Catastrophic expenditure to pay for surgery worldwide: a modelling study

Abstract

Background: Approximately 150 million individuals worldwide face catastrophic expenditure each year from medical costs alone, and the non-medical costs of accessing care increase that number. The proportion of this expenditure related to surgery is unknown. Because the World Bank has proposed elimination of medical impoverishment by 2030, the effect of surgical conditions on financial catastrophe should be quantified so that any financial risk protection mechanisms can appropriately incorporate surgery.

Methods: To estimate the global incidence of catastrophic expenditure due to surgery, we built a stochastic model. The income distribution of each country, the probability of requiring surgery, and the medical and non-medical costs faced for surgery were incorporated. Sensitivity analyses were run to test the robustness of the model.

Findings: 3·7 billion people (posterior credible interval 3·2-4·2 billion) risk catastrophic expenditure if they need surgery. Each year, 81·3 million people (80·8-81·7 million) worldwide are driven to financial catastrophe-32·8 million (32·4-33·1 million) from the costs of surgery alone and 48·5 million (47·7-49·3) from associated non-medical costs. The burden of catastrophic expenditure is highest in countries of low and middle income; within any country, it falls on the poor. Estimates were sensitive to the definition of catastrophic expenditure and the costs of care. The inequitable burden distribution was robust to model assumptions.

Interpretation: Half the global population is at risk of financial catastrophe from surgery. Each year, surgical conditions cause 81 million individuals to face catastrophic expenditure, of which less than half is attributable to medical costs. These findings highlight the need for financial risk protection for surgery in health-system design.

Funding: MGS received partial funding from NIH/NCI R25CA92203.

Figure 1

Individuals in low- and middle-income countries are at high risk of catastrophic expenditure if surgical care is necessary. Red = high risk of catastrophic expenditure. Yellow = low risk of catastrophic expenditure.

Figure 2

Catastrophic expenditure by wealth quintile and national income group, conditional on seeking surgery. Of all patients facing surgery, the poorest face the highest risk of catastrophic expenditure than the richest, and the risk of catstrophic expenditure is greatest in low- and low-middle income countries than in higher income countries. Panel (a): Global estimate. Panels (b)-(d): Estimates by World Bank country income groups.

Figure 2

Catastrophic expenditure by wealth quintile and national income group, conditional on seeking surgery. Of all patients facing surgery, the poorest face the highest risk of catastrophic expenditure than the richest, and the risk of catstrophic expenditure is greatest in low- and low-middle income countries than in higher income countries. Panel (a): Global estimate. Panels (b)-(d): Estimates by World Bank country income groups.