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Adv Ther
Adv Ther
Advances in Therapy
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39126597
2958
10.1007/s12325-024-02958-y
Original Research
The Economic Burden of Childhood Ocular Morbidity in Bangladesh
Hussain A. H. M. Enayet 1
Islam Labida 23
Mashreky Saidur Rahman 23
Viitasara Eija 1
http://orcid.org/0000-0001-7393-796X
Dalal Koustuv Koustuv.dalal@miun.se
koustuv2010@hotmail.com

1
1 https://ror.org/019k1pd13 grid.29050.3e 0000 0001 1530 0805 Division of Public Health Science, Department of Health Sciences, Mid Sweden University, Sundsvall, Sweden
2 grid.517648.9 Centre for Injury Prevention and Research Bangladesh, Dhaka, Bangladesh
3 grid.459397.5 0000 0004 4682 8575 Bangladesh University of Health Sciences, Dhaka, Bangladesh
10 8 2024
10 8 2024
2024
41 10 38203831
4 6 2024
25 7 2024
© The Author(s) 2024
2024
https://creativecommons.org/licenses/by-nc/4.0/ Open Access This article is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License, which permits any non-commercial use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc/4.0/.
Introduction

Childhood eye morbidity is a great public health problem, especially in low-income countries. This study aimed to determine the economic burden of childhood ocular morbidity on attending tertiary hospitals in Bangladesh. This study also assessed the catastrophic health expenditure (CHE) for childhood ocular morbidity in Bangladesh.

Methods

A cross-sectional mixed method was used for this study from April to October 2023 at two tertiary hospitals in Bangladesh, one government-funded and one private. Face-to-face interviews using a semi-structured quantitative questionnaire with the caregivers/parents and in-depth interviews (IDIs) were conducted among the same respondents of these two hospitals, and a workshop was conducted with the stakeholders during the study period.

Results

This was the first study in Bangladesh to determine the cost of pediatric ocular morbidity. Among 335 patients, the total median direct cost at a single time was 3740 ± 18,285 BDT (34 ± 166.2 USD) at the government hospital and 7300 ± 40,630 BDT (66.36 ± 369.36 USD) at the private hospital. The disease-specific median overall cost from diagnosis of the disease was 65,000 BDT (591 USD) for squint, 50,000 BDT (454.54 USD) for cataract, and 30,000 BDT (272.72 USD) for eye injury. Almost 90% of the caregivers/parents faced CHE due to different pediatric ocular morbidity.

Conclusions

These cost estimates can be used as an initial basis for financial decisions that aim to enhance access to care, management, and follow-up of children with ocular morbidity. These cost estimates also offer helpful information for organizational and financial sustainability initiatives. Policymakers can consider serious immediate interventions for securing ocular health services in Bangladesh and prevent families from CHE.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12325-024-02958-y.

Keywords

Catastrophic health expenditure (CHE)
Ocular morbidity
Children
LMICs
Bangladesh
Mid Sweden UniversityOpen access funding provided by Mid Sweden University.

issue-copyright-statement© Springer Healthcare Ltd., part of Springer Nature 2024
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pmcKey Summary Points

Why conduct this study?	
There were no earlier studies of catastrophic health expenditure (CHE) for childhood ocular morbidity.	
The current study is the first to determine the economic burden of childhood ocular morbidity on attending tertiary hospitals and to assess the CHE for childhood ocular morbidity in Bangladesh.	
What was learned from the study?	
Almost 90% of the caregivers/parents faced CHE due to different pediatric ocular morbidity.	
Lack of trust in the nearby facility, treatment incompetency, and lack of awareness were the main factors that triggered the highest out-of-pocket expenditure of the parents of children with ocular morbidity.	

Introduction

Eye health is a vital component of general health and well-being, as well as early childhood development [1, 2]. Some childhood ocular problems might result in blindness or visual impairment if left untreated [3]. Ocular morbidity and childhood impairment are serious public health concerns worldwide. The early years are crucial for the development of vision. When issues do develop, children might not be able to express their displeasure or difficulties, and parents may not recognize the possibility of such visual issues. Intervention delays run the risk of causing moderate to severe long-term visual problems [4].

A study conducted in India showed that the prevalence of pediatric ocular morbidity was 29.35% [5]. Most of the available studies demonstrated that refractive error was the most common of pediatric ocular morbidity [5–7]. The prevalence of ocular morbidity in Bangladesh in peri-urban settings aged 15 years was 5.63% [6].

Roughly 1.4 million children worldwide are expected to be blinded by preventable causes, and three-quarters of them reside in the world’s poorest regions—Africa and Asia. Within the context of the World Health Organization (WHO) Vision 2020—The Right to Sight Programme, the prevention of blindness in children is given top attention [8, 9].

More than 90% of blind youngsters do not attend school and will never reach their full potential. Therefore, although it only makes up 4% of the total amount, blindness in children accounts for one-third of the economic cost of blindness [10]. Data shows that an estimated 70 million blind-person years are caused by blindness among children [11].

The cost analysis of childhood ocular morbidity is mandatory to quantify the disease burden. However, many studies illustrated the cost-effectiveness of adult cataract surgery and glaucoma [12–14], and few studies have been conducted to evaluate the cost of pediatric cataract surgery and glaucoma [12–14]. Additionally, data indicated that the cost of treating several diseases, including multiple sclerosis, cancer, and liver diseases, was catastrophic [15–18]. Although catastrophic health expenditure (CHE) was calculated for various diseases, the CHE for childhood ocular morbidity has yet to be calculated. No existing study has objectively analyzed the cost and CHE of childhood ocular morbidity in Bangladesh. This study aimed to determine the economic burden of childhood ocular morbidity, including cataracts, eye injury, and squints, in patients who were attending two tertiary hospitals in Bangladesh. This study also assessed the CHE for childhood ocular morbidity in Bangladesh.

Methods

This was a mixed-method cross-sectional study. Quantitative and qualitative methods were used to evaluate the cost of pediatric ocular morbidity and explore the eye health care-seeking practices of caregivers/parents of children with ocular morbidity. A face-to-face interview was conducted among the caregivers/parents with children with ocular morbidity in the two tertiary hospitals of Bangladesh, the government-funded National Institute of Ophthalmology (NIO) and the private Ispahani Islamia Eye Institute and Hospital. In-depth interviews (IDIs) were conducted with the same study population, and a workshop was held with the stakeholders. The study period was from April to October 2023.

Data Collection

Parents/caregivers of children with ocular morbidity were interviewed in this study. A pre-tested semi-structured questionnaire was used for the face-to-face interview (enclosed in a supplementary file). A team of two data collectors conducted the interviews. Prior to data collection, the research team carried out 2 days of extensive training on data collection procedures with the data collectors. Along with the research coordinator, one field supervisor supervised all the field activities. Data collectors collected data from the hospitals from June to September 2023. All children with ocular morbidity aged 0 months to 18 years were included in this study (109 children from NIO and 226 children from Ispahani Islamia Eye Institute and Hospital) during the data collection period. A total of 335 parents/caregivers of children with ocular morbidity were interviewed to evaluate the cost related to ocular morbidity as well as their eye health-seeking behavior. Sociodemographic characteristics like age, gender, parental education, parental/caregiver occupation, and income were included in this study.

A total of nine IDIs were conducted using a topic guide containing specific questions about the out-of-pocket (OOP) expenditure of eye health care, why the burden is so high, and recommendations to mitigate the problem with the parents and one workshop was conducted with the stakeholders. The nine IDIs were conducted as we reached thematic saturation after finishing those interviews. Parents had children with ocular morbidity treated at the tertiary hospitals. Stakeholders were pediatric ophthalmologists, non-government organizations (NGOs), international non-government organization (INGO) professionals, and government officers related to the healthcare sector. These interviews aimed to gather insights and perspectives from parents whose children were admitted to the hospital where we collected the quantitative data. The parents were randomly selected for IDIs, and stakeholders were selected on the basis of their expertise and experience in eye and healthcare services in Bangladesh. A diverse range of perspectives and insights were obtained, contributing to a more comprehensive understanding of the topic under investigation. The qualitative interviews were conducted by the researcher and two research assistants. IDIs were conducted in the same setting where quantitative data were collected. Parents were interviewed in a hospital where patient confidentiality was protected by the authorities. A dedicated interview room was provided, but this was not noise-free because of the massive influx of patients in the hospital. Interviewees became distracted by their sick child and background noise. However, they helped our entire team and finished the interview on schedule. Each interview lasted 30–40 min. The whole interview process took 10 days to complete in September 2023. The workshop was conducted in a specific, well-lit hall room in a calm environment where no disturbance occurred during the process. A 1-day workshop was held for 3 h. During the interviews and discussions during the workshop, all participants were assured of confidentiality and anonymity. The interviews and workshop were audio-recorded with the consent of the participants, and detailed hand-written notes were taken to capture additional information and nuances where appropriate. This combination of audio-recording and note-taking allowed for comprehensive documentation of the interviews and ensured accuracy in capturing the participants’ responses.

Data Analysis

A descriptive analysis was carried out to describe the population characteristics both for the children and the households. Data were analyzed using the Statistical Package for the Social Sciences (SPSS) software version 26. Direct costs were calculated as bed, medicine, food, diagnostic, and transport costs. Indirect costs were calculated as caregiver accommodation costs, caregiver food costs, local transport costs during hospital stays, and income loss of the patient’s wage earner. CHE was measured when OOP healthcare costs exceeded 10% of total household expenditure [15, 16]. There was a high level of skewness in all the cost data. Median and interquartile range (IQR) was used to determine the cost as data were not symmetrically distributed [19]. Bangladeshi taka (BDT) was converted to US dollar (USD) using Bangladesh Central Bank’s interbank exchange rate (1 USD = 110 BDT).

Analysis of Qualitative Data

The qualitative information was meticulously transcribed. Two trained and experienced researchers independently coded the transcription. The transcriptions were made in Bangla first and then translated into English. The language was checked and validated by two senior researchers. To ensure quality, translation and back-translation of sample transcripts were ensured. Through content analysis, major themes were identified, coded, and categorized [20]. To ensure validity, the researchers compared their findings with each other under the supervision of a senior researcher (professor).

Operational Definitions

Children: This term encompassed any children under 18 years of age group according to the WHO [20].

Ocular morbidity: Prior to developing this study’s tool, we assessed inpatients’ hospital record books (for ocular morbidity) with the permission of the authority and ethical committee. We found that there were three kinds of patients with pediatric ocular morbidity admitted to the hospital: cataract, ocular injury, and squint—these were included as three major pediatric ocular morbidities in this study.

Ethical Approval

Ethical clearance was obtained from the BMRC (Bangladesh Medical and Research Council) ethical review board. Written informed consent was taken from the parents on behalf of all respondents.

Results

Table 1 lists the basic characteristics of the study participants included in the study. Most of the patients were 5 to under 10 years old (46.3%). More than half of the patients were male (59.7%). Two-thirds (67.5%) of participants were treated at the private hospital. The majority of the patients were students (49.6%), and both mothers and fathers had secondary education (39.1% and 29.9%). The majority of the patients’ mothers were housewives (88.4%), and the fathers were in the service sector (37.6%). Most families’ monthly income was 10,000–30,000 BDT (91–272.72 USD).Table 1 Demographic distribution of the participants (n = 335)

Variables	Categories	Frequency (n)	%	
Age of the patients	< 5 years	138	41.2	
5 to < 10 years	155	46.3	
10–18 years	42	12.5	
Sex of the patients	Male	200	59.7	
Female	135	40.3	
Type of facility	Government	109	32.5	
Private	226	67.5	
Occupation of mother	Housewife	296	88.4	
Service	26	7.8	
Business	2	0.6	
Student	6	1.8	
Others	5	1.5	
Occupation of father	Service sector	126	37.6	
Business	50	14.9	
Day laborer	112	33.4	
Skilled worker	4	1.2	
Others	43	12.8	
Education of mother	Illiterate	34	10.1	
Up to class 5 or equivalent	49	14.6	
Class 6–10 or equivalent	131	39.1	
SSC completed or equivalent	52	15.5	
Class 11–12 or equivalent	5	1.5	
HSC completed or equivalent	31	9.3	
Graduation completed	18	5.4	
Post-graduation completed	15	4.5	
Education of father	Illiterate	51	15.2	
Up to class 5 or equivalent	70	20.9	
Class 6–10 or equivalent	100	29.9	
SSC or equivalent	46	13.7	
Class 11–12 or equivalent	3	0.9	
HSC or equivalent	30	9	
Graduate	14	4.2	
Postgraduate	21	6.3	
Type of family	Nuclear family	270	80.6	
Joint family	65	19.4	
Average monthly family income (BDT)	≤ 10,000	67	20	
10,000–30,000	214	63.9	
> 30,000	54	16.1	
Average monthly family expenditure (BDT)	≤ 10,000	88	26.3	
10,000–30,000	213	63.6	
> 30,000	33	9.9	
Total	335	100	
HSC higher secondary certificate

Half (49.9%) of the diagnosed cases were cataracts, and 10.7% of cases were childhood ocular injuries.

Table 2 shows that the government hospital had the cheapest package in terms of bed, medicine, and food costs (median ± IQR 940 ± 1890 BDT, 8.54 ± 17.2 USD). Also, patients’ parents paid the government hospital’s diagnostic costs (median ± IQR 0 ± 450 BDT, 0 ± 4.1 USD) and transport costs (2000 ± 8950 BDT, 18.2 ± 81.36 USD), totalling the hospital stay costs (median ± IQR 3740 ± 18,285 BDT, 34 ± 166.2 USD). On the other hand, in private hospitals, patients spent the most on medicine costs (median ± IQR 1500 ± 9700 BDT, 13.6 ± 88.2 USD), diagnostic costs (2400 ± 38,700 BDT, 21.8 ± 351.8 USD), and transport costs (1500 ± 9000 BDT, 13.6 ± 81.8 USD). The total costs during hospital stay were 7300 ± 40,630 BDT (66.4 ± 369.4 USD).Table 2 Details of direct costs by facility type

Type of facility	Bed, medicine, and food costs	Diagnostic costs	Transport costs	Total cost during hospital stay	
Government hospital	940 ± 1890 BDT (8.54 ± 17.2 USD)	0 ± 450 BDT (0 ± 4.1 USD)	2000 ± 8950 (18.1 ± 81.4 USD)	3740 ± 18,285 (34 ± 166.2 USD)	
Private hospital	600 ± 600 (5.5 ± 5.5 USD)	1500 ± 9700 (13.6 ± 88.2 USD)	600 ± 900 (5.5 ± 8.2 USD)	2400 ± 38,700 (21.8 ± 351.8 USD)	1500 ± 9000 (13.6 ± 81.8 USD)	7300 ± 40,630 (66.4 ± 369.4 USD)	
Costs are presented as median ± IQR

The government hospital had the lowest caregiver accommodation costs (median ± IQR 0 ± 0 BDT, 0 ± 0 USD), whereas the private hospital had the highest (median ± IQR 0 ± 7500 BDT, 0 ± 68.2 USD) (Table 3). Caregiver food and local transport costs were economical in government hospitals (median ± IQR 900 ± 4000 BDT, 8.2 ± 36.4 USD and 0 ± 2000 BDT, 0 ± 18.2 USD) but expensive in the private hospital (median ± IQR 1200 ± 7000 BDT, 10.9 ± 63.6 USD and 85 ± 70,000 BDT, 0.77 ± 63.6 USD). On the other hand, the income loss of a wage earner of the patient was lower in the government hospital (median ± IQR 2000 ± 15,000 BDT, 18.2 ± 136.4 USD) than in the private hospital (median ± IQR 3000 ± 200,000 BDT, 27.3 ± 1818.2 USD).Table 3 Details of indirect costs by facility type

Type of facility	Caregiver accommodation costs	Caregiver food costs	Local transport costs during hospital stays	Income loss of a wage earner of the patient	
Government hospital	0 ± 0 (0 ± 0 USD)	900 ± 4000 (8.2 ± 36.4 USD)	0 ± 2000 (0 ± 18.2 USD)	2000 ± 15,000 (18.2 ± 136.4 USD)	
Private hospital	0 ± 7500 (0 ± 68.2 USD)	1200 ± 7000 (10.9 ± 63.6 USD)	85 ± 7000 (0.77 ± 63.6 USD)	3000 ± 200,000 (27.3 ± 1818.2 USD)	
Costs are presented as median ± IQR

Figure 1 demonstrates that patients’ maximum median hospital cost was about BDT 10,030 in total (direct cost BDT 7850; indirect cost BDT 2500) which is due to squint. The second highest was cataract, which is around BDT 9900 (direct cost BDT 6800; indirect cost BDT 2120). The median government hospital cost was 4870 BDT, and the private median hospital cost was 10,500 BDT.Fig. 1 Summary of median hospital cost according to disease type

Figure 2 shows that squint had the highest OOP expenses with a median of BDT 65,000. The second highest OOP expenditure was caused by cataracts, with a median of BDT 50,000, followed by injuries, with a median OOP cost of BDT 30,000. This cost was calculated on the basis of the diagnosis of the disease and expenses to date.Fig. 2 Summary of median overall cost according to disease type

Almost 89% of parents have CHE due to eye-treatment costs for their children. Results in Table 4 show that the prevalence of CHE is highest for cataracts (95.2%), followed by squint (92.9%).Table 4 Catastrophic health expenditure of different childhood eye disease

Variables	Number	CHE (%)	
Cataract	167	159 (95.2)	
Eye injury	36	30 (83.3)	
Squint	28	26 (92.9)	
Others	104	84 (80.8)	

Only 6.9% of the respondents ever received treatment from a traditional healer, and more than half (56.5%) of the respondents received treatment from them before the diagnosis of the disease. The most common reason for visiting traditional healers was superstition/belief (52.2%) and around 26.1% visited because of cost (Fig. 3).Fig. 3 Summary of treatment by a traditional healer

Figure 4 shows that almost two-thirds of the patients managed the cost either by taking loans (32%), financial support from others (19%), or selling assets (8%). At the same time, only 39% were able to support the cost by their regular family income.Fig. 4 Summary of patient cost management

Qualitative Findings

During the thematic analysis, four main themes emerged from the data. Theme one highlighted the need for trusting nearby facilities regarding eye health care seeking for their children. Themes two and three focused on the referred-to capital city tertiary hospital with modern facilities and the treatment incompetency of the nearby hospital/facility. Theme four emphasized the need for more knowledge about where to seek eye health care, which is also reflected in the quantitative results.

Lack of Trust in the Nearby Facility

Most of the participants (five respondents out of nine) in the qualitative interview stated that they did not have that much trust in their nearby facility to seek eye care for their children; thus, they went directly to the Capital City Hospital. They mention that some of their relatives and neighbors went to the nearby facility for the treatment of other diseases, but they still needed more.

One of the participants said,“I went to the nearby facility for myself, but there was not enough manpower or equipment available. After that, when I noticed my child faced eye problems, me and my wife did not take my children there” (P-1).

Another participant highlighted that,“I took my child to a neighboring hospital after suspecting that she might have an eye condition, but she did not receive enough care there, so I took her to another hospital” (P-4).

Referral to Capital City Tertiary Hospital with Modern Facility

Referral to the Capital City Hospital with a modern facility played a key factor in increasing the OOP expenditure of the parents, as explained by three participants. Participants noted that most of the time, they went to the nearby hospital for their children, but they were referred to the capital city hospital with modern facilities.

Participants said the same thing about the referral:“His child was diagnosed with a squint in a nearby facility and they referred him to National Institute of Ophthalmology saying that this treatment is not possible here” (P-3, 9).

Another participant narrated that,“My child had myopia, so I went to the nearby health complex to change his glass[es], but they referred us to another hospital and told us they do not have enough equipment to check the eye power” (P-7).

Treatment Incompetency of the Nearby Hospital/Facility

Treatment incompetency is another factor in CHE. Some of the parents emphasized that as a result of treatment incompetency, they had to spend a lot of money on their children’s eye treatment. Out of the nine IDI participants, four also highlighted that they had to take loans or sell their assets for that treatment purpose.“My children were involved in an accident that resulted in eye injuries. A local hospital began treating them, but after two days, they informed me that they weren’t eligible for any more care. Additionally, they ordered us to remove my child, but they did not specify where this treatment could be found. After numerous attempts to get him admitted, we finally transported him to Capital City Hospital” (P-2).

Lack of Knowledge

Few participants (two) agreed that they needed more knowledge of where to seek eye care for their children. As a result, they went here and there for treatment purposes, leading parents to incur high costs when they finally sought treatment.

Two respondents explained:“I regularly run here and there for treatment of my children because I was unaware that there was a medical facility in our district that specialized pediatric eye care” (P-5, 8).

These qualitative findings highlight the critical factors of high OOP expenditure that hinder parents’ ability to seek appropriate eye health care for their children. Addressing these barriers is crucial for improving childhood eye care utilization and ensuring timely interventions for children’s ocular health.

Discussion

To the best of the authors’ knowledge, this is the first study conducted in a low-income country using the context of Bangladesh that assessed cost-analysis and economic burden of childhood ocular morbidity using data from caregivers’ perspectives attending two tertiary hospitals. Though CHE was calculated for various diseases [15, 17], that due to childhood ocular morbidity had not been calculated. The current study found that almost 90% of families suffer from CHE due to childhood ocular morbidity.

Globally, ocular morbidity and disability among children are major public health concerns. In this study, 49.9% of the diagnosed cases were pediatric cataracts. In order to develop a targeted and financially viable approach to address the problem, data on the cost of treatment of ocular morbidity in children are essential.

This study revealed that the disease-specific median cost of pediatric ocular morbidity was 50,000 BDT (454.55 USD) for cataract, 30,000 BDT (272.73 USD) for injury, and the highest cost accounts was for squint, 65,000 BDT (590.90 USD). Also, the results demonstrate that total hospital costs for cataracts, injury, and squint were BDT 9900, 5040, and 10,030 (90, 45.81, 91.18 USD), respectively. Facility bed, medicine, and food costs in the government hospital were BDT 940 (8.54 USD) (median cost). In the private hospital, the median cost for medicine was BDT 1500 (13.6 USD), and diagnostic cost was BDT 2400 (21.8 USD).

Data also showed that the income loss of a patient’s wage earner in the government and private hospitals was BDT 2000 and 3000, respectively (USD 18.1 and 27.27) (median cost).

A study conducted in India on cost analysis of pediatric cataracts showed that, per surgery, the cost of personnel was 5300 INR [21], whereas in our study, the median direct hospital cost of cataracts was 6800 BDT (61.82 USD).

Evans et al. reported that the annual treatment cost of pediatric cataract surgery in Malawi and Zambia was $9550 and $18,605, respectively [13]. This could be because the study analysis’s equipment, labor, therapy, and medication costs were all involved.

Our study findings showed that more than half (56.7%) of pediatric ocular morbidity was first diagnosed in a private clinic, which differs from the previous study conducted nationally in community settings [4].

The results also show that 90% of our study participants faced CHE due to pediatric eye treatment. Among all of them, cataracts account for the highest CHE (95.2%), followed by squints (92.9%) and eye injury (83.3%). The quantitative findings of this study were supported by the qualitative findings. Participants of this study explained that lack of trust, being referred to another hospital, treatment incompetency, and lack of knowledge were the key factors that increased OOP expenditure. To meet these expenses, they had to take loans, sell their assets, and bear the expenses of another person who stayed with them; thus, they faced CHE.

Data suggested that superstition/belief is the most common cause of visiting a traditional healer, which could be explained by the low parental education—the majority are illiterate, primary or secondary educated (totalling, 64% for mothers and 66% for fathers). The nuclear family has problems with access to eye care facilities as the fathers are mainly breadwinners and the mothers are homemakers. Also, this completely aligned with the results of a previous study on barriers to eye health-seeking behavior [4]. Hussain et al. revealed that financial constraints hinder the eye health-seeking practices of parents of children with ocular morbidity [4]. In contrast to that study, our study also found that almost two-thirds of the patients managed the treatment cost either by taking loans (32%), financial support from others (19%), or selling assets (8%).

Strengths and Limitations

To the best of the authors’ knowledge, this is the first study conducted in Bangladesh to assess the cost analysis, including CHE, and economic burden of childhood ocular morbidity in Bangladesh. The findings from our study are expected to have an enormous impact on lowering OOP costs for the treatment of ocular morbidity in children. Policymakers can utilize this knowledge to formulate a strategic plan to reduce the economic burden of childhood ocular morbidity by integrating intra- and inter-sectoral intervention. Though this is the first study to assess the economic burden of childhood ocular morbidity in the two tertiary hospitals of Bangladesh, this is not a nationally representative study.

Policy Implications

So, high CHE must be the major hindrance to achieving the Bangladesh government’s target of SDG beyond 2030, especially in addressing Universal Health Coverage. Many approaches can be taken to lessen this issue. To begin with, people-centered eye care should be incorporated, digitalization of the eye health sector, community involvement, and integration of the health sector and beyond health sectors. Other measures are incorporating antenatal care with pediatric eye health and strengthening the immunization programme through health promotion, demand-side financing, and strengthening the referral system. Additionally, raising awareness related to pediatric eye diseases is essential.

Conclusion

Almost 90% of the parents faced CHE due to pediatric ocular morbidity. Lack of trust in the nearby facility, treatment incompetency, and lack of awareness were the main factors that triggered the highest OOP expenditure of the parents of children with ocular morbidity. A comprehensive plan to address the treatable issue of childhood ocular morbidity should be facilitated by quantifying the financial need associated with pediatric ocular morbidity and by continuing efforts to identify the educational and logistical barriers related to delayed presentation and inadequate follow-up.

Supplementary Information

Below is the link to the electronic supplementary material.Supplementary file1 Supplementary file: Questionnaire (original in Bengali language) & English translated (DOCX 34 KB)

Supplementary file2 (PDF 519 KB)

Acknowledgements

This study was conducted in two hospitals in Bangladesh: National Institute of Ophthalmology (NIO) and the Ispahani Islamia Eye Institute and Hospital. These two hospitals provided administrative and technical support in the data collection procedures. We are also grateful to the ophthalmologists and stakeholders who took part in the workshop. We are thankful to the members of the Office of the Director General of Health Services and the Bangladesh Medical and Research Council (BMRC) for their technical support in the validation of our research materials. Finally, we are thankful to all the participants who took part in this study.

Author Contributions

AHM Enayet Hussain and Koustuv Dalal were mainly responsible for the study’s design and supervision. AHM Enayet Hussain and Labida Islam were involved in the data collection. AHM Enayet Hussain prepared the first draft. All named authors wrote the manuscript. Koustav Dalal critically reviewed and edited the article. AHM Enayet Hussain, Labida Islam, Saidur Rahman Mashreky, Eija Viitasara, and Koustav Dalal wrote, revised, and approved the final manuscript.

Funding

Open access funding provided by Mid Sweden University.

Data Availability

The datasets used in the current study are available from the corresponding author upon reasonable request to Dr. AHM Enayet Hussain. Email: enayet.hussain@miun.se.

Declarations

Conflict of Interest

All named authors declare no conflicts of interest in any research steps.

Ethical Approval

Ethical clearance was obtained from the BMRC (Bangladesh Medical and Research Council) ethical review board. Written informed consent was taken from the parents on behalf of all respondents.
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