Out-of-pocket expenses incurred by patients obtaining free breast cancer care in Haiti: A pilot study

doi:10.1016/j.surg.2015.04.040

Surgery

Volume 158, Issue 3, September 2015, Pages 747-755

Presented at the 10th Annual Academic Surgical Congress in Las Vegas, NV, February 3–5, 2015.

https://doi.org/10.1016/j.surg.2015.04.040 Get rights and content

Background

Women in low- and middle-income countries account for 51% of breast cancer cases globally. These patients often delay seeking care and, therefore, present with advanced disease, partly because of fear of catastrophic health care expenses. Although there have been efforts to make health care affordable in low- and middle-income countries, the financial burden of out-of-pocket (OOP) expenses for nonmedical costs, such as transportation and lost wages, often is overlooked.

Methods

An institutional review board exemption was granted from Boston Children's Hospital and Partners in Health/Zanmi Lasante for this cross-sectional study. In total, 61 patients receiving breast cancer care free of charge at Hôpital Universitaire de Mirebalais (HUM) in Haiti were selected via convenience sampling. They were interviewed between March and May 2014 to quantify the expenses they incurred during the course of diagnosis and treatment. These expenses included medical costs at outside facilities, as well as nonmedical costs (eg, transportation, meals, etc).

Results

The median, nonmedical OOP expenses incurred by breast cancer patients at HUM were $233 (95% confidence interval [95% CI] $170–304) for diagnostic visits, $259 (95% CI $200–533) for chemotherapy visits, and $38 (95% CI $23–140) for surgery visits. The median total OOP expense (including medical costs) was $717 (95% CI $619–1,171). To pay for these expenses, 52% of participants stated that they went into debt; however, the amount of debt was not quantified. The median income of these patients was $1,333 (95% CI $778–2,640), and the median sum of OOP expenses and lost wages was $2,996 (95% CI $1,676–5,179).

Conclusion

Despite receiving free care: at HUM, more than two-thirds of participants met conservative criteria for catastrophic medical expenses (defined as spending more than 40% of their potential household income on OOP payments). Further studies are needed to understand the magnitude of OOP health care expenses for the poor worldwide, how to aid them during their treatment program, and its impact on their health outcomes.

Section snippets

Methods

Institutional research board exemption was granted from Boston Children's Hospital and Partners in Health/Zanmi Lasante for this cross-sectional study. Participants were selected by convenience sampling²² of all patients coming to the breast cancer center at the hospital for diagnosis, chemotherapy, or surgery during days when the research assistant was available to conduct interviews.

HUM, a university hospital that provides free health care in Mirebalais, Haiti, was the site chosen for the

Results

Demographics are presented in Table I. The median age of patients interviewed (n = 61) was 46 years (mean = 49; σ = 9.8; range = 34–70). Nearly all participants were female (n = 60). The median number of children per household was 3, with 93% of participants having at least one child.

Discussion

Medical expenses can be catastrophic for patients and families,² but few studies have analyzed the non-medical along with the medical OOP costs for patients seeking oncology care in LMICs. We sought to examine further the magnitude and impact of these expenses for patients receiving “free” oncology care at a hospital in rural Haiti. Some investigators have argued that if health care is provided free of charge, patients will not be invested in their health²⁴; however, for the participants in

References (34)

D. McIntyre et al.
What are the economic consequences for households of illness and of paying for healthcare in low- and middle-income country contexts?
Soc Sci Med
(2006)
M. Whitehead et al.
Equity and health sector reforms: can low-income countries escape the medical poverty trap?
Lancet
(2001)
W.K. Asenso-Okyere et al.
Household cost of seeking malaria care. A retrospective study of two districts in Ghana
Soc Sci Med
(1997)
R. Sauerborn et al.
Household strategies to cope with the economic costs of illness
Soc Sci Med
(1996)
P. Farmer et al.
Expansion of cancer care and control in countries of low and middle income: a call to action
Lancet
(2010)
H.P. Freeman
Poverty, race, racism and survival
Ann Epidemiol
(1993)
M. Kagawa-Singer
Socioeconomic and cultural influences on cancer care of women
Semin Oncol Nurs
(1995)
K. Xu et al.
Household catastrophic health expenditure: a multicountry analysis
Lancet
(2003)
S. Pannarunothai et al.
The poor pay more: health-related inequality in Thailand
Soc Sci Med
(1997)
D.T. Jamison et al.
Global health 2035: a world converging within a generation
Lancet
(2013)

S. Gottlieb

Medical bills account for 40% of bankruptcies

BMJ

(2000)

M. Claeson et al.

Health, nutrition and population

M. Koopmanschap et al.

The impact of indirect costs on outcomes of health care programs

Health Econ

(1994)

N. Attanayake et al.

Household costs of ‘malaria’ morbidity: a study in Matale district, Sri Lanka

Trop Med Int Health

(2000)

M. Ettling et al.

Economic cost of malaria in Rwanda

Trop Med Parasitol

(1991)

F.M. Knaul

10 Facts about Breast Cancer. Global Task Force on Expanded Access to Cancer Care and Control in Developing Countries

(2011)

Cited by (29)

The cancer epidemic in the Caribbean region: Further opportunities to reverse the disease trend
2022, The Lancet Regional Health - Americas
Citation Excerpt :
A study conducted by Balas et al. among Jamaican women found that some of the barriers to breast cancer screening included being a younger woman under the age of 50, being at the stage of pre-contemplating breast cancer screening, having more than three children and needing assistance with childcare, lack of screening facilities, and high cost of screening.58 Another study in Haiti also found that the cost of screening and care was a significant limiting factor to accessing health care.59 The absence of universal health coverage, leading to financial strain for care, was also found to be a significant problem in other Caribbean and Latin American countries.60
Cancer incidence has been rising in the Caribbean and is expected to have significant adverse implications for the health of people in the region and health systems in this decade. While developed countries, for the most part, enjoy the benefits of advanced technologies and adaptive systems in cancer control and management, a different experience confronts a large segment of the Caribbean population. The region has experienced some success in enhancing cancer services, however, there is a need to address gaps in several areas through nationally and regionally tailored initiatives. This Review complements previous publications on the challenges, actions, and progress towards cancer prevention and care in Caribbean countries but also further outlines potential positive impacts that can be derived from addressing gaps pertaining to cancer education, data management, screening and risk assessment, navigation services, gender factors, and resource development. The proposed approaches encapsulate concepts of health theories that are applicable across the ecological domains. When implemented in combination, the proposals may effectively contribute to reducing the cancer burden in the region.
Financial burden associated with attendance at a public hospital emergency department in Johannesburg
2022, African Journal of Emergency Medicine
Citation Excerpt :
As per a 2005 report by the World Health Organization (WHO), catastrophic health care expenditure (CHCE) which can be defined as out-of-pocket expenditure on medical care that leads to a severe financial burden for the individual or the household, affected 150 million individuals from 44 million households globally [7]. Various individual studies have also indicated that CHCE is a global problem [8–12], with those living in low-income regions being most affected [13]. Costs involved when attending healthcare services have the potential to create a significant financial burden on a patient, or even the person accompanying a patient to the hospital.
Introduction: More than half of South Africans live below the poverty line. Indirect medical costs can contribute significantly to the financial burden of patients seeking medical care. The aim of this study was to determine the expenses incurred by patients and/or their escorts during a visit to the emergency centre (EC).
Methods: Patients and/or their escorts presenting to an EC in Johannesburg were asked to complete the study questionnaire relating to expenses incurred during a visit to the EC.
Results: Of the total 396 participants that completed the questionnaire, 108 (27.2%) did not have any source of income, 146 (36.9%) were the sole breadwinner in their household and 36 (9.1%) belonged to zero-income households. Among those earning ≤R2000 per month, the mean expenses relating to the EC visit was R240 (SD R372), equating to an average of 33.2% of mean monthly income. Transport costs were the most common expense (n=302, 76.3%), while general practitioner (GP) fees incurred prior to the EC visit accounted for the bulk of the expenses (median R450, IQR 350-820). Participants that earned >R2000 per month were significantly more likely to incur GP fees (p =0.012), while those earning ≤R2000 per month were significantly more likely to take a loan to cover EC related expenses (p =0.014).
Conclusion: A visit to the EC can have a substantial financial impact on patients and their accompanying escorts in South Africa. Strategies should be aimed at identifying and assisting those that are in need of financial assistance to cover indirect healthcare costs.
Barriers to timely surgery for breast cancer in Rwanda
2019, Surgery (United States)
Citation Excerpt :
Among the patients for whom reasons for delays and disruptions were documented, financial and social barriers were common despite several very helpful programs that seek to minimize financial barriers to care at BCCOE; these programs include a robust national health insurance system, free cancer medications, and financial support for transportation expenses. This finding is consistent with a study from Haiti demonstrating that high out-of-pocket costs can pose a huge, often insurmountable barrier even in settings where cancer care is ostensibly free.23 In our study, 4 patients were documented as refusing recommended breast surgery (5% of those referred).
Ensuring timely and high-quality surgery must be a key element of breast cancer control efforts in sub-Saharan Africa. We investigated delays in preoperative care and the impact of on-site versus off-site operation on time to operative treatment of patients with breast cancer at Butaro Cancer Center of Excellence in Rwanda.
We used a standardized data abstraction form to collect demographic data, clinical characteristics, treatments received, and disease status as of November 2017 for all patients diagnosed with breast cancer at Butaro Cancer Center of Excellence in 2014 to 2015.
From 2014 to 2015, 89 patients were diagnosed with stage I to III breast cancer and treated with curative intent. Of those, 68 (76%) underwent curative breast operations, 12 (14%) were lost to follow-up, 7 (8%) progressed, and 2 declined the recommended operation. Only 32% of patients who underwent operative treatment had the operation within 60 days from diagnosis or last neoadjuvant chemotherapy. Median time to operation was 122 days from biopsy if no neoadjuvant treatments were given and 51 days from last cycle of neoadjuvant chemotherapy. Patients who received no neoadjuvant chemotherapy experienced greater median times to operation at Butaro Cancer Center of Excellence (180 days) than at a referral hospital in Kigali (93 days, P = .04). Most patients (60%) experienced a disruption in preoperative care, frequently at the point of surgical referral. Documented reasons for disruptions and delays included patient factors, clinically indicated treatment modifications, and system factors.
We observed frequent delays to operative treatment, disruptions in preoperative care, and loss to follow-up, particularly at the point of surgical referral. There are opportunities to improve breast cancer survival in Rwanda and other low- and middle-income countries through interventions that facilitate more timely surgical care.
Breast Health Awareness: Understanding Health-Seeking Behavior in Western Kenya
2024, Annals of Surgical Oncology
Determining the cost and cost-effectiveness of childhood cancer treatment in Haiti
2024, ecancermedicalscience
Patients’ experiences undergoing breast evaluation in Rwanda’s Women’s Cancer Early Detection Program
2023, Breast Cancer Research and Treatment

View all citing articles on Scopus

: Rowan Gillies, MBBS, and Ruth Damuse, MD, are senior coauthors.

: Boston Children's Hospital and Partners in Health provided funding for this study.

View full text

Global SurgeryOut-of-pocket expenses incurred by patients obtaining free breast cancer care in Haiti: A pilot study

Background

Methods

Results

Conclusion

Section snippets

Methods

Results

Discussion

Soc Sci Med

Lancet

Soc Sci Med

Soc Sci Med

Lancet

Ann Epidemiol

Semin Oncol Nurs

Lancet

Soc Sci Med

Lancet

Medical bills account for 40% of bankruptcies

BMJ

Health, nutrition and population

The impact of indirect costs on outcomes of health care programs

Health Econ

Household costs of ‘malaria’ morbidity: a study in Matale district, Sri Lanka

Trop Med Int Health

Economic cost of malaria in Rwanda

Trop Med Parasitol

10 Facts about Breast Cancer. Global Task Force on Expanded Access to Cancer Care and Control in Developing Countries

Global Surgery
Out-of-pocket expenses incurred by patients obtaining free breast cancer care in Haiti: A pilot study