Evaluating the Economic Sustainability of Plastic and Reconstructive Surgical Efforts in the Developing World

Purpose: The lack of surgical capacity in the developing world causes substantial disability, affecting approximately five billion people worldwide.¹ In response, surgical communities provide specialty surgical care to individuals living in low- and middle-income countries (LMICs). Plastic surgeons commonly participate in short-term mission trips to deliver high volume surgical care. However, these trips are costly and often funded by charitable institutions. Evaluating the economic impact of these outreach efforts is principal to the development of sustainable healthcare in LMICs. 

Methods: We performed a retrospective analysis of clinical and cost data from ReSurge International, a non-profit organization providing plastic and reconstructive surgical care in LMICs. Using both the clinical and cost data, we conducted a (1) cost-effectiveness and (2) cost-benefit analysis to examine the economic sustainability of the interventions. We used WHO-CHOICE thresholds to evaluate the cost-effectiveness of the interventions.² We assigned a disability weight for each surgical case to calculate disability-adjusted life years (DALYs). The cost-effectiveness was reported as cost per DALY-averted. This represents the cost to avert a particular amount of disability. Additionally, we stratified cost-effectiveness by procedure type. We adopted a value of a statistical life year approach to cost-benefit analyses to calculate the economic benefit.

Results:  We examined data from 22 mission trips performed between 2015 and 2017. We analyzed a total of 778 surgical cases performed in eight different countries. Procedures performed included orofacial cleft repair (28%), burn contracture release (25%), eye ptosis repair (12%), excision for abnormal soft-tissue masses (13%), and other reconstructive surgeries (22%). The cost per DALY-averted for each trip ranged from USD$57-$11,364 and was less than three times the GDP per capita in the host country. Thus, according to WHO-CHOICE thresholds, all of these interventions are considered cost-effective or very cost-effective. When separating the procedures, orofacial cleft repair was the most cost-effective (cost per DALY-averted: USD$31). The net economic benefit ranged from USD$66,7404 to $16,046,027 for each trip. The total net economic benefit of plastic surgical outreach trips was USD$118,778,585.

Conclusions: Plastic surgery is economically sustainable in a resource-limited setting. These results indicate a substantial economic benefit of mission trips, indicating a return on investment for surgical procedures performed in LMICs. Furthermore, this study highlights the importance of adherence to a standardized checklist to collect data on mission trips performed in LMIC to provide a comprehensive framework to assess the health and economic impact of surgical mission trips in the future.

Level of Evidence:  III

References:

1. Meara JG, Leather AJM, Hagander L, et al. Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. 386(9993):569-624.
2. Edejer TT-T. Making choices in health: WHO guide to cost-effectiveness analysis. Vol 1: World Health Organization; 2003.