Background: Catastrophic health expenditure (CHE) and impoverishing health expenditure (IHE) are significant barriers to surgical care. Worldwide, 3.7 billion people risk financial catastrophe if they require surgery, mostly affecting the poorest populations in LMICs. Surgical CHE and IHE are not described in the South African context. The objectives of this study were: 1) to determine the proportion of surgical participants at New Somerset Hospital (NSH) ), a second-level public sector South African hospital, who experienced CHE and IHE and 2) to determine the risk factors associated with out-of-pocket (OOP) payments. Methods: This study used a cross-sectional retrospective questionnaire administered to participants admitted to any department of surgery (obstetrics, gynaecology, general surgery, urology, otorhinolaryngology, or orthopaedics) for a surgical procedure at NSH. Direct healthcare expenditure for the surgical admission was defined to be catastrophic according to three definitions: 1) OOP payments 10% or more of annual household expenditure (HHE) (CHE10); 2) OOP payments 25% or more of annual HHE (CHE25); 3) OOP payments 40% or more of capacity to pay (CHE40). IHE was based on the national poverty lines and was defined according to new impoverishment or worsening impoverishment, as a result of OOP expenditure on the surgical admission. Multivariate regression analysis was used to assess the relationship between OOP payments and per capita HHE, age, type of procedure, department to which participant was admitted, distance from NSH, and length of stay. Results: Out of the 274 participants interviewed: 263 were included in the analysis (4% attrition rate). Two (0.8%), five (1.9%), and three (1.1%) participants experienced CHE according to the CHE40, CHE10, and CHE25 definitions, respectively. About 98.5% of participants spent less than 10% of their annual HHE, while 95.4% spent less than 10% of their annual non-food expenditure OOP. Median OOP expenditure was R100 (IQR R15 – R350). About 23% of the participants (n=62) were not charged for their surgical admission. Low per capita HHE (p=0.02), cancer (p=0.001), having a non-generous health insurance plan (p=0.002), and the hospital bill amount (p<0.001) correlated positively with OOP expenditure on healthcare. Linear regression revealed that there was no correlation between the proportion of OOP payments and LOS or distance. One in five patients (n=50, 19%) experienced new or worsening impoverishment and were pushed below the poverty line for receiving surgical care at a public hospital. Furthermore, 65 (25%) patients reported their household was unable to cope or household still recovering from the financial burden of the surgical admission. Discussion: Surgical CHE was not common among this study population, however IHE was substantial and the majority of participants incurred OOP for surgical care, with the main drivers of OOP costs being the hospital bill and transport. Financial catastrophe might have been low because: 1) most participants were protected by the uniform patient fee schedule and therefore did not incur a medical bill and 2) direct non-medical costs did not account for a significant proportion of OOP payments. Understanding the financial impacts of OOP health care expenditure is essential in the planning of the impending National Health Insurance in South Africa.

A global surgical rotation program has been developed at La Loma Luz Adventist Hospital in San Ignacio, Belize, by the Department of Surgery at East Tennessee State University in 2014. It encompasses a one-month rotation for surgery residents to travel to Belize, accompanied by a senior surgical attending, to participate in direct patient care. Residents are able to operate under supervision and practice both perioperative and medical management. Practitioners often collaborate with permanent facility surgeons and internists in order to assist with cases, discuss different practice strategies, and, ultimately, tailor patient care. In addition to providing residents with surgical experience, this rotation aims to advance the overall standard of medical care available to the community. Additional aims include healthcare promotion and education of patients. While this rotation was developed to provide residents surgical experience in an underserved country, we hope that it will further cultivate volunteerism and foster future participation.

Background Surgery has traditionally been considered more expensive than many other health care interventions and with little impact on the burden of disease in a global perspective. One of the reasons behind this misconception is that the effects of surgical conditions and their treatment have not been factored into the equation. Cost-effectiveness analyses of surgical interventions have largely been missing. An estimated 20 million herniorrhaphies are carried out annually but over 200 million people suffer from groin hernias. Herniorrhaphy is one of the most commonly performed surgical procedures also in Low and Middle Income Countries (LMIC). However, the surgical repair method is not the same due to financial constraints. In high income countries a synthetic mesh is used and has reduced the risk of recurrence. This 125 USD mesh is too costly for the majority in LMIC. Mosquito mesh, which is cheaper but very similar to commercial meshes, is used in several settings but outcomes need to be investigated more extensively before this practice can be recommended in routine surgical service. The Aims of this thesis were to define the prevalence of groin hernia, to relate it to the surgical capacity, outcomes and costs of surgery in eastern Uganda and to investigate the feasibility and difference in cost and cost-effectiveness of replacing a commercial mesh with a mosquito mesh in groin hernia surgery. Methods Three studies (1-3) were carried out in eastern Uganda. 1: A cross sectional study investigating the prevalence of groin hernia in adult males in the Health and Demographic Surveillance Site (HDSS) in Iganga and Mayuge districts. 2: A facility based study with prospective data collection of all surgeries undertaken in the two hospitals providing surgery for the HDSS population. 3: A double blinded, randomised controlled trial comparing the outcomes of using a mosquito mesh relative using a commercial mesh in groin hernia surgery. Results 1: the prevalence of untreated groin hernia among the study participants was 6.6%. 2: the rate of groin hernia surgery was 17 per 100 000 population. Thus, less than 1% of the estimated number of cases of groin hernia in the catchment area of the two hospitals are operated per year. A herniorrhaphy costs around 60 USD to perform. This corresponds to a third of the cost of TB treatment and a 15th of the cost of HIV/AIDS treatment per year in Uganda. 3: No significant differences in terms of recurrence rates, post operative and chronic complications and patient satisfaction were demonstrated between the patients operated using the mosquito mesh and the commercial mesh. Cost-effectiveness was very high for both materials but total cost in the mosquito mesh group was 124 USD lower per surgery than in the commercial mesh group. Conclusion There is a vast unmet need for groin hernia surgery. Cost of surgery compares favourably with other health care interventions prioritised by the international organisations and funders. A superior technique can be used in groin hernia surgery at low cost, with high cost-effectiveness in a Low Income Country.

Global surgery describes the systematic way to reduce health disparities and realize accessibility and sustainability in surgical care. Nearly five billion individuals lack access to adequate and necessary surgical and peri-surgical care. The contemporary model of global surgery is that of short-term surgical trips, which have origins in European and North American colonialism. The current state of global surgery in the surgical subspecialty of otolaryngology and head & neck surgery (OHNS) care fails to meet an adequate ethical threshold based on traditional bioethical principles. In order to improve the system of global OHNS care to promote sustainability and long-term impact, global OHNS care needs to shift away from providing direct clinical care. This work presents an ethical framework composed of four primary domains—(1) preparation and understanding the local context, (2) education, (3) partnership and exchange, (4) research and evaluation. This model can be used to shephard a future with stronger ethical global OHNS care. / Urban Bioethics