Last time we talked about the ultimate big picture of the economic value of surgical care globally and reviewed the modeling done by the Lancet Commission on Global Surgery. That article gave a look at what the consequences are from an economic perspective of surgical disease going untreated. This week we continue with the economics of global surgical care but we look at the financial consequences of requiring surgical care to the individual person.
This week’s article looks at specific countries and makes the point that development of health care access, specifically surgical access, does not occur in a vacuum. In order to reap the economic (and non-economic) benefits of expansion of access to surgical care, the associated financial burden must be understood as well.
Shrime, Dare, Alkire, and Meara, in A global country-level comparison of the financial burden of Surgery, examined the proportion of the population within individual countries that would incur catastrophic expenditure or impoverishing expenditure if a family member required surgical care. They differentiate between the terms catastrophic expenditure and impoverishing expenditure as being whether one incurs cost that pushes individuals below the national or international defined poverty level (impoverishing) or the cost is simply greater than what is deemed their inability to pay, defined as either 10 percent of an individual’s pre-health-shock total income, or 40 percent of their income left over after subsistence spending (catastrophic).
Even without considering the associated non-medical costs, the authors found that 44% of the world’s population is at risk of catastrophic expenditure from out of pocket costs for surgical care, and 31% are at risk of being rendered below their national poverty threshold. At the $2 per day level, 57% are at risk of impoverishment. Not surprisingly, these risks are greater in low income countries, e.g., 96% of the population is at risk in Bangladesh or Pakistan, while less than 1% is at risk in Japan and 3% in the US. This can be qualified by stating that a greater proportion of GDP devoted to healthcare and less reliance on outside funding are correlated with less risk for the population of financial hardship due to surgical care. Translating the risk of financial disaster into actual lives, 30 million people incur catastrophic expenditure and 11 million are pushed into poverty per year due to surgical costs.
The supplementary material to this article available through the online version contains Table S4 showing the probability of catastrophic expenditure for an individual if surgery is required by country by quintile of wealth.
A major take home message of this paper is that the potential financial ramifications on the individual of obtaining surgical care are an integral aspect of increasing access to care. In general, people living in poorer countries are more likely to be at risk, but country policy plays a role that can ameliorate this. The ultimate message from this paper is that even if surgical capacity is scaled up to meet the determined need of a country, the economic benefits that would be anticipated and the likely utilization of surgical services are not likely to be met unless the financial burden of accessing surgery is addressed in national policies.