Introduction

Sri Lankan government provides universal health coverage through a well-established public health care delivery system. The quality of clinical care in the public sector, which cater to the health care needs of the majority of Sri Lankans, is known to be comparable to that provided in the private sector, which delivers health care services only to a minority of the population1. In addition, there is more public trust towards the government health system2. Health care in this free public sector is universally accessible and provides unlimited health care for all citizens. This may have aided Sri Lanka to achieve better health care indices compared to other countries with a similar socioeconomic status3-5.
Curative services in the public sector are provided through government hospitals. There are several strata of hospitals based on physical and human resources, ranging from primary care centers such as rural hospitals to tertiary care centers with advanced facilities that are located in major cities in association with medical schools. There is no compulsory referral system, hence patients seek treatment from different centers based on their preference3-5.
Sri Lankans who are treated in government hospitals should ideally receive equal care across different hospitals. If absolute equity is maintained patients of all socioeconomic levels should receive equal care. It should be cost-free as the public health system is funded by taxpayers and has been designed to eliminate costs to the consumer. In this context, this study was planned to answer the following questions: Is the government health care system completely cost-free? If not, what are the costs borne by the patient? Is the current system equitable?

Methods

This study was carried out in the largest and most equipped tertiary care center in the country, among patients with cirrhosis of liver who were in-patients in two general medical wards, and referred to the Gastroenterology and Hepatology Unit. Ethical clearance was obtained from the institutional review board of the hospital.
Patients were selected from two medical wards and both patients and their caregivers were interviewed by the principal investigator (IK). Quota sampling was used to ensure equal participation of both genders and to include participants belonging to all income quintiles according to 2012 national data 6. Sampling was done until data saturation was achieved. Selected patients who consented to participate were first interviewed to obtain their household income, occupation and disease status. This information was used to stratify patients (table 1) into different sample groups.
Twelve medical doctors from the relevant wards were interviewed in order to acquire their perception on the issues raised based on the interviews with the patients and their caregivers. Their perspectives were also sought to obtain possible solutions to the questions that were raised during analysis.
During the interview, both guiding questions and open-ended questions were used. All interviews were carried out by the principal investigator. Interviews were done in the patient clerking room of the respective wards to maintain privacy and confidentiality. The interviews were tape recorded (with patients’ consent) and transcribed later and these recordings and transcripts were stored securely. Coding was done both manually and using NVivo version 10 qualitative analysis software (QSR International). All transcripts and computer databases were anonymously and securely stored.
Thematic framework method was used to analyze data7. The framework was created and reviewed using emerging data to identify commonly occurring themes. The themes were indexed in each transcript and later collated by mapping under common themes.

Results