Evaluating Access Improving Interventions: An Economic Evaluation of Surgical Task-Shifting for C-Sections in Sierra Leone.

Abstract

Background: Access to safe, timely and affordable surgical care is lacking globally. Less than 6% of all surgical operations are carried out in low- and middle-income countries, where over a third of the world's population lives. CapaCare, an NGO operating in Sierra Leone, have developed a surgical training programme (STP) for Associate Clinicians based on principles of task-shifting to improve access. Interventions to increase healthcare access have the same value evidence requirements as new technologies but their evaluation presents methodological challenges as access is not routinely incorporated explicitly in economic evaluations.

Objective: To evaluate the cost-effectiveness of surgical task-shifting in Sierra Leone, implemented through the CapaCare STP, to increase provision of caesarean section (C-section).

Methods: We evaluated the impact of the STP on the provision of C-section and subsequent maternal and child outcomes, measured in disability-adjusted life-years (DALYs), relative to the costs using a healthcare system perspective and decision-tree model parameterised using data from surgical logbooks, national data, and the literature.

Results: Results indicate that the surgical task-shifting programme in Sierra Leone would be considered cost-effective in increasing provision for C-section. It is cost saving (USD - 16.77) and results in 2.14 DALYs averted, per women with an indication for C-section, due to avoidance of maternal and child deaths as well as reduced complications.

Conclusion: Investment in surgical task-shifting initiatives should be considered by policymakers as a potentially cost-effective way to increase access to quality surgical services. Future evaluations of access-increasing interventions should seek to capture the distributional impact of this strategy and system benefits.