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)

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

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

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

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.