Introduction

Pakistan is a South Asian lower-middle-income country with an ethnically diverse population of over 220 million [1]. It has one of the most decentralized healthcare systems in the world, with nearly all of the decision-making being done on the provincial level [2]. Current governmental healthcare expenditure stands at only 1.5% of the Gross Domestic Product [3]. Surgical care is considered to be a specialized service that is complex and expensive and hence has been largely omitted from health agendas and initiatives in lower and middle-income countries (LMICs) [1, 4, 5]. Pakistan is not an exception to this rule despite modeled estimates of 187 deaths per 100 000 people per year from acute surgical conditions.

Pakistan is a vast [1], geographically diverse country with underdeveloped transportation infrastructure. This situation leads to significant challenges in access to health facilities since the few tertiary care facilities providing the bulk of surgical services are located in large urban centers. Travel times to access care can therefore be very long, resulting in compromised surgical care, especially in rural and distant parts of the country. In order to allow for the development of health policies and programs that address this reality, a thorough understanding of access challenges faced by patients is necessary.

Compounding the difficulties in geographical access, costs related to surgical care can pose insurmountable barriers to patients in Pakistan. In the absence of adequate financing and insurance schemes, surgery can impose severe financial hardship on patients and their households. Impoverishing Health Expenditure (IHE) and Catastrophic Health Expenditure (CHE) are measures quantifying the financial burden put on people when seeking care in a certain country or region [6]. Current literature has looked predominantly into the relationship between IHE/CHE and surgery in sub-Saharan Africa, showing that poor patients are at very high risk of experiencing CHE or IHE when seeking surgical care. Data from Asia is largely absent in literature [7], and this remains an area that needs to be studied beyond the African continent.

The Lancet Commission on Global Surgery recommended six core indicators to measure the accessibility, availability and safety of surgical care, including indicators looking into 2-hour access and financial risk protection as measured by CHE and IHE [4]. Robust and nationally representative data on surgical care, including the aforementioned surgical indicator data was unavailable for Pakistan. The importance of systematic data on surgical care to understanding the true state of surgical services has been emphasized by the Lancet Commission as an essential step in understanding and subsequently addressing gaps in surgical care delivery [4]. This study aims to assess access to and utilization of surgical care, as well as impoverishing and catastrophic health expenditure (IHE and CHE, respectively) as a result of seeking surgical care at public tertiary care hospitals in each province of Pakistan.

Methods

Results

Discussion

This is the first systematic national survey to document access and financial protection indicators for surgical patients in Pakistan. We found that a substantial number of patients face long travel times to access essential care, and a high percentage of patients experience IHE and CHE during this process.

The most common surgical procedure in our patients was C-section, and this number was limited by our cap of any single procedure not exceeding 50% of the patients interviewed. Our non-C-section patients were predominantly male, low-educated, poor, and between the ages of 18–45 years, which is reflective of the segment of the Pakistani population reliant on public sector hospitals for care. This demographic also aligns fairly well with data from neighboring countries [18]. However it should be noted that direct comparisons are difficult because of different settings, time frames in which data was collected, and different inclusion and exclusion criteria between studies [18, 19]. The gender disparity in accessing surgical care is a source of concern. Similar to our findings, previous studies from Pakistan have demonstrated a male preponderance in patients presenting with acute abdomen injuries [18, 19]. An Indian [20] and Afghan [21] cohort had a male predominance (58% in both studies) in patients with acute abdomen presenting to tertiary care facilities. This gender disparity is more marked in our cohort, where 70% of all patients who underwent a laparotomy were male. A study from rural Northern Pakistan showed that the prevalence of acute abdomen increased with the age of the patient [18, 19]. In contrast, our patient cohort was predominantly in the 18–45 years category.

These comparisons between the demographics of surgical patients indicate that the findings of our study are not unique to the Pakistani setting. Further research is needed to explore whether the male predisposition for acute abdomen and the stark differences in age at presentation with an acute abdomen is due to biological differences or due to certain segments of the population (e.g., women and the elderly) facing additional hindrances in the ability to access care.

A well-known way to assess different delays faced by patients seeking care is the three-delays model. The first delay is due to the time taken by patients or their family members to decide to seek appropriate care; the second delay happens when seeking transportation and trying to physically access a facility; while the third delay occurs when patients have reached an appropriate facility but are required to wait to receive the necessary care [22]. Our study and others [19] show that Pakistanis face any combination of these delays when seeking care. This is reflected in the access indicator in our study, where 26% of patients reported a travel time of more than 2 hours to reach the healthcare facility.

Studies from Afghanistan [21] and India [20] showed similar results of delays experienced before reaching a hospital with adequate surgical facilities. In the Indian study, two out of three patients only reached a medical facility with the capacity to treat an acute abdomen more than 24 hours after symptom onset. Predominantly because patients tended to seek care closer to home from facilities, providers were unable to identify the true extent of the disease or because services weren’t available [20]. Similarly, a 2002 study from rural Northern Pakistan showed that a majority of patients sought initial care close to home before eventually reaching the first level or specialized hospital, with eventually only 13% of patients accessing the necessary surgical care [18]. A study from Karachi mapped the geographical origins of patients who sought care at a tertiary hospital with an acute abdomen [23]. The results showed that 30% of the patients in their cohort came from outside of the city, some as far as Kashmir and KP. The researchers summarized that this is due to a lack of adequate surgical care closer to home, understaffing of surgeons at public hospitals, and the high out-of-pocket expenses incurred at private hospitals. Our study recorded an even higher number of patients (50%) seeking care from outside the city where the tertiary hospital is located. Such delays in accessing care are inevitably linked with increased morbidity and mortality on the one hand, and increased financial burden on the other [24]. It also affects efficiency at the tertiary care hospitals that receive a high volume of less complicated cases that could well be managed at first-level facilities closer to home [25, 26, 27]. Resources that should be used for specialized care services, research, and education are thus diverted to essential care provision. Facing multiple types of delays and having to seek care at different types of health facilities before being able to receive adequate care seems to be a critical challenge across the region that needs to be addressed systematically.

CHE affects poor people everywhere in the world and is not an issue unique to LMICs [28]. Certain factors predispose populations to be more affected by CHE. These factors include: lack of social security, including universal health coverage, availability of advanced medical services requiring out-of-pocket payment, and pre-existing poverty or inability to pay [28, 29]. Pakistan’s health care system provides a perfect mix of these factors [30, 31], explaining the high rates of CHE and IHE we identified in our cohort. For example, medicines, supplies, and laboratory tests are often not available at public sector hospitals and need to be paid for by the patient’s family as an out-of-pocket expenditure [30]. The unavailability of consumables and services in the public sector is not unique to Pakistan: inefficient supply chain processes and poor healthcare governance is well documented in many low-and-middle-income countries [23]. A large portion of direct expenditures consists of non-medical expenses, such as transportation and accommodation, which are inevitably higher when patients must travel long distances and spend prolonged time away from home. Unsurprisingly, this results in a significant proportion of non-poor patients becoming newly impoverished, as evidenced by our data.

Shrime and colleagues used economic modeling to determine the specific risk of CHE when seeking surgical care and found that countries in sub-Saharan Africa and South Asia were at greatest risk [6]. This is in stark contrast with the risk of CHE for all health conditions which is more evenly spread around the globe [28]. These results seem to indicate that, as compared to other types of medical care, surgical care has not been integrated into social security and health insurance packages. Additionally, based on multi-country comparisons, two factors have been identified to be responsible for driving the risk of CHE in case of surgery upwards: reliance of the health care system on outside funding and a smaller percentage of the GDP dedicated to health [6]. Pakistan is known to spend a notoriously low percentage of its GDP on health, about 1.5%, which is well below the World Health Organization’s (WHO) recommended minimum of 5% and significantly less than other LMICs [3]. For Pakistan specifically, authors have estimated that 75.2% of the Pakistani population was at risk of CHE if immediate surgery was needed, with this percentage ranging from 46.2% to 96.2% among the richest and poorest quintiles respectively [6]. Our results are well aligned with these estimations for Pakistan: we found a slightly higher overall risk of CHE at 79% for the cohort and a markedly high 85% risk of CHE for patients in need of fracture repair. It is important to note that while previous estimates for the financial impact of surgery in Pakistan were mainly based on modeling techniques, our study is the first to quantify financial impact based on primary, nationwide data.

Much less data is available in literature about the risk of IHE after seeking surgical care. A study from Sierra Leone found that people from the lowest and second lowest income quintile have a risk of 85% and 75% respectively of experiencing IHE after a C-section, compared to only a 10% risk of IHE in the highest income quintile. Additionally, this study found that uneducated people and people with lower incomes spend more on transport, food and accommodation when seeking care compared to the richer quintiles, inevitably leading to a higher risk of IHE. In our cohort, 34% of women were newly impoverished and 68% of women experienced IHE and were living under the poverty line after their C-section [32]. These numbers suggest that public tertiary hospitals in Pakistan cater for patients of the lower income quintiles, but most likely the poorest of the poor do not make it to tertiary hospitals and seek care elsewhere at a hospital or clinic closer to home, or not at all. A focus on strengthening surgical services at the first level could improve access significantly.

Several limitations are present in the design and conduct of this study. First, only patients who received surgical care were included in the survey. Patients who never sought care or who were unable to receive a procedure were not included. Second, the survey only captures costs before and during the operative period. All costs incurred post-operatively or for long-term care or rehabilitation were not assessed. Consequently, our results may be an underestimate of the financial burden of surgical care in Pakistan. Only patients seeking care at a public tertiary care hospital were included in this study, which limits the generalizability of our results to the entire population since a majority of Pakistanis access care in the private sector. We believe more accurate assessments of surgical systems are only possible by integrating relevant questions in the large-scale household survey conducted by local and international organizations.

Despite the limitations, this study provides valuable baseline data to health policymakers for reform efforts that are underway. Strengthening surgical infrastructure and services at the existing network of public sector first-level facilities have the potential to dramatically improve emergency and essential surgical care across the country. Availability of care closer to home would improve accessibility for high-burden procedures and minimize delays, and at the same time reduce the financial burden of transportation outside of urban areas. Pakistan is the first country in South Asia to embark on a national surgical system strengthening effort. The government launched the National Vision for Surgical Care 2020–25 in July 2021, with concrete plans to implement an Essential Package of Health Services, which has a strong component of surgical care. These are vital steps towards universal health coverage, of which surgical care is an integral component, to increase access and decrease the risk of CHE for patients when seeking surgical care in Pakistan. We believe that this study can serve as a blueprint for further studies in the region, and beyond and can serve as guidance for further research. The impact of the planned Universal Health Coverage (UHC) package on the accessibility and affordability of surgical care in Pakistan will have to be further explored, evaluated, and, if necessary, further addressed through policy changes. The inevitable dynamic between local beliefs, culture, and health- seeking behavior for surgical care deserves further attention as well, and will be necessary to understand better if we want to truly provide access to care for every Pakistani by 2030. Last but not least, understanding how patients interact with the health care system before reaching a facility is paramount to better understanding the needs and gaps at the secondary level.

Additional File

The additional file for this article can be found as follows: