Catastrophic Health Expenditure Among Gastrointestinal Cancer Patients Undergoing Surgery in Uganda: A Prospective Study

ABSTRACT Background The global burden of gastrointestinal (GI) cancers is projected to rise by 2050, with incidence and mortality in Africa nearly double global estimates. Surgery remains the cornerstone of treatment but imposes substantial financial burdens. In Uganda, where no national health insurance scheme exists, patients are especially vulnerable. We therefore investigated the magnitude of catastrophic health expenditure (CHE) among GI cancer patients undergoing surgery in public hospitals. Methods A prospective study was conducted over 10 months in the GI surgery wards of a tertiary hospital, with ethics approval. Adults with GI cancer scheduled for surgery were consecutively recruited. Sociodemographic, clinical, and household expenditure data were collected at baseline and discharge. Out-of-pocket (OOP) costs, annual household expenditure, non-food expenditure, and capacity to pay were derived. CHE was assessed using Wagstaff/van Doorslaer and Xu thresholds and determinants of CHE assessed. Results 164 participants were recruited, 54.3% were male and 75.0% aged above 50 years. The median out-of-pocket (OOP) expenditure for GI cancer surgery was USD 663, nearly twice the median annual household income. At the 10% threshold, the prevalence of CHE was 64%. Sources of financing for OOP varied by socioeconomic status (SES): households in the highest SES relied primarily on savings, whereas those in the lowest SES depended on asset sales and loans. School fees payment was disrupted, particularly among middle- and low-SES households. Factors independently associated with higher CHE included female sex, formal employment, curative intent of surgery, and low household SES. Conclusion Over half of patients experienced financial toxicity, often selling assets and compromising long-term security. The burden was greatest among poorer households, women, and those undergoing curative surgery. Findings highlight the urgent need for national health insurance in Uganda. Although recall bias may have influenced reporting, critical gaps in financial protection for cancer surgery patients are evident. Summary Box What is already known about this topic Gastrointestinal cancers are rising in incidence across Africa yet treatment of GI cancers is costly due to the multimodal treatment approaches. GI cancer treatment and surgery lead to catastrophic health expenditures even in high income countries. What this study adds This study evaluates surgery as a key management modality for gastrointestinal cancers and quantifies the catastrophic health expenditure associated with it, found to be 64% . It identifies risk factors for CHE in this context, emphasizing the vulnerability of households undergoing surgical cancer care. It highlights differences in sources of health care financing across socioeconomic strata, revealing inequities in how households mobilize funds. It highlights basic needs that are negatively affected by the shortage of resources such as education, and reveals a high likelihood of future financial hardship due to the impact of crowding out effect on income generating activities. How might this impact on clinical practice? Surgery remains one of the most cost-effective and potentially curative modalities for gastrointestinal cancers, these findings stress the urgent need for financial risk protection strategies in Uganda. National cancer plans should prioritise procurement of specialised surgical equipment and safe guard vulnerable individuals especially females and financially deprived who stand to benefit from curative surgery.