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Gaining Access to Major Elective Surgeries in a Public Tertiary Health Institution in Southeast Nigeria: Evaluating Household Payment Coping Strategies

Ikenna Ifeanyi Nnabugwu,1, 2 Chikezie Nwankwor,1 Fredrick Ugwumba1, 2
1 College of Medicine, University of Nigeria Enugu Campus
2 University of Nigeria Teaching Hospital
Correspondence to: Dr. Nnabugwu Ikenna, PMB 01129 Ituku-Ozalla; email: ikenna.nnabugwu@unn.edu.ng


Background: The Lancet Commission on Global Health recommends that by 2030 no household should be impoverished while accessing needed surgical operation. Meeting this target in Nigeria is challenging. This study aims to evaluate the payment coping strategies adopted by households in southeast Nigeria in gaining access to needed major surgeries electively. The findings will aid in designing policies towards improving access to needed surgical care. Methods: A hospital-exit cross-sectional survey of households that accessed major surgeries electively from the study health institution from July to December 2017. Payment coping strategies were compared across household wealth quintiles and household characteristics. SPSS® version 20 was used for analysis. Results: Household characteristics associated with deployment of extreme payment coping strategies were: household size >6 persons (p=0.001), female-headed households (p=0.001) and lower formal education of household heads (p=0.004), but not household socio-economic status (p=0.16). Whereas 98.7% of uninsured households and 88.5% of insured households drew from household savings, 61.4% of uninsured households and 26.9% of insured households deployed further payment coping strategies beyond drawing from savings (p=0.05). Conclusion: Extreme hardship financing is evidently prevalent among uninsured households accessing major surgical operation electively, irrespective of household socio-economic status.


Key words: Hardship financing, Payment coping strategies, Out-of-pocket payment

Ann Afr Surg. 2019; 16(2):69–74


Conflicts of Interest: None

Funding: None

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Gaining access to healthcare services including surgical care remains a dominant feature of discussions on improving health systems worldwide (1). During the 68th World Health Assembly of the World Health Organization (WHO) on 22 May 2015, delegates unanimously adopted “essential surgical care and anaesthesia” as a component of universal health coverage (2). Therefore, in low and medium income countries (LMIC) such as Nigeria where social security infrastructure development is still rudimentary (3), the need is urgent to address financial access to surgical care. Poverty limits household access to curative, rehabilitative and palliative surgical care, posing increased risk of financial hardship or catastrophe upon accessing needed surgical care (4). In Nigeria, the national strategic health development plan framework 2009–2015 observes that healthcare costs contribute significantly to poor utilization of healthcare services by individuals and households, leading to poor health outcomes, and that poverty is a major factor in decision making by individuals and households on when and how to utilize available healthcare services (4). Regrettably, more than 90% of the households in southeast Nigeria do not have any form of social insurance on health and hence purchase healthcare at all times by direct out-of-pocket payment mechanism (3, 5). Unlike the prepayment mechanisms of financing healthcare services underpinning the different insurance and tax-based health financing models, direct out-of-pocket (OOP) payment makes an unexpected demand on an individual’s or a household’s income, which very often cannot be met by routine household budget, a situation known as hardship financing of needed medical care. Such hardship financing can occur irrespective of the socio-economic status of the household (6).

Accessing major surgical operations has high cost implications irrespective of the society involved with an estimate of nearly half of the world’s population, mostly within sub- Saharan Africa, being at risk of financial catastrophe when in need of surgery (7, 8). There is financial catastrophe when more than a reasonable proportion (usually greater than 40%) of limited household income after subsistence expenses is spent on accessing needed medical care.

Drawing from savings as a payment coping strategy, where regular household budget becomes inadequate, has been proposed by Madan et al. (9) as a proxy for identifying financial hardship: being predictable, convenient and handy whenever available. However, such drawings from household savings may not be readily differentiated from spending from regular household income among the low income households (10). Other payment coping strategies such as borrowing from formal and informal sources, raising funds through sale of valuable assets, taking up extra jobs or working extra hours, forfeiting foods, undue postponement in defraying fees for accessed services, and asking for charity or begging for alms could be used where household savings is non-existent or adjudged to be incapable of addressing the financial concerns of the household (11). Adopting these extreme payment coping strategies arguably points towards deeper financial hardship on households as well as presents longer lasting impoverishing consequences on the household (12).

An insight into the payment coping mechanisms adopted by households to gain access to major surgical operations electively will be of great value in proposing appropriate policies towards achieving the universal health coverage target of eliminating hardship financing of healthcare services by 2030. The aim of this study is to evaluate the payment coping strategies households deploy to successfully gain access to major surgical operations electively from the University of Nigeria Teaching Hospital, Enugu, southeast Nigeria. Emphasis is on the extreme payment coping strategies deployed by households beyond drawing from household savings. The findings will aid in providing appropriate considerations for policy changes in health system financial risk protection strategies.


Materials and Methods

This was a hospital- exit quantitative survey of households whose adult members gained access to major elective surgeries from July to December 2017 from the University of Nigeria Teaching Hospital, a public tertiary hospital located in southeast Nigeria. The surgery section of the hospital has 176 lying-in beds. The study population comprised households accessing surgical care in the department of surgery of the health institution; individual households that gave consent for the study constituted the study units. The major surgeries accessed electively were within general surgery, urology, gynaecology and orthopaedic surgery units.

Southeast Nigeria has a projected population of 21 million people with approximately 62% adults (13). The survey used an exit questionnaire to gather information from every household whose adult household member (patient) accessed major elective surgery within the survey period. Major surgery was defined as a surgical procedure that posed substantive risk to life of the patient, and usually required general anaesthesia or regional anaesthesia. Study questionnaires were administered upon discharge from hospital and complete settlement of hospital bills. Pre-tutored trainee-surgeons, acting as research assistants, administered the questionnaires to the household member who acted as lead caregiver during the period of hospital admission. The questionnaire had 3 sections: first section sought to identify household characteristics—number of persons in the household (adults and children), gender, age and formal education