Bulletin of the World Health Organization · 8 authors, 8 centres
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Investing in eye health (correcting refractive errors and cataracts) in low- and middle-income countries yields a median benefit-cost ratio of 36, which is six times higher than the typical global development investment (ratio of 6). These returns are comparable to best-buy interventions, supporting the inclusion of eye health in broader development strategies.
**Background:** Vision impairment affects 2.2 billion people globally, yet eye health services are underfunded, receiving less than 0.06% of development spending. Traditional cost-effectiveness metrics (e.g., cost per DALY averted) undervalue eye health because they overlook productivity and welfare gains. This study uses benefit-cost analysis to assess returns from correcting refractive errors and cataracts in low- and middle-income countries (LMICs).
**Methods:** Two complementary approaches were used. First, a systematic review (PubMed and Web of Science, 14 August 2023) identified studies from LMICs measuring productivity, income, or learning impacts of vision correction. Benefit-cost ratios were calculated using a societal perspective, 3% discount rate, and assumptions about eyeglass lifespan (3 years for adults, 1 year for children) and lifetime benefits for cataract surgery. Second, an economic model based on micro-costing data from six Indian eye health providers (screening 2.3 million people) estimated benefit-cost ratios for four case-finding strategies: vision centres, eye camps, door-to-door screening, and school screening. Benefits included increased employment, reduced mortality, productivity gains, and learning improvements (0.18 SD test score increase associated with 20% higher adult income). Costs included provider and patient costs. Probabilistic sensitivity analysis used 10,000 Monte Carlo simulations.
**Key Results:** The systematic review yielded 21 studies (33 outcomes) from 10 countries; 17 outcomes were used for benefit-cost analysis. Median benefit-cost ratio was 36 (mean 40), ranging from 2 (cataract surgery in Ethiopia) to 104 (eyeglasses for farmers in Cambodia). For studies with low/moderate risk of bias, median ratio was also 36. The economic model for India produced ratios of 28 (vision centres), 38 (eye camps), 29 (door-to-door), and 42 (school screening), with an aggregate ratio of 31. Total annualized cost was US$2.1 million, annualized benefits US$67.4 million (US$143 per person treated). Compared to 652 global development investments (median ratio 6), eye health returns six times more benefits. Eye health ratios (median 36) also exceeded those for noncommunicable disease (9) and nutrition (13) interventions.
**Clinical Implications:** Eye health investments yield substantial societal returns, comparable to best-buy global development interventions. Decision-makers should consider broader welfare benefits beyond DALYs. Ministries of health, education, agriculture, and finance can justify expanded investment in vision screening and cataract surgery, particularly in LMICs. However, evidence is limited to selected countries and contexts, and many studies had serious risk of bias. Further research using rigorous methods (RCTs, quasi-experimental designs) and comprehensive cost data is needed, especially in underrepresented regions and sectors.