|COMMUNITY EYE CARE
|Year : 1998 | Volume
| Issue : 3 | Page : 169-172
Economic burden of blindness in India
BR Shamanna, L Dandona, GN Rao
Public Health Ophthalmology Service, L.V. Prasad Eye Institute, Hyderabad, India
B R Shamanna
Public Health Ophthalmology Service, L.V. Prasad Eye Institute, Hyderabad
Source of Support: None, Conflict of Interest: None
Economic analysis is one way to determine the allocation of scarce resources for health-care programs. The initial step in this process is to estimate in economic terms the burden of diseases and the benefit from interventions for prevention and treatment of these diseases. In this paper, the direct and indirect economic loss due to blindness in India is calculated on the basis of certain assumptions. The cost of treating cataract blindness in India is estimated at current prices. The economic burden of blindness in India for the year 1997 based on our assumptions is Rs. 159 billion (US$ 4.4 billion), and the cumulative loss over lifetime of the blind is Rs. 2,787 billion (US$ 77.4 billion). Childhood blindness accounts for 28.7% of this lifetime loss. The cost of treating all cases of cataract blindness in India is Rs. 5.3 billion (US$ 0.15 billion). Similar estimates for causes of blindness other than cataract have to be made in order to develop a comprehensive approach to deal with blindness in India.
Keywords: Economic analysis, blindness, economic loss, cost-effectiveness
|How to cite this article:|
Shamanna B R, Dandona L, Rao G N. Economic burden of blindness in India. Indian J Ophthalmol 1998;46:169-72
Allocation of limited resources for health should be prioritised based on returns to society. This partly depends on how cost-effective interventions for various diseases are. The first step in understanding this process would be to estimate the burden of diseases in economic terms. The traditional approach used to estimate the economic effect of a disease is to undertake a cost-of-illness study. This comprises the direct medical care costs, the indirect costs in terms of production losses owing to morbidity or premature mortality, and the intangible costs associated with illness (which is rarely estimated because of measurement difficulties). We have used this method in this paper as it has proved to be an important decision-making tool for allocation of scarce resources in health care. Economic analysis seeks to identify and to make explicit a set of criteria which may be useful in prioritising the use of scarce resources.
In this paper, we estimate the economic burden of blindness in India. We also calculate how much it would cost to treat the country's cataract blind at current prices.
| Materials and Methods|| |
In economic terms, the cost of blindness depends on the direct cost incurred by the blind person due to loss of productivity, and the indirect cost incurred by the family to take care of the blind person. Those blinded during childhood or at birth incur a higher economic cost to their family members and society over their lifetime than adults blinded later in life. The cost of blindness also depends upon how many blind persons would enter economic activity if they were able to do so. In order to estimate the economic burden of blindness in India in the year 1997, we estimated the direct cost resulting from the loss of per capita gross national product (GNP) for adult blindness in the productive age group, and the indirect cost incurred by the family to take care of the blind. We also calculated the cumulative lifetime economic losses from blindness based on certain assumptions. Lastly, we calculated the cost of treating all cases of cataract blindness in India at present rates. The assumptions made to arrive at the economic burden of blindness in India are:
- 1. The average number of working years lost due to adult blindness is 10 years.
- 2. The average age of blind children is 8 years, and all of them would have become productive members of the community after 7 years, that is, at age 15. The life expectancy of a blind child is assumed to be 48 years, resulting in a loss of 33 working years.
- 3. 10% of the productive time of one economically productive member of the family of each blind person is lost in taking care of the dependent blind.
- 4. 20% of all those who are blind are economically productive at 25% the productivity level of a member of the labour force. The remaining 80% blind are not economically productive.
- 5. 75% of adult blindness and 50% of childhood blindness is either curable or preventable.
The following data were used to calculate the economic burden of blindness. According to World Health Organisation (WHO) estimates, the prevalence of blindness (defined as visual acuity <3/60 in the better eye) in India is 1%. The current population of India is estimated to be 961 million, and the per capita annual GNP Rs. 11,160 (US$ 310), growing at 5% per annum. In children ≤15 years of age, the prevalence of childhood blindness in India is estimated at 5 - 10 per 10,000., For our calculation, we used the rate of 6.5 per 10,000 children. Children ≤15 years of age make up 40% of the population in India. The total labour force of the country, age group 16-64 years, is 43% of the population. The total GNP is the contribution of the labour force between 16-64 years. In India, close to 60% of all the blindness occurs in the age group 30-64 years., The average life expectancy for an Indian today is 62 years.
These assumptions and data were used to calculate the loss of GNP in India due to blindness in the year 1997. The cumulative GNP loss due to preventable or curable blindness in India for the lifespan of the blind was also calculated.
To calculate the cost of treating cataract blindness, which accounts for about half of the blindness in India, we took into consideration the suggestion by the Government of India under the World Bank Assisted Cataract Blindness Control Project. That is, to tackle the problem of the backlog of cataract blindness in India, 11 million sight-restoring cataract surgeries would be done in 7 years in the 7 states which have nearly two-thirds of India's cataract blindness, 70% of which would be with the intracapsular cataract extraction (ICCE) technique and the remaining by the extracapsular cataract extraction (ECCE) technique. The World Bank has invested Rs. 5,543.6 million (US$ 154 million) to assist the National Program for Control of Blindness for this purpose. The cost of an ICCE with aphakic spectacles in a community-based camp setting in India has been estimated to be Rs. 775 (US$ 21.5). To estimate the cost of a single procedure of ECCE with intraocular lens (IOL), the budget for the program minus the grant-in-aid to non-government organisations for ICCE surgery was divided by the number of surgeries by ECCE with IOL. This was calculated to be Rs. 1,445 (US$ 40). An earlier report estimated the cost of the ECCE with IOL to be Rs. 2,000 (US$ 55.5) in a hospital setting which includes infrastructure costs. For our calculations, we used Rs. 1,750 (US$ 48.6) as the cost for one ECCE with IOL.
| Results|| |
The economic burden of blindness in India for the year 1997 based on our assumptions is Rs. 159 billion (US$ 4.4 billion) [Table - 1]. The direct loss of GNP due to blindness in India for the year 1997 is Rs. 146 billion (US$ 4.0 billion). The indirect loss for both adult and childhood blindness was calculated to be Rs. 24.9 billion (US$ 0.70 billion). The economic productivity of blind persons as per our assumptions is calculated to be Rs. 12.1 billion (US$ 0.33 billion) for 1997.
With the assumption that an adult loses 10 working years as a result of blindness, the cumulative loss during the lifespan of the adult blind amounts to Rs. 1,986 billion (US$ 55.2 billion). When the cumulative loss for childhood blindness was calculated for the lifetime of 0.25 million blind children with 33 working years of life lost, it was found that the losses amounted to Rs. 801 billion (US$ 22.2 billion). The cumulative loss due to preventable or curable blindness for the life span of the blind is estimated at Rs. 1,890 billion (US$ 52.5 billion) which is 67.8% of the total cumulative loss due to blindness.
The current estimated cost of treating cataract blindness in India, according to our assumptions, is Rs. 5.3 billion (US$ 0.15 billion) [Table - 2].
| Discussion|| |
The total GNP at current prices in India is Rs. 11,017 billion (US$ 306 billion). The net loss of GNP for the year 1997 due to blindness is Rs. 159 billion (US$ 4.4 billion) which is 1.45% of the total GNP. This is about 72.5% of what the government spends for the health sector in a year. The total GNP loss estimated in the year 1993 for countries with low income economies is US$ 9.7 billion. If a growth rate of 5% is assumed, this loss becomes US$ 11.8 billion for 1997. As compared with this, the net loss of GNP due to blindness for India for the year 1997 is 37.3% of the losses for all low-income economies. With the assumption that an adult loses 10 working years as a result of blindness, the cumulative loss during the life span of blind adults amounts to Rs. 1,986 billion (US$ 55.2 billion). The cumulative loss for childhood blindness for the lifetime of 0.25 million childhood blind and for 33 working years of life lost is Rs. 801 billion (US$ 22.2 billion), which is 28.7% of the cumulative GNP loss due to all blindness. Initially, the family associated with childhood blindness bears only the indirect loss. After age 15 years, there is also productivity loss, taking into account the growth rate. Although the number of blind children is a small proportion of all the blind in India, the economic loss over their lifetime is considerable.
The total lifetime productivity losses for HIV/AIDS in India estimated in the year 1995 with the assumption of a minimum wage of Rs. 14,460 was Rs. 3,447 billion (US$ 95.8 billion). The estimated lifetime loss due to blindness of Rs. 2,787 billion (US$ 77.4 billion) at current prices seems to be of the same order of magnitude as the loss due to HIV/AIDS. This is an example of how comparative analysis of economic loss due to diseases can help in forming a macro perspective of health care.
The cost of an ECCE with IOL in India is estimated to range from Rs. 1,445 (US$ 40) to Rs. 2,000 (US$ 55.5) based on reports., For our calculations, we assumed a rate of Rs. 1,750 (US$ 48.6) as the cost of a single procedure. Even if 52% of the country's blindness due to cataract is treated with an investment of Rs. 5.3 billion (US$ 0.15 billion), and if we assume that 80% of those operated are not blind after surgery, and 45% of the cataract blind are in the labour force age group, the savings in the annual GNP would be Rs. 40 billion ( US$ 1.1 billion). This shows that the treatment for cataract blindness is a very cost-effective intervention. This is one of the reasons for the World Bank assistance to India to develop infrastructure and manpower to reduce cataract blindness. The cost-effectiveness analysis for treatment of cataract blindness is used as an example of how this can help in prioritisation of resource utilisation. In order to get a complete picture of the resources that would be involved in dealing with all causes of blindness in India, similar cost-effectiveness analysis has to be done for the prevention and treatment of causes of blindness other than cataract.
We have used the cost-of-illness methodology to arrive at the economic burden of blindness. An alternative to this is the cost-utility methodology which assesses the morbidity, life expectancy, and quality of life of those afflicted with disease with or without a particular intervention.
In an environment of competing resources, justification for higher priority by policy makers would depend on such estimates of cost-effectiveness. However, it is important to remember that while economic analysis is one important way of prioritising meagre resources, it should not be the only method of doing so. It is conceivable that some health-care interventions which are relatively less cost-effective may in the long term have broad beneficial effects on societal development. Societal values and felt needs of the community, apart from economic analysis, have to be taken into account while determining allocation of resources.
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[Table - 1], [Table - 2]