This post is intended as a quick overview and primer on essential surgeries for those of us who care deeply about the relief of poverty in the developing world, but don’t actually know much about it.
Surgical interventions, until recently the “neglected stepchild” of public health, are getting increasing attention from public health professionals as new evidence emerges of their cost-effectiveness. While it may still be too early to say if there are any specific charities which are as cost effective as Giving What We Can’s recommendations, essential surgeries should definitely be on our collective radar.
Much of the information in this post comes from the Disease Control Priorities 3 (DCP3) report on essential surgeries, released in February 2015.
What is essential surgery?
Essential surgeries, as defined in Disease Control Priorities 3, are 44 surgical procedures which have been selected because they:
- Address substantial needs
- Are cost-effective
- Are feasible to implement
Some examples of essential surgeries are caesarean births and cleft palate repair.
To the contrary, organ transplants (too expensive), and most cosmetic surgery (which does not address substantial need) count as non-essential surgeries.
Surgery is a ‘horizontal’ healthcare service provision, defined by the healthcare capabilities it requires rather than by the condition treated. Horizontal provisions tend to be provided by publicly funded health systems (i.e. government, not charity).
The required capabilities to perform surgery are:
- Preoperative assessment
- Anaesthesia
- Carrying out the operation
- Postoperative care
Although surgery itself is a horizontal provision, many charitable interventions use a ‘vertical’ approach, treating particular conditions; either by sending surgical missions, or by employing/training local surgeons. Different types of essential surgery have different costs and benefits. Donors may therefore prefer to fund types of surgery which are particularly cost-effective. There may be significant benefits to both horizontal approaches as well as vertical approaches.
How many deaths can it prevent?
It is estimated that universal provision of essential surgical procedures would avert about 1.5 million deaths per annum. This represents 6-7% of all avertable deaths in lower and middle-income countries.
Much of the disease burden associated with essential surgery results in severe disability rather than death. For example, cataracts is a leading cause of blindness in the developing world but can be easily fixed with a simple surgery. The total avertable DALY burden for essential surgical procedures is 87 million.
What needs does it treat and how?
Essential surgeries treat conditions across the spectrum of healthcare but most can be split into 5 categories.
The first three are generally treated at first-level hospitals (which have about 50-200 beds and basic surgical capabilities) and treatment is often urgent:
- Injury: Largely trauma-related
- Maternal-neonatal: C-sections and other birth-related surgeries
- Digestive diseases: e.g. appendix removal
The remaining two categories generally have to be treated at specialised facilities but as they tend to be elective rather than urgent, patients can be scheduled efficiently, improving cost-effectiveness:
- Congenital: Cleft palates and other birth defects
- Visual impairment: Cataract extraction and eyelid surgery
Essential surgeries can also be carried out by short-term surgical missions or on self-contained mobile platforms.
Much of the charitable contribution to treating essential surgeries is through running surgical missions to address these more specialised corrective surgeries.
Why are people talking about it?
Increasingly, essential surgery is viewed as cost effective.
Historically, surgery has been regarded by experts in public health as a luxury which only the relatively wealthy can afford. This is no longer the case. There is an increasing body of evidence which demonstrates that essential surgery is within the range of interventions which should be considered the most effective available. In some cases, the cost per DALY averted seems to be in a comparable range to interventions recommended by Giving What We Can.
Conditions requiring surgical treatment are an increasing proportion of the disease burden in developing countries.
DCP3 indicates a large part of the surgically treatable disease burden comes from injuries. As injuries, particularly road traffic accidents, increase in low income countries as an unfortunate consequence of development, there is a greater need to treat them effectively.
How effective is it?
In 2014, Chao et al. conducted a review of studies on the cost-effectiveness of surgical interventions. This yielded 121 cost-effectiveness studies in seven categories of surgical intervention.
The most effective surgical interventions were:
- Adult male circumcision (median of $14 per DALY)
- Cleft lip or palate repair (~$48)
- General surgery (~$82)
With the exception of male circumcision (which reduces the risk of HIV infection), for which only three datapoints were available, and for which the estimates are probably most unreliable (because of the epidemiological factors), surgical interventions cost-effectiveness estimates could be more robust than those of horizontal health interventions. This is because when a patient comes into a hospital for surgery, there is low uncertainty about the cost of the hospital and the surgery, the associated disease burden, and the health outcome can be measured quite exactly. Nevertheless, these figures might be an overestimate of the true cost. But these estimates are in the same range of the cost effective interventions for infectious diseases:
- Soil-transmitted helminths (worms) (~$100 per DALY averted and having effects on earnings)
- Malarial bednets (~$100 per DALY averted)
- Vaccines (~$13-$26) (which might not have much room for more funding due to GAVI's big budget)
And surgery might be more cost effective than other widely accepted interventions:
- Antiretroviral therapy ($454-$648)
Other systematic reviews of the literature in DCP3 and Grimes et al. (2014) came to similar conclusions (although the range for the effectiveness of male circumcision was much higher).
I want to donate to essential surgeries, how should I do it?
Givewell undertook a review of corrective surgery charities in 2010. Their top rated charity was ReSurge International (formerly Interplast), who send surgical missions to treat cleft lips and palates, as well as running outreach centres and some training.
Alternatively, you could consider donating to a larger charity whose cost-effectiveness is difficult to measure. MSF run hospitals treating a range of trauma injuries. Evidence on the cost-effectiveness of two of their hospitals ($172 and $223 per DALY) can be found here (journal subscription required).
Would you recommend donating to charities that carry out essential surgeries?
Probably not at this point. This is why:
- The evidence that does exist suggests that, while essential surgery might be more effective than many current interventions, only some surgeries are as cost effective as the most effective interventions and we do not know of a charity that prioritizes these highly cost-effective surgeries.
- There remains significant uncertainty about the cost-effectiveness of surgery. The volume of existing evidence, while growing, remains limited relative to the most effective interventions. Conducting or funding additional research may be another area to look at, although this may be best left to the experts.
- Money may not be the constraining factor in providing effective surgery interventions. There is a chronic shortage of surgeons in developing countries and funding surgical missions may just change who gets treated, rather than how many. One interesting area for further research is in surgical task-shifting, allowing non-surgeon health workers to undertake some surgical procedures. However, there is some concern that this may lead to lower quality of care. A more long term solution would be training additional surgeons.
Overall, essential surgeries are important and effective interventions, but at this stage we should continue prioritising giving to the most effective charities.