• Users Online: 748
  • Print this page
  • Email this page

Table of Contents
Year : 2019  |  Volume : 24  |  Issue : 2  |  Page : 89-94

Second-phase delay in accessing major elective surgeries from a public tertiary health institution in Nigeria: The role of financial constraints

1 Department of Surgery, College of Medicine, University of Nigeria Ituku-Ozalla, Enugu, Nigeria; Department of Health Administration and Management, Faculty of Health Sciences, University of Nigeria Enugu Campus, Enugu, Nigeria
2 Department of Surgery, College of Medicine, University of Nigeria Ituku-Ozalla, Enugu, Nigeria

Date of Web Publication18-Nov-2019

Correspondence Address:
Dr. Ikenna I Nnabugwu
Department of Surgery, College of Medicine, University of Nigeria, Ozalla Campus, Ituku PMB 01129, Enugu.
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijmh.IJMH_16_19

Rights and Permissions

Background: Many factors contribute to second-phase delay in accessing surgical care electively especially in low-income settings. The aim of this study was to evaluate second-phase delay in elective surgical care in a tertiary hospital. Materials and Methods: This study is a hospital-based cross-sectional survey conducted at a tertiary health institution in Nigeria from February to September 2017. Sampling units were households that accessed major elective surgical operation from the general surgery and urology units of the institution for an adult member (≥18 years of age) of the household. Analysis was performed using the Statistical Package for Social Sciences software version 20.0 (IBM SPSS Inc, Chicago, USA). Results: In total, 495 households representing same number of patients participated in the study. Second-phase interval was within one month in 16.2% of households. It was delayed 2–6 months in 55.2% of households, 6–12 months in 16.2% of households, and more than 12 months in 12.5% of households. Financial constraint was reported as reason for the observed second-phase interval in 54.7% of households with 93.4% of these households delayed for longer than one month and 38.0% for more than six months. Financial constraint was significantly more prevalent among larger households (OR 7.64; 95%CI 1.89–30.78; P < 0.01) and households in the lower wealth quartiles (OR 0.73; 95%CI 0.55–0.97; P = 0.03). Few households (7.1%) accessed health insurance for the prescribed major surgery and only 8.6% of those insured households reported financial constraints. Conclusion: Longer second-phase delay attributable to financial constraints is prevalent among larger households comprising mostly children, households in the lower socioeconomic quartiles, and uninsured households.

Keywords: Delay, elective-surgery, financial constraints, households

How to cite this article:
Nnabugwu II, Ugwumba FO, Ede JK. Second-phase delay in accessing major elective surgeries from a public tertiary health institution in Nigeria: The role of financial constraints. Int J Med Health Dev 2019;24:89-94

How to cite this URL:
Nnabugwu II, Ugwumba FO, Ede JK. Second-phase delay in accessing major elective surgeries from a public tertiary health institution in Nigeria: The role of financial constraints. Int J Med Health Dev [serial online] 2019 [cited 2023 Jun 6];24:89-94. Available from: https://www.ijmhdev.com/text.asp?2019/24/2/89/271083

  Introduction Top

Access to needed quality surgical care and anesthesia is an important component of universal health coverage (UHC).[1],[2],[3] The poor health indices prevalent especially in many low- and medium-income countries (LMICs)[4],[5] underpin the need to improve on access as well as on other key indicators of quality surgical and anesthetic care in these countries as recommended by Global Surgery 2030.[3] However, physical, social, and financial themes are recognized aspects to access barriers to surgical care.[6] The contribution of each of these varies during different phases of health-seeking commencing from the decision to seek medical assistance to the successful use of recommended care.[7]

Unlike the 1994 description of three delays by Thaddeus and Maine[7] working in west Africa, Kong et al.[8] analyzing a rural setting in South Africa identified two phases of delay as “behavioral delay” phase and “assessment delay” phase representing intervals from symptom(s) to presentation to health-care facility, and from presentation to effective therapy, respectively. Similar to Kong et al.,[8] Samad et al.[9] in Pakistan described “first interval” and “second interval” delays, respectively. Although the first interval delay in surgical care is attributable to factors such as proximity of health-care facility, perceived quality and cost of surgical care obtainable, cultural belief and value system, as well as some household socioeconomic characteristics, the second interval delay is contributed to the availability of appropriate mix of human and material resources available in the health-care facility.[10]

Having been informed that major surgical operation is to be undertaken electively as the most appropriate approach to treatment, a patient (or household) is faced with some challenges: giving an informed consent;[11],[12] identifying acceptable mechanisms of payment for the cost of the recommended surgical procedure especially in the absence of recognized social security on health or in the presence of significant user fees;[13] and choosing an appropriate date with due consultations with the surgical care unit.[14] These factors contribute variously to the interval from recommendation of elective surgery to actual access of the recommended surgery.[15]

Although the issue of surgeon’s long-waiting list is prevalent in advanced health systems with robust social security on health,[16],[17],[18],[19] a different scenario may be obtainable in less-advanced health systems with poorly developed health insurance such as Nigeria. The mix of poverty, low literacy level, culture, and value system obtainable in southeast Nigeria interacts with the hospital-related factors to influence second-phase delays in accessing elective surgical procedures.

The aim of this study, therefore, was to assess, from the households’ perspective, the contribution of household socioeconomic factors and hospital-related factors to second-phase delays in our low-income, low-literacy health-care setting with poorly-developed health insurance.

  Materials and Methods Top

This study is an interviewer-administered questionnaire-based cross-sectional survey of households accessing major surgical care from a tertiary health institution in Nigeria. The survey was conducted from February to September 2017. All households that accessed major elective surgical operation from the general surgery and urology units of the institution for an adult member (≥18years of age) of the household were eligible to participate. Second-phase interval is defined as the interval between the recommendation and the actual access of the surgical procedure. An interval greater than 1 month is taken as delayed. The institution’s Bioethics Committee approved of the study. Written informed consent to participate in the study was obtained from each participating household after the nature of the study was duly explained.

The questionnaire was classified into three sections: the first section dwelt on household characteristics, whereas the second section captured household durable assets and living conditions patterned after the Harmonized Nigerian Living Standard Survey 2009/10: core welfare indicator questionnaire survey 2009 (part A) (National Bureau of Statistics www.nigerianstat.gov.ng). The third section determined, from the household’s perspective, the time interval from recommendation of surgery to effective access of the recommended surgery as well as the reasons for this interval.

Data from the second section were used to construct household socioeconomic quartiles through principal component analysis. Ordinal regression was used to analyze the factors that significantly impact on second-phase delay, whereas binary regression was used to determine the factors that significantly relate to financial constraints as reason for the delay in accessing recommended surgery. The Statistical Package for Social Sciences software version 20.0 was used for data analysis.

  Results Top

Within the period, 495 households representing the same number of patients participated in the study. The sociodemographic features of the study participants are shown in [Table 1].
Table 1: Frequency distribution of sociodemographic features of study participants (n = 495)

Click here to view

From the household’s perspective, the second-phase duration was within one month in only 16.2% of households. It was delayed 2–6 months in 55.2% of households, 7–12 months in 16.2% of households, and longer than 12 months in 12.5% of households. [Table 2] gives further detail on the spread of the second-phase durations across wealth indices, payment mechanisms, and reasons for the reported second-phase delay.
Table 2: Frequency distribution of second-phase intervals according to socioeconomic status quartiles, mechanism of payment for recommended surgery, and reasons proffered by households for the observed time interval

Click here to view

The result of subsequent multivariate regression analysis of the association between various household features and the dependent variable “second-phase duration” is shown in [Table 3].
Table 3: Ordinal logistic regression analysis of the relationship between household characteristics and second-phase interval from household perspective

Click here to view

Analysis of variables associated with financial constraints as household’s reason for second-phase duration longer than one month was carried out using logistic regression. The result is shown in [Table 4].
Table 4: Ordinal logistic regression analysis of household characteristics associated with financial constraints as reason for delay in accessing elective surgical procedure

Click here to view

  Discussion Top

Households experience various durations of delay in accessing recommended major elective surgical care; the reasons for which vary from health system to health system.[20] Irrespective of the reasons for delay, it is an objective of UHC to significantly reduce access barriers to quality health-care (inclusive of surgical care) by 2030.[3],[21]

Toward achieving this UHC objective, an understanding of the factors contributing to delay in accessing recommended surgical care within specific health systems is required. If the poor health indices generated by the Nigerian health system[22] are to be addressed, attention must be given to identifying the factors that relate to access barriers to surgical care.[23] It is very important that these factors are viewed from the perspective of the consumers of the services as well. From this study, only 83.8% of the households were unable to access needed surgical care within one month of their recommendation. In Pakistan, Samad et al.[9] reported that 61.8% of patients experienced delays in accessing recommended surgical care, whereas in Vietnam, Swanson et al.[24] observed that 52.0% of cleft patients experienced delays in accessing surgical repair. When there is delay in accessing prescribed surgery for a diagnosed health challenge, anxiety is bound to worsen,[19] thereby increasing the burden of the health challenge on patient and household. Majority of the respondents in this study may have suffered such fate.

Hospital-related factors may contribute predominantly to second-phase delay.[10] However, beyond hospital-related factors, other contributing factors to second-phase delay to surgical care can be within the domains of failure to obtain informed consent from the patient,[25] financial constraints in the absence of a robust social security on health,[26],[27] and physical access barriers.[19] Although Bickley et al.[28] in Tanzania reported the failure of consent as the most prevalent reason for access barriers among patients with trichiasis surgery, our study reveals financial constraints as the most prevalent reason for the reported second-phase interval [Table 1]. However, delayed informed consent and hospital-related factors contribute significantly to the observed second-phase delay as well [Table 2]. A good proportion of the respondents in this study acquired formal education beyond the primary level, a scenario that may facilitate obtaining informed consent resulting instead in financial constraints being more prevalent as access barrier.

A number of household characteristics are significantly associated with financial constraints as reason for the reported second-phase delay. Analysis reveals that households in the higher wealth indices significantly reported less second-phase delay attributable to financial constraints (OR 0.73; 95%CI 0.55–0.97; P = 0.03; [Table 4]). This relationship is understandable in a health system with significant direct out-of-pocket payment for health-care products and services.[29],[30] Households with less capacity to pay at the point of accessing surgical care reportedly had longer delays in accessing recommended surgical care. This unacceptable inequity can only be remedied through a robust health insurance system.

Larger households tend to have longer delays (OR 7.64; 95%CI 1.89–30.78; P < 0.01) attributable to financial constraints. This is especially so where the large family size is contributed to mostly by children as a greater number of adults within households are associated with shorter delays (OR 0.04; 95%CI 0.01–0.22; P < 0.001). This may be because larger households have limited household capacity to pay and therefore are more prone to hardship financing of such major surgical care.[30] Although a greater number of household members are adults that can partly fend for themselves and partly support the household common purse in times of need, the financial burden of purchasing surgical care is less because of such existing high social capital.

Only 8.6% of households accessing major surgical care electively using the Nigerian National Health Insurance Scheme payment mechanism reported financial constraints as reason for second-phase interval beyond one month [Table 2], and none beyond six months. This finding suggests good impact of the Nigerian National Health Insurance Scheme on households, although the associated indirect costs still pose some access barrier.[29],[31] To this regard, extra financial support to these households may help alleviate the financial burden, thereby improving access to needed surgical care as has been noted elsewhere.[32]

Female-headed households did not report financial constraints more frequently than male-headed households (P = 0.875), thus supporting report elsewhere that female-headed households may not be more prone to catastrophic health expenditure.[33] Similarly, households with heads that acquired higher formal education did not report financial constraints less frequently (P = 0.305), thus supporting quite unlike reports that households with minimal formal education have higher risk of financial catastrophe with health-care expenditure.[34]

Insofar as delay in accessing recommended surgical care can be associated with stress, anxiety, and frustration.[19] In addition to indulging in some unwholesome health practices,[35] there is the need to eliminate delay completely or get it reduced to the minimum. This study has revealed that delay in accessing recommended elective major surgical care is prevalent in our setting, and is significantly contributed to household financial constraints, by delay in giving treatment consent, and by hospital-related factors. Households within lower wealth indices and households with greater number of members tend to have longer delays attributable to financial constraints.

In conclusion, in our low socioeconomic setting and, from the households’ perspective, second-phase delay is prevalent. Financial constraint is the most prevalent reason for such delays. Larger households comprising mostly children and households in lower wealth indices reported financial constraints more frequently. The few households that accessed health insurance showed evidence of some financial risk protection.

  Recommendations Top

It is recommended that more efforts be made to increase the coverage of the National Health Insurance Scheme. This singular factor shows capacity to counter the contributory effects of lower household socioeconomic status, delay in obtaining consent, and poor formal education on second-phase delay in accessing major elective surgeries. Further studies are needed to support this finding that financial risk protection in accessing major elective surgeries is the key to reducing delay to a minimum.

  Limitations Top

Information recall in this study is subject to recall bias.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Price R, Makasa E, Hollands M. World health assembly resolution WHA68.15: “Strengthening emergency and essential surgical care and anesthesia as a component of universal health coverage”—addressing the public health gaps arising from lack of safe, affordable and accessible surgical and anesthetic services. World J Surg 2015;39:2115-25.  Back to cited text no. 1
Ahmed F, Michelen S, Massoud R, Kaafarani H. Are the SDGS leaving safer surgical systems behind? Int J Surg 2016;36: 74-5.  Back to cited text no. 2
Cooper MG, Wake PB, Morriss WW, Cargill PD, McDougall RJ. Global safe anaesthesia and surgery initiatives: Implications for anaesthesia in the pacific region. Anaesth Intensive Care 2016;44:420-4.  Back to cited text no. 3
Bruneel L, Luyten A, Bettens K, D’haeseleer E, Dhondt C, Hodges A, et al. Delayed primary palatal closure in resource-poor countries: Speech results in ugandan older children and young adults with cleft (lip and) palate. J Commun Disord 2017;69:1-14.  Back to cited text no. 4
Vanderpuye V, Grover S, Hammad N, Pooja P, Simonds H, Olopade F, et al. An update on the management of breast cancer in Africa. Infect Agent Cancer 2017;12:13.  Back to cited text no. 5
Shrime MG, Sekidde S, Linden A, Cohen JL, Weinstein MC, Salomon JA. Sustainable development in surgery: The health, poverty, and equity impacts of charitable surgery in uganda. PLos One 2016;11:e0168867.  Back to cited text no. 6
Thaddeus S, Maine D. Too far to walk: Maternal mortality in context. Soc Sci Med 1994;38:1091-110.  Back to cited text no. 7
Kong VY, Aldous C, Clarke DL. Understanding the reasons for delay to definitive surgical care of patients with acute appendicitis in rural South Africa. S Afr J Surg 2014;52:2-5.  Back to cited text no. 8
Samad L, Jawed F, Sajun SZ, Arshad MH, Baig-Ansari N. Barriers to accessing surgical care: A cross-sectional survey conducted at a tertiary care hospital in Karachi, Pakistan. World J Surg 2013;37:2313-21.  Back to cited text no. 9
Tansley G, Stewart BT, Gyedu A, Boakye G, Lewis D, Hoogerboord M, et al. The correlation between poverty and access to essential surgical care in Ghana: A geospatial analysis. World J Surg 2017;41:639-43.  Back to cited text no. 10
Eyesan SU, Obalum DC, Nnodu OE, Abdulkareem FB, Ladejobi AO. Challenges in the diagnosis and management of musculoskeletal tumours in Nigeria. Int Orthop 2009;33:211-3.  Back to cited text no. 11
Peeters GK, Ribera JM, Erhart A, Hoibak S, Ravinetto RM, Gryseels C, et al. Doctors and vampires in sub-Saharan Africa: Ethical challenges in clinical trial research. Am J Trop Med Hyg 2014;91:213-5.  Back to cited text no. 12
Shrime MG, Verguet S, Johansson KA, Desalegn D, Jamison DT, Kruk ME. Task-sharing or public finance for the expansion of surgical access in rural Ethiopia: An extended cost-effectiveness analysis. Health Policy Plan 2016;31:706-16.  Back to cited text no. 13
Sobolev BG, Sanchez V, Kuramoto L, Levy AR, Schechter M, Fitzgerald JM. Evaluation of booking systems for elective surgery using simulation experiments. Healthc Policy 2008;3:113-24.  Back to cited text no. 14
Caesar U, Karlsson J, Olsson LE, Samuelsson K, Hansson-Olofsson E. Incidence and root causes of cancellations for elective orthopaedic procedures: A single center experience of 17,625 consecutive cases. Patient Saf Surg 2014;8:24.  Back to cited text no. 15
Epari KP, Mukhtar AS, Fletcher DR, Samarasam I, Semmens JB. The outcome of patients on the cholecystectomy waiting list in Western Australia 1999-2005. ANZ J Surg 2010;80:703-9.  Back to cited text no. 16
Howell GP, Richardson D, Forester A, Sibson J, Ryan JM, Morgans BT. Long distance travel for routine elective surgery: Questionnaire survey of patients’ attitudes. Bmj 1990;300:1171-3.  Back to cited text no. 17
Ballini L, Negro A, Maltoni S, Vignatelli L, Flodgren G, Simera I, et al. Interventions to reduce waiting times for elective procedures. Cochrane Database Syst Rev 2015;23:CD005610.  Back to cited text no. 18
Gregory DM, Temple NJ, Twells LK. Patients’ perceptions of waiting for bariatric surgery: A qualitative study. Int J Equity Health 2013;12:86.  Back to cited text no. 19
Grimes CE, Bowman KG, Dodgion CM, Lavy CB. Systematic review of barriers to surgical care in low-income and middle-income countries. World J Surg 2011;35:941-50.  Back to cited text no. 20
Haider A, Scott JW, Gause CD, Meheš M, Hsiung G, Prelvukaj A, et al. Erratum to: Development of a unifying target and consensus indicators for global surgical systems strengthening: Proposed by the global alliance for surgery, obstetric, trauma, and anaesthesia care (the G4 alliance). World J Surg 2017;41:2423-5.  Back to cited text no. 21
Odeyemi IA, Nixon J. Assessing equity in health care through the national health insurance schemes of Nigeria and Ghana: A review-based comparative analysis. Int J Equity Health 2013;12:9.  Back to cited text no. 22
Awowole IO, Badejoko OO, Kuti O, Ijarotimi OA, Sowemimo OO, Ogunduyile IE. Maternal mortality in the last triennium of the millennium development goal era at the Obafemi Awolowo University Teaching Hospitals Complex Ile-Ife, Nigeria. J Obstet Gynaecol 2018;38:189-93.  Back to cited text no. 23
Swanson JW, Yao CA, Auslander A, Wipfli H, Nguyen TH, Hatcher K, et al. Patient barriers to accessing surgical cleft care in Vietnam: A multi-site, cross-sectional outcomes study. World J Surg 2017;41:1435-46.  Back to cited text no. 24
Bhattacharyya S, Issac A, Rajbangshi P, Srivastava A, Avan BI. “Neither we are satisfied nor they”––users and provider’s perspective: A qualitative study of maternity care in secondary level public health facilities, Uttar Pradesh, India. BMC Health Serv Res 2015;15:421.  Back to cited text no. 25
Robb JL, Clapson BJ. The unfunded costs incurred by patients accessing plastic surgical care in northern Saskatchewan. Plast Surg (Oakv) 2014;22:88-90.  Back to cited text no. 26
Ibrahim N, Pozo-Martin F, Gilbert C. Direct non-medical costs double the total direct costs to patients undergoing cataract surgery in Zamfara state, northern Nigeria: a case series. BMC Health Serv Res 2015;15:163.  Back to cited text no. 27
Bickley RJ, Mkocha H, Munoz B, West S. Identifying patient perceived barriers to trichiasis surgery in Kongwa district, Tanzania. Plos Negl Trop Dis 2017;11:e0005211.  Back to cited text no. 28
Etiaba E, Onwujekwe O, Torpey K, Uzochukwu B, Chiegil R. What is the economic burden of subsidized HIV/AIDS treatment services on patients in Nigeria and is this burden catastrophic to households? PLoS One 2016;11:e0167117.  Back to cited text no. 29
Zhou C, Long Q, Chen J, Xiang L, Li Q, Tang S, et al. Factors that determine catastrophic expenditure for tuberculosis care: A patient survey in china. Infect Dis Poverty 2016;5:6.  Back to cited text no. 30
Melese M, Alemayehu W, Friedlander E, Courtright P. Indirect costs associated with accessing eye care services as a barrier to service use in Ethiopia. Trop Med Int Health 2004;9:426-31.  Back to cited text no. 31
Fiander AN, Vanneste T. TransportMYpatient: An initiative to overcome the barrier of transport costs for patients accessing treatment for obstetric fistulae and cleft lip in Tanzania. Trop Doct 2012;42:77-9.  Back to cited text no. 32
Adisa O. Erratum to: Investigating determinants of catastrophic health spending among poorly insured elderly households in urban Nigeria. Int J Equity Health 2015;14:79.  Back to cited text no. 33
Fazaeli AA, Ghaderi H, Abbas Fazaeli A, Lotfi F, Salehi M, Mehrara M. Main determinants of catastrophic health expenditures: a Bayesian logit approach on Iranian household survey data (2010). Glob J Health Sci 2015;7:335-40.  Back to cited text no. 34
Alfonso NY, Alonge O, Hogue DME, Baset KU, Hyder AA, Bishai D. Care-seeking patterns and direct economic burden of injuries in Bangladesh. Int J Environ Res Public Health 2017;14:E472.  Back to cited text no. 35


  [Table 1], [Table 2], [Table 3], [Table 4]

This article has been cited by
1 Financing of surgery and anaesthesia in sub-Saharan Africa: a scoping review
Martilord Ifeanyichi, Ellis Aune, Mark Shrime, Jakub Gajewski, Chiara Pittalis, John Kachimba, Eric Borgstein, Ruairi Brugha, Rob Baltussen, Leon Bijlmakers
BMJ Open. 2021; 11(10): e051617
[Pubmed] | [DOI]


    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

  In this article
Materials and Me...
Article Tables

 Article Access Statistics
    PDF Downloaded213    
    Comments [Add]    
    Cited by others 1    

Recommend this journal