Mark Shrime

Mark Shrime

O'Brien Chair of Global Surgery, Institute of Global Surgery, Royal College of Surgeons in Ireland
Lecturer in Global Health and Social Medicine, Harvard Medical School

Dissertation Title:  "Health, Poverty, and Surgery in the US and around the World"

The goal of this dissertation is to examine the effects of policies and platforms for global surgical delivery on health, impoverishment, and inequity, and to determine how individuals value tradeoffs among these outcomes.

Paper 1 investigates the role of government policies for increasing surgical access in public hospitals. This extended cost-effectiveness analysis utilizes publicly available data from Ethiopia to evaluate the health, financial, and equity impacts on rural patients of nine essential surgical procedures. Five policies addressing supply- and demand-side barriers to surgical access are examined: 1) universal public financing (UPF), 2) task-sharing (TS), 3) UPF with the addition of vouchers (V) to address the nonmedical costs of care, 4) UPF + TS, and 5) UPF + TS + V. I find that, while all policies are likely to improve health, a tradeoff exists: TS averts deaths most dramatically, but does so at the cost of a large increase in financial catastrophe. UPF is more financially risk protective, but has a much smaller impact on health. Only policies that include vouchers to address the non-medical costs of getting to care are found to provide an equitable distribution of benefits; the remainder continue to impoverish the poor.

Paper 2 compares surgical delivery by charitable organizations with the governmental policies examined in Paper 1. Using an agent-based model of cancer care in Uganda, the three common charitable platforms for surgical delivery—two-week “mission trips”, mobile surgical units, and free-standing specialty hospitals—are evaluated against combinations of UPF, TS, and V. Health and catastrophic expenditure are examined, as in Paper 1, in addition to two novel metrics that 1) incorporate the familial financial impact of a lack of access and 2) formalize the equitable distribution of benefits into a concentration index. I find that mobile surgical delivery platforms by non-governmental organizations can provide health and financial benefits equitably and efficiently and that they perform well when compared to health-system-strengthening policies. Other charitable platforms are equitable but less efficient than government policies. The results of this analysis also confirm the finding from Paper 1, that equitable delivery platforms must address the non-medical costs associated with getting to care.

Paper 3 tests the hypothesis that, in the setting of lethal disease, individuals value cure at all costs. A discrete choice experiment is undertaken in a nationally representative US sample of 2359 individuals. Respondents are asked to choose between two hypothetical treatments for a lethal disease, differing only in their chance of cure and their risk of bankruptcy. I find that the resulting indifference curve is multiplicative, and that Americans are less willing to shoulder high risks of bankruptcy to increase their probability of cure than has been previously assumed. Subgroup and sensitivity analyses do not alter this relationship, although, in some groups, the preference difference between bankruptcy and cure is not statistically significant. Significantly, however, I find no evidence a preference for cure at any cost in the American population.

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