title: Cost-effectiveness of surgery and its policy implications for global health: a systematic review and analysis.
abstract: BACKGROUND
  The perception of surgery as expensive and complex might be a barrier to its widespread acceptance in global health efforts. We did a systematic review and analysis of cost-effectiveness studies that assess surgical interventions in low-income and middle-income countries to help quantify the potential value of surgery.
  
  
  METHODS
  We searched Medline for all relevant articles published between Jan 1, 1996 and Jan 31, 2013, and searched the reference lists of retrieved articles. We converted all results to 2012 US$. We extracted cost-effectiveness ratios (CERs) and appraised economic assessments for their methodological quality using the 10-point Drummond checklist.
  
  
  RESULTS
  Of the 584 identified studies, 26 met full inclusion criteria. Together, these studies gave 121 independent CERs in seven categories of surgical interventions. The median CER of circumcision ($13·78 per disability-adjusted life year [DALY]) was similar to that of standard vaccinations ($12·96-25·93 per DALY) and bednets for malaria prevention ($6·48-22·04 per DALY). Median CERs of cleft lip or palate repair ($47·74 per DALY), general surgery ($82·32 per DALY), hydrocephalus surgery ($108·74 per DALY), and ophthalmic surgery ($136 per DALY) were similar to that of the BCG vaccine ($51·86-220·39 per DALY). Median CERs of caesarean sections ($315·12 per DALY) and orthopaedic surgery ($381·15 per DALY) are more favourable than those of medical treatment for ischaemic heart disease ($500·41-706·54 per DALY) and HIV treatment with multidrug antiretroviral therapy ($453·74-648·20 per DALY).
  
  
  CONCLUSIONS
  Our findings suggest that many essential surgical interventions are cost-effective or very cost-effective in resource-poor countries. Quantification of the economic value of surgery provides a strong argument for the expansion of global surgery's role in the global health movement. However, economic value should not be the only argument for resource allocation--other organisational, ethical, and political arguments can also be made for its inclusion.
authors.affiliation: Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA; Department of Surgery, Massachusetts General Hospital, Boston, MA, USA. Electronic address: tchao@partners.org.
authors.forename: Tiffany E
authors.initials: TE
authors.lastname: Chao
authors.affiliation: Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA; Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, St Louis, MO, USA.
authors.forename: Ketan
authors.initials: K
authors.lastname: Sharma
authors.affiliation: Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA; Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, MA, USA; University of Miami Miller School of Medicine, Miami, FL, USA.
authors.forename: Morgan
authors.initials: M
authors.lastname: Mandigo
authors.affiliation: Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA; Department of Pediatric Surgery, Lund University Children's Hospital, Lund, Sweden; Department of Clinical Sciences in Lund, Faculty of Medicine, Lund University, Lund, Sweden.
authors.forename: Lars
authors.initials: L
authors.lastname: Hagander
authors.affiliation: Center for Health Decision Science, Harvard School of Public Health, Boston, MA, USA.
authors.forename: Stephen C
authors.initials: SC
authors.lastname: Resch
authors.affiliation: Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA.
authors.forename: Thomas G
authors.initials: TG
authors.lastname: Weiser
authors.affiliation: Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA; Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, St Louis, MO, USA; Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, MA, USA.
authors.forename: John G
authors.initials: JG
authors.lastname: Meara
mesh_terms: D003362:Cost-Benefit Analysis; D003906:Developing Countries; D006801:Humans; D007182:Income; D011203:Poverty; D013514:Surgical Procedures, Operative / Q000191:economics*