Groin hernias and unmet need for surgery in Uganda : Epidemiology, mosquito nets and cost-effectiveness

Abstract: Background Surgery has traditionally been considered more expensive than many other health care interventions and with little impact on the burden of disease in a global perspective. One of the reasons behind this misconception is that the effects of surgical conditions and their treatment have not been factored into the equation. Cost-effectiveness analyses of surgical interventions have largely been missing.An estimated 20 million herniorrhaphies are carried out annually but over 200 million people suffer from groin hernias. Herniorrhaphy is one of the most commonly performed surgical procedures also in Low and Middle Income Countries (LMIC). However, the surgical repair method is not the same due to financial constraints. In high income countries a synthetic mesh is used and has reduced the risk of recurrence. This 125 USD mesh is too costly for the majority in LMIC. Mosquito mesh, which is cheaper but very similar to commercial meshes, is used in several settings but outcomes need to be investigated more extensively before this practice can be recommended in routine surgical service.The Aims of this thesis were to define the prevalence of groin hernia, to relate it to the surgical capacity, outcomes and costs of surgery in eastern Uganda and to investigate the feasibility and difference in cost and cost-effectiveness of replacing a commercial mesh with a mosquito mesh in groin hernia surgery.Methods Three studies (1-3) were carried out in eastern Uganda. 1: A cross sectional study investigating the prevalence of groin hernia in adult males in the Health and Demographic Surveillance Site (HDSS) in Iganga and Mayuge districts. 2: A facility based study with prospective data collection of all surgeries undertaken in the two hospitals providing surgery for the HDSS population. 3: A double blinded, randomised controlled trial comparing the outcomes of using a mosquito mesh relative using a commercial mesh in groin hernia surgery.Results 1: the prevalence of untreated groin hernia among the study participants was 6.6%. 2: the rate of groin hernia surgery was 17 per 100 000 population. Thus, less than 1% of the estimated number of cases of groin hernia in the catchment area of the two hospitals are operated per year. A herniorrhaphy costs around 60 USD to perform. This corresponds to a third of the cost of TB treatment and a 15th of the cost of HIV/AIDS treatment per year in Uganda. 3: No significant differences in terms of recurrence rates, post operative and chronic complications and patient satisfaction were demonstrated between the patients operated using the mosquito mesh and the commercial mesh. Cost-effectiveness was very high for both materials but total cost in the mosquito mesh group was 124 USD lower per surgery than in the commercial mesh group.Conclusion There is a vast unmet need for groin hernia surgery. Cost of surgery compares favourably with other health care interventions prioritised by the international organisations and funders. A superior technique can be used in groin hernia surgery at low cost, with high cost-effectiveness in a Low Income Country.