Utilization of major surgery in South India

In an effort to bridge the information gap in utilization of major surgery in India, the George Institute for Global Health has audited hospital claims from the Rajiv Gandhi Aarogyasri Community Health Insurance Scheme (RACHIS) that provides access to free tertiary care for major surgery through state funded insurance to 68 million beneficiaries with limited household incomes, 81% of population in states of Telangana and Andhra Pradesh. 

Publicly available de-identified hospital claim data for all surgical procedures conducted between mid-2008 and mid-2012 were compiled across all 23 districts in Telangana and Andhra Pradesh. Beneficiary households receive an annual coverage of INR 200,000[US$3333] for admissions to any empanelled public or private hospital.

The findings reveal that even when free or subsidised access to surgery is made available by the state, allied costs make utilisation difficult. A poster detailing the findings  was presented at the launch of the Lancet Global Commission on Surgery on Monday. 

A total of 677,332 surgical admissions (80% at private hospitals) were recorded at a mean annual rate of 259 /100,000 beneficiaries, excluding cataract and caesarean sections. Males accounted for 56 per cent of the admissions. Injury was the most common cause for surgical admission (27%) with surgical correction of long bone fractures being the most common procedure (18%) identified in the audit. 

Diseases of digestive (16%), genitourinary (12%), and musculoskeletal system (10%) were other leading causes for surgical admissions. Most hospital bed-days were utilized for injuries (31%), diseases of digestive (17%), and musculoskeletal system (11%) costing 19%, 12%, and 11% of claims. Cardiovascular surgeries (8%) alone accounted for 21% of cost. Annual per capita cost of surgical claims was US$1•49.

“It came as a surprise to us that despite universal access, the uptake of surgery was still at the level of a low-income country,” said Dr.  Vivekanand Jha, Executive Director, The George Institute for Global Health, India. 

“Just making a scheme available doesn’t automatically mean utilization will happen. There are a number of factors preventing uptake, including that the scheme only covers the cost of the surgery, while there are a number of steps before the stage of surgery that are not trivial in terms of their implication on cost, and the person needing to be away from his or her livelihood. They might live in remote areas, or other family members might be prioritised,” Dr. Jha said.

 The findings suggest in economically poor populations, even with near universal access for major surgery, utilization continues to remain low, and at levels expected in countries with per capita health expenditure below US$100, and lower than a tenth of rates estimated at spending levels comparable to financial access provided [US$400-1000]. Hence, strategies beyond traditional financing for care are required to improve utilization of surgery in LMICs.

This even as the Lancet reported today that five billion people globally do not have access to safe, affordable surgery and anaesthesia when they need them.

A third of all deaths in 2010 — nearly 17 million lives lost in all — was from conditions treatable with surgery, such as appendicitis, fractures and childbirth complications, the researchers found.

The Global Surgery 2030 Commission, published in The Lancet medical journal and released early on Monday, was written by 25 experts in surgery and anaesthesia, with contributions from more than 110 countries, including India.

Even among those who are able to access surgery, its costs often lead to financial ruin, the commission said. A quarter of people worldwide who have a surgical procedure incur costs that they cannot afford, pushing them into poverty.

Cost then becomes a significant barrier. Using data from the nationally representative Million Death Study, researchers found that postal code areas with high incidence of acute abdominal mortality in India were more likely to be located further from a hospital capable of providing appropriate emergency surgical care than areas with low mortality. The odds only grew with distance from the hospital.

“In the absence of surgical care, common, easily treatable illnesses become fatal,” said Andy Leather, Director of the King’s Centre for Global Health, King’s College London, and one of the commission’s lead authors.

Scale-up of levels of access to surgery will need investment, the commission’s authors said.

“Although the scale-up costs are large, the costs of inaction are higher and will accumulate progressively with delay,” The commission’s lead author, John Meara, Kletjian Professor in Global Surgery at Harvard Medical School and Associate Professor of Surgery at Boston Children’s Hospital, USA, said.

“Scale-up of surgical and anaesthesia care should be viewed as a highly cost-effective investment, rather than a cost,” he said.