Economic Analysis of Children's Surgical Care in Low- and Middle-Income Countries: A Systematic Review and Analysis

Abstract

Background: Understanding the economic value of health interventions is essential for policy makers to make informed resource allocation decisions. The objective of this systematic review was to summarize available information on the economic impact of children's surgical care in low- and middle-income countries (LMICs).

Methods: We searched MEDLINE (Pubmed), Embase, and Web of Science for relevant articles published between Jan. 1996 and Jan. 2015. We summarized reported cost information for individual interventions by country, including all costs, disability weights, health outcome measurements (most commonly disability-adjusted life years [DALYs] averted) and cost-effectiveness ratios (CERs). We calculated median CER as well as societal economic benefits (using a human capital approach) by procedure group across all studies. The methodological quality of each article was assessed using the Drummond checklist and the overall quality of evidence was summarized using a scale adapted from the Agency for Healthcare Research and Quality.

Findings: We identified 86 articles that met inclusion criteria, spanning 36 groups of surgical interventions. The procedure group with the lowest median CER was inguinal hernia repair ($15/DALY). The procedure group with the highest median societal economic benefit was neurosurgical procedures ($58,977). We found a wide range of study quality, with only 35% of studies having a Drummond score ≥ 7.

Interpretation: Our findings show that many areas of children's surgical care are extremely cost-effective in LMICs, provide substantial societal benefits, and are an appropriate target for enhanced investment. Several areas, including inguinal hernia repair, trichiasis surgery, cleft lip and palate repair, circumcision, congenital heart surgery and orthopedic procedures, should be considered "Essential Pediatric Surgical Procedures" as they offer considerable economic value. However, there are major gaps in existing research quality and methodology which limit our current understanding of the economic value of surgical care.

Fig 1. Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) flow diagram of the literature reviewing process on the economics of pediatric surgery in low- and middle-income countries.

4,125 articles were identified through our initial search, and altogether 86 studies met the full inclusion criteria to be included in our review.

Fig 2. Cost-effectiveness (2015 USD/DALY) of 11 pediatric surgical intervention categories.

Individual article references shown in brackets. Red diamonds represent median costs, black lines represent the range of values from each article. Abbreviations include: ENT ear, nose and throat; PRS plastic and reconstructive surgery; DALY disability-adjusted life year; USD United States dollar.

Fig 3. Societal economic benefit of 11 pediatric surgical intervention categories, measured using a human capital approach.

Individual article references shown in brackets. Red diamonds represent median values, black bars represent the range of values from each article. Abbreviations include: ENT ear, nose and throat; PRS plastic and reconstructive surgery; USD United States dollars.