Catastrophic expenditure and impoverishment after caesarean section in Sierra Leone: An evaluation of the free health care initiative.

Alex J Van Duinen,Hampus Holmer,Håkon A Bolkan,Lars Hagander,Mark G Shrime,Arne Wibe,Alimamy P Koroma,Thomas Ashley,Andrew J M Leather,Josien Westendorp,Susan Horton

doi:10.1371/journal.pone.0258532

Abstract

BackgroundUtilizing surgical services, including caesarean sections, can result in catastrophic expenditure and impoverishment. In 2010, Sierra Leone introduced the Free Health Care Initiative (FHCI), a national financial risk protection program for the most vulnerable groups. Aim of this study was to investigate catastrophic expenditure and impoverishment related to caesarean section in Sierra Leone and evaluate the impact of the FHCI.MethodsWomen who delivered by caesarean section in nine hospitals were followed up with home visits one month after surgery, and data on medical and non-medical expenditures were collected. Individual income was estimated based on household characteristics and used to determine catastrophic expenditure and impoverishment for each patient. The impact of the FHCI was assessed by comparing actual expenditure with counterfactual expenditures had the initiative not existed.ResultsFor the 1146 patients in the study, the median expenditure was 23 (IQR 4; 56) international dollars (Int$). Patients in the poorest quintile spent a median Int$ 59 (IQR 28; 76), which was significantly more than patients in the richest quintile, who spent a median Int$ 17 (IQR 2; 38, p<0.001). Travel (32.9%) and food (28.7%) were the two largest expenses. Catastrophic expenditure was encountered by 12.0% and 4.0% (10% and 25% threshold, respectively) of the women. Without the FHCI, 66.1% and 28.8% of the women would have encountered catastrophic expenditure.ConclusionMany women in Sierra Leone face catastrophic expenditure related to caesarean section, mainly through food and travel expenses, and the poor are disproportionally affected. The FHCI is effective in reducing the risk of catastrophic expenditure related to caesarean section, but many patients are still exposed to financial hardship, suggesting that additional support is needed for Sierra Leone’s poorest patients.

Highlights

Catastrophic expenditure and impoverishmentSurgery has been acknowledged as an integral component of universal health coverage [1]
Many women in Sierra Leone face catastrophic expenditure related to caesarean section, mainly through food and travel expenses, and the poor are disproportionally affected
The Free Health Care Initiative (FHCI) is effective in reducing the risk of catastrophic expenditure related to caesarean section, but many patients are still exposed to financial hardship, suggesting that additional support is needed for Sierra Leone’s poorest patients

Summary

Introduction

Catastrophic expenditure and impoverishmentSurgery has been acknowledged as an integral component of universal health coverage [1]. Surgery is considered highly costeffective [3], utilizing surgical services can have negative financial consequences for individuals owing to high out-of-pocket expenditure [4]. Reflecting the importance of financial risk protection for surgical care, two of the six indicators from the Lancet Commission on Global Surgery to measure surgical care at the global level are dedicated to financial consequences: catastrophic expenditure and impoverishment [5]. An estimated 81 million people face catastrophic expenditure every year because of expenses related to surgical care [4]. Utilizing surgical services, including caesarean sections, can result in catastrophic expenditure and impoverishment. In 2010, Sierra Leone introduced the Free Health Care Initiative (FHCI), a national financial risk protection program for the most vulnerable groups.

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Results

Conclusion