Out-of-pocket expenditure in a country with universal health coverage: A
qualitative study on patients with liver cirrhosis in Sri Lanka
Abstract
Abstract Rationale, aims and objectives: Sri Lanka has a
well-established government-funded universal health coverage which
provides free health care to all citizens. The aim of this qualitative
study was to examine the out-of-pocket expenses incurred by patients
with cirrhosis during admission to a tertiary care government hospital
in Sri Lanka, and the impact such expenses might have on equity of care
and patient outcome. Methods This is a qualitative study conducted among
patients with cirrhosis admitted to a tertiary-care hospital, their
caregivers and physicians. Quota sampling was used until data saturation
was achieved. Data was collected through individual interviews and small
group discussions using directed and open-ended questions. Thematic
framework method was used to analyze data. Out-of-pocket expenses
incurred by patients, its impact on equity of patient care and outcome
were investigated. Results Costs for laboratory investigations, drugs
purchased from the private sector and hired caretakers for hospitalized
patients were reported as direct expenses. Loss of work and other
sources of income were the primary indirect expenses. The impact of such
expenses was higher in patients and families from lower socioeconomic
categories, especially among those who were dependent on a daily income.
Health care workers actively tried to minimize these out-of-pocket
expenses, resulting in choice on investigations, drugs and other
interventions often being made by the clinician and occasionally not
being discussed with the patient, resulting in poor patient
satisfaction. Conclusion This study reveals a substantial direct and
indirect economic impact on patients despite being cared for in a
government hospital with universal health coverage. The impact was more
in patients from lower socioeconomic strata, potentially resulting in
inequity in the care provided as well as the health outcomes.