Electronic Thesis and Dissertation Repository

Thesis Format

Integrated Article

Degree

Master of Science

Program

Epidemiology and Biostatistics

Supervisor

Martin, Janet

2nd Supervisor

Ali, Shehzad

Co-Supervisor

Abstract

Globally, 5 billion people lack access to safe, timely, and affordable surgical, obstetric, and anaesthetic care. Increasing access to surgery saves lives, promotes economic growth, and drives equitable global development. Essential surgery includes caesarean section, laparotomy, and open fracture treatment, otherwise known as the Bellwether procedures. Thesis objectives included conducting a systematic review examining cost-effectiveness of undergoing or increasing access to Bellwether procedures in resource restricted settings and performing an economic evaluation of increasing access to caesarean section for obstructed labour compared to existing care in the South African Development Community region. Our systematic review found that Bellwether procedures were likely to be highly cost-effective. Our economic evaluation demonstrated that increasing access to caesarean section to 80% costs $52.97 per disability-adjusted life year averted from a health systems perspective, relative to existing care (30% access). Future research should focus on improved estimates of cost, effectiveness, and unmet need related to essential surgery.

Summary for Lay Audience

Globally, 5 billion people lack access to safe, timely, and affordable surgical care. Lack of surgical access is inequitably distributed in low-and middle-income countries and is largely responsible for the number of deaths and time spent in disability from conditions that can be treated. The three procedures that account for most of this burden are caesarean section, laparotomy, and treatment of open fracture, otherwise known as the Bellwether procedures. Research has found that increasing access to essential surgery, defined as the Bellwether procedures, is likely to be cost-effective. However, limitations such as lack of high-quality synthesized evidence and funding impede health policy decision-making. Therefore, it is important to examine best available evidence on health and economic impacts of increasing access to essential surgery in resource restricted settings to address this gap in knowledge and better inform policymakers and stakeholders. The objectives of this thesis were to first, systematically review all existing cost-effectiveness analyses on increasing access or undergoing the Bellwether procedures in low-and middle-income countries; and second, to inform a subsequent de novo economic model that evaluates the costs and health impacts of increasing access to caesarean section to 80% for obstructed labour compared to existing care (30% access) in the South African Development Community region. From the review of existing studies, we found that undergoing a Bellwether procedure was likely to be highly cost effective. However, the identified studies varied in quality, context, and methodology, while excluding neonates and unmet need from their analyses. Consequently, an economic model was constructed to assess the costs and health impacts of increasing access to caesarean section for treatment of obstructed labour to 80% compared to the 30% level of access in existing care. Results from our analyses suggested that increasing access is likely cost-effective at $52.97 and $19.77 per disability-adjusted life year averted compared to existing care for mothers and babies, respectively. A combined estimate for mothers and babies cost $32.00 per disability-adjusted life year averted, assuming additivity. Future economic evaluations would greatly benefit from improved evidence in essential surgery related to costs, effectiveness, and the number of individuals in need of care that cannot access it.

Creative Commons License

Creative Commons Attribution-Noncommercial 4.0 License
This work is licensed under a Creative Commons Attribution-Noncommercial-Share Alike 4.0 License.

Available for download on Thursday, September 01, 2022

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