Catastrophic expenditure and impoverishment after caesarean section in Sierra Leone: An evaluation of the free health care initiative

Abstract

Background: Utilizing surgical services, including caesarean sections, can result in catastrophic expenditure and impoverishment. In 2010, Sierra Leone introduced the Free Health Care Initiative (FHCI), a national financial risk protection program for the most vulnerable groups. Aim of this study was to investigate catastrophic expenditure and impoverishment related to caesarean section in Sierra Leone and evaluate the impact of the FHCI.

Methods: Women who delivered by caesarean section in nine hospitals were followed up with home visits one month after surgery, and data on medical and non-medical expenditures were collected. Individual income was estimated based on household characteristics and used to determine catastrophic expenditure and impoverishment for each patient. The impact of the FHCI was assessed by comparing actual expenditure with counterfactual expenditures had the initiative not existed.

Results: For the 1146 patients in the study, the median expenditure was 23 (IQR 4; 56) international dollars (Int$). Patients in the poorest quintile spent a median Int$ 59 (IQR 28; 76), which was significantly more than patients in the richest quintile, who spent a median Int$ 17 (IQR 2; 38, p<0.001). Travel (32.9%) and food (28.7%) were the two largest expenses. Catastrophic expenditure was encountered by 12.0% and 4.0% (10% and 25% threshold, respectively) of the women. Without the FHCI, 66.1% and 28.8% of the women would have encountered catastrophic expenditure.

Conclusion: Many women in Sierra Leone face catastrophic expenditure related to caesarean section, mainly through food and travel expenses, and the poor are disproportionally affected. The FHCI is effective in reducing the risk of catastrophic expenditure related to caesarean section, but many patients are still exposed to financial hardship, suggesting that additional support is needed for Sierra Leone's poorest patients.

Fig 1. Income distribution by wealth quintile.

Graphical representation of estimated household income with each curve representing a different wealth quintile (WQ). These gamma distributions are based on the Sierra Leonean Gross Domestic Product (GDP) per capita (purchasing power parity, constant 2011 international dollars) from 2017, income share per wealth quintile, and the GINI coefficient (data.worldbank.org).

Fig 2. Study hospitals by category, patient inclusion and wealth quintile distribution.

^aFollow-up with complete data and included in the analysis. ^b2013 Sierra Leone Demographic and Health Survey. Pnp = private non-profit.

Fig 3. Expenditure in relation to the 10 and 25% thresholds for catastrophic expenditure.

Graphical representation of the cumulative percentage of patients. The red dotted line represents the 10% threshold, and the green dotted line the 25% threshold of catastrophic expenditure. The blue line represents the current situation with the Free Health Care Initiative (FHCI) and the purple line represents the scenario without the FHCI.

Fig 4. Income minus total medical and non-medical expenses in relation to the poverty line.

Graphical representation of annual income minus the total of medical and non-medical expenses in international dollars (Int$). The red dotted line represents the poverty line of Int$ 1.90 per day (or Int$ 694 international dollars annually). The blue line represents the current situation with the Free Health Care Initiative (FHCI) and the purple line represents the scenario without the FHCI.