Economic value of international missions and domestic initiatives to strengthen surgical care in low- and middle-income countries: systematic review

Background: In many low- and middle-income countries (LMICs), domestic investments to strengthen surgical services compete with services delivered by international missions. While addressing the high burden of unmet surgical need is a priority, there remains limited evidence on the comparative economic value of different delivery options to guide investment decisions. Methods: Four databases and grey literature were searched for publications in any language from January 2013 to January 2023. Eligible studies evaluated the cost-effectiveness, cost-utility, or cost-benefit of international missions and domestic initiatives used for scale up of surgical care. Average cost-effectiveness ratios were computed for each intervention and then converted to 2022 international dollars (I$). Findings were synthesized narratively. Results: A total of 32 studies were identified (17 studies evaluated domestic surgical system strengthening programmes, 14 studies assessed international missions, and 1 study directly compared a domestic surgical development initiative against international missions). Financial protection schemes, investments in physical infrastructure, surgical residency training, and local missions were cost-effective, as were most of the international missions, compared with status quo or no intervention. However, when compared head-to-head, the unit costs per disability-adjusted life-year averted of domestic initiatives were significantly lower relative to the international missions—mean (standard deviation) I$27 051 (I$65 360) and median (interquartile range) I$498 (I$602) versus mean (standard deviation) I$515 500 (I$1 528 716) and median (interquartile range) I$5068 (I$31 618). The difference was statistically significant (Wilcoxon rank-sum test: z = 2.412; P = 0.016). Conclusion: Investments in domestic surgical system strengthening efforts provide better value for money than international missions and should be prioritized over international missions.