Ever thought about how a quick cataract surgery or a new pair of glasses might change not just someone's life, but an entire community's future?

Imagine being in a world where something as small as improved vision unlocks work, learning and social connection, sparking economic growth and personal independence.

Today we're diving into that idea, exploring how the economics of healthcare, especially eye health, can spark big changes globally.

Our guest today, Jack Hennessey, is a veteran in this field with over 10 years of experience tackling big challenges in health economics.

He's not only shaped policies in Australia, but also steered eye health projects across South Asia, Africa and the Pacific.

Jack's work shows us that making eye care accessible isn't just a health win.

It's a key to driving development and lifting communities out of hardship.

In this episode, we chat about the real world impact of affordable eye care.

How can a simple eye exam or timely cataract surgery bring new opportunities to individuals and economies alike?

Jack will share insights from his hands on work, demystifying how small interventions in eye health can lead to significant, significant benefits far beyond the clinic.

My name is Hetul Daman and you're listening to the Global Health Pursuit.

You've spent your last decade in the world of health economics.

I think that for our audience, what, in your own terms is health economics?

Yeah, good question.

Economics is generally like the study of how resources are allocated.

Essentially there's scarce resources in the world and economists want to study how to optimize their allocation.

So when it comes to economics, obviously people think about money straight away just because it happens to be like sort of one of the most important and scarce resources in the world.

But sort of more and more lately, economists have branched out into other types of fields.

So things like health economics, development economics, environmental economics, because these are all sort of resources that are scarce.

And we sort of study as health economists, I guess, as a sort of sub discipline of economics, how scarce resources such as health services, such as money for health services, etc.

How they could be sort of, I guess, optimally distributed.

Really for me, health economics is really the study at the moment or finding ways of achieving universal health coverage.

So that's kind of the idea that, you know, there should be healthcare accessible for everyone, right?

And it shouldn't be that healthcare is free for everyone.

Maybe if you have a bit more money, there are ways that mechanisms, financing mechanisms that could allow you to pay for health services.

But if you don't have as much money, that for sure shouldn't mean that you can't access these health services.

So I guess as a whole, health economics is about how we enable universal health coverage and how we enable everyone to access services for health, no matter if they're rich or they don't have as much money.

That's kind of how I would describe it.

Give me an example of how health economics actually impacts people.

An example is, say there's a country where there's only 10 ophthalmologists doing.

Doing cataract surgeries, right?

But if we just let things go, I guess as a free market, maybe, maybe naturally we'd probably find that the only people that get these types of services are people that have lots and lots of money and they can afford to pay these services and maybe skip the line.

But what we want to do is, as healthc economists, is make sure that everyone can get these services.

And it doesn't matter if you have lots of money or a little bit of money.

We want to find ways to either if it's setting up sort of government systems, whether it's through taxation or whether it's through foundations like the Fred Hollows foundation, or through other sort of financing mechanisms, set up innovative ways to increase access to these services for everyone, no matter how much money you have.

So you help people access healthcare services no matter how much money they have.

And in a previous conversation that we had, you said that you actually worked for the bad guys in this realm, right?

Yeah, I think.

I'm not sure if I should ever describe anyone I've worked for as the bad guys, quote, unquote.

But, you know, so I think so, certainly more often than not, people are trying to do the right thing.

I think economists sometimes get a little bit of a bad rap because, you know, a lot of the time what we're doing is modeling costs and benefits associated with a program that, that we might want people to invest in.

And if it's for a private firm or if it's for a government with a certain political agenda, often there's a bit of pressure to, I guess, skew, skew the results in certain ways.

And so we see this all the time, right, with sort of any health intervention, any big infrastructure project, you know, if they want a new.

If they want to build a new football stadium in Kansas City, right?

They say the return on investment for the economy is going to be, you know, $300 billion.

People do it the same with healthcare, right?

So if there's a pharmaceutical company that's really pushing for FDA approval or Medicare approval in Australia, there's these cost effectiveness studies or return on investment studies that say, hey, yeah, this is a great investment, it's a great investment.

So that's when I was kind of framing individuals that there's bad guys.

And it's certainly not the case, but I guess with what I would call the good guys at the Fred Hollows foundation, where I've been for about five years now, it's certainly not the case there because we kind of have these very stringent approaches to cost effectiveness.

And there's a book by Peter Singer called the life you can save and this philosopher, but he essentially talks about this sort of concept.

You know, there's, there's basically every intervention gets shown as being pretty cost effective or having a good return on investment.

There's, there's not too many economists who are doing these things and saying, hey, you know, that's a, that's a really bad idea.

But there is when you follow quite a scientific approach and you know, I'm pretty privileged to work at the foundation where they, they take that relatively scientific approach to things.

And I'm not having to go out there and justify interventions that I know might not be best for the population.

And the fact is that, you know, it's, I always say it's like kind of like a dream job for health economists working in eye health because we have cataract surgery and refractive air treatment for glasses are two of the most cost effective interventions on the planet.

So I'm not out there trying to prove the cost effectiveness that's been done.

That's like a fact of science already.

I'm out there working with governments to see how we can get these services to the people who are most vulnerable.

I guess that's the sort of dichotomy of maybe bad and good in that respect.

Explain to me a little bit what cost effectiveness is and why this pertains to eye health.

I think people throw it around a lot.

It's got kind of like a technical term which is like the cost per health outcome in health economics is, is what you look at.

So if you're talking about cost effectiveness of something, it might be the cost per number of glasses distributed, the cost per cataract, surgery, etc.

But the way to say something is cost effective compared to other health interventions, et cetera, is to sort of standardize this approach.

So health economists use a thing called usually quality adjusted life years.

It's essentially saying like a particular health intervention, whether it's, you know, cancer, a type of cancer treatment, or whether it's cataract surgery, this might result in X number of additional life years live, so it might enable you to live longer.

But what quality adjusted life years do is they take into account the quality of life lived during those years.

So essentially we look at health interventions as we judge cost effectiveness by the dollar per qaly added.

So for instance, if you get a health treatment, say, say you get some type of surgery and it enables you to stay alive longer, but you extremely cognitively, like, you know, reduce cognitive abilities and stuff like that, we can't just say, hey, it's the same as living another five life years.

We might equate that to like two quality adjusted life years or something like that.

And so that's what we talk about when we talk about sort of cost effectiveness from a technical point of view.

It kind of allows us to assess and standardize and prioritize health interventions based on a ratio of cost to qualities added.

That makes a lot of sense because I feel like with eye health you can just throw on a pair of glasses or do a quick cataract surgery and then you're able to see and you're able to work and all of that, right?

So your quality of life is way higher than say you have cancer and you have to go through chemotherapy and that chemotherapy has a lot of different side effects.

Yeah, absolutely.

I think the main thing about why cataract surgery and refractive air treatments are consistently like top 10 in the world amongst immunizations, et cetera, as being the most cost effective interventions is because cataract surgery, right, you do it with minimal equipment, you do it in like eight minutes and someone goes from bilaterally blind, like literally potentially hasn't been able to see for 10 years, a decade or whatever, and suddenly they can see again.

So the cost of this surgery is really, really low.

But that effectiveness in terms of the quality of life impact, ability to hang out with your friends, look after your children, you know, go back to work, is what a lot of governments care about these days.

That's, that's why it's so, so cost effective.

So it's not just because it's low cost.

It's like a low cost plus it's one of the most effective changes that you see so quickly.

Some of the work that you do right now with the Fred Hollows foundation is kind of negotiating with the government and different public health entities to fund eye health treatments.

Why is it, why is that such a difficult thing to do?

Like, why is that such a hurdle when like, like what you just said?

You know, it's Just an eight minute procedure or you can throw on some glasses.

Why is that so almost like deprioritized in governments?

Yeah, that's a, it's a, it's a great question.

And I guess like that is the, the, the challenge and the privilege of being a health economist at the Fred Hollis foundation.

Because you know, if you looked back 100 years ago, right, and you, and you say, hey, like someone who's completely, you know, bilaterally blind, we say in eight minutes you can see again.

Like we would all be like celebrating in the streets and be like, we've got it, we've got the cure.

Like, that's awesome.

Like there's no reason really.

Like, you know, polio vaccine came in the 50s or whatever, in 10 years, polio is essentially eradicated.

Like it's, this is the great challenge of what we do.

And my role is why isn't this prioritized?

So there's, there's a couple of reasons, I guess.

In, in more resource heavy settings, in more developed countries, sort of like Australia and the US we have really stringent ways that, that health interventions are prioritized for public funding.

So in Australia, for instance, we've got Medicare and so this is publicly funded health services.

So for anything to be funded through that, essentially you have to have quite a rigorous cost effectiveness study to be done.

And for instance, things like cataract, et cetera, they pass these rigorous cost effectiveness tests and often they are publicly funded.

So it's, it's, it's not as much of an issue in, in these countries, but in low resource settings, especially countries with sort of fledgling health financing systems, you know, they don't have necessarily universal health care set up.

They don't have things like, we call it Medicare in Australia, but it's obviously a different meaning in the US but essentially publicly funded health systems for people who need it.

And so a lot of these resource, I guess, constrained settings, they don't have huge teams of, you know, Ministry of Health health economists who are doing all these sort of studies and prioritizing interventions.

And in fact that's where most of our work is done.

So we'll work with governments and we'll say, hey, you know, what do you need to, we'll show you this intervention, we show you cataract surgery, we show you refractive error, we show you our ability to scale service delivery throughout these countries and treat large proportions of the population really, really cheaply.

We say, do you need a cost effectiveness study?

Do you need more evidence?

Like what's what's the thing stopping you from funding this?

And it might just be lack of resources where we end up cost sharing with them for a little bit.

There's, there's so many different things, things that we do to, to sort of advocate for, for eye health to be prioritized.

One thing I'll just touch on and something.

One of like my big research projects is at the moment when I was talking about those quality adjusted life years, which again, like the, a silly technical term, but something very similar called a disability adjusted life.

Here it's kind of just the opposite.

So quality adjusted life years we want to add through an intervention, disability adjusted life years, we, we want to like, save.

So they're kind of like a bad thing.

So what happens is the Institute of Health Metrics and Evaluation, based in Seattle, they publish these things called the Global Burden of Disease Disability weights.

And essentially it weights like all different qualities of life between zero, which is like, like essentially full health, and, and one, which is, which is death in this.

You know, it seems really arbitrary to do that, but it rates this on this scale.

And so blindness, for instance, used to be rated up at like 0.6.

So that was saying essentially, you know, again, very arbitrary, but saying, you know, being bilaterally blind is, you know, you're 0.6 and, and 1 is death.

It's really, really bad on your quality of life.

But these got reviewed like 10 years ago and that they assess these in a number of different ways and that dropped right down to, I think it's at 0.19 now.

So 0.2.

So essentially they're saying, you know, it's really not that bad at all.

I think, you know, compared to other things like skin conditions and like, you know, mild alcoholism is like higher than really blindness, mild alcoholism, 0.26, rheumatoid arthritis, 0.29.

So we are essentially undertaking a big sort of systematic review to delve into like, the methods that we use to calculate these weights.

And they do them in a bunch of different ways.

But this is, this is one of my main projects this year, is working with London School of Hygiene and Tropical Medicine to really challenge why this happened, what's going on.

Because to say that bilateral blindness is a 0.19, when a moderate skin disfigurement with an itch or the pain, or a pain is 0.19 as well.

There's.

There's something going wrong.

So, so yeah, so this is when I was talking about how governments use cost effectiveness analysis to prioritize interventions that cost effectiveness analysis inherently has to use these weights.

So that's why, despite so much research showing that these are these incredible cost effective interventions, when they actually take it to trial and they try and prove this to a government, often they'll come out as potentially less cost effective when they're using these standardized disability weights as the metric.

Tell me if I'm wrong, but one of these metrics is mortality as well.

Does it cause death?

So, yeah, exactly.

That's the, the crux of it.

So those, those metrics don't go into the, the weight calculation but for the quality or the daily calculation for sure.

And that's again why when we were talking about cancer treatments before, obviously like a year of extra life is weighted the most like for, for, for everyone.

That's, that's the goal, right, to, for everyone working in health economics, the goal is to, to live another year longer.

Right.

And so when it comes to eye health, there's a fair bit of evidence showing that, you know, poor vision is related to increase of risk of falls in, in older people and this might contribute to mortality, but essentially there's no mortality involved in that calculation of that disability weight.

When you compare to things like, as we said before, cancer treatments, where, you know, these treatments, although they might be really expensive, they have the potential to avoid mortality.

So that's, again, you're spot on.

That's the reason why perhaps some governments don't necessarily prioritize these eye health interventions.

I think my question is why?

How did it reduce so much from 0.6 to 0.2?

That's like a huge drop.

It's enormous.

There's been a number of people in this sector that have sort of challenged this over time.

Hugh Taylor, who's a researcher at University of Melbourne and great friend of the foundation, has been pretty vocal about challenging this.

And I think, you know, we're sort of taking that next step now, trying to produce some rigorous evidence and really articulate why it has been done.

These studies have a relatively consistent approach, but estimating those weights can, can take a number of different, I guess, experimental processes.

So there's things like health state preference surveys where they go out to, you know, 10,000 people in certain regions and they say, would you rather live with, you know, a range of comorbidities of a health state or would you rather this health state?

And so within those that might have like poor vision, it's like, would you.

Rather be blind or deaf?

Literally?

Quite literally, yeah.

Yeah.

So would you rather be, would you rather be blind or Would you rather have a limb amputation and things like this?

Right.

And they, it's, it's not as, it's not as coarse as that, but that's, that's essentially how they do it.

Health state preference surveys.

So the methods of those can range from, you know, smaller sample sizes in discrete regions that actually go up to this, you know, this, this disability way that's influencing health service priority for literally billions of people worldwide.

And some of these methods aren't necessarily as robust as others.

That's insane behavior, I feel like, to do that.

I mean, like, it's because like, obviously.

I would say I don't want my limb amputated, you know, so.

Yeah, yeah, yeah.

But I don't, yeah, I don't want to be bilaterally blind either.

Like, can, can I have something else?

It's, it's, yeah, it's, it's fraught with, it's fraught with measurement error and it's a really hard thing.

Right, because clearly people aren't going to have those sort of preferences.

That's why a lot of people are doing importance on like outcome related quality of life.

Right.

So would you rather be able to, like not saying like about a health state specifically, but you know, would you rather be able to.

How much do you value being able to play outside with your children, for instance?

And these types of sort of outcome based quality of life type surveys are getting used more and more.

And I think that's, that's, you know, we're only about a quarter of the way through this study, but that's probably likely a method that we're going to sort of push for including in disability weights associated with eye health as well.

Also about how they, they ask the question, you know, would you rather this one, would you want to do this, et cetera, all that can influence how these are measured.

And again these, these weights are just used by, by governments and decision makers all over the world.

And sometimes, yeah, we think they're very wrong.

That's so interesting.

I wonder, and I'm sure this has been done, but I wonder if there's been a study where they just follow, you know, people who are bilaterally blind and just study the way that they live.

Right.

And then do a study on that.

But it's just like that's, I feel like that's so much harder than just asking the question.

It's, it's hard because like, I'm certainly not trying to knock what the Global Burden of Disease team have done because you're estimating one Disability weight for the world.

Right.

And so being bilaterally blind in Australia, in living in Melbourne is very different on my quality of life.

If I'm bilaterally blind living in rural Cambodia, for instance.

And so there's, it's, it's very hard to sort of standardize these measures.

We've done lots of research on the impact of eye health on quality of life and obviously like you're saying, you know, these, when we sort of follow people pre and post cataract surgery or pre and post refractive area treatment, the benefits aren't limited to just being able to see.

Right.

You know, it's all the social interactions that they can have.

They can return to work, they can increase productivity, et cetera.

You know, all these benefits we know, but measuring it on that small scale in sort of more primary data collection research studies with smaller populations, we always see the benefits.

But it's when you're trying to sort of aggregate these at a global level, I think is where we run into difficulties.

Right, that makes a lot of sense.

I think that, I think my next question is really just all about like investing in eye health.

Right.

As a health economist, why and how would investing in eye health actually boost the economy?

So how does, how does actually improving somebody's eye health improve the economy in terms of money, for sure.

Great, great question again.

I think.

Yeah.

You know, I still have friends who ask me to like help with their taxes so bad with that sort of stuff.

So that's what economics does to you, I get.

But, but you're 100% right.

So kind of before when we were talking about, you know, how do we advocate to some, some governments about prioritizing eye health?

Well, one of these methods is showing that investing in iHealth can actually impact their bottom line.

So a lot of, you know, a lot of policymakers, a lot of governments, maybe they're only in power for, you know, one to five years, sometimes less.

And so they want to keep their, they want to manage their budget and they want to get return on investment within their budget for the intervention.

So this is kind of something we started thinking about over the last sort of three to four years.

And it's and it's by no means a new idea, but the fact that after, you know, so many decades and so many years of having these really affordable life changing treatments, why hasn't it been prioritized by governments?

And is the, is the individual benefit to someone going from, again, from having really poor vision to full sight, isn't that enough to, to get Governments to invest, you would think.

Clearly it wasn't so.

Yeah, you think so?

So, so, yeah.

We did a study that we released about a year ago.

It's called our sort of Investment Case for Eye Health.

And, and what we did is we essentially went to sort of 19 countries where the foundation works and we did some pretty rigorous costing around what each of these interventions might cost in, in each country.

So we did it for cataract surgery and for, and for refractive error treatment, giving people glasses.

And we essentially collected a whole bunch of data.

So it was based on sort of a health systems cost.

So we, so we know that there's this, you know, eight minute cheap surgery that we can do for like 25 bucks in some places.

25 bucks?

That's like a, that's a really significant number.

Yes, yeah, yeah.

For the direct medical cost, for sure.

But when we did this study, we took a more sort of, I guess, holistic approach to sort of health system development.

So we were talking about, you know, trying to factor in all the things like, you know, surgical outcome monitoring, management and monitoring and evaluation, case finding exercises within the community to get like a really, I guess, real picture of, hey, in donors, governments, etc.

If you actually want to fund this, like, this is what it's, this is what it's going to cost.

And we compared that to the estimated benefit in terms of three sort of benefit pathways, I guess.

So.

The first was increased returns on investment for education.

So often children, if they're in school in Southeast Asia and South Asia as a whole, there's a real sort of epidemic of myopia, which is what I have when you can't see things far away that well.

And essentially there's lots and lots of evidence saying that children are not getting the right education.

And in fact, a lot of them are dropping out of school and entering the workforce, et cetera, because they're experiencing these learning difficulties which can manifest as, you know, it's, it's not easy for a child to be able to, you know, see the chalkboard, say, oh, it's because I can't see the blackboard.

Yeah, that's, that's why I'm, that's why I'm messing up at school, et cetera.

So that's one of the benefit pathways we modeled.

The second was an increase in labor force participation.

So this is people often with, with more severe levels of visual impairment who, you know, economists talk about the labor force and essentially that's people who are willing and able to work, but there's a whole bunch of other people who, for various reasons, whether it's health conditions or otherwise, they're not even considering work.

So you know, I haven't applied for a job in 10 years because I'm blind and I couldn't do anything in the region where I'm working.

Say I'm in a agricultural region in India for instance.

Be very difficult for me to enter the labor force.

And the third was returns on investment for people who are already in the labor force, but they can increase their productivity while they're at work.

So there's lots and lots of research on this both for cataract and refractive error.

If you think of people in, you know, there's lots of manufacturing in South Asia and in Africa and a lot of the continents and countries where we work.

And some of this is, you know, really small tasks.

Some of these people, you know, sort of 40 to 40 plus years old and they might get presbyopia where they can't see things in front of them so well.

So there's been lots of studies in, you know, on tea pickers in India for instance, that showed, you know, giving press biobic glasses which are, you know, sort of reading glasses essentially can really improve significantly productivity.

And so essentially that's, that's a summary of what, what the sort of economic benefits we looked at in this study, but we found with, with cataract surgery in particular, it was about a 20.5 to $1 return on investment.

So what we found in the parameters again were 19 countries where hollows worked.

We said, okay, hypothetically if we increased cataract surgery surgical coverage by 40 percentage points and we increased refractive area coverage by 30 percentage points, which are World Health Organization goals for until 2030.

If we did that, the economy in these individual countries all, all aggregated up would be an average of 20 to 1, which is an enormous return on investment that's returned to the government's bottom line.

Right?

That's, that's the economic contribution that would happen as a result.

And obviously the government would have, you know, income taxes, et cetera, in formal situations that is, is returned at this point.

So it's, it's really sort of a no brainer in investment from that perspective.

Brad Wong from Saver and he works at IPB as well, did a, did a pretty similar model but looked at India and found even, even higher returns on investment.

When we looked at things like, you know, even zooming in on places in our investment case study looking at Laos for instance, had an over $50 return on investment for refractive error treatment.

So essentially that's saying 50 for every $1 that you put in for refractive error treatment programs.

That's, that's because of the demographic distribution.

In Laos there's lots and lots of young people in school.

So we found that a lot more of them would, would be likely to stay in school and have returns on investment to education later on.

That's enormous for these low cost treatments.

And you know, I know it's, it's certainly not a competition amongst, well unfortunately sometimes it is a competition amongst prioritization of eye health interventions.

But you know, things that have been modeled in similar studies.

Team we worked at, with Victoria University have written a number of these types of papers.

World Health Organization publishes a lot of investment cases and they're quite, quite rigorous.

But when we're Talking about a 20 to 1 return on investment for cataract.

Across the countries where we worked similar investment cases, there's been one that's modeled treatments for anxiety and depression that was a 4 to 1 return on investment.

Treatments on adolescent health and Wellbeing was about a 10 to 1.

And treatments on cardiovascular health, which obviously, you know, hugely burdensome on the economy and health around the world was about 11 to 1 return on investment as well.

And again that's not saying like one is, is better or worse than the other, but it's just a reflection of how cheap these interventions are.

And kind of what we talked about earlier, that, that quality of life impact and the economic return associated with that is just so massive compared to these, you know, broader sort of wraparound treatments that are more comprehensive.

For instance, cardiovascular health isn't just one little intervention.

And when you're measuring like the return, are you estimating like somebody's given salary or something like that, you know, over the years and how much they spend and feel like there's just so many, so many nuanced things that you have to estimate and assume.

And this is my like engineering brain working right now because I'm like how would you do a study like this and how would you, what, what would be all the factors that you have to assume and what would be the controls?

Yeah, for sure.

So, so there's so many, you can, you know, if anyone interested, I'm always happy to chat to them.

But we've got the report online, our investment case for iHealth.

So, so things like, essentially it was a, it was a model.

So we incorporated a number of assumptions from specific studies.

For instance, saying that a child who would be given glasses is more likely to stay in school for, for one more year.

And there's a number of other studies that say that staying in school and they, and they disaggregate by country.

Staying in school for an extra year in this country increases their potential earning by X amount of dollars.

Right.

And so we essentially bring in a number of these assumptions.

There's similar ones for productivity improvements in eye health and labor force participation and where we could be disaggregated by country and used, you know, probabilistic assumptions otherwise and essentially extrapolated that out.

And we had, you know, it was, it was quite a detailed model.

We looked at, you know, your lifelong productivity curve.

You get sort of more productive up to the point where you're about close to 40.

I'm not quite there yet, if, if my, if my manager's listening.

So it's a good time to invest and then, then, then drop off afterwards.

So we incorporated all these, these assumptions within the model and essentially extrapolated that out to a return on the GDP per per capita per country.

And so that was the quote, unquote, economic return.

It's really, it's, it's a little bit difficult.

And sometimes I've struggled to grapple with this.

You don't see economists too much saying, hey, this is the X percent return that you're literally going to get in your pocket as a, as a government budget holder.

It's like the equity kind of thing.

Yeah.

Or something like that.

Yeah, yeah.

Because.

Because what economists try and do is, is bring this sort of this economic cost together and say, because obviously, you know, even if you're getting X amount from income tax return, you're investing in these interventions.

So you have to take out the costs, you have to take out these holistic treatments.

And so that's why we used GDP as this sort of proxy for economic returns, because it's the most consistent way for us to estimate the returns to the economy as a whole.

And GDP per capita is, you know, if you ask most economists, saying it's probably the best indicator for economic wellbeing and prosperity in a country.

So essentially the argument extended is that, you know, investing in eye health can't just.

Won't just help individuals and their families, but will increase your country's gdp, you'll start being more productive, you'll become a larger player on the global scene, and eventually you'll be able to fund these interventions yourself without the need for foundations, et cetera, to step in, which is, which is the ultimate goal.

You mentioned that there are places in the world that are tackling this in the case of eye health and you mentioned LV Prasad Eye Institute and that it's like the gold standard of eye treatment and it's in India.

Like why do you think that that works so well?

This is, you know, this is, if you go to any eye health conference, it's kind of the question that, that people seem to ask every year.

And the, the LV Prasad model and, and some other models in India in particular are based on kind of like this, this almost fundamental aspect of universal healthcare.

So individuals who can, can afford to pay for, for treatments will, will pay for them or, and often pay a premium for a premium service if they, if that's kind of what they're after.

And essentially these models, these, these eye clinics or eye hospitals cross subsidize those fee paying patients to other individuals who can't afford.

So they essentially are funding, you know, paying a premium for a service knowing that they'll both get a, they'll get a great service, but also some of this will be used to fund those who can't afford this service and truly deserve it.

So that model, in my, you know, limited experience, I haven't worked extensively in India, only a little bit.

But from what I've seen, that sort of model of altruism works especially well contextually in India.

And I think there's, you know, a number of different factors that, that might contribute to that perhaps that notion of altruism and I guess charitable giving in a sense is just more ingrained in some cultures within or throughout India.

They've tried to replicate this model and others have tried to replicate this model in a number of other countries and it hasn't worked as successfully.

So that's something we're still looking at.

You know, it's, it's, it's one of many financing mechanisms that we're looking at more and more.

There's things like large institutional donors or large family foundations, high net worth individuals, et cetera, who are really focused on impact investing and outcomes based financing, social investment schemes, et cetera.

So we're certainly looking at a lot of those as well.

You know, there's things like social impact guarantees where a big high net worth individual or a foundation or someone might come along and say, hey, you know, a cataract hospital in, in Vietnam, we'll pay you X amount of dollars as long as you achieve a certain number of outputs and a certain amount of quality.

And so a donor might say that, then you have a guarantor who says, okay, no matter what, if there's some months that you don't achieve that quality, we'll work with you to improve that, but also we'll pay the donor back for you for those things.

So there's all these sort of, I guess innovative financing mechanisms these days that are being explored to sort of de risk the risk of investing in iHealth for some of these countries that might be kind of on the fence about prioritizing it.

I just had a thought because, you know, my family's from India and I, I know that in India it's a pay first model, right.

You have to go and you have to show the money and then you get treated.

Right.

I just wonder why it's so different when it comes to eye health.

You know, in this model.

And yes, in India there is a, there is a sense of altruism, but then there's also a for like the very poor, if they break a leg, then they have to sell their cow and you know, get surgery like that.

But I just wonder like how it, how could it be translated to like all of these other conditions.

Right.

Whether it be cancer or trauma.

Yeah, I, I think, and I, and I think one of the things is again, these, these interventions are so quick and low cost, right.

These hospitals, they, they churn out cataract interventions.

So there's not this point of, you know, it's not a long like trauma based service and we can't sort of accurately predict demand for paying for these things.

You know, they're based on literal life events, cataract and refractive error.

You can relatively easily predict, you know, insulin incidence, prevalence, etc.

And kind of develop these business models around treatment, knowing that you'll get a certain proportion of the population willing to pay X amount for these services.

So I think maybe it's comes from the sort of the ease of planning for these interventions and the ease of setup.

You know, you don't need these gigantic.

Like a CR or anything like that.

Yeah, exactly.

The eye hospitals like that we visit a lot of the time, you know, it feels like you're in like a portable or in like a school or something like that.

They're not necessarily these grand sort of white structures that we're used to associating with hospitals.

So yeah, maybe, maybe that's something to.

It, but it's like a one undone kind of thing.

And then you can just be like, oh, well, you're paying this premium.

But it's not that much for people who actually have.

Yeah.

And you'll see the benefit relatively straight away.

So you work for Fred Hollows Foundation.

I want to go into a little bit to talk about who Fred Hollows is and the mission behind the foundation.

Sure.

So Fred Hollows was an ophthalmologist in Australia.

Foundation's been going, I think, for about 32 years now, and Fred Hollows has passed away.

But obviously we continue his legacy.

And he was sort of a personification of altruism in some respects, where he was.

And I think when there are these health interventions and these miraculous, literally health interventions such as cataract surgery, there's no reason to prioritize people who are wealthy versus people who might not have as much money.

And so I think he's got a quote talking about, you know, doing a cataract surgery on, you know, a child or a person in Nepal is the same as if you were doing it on the Queen of England.

Very, very Australian thing to relate it to.

But that was that.

That was his whole purpose in life, the thing that was making cataract surgery a little bit more expensive with these intraocular lenses.

And it still does, to be honest, in some.

Some regions.

But essentially, when you do cataract surgery, you.

You have this clouded lens and you.

And you suck it out or you cut it out and then you put in a new lens and so.

So you can see again.

It's not opaque anymore.

And these lenses were being manufactured by, you know, big pharmaceutical companies, and they're charging an arm and a leg for them.

But what sort of Fred did was went to places like Nepal and Eritrea and established literally, intraocular lens laboratories or factories to make these on mass for extremely low cost.

So in that way, he kind of revolutionized cataract surgery in terms of making it way cheaper and way more accessible.

And obviously, he.

He trained a lot of ophthalmologists everywhere, and we try and continue that legacy as well.

For Fred Hollow's foundation, if, if we're talking about our mission, I think it's pretty simple in that, you know, we want to see a world where no one lives with needlessly or with avoidable blindness or vision impairment.

A privilege and a challenge of working here is that these.

These treatments exist.

Right?

They're cost effective.

And whether it's from, you know, failures of government resource allocation or failures from people, the amount of training that people need or prioritization or equipment or whatever, whatever is happening in the world, for some reason, there's still 1.7 million people who are.

Who are blind.

1.7 billion, sorry, who are blind or visually impaired throughout the world.

And nine out of ten of these people, they can be treated, right?

That's the crux of everything.

How do we get treatment to these people?

And that's where I think health economics is coming in more and more.

And that's why you see a lot of health economists working for governments and things like that.

Because we're kind of past the point where it's this treatment, this cost effective treatment exists.

But how do we work together to make sure people can access this treatment?

And that's kind of where Hollows has shifted a little bit lately.

I kind of call it like the old school world of development was kind of like flying in trained surgeons from Australia or something like that, going and doing a camp for two weeks, doing how many thousand cataract surgeries?

That's, that's awesome.

And that's for sure needed in some contexts.

But what we're moving towards more now is looking at, you know, health system strengthening approaches.

Can we set up optometry schools in Vietnam?

Can we, you know, can we work with governments on blended financing mechanisms with guarantors and donors to fund these things to show you that it's worthwhile and then slowly pull away our investment over a period of five years so that you keep doing it right?

So we're taking this sort of health system strengthening approach to development now, which in my opinion is the way to go.

Because if a country isn't funding this themselves, if they're always relying on external resources, then how's that ever sustainable?

That's the key word, right?

Sustainability.

How do you make it so that you're working with the communities and the governments to build their, their system?

What do you hope to see in like the next year when it comes to eye health?

One year, what do I want to see is an increased focus on eye health and the impacts it has as a development issue.

It appears that just showing that these enormous improvements in health, right from someone being able to go from sort of bilaterally blind to be able to see again, that's not enough for people to prioritize or invest in these things.

So I would like people to see eye health much more broadly is a development issue.

For instance, it's eye health conditions are holding people back at school is affecting how people interact at work.

Eye health is affecting development of countries, literal economic development of countries as a whole.

And I think when people realize and see it that way and see how cost effective it is to treat these things, that that's a point where iHealth will, will sort of be prioritized.

And I know I've talked like a lot about economic impacts, about sort of, you know, formal workforces and productivity and stuff like that, but I think, you know, there's, there's a great quote from I think Caroline Criado Perez.

I'm not sure if you've read the book Invisible Women, Data Bias in a World Designed for Men.

Really, really great book.

And she essentially says there's, there's no such thing as a woman who doesn't work.

There's only such thing as a woman who isn't paid for her work.

And so this is a lot of what's sort of driven some of the resource research that we're doing now.

It's that in a lot of countries where we're working, these eye health is not only affecting, you know, formal labor and you know, labor markets where people are working, you know, an office job or a factory and things like that.

There's so much unpaid work that's often, you know, happening to a woman at home.

And you look at things like maybe, maybe an example of a woman who has cataract and her whole job is to look after her family.

Right.

This is what we would classify as unpaid work as economists, but you know, she's, she's doing 80 hour weeks or whatever and not getting paid for it.

And this is kind of the missing link in terms of what we've looked at eye health in the past.

So we're now starting to look much more into this unpaid work aspect of research because we know we've done two trials now in Burundi and in India showing that eye health has a significant impact on a person's ability to look after a family and to care for their loved ones.

And often in some extreme cases, for instance, say if there's an elderly woman at home who normally looks after the family, cares for others, etc.

Say she has, you know, really poor visual health from cataract.

She might need help from someone else in the family to, to, to do all this unpaid work which, which previously, you know, sort of had gone, you know, unaccounted for because it's not in this formal, formal work setting.

And you can picture where younger individuals of the family, often the daughter, yeah.

Is the one who has to stay home from school and look after this person, look after this unpaid work that previously isn't, isn't really quantified.

And you can imagine the sort of intergenerational impacts of that getting stuck in the poverty cycle if you can't get an education for these individuals.

So yeah, that's, I guess, kind of an example of what we're looking at in terms of showing that interventions are cheap and the benefit is beyond just the health impact of the individual.

The benefit to the family, to the society, to the country is much greater than the individual.

So yeah, if people can see that and understand eye health as a sort of development issue more broadly in a year, I'd be happy.

Thanks for listening to this episode.

If you want to learn more about the Fred Hollows foundation, go to Hollows Dot or click the link in the show notes.

All of the resources will be linked in the show notes.

This episode was hosted, produced, edited and all of the above by me and huge shout out to my coach, Anna Xavier of the Podcast Space, who continues to push me to create meaningful content in the field of global health.

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Until next time.