Table 2.

Representative quotations for each theme/subtheme

Theme	Representative quotation
High costs
Direct costs	‘The financial outlay to manage these conditions appeared to be more than simply the sum of expenditures for each condition’. 68 ‘The incidental costs of seeking healthcare, such as transportation and parking were a barrier that hindered some participants’ access to medical care. Transportation related issues included: not being able to drive independently, having to travel prohibitively long distances to healthcare facilities, costs of gasoline, and the cost of parking at hospitals and doctors’ offices’. 36 ‘The medications are just astronomical when it comes to money, to paying for them. I pay over, I think, $300 a month just on medications’ 51 ‘To go to the doctor is expensive. For example, going to pick up medication at the insurance company including a round trip by taxi, and buying the medication cost a lot of money […] Everything is expensive’ 41
Indirect costs	‘No, I’m not working. And, like I say, when I was working at [name of employer], I stopped taking that medicine for a whole year, trying to keep the job ‘cause I was having lotta side effects from the medicines and I couldn't do both’. 78 ‘The long‐term nature of this burden was aggravated by having to cease employment prematurely due to ill health. Apart from the impact that might be anticipated to result from employment loss on other domains of life, it clearly increased the financial strain associated with the management of chronic conditions’. 35
Health insurance and government supports
Insufficient coverage and insufficient care	‘I rarely came to the hospital because we don't have health insurance cover for going to see doctors in the outpatient clinic here’. 57 ‘Oh my God, it's awful. When I’m charged through [Medicaid managed care plan], they charge one dollar for each prescription, and I take like 20‐25 medications…plus the Lantis (insulin) and Humalog (insulin) and the syringes, the needles, the sticks, that's an extra $5 on top of the $25 I already pay…that's $30 per month, and I cannot afford that, and because of that, I’m having to pick and choose which medication to take and which medication to leave because I can't afford to buy them, and it's causing a lot of health problems’. 40
Safety net	‘I'm surviving financially because of the welfare system’ 38 ‘[without private health insurance], you'd be out in the middle of the dead less sea’. 34
Complexity	‘The fee…they said it could be like a sliding scale. But I assumed that it couldn't slide that far down for me’. 36 ‘For our health insurance company we are high maintenance people. So they restraint [SIC] us from receiving quality services such as referrals to medical specialists, treatments, procedures and diagnostic tests on time. For example, six months ago we went to the doctor for a follow up visit where we were expecting to find out how my health was but the doctor limited the visit to refilling my prescription of Morphine and nothing else’ 41
Coping strategies to manage costs
Accessing informal supports	‘There was a time that a medication was prescribed for me and that costs GH¢150.00. It was my sister's child who gave me money to purchase that medicine’. 63 ‘One son kind of manages the money and lends me money when I need it and then I pay him back when I get my government [pension]’. 67
Making sacrifices	‘I take my medicine only when I feel my sugar is high. Those drugs are not free you know. I pay $30 for one drug that I take for a month and I take about 9 drugs. So I don't fill them every month’ 65 ‘All my money goes on my health aside from basic bills. I do not buy treats, clothes, haircuts, toiletries, things for the house […] Have to spend a lot of time and energy on budgeting and I delay treatment sometimes as I have to save up’ 73 ‘it costs us $330 a month just for our health insurance, now that on a pension is a very very big constraint and that is why we sold our house’. 39
Reduced well‐being	‘The costs are many. The drugs are expensive and sometimes I cry when I hear of the cost of the drugs’. 59 ‘When you work you're whole, but when you get to the point of having to depend on other people for your income… It's like you don't become a whole person anymore. You become pieces. And if you don't have that piece to help you through that life you can't be whole. It's like you're lost’. 36 ‘Sheila advocated for herself but became frustrated when the physician offered her an additional prescription. The offer demonstrated to Sheila the physician's lack of care and inability to grasp her real‐life constraints: a difficult journey to the clinic and a limited income and how she could ill support a double medication fee’ 75