Costs and benefits of neurosurgical intervention for infant hydrocephalus in sub-Saharan Africa

Clinical article

Restricted access


Evidence from the CURE Children's Hospital of Uganda (CCHU) suggests that treatment for hydrocephalus in infants can be effective and sustainable in a developing country. This model has not been broadly supported or implemented due in part to the absence of data on the economic burden of disease or any assessment of the cost and benefit of treatment. The authors used economic modeling to estimate the annual cost and benefit of treating hydrocephalus in infants at CCHU. These results were then extrapolated to the potential economic impact of treating all cases of hydrocephalus in infants in sub-Saharan Africa (SSA).


The authors conducted a retrospective review of all children initially treated for hydrocephalus at CCHU via endoscopic third ventriculostomy or shunt placement in 2005. A combination of data and explicit assumptions was used to determine the number of times each procedure was performed, the cost of performing each procedure, the number of disability-adjusted life years (DALYs) averted with neurosurgical intervention, and the economic benefit of the treatment. For CCHU and SSA, the cost per DALY averted and the benefit-cost ratio of 1 year's treatment of hydrocephalus in infants were determined.


In 2005, 297 patients (median age 4 months) were treated at CCHU. The total cost of neurosurgical intervention was $350,410, and the cost per DALY averted ranged from $59 to $126. The CCHU's economic benefit to Uganda was estimated to be between $3.1 million and $5.2 million using a human capital approach and $4.6 million–$188 million using a value of a statistical life (VSL) approach. The total economic benefit of treating the conservatively estimated 82,000 annual cases of hydrocephalus in infants in SSA ranged from $930 million to $1.6 billion using a human capital approach and $1.4 billion–$56 billion using a VSL approach. The minimum benefit-cost ratio of treating hydrocephalus in infants was estimated to be 7:1.


Untreated hydrocephalus in infants exacts an enormous price from SSA. The results of this study suggest that neurosurgical intervention has a cost/DALY averted comparable to other surgical interventions that have been evaluated, as well as a favorable benefit-cost ratio. The prevention and treatment of hydrocephalus in SSA should be recognized as a major public health priority.

Abbreviations used in this paper: CCHU = CURE Children's Hospital of Uganda; CPC = choroid plexus cauterization; DALY = disability-adjusted life year; ETV = endoscopic third ventriculostomy; GNI = gross national income; IE-VSL = income elasticity of VSL; PIH = postinfectious hydrocephalus; PPP = purchasing power parity; SSA = sub-Saharan Africa; VSL = value of a statistical life.

Article Information

Address correspondence to: Benjamin C. Warf, M.D., Department of Neurosurgery, 300 Longwood Avenue, Boston, Massachusetts 02115. email:

© AANS, except where prohibited by US copyright law.



  • View in gallery

    Treatment and outcome flowchart for 2005 CCHU cohort.

  • View in gallery

    Flowchart showing assumed outcomes for 2005 CCHU cohort if they had not undergone neurosurgical intervention (see Appendix). Dashed-line boxes indicate that the outcomes in that box contribute toward total DALYs; solid-line boxes indicate that the outcomes in that box do not contribute toward total DALYs.

  • View in gallery

    Flowchart showing assumed outcomes for 2005 CCHU cohort having undergone neurosurgical intervention (see Appendix). Dashed-line boxes indicate that the outcomes in that box contribute toward total DALYs; solid-line boxes indicate that the outcomes in that box do not contribute toward total DALYs.


  • 1

    Aldy JEViscusi WK: Adjusting the value of a statistical life for age and cohort effects. Rev Econ Stat 90:5735812008

  • 2

    Alkire BHughes CDNash KVincent JRMeara JG: Potential economic benefit of cleft lip and palate repair in sub-Saharan Africa. World J Surg 35:119412012011

  • 3

    Anand SHanson K: Disability-adjusted life years: a critical review. J Health Econ 16:6857021997

  • 4

    Black PM: The future of neurosurgery: a call to leadership. Clin Neurosurg 54:1851912007

  • 5

    Chi JHFullerton HJGupta N: Time trends and demographics of deaths from congenital hydrocephalus in children in the United States: National Center for Health Statistics data, 1979 to 1998. J Neurosurg 103:2 Suppl1131182005

  • 6

    Chotivitayatarakorn PChotivitayatarakorn PPoovorawan Y: Cost-effectiveness of rotavirus vaccination as part of the national immunization program for Thai children. Southeast Asian J Trop Med Public Health 41:1141252010

  • 7

    Chumas PTyagi ALivingston J: Hydrocephalus—what's new?. Arch Dis Child Fetal Neonatal Ed 85:F149F1542001

  • 8

    Debas HTGosselin RMcCord CThind ASurgery. Jamison DTBreman JGMeasham AR: Disease Control Priorities in Developing Countries ed 2New YorkOxford University Press2006. 12451260

  • 9

    El Khamlichi A: Neurosurgery in Africa. Clin Neurosurg 52:2142172005

  • 10

    Environmental Protection Agency National Center for Environmental Economics: Frequently Asked Questions on Mortality Risk Valuation ( [Accessed August 29 2011]

  • 11

    Farmer PEKim JY: Surgery and global health: a view from beyond the OR. World J Surg 32:5335362008

  • 12

    Fox-Rushby JAHanson K: Calculating and presenting disability adjusted life years (DALYs) in cost-effectiveness analysis. Health Policy Plan 16:3263312001

  • 13

    Gosselin RAGialamas GAtkin DM: Comparing the cost-effectiveness of short orthopedic missions in elective and relief situations in developing countries. World J Surg 35:9519552011

  • 14

    Gosselin RAMaldonado AElder G: Comparative cost-effectiveness analysis of two MSF surgical trauma centers. World J Surg 34:4154192010

  • 15

    Gosselin RAThind ABellardinelli A: Cost/DALY averted in a small hospital in Sierra Leone: what is the relative contribution of different services?. World J Surg 30:5055112006

  • 16

    Hammitt JKHaninger K: Valuing fatal risks to children and adults: effects of disease, latency, and risk aversion. J Risk Uncertain 40:57832010

  • 17

    Hammitt JKRobinson LA: The income elasticity of the value per statistical life: transferring estimates between high and low income populations. J Benefit-Cost Anal 2:Article 12011

  • 18

    Hoppe-Hirsch ELaroussinie FBrunet LSainte-Rose CRenier DCinalli G: Late outcome of the surgical treatment of hydrocephalus. Childs Nerv Syst 14:97991998

  • 19

    Kim SYLee GGoldie SJ: Economic evaluation of pneumococcal conjugate vaccination in The Gambia. BMC Infect Dis 10:2602010

  • 20

    Laurence KMCoates S: The natural history of hydrocephalus. Detailed analysis of 182 unoperated cases. Arch Dis Child 37:3453621962

  • 21

    Li LPadhi ARanjeva SLDonaldson SCWarf BCMugamba J: Association of bacteria with hydrocephalus in Ugandan infants. Clinical article. J Neurosurg Pediatr 7:73872011

  • 22

    Lindquist BCarlsson GPersson EKUvebrant P: Learning disabilities in a population-based group of children with hydrocephalus. Acta Paediatr 94:8788832005

  • 23

    Lopez ADMathers CDEzzati MJamison DTMurray CJL: Global Burden of Disease and Risk Factors New YorkOxford University Press2006

  • 24

    Mainthia RTye GWShapiro JDoppenberg EMWard JD: A model for neurosurgical humanitarian aid based on 12 years of medical trips to South and Central America. Clinical article. J Neurosurg Pediatr 4:492009

  • 25

    McCord CChowdhury Q: A cost effective small hospital in Bangladesh: what it can mean for emergency obstetric care. Int J Gynaecol Obstet 81:83922003

  • 26

    Murray CJAcharya AK: Understanding DALYs (disability-adjusted life years). J Health Econ 16:7037301997

  • 27

    Piatt JH JrCosgriff M: Monte Carlo simulation of cerebrospinal fluid shunt failure and definition of instability among shunt-treated patients with hydrocephalus. J Neurosurg 107:6 Suppl4744782007

  • 28

    Sachs JD: Macroeconomics and Health: Investing in Health for Economic Development. Report of the Commission on Macroeconomics and Health GenevaWorld Health Organization2001

  • 29

    Shillcutt SDClarke MGKingsnorth AN: Cost-effectiveness of groin hernia surgery in the Western Region of Ghana. Arch Surg 145:9549612010

  • 30

    Stouthard MEAEssink-Bot MLBonsel GJ: Disability weights for diseases: a modified protocol and results for a Western European region. Eur J Public Health 10:24302000

  • 31

    Thaver DZaidi AK: Burden of neonatal infections in developing countries: a review of evidence from community-based studies. Pediatr Infect Dis J 28:1 SupplS3S92009

  • 32

    US Department of Transportation Office of the Secretary of Transportation: Treatment of the Economic Value of a Statistical Life in Departmental Analyses ( [Accessed August 29 2011]

  • 33

    Vergnano SSharland MKazembe PMwansambo CHeath PT: Neonatal sepsis: an international perspective. Arch Dis Child Fetal Neonatal Ed 90:F220F2242005

  • 34

    Viscusi WKAldy JE: The value of a statistical life: a critical review of market estimates throughout the world. J Risk Uncertain 27:5762003

  • 35

    Warf B: Educate one to save a few. Educate a few to save many. World Neurosurg [in press]2011

  • 36

    Warf BOndoma SKulkarni ADonnelly RAmpeire MAkona J: Neurocognitive outcome and ventricular volume in children with myelomeningocele treated for hydrocephalus in Uganda. Clinical article. J Neurosurg Pediatr 4:5645702009

  • 37

    Warf BC: Comparison of 1-year outcomes for the Chhabra and Codman-Hakim Micro Precision shunt systems in Uganda: a prospective study in 195 children. J Neurosurg 102:4 Suppl3583622005

  • 38

    Warf BC: Comparison of endoscopic third ventriculostomy alone and combined with choroid plexus cauterization in infants younger than 1 year of age: a prospective study in 550 African children. J Neurosurg 103:6 Suppl4754812005

  • 39

    Warf BC: Hydrocephalus in Uganda: the predominance of infectious origin and primary management with endoscopic third ventriculostomy. J Neurosurg 102:1 Suppl1152005

  • 40

    Warf BC: Pediatric hydrocephalus in East Africa: prevalence, causes, treatments, and strategies for the future. World Neurosurg 73:2963002010

  • 41

    Warf BCCampbell JW: Combined endoscopic third ventriculostomy and choroid plexus cauterization as primary treatment of hydrocephalus for infants with myelomeningocele: long-term results of a prospective intent-to-treat study in 115 East African infants. Clinical article. J Neurosurg Pediatr 2:3103162008

  • 42

    Warf BCDagi ARKaaya BNSchiff SJ: Five-year survival and outcome of treatment for postinfectious hydrocephalus in Ugandan infants. Clinical article. J Neurosurg Pediatr 8:5025082011

  • 43

    Warf BCKulkarni AV: Intraoperative assessment of cerebral aqueduct patency and cisternal scarring: impact on success of endoscopic third ventriculostomy in 403 African children. Clinical article. J Neurosurg Pediatr 5:2042092010

  • 44

    Warf BCMugamba JKulkarni AV: Endoscopic third ventriculostomy in the treatment of childhood hydrocephalus in Uganda: report of a scoring system that predicts success. Clinical article. J Neurosurg Pediatr 5:1431482010

  • 45

    Warf BCStagno VMugamba J: Encephalocele in Uganda: ethnic distinctions in lesion location, endoscopic management of hydrocephalus, and survival in 110 consecutive children. Clinical article. J Neurosurg Pediatr 7:88932011

  • 46

    Winkler ASTluway ASlottje DSchmutzhard EHärtl R: The pattern of neurosurgical disorders in rural northern Tanzania: a prospective hospital-based study. World Neurosurg 73:2642692010


Cited By



All Time Past Year Past 30 Days
Abstract Views 147 147 29
Full Text Views 127 127 9
PDF Downloads 123 123 2
EPUB Downloads 0 0 0


Google Scholar