Surgery has long been the neglected stepchild of global health due to the commonly accepted and unquestioned notion that it is not cost-effective compared to better studied problems such as malnutrition, infectious diseases (HIV, malaria, TB), or maternal and child health (at-risk pregnancy, vaccination) [1] and relies on resources that are too specialized to be part of the basic health-care package for low- and middle-income countries (LMICs). This concept is increasingly being challenged in new studies that use the same methodologies and metrics that are used to show the benefits of other interventions and that were previously used to exclude surgical care [2–4].

Development has brought about a general increase in life expectancy with its attendant chronic diseases, while the rapid motorization of transport and mechanization of farming and industry have fueled an epidemic of high-energy injuries. Because of these irreversible changes, the need for surgical care is growing globally and will likely accelerate, although the true unmet need is unknown. What is known is the inequity in the distribution of surgical care: more than one third of the world’s population live in low-income countries (LICs), yet they receive only 3.5% of the global surgical volume [5]. The multitude of studies spawned by the Lancet Commission on Global Surgery have confirmed this: 5 billion people lack access to safe and affordable surgical and anesthesia care, and 143 million additional surgical procedures would be needed yearly to answer the unmet need (www.​lancetglobalsurg​ery.​org). There is no longer any doubt that investing in surgical and anesthesia care is very cost-effective.

A cost-effectiveness analysis (CEA) is an analytical technique or tool that correlates the effectiveness of a health intervention to its costs. It is but one tool that health systems managers and public health policy makers use for the allocation of scarce health-care resources, as they are also bound by political, moral, and ethical imperatives, both locally, nationally, and internationally. The technical advantage of a CEA is that it allows comparisons of different interventions using the same units of measurement, also called metrics. Many such metrics exist. Simple examples are dollars spent per life saved or dollars spent per complication averted, while more complex examples might add quality of life (QoL) components.

Composite metrics aim to capture different dimensions of a given condition into one summary measure and are widely used in cost-effectiveness analysis. Quality-adjusted life year (QALY), health-adjusted life expectancy (HALE), and disability-adjusted life year (DALY) are such measures. The Global Burden of Disease study (GBD) from the WHO, World Bank, and Harvard School of Public Health introduced the concept of DALY and used it as their metric of choice to determine the health burden of dissimilar diseases and conditions. The DALY is the most widely used metric within the political, economic, and social arenas of global health [6]. It is beyond the scope of this text to analyze its pros and cons, except to say that it does not meet with unanimous approval by all actors.

The DALY , like other composite metrics, is applied to populations not individuals and is the equivalent of 1 year of life lived in less than perfect health. It measures a condition that is to be avoided or minimized, as opposed to a QALY, which measures a positive goal or outcome. The DALY summarizes into one measure the two fundamental components of any disease or condition: mortality and morbidity. Premature mortality is measured in years of life lost (YLL) attributed to a given disease or condition, and morbidity is measured in years lived with disability (YLD) attributed to said disease condition. DALYs are the sum of YLLs and YLDs for a particular condition and thus represent its health burden.

As stated above, DALYs measure disease within a population. In the example of diabetes, an individual cannot be both dead and blind from it. However, to give a more accurate idea of the health burden of diabetes within a population, those living with the various disabilities caused by the disease are measured and added to the number who died prematurely from the disease. DALYs allow global or regional burdens of disparate diseases such as TB, ischemic heart disease, melanoma, or clubfeet to be measured and compared.

Other composite metrics, such as QALYs and HALEs , are used for different purposes by different organizations, seeking answers to specific questions, in various settings. For example, insurance companies, hospital management, or NGOs might measure their respective levels of success or failure in any one setting by a different metric.

Using these metrics, cost-effectiveness analysis refers to the amount of burden from condition X that can be averted by intervention Y at cost Z. In short, a CEA correlates the costs to achieve effectiveness of treatment Y on condition X and is calculated in dollars, (euro, yen, etc.) per DALY averted. This levels the playing field, making CEAs of such diverse programs as immunizations, tobacco prevention, or cataract surgery comparable since they are all measured using the same metric: dollar per DALY averted. The reader is referred to the GBD study for methodological details [6].

Only with the second edition of the Disease Control Priorities in Developing Countries (www.​dcp2.​org) in 2006 were surgery and its cost-effectiveness deemed deserving of a chapter [7]. Estimates of DALYs averted for the studied surgical interventions varied by region but were in the same ballpark: between $35 and $90 per DALY averted in LMICs at the district hospital level. These numbers came as a big surprise to most analysts and earned the unexpected “very good buy” recommendation from health economists. The third edition, published in 2015, is a collection of eight separate books, one entirely on essential surgery. It strongly reinforces the premise that essential surgical care is very cost-effective (www.​dcp3.​org).

Since this publication an increasing body of evidence has been published, supporting this recommendation: $11/DALY averted in a general hospital in Bangladesh performing general surgical and obstetric procedures [2]; $38/DALY averted in a general surgical, orthopedic, and pediatric hospital in Sierra Leone [3]; $78/DALY averted in a district trauma hospital in Cambodia for IM nailing femur fractures [4]; $9/DALY averted for cataract surgery in India; and $13/DALY averted for hernia surgery in Ghana. Though these costs are slightly more than the $10/DALY averted for measles immunization or the $15/DALY averted for insecticide-impregnated mosquito nets for malaria prevention, they compare favorably with antiretroviral therapy for HIV at around $400/DALY averted or the $500/DALY averted for tobacco prevention programs.

Certain surgeries in developing country settings turn out to be not only more cost-effective than many of the widely supported and politically correct nonsurgical public health initiatives, but when compared with procedures done in the USA—estimated $3800/DALY averted for a tibial nailing of a 20-year-old male or $48,000/DALY averted for total hip replacement in a 60-year-old male—they look to be veritable bargains.

More research is under way, and new or better methodologies are being developed to further define the surgical procedures that are cost-effective in resource-poor environments. This is a good example of how a CEA can make a strong argument for those advocating the inclusion of basic surgical care into the primary health-care armamentariums in developing countries, especially considering the need for surgical treatment of various acute and chronic conditions that will continue to increase for the foreseeable future.