10.02 Does Insurance Protect Individuals from Catastrophic Payments for Surgical Care in Ghana?

J. S. Okoroh1,4, S. Essoun3, R. Riviello2, H. Harris1, J. S. Weissman2  1University Of California – San Francisco,Department Of Surgery,San Francisco, CA, USA 2Brigham And Women’s Hospital,Center For Surgery And Public Health,Boston, MA, USA 3University Of Ghana,Korle-Bu Teaching Hospital/ Department Of Surgery,Accra, GREATER ACCRA, Ghana 4Fogarty International Center,UcGloCal Consortium,Bethesda, MD, USA

According to the WHO, essential surgery should be recognized as integral to achieving Universal Health Coverage. We previously reported that surgical conditions were commonly included in national health plans, yet catastrophic health expenditures persist. Insurance is associated with a reduction in maternal mortality and improved access to essential medications in Ghana, but whether it eliminates financial barriers to care for surgical patients is unknown. We sought to describe amounts and payments for general surgical conditions included under Ghana’s national health insurance scheme, and test the hypothesis that insurance protects surgical patients against financial catastrophe. 

We interviewed patients admitted to the general surgery wards of Korle-Bu Teaching Hospital between February 1 – June 30, 2017 to obtain demographic data, annual income, occupation, household expenditures and insurance status. Surgical diagnoses and procedures, procedural fees, anesthesia fees, medicines and all other costs incurred were collected through chart review. The data was collected on a Qualtrics platform and analyzed in STATA. T-tests and chi-square tests were used to compare insured and uninsured groups. Threshold for financial catastrophe was defined as >10% of annual household expenditures, >40% of non-food expenditures, or >20% of individual income. 

Among 107 enrolled patients, demographic characteristics did not significantly differ between the insured and uninsured except the insured were slightly older [mean 49 years vs 40 years P<0.05.] and more likely to be female [65% vs 40% p<0.05]. The most common surgical procedures for both groups were laparotomy, inguinal hernia repair and appendectomy. Insurance paid on average 40% of the total cost of surgical care, thus protecting some patients from financial catastrophe. However, 50% of the insured patients experienced financially catastrophic payments and almost all reported out-of-pocket payments in addition to hospital payments for medicines and laboratory tests. 

This study—the first to evaluate the impact of insurance on financial risk protection for surgical patients in a resource-limited setting—shows that despite its benefits, about half of insured surgical patients are not protected from financial catastrophe under the Ghanaian national health insurance scheme due to out-of- pocket payments. Government-specific strategies to enroll uninsured individuals at the point of care and to increase the proportion of cost covered are crucial to protecting individuals from financial catastrophe due to surgical care in Ghana thus achieving Universal Health Coverage.