Do these expenses affect equity of care?
All interviewed patients claimed to incur both direct and indirect costs due to the hospital admission. This was seen across all socioeconomic classes and income quintiles. However, the demand for out-of-pocket expenses due to prescription of investigations and drugs varied among the patients. It was observed that the health care workers looking after the patients were aware of the difficulties faced by the poorer patients. They reacted by either looking for alternative funding sources and sponsors, or by prescribing the least amount of investigations and medications that need to be obtained from the private sector for selected patients with financial difficulties. Doctor C stated, “There are instances where the patient cannot afford to do an investigation that is essential, but the investigation is also not available in our hospital. We try to find funds for such patients. Failing which, we try to settle for the next best thing for patient diagnosis and management.” This reflects the practice of health care workers in minimizing costs for poorer patients by choosing the next best alternative investigation or drug. Therefore, people from lower socioeconomic backgrounds received fewer prescriptions for investigations and medicines from the private sector.
This issue, however, was not always directly discussed with the patient. Targeted questioning revealed that some patients were unaware of the requirement of additional investigations that were available only in private sector laboratories. This was further reflected in the following statement by doctor B: “If it is a poor patient, we try our best to avoid ordering investigations from private laboratories. We look for an alternative or sometimes just do without that particular investigation. It is the same case with drugs where we sometimes ask patients to buy from pharmacies. For poor patients, despite being aware that a certain drug that is available in the private sector pharmacy is a better choice, we try to use alternatives (E.g. different antibiotics) that are available in the hospital. We don’t even tell these patients about the tests available in the private sector which they can’t afford.”
This practice resulted in patients from middle or higher socioeconomic backgrounds incurring a higher out-of-pocket expenditure for investigations and medications prescribed from the private sector. On the other hand, in trying to limit such expenses incurred by patients from lower socioeconomic backgrounds and resorting to what is available in the hospital, especially when done without consulting with the patient, optimum investigations and best options of drugs may not have been offered to such patients.