SURGICAL CARE IN ETHIOPIA:

Transcription

1 SURGICAL CARE IN ETHIOPIA: TASK-SHIFTING, PUBLIC FINANCE, OR BOTH? M ARK G. S HRIME, MD MPH FACS S TEPHANE V ERGUET, MS MPP P HD K JELL A RNE J OHANSSON, MD P HD D EAN JAMISON, P HD M ARGARET E. K RUK, MD MPH

2 Outline The question The model The results

3 THE QUESTION

4 Surgical care in rural Ethiopia is limited 83% of Ethiopia is rural Fewer than 4 surgeons in the country 1,2 16.5% of women deliver in a facility every year 3 83% in Addis Ababa As few as 3% in rural Ethiopia 1 Berhan Y (28). Medical doctors profile in Ethiopia: production, attrition, and retention. Ethiop Med J 46(S1): Surgical society of Ethiopia ( 3 Central Statistical Agency [Ethiopia] and ICF International (212). Ethiopia Demographic and Health Survey, 211.

5 Barriers to care are legion OBSTETRIC SURGICAL CARE Most patients list care not needed or care not customary 1% list cost/transportation 6-25% list lack of provider NON-OBSTETRIC SURGICAL CARE Few list care not needed or care not customary 2-25% list cost/transportation 15-3% list lack of provider/quality 5-65% list both 1 Central Statistical Agency [Ethiopia] and ICF International (212). Ethiopia Demographic and Health Survey, 211.

6 Addressing the barriers COST Free-at-the-point-of-care Universal public finance PROVIDER Task-shifting BOTH Task-shifting + UPF

7 THE MODEL

8 Life- and limb-threatening conditions OBSTETRIC SURGICAL CARE Caesarian section Abortion/D&C Ectopic pregnancy Obstructed labor Uterine rupture Uterine sepsis Hysterectomy NON-OBSTETRIC SURGICAL CARE Appendectomy Trauma Abdominal trauma Thoracic trauma Amputation Uncomplicated fracture

9 Model inputs SOURCES Procedure cost Periop mortality Mortality, untreated Major complication rate Minor complicati on rate Prevalence Ethiopia 211 DHS survey WHO Global health observatory Literature search Ethiopia Sub-Saharan Africa Other developing nations/regions Developed nations Assumption Obstructed Labor $ Uterine Sepsis $ Uterine rupture $ Hysterectomy $ Ectopic Pregnancy $ * D&C $ C-section $ Appendectomy $ Abdominal Trauma Long-bone fracture Thoracic trauma Need for amputation $ $ * $ * $ Obstetric conditions:.2354 Appendicitis:.3 Traumatic conditions:.6285

10 Model structure

11 Other assumptions Direct, non-medical costs included 1 Varied by where care was rendered Friction costs excluded Patients who would have received care from a surgeon in the status quo still received care from a surgeon under task-shifting No spillover 1% increase in demand for obstetric services under UPF Sensitivity analysis: increased demand to meet utilization in Addis Ababa Poverty creation Absolute threshold used 1 Kifle YA and Nigatu TH (21). Cost-effectiveness analysis of clinical specialist outreach as compared to referral system in Ethiopia: an economic evaluation. Cost Eff Res Alloc 8:13

12 Other assumptions Surgical care by a technician was more morbid and less expensive times the morbidity/mortality 1.7 times the cost 2 1 Gessessew A, et al (211). Task shifting and sharing in Tigray, Ethiopia to achieve comprehensive emergency obstetric care. Int J Obs Gyn 113: Vlassof M, et al (28). Economic impact of unsafe abortion-related morbidity and mortality: evidence and estimation challenges. IDS Research Report 59, University of Sussex, Brighton, UK

13 Model calibration DEATHS PER THOUSAND GBD estimates Model estimates *GBD 1 estimates for all of Ethiopia; model estimates for rural Ethiopia MATERNAL MORTALITY RATIO WB: 2 35 Model: 374 MATERNAL DEATHS Unicef: 3 9 Model: 9255 APPENDICITIS TRAUMA MATERNAL CAUSES 1 WHO Global Burden of Disease, 24 2 World Bank data, (Accessed 1 June 213) 3 WHO, Unicef, UNFPA, World Bank (212). Trends in Maternal Mortality:

14 THE RESULTS

15 Dashboard Deaths averted Cases of poverty averted System cost UPF Task shifting Both UPF Task shifting Both UPF Task shifting Both Wealth quintile Poorest Poor Middle Rich Richest Obstetric Appendicitis Trauma Total Obstetric Appendicitis Trauma Total Obstetric Appendicitis Trauma Total Obstetric Appendicitis Trauma -11,666-16, , Total -12,422-17, , Obstetric Appendicitis Trauma -21,357-31, Total -22,716-32, Obstetric Appendicitis Trauma -1, ,117 21, Total -13, , , Obstetric $9,52 $6,114 $56,323 $64,173 $36,44 Appendicitis $11,291 $78,634 $72,537 $86,724 $26,713 Trauma $32,919,344 $22,927,684 $21,15,143 $25,286,59 $7,789,62 Total $33,122,766 $23,66,432 $21,279,3 $25,437,487 $7,852,18 Obstetric $25,263 $46,955 $28,843 $42,85 $1,192 Appendicitis $6,51 $3,8 $4,241 $ $ Trauma $1,94,912 $1,112,3 $1,24,883 $ $ Total $1,936,685 $1,162,785 $1,273,967 $42,85 $1,192 Obstetric $97,386 $119,41 $83,586 $118,777 $74,588 Appendicitis $21,551 $1,611 $97,629 $88,937 $26,714 Trauma $47,433,318 $29,365,23 $28,496,849 $25,926,73 $7,789,62 Total $47,732,255 $29,585,242 $28,678,63 $26,134,444 $7,89,364

16 Proportion of deaths averted, by income quintile and disease category, UPF Obstetric Appendicitis Trauma Overall Deaths averted: UPF By income quintile and disease category Poorest Poor Middle Rich Richest

17 Proportion of deaths averted, by income quintile and disease category, Task shifting Obstetric Appendicitis Trauma Overall Deaths averted: Task shifting By income quintile and disease category Poorest Poor Middle Rich Richest

18 Proportion of deaths averted, by income quintile and disease category, Task shifting + UPF Obstetric Appendicitis Trauma Overall Deaths averted: Task shifting + UPF By income quintile and disease category Poorest Poor Middle Rich Richest

19 Cases of poverty averted 2 Health vs. Financial risk protection per $1, spent, overall Health versus FRP Per $1, spent Deaths averted UPF Task shifting UPF + Task shifting

20 Cases of poverty averted Cases of poverty averted Cases of poverty averted Health versus FRP Cases of poverty averted UPF Task shifting Task shifting + UPF Rich Richest Poor Poorest Deaths averted Middle Poorest Rich Deaths averted Poor Richest Middle Rich Richest Poor Poorest Deaths averted Middle The rich get richer The poor get healthier The rich get healthier (and poorer) The poor get poorer (and healthier)

21 Cases of forced borrowing/selling averted Cases of forced borrowing/selling averted Cases of forced borrowing/selling averted Cases of forced borrowing/selling averted Health versus FRP Cases of forced borrowing and selling averted Borrowing and Selling vs. Deaths averted/$1, spent Rich Deaths averted Poor UPF TS UPF + Task shifting Deaths averted Poorest Task shifting Rich Richest Richest UPF Task shifting + UPF Middle Poorest Poor Middle Deaths averted Richest Rich Poor Middle Poorest Deaths averted

22 CONCLUSIONS

23 Conclusions Health improvement and financial risk protection are in tension UPF improves FRP with small effect on deaths Task shifting creates cases of poverty, but averts significantly more deaths The distribution of benefits among rural Ethiopia depends on the intervention UPF improves the health of the poorest and the financial state of the richest Task shifting improves the health of the richest, and creates more poverty in the poorest

24 Cases of poverty averted Cases of poverty averted Cases of poverty averted Questions? UPF Task shifting Task shifting + UPF Rich Richest Poor Poorest Deaths averted Middle Poorest Rich Deaths averted Poor Richest Middle Rich Richest Poor Poorest Deaths averted Middle