title: "I go I die, I stay I die, better to stay and die in my house": understanding the barriers to accessing health care in Timor-Leste.
abstract: Despite public health care being free at the point of delivery in Timor-Leste, wealthier patients access hospital care at nearly twice the rate of poorer patients. This study seeks to understand the barriers driving inequitable utilisation of hospital services in Timor-Leste from the perspective of community members and health care managers.
  
  
  
  This multisite qualitative study in Timor-Leste conducted gender segregated focus groups (n = 8) in eight districts, with 59 adults in urban and rural settings, and in-depth interviews (n = 8) with the Director of community health centres. Communication was in the local language, Tetum, using a pre-tested interview schedule. Approval was obtained from community and national stakeholders, with written consent from participants.
  
  
  
  Lack of patient transport is the critical cross-cutting issue preventing access to hospital care. Without it, many communities resort to carrying patients by porters or on horseback, walking or paying for (unaffordable) private arrangements to reach hospital, or opt for home-based care. Other significant out-of-pocket expenses for hospital visits were blood supplies from private suppliers; accommodation and food for the patient and family members; and repatriation of the deceased. Entrenched nepotism and hospital staff denigrating patients' hygiene and personal circumstances were also widely reported. Consequently, some respondents asserted they would never return to hospital, others delayed seeking treatment or interrupted their treatment to return home. Most considered traditional medicine provided an affordable, accessible and acceptable substitute to hospital care. Obtaining a referral for higher level care was not a significant barrier to gaining access to hospital care.
  
  
  
  Onerous physical, financial and socio-cultural barriers are preventing or discouraging people from accessing hospital care in Timor-Leste. Improving access to quality primary health care at the frontline is a key strategy for ensuring universal access to health care, pursued alongside initiatives to overcome the multi-faceted barriers to hospital care experienced by the vulnerable. Improving the availability and functioning of patient transport services, provision of travel subsidies to patients and their families and training hospital staff in standards of professional care are some options available to government and donors seeking faster progress towards universal health coverage in Timor-Leste.
authors.affiliation: School of Public Health and Community Medicine, University of New South Wales, Botany Street, Sydney, Australia. jenniferprice.unsw@gmail.com.
authors.forename: Jennifer A
authors.initials: JA
authors.lastname: Price
authors.affiliation: Ministry of Health, Edifcio dos Servisos Centrais do Ministrio da Saude, Rua de Caicoli, Caixa Postal 374, Dili, Timor-Leste.
authors.forename: Ana I F Sousa
authors.initials: AI
authors.lastname: Soares
authors.affiliation: School of Public Health and Community Medicine, University of New South Wales, Botany Street, Sydney, Australia.
authors.forename: Augustine D
authors.initials: AD
authors.lastname: Asante
authors.affiliation: Faculty of Medicine and Health Sciences, National University of East Timor, Rua Jacinto Candido, Dili, Timor-Leste.
authors.forename: Joao S
authors.initials: JS
authors.lastname: Martins
authors.affiliation: Liga Inan mHealth program, Catalpa International, Rua Quinze de Outubro Culuhun, Dili, Timor-Leste.
authors.forename: Kate
authors.initials: K
authors.lastname: Williams
authors.affiliation: School of Public Health and Community Medicine, University of New South Wales, Botany Street, Sydney, Australia.|Department of Global Health and Development, London School of Hygiene and Tropical Medicine, Keppel Street, London, UK.
authors.forename: Virginia L
authors.initials: VL
authors.lastname: Wiseman
mesh_terms: D000328:Adult; D000368:Aged; D003151:Community Health Centers / Q000706:statistics & numerical data; D005260:Female; D017144:Focus Groups; D005102:Health Expenditures; D006296:Health Services / Q000191:economics / Q000706:statistics & numerical data; D006297:Health Services Accessibility / Q000191:economics / Q000592:standards*; D054625:Healthcare Disparities / Q000191:economics; D006760:Hospitalization / Q000191:economics / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D008519:Medicine, Traditional / Q000706:statistics & numerical data; D008875:Middle Aged; D010342:Patient Acceptance of Health Care / Q000706:statistics & numerical data*; D011320:Primary Health Care / Q000706:statistics & numerical data; D036301:Qualitative Research; D012017:Referral and Consultation; D012111:Residence Characteristics; D012423:Rural Health; D049648:Timor-Leste; D014195:Travel / Q000191:economics / Q000706:statistics & numerical data; D019472:Universal Health Insurance / Q000191:economics / Q000706:statistics & numerical data; D014504:Urban Health; D055815:Young Adult
keywords: Barriers; Demand-side; Determinants; Hospital services; Out-of-pocket payments; Referrals; Supply-side; Timor-Leste; Traditional medicine; Universal access