The determinants and costs of bypassing small hospitals in a ‘free’ health system: A cross sectional study in Sri Lanka

Background: Rising out-of-pocket health expenditure due to policy issues is a major factor contributing to deterioration of efficiency and equity of healthcare systems.

Objective: The objective of this study was to estimate the determinants of bypassing divisional hospitals in Sri Lanka, and to estimate the effect of bypassing behaviour on the direct out of pocket costs of the patients.

Methods: The study employed a hospital based cross sectional analytical design. Out patients department of District General Hospital – Gampaha was selected as the referral facility. Out patients departments of the two selected divisional hospitals were selected as the bypassed facilities. The patients who bypassed the two divisional hospitals and attended the out patients department of the general hospital were identified using a screening tool and a map. The reasons for bypassing were evaluated among those who bypassed. Out of pocket costs of the bypassed were assessed using an interviewer administered questionnaire and compared with the patients who did not bypass the divisional hospitals. Bivariate analysis of the out of pocket expenditure was performed using the Mann-Whitney test, placing the level of significance at 0.05.

Results: Patients who bypassed the divisional hospitals were more likely to be married, permanently employed, and have monthly incomes above Rs. 20000. The mean out of pocket expenditure for travelling of bypassed patients and their family members was more than four folds higher than those who did not bypass. The out of pocket expenditure on meals and snacks was also higher among the bypassed. However, more patients among the bypassed group had to spend on outside purchase of medicine and investigations. The average out of pocket expenditure among the bypassed group was about 75% greater than (Rs 63/= more) their counterparts who did not bypass.

Conclusions: Bypassing increases the out of pocket expenditure of patients. A primary care based model with designated draining areas and proper referral policies would help to address the issue.