These low-volume providers are critical to reaching a population of fistula patients that is widely dispersed. However, the small scale of these organizations meant that they were beyond the reach of traditional funding approaches.
The local surgeons’ general lack of administrative capacity meant that we would need to build a focused and light oversight infrastructure. In effect, this meant developing a mechanism to remotely evaluate safety and quality in places we had never visited, with people we had never met. Achieving our three ambitious goals required an adaptive style of project management that compelled us to experiment to find best practices and then to tirelessly test and improve them.
We did not start with the idea of funding individuals. But when we realized that we could only reach the unmet need with a direct approach, we adapted our system to focus primarily on quality of care. Our grants were only distributed when surgeons provided comprehensive quality data. This data-focused approach allowed us to initiate more partnerships that we could fluidly monitor and assist.
This adaptability is best illustrated with surgical throughput. We believed funding would result in incremental surgeries and set an aggressive throughput objective for the pilot program. While this thesis held firm in Malawi, where we saw a 198% annual increase, preliminary data from other countries showed a mismatch between complexity of case and skill of surgeon. Data enabled us to credibly guide local partners to reduce their throughput and focus on simple and intermediate cases, while experts handled difficult and complicated cases. Success rates migrated to an optimal distribution where local surgeons had higher success rates than their expert peers.
The average patient was 30.4 years old when she arrived at treatment and had lived with fistula for 6.4 years before treatment. Small in stature at 149 cm (4’10”) tall and weighing 46 kg (101 lbs), many women (24%) had body mass index measures that indicated severe malnutrition. While causative delivery occurred at age 24 on average, the majority of women first became wives and mothers much earlier. The average age at marriage was 17.9 years and 59% who reported husband ages indicated that their husbands were 5 or more years older. 68% of women had their first pregnancy as teenage girls and 62% of these girls had first pregnancies within 3 years of their first menstruation.
While it is often assumed that women get fistula because they cannot reach healthcare, an astounding 63% had the causative delivery at the hospital. This indicates that timing or quality of care at the facility may be an issue. C-section caused fistula for 31% of the women who received this operative intervention.
The vast majority (81%) of causative deliveries resulted in stillbirth. Only 13% of babies born in the causative delivery survived infancy. Of the 36 early neonatal deaths, 50% were born and died at the hospital.
Our output-driven approach has succeeded in providing quality care for fistula, in a cost-effective manner. We calculated a “no frills” DALY and our project averted an astounding 7,956 DALYs (or 10.6 years per patient). In other words, every woman we treated gained back, on average, nearly 11 years of healthy life that would otherwise have been lost to living with fistula.
We treated four times more than our original patient target. In meeting the demand for our funding, our innovative methods enabled us to deliver exceptional value for money in terms of efficiency ($190-$288 per surgery) and cost-effectiveness ($18-$27 per disability-adjusted life year averted). We learned that the efficiency of our intervention model placed us as one of the most cost-effective global health interventions possible.
We only closed the pilot because the demand far outpaced our organization’s ability to meet it. We have spent the last year building the partnerships required to bring this transformative innovation to scale. Our preliminary discussions with organizations working in fistula and global surgery, as well as with Ministries of Health and major donors, have revealed a combination of quality-focused partners in our plan to transform fistula and beyond. However, to realize this potential, we need to build a technology platform that will enable scale.