GLOBAL HEALTH AND POLICY RESEARCH
Authors: Ashraf M. , Ali Muhammad A. , Shoman H. , Fatima I. , Samad L. 
Published: August 2020

Research ObjectivePoor access and out‐of‐pocket expenses are barriers to equitable coverage of surgical care. We sought to identify the logistical and financial challenges faced by patients receiving surgical care at the public sector, tertiary care hospitals in Pakistan.Study DesignThis is a cross‐sectional study. Patients who underwent Bellwether procedures (C‐section, laparotomy, and fracture fixation) were interviewed. Data regarding their socioeconomic status, place of residence, prehospital transport, and the cost incurred in seeking care were collected. Patients were categorized as having timely 2‐hour access on the basis of reported travel time to the hospital. Costs were divided into direct medical costs, direct nonmedical costs, and indirect costs. Direct medical costs include the cost of admission, medicines, bandages, laboratory, and imaging, while direct nonmedical cost includes cost of patient and attendants transport, accommodation, and food during a hospital stay. Indirect costs include need to borrow money, opportunity cost, and loss of employment. Costs were converted to PPP (2011 $) were summarized as the median and interquartile range (IQR). Kruskal‐Wallis test was used to assess statistically significant differences in costs. Chi‐square test was applied to study the association between categorical variables.Population StudiedWe used purposive sampling to select 10 tertiary‐care public‐sector hospitals from across the country to ensure geographic representation from all provincial and regional territories. We interviewed a total of 411 patients: 195 C‐section, 113 laparotomy, and 103 open fracture fixation patients.Principal FindingsAt baseline, 58.6% of patients were impoverished below the poverty line of $3.2 (PPP 2011) per day. Travel time to reach the facility was more than 2 hours for 188 (45.7%) patients; 52.7% of them were already facing poverty. Median total direct costs for C‐Section, laparotomy, and fracture fixation were $338 ($405), $447 ($735), and $592 ($779), respectively (P‐value .0001). Total direct costs exceeded the monthly income for 122 (29.6%) patients. Median total direct and direct nonmedical cost was significantly higher for patients who traveled more than 2 hours (Table 1). About 220 (53.5%) patients had to borrow money; 64% of them were poor at baseline. Moreover, 45.7% of patients were unable to afford transport costs.ConclusionsA significant proportion of the patients receiving surgical care are impoverished at baseline. The inadequate resources at public secondary care level hospitals compel patients to travel more than 2 hours to receive care at the tertiary care hospitals. Despite the free‐of‐cost service model, patients incur out‐of‐pocket expenditure which significantly impacts them financially.Implications for Policy or PracticeThe Bellwether procedures are basic emergency and essential procedures that should be provided at the secondary level hospitals. Investments in developing capacity for emergency and essential surgical care at secondary care hospitals will significantly reduce the burden of direct nonmedical cost on the poor patients who seek care in the public sector.Primary Funding SourceHarvard Medical School ‐ Center of Global Health Delivery, Dubai.