The Cost of Providing District-Level Surgery in Malawi

Surgery has for long been neglected in low- and middle-income countries (LMIC), as a result of which more than 95% of the population in South Asia and most of sub-Saharan Africa do not have access to basic surgical care [1]. In 2010, an estimated 16.9 million lives were lost from conditions needing surgical care; this represented almost a third (32.9%) of all deaths worldwide [2]. Only 6% of the 313 million procedures undertaken each year occur in the poorest countries, where over a third of the world’s population lives, and 143 million additional surgical procedures are needed each year to save lives and prevent disability [3].

One of the four working groups of the Lancet Commission on Global Surgery focused on the economics and financing of surgical and anaesthesia care. The group has shown that without an accelerated investment in the scale-up of surgery, LMIC will face enormous losses in economic productivity which may accumulate to around US$ 12 trillion between 2015 and 2030 [3]. The annual value of lost economic output secondary to surgical conditions will have a profound effect, especially in LMIC, where by the year 2030 surgical conditions could reduce annual growth in gross domestic products by almost 2%.

While the need for functional health systems and the structural availability of human resources, infrastructure and supplies to deliver essential surgery is clear, financing is uncertain in many LMIC and financial mechanisms inadequate. Moreover, the way health services are organised and financed in most countries does not allow a good insight into how much it actually costs to provide essential surgery, leave alone how much extra money would be required to scale up surgery in order to meet the demand.

Malawi’s national health care system is organised around district hospitals which provide first-level services to patients who are referred by primary health care units. These district hospitals in turn refer certain patients to one of the four central hospitals which provide specialist care. The bulk of the clinical care at district hospitals is provided by clinical officers. These are non-physician clinicians who, amongst many other tasks, undertake obstetric, gynaecological and basic general surgery, of which the post-operative outcomes are comparable to procedures that are performed by medical officers [4, 5]. Since 2013, the University of Malawi College of Medicine has been providing training in surgery to clinical officers, through a BSc in surgery, that received funding during the first four years through the Clinical Officers Surgical Training in Africa project (COST-Africa, see www.​costafrica.​eu). This matched pair randomised controlled trial (RCT) research project, which was funded by the European Union under its Framework Programme 7, aimed to demonstrate the effectiveness and cost-effectiveness of increasing the surgical capacity of non-physician clinicians in rural Malawi and Zambia. The trial was registered in the ISRCTN registry on 27 February 2014, under registration number 66099597.

This paper identifies the resources and estimates the costs of delivering surgery at district hospitals in Malawi; it expresses the cost of surgery as a percentage of the total annual cost of running a district hospital and calculates unit costs of selected surgical procedures.

In order to determine the annual costs of providing surgery, two questions guided the study:

Three district hospitals formed the setting of the study. Each had received two COST-Africa sponsored BSc students, who were undergoing in-service training through weekly visits from surgeon trainers. The hospitals were selected for this economic analysis out of eight candidates, mainly for reasons of convenience: Mangochi district hospital (MaDH), Mulanje district hospital (MuDH) and Nsanje district hospital (NsDH), all situated in the country’s southern region. The three hospitals are similar in terms of infrastructure and service packages offered. Each has one main operating theatre for major surgery cases and a smaller theatre for minor cases; in addition, MuDH and NsDH each have a small operating theatre within the outpatient department (OPD) for minor surgery. None of the three hospitals have designated surgical wards.

OT registers were used to count the number of surgical procedures performed over a 12-month period (from 1 July 2013 to 30 June 2014) and categorise them into four types: pregnancy-related and obstetric surgery, emergency and disability preventive surgery, injury-related surgery and other major or minor procedures, as shown in Box 1.

Step-down accounting was applied for costing. This is a relatively simple method that is recommended by the World Health Organization for generating costs and unit cost data at the health facility level in low- and middle-income countries. It identifies and quantifies the various inputs used by a health facility, estimates the total cost of each of these inputs, allocates them to cost centres and links them to the various services that are provided [6, 7]. It involves six steps of which detailed descriptions are given in Online Resource 1: (1) define the final product(s) of interest; (2) define the final, intermediate and ancillary cost centres; (3) identify all inputs and calculate the full costs of each input; (4) assign inputs to the appropriate cost centres; (5) allocate all direct costs and appropriate proportions of the costs of the inputs used at ancillary and intermediate cost centres to the final cost centre; and (6) calculate the unit cost for each service provided at the final cost centre.

Data collection took place between November 2014 and March 2015, and all data pertain to the financial year July 2013–June 2014. Online Resource 1 also describes the electronic model that was constructed to enter the data into spreadsheets, allocate costs to surgery, calculate unit costs of individual surgical procedures and estimate the cost implications of various alternatives for scaling up district-level surgery.

The key parameters of the three hospitals involved in the study are shown in Table 1.

Of note is the low bed occupancy rate at NsDH (17% compared to 50–58% at the other two hospitals), indicating overcapacity or under-utilisation of inpatient services. The total staff complement in each hospital ranged from 302 (at NsDH) to 378 (MaDH) of which about two-thirds were support staff such as hospital attendants, kitchen staff, mortuary attendants, grounds men and security guards. Clinical officers were the largest cadre of clinicians at these district hospitals, ranging from 17 to 24 per hospital, of which two (in MaDH and NsDH) or three (in MuDH) received additional surgical training through COST-Africa. MaDH had five medical officers, compared with two at MuDH and just one at NsDH. MaDH had only one trained anaesthetist versus three at the other two hospitals. In spite of its higher bed occupancy rate, MaDH had the fewest qualified nursing officers. MaDH and MuDH had much higher annual ORT budgets¹ to cover recurrent expenditure than NsDH, but the latter hospital compensated this to some extent with more external funding (from donors), which brought in almost as much as the Government ORT funding.

This paper has quantified the monetary cost of providing surgery at district hospitals in Malawi. Much of this cost is hidden to the general public and to health providers themselves, but identifying the various types of resources used in surgery, the quantities involved and their price tags, and allocating the cost of resources that are shared between the operating theatre and other departments to the appropriate services does enable a better understanding of the main cost drivers of surgery.