Low- and lower-middle–income countries (LMICs) represent half of the world’s population but receive only 12% of all surgical procedures.1 When untreated, reconstructive surgical conditions can cause not only significant morbidity and life-threatening complications, but also a large economic and societal toll through chronic disabilities.2 For example, untreated burn contractures can have devastating functional impact on ability to work, and patients may even require an additional caregiver for assistance with activities of daily living. Unfortunately, reconstructive surgical capacity remains inadequate in LMICs, largely due to the need for advanced technical skills and training.2 While surgery has been increasingly acknowledged as a critical component in addressing the Global Burden of Disease (GBD),3,4 funding is limited and informed decisions must be made regarding the most effective, efficient, and sustainable means of increasing surgical capacity in LMICs.
By quantifying the ability of various interventions to prevent disability and their subsequent economic impact, cost-effectiveness and cost-benefit analyses can assist policymakers, charitable organizations, and donors in determining how to allocate limited resources. The cost-effectiveness and economic benefit of international reconstructive surgery interventions providing direct care, including traditional surgical team trips and care centers,5–13 have now been well-established in the literature. While these interventions provide value by addressing the burden of reconstructive surgery disease in the short-term, increasing attention has been called to sustainably developing long-term local surgical capacity through newer “diagonal” approaches in global surgery.14,15 Diagonal interventions integrate vertical models of care delivery, which are short-term interventions that for example may focus on cleft surgery alone, with horizontal models, which emphasize developments in healthcare systems and infrastructure. This concept combines the practicality and efficiency of delivery of traditional approaches with a focus on long-term strengthening of local healthcare systems including interdisciplinary care. In particular, there is a growing emphasis on expanding the critically inadequate global surgical workforce through teaching and training.16–19
ReSurge International, a US-based nongovernmental organization, has developed the ReSurge Global Training Program (RGTP) to improve surgical capacity in LMICs by training the local workforce in principles and techniques of full-scope reconstructive surgery.20 Over the last 5 years, ReSurge International has conducted 12 visiting educator (VE) trips to 3 partner hospitals in Vietnam.21 During the VE trips, reconstructive surgeons travel to serve as educators at a partner LMIC hospital, providing lectures and training in reconstructive surgery through supervised operations with graduated independence through a competency-based assessment system.20 In addition, a visiting anesthesiologist, pediatrician, nurse, or therapist often provides training to local staff, thereby enhancing multidisciplinary surgical care. Previous work has shown that the RGTP VE trip program in Vietnam contributes to sustainably increased local case volume in trained procedures.21 However, this initial analysis only addressed immediate costs and initial outcomes in terms of increased number of independent operations and patients treated. While these findings demonstrate the overall effectiveness of training from a capacity-building standpoint, a macroeconomic approach is needed to quantify value and efficiency based on burden of disease and economic impact to better aid in global surgery decision-making.
Despite the widespread push toward education to enhance local delivery of care, the long-term cost-effectiveness and economic value of training trips as a method of LMIC surgical capacity building are largely unknown. Surgical trips focused on training tend to perform fewer operations during the trip itself, as the goal is instead to train the local healthcare providers to perform an increased quantity and quality of procedures in the long term. The primary health and economic benefits of training therefore occur after departure of the visiting team.9 The purpose of this study is to capture these downstream effects in a cost-effectiveness and economic benefit analysis of a reconstructive surgery VE program in the LMIC setting.
Data Sources and Cost Calculations
Data regarding VE trips and corresponding independently-performed surgical procedures between 2014 and 2019 were previously collected from 3 Vietnamese hospitals partnered with ReSurge International through the RGTP.21 The data were updated in this follow-up study. Partner hospitals, located in Hanoi, Ho Chi Minh City, and Hue, are large tertiary-level hospitals. Topics of training were varied based on local needs and included craniofacial surgery, hand surgery, microsurgery, and others. Clinical data included patient age, diagnosis, procedure, and year of treatment. When information on age or gender were missing, the average age and an equal number of females and males were assigned. Patients were excluded if the procedure did not correspond to training topics. All data were deidentified and the study was approved by the Stanford Institutional Review Board.
Costs were analyzed from the healthcare system perspective and the perspective of the organization. Data from a prior cost analysis for each trip included costs of travel, lodging, food, supplies, patient care, as well as associated overhead and staff costs.21 This analysis also calculated the value of donated services by volunteers or opportunity cost. Average procedural costs, including the cost of the facilities, surgeon and staff fees, hospitalization, and medications/supplies, were estimated for each procedure at each hospital by local staff. Any other expenses incurred by the patients, such as transportation and caregiver expenses, were not included. The base case analysis includes all of these costs. All costs were converted to June 2019 U.S. dollars using the consumer price index.22 These data were then used to perform 2 key analyses: cost-effectiveness and cost-benefit.
A cost-effectiveness analysis was performed using standardized methodology from the World Health Organization project on CHOosing Interventions that are Cost-Effective.23 The outcome measure was cost per disability-adjusted life year (DALY) averted, where a DALY represents a healthy year of life accounting for morbidity and mortality due to disease. As residual treated disability weights (DWs) are not available for most reconstructive conditions,24 DALYs averted were calculated for each condition using the following equation:25
DWs for each condition were calculated from the 2017 GBD study,26 and encompass healthy life years lost through disability and premature mortality. For diagnoses without specific DWs from the GBD, values were extracted from previous studies or estimated from a matched condition with similar disability.7,10 Due to potential variations in disability for different patients, sensitivity analyses were carried out using the uncertainty range of each DW from the GBD (Appendix, Supplemental Table 1, https://links.lww.com/AOSO/A134). Average life expectancy was obtained for Vietnam from the WHO country-specific tables.27 Likelihood of permanent disability and likelihood of treatment success were estimated using a common scoring system, with a maximal likelihood of treatment success of 0.7.9,28–31
Cost per DALY averted was calculated as the total cost divided by the cumulative DALYs averted through surgical interventions following corresponding training trips. The base analysis included only new cases performed by local surgeons corresponding to topics of training, calculated using the increase in the procedures performed when compared to mean annual case number before training for each procedure category. To account for potential improvements in treatment success due to training, an “all case” analysis was also performed in which additional incremental DALYs are averted from baseline case volume due to a 1.5- to 2-fold improvement in likelihood of treatment success. This assumption of improvement in treatment success from training interventions is based on estimates from our partner surgeons and relevant published literature.32–34 The cost-effectiveness analysis was also performed from the organization’s perspective, including only direct and indirect costs of the VE trip program incurred by ReSurge International.
Health benefits were discounted to the present at a fixed rate of 3% per year. A sensitivity analysis was performed to a discount rate of 0% as suggested by the WHO guidelines,23 including a rate of 1.5% as suggested by some authors.35–37 Non-uniform age weighting is no longer recommended in standard methodology and is not used in this analysis.3,23,38
Interventions were considered cost-effective if their cost per DALY averted was less than triple the per capita GDP for Vietnam, the threshold suggested by the WHO. Interventions were considered very cost-effective if their cost per DALY averted was less than the per capita GDP, or $2566.60 for Vietnam according to the World Bank.39
A cost-benefit analysis was then conducted to determine economic benefit by converting DALYs to dollars. The outcome of interest was economic value as defined by the benefit-cost ratio (BCR). The macroeconomic benefit of these interventions was evaluated using both the human capital approach and the value of a statistical life (VSL). Economic benefit using the more conservative human capital approach was calculated as the total DALYs averted multiplied by the gross national income per capita for Vietnam, or $6930 based on purchasing power parity estimates from the World Bank.40
The economic benefit was also calculated using the VSL approach, the method favored by economists.41 Depending on the specific methodology, a willingness to pay method results in a VSL of $186,835 and a willingness to accept method results in a VSL of $1,246,490 in Vietnam.42 The midpoint of these 2 estimates is $716,663 and was used in this analysis. With an average life expectancy of 76.3 years, the VSL per year is estimated at $9,393. To be internally consistent with calculations of DALYs averted, constant age weighting was used.
All monetary values were converted to 2019 U.S. dollars and benefits were discounted to present value using a discounting rate of 3%. The BCR was calculated as the benefits divided by the costs, using all costs and repeated with only VE program costs. A BCR greater than one indicates good economic value, as the benefits are greater than the costs.
Cost-Effectiveness of Training Trip Programs
Cumulative direct and indirect costs for the VE trip program were $191,290 when converted to 2019 U.S. dollars.21 This basic cost analysis was presented in a previous study. Value of donated services totaled $727,844 for 7 volunteer VEs to Hanoi, 6 to Ho Chi Minh City, and 17 educators to Hue. The estimated local operating costs for performing all subsequent related procedures independently were estimated to be $1,256,192 for 1395 surgeries in Hanoi, $15,855 for 44 surgeries in Ho Chi Minh City, and $321,042 for 689 surgeries in Hue (Table 1). When only including additional procedures performed over baseline case volume, costs decrease to $660,923 for 553 operations in Hanoi, $6666 for 19 operations in Ho Chi Minh City, and $227,027 for 479 operations in Hue.
TABLE 1. -
Costs From Healthcare System Perspective
||Direct and Indirect Cost, VE Trips
||Cost Per VE Trip, Average
||Value of Donated Services, VE Program
||Est. Local Operating Cost of New Procedures Performed
||Est. Local Operating Cost of All Subsequent Procedures Performed
|Ho Chi Minh City
VE program costs from prior cost analysis.21
All costs in 2019 U.S. dollars.
Average DALYs averted per patient were calculated for each condition corresponding to topics of training during VE trips, and ranged between 0.2 and 8.6 DALYs averted per treated patient (Table 2). DWs and average DALYs averted were comparable to or more conservative than those reported in other studies.7,9–11,24 In the base case analysis, a total of 3121 DALYs were averted from the VE program (Table 3). In Hanoi, an increased volume of surgeries resulted in 2245 DALYs averted after discounting. When accounting for a potential improvement in treatment success from training, an additional 1247 DALYs were averted, for a total of 3492 DALYs averted. Microtia training in Ho Chi Minh City surgeons led to between 44 and 64 DALYs averted through new cases, a relatively low number which is unique to the condition and will be addressed in the Discussion. The VE program to Hue accounted for between 832 and 1010 additional DALYs averted.
TABLE 2. -
Disability Adjusted Life Years (DALYs) Averted Per Patient, by Condition
||Average DALYs Averted Per Patient
|Complex craniofacial (eg, craniosynostosis, hypertelorism)
|Soft tissue defect
DALYs averted are reported after discounting at a rate of 3%.
TABLE 3. -
Base Case Analysis of Cost Per DALY Averted by Reconstructive Surgery, in 2019 U.S. Dollars
|Number of DALYs Averted
||Cost per DALY Averted
||Number of DALYs Averted
||Cost per DALY Averted
|Ho Chi Minh City
Cost includes direct costs, indirect costs, value of donated services, and cost of procedures performed. New cases count DALYs averted from only the increase in case of numbers following training. All cases also account for incremental DALYs averted from existing cases due to an assumed two-fold improvement in outcomes. Cost per DALY averted <$2567 is considered very cost-effective, and <$7700 is considered cost-effective, per WHO-CHOICE criteria GDP per capita in Vietnam.
VE trip programs to each site were either cost-effective or very cost-effective regardless of whether considering only increase in case volume or accounting for treatment improvements for existing case levels. For new cases, the cost-effectiveness of VE trips at each site ranged between $384 and $3530 per DALY averted, with an overall cost-effectiveness of $581 per DALY averted across all sites. When considering all cases, the cost per DALY averted was between $417 and $2557 with an overall cost-effectiveness of $550 per DALY averted.
In 2-way sensitivity analyses of costs with ranges of DW estimates and discount rates, the overall VE program remained very cost-effective in all analyses (Table 4). When considering only costs to the organization, all VE trip programs were very cost-effective, at $61 per DALY averted overall and ranging between $19 and $792 per DALY averted by site. The cost-effectiveness of the microtia VE program in Ho Chi Minh City was sensitive to lower DW, but other more comprehensive reconstructive surgery programs in Hanoi and Hue remained very cost-effective even with the lowest DW estimates. As expected, less discounting of health effects over time increased magnitude of cost-effectiveness.
TABLE 4. -
Sensitivity Analysis of Cost Per DALY Averted by Reconstructive Surgery, in 2019 U.S. Dollars
||Base Analysis, New Cases (All Cases)
||VE Costs, New Cases (All Cases)
||Low DW Estimate, New Cases
||No Discounting, New Cases
||Lower Discount Rate, 1.5%, New Cases
|Ho Chi Minh City
VE costs refer to direct and indirect costs of the program to the organization only. Base analysis derived from Table 2
. Analyses with total costs and repeated with direct and indirect programmatic costs for VE trips only. Low DW estimate uses the lowest reported DW in the GBD and literature in calculating DALYs averted. Base discounting rate of 3% is adjusted to 1.5% and 0% for health effects.
Economic Value Through Cost-Benefit Analysis
The total economic benefit of the VE trip program to all sites was $21.6 million using the human capital approach and $29.3 million using the VSL approach (Table 5). Inclusion of all relevant cases performed following corresponding training yielded a total net economic benefit of $31.6 million using the human capital approach and $42.9 million using the VSL approach. Regardless of the approach used, interventions were considered to be of good economic value at each site. When considering all potential costs to the healthcare system, we found a 12- to 16-fold return on investment. However, when considering only the subset of costs incurred by the organization for the VE program, economic value increases to a 113-fold return on investment by the organization using the human capital approach and a 153-fold return on investment using the VSL approach.
TABLE 5. -
Cost-benefit Analysis of VE Program Using Human Capital Methodology and Lost Welfare (VSL) Methodology, in 2019 U.S. Dollars
|Economic Benefit, New Cases (BCR With All Costs, BCR With VE Costs)
||Economic Benefit, All Cases (BCR With All Costs, BCR With VE Costs)
||Economic Benefit, New Cases (BCR With All Costs, BCR With VE Costs)
||Economic Benefit, All Cases (BCR With All Costs, BCR With VE Costs)
||$15,555,368 (18.0, 368.2)
||$24,198,923 (16.6, 572.8)
||$21,083,921 (24.5, 499.1)
||$32,799,493 (22.5, 776.4)
|Ho Chi Minh City
||$304,408 (2.0, 8.8)
||$445,223 (2.7, 12.8)
||$412,598 (2.7, 11.9)
||$603,460 (3.7, 17.4)
||$5,766,252 (7.2, 50.5)
||$7,000,879 (7.9, 61.3)
||$7,815,642 (9.8, 68.4)
||$9,489,070 (10.7, 83.0)
||$21,626,028 (11.9, 113.1)
||$31,645,025 (12.6, 165.4)
||$29,312,161 (16.2, 153.2)
||$42,892,023 (17.1, 224.2)
Benefit-cost ratio (BCR) of >1 is considered good economic value.
BCR indicates benefit-cost ratio.
Our analysis demonstrates the cost-effectiveness and economic value of a reconstructive surgery VE program in a LMIC setting. The key indicators in our study include cost per DALY averted and benefit-cost ratio using both total costs to the healthcare system as well as only costs to the organization, with intermediate measures of total DALYs averted and economic benefit. We found that a VE program in Vietnam resulted in significant benefit both in terms of burden of disease and economic value, and is a very cost-effective intervention in expanding local LMIC surgical capacity with high returns on investment.
Inadequate reconstructive surgery capacity in LMICs has contributed to disability of significant magnitude and economic value. For example, the GBD study estimates that there are 21,905 preventable deaths and 1,705,359 avertable DALYs associated with scaling up cleft lip and palate surgical care in South Asia alone.2 Alkire et al estimate that the potential economic benefit of cleft lip and palate repair in just sub-Saharan Africa is over $5.4 billion.41 The results of our study, which show significant DALYs averted and economic benefit following a VE program at relatively low cost, suggest that targeted training trip programs may help alleviate this burden of reconstructive surgical disease sustainably and economically through LMIC surgical workforce capacity building.
The VE program in Vietnam compares favorably to the reported cost-effectiveness of other reconstructive surgery interventions as reported in the existing literature, although direct comparisons are difficult due to differences in assumptions and cost calculations. Traditional surgical mission trips for cleft lip and cleft palate have been demonstrated to be cost-effective at between $52 and $1827 per DALY averted.6–8 Similar short-term surgical trips to LMICs have also ranged between $222 and $1525 per DALY averted for hand surgery and $52–$2296 per DALY averted for overall reconstructive surgery,9,10 although these studies did not include value of donated volunteer time as a cost. Studies of comprehensive cleft care centers are also cost-effective, costing between $29 and over $400 per DALY averted.8,11
The value of donated services by volunteers is a significant contributor to cost when compared to actual direct and indirect costs of the VE trip program, at nearly 4 times the program costs. When comparing our results with other studies, it is important to note that this cost appears to be infrequently included elsewhere.7 Nonetheless, it can be considered an opportunity cost for work that could have been contributed to their own regional healthcare system. Even when including volunteer opportunity costs and local costs in our base analysis, the VE program to Ho Chi Minh City is cost-effective and those to Hue and Hanoi are very cost-effective, with an overall cost-effectiveness of $581 per DALY averted across all sites. When considering only the cost to the organization to conduct VE trips, as most other analyses have done, the program is remarkably cost-effective at $61 per DALY averted across all sites.
There are several other reasons why we believe the current analysis also underestimates effects of training trips. Case volume is measured only through June 2019, although the benefits to patients continue to accrue over their entire professional lifetime of the trainee surgeon. Surgeons also subsequently train local residents and regional surgeons, creating a multiplier effect long term.21,43,44 The ongoing accumulation of case volume is also important because greater surgical volume may decrease morbidity and mortality.45,46 Additionally, by measuring case volume, we do not assess the benefits of nonoperative care provided to patients as a result of VE trip education, which can also contribute to reducing patient morbidity and disability.2 In essence, the VE trip model utilizes intermittent cost to provide sustained health effects and economic benefit, of which only a portion is captured in this analysis. Future analyses to model the cumulative long-term effects of training would be valuable but are beyond the scope of the present study.
While the overall VE program is very cost-effective and economically valuable in all analyses performed, our programs have varied in cost-effectiveness and benefit-cost ratio across the 3 sites. Both trips to Ho Chi Minh City focused on microtia reconstruction and were cost-effective. However, the cost-effectiveness was sensitive to large changes in patient disability level, likely due to relatively lower disability and volume when compared to other conditions. Our analysis confirms that interventions should preferably train for conditions associated with greater disability to remain cost-effective, but that training for conditions with lower disability can still be cost-effective if training can be completed in 1 or 2 visiting trips.
This study, like all cost-utility studies, is inherently subject to some limitations. While the DALY and DWs are now standard metrics, they have methodological criticisms and can be inconsistent.47 Discounting of health effects is controversial, and several authors have suggested that health effects should be discounted less or not at all.35,48–52 In this study, attempts were made to provide a conservative estimate of both costs and health effects. As expected, using a lower discount rate or eliminating discounting altogether substantially increases the degree of cost-effectiveness of the VE program. With regard to estimating economic benefit of an intervention, the 2 commonly used approaches can differ significantly as they measure conceptually different values.41 The human capital approach likely undervalues benefit to society and accounts only for an individual’s ability to contribute to their national economy.53,54 By considering non-market welfare losses, estimates using the VSL are larger but are considered to be a better measure of benefits from a human welfare standpoint.41 The country-specific VSL utilized in our analysis is less than or comparable to values used in other economic benefit studies in cleft lip and palate in Nepal and sub-Saharan Africa.11,41 Overall, regardless of which method is used, the VE program in Vietnam has created an impressive $21.6–$42.9 million in economic value through improvements in health, corresponding to a 113- to 224-fold return on investment by donors and the organization.
It should be noted that many factors contribute to surgical capacity, including potential changes in local healthcare infrastructure or policy, epidemiology, patient interest or awareness, or other avenues of training and education. ReSurge International’s goal is to work synergistically with these other improvements, but we acknowledge that the changes observed may not be attributable to any one given intervention. Given the large remaining margin to reach the World Health Organization project on CHOosing Interventions that are Cost-Effective thresholds of cost-effectiveness or economic value, even accounting for a fraction of the health benefits would have relatively minor impact on our final determination of cost-effectiveness or economic value. We also note that our results reflect a program in Vietnam, a lower-middle-income country by World Bank guidelines,55 and might not be generalizable to other countries due to potential differences in local costs, infrastructure, and usual care. Finally, reliable data regarding long-term surgical outcomes in LMICs remain difficult to obtain and are rarely available in economic studies in this setting.56,57 In the absence of such data, our analyses utilize a conservative likelihood of treatment success to reflect expected complications from prior studies of surgical outcomes in resource-constrained settings.58–60 We and others believe that this method offers a reasonable estimate of imperfect health benefits.9,10,24,29–31 Furthermore, the investment in bringing VEs in anesthesia, therapy, and other fields potentially contributes to improved outcomes through training in comprehensive multidisciplinary peri-surgical care.2 As estimated in our analysis, incremental improvements in outcomes due to training could lead to approximately an additional 1445 DALYs averted and $10 million in economic benefit in just several years.
To our knowledge, our study is the first to estimate the cost-effectiveness and economic impact of a visiting training program to a LMIC incorporating downstream effects on surgical capacity. We have shown that VE programs are a cost-effective and economically valuable intervention to improve local reconstructive surgical capacity in a resource-constrained environment. In conjunction, our analyses provide evidence to continue to prioritize funding and support for these efforts. Investment in training can lead to large amounts of disability averted at a low cost, along with high economic benefit and return on investment for both the global healthcare system and for nonprofit organizations.
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