• M G Shrime, A Dare, B C Alkire, and J G Meara.
• Program in Global Surgery and Social Change, Harvard Medical School, Massachusetts, USA. shrime@mail.harvard.edu.
• Br J Surg. 2016 Oct 1; 103 (11): 1453-61.

BackgroundApproximately 30 per cent of the global burden of disease is surgical, and nearly one-quarter of individuals who undergo surgery each year face financial hardship because of its cost. The Lancet Commission on Global Surgery has proposed the elimination of impoverishment due to surgery by 2030, but no country-level estimates exist of the financial burden of surgical access.MethodsUsing publicly available data, the incidence and risk of financial hardship owing to surgery was estimated for each country. Four measures of financial catastrophe were examined: catastrophic expenditure, and impoverishment at the national poverty line, at 2 international dollars (I$) per day and at I$1·25 per day. Stochastic models of income and surgical costs were built for each country. Results were validated against available primary data.ResultsDirect medical costs of surgery put 43·9 (95 per cent posterior credible interval 2·2 to 87·1) per cent of the examined population at risk of catastrophic expenditure, and 57·0 (21·8 to 85·1) per cent at risk of being pushed below I$2 per day. The risk of financial hardship from surgery was highest in sub-Saharan Africa. Correlations were found between the risk of financial catastrophe and external financing of healthcare (positive correlation), national measures of well-being (negative correlation) and the percentage of a country's gross domestic product spent on healthcare (negative correlation). The model performed well against primary data on the costs of surgery.ConclusionCountry-specific estimates of financial catastrophe owing to surgical care are presented. The economic benefits projected to occur with the scale-up of surgery are placed at risk if the financial burden of accessing surgery is not addressed in national policies.© 2016 BJS Society Ltd Published by John Wiley & Sons Ltd.

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