The bottom line for donors

We haven't yet found a charity focusing on surgery that we can confidently recommend. We believe the Aravind Eye Care System is a standout organization, but as our full review states, it does not require donations to support its operations, as it is able to cover its costs by charging for some (not all) of the surgeries it performs.

For donors interested in improving health in the developing world, we recommend our top charities, which focus on non-surgical interventions.

For donors committed to supporting corrective surgery, we recommend starting with Interplast, which we feel stands above other charities in this area for reasons outlined in our Interplast writeup. We also recommend asking the following questions

For charities focusing on surgical missions (i.e., flying developed-world doctors overseas to perform procedures):

• Do you have volunteer surgeons available for unfunded trips? (i.e., are there trips that you could fund if you had more money, or is there a labor bottleneck?)
• Many surgeries require follow-up treatment (including additional surgeries). Do you have a way of providing these to patients?
• How do you assess whether surgeries are completed competently and appropriately? What process do you use to monitor this and can you share past results from this process?
• What is the rate of complications during and following surgery?

For charities focusing on funding local surgeons:

• How do you assess whether surgeons are performing additional surgeries that they would have not had the funding or motivation to perform otherwise?
• Related: how do you assess whether surgeons are charging their patients for the surgeries you fund?
• How do you assess whether surgeries are completed competently and appropriately? What process do you use to monitor this and can you share past results from this process?
• What is the rate of complications during and following surgery?

For charities focusing on training local surgeons:

• Do you follow up with the surgeons you've trained to assess whether they are correctly applying their training?
• What information is available on the activities - and competence - of the surgeons you've trained?
• Where do surgeons work after completing training? Do they serve poor patients?

More detail

The basics: types of surgeries and costs

In general, the charities we've seen that work on surgeries focus on addressing the following conditions.

Cataracts

Most of our information about cataract surgery comes from the Aravind Eye Care System, reviewed here. Aravind appears to perform surgeries for ~$35 each, employing local surgeons in India (and recouping its costs by charging some - though not all - of its patients). From very limited information, its surgeries appear to significantly improve vision quality. The Disease Control Priorities report seems to estimate the costliness of these surgeries as much higher, at $183 per disability-adjusted life-year (DALY) averted.1 (If a $30 surgery resulted in a single year of blindness averted, it would be equivalent to $60 per DALY averted since a year of blindness is equivalent to 0.5 DALYs.2) More on the DALY metric here.

Cleft lip/palate

A split in the lip or the roof of the mouth (palate) can lead to an extreme facial deformity (see diagrams).3 If surgery and speech therapy are not available, a child may have problems with eating, speech, hearing, and increased risk of cavities, as well as facing the social consequences of a facial deformity.4

Note that people with cleft lips or palates generally need far more than a single surgery. In the United States, children receiving cleft lip and palate surgeries generally receive 2-4 surgeries by the time they are 16. In addition, they typically receive orthodontic care and speech therapy over a number of years.5 It appears that very little is known about the long-term impact of a single surgery, in a developing nation without a comparable support system.6

Our best information about the costs of developing-world cleft surgery comes from our 2007-2008 review of Interplast. We estimate that a surgical mission (i.e., flying developed-world doctors overseas to perform procedures) can perform one cleft surgery for every ~$1400 spent.7 The use of local surgeons can be significantly cheaper: a total cost - including administrative expenses - of ~$400 per surgery, although this approach raises some additional concerns about quality and use of skilled labor (discussed further below).8

A paper by Interplast's Chief Medical Officer estimates that each surgery in this category is equivalent to 4.6 disability-adjusted life-years (DALYs) averted,9 which would imply that missions cost ~$300 per DALY averted and local operations cost ~$87. (More on the DALY metric here).

Obstetric fistula

Obstetric fistula is a term for a "hole between the mother's vagina and bladder ... or between the vagina and rectum ... or both" resulting in "leaking of urine or faeces or both."10 It appears that technical literature on this condition is relatively thin, perhaps because the condition is extremely rare outside of the developing world.11 A Lancet publication on a specific type of obstetric fistula (vesicovaginal12) implies that reconstructive surgery is possible, but relatively complex with a significant failure rate,13 and may leave women incontinent even after the hole is closed.14 The details of how surgery is performed appear not to be standardized, and variations may be important to the outcome.15

We find fistula repair surgery to be an extremely promising intervention that addresses a devastating problem, but we have found very little non-anecdotal information on it. We have not identified a charity we can be confident in in this area, nor are we able to provide any reliable information on cost-effectiveness aside from an unsourced claim by the Campaign to End Fistula that "The average cost of fistula treatment —including surgery, post-operative care and rehabilitation support—is $300."16 It seems unlikely to us that fistula repair is less costly than cleft repair (which we estimate as costing significantly more than $300 per surgery, as discussed directly above), since fistula repair appears to have more complexity and a higher failure rate.

Charities working to address this problem are engaged in a wide variety of activities including funding general hospitals and specialty fistula centers, training surgeons in fistula repair techniques, increasing public awareness of the problem through written and documentary film mediums, and funding research and technical publications to increase knowledge of the subject.

Other conditions

Interplast addresses a variety of other conditions including hand conditions and burn scars.17 Burn scar repair appears slightly, though not much, costlier than other surgeries;18 we are not able to estimate the costs of other surgeries separately. We believe that the severity of these conditions and the impact of surgery varies extremely widely,19 though Interplast's representative has stated to us that they are generally highly debilitating.20

General concerns about surgeries

Before supporting a charity in this area, we would need to have substantial information addressing the following concerns:

1. What is the bottleneck to more surgeries: money or skilled labor?

We believe that in many cases, funding isn't the bottleneck to more surgeries - surgeons are. In addition to our general concern about diverting skilled labor within the developing world, we have some additional specific reasons for concern in this area:

• A discussion of this problem with an Interplast representative who stated that surgical centers are often overbooked and charitable funding of local surgeons may result in changes in which people (rather than how many people) are treated.21
• Financial data from Smile Train, a large organization that focuses on utilizing developing-worlds surgeons (rather than on flying developed-world surgeons overseas), indicates that a large proportion of funds are regranted to other (mostly large) charities22raising the question of whether additional funds can be productively used for the core activity of supporting local surgeons.

• We are also concerned about possible distortive effects of fees paid to surgeons. For example, Interplast states that a cleft palate surgery is more time-consuming than a cleft lip surgery, while the time to perform burn surgeries varies dramatically.23 (Note that a cleft palate is believed to have a higher effect on quality of life than a cleft lip).24 Flat fee-per-surgery arrangements may therefore result in surgeons' shifting toward shorter, simpler surgeries.

• We are generally concerned that the model of paying developing-world surgeons to perform more surgeries may result in more revenue for surgeons or changes in whom they treat, but does not increase the supply of skilled labor and thus ultimately does not result in more surgeries.
• A similar problem may apply to missions (i.e., flying developed-world surgeons overseas). Missions rely on volunteer surgeons,25 without which they would likely be far more expensive than the numbers that are generally quoted (numbers that are fairly expensive as is).26

Before donating to a charity that funds local surgeons, we would require a compelling answer to the question of how more funds will translate to more surgeries - for example, credible data on surgeons eligible for funding but not receiving it because of limited available funds.

Similarly, before donating to a charity that conducts overseas trips, we would require information about available volunteer surgeons and trips that could be carried out if more funds were available.

Many charities put some effort into training local surgeons, but from what we've seen, such effort is generally a tiny part of their budgets and is not accompanied by long-term followup on whether surgeons are correctly and consistently applying what they've learned.27

2. How is quality assured?

Charities that fly developed-world surgeons overseas may be putting them in highly unfamiliar environments with unusually difficult conditions. Charities that support developing-world surgeons are relying on people whose medical education may be very different from what is standard in the developed world. In either case, we find it very important that a charity share information about how the quality of surgeries is assessed, what the complication rate is, etc.

In addition, charities that send money to developing-world surgeons should share information about how they ensure that these surgeons are not taking payment for surgeries that they've charged patients for separately, or otherwise violating guidelines. The evaluation materials we have seen raise significant concerns about how quality and compliance are ensured.28

3. Is one surgery enough?

As discussed above, surgeries may require significant followup care. From what we've seen, there is relatively little information available about the long-term life impact of some surgeries when unaccompanied by followup care.

This is a particularly strong concern for charities that fly developed-world surgeons overseas, rather than supporting local surgical capacity.

Charities we've examined

We have examined the following surgery-focused charities. We do not feel confident enough in any to recommend them to donors overall, as we have have seen little information to address our above concerns. We feel that Aravind and Interplast stand above the others.

Note: we were in contact with all six charities listed below except for CURE International. After we learned more about the cause of developing-world reconstructive surgery (through conversations with some of the charities listed below), we concluded that it was unlikely we would recommend an organization working solely in this area.

Recently, we had an email exchange with a website visitor interested in supporting the Fistula Foundation. We believe that this exchange is of interest to donors interested in supporting this cause. You can read the exchange (reprinted with permission, with minor edits) here.

Sources

• Corlew, Scott. 2007. "An Economic Assessment of a Surgical Intervention Program in Developing Countries." Unpublished draft provided to us by the author.
• Disease Control Priorities Project. 2006. "Disease Control Priorities in Developing Countries." Available online, accessed 7/6/09.
• Campaign to End Fistula. Organization website. Online at http://www.endfistula.org/, accessed 7/9/09.
• WebMD. 2009. "Cleft Lip and Cleft Palate." Online at http://www.webmd.com/oral-health/cleft-lip-cleft-palate, accessed 7/9/09.

1. 1.

   DCP 2006, Pg 60.

2. 2.

   See http://dcp2.org/pubs/GBD/3/Table/3.A6, accessed 7/6/09.

3. 3.

   http://www.webmd.com/hw-popup/normal-and-cleft-palate, accessed 7/7/09.
   http://www.webmd.com/hw-popup/cleft-lip-15924, accessed 7/7/09.
   

4. 4.

   WebMD 2009.

5. 5.

   "A child born with a cleft frequently requires several different types of services, e.g., surgery, dental/orthodontic care, and speech therapy, all of which need to be provided in a coordinated manner over a period of years. This coordinated care is provided by interdisciplinary cleft palate/craniofacial teams comprised of professionals from a variety of health care disciplines who work together on the child’s total rehabilitation." http://www.cleftline.org/parents/about_cleft_lip_and_palate, accessed 7/6/09.

6. 6.
   • "As is common with surgical data, most quality improvement work relates to anesthetic considerations, and the protocols in place reduce anesthetic problems to a minimum. What is more difficult to measure, however, is the actual quality of the long-term results of the operations. Even palatal fistula rate is difficult to quantify without being able to see all of the children long term. For so many of these patients, their geographic isolation makes this quite a far-reaching (and expensive) endeavor. The advisability of even pursuing projects such as these in the developing world has been questioned, and the increasing numbers and ability of surgeons in the developing world has led Interplast to change its strategic direction from that of service to that of education, and to increase its emphasis on problems such as burn scar contractures and hand problems rather than clefts." Corlew 2007, Pg 13.

   • "GIVEWELL: We're concerned about the possibility – especially with team trips – of a person's coming in for the initial surgery. but never receiving follow-up care. What would this person's life be like? Would they talk normally, eat normally, interact normally?

     INTERPLAST REPRESENTATIVE: …That is the same question I asked in my thesis. I looked far and wide in the literature at the time and there was nothing on this question. WHO’s Global Burden of Disease doesn’t really give us enough information. We know from UNICEF that only 3 percent of disabled children in developing countries go to school, but every culture/community is a little different on what they consider a disability. In some places, there are children with cleft lips going to school and in others, they are systematically abandoned as babies. And what does it mean for quality of life if someone has a beautifully repaired lip but her teeth remain unfixed? There really is nothing on that.

     That being said, there is a Ph.D. student at UCSF who is hoping to do ask that exact question in Nepal over the next couple of years. She's going to focus on the sociological rather than the surgical aspect – if you go rural Nepal, and find an unrepaired adult, are they working? What's their social life like? This Ph.D. student at UCSF is going to take at least 2-3 years for her study, which will at least give a start on the question you asked." Phone conversation with Scott Corlew, Interplast Chief Medical Officer, 6/2/09.

7. 7.

   Calculation at http://www.givewell.net/node/40 (2007-2008 review of Interplast).

8. 8.

   Calculation at http://www.givewell.net/node/40 (2007-2008 review of Interplast).

9. 9.

   "For all procedures combined, without age weighting and discounting the DALYs averted totaled 10.3 per person and 9353 aggregate. Including age weighting and discounting decreased these to 4.6." Corlew 2007, Pg 7. Note that the DALYs from the Disease Control Priorities report (DCP), which we use in most other places, are not calculated exactly equivalently: they use discounting but not age-weighting (see DCP, Pg 29). We believe that Corlew's (2007) second figure is likely to be closer to equivalent (for a rough illustration, see the Disease Control Priorites Project's "Global Burden of Disease", Pg 402, accessed 7/6/09). The DCP itself does not provide estimates in these terms for cleft surgeries (and on Pg 1255 it states that "Data on the cost-effectiveness of surgical interventions for specific conditions in developing countries are scarce.")

10. 10.

    http://www.endfistula.org/q_a.htm, accessed 7/6/09.

11. 11.

    "Fistula from obstructed labour was eradicated from industrialised nations by the middle of the 20th century as effective systems of obstetric care were developed to cover the entire population of childbearing women. As a result of this success, contemporary published work on obstetric fistulas is woefully inadequate by the standards of 21st century evidence-based medicine, a situation that is not uncommon for medical problems that are largely confined to poor countries. A comprehensive review in 2005 of existing medical and surgical reports on obstetric fistulas concluded that "the Western medical literature on obstetric fistulas is old and relatively uncritical by current scientific criteria. This literature consists mainly of anecdotes, case series (some quite large), and personal experiences reported by dedicated surgeons who have labored in remote corners of the world while facing enormous clinical challenges with scanty or absent resources at their disposal." Wall 2006.

12. 12.

    "Vesicovaginal fistula is a devastating injury in which an abnormal opening forms between a woman's bladder and vagina, resulting in urinary incontinence." Wall 2006.

13. 13.

    "The ultimate goal of fistula surgery is to restore normal function of the lower urinary tract and any other pelvic structures affected. This process is more challenging than simply closing the fistula, which has been done with a high degree of success in 80—95% of cases in most series. The best chance of fistula closure is generally agreed to be at the time of the first operation. In a large series of 2484 patients, Hilton and Ward reported successful fistula closure in 83% of patients at the first attempt, whereas successful closure was achieved in only 65% of patients who needed two or more operations." Wall 2006.

14. 14.

    "The emphasis on vesicovaginal fistulas as a cause of urinary incontinence in developing countries often leads to the assumption that closure of the fistula is all that is necessary to restore continence in affected women. Unfortunately, even in cases where the fistula has been successfully repaired, 16—32% of women remain incontinent." Wall 2006.

15. 15.

    "Treatment of women with persistent stress incontinence after fistula closure is frequently challenging, because of the extensive scar tissue that often forms around the affected tissues. Several authors have recommended the routine placement of urethral suspension stitches at the time of fistula closure to prevent post-repair incontinence, but these techniques have only had limited success ... The best results seem to be obtained with procedures that involve some combination of urethrolysis, which frees the urethra from entrapment in scar tissue, and the addition of some type of compressive suburethral sling." Wall 2006.

16. 16.

    http://www.endfistula.org/q_a.htm, accessed 7/6/09.

17. 17.

    See http://www.givewell.net/node/40 (2007-2008 review of Interplast).

18. 18.

    Calculations at http://www.givewell.net/node/40 (2007-2008 review of Interplast).

19. 19.

    Corlew's (2007) attempt to estimate cost-effectiveness for corrective surgery states that "Because of the wide variability associated with burn releases and hand procedures, these patients were not included in the study. It was determined that attempting to assess the effects of these procedures was not possible without further detailed data collection." Corlew 2007.

20. 20.

    "GIVEWELL: It seems like hand deformities could vary a lot in terms of how debilitating they are. Some might render a person's hands unusable whereas other deformities might affect only a couple of fingers.

    INTERPLAST REPRESENTATIVE: Definitely. If you look at the original World Health Organization’s Global Burden of Disease study, they didn't even try to assign disability weights to hand injuries because it's too wildly varied. We're generally going to try to treat people who have major and largely correctable disabilities or deformities. If we can give someone the ability to feed themselves or to hold a pencil, we will do whatever we can to help.

    GIVEWELL: Can you give us your educated guess on what the frequency distribution looks like, i.e., out of 100 burn scars treated – about how many are totally debilitating, vs. significantly debilitating, vs. minor/cosmetic?

    INTERPLAST REPRESENTATIVE: Approximately 10-15 percent are totally debilitating, around 85-90 percent are significantly debilitating and about 2 percent are minor." Phone conversation with Scott Corlew, Interplast Chief Medical Officer, 6/2/09.

21. 21.

    "INTERPLAST REPRESENTATIVE: Interplast supports local surgeons with training opportunities, funding and oversight (quality assurance). These local surgeons operate on their own and always have, but they can't take care of all the poor people for free. We're able to pay enough to put the poor people at the head of the line with the people who can pay for themselves. For example, if you have the capacity to serve 30 people, but 100 are lined up, of which 60 can pay, you'd ordinarily treat only people who can pay, but Interplast pays for free surgeries and that puts the people who can't pay on the same basic footing in terms of priority.

    GIVEWELL: That seems to imply that the Outreach Centers do a constant number of surgeries, because of limited capacity, and your expectation is that the Interplast funds reallocate some of those surgeries from wealthier patients to patients who are unable to pay.

    INTERPLAST REPRESENTATIVE: Right. In India, for example, the public-sector capacity isn't there. People who need treatment mostly seek it from the private sector. I like to think that we're able to take people who would otherwise fall through the cracks and put them on more equal footing with wealthier people. I think that's what happens and that's certainly what I want to happen.

    GIVEWELL: So do you think that by paying for free surgeries, Interplast is reducing the number of surgeries done for people who can pay?

    INTERPLAST REPRESENTATIVE: I do not think that is true at all. People who can pay generally get taken care of. Generally, people paying for themselves will pay more than what Interplast can pay.

    GIVEWELL: Do you think Interplast's activities are increasing the surgical capacity in these countries overall? It sounds to me from what you're saying like Interplast isn't increasing capacity – it's more increasing equity of access to surgical care.

    INTERPLAST REPRESENTATIVE: I think both. By providing surgical care for a large segment of the population who had no other access to care, I think that we are definitely increasing capacity. We also have partner surgeons who do more operations now, caring for more people, because they have funding to care for the poor. For example, there's a surgeon who works until 2 in the morning one day a week (after his government hospital job) to care for the poor, and if not for our program I don't think he would be able to do that. Our educational programs---from our visiting educators to our medical scholars---are also helping to build capacity in the countries in which we work. Three of our SOC directors have started the first plastic surgery resident programs in their countries, so that is another way of increasing capacity." Phone conversation with Scott Corlew, Interplast Chief Medical Officer, 6/2/09.

22. 22.

    See http://givewell.net/node/405#Whichactivitiesarefocusedon, accessed 7/6/2009.

23. 23.

    "but generally a cleft lip will take 45 minutes to an hour; a cleft palate will take about 1.5 hours. Burn cases vary dramatically and go from under an hour to more than two hours, per procedure." Phone conversation with Scott Corlew, Interplast Chief Medical Officer, 6/2/09.

24. 24.

    "Because of the greater functional significance of cleft palate, with the associated greater disability weighting factor, palate repair resulted in greater gain than did lip repair." Corlew 2007, Pg 7.

25. 25.

    See http://givewell.net/node/40#Surgicalteamtrips, accessed 7/6/2009.

26. 26.

    As stated above, our best estimate of missions' costs is $1400 per surgery performed or $300 per DALY. See our list of priority programs for context on these figures; $300 per DALY is relatively high for developing-world interventions.

27. 27.

    See our reviews of Interplast (http://givewell.net/node/40, accessed 7/6/09) and Smile Train (http://givewell.net/node/405, accessed 7/6/09) for examples.

28. 28.

    See http://givewell.net/node/405#Activity1treatmentpartnerships, accessed 7/6/2009.