A handful of cost-effective medical solutions have helped reduce the number of deaths from infectious diseases and childbirth complications. Still, more and more people are dying from surgically-treatable conditions. It is time to shift our focus on strengthening surgical systems. But is it worth the investment?

© Gradian Health Systems
© Gradian Health Systems

Over the past few decades, the world has made unprecedented strides improving health in low- and middle-income countries, where most premature, preventable deaths occur. Since 1990, maternal and child mortality have been cut in half. Deaths from infectious diseases like malaria have followed similar trend lines. Even as HIV/AIDS continues to affect tens of millions of people, death rates have fallen dramatically – one of the most remarkable medical achievements in human history.

Many factors have contributed to this progress, but the world’s preeminent experts on health investments credit a handful of low-cost, easy-to-access solutions for the world’s most vulnerable people, particularly in sub-Saharan Africa and South Asia. We’ve vastly improved our ability to provide affordable interventions like contraception and vaccines, which have helped millions of women avoid life-threatening childbirths and millions of children avoid fatal illnesses like pneumonia and diarrhea. Likewise, one of the ways we’ve reduced malaria mortality is through the distribution of bed nets – another inexpensive intervention – and we’ve greatly expanded access to antiretroviral (ARV) treatment for HIV/AIDS, prolonging lives that would have otherwise been lost to the virus.

Investing in these basic public health products and services is a straightforward calculation: modern contraceptives, vaccines and bed nets cost only a few dollars per unit, and while ARV drugs can cost thousands of dollars a year, commitments from companies and donors have helped bring prices below $100 in many countries. The return on these investments comes in the form of countless lives saved and improved – making them among the most cost-effective in global health.



What about surgery?

Rarely mentioned in the conversation about cost-effective health investments is safe surgery – and what it would take to improve access to this vital health service. Surgical conditions comprise a third of the global burden of disease, with nearly 17 million people dying every year from illnesses, injuries and emergencies that could be treated with basic surgical care. These conditions claim more lives than HIV/AIDS, malaria, tuberculosis and childhood illnesses combined, yet most of the world lacks access to surgical treatment. So why is surgery not a priority in global health and for development actors?


One obvious reason is that surgical systems can be quite expensive to set up. A suite of medical devices is needed to equip any operating room, along with supplies like breathing tubes and anesthetic drugs; infrastructure such as power and medical oxygen are required to use the surgical equipment; and the human resources needed are highly specialized: performing surgery safely hinges on many years of medical education and training for each clinician involved. On top of that, all health systems need strong referral and transport networks to ensure people have access to surgical services, which can be costly to create and maintain.

Given these baseline requirements just to offer the first safe surgical procedure in a developing country, it’s understandable that surgery is viewed as a pricey intervention. But that perspective overlooks surgery’s long-term health and economic impacts, which combine to position it as one of the most cost-effective investments we can make.


Surgery’s far-reaching return on investment

First and foremost, safe surgery can prevent massive economic losses incurred when people are killed or injured from a surgically-treatable condition. Many conditions that require surgery –childbirth emergencies, broken bones, trauma, cleft lip, etc. – occur in young populations, meaning a failure to treat them affects decades of future productivity. Road traffic injuries, for instance, are the leading cause of death among people aged 15 to 29 – concentrated heavily in low-income countries. Without access to surgery, these common injuries can become lifelong disabilities that preclude victims from working or finishing their education, eliminating valuable sources of income and contributing to a cycle of poverty.

One group of surgery experts – the Lancet Commission on Global Surgery – estimates that low- and middle-income countries are on pace to lose $12.3 trillion in income by 2030 if they fail to improve access to surgical care – not to mention the losses in quality of life when people suffer injuries that go untreated. However, an investment of $420 billion by 2030 would be enough to scale up surgical services to meet the global need – yielding a 29:1 economic return on investment, along with tens of millions of deaths averted each year.

Another way of looking at cost-effectiveness in global health is through disability-adjusted life years (DALYs) – in other words, how much does it cost to ensure one “healthy” year that would otherwise be lost due to death or injury?

As the Lancet Commission notes, surgery “compares favorably to the delivery of other common public health interventions, such as childhood vaccines, HIV medicines and distribution of bed nets to prevent malaria.” For example, cataract surgery costs about $7 per DALY – on par with standard vaccinations (between $13 and $26 per DALY) and bed net provision (between $6.50 and $22 per DALY). Likewise, C-section procedures cost roughly $315 per DALY – significantly less than ARVs, which run between $450 and $650 per DALY. Even cleft lip, palate repair and general surgery cost in the range of $50 to $80 per DALY – a reasonable trade-off for such crucial health interventions.


The bottom line is more than the bottom line

Ultimately, the true cost-effectiveness of surgery lies in its ripple effects across a health system. Investing in surgery means laying the foundation for health services that would otherwise be impossible. When a doctor receives training on ventilating patients for an operation, she is better suited to perform that same skill on a patient in the ICU. When a hospital ensures reliable electricity and medical oxygen for surgical equipment, it is availing those resources to everyone in the hospital. When a country invests in roads and ambulances to refer surgical patients, it provides better access to hospitals for all of its patients.

Unlike health interventions that revolve around a single pill or dose, surgery revolves around a system – a far more expensive endeavor. But once that system is in place, it enables entire populations to have access to a range of healthcare services for years to come, saving countless lives and doing so as cost-effectively as many other global health investments. As we continue to devote limited resources to a menu of health challenges in low-income countries, we would do well to keep surgery on the (operating) table.


The opinions expressed on this blog are those of the authors and do not necessarily reflect the official position of their institutions or of AFD.

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