Abstract
BackgroundHaving to pay out-of-pocket for health care can be prohibitive and even cause financial catastrophe for patients, especially those with low and irregular incomes. Health services at Government-owned hospitals in Malawi are provided free of charge but patients do incur costs when they access facilities and some of them forego income. This research paper presents findings on the direct and indirect expenditure incurred by patients who underwent hernia surgery at district and central hospitals in Malawi. It reports the main cost drivers, how costs relate to patients’ household incomes, the financial burden of undergoing surgery and the extent to which hernia patients had recovered and restored their capacity to work and earn an income.Materials and methodsUsing a cross-sectional study design, surveys were held with patients who had undergone hernia surgery in four district and two central hospitals in Malawi. Interviews were conducted by surgically trained clinical officers, trained in survey administration, and included, inter alia, questions about patients’ hospital stay, the direct and indirect cost they incurred in accessing surgery, and how they financed the expenditure. Follow-up interviews by telephone were held 8–10 weeks after discharge.ResultsThe sample included 137 patients from district and 86 patients from central hospitals. The main direct cost drivers were transport and food & groceries. More than three quarters of patients who had their surgery at a district hospital incurred indirect costs, because of income lost due to hospital admission, compared with just over a third among central hospital patients. Median reported income losses were US$ 90 and US$ 71, respectively. Catastrophic expenditure for surgery occurred in 94% of district and 87% of central hospital patients. When indirect costs are added to the out-of-pocket expenditure, it constituted more than 10% of the monthly per capita income for 97% and 90% of the district and central hospital patients, respectively.ConclusionOut-of-pocket household expenditure associated with essential surgery in Malawi is high and in many instances catastrophic, putting households, especially those who are already poor, at risk of further impoverishment. The much needed scaling-up of surgical services in rural areas of Malawi needs to be accompanied by financial risk protection measures.
Highlights
Whereas approximately 30 percent of the global burden of disease is surgical, nearly 5 billion people worldwide are without access to safe, affordable and timely surgical and anaesthesia care [1]
One fifth of the interviewees (14 patients; 21%) reported a deterioration of their economic situation, with a similar number reporting no change (13 patients; 20%). This is the first empirical study from Malawi that quantifies the financial burden of surgery from the perspective of households
National patient-level data for out-of-pocket expenditure for surgery have been collected through patient exit interviews in Ghana, Kenya, Uganda, Zambia and India, by the Access, Bottlenecks, Costs and Equity (ABCE) project of the Institute of Health Metrics and Evaluation [27]
Summary
Whereas approximately 30 percent of the global burden of disease is surgical, nearly 5 billion people worldwide are without access to safe, affordable and timely surgical and anaesthesia care [1] Among those who do access care, an estimated 33 million every year face financial hardship from the direct costs of surgery, with another 48 million incurring financial catastrophe from the non-medical costs of transportation, food and lodging necessary to obtain surgery [2]. This research paper presents findings on the direct and indirect expenditure incurred by patients who underwent hernia surgery at district and central hospitals in Malawi. It reports the main cost drivers, how costs relate to patients’ household incomes, the financial burden of undergoing surgery and the extent to which hernia patients had recovered and restored their capacity to work and earn an income. The much needed scaling-up of surgical services in rural areas of Malawi needs to be accompanied by financial risk protection measures
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