“If you are looking at the economic impact of surgery on women and their households, then the costs associated with surgery are not straightforward.”
Lesong is a senior lecturer in health economics at Imperial College London. Her research focuses on low- and middle-income country (LMIC) health economics and health system research, primarily in sub-Saharan Africa. She’s a Commissioner on the Lancet Commission on Global Surgery.
Your background is in health economics and infectious diseases. Did anything surprise you when you first started looking at global surgery?
Lack of economic evidence. I assumed there would be more data on the costs, cost effectiveness and financing of surgery, but what we have is so disparate.
The clinical evidence for surgery is of course strong, but we’re also forced to acknowledge there’s a fixed budget. A minister of finance – who is often equally important as a minister of health in decisions about health provision – needs a strong case for why they should invest in surgery and not some other health or non-health activity.
It’s hard to make your case for investment when you don’t have the data to support you.
Global surgery isn’t a new concept. Why do you think it has taken time for momentum to develop?
Surgery doesn’t have its own Millennium Development Goal [MDG] – it’s subsumed in with the other issues. When we say ‘surgery’ it means so many different things to people that it gets diluted and does not have a clear ‘identity’ or ‘brand’ that people can quickly understand.
When you start talking about an essential package of surgical care even surgeons themselves find it hard to reach a consensus. And if those inside the tent can’t agree, it’s hard for those outside to appreciate what surgery does.
Part of the problem is a limited number of surgeons who have time set aside to advocate for global surgery. They’re so busy that it’s hard for them to protect time to reach out and build a global movement.
Why do you think surgery is an essential component of women’s health, of global health?
It touches everyone, at every age. It relates to the focused MDG on maternal health and also shapes the broader MDG that promotes gender equality and empowerment of women.
It is often life changing, you can go in for your operation, you’re incredibly unwell – then you have surgery and within a matter of minutes, hours, days, you can be back to full capacity.
You could almost couch this in a human rights narrative. It’s a human right for women to access essential, safe, good quality surgical interventions.
What’s the economic perspective?
The first question to ask here is who’s economic perspective?
If you are talking about the Ministry of Health, then when you look at providing surgery it can be very expensive. However, it’s a perfect example of what economists refer to as economies of scope. Build the theatres and suddenly you can provide a range of services and operations. Your costs aren’t necessarily going to escalate linearly and you can do a lot, you can help a lot of people.
If you are looking at the economic impact of surgery on women and their household’s, then the costs associated with surgery are not straightforward. Costs of not accessing care can be catastrophic, however the financial cost of having an operation can also be very high, certainly when there is out of pocket expenditure for the operation itself and add to that costs of transport and food etc. Therefore it is important to compare the cost of surgery to the cost of living with certain conditions for a lifetime, then not only is there a clear health benefit, but there is likely to be a clear economic case for surgery.
And of course from a macroeconomic perspective it makes sense to have these women who need surgery healthy again, contributing to the economy and helping bring up the next generation.
How else do you rationalize the need for global surgery?
What I’m aware of now, as we start this work with the Lancet Commission, is that there is – in a way that works against surgery – emphasis on primary and preventative healthcare. Surgery seems almost a luxury until you have those other things covered.
But as we move to universal healthcare we have to realize that you can’t have either or. Surgery isn’t a substitute, it’s integral to reaching some of these goals.
It touches all of us, in our everyday lives. So the question is, how do you relate the importance of surgery, how do you get peoples’ attention? We all know someone who has had an operation, and that’s a central narrative coming out of our first Lancet meeting. The human element.