TASK-SHARING OR PUBLIC FINANCE FOR THE EXPANSION OF SURGICAL ACCESS IN RURAL ETHIOPIA: AN EXTENDED COST-EFFECTIVENESS ANALYSIS

Monday, October 20, 2014
Poster Board # PS2-4

Candidate for the Lee B. Lusted Student Prize Competition

Mark G. Shrime, MD, MPH, Harvard University Interfaculty Initiative in Health Policy, Cambridge, MA, Stephane Verguet, MPP, PhD, University of Washington, Department of Global Health, Seattle, WA, Kjell Arne Johansson, MD PhD, Department of Global Public Health and Primary Care, Bergen University, Bergen, Norway, Dawit Desalegn, MD, Department of Obstetrics and Gynecology, Addis Ababa University School of Medicine, Addis Ababa, Ethiopia, Dean Jamison, PhD, Department of Global Health, University of Washington, Seattle, WA and Margaret Kruk, MD, MPH, Columbia Mailman School of Public Health, New York, NY

Purpose:   Despite a high burden of surgical disease, access to surgical services in low- and middle-income countries is often limited.  The objective of this paper is to compare policies for the expansion of access to basic surgery in rural Ethiopia.

Method:   An extended cost-effectiveness analysis was performed. Deterministic and stochastic models of surgery in rural Ethiopia were constructed, utilizing pooled estimates of costs and probabilities from national surveys and published literature. Model calibration and validation were performed against published estimates. Sensitivity analyses on model assumptions were conducted to check for robustness.  Outcomes of interest were the number of deaths averted, the number of cases of poverty averted, and the number of cases of catastrophic expenditure averted for each policy, nominally and per dollar spent, divided across wealth quintiles.

Result:   Health benefits from each of the examined policies accrued primarily to the poor. However, without travel vouchers, these policies also induced impoverishment in the poor; some prevented poverty in the rich. Adding travel vouchers removed the impoverishing effects of a policy but decreased the health benefit per dollar spent. The distributional pattern of health and financial benefits was robust to most sensitivity analyses.

Conclusion: Health benefits and financial risk protection are in tension in the expansion of access to surgical care in rural Ethiopia.  Policies to increase surgical access may improve health at the cost of increasing impoverishment. Adding travel vouchers improves the financial risk protection of each policy but decreases how much health benefit can be bought per dollar.


Figure:  Health protection versus financial risk protection per $100,000 spent, by policy (see text for details). Note that, in the absence of vouchers, policies create cases of poverty, driven, in large part, by direct non-medical costs, which are averted by the introduction of vouchers.  UPF = universal public finance

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