RESUMEN
BACKGROUND: Women with breast cancer in low-income and middle-income countries (LMICs) account for 51% of cases globally and often present with advanced disease. Fear of costs contributes to delay in seeking care, as health expenditures are financially catastrophic for families worldwide. Despite efforts to improve affordability of health care in LMICs, the financial burden of indirect costs (eg, transportation and lost wages) is often overlooked. We aimed to identify and quantify the expenditures of patients seeking breast cancer care in a LMIC. METHODS: Patients receiving breast cancer care free of charge at Hôpital Universitaire de Mirebalais (HUM) in Haiti were interviewed to quantify their costs and assess the effect of these costs on patients and families. These costs included expenses for food, lodging, transportation, childcare, medical costs at other institutions, and lost wages. 61 patients were interviewed during diagnostic, chemotherapy, and surgical visits between March 1, and May 12, 2014. Institutional review board exemption was granted from Boston Children's Hospital and Partners in Health/Zanmi Lasante. FINDINGS: The median non-medical out-of-pockent expenses incurred by breast cancer patients at HUM were US$233 (95% CI 170-304) for diagnostic visits, US$259 (95% CI 200-533) for chemotherapy, and US$38 (95% CI 23-140) for surgery. The median total out-of-pockent expense (including medical costs) was US$717 (95% CI 619-1171). These costs forced 52% of participants into debt and 20% to sell possessions. The median percentage of potential individual income spent on out-of-pocket costs was 60%. The median sum of out-of-pocket costs and lost wages was US$2996 (95% CI 1676-5179). INTERPRETATION: In Haiti, 74% of people earn less than US$2 per day. Even when breast cancer treatment is provided for free, out-of-pocket expenses could account for more than 91% of annual earnings at this income level. This financial burden is an overwhelming obstacle for Haiti's poorest citizens, and probably for many patients in LMICs. High-powered, multisite studies are needed to further characterise this burden worldwide. Funders and health-care providers should reduce indirect costs to achieve equitable access to oncology care. FUNDING: Boston Children's Hospital and Partners in Health.
RESUMEN
BACKGROUND: In resource-limited settings, efficiency is crucial to maximise resources available for patient care. Time driven activity-based costing (TDABC) estimates costs directly from clinical and administrative processes used in patient care, thereby providing valuable information for process improvements. TDABC is more accurate and simpler than traditional activity-based costing because it assigns resource costs to patients based on the amount of time clinical and staff resources are used in patient encounters. Other costing approaches use somewhat arbitrary allocations that provide little transparency into the actual clinical processes used to treat medical conditions. TDABC has been successfully applied in European and US health-care settings to facilitate process improvements and new reimbursement approaches, but it has not been used in resource-limited settings. We aimed to optimise TDABC for use in a resource-limited setting to provide accurate procedure and service costs, reliably predict financing needs, inform quality improvement initiatives, and maximise efficiency. METHODS: A multidisciplinary team used TDABC to map clinical processes for obstetric care (vaginal and caesarean deliveries, from triage to post-partum discharge) and breast cancer care (diagnosis, chemotherapy, surgery, and support services, such as pharmacy, radiology, laboratory, and counselling) at Hôpital Universitaire de Mirebalais (HUM) in Haiti. The team estimated the direct costs of personnel, equipment, and facilities used in patient care based on the amount of time each of these resources was used. We calculated inpatient personnel costs by allocating provider costs per staffed bed, and assigned indirect costs (administration, facility maintenance and operations, education, procurement and warehouse, bloodbank, and morgue) to various subgroups of the patient population. This study was approved by the Partners in Health/Zanmi Lasante Research Committee. FINDINGS: The direct cost of an uncomplicated vaginal delivery at HUM was US$62 and the direct cost of a caesarean delivery was US$249. The direct costs of breast cancer care (including diagnostics, chemotherapy, and mastectomy) totalled US$1393. A mastectomy, including post-anaesthesia recovery and inpatient stay, totalled US$282 in direct costs. Indirect costs comprised 26-38% of total costs, and salaries were the largest percentage of total costs (51-72%). INTERPRETATION: Accurate costing of health services is vital for financial officers and funders. TDABC showed opportunities at HUM to optimise use of resources and reduce costs-for instance, by streamlining sterilisation procedures and redistributing certain tasks to improve teamwork. TDABC has also improved budget forecasting and informed financing decisions. HUM leadership recognised its value to improve health-care delivery and expand access in low-resource settings. FUNDING: Boston Children's Hospital, Harvard Business School, and Partners in Health.
RESUMEN
BACKGROUND: Women in low- and middle-income countries account for 51% of breast cancer cases globally. These patients often delay seeking care and, therefore, present with advanced disease, partly because of fear of catastrophic health care expenses. Although there have been efforts to make health care affordable in low- and middle-income countries, the financial burden of out-of-pocket (OOP) expenses for nonmedical costs, such as transportation and lost wages, often is overlooked. METHODS: An institutional review board exemption was granted from Boston Children's Hospital and Partners in Health/Zanmi Lasante for this cross-sectional study. In total, 61 patients receiving breast cancer care free of charge at Hôpital Universitaire de Mirebalais (HUM) in Haiti were selected via convenience sampling. They were interviewed between March and May 2014 to quantify the expenses they incurred during the course of diagnosis and treatment. These expenses included medical costs at outside facilities, as well as nonmedical costs (eg, transportation, meals, etc). RESULTS: The median, nonmedical OOP expenses incurred by breast cancer patients at HUM were $233 (95% confidence interval [95% CI] $170-304) for diagnostic visits, $259 (95% CI $200-533) for chemotherapy visits, and $38 (95% CI $23-140) for surgery visits. The median total OOP expense (including medical costs) was $717 (95% CI $619-1,171). To pay for these expenses, 52% of participants stated that they went into debt; however, the amount of debt was not quantified. The median income of these patients was $1,333 (95% CI $778-2,640), and the median sum of OOP expenses and lost wages was $2,996 (95% CI $1,676-5,179). CONCLUSION: Despite receiving free care: at HUM, more than two-thirds of participants met conservative criteria for catastrophic medical expenses (defined as spending more than 40% of their potential household income on OOP payments). Further studies are needed to understand the magnitude of OOP health care expenses for the poor worldwide, how to aid them during their treatment program, and its impact on their health outcomes.