Published in PLOS One on 2026-02-06, this study is presented as an attributed evidence briefing. The excerpts below are the original researchers’ words, reproduced under their Creative Commons Attribution licence. Health Signal has selected the abstract and, where needed, opening background paragraphs; the complete methods, results, limitations and references remain in the linked paper.
Original authors: Yohannes Hailemichael, Tigist Eshetu, Sewit Timothewos, Andualem Deneke, Amezene Tadesse, Ahmed Abdella, Abebe Bekele, Andrew Leather, Girmay Medhin, Martin Prince, Charlotte Hanlon
Source: PLOS One • DOI 10.1371/journal.pone.0294215
Read the complete primary study ↗ · Creative Commons Attribution licence
From the researchers
Abstract
The objective of this study was to assess the household costs, catastrophic out-of-pocket (OOP) health expenditure, impoverishment and coping mechanisms used to pay for surgical care in a predominantly rural area of Ethiopia.
We conducted a community-based, cross-sectional household survey of 182 people who had undergone a surgical procedure. Participants were interviewed in their homes at six weeks post-operation. Using a contextually adapted version of the Study of global AGEing and adult health (SAGE) questionnaire, we estimated direct and indirect costs of surgical care from a household perspective. Catastrophic out-of-pocket (OOP) health expenditure was estimated using thresholds of 10% and 25% of annual household consumption expenditure. Impacts of surgical care payments on poverty levels was estimated by comparing pre- and post-operative OOP payments. Analysis of variance, t-test and a logit model were used to assess factors associated with catastrophic OOP health expenditure.
Most surgical patients were women (87.9%), with 65.0% receiving obstetric surgical care. Direct costs dominated expenditure: direct average medical costs Birr 1649.5 (44.6%), direct average non-medical costs Birr 1226.5 (33.2%), indirect average costs Birr 821.9 (22.2%). Catastrophic OOP surgical care expenditure was experienced by 69.2% households at the 10% threshold and 45.6% at the 25% threshold. The increase in average normalized poverty gap due to OOP surgical care expenditure was higher in non-obstetric (14.1%) compared to obstetric (5.8%) procedures, and for non-emergency (13.3%) compared to emergency care (6.3%). To pay for surgical care, 38.0% of households had sold assets and 5.0% had borrowed money.
Due to surgical care, households faced severe financial burdens leading to impoverishment. To mitigate the resulting financial constraints, households implemented hardship coping strategies. Provision of free obstetric surgical care reduced, but did not eliminate, these burdens. There is a pressing need to tailor financial risk protection mechanisms to achieve universal coverage for surgical care.
Background
In low-income and lower-middle-income countries, over nine out of ten people cannot access safe, timely and affordable surgical and anaesthesia care [1]. Key barriers include the direct and indirect costs related to surgical services [2,3]. Surgical conditions additionally can have a severe impact on the person’s day-to-day activities and result in a loss of income to the household, either in the form of wage losses from the patient or caregivers, or due to losses in agricultural output or other earnings. Shrime et al. (2016) reported that half of the world population, or 3.7 billion people (posterior credible interval: 3.2–4.2 billion), are at risk of catastrophic expenditure if they were to need surgery because they do not have financial risk protection [4]. Each year, an estimated 81 million people worldwide are driven to financial catastrophe due to the cost of surgery and its associated indirect costs, with the biggest burden borne by people in low- and middle-income countries (LMICs) [5]. In patients who underwent surgery at a government hospital in Uganda, 31% faced catastrophic expenditure [6]. In Malawi, 94% of district and 87% of central hospital patients experienced catastrophic expenditure for surgical care [7].
Reading this evidence
Use the full paper to check the study design, participant selection, comparator and outcome definitions before drawing a practical conclusion. An association does not by itself show cause and effect. A reported performance measure needs its denominator and uncertainty. A finding from a particular facility, sample or time period should retain that scope when it is discussed elsewhere.
This briefing makes the source accessible within the wider financing & policy desk. It does not assess an individual patient or certify a product. When considering relevance to another health system, examine the original authors’ account of context and limitations, then seek local implementation evidence. The related reporting below provides other studies to read alongside this one; it is a topic connection, rather than a claim that their results are directly comparable.
© 2026 Yohannes Hailemichael, Tigist Eshetu, Sewit Timothewos, Andualem Deneke, Amezene Tadesse, Ahmed Abdella, Abebe Bekele, Andrew Leather, Girmay Medhin, Martin Prince, Charlotte Hanlon. Excerpts reproduced under CC BY. Selection, formatting and contextual notes by Health Signal. The researchers are the authors of the source study, not members of Health Signal’s staff.
Explore connected evidence
- Evidence brief: Out-of-pocket payments and associated factors among hypertensive patients insured under the National Health Insurance Scheme in a referral hospital, Ghana
- Evidence brief: Urban-rural disparities in receipt of treatment for obstetric complications in Ethiopia: A multivariate decomposition analysis
- Evidence brief: Productivity losses and treatment cost of benign prostatic hyperplasia in Ghana
