Catastrophic expenditure to pay for surgery worldwide: a modelling study.
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.


RESULTS
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.


CONCLUSIONS
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.


BACKGROUND
MGS received partial funding from NIH/NCI R25CA92203.
Department of Global Health and Population, Harvard School of Public Health, Boston, MA, USA; Department of Otology and Laryngology, Harvard Medical School, Boston, MA, USA; Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA. Electronic address: shrime@mail.harvard.edu.
Mark G
MG
Shrime
King's Centre for Global Health, King's Health Partners, King's College London, London, UK.
Anna J
AJ
Dare
Department of Otology and Laryngology, Harvard Medical School, Boston, MA, USA; Office of Global Surgery, Massachusetts Eye and Ear Infirmary, Boston, MA, USA; Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA.
Blake C
BC
Alkire
University of Pennsylvania Medical School, Philadelphia, PA, USA.
Kathleen
K
O'Neill
Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA; Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, MA, USA.
John G
JG
Meara
D058443:Catastrophization / Q000191:economics; D014943:Global Health; D005102:Health Expenditures; D006297:Health Services Accessibility; D006801:Humans; D008962:Models, Theoretical; D013043:Specialties, Surgical / Q000191:economics*