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Surgeons’ Out of Pocket Expenditure Dr Aruyaru Blog Post 26

Surgeons’ Out of Pocket Expenditure

When you hear ‘Out of Pocket Expenditure’ for surgery, what goes through your mind? Probably a patient paying to get surgery. 

How about a surgeon paying to do surgery? This was the rude but pleasant shock I was met with when I sat through a laparoscopy workshop in Kiambu County last month. Surgeons from mostly non-metropolitan areas of Kenya gathered to share their insights gained in pushing for adoption of keyhole surgery (laparoscopy) in rural Kenya. 

Surgeons’ Out of Pocket Expenditure Dr Aruyaru Blog Post Section Images laparoscopy 3 700x350

It sounds correct to call these kinds of talks ‘the last mile’ but we are far from even the last 100 miles of access to laparoscopy. Because, all these efforts happening at county referral hospitals and regional faith based facilities. Prior research has shown that only 2 out of every 10 sub-county hospitals in Kenya (where the real last mile surgery access can happen) have a surgeon. The gist of the workshop talks was to focus on what we call gasless laparoscopy-where a special device is utilized to lift the abdominal wall and create space for surgeons to work in the belly. This is contrary to conventional laparoscopy practice of blowing carbon dioxide into the abdominal cavity to distend the abdominal wall and afford the surgeon a working space. 

Surgeons’ Out of Pocket Expenditure Scheme gasless laparoscopy with the help of LAPAROLIFT
FIG: Scheme gasless laparoscopy with the help of LAPAROLIFT

But the talks slowly drifted to the access to laparoscopic surgery in the far (and not so far) flung facilities. Surgeon after surgeon took to the podium and shared their experiences: changing an entrenched culture, training staff using their own resources, paying salaried staff some allowance to assist in laparoscopy, teaming up and moving across hospitals and counties doing the specialized surgical procedures at their own cost, sometimes during off hours…name it.

Defaulted Loan

One knife bearer spoke of how he got a loan to procure the expensive laparoscopy machines and instruments. He would then package all these machine parts in transport boxes and fold the back row seats in his hatch back and use it as transport. The gadgets would be assembled in the theatre and once the cases were over, dismantled gently packaged again for the next trip. He would team up with colleagues and move from hospital to hospital to perform keyhole surgeries, often timing their theatre lists to coincide with the shifts when the nurses they had trained were on duty, otherwise he would have to occasionally cough out some stipend for the valued assistants. Everyone in the conference room excitedly held their breath. It was a moving story. Then there was a plot twist. With a dwindling economy, he colleague defaulted on his loan repayments and the creditor confiscated the equipment. It was back to square zero! For him. For the two counties unknowingly depending on him. For the hundreds of needy patients that had been lined up to benefit.

Surgeons’ Out of Pocket Expenditure Dr Aruyaru Blog Post Section Images laparoscopy 2 700x350

All other colleagues who spoke struck a similar cord. Of going out of their way to support and fund a scope of surgery that is an accepted standard elsewhere but a fledgling starter in the global south. 

The global south countries continue to lag behind their global north peers in terms of wealth, technology, politics and demography; so say the experts. Often, healthcare will be purchased out of pocket. Out of pocket expenditure is another development yardstick economists and health policy experts use, combining it with the all familiar phrases “impoverishing health expenditure” and “catastrophic health expenditure” to tell us how badly we are doing in terms of access to health. 

It so seems the same terms can be applied to surgeons purchasing healthcare for their patients. And at a time when the public may have unkind words for doctors, I have the deepest appreciation and admiration for my colleagues going this extra mile. It cannot be in vain. 

“Listening to Madaraka and Stanley felt like going through a therapy session,” another surgeon stated as he took the microphone and started his presentation.

It was a moment of group therapy. People were sharing hitherto personal afflictions and troubles, thinking they were the only ones going through this. Unknowingly, they had opened the floodgates of ventilation. The workshop had moved from a scientific intercourse to a group therapy session. 

MANing Up

My wife who is in business development refers to an acronym she uses to profile her prospective clients-MAN. She asks herself whether the person has Money (to make true the desire by purchasing the product), Authority (to make the sale happen by allocating funds and the necessary directive) and Need (the only way to start off is by meeting a customer’s need-the quintessential intrinsic motivation). This acronym helps her triage (sorry, I used a medical term) her clients and dispense with gate keepers (without authority), mere unqualified leads (without need) and ‘not now’ (without money) kinds of clients before qualifying them. For her, a qualified lead must MAN up- have the need for the product, the money to purchase it and the authority to allocate that money to the product being sold. 

I have previously spoken on the dearth of surgical specialists in rural Kenya, going by the Lancet Commission that puts the Kenyan surgical and anesthesia care providers at 2.3 (against the global target of 20) per 100,000 population. The need is there. I hope a person with MAN gets to read this. Actually, we just need one with MA, we have already established the existence of the Need. Please share this with anyone you know who can MAN up to support the procurement of more surgical equipment for our hospitals. Surgeons have been trying but they are deficient of vitamin M, which exposes them to ‘impoverishing health expenditure’.

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About the Author

Dr. Stanley Aruyaru

Dr. Aruyaru is a Consultant General and Laparoscopic Surgeon and a Healthcare Manager. He has solid experience in managing busy surgical units and leading clinical teams to deliver in the lines of quality health provision and evidence based surgical practice.

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