Access to surgical care is a multidimensional concept that includes availability, geographical accessibility, safety, timeliness, and financial affordability[1] (ref). Protection of all surgical patients from CE resulting from accessing surgical care by 2030 is one of the recommendations made by the LCoGS. The LCoGS estimates that 81.2 million people endure CE from accessing surgical care every year. However, these estimates do not consider patients who are not able to access surgical and anesthesia care in the first place. Globally, about half of the population are at risk of CE if they have to need surgery [1, 5]. Estimates of rate of catastrophic expenditure for surgical care in Sub Saharan Africa is highly variable across countries, the highest being 91% for Burundi [11].
Apart from modeling studies and nationwide estimates, studied on surgical patients undergoing specific procedures in Sub Saharan African countries have shown significant risk of CE. Study from Malawi showed that out of 137 patients who underwent hernia surgery in central and district hospitals, 90 to 97% of patients sustained CE [12]. This was higher to CE from our patients, which can be explained by the fact that the study from Malawi added opportunity costs due to income forgone because of hospital admission for surgery as indirect expenditure. They found that such costs often exceeded the direct medical costs [12].
Another study from Rwanda showed CE that 28% patients were at risk of catastrophic health expenditure from surgery for peritonitis. About 98% of their patients had CBHI. The rate of CE was comparable to our patients who had CBHI[13]. In similar study from Uganda where surgical care is free in government hospitals, 31% of patients faced a catastrophic expenditure of more than 10% of their estimated total yearly expenses [10].
Despite the low cost of procedures and ward services, many patients incurred CE due to diagnostics and medications. Key cost drivers accounting for more than 70% of the total cost of treatment of our patients included payment for medications and imaging. In our study, these costs were driven up because they were not available within the care facilities and involved external referral to private facilities. For example, an abdominal ultrasound costs 53ETB in Yekatit 12 Hospital, while it costs from 500ETB to 900ETB in private diagnostic centers as was noticed during data collection. Unavailability of these services was also the main factor for patients to sustain CE in a study from Uganda, where surgical service is provided for free [10]. Therefore, provision of quality diagnostic service and basic medications at government hospitals could significantly alleviate the burden of CE.
Overall, with only 8 years left from 2030, by which time according to LCoGS all surgical patients should be protected from CE, our results suggest that more work is necessary within the Ethiopian health system to achieve that goal.
CBHI and other insurance schemes in Ethiopia
Attempts to address a long history of underfinancing of Ethiopian healthcare led to development of health care financing strategy in 1998 [14]. The strategy suggested health insurance as a tool to generate more revenue and increase health service utilization. The Federal Ministry of Health of Ethiopia identified Social Health Insurance (SHI) for the formal sector employees and Community Based Health Insurance (CHBI) for the informal sector to be utilized as insurance schemes. However, SHI didn't get implemented, while in 2010, pilot studies in some rural Ethiopia implementing CBHI showed promising results[15]. Based on such findings, in 2011, CBHI was launched to wider parts of the country. The scheme would set premiums of 350ETB per household that will finally cover all healthcare expenses in public facilities [8].
In 2017, CBHI was implemented in Addis Ababa under regulation number 86/2017[16]. The CBHI covers all medical expenses in any government hospital, except long term dialysis and sight glass purchase, however, CBHI subscribers can only be those working in the informal sector. Families who are indigent can subscribe to the CBHI for free and still get the same service as those who are paying. Apart from CBHI, some employers provide a variable degree of health insurance ranging from payment for medication and procedures, to all costs including transportation and lodging.
In our study, having insurance was the only independent variable associated with significantly lower risk of sustaining CE. This is consistent with findings from similar study in Rwanda[13]. Rate of CE using > 10% annual expenditure is 28.5% in patients who have insurance and 80.3% in noninsured patients (p < 0.0001). Similarly, using the other criteria (> 40% annual nonfood expenditure), 25.7% patients with insurance had sustained CE while 74.7% of noninsured patients sustained CE (p < 0.0001). If these patients did not have insurance, CE among these groups would have been 80.0% and 65% using 10% and 40% cut offs, making the rate of CE comparable to noninsured patients.
Although having insurance was significantly associated with lower CE in our patients, it did not absolutely protect all patients from financial risk of surgery. This was mainly because many medications and basic imaging like ultrasound and CT scan were not available or accessible at the treating hospitals as was in similar study from Uganda[10]. Provision of these services could help protect from CE for both insured and noninsured patients.