A Cost-Effectiveness Analysis of a Pediatric Operating Room in Uganda


      This study examines the cost-effectiveness of constructing a dedicated pediatric operating room (OR) in Uganda, a country where access to surgical care is limited to 4 pediatric surgeons serving a population of over 20 million children under 15 years of age.


      A simulation model using a decision tree template was developed to project the cost and disability-adjusted life-years saved by a pediatric OR in a low-income setting. Parameters are informed by patient outcomes of the surgical procedures performed. Costs of the OR equipment and a literature review were used to calculate the incremental cost-effectiveness ratio of a pediatric OR. One-way and probabilistic sensitivity analysis were performed to assess parameter uncertainty. Economic monetary benefit was calculated using the value of a statistical life approach.


      A pediatric OR averted a total of 6,447 disability-adjusted life-years /year (95% uncertainty interval 6,288–6,606) and cost $41,182/year (UI 40,539–41,825) in terms of OR installation. The pediatric operating room had an incremental cost-effectiveness ratio of $6.39 per disability-adjusted life-year averted (95% uncertainty interval of 6.19-6.59), or $397.95 (95% uncertainty interval of 385.41-410.67) per life saved based on the country's average life expectancy in 2015. These values were well within the WHO guidelines of cost-effectiveness threshold. The net economic benefit amounted to $5,336,920 for a year of operation, or $16,371 per patient. The model remained robust with one-way and probabilistic sensitivity analyses.


      The construction of a pediatric operating room in Uganda is a cost-effective and worthwhile investment, endorsing future decisions to enhance pediatric surgical capacity in the resource-limited settings of Sub-Saharan Africa.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Ozgediz D
        • Riviello R
        • Rogers S
        The surgical workforce crisis in Africa: a call to action.
        Bull Am Coll Surg. 2008; 93: 10-16
        • Sekabira J
        Paediatric surgery in Uganda.
        J Pediatr Surg. 2015; 50: 236-239
        • Bickler S
        • Rode H
        Surgical services for children in developing countries.
        Bull World Health Organ. 2002; 80: 829-835
        • Badrinath R
        • Kakembo N
        • Kisa P
        • Langer M
        • Ozgediz D
        • Sekabira J
        Outcomes and unmet need for neonatal surgery in a resource-limited environment: estimates of global health disparities from kampala, Uganda.
        J Pediatr Surg. 2014; 49: 1536-1543
        • ARCHIE
        A history of ARCHIE—transforming children's healthcare.
        (Accessed May 18, 2017)
        • Mock C
        • Donkor P
        • Gawande A
        Essential surgery: key messages from Disease Control Priorities.
        Lancet. 2015; 385 (3rd edition): 2209-2219
        • Shrime M
        • Alkire B
        • Grimes C
        • Chao T
        • Poenaru D
        • Verguet S
        Cost-effectiveness in global surgery: pearls, pitfalls and a checklist.
        World J Surg. 2017; 41: 1401-1413
        • World Health Organization
        WHO table: threshold values for intervention cost-effectiveness by region.
        (Accessed May 18, 2017)
      1. Circular No. A-76—Revised appendix 3: useful life and disposable values. The White House Archives: Office of Management and Budget March

        • Knoema
        Uganda inflation rate—1980–2016.
        Knoema, 2017
        • Mathers C
        WHO methods and data sources for global burden of disease estimates 2000–2015.
        World Health Organization, Geneva2017
        • Fox-Rushby J
        • Hanson K
        Calculating and presenting disability adjusted life years (DALYs) in cost-effectiveness analysis.
        Health Policy Plan. 2001; 16: 326-331
        • Poenaru D
        • Pemberton J
        • Frankfurter C
        • Cameron B
        Establishing disability weights for congenital paediatric surgical disease: a cross-sectional, multi-modal study.
        World J Surg. 2015; 39: 2198-2206
        • Poenaru D
        • Pemberton J
        • Frankfurter C
        • Cameron B
        • Stolk E
        Establishing disability weights for congenital pediatric surgical conditions: a multi-modal approach.
        Popul Health Metr. 2017; 15
        • McCord C
        • Chowdhury Q
        A cost effective small hospital in Bangladesh: what it can mean for emergency obstetric care.
        Intl J Gynecol Obstet. 2003; 81: 83-92
      2. Dodou JA. WHO Uganda statistics. 2015.

        • Alkire B
        • Vincent J
        • Meara J
        Chapter 21: Benefit-cost analaysis for selected surgical interventions in low- and middle-income countries.
        Essential Surgery: Disease Control Priorities. 3rd Edition. International Bank for Reconstruction and Development / The World Bank, Washington DC2015: 361-380
        • Corlew D
        • Alkire B
        • Poenaru D
        • Meara J
        • Shrime M
        Economic valuation of the impact of a large surgical charity using the value of lost welfare approach.
        J Glob Health. 2016; 1
        • Chao T
        • Sharma K
        • Mandigo M
        Cost-effectiveness of surgery and its policy implications for global health: a systematic review and analysis.
        Lancet Glob Health. 2014; 2: e334-e345
        • Wu V
        • Poenaru D
        Burden of surgically correctable disabilities among children in the Dadaab Refugee Camp.
        World J Surg. 2013; 37: 1536-1543
        • Eeson G
        • Birabwa-Male D
        • Pennington M
        • Blair G
        Costs and cost-effectiveness of pediatric inguinal hernia repair in Uganda.
        Wolrd J Surg. 2015; 39: 343-349
        • Poenaru D.
        Getting the job done: analysis of the impact and effectiveness of the SmileTrain program in alleviating the global burden of cleft disease.
        World J Surg. 2013; 37: 1562-1570
        • Laxminarayan R
        • Chow J
        • Shahid-Salles S
        Intervention cost-effectiveness: overview of main messages (chapter 2). Disease Priorities Control.
        2nd Edition. The International Bank of Reconstruction and Development / The World Bank, Washington DC2006
        • Chatterje S
        • Laxminarayan R
        • Gosselin R
        Cost per DALY averted in a surgical unit of a private hospital in India.
        World J Surg. 2015; 40: 1034-1040
        • Gosselin R
        • Thind A
        • Bellardinelli A
        Cost/DALY averted in a small hospital in Sierra Leone: what is the relative contribution of different services?.
        World J Surg. 2006; 30: 505-511
        • Musuuza J
        • Singer M
        • Mandalakas A
        • Katamba A
        Key actors' perspectives on cost-effectiveness analysis in Uganda: a cross-sectional survey.
        BMC Health Serv Res. 2014; 14
        • Meara JG
        • Leather AJ
        • Hagander L
        • et al.
        Global surgery 2030: evidence and solutions for achieving health, welfare, and economic development.
        Lancet. 2015; 386: 569-624