Economic Analyses of Surgical Trips to the Developing World: Current Concepts and Future Strategies

Synopsis

The surgical burden of disease disproportionately affects individuals living in the developing world. In response, the surgical community has increased their efforts to provide care to patients in these countries during short-term surgical trips. In this article, the authors (1) summarize the current concepts used in the economic evaluation of surgical outreach and (2) present a conceptual model to describe the ideal approach to performing an economic analysis of surgical interventions in developing countries. This model may ensure that policy makers are provided with information to decrease cost and improve the access to specialty surgery in the developing world.

Introduction

Over 4.8 billion individuals lack access to basic surgical care worldwide, most of whom live in low- and middle-income countries (LMICs).¹ The lack of surgical care in LMICs is considered a neglected epidemic.² Prior to the 1990s, the majority of global outreach efforts focused on providing medical care for communicable diseases such as HIV/AIDS, malaria, and tuberculosis.³ Whereas approximately 3.83 million lives were lost in 2010 because of HIV/AIDS, malaria, and tuberculosis, a substantially greater number, 16.9 million lives, were lost because of insufficient surgical care in the same year.⁴ Despite the outdated notion that surgery is too complex to be performed in a low-resource setting, global surgical outreach is becoming progressively recognized as an imperative element of global health development.^2,5

Individuals with surgically amenable conditions face substantial economic challenges, because 21 trillion dollars will be lost in economic output as a result of the surgical burden of disease from 2015 to 2030.¹ This loss of economic output is attributed to the barriers in access, availability, affordability, and acceptability of surgical care in LMICs.⁶ For example, some individuals are unable to access appropriate surgical specialists for treatment, resulting in severe disability or even death. The Lancet Commission on Global Surgery was established in 2014 to help combat the direct and indirect consequences of the surgical burden of disease.⁷ The commission focuses on improving global healthcare delivery, education, economics, and management to address the gaps in safe and affordable surgical care.^1,8 The surgical community has since increased their outreach efforts to echo the mission of this organization.

Surgery in the developing world primarily consists of basic services for Caesarean sections laparotomies, trauma management, and pediatric surgery.⁹ Many of the conditions in LMICs require subspecialty surgical care. For instance, orthopaedic surgeons are needed to help treat individuals with deformations of the musculoskeletal system due to severe trauma.¹⁰ The surgical community uses a variety of ways to provide subspecialty surgical care to individuals living in LMICs, commonly through short-term surgical trips.¹¹ Evaluating the health and economic impacts of the surgical interventions performed during surgical outreach, using an assortment of analyses, is vital to the sustainability of these surgical outreach efforts.

Numerous economic analyses have been performed to evaluate the sustainability of particular surgical interventions in LMICs. Our objectives are to (1) summarize the current concepts used in the economic evaluation of surgical global outreach efforts and (2) identify potential areas of improvement that may lead to the advancement of such evaluations. Furthermore, the authors created a conceptual model to describe the ideal approach for economic analyses of surgical trips in LMICs.

Current Concepts

The World Health Assembly declared surgical care a priority initiative in 2015, requesting the “awareness of cost-effective [surgical] options be made more apparent.”¹² As a result, there have been extensive cost-effectiveness analyses examining the feasibility of specific surgical interventions in the fields of plastic surgery,^13–15 neurosurgery,¹⁶ pediatric surgery,¹⁷ and ophthalmology,^18–20 as well as other subspecialties.^21–23 Despite suggestions that surgery is too expensive to be performed in LMICs,²⁴ research has shown some surgical interventions in LMICs may be cost-effective.²⁵ The current model focuses on conducting cost-effectiveness analyses to determine which surgical interventions should be prioritized in a resource-limited environment to make the greatest impact (Figure 1).^26,27

Figure 1.

Current Concepts in Economic Analyses of Surgical Interventions in the Developing World.

Cost-effectiveness analyses assess the costs and related benefits of a health intervention.^28,29 Common metrics for cost-effectiveness analyses include cost per quality-adjusted life years (QALYs) or cost per disability-adjusted life years (DALYs), both of which take into account the costs and benefits of averting mortality and morbidity.³⁰ When examining the health benefits of a surgical intervention performed in LMICs, researchers usually report the cost-effectiveness in terms of cost per DALY-averted.^15,16,19,22 The cost per DALY-averted represents the cost, in monetary terms, required to avert one year of life that would otherwise be lost because of the morbidity and mortality of a particular surgical condition.^31,32

The World Health Organization developed CHOosing Interventions that are Cost-Effective (WHO-CHOICE) methods to standardize cost-effectiveness analyses on global health interventions. WHO-CHOICE methods have requirements on describing the overall study design, estimating costs, approximating health effects, and discounting costs.^33,34 Nolte et al. performed a systematic review of economic analyses of surgical trips to examine the adherence to this standardized criterion. The authors concluded that none of the cost-effectiveness analyses in this review adhered to the WHO-CHOICE methods.³⁵ If a standardized methodology is not used to report the findings of a cost-effectiveness analysis, then the implications of the investigations are questioned. Although some individuals have concluded that certain surgical interventions in the developing world are not cost-effective, it is not indicative that the intervention should be considered low priority or that that intervention should not be performed in a low resource setting. Rather, further, more detailed, analyses are needed to determine (1) how the surgery can become more cost-effective and (2) how monetary support for interventions performed in LMICs can continue.

Development of Economic Analyses

Economic analyses must be used in conjunction with one another to have meaningful effects on the development of global surgery. Table 1 provides a summary of the various economic analyses used to assess global health interventions. Figure 2 illustrates the ideal approach for economic analyses of surgical interventions in LMICs. If an intervention is not considered cost-effective, then further research is needed to determine potential drivers of cost variation. These predictors of cost variation can then be used to implement policy focused on reducing cost in that area of spending. Conversely, if an intervention is not considered cost-effective and no cost variation is identified, then prioritization decisions must be made.

Table 1.

Economic Analyses Used to Assess Surgical Interventions in the Developing World

Type of Economic Analysis	Definition	Purpose	Metric Reported
Cost-effectiveness	An analysis used to assess the monetary cost and related health benefits of a particular surgical intervention	Define the cost of a particular health outcome	Cost per DALYs-averted Cost per QALYs-gained
Cost-benefit	An analysis used to measure both the costs and benefits of a surgical intervention in monetary units	Determine which health intervention has the highest return on investment	Dollars ($)
Cost Variation	An analysis used to identify whether high variance exists for a particular area of spending	Identify drivers of cos variation that can be used to reduce the cost of a particular area of spending	—

Figure 2.

Conceptual Model for Development of Economic Analyses of Surgical Interventions in the Developing World.

In addition to cost-effectiveness analyses, cost-benefit analyses should be used to convey the economic benefit of particular health interventions on society.^36,37 Cost-benefit analyses differ from cost-effectiveness analyses by measuring both the costs and benefits of an intervention in monetary units. Conversely, cost-effectiveness analyses use the amount of DALYs-averted, or QALYs-gained, to measure benefits. The results of a cost-benefit analysis can be used to decide which programs have the highest return on investment.^36,37 If the results of a cost-benefit analysis suggest that a net economic benefit exists, then a cost variation analysis is not needed. Conversely, if there is no net economic benefit, then a cost variation analysis may help improve the net economic benefit of the surgical interventions performed. Cost-benefit analyses, in conjunction with cost-effectiveness analyses, should be used to determine whether a cost variation analysis is warranted (Figure 3).

Figure 3.

Implementing Policy Based on Cost Variation Analyses.

Cost-Effectiveness Analyses

Researchers examining the cost-effectiveness of surgical trips to LMICs should adhere to standardized WHO-CHOICE methods.³⁰ The lack of adherence to a standard makes it difficult for policy makers to compare the effectiveness of different interventions. For example, various cost-effectiveness analyses lack similarity in their accounting methodology. Tadisina et al. conducted a cost-effectiveness analysis of hand surgery performed during a surgical trip to Honduras. In this analysis, the authors did not discount the costs of the surgical trip.¹³ Alternatively, Baltussen et al. examined the cost-effectiveness of cataract surgery in developing countries and discounted the costs at an annual rate of 3%, as suggested by WHO-CHOICE methods.¹⁹ The two studies did not adhere to similar methods in their investigations: one study is overestimating the costs. whereas another is underestimating the costs. Thus, it may be troublesome when the results of both studies are used to implement policy regarding resource allocation.

Efforts to educate local providers in the developing world during short-term surgical trips has become increasingly common.^38–40 For example, ReSurge International performs visiting educator surgical trips, where the traveling organization educates local surgeons on particular operations.⁴¹ The impact of these trips are usually made after the organization leaves the host country. To the best of our knowledge, no methodology exists to evaluate the cost-effectiveness of such surgical trips. With an established methodology, policy makers would be able to better understand the economic impact of educating local physicians on treating surgical conditions.

The results of economic analyses are most meaningful when they are compared to other widely accepted interventions. Grimes et al. determined that elective inguinal hernia repair surgery is considered cost-effective in LMICs by comparing the cost-effectiveness to accepted global health interventions, such as oral rehydration therapy or breast feeding promotion.¹⁸ This comparison helps provide evidence that both interventions are beneficial and require similar attention. Although cost-effectiveness analyses are of interest to decision-making bodies, cost-benefit analyses appeal to those providing funding and support of global surgery outreach efforts to LMICs.

Cost-Benefit Analyses

Cost-benefit analyses are used to determine the economic benefit of an intervention in monetary terms.^36,42 They are of interest to program financiers because they demonstrate the value of an intervention using a simple metric (dollar). Although such analyses are of interest to decision-making bodies, there are few publications in global surgery literature.^43–45 This underutilization is attributed to the difficulty of placing a monetary value on health benefits.^43,46

To perform a cost-benefit analysis, one must:

1. determine the total cost of the surgical trip,

2. calculate the potential benefits of the health interventions, and

3. convert the health benefits to monetary terms.

Researchers use different approaches to convert the potential health benefits of an intervention to a monetary value. These include the value of a statistical life year approach, in which value is placed on an individual’s willingness to pay for a reduction in mortality risk, the human capital approach, in which value is placed on an individual’s potential economic productivity, or the willingness to pay approach, in which value is place on an individual’s willingness to pay for certain health benefits.^37,43,47 The most common method used is the value of a statistical life year approach.^43,44,48,49

A cost-benefit analysis of cleft lip and palate interventions was performed at a single center in Nepal to estimate the economic impact cleft lip and cleft palate repair. Using the value of a statistical life approach, the net economic benefit at this single center was between $56,919 to $143,363 for cleft lip repair and $152,372 to $375,412 for cleft palate repair.⁴⁴ The authors concluded that cleft lip and cleft palate repairs performed at this center had a substantial impact on the economic health in Nepal. Calculation of the net economic benefit informs policy makers on the cost-saving impact each dollar spent on the program will have.

Cost Variation Analyses

Global healthcare spending is expected to increase from 9.2 trillion to 24.2 trillion dollars between 2014 and 2040.⁵⁰ Increases in the expenditure of United States nonprofit and volunteer divisions have also been observed.⁵¹ Policy makers are trying to develop different strategies that minimize discrepancy spending in hopes of providing high-quality and low-cost care to patients in LMICs. One strategy used to decrease spending in healthcare is determining variations in spending. In the United States, variations in hospital costs have been studied in various fields including plastic, ⁵² general,⁵³ and cardiac surgery.⁵⁴ Similar analyses can be used to determine drivers for cost variation and increase the effectiveness of surgical trips in the developing world. Exploring various ways to reduce costs while conserving high-quality care should be a priority for surgical outreach organizations.

To perform a cost variation analysis of a surgical trip conducted in the developing world, one must:

1. calculate the difference between the incurred and expected cost of a surgical trip,

2. create a model to assess the link between possible predictors and total cost of the surgical trip, and

3. perform a root cause analysis to determine the cause expenditure variation.

These predictors may include organization, number or profession of personnel needed on the surgical trip, cost classifications (personnel, materials and supplies, donated materials), among others. In a cost variation analysis published by Harris et al., the authors examined the cost of urethroplasty procedures. First, they developed a log cost linear regression model to determine which variables were associated with increased cost. Procedures with extreme cost, those in the top 20^th percentile, were then identified using the same variables as for log cost. Finally, they compared the variables between the extreme cost category and increased procedural cost category to determine predictors of cost variation. When determining these predictors, the authors controlled for patient age, race, and year using a multivariable analysis.⁵⁵ Although this analysis did not examine cost variation of global outreach programs, the methods used by Harris et al. may serve as a model for cost variation analyses of surgical trips to LMICs.

Cost variation analyses may help increase the cost-effectiveness and improve the overall net economic benefit of surgical interventions performed in LMICs (Figure 3). If surgical interventions performed in a surgical trip are considered cost-effective and a net economic benefit exists, then no cost variation analysis is warranted. Conversely, if an intervention is not considered cost-effective, or if no economic benefit is observed, then a cost variation analysis should be done to determine areas of spending that can be reduced to improve both the cost- effectiveness and overall economic benefit. For example, a hypothetical cost variation analysis may show that travel expenses for personnel is a predictor for increased cost. When performing a root cause analysis, policy makers determine that airfare for personnel is the reason for increased travel cost. Policy makers may then require that local volunteers are recruited during various surgical trips to help with trivial tasks, rather than flying out volunteers to help with the same responsibilities. Additionally, policy makers may strive to increase the economic impact by implementing programs that focus on educating local providers. This may permit local providers to perform the learned procedure on thousands of individuals and maximize the impact of the surgical trip. After implementation of such policy, cost-effectiveness and cost-benefit analyses must be performed to determine if the new policy had reduced surgical trip cost. Cost variation analyses may ensure that priority setting decisions are only used as a last resort.

Implications of Economic Analyses

Surgical care delivery in LMICs is hindered by the (1) lack of material resources, (2) inexperienced healthcare personnel, and (3) inefficient resource management strategies.^56–60 Economic analyses provide insight about the value of the surgical health interventions performed in the developing world.⁶¹ Because the resource-limited settings in the developing world, policy makers must determine which treatments should be prioritized and develop strategies to reduce the costs of interventions that are too costly to be performed in a resource-limited environment. These policy makers include government departments, non-governmental organizations, individual or institutional decision-makers, private enterprises, consumers, and external donors.⁶² Policy makers consider information on cost-effectiveness, economic benefit, medical suitability, and epidemiological appropriateness when developing strategies used to guide global health development.^63,64 Understanding the economics of the various global surgery interventions are vital to the development of these efforts in LMICs.

Conclusion

As the surgical burden of disease continues to grow, it becomes imperative to study the effectiveness of the interventions used to alleviate the burden. Healthcare resources in LMICs are limited, thus policy must be implemented to maximize the benefits of the interventions, while minimizing the cost. Policy makers must focus on implementing cost reduction policies before making decisions regarding priority settings. A combination of cost-effectiveness, benefit, and variation analyses will provide policy makers with the appropriate information to develop the most effective policy. Each economic analysis provides different evidence, independently appealing to a different audience.

Moving forward, research on the economic value of surgery in the developing world must focus on standardized cost-effectiveness analyses in conjunction with cost-benefit and cost variation analyses. The development of a methodological standard for cost-benefit and cost variation analyses is also warranted, as it may increase the reliability of economic analyses. Additionally, more detailed data on cost and clinical outcomes of the interventions performed in the developing world will help promote additional research on the effectiveness and sustainability of such humanitarian outreach efforts.

Key Points.

• Current economic analyses of surgical trips are commonly non-standardized cost-effectiveness analyses, therefore restricting policy makers from making proper comparisons of the health interventions.

• Standardized cost-effectiveness analyses need to be used in conjunction with cost-benefit analyses to provide policy makers with a more comprehensive representation of the health and economic impact.

• Subsequent to the cost-effectiveness and cost-benefit analyses, research on predictors of cost variation must be performed to identify drivers of cost reduction for policy implementation.