A commentary by Anthony Saxton, Emily Smith and Henry Rice
Imagine that your child needs to have surgery. You’d do anything possible to get her the care she needs, right? You’d make appointments with specialists and schedule the surgery as soon as possible at your local hospital—or maybe travel to one that specializes in your child’s health problem.
Now imagine that your child needs to have surgery, but there are no specialists or hospitals in your area, and no viable way to travel hundreds of miles to the “nearest” facility that can provide this care. Surgery is simply not an option. You have no choice but to see your child continue to suffer.
This second scenario is the reality for millions of families in low and middle income countries (LMICs). Ninety percent of people living in LMICs can’t get even basic surgical care. The United States enjoys the benefit of more than 18 pediatric surgeons per one million children, but Ghana, for example, has only about one pediatric surgeon for every two million children. And for many families living in rural areas, traveling to that one hospital that can provide the care their child needs is financially prohibitive, logistically impossible or extremely risky due to the gravity of the child’s condition.
So we’ve got millions of children across the world living with chronic debilitating pain or disability, and in some cases dying, from conditions that are relatively easy to treat. Inguinal hernias, for example, take only about 20 minutes to repair, but they often remain untreated for years in countries like Guatemala.
How Did We Get Here?
Global health legends Paul Farmer and Jim Kim have referred to surgery as “the neglected stepchild of global health.” Until the Lancet Commission on Global Surgery (2013-2015) and a few other recent initiatives, the importance of surgery has been largely overlooked in the global health agenda. Over the past few decades, the field has been dominated by disease-focused initiatives such as prevention and treatment of malaria, tuberculosis and HIV/AIDS, often addressed in silos in accordance with the Millennium Development Goals.
Why the neglect? Surgery is expensive. Or at least that’s been the perception of ministers of health and finance, policy makers, providers and others involved in making decisions about health priorities. And it’s true—it does cost a lot to build facilities and infrastructure, equip hospitals and develop and retain surgeons. It’s also true, of course, that surgery is financially out of reach for far too many families, especially when the need arises suddenly, as it often does with surgical conditions.
But the big picture reality is that at a societal level, surgery is extremely cost-effective. The Lancet Commission demonstrated that “Delivery of a platform of surgical and anesthesia services at the first-level (district) hospital … compares favorably to the delivery of other common public health interventions in LMICs, such as childhood vaccines, HIV medicines, and distribution of bed nets to prevent malaria.” The Commission also noted that “surgical conditions, especially when left untreated, can reduce economic productivity … reducing annual GDP growth by as much as 2% in lower-middle income countries.”
Pediatric Surgery Is Cost-Effective, Too
While the Lancet Commission’s multi-faceted analysis has been instrumental in elevating the priority of global surgery, it doesn’t directly address pediatric surgery, which has different cost concerns and drivers and entails different procedures and support systems. That’s why we decided to undertake an economic analysis of children’s surgical care in low and middle income countries.
We identified relevant articles, summarized reported cost information for individual interventions by country and calculated the median cost-effective ratio and societal economic benefits by procedure group. Our findings paralleled those of the Commission: many areas of children’s surgical care are extremely cost-effective in LMICs, provide substantial societal benefits and warrant enhanced investment.
Based on the current literature, we found six particularly cost-effective procedure types that are supported by high-quality evidence and should be considered essential: inguinal hernia repair, trichiasis surgery, cleft lip and palate repair, circumcision, congenital heart surgery and orthopedic procedures. However, we believe additional research would reveal that many more procedures are just as cost-effective. And furthermore, once capacity exists to perform these surgeries in low-resource settings, expanding the scope of surgical capability would require only minimal additional investment, relatively speaking.
Expanding the Research Base Will Help Move the Needle
Our analysis lays a solid foundational case to invest in pediatric surgery in low and middle income countries, from building more hospitals to expanding surgical training programs and developing innovative approaches to improve surgical access, such as telemedicine and task sharing.
But we’ve only just scratched the surface. To strengthen our case, we’ve got to deepen the research base on pediatric surgical care. We need improvements in research methods to define the costs and value of surgical care. This includes refining the use of health outcome measurements such as disability-adjusted life years, promoting consistent use of World Health Organization guidelines that define appropriate costs for economic analyses and using national datasets to minimize variation between hospitals and researchers.
Our Vision: From Policy to Family
Economic analyses can be powerful in driving data into policy, but other criteria such as poverty reduction and disease severity should also be considered in setting health care priorities.
And at the end of the day, economics aside, we believe all children have the right to pediatric surgical care. What we really want is for these health system changes, once implemented, to trickle down to individual families—so those parents in rural Tanzania who just learned their child needs surgery have a place to go where their child’s needs can be met with timely, high-quality, affordable care.
Learn more about our analysis, published on October 28 in PLOS One: “Economic Analysis of Children’s Surgical Care in Low- and Middle-Income Countries: A Systematic Review and Analysis,” by Anthony T. Saxton, Dan Poenaru, Doruk Ozgediz, Emmanuel A. Ameh, Diana Farmer, Emily R. Smith and Henry E. Rice.
Anthony Saxton is a 2016 graduate of the Duke Global Health Institute’s (DGHI’s) Master of Science in Global Health program and is currently working as a senior clinical trials specialist in the department of surgery at Duke.
Emily Smith is a research scholar at the Duke Global Health Institute and the department of global neurosurgery and neuroscience.
Henry Rice is a professor of surgery and global health and the division chief of pediatric surgery at Duke.
The big picture reality is that at a societal level, surgery is extremely cost-effective.