Economic value of international missions and domestic initiatives to strengthen surgical care in low- and middle-income countries: systematic review.

Abstract

In many low- and middle-income countries (LMICs), domestic investments to strengthen surgical services compete with services delivered by international missions. While addressing the high burden of unmet surgical need is a priority, there remains limited evidence on the comparative economic value of different delivery options to guide investment decisions. Four databases and grey literature were searched for publications in any language from January 2013 to January 2023. Eligible studies evaluated the cost-effectiveness, cost-utility, or cost-benefit of international missions and domestic initiatives used for scale up of surgical care. Average cost-effectiveness ratios were computed for each intervention and then converted to 2022 international dollars (I$). Findings were synthesized narratively. A total of 32 studies were identified (17 studies evaluated domestic surgical system strengthening programmes, 14 studies assessed international missions, and 1 study directly compared a domestic surgical development initiative against international missions). Financial protection schemes, investments in physical infrastructure, surgical residency training, and local missions were cost-effective, as were most of the international missions, compared with status quo or no intervention. However, when compared head-to-head, the unit costs per disability-adjusted life-year averted of domestic initiatives were significantly lower relative to the international missions-mean (standard deviation) I$27 051 (I$65 360) and median (interquartile range) I$498 (I$602) versus mean (standard deviation) I$515 500 (I$1 528 716) and median (interquartile range) I$5068 (I$31 618). The difference was statistically significant (Wilcoxon rank-sum test: z = 2.412; P = 0.016). Investments in domestic surgical system strengthening efforts provide better value for money than international missions and should be prioritized over international missions.