Table 2 Summary of barriers to accessing hospital services in Timor-Leste
Geographic accessibility | Availability | Financial Affordability | Acceptability |
|---|---|---|---|
Supply-side factors Service location Hospital coverage - long distances to hospital - 13 districts, only 6 hospitals - 25 % patients >2 h to primary facility Patient transport provided by health service - cannot access all areas - limited availability during wet season - no service to transfer patient home - recovering patients stranded Demand-side factors User’s location Isolated communities - Infrastructure poor - rugged terrain, poor roads + bridges - ambulance cannot reach patient - patient journey to services difficult Public transport - no connections to distant villages - infrequent services Private/community transport - uncomfortable, difficult journey being carried the ‘traditional way’ - walk, use porters, horse - unreliable, ad hoc arrangements - family/community vehicle, police - need to hire private car, truck, motorbike | Supply-side factors Health workers, drugs, equipment Patient transport - too few ambulances - lack of coverage - poorly maintained - out of service, no fuel, no driver Service delivery Short opening hours - unable to access services after 3 pm - facility phone not answered 24 h Ambulance not available 24 h - no emergency service outside hours - no referral to hospital outside hours Long waiting times at hospital - staff not assisting lost patients - randomly rescheduling appointments Laboratory tests, blood supplies - few service locations - service availability erratic Medicines – regular stockouts Human resources Staff often not available to accompany patient in ambulance - rely on companion for clinical support Demand-side factors Patient transport Fear of being stranded after hospital visit - no fee support for transport home - patients stranded while still in recovery Repatriating deceased relatives - limited provision through health services - no established private providers | Supply-side factors Medicine stockouts in public sector - purchase medicines from private sector Blood supplies limited - high cost of blood from private donor - no standard charge Demand-side factors Costs and prices of accessing services Out-of-pocket expenses - Ambulance - patients/family pay for fuel - patients/family pay driver - costs to return home after transfer Transport charges - private car, truck, motorbike - public transport fares - repeat visits extra burden Indirect costs - food, accommodation, transport - recuperation period - companion/s costs - gifts, contribution to host family - opportunity costs - lost income - divert money needed for essentials Repatriation of the deceased - provider surcharge to carry deceased - large families, costs multipled - previously experienced prohibitive costs - families choose to not seek care - reserve money for funeral costs User’s resources and willingness to pay Ability to pay limited, poverty rate high - 44.3 % population below US$1.25 per day - direct + indirect costs barrier to access | Supply-side factors Characteristics of health services Staff conduct - blame and shame attitude to vulnerable - shouting at patients - delaying care, prolonging labour Nepotism - ignoring patient requests for assistance - fast track wealthier patients, family Provision - service coverage poor - six hospitals to cover 13 districts -laboratory tests - irregular availability - patient transport poor quality Demand-side factors User’s attitudes and expectations Dissatisfaction with quality of services - fear journey/transfer to hospital without medical supervision - disrespectful staff attitudes, nepotism Social isolation visiting hospital - hospital far from home, unfamiliar area - overwhelmed by hospital systems - depend on family support near hospital - resignation/preference to ‘die at home’ Medicines - unconvinced medicines effective - given same medicine, different illnesses Traditional medicines - strong cultural belief supports efficacy - acceptable substitute/preferred option - used to complement medicines |