During the past five years, considerable efforts were made by public health authorities in Nepal towards the elimination of VL such as the decentralisation and provision of free diagnosis and treatment and the introduction of the oral drug miltefosine in the public health system. In this study we studied the health seeking behaviour and documented household costs and coping strategies for one episode of VL from the perspective of the patient in a miltefosine-based treatment program. From our findings, the following observations can be made.
First, our results showed that the cost of a VL episode to patients and their family was high notwithstanding the free provision of drugs and diagnostics by the government. With a median total cost of US$ 165 per episode, the economic burden of VL across all households was 11% of annual household income or 57% of median annual per capita income (). This cost included both direct costs (medical and non-medical out-of-pocket expenditures) and indirect costs (productive time losses due to illness). While about half (51%) of the households exceeded the catastrophic threshold of 10% of annual household income, it would be wrong to conclude that the economic consequences of VL illness were not significant for the other households. Because VL is a disease of poverty primarily affecting the poorest income groups 
, the ability to cope with the costs of VL illness are limited. This was evident from the coping strategies households used whereby a majority of households were forced to take a loan to pay for the costs of care and/or use all their savings. However, without the free provision of VL drugs the median cost of an episode of VL would be US$ 226 and the proportion of households exceeding the catastrophic threshold would increase from 51% to 74% (assuming a drug cost of US$63 for a 28-days course of miltefosine at WHO preferential prices 
Summary of direct and indirect costs per VL episode (Rs. and in US$ 2010).
Secondly, direct costs accounted for 47% of total costs and were largely caused by out-of-pocket expenditures households made on ancillary drugs and food. Households that visited private-for-profit health providers incurred substantial expenditures on ancillary drugs. These ancillary drugs, most frequently antibiotics, antipyretics or vitamin injections, were given to patients prior to their referral to a public hospital for VL treatment. From our study we cannot say whether the prescription of these ancillary drugs were justified on medical grounds. Besides the ancillary drugs, another important direct cost component were the high food costs for the patient and accompanying relatives and was caused by the extensive stay at the hospital for treatment. Although miltefosine is an oral drug, patients stayed at the hospital for a median of 10 days.
A number of studies had been carried out prior to the VL elimination initiative 
. Our findings seem to suggest that, compared to these studies, the economic burden of VL (as a % of household income) has decreased. In particular the magnitude of indirect costs (as a % of total costs) was less in our study likely due to a shorter patient delay. We cannot say whether the shorter patient delay observed in this study was the result of increased patient knowledge of VL, but the previous studies reported that traditional providers were most commonly the patient's first choice of provider, which may have lengthened the delay until VL diagnosis. However, these conclusions need to be considered as tentative. For instance the total cost of VL in our study was higher compared to Rijal et al
. (2006) but much lower compared to Adhikari & Maskay (2005) and Adhikari et al.
(2009) while the household income of VL affected households in our study was higher compared to all three studies (to enable comparisons the cost data in these articles were adjusted to the year 2010 using the consumer price index 
). While daily wages in Nepal have increased over the years, partly to compensate for the high inflation rate, methodological differences between the studies and in particular the small sample sizes of the first two studies (respectively 18 and 7 households) limit their generalizability beyond the communities or villages where these studies were carried out.
Despite the provision of free VL drugs, we have shown that households still incurred substantial medical out-of-pocket expenditures, especially at private providers. It remains to be seen, however, if these medical costs can be prevented or at least diminished. While prepayment schemes, such as community-based health insurance, may be a solution, coverage in Nepal is very low and expansion of coverage to VL affected households is unlikely in the near future. More realistic and feasible approaches consist of reducing indirect costs and vector control. Treatment duration can be reduced substantially by considering alternative VL drugs to miltefosine as single-dose liposomal amphotericin B or a short course combination therapy 
). Vector control, such as indoor residual spraying, has been shown to be effective in reducing the number of sandflies inside the house 
and may therefore reduce disease transmission. Since 2011, the Government of Nepal has also introduced a conditional cash transfer programme whereby households receive Rs. 1,000 (US$13.5) upon completion of treatment at a public hospital 
. This payment can be used to cover transportation costs but was not yet in place when we carried out the household survey. However from our study, the total transportation costs of households were smaller than Rs. 1,000 while food costs were higher. The conditional cash programme therefore ought to be expanded to include food costs as well.
This study had a number of limitations. Because patients were selected from the medical records of the District Public Health Offices and the BPKIHS, only patients treated at public health facilities were included in the study. The records kept by the District Public Health Offices are obtained through passive surveillance from cases detected and treated by public health facilities. Private for-profit providers are not required to report patients treated at their facilities. Due to the low incidence of VL and the high number of private practioners in Nepal, it would have been difficult and costly to find and interview these patients. Because patients exclusively treated at private-for-profit providers were excluded, we probably underestimated the true burden of VL. Despite this limitation, our findings were still representative for a large proportion of the VL population because in Nepal, contrary to India, a relatively small proportion of patients seek VL treatment from private-for-profit providers (about 11% of patients according to 
. Nonetheless, efforts should be made in the future to include the private sector in the control of VL.
A second limitation is related to the recall bias. With decreasing VL incidence rates in Nepal, we have chosen a recall of 12 months to allow the identification of a sufficient number of households. To minimize the recall bias we only analysed the most recent case of VL in the household. Because of the clustering of VL in communities and villages, several cases of VL often occur in the same household. For instance, in 44% of households in our study one or more members had been treated for VL before, often within a few years. The occurrence of more than one case of VL in the same household would significantly increase the economic impact of VL to households. And even if these cases do not occur in the same year, the risk of impoverishment and indebtedness would still be much higher.
With a shorter delay to diagnosis once the patient has presented to a qualified health provider and the free provision of the correct first-line drug, our study indicates that the case management component of the Nepalese VL programme performs rather well. In particular free VL diagnosis and drugs at public health facilities have been an important policy measure in Nepal to lower financial barriers and improve access to VL diagnosis and care. Without this policy the economic burden of VL would have been much higher. However, the economic impact of VL is still considerable and intensified efforts are needed to further reduce the burden of VL to affected households or prevent the transmission of VL. These include shortening the duration of stay at the hospital and expanding demand side financing mechanisms to cover a wider range of costs incurred by households.