What is the financial burden to patients of accessing surgical care in Sierra Leone? A cross-sectional survey of catastrophic and impoverishing expenditure

Objectives To measure the financial burden associated with accessing surgical care in Sierra Leone. Design A cross-sectional survey conducted with patients at the time of discharge from tertiary-level care. This captured demographics, yearly household expenditure, direct medical, direct non-medical and indirect costs for surgical care, and summary household assets. Missing data were imputed. Setting The main tertiary-level hospital in Freetown, Sierra Leone. Participants 335 surgical patients under the care of the hospital surgical team receiving operative or non-operative surgical care on the surgical wards. Outcome measures Rates of catastrophic expenditure (a cost >10% of annual expenditure), impoverishment (being pushed into, or further into, poverty as a result of surgical care costs), amount of out-of-pocket (OOP) costs and means used to meet these costs were derived. Results Of 335 patients interviewed, 39% were female and 80% were urban dwellers. Median yearly household expenditure was US 3569. Mean OOP costs were US 243, of which a mean of US 24 (10%) was spent prehospital. Of costs incurred during the hospital admission, direct medical costs were US 138 (63%) and US 34 (16%) were direct non-medical costs. US 46 (21%) were indirect costs. Catastrophic expenditure affected 18% of those interviewed. Concerning impoverishment, 45% of patients were already below the national poverty line prior to admission, and 9% of those who were not were pushed below the poverty line following payment for surgical care. 84% of patients used household savings to meet OOP costs. Only 2% (six patients) had health insurance. Conclusion Obtaining surgical care has substantial economic impacts on households that pushes them into poverty or further into poverty. The much-needed scaling up of surgical care needs to be accompanied by financial risk protection.