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Catastrophic expenditure and impoverishment after caesarean section in Sierra Leone: An evaluation of the free health care initiative

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Alex J. van Duinen, Josien Westendorp, Thomas Ashley, Lars Hagander, Hampus Holmer, Alimamy P. Koroma, Andrew J.M. Leather, Mark G. Shrime, Arne Wibe, Håkon A. Bolkan

Original languageEnglish
Article numbere0258532
JournalPLoS ONE
Issue number10
PublishedOct 2021

Bibliographical note

Funding Information: This study was funded by the Liaison Committee between the Central Norway Regional Health Authority and the Norwegian University of Science and Technology 2015/18873 (, together with the Laerdal Foundation grant 40313 ( MGS receives funding from the Damon Runyon Cancer Research Foundation ( and Mercy Ships ( for work unrelated to the present paper. HH is funded by the Swedish Research Council ( and the Swedish Society of Medicine ( AL is supported by the National Institute of Health Research (NIHR) Global Health Research Unit on Health System Strengthening in sub-Saharan Africa, King's College London (GHRU 16/136/54) ( The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. We thank all the women who took part in the study, as well as all anaesthesia teams, associate clinicians and medical doctors in the participating hospitals. We also thank Abu Bakarr Dumbuya, Abdul Rahman Moijue, Musa Sumah and Mohammed S Bah who travelled all over Sierra Leone to collect data, Katarzyna G?siorek for data entry and Matthew Quaife and Kees Kostermans for their input in the manuscript. Publisher Copyright: © 2021 van Duinen et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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Background Utilizing surgical services, including caesarean sections, can result in catastrophic expenditure and impoverishment. In 2010, Sierra Leone introduced the Free Health Care Initiative (FHCI), a national financial risk protection program for the most vulnerable groups. Aim of this study was to investigate catastrophic expenditure and impoverishment related to caesarean section in Sierra Leone and evaluate the impact of the FHCI. Methods Women who delivered by caesarean section in nine hospitals were followed up with home visits one month after surgery, and data on medical and non-medical expenditures were collected. Individual income was estimated based on household characteristics and used to determine catastrophic expenditure and impoverishment for each patient. The impact of the FHCI was assessed by comparing actual expenditure with counterfactual expenditures had the initiative not existed. Results For the 1146 patients in the study, the median expenditure was 23 (IQR 4; 56) international dollars (Int$). Patients in the poorest quintile spent a median Int$ 59 (IQR 28; 76), which was significantly more than patients in the richest quintile, who spent a median Int$ 17 (IQR 2; 38, p<0.001). Travel (32.9%) and food (28.7%) were the two largest expenses. Catastrophic expenditure was encountered by 12.0% and 4.0% (10% and 25% threshold, respectively) of the women. Without the FHCI, 66.1% and 28.8% of the women would have encountered catastrophic expenditure. Conclusion Many women in Sierra Leone face catastrophic expenditure related to caesarean section, mainly through food and travel expenses, and the poor are disproportionally affected. The FHCI is effective in reducing the risk of catastrophic expenditure related to caesarean section, but many patients are still exposed to financial hardship, suggesting that additional support is needed for Sierra Leone's poorest patients.

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