What are the costs to the patients and the family?
All interviewed patients reported direct and indirect costs related to hospital admission. Patients were asked to list different modalities of expenses incurred and the doctors treating these patients were also asked to list the out-of-pocket expenses for patients. The expenses identified are listed in table 2.
Although the patients were admitted to a government hospital, certain investigations were requested to be obtained from private sector laboratories. This is usually done in government hospitals when a particular investigation is unavailable in that hospital. Examples for such investigations include (but are not limited to) dengue antigen tests, lipid profile, urine protein quantification, rheumatoid factor, anti DS-DNA antibodies (some of these have been made available in some Sri Lankan government hospitals by the time of writing this manuscript). However, at times, tests that were available at the hospital such as complete blood counts, renal functions, serum calcium measurements and urine full reports were requested to be obtained from private laboratories.
Most of the patients interviewed or their family members were not aware of the reasons behind these investigations being ordered from the private sector. Some believed that they were not available in the hospital. Doctors, on the other hand, mentioned that in addition to unavailability of some required investigations, several other reasons such as incorrect reports from the hospital laboratories and delay in obtaining reports prompted the staff to order investigations from the private sector.
Doctor A from ward X mentioned; “test results issued from our (i.e. the hospital) laboratory are sometimes incorrect, especially those carried out in the night. Therefore, we are sometimes compelled to send common investigations to private laboratories. Sometimes reports get delayed, and there were some instances where the reports got lost. There were times that the report is ready in the laboratory, but we don’t have a staff member to collect it from the lab and bring it over to the ward. It matters a lot in acute situations like dengue fever, acute renal failure.” All doctors interviewed raised these issues.
Doctor B from ward Y said: “Hospital authorities discourage, and we too try our best to avoid ordering investigations from private laboratories. This is only done in situations where an investigation is not available in our hospital or cannot be done on time. When we order however, we explain the requirement to the patient and give the choice to the patient.”
Seriously ill or disabled patients in some wards were requested to keep a bystander or a caretaker during their in-ward stay. Some patients were looked after by a hired caregiver and the cost for this ranges between Rupees 1500 to 2500 per day. These paid caregivers did a variety of patient-related duties such as cleaning the patient, taking him/her to the toilet, monitoring patients (e.g. urine output, diarrheal episodes), keeping the patient restricted to bed and accompanying patients to other units when needed (e.g. for referrals and investigations). In some patients, family members chose to act as the caregiver for the period of hospitalization. “While I was with my father in the ward, I had to push his wheelchair to take him for his X ray. I also monitored his urine output and wrote it down as instructed. I saw how some patients’ investigations, procedures and monitoring was delayed or not done because they didn’t have anyone staying with them. My father stayed in the ward for six days. For the days on which I couldn’t stay, I hired a paid bystander. I am unhappy about the way he looked after my father”, said one patient’s son who stayed with his father in the hospital during his admission.
Other direct expenses of hospitalization included purchasing food and other consumables for the patients. Government hospitals provide three meals a day for all in-patients free of charge. However, some patients preferred homemade food or food from other sources. In addition, many milk-based food products including dietary supplements and fortified milk products were purchased by patients. Transport of the patients as well as their visitors to and from the hospital added to these costs.
All patients interviewed stated that in addition to these direct expenses, there were indirect expenses incurred by them. If the patient was employed, hospitalization led to loss of income in some patients, especially when they were employed in daily-paid jobs or were self-employed. If the family member acting as the bystander of the patient was employed, this led to an additional loss of income. Furthermore, some patients pointed out that they had additional expenses during periods of hospitalization as they had to meet household requirements that are usually carried out by the patient, bystander or other family members who can no longer perform their usual duties as a result of the hospital admission.