Effect of removing the barrier of transportation costs on surgical utilisation in Guinea, Madagascar and the Republic of Congo

Abstract

Background81 million people face impoverishment from surgical costs every year. The majority of this impoverishment is attributable to the non-medical costs of care—for transportation, for food and for lodging. Of these, transportation is the largest, but because it is not viewed as an actual medical cost, it is frequently unaddressed. This paper examines the effect on surgical utilisation of paying for transportation.MethodsA hierarchical logistic regression was performed on 2692 patients presenting for surgical care to a non-governmental organisation operating in the Republic of the Congo, Guinea and Madagascar. Controlling for distance from the hospital, age, gender, the need for air travel and time between appointments, the effect of payment for transportation on the surgical no-show rate was evaluated.ResultsAfter adjustment for observed confounders, paying for transportation drops the surgical no-show rate by 45% (OR 0.55; 95% CI 0.40 to 0.77; p<0.001). Age, delay between appointments and the number of hours travelled for surgery also predict surgical no-show. For 28% of no-show patients, the cost of transportation from their homes to a nearby predetermined pick-up point remained a barrier, even when transportation from the pick-up point to the hospital was free.ConclusionTransportation costs are a significant barrier to surgical care in low-resource settings, and paying for it halves the no-show rate. This finding highlights that decreasing demand-side barriers to surgical care cannot be limited only to the removal of user fees.

How much is enough? Exploring the dose-response relationship between cash transfers and surgical utilization in a resource-poor setting

“…The model was validated against the known population density in Guinea, against demographic parameters for the Guinean population, and against previously-published no-show rates. [14] The model was constructed using the AnyLogic modeling platform (v.8.1.0, St. Petersburg). Data analysis was performed in R (v.3.4.0).…”

“…[12,13] Simply offering free surgery is insufficient: patients often continue to report cost barriers, even with free surgery. [14] A recent retrospective study of surgery at a charitable institution in three sub-Saharan African countries, where the majority of the population lives in rural settings, demonstrated that non-medical costs and a lack of transportation were a major barrier to care access. Controlling for confounders, patients seeking care at this institution, which provides surgery itself for free, had a no-show rate of 28% if transportation was not paid for.…”

“…When transportation was provided, the no-show rate dropped to 15%. [14] Cash transfers-in which participants are given a small bolus of cash, either unconditionally or conditional on their adherence to a behavior-have been used to incentivize salutary action around nutrition, [15,16] maternal care, [17,18] HIV prevention and care, [19,20] and education. [21] These studies have shown mixed effects, not all of which have been positive.…”

Implementation and evaluation of nationwide scale-up of the Surgical Safety Checklist

“…The study was a collaboration between the non‐governmental organization Mercy Ships, the Benin Ministry of Health and the academic institution, King's College London. Mercy Ships visits countries at the invitation of the Head of State, typically spending 10 months delivering free operations and training in partnership with the Ministry of Health, aiming to strengthen the surgical ecosystem, and advocate access to safe affordable timely surgery and development of national surgical plans.…”

Access to safe surgery

“…Transportation costs are one of the most important barriers to seeking surgical care. The second research paper in this supplement, by Shrime and colleagues, 5 shows that ‘when transportation costs are paid for, the surgical no-show rate drops by approximately half’. This important study identifies the need to include transportation costs as part of medical costs and appropriately suggests that all types of surgical service providers should subsidise or eliminate transportation costs.…”