One Crisis Away From Poverty

In Somaliland, paying for an emergency such as pediatric surgery can push a family deep into poverty. But reducing out-of-pocket expenses by even as much as 30 percent would provide a safety net for only the richest families in the young African nation, according to a new study published in the British Medical Journal.

“This study shows there needs to be more than just giving money or financial protection to the country,” says Emily Smith, an epidemiologist and an assistant professor of surgery and global health at Duke who led the research. “It’s about implementing country level measures to reduce poverty. That’s the story of this paper: they need more than individual handouts.”

Smith says she was surprised by the findings and initially expected reducing out-of-pocket expenses by even 10 percent would help poor families.

Instead, researchers say a broad combination of financial supports is needed to alleviate financial burdens for families in the country, including universal health coverage, vouchers for those in need and increased funding from organizations such as the United Nations and the World Health Organization.

“If health is a human right, and health is defined as more than just the absence of disease, it’s a moral obligation to give preferential option to the poor,” Smith says.

Half of Somaliland’s 4 million residents are children under 16. Pediatric surgeries are common to correct genetic anomalies such as hydrocephalus and gastroschisis or to treat bone fractures and burns.

As is the case in many low-income countries, families in Somaliland typically pay for the surgery itself. In addition, families pay for other out-of-pocket costs associated with surgery such as medications, transportation to and from the hospital and even food, Smith says. Families sometimes sell property or livestock or borrow money to pay for surgeries. Others put off care or don’t seek it at all.

The travel and time required to seek care can also be a barrier. While the country is mostly rural, hospitals tend to be in urban areas. Families can wait hours or even days for children to be seen, says Tessa Concepcion MS’18, a co-author on the study who helped train data collectors in Somaliland in 2017 .

Concepcion supports more external funding to help families, but warns against “thoughtless donations” or funding that doesn’t go directly to the need.”

“It’s important to remove the number of strings attached to funding and for us to trust countries and systems to do what’s best for them,” she says. “Systems know their gaps in care better than any funder. Our role should be to support that, fill training gaps and be behind-the-scenes.”

Smith says poverty leaves no margin of error for families to handle unexpected expenses such as surgery. She points to funding structures such as the International Cancer Care Research Excellence Foundation (iCCARE) as one possible model for Somaliland. The organization was co-founded by Kristin Schroeder, M.D., an assistant professor of pediatrics and global health at DGHI. iCCARE helps families with the cost of medications and chemotherapy administration for pediatric cancer patients at Bugando Medical Centre in Mwanza, Tanzania. In 2019, the hospital reported the rate of families abandoning treatment dropped from 50 percent to 30 percent.

One of Smith’s inspirations for working in Somaliland is Edna Adan Ismail, a nurse-midwife and Somaliland’s first female foreign minister. They met in 2016 at a conference on global children’s surgery. When Smith asked how she could help in the country, Ismail pointed to gaps in pediatric surgical care.

“We have to start with the poorest of the poor and work our way up,” Smith says. “I don’t think we need more wealth, we need it to be distributed equitably. A rising tide lifts all boats. I hope we can do something about it and not just talk about it.”