ORIGINAL SCIENTIFIC REPORT
Out-of-Pocket and Catastrophic Expenses Incurred by Seeking
Pediatric and Adult Surgical Care at a Public, Tertiary Care
Centre in Uganda
Internationale de Chirurgie 2018
Background Surgical care is critical to establish effective healthcare systems in low- and middle-income countries,
yet the unmet need for surgical conditions is as high as 65% in Ugandan children. Financial burden and geographical
distance are common barriers to help-seeking in adult populations and are unmeasured in the pediatric population.
We thus measured out-of-pocket (OOP) expenses and distance traveled for pediatric surgical care in a tertiary
hospital in Mbarara, Uganda, as compared to adult surgical and pediatric medical patients.
Methods Patients admitted to pediatric surgical (n = 20), pediatric medical (n = 18) and adult surgical (n = 18)
wards were interviewed upon discharge over a period of 3 weeks. Patient and caregiver-reported expenses incurred
for the present illness included prior/future care needed, and travel distance/cost. The prevalence of catastrophic
expenses (C10% of annual income) was calculated and spending patterns compared between wards.
Results Thirty-ﬁve percent of pediatric medical patients, 45% of pediatric surgical patients and 55% of adult surgical
patients incurred catastrophic expenses. Pediatric surgical patients paid more for their current treatment
(p \ 0.01)—speciﬁcally medications (p \ 0.01) and tests (p \ 0.01)—than pediatric medical patients, and com-
parable costs to adults. Adult patients paid more for treatment prior to the hospital (p = 0.04) and miscellaneous
expenses (e.g., food while admitted) (p = 0.02). Patients in all wards traveled comparable distances.
Conclusions Seeking healthcare at a publicly funded hospital is ﬁnancially catastrophic for almost half of patients.
Out-of-stock supplies and broken equipment make surgical care particularly vulnerable to OOP expenses because
analgesics, anaesthesia and preoperative imaging are prerequisites to care.
The Lancet Commission on Global Surgery has recently
emphasized the need for surgical care in low- and middle-
income countries (LMICs) to establish effective healthcare
systems. Mortality and morbidity from surgically cor-
rectable conditions are increasing disproportionately to the
increase in many other medical conditions, yet little effort
has been made to narrow this gap. Without surgical care,
conditions such as appendicitis, fractures or congenital
anomalies have fatal outcomes . Investing in speciﬁc
surgical treatments has further economic beneﬁts; for
example, pediatric inguinal hernia repair has been shown to
Electronic supplementary material The online version of this
article (https://doi.org/10.1007/s00268-018-4691-x) contains supple-
mentary material, which is available to authorized users.
& Dan Poenaru
Faculty of Medicine, McGill University, Montreal, Canada
Center for Global Surgery, McGill University Health Centre,
Mbarara Regional Referral Hospital, Mbarara, Uganda
Montreal Children’s Hospital, Rm. B- 04.2022, 1001
carie, Montreal, QC H4A 3J1, Canada
World J Surg