Costs, Effectiveness, and Cost-Effectiveness of Selected Surgical Procedures and Platforms

This volume has shown that universal provision of a package of essential surgical services would avert an estimated 1.5 million deaths per year, or 6–7 percent of all avertable deaths in LMICs (Debas and others 2006; Mock and others 2015). Although approximately 234 million surgeries are performed worldwide each year, the distribution is very inequitable (Funk and others 2010). Nearly two billion people live in areas with a density of less than one operating room per 100,000 population (Funk and others 2010); in high-income countries (HICs), the density is 14 per 100,000. With this scarcity of surgical services in low- and middle-income countries (LMICs), the need for scaling up is imperative. Challenges to the implementation of surgical services in resource-limited environments are substantial and include limited human resources, transportation systems, and access to electricity and water (Hsia and others 2012; Kruk and others 2010). Moreover, evidence on the different attributes of scaling up is insufficient. Scaling up requires increasing the share of current income devoted to spending on health, as well as major investments in facilities and human resources. Priority interventions in LMICs are those that are cost-effective and reasonable in cost; is defined relative to the prevalence of the condition and size of the government health budget. Feasibility is important, particularly in low-income countries (LICs), which lack many health systems resources. Some deficiencies can be remedied if cost and cost-effectiveness considerations identify additional investments that provide good value. For example, purchasing more radiotherapy equipment or training additional personnel may make a substantial difference. Other deficiencies are harder to remedy. LMICs typically have limited ability to manage resources, which restricts how referral or organized screening systems work. In this chapter, we discuss evidence showing that some types of surgery can be both highly cost-effective—saving lives or improving the quality of life—and affordable. We focus on a set of surgical interventions that can be undertaken at first-level hospitals, or in some cases, in clinics or mobile facilities. These interventions include selected emergency surgeries, surgeries associated with reproductive functions, and nonemergency surgeries. We do not cover other types of surgery that also may be cost-effective and even modest in cost but that are more suited to referral hospitals in LMICs, namely, surgery for cardiovascular disease, cancer, organ transplantation, and neurosurgery. Surgical interventions for cardiovascular disease, such as left main coronary artery bypass graft surgery and percutaneous transluminal coronary angioplasty, have been very cost-effective in certain population groups in HICs, compared with medical management (Tengs and others 1995); this outcome is likely to apply to some population groups in LMICs. Basic surgical interventions for cancer treatment are likely to be cost-effective and, in some cases, feasible at the first-level hospital, for example, oophorectomy, simple hysterectomy, radical mastectomy, and colectomy. Very few cost-effectiveness results are available on these interventions, surveyed in Horton and Gauvreau (2015) and not discussed further here. Kidney transplants, although relatively costly, may be cost-effective (Tengs and others 1995). We do not cover neurosurgery, such as surgery to treat epilepsy or to treat infant hydrocephalus, although Warf and others (2011) show that such surgeries can be cost-effective in Sub-Saharan Africa. Cost-effectiveness of reproductive surgery is considered in volume 2, (Black and others forthcoming). Dental surgery is not covered because of a lack of studies using quality-adjusted life year (QALY), disability-adjusted life year (DALY), life year saved (LYS), and death-averted outcome measures. The set of conditions covered in the chapter is listed in annex 18A and includes interventions discussed in other chapters in this volume; chapter 1 provides a more comprehensive list of the detailed procedures considered. These are surgery types that can feasibly be undertaken at first-level hospitals, although they may also be undertaken at second-level hospitals, often when urgent cases arrive at these emergency units. Some can be undertaken in specialized facilities, for example, a cataract hospital, a specialized mobile facility, a short-term surgical mission focused on specific surgical conditions, or a trauma center. We briefly summarize the literature on the cost-effectiveness of different ways of organizing facilities for surgery. Equity and affordability are important considerations when prioritizing care. We review both of these issues before discussing data limitations and presenting conclusions. This chapter uses World Health Organization (WHO) geographical regions: Africa, the Americas, South-East Asia, Europe, Eastern Mediterranean, and Western Pacific.