What is the financial burden to patients of accessing surgical care in Sierra Leone? A cross-sectional survey of catastrophic and impoverishing expenditure

Research output: Contribution to journalArticlepeer-review


  • Manraj Phull
  • Caris E Grimes
  • Thaim B Kamara
  • Haja Wurie
  • Andrew J M Leather

Colleges, School and Institutes


Objectives: To measure the financial burden associated with accessing surgical care in Sierra Leone. 
Design: A cross-sectional survey conducted with patients at the time of discharge from tertiary level care. This captured demographics, yearly household expenditure, direct medical, direct non-medical, and indirect costs for surgical care, and summary household assets. Missing data were imputed.
Setting: The main tertiary level hospital in Freetown, Sierra Leone. Participants: 335 surgical patients under the care of the hospital surgical team receiving operative or non-operative surgical care on the surgical wards.
Outcome measures: Rates of catastrophic expenditure (CE) (a cost > 10% of annual expenditure), impoverishment (being pushed into, or further into, poverty as a result of surgical care costs), amount of out-of-pocket (OOP) costs, and means used to meet these costs were derived. Results: Of 335 patients interviewed, 39% were female and 80% were urban dwellers. Median yearly household expenditure was US$3569. Mean OOP costs were US$243, of which a mean of US$24 (10%) was spent pre-hospital. Of costs incurred during the hospital admission, direct medical costs were US$138 (63%) and US$34 (16%) were direct non-medical costs. US$46 (21%) were indirect costs. Catastrophic expenditure affected 18% of those interviewed. Concerning impoverishment, 45% of patients were already below the national poverty line prior to admission, and 9% of those who were not were pushed below the poverty line following payment for surgical care. 84% of patients used household savings to meet OOP costs. Only 2% (6 patients) had health insurance. 
Conclusion: Obtaining surgical care has substantial economic impacts on households which pushes them into poverty or further into poverty. The much-needed scaling up of surgical care needs to be accompanied by financial risk protection. 


Original languageEnglish
Article numbere039049
Number of pages9
JournalBritish Medical Journal Open
Issue number3
Publication statusPublished - 8 Mar 2021