“One way to contextualise the impact of disease is to estimate the economic consequences it imposes.” (Alkire et al)
Over the past thirty years, the primary argument for failing to support surgical care as an integral part of health care development in economically disadvantaged countries has been that the cost is prohibitive. On the surface, this is not unreasonable. While a vaccine can be administered by a single health care worker (MD not required), surgical care involves multiple people (surgeons, anesthesia providers, OR assistants, nurses, laboratory, etc.). There also is the question of facilities - safe surgery requires an appropriate place to operate and to provide post-operative care. Then there is the issue of equipment - surgical instruments, anesthesia circuits, even hospital beds. So, given these apparent costs, why did the World Health Assembly pass Resolution 68.15 in 2015, and why did the Lancet assemble a commission to examine global surgery? Why is so much effort today going into the development of surgical care in countries with many needs?
The first answer is simply human. Why, given the knowledge and resources existent in the world, should a child die of appendicitis? Or a 30-year-old man be essentially disabled from available productive work by an inguinal hernia? Or a similar young man be permanently disabled by a malunion of a simple lower extremity fracture? Or a young woman be condemned to spend the rest of her life with a recto- or cysto-vaginal fistula simply because she gave birth to a member of the next generation of humanity? Or a similar young woman die in that process of giving birth? Obviously, this list could go on for thousands of examples, and yet, the humanitarian consequences of poor access to surgery have long been known. What changed?
That second answer is economics. If the original concern about developing surgical care is cost, the corresponding answer is return on the investment of that cost. There is an expanding body of literature examining this very topic, and a clear consensus has emerged: investing in surgical care is a wise economic choice. Surgical care enables all of the people in the examples above to remain in the workforce. It enables their family members to remain in the workforce rather than become home-bound caregivers. It can extend quality of life so that the older generation can potentially remain independent. In short, surgical care adds far more economic value to society than its cost, which brings us back to the original question of why the fuss over “expensive” surgical care?
The primary goal of the economic analyses that have been performed by the PGSSC and related authors has been to examine what the effect of surgical care is, has been, or is reasonably projected to be over the lifetimes of the beneficiaries in economic terms. Expressing health benefits in economic terms produces a metric that is fungible across sectors. While it is difficult to compare the societal good of a health system in which femur fractures are properly managed with the societal good of filling potholes, this comparison is made possible when outcomes are expressed as potential economic benefit in monetary terms.
This blog series, Selected Readings, will review publications of the PGSSC over the past several years, providing a background on the economic concepts that underpin the analysis of surgical benefit. Stay tuned for the next post!