A. C. Matousek1,4, S. R. Addington1, R. R. Jean Louis2, J. Hamiltong Pierre3, J. Fils4, M. Hoyler4, S. B. Matousek1,5, J. Pyda4, P. Farmer4, J. G. Meara4, R. Riviello1,4 1Brigham And Women’s Hospital,The Center For Surgery And Public Health,Boston, MA, USA 2Hopital Albert Schweitzer,Surgery,Deschapelles, ArtIBONITE, Haiti 3Hopital Bon Sauveur,Zanmi Lasante,Cange, CENTRAL, Haiti 4Harvard Medical School,Program in Global Surgery And Social Change, Department Of Global Health And Social Medicine,Boston, MA, USA 5Boston University School Of Public Health,Department Of Health Policy And Management,Boston, MA, USA
Introduction: Health systems must deliver care equitably in order to serve the poor. Both Hospital A and Hospital B have longstanding commitments to provide equitable surgical care in rural Haiti. Hospital A charges fees that demonstrate a preference for the rural population near the hospital, with free care available for the poorest. Hospital B does not charge fees. The two hospitals are otherwise similar in surgical capacity and rural location.
Methods: We retrospectively reviewed operative case-logs at both hospitals from June 1 to Aug 31, 2012. The records were compared by total number of operations, geographic distribution of patients and number of elective operations. Hospital A defines a rural service area comprised of the nearby administrative units. Hospital B does not define a service area. To align with its mission to provide a preferential option for the poor, we defined the service area of Hospital B to include the entire nation except urban areas that contain other hospitals providing surgical care. For Hospital A, we analyzed the number of operations performed on patients from the most and least poor regions within the service area.
Results: Hospital A performed 348 operations and Hospital B performed 410 operations during the study period. Rural patients received 86% of operations at Hospital A compared to 53% at Hospital B (p<0.0001). Urban patients with elective conditions accounted for only 1% of all operations at Hospital A compared to 15% at Hospital B (p<0.0001). Within its rural service area, Hospital A performed 10.1 operations per 10,000 residents of less impoverished locations compared to 4.0 operations per 10,000 residents of severely destitute areas (p<0.0001).
Conclusion: Using fees as part of an equity strategy will likely disadvantage the poorest patients, while providing care without fees may encourage patients to travel from urban areas that contain other hospitals. Health systems striving to serve the poor should continually evaluate and seek to improve equity, even within systems that provide free care.
