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 lowand 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; reasonable 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 costeffective— 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