how much do health services cost? findings from three districts

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


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


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


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


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


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)


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


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


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

how much do health services cost? findings from three districts

Documents

msd data

facilitytreasury data

accessible data

data sourcesdrug expenditures

private hospitals

private laboratories

private doctors

central mohtreasury