublished analysis by Institute for Health Policy commissioned by the Rockefeller Foundation as input for the Foundation’s ongoing “Good Health at Low Cost 2010” study.
Figure 4: Health outcomes against income, relative country performance, Sri Lanka and other Asia-Pacific nations
Explanations
65. Evidently, controlling for its levels of income, education, nutrition and sanitation, Sri Lanka continues to perform far better than average in terms of health outcomes. An increasing body of evidence indicates that this exceptional performance is directly linked to the superior performance of both curative and preventive health services delivery in the island and the extensive provision of health services (Caldwell et al. 1989; De Silva et al. 2001; Rannan-Eliya and Sikurajapathy 2009). So this achievement must be largely credited to the government’s healthcare policies, which have fostered universal access to basic healthcare services since the 1930s.
66. These low mortality outcomes are the result of rapid and continuous improvements over half a century (Meegama 1986). In the past, there has been academic debate about whether Sri Lanka’s achievements were merely the consequence of a very rapid initial decline, and how good its subsequent performance was (Aturupane, Glewwe, and Isenman 1994). However, from the late 1970s onwards, and again in the 1990s, the rate of decline in IMR has accelerated. This is exceptional, since during most of this latter period Sri Lanka experienced almost continual internal conflict and declining numbers of physicians. The acceleration in the reduction of the IMR can also be contrasted with the experience with the other developing country that liberalized its economy in the late 1970s – China, which has seen stagnating health indicators, despite much faster growth in incomes. The distinct divergence in performance of Sri Lanka from that of China can largely be explained by the
China
China
ChinaIndia India
India
Indonesia
Indonesia
Indonesia
Japan
Japan
Japan
Korea
Korea
KoreaMalaysia
Malaysia
Malaysia
PhilippinesPhilippines
Philippines
Singapore
Singapore
Singapore
Thailand
Thailand
Thailand
Vietnam Vietnam
Sri Lanka
Sri Lanka Sri Lanka
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1960 1990 2006
GH
ALI
Inde
x
67
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0.9
1.5
1.8
2.0
2.1
2.1
3.9
4.2
4.3
4.9
5.4
5.7
5.9
6.4
6.7
9.3
10.5
13.0
13.4
0 2 4 6 8 10 12 14 16
Papua New Guinea
Solomon Islands
China
Viet Nam
Thailand
Fiji
Brunei Darussalam
Malaysia
New Zealand
Sri Lanka
Asia-17
Mongolia
Macao
Australia
OECD
Singapore
Hong Kong
Korea
Japan
Consultations with physicians per capita
36
38
60
75
79
89
102
107
109
113
120
125
137
140
145
162
163
228
234
254
0 50 100 150 200 250 300
Papua New Guinea
Bangladesh
China
Solomon Islands
Macao
Fiji
Singapore
Japan
Malaysia
Brunei Darussalam
Viet Nam
Asia-18
Thailand
New Zealand
OECD
Korea
Australia
Mongolia
Hong Kong
Sri Lanka
Hospital discharges per 1000 capita
Health services utilization, Sri Lanka and regional countries
68
Source: IHP-OECD AP HaG 2010 Database
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Utilization of healthcare services, 2003
45%
55%
Outpatient
69
96%
4%
Inpatient
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Concluding Thoughts on Sri Lanka’s Mix • To a large extent achieves comparable clinical quality across
income levels – Except expensive services for the better off – Segregation is largely achieved through differences in interpersonal
quality • But
– Improving quality overall probably does need to address interpersonal quality
• Important for patient perception • Related to better management of NCDs
• Quality in public sector – Largely constrained by resource/funding levels – Private sector cannot provide that better quality at comparable cost
levels, so improvements in system quality will depend on increased public financing
70