title: Cost-effectiveness of extracorporeal shock wave lithotripsy in a poor resource setting: The Okada, Nigeria experience.
abstract: BACKGROUND
  The first extracorporeal shock wave lithotripsy (ESWL) used in Nigeria was at Igbinedion Hospital and Medical Research Centre (IHMRC), Okada in 1992 and it functioned for 6 consecutive years. The objectives of this study were to analyze the cost-effectiveness of the procedure and highlight the associated factors that led to its failure.
  
  
  METHODS
  A retrospective study of medical records and publications associated with the use of ESWL at IHMRC, Okada, for the period of 1992 to 1998. The study was conducted between January 2003 and November 2008. Unclassified authentic information relating to the use of ESWL and treatment of upper urinary tract stones was obtained from the IHMRC Okada and some government hospitals on hospital bills. Relevant documents in public domains related to the national and international wages and emoluments of medical workers and socioeconomic development of Nigeria within the time the ESWL functioned were studied.
  
  
  RESULTS
  A total of 32 patients were treated with 51 treatment sessions which is an average of nine patients per year and an average of two treatment sessions per patient were involved. The reasons for the low patronage were the extremely low stone formation rate of Nigerians, poverty, and out-of-pocket payment system. In addition, each treatment session of ESWL at Okada cost an average of $681.8 compared to $227.3 for open nephrolithotomy in a nearby high profile teaching hospital. The IHMRC, Okada, paid an average annual salary of ₦180,000 ($8,181.8) for each medical consultant compared to ₦120,000 ($5,454.5) paid by federal teaching hospitals in Nigeria within the period. Expatriate consultant doctors from Europe and USA who initially manned the lithotriptor at IHMRC, Okada, were paid much higher salaries. Average annual income of $5,909 for each of the 6 years amounting to a total of $34,771.7 for the six years was realized which could not maintain staff salaries in the hospital leading to staff emigration, decline of the hospital services, and eventual closure of the ESWL procedure center in the hospital in 1998.
  
  
  CONCLUSIONS
  ESWL at Okada was not cost-effective both to patients and the hospital management. Despite these, ESWL is desirable in poor-resource countries because of its noninvasiveness, low morbidity, and usability in patients who are unfit for open surgery. Purchasing high technological medical equipment as commodities by sub-Saharan Africans without considering the prevalence of diseases they are meant to cater for, their maintenance for steady function during useful lifespan, their cost-effectiveness and how to recoup the money spent on investments depletes the scarce foreign exchange reserve of the home countries and is eventually counterproductive as exemplified by this case.
authors.affiliation: Department of Radiology, Faculty of Medicine, College of Health Sciences, Nnamdi Azikiwe University, Awka, Anambra State, Nigeria.
authors.forename: Kenneth C
authors.initials: KC
authors.lastname: Eze
authors.affiliation: Department of Surgery (Urology Unit), Faculty of Clinical Sciences, College of Medicine, Ambrose Alli University, Ekpoma, Edo State, Nigeria.
authors.forename: E
authors.initials: E
authors.lastname: Irekpita
authors.affiliation: Department of Medicine, Faculty of Clinical Sciences, College of Medicine, Ambrose Alli University, Ekpoma, Edo State, Nigeria.
authors.forename: T A
authors.initials: TA
authors.lastname: Salami
keywords: Calculi; Nigeria; cost; cost-effectiveness; developing countries; extracorporeal shock wave lithotripsy; high personnel cost; poverty; prevalence