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\begin{document}

\title{Out-of-pocket expenditure in a country with universal health coverage: A
qualitative study on patients with liver cirrhosis in Sri Lanka}



\author[1]{Isurujith Kongala Liyanage}%
\author[2]{Dinesha Jayasinghe}%
\author[3]{Kremlin Khamaj Wickramasinghe }%
\author[4]{Pubudu de Silva}%
\author[4]{Eranga Thalagala}%
\author[4]{Rayno Navinan}%
\author[4]{Jevon  Yudhishdran }%
\author[2]{Indika Karunathilake}%
\affil[1]{University of Sri Jayewardenepura Faculty of Medical Sciences}%
\affil[2]{University of Colombo Faculty of Medicine}%
\affil[3]{WHO Collaborating Centre on Population Approaches for NCD Prevention, Nuffield Department of Population Health, University of Oxford}%
\affil[4]{Ministry of Health and Indigenous Medical Services, Colombo}%


\vspace{-1em}



  
  \date{June 13, 2024}


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\selectlanguage{english}
\begin{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.%
\end{abstract}%



\sloppy


\textbf{}

\subsection*{}

{\label{out-of-pocket-expenditure-in-a-country-with-universal-health-coverage-a-qualitative-study-on-patients-with-liver-cirrhosis-in-sri-lanka}}

\subsection*{Introduction}

{\label{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 population\textsuperscript{1}. In addition, there
is more public trust towards the government health
system\textsuperscript{2}. 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
status\textsuperscript{3-5}.

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 preference\textsuperscript{3-5}.

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?

\subsection*{Methods}

{\label{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 \textsuperscript{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 data\textsuperscript{7}.
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.

\subsection*{Results}

{\label{results}}

\textbf{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.

\textbf{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.

\textbf{Indirect expenses}

Loss of income due to hospitalization of the patient or a family member
who has to stay with a patient in the hospital was observed in all
income quintiles. We classified the employment status of the patients
into three categories; as those who were 1. Unemployed 2. Employed with
a daily wage or non-fixed income (daily-paid workers), 3. Employed with
a monthly salary or retired with a pension.

The worst impact of hospital admission on household economy was seen in
patients earning a daily wage or those whose mode of income was
small-scale self-employment (e.g. manual laborers, owners of small
shops, taxi drivers). The loss of income of hospitalization had a direct
impact on their households. A patient who is a manual laborer mentioned,
``I have been in the hospital for the last eight days. My household
income is totally lost, and my wife had to leave the children with our
neighbor and find daily-paid manual work. We also borrowed money from
relatives.''

The impact was also seen to be higher among the poorer people who had
minimal or no savings. This is illustrated in the following statement of
a patient who was a manual laborer, belonging to the second income
quintile: ``Me and my son are the two breadwinners of the family. My
wife stays at home and our two daughters are still schooling. I have
been in the hospital for the last five days and my son has to stay with
me. My son has to pay daily to the owner of the three-wheeler, which he
drives. Thankfully he has been given a months' time to pay his debt. My
wife's brother is helping us.''

On the other hand, loss of income was not a problem or was only a minor
problem for patients with more stable, fixed-income occupations in
either the government or private sector. A patient's income is not
affected if they are paid a monthly salary and the duration of hospital
admission is within the approved quota for medical leave.

Patients with long-standing diseases such as cirrhosis are likely to be
affected more by recurring out-of-pocket expenditures and disruptions to
household income. Many of these patients had multiple medical problems
requiring numerous hospital visits and admissions. As a result of their
illness, most of their household activities and functions were also
disturbed. Furthermore, there were patients whose illnesses have
rendered them unsuitable to carry out their occupations and/or for
employment.

Patients of lower income categories were less protected from these
direct and indirect costs due to lack of savings, support, compensation
or inability to find an alternative occupation. Patients from lower
economic backgrounds often used terms such as ``helpless, disrupted,
lost, devastated'' when describing the household impact of illness and
hospital admission. The impact on patients in middle- and higher-income
categories was less, mainly due to the availability of a monthly wage or
pension, savings and stronger family support.

\textbf{Patient satisfaction}

Overall, patient satisfaction regarding the quality of care was observed
to be high in this population. This trend was seen in patients of all
socioeconomic levels. One patient stated, ``The ward staff and doctors
treated us nicely. They were kind even though they are very busy and
overworked''.

However, some patients who were in the lower socioeconomic quintiles
were less satisfied about the care they received. They perceived that
they were at a relative disadvantage and many used phrases such as
``although they treated him/her well'' to mention a patient whom they
perceived to have been treated better than themselves by the staff.
``Some staff members were rude to us. They treated a patient who is
related to a hospital staff member very well and ignored me. I don't get
medicines on time for the pain in my leg (pointing towards her knee
joints)'', said one patient who was not very satisfied with the quality
of care she received.

In general, patients in higher income quintiles were more satisfied
about the care they received. In one ward, a patient belonging to the
highest income quintile expressed his concern over the way the staff
treated other ``poor, less connected patients''.

\subsection*{Discussion}

{\label{discussion}}

In Sri Lanka, government funded public hospitals provide curative
services free of charge to all its citizens. These include out-patient
consultations, in-ward treatment, medicines, investigations, other
supportive services including linen and meals for in-patients. Sri Lanka
is listed as a country with a low out-of-pocket expenditure for health,
with less than 5\% of households spending more than 10\% of total
expenditure on health care. Catastrophic economic impacts of ill health
are minimal in Sri Lankans due to this system\textsuperscript{5}. In an
ideal situation, a publicly funded health care system should minimize
the impact of ill health on individual households and reduce inequity in
health care.

This study revealed different situations in which out-of-pocket expenses
are incurred by patients and their households during a hospital
admission. The impact of these expenses was greater in individuals of
lower economic backgrounds. Those obtaining a daily wage or those whose
income depended on small-scale self-employment were affected by loss of
income due to hospitalization, sometimes severely disrupting the
functions of their households. However, loss of income was not a major
concern in individuals belonging to middle- and higher-income
categories. This seems to create an important inequity in the household
economic impact of ill health and hospitalization despite the
availability of state sponsored health care.

The findings of the study support previous observations that patients
with chronic diseases are more likely to encounter higher out-of-pocket
expenditures \textsuperscript{8}. Sri Lanka is facing a rapidly rising
epidemic of non-communicable diseases. The relative inability of the
state health care system to prevent significant incapacitation of the
household economy in patients with chronic and multiple diseases may
have a negative impact on the overall acceptance of its health care
system\textsuperscript{4}. This needs to be addressed by further
discussion and improvement of economic security of low-income groups.
The National Insurance scheme is an example where loss of income during
hospitalization can be buffered by compensation.

Sri Lanka is a country with significant inequality in income
distribution and household expenditure\textsuperscript{9}. However, due
to the structure of its public health system, Sri Lanka has minimal
inequities in health care utilization. Utilization of inpatient
facilities is equal across all economic quintiles. Outpatient facilities
however, are utilized more by the pro-poor patients, as a result of the
rich electively opting for private sector care\textsuperscript{10,11}.
Public health sector in Sri Lanka is funded by a tax-based
method\textsuperscript{3,11}. Hence every citizen contributes towards
the funding of this service and has an equal right for equitable
services from the government health sector. In this survey we
demonstrate that other forms of inequity beyond utilization of health
care exist, especially with regards to spending for health care, at
patient level.

We observed inequities in expenses incurred, satisfaction, patient
management and possible clinical outcome across all quintiles based on
the individual's household income. Wealthy patients were more likely to
receive requests for investigations from private laboratories and drugs
to be purchased from pharmacies. The poorer patients are given fewer
requests depending on their financial capabilities and were largely
unaware that they are receiving a ``different'' standard of care. This
``informal exemption'' of the poor from out-of-pocket expenses has been
documented previously in Sri Lanka and Thailand\textsuperscript{5}. Its
impact on clinical outcome, however, has not been studied. We observed
that there is significant inequity in patients being informed of their
choices and available options based on their economic status. Although
this appears to be an attempt to ``safeguard'' poorer patients from
being unhappy about their treatment, this cannot be justified from an
ethical point of view. Having a choice is one of the key principals of
equity in health care \textsuperscript{12}, and it is necessary to take
measures to change the current practices of the doctors when handling
such situations. In addition, a universal health care plan should have
horizontal equity where all patients are treated equally
\textsuperscript{12}. In this perspective, it can be argued that the
government should ideally fund/cover direct costs incurred by the
patient when it is inevitable.

The current evidence supports that patients belonging to low
socioeconomic groups are less satisfied with health
services\textsuperscript{13}. A health system funded by the public
should, however, attempt to minimize this. The difference in
satisfaction and examples provided by the patients in our study further
emphasize that not having a choice and the perception of being treated
unequally has contributed to this lack of satisfaction. This evidence
calls for an attitudinal change among health care workers, including
doctors and supportive staff.

Some expenses incurred by the patients cannot be justified in a
government-funded health care system. Examples noted were the requests
for investigations from private laboratories due to inaccurate reports
or delays in the in-house laboratory services, and the need for
bystanders to carry out patient-related work. These concerns need to be
addressed and corrected as an internal exercise. Since data collection
for this study, local authorities have implemented activities to improve
laboratory and service standards. Current hospital policy (implemented
after data collection for this study) has restricted medical staff on
ordering investigations and obtaining medicines or equipment from the
private sector for in-ward patients. Special permission from the
director of the hospital is now required before obtaining these services
or goods from the private sector after confirming that the good or
service requested is not available in the state sector.

\textbf{Limitations and scope for further assessment}

Quantification of the out-of-pocket expenditure was not done in this
qualitative survey, as the sampling strategy would not permit the
results to be generalized. Further studies are needed to quantify the
costs and assess the trends across hospitals.

This study only involved a few wards in the main tertiary care hospital
in the capital city. The observations of this study need to be compared
with similar studies in other health care institutions, especially
smaller hospitals with minimum laboratory and imaging facilities where
we believe that out-of-pocket costs borne by patients are much higher.

\textbf{Conclusions and recommendations}

This study highlights the complexity of achieving equity even in a
country with a fully state-funded universal health coverage. Although
the state spends on universal health coverage, Sri Lankan patients incur
direct and indirect costs when receiving hospitalized care in government
hospitals. Some of these expenses can be avoided if the current system
is improved with regards to quality, efficiency and staff training.
Health care workers try to minimize the burden of these expenditures in
less wealthy patients, but in the process, the patients are deprived of
being fully informed about the range of choices in the investigation and
treatment of their diseases. The impact of out-of-pocket expenditure is
more on pro-poor households, especially among daily paid workers. There
was inequity in patient satisfaction and type of care received, which
increased the likelihood of the existence of inequity in the overall
outcome. Household economic impact of ill-health and hospitalization is
seen more in chronic diseases, which are rapidly rising in Sri Lanka.

\textbf{References}

1. Rannan-Eliya RP, Wijemanne N, Liyanage IK, et al. Quality of
inpatient care in public and private hospitals in Sri Lanka.
\emph{Health policy and planning.} 2015;30(suppl 1):i46-i58.

2. Russell S. Treatment-seeking behaviour in urban Sri Lanka: trusting
the state, trusting private providers. \emph{Social science \&
medicine.} 2005;61(7):1396-1407.

3. Jayasekara RS, Schultz T. Health status, trends, and issues in Sri
Lanka. \emph{Nursing \& health sciences.} 2007;9(3):228-233.

4. Sri L, Department of Health S. Annual health bulletin, Sri Lanka.
\emph{Annual health bulletin, Sri Lanka.} 2013.

5. Van Doorslaer E, O'Donnell O, Rannan-Eliya RP, et al. Paying
out-of-pocket for health care in Asia: Catastrophic and poverty impact.
\emph{Erasmus University, Rotterdam and IPS, Colombo.} 2005.

6. Sri Lanka. Deparment of Census and Statistics. \emph{Household income
and expenditure survey 2012/2013.}Ministry of Finance and Planning;
2014.

7. Ritchie J, Spencer L. Qualitative data analysis for applied policy
research. In: \emph{The qualitative researcher's companion.}
2002:305-329.

8. Paez KA, Zhao L, Hwang W. Rising out-of-pocket spending for chronic
conditions: a ten-year trend.\emph{Health Aff (Millwood).}
2009;28(1):15-25.

9. Baba Y, Arai Y, Yasui H, Yonezawa K. Area Disparity of income and
expenditure in Sri Lanka. In: Maki A, ed. \emph{Poverty, Inequality and
Growth in Developing Countries: Theoretical and Empirical Approaches.}
Taylor Francis; 2015.

10. O'Donnell O, Van Doorslaer E, Rannan-Eliya RP, et al. The incidence
of public spending on healthcare: comparative evidence from Asia.
\emph{The World Bank Economic Review.}2007;21(1):93-123.

11. Rannan-Eliya RP, Sikurajapathy L. Sri Lanka:``Good practice'' in
expanding health care coverage.\emph{Good practices in health financing:
lessons from reforms in low-and middle-income countries Washington, DC:
World Bank.}2008:311-354.

12. Bambas A, Casas JA. Assessing equity in health: conceptual criteria.
\emph{Pan American Health Organization, editor Equity and health Views
from the Pan American Sanitary Bureau Washington DC: Pan American Health
Organization.}2001:12-21.

13. Thiedke CC. What do we really know about patient satisfaction?
\emph{Family practice management.}2007;14(1):33.

\textbf{Acknowledgements}

We would like to acknowledge the support given by the participants of
this study, staff of wards 55 and 56B at the National Hospital of Sri
Lanka and the Department of Medical Education, Faculty of Medicine,
University of Colombo.

\textbf{Author declaration}

The authors of this study have no conflict of interest with regards to
the contents of this study. All authors have reviewed and approved this
manuscript.

\textbf{Funding}

This research did not receive any specific grant from funding agencies
in the public, commercial, or not-for-profit sectors.



\textbf{Tables}

\textbf{Table 1:} Household yearly income quintiles according to 2012
data in Sri Lanka and the purposive sample based on the income
quintiles.\selectlanguage{english}
\begin{longtable}[]{@{}lllll@{}}
\toprule
Quintile & Household Income (USD) & Interviewed individuals & Mean age
(years) & Occupations\textsuperscript{+}\tabularnewline
\midrule
\endhead
1 & \textless{}90 & 8 & 53.4 & Manual laborer, farmer, shopkeeper/
salesman\tabularnewline
2 & 90 - 139 & 10 & 45.5 & Shop owner, motor mechanic, truck driver,
manual laborer, skilled laborer\tabularnewline
3 & 140 - 199 & 8 & 38.6 & Driver, clerk, Retired teacher, fish monger,
carpenter\tabularnewline
4 & 200 - 314 & 8 & 42.4 & Three-wheel/taxi driver, businessman,
clerk\tabularnewline
5 & \textgreater{}315 & 6 & 36.1 & Teacher, Businessman, Three-wheel
owner/driver\tabularnewline
\textsuperscript{+} Participants' occupations excluding unemployed
people and housewives & \textsuperscript{+} Participants' occupations
excluding unemployed people and housewives & \textsuperscript{+}
Participants' occupations excluding unemployed people and housewives &
\textsuperscript{+} Participants' occupations excluding unemployed
people and housewives & \textsuperscript{+} Participants' occupations
excluding unemployed people and housewives\tabularnewline
\bottomrule
\end{longtable}

\textbf{Table 2} : Expenses identified by patients and doctors\selectlanguage{english}
\begin{longtable}[]{@{}ll@{}}
\toprule
\begin{minipage}[b]{0.47\columnwidth}\raggedright\strut
\textbf{Direct costs}\strut
\end{minipage} & \begin{minipage}[b]{0.47\columnwidth}\raggedright\strut
\textbf{Indirect costs}\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Investigations from private laboratories\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Income loss of patient\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Hiring of paid bystanders\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Income loss of bystander\textsuperscript{+}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Expenses to transport the patient to and from the hospital\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Income loss of others at home\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
Purchase of food and consumables for the
patient\textsuperscript{+}\strut
\end{minipage} & \begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
Costs of alternatives for duties the patient used to carry out for the
family (e.g. cooking -- having to buy food for family, hire a taxi for
transport)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Expenses to visit the patient\textsuperscript{+}\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Purchase of drugs from pharmacies\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Purchase of equipment for procedures/patient care E.g. haemodialysis
cartridges, air mattress, compression stockings\textsuperscript{++}\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
\textsuperscript{+} expenses recognized only by patients;
\textsuperscript{++} expenses recognized only by the doctors\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
\textsuperscript{+} expenses recognized only by patients;
\textsuperscript{++} expenses recognized only by the doctors\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

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