THE LANCET COMMISSION ON GLOBAL SURGERY
BOSTON JAN 2014
FINANCE AND ECONOMICS
Working Group Terms of Reference
WORKING GROUP MEMBERSHIP
Group Lead:
Gavin Yamey
Commissioners:
Lesong Conteh, Anna Dare, John Meara, Gavin Yamey, Winnie Yip
Facilitator:
Anna Dare
Research Assistants:
Morgan Mandigo, Lily Gutnik, Kathleen O’Neill
TERMS OF REFERENCE OVERVIEW
I.
Economic Impact
II.
Financing
TABLE OF CONTENTS
Introduction ........................................................................................................................................................ 1
Objectives............................................................................................................................................................ 2
Key Stakeholders................................................................................................................................................ 2
Working Group Outline ................................................................................................................................... 3
White Papers ....................................................................................................................................................... 5
Cases .................................................................................................................................................................... 5
Possible Primary Research Papers ................................................................................................................... 5
Supporting Documents ..................................................................................................................................... 5
INTRODUCTION
THE LANCET COMMISSION ON GLOBAL SURGERY
BOSTON DEC 2013
The perception of exorbitant costs has historically been a barrier to the inclusion of surgery in the
global health agenda. Both governments (including ministers of health and finance) and NGOs are
tasked with the judicious use of resources when determining health priorities and policies. As such, a
discussion of the inclusion of surgery among essential healthcare services must also include a
thorough cost-benefit analysis, as well as an examination of sustainable funding mechanisms.
OBJECTIVES
1. Written. By Monday 10th May 2014, each working group will submit a four to five thousand
word output document encapsulating the terms of reference within the framework of
current state, barriers to implementation and solutions. The working group output
documents will be the substance of the final commission report, and will include:
a. At least 2 tables and 2 figures to be used in the commission report.
b. Focused recommendations to key stakeholders
2. Presentation. During the second commissioners meeting, each working group will present on
their topic to the larger commission group. This will be a 15-minute presentation with an
hour for commentary and review.
KEY STAKEHOLDERS
1. Governments (Ministries of Health & Finance in LMICs)
2. WHO
3. Multilateral/Bilateral Organizations (World Bank, USAID)
4. Foundations
5. Educational
6. Academic & Professional Entities
7. Industry
TIMELINE
Jan 7
Background documents received by Commissioners
Jan 17-18
First working group session during the January Commission meeting in
Boston.
By the end of the meeting, the working groups will have determined:
o Content: The body of the work which needs to be done
o Process: The work plan for the coming months
Jan 19 – May 10
Area of Metrics focus communicated with Information Working Group
Each working group will (e-)meet several additional times between January
and May
May 10
Each working group will submit their Output Document, including tables,
figures, and recommendations to be distributed to the commissioners for
review
May 23-24
Each working group will present their findings to the whole commission group
during the second Commission meeting in Sierra Leone
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THE LANCET COMMISSION ON GLOBAL SURGERY
BOSTON DEC 2013
WORKING GROUP OUTLINE
1. Economic Impact
a. Patient costs of surgical care
i. Out of pocket costs
1. Can we find out what percentage is surgical from the literature on
this topic, particularly for “acute care”?
2. Possible panel on anecdotes and pilot data about out of pocket costs:
a. Sierra Leone data about percentage of surgical patients who
abscond due to costs
b. Johanna Riesel (PGSSC) may be able to generate data from
Liberia about patients detained in surgical wards; data
probably available for other countries as well
c. India – patients must pay costs for surgery up front
d. Kenya – babies are witheld from mothers who can’t pay for
obstetric care
e. Haiti – PGSSC doing a study of indirect costs for free
surgeries (e.g., travel, opportunity costs, meals, companion
costs)
f. Anna Dare has contacts in the legal field regarding human
rights violations of detained surgical patients
3. How do people finance catastrophic out of pocket costs? (Margaret
Kruk papers)
ii. Patient/family productivity losses - During lengthy hospital stays or
rehabilitation, family must often provide basic nursing care
b. Health system costs of surgical care
i. Costing methods - Depending on which method of costing is used, (e.g., topdown approach, activity based costing, time-driven activity based costing)
drastically different results can be obtained.
1. How much does TDABC cost to implement? (PGSSC)
ii. Costs to develop surgical infrastructure and ancillary support
iii. Marginal costs of surgery - After infrastructure has been established, what is
the cost of a single operation
c. Return on surgical investment
i. Cost effectiveness analysis - Review different methods to compare the total
cost with an outcome (e.g., LY, DALY, QALY, HALY) and assess literature
examining cost effectiveness of various surgical procedures at a variety of
time points in a variety of countries
1. Review strengths and weaknesses of this approach
a. Important weakness: Doesn’t account for implementability
ii. Valuation of a full-health life - Reviewing the strengths and weaknesses of
this approach to describing economic gains; analyzing different methods
(e.g., human capital approach, value of a statistical life)
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THE LANCET COMMISSION ON GLOBAL SURGERY
BOSTON DEC 2013
iii. Family productivity gains - This benefit is not accounted for in cost
effectiveness analyses, but can be quite significant when family members
provide care for sick individuals and are unable to contribute to family
income
iv. Nationwide economic impact - Increase in GDP and decreases in measures
of poverty and inequity resulting from surgical investments
v. Can we actually create a model for the broader economic impact of not
treating surgical conditions among men and women ages 15-49?
vi. Bill Gates is interested in how surgical investment can benefit children (e.g.,
childhood education, children’s IQs, school attendance, school
performance). Maternal health is another priority.
1. Pediatric surgery
2. Obstetric surgery
3. Children impacted when they accompany sick parents to hospitals
4. Children impacted when they are caretakers for sick parents
5. Surgery improves hospitals, which are needed for childhood illnesses
like pneumonia, malaria, asthma. Improved oxygen and blood
services would improve treatment of these medical conditions.
vii. Surgery as a means of strengthening the entire health system by improving
district hospitals.
2. Financing
a. Barriers
i. Donor investment – how much has gone into surgery?
b. Estimates of the bottom line - See Investing in Healthcare Lancet Commission for
similar analysis for entire health systems
c. Payment models
i. Government investment - See Investing in Healthcare Lancet Commission
for analysis of increases to GDP as a result of improved healthcare, as well as
priorities for national health plans (i.e., progressive universalism)
1. What surgical procedures should be included in the most basic
package
ii. Insurance vehicles - Review examples in LMICs (e.g., Colombia, Mexico) and
strengths/weaknesses of various approaches
iii. Innovative financing approaches –- Julia Fan Li’s work with Gates/Oxford
(e.g., tourist taxes, bonds, etc)
d. Access - Does improved surgical infrastructure merely increase health disparities as
the rich are disproportionately able to overcome obstacles to care?
i. See analysis in Investing in Healthcare Lancet Commission regarding national
health plan recommendations to reduce access inequities
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THE LANCET COMMISSION ON GLOBAL SURGERY
BOSTON DEC 2013
e. Scorecard – Can we make an allocative efficiency scorecard for surgical funding?
(Gates Foundation values these.)
WHITE PAPERS
1. Cost Effectiveness Analysis (Tiffany Chao)
POSSIBLE CASES
1. TDABC at Hôpital Universitaire de Mirebalais in Haiti (Partners in Health)
2. Sharia Law in Pakistan as an example of innovative funding mechanisms?
POSSIBLE PRIMARY RESEARCH PAPERS
1. To be determined
SUPPORTING DOCUMENTS
1. Debas HT et al, Disease Control Priorities in Developing Countries 2nd edition, Chapter 67:
Surgery.
2. Jamison DT et al, Global health 2035: a world converging within a generation, Lancet 2013.
3. Silbiger SA, Ten Day MBA, Day Three: Accounting
4. van Doorslaer E et al, Effect of payments for health care on poverty estimates in 11
countries in Asia: an analysis of household survey data, Lancet 2006.
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