Cost-eff ectiveness of surgery and its policy implications for global health: a systematic review and analysis

Background The perception of surgery as expensive and complex might be a barrier to its widespread acceptance in global health eff orts. We did a systematic review and analysis of cost-eff ectiveness studies that assess surgical interventions in low-income and middle-income countries to help quantify the potential value of surgery. Methods We searched Medline for all relevant articles published between Jan 1, 1996 and Jan 31, 2013, and searched the reference lists of retrieved articles. We converted all results to 2012 US$. We extracted cost-eff ectiveness ratios (CERs) and appraised economic assessments for their methodological quality using the 10-point Drummond checklist. Findings Of the 584 identifi ed studies, 26 met full inclusion criteria. Together, these studies gave 121 independent CERs in seven categories of surgical interventions. The median CER of circumcision ($13·78 per disability-adjusted life year [DALY]) was similar to that of standard vaccinations ($12·96–25·93 per DALY) and bednets for malaria prevention ($6·48–22·04 per DALY). Median CERs of cleft lip or palate repair ($47·74 per DALY), general surgery ($82·32 per DALY), hydrocephalus surgery ($108·74 per DALY), and ophthalmic surgery ($136 per DALY) were similar to that of the BCG vaccine ($51·86–220·39 per DALY). Median CERs of caesarean sections ($315·12 per DALY) and orthopaedic surgery ($381·15 per DALY) are more favourable than those of medical treatment for ischaemic heart disease ($500·41–706·54 per DALY) and HIV treatment with multidrug antiretroviral therapy ($453·74–648·20 per DALY). Interpretation Our fi ndings suggest that many essential surgical interventions are cost-eff ective or very cost-eff ective in resource-poor countries. Quantifi cation of the economic value of surgery provides a strong argument for the expansion of global surgery’s role in the global health movement. However, economic value should not be the only argument for resource allocation—other organisational, ethical, and political arguments can also be made for its inclusion