Catastrophic health expenditure associated to bellwether surgery care in Northcentral Ethiopia

Bellwether procedures-caesarean section, laparotomy, and open fracture management- are core indicators for monitoring safe, equitable, and affordable surgical care in a country. Although effective surgical care is essential for achieving universal health coverage and the Sustainable Development Goals, spending on surgical care leading catastrophic health expenditure among surgical patients, particularly low-income and middle-income countries (LMICs). This study assesses catastrophic health expenditure (CHE) associated with bellwether surgery to quantify financial risk and inform future equitable health financing reforms.

A prospective institutional-based observational cohort study was conducted at Debre Tabor Specialized Hospital, South Gondar. Using systematic random sampling, 425 patients undergoing bellwether procedures were enrolled. Catastrophic expenditures assessed with the validated Financial Risk Protection tool developed by the Harvard Program in Global Surgery and Social Change. Categorical variables were compared using χ² tests, while continuous data were evaluated for normality with the Shapiro-Wilk test and histograms. Means (± SD) and medians (± IQR) were reported accordingly. Bivariable and multivariable binary logistic regression identified predictors, with adjusted odds ratios (95% CI); p < 0.05 to declare statistical significance.

A total of 425 patients undergoing bellwether procedures were included, representing all woredas and city administrations of South Gondar, Northwest Ethiopia. The median age was 36 years (IQR 24-52), and the majority were classified as ASA I/II. Emergency laparotomy accounted for the largest proportion of procedures (55.8%). Within the three-delay framework, the median duration of Delay 1 (care-seeking) was 12.0 h (IQR 6-24). The overall postoperative complication rate was 21.3%, while in-hospital mortality was 0.9%. At the 10% threshold, catastrophic health expenditure (CHE) was observed in 76.0% of households lacking community-based insurance or free health initiatives. CHE at this threshold was significantly associated with referral delay (Delay 2; adjusted odds ratio [AOR] 1.06, 95% CI 1.01-1.10 per hour), emergency bone fixation (AOR 22.9, 95% CI 7.4-70.4), and emergency laparotomy (AOR 3.3, 95% CI 1.6-6.9).

Approximately two-thirds of patients undergoing bellwether surgery experienced catastrophic health expenditure, declined to one-third among those enrolled in community-based or family health insurance. Catastrophic health expenditure was greatest with delayed presentation, rural residence, long travel distance, and prolonged hospital stay. Expanding insurance coverage, improving access, and integrating surgical services into primary health care are essential to achieve safe, timely, and affordable surgery in line with global targets.