Financial Impact of Transportation Costs for Ugandan Pediatric Colorectal Patients

Pediatric colorectal conditions cause significant morbidity and financial strain in low- and middle-income countries, but little is known regarding catastrophic health expenditure (CHE) for pediatric surgical management in sub-Saharan Africa. We examined the familial financial impact of travel expenses for pediatric colorectal disease in Uganda.

Patients with ostomies who are awaiting elective surgery in southwestern Uganda were enrolled. Caregivers completed surveys on income, assets, and travel expenses. Group comparisons were analyzed.

One-hundred ten patients consisting of 78 males (71%) and 32 females (29%) were enrolled. Most had anorectal malformations (n = 59, 54%) followed by Hirschsprung's disease (n = 22, 20%) and were otherwise healthy (n = 96, 87%). Caregivers were mostly young mothers (n = 86, 78%) of median age 29 years, who worked as farmers (n = 69, 63%), and 65% (n = 72) had less than a secondary education. Median monthly household income was 300,000 UGX ($78). Families took a median of four trips to the hospital, traveled a median one-way distance of 200 km, and spent a median of 79,000 UGX ($20) on transportation. Based on transportation costs alone, 28% (n = 30) of households experienced CHE. All families were uninsured; most relied on savings (n = 79, 72%) or financial support from nongovernmental organizations (n = 31, 28%). Risk of CHE increased as monthly income decreased (p < 0.001). Lower income households (< 150K UGX; < 38) were at particular risk of CHE, with 73% (n = 14) spending more than 10% of their income on transportation expenses.

At least 28% of colorectal patients in our study experienced CHE from transportation costs alone. Much of this transportation was repeated trips to the hospital in unsuccessful attempts to obtain surgical care. Accounting for other out-of-pocket expenses and additional surgeries not included outside of the study period, it is likely that the rate of CHE is higher. In the future, a care coordination program to minimize wasted travel may reduce CHE.