Task-sharing or public finance for the expansion of surgical access in rural Ethiopia: an extended cost-effectiveness analysis

Abstract

Despite a high burden of surgical disease, access to surgical services in low- and middle-income countries is often limited. In line with the World Health Organization's current focus on universal health coverage and equitable access to care, we examined how policies to expand access to surgery in rural Ethiopia would impact health, impoverishment and equity. An extended cost-effectiveness analysis was performed. Deterministic and stochastic models of surgery in rural Ethiopia were constructed, utilizing pooled estimates of costs and probabilities from national surveys and published literature. Model calibration and validation were performed against published estimates, with sensitivity analyses on model assumptions to check for robustness. Outcomes of interest were the number of deaths averted, the number of cases of poverty averted and the number of cases of catastrophic expenditure averted for each policy, divided across wealth quintiles. Health benefits, financial risk protection and equity appear to be in tension in the expansion of access to surgical care in rural Ethiopia. Health benefits from each of the examined policies accrued primarily to the poor. However, without travel vouchers, many policies also induced impoverishment in the poor while providing financial risk protection to the rich, calling into question the equitable distribution of benefits by these policies. Adding travel vouchers removed the impoverishing effects of a policy but decreased the health benefit that could be bought per dollar spent. These results were robust to sensitivity analyses.

Sustainable Development in Surgery: The Health, Poverty, and Equity Impacts of Charitable Surgery in Uganda

“…[31] By design, these models are stochastic, facilitating the incorporation of uncertainty (around, for example, estimates of cost and mortality). They also relax the assumption, made in prior policy analyses,[1, 32–34] that individuals are independent of each other—a feature necessary for the measurement of impoverishment (as defined below).…”

“…Poverty can be both a barrier to healthcare [1] and its result, especially in low- and middle-income countries (LMICs), where catastrophic spending on health is common [1–4]. For cancer patients, this financial burden also drives poor health outcomes.…”

“…Policies that alleviate medically-related financial burden have shown only minimal impacts on health [1, 6]. On the other hand, increasing the number of healthcare providers may, by inducing demand for services with significant costs, counterintuitively increase the risk of financial catastrophe.…”

“…On the other hand, increasing the number of healthcare providers may, by inducing demand for services with significant costs, counterintuitively increase the risk of financial catastrophe. [1]…”

Half a billion surgical cases: Aligning surgical delivery with best-performing health systems

“…Although 30% of the global burden of disease could benefit potentially from surgical management, 1,2 surgery has not to date played an extremely prominent role in discussions of health-system strengthening. 3 This lack of involvement has led to extreme variability in global surgical delivery across countries: some countries provide fewer than 150 operations per 100,000 in their population, whereas others provide almost 30,000.…”