Acknowledgement

This dissertation would not have been possible without the guidance and the help of
several individuals who in one way or another contributed and extended their valuable
assistance in the preparation and completion of this study.
First and foremost, my utmost gratitude is to Dr. Rohan P Perera, my Supervisor and I
specially thank Mrs. Kamani Mathotarachchi, coordinator of Service Management Unit,
for her guidance and support given me all the time. I gratefully acknowledge Mr. C.
Athapattu Senior Lecturer University of Colombo, his attentive comments and
supervision made my project a success.
I specially thank to Dr. Anil Jasinghe, Director/NHSL for his immense support and
guidance given me during whole process. I thank all other officials in NHSL and my
colleagues at Out Patient Department, National Hospital Sri Lanka who always
encouraged and kept me relaxed with moral support.
I would gratefully appreciate former health minister Mr. Maithreepala Sirisena and
present health minister Dr. Rajitha Senarathne for their support with positive aptitude on
this study. Furthermore I highly appreciate Dr. Palitha Maheepala, Director General,
Health Services, and all supportive officers in Ministry of Health and National Hospital
for their support given me during the research.
I acknowledge the academic and research panel of Sri Lanka Society for Medical
Laboratory Science (SLSMLS), for their immense support given in primary data
collection of my research.
Last but not the least; I am extremely grateful for all my family members for being with
me all the time and for their gigantic support and encouragement.

Abstract
Government of Sri Lanka maintains the policy of free services in government institutions
and every citizen can obtain free health care service at state institution. It is expected to
cover the health expenditure with no out of pocket share as a mode of allocation.
Therefore government health expenditure is an important fraction for country health
system. Present situation reveals government free health care services have not been able
to cover every citizens health care needs completely under free health system and which
has been created a challenging situation in free health concept of the country.
This study was based on the analysis of present situation through economic and social
sustainability. Economic sustainability has been studied through health financing system
analysis and calculating cost per patient. These two were carried out by using secondary
data. Cost per patient was calculated considering data of National Hospital of Sri Lanka
as a model of free health institutions Social sustainability has been studied by social
outcome through patient (main stake holder) satisfaction. It was carried out by using
primary data of a survey done on clinic, OPD and Inward patients via a questionnaire.
Questionnaire was analyzed by SPSS software for satisfaction on staff, treatment and
facilities as independent variables and overall satisfaction and recommendation as
dependent variables. The out of pocket contribution was also analyzed.
Secondary data have proven a gap between state health financing and total health
expenditure and increased out of pocket share of health financing during last ten years.
Cost per patient on recurrent health expenditure is at fairly unaffordable state and overall
satisfaction of patient is moderate. Patients have better satisfaction on staff than on
treatment and facilities. Clinic patients and Inward patients have spent most of the time
out of pocket in order to complete the health care requirements.
Increasing the GDP contribution as the principal mode of health financing and use of
suitable strategy such as budget allocation via tax, funds of NGO and donations etc.
should be introduced to cover up the gap of total health expenditure. On the other hand
reconsideration of health policy for improving national health profile, with existing GDP
contribution is important while looking after low income population and provision of
quality service to the high income population.

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List of Tables
Table

Name

Page

Table 4.1

Total expenditure on health. 24

Table 4.2

Expenditure on health (% Total) 1993 -2005. 25

Table 4.3

Trends in health care spending, 1953-2005....................... 27

Table 4.4

Use of free health facilities. 28

Table 4.5

Summary of NHSL health expenditure...31

Table 4.6

Patient statistics of NHSL... 31

Table 4.7

Cost per patient at NHSL in year 2012 and 201432

Table 4.8

Cronbach's alpha table for variables....33

Table 4.9

Descriptive statistics....33

Table 4.10

Statistics of responses.. 34

Table 4.11

Frequency table... 34

Table 4.12

Model summary....35

Table 4.13

ANOVAb. .35

Table 4.14

Coefficients a....36

Table 4.15

Tests of normality.... 37

Table 4.16

Summary of clinic patients statistics.... 39

Table 4.17

Clinic patient overall satisfaction frequency table.. 39

Table 4.18

Clinic patients recommendations frequency table.. 39

Table 4.19

Clinic patients private sector utility frequency table.... 40

Table 4.20

Summary of OPD patients statistics...40

Table 4.21

OPD patients overall satisfaction frequency table. 40

Table 4.22

OPD patients recommendations frequency table.. 41

Table 4.23

OPD patients private sector utility frequency table.. 41

Table 4.24

Summary of Inward patients statistics.. 41

Table 4.25

Inward patients overall satisfaction frequency table. 42

Table 4.26

Inward patients recommendations frequency table. 42

Table 4.27

Inward patients private sector utility frequency table.. 42

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List of Figures
Figure

Name

Page

Figure 2.1

Social determinants of health.....06

Figure 2.2

Triple bottom lines of sustainability.......12

Figure 3.1

Conceptual framework for healthcare sustainability.....15

Figure 4.1

Total health expenditure of Sri Lanka (% of GDP)....21

Figure 4.2

Estimated growth of health expenditure by Sri Lanka, 2001-2015...22

Figure 4.3

Public health expenditure (% of Total health expenditure)....22

Figure 4.4

Share of total health expenditure, 2002......23

Figure 4.5

Contribution of private and government sector for health financing......25

Figure 4.6

Private health financing..... 26

Figure 4.7

Health financing in Sri Lanka.29

Figure 4.8

Scatter plot for dependent variable.37

Figure 4.9

Q-Q plot of standardized residual...38

ix

Abbreviations
AIDS

Acquired Immune Deficiency Syndrome

ENT

Ear Norse and Throat

ETF

Employees Trust Fund

GDP

Gross Domestic Product

IHP

Institute of Health Policy

JICA

Japan International Cooperation Agency

MoH

Ministry of Health

MoHP

Ministry of Health and Population

NGO

Non Government Organization

NHSL

National Hospital of Sri Lanka

NIC

National Insurance Contribution

OPD

Outpatient Department

UN

United Nations

WHO

World Health Organization

Annexures
Annexure - 01

Country Health Profile Sri Lanka

Annexure - 02

Health care spending around the world country by country, 2012

Annexure - 03

Questionnaire and Answer summery

Annexure - 04

The World Health Organization Ranking

Annexure - 05

Summary of Health Expenditure 2002 2012

Annexure - 06

Estimates 2012, Ministry of Health

Annexure - 07

Annual Hospital Statistic Bulletins National Hospital

1. Annual Hospital statistic bulletin 2012
2. Annual Hospital statistic bulletin 2013

Annexure - 08

Supervisory Report

xi