67. Surgery

The estimated economic costs in this chapter assume staffing and service levels generally derived from World Health Organization recommendations for developing countries (Mulligan and others 2003), but in many places, surgical services are delivered in much simpler and less expensive facilities. Independent project hospitals (NGO hospitals) often operate on remarkably tight budgets. Private hospitals, often set up in private houses by individual surgeons, use locally trained staff with minimal "hotel" service. Extremely poor countries operate hospitals with a cost per patient per day of US$10 or less simply because they cannot afford more. Such hospitals achieve financial savings in several ways:

• Unpaid family members provide personal nursing care and food, eliminating the need for a kitchen and many trained nurses.

• Locally trained staff members substitute for professionally trained personnel.

• Many staff members have duplicate functions. In the operating room the same person may work as surgical assistant, scrub nurse, and orderly who cleans instruments or transports patients.

• Day staff members cover night calls for emergencies.

• Specialized services are provided by general physicians or technicians trained to do surgery or give anesthesia.

• Laboratory tests and x-rays are used sparingly. The only laboratory procedure for an obstetrical patient could be a hemoglobin determination.

• Only basic medicines are provided. More expensive or complicated supplies are purchased outside the hospital by the family.

For one independent, nongovernmental hospital in Bangladesh, we were able to obtain the actual financial cost of all aspects of hospital operations during a three-month period. These costs included salaries, supplies, hotel costs, and depreciated cost of equipment and buildings, as well as an overhead estimate to allocate a share of the total project cost for administration, electricity, transportation, and so on. Separating the surgical service costs for 3 months, extrapolated to 12 months and a 100-bed hospital, we come up with a much lower total cost than the low estimate in this chapter for the economic costs of a model district hospital, as shown in the table below. Part of the difference is caused by differing cost definitions (financial versus economic), but a good part is owing to the use of low-cost approaches to the delivery of surgical care.