The net present value of human lives lost due to coronavirus disease (COVID-19) in the Islamic Republic of Iran

Objective: As of 11 April 2020, there were 68,192 confirmed cases, including 4,232 deaths. This study aimed to estimate the net present value of human lives lost due to COVID-19 in Iran as of 11 April 2020. Results: The 4,232 human lives lost had a total net present value of Int$ 436,275,007. The average net present value per human life was Int$103,090. Re-estimation of the economic model with 5% and 10% discount rates resulted in a reduction in the expected total net present value by Int$ 64,881,144 (14.9%) and Int$ 168,066,782 (38.5 %), respectively. Additional re-calculation of the economic model using the highest life expectancy in the world (i.e., that of the Japanese Females) increased the total net present value of human lives lost by 114%.


Introduction
The Islamic Republic of Iran, an upper-middle-income economy, is one of the 21 Member States of the WHO Eastern Mediterranean Region (EMR) [1]. The country has a population of 84.1 million persons, a gross domestic product (GDP) of Int$ 1,500.5 billion, and a per capita GDP (PCGDP) of Int$ 17,832 [2].
Why has Iran borne a disproportionate share of COVID-19 cases and deaths? It could be due to gaps in the Universal Health Coverage (UHC), International Health Regulations (IHR), and coverage of water and sanitation. UHC, which means Iranians receive the essential health services they need without suffering financial hardship, can be viewed as a proxy indicator of the strength and resilience of the underlying national health system [4]. Iran has a UHC service coverage index of 65%, implying a 35% gap in the coverage of reproductive, maternal, new-born and child health, infectious diseases (such as ; non-communicable diseases; and service capacity and access. About 3.8% of the population spent above 25% of their income on health care.
The IHR capacities are a proxy of the vibrancy of the national disease surveillance system [5]. In 2018 IHR capacities of chemical events, laboratory, health service provision, national health emergency framework, and legislation and financing had a rating of 100% [6]. The IHR coordination and national IHR focal point functions, food safety, surveillance, human resources, risk communication, and radiation emergencies had a rating of 80%, implying a 20% gap. While the points of entry, the zoonotic events, and the human-animal interface IHR capacities had a rating of 60%, implying a gap of 40%. The average of 13 IHR core capacity scores was 85%, implying an overall gap of 15% [7].
The coverage of basic water and sanitation services are proxy indicators for the performance of systems that tackle social determinants of health. In 2017, 88% of the Iranian population was using at least basic sanitation services, implying that 12% were not [8]. In the same year, 92% of the population were using safely managed drinking-water services, implying that 8% were not [9].
Iran's current health expenditure per capita of US$475.5 in 2017 [10], although within the range of US$ 297 (minimum) to US$984 (maximum), it was lower than the upper-middle-income countries recommended population-weighted mean of US$536 per person [11].
Thus, there is a need for evidence on the net present value of human lives for use in advocating for increased investments in expanding coverage of essential health services, water and sanitation, and IHR capacities. To the best of our knowledge, no study has estimated the net present value of human lives lost from COVID-19 in Iran. This study aimed to estimate the net present value of human lives lost due to COVID-19 in Iran as of 11 April 2020.

Estimating the net present value of human lives lost
The current study used the human capital approach (HCA) pioneered Petty [13] in the 16 th Century and further refined by Farr [14] in the 18 th Century. Fein [15], Mushkin and Collings [16], Landefeld and Seskin [17], Linnerooth [18], and Weisbrod [19] provides the theoretical foundations for applications of HCA to value human life.
According to Weisbrod [19], "..the value of a person to others is measured by any excess of his contribution to production over what he consumes from production…The present value of a man at any given age may be defined operationally as his discounted expected future earnings stream (net of his consumption)" (pp.426-427). Also, the WHO guide to identifying the economic consequences of disease advises that the expenditures on health should be removed GDP in the valuation of a human life lost [20]. This study followed the counsel of Weisbrod [19] and WHO [20] to estimate the net present value of human lives lost (NPVHL) due to COVID-19 in Iran.
The formulas developed and applied in a recent study on the fiscal value of human lives lost due to COVID-19 deaths in China [21] were adapted and used to estimate the total NPVHL from COVID-19 in Iran ( ). The only difference was that while the China study assessed value of human lives lost for three age groups (24-49 years, 50-64 years, and 65 years and above), the Iran study appraised the NPVHLL for nine age groups, including the 0-9-year-old ( 0−9 ), 10-19-year-old   COVD is the number of human lives lost from COVID-19 in the j th age group. The base year was 2020. The detailed model and illustration of how to estimate the equations can be found in Kirigia and Muthuri [21].

Data and data sources
The data and sources are contained in Table 1.  Table 2 shows the distribution of the net present value of human lives lost from COVID-19 by age group.

Limitations
Our study had some limitations. First, according to the WHO World Health Statistics Report 2019, the completeness of cause-of-death data was 65% in 2017 [7]. The cause-of-death for about 35% of deaths is not recorded. Therefore, the number of notified COVID-19 cases and deaths are likely to be an underestimate. Should that be the case, the total net present value of human lives lost reported in this paper would also be an underestimate.
Second, our study omits the COVID-19 health system costs related to prevention (water, soap, sanitizers, personal protective equipment), testing (diagnosis), case tracing, quarantine, and hospitalization of severe cases, and post-mortem. We also did not take into account funeral-related costs, including the purchase of caskets, hiring of a hearse, transport of the bodies (and family and friends), funeral ceremonies, and time of family and friends preparing and attending the funerals [21].
Third, given the limited scope, this study did not take into account the macroeconomic impact of COVID-19 pandemic on agriculture, education, financial services (e.g., banking and stock exchange), hydrocarbon (oil and gas), international trade and commerce, tourism and travel, and manufacturing sectors [23].
Finally, when strictly applied, the human capital approach employed in the current study would value the contributions of housewives, the elderly, the handicapped (physically and mentally), and children at zero [23]. To avoid human rights and ethical issues, we valued all the years of life lost, irrespective of age, gender, and economic status, using the same numeraire, i.e., net GDP per capita.