The Global Initiative for the Elimination of Avoidable Blindness (Vision 2020: The Right to Sight) sets a major challenge requiring a significant increase in the provision and uptake of eye care services. If the increasing trend in blindness is to be reversed, then access to eye care services needs to be made more widely available. One of the most significant barriers to accessing these services is affordability. The shrinking economies of many of the world’s poorest countries is placing increasing pressure on health care budgets that are already severely over stretched. Competing demands from life threatening diseases such as AIDS, malaria, and TB are pushing eye health services further down the agenda list of public health priorities. Simultaneously, the increasing cost of health care is forcing many governments to reform the structure of their health delivery systems. Many are choosing to introduce cost recovery mechanisms, as a means of controlling the overall rising costs of providing health care services.
Articles in this issue focus primarily on the supply issues of service delivery, looking particularly at how increasing operational and manufacturing efficiencies can reduce costs to an affordable level. But to place affordability within the reach of ordinary people, their families and the communities in which they live, we also need to understand the demand issues which place additional cost burdens that do not allow access to eye care.
The costs are many and complex and the intention of this article is to explore what these might be (direct and indirect), and to offer some suggestions as to what might be done in order to make eye care more affordable to those who can least afford it.
In an effort to provide sustainable services, many public and NGO health care providers throughout the world are increasingly moving towards the introduction of user fees. However, in reaching out to poor and marginalised communities, the effects of these strategies are widely believed to have negative outcomes on both utilisation and equality in service uptake. A number of barrier studies (conducted primarily in India) have found that direct costs, such as those for transport, treatment, surgery, drugs, glasses and optical devices like IOLs etc. act as major deterrents for those who can least afford them. When these are removed, for example in offering free surgery, transport and food, not surprisingly there has been an increased uptake of services.1 However, these same studies have also shown that the removal of these costs alone is still not enough to encourage full service utilisation. In fact, one study in particular in India demonstrated that the provision of highly subsidised fees had little impact on improved uptake of services.2
Calculating the cost impact of direct fees in real terms for the individuals concerned is not an easy task. An affordability study carried out in Jamaica provides an enlightening approach to calculating what these costs might possibly be. Using national income data, the average daily income was calculated at the 30th, 60th and 90th percentile. The study then calculated how many days an average worker at each percentile point, would need to work in order to afford a simple eye examination and an average pair of prescription glasses. The study showed that those on average income at the 60th percentile would need to work over 52 days in order to afford the necessary fees. This contrasted dramatically with 3.4 days in the USA for the same percentile level.3 Whilst the removal of treatment fees or the introduction of subsidies may improve the problem, the issues of affordability are far more complex. To increase the uptake of services, we also need to examine and understand the nature and social context of indirect cost barriers.
The nature of indirect costs will very much depend on circumstances, but they will relate to the cost of time, effort and disturbance of daily activity for both the individual concerned and, importantly, their families. In a Participatory Rural Appraisal study carried out in India, 40% of respondents quoted such indirect costs, as the major reason for non-attendance. Here, the cost of lost income to attend treatment for both the individual and their accompanying minder, as well as concerns about the length of recovery time, were given as the main reasons for not accessing services.4 This is particularly interesting because the recovery time for cataract surgery (which if performed early, is only a matter of a few days with ECCE and an IOL implant) is more likely to be affected by associated complications arising from late presentation. As the onset of cataract is painless and is characterised by a slow decline in vision, the pressure of affordability delays the decision to come forward early, thus increasing the risks of complications and, consequently, lengthening the time of recovery and cost to the individual and their families.
Another study in Uganda recorded reasons such as ‘too busy’ to be a major deterrent for accessing services.5 Here the issue is one of ‘opportunity cost’ where in a typically rural subsistence community the meeting of basic living needs, such as food production to feed the family, override all other concerns (like the gradual clouding of vision) which are regarded as non-essential.
Once vision deteriorates to a point where daily functions can no longer be performed, the sufferer soon becomes completely dependent on other family members for their sustained well-being. Even at this point where the problem has become obvious, barrier studies have shown that people still may not present for such reasons as ‘no one to accompany them’ or ‘family opposition’. There is no doubt that in many very poor communities, the opportunity cost of a family member accompanying a blind relative to hospital may be too great a price to pay, if the lost time is at the expense of providing the family with basic needs such as food. Elderly people suffering from cataract blindness frequently have little say over how the family resources are utilised and, in this respect, ‘family opposition’ may well be an expression of discrimination, where the family concludes that investment of minimal resources on an ageing relative is of little value when weighed against other competing demands.
As we have seen, the issues of affordability are many and complex and whilst barrier studies show a remarkable similarity of results, it is also true that there will be variation in cost deterrents, depending upon the circumstances of specific situations. The challenge is to design a delivery system that is sensitive and responsive to these cost barriers in order to make eye care more affordable.