Catastrophic Healthcare Expenditure from Typhoid Perforation in Children in Nigeria

Abstract

Background:

Out-of-pocket payments and catastrophic healthcare expenditures (CHE) are important barriers to achieving equity and access to emergency and essential surgical care in low- and middle-income countries (LMICs), with important implications for universal health coverage (UHC). However, data on CHE for surgical care in these settings are limited, especially with regard to infections.

Methods:

We performed a retrospective review of 32 children receiving laparotomy for typhoid intestinal perforation in a four-year period. Data on medical costs were reviewed. Because of the lack of reliable data on household incomes and average national incomes for Nigeria, gross domestic product per capita was used to calculate CHE. The GDP per capita for the country during the study period was $2,028.182. Expenditure >10% GDP per capita (or > $202.82) was considered CHE.

Results:

There were 15 boys and 17 girls aged 2–15 years (mean 7.72 years). Seventeen patients (53%) were referred from district/general hospitals or mission hospitals. After surgical treatment, 16 patients (50%) developed complications (intra-abdominal abscesses and incision complications), and nine (28.1%) required re-operation. Seven patients (21.9%) required intensive care (ICU) treatment and three (9.4%) died from overwhelming infection. The hospital stay was 3–93 days (mean 23 days). The average total medical cost was $452 (range $236–$1,700). The total medical costs exceeded 10% of GDP ($202.82) for all patients. Total expenditure for four patients requiring intensive care exceeded $202.82 for the ICU care alone.

Conclusion:

Surgical treatment of typhoid intestinal perforation in children is associated with a high rate of CHE if care is provided at tertiary hospitals. Investments in prevention and control of this and other surgical infections as well as scale up of capacity at district hospitals to provide such care are important in preventing CHE.

Achieving universal health coverage (UHC) requires a commitment to ensuring equity in access to health services, delivery of health services good enough to improve the health of those receiving the services, and protection against financial risk [1]. The enormity of the burden of surgical conditions, the proved cost effectiveness of emergency and essential surgery, and population demand for surgical services have buttressed the need for financing universal coverage of essential surgery early in the quest to achieve UHC.

Nigeria is a lower middle-income country with an estimated 2020 population of more than 200 million [2]. About 50% of the population is children and adolescents. A 2019 report by the United Nations Development Program and Oxford Poverty and Human Development Initiative reveals that 51% of Nigerians, more than 100 million people, are multi-dimensionally poor [3]. According to the World Bank, 53.5% of Nigerians lived on less than $1.90 a day in 2019 [4]. Incomes in the country differ quite widely, and a large proportion of the population is not employed in the formal sector, making it difficult to ascertain average national incomes. A medical graduate may earn a salary of < $600 monthly, but a large proportion of this is spent on subsistence.

A National Health Insurance Scheme (NHIS) was established in 2004 with the aim of providing easy access to healthcare for all Nigerians [5]. Despite this initiative, out-of-pocket payments (OOPs) for healthcare increased from 65% in 2004 to 77% in 2017 with a decline in government health spending as a percentage of gross domestic product (GDP) [6]. Catastrophic expenditure from healthcare is defined as more than 40% of income remaining after subsistence needs have been met [7] or more than 40% of non-food household expenditure [8], or more than 10% of overall household expenditure [9]. Where data on household expenditure or income are not available, 10% of GDP per capita is used [10].

There are very few studies on catastrophic health expenditure (CHE) in Nigeria, and the few available are neither specific to surgical conditions nor to children [11,12]. In a 2016 report, the authors computed that the total expenditure in urban areas in Nigeria was NGN376,996.91 (US$1,047.21) and health expenditure NGN118,583.99 ($329.40), whereas the total expenditure in rural areas was NGN316,547.84 ($879.30) with health expenditure of NGN115,538.76 ($320.94) [13]. This results in a health expenditure as a percentage of total expenditure of 31.45% in urban areas and 36.44% in rural areas [13]. In the absence of financial risk protection, surgery can be catastrophically expensive [10].

Typhoid intestinal perforation is one of the commonest indications for emergency abdominal surgery in children in Nigeria [14]. Evaluating the risk of catastrophic expenditure from accessing pediatric surgical care is important for advancing policies and advocating for interventions that would strengthen surgical systems for children and contribute to achieving universal coverage of essential surgery (UCES) and UHC. It also would help in advocacy for investments in prevention and control of surgical infections.

In 2017, Nigeria embarked on the creation of a National Surgical, Obstetrics, Anaesthesia and Nursing Plan (NSOANP), which was concluded in 2019 [15]. The evaluation for CHE was done as part of the baseline assessment for the NSOANP.

Patients and Methods

This was a retrospective case series of 48 children aged 0–15 years undergoing laparotomies for typhoid intestinal perforation at National Hospital, Abuja, in Federal Capital Territory, Nigeria, from January 2014–December 2017. Typhoid infection was confirmed by histopathology examination of the resected intestinal segment.

During the time period, 946 operations were performed on children age 15 and younger, including 438 emergency operations and 304 laparotomies. Of these, 48 patients underwent 59 operations (19.4% of laparotomies) for peritonitis from typhoid intestinal perforation and associated procedures. Thirty-two of these 48 patients had adequate records and have been reviewed. Data on medical costs of actual hospital care, including bed fees, medications, surgery, intensive care unit (ICU), and feeding were obtained from the hospital records of the patients, including medications paid for and obtained directly from the hospital. Information on medications purchased from pharmacy shops outside the hospital was not available. Information regarding non-medical costs (transportation, feeding of caregiver, etc.) likewise was not available and has not been included in the data analysis.

Because of the lack of reliable data on the actual annual income of the patients' families, we have used expenditure of >10% of Nigeria's GDP per capita as the indicator of CHE [10]. The prevailing annual minimum wage in Nigeria is NGN360,000 or $1,000 (monthly wage of NGN30,000 or $83.30). At the time of the study, the prevailing Naira to U.S. dollar exchange rate was NGN360 to $1.

Ethical approval was obtained from the Health Research and Ethics Committee of the National Hospital, Abuja, Nigeria, as part of the baseline assessment for the NSOANP.

Results

Demographics

There were 15 boys and 17 girls aged 2–15 years (mean 7.72 ± 3.61 years). The mean duration of symptoms before presentation was 12 days (range 4–21 days).

Referring hospital

Sixteen of the patients (50%) were referred from district (general) hospitals and the others from private, tertiary, and Catholic mission hospitals (Table 1). The reason for referral usually was a lack of expertise to undertake the required surgery in children.

Table 1.

Source of Referral

Type of hospital (n = 32)	No. (%)
District/general	16 (50.0)
Private	7 (21.9)
Tertiary	5 (15.6)
Mission	1 (3.1)
Missing	3 (9.4)

Evaluation

All patients presented with a history of abdominal pain and fever. Among the other symptoms were vomiting, passage of blood in stools, and abdominal distension. Common examination findings included dehydration and abdominal tenderness. Jaundice was not a common finding (Table 2).

Table 2.

Clinical Features of Patients

Sign or symptom	Frequency (%)
Fever	32 (100)
Abdominal pain	32 (100)
Diarrhea	30 (93.8)
Vomiting	30 (93.8)
Abdominal distension	29 (90.6)
Constipation	19 (59.4)
Blood in stools	3 (9.4)
Temperature at presentation
Normal	6 (18.1)
Hypothermia	1 (3.1)
Low-grade fever	5 (15.6)
High-grade fever	6 (18.8)
Jaundice	3 (9.4)
Dehydration	31 (96.9)
Pallor	18 (56.3)
Crepitations in the lungs	5 (15.6)
Abdominal distension	31 (96.9)
Abdominal tenderness	31 (96.9)

Dyselectrolytemia was a common finding, and 23 patients (71.9%) had hypoalbuminemia. Twenty-two (84.4%) were anemic.

Resuscitation lasted an average of 31 hours (range 12–101 hours) before surgery.

Treatment and outcome

The type of surgery performed (segmental resection or damage-control ileostomy) depended on the site and extent of the perforation, the surgeon's preference, and the clinical status of the patient. All patients received broad-spectrum antibiotics (ciprofloxacin or ceftriaxone, metronidazole, and amikacin).

Sixteen patients developed post-operative complications including enterocutaneous fistula (five; 15.6%), intra-abdominal abscess (six; 18.8%), burst abdomen (three; 9.4%), and sepsis and septic shock (two; 6.3%) (Table 3). Nine patients (28.1%) required re-operation for intra-abdominal abscess or incision complications, and seven (21.9%) were admitted to the ICU. The average length of the hospital stay was 23 days (range 3–93 days), and three patients (9.4%) died from overwhelming infection.

Table 3.

Post-Operative Complications

	Frequency (%)
Enterocutaneous fistula	5 (15.6)
Intra-abdominal abscess	6 (18.8)
Burst abdomen	3 (9.4)
Sepsis and septic shock	2 (6.3)

Cost analysis and expenditure

The actual family income was not known because of lack of records. However, the parents' occupation, as shown in Table 4, revealed that only 11 of the parents (24.4%) whose occupations were documented were employed in a formal sector. Thirty-one patients (96.9%) did not have health insurance.

Table 4.

Occupations of Parents

Father		Mother
Businessman	6	Housewife	10
Trader	5	Trader	4
Civil servant	4	Teacher	2
Teacher	3	Businesswoman	2
Policeman	1	Student	1
Engineer	1	Banker	1
Construction worker	1	Cleaner	1
Software programmer	1	Printing press worker	1
Welder	1	Unknown	10
Unknown	9

Bed fees

The average bed cost was $133 (range $22–$539). Five patients (15.6%) spent more than $202.82 on bed costs alone. The bed fee per day at the hospital was ₦2,000 ($5.56), and the per week cost for children at district or general hospitals in Abuja and its environs was $5.56. For the longest duration of hospital stay, a patient who spent 97 days after admission, the total bed fee would be $77.84 in a district/general hospital or 14.4% of what the patient paid at the National Hospital.

Surgery fees

The average cost of surgery was $286 (range $208–$1,250). All patients spent more than $202.82 on surgery. The average cost of surgery at district or general hospitals was $111.11. This is less than 50% of the cost at this hospital.

Intensive care unit cost

The average ICU cost was $173 (range $27–$360). Four of the seven patients admitted to the ICU spent more than $202.82 on that care.

Total costs

The average total medical cost of treating typhoid intestinal perforation at this hospital was $452 (range $236–$1,700). All patients spent more than $202.82 on total medical costs.

Catastrophic expenditure (Table 5)

In 2017, the prevailing GDP per capita for Nigeria was $2,028.182 [16]. Expressing CHE as spending more than 10% of GDP per capita (10% of $2,028.182) on health care, a family would experience CHE if the total medical cost exceeded $202.82. In this report, all families are at risk of CHE from surgical care for typhoid intestinal perforation in their children. As noted, four patients' families spent > $202.82 on ICU care alone.

Table 5.

Cost analysis (₦ = Nigerian Naira)

Cost	No. of patients	Mean ₦ (US$)	Minimum ₦ (US$)	Maximum ₦ (US$)
Total	32	162,984 (452)	85,000 (236)	612,300 (1,700)
Bed	31	47,710 (133)	8,000 (22)	194,000 (539)
Intensive care unit	7	62,357 (173)	10,000 (27)	129,700 (360)
Operation	32	103,125 (286)	75000 (208)	450,000 (1,250)
Total medical as % of GDP per capita	32	22.29	11.64	83.82

There was no statistically significant association between the presence of post-surgical complications, re-operation, or ICU admission and the risk of CHE.

Discussion

Surgical illnesses account for about 30% of the global burden of disease [17]. Although the cost effectiveness of lifesaving surgical care across all country income groups, and especially in low-resource settings, is well known [18], the reality is that investment in the delivery of surgical care is still low in these settings. Worldwide, 3.7 billion people are at risk of financial catastrophe if they need surgery, and 33 million experience CHE needs annually from medical costs and 81 million from medical and non-medical costs after access to surgical care [10]. Most of these cases are in LMICs, with the lower-income population groups being most affected in any country. An estimated 1.7 billion children and adolescents worldwide did not have access to surgical care in 2017, and 453 million children younger than 5 years did not have access to basic lifesaving surgical care [19]. There is little information on CHE for children requiring surgical care and from surgery for infections. Providing information on the latter would help to advance global advocacy for investments in prevention and control of surgical infections.

Although African Union countries were mandated by the Abuja Declaration on Health to commit at least 15% of their national budgets to healthcare [20], in 2020, Nigeria earmarked only 4.03% of its budget for healthcare [21]. This clearly has implications for investment in and scaling up of surgical care.

The 2018 Nigeria Demographic and Health Survey (NDHS 2018) revealed that 97% of Nigerians do not use health insurance to access healthcare [22]. There is a strong correlation between the level of OOPs and financial risk protection from catastrophic and impoverishing expenditure while accessing healthcare [23].

Catastrophic expenditure from healthcare is an expenditure of more than 40% of income remaining after subsistence needs have been met [7], or more than 40% of non-food household expenditure [8], or 10% of overall household expenditure or income on accessing healthcare OOP [9]. Where data on household expenditure or income are not available, 10% of GDP per capita is used [10]. The most current GDP per capita estimate for Nigeria by the World Bank was in 2018, and it was estimated to be $2,028.18 [16]. Spending more than $202.82 on healthcare would be a catastrophic expenditure. It is estimated that about 150 million people globally are at risk of CHE from medical costs, with an increase if non-medical costs related to accessing care are added [10].

The medical costs of treating typhoid intestinal perforation in children in Nigeria are substantial considering a population where half are multi-dimensionally poor [3] and only about 3% use health insurance [6]. Of note is that most of the current health insurance policies being used do not offer comprehensive coverage for the management of major surgical conditions, resulting in OOP expenditure even for those with “health insurance.”

Out-of-pocket costs often are barriers to healthcare when it is needed. The prevalent late presentation noted in the present report may not be unrelated to the financial implications of seeking care, which is a significant factor contributing to delay in care and is invariably associated with worse outcomes [24].

The risks of catastrophic and impoverishing expenditure are two of the Lancet Commission on Global Surgery core indicators, with targets of 100% risk protection by 2030 [25]. In the present report, the average total surgery cost was $452 (range $236–$1,700), implying that all children were at risk of CHE from total medical costs of treating typhoid intestinal perforation. More profoundly revealing is the average cost of surgery of $286 (range $208–$1,250), resulting in a CHE of 100% from the cost of surgery alone. This may imply a tendency toward impoverishing expenditure by a similar percentage if non-medical costs, which usually are substantial, are added. A survey of family members of post-operative pediatric surgical patients in Uganda showed that although pediatric surgical services formally are provided free by the public sector, 16% of families incurred CHE from direct costs, and this rate rose to 27% when indirect cost was included [26].

In Rwanda, however, the risk of catastrophic expenditure from medical costs for treatment of peritonitis in adults and children was 13.5%, and this rose to 30%–78% when non-medical costs were considered [27]. A factor that increased protection against catastrophic expenditure in Rwanda was the use of community-based health insurance (CBHI). At the moment, health insurance does not play much role in financial risk protection against CHE in Nigeria because of the limited coverage of the population. The risk of CHE for uninsured patients in the United States undergoing emergency surgery was 71.4% [28]. In Malawi, where OOP expenditure for essential surgery is high, and the income lost from admission for surgery often exceeds patients' direct OOP expenditure; 94% of district hospital patients and 87% of central hospital patients were found to experience CHE while accessing essential surgical care [29]. Seeking healthcare at a publicly funded hospital was financially catastrophic for almost half of the adult and pediatric patients in Uganda [30]. In India, CHE after hospitalization for injuries was 22.2%, with 12.2% slipping below the poverty line [31].

The development of the Nigeria NSOANP [15] (which is focused on strategies to achieve the LCOGs indicator targets) with commencement of implementation clearly is a step in the right direction. The findings in the present report emphasize the critical state of surgical care nationally and the enormity of the task required to achieve the 2030 LCOGs indicator targets. The provision of needed high-quality care at low cost to patients and the system should remain the goal [25]. A comparison of the cost of bed and surgery at the present hospital (a tertiary health center) and general/district hospitals within and around the city showed a significant disparity in cost, with the surgery fee at the general/district hospital being less than 50% of the cost and bed fee, about 14% of the cost at the National Hospital. Typhoid intestinal perforation and typhoid are common in Nigeria, and LMICs and clearly are public health problems. The high rate of CHE from surgical care for typhoid perforation in this report is an indication that investments are required to prevent and control, as well as to treat, surgical infections in this setting. Half of the patients in this report were referred from district/general hospitals, where the cost of care is much lower, because of the lack of capacity to provide emergency and essential surgical care for children. Scaling up the capacity at these hospitals could mitigate the risk of CHE for many families. Laparotomy (for children), one of the bellwether procedures, needs to be provided; and basic skills and techniques for source control for intra-abdominal infections would be helpful. This is one of the implementation pathways that has been described for the NSOAP.

Children's surgical care should be an integral component of NSOAPs to ensure that emergency and essential surgical care can be provided for them at district hospitals, particularly given the high proportion of children in LMICs.

Conclusion

Surgery for infections can produce overwhelming CHE, and efforts need to be made to expand the capacity for such care at district/general hospitals. Advocacy needs to be intensified to invest in prevention and control of surgical infections in LMICs. The current state of healthcare financing, the financial burden of surgical care on patients, and ultimately the implications for timeliness in seeking care and the outcomes of surgical care fall far below acceptable standards. Well-designed policies, strategies, and interventions to reduce and eliminate the need for OOPs, especially for emergency surgical conditions, will help guide a change in the situation. For countries that already have surgical plans, a commitment to and commencement of implementation is urgently needed. Development of surgical plans by those who do not already have them will be a step in the right direction.

Limitation of the Study

The lack of adequate information on actual income and socioeconomic status of families made it difficult to highlight the actual impact.

Footnotes

Funding Information

No funding was received.

Author Disclosure Statement

No competing financial interests exist.

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