Finance and Economics

The Lancet Commission on Global Surgery Boston Dec 2013

Finance and Economics

Working GroupTerms of Reference

Working Group Membership

Group Lead: Gavin Yamey

Commissioners: LesongConteh, Anna Dare, John Meara, Gavin Yamey, Winnie Yip

Facilitator: Anna Dare

Research Assistants: Morgan Mandigo, Lily Gutnik, Kathleen O’Neill

Terms of Reference Overview

1. Economic Impact
2. Financing

Table of Contents

Introduction

Objectives

Key Stakeholders

Working Group Outline

White Papers

Cases

Possible Primary Research Papers

Supporting Documents

Introduction

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:

1. At least 2 tables and 2 figures to be used in the commission report.
2. 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

• Content: The body of the work which needs to be done
• Process: The work plan for the coming months

Working Group Outline

1. Economic Impact
2. Patient costs of surgical care
3. Out of pocket costs
4. Can we find out what percentage is surgical from the literature on this topic, particularly for “acute care”?
5. Possible panel on anecdotes and pilot data about out of pocket costs:
6. Sierra Leone data about percentage of surgical patients who abscond due to costs
7. 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
8. India – patients must pay costs for surgery up front
9. Kenya – babies are witheld from mothers who can’t pay for obstetric care
10. Haiti – PGSSC doing a study of indirect costs for free surgeries (e.g., travel, opportunity costs, meals, companion costs)
11. Anna Dare has contacts in the legal field regarding human rights violations of detained surgical patients
12. How do people finance catastrophic out of pocket costs? (Margaret Kruk papers)
13. Patient/family productivity losses - During lengthy hospital stays or rehabilitation, family must often provide basic nursing care
14. Health system costs of surgical care
15. Costing methods - Depending on which method of costing is used, (e.g., top-down approach, activity based costing, time-driven activity based costing) drastically different results can be obtained.
16. How much does TDABC cost to implement? (PGSSC)
17. Costs to develop surgical infrastructure and ancillary support
18. Marginal costs of surgery - After infrastructure has been established, what is the cost of a single operation
19. Return on surgical investment
20. 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
21. Review strengths and weaknesses of this approach
22. Important weakness: Doesn’t account for implementability
23. 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)
24. 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
25. Nationwide economic impact - Increase in GDP and decreases in measures of poverty and inequity resulting from surgical investments
26. Can we actually create a model for the broader economic impact of not treating surgical conditions among men and women ages 15-49?
27. 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.
28. Pediatric surgery
29. Obstetric surgery
30. Children impacted when they accompany sick parents to hospitals
31. Children impacted when they are caretakers for sick parents
32. 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.
33. Surgery as a means of strengthening the entire health system by improving district hospitals.

1. Financing
2. Barriers
3. Donor investment – how much has gone into surgery?
4. Estimates of the bottom line- See Investing in Healthcare Lancet Commission for similar analysis for entire health systems
5. Payment models
6. 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)
7. What surgical procedures should be included in the most basic package
8. Insurance vehicles - Review examples in LMICs (e.g., Colombia, Mexico) and strengths/weaknesses of various approaches
9. Innovative financing approaches –- Julia Fan Li’s work with Gates/Oxford (e.g., tourist taxes, bonds, etc)
10. Access - Does improved surgical infrastructure merely increase health disparities as the rich are disproportionately able to overcome obstacles to care?
11. See analysis in Investing in Healthcare Lancet Commission regarding national health plan recommendations to reduce access inequities
12. 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 HôpitalUniversitaire 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. DebasHT 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.

1

Finance and Economics