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Effect of removing the barrier of transportation costs on surgical utilisation in Guinea, Madagascar and the Republic of Congo
  1. Mark G Shrime1,2,
  2. Mirjam Hamer3,4,
  3. Swagoto Mukhopadhyay1,
  4. Lauren M Kunz5,
  5. Nathan H Claus4,
  6. Kirsten Randall4,
  7. Joannita H Jean-Baptiste6,
  8. Pierre H Maevatombo7,
  9. Melissa P S Toh4,8,
  10. Jasmin R Biddell4,
  11. Ria Bos4,
  12. Michelle White4,9
  1. 1 Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
  2. 2 Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, USA
  3. 3 Paediatric Intensive Care Unit, University Medical Center, Utrecht, The Netherlands
  4. 4 Mercy Ships, Lindale, USA
  5. 5 National Institutes of Health, Bethesda, USA
  6. 6 Freedom from Fistula Foundation, Toamasina, Madagascar
  7. 7 WISE, Project on Reproductive Health, Toamasina, Madagascar
  8. 8 Operation Fistula, Austin, USA
  9. 9 Anaesthesia, Great Ormond Street Hospital, London, UK
  1. Correspondence to Dr Mark G Shrime, Harvard Medical School, Huntington Avenue, Boston, MA 02115 USA ; shrime{at}mail.harvard.edu

Abstract

Background 81 million people face impoverishment from surgical costs every year. The majority of this impoverishment is attributable to the non-medical costs of care—for transportation, for food and for lodging. Of these, transportation is the largest, but because it is not viewed as an actual medical cost, it is frequently unaddressed. This paper examines the effect on surgical utilisation of paying for transportation.

Methods A hierarchical logistic regression was performed on 2692 patients presenting for surgical care to a non-governmental organisation operating in the Republic of the Congo, Guinea and Madagascar. Controlling for distance from the hospital, age, gender, the need for air travel and time between appointments, the effect of payment for transportation on the surgical no-show rate was evaluated.

Results After adjustment for observed confounders, paying for transportation drops the surgical no-show rate by 45% (OR 0.55; 95% CI 0.40 to 0.77; p<0.001). Age, delay between appointments and the number of hours travelled for surgery also predict surgical no-show. For 28% of no-show patients, the cost of transportation from their homes to a nearby predetermined pick-up point remained a barrier, even when transportation from the pick-up point to the hospital was free.

Conclusion Transportation costs are a significant barrier to surgical care in low-resource settings, and paying for it halves the no-show rate. This finding highlights that decreasing demand-side barriers to surgical care cannot be limited only to the removal of user fees.

  • health economics
  • health policy
  • public health
  • surgery

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

https://doi.org/10.1136/bmjgh-2017-000434

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    Footnotes

    • Handling editor Seye Abimbola

    • Contributors Conception or design of the work: MGS, MH, MCW. Acquisition of data: all authors except LK. Analysis or interpretation of data for the work: MGS, LK, MH. Drafting the work: MGS, MH, SM. Revising it critically for important intellectual content: all authors. Final approval of the version to be published: all authors.

    • Funding MGS receives support from the GE Foundation Safe Surgery 2020 project and from the Damon Runyon Cancer Research Foundation. No specific funding was obtained for this paper.

    • Competing interests None declared.

    • Ethics approval Mercy Ships IRB and Massachusetts Eye and Ear IRB.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data sharing statement Data sharing requests are subject to approval by the Mercy Ships Institutional Review Board.