Cost-Effectiveness of Cataract Surgery in a Public Health Eye Care Programme in Nepal

By Marseille, E. | Bulletin of the World Health Organization, May-June 1996 | Go to article overview

Cost-Effectiveness of Cataract Surgery in a Public Health Eye Care Programme in Nepal


Marseille, E., Bulletin of the World Health Organization


Introduction

Programme planners and policy-makers are turning increasingly to cost-effectiveness assessments to guide the allocation of health care resources. The World Bank, for example, has systematically applied cost-effectiveness criteria to establish priorities for health spending in low-income countries. In 1993 it included cataract surgery in the "most highly cost-effective" category of health interventions (1, 2). This article presents a re-assessment of the cost-effectiveness of cataract surgery using cost and services data from the Lumbini Zonal Eye Care Programme in Nepal. The findings suggest that cataract surgery may be even more cost-effective than previously believed (cataract surgery was found to have a cost per "disability-adjusted life year" (DALY) of US$ 5.06). This is in the same range of cost-effectiveness as other well-accepted public health interventions.

The cataract programme run by Seva, a US/Canadian nongovernmental organization, is used as the basis for the cost and benefits data presented here. Since 1985, Seva has been running a comprehensive blindness programme serving the 2 million people living in the Lumbini Zone, south-central Nepal. Besides supporting a base eye hospital, Seva's programme emphasizes field-based services including eye camps, screening camps, district-level clinics, and the training of village primary eye-care volunteers.

Cataract surgery in the Lumbini Eye Care Programme is performed on an outpatient basis under local anaesthetic followed by 7 days of observation at the eye hospital or eye camp. Typically patients underwent extracapsular cataract removal followed by insertion of a posterior chamber intraocular lens. A significant percentage of patients underwent intracapsular cataract extraction and received standard + 10 dioptre cataract spectacles. Since intraocular lenses were donated to the programme, for cost purposes it was assumed that all patients received aphakic spectacles.

Methods

Cost-utility analysis is a specific approach that is useful for determining the contribution of an intervention to both the length and quality of life (3). The method depends on assigning weights to different health states (O for death, through 1.00 for perfect health) (4, 5). These weights are then multiplied by the number of years that the health state exists, and discounted to the present. The final figure expressed in DALYs summarizes the value of the health state multiplied over the number of years that health state is expected to persist. By subtracting the discounted number of DALYs the patient would experience with no intervention from the number of discounted DALYs produced by an intervention, the net DALYs resulting from the intervention are obtained. Division of the net DALY by the discounted cost of the intervention yields the cost per DALY. The latter value expressed in dollars per DALY can then be used to compare the value of alternative interventions. In general, the cost of one net DALY can be calculated using the expression shown in Fig. 1, where N = remaining years of life; r = discount rate; [m.sub.1] = mortality rate given option 1, and [m.sub.2] = mortality rate given option 2.

Estimating the value of the parameters

In the analysis, "option 1" was cataract extraction and "option 2" no cataract extraction. On the basis of empirical data from ratings from the general public, experts and patients, Sackett & Torrance assigned a utility value of 0.39 to a lifetime of blindness. Other utility values from this seminal study are presented in Table 1, for comparison purposes (6).

Table 1: Reported utility of various stateS of health

Healthy                             1.00
Life with menopausal symptoms       0.99
Mild angina                         0.90
Kidney transplant                   0.84
Physical limitation with some pain  0.67
Deaf, dumb or blind                 0.399
Dead                                0
Confined to bed with severe pain   <0

The length of expected life following intervention and the length of expected life with no intervention are key parameters for estimating the utility of cataract surgery. …

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