Cost-effectiveness of surgical interventions in low-income and middle-income countries: a systematic review and critical analysis of recent evidence

BACKGROUND: Cost-effectiveness evidence is a critical tool to support resource allocation decisions. There is growing recognition that the development of benefit packages for surgical care should be guided by such evidence, particularly in resource-constraint settings. METHODS: We conducted a systematic review of evidence (Medline, Embase, Global Health, EconLit and grey literature) on the cost-effectiveness of surgery across low-income and middle-income countries published between January 2013 and January 2023. We included studies with minor and major therapeutic surgeries and minimally invasive intraluminal and endovascular interventions. We computed and compared the average cost-effectiveness ratios (ACERs) for different surgical interventions to the respective national gross domestic product per capita to determine cost-effectiveness and to common traditional public health interventions. RESULTS: We identified 87 unique studies out of 20 070 articles screened. Studies spanned 23 countries, with China (n=20), Thailand (n=12), Brazil (n=8) and Iran (n=8) accounting for about 55% of the evidence. Overall, the median ACERs across procedure groups ranged from I$17/disability-adjusted life year (DALY) for laparotomies to I$170 186/DALY for bariatric surgeries. Most of the ACER estimates were classified as cost-effective (89%) or very cost-effective (76%). Low-complexity surgical interventions compared favourably to common public health interventions. CONCLUSION: These findings reinforce the growing body of evidence that investments in surgery are economically smart. There remains however paucity of high-quality evidence that would allow decision-makers to assess the comparative cost-effectiveness of surgery and to determine best buys across a wide range of specialties and interventions. A concerted effort is needed to advance the generation and utilisation of economic evidence in the drive towards scale-up of surgical care across low-income and middle-income countries.