title: A global country-level comparison of the financial burden of surgery.
abstract: BACKGROUND
  Approximately 30 per cent of the global burden of disease is surgical, and nearly one-quarter of individuals who undergo surgery each year face financial hardship because of its cost. The Lancet Commission on Global Surgery has proposed the elimination of impoverishment due to surgery by 2030, but no country-level estimates exist of the financial burden of surgical access.
  
  
  METHODS
  Using publicly available data, the incidence and risk of financial hardship owing to surgery was estimated for each country. Four measures of financial catastrophe were examined: catastrophic expenditure, and impoverishment at the national poverty line, at 2 international dollars (I$) per day and at I$1·25 per day. Stochastic models of income and surgical costs were built for each country. Results were validated against available primary data.
  
  
  RESULTS
  Direct medical costs of surgery put 43·9 (95 per cent posterior credible interval 2·2 to 87·1) per cent of the examined population at risk of catastrophic expenditure, and 57·0 (21·8 to 85·1) per cent at risk of being pushed below I$2 per day. The risk of financial hardship from surgery was highest in sub-Saharan Africa. Correlations were found between the risk of financial catastrophe and external financing of healthcare (positive correlation), national measures of well-being (negative correlation) and the percentage of a country's gross domestic product spent on healthcare (negative correlation). The model performed well against primary data on the costs of surgery.
  
  
  CONCLUSIONS
  Country-specific estimates of financial catastrophe owing to surgical care are presented. The economic benefits projected to occur with the scale-up of surgery are placed at risk if the financial burden of accessing surgery is not addressed in national policies.
authors.affiliation: Program in Global Surgery and Social Change, Harvard Medical School, Massachusetts, USA. shrime@mail.harvard.edu.|Office of Global Surgery, Massachusetts Eye and Ear Infirmary, Boston Children's Hospital, Boston, Massachusetts, USA. shrime@mail.harvard.edu.
authors.forename: M G
authors.initials: MG
authors.lastname: Shrime
authors.affiliation: Department of Surgery, University of Toronto, Toronto, Canada.
authors.forename: A
authors.initials: A
authors.lastname: Dare
authors.affiliation: Office of Global Surgery, Massachusetts Eye and Ear Infirmary, Boston Children's Hospital, Boston, Massachusetts, USA.
authors.forename: B C
authors.initials: BC
authors.lastname: Alkire
authors.affiliation: Program in Global Surgery and Social Change, Harvard Medical School, Massachusetts, USA.|Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, Massachusetts, USA.
authors.forename: J G
authors.initials: JG
authors.lastname: Meara
mesh_terms: D017281:Cost of Illness; D004180:Direct Service Costs; D014943:Global Health / Q000191:economics*; D005102:Health Expenditures; D006801:Humans; D018803:Models, Economic; D011203:Poverty / Q000191:economics; D012111:Residence Characteristics / Q000706:statistics & numerical data; D018570:Risk Assessment; D013514:Surgical Procedures, Operative / Q000191:economics*