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Shrime MG, Dare A, Alkire BC, Meara JG. A global country-level comparison of the financial burden of surgery. Br J Surg 2016; 103:1453-61. [PMID: 27428044 DOI: 10.1002/bjs.10249] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Revised: 11/11/2015] [Accepted: 05/23/2016] [Indexed: 11/09/2022]
Abstract
BACKGROUND Approximately 30 per cent of the global burden of disease is surgical, and nearly one-quarter of individuals who undergo surgery each year face financial hardship because of its cost. The Lancet Commission on Global Surgery has proposed the elimination of impoverishment due to surgery by 2030, but no country-level estimates exist of the financial burden of surgical access. METHODS Using publicly available data, the incidence and risk of financial hardship owing to surgery was estimated for each country. Four measures of financial catastrophe were examined: catastrophic expenditure, and impoverishment at the national poverty line, at 2 international dollars (I$) per day and at I$1·25 per day. Stochastic models of income and surgical costs were built for each country. Results were validated against available primary data. RESULTS Direct medical costs of surgery put 43·9 (95 per cent posterior credible interval 2·2 to 87·1) per cent of the examined population at risk of catastrophic expenditure, and 57·0 (21·8 to 85·1) per cent at risk of being pushed below I$2 per day. The risk of financial hardship from surgery was highest in sub-Saharan Africa. Correlations were found between the risk of financial catastrophe and external financing of healthcare (positive correlation), national measures of well-being (negative correlation) and the percentage of a country's gross domestic product spent on healthcare (negative correlation). The model performed well against primary data on the costs of surgery. CONCLUSION Country-specific estimates of financial catastrophe owing to surgical care are presented. The economic benefits projected to occur with the scale-up of surgery are placed at risk if the financial burden of accessing surgery is not addressed in national policies.
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Affiliation(s)
- M G Shrime
- Program in Global Surgery and Social Change, Harvard Medical School, Massachusetts, USA. .,Office of Global Surgery, Massachusetts Eye and Ear Infirmary, Boston Children's Hospital, Boston, Massachusetts, USA.
| | - A Dare
- Department of Surgery, University of Toronto, Toronto, Canada
| | - B C Alkire
- Office of Global Surgery, Massachusetts Eye and Ear Infirmary, Boston Children's Hospital, Boston, Massachusetts, USA
| | - J G Meara
- Program in Global Surgery and Social Change, Harvard Medical School, Massachusetts, USA.,Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
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Sullivan R, Alatise OI, Anderson BO, Audisio R, Autier P, Aggarwal A, Balch C, Brennan MF, Dare A, D'Cruz A, Eggermont AMM, Fleming K, Gueye SM, Hagander L, Herrera CA, Holmer H, Ilbawi AM, Jarnheimer A, Ji JF, Kingham TP, Liberman J, Leather AJM, Meara JG, Mukhopadhyay S, Murthy SS, Omar S, Parham GP, Pramesh CS, Riviello R, Rodin D, Santini L, Shrikhande SV, Shrime M, Thomas R, Tsunoda AT, van de Velde C, Veronesi U, Vijaykumar DK, Watters D, Wang S, Wu YL, Zeiton M, Purushotham A. Global cancer surgery: delivering safe, affordable, and timely cancer surgery. Lancet Oncol 2016; 16:1193-224. [PMID: 26427363 DOI: 10.1016/s1470-2045(15)00223-5] [Citation(s) in RCA: 409] [Impact Index Per Article: 51.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2015] [Revised: 08/07/2015] [Accepted: 08/07/2015] [Indexed: 12/20/2022]
Abstract
Surgery is essential for global cancer care in all resource settings. Of the 15.2 million new cases of cancer in 2015, over 80% of cases will need surgery, some several times. By 2030, we estimate that annually 45 million surgical procedures will be needed worldwide. Yet, less than 25% of patients with cancer worldwide actually get safe, affordable, or timely surgery. This Commission on global cancer surgery, building on Global Surgery 2030, has examined the state of global cancer surgery through an analysis of the burden of surgical disease and breadth of cancer surgery, economics and financing, factors for strengthening surgical systems for cancer with multiple-country studies, the research agenda, and the political factors that frame policy making in this area. We found wide equity and economic gaps in global cancer surgery. Many patients throughout the world do not have access to cancer surgery, and the failure to train more cancer surgeons and strengthen systems could result in as much as US $6.2 trillion in lost cumulative gross domestic product by 2030. Many of the key adjunct treatment modalities for cancer surgery--e.g., pathology and imaging--are also inadequate. Our analysis identified substantial issues, but also highlights solutions and innovations. Issues of access, a paucity of investment in public surgical systems, low investment in research, and training and education gaps are remarkably widespread. Solutions include better regulated public systems, international partnerships, super-centralisation of surgical services, novel surgical clinical trials, and new approaches to improve quality and scale up cancer surgical systems through education and training. Our key messages are directed at many global stakeholders, but the central message is that to deliver safe, affordable, and timely cancer surgery to all, surgery must be at the heart of global and national cancer control planning.
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Affiliation(s)
- Richard Sullivan
- Institute of Cancer Policy, King's Health Partners Comprehensive Cancer Centre, London, UK; King's Centre for Global Health, King's Health Partners and King's College London, London, UK.
| | | | - Benjamin O Anderson
- University of Washington School of Medicine, Seattle, WA, USA; Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | | | | | - Ajay Aggarwal
- Institute of Cancer Policy, King's Health Partners Comprehensive Cancer Centre, London, UK; Guy's and St Thomas' NHS Foundation Trust, London, UK; London School of Hygiene & Tropical Medicine, London, UK
| | - Charles Balch
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | - Anna Dare
- Centre for Global Health Research, St Michael's Hospital, Toronto, ON, Canada; Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Anil D'Cruz
- Department of Surgical Oncology, Tata Memorial Centre, Mumbai, Maharashtra, India
| | | | - Kenneth Fleming
- Green Templeton College, University of Oxford, Oxford, UK; Oxford University Hospitals NHS Trust, Oxford, UK
| | - Serigne Magueye Gueye
- University Cheikh Anta Diop, Dakar, Senegal; Grand Yoff General Hospital, Dakar, Senegal
| | - Lars Hagander
- Paediatric Surgery and Global Paediatrics, Department of Paediatrics, Lund University, Lund, Sweden
| | - Cristian A Herrera
- Cabinet of the Minister, Ministry of Health, Santiago, Chile; Department of Public Health, School of Medicine, Pontificia Universidad Católica, Santiago, Chile
| | - Hampus Holmer
- Paediatric Surgery and Global Paediatrics, Department of Paediatrics, Lund University, Lund, Sweden
| | - André M Ilbawi
- University of Texas MD Anderson Cancer Centre, Houston, TX, USA; Union for International Cancer Control, Geneva, Switzerland
| | - Anton Jarnheimer
- Paediatric Surgery and Global Paediatrics, Department of Paediatrics, Lund University, Lund, Sweden; Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Jia-Fu Ji
- Peking University Cancer Hospital and Institute, Beijing, China; Chinese Anti-Cancer Association, Tianjin, China
| | | | | | - Andrew J M Leather
- King's Centre for Global Health, King's Health Partners and King's College London, London, UK
| | - John G Meara
- Program in Global Surgery and Social Change, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Swagoto Mukhopadhyay
- Program in Global Surgery and Social Change, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Shilpa S Murthy
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard School of Public Health, Boston, MA, USA; Department of General Surgery, Indiana University, Bloomington, IN, USA
| | | | - Groesbeck P Parham
- Department of Obstetrics and Gynecology, Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA; University of Zambia, Lusaka, Zambia
| | - C S Pramesh
- Department of Surgical Oncology, Tata Memorial Centre, Mumbai, Maharashtra, India
| | - Robert Riviello
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard School of Public Health, Boston, MA, USA
| | - Danielle Rodin
- Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Luiz Santini
- INCA (Brazilian National Cancer Institute), Rio de Janeiro, Brazil
| | | | - Mark Shrime
- Program in Global Surgery and Social Change, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Robert Thomas
- Department of Health & Human Services, Melbourne, VIC, Australia
| | - Audrey T Tsunoda
- Gyne-Oncology Department, Barretos Cancer Hospital, Barretos, Brazil
| | - Cornelis van de Velde
- Department of Surgical Oncology, Endocrine and Gastrointestinal Surgery, Leiden University Medical Centre, Leiden, Netherlands
| | | | | | - David Watters
- Deakin University, Geelong, VIC, Australia; Barwon Health, Geelong, VIC, Australia
| | - Shan Wang
- Peking University People's Hospital, Beijing, China; Chinese College of Surgeons, Beijing, China
| | - Yi-Long Wu
- Guangdong Lung Cancer Institute, Guangdong General Hospital, Guangzhou, China; Guangdong Academy of Medical Sciences, Guangzhou, China; Chinese Society of Clinical Oncology, Beijing, China
| | - Moez Zeiton
- Sadeq Institute, Tripoli, Libya; Trauma and Orthopaedic Rotation, North-West Deanery, Manchester, UK
| | - Arnie Purushotham
- Institute of Cancer Policy, King's Health Partners Comprehensive Cancer Centre, London, UK; King's Centre for Global Health, King's Health Partners and King's College London, London, UK; Guy's and St Thomas' NHS Foundation Trust, London, UK
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Shrime MG, Dare AJ, Alkire BC, O'Neill K, Meara JG. Catastrophic expenditure to pay for surgery worldwide: a modelling study. Lancet Glob Health 2015; 3 Suppl 2:S38-44. [PMID: 25926319 PMCID: PMC4428601 DOI: 10.1016/s2214-109x(15)70085-9] [Citation(s) in RCA: 188] [Impact Index Per Article: 20.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Approximately 150 million individuals worldwide face catastrophic expenditure each year from medical costs alone, and the non-medical costs of accessing care increase that number. The proportion of this expenditure related to surgery is unknown. Because the World Bank has proposed elimination of medical impoverishment by 2030, the effect of surgical conditions on financial catastrophe should be quantified so that any financial risk protection mechanisms can appropriately incorporate surgery. METHODS To estimate the global incidence of catastrophic expenditure due to surgery, we built a stochastic model. The income distribution of each country, the probability of requiring surgery, and the medical and non-medical costs faced for surgery were incorporated. Sensitivity analyses were run to test the robustness of the model. FINDINGS 3·7 billion people (posterior credible interval 3·2-4·2 billion) risk catastrophic expenditure if they need surgery. Each year, 81·3 million people (80·8-81·7 million) worldwide are driven to financial catastrophe-32·8 million (32·4-33·1 million) from the costs of surgery alone and 48·5 million (47·7-49·3) from associated non-medical costs. The burden of catastrophic expenditure is highest in countries of low and middle income; within any country, it falls on the poor. Estimates were sensitive to the definition of catastrophic expenditure and the costs of care. The inequitable burden distribution was robust to model assumptions. INTERPRETATION Half the global population is at risk of financial catastrophe from surgery. Each year, surgical conditions cause 81 million individuals to face catastrophic expenditure, of which less than half is attributable to medical costs. These findings highlight the need for financial risk protection for surgery in health-system design. FUNDING MGS received partial funding from NIH/NCI R25CA92203.
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Affiliation(s)
- Mark G Shrime
- Department of Global Health and Population, Harvard School of Public Health, Boston, MA, USA; Department of Otology and Laryngology, Harvard Medical School, Boston, MA, USA; Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA.
| | - Anna J Dare
- King's Centre for Global Health, King's Health Partners, King's College London, London, UK
| | - Blake C Alkire
- Department of Otology and Laryngology, Harvard Medical School, Boston, MA, USA; Office of Global Surgery, Massachusetts Eye and Ear Infirmary, Boston, MA, USA; Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - Kathleen O'Neill
- University of Pennsylvania Medical School, Philadelphia, PA, USA
| | - John G Meara
- Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA; Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, MA, USA
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