Economics of Surgery Worldwide: Developing Countries
Summary
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Despite the high incidence of potential ocular complications, surgery should usually be the first-line treatment in developing countries because medical management of the glaucoma is not practical. The question is how to address the issue of low uptake of glaucoma surgery when most of the 70 million potential patients are found in developing countries.
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Four barriers have been identified and all are related to economics: lack of awareness, bad surgical outcome, cost of surgery, and distance.
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There is a paucity of studies related to the economics of glaucoma surgery in the developing world and this is a great challenge to those in the developing world.
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Early detection and primary surgery are strongly recommended.
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For all patients needing glaucoma surgery to receive it, it is recommended to explore the possibility of cost recovery, government subsidies, and insurance schemes, with the goal of making the service affordable for all.
Introduction
According to the latest WHO estimates, about 314 million people worldwide live with visual impairment due to either eye diseases or uncorrected refractive errors. Of these, 45 million are blind, of whom 90% live in low-income countries.1
Currently, it is estimated that worldwide, there are 8.4 million people blind due to glaucoma alone. Published estimates are that there are nearly 70 million people suffering from glaucoma.2 Glaucoma distribution varies around the globe, with higher rates of angle-closure glaucoma in individuals of Asian origin and higher rates of open-angle glaucoma among persons of African origin; hence, the majority of glaucoma is found in the developing world. Given the aging of the world population, this may increase to almost 80 million by the year 2020. Glaucoma is the second leading cause of blindness worldwide, disproportionately affecting women and Asians.2
This chapter will help us understand the elements that need to be considered in the economics of glaucoma surgery in the developing countries, and the way forward to address glaucoma blindness in the developing world. Economics contributes useful information for the resource allocation process. Multiple stakeholders are concerned with resource allocation: society as a whole, manufacturers, healthcare payers, providers, employers, and patients. Government can be included in this list as well. Different stakeholders are going to be interested in different types of cost or different ways of characterizing the costs.3
Two types of cost require definition. Direct costs involve in general the exchange of money. Healthcare and transportation costs are examples of direct costs. Indirect costs involve the value of time for patients.4 Time may be lost seeking care or just being ill. Productivity may be lost as a result of missing work or being less productive.
Glaucoma is undiagnosed in nine of ten affected people worldwide, although in developed countries the proportion diagnosed rises to 50%;1 thus, improved case detection is needed. Population screening outside the healthcare system is not cost-effective, because it needs detailed examination of optic disc structure and formal visual field testing.5
In glaucoma, we have a risk factor, intraocular pressure (IOP), which has economic implications in the sense that it may lead to the development of glaucoma and subsequently to progression of glaucomatous damage. When detected, it leads to treatment, generally chronic, and hence to long-term resource consumption. Treating a risk factor situates management of glaucoma in the prevention setting, requiring long-term analysis. When we reduce IOP in an attempt to avoid potential progression of the disease, cost-savings may result from patients not developing the disease at all, or from avoiding or delaying the health states where vision is severely impaired and that are associated with high cost and low quality of life (QoL). In other words, the direct impact of treating a risk factor is not directly measurable, but has to be assessed in an equation combining natural disease progression and the effectiveness of treatment to change the natural history of progressive worsening.
Glaucoma is characterized by destruction of the optic nerve. It is most often a continuous, chronic eye disease and the most frequent diagnosis is primary open-angle glaucoma (POAG). POAG is mostly associated with intraocular hypertension which can be treated by medication, surgery or laser therapy. The principles of glaucoma management should be the same the world over.6 Considering the paucity of resources and competing opportunity costs, countries with limited resources have to use surgery as the first line of treatment for glaucoma because lifelong medical therapy is not practical. Medicines are not readily available everywhere in developing countries. These drugs are found mainly in pharmacies in the large cities, whereas the patients are found everywhere. Due to low levels of literacy, lack of awareness about the disease becomes one of the reasons why medical therapy does not work well in the developing world.
The main issue here is poor compliance due to the cost of treatment, the lack of availability of the medication, and lack of awareness. According to the United Nations and the World Bank, over 1.3 billion people live on less than US$1 per day, and most if not all of these are found in the developing countries. Studies reveal that the daily cost of an eye drug such as latanoprost is US$0.87 in the developed world,7 and may be even more in developing countries.
The cost of surgical reduction of intraocular pressure (IOP) reduces with time. It is high during the first 3 years, but when one divides the cost by the years of life expectancy and compares it with the cost of lifelong medication it is cost-effective to opt for the surgical approach in developing countries. According to an early Scottish study by Ainsworth and Jay, early surgery is less expensive8 (Fig. 68-1).
Figure 68-1.
Health economics in glaucoma.
(From Gisela Kobelt, IGR: Glaucoma and Health Economics March, 2008.)
A recent review of our data reveals a dramatic increase in the number of people receiving treatment, but very few of these opt for surgery. Studies have shown that treatment costs are directly related to the severity of the glaucoma.9
As a chronic, progressive and irreversible disease, early treatment, in this case primary surgery, should be a good option for glaucoma treatment in the developing world. One of the greatest challenges with performing glaucoma surgery, however, is that glaucoma patients with good vision are reluctant to undergo surgery. Fortunately, eye health is performed by a team and the counsellor should be able to handle this.
Social and Economic Burden
In a number of studies, although the objective and subjective effects of long-term medication were not significant, the financial constraints were high. Because of this over 70% of the patients would opt out of medication and consider surgery or laser treatment in the management of their glaucoma.10
The socioeconomic burden of glaucoma can be categorized conveniently into three: direct cost, indirect cost, and intangible cost.
1.
Direct care costs are mainly due to health personnel consultations and drug treatment.
2.
Indirect costs include loss of productivity and earnings of people accompanying the patients for treatment and doing other errands instead of being engaged in productive activity.
3.
Intangible costs range from relatively small adverse effects on the quality of life resulting from glaucoma, to major impairments due to glaucoma which lead to loss of income because of visual loss. In many developing countries, able-bodied persons act as guides for blind relatives and this adds to the loss of productivity.11
Low Surgical Uptake
Most of the 70 million people suffering from glaucoma live in developing countries. The suggested first line of treatment in these countries is surgery, but the current uptake of surgery is very low. Currently, some programs have as few as 20 glaucoma surgeries per million of population. The economy of scale suggests that the cost per case reduces if the number of cases increases, keeping in mind good-quality surgery. Therefore, if the number of cases operated increases, the cost per surgery will reduce considerably.
Barriers
The barriers to glaucoma surgery can be summarized as:
1.
Lack of awareness.
2.
Bad surgery or poor surgical outcome.
3.
Cost.
4.
Distance from the patient to the service provider.
The last three elements are interrelated with poor economy. The various points are elaborated below.
1. Lack of Awareness.
Because of the nature of glaucoma, being asymptomatic, and family history being a risk factor, patients feel the disease has been imposed on them, especially when their visual acuity is still normal. They actually accept the blindness because they know their grandfather or grand mother went blind when they were old, and their father or mother also. They even attribute it to witchcraft because the eyes look normal but they cannot see anything. There is need for deliberate awareness creation and for this need to be budgeted for, because it is a costly exercise. There is lack of health education materials appropriate for the area in the patients' own language. A deliberate program should be established to create awareness among the various populations, emphasizing the risk factors, as no good or practical population-based glaucoma screening tests are available. This will improve the understanding of the disease. Programs will require the services of counsellors who will work with these patients who have developed glaucoma and are at risk of becoming blind.
2. Bad Surgery or Poor Surgical Outcome.
If fewer surgical procedures are undertaken, the experience and confidence of the surgeon and team diminishes and the outcome may be poor. The main aim of glaucoma surgery is to be able to successfully lower the IOP to minimize the risk of subsequent visual loss. This makes it critical that the surgeon and team are well-trained and have the appropriate instruments and supplies for surgery. Some investment needs to be expended to make sure there is an enabling environment for this type of surgery.
Use of inappropriate instruments and supplies due to budgetary constraints can adversely affect quality also. There is need to retrain and equip teams to perform quality surgery. Outreach teams should practice comprehensive eye services, including glaucoma, when they are on their outreach. Refresher courses at all levels should include glaucoma as well.
3. Cost of the Surgery to the Patient.
Currently, many programs in the developing world charge the same or similar fees for both cataract surgery and glaucoma surgery. Glaucoma patients, even if they have been counselled, expect an improvement to their vision postoperatively just like their counterparts who have undergone cataract surgery. It may be useful if the cost of the surgery can be subsidized somehow for glaucoma patients. There are patients who still refuse to come forward even if the charge is waived. This tells us that there are other costs which we do not take into account.
4. Distance from the Patient to the Service Provider.
Bowman and Kirupananthan12 suggest that surgery should select techniques based on the assumption that the patient may not be seen again after discharge. Distance is a barrier, and many patients need funds to travel and, because they are visually impaired, will require someone to escort them. The program should also make provision for bringing the service closer to the patients. Melese et al. suggest that effort be made to create mechanisms that bridge communities and eye care facilities.13
Cost Analysis
Cost analysis is simply part of good program budgeting and accounting practices, and allows managers to determine the true cost of providing a given unit of service. There is need to perform a cost analysis of glaucoma surgery.
At the program or agency level, it basically means setting up budgeting and accounting systems in a way that allows program managers to determine a unit cost or cost per surgery. This information is primarily a management tool. For example, for evaluation purposes, one might want to know the average cost per eye of conducting a filtering surgery such as trabeculectomy. There are two parts to this: fixed costs, which include the costs of staff salaries, electricity, water, theater time charge; and variable costs, which are basically the cost of the consumables used.
Cost analyses can provide three types of information:
1.
Cost analyses can provide estimates of what a program's costs and benefits are likely to be, before it is implemented.
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Cost analyses may improve understanding of program operation, and tell what levels of intervention are most cost-effective.
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Cost analyses may reveal unexpected costs. For example, a patient may be too poor to afford transport to come for surgery. In some cases the program may have to provide this service.
If steps are put in place for improvement of the uptake of surgical services, the cost per surgery will definitely come down.
There is a paucity of studies related to the economic evaluation in glaucoma in the developing world. The majority of the available data come from developed countries and most of the facts gathered do not necessarily apply to developing countries. There is an urgent need for programs in developing countries to conduct studies related to the economics of glaucoma.
Cost-Effectiveness of Screening
Population screening or guideline-level treatment scenarios are generally not cost-effective in developing countries with younger populations and higher mortality at younger ages, but treating self-referring patients with a hypothetical one-time primary surgery is highly cost-effective.
Sources of Funds for the Surgery
Socialized medicine is practiced in most developing countries. About 80% of all health facilities are owned by the government and these are poorly resourced due to competing needs. Below are different models that can be found in different parts of the developing world:14
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Cost recovery from patients: This is the 'robbing Peter to pay Paul' concept. Those who have a high income can be charged enough to cover their treatment and subsidize services for low-income patients.
2.
Government subsidy: Governments in developing countries have very limited, and often decreasing, resources for healthcare, but they have employed all the workers and they own the infrastructure, and this is a great assistance to the program. With a bit more advocacy and networking, more assistance can be obtained from the governments.
3.
Insurance schemes: Private or governmental health insurance schemes are available in a number of countries, even in the developing world, to assist patients in covering the cost of medical treatment. There is a need to make sure that glaucoma surgery is on the list of conditions they cover.
Recommendations
1.
There is a strong need to increase the quantity and quality of studies on treatment options and the burden of the disease in developing countries. Such studies are essential in order to enable the development of adequate strategies to deal with the problem.
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Glaucoma is asymptomatic and this leads to late presentation of the patients. It is recommended that an aggressive awareness campaign be considered by all the Ministries of Health on glaucoma.
3.
The first line of treatment as soon as the diagnosis has been made is surgery, considering the challenges the patients go through to purchase the medication. compliance on the administration of the medications.
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