Patterns of expenditure and coping mechanisms among urban slum dwellers admitted for emergency surgeries in Ibadan, Nigeria

Abstract

Introduction: The Universal Health Coverage (UHC) mandates that everyone should be able to access promotive, preventive, curative, rehabilitative and palliative health services effectively, while also ensuring that the use of these services does not expose the users to financial hardship. This has been accomplished at different stages for different populations. Rapid formation of slums as a result of urbanization, for instance, has continued to place the slum dwellers at a heightened risk of impoverishment when a sudden health issue arises. Aims: The broad objective of this research assessed the burden of out-of-pocket health care payments on payers1 of hospital bills incurred by households from urban slums and non-slums, with a patient that is admitted for an emergency surgery. Precisely, the study (i) estimated the expenditure patterns of both groups of participants 1month before surgery, (ii) estimated the prevalence of catastrophic health expenditure incurred during the admission process (iii) conducted an exploratory interview (with a subsample) on how those that incurred catastrophic expenditures coped with the hospital costs and practices. Methods: The study utilized a prospective study design using a mixed methods approach. A sequential explanatory design was used in which the quantitative component [objective (i) and (ii) above] was conducted before the qualitative component (objective iii). A total of 450 respondents (payers of hospital bills for patients scheduled for emergency surgery) were recruited from selected hospitals. The quantitative component consisted of 2 phases. During the first phase of the quantitative data collection, respondents were provided with cost diaries to recount household expenditure a month prior to the admission. The second phase required respondents to document all hospital costs during admission in a bid to estimate how catastrophic the hospital costs were. The qualitative component was conducted among a sub-sample of payers (13 slum dwellers and 18 non-slum dwellers) that had incurred catastrophic health expenditure from the quantitative phase. These payers were interviewed to explore their perceptions of hospital services and coping mechanisms one-month post-discharge from the facility. Analysis was conducted quantitatively using STATA Release 13 [1] while the qualitative data was analyzed using Atlas Ti [2] to extract relevant information required to answer the study objectives. Key Findings: Earning capacity was much lower for slum dwellers compared to the non-slum dwellers. As documented extensively in literature, food constituted a major share of expenditure among both groups while the other household items varied largely between the two groups. At 5% threshold, the prevalence of catastrophic health expenditures was significantly higher among slum dwellers compared to their non-slum counterparts (F=8.59; p=0.019). It was observed that 65.6% of the entire population of households recruited for the study experienced catastrophic expenditure. Multiple logistic regression showed that the significant predictors of CHE were insurance status of the payer (p=0.012) and setting of residence of the household payer (p=0.019). Coping with hospital costs was associated with delays in payment, borrowing and relying on social networks. Not being able to pay was accompanied by hospital practices such as interrupted treatment and incarceration2. Managing catastrophic expenditure was exacerbated by confusing billing practices such as double billing and the absence of flexible payment mechanisms. Conclusion: Slum dwellers are not the only group at risk of incurring catastrophic expenditure as non-slum dwellers are also prone, though to a lesser extent. The protection of households against catastrophic health expenditures is still largely deficient. Hospital services are still erratic and require concerted health policy reforms to improve the transparency with billing in the secondary and tertiary facilities. Solidarity schemes that cushion the effect of out-of-pocket health expenditures are also desired to support families in need of urgent health care services especially in emergency situations.