Challenges in healthcare financing for surgery in sub-Saharan Africa.

One-third of the global burden of disease is attributed to surgical conditions yet, 5 billion people globally, lack access to surgery. The Lancet Commission on Global Surgery, Obstetrics, and Anesthesia (LCOGS) published guidelines for improving access by reducing catastrophic health expenditures (CHEs) by 2030. This is especially important in sub-Saharan Africa (SSA) where 90% of the extreme poor reside. In this paper, we provide a narrative review of four studies on CHEs for surgical care in SSA published since 2015. We discuss healthcare financing in the countries and summarize the authors' key findings of out-of-pocket payments (OOP) and CHEs. Briefly, the studies enrolled 130 to 300 patients and collected direct OOPs via chart review of health costs or patient interviews. Indirect costs were calculated from lost wages and transportation costs. CHEs were defined as health costs exceeding 10% of the GDP per capita or the household income. Despite healthcare being reported as free in all studies, 60%-90% of surgical patients had CHEs with all costs considered. OOPs persists for medicines and anesthesia that should be covered under any health insurance scheme. In some cases, indirect costs associated with transportation and wages were major drivers of CHEs for surgery. Without addressing these gaps in coverage, more people will risk impoverishment in seeking surgical care in SSA.

Racial and Ethnic Disparities in Patient Safety.

BACKGROUND: Although there is extensive evidence on disparities in the process and outcomes of health care, data on racial and ethnic disparities in patient safety remain inconclusive in the United States. OBJECTIVES: The aims of this study were to (1) explore differences in reporting race/ethnicity in studies on disparities in patient safety; (2) assess adjustment for socioeconomic status, comorbidity, and disease severity; and (3) make recommendations on the inclusion of race/ethnicity for future studies on adverse events. METHODS: We searched PubMed database (for articles published from 1991 to May 1, 2013) using a predetermined criteria for studies on racial and ethnic disparities in patient safety. Only quantitative studies that used chart review or administrative data for the detection of adverse events were considered for eligibility. Two reviewers independently extracted data on inclusion of race/ethnicity in baseline characteristics and in stratification of outcomes. RESULTS: A total of 174 studies were initially obtained from the search. Of these, 24 met inclusion criteria and received full-text review. Meta-analysis was not performed because of the methodological and statistical heterogeneity between studies. Eight studies included race/ethnicity in baseline characteristics and adjusted for confounders. Hospital-level variations such teaching status and percentage of minorities served were infrequently analyzed. CONCLUSIONS: To our knowledge, this is the first methodological review of racial/ethnic disparities in patient safety in the United States. The evidence on the existence of disparities in adverse events was mixed. Poor stratification of outcomes by race/ethnicity and consideration of geographic and hospital-level variations explain the inconclusive evidence; variations in the quality of care at hospitals should be considered in studies using national databases.