C.P. Nicholson1,2, A. Saxton2, K. Young4, E.R. Smith6,7, M.G. Shrime8,9, J. Fielder5, T. Catena4, H.E. Rice2,6,7 1University Of California – Los Angeles, Surgery, Los Angeles, CA, USA 2Duke University Medical Center, Surgery, Durham, NC, USA 4Mother of Mercy-Gidel Hospital, Gidel, NUBA MOUNTAINS, Sudan 5African Mission Healthcare, DeLand, FL, USA 6Duke Center for Global Surgery and Health Equity, Surgery, Durham, NC, USA 7Duke Global Health Institute, Durham, NC, USA 8Mercy Ships, Garden Valley, TX, USA 9Harvard Medical School, Division Of Global Health And Social Medicine, Cambridge, MA, USA
Introduction: The delivery of healthcare in conflict regions poses tremendous strains to health systems, and the economic value of surgical care in conflict settings remains poorly understood. Our aims were to evaluate the cost-effectiveness, societal economic benefits, and return on investment (ROI) for surgical care in a conflict zone in Sudan.
Methods: We conducted a retrospective study of surgical care at the Mother of Mercy-Gidel Hospital (MMH) in Sudan from January to December 2022. We collected data on all patients undergoing surgical procedures (n=3016), including age, condition, and procedure. We used the MMH budget and financial statements to measure direct medical and non-medical expenditures (costs) for care. We estimated the proportion of expenditures for surgical care through a five-day survey of surgical vs non-surgical beds. The benefits of care were calculated as averted disability-adjusted life-years (DALYa) based on predicted outcomes for the most common 81% of procedures, and then extrapolated to the overall cohort. We calculated the average cost-effectiveness ratio (CER) of care. The societal economic benefits of surgical care were modeled using a human capital approach, and we performed a ROI analysis. Uncertainty was estimated using sensitivity analysis.
Results: We found that the CER for all surgical care was $72.54/DALYa. This CER is far less than the gross domestic product per capita in the culturally and politically similar comparator economy of South Sudan ($585), qualifying it as very cost-effective by World Health Organization standards. The total societal economic impact of surgical care was $9,124,686, yielding a greater than 14:1 ROI ratio. Sensitivity analysis confirmed relative confidence in all output models.
Conclusion: Surgical care at MMH in Sudan is very cost-effective, provides substantial societal economic benefits, and a high return on investment. Expansion of surgical capacity in this conflict region may address local health needs as well as improve the regional economy.