Surgical Catastrophic Health Expenditure and Risk Factors for Out-of-Pocket Expenditure at a South African Public Sector Hospital.

Abstract

Worldwide, 3.7 billion people risk financial catastrophe if they require surgery, mostly affecting the poorest populations. Surgical care associated with catastrophic health expenditure (CHE) has not been well-described in the South African context. The objectives of this study were to determine: (1) the proportion of surgical patients at a South African hospital who experienced CHE and impoverishing health expenditure (IHE); and (2) the risk factors for out-of-pocket (OOP) payments. A cross-sectional prospective questionnaire was administered to participants admitted for a surgical procedure at New Somerset Hospital, Cape Town. CHE was defined in three ways: (1) 40% or more of capacity-to-pay, (2) 25% of annual household expenditure, or (3) 10% of annual household expenditure. IHE was described as the number of participants who experienced new or worsening impoverishment after surgery. Two hundred and seventy-four participants were interviewed, and 263 were included in the analysis (4% attrition rate). Two (0.8%) participants experienced CHE. 98.5% of participants spent less than 10% of their annual household expenditure and 43 participants (16.7%) experienced IHE. Risk factors for OOP expenditure were cancer diagnosis (p = 0.0386), an elective procedure (p = 0.0001), and having a limited health insurance plan (p = 0.0492). Most participants undergoing a surgical procedure did not experience CHE. Participants were relatively protected from financial catastrophe owing to subsidized user fees and the provision of transport. However, 17% of patients experienced IHE, suggesting even small payments resulted in impoverishment. Ensuring low financial vulnerabilities around surgical care is an important consideration for national surgical planning in South Africa.