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 Table of Contents  
Year : 2012  |  Volume : 1  |  Issue : 4  |  Page : 457-466

Health systems responsiveness and its correlates: evidence from family planning service provision in Sri Lanka

1 Acting Consultant Community Physician, Ministry of Health, Sri Lanka
2 Public Health Physician (FAFPHM), Course Coordinator, Master of Health and International Development, Discipline of Public Health, School of Medicine, Flinders University, Adelaide, Australia
3 Head/Department of Community Medicine, Faculty of Medicine, University of Colombo, Sri Lanka
4 Country Representative, World Health Organization, Bangladesh

Date of Web Publication25-May-2017

Correspondence Address:
W L S P Perera
Acting Consultant Community Physician, Ministry of Health
Sri Lanka
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DOI: 10.4103/2224-3151.207048

PMID: 28615611

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Background: The World Health Organization has described health systems responsiveness (HSR) as a multi-domain concept encompassing eight non-medical expectations of health-care service seekers. HSR is a valuable measure of health systems performance, providing policy-makers and service providers much information to improve services. This paper presents findings of a cross-sectional survey conducted to assess HSR and its correlates through family planning (FP) services in Colombo district, Sri Lanka.
Methods: A Health Systems Responsiveness Assessment Questionnaire, developed and validated in Sri Lanka, was used. Trained interviewers administered the questionnaire in 38 FP clinics randomly selected to sample 1520 clients.
Results: The rating of responsiveness as ‘good’ for six domains ranged from 88% (n=1338) to 72% (n=1094). The overall HSR was rated to be ‘good’ by 83.4% (1268). Ethnicity being majority Sinhalese, persons who were currently employed and those using oral contraceptive pills (OCP) or condoms were negatively associated with rating of HSR. Positive associations with the HSR assessment were a family income of less than Rs 40 000 (US$ 303) per month, satisfaction with current FP method, use of only one method within the past year, use of only one FP clinic within the past year, health service provider being a medical officer, intention to use the FP clinic services in future, and satisfaction with overall services of the clinic.
Conclusions: Though overall HSR was rated by the majority as ‘good’, some aspects need more attention in delivering FP services.

Keywords: health systems responsiveness, family planning, Sri Lanka.

How to cite this article:
Perera W, Mwanri L, de A Seneviratne R, Fernando T. Health systems responsiveness and its correlates: evidence from family planning service provision in Sri Lanka. WHO South-East Asia J Public Health 2012;1:457-66

How to cite this URL:
Perera W, Mwanri L, de A Seneviratne R, Fernando T. Health systems responsiveness and its correlates: evidence from family planning service provision in Sri Lanka. WHO South-East Asia J Public Health [serial online] 2012 [cited 2022 Jan 22];1:457-66. Available from: http://www.who-seajph.org/text.asp?2012/1/4/457/207048

  Introduction Top

Health systems responsiveness

The 2000 World health report (WHR), published by the World Health Organization (WHO), identified three main goals to improve the performance of health-care systems.[1] The degree to which the legitimate non-medical expectations of people were met was one of these goals, named health systems’ responsiveness (HSR).[1],[2]

Assessment of HSR

The need to assess and improve national HSR has been documented. The assessment, essentially, has to be made by the service seeker who is in the best position to state how non-medical expectations were met.[1],[2] Assessments based on individual perspectives are influenced by sociodemographic factors of the respondents as well as the sociocultural milieu. Nevertheless, this approach can provide valuable information on the performance of health-care systems, especially if the assessment tool is tailored to the specific sociocultural context of the country.[2],[3]

WHO assessed HSR in 71 Member States in 2002–2004 during the World Health Survey (WHS).[4] Inpatient and outpatient ‘modules’ were used for the assessment, which covered the entire health system of the country and included government, private and traditional medicine systems. Results were presented as a percentage of respondents, rating each item of the modules as moderate, bad or very bad. [Table 1] describes the published data on patient services for Sri Lanka.
Table 1: Health system responsiveness in Sri Lanka

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While assessing the responsiveness of the entire health system is important, assessing a specific service or institution would have much practical value.[2] In line with this recommendation, a tool has been developed and validated in the Sri Lankan setting to assess HSR of family planning services.[5],[6]

Correlates of HSR

Many factors – related to both the health sector as well as the sociocultural context – determine people’s assessment of HSR. These correlates play an important role in the assessment and could provide insight for policy-makers and service providers to improve service provision. To our knowledge, these factors have not been scientifically appraised and published.

Family planning services in Sri Lanka

Family planning (FP) services were introduced to Sri Lanka in 1953 and were well accepted.[7] Today, they are a key component of the maternal and child health (MCH) package provided by the Government with the objective of improving the health and quality of life of families.[7],[8] The Family Health Bureau of the Ministry of Health coordinates provision of services within the government sector and registers FP clinics. Five methods of FP are provided through these registered clinics.

Though applicable to every facet of health-care delivery, HSR is especially relevant for services that are sought repeatedly over many years, e.g. long-term use of FP. Family planning is a sensitive topic in Sri Lanka where non-medical expectations of clients often determine their willingness to use services, even if they are widely available. Also, the satisfaction of clients plays a critical role in ensuring the proper use of FP methods, and minimizing method failure. This paper describes the findings of a cross-sectional survey conducted to assess the responsiveness of FP services of the public health sector through examination of HSR correlates.

  Methodology Top

Sri Lanka, with an estimated population of 20.86 million, is divided into 25 administrative districts.[9] The Colombo district houses approximately 20% of this population and has a network of public as well as private health-care institutions providing FP services. The public health sector runs 64 registered FP clinics in 12 Medical Officer of Health (MOH) divisions.[7],[8]

A cross-sectional study was conducted on clients seeking services from FP clinics of MOH divisions in Colombo district. Sample size was calculated using the formula for estimating prevalence for descriptive studies.[10] Prevalence of ‘good’ HSR was taken as 60% as it was the lowest estimation made in the country to ensure maximum sampling size.[4],[10] Estimated sample size was 753 for a precision of 3.5%. Cluster sampling was used: clients attending one clinic session comprised a cluster. Cluster size was 40 patients[13] and the sample size was multiplied by two to account for design effect.[11],[12] Thirty-eight clinics were randomly selected from the list of registered FP clinics and within the clinic, systematic sampling was used to identify study participants.[13] The calculated sample size was 1506 and a total of 1520 was taken as final.

We developed and validated the Health Systems Responsiveness Assessment Questionnaire (HESRAQ) in Sri Lanka to assess the HSR of FP services.[5],[6] Since correlates of HSR had not been identified earlier, focus group discussions and in-depth interviews were conducted with clients and non-users of FP, service providers and policy-makers to identify possible correlates. Twenty-five factors were identified and assessed in the cross-sectional survey. The tool was administered by trained research assistants who were pre-intern medical officers to persons as they left the FP clinics.

The results of the rating of HSR were categorized into three groups. Group 1 combined ‘very good’ and ‘good’ and indicated good HSR; Group 2 contained the ‘moderate’ responses, indicating neutrality; and Group 3 consolidated ‘bad’ and ‘very bad’, signifying that the HSR was bad. Correlates were identified using logistic regression analysis. First, bivariate analysis was performed using chi square test followed by logistic regression with significant variables. SPSS version 16 was used to determine the odds ratios (OR) and 95% confidence intervals (95% CI) of the correlates for rating the overall HSR as ‘good’ or ‘bad’.

  Results Top

Response rate was 100%. All respondents were married females and came from different socioeconomic backgrounds. The sociodemographic characteristics of respondents and their FP use are presented in [Table 2].
Table 2: Sociodemographic characteristics and use of modern family planning methods among respondents

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The findings of the assessment carried out using HESRAQ are given in [Table 3].
Table 3: Health systems responsiveness assessment of family planning services

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Although the vast majority (83.4%) of participants stated that the overall HSR of FP services was good, 3.8% were unhappy and a further 12.8% remained neutral in their assessment. The highest rated domain was ‘being treated with dignity’ (88%). Regarding the confidentiality maintained on medical information, and the ease of access to FP services, 84% and 83% of respondents were happy, respectively. On the other hand, almost one fifth expressed dissatisfaction or remained neutral about the state of the clinic environment, with another 23.9% stating the same regarding adequate communication during medical encounters. ‘Client choice’ was rated lowest with 28% of respondents stating they were either unhappy or neutral on the adequacy of choice given to them on the clinic, provider and FP method.

Though 25 correlates were identified, only 10 were found to be associated with an HSR rating. Logistic regression analysis of a rating being ‘good’ is summarized in [Table 4].
Table 4: Correlates of ‘good’ health systems responsiveness

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Domains that had negative HSR outcomes were Sinhalese ethnicity (OR=0.189, CI 0.062–0.579), being employed (OR=0.247, CI 0.104–0.587) and using OCP/condoms as contraception (OR =0.09, CI 0.02–0.31). On the other hand, factors associated with positive HSR were a family income of less than Rs 40 000 (US$ 303) per month (OR =19.31, CI 4.70–79.27), satisfaction with current FP method (OR =10.68, CI 4.80–23.74), use of only one method in the past year (OR =6.69, CI 2.74–16.33), use of only one FP clinic in the past year (OR =9.91, CI 3.87–25.36), health service provider being a medical officer (OR =19.77, CI 3.59–108.88), intention to use the clinic for FP services in future (OR =14.24, CI 4.13–49.08) and satisfaction with overall services of the clinic (OR =69.07, CI 20.31–234.87).

  Discussion Top

Our study showed that the majority of respondents were happy with the HSR in relation to FP services provided by the Government. This is consistent with findings of the only other local assessment on HSR in the WHS.[4] Since the WHS only published the percentage of respondents rating each item as ‘moderate/bad/very bad’, and only on a five-point Likert-like scale, the percentage rating of each item as ‘good/very good’ would be reasonably interpreted as the balance percentage of respondents. This percentage would reasonably compare with the percentage rating items as ‘very good/good’ in the present study. Other studies conducted in Sri Lanka on patient satisfaction and quality of health care – two concepts with similarities to HSR – also reveal a high rating of non-medical aspects of health-care delivery by the Government.[14],[15],[16],[17],[18] Though the overall rating was high, there was much variation in different domains of HSR.

Respondents expressed satisfaction on being treated with dignity in clinics. The domain ‘dignity’ of the WHS module assessing outpatient department (OPD) settings is comparable with the domain in the present study.[4] The two items comprising the domain in WHS were rated as very good/ good by 86.9% and 76.8% of respondents respectively, while the rating in the present study was 88%.[4] There is much respect for dignity of mothers attending MCH clinics in the local culture compared with general medical services.[14] Also, the closeness of clients to service providers, who are mainly public health midwives, leads to much respect between the client and service provider in the field.[5]

Confidentiality was the second highest rated domain. The ratings in the WHS were lower, i.e. 75.7% against 76.7% in the present study.[4] Since the WHS was a general OPD assessment, the higher rating in the present study could be explained by the cultural respect for mothers seeking FP services in relation to their confidentiality, in addition to there being very little medical information collected at the FP clinic as opposed to OPD settings.[5],[19]

Ease of access to services was rated by 83.0% as being good. The domain ‘prompt attention’ was comparable with this domain in our study.[4],[5] Both elements were rated as very good and good in the WHS (70.2% and 62%, respectively). The WHS was an overall assessment on OPD services where the time travelling to larger but far-away hospitals and the longer waiting time in overcrowded hospital settings is reflected in the results. FP services, which are provided at smaller institutions and outreach clinics, offer services closer to home, and reduce the waiting time, given that mothers are generally given a specific time to attend the clinic.[5]

The majority of respondents expressed satisfaction with the environment of FP clinics. The WHS assessed OPD facilities under the domain ‘basic amenities’, where the items were rated very good and good by 69.4% and 59.3%. The higher levels of rating in our study could be explained because the setting was an FP clinic at which a limited number of mothers attend, unlike OPD settings which are generally overcrowded, especially in larger hospitals where most people go for outpatient services. Therefore, it is evident that the FP clinic setup – the general MCH setup in the public health sector – offers a better environment than the general OPD facilities.[5]

Communication in the WHS was assessed on two items: clear explanations and time for questions, rating very good or good at 82.6% and 70.8% respectively. Only 76.1% of respondents in our study said that their expectations had been met with regard to communication. The reason for this may be a lack of explanation on the more technical aspects of FP methods and even the side effects of FP methods.[6] On the contrary, the time given for questions was rated lower in the WHS, given the general overcrowding and thus waiting time in OPD settings for patients to receive clarifications.

The client choice was rated lowest, i.e. either bad or average, at 28%. The WHS assessed the aspect of choice in two domains, namely autonomy and choice of provider.[4],[5] The choice of provider in the WHS study met the expectations of 69.1% of people, which largely matched the finding of our study. Autonomy, or the involvement of patients in making decisions in OPD settings was rated lower in the WHS, assessed on providing treatment information and involvement in deciding treatment. Only 66.9% and 70.4% rated these aspects very good/good respectively. Involving the patient in decision-making was similar in the present study, although the provision of treatment information was lower in the WHS. This could reflect a lack of attention to informing patients adequately on their medical condition in the general outpatient settings.[4]


Regarding the analysis of ethnicity, the Sinhalese (the majority in Sri Lanka) rated the HSR lower. However, qualitative research on HSR by the Principal Investigator in Sri Lanka showed that non-Sinhalese respondents had lower levels of expectations.[5] Literature presumes that minority ethnic groups may have lower expectations of government services when the majority of the workforce comprises the ethnic majority.[20],[21] Some literature suggests that minorities could be discriminated against and marginalized in health-care delivery and that they could rate HSR poorly; this was not supported in the present study.[3],[22]

Being currently employed showed a negative association with the rating of HSR. This could be explained by the fact that the employed have less time to visit clinics, which are generally open only during working hours.[5] This observation is supported in the literature, which states that respondents in the labour force might have higher non-medical expectations, especially regarding efficient services.[22],[23],[24] Literature on patient satisfaction suggests that currently employed respondents may be more educated with a higher monthly income and a higher level of expectations.[25],[26],[27] In our study, the majority of the currently employed had a lower family income level than those who were employed on a daily basis, and many had to lose a day’s work to seek services.

Monthly family income was analysed on two levels, with a cut-off based on the median income. A monthly family income of less than Rs 40 000 (US$ 303) had a positive effect on the HSR rating. Respondents with a higher family income may have higher expectations and hence tend to be ‘harsher raters’.[22] Though respondents with high income have the option of obtaining services from the private sector, there was more confidence in the government public health services despite the inconvenience.[5]

Contraceptive methods were categorized into two groups; methods that can be obtained during domiciliary services (OCP/condoms) and methods that can only be obtained from an FP clinic (DMPA/implant/IUD). Use of 0CP and condoms showed a negative association with rating of HSR. The present study revealed that, though the clinics have to provide all five methods of FP, users generally seek DMPA, implant and IUD services. Service providers expect OCP and condom users to use public health midwives and are not well received at clinics, as providing these FP methods is sometimes treated as adding to the already overburdened clinics.[5]

Satisfaction with the current method was positively associated with the HSR rating. As already shown, this matches the satisfaction expressed by this group with all aspects of care in clinics.[5] The main objective of visiting the clinic was to obtain a method of choice that would satisfy the respondent. Therefore, obtaining a satisfactory method ‘free at the point of delivery’ in the local context was adequate, and shortcomings in other aspects were secondary issues. The literature supports the findings that, irrespective of the level of expectation, the service seeker’s satisfaction with medication, etc. could lead to a higher rating.[3],[24]

Having used only one method within the previous year was positively associated with HSR rating. The literature states that experimenters and frequent changers are the hardest to satisfy during any health-care provision, and that the personality of the client plays a role in the satisfaction with the care received.[25] This was not taken into consideration in our study. Some respondents had to change method due to the unavailability of another at some point.[5] These clients were unsatisfied with the general medical services of the clinic due to such shortages.

Obtaining services from only one clinic over the previous year was associated with a positive rating of HSR. The literature suggests that doctor shoppers are harder to please.[20],[28] Local literature also confirms that clients who visit several places are unhappier with their medical and non-medical care.[5] In addition, regular service seekers are generally from the surrounding area and know the public health midwife and other health providers, making the clinic environment more friendly.[5]

Attendance by a medical officer showed a positive association with rating of HSR and was an expectation of many when seeking any form of health service. In addition, female clients often had more confidence in a male medical officers, who were thought to be more skilled. In relation to invasive procedures such as implants and IUDs, medical officers were believed to be more trained compared with even the most experienced nursing officer.[5]

Intention to use the clinic for FP services in the future had a positive association with HSR. In addition to noting satisfaction, such respondents did not wish to make a lower assessment of HSR for fear of discrimination in case the health-care providers became aware of their response, despite assurance of confidentiality.[5]

The strongest positive association was being satisfied with the overall clinic services.[5] The literature emphasizes that patients’ assessment of the health-care delivery system is mainly dependent on their satisfaction with the medical care provided.[24],[25]

  References Top

World Health Organization. World health report, health systems: improving performance. Geneva: WHO, 2000.  Back to cited text no. 1
World Health Organization. Report on WHO meetings of experts: responsiveness concepts and measurement. Geneva: WHO, 2000.  Back to cited text no. 2
Murray CJL, Evans DB. Health systems performance assessment: debates, methods and empiricism. Geneva: World Health Organization, 2001.  Back to cited text no. 3
World Health Organization. World health survey. Geneva: WHO - http://www.who.int/healthinfo/ survey/whslka-srilanka.pdf - accessed 16 April 2013.  Back to cited text no. 4
Perera WLSP. Health systems responsiveness of family plannig services in colombo district. Colombo: Postgraduate Institute of Medicine, 2011.  Back to cited text no. 5
Perera WLSP, Seneviratne RDA, Fernando HTEI. Development and validation of a tool to assess health systems responsiveness. South East Asia Journal of Public Health Bangladesh. 2011; 1(1): 21-27.  Back to cited text no. 6
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De Silva A, Valentine N. Measuring responsiveness: Results of a key informants survey in 35 countries. Geneva: World Health Organization, 2002.  Back to cited text no. 22
Strengthening health systems to improve health outcomes, everybody’s business. Geneva: World Health Organization, 2007.  Back to cited text no. 23
Valentine N, Darby C, Bonsel GJ. Which aspects of non-clinical quality of care are most important? Results from WHO’s general population surveys of “health systems responsiveness” in 41 countries. Social Sciences and Medicine. 2008; 66(9): 1939-50.  Back to cited text no. 24
Mendonca KMPP, Guerra RO. Development and validation of an instrument for measuring patient satisfaction with physical therapy. Rev Bras Fisioter. 2007; 11: 369-76.  Back to cited text no. 25
Daoud-Marakchi M, Fendri-Elouze S, Ill CH. Development of a Tunisian measurement scale for patient satisfaction: Study case in Tunisian private clinics. World Academy of Science, Engineering and Technology. 2008; 45: 208-219.  Back to cited text no. 26
Loblaw DA, Bezjak A, Bunston T. Development and testing of a visit-specific patient satisfaction questionnaire: The Princess Margaret Hospital satisfaction with doctor questionnaire’. Journal of Clinical Oncology. 1999; 17(6): 29 - 40.  Back to cited text no. 27
Valentine NB, Bonsel GJ, Murray CJ. Measuring quality of health care from the user’s perspective in 41 countries: psychometric properties of WHO’s questions on health systems responsiveness. International Journal in Quality Healthcare. 2007; 16(7): 1107-25.  Back to cited text no. 28


  [Table 1], [Table 2], [Table 3], [Table 4]


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