title: Direct non-medical costs double the total direct costs to patients undergoing cataract surgery in Zamfara state, Northern Nigeria: a case series.
abstract: BACKGROUND
  Cost is frequently reported as a barrier to cataract surgery, but few studies have reported costs of accessing surgery in Africa. The purpose of this prospective, facility based study was to compare direct non-medical cost with total direct cost of cataract surgery to patients, and to assess how money was found to cover costs.
  
  
  METHODS
  Participants were those aged 17 years and above attending their first post-operative visit after first eye, subsidised, day case cataract surgery. Systematic random sampling was used to select participants who were interviewed to obtain data on socio-demographic details, and on expenditure during the assessment visit, the surgical visit, and the first follow-up visit. Costs were a) direct medical costs (patients' costs for registration, investigations, surgery, medication), and b) direct non-medical costs (patients' and escorts' costs for transport, accommodation, meals). The source of funds to pay for the services received was also assessed.
  
  
  RESULTS
  Almost two thirds (63%) of the 104 participants were men. The mean age of men was 64 (± 12.5) years, being 63 (± 12.9) years for women. All men were married and 35% of women were widows. 84% of men were household heads compared with 6% of women. The median total direct cost for all visits by all participants was N8,245 (US$51), being higher for men than women (N9,020; US$56 and N7,620; US$47) (p < 0.09) respectively. Direct non-medical cost constituted 49% of total direct cost. 92% of participants had adequate money to pay, but 8% had to sell possessions to raise the money. 20% of unmarried women sold possessions or took out a loan.
  
  
  CONCLUSIONS
  Despite the subsidy, cost is still likely to be a barrier to accessing cataract surgery, as the total direct costs represented at least 50 days income for 70% of the local population. Provision of transport would reduce direct non-medical costs.
authors.affiliation: Zamfara State Eye Care Programme, Ministry of Health, Gusau, Nigeria. nibrahim@sightsavers.org.
authors.forename: Nazaradden
authors.initials: N
authors.lastname: Ibrahim
authors.affiliation: Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, UK. Francisco.Pozo-Martin@lshtm.ac.uk.
authors.forename: Francisco
authors.initials: F
authors.lastname: Pozo-Martin
authors.affiliation: Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, UK. clare.gilbert@lshtm.ac.uk.|International Centre for Eye Health, Department of Clinical Research, London School of Hygiene & Tropical Medicine, Keppel Street, WC1E 7HT, London, UK. clare.gilbert@lshtm.ac.uk.
authors.forename: Clare
authors.initials: C
authors.lastname: Gilbert
mesh_terms: D000349:Africa; D000368:Aged; D002387:Cataract Extraction / Q000191:economics*; D005191:Family Characteristics; D005260:Female; D005382:Financing, Personal / Q000191:economics*; D005102:Health Expenditures; D006801:Humans; D007407:Interviews as Topic; D008297:Male; D008875:Middle Aged; D009549:Nigeria; D011446:Prospective Studies; D036301:Qualitative Research