Task-Sharing or Public Finance for Expanding Surgical Access in Rural Ethiopia: An Extended Cost-Effectiveness Analysis

Excerpt

A large fraction of the disease burden is attributable to conditions potentially amenable to surgical treatment (Bickler and others 2015; Mock and others 2015; Shrime, Sleemi, and Thulasiraj 2014). In low- and middle-income countries (LMICs), however, the utilization of surgical services is low, often because of a lack of surgical capacity, sociocultural factors, and cost (Chao and others 2012; Hsia and others 2012; Ilbawi, Einterz, and Nkusu 2013; Knowlton and others 2013; Linden and others 2012). Numerous policies have been proposed to improve access, including making surgery free at the point of care and task-sharing (Bucagu and others 2012; Jadidfard, Yazdani, and Khoshnevisan 2012; Kruk and others 2007).

In Ethiopia, more than 80 percent of the population of 92 million people lives in rural areas (WHO 2012; World Bank 2012), while surgeons are primarily located in urban centers (Berhan 2008; Surgical Society of Ethiopia 2013). As a consequence, access to surgery is particularly low. For example, in 2010, 3.3 percent of women delivered their most recent child by cesarean section—20 percent of the women in Addis Ababa, but as few as 0.5 percent of the poorest women in rural Ethiopia (Central Statistical Agency [Ethiopia] and ICF International 2012). Although traditional preferences for home delivery play a role, rural women also point to the high cost of care and a lack of providers as reasons for low utilization (Central Statistical Agency [Ethiopia] and ICF International 2012; Shiferaw and others 2013). A patient undergoing surgery in Ethiopia would face, on average, 1,125 Ethiopian birr (Br; I$204) in direct medical costs, as well as Br 1,633 to Br 3,358 (I$297 to I$611) in direct nonmedical costs (Kifle and Nigatu 2010; UN 2014). Even if surgery were publicly financed, the patient would still face direct nonmedical costs, which, in some settings, may be large enough to cause impoverishment.

The World Health Organization (WHO) has stated that health systems have three objectives: to improve health, to provide financial protection, and to advance the equitable distribution of the two (WHO 2007). While health policies typically focus on the first objective, improving health may be in tension with an improvement in either of the other two objectives. In addition, standard health economic evaluations of policies sometimes ignore their expected impact on the private economy of households. Methods for extended cost-effectiveness analyses (ECEAs) have recently been developed to examine all three objectives simultaneously (Verguet, Laxminarayan, and Jamison 2014).

This chapter studies the health and financial risk protection benefits of policies for improving access to surgical care in rural Ethiopia. Using the ECEA framework (Verguet, Gavreau, and others 2015; Verguet, Laxminarayan, and Jamison 2014; Verguet, Murphy, and others 2013), we compare the following:

1. A policy of universal public financing (UPF) that makes surgery free at the point of care but does not pay for nonmedical costs

2. A policy of task-sharing of surgery with nonsurgeon providers

3. A combination of UPF and task-sharing

In addition, because direct nonmedical costs to patients—for transportation, food, and lodging—can be significant drivers of both catastrophic expenditures and decisions to avoid care (Kowalewski, Mujinja, and Jahn 2002), we examine two additional policies:

1. UPF with the addition of travel vouchers

2. A combination of UPF, task-sharing, and travel vouchers

Finally, we quantify the distribution of these benefits across wealth groups.