Sri Lanka, as a developing country has achieved remarkable health outcomes among south Asian countries and some developing countries. This is especially true of infant mortality, maternal mortality rate and child mortality rate has been declining over last two decades by acquiring benchmark status of millennium development goals. Compare with social factors among regional country, life expectancy rate, as well as literacy rate has increased up to higher level. Health sector in Sri Lanka could have achieved these successful results as a result of welfare oriented economic and good health policies. Under this circumstance, I can highlight free education, widespread networks of free health care services and food subsidies as the major influenced policies had taken in the past. Hence, especially health sector of Sri Lanka has brightened as “Good health at low cost” in the world. (Hsiao and Associates 2001).
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Nevertheless, Sri Lanka as a developing country is also confronting universal phenomenon of the “cost increasing of health care” which is an immense challenge to the government. Growing expectation towards quality health care has made an extra burden to the government to think about quality of service and enhancement of health infrastructures. Moreover, increasing elderly population, changing of diseases pattern from communicable disease to Non-communicable diseases has been increasing health care expenditure on both preventive and curative. Always, improvement of technology and education level of the society causes to increase the demand for health care consumption. However health care service in Sri Lanka has failed to fulfill its demand. Likewise, lack of resources may trend to form less quality of services, long queue in the health centers due to inefficient of resource allocation and production services. It has revealed that the transition of demographical and epidemiological have caused to increase health expenditure in tremendously in all the in the world. Specially, health sector of Sri Lanka has confronted to this problem by opening new gateway to reorganize the comprehensive health care delivery system. In this case, many researchers has shown that the way of rationalized health care system involves expansion of primary and secondary care health units rather than establish new hospitals (Somanathan, 1998). One of the optimal solutions is the increasing efficiency in hospitals to address less quality as well as inefficient recourses mobilization of health care services. As a policy implementation for these problems, government has implemented 10 year master plan towards( 2007-2016) “Healthy and Shining Island in the 21st century” (The Health Master Plan ,HMP, 2005).
Research Focal point – North Western Province
North Western Province is the second largest province of the country. It has a population of 2,372,528 and comprise of two districts, Kurunegala and Puttalam. The land area of the province is 7888 sq Km and the population density is 303 persons per sq Km. The majority of the population are Sinhalese while the rest are Tamil, Muslim and Malay.
The province is bounded by the sea on the west, by Central province on the east, by North Central province on the north and by Sabaragamuwa and central province on the south. It is situated about 500 meters above the mean sea level.
The province basically has a dry climate and number of small and large lakes were scattered throughout the province. Since, from the old days the economy of the province was based on agriculture. Majority of the work force are engage in jobs based on agriculture.
The capital of the province is Kurunegala and it has a historical importrance. Due to the frequent invasions of the South India and malaria epidemics the capital of Sri Lanka was shifted from Anuradapura and Polonaruwa to the North Western Province. Dabadeniya, Yapahuwa and Kurunegala become the capital of the country which was situated in the geographical limit of the present North Western Province.
Administratively the province is governed by the North Western Province, Provincial council headed by the Governor.
Health Care services in North Western Province
The health care services in the province are mainly provided by the Provincial Department of Health Services of NWP, headed by the Provincial Director of Health Services (PDHS) who is administratively responsible to the Ministry of Health, Indigenous Medicine, Sports and Youth affairs of NWP. The Office of the Provincial Director of the Health Services is the main administrative centre of the Department of Health Services of the North- Western Province, which is located in Kurunegala. In addition there are two Deputy Provincial Directors of Health Services (Renamed as Regional Directors of Health Services -RDHS) for Kurunegala and Puttalam districts.
Curative care services are provided by 141 health care institutions and preventive care is promoted by the 29 Medical Officer of Health (MOH) offices in the province. Other than this anti malaria campaign, anti filarial campaign, Rabies control program, Tuberculosis and Chest disease control programe and Sexually Transmitted Infection prevention program play a major role in preventive care in the province. People in some part of Puttalam district had been suffering from thirty year in many ways by terrorist struggle which has ended in last year. Health situation in those areas are fairly worse. It is also a direct specific challenge to the provincial health department to be solved.
Health Indicators
Indicator
2005
2006
2007
2008
Kurunegala
Puttlam
Kurunegala
putttlam
Kurunegala
putttlam
Kurunegala
Putttlam
Infant Mortality Rate
(for 1000 Live Births)
14
13.9
12.2
10.3
12.2
11
12
11
Maternal Mortality Rate
(for 100000 live births)
30.8
61.0
33.5
45.8
32.8
32.4
32.1
45.4
Still Birth rate
18.4
15.9
9.6
18.3
9.3
8
8
7
Crude death rate
5.6
4.6
5.7
5.4
6.13
5.5
5.8
5.4
Table 1Source:- H-509 Kurunegala & Puttalam Distrct and Family Health Bureau, 2008.
Problems and Its Significance:
In Sri Lanka both private and public sectors provide health care services. Most of the private sectors perform mainly only urban area. Therefore, private medical service is not affordable for everyone who needs it in Sri Lanka. Public sector is the main health care provider in both curative and preventive care services. All these services almost funded by government budget and provide in point of delivery. It is given free of charge to the patients without considering income or any other level. Even so, increasing health care cost continuously has created a big challenge to cater for free health care services, moreover. Therefore, government needs to implement new program and policy to finance health care system in Sri Lanka. As mentioned above, health services in Sri Lanka free of charge at the point of delivery. Even so, according to Sri Lankan National Health Account, More than 50% of total health care expenditure has burden to the private sector and more than 85% from it comes from out of pocket. This evidence shows us that patients have been bearing some of their medical cost, but still government provides it free.
Point 4
Point 3
Point 1
Point 2Increasing health care cost creates new problems in Sri Lanka. Mainly budget constrains, drug shortage, less usage of medical technology in the hospitals, poor maintain the whole system and week strengthening hospitals, moreover. Increasing people’s expectation or demand for health towards quality health care has made another burden to the government health sector to think about the quality of service and enhancement of health infrastructures. Another problem is that span of the hospital utilization rates is more varying in between secondary and tertiary care hospitals because of most of the time patient is trying to bypass the secondary care hospitals without referrals due to the pleasant facilities in the big hospitals (Attanayake, 1993). This phenomenon creates overcrowding or over utilization of tertiary care facilities and on the other hand, underutilized in secondary care facilities,
However, the government has not decided to puss burden of health expenditure and educational expenditure towards their people but however indirectly affected the people due to imposing direct and indirect tax for financing.
One of the best solutions for these problems is increasing hospital efficiency by allocating resources in the proper manner. As evidence, MOH has started a threefold project collaboration with Japanese international corporation agency (JICA) to answer major three problems that have faced in the last decade. This project has launched in the north western province by (1) implementing the cost accounting system for the hospitals, (2) improving hospital productivity by absorbing 5S and TQM techniques and (3) conducting NCD prevention program.
Scope of the study
The scope of the study is to evaluate the inpatient care hospitals in north western province of Sri Lanka in terms of provider prospective by the technical and scale efficiencies. And, the study is focus to identify marginal effect of factors which is affect to them.
Research Questions:
What is the technical efficiency score in secondary and tertiary care government hospitals in the north western province in Sri Lanka?
What is the scale efficiency score in secondary and tertiary care government hospitals in the north western province in Sri Lanka?
What may be the most affect influence factors for the efficiency?
Objectives:
General Objectives:
To calculate the hospital technical efficiency (TE) and scale efficiency (SE) of secondary and tertiary care hospitals in North Western Province.
Specific Objectives:
To evaluate the technical efficiency (TE) of secondary and tertiary care government hospitals in the north western province of Sri Lanka.
To evaluate the scale efficiency (SE) of secondary and tertiary care government hospitals in north western province of Sri Lanka.
To determine the factors affecting to change efficiency.
Benefits of this study
Basically, we can identify individual efficiency of each hospital to evaluate among them. These findings will be helpful to pay much attention about factors which is affecting to acquire higher level efficiency, in the policy making process as a guideline. Also, hospital administrators of inefficient hospitals can identify their level of efficiency and weaknesses with respect to the higher level efficient hospital in same level and they can eliminate and reduce the unnecessary costs from their process and can proceed in strategies, which have been followed by the best hospitals. And also these study results can be use for the provision of resources and mobilization efficiently manner in point of budgeting and allocation. Hospital utilization gap can be reduced by implementing the appropriate solutions for relevant MDUs after identifying the efficiency level.
Methodology:
Data Envelopment Method (DEA) which has been wildly used by the many researchers is used to calculate the technical efficiency (TE) and scale efficiency (SE). Secondly, this study used linear regression model (OLS) to analyze the relationship among efficiency and factors, which may affect to change it.
Selection of Data
I use Secondary panel data where belongs to the period of year 2008-2010 in 63 hospitals
Data sources
Mainly, secondary data will be used for this study from medical record unit & planning department in department of health services, north western province. Secondly, primary data which is not available in department level will be collected from each hospital.
Inputs for DEA
# of beds
# of medical doctors ( Consultant + Medical Officers + Register
Medical Offices + Dentists)
# of nursing officers ( Nursing Officers + Nursing Sisters+ Matrons)
Other staff ( Pharmacist + X-ray and other technicians+ attendants + etc)
Outputs DEA
# of OPD visits
Total inpatient days
# of visits for clinic (only first visit)- [Eye, Medical, Surgical,
Pediatric, Baby, Gynecological, Antenatal]
Bed occupancy rate [(patient days*100)/(beds*365)
Variables for RA.
Death rate (Deaths/Inpatient addmision)- quality of service
Average length of stay – Resources consumption
Doctors and Nurses ratio -Labor cost
Beds and doctors ratio – Capital expenditure
Bed occupancy ratio – Bed utilization
No of Clinic visits per doctor – Utilization of hospital
IP addmissions and doctor ratio –
OP visit and doctor ratio –
Patient transfer rate to higher level hospitals – Risk and cost of ambulance.
Urban and semi urban and rural – [Dummy]- Resource allocation
Number of wards and mision centers –
Sample size acording to the Hospital Hierarchy
(Hospital Re-categorization,2007)
Type of service
Type of Institution
Bed Range
Sample Size
Lower
Upper
Tertiary Care
Teaching Hospital
257
3264
01
Provincial Hospitals
255
1328
01
Base Hospitals
67
816
06
Secondary Care
District Hospitals
16
484
17
Peripheral Unit
17
147
17
Rural Hospital
4
112
21
Primary Care
CD & MH
1
41
N/C
CD
1
10
N/C
Special Hospital
Others
11
1325
N/C
Total Decision Making Units
63
Note: N/C – Not consider in this study
Decision Making Units (DMUs)
Serial #
Hospital
Category
Bed Strength
Dummy *
Urban/Semi=1 Rural = 0
1
Krunegala
TH
N/A
1
2
Chilaw
GH
N/A
1
3
Kuliyapitiya
BH
402
1
4
Nikaweratiya
BH
273
1
5
Galgamuwa
BH
117
1
6
Dambadeniya
BH
169
1
7
Puttalam
BH
N/A
1
8
Marawila
BH
N/A
1
9
Alawwa
DH
98
1
10
Bingiriya
DH
78
1
11
Gokarella
DH
121
1
12
Hettipola
DH
79
1
13
Hiripitiya
DH
119
1
14
Katupotha
DH
66
1
15
Maho
DH
110
1
16
Mawathagama
DH
106
1
17
Polgahawela
DH
93
1
18
Polpithigama
DH
107
1
19
Ridigama
DH
93
1
20
Sandalankawa
DH
104
1
21
Wariyapola
DH
124
1
22
Anamaduwa
DH
N/A
1
23
Dankotuwa
DH
N/A
1
24
Kalpitiya
DH
N/A
1
25
Mundalama
DH
N/A
1
26
Ambanpola
PU
80
0
27
Dunakadeniya
PU
20
0
28
Giribawa
PU
N/A
0
29
Kadanegedara
PU
50
0
30
Kobaigane
PU
48
0
31
Kotawehera
PU
26
0
32
Mahagirilla
PU
23
0
33
Mahananneriya
PU
29
0
34
Meegaleewa
PU
61
0
35
Muwanhela
PU
26
0
36
Narammala
PU
60
1
37
Nikawawa
PU
57
1
38
Pahalagiribawa
PU
55
0
39
Thalampitiya
PU
52
0
40
Galmuruwa
PU
N/A
0
41
Lunuwila
PU
N/A
0
42
Madampe
PU
N/A
0
43
Ahatuwewa
RH
12
0
44
Atharagalla
RH
12
0
45
Bopitiya
RH
16
0
46
Delwita
RH
35
0
47
Gonawa
RH
17
0
48
Gonigoda
RH
42
0
49
Idulgodakanda
RH
16
0
50
Karambe
RH
20
0
51
Koshena
RH
11
0
Serial #
Hospital
Category
Bed Strength
Dummy *
Urban/Semi=1 Rural = 0
52
Mahamukalanyaya
RH
33
0
53
Nagollagama
RH
20
0
54
Nawathalwatte
RH
18
0
55
Rajanganaya
RH
18
0
56
wallawa
RH
37
0
57
Weerapokuna
RH
12
0
58
Anawilundawa
RH
N/A
0
59
Kottukachchiya
RH
N/A
0
60
Mahakumbukkadawala
RH
N/A
0
61
Nawagattegama
RH
N/A
0
62
Thabbowa
RH
N/A
0
63
Udappu
RH
N/A
0
Note: N/A – Not available at this time
GH- General Hospital, BH- Base Hospital, DH- District Hospital
* – Tentative dummy classification
Maps
Hospitals in Kurunegala District
Teaching Hospital – 01
Base Hospitals – 04
District Hospitals – 13
Peripheral Units – 13
Rural Hospitals – 15
Central Dispensaries – 57
Roads
Hospitals In Puttalam District
General Hospital – 01
Base Hospitals – 02
District Hospitals – 04
Peripheral Units – 03
Rural Hospitals – 06
Central Dispensaries – 24
Roads
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