New Data: Fistula Surgery Yields High Impact at a Very Low Cost

Graphic with smiling patient that says "Fistula surgery has a cost per disability-adjusted life year (DALY) averted of $58."

Peer-reviewed research demonstrates that treating fistula is highly cost-effective—more so than comparable interventions.

How far does a fistula-care dollar go? According to peer-reviewed research conducted by members of the Fistula Foundation program staff, a dollar spent on treating obstetric fistula goes remarkably far toward improving the quality of a woman’s life. Using a widely accepted method for measuring the relative value of diverse health interventions, our team rigorously analyzed the cost-effectiveness of fistula repair surgery across 143 hospital sites in 27 countries. The results of their work—published this month by the International Journal of Gynecology and Obstetrics—show that fistula surgery achieves high impact at a relatively low cost.

Masthead for IJGO publication of Fistula Foundation paper on cost-effectiveness of fistula surgery.

“We already know that fistula surgery is one of the best bargains in the field of global health,” said Kate Grant, CEO of Fistula Foundation. “With this newly released study, we now have precise data on the incredible ‘bang for the buck’ that our partners deliver when they provide transformative healing to women with fistula. I applaud the great work of our program team in publishing these findings that reinforce the case for investing in fistula treatment at scale.”

In the study, coauthors Keerthana Rajagopal (associate program manager), Lindsey Pollaczek (chief program officer), Jesse Chu (former senior program manager), and Hannah Mann (former program intern) applied a health metric known as “DALYs,” or “disability-adjusted life years.” One DALY translates into the loss of one year of healthy life. Using this metric makes it possible to assess the relative “burden” of any given condition, and to compare the disease burden of various conditions.

In evaluating the impact of an intervention like fistula repair surgery, the relevant metric is DALYs averted—the number of disability-adjusted years of healthy life that the intervention will save or restore. Quantifying impact in this way enables researchers to assess the improvement in quality of life per dollar spent on the intervention. To measure the cost-effectiveness of an intervention, researchers simply divide the cost of delivering it by the number of DALYs averted.

In 2021 and 2022, Fistula Foundation supported 13,235 surgeries for either rectovaginal fistula (RVF) or vesicovaginal fistula (VVF). An analysis of the total DALYs averted as a result of these surgeries, and of the cost of providing those procedures, revealed a cost per DALY averted of $58.

For this analysis, we did not include other types of surgery that Fistula Foundation supports, including perineal tear repair and urethral repair. The Institute for Health Metrics and Evaluation (IHME) does not publish disability-weighted assessments for those conditions. We also weighted only surgeries that resulted in a closed fistula with restored continence. This cautious approach ensured that our analysis would not overstate the effectiveness of our intervention.

To calculate the DALYs averted for RVF and VVF surgery, we compiled country-specific data on the average post-surgery lifespan of women who undergo this treatment. Next, we multiplied that data on years of restored continence by the number of successful RVF and VVF surgeries in each country. Then, crucially, we applied disability weights to the totals for each type of surgery. According to the Global Burden of Disease study conducted in 2019 by IHME, the disability weight for RVF is 0.501, and the disability weight for VVF is 0.342. Applying these weights to the RVF and VVF repairs that we supported in 2021 and 2022 yields a DALYs-averted total of 131,433.

Across our global network of partners, the total cost of providing RVF and VVF repair procedures in 2021 and 2022 was $7.6 million. (That figure encompasses direct treatment expenses, health provider fees, and costs associated with medical supplies and pre- and post-operative care.) Dividing that number by the DALYs-averted total results in a cost per DALY averted of $58.

That number compares favorably with the results of studies that apply the same DALYs-averted methodology to other interventions. A study of Operation Rainbow, an organization that provides orthopedic surgeries to children, yielded a cost per DALY averted of $343. Similarly, a study of efforts to bring full immunization to children calculated a cost per DALY averted of $438.

Another way to put the study’s finding in context is to compare the cost-per-DALY-averted figure for fistula surgery with the per-capita gross domestic product (GDP) of countries where fistula remains prevalent. According to a standard established by the WHO-CHOICE program, an intervention is highly cost-effective if the cost per DALY averted falls below that threshold. Across the 27 countries covered in the study, the average per-capita GDP is $1,212 and the lowest per-capita GDP is $364—figures that far exceed the $58-per-DALY-averted cost of fistula surgery.

Published on April 11, 2024

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