Costs of blindness and poverty alleviation

BLINDNESS has profound human and socioeconomic consequences. The costs of lost productivity and of rehabilitation and education of the blind constitute a significant economic burden for the individual, the family and society. The economic effects of visual impairment can be divided into direct and indirect costs. The direct costs are those of the treatment of eye diseases, including the relevant proportions of costs for running medical and allied health services, pharmaceuticals, research and administration.
The indirect costs include lost earnings of visually impaired people and their caregivers and costs for visual aids, equipment, home modifications, rehabilitation, welfare payments, lost taxation revenue and the pain, suffering and premature death that can result from visual impairment.
The most comprehensive national assessment of the economic cost of visual impairment was conducted in Australia, where five principal eye conditions -- cataract, age-related macular degeneration, glaucoma, diabetic retinopathy and refractive error -- account for about 75% of all visual impairments. The analysis predicted that the direct cost of treating eye disease in Australia in 2004 could be A$1.8 billion.

Estimated total costs of eye disease in Australia, 2004
-Suffering and premature death associated with visual impairment A$4818 million
-Direct medical costs A$1824 million
-Lost earnings for the visually impaired A$1781 million
-Cost of caregivers, including their lost earnings A$845 million
-Aids, equipment, home modifications and other indirect costs A$371 million
-Taxation revenue forgone and welfare payments A$208 million

Global scenario: Disability adjusted life years (DALYs) from visual disability in comparison to other diseases

-Perinatal condition
-Lower respiratory tract infection
-Ischaemic heart disease
-Cerebrovascular disease
-HIV/AIDS
-Visual disorders
-Diarrhoeal disease
-Unipolar depressive disorders
-Malaria
-Pulmonary disease
-Chronic obstructive disease
Avoidable visual impairment: A human, social and development issue
Cataract is by far the main cause of readily curable blindness. As there are no known effective means of preventing the commonest forms of cataract, surgery should be provided to all those in need. Cataract surgery can be one of the most cost-effective of all health interventions, with a cost per DALY saved in the order of $20-40. Good-quality, high-volume cataract surgery can be provided at less than $10 per DALY in some settings. Cataract interventions are thus as cost-effective as immunisation and can significantly and rapidly reduce avoidable blindness.
Onchocerciasis has been brought under control in many parts of West Africa through the WHO Onchocerciasis Control Program, and the disease has been eliminated as a public health problem in 11 countries, equating to more than 600,000 cases of blindness prevented, 5 million years of productive labour added and 25 million hectares of land made use of. The economic return rate, a measure of the total economic benefit of a program in comparison with its total cost, has been estimated to be highly satisfactory.
Trachoma requires a range of medical, behavioural and environmental interventions. Data from some endemic countries show that both non-surgical (education and antibiotics) and surgical interventions (lid surgery for trichiasis) are among the most cost-effective measures for controlling blindness.
In the field of childhood blindness, control of xerophthalmia has also been shown to be cost-effective. Mass distribution of vitamin A capsules twice a year is one of the best health interventions available, with a cost per DALY saved of only $9. The comparable cost for vitamin A fortification would be about $29 per DALY saved.
Economic models at this level of detail are not yet available at a global level; however, according to a conservative analysis published in 2003 of the loss of productivity of individuals with visual impairment, the annual global economic impact of blindness and low vision in 2000 was $42 billion. In the absence of a decrease in the prevalence of blindness and low vision, this figure was projected to rise to $110 billion per year by the year 2020.
With successful implementation of VISION 2020, the annual loss of productivity of individuals with visual impairment was projected to rise only $58 billion in 2020, equivalent to an overall global saving of $223 billion over 20 years.
Projected worldwide cost of reduced productivity due to visual impairment during 2000-2020
World Health Organisation (WHO) has estimated that up to three-quarters of all blindness worldwide is avoidable. In children, about one-half of the causes can be prevented or treated, and the patterns of the causes of blindness in adults and children vary considerably from region to region.
In an effort to eliminate avoidable blindness from the earth by the year 2020 an action plan for 20 years was undertaken by WHO in collaboration with the International Agency for the Prevention of Blindness (IAPB) in 1999 through Beijing Declaration. The program is known as Vision 2020: The Right to Sight. Bangladesh ratified the vision 2020 global initiative in 2000, and is one of the first few countries in the world to do so.
Socioeconomic studies have shown that the prevention and treatment of avoidable blindness promote and accelerate progress towards a broader global development agenda, such as the Millennium Development Goals.
Without implementation of the Vision 2020 Program, the amount of lost productivity in 2000 was $42 billion per year, and could be $110 billion per year in 2020.
With the successful implementation of Vision 2020 Program, the amount of lost productivity in 2020 could be reduced to $58 billion per year.
The direct links between the activities of VISION 2020: The Right to Sight global program and human social and economic development must be strongly expressed and disseminated to decision makers at all levels.
Cost of blindness and poverty reduction in Bangladesh
There has been no study in Bangladesh to estimate the economic burden of blindness in the country and the cost of care. A South Asian study (India) revealed that not only did 85% of the men and 58% of the women who regained their sight return to work, but that there was also a financial return of 1,500% on the expense in the year following the surgery.
The economic burden of blindness in India for the year 1997, based on current assumptions, was $4.4 billion, and the cumulative loss over lifetime of the blindness was $77.4 billion. Childhood blindness accounts for 28.7% of this lifetime loss. The cost of treating all cases of cataract blindness in India was $0.15 billion (Shamanna et al. 1998).
In Bangladesh, it is estimated that there are about 550,000 cataract blind adults and 40,000 blind children in the country. The cost of blindness due to lost productivity is estimated to be Tk.2,500 crore ($350 million) in 2008, and the cumulative loss over lifetime of the blind is Tk.42,250 crore ($6 billion).
The cost of treating all causes of cataract blindness in Bangladesh is estimated to be Tk.350 crore ($50 million) only. ORBIS experience in Manikgonj district in eliminating cataract blindness revealed that the immediate internal rate of return of cataract surgery is 1,000% in the following year.
The current rate of resource allocation to treat national blindness is very low (about Tk.4 crore per year). This little amount cannot free the country from blindness as new cases will pile up over the years. It is well established that poverty and blindness are tied together; one causes the other. Resource allocation needs to be increased urgently to Tk.60-70 crore per year for the next five years for the effective elimination of avoidable blindness. This, in return, will contribute to the national economic productivity and, thereby, in poverty reduction.

Dr. Abu Raihan is ORBIS Country Director