Effective surgery fails to attract patients unless costs are low

Researchers at the Johns Hopkins Bloomberg School of Public Health who assessed the willingness of people in the Republic of The Gambia to undergo surgery to correct their trichiasis (a blinding disease common in some developing countries) have found that many people with the condition choose not to have the simple and relatively successful operation, and that the procedure's costs may be a barrier. The researchers found, however, that if the surgery could be provided locally rather than at more distant regional centers, many more people would agree to have the operation. The study, the first to look at the actual dollar costs to patients, appears in the latest issue of Ophthalmic Epidemiology.

Kevin Frick, PhD, an assistant professor of health policy and management at the Johns Hopkins Bloomberg School of Public Health, said, "We found that the surgery itself costs just a tenth of what a trichiasis patient's visual impairment over a lifetime will cost The Gambia in lost economic productivity. If more people could be convinced to get surgery in The Gambia -- principally by making the surgery available at the local level -- the gains in productivity from those additional surgeries would substantially exceed the costs of setting up local clinics." The researchers said they hope their findings will encourage policy makers to set up local surgery clinics, thus making it easier for people with trichiasis to get the corrective surgery.

The study first identified 158 persons in The Gambia with trichiasis and then offered half the patients surgery in local health centers and the other half surgery at more distant regional clinics. The researchers used three methods to assess the cost of the trichiasis surgery and its value to the patients: the cost of the surgery itself; how much individual patients were willing to pay for the corrective procedure; and the cost of the disorder to society in terms of an untreated patient's reduced economic productivity over a lifetime.

Patients in the study paid nothing out-of-pocket for the surgery. Their costs consisted of the time needed for the operation (an average of 20 minutes per eye) and for traveling to and from a clinic, as well as the price of any public transportation. On average, individuals getting surgery at a regional center must wait an additional two hours because no appointment system is used.

The researchers determined that, if left untreated, trichiasis will cost a patient and society an average of $89 in lost production over a lifetime (all monetary figures are reported in 1998 U.S. dollars). The total cost per surgery was calculated at $6.13, including $0.86 for transportation to the village. The inferred average amount people were willing to pay was $1.43. This sum, although negligible to a person living in a developed nation, is considerable in a country where the average wage is 11 cents per hour. The average costs associated with transportation and waiting time totaled $1.74 for individuals who had to travel to a regional health center, but only $0.22 for individuals who could obtain the surgery locally.

An increase in the cost of obtaining surgery was significantly associated with a decrease in patients’ willingness to undergo surgery. Initially, 59 of patients assigned to a regional clinic for surgery said they would be willing to have the procedure done; however, the researchers’ statistical projections predict that an additional 18 of these patients would be willing to get the surgery if it could be provided locally.

The additional cost of performing all surgeries at the local level rather than at regional clinics was $110; the total costs of moving the 59 surgeries done at regional clinics to local clinics was $51, for a total of $161. But just two additional surgeries would provide gains in lifetime economic productivity that would offset this cost.

The researchers conclude that planners in regions of the world where trichiasis is a problem need to consider the tradeoffs between immediate cost recovery and long-term gains in economic productivity that require additional expenditures up front.

Support for this study was provided by the International Trachoma Initiative and by a grant from Sight Savers International.