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.