Sustainable Development in Surgery: The Health, Poverty, and Equity Impacts of Charitable Surgery in Uganda

Abstract

BackgroundThe recently adopted Sustainable Development Goals call for the end of poverty and the equitable provision of healthcare. These goals are often at odds, however: health seeking can lead to catastrophic spending, an outcome for which cancer patients and the poor in resource-limited settings are at particularly high risk. How various health policies affect the additional aims of financial wellbeing and equity is poorly understood. This paper evaluates the health, financial, and equity impacts of governmental and charitable policies for surgical oncology in a resource-limited setting.MethodsThree charitable platforms for surgical oncology delivery in Uganda were compared to six governmental policies aimed at improving healthcare access. An extended cost-effectiveness analysis using an agent-based simulation model examined the numbers of lives saved, catastrophic expenditure averted, impoverishment averted, costs, and the distribution of benefits across the wealth spectrum.FindingsOf the nine policies and platforms evaluated, two were able to provide simultaneous health and financial benefits efficiently and equitably: mobile surgical units and governmental policies that simultaneously address surgical scaleup, the cost of surgery, and the cost of transportation. Policies that only remove user fees are dominated, as is the commonly employed short-term “surgical mission trip”. These results are robust to scenario and sensitivity analyses.InterpretationThe most common platforms for increasing access to surgical care appear unable to provide health and financial risk protection equitably. On the other hand, mobile surgical units, to date an underutilized delivery platform, are able to deliver surgical oncology in a manner that meets sustainable development goals by improving health, financial solvency, and equity. These platforms compare favorably with policies that holistically address surgical delivery and should be considered as countries strengthen health systems.

Health-system-adapted data envelopment analysis for decision-making in universal health coverage

“…Notes: We applied the three data analysis methods to a previously published cost–effectiveness analysis of government policies and nongovernmental platforms for improving the delivery of surgical oncology services in Uganda ( Table 3 ). 5 Data envelopment analysis does not give any guidance on how to decide among the six proposed policies. Cost–effectiveness analysis and health-adapted superefficiency data envelopment analysis favour similar policies.…”

“…We tested our health-adapted superefficiency data envelopment analysis method by applying it to data from three previously published extended cost‒effectiveness analyses of policy inteventions. 4 , 5 , 8 The first example was an analysis of policies to increase access to surgery in Ethiopia in terms of the cost, health benefits and effects on financial risk protection ( Table 1 ). The second example was a synthesis of different preventive and curative health interventions from several analyses, reporting the cost, health benefits and financial risk protection of the interventions ( Table 2 ).…”

“…a Equity scores were scaled from 1 (most favourable to poorer patients) to −1 (most favourable to richer patients). Notes: The data were from a previously published study 5 and were used to test the health-adapted superefficiency data envelopment analysis method, producing the policy ranking shown in Table 6. As defined in the original paper, universal public finance refers to making surgery free at the point of care.…”

Surgical Outreach for Children by International Humanitarian Organizations: A Review

“…Furthermore, while the vast majority of surgical organizations incorporate training and education into their missions [ 24 ], this may be counterbalanced by stresses on local infrastructure and distortion of local health markets and systems [ 33 ]. A recent modeling study investigating the impact of nine policy changes for surgical access on health benefit, cost, and equity in Uganda found that the ‘mission trip’ platform for surgical care delivery was more expensive and less effective than nearly all other platforms studied [ 34 ]. An additional limitation of this model is the lack of harmonization that stems from multiple distinct organizations functioning within the same space without coordination of their efforts, which is a condition common in international aid and addressed by the Paris Declaration on Aid Effectiveness [ 35 ].…”

Facilitating access to surgical care through a decentralised case-finding strategy: experience in Madagascar

“…There are various models for expanding access to surgical care that include task-shifting, 22 use of mobile platforms 23 and impact of government policy, 24 but little is known regarding case-finding strategy. We sequentially evaluated two selection strategies: a centralised selection strategy that focused on the larger population centres in Madagascar and a decentralised strategy that deliberately targeted remote areas of Madagascar, where access to surgical care was limited.…”