Surgical Catastrophic Health Expenditure and Risk Factors for Out-of-Pocket Expenditure at a South African Public Sector Hospital.

BACKGROUND: Worldwide, 3.7 billion people risk financial catastrophe if they require surgery, mostly affecting the poorest populations. Surgical care associated with catastrophic health expenditure (CHE) has not been well-described in the South African context. The objectives of this study were to determine: (1) the proportion of surgical patients at a South African hospital who experienced CHE and impoverishing health expenditure (IHE); and (2) the risk factors for out-of-pocket (OOP) payments. METHODS: A cross-sectional prospective questionnaire was administered to participants admitted for a surgical procedure at New Somerset Hospital, Cape Town. CHE was defined in three ways: (1) 40% or more of capacity-to-pay, (2) 25% of annual household expenditure, or (3) 10% of annual household expenditure. IHE was described as the number of participants who experienced new or worsening impoverishment after surgery. RESULTS: Two hundred and seventy-four participants were interviewed, and 263 were included in the analysis (4% attrition rate). Two (0.8%) participants experienced CHE. 98.5% of participants spent less than 10% of their annual household expenditure and 43 participants (16.7%) experienced IHE. Risk factors for OOP expenditure were cancer diagnosis (p = 0.0386), an elective procedure (p = 0.0001), and having a limited health insurance plan (p = 0.0492). DISCUSSION: Most participants undergoing a surgical procedure did not experience CHE. Participants were relatively protected from financial catastrophe owing to subsidized user fees and the provision of transport. However, 17% of patients experienced IHE, suggesting even small payments resulted in impoverishment. Ensuring low financial vulnerabilities around surgical care is an important consideration for national surgical planning in South Africa.

Building on "The concept of prevention: a good idea gone astray?".

BACKGROUND: In the article by Starfield and colleagues, it was suggested that the concept of prevention has gone astray. This article aims to extend their ideas. METHODS: Our methods are to take the Starfield et al article and argue that it is possible and useful to see prevention in a wider context, going beyond prevention in healthcare and viewing prevention as a social good. RESULTS: This wider view results in some questioning of the nature of the benefits of prevention. At the same time, it suggests that the values of informed citizens might be more often elicited to help establish the principles underpinning the concept of prevention. CONCLUSION: There is a need for further debate involving various disciplines to examine the concept of prevention in greater depth.