Health impact and economic analysis of NGO-supported neurosurgery in Bolivia

Abstract

Object Bolivia, one of the poorest countries in the world, ranks 108th on the 2013 Human Development Index. With approximately 1 neurosurgeon per 200,000 people, access to neurosurgery in Bolivia is a growing health concern. Furthermore, neurosurgery in nonindustrialized countries has been considered both cost-prohibitive and lacking in outcomes evaluation. A non-governmental organization (NGO) supports spinal procedures in Bolivia (Solidarity Bridge), and the authors sought to determine its impact and cost-effectiveness. Methods In a retrospective review of prospectively collected data, 19 patients were identified prior to spinal instrumentation and followed over 12 months. For inclusion, patients required interviewing prior to surgery and during at least 2 follow-up visits. All causes of spinal pathology were included. Sixteen patients met inclusion criteria and were therefore part of the analysis. Outcomes measured included assessment of activities of daily living, pain, ambulation, return to work/school, and satisfaction. Cost-effectiveness was determined by cost-utility analysis. Utilities were derived using the Health Utilities Index. Complications were incorporated into an expected value decision tree. Results Median (± SD) preoperative satisfaction was 2.0 ± 0.3 (on a scale of 0–10), while 6-month postoperative satisfaction was 7 ± 1.4 (p < 0.0001). Ambulation, pain, and emotional disability data suggested marked improvement (56%, 69%, and 63%, respectively; p = 0.035, 0.003, and 0.006). Total discounted incremental quality-adjusted life year (QALY) gain was 0.771. The total discounted cost equaled $9036 (95% CI $8561–$10,740) at 2 years. Computing the incremental cost-effectiveness ratio resulted in a value of $11,720/QALY, ranging from $9220 to $15,473/QALY in a univariate sensitivity analysis. Conclusions This NGO-supported spinal instrumentation program in Bolivia appears to be cost-effective, especially when compared with the conventional $50,000/QALY benchmark and the WHO endorsed country-specific threshold of $16,026/QALY. However, with a gross domestic product per capita in Bolivia equaling $4800 per year and 30.3% of the population living on less than $2 per day, this cost continues to appear unrealistic. Additionally, the study has several significant limitations, namely its limited sample size, follow-up period, the assumption that patients not receiving surgical intervention would not make any clinical improvement, the reliance on the NGO for patient selection and sustainable practices such as follow-up care and ancillary services, and the lack of a randomized prospective design. These limitations, as well as an unclear understanding of Bolivian willingness-to-pay data, affect the generalizability of the study findings and impede widespread economic policy reform. Because cost-effectiveness research may inevitably direct care decisions and prove that an effort such as this can be cost saving, a prospective, properly controlled investigation is now warranted.

Temporal Delays Along the Neurosurgical Care Continuum for Traumatic Brain Injury Patients at a Tertiary Care Hospital in Kampala, Uganda

“…As is often the case in LMIC studies, this limitation underscores the need for improved clinical documentation both for facilitating patient care and research to improve patient outcomes. 23,28,29 Through our continued partnership, we have improved documentation and supported capacity building for long-term data collection such that future studies may draw upon more extensive data.…”

Engagement of non-governmental organisations in moving towards universal health coverage: a scoping review

“…[ 64 ] Africa, Central/Eastern Europe and Central Asia, Latin America and the Caribbean, 2006 Qualitative study In-depth interviews ***** African NGOs most likely to use peer education and community awareness events; Eastern European NGOs most likely to offer needle exchange; Latin American NGOs to have resource centres and offer risk reduction programmes; and Caribbean organisations to use mass education approaches Mercer, M. A. [ 65 ] Uganda, India, Brazil, Swaziland, Thailand, Zambia and Kenya, 1991/ LI, LMI, HI Qualitative study In-depth explanation *** Providing educational materials to specific groups, peer education, experimental drugs, counselling and healthcare to people with AIDS Ambrosini, M. [ 66 ] Italy, 2015/ HI Case studies Observation, analysing documents and interviewing ***** Providing free health care to irregular immigrants Ament, J. D. [ 67 ] Bolivia, 2014/ LMI Cross-sectional Questionnaires/ Interview ***** Support for spinal procedures Andrade, M. [ 68 ] Brazil, 2018/ UMI Non-randomised trial N/A ***** Providing diagnostic mammography and biopsies as well as anatomo-histopathological and immunohistochemical analysis Bader, F. [ 69 ] Jordan, 2009/ UMI Survey Interviews ***** Providing mental health services for displaced Iraqis Baig, M. B. [ 70 ] India, 2014/ LMI mixed method Semi-structured questionnaire/ Interview ***** Providing primary health centres services Baqui, A. H. [ 71 ] India, 2008/ LMI Quasi-experimental study Questionnaire ***** Providing maternal and newborn health services Barzin, Y.…”

“…[ 64 ] * * * * * * * Mercer, M. A. [ 65 ] * * Ambrosini, M. [ 66 ] * * * * * Ament, J. D. [ 67 ] * * * * Andrade, M. [ 68 ] * * Bader, F. [ 69 ] * * Baig, M. B. [ 70 ] * * * Baqui, A. H. [ 71 ] * * Barzin, Y.…”

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“…Cost-effectiveness and ultimate value of the intervention both shape the cost-utility notion ( Ament et al, 2014 ; Richardson, 1994 ; Redelmeier & Weinstein, 1999 ). To evaluate accuracy, proper understanding of the determinants of R&D investments is mandatory.…”