Out-of-Pocket Expenses for Patients Seeking Surgical Care in Rural Haiti. Study Conducted at St. Boniface Located in Fonds Des Blancs

Abstract

The objective of this study is to investigate the impact of costs related to the surgery on household economic status and the lived-experience of patients and families. Methods: We conducted an explanatory, sequential mixed-method study. We performed a survey and medical chart abstraction for 159 patients over July-August 2017. We reported patients’ socio-demographic, economic characteristics and their surgical interventions. We calculated catastrophic health spending using World Health Organization and World Bank methods. Eighteen patients with the lowest economic status whose surgical procedures were among the most frequently performed in the study period were selected for semi-structured interviews. We used narrative analysis and grounded theory to synthesize interview data into key ideas and themes. Results: The median total household expenditure in the previous one month was USD385.6, lower than GDP per capita in Haiti (USD729.3). Few participants had health insurance (6%). The most frequent procedures performed were: C-section (20.1%), excisional biopsy (14.5 %), hysterectomy (11.3%), hernioplasty (8.2%), myomectomy (5%), and mastectomy (4.4%). The most common coping strategy to pay for surgical costs is borrowing and donation (69.8%). Using the WHO method, 76.7% of the households had catastrophic health spending due to direct and indirect costs, 51.3% experienced catastrophic health expenditures resulting from direct costs, and 41.7% of households faced catastrophic spending due to indirect costs. The World Bank method showed similar, if higher proportion of households with catastrophic health spending due to direct and indirect costs, 86%. Qualitative results made visible what was at stake; prominent themes from the qualitative interviews include hidden costs of care-seeking, trajectory of care and social suffering. Discussion and conclusion: Among those experiencing catastrophic expenditures, our results show the consequences are severe and may impact subsequent generations. The proportion of patients experiencing these impacts is often underestimated, as WHO’s definition of out-of-pocket health spending does not include the indirect costs such as transportation, housing, food expense and lost earnings. Opportunities for improvement exist at the facility level—offering more services or collaborating with local providers for services at reduced cost—and at the national levels—increased access to health insurance and subsidies for indirect costs.