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Yap A, Olatunji BT, Negash S, Mweru D, Kisembo S, Masumbuko F, Ameh EA, Lebbie A, Bvulani B, Hansen E, Philipo GS, Carroll M, Hsu PJ, Bryce E, Cheung M, Fedatto M, Laverde R, Ozgediz D. Out-of-pocket costs and catastrophic healthcare expenditure for families of children requiring surgery in sub-Saharan Africa. Surgery 2023; 174:567-573. [PMID: 37385869 DOI: 10.1016/j.surg.2023.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 05/04/2023] [Accepted: 05/24/2023] [Indexed: 07/01/2023]
Abstract
BACKGROUND Out-of-pocket healthcare costs leading to catastrophic healthcare expenditure pose a financial threat for families of children undergoing surgery in Sub-Saharan African countries, where universal healthcare coverage is often insufficient. METHODS A prospective clinical and socioeconomic data collection tool was used in African hospitals with dedicated pediatric operating rooms installed philanthropically. Clinical data were collected via chart review and socioeconomic data from families. The primary indicator of economic burden was the proportion of families with catastrophic healthcare expenditures. Secondary indicators included the percentage who borrowed money, sold possessions, forfeited wages, and lost a job secondary to their child's surgery. Descriptive statistics and multivariate logistic regression were performed to identify predictors of catastrophic healthcare expenditure. RESULTS In all, 2,296 families of pediatric surgical patients from 6 countries were included. The median annual income was $1,000 (interquartile range 308-2,563), whereas the median out-of-pocket cost was $60 (interquartile range 26-174). Overall, 39.9% (n = 915) families incurred catastrophic healthcare expenditure, 23.3% (n = 533) borrowed money, 3.8% (n = 88%) sold possessions, 26.4% (n = 604) forfeited wages, and 2.3% (n = 52) lost a job because of the child's surgery. Catastrophic healthcare expenditure was associated with older age, emergency cases, need for transfusion, reoperation, antibiotics, and longer length of stay, whereas the subgroup analysis found insurance to be protective (odds ratio 0.22, P = .002). CONCLUSION A full 40% of families of children in sub-Saharan Africa who undergo surgery incur catastrophic healthcare expenditure, shouldering economic consequences such as forfeited wages and debt. Intensive resource utilization and reduced insurance coverage in older children may contribute to a higher likelihood of catastrophic healthcare expenditure and can be insurance targets for policymakers.
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Affiliation(s)
- Ava Yap
- Center of Health Equity in Surgery and Anesthesia, University of California San Francisco, San Francisco, CA.
| | | | - Samuel Negash
- Department of Paediatric Surgery, Menelik II Hospital, Addis Ababa, Ethiopia
| | - Dilon Mweru
- Department of Surgery, Centre Hospitalier Bethesda, Goma, Democratic Republic of Congo
| | - Steve Kisembo
- Department of Surgery, Centre Hospitalier Bethesda, Goma, Democratic Republic of Congo
| | - Franck Masumbuko
- Department of Surgery, Hôpital Provincial Général de Reférence de Bukavu, Bukavu, Democratic Republic of Congo
| | - Emmanuel A Ameh
- Department of Paediatric Surgery, National Hospital Abuja, Abuja, Nigeria
| | - Aiah Lebbie
- Department of Surgery, Connaught Hospital, Freetown, Sierra Leone
| | - Bruce Bvulani
- Department of Surgery, University Teaching Hospital, Lusaka, Zambia
| | - Eric Hansen
- Department of Surgery, Kijabe Hospital, Kijabe, Kenya
| | | | - Madeleine Carroll
- Department of Surgery, Yale University School of Medicine, New Haven, CT
| | - Phillip J Hsu
- Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Emma Bryce
- Kids Operating Room, Edinburgh, Scotland, United Kingdom; Usher Institute of Population Health Sciences and Informatics, The University of Edinburgh, Edinburgh, Scotland, United Kingdom
| | - Maija Cheung
- Department of Surgery, Yale University School of Medicine, New Haven, CT
| | - Maira Fedatto
- Kids Operating Room, Edinburgh, Scotland, United Kingdom
| | - Ruth Laverde
- Center of Health Equity in Surgery and Anesthesia, University of California San Francisco, San Francisco, CA
| | - Doruk Ozgediz
- Center of Health Equity in Surgery and Anesthesia, University of California San Francisco, San Francisco, CA
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Tsawe M, Susuman AS. Inequalities in maternal healthcare use in Sierra Leone: Evidence from the 2008-2019 Demographic and Health Surveys. PLoS One 2022; 17:e0276102. [PMID: 36228021 PMCID: PMC9560049 DOI: 10.1371/journal.pone.0276102] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 09/28/2022] [Indexed: 11/05/2022] Open
Abstract
Background Sierra Leone is one of the countries with poor health outcomes. The country has made some progress in the uptake of maternal health services. Despite improvements in the national coverage rates, there is no evidence of how equal these improvements have been. Objective To estimate inequalities in maternal healthcare use in Sierra Leone. Methods Using cross-sectional study data from 2008, 2013, and 2019 Demographic and Health Surveys (DHS), we study inequalities in maternal health services by computing rate ratios, and concentration indices (as well as concentration curves) using selected inequality stratifiers such as household wealth index, maternal education, and rural/urban place of residence. Results We found that considerable progress has been made in increasing the uptake of maternal health services as well as reducing inequalities over time. We also found that inequalities in the selected health indicators favoured women from wealthy households, educated women, as well as women from urban areas. Although inequalities declined over time, the use of delivery services was highly unequal. However, of the selected health interventions, the use of four or more antenatal visits was almost at perfect equality in 2013 and 2019. Conclusion Although efforts have been made to increase the use of maternal healthcare services among women with a lower socioeconomic status, the use of maternal health services remains favourable to women with a higher socioeconomic standing. Therefore, policy initiatives need to prioritise women of lower socioeconomic status through projects aimed at increasing women’s educational levels as well as focusing on poverty reduction.
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Affiliation(s)
- Mluleki Tsawe
- Department of Population Studies and Demography, North-West University, Mahikeng, South Africa
- Faculty of Humanities, Population and Health Research Focus Area, North-West University, Mahikeng, South Africa
- * E-mail:
| | - A Sathiya Susuman
- Department of Statistics & Population Studies, University of the Western Cape, Cape Town, South Africa
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van Kesteren J, van Duinen AJ, Marah F, van Delft D, Spector AL, Cassidy LD, Groen RS, Jabbi SMBB, Bah S, Medo JA, Kamanda-Bongay A, van Leerdam D, Westendorp J, Mathéron HM, Mönnink GLE, Vas Nunes J, Lindenbergh KC, Hoel SK, Løvdal SM, Østensen MN, Solberg H, Boateng D, Klipstein-Grobusch K, van Herwaarden D, Martens JPJ, Bonjer HJ, Sankoh O, Grobusch MP, Bolkan HA. PREvalence Study on Surgical COnditions (PRESSCO) 2020: A Population-Based Cross-Sectional Countrywide Survey on Surgical Conditions in Post-Ebola Outbreak Sierra Leone. World J Surg 2022; 46:2585-2594. [PMID: 36068404 PMCID: PMC9529684 DOI: 10.1007/s00268-022-06695-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/28/2022] [Indexed: 11/27/2022]
Abstract
Background Understanding the burden of diseases requiring surgical care at national levels is essential to advance universal health coverage. The PREvalence Study on Surgical COnditions (PRESSCO) 2020 is a cross-sectional household survey to estimate the prevalence of physical conditions needing surgical consultation, to investigate healthcare-seeking behavior, and to assess changes from before the West African Ebola epidemic. Methods This study (ISRCTN: 12353489) was built upon the Surgeons Overseas Surgical Needs Assessment (SOSAS) tool, including expansions. Seventy-five enumeration areas from 9671 nationwide clusters were sampled proportional to population size. In each cluster, 25 households were randomly assigned and visited. Need for surgical consultations was based on verbal responses and physical examination of selected household members. Results A total of 3,618 individuals from 1,854 households were surveyed. Compared to 2012, the prevalence of individuals reporting one or more relevant physical conditions was reduced from 25 to 6.2% (95% CI 5.4–7.0%) of the population. One-in-five conditions rendered respondents unemployed, disabled, or stigmatized. Adult males were predominantly prone to untreated surgical conditions (9.7 vs. 5.9% women; p < 0.001). Financial constraints were the predominant reason for not seeking care. Among those seeking professional health care, 86.7% underwent surgery. Conclusion PRESSCO 2020 is the first surgical needs household survey which compares against earlier study data. Despite the 2013–2016 Ebola outbreak, which profoundly disrupted the national healthcare system, a substantial reduction in reported surgical conditions was observed. Compared to one-time measurements, repeated household surveys yield finer granular data on the characteristics and situations of populations in need of surgical treatment. Supplementary Information The online version contains supplementary material available at 10.1007/s00268-022-06695-7.
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Affiliation(s)
- Jurre van Kesteren
- Amsterdam UMC Location Vrije Universiteit, Department of Surgery, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands.
- Global Surgery Amsterdam, Amsterdam, The Netherlands.
| | - Alex J van Duinen
- Institute of Clinical and Molecular Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Clinic of Surgery, St. Olavs Hospital HF, Trondheim University Hospital, Trondheim, Norway
- CapaCare, Trondheim, Norway
| | - Foday Marah
- CapaCare, Trondheim, Norway
- Masanga Hospital, Tonkolili District, Masanga, Sierra Leone
| | - Diede van Delft
- CapaCare, Trondheim, Norway
- Masanga Hospital, Tonkolili District, Masanga, Sierra Leone
- Masanga Medical Research Unit, Tonkolili District, Masanga, Sierra Leone
| | - Antoinette L Spector
- Institute for Health & Equity and Epidemiology Division, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Laura D Cassidy
- Institute for Health & Equity and Epidemiology Division, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Reinou S Groen
- Johns Hopkins School of Medicine, Baltimore, USA
- SOS - Surgeons OverSeas, New York, NY, USA
| | | | - Silleh Bah
- Statistics Sierra Leone, Tower Hill, Freetown, Sierra Leone
| | - James A Medo
- Statistics Sierra Leone, Tower Hill, Freetown, Sierra Leone
| | | | - Daniel van Leerdam
- CapaCare, Trondheim, Norway
- KIT, Royal Tropical Institute, Amsterdam, The Netherlands
| | - Josien Westendorp
- Institute of Clinical and Molecular Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- CapaCare, Trondheim, Norway
| | - Hanna M Mathéron
- Masanga Medical Research Unit, Tonkolili District, Masanga, Sierra Leone
- Amsterdam UMC location University of Amsterdam, AMC, Centre of Tropical Medicine and Travel Medicine, Amsterdam, The Netherlands
| | - Giulia L E Mönnink
- Amsterdam UMC location University of Amsterdam, AMC, Centre of Tropical Medicine and Travel Medicine, Amsterdam, The Netherlands
| | - Jonathan Vas Nunes
- Masanga Medical Research Unit, Tonkolili District, Masanga, Sierra Leone
- Amsterdam UMC location University of Amsterdam, AMC, Centre of Tropical Medicine and Travel Medicine, Amsterdam, The Netherlands
| | - Karel C Lindenbergh
- Faculty of Medicine, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Sara K Hoel
- Institute of Clinical and Molecular Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Sofie M Løvdal
- Institute of Clinical and Molecular Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Mia N Østensen
- Institute of Clinical and Molecular Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Helene Solberg
- Institute of Clinical and Molecular Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Daniel Boateng
- Julius Global Health, Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Kerstin Klipstein-Grobusch
- Julius Global Health, Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | | | | | - H Jaap Bonjer
- Amsterdam UMC Location Vrije Universiteit, Department of Surgery, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
- Global Surgery Amsterdam, Amsterdam, The Netherlands
| | - Osman Sankoh
- Statistics Sierra Leone, Tower Hill, Freetown, Sierra Leone
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Heidelberg Institute of Global Health, University of Heidelberg Medical School, Heidelberg, Germany
| | - Martin P Grobusch
- Masanga Medical Research Unit, Tonkolili District, Masanga, Sierra Leone
- Amsterdam UMC location University of Amsterdam, AMC, Centre of Tropical Medicine and Travel Medicine, Amsterdam, The Netherlands
- Institute of Tropical Medicine, University of Tübingen, Tübingen, Germany
- Centre de Recherches Médicales en Lambaréné (CERMEL), Lambaréné, Gabon
- Institute of Infectious Diseases and Molecular Medicine (IDM), University of Cape Town, Cape Town, South Africa
| | - Håkon A Bolkan
- Institute of Clinical and Molecular Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Clinic of Surgery, St. Olavs Hospital HF, Trondheim University Hospital, Trondheim, Norway
- CapaCare, Trondheim, Norway
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Eze P, Lawani LO, Agu UJ, Acharya Y. Catastrophic health expenditure in sub-Saharan Africa: systematic review and meta-analysis. Bull World Health Organ 2022; 100:337-351J. [PMID: 35521041 PMCID: PMC9047424 DOI: 10.2471/blt.21.287673] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 02/24/2022] [Accepted: 02/28/2022] [Indexed: 11/27/2022] Open
Abstract
Objective To estimate the incidence of, and trends in, catastrophic health expenditure in sub-Saharan Africa. Methods We systematically reviewed the scientific and grey literature to identify population-based studies on catastrophic health expenditure in sub-Saharan Africa published between 2000 and 2021. We performed a meta-analysis using two definitions of catastrophic health expenditure: 10% of total household expenditure and 40% of household non-food expenditure. The results of individual studies were pooled by pairwise meta-analysis using the random-effects model. Findings We identified 111 publications covering a total of 1 040 620 households across 31 sub-Saharan African countries. Overall, the pooled annual incidence of catastrophic health expenditure was 16.5% (95% confidence interval, CI: 12.9-20.4; 50 datapoints; 462 151 households; I 2 = 99.9%) for a threshold of 10% of total household expenditure and 8.7% (95% CI: 7.2-10.3; 84 datapoints; 795 355 households; I 2 = 99.8%) for a threshold of 40% of household non-food expenditure. Countries in central and southern sub-Saharan Africa had the highest and lowest incidence, respectively. A trend analysis found that, after initially declining in the 2000s, the incidence of catastrophic health expenditure in sub-Saharan Africa increased between 2010 and 2020. The incidence among people affected by specific diseases, such as noncommunicable diseases, HIV/AIDS and tuberculosis, was generally higher. Conclusion Although data on catastrophic health expenditure for some countries were sparse, the data available suggest that a non-negligible share of households in sub-Saharan Africa experienced catastrophic expenditure when accessing health-care services. Stronger financial protection measures are needed.
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Affiliation(s)
- Paul Eze
- Department of Health Policy and Administration, 504A Donald H. Ford Building, Pennsylvania State University, University Park, Pennsylvania, PA16802, United States of America
| | - Lucky Osaheni Lawani
- Institute of Health Policy, Management & Evaluation, University of Toronto, Toronto, Canada
| | - Ujunwa Justina Agu
- Department of Community Medicine, Enugu State University Teaching Hospital, Parklane, Nigeria
| | - Yubraj Acharya
- Department of Health Policy and Administration, 504A Donald H. Ford Building, Pennsylvania State University, University Park, Pennsylvania, PA16802, United States of America
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