title: Sustainable Development in Surgery: The Health, Poverty, and Equity Impacts of Charitable Surgery in Uganda.
abstract: BACKGROUND
  The recently adopted Sustainable Development Goals call for the end of poverty and the equitable provision of healthcare. These goals are often at odds, however: health seeking can lead to catastrophic spending, an outcome for which cancer patients and the poor in resource-limited settings are at particularly high risk. How various health policies affect the additional aims of financial wellbeing and equity is poorly understood. This paper evaluates the health, financial, and equity impacts of governmental and charitable policies for surgical oncology in a resource-limited setting.
  
  
  METHODS
  Three charitable platforms for surgical oncology delivery in Uganda were compared to six governmental policies aimed at improving healthcare access. An extended cost-effectiveness analysis using an agent-based simulation model examined the numbers of lives saved, catastrophic expenditure averted, impoverishment averted, costs, and the distribution of benefits across the wealth spectrum.
  
  
  RESULTS
  Of the nine policies and platforms evaluated, two were able to provide simultaneous health and financial benefits efficiently and equitably: mobile surgical units and governmental policies that simultaneously address surgical scaleup, the cost of surgery, and the cost of transportation. Policies that only remove user fees are dominated, as is the commonly employed short-term "surgical mission trip". These results are robust to scenario and sensitivity analyses.
  
  
  CONCLUSIONS
  The most common platforms for increasing access to surgical care appear unable to provide health and financial risk protection equitably. On the other hand, mobile surgical units, to date an underutilized delivery platform, are able to deliver surgical oncology in a manner that meets sustainable development goals by improving health, financial solvency, and equity. These platforms compare favorably with policies that holistically address surgical delivery and should be considered as countries strengthen health systems.
authors.affiliation: Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, United States of America.|Office of Global Surgery, Massachusetts Eye and Ear Infirmary, Boston, MA, United States of America.
authors.forename: Mark G
authors.initials: MG
authors.lastname: Shrime
authors.affiliation: Aspen Global Health and Development, Aspen Institute, Aspen, CO, United States of America.
authors.forename: Serufusa
authors.initials: S
authors.lastname: Sekidde
authors.affiliation: Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA, United States of America.
authors.forename: Allison
authors.initials: A
authors.lastname: Linden
authors.affiliation: Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, United States of America.
authors.forename: Jessica L
authors.initials: JL
authors.lastname: Cohen
authors.affiliation: Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, MA, United States of America.|Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, United States of America.
authors.forename: Milton C
authors.initials: MC
authors.lastname: Weinstein
authors.affiliation: Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, United States of America.|Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, United States of America.
authors.forename: Joshua A
authors.initials: JA
authors.lastname: Salomon
mesh_terms: D003247:Conservation of Natural Resources / Q000191:economics*; D003362:Cost-Benefit Analysis / Q000191:economics; D005249:Fees and Charges; D013502:General Surgery / Q000191:economics*; D005102:Health Expenditures; D006297:Health Services Accessibility / Q000191:economics*; D006801:Humans; D011203:Poverty / Q000191:economics*; D014454:Uganda