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
Outline The question The model The results
THE QUESTION
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):1-77 2 Surgical society of Ethiopia (www.sseth.org) 3 Central Statistical Agency [Ethiopia] and ICF International (212). Ethiopia Demographic and Health Survey, 211.
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.
Addressing the barriers COST Free-at-the-point-of-care Universal public finance PROVIDER Task-shifting BOTH Task-shifting + UPF
THE MODEL
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
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 $12.183.282.3.194.742 Uterine Sepsis $12.183.22.3.154.22 Uterine rupture $12.183.214.3.14.27 Hysterectomy $12.183.2.3.14.27 Ectopic Pregnancy $12.183.3.75*.46.46 D&C $12.183.22.3.154.22 C-section $12.183.282.3.194.742 Appendectomy $122.265.12.7.354.14 Abdominal Trauma Long-bone fracture Thoracic trauma Need for amputation $159.89.133.923.5.242 $143.18 *.6.2.667 $159.89.16 1.*.15.263 $143.18.29.75.86.248 Obstetric conditions:.2354 Appendicitis:.3 Traumatic conditions:.6285
Model structure
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
Other assumptions Surgical care by a technician was more morbid and less expensive 1.125 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 113:28-31 2 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
.28.175.17.133.66 1.38 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, http://data.worldbank.org/indicator/sh.sta.mmrt (Accessed 1 June 213) 3 WHO, Unicef, UNFPA, World Bank (212). Trends in Maternal Mortality: 199 212
THE RESULTS
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 241.2517 158.36533 148.941 144.5493 23.696 Appendicitis 54.7661 26.4232 27.84618 Trauma 1876.7497 95.38483 954.24687 Total 2172.5424 19.1749 113.99715 144.5493 23.696 Obstetric 165.4677 37.54867 188.91785 275.6472 66.7587 Appendicitis 79.3847 46.3421 51.71177 Trauma 266.2974 1553.77 1732.9561 Total 295.14917 196.89145 1973.5823 275.6472 66.7587 Obstetric 44.26 465.57 336.6251 419.529613 92.2391 Appendicitis 497.2945 219.3674 24.7397.9587956 Trauma 16579.4527 7344.5123 87.3689 32.82272363 Total 1748.9532 828.934 8647.7338 452.4482162 92.2391 Obstetric -646-798 -419 Appendicitis -11-81 183 Trauma -11,666-16,976 231,582 9633 Total -12,422-17,855 232,246 9633 Obstetric -124-12 -61 Appendicitis -119-15 -7 Trauma -21,357-31,63-153 Total -22,716-32,773-68 -153 Obstetric -1912-132 544-146 Appendicitis -541-72 979 Trauma -1,965-147,117 21,27 9633 Total -13,418-149,139 211,73 9487 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
Proportion of deaths averted, by income quintile and disease category, UPF Obstetric Appendicitis Trauma Overall Deaths averted: UPF By income quintile and disease category.6.5.4.3.2.1 Poorest Poor Middle Rich Richest
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.5.45.4.35.3.25.2.15.1.5 Poorest Poor Middle Rich Richest
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.6.5.4.3.2.1 Poorest Poor Middle Rich Richest
Cases of poverty averted 2 Health vs. Financial risk protection per $1, spent, overall Health versus FRP Per $1, spent 1-1 -2-3 Deaths averted 2 4 6 8 1 12 14 16 18-4 -5-6 -7-8 UPF Task shifting UPF + Task shifting
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 6 5 4 3 2 1-1 Rich Richest Poor Poorest 1 2 3 4 5 6 7 Deaths averted Middle 2-2 -4-6 -8-1 -12-14 -16 Poorest Rich 1 2 3 4 5 6 7 Deaths averted Poor Richest Middle 6 5 4 3 2 1-1 -2-3 -4 Rich Richest Poor Poorest 5 1 15 2 25 3 35 4 Deaths averted Middle The rich get richer The poor get healthier The rich get healthier (and poorer) The poor get poorer (and healthier)
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 1 8 6 4 2-2 -4-6 -8 5 Borrowing and Selling vs. Deaths averted/$1, spent 5 1 15 2 9 8 7 6 5 4 3 2 1 Rich Deaths averted -1 1 2 3 4 5 6 7-2 Poor UPF TS UPF + Task shifting Deaths averted Poorest Task shifting Rich 1 2 3 4 5 6 7 1 8 6 Richest Richest UPF Task shifting + UPF Middle -5 4-1 -15-2 Poorest Poor Middle Deaths averted Richest 2-2 -4-6 Rich 5 1 15 2 25 3 35 4 Poor Middle Poorest Deaths averted
CONCLUSIONS
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
Cases of poverty averted Cases of poverty averted Cases of poverty averted Questions? UPF Task shifting Task shifting + UPF 6 5 4 3 2 1-1 Rich Richest Poor Poorest 1 2 3 4 5 6 7 Deaths averted Middle 2-2 -4-6 -8-1 -12-14 -16 Poorest Rich 1 2 3 4 5 6 7 Deaths averted Poor Richest Middle 6 5 4 3 2 1-1 -2-3 -4 Rich Richest Poor Poorest 5 1 15 2 25 3 35 4 Deaths averted Middle