Have you been anywhere in Africa? More to the point, have you worked in an African hospital?
These things are done out of pure necessity, not because they're "net efficient."
In many African** countries the number of fully trained operating surgeons is vanishingly small. Perhaps that country has a horrid education system (i.e. when the Belgian Congo won its independence, there were a total of 12 people in the nation with a college degree). Perhaps doctors migrate to the West as soon as possible, either due to a decimated Ministry of Health (i.e. Malawi) or protracted civil war (Angola, Liberia, Mozambique). Most others can literally only afford to eat if they serve exclusively private patients. And the volume of cases at these hospitals has to be seen to be believed-- attendings can't possibly cover all of them. So the residents in the public hospitals-- again, small in number compared to training programs here-- assume the responsibilities of an attending here in the US simply because they're stepping into a vaccum.
One thing that works very well there (but not here) is the existence of para-medical technicians trained to perform very specific health care roles that in the West are covered only by MDs. For example, in my past life I once had a gig running a field team in West Africa studying a trachoma outbreak. As part of the team I hired someone called a "Special Ophthalmic Nurse." He wasn't in fact a nurse, and he had completed the equivalent of the 10th grade here (meaning he was literate, numerate and spoke beautiful French), but he'd received 1 year of specialized training in trichiasis surgery. We'd travel around the bush and let the bush telegraph get going re: our presence. Patients would walk for miles to see us, already blind or close to it. I'd hold their heads in my lap outside under a nice shady tree and the Special Ophthlamic Nurse would perform the trichiasis surgery under local. I'd apply antibiotic ointment, bandage them up and continue on with my epidemiological study. That's all he could do-- trichiasis surgery-- but he could do it very, very well.
But since we're comparing US and African health care: was there post-op care? No. Was the surgery, in fact, conducted on my lap under a tree? Yes. Did the patients obtain relief from the pain of trichiasis, and halt the progression of blindness? We certainly hope so. So the "outcome" might be considered quite good-- I believe a fair sight better than not intervening at all-- but I highly doubt the outcome is superior or comparable to similar procedures if they were performed in the US (not that we even see that particular pathology-- I've seen more trichiasis and blinding trachoma than all the ophthalmologists at Columbia University Medical Center combined).
Lastly, the point made about fees is a very good one. For kicks sometime check out the average per capita annual income in various Sub-Saharan nations. Remember that outside of the cities (and even in certain markets within them) people still live in a largely cashless, barter-based subsistence agricultural economy. The fee for your lap chole is often half of a family's annual cash income-- and nobody's going to loan them anything, nobody's going to perform it for free. Surgical care is still very much out of reach for a large number of people.
**Caveat: "Africa" is certainly not a homogenous place. This isn't true everywhere-- Nigeria and Ghana come to mind as exceptions.
