• Improving hospitals’ record keeping systems recommended

The timely maintenance of and planning concerning laboratory equipment will also help reduce the cost of laboratory investigations.

These recommendations were made in an article on the "Cost study of three selected laboratory investigations at different levels of health care institutions in the Western Province" which was authored by H.M.P. Perera and P.G.P.S. Karunarathna (both attached to the Colombo East Base Hospital in Mulleriyawa), and D. De Silva (attached to the Peradeniya University's Community Dentistry Department) and published in the Sri Lankan Journal of Medical Administration's 23rd Volume's First Issue in December 2022.

In Sri Lanka, laboratories are available in both the Government and private hospitals. In the Government sector, curative care institutions can be categorised into three levels (according to the Annual Health Bulletin of 2016), namely, primary care institutions (Divisional Hospitals Types A, B and C, and the Primary Medical Care Units), secondary care institutions (Base Hospitals Types A and B) and tertiary care institutions (the National Hospitals, Teaching Hospitals, Provincial General Hospitals, and District General Hospitals). Laboratory investigations are available at all these levels as appropriate to each. Laboratory services, per the Manual on Laboratory Services (2011), are imperative for confirming the diagnosis, seeing the effectiveness of the treatment, and identifying possible risk factors by screening for diseases. Therefore, the availability of quality laboratory services is vital.

Cost awareness is a way of achieving optimised services and resource utilisation. P. Athapaththu's "An assessment of the cost of the blood investigation component of the antenatal package - A case study in the Monaragala District" mentions that the underutilisation of primary health care and gaps in prioritising laboratory services can be identified as out of pocket expenditures.

Offering quality laboratory services for screening, diagnosing, monitoring, and maintaining proper care is imperative. Focusing on the cost at different levels of hospitals is important since it allows the costs to be linked to differences in resource availability and the patterns of facility utilisation.

A. De Silva, K. Dalpadadu, S. Samarage and A. Das's "Assessment of the prospect of paying wards in Government hospitals as complementary financing for hospitals in Colombo" notes that Sri Lanka is a country that provides free health services to all its citizens while struggling to cope with trending economic challenges and evolving global market conditions. The health care expenditure in Sri Lanka has consistently shown a similar pattern with 72% spent on curative services and only 3% on preventive services, while 20% is spent on purchasing drugs, medical equipment, and supplies for medical investigations over the years from 2014–2016. Thus, G. Ranasinghe's "Study of out of pocket expenditure for laboratory investigations incurred by patients attending the diabetic clinic at the Panadura Base Hospital" observes that accurate allocations to different components will be well guided if the costs of different service provisions are available.

The study by Perera et al. selected the Lady Ridgeway Hospital for Children in Colombo (LRH) as a tertiary care institution, the Horana Base Hospital as a secondary care institution, and the Bandaragama Divisional Hospital as a primary care institution. These institutions have similar socio-economic backgrounds and epidemiological patterns. A cross sectional, descriptive study was carried out. The laboratories of all three Hospitals receive samples directly from the wards and the Outpatient Departments (OPDs). The Full Blood Count (FBC), the C-Reactive Protein (CRP - CRP is a protein that the liver makes and normally, one has low levels of c-reactive protein in one's blood but one's liver releases more CRP into the bloodstream if one has an inflammation in the body, and therefore, high levels of CRP may mean that one has a serious health condition that causes inflammation) test, and the Urine Full Report (UFR) were selected considering the availability at all levels. The study was conducted from May to July 2019. The data were extracted from the laboratory records. The total number of investigations done during the study period at each institution was considered and therefore, all the FBC, the UFR, and the CRP tests that were performed at the OPDs laboratory settings during the study period were included, but investigations performed in the wards or at night were excluded. The total cost of each investigation included all the costs from the time of drawing blood to the issuing of the report. All the identified elements that had contributed to the cost related to the selected investigations were listed. The list included direct, indirect, and other costs including salaries, material costs, equipment costs, and other relevant costs incurred to sustain the laboratory operations. Finally, the total cost was determined based on the step down method (D.L. De Lanerolle's "Cost analysis of patient management in an OPD and the study of the impact of a cost awareness programme on prescribing practices") of costing. In this cost analysis, the fixed capital cost (land, buildings, furniture, equipment, and the cost of other fixed assets) and recurrent and variable costs (water, electricity, cleaning, telephone, stationary, consumables, reagents, and staff salaries) were considered under the relevant heads of direct, indirect, and other costs. However, the buildings are more than 25 years old in all three Hospitals while the land cost tends to vary significantly due to the prevailing market conditions. Therefore, per C. Perera's "Estimation of the provider cost, out of pocket expenditure for cataract surgery, Homagama Base Hospital" and J.H. Dassanayaka's "Cost per patient day in the intensive care unit and cost awareness among medical officers and nursing staff at the Horana Base Hospital", the costs of buildings and land were ignored due to the fact that adding those values can impart a huge impact on the final cost estimation.

Accordingly, the cost of a FBC in the LRH, the Horana Base Hospital, and the Bandaragama Divisional Hospital was Rs. 301.16, Rs. 255.19, and Rs. 380.83, respectively while the cost of a CRP test was Rs. 264.46, Rs. 237.70, and Rs. 85.63 and the cost of a UFR was Rs. 130.21, Rs. 126.42, and Rs. 81.83, respectively, in the same Hospitals.

Though there was no wide variation in the percentage of the recurrent cost for the FBC testing at the cost centres, a significant difference was observed in the range of the cost at the cost centres. The lowest value was seen at the Horana Base Hospital. In the Bandaragama Divisional Hospital, it recorded the highest value as there was a considerably higher contribution of the equipment cost with a lesser number of tests being performed. The cost of a FBC was the highest in the Bandaragama Divisional Hospital and the lowest at the Horana Base Hospital. It was because of the unusually high cost of equipment at the Bandaragama Divisional Hospital. The considerations on the calculation of the capital and recurrent cost for the CRP test were similar to the FBC. There was a significant variation in both the capital and recurrent costs at the cost centres. The highest capital cost contribution for the CRP testing was recorded at the LRH due to the higher capital cost of equipment. The lower capital cost was due to manual methods of performing tests and therefore, there was no added equipment cost. In the recurrent cost, there was no significant difference. The reason for the higher cost at the LRH was mainly due to the high cost of the equipment used.

In all three Hospitals, the UFR is done manually. However, the cost of a UFR at the Bandaragama Divisional Hospital was comparatively low due to the lower salary and cleaning costs associated with less human resource use. In the LRH, the cost of the UFR was Rs. 130.21 while it was Rs. 81 at the Bandaragama Divisional Hospital. Compared to the LRH and the Horana Base Hospital, the number of UFR tests performed at the Bandaragama Divisional Hospital was low. This can be due to the lower density of the draining population. However, the Bandaragama Divisional Hospital exceeded the human resource efficiency compared to the other two Hospitals.

The cost of a CRP test in the order of the highest to the lowest was the LRH, the Horana Base Hospital and the Bandaragama Divisional Hospital. The reason for the lowest cost of a CRP at the Bandaragama Divisional Hospital could be attributable to the non-availability of reagents and less equipment cost associated with manual handling. Laboratory cleaning was done by the ordinary labourer attached to the laboratory. Therefore, no additional cost was incurred as at the LRH and the Horana Base Hospital. Many types of investigations in large numbers are done in the same biochemistry analyser in the LRH leading to less equipment cost assignable to each investigation. However, the regent cost at the LRH is considerably high due to high tech, machine specific reagents. The reason for the high equipment costs at the Horana Base Hospital could be attributable to the high depreciation cost.

If the FBC, the CRP, and the UFR testing were done in the private sector in the Western Province, the average cost for testing amounted to Rs. 630, Rs. 760, and Rs. 540, respectively. This revealed that the provision of Government services in terms of providing laboratory services can be highly effective in reducing out of pocket expenditure. On the other hand, there is a higher public expectation of the reliability of the Government services. These facts justify the provision of effective, efficient, and quality laboratory services in the public health sector. Therefore, all possible measures should be taken to optimise the utilisation of resources.

This study suggests minimal manpower for testing and cleaning, emphasising on the need for the evidence based management of resources for higher cost effectiveness. The less cost is associated with the less use of human resources. Therefore, the introduction of cost reduction strategies through the awareness of the health staff and the patients will help to reduce the overall cost of care. Improving the hospital record keeping system is also recommended.