Abstract
The perception of surgery as expensive and complex might be a barrier to its widespread acceptance in global health efforts. We did a systematic review and analysis of cost-effectiveness studies that assess surgical interventions in low-income and middle-income countries to help quantify the potential value of surgery. We searched Medline for all relevant articles published between Jan 1, 1996 and Jan 31, 2013, and searched the reference lists of retrieved articles. We converted all results to 2012 US$. We extracted cost-effectiveness ratios (CERs) and appraised economic assessments for their methodological quality using the 10-point Drummond checklist. Of the 584 identified studies, 26 met full inclusion criteria. Together, these studies gave 121 independent CERs in seven categories of surgical interventions. The median CER of circumcision ($13·78 per disability-adjusted life year [DALY]) was similar to that of standard vaccinations ($12·96-25·93 per DALY) and bednets for malaria prevention ($6·48-22·04 per DALY). Median CERs of cleft lip or palate repair ($47·74 per DALY), general surgery ($82·32 per DALY), hydrocephalus surgery ($108·74 per DALY), and ophthalmic surgery ($136 per DALY) were similar to that of the BCG vaccine ($51·86-220·39 per DALY). Median CERs of caesarean sections ($315·12 per DALY) and orthopaedic surgery ($381·15 per DALY) are more favourable than those of medical treatment for ischaemic heart disease ($500·41-706·54 per DALY) and HIV treatment with multidrug antiretroviral therapy ($453·74-648·20 per DALY). Our findings suggest that many essential surgical interventions are cost-effective or very cost-effective in resource-poor countries. Quantification of the economic value of surgery provides a strong argument for the expansion of global surgery's role in the global health movement. However, economic value should not be the only argument for resource allocation--other organisational, ethical, and political arguments can also be made for its inclusion.
Highlights
Global health efforts, guided in part by the Millennium Development Goals (MDGs),[1] have focused mainly on the prevention and treatment of malnutrition, obstetric disorders, and communicable diseases.[2]
Road-traffic injuries accounted for 75·5 million disabilityadjusted life-years (DALYs) in 2010, up nearly 20 million DALYs from 1990
Surgically treatable disease was estimated to account for at least 11% of the total global burden of disease,[4] which might be an underestimate because other studies have reported that about 25% of people in Sierra Leone need surgical assessment,[5] and as many as 85% of paediatric patients in Africa have a surgically treatable disorder by the age of 15 years.[6]
Summary
Global health efforts, guided in part by the Millennium Development Goals (MDGs),[1] have focused mainly on the prevention and treatment of malnutrition, obstetric disorders, and communicable diseases.[2] With the exception of a few surgical procedures—eg, caesarean delivery and male circumcision, which have a role in the prevention of maternal and neonatal deaths and the transmission of some communicable diseases—surgical interventions have been largely ignored. Findings from the Global Burden of Disease 2010 study show that the growing burden of both non-communicable diseases and injuries includes many surgically treatable problems.[3] For example, road-traffic injuries accounted for 75·5 million disabilityadjusted life-years (DALYs) in 2010, up nearly 20 million DALYs from 1990. Cancer has caused 76% more disability globally in the same timeframe. The substantial and growing burden of surgically treatable disease necessitates careful assessment of a wide range of surgical interventions to establish their priority within the expanding global health movement.[7]
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