Contributions of public and private sectors to the Iranian cataract surgery output

EMHJ  •  Vol. 21  No. 8  •  2015

Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale

Short communication

Contributions of public and private sectors to the Iranian cataract surgery output H. Hashemi,1 F. Rezvan,1 A. Fotouhi,2 M. Khabazkhoob,3 H. Gilasi,4 K. Etemad,3 A. Mahdavi 1 and S. Asgari 2

‫ـة‬ ‫ـت يف مجهوريـ‬ ‫ـات الكاتاركـ‬ ‫ـاج جراحـ‬ ‫ـاص يف نتـ‬ ‫ـام واخلـ‬ ‫ـن العـ‬ ‫ـامهات القطاعـ‬ ‫ـائدة يف مسـ‬ ‫ـات السـ‬ ‫ـة االجتاهـ‬ ‫ـذه الدراسـ‬ ‫ـددت هـ‬ ‫حـ‬ ‫ لقـ‬:‫ـة‬ ‫اخلالصـ‬ َ ‫ـد‬ ‫ـن‬ ‫ـاد مـ‬ ‫ـاء البـ‬ ‫ـع أنحـ‬ ‫ـة يف مجيـ‬ ‫ـز اجلراحيـ‬ ‫ـت يف املراكـ‬ ‫ـي أجريـ‬ ‫ـت التـ‬ ‫ـات الكاتاركـ‬ ‫ـة بجراحـ‬ ‫ـات املتعلقـ‬ ‫ـتخراج البيانـ‬ ‫ـم اسـ‬ ‫ـد تـ‬ ‫ لقـ‬.‫ـامية‬ ‫ـران اإلسـ‬ ‫إيـ‬ ‫ـا‬ ‫ـغ جمموعهـ‬ ‫ـي بلـ‬ ‫ والتـ‬2010 ‫ـام‬ ‫ـت يف عـ‬ ‫ـي أجريـ‬ ‫ـات التـ‬ ‫ـبة للعمليـ‬ ‫ بالنسـ‬.)2010 ‫ـام‬ ‫ـى عـ‬ ‫ وحتـ‬2006 ‫ـام‬ ‫ـن عـ‬ ‫ (مـ‬،‫ـنوات‬ ‫ سـ‬5 ‫ـدة‬ ‫ـرىض ملـ‬ ‫ـجالت املـ‬ ‫سـ‬ ‫ـدد‬ ‫ـد أن العـ‬ ‫ـا وجـ‬ ‫ كـ‬.)% 38.3( ‫ـاص‬ ‫ـاع اخلـ‬ ‫ـز القطـ‬ ‫ـري يف مراكـ‬ ‫ـا أجـ‬ ‫ـر ممـ‬ ‫) أكثـ‬% 61.7( ‫ـام‬ ‫ـاع العـ‬ ‫ـز القطـ‬ ‫ـا يف مراكـ‬ ‫ـري منهـ‬ ‫ـا أجـ‬ ‫ـد أن مـ‬ ‫ وجـ‬،273 516 ‫ـا‬ ‫ـادة قدرهـ‬ ‫ـاص زيـ‬ ‫ـام واخلـ‬ ‫ـن العـ‬ ‫ـبية للقطاعـ‬ ‫ـامهات النسـ‬ ‫ـل املسـ‬ ‫ـر حتليـ‬ ‫ وأظهـ‬.2010 ‫ و‬2006 ‫ـي‬ ‫ـن عامـ‬ ‫ بـ‬% 59.1 ‫ـبة‬ ‫ـع بنسـ‬ ‫ـات ارتفـ‬ ‫ـكيل للعمليـ‬ ‫الـ‬ ‫ـت كان يف القطاع‬ ‫ـات الكاتاركـ‬ ‫ـو جراحـ‬ ‫ـدل نمـ‬ ‫ـإن معـ‬ ‫ فـ‬،‫ـايل‬ ‫ وبالتـ‬.‫ـنوات‬ ‫ سـ‬5 ‫ــ‬ ‫ـرة الـ‬ ‫ـال فـ‬ ‫ـة خـ‬ ‫ـز اخلاصـ‬ ‫ يف املراكـ‬% 100.5 ‫ـة و‬ ‫ـز العامـ‬ ‫ يف املراكـ‬% 41 ‫ـت‬ ‫ـت كانـ‬ ‫ـات الكاتاركـ‬ ‫ـايل جلراحـ‬ ‫ـدد اإلمجـ‬ ‫ـاص يف العـ‬ ‫ـاع اخلـ‬ ‫ـامهة القطـ‬ ‫ـن أن مسـ‬ ‫ـم مـ‬ ‫ـى الرغـ‬ ‫ فعـ‬.‫ـام‬ ‫ـاع العـ‬ ‫ـه يف القطـ‬ ‫ـاف مثيلـ‬ ‫ أضعـ‬2.7 ‫ـاص‬ ‫اخلـ‬ .‫ـو‬ ‫ـدل النمـ‬ ‫ـرة يف معـ‬ ‫ـادة كبـ‬ ‫ـهد زيـ‬ ‫ـه شـ‬ ‫ـر إال أنـ‬ ‫أصغـ‬ ABSTRACT This study determined trends in the contributions of the public and private sectors to the cataract surgery output in the Islamic Republic of Iran. Data about cataract surgeries performed at surgical centres throughout the nation were extracted from patient charts for a 5-year period from 2006 to 2010. Of the total 516 273 surgeries performed in 2010, more were done in public sector centres (61.7%) than private ones (38.3%). The total number of surgeries increased by 59.1% between 2006 and 2010. Analysis of the relative contributions of the public and private sectors showed a 41.0% increase in surgeries in public centres and 100.5% in private centres over the 5-year period. Thus the rate of growth of cataract surgery in the private sector was 2.7 times greater than that in the public sector. Despite a smaller contribution to the total number of cataract surgeries, the private sector has experienced a substantial rate of growth.

‫ـهيال‬ ‫ سـ‬،‫ـدوي‬ ‫ـا مهـ‬ ‫ـي رضـ‬ ‫ عـ‬،‫ـاد‬ ‫ـوروش اعتـ‬ ‫ كـ‬،‫ـايس‬ ‫ـا غيـ‬ ‫ـد رضـ‬ ‫ محيـ‬،‫ـوب‬ ‫ـدي خبازخـ‬ ‫ مهـ‬،‫ـي‬ ‫ـر فتوحـ‬ ‫ أكـ‬،‫ـوان‬ ‫ـاد رضـ‬ ‫ فرهـ‬،‫ـمي‬ ‫ـن هاشـ‬ ‫حسـ‬ ‫ـغري‬ ‫عسـ‬

‫مسامهات القطاعني العام واخلاص يف نِتاج جراحات الكاتاركت يف إيران‬

Contribution des secteurs public et privé au nombre de chirurgies de la cataracte en Iran RÉSUMÉ La présente étude a déterminé les tendances dans la contribution des secteurs public et privé au nombre de chirurgies de la cataracte en République islamique d’Iran. Les données sur les chirurgies de la cataracte réalisées dans des centres chirurgicaux de l’ensemble du pays ont été extraites des dossiers des patients sur une période de 5 ans, de 2006 à 2010. Sur un total de 516 273 chirurgies de la cataracte réalisées en 2010, 61,7 % l'ont été réalisées dans des centres publics contre 38,3 % dans le privé. Le nombre total de chirurgies a augmenté de 59,1 % entre 2006 et 2010. L’analyse de la contribution relative des secteurs public et privé a révélé une hausse de 41,0 % dans les centres publics et de 100,5 % dans les centres privés sur cinq ans. Le taux d'augmenter de la chirurgie de la cataracte dans le secteur privé était donc 2,7 fois supérieur à celui du secteur public. Malgré une contribution moindre au nombre total de chirurgies de la cataracte, le secteur privé a connu un taux d'augmentation important en la matière.

Noor Ophthalmology Research Centre, Noor Eye Hospital, Tehran, Islamic Republic of Iran (Correspondence to S. Asgari: soheilaasgari@gmail. com). 2Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Islamic Republic of Iran. 3Department of Epidemiology, Faculty of Public Health, Shahid Beheshti University of Medical Sciences, Tehran, Islamic Republic of Iran. 4 Department of Public Health and Biostatistics, Faculty of Health, Kashan University of Medical Sciences, Kashan, Islamic Republic of Iran. 1

Received: 27/10/14; accepted: 24/05/15

606

‫املجلد احلادي و العرشون‬ ‫العدد الثامن‬

‫املجلة الصحية لرشق املتوسط‬

Introduction Blindness, which is most commonly caused by cataract, is one of the most important public health problems in the Eastern Mediterranean Region where the mean prevalence of blindness reaches about 1.5% (1). More than 60% of the blind people in this Region reside in Afghanistan, Islamic Republic of Iran, Iraq and Pakistan. Blindness is an economic burden due to lost productivity and the costs of rehabilitation and education, especially in developing countries (1). Since cataract is the major cause of avoidable blindness, its timely diagnosis and treatment is very important. Cataract surgery is one of the most cost-effective health-care interventions (2). In the Islamic Republic of Iran, the operation is offered in the public and private sectors. The public sector includes mainly university-affiliated centres, non-university centres (military or charity) and surgery centres affiliated with the Iranian national Social Security Organization. Patients referring to these centres are often covered by health insurance or the Social Security Organization. In the private sector, however, expenses are mostly paid out-of-pocket. In 2010, cataract surgery centres were available in all provinces of the Islamic Republic of Iran. About 43.1% of the national health expenditure was allocated to the public sector in 2006, while in 2010 the rate was 40.2%. For the private sector, the share of health

expenditure increased from 56.8% in 2006 to 59.8% in 2010 (3). However, these expenditures are not allocated exclusively to eye surgery services, but to the whole health sector. If we could determine sector-specific expenditures, we would be able to demonstrate the impact of this reduction on the public sector. In this study, we aimed to compare the contributions of the public and private hospital sectors to the cataract surgery output in 2010 and to the 5-year trends from 2006–10.

The Persian calendar is a solar seasonal one tied to the vernal equinox. To assign time frames, after excluding the first 2 weeks of spring (i.e. the first 2 weeks of the year), which are national holidays, 1 week per season was randomly selected for each unit using the above method with replacement. Then the records of all cataract surgeries conducted during these weeks were reviewed. The total number of surgeries in each season was thus determined and multiplied by 50/4 (12.5) to calculate the annual number of surgeries for any given year.

Methods This study was part of the Iranian Cataract Surgery Survey in which information about cataract surgeries performed at surgical centres throughout the nation were extracted from patient records. Data extraction was conducted by a team of 10 trained personnel under the supervision of an ophthalmologist. The study methods have been described in a previous report (4). In brief, the list of cataract surgical centres was provided by the Iranian Ministry of Health, Treatment and Medical Education. After categorization of public and private centres, we randomly selected a proportional number of them using Microsoft Excel software and the RANDBETWEEN (bottom, top) command without any replacement. The weights of each sector were determined based on the number of selected centres in each sector.

Results In 2010, there were 160 public and 81 private cataract surgery centres in the Islamic Republic of Iran. Of these, 77 public (weight: 2.08) and 60 private (weight: 1.35) centres were sampled for the survey. In that year a total of 516 273 surgeries were performed at the sampled centres: 318 289 (61.7%) in the public sector and 197 984 (38.3%) in the private sector (Table 1). The private centres’ share of national cataract surgeries was 30.4% in 2006 and this increased to 38.3% in 2010. A corresponding decrease in the public centres’ share was seen from 69.6% in 2006 to 61.7% in 2010 (Table 1). Table 1 and Figure 1 show the trend in cataract surgery operations over the study period (2006–10). The total number of surgeries performed rose from 324 508 in the year 2006 to 516 273 in

Table 1 Contribution of the public and private sectors to the total number of cataract surgeries in the Islamic Republic of Iran, 2006–2010 Year Total No. 2006 2007 2008 2009 2010 324 508 366 549 459 367 449 826 516 273 Cataract surgeries performed Public sector centres (n = 77/160) No. 225 770 247 494 303 002 280 595 318 289 % 69.6 67.5 66.0 62.4 61.7 Private sector centres (n = 60/81) No. 98 738 119 055 156 365 169 231 197 984 % 30.4 32.5 34.0 37.6 38.3

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EMHJ  •  Vol. 21  No. 8  •  2015

Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale

Public 600,000

Private

500,000 No. of surgeries

400,000

300,000

200,000

100,000

0

2006

2007

2008 Year

2009

2010

Figure 1 Number of cataract surgeries performed in the public and private sectors in the Islamic Republic of Iran, 2006–2010

the year 2010, a 59.1% increase. Analysis of the relative contributions of the public and private sectors to the increase showed that in the public centres there was a 41.0% increase in the number of surgeries from 225 770 to 318 289 over the 5-year period, while in private centres surgeries rose 100.5% from 98 738 to 197 984. Thus, the rise in the number of cataract surgeries was 2.7 times greater in private centres compared with public ones.

Discussion “Vision 2020: the right to sight” was launched by the World Health Organization and the International Agency for the Prevention of Blindness with the goal to eliminate avoidable blindness by 2020 (5). Cataract is the leading cause of avoidable blindness, and the rate of blindness due to cataract has a wide range across different parts of the world (6). In developed countries, the onset of cataract is typically after the age of 50 years, but it tends to start at younger ages in developing countries (7). Cataract surgery is a successful and cost-effective 608

intervention for this condition and can enhance patients’ quality of life (8,9). The results of the present study indicated that public centres take on a greater share of service provision than private ones. The public sector’s greater share may be due to the high number of university centres, the favourable distribution of these centres and the presence of training resident surgeons in universities. In addition, the Social Security Organization has a 58% population coverage (10) and plays a major role either directly or through other public services. On the other hand, we saw a 59.1% increase in the number of cataract surgeries over the 5-year period of the study, which was greater in the private than the public sector. During these years, the national income per person has increased 16.7fold (11) and the purchasing power parity, i.e. the gross domestic product, has increased by 1.8-fold (12). This could be one explanation for the increased service uptake in the private sector. During the 5-year study period, there was a 41.0% increase in cataract surgeries in the public sector, while the over 50-year-old population, which is susceptible to cataract, increased by 35.9%

(11). Therefore, services seem to have increased proportionate to the growth of the susceptible population. Appropriate policy-making and planning is needed to improve and maintain this balance. Nonetheless, studies have reported relatively long waiting times for surgery at Iranian university hospitals (13–15). To our knowledge, there is no report concerning waiting times for cataract surgery in the Islamic Republic of Iran. The list from the Iranian Ministry of Health showed that private cataract surgery services are well-distributed throughout the country. Although the number of private centres was around half that of the public ones, their cataract surgery rate showed a more than 100% growth during this 5-year period. This growth is not proportionate with the growth in the population of over-50-year-olds. However, an advantage of increased service provision in this sector is reduced waiting time and the possibility of having surgery shortly after diagnosis. Extensive needs assessment surveys are required to determine the capacity needed for cataract surgery in the private sector.

Conclusion The public sector in the Islamic Republic of Iran makes a larger contribution to cataract surgery service provision than the private sector, and its growth is not proportionate to the over-50-year-old population growth. Operations in the private sector, however, seem to show a trend towards a greater share of the total of operations, but this growth needs to be proportionate with the needs of the nation and the elderly population of the country.

Acknowledgements Funding: This research was supported by the noncommunicable disease unit of the Iranian Ministry of Health, Treatment and Medical Education Competing interests: None declared.

‫املجلد احلادي و العرشون‬ ‫العدد الثامن‬

‫املجلة الصحية لرشق املتوسط‬

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