A couple months ago, I had the opportunity to listen to a presentation
from an NGO director. Towards the end of her presentation, she expressed her dismay
for receiving a lower grading from the previous year on a non-profit score
report. This was partly due to the increased attention on surgical care within
the organization. According to evaluators, surgical care was not deemed as
cost-effective as other interventions such as mental care, where you could
treat many more patients with less resources and time. Naturally, I thought of
the many problems associated with this assumption – the misconceptions about
surgical intervention, and the ethics, limitations, and over-reliance on a
cost-effective analysis.
Misconception #1:
Surgical intervention only addresses rare problems, which are a small part of
the Global Burden of Disease.
WHO has reported that more than 90% of deaths from injuries
occur in low and middle income countries (1). Injuries kill more than 5 million
people worldwide each year, with one third of injury-related mortalities among
15-44 year olds, the most economically productive population (1). Despite these
figures, developing countries only receive 3.5% of surgical procedures
conducted worldwide (1). Surgical conditions extend beyond injuries which
include: malignancies, obstetrics complications, congential anomalies,
cataracts and glaucoma, perinatal conditions, and trauma emergencies. The
Global Burden of Disease 2010 study also notes an increase in non-communicable
diseases, several which can be surgically treated. By implementing surgical
interventions, we can further accelerate advancements in several of the MDGs
and the post-2015 agenda.
Misconception #2: Surgical
intervention is often considered too expensive, especially when compared to
other public health measures such as vaccines. On the contrary, recent studies
have shown that surgery is very cost-effective. To compare benefits between two
interventions, analyses usually compare DALYs (Disability-Adjusted Life Year).
This can often be thought of as one lost year of “healthy” life.
Cost-effectiveness ratios (CER) are also used to determine the increase in
costs for the benefits of an intervention/treatment.
|
Cost
effectiveness of interventions:
|
|
|
Measles
vaccine
|
$1-5/DALY
averted
|
|
ARVs for
HIV
|
$300-500/DALY
averted
|
|
Surgery
|
$7-200/DALY averted
|
Figure 1: Taken from the
CUGH presentation via the Disease Control Priorities Project (2)
Despite the greater cost-effectiveness of surgery, injury and
road accidents are still 100x under-funded compared to HIV/AIDS (2).
Figure 2: Taken from
Chao TE, et al (The Lancet Global Health, 2014).
Three surgical procedures are comparable to the Expanded
Program of Immunization and bednets for malaria prevention (red stars). Several
procedures have median CERs that are similar to that of BCG vaccine (blue
arrows). Caesarean deliveries and orthopaedic surgery had the highest median
CERs from the listed surgical categories, but they still are much more
cost-effective than treatment for chronic ischaemic heart disease and HIV
treatment (7).
Misconception #3: Surgery is too
difficult to implement because it requires more infrastructure - clean
operating rooms, anaesthesia, electrical power, and laboratory services – and
skilled workers.
Yes, it is true
that surgical intervention requires more infrastructure. However, it also has
greater potential to be sustainable over vertical programs. An increase of
long-term infrastructure-related investments also strengthens horizontal
health-care delivery. We also don’t have to build all new facilities. District
hospitals can be surprisingly efficient and produce good results at lost cost
(7). Part of scaling up surgery
requires a new approaches, in particular, partnerships. In the past, surgical
intervention relied of volunteerism and short-term missions (7). Today, surgery
should focus on building up research and
training for long-term. By creating collaborations with universities and hospitals in
developing countries, we can help teach and train students and physicians, while
innovating low tech diagnostic and treatment methods. Creating opportunities "in-country" can also reduce the “brain-drain” problems many of these countries have. Furthermore,
instead of creating a population of specialist surgical physicians, we can
scale-up community health workers to perform simple surgical procedures such as
obstetric care, which can help increase the population of skilled workers.
The limitations and ethics of a
cost-effective analysis
Although recent positive results from cost-effectiveness
analysis on surgery continue to debunk misconceptions, economical value should
not solely determine the appropriateness of interventions. Like
many other statistical models, cost-effectiveness is an inexact process with
several inherent limitations. First, there are uncertain inputs into the
equation, which calls for imputing data from one data source to another that
may be inappropriate for certain situations. This also includes assigning a
value to “the priceless.” While
costs are easily determined (eg. cost of a treatment, a medicine, etc.), the benefits, which include human life,
are often more difficult to assign value to.
A negative result should also not be a deterrent for new
programs. Many of today’s most popular treatments, such as ARTs, were not
deemed cost-effective. It was only through the tireless work of many
individuals that the costs of such treatments were lowered. Dr. Paul Farmer
initiated an MDR treatment program in the 90s despite the staggering costs (3).
Despite skepticism of the global community on providing MDR-TB treatment,
Farmer proved many wrong by carrying out a treatment program in Peru
successfully. As Dr. Farmer points out, “failure of imagination is a greater
threat that condemns many men and women in the developing world to unnecessary
disability and untimely death.” (5) Existing policies often convince
physicians, as well as governments and the WHO, that it is too expensive and too
logistically difficult to provide modern drugs to many sick in poor countries (5). Instead
of a defeatist attitude, it is our duty to advocate for lower costs for these
treatments in developing countries. Farmer notes that calculating “cost
effectiveness” of care becomes a convenient excuse for failing to provide
treatment for those in need (5).
Despite the results that cost-effectiveness reveals, any type of intervention will still be better than nothing. I liked this quote from a lecture given by Dr. Farmer (taken from a newspaper report):
“[The Clinton Foundation] … found that community health
workers [accounted for] 4 percent of the total cost, 9 percent of the labor
cost. So if you want to use the term cost-effectiveness, which I do, it’s about
as cost-effective as you can get. But remember, this is not about HIV or TB or
malaria. It’s about all of it. So to rebuild these hospitals … labor is the
biggest expenditure. And if you go into an area where unemployment is 60
percent, are you embarrassed to spend 45 percent of your budget on labor? I’m
not. I think it’s good. And if you go into a place where there’s a lot of
hunger—happily, medical science, through revolutionary breakthroughs, has given
us a treatment for hunger called food. And spending 19 or 20 percent of
your budget on food is not an embarrassment, either.” (4)
The argument over cost-effectiveness is not only present in
global health interventions, but also health insurance and coverage of
procedures. Many countries – including Canada, Britain, and the Netherlands,
ration health care based on cost-effectiveness and a place a $50,000
threshold-value to any new treatments (6). In other words, if a new procedure
goes beyond the threshold value, insurance will not cover it. While many
interpret this threshold value as assigning a value to human life, others argue
that we already practice it in many other situations such as payouts for
soldiers killed in action (6). The study of value and life is a tricky one. It forces us to assign values to things we would otherwise deem priceless. No amount or value could probably ever be sufficient, and so cost-effective analyses will never be perfect. Finding a balance in making decisions tightly or loosely based on cost-effective analysis is part of the challenge. While I understand why many believe there is
a benefit and practicality in using it, part of me would like to ignore it all
together. As public health workers, we can often get caught up in the numbers,
but we should not forget our purpose – to provide services to those most in
need.
References
(5) http://www.newrepublic.com/article/books-and-arts/magazine/79737/despair-paul-farmer-medicine
(7) Chao TE, et al. Cost-effectiveness of surgery and its
policy implications for global health: a systematic review and analysis. The
Lancet Global Health (2014); 2: e334-45.
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