Demonstrating the cost effectiveness of eye health interventions

Peter Ackland - IAPB

Zoe Gray - IAPB

GBM roundelCost Effectiveness (or cost utility) Analysis (CEA) provides information that policy makers use to help determine which health interventions give best value for money. CEA measures quality and length of life, specifically additional years lived in good health / without morbidity, due to a specific health intervention and express this in terms of cost per Disability Adjusted Life Year (DALY) averted or Quality Adjusted Life Year (QALY) gained.

Interventions that cost less than the GDP per capita of a country per QALY/DALY are ‘very cost effective’ and those costing less than three times GDP are ‘cost effective’

Surveys provide proof

Baltussen and Smith conducted a CEA of several strategies to combat vision loss in 20 Sub-Saharan Africa and seven South East Asia countries. Their findings are shown in figure 1. Lansingh et al conducted a CEA of Cataract surgery in nine countries around the world. The findings showed that in all countries the cost effectiveness ratio was considerably less than the GDP per capita, making Cataract surgery very cost effective in all locations, as shown in figure 2 below.

Variations in the actual cost per QALY gained or DALY averted may be attributable to a number of factors including the burden of Cataract disease in the country, the efficiency with which Cataract surgical services are provided, the type of surgery practised (phacoemulsification or manual techniques) and market penetration of high-quality, low-cost intra-ocular lenses. Wittenborn and Rein found one-time laser treatment for Glaucoma for self-referring patients to be very cost effective at a cost per DALY averted of $1,528 in Barbados and $1,771 in Ghana. Tahhan et al estimated the cost of correction of refractive error to be in the order of Aus$140 per QALY gained, compared with a GDP per capita of close to Aus$20,000, while the ‘Disease Control Priorities Project’ put the cost per DALY averted by mass drug administration for Onchocerciasis (River Blindness) in Africa at less than US$10, one of the most cost-effective of all interventions.

Surgery is well worth it

A systematic review of the cost effectiveness of a range of surgical interventions conducted by Chao et al confirmed that the median cost of $136 per DALY averted (2012 prices) for a host of ophthalmic interventions was ‘very cost effective’ and recommended the inclusion of Cataract surgery within a small group of ‘top-priority disorders’ requiring surgical scale up. Another review by Grimes et al found the cost of Cataract surgery to be between US$5-106 per DALY averted; very cost effective and on a par with other interventions such as hernia repair, male circumcision, emergency caesarean section and cleft lip and palate repair.

CEA studies have invariably demonstrated that many eye health interventions are very cost effective. The World Bank acknowledged this in its seminal publication Essential Surgery and included both Cataract and Trichiasis surgery within a list of 44 essential procedures

Essential Surgery book cover

The evidence is clear

In conclusion, Cost Effectiveness Analysis studies have invariably demonstrated that many eye health interventions are very cost effective. The World Bank acknowledged this in its seminal 2015 publication Essential Surgery and included both Cataract and Trichiasis surgery within a list of 44 essential surgical procedures drawn up on the basis that they address substantial needs, are cost-effective and can be feasibly implemented.

Figure 1: Examples of Disability Adjusted Life Year (DALY) averted
AFRICA

Africa

SE ASIA

South-East Asia

Cataract Surgery
Average cost per DALY averted ($Int)

$Int116

$Int97

Trichiasis Surgery
Average cost per DALY averted ($Int)

$Int71-189

$Int285-848

Annual screening of school children & correction of refractive error
Average cost per DALY averted ($Int)

$Int190-521

$Int112-444

The GDP per capita for these countries at the time of the study data (2005) was in the order of $Int2,000, making all these interventions ‘very cost-effective’.

Figure 2: Cost effectiveness of Cataract surgery across nine countries world-wide, including five in Sub-Saharan Africa
SUB-SAHARAN AFRICA

Sub-Saharan Africa

(Five countries)

Average cost per QALY Gained (US$)

$25-$55

GDP
(US$)

$114-$542

NEPAL & INDIA

Nepal and India

Average cost per QALY Gained (US$)

$4-$36

Nepal GDP
(US$)

$245

India GDP
(US$)

$546

BRAZIL

Brazil

Average cost per QALY Gained (US$)

$61

GDP
(US$)

$3,027

CHINA

China

Average cost per QALY Gained (US$)

$254-$834

GDP
(US$)

$1,251

Our Supporters