A bolder vision for eye care

MANILA — In 1999, a group of organizations working on eye health had a vision: To rid the world of avoidable blindness in two decades. But as the initiative approaches its final year, advocates indicate the goal is unlikely to be met. In hindsight, they admit they could have framed the target better.

“We haven't really defined what we mean by elimination of avoidable blindness,” said Dominic Haslam, director of policy and program strategy at international charity Sightsavers. 

“One of the lessons I think we're learning ... is around the need to be really clear about what it is that you're aiming for in order to galvanize support and resources around that goal,” he said.

To be sure, in the 19 years since the goal was set, visual impairment has become less prevalent. But the fight didn’t gain the urgency it could have. Insufficient coordinated action and unity, Haslam said, contributed to the failure to get the issue of eye health a mention in the Sustainable Development Goals.

And there have been other challenges, strongly related to the lack of understanding of poor vision’s impact on people’s broader socioeconomic outcomes, and to the lack of direction for countries to make informed decisions on what interventions to prioritize and how.

Poor vision can have a deep impact on education and work opportunities, but it is not always obvious to those outside the sector, said Megan McCoy, technical officer for the World Health Organization.

Even in situations where relevant government ministries understand the importance of eye care and are eager to address it, they are often faced with questions on what to do, where to start, and how to increase access to eye care services. It’s not as simple as giving away free glasses.

“On the face of it, it seems pretty simple. Someone has a test, you work out whether or not they need glasses, you get the right glasses, you provide them,” McCoy said, referring to one of the most common eye disorders, refractive errors, which can come in the form of nearsightedness (myopia), farsightedness (hyperopia), or simply blurred vision (astigmatism).

But as with most health interventions, solutions can be complicated. Addressing refractive errors requires having people with the right skill set to do the testing in proximity to where people live, ensuring that patients receive the right glasses, and are then able to adjust them accordingly as their visual condition changes.

This highlights the question of how countries can build the workforce they need, and have them in locations where they are needed most. In many cases that means in remote, rural areas where health care services are almost nonexistent.

“When we start to think in those terms and the sorts of decisions that ministries will have to make … it does require good evidence [and] it cuts across many different areas of health, from procurement to equipment to human resources,” McCoy said.

This is perhaps one of the reasons why uncorrected refractive errors rank as a major cause of moderate to severe vision impairment, covering as much as 49 percent of the global total, followed by cataract (25 percent), age-related macular degeneration (4 percent), glaucoma (2 percent), and diabetic retinopathy (1 percent).

‘A ticking time bomb’

Prevalence of visual impairment declined from 4.58 percent in 1990 to 3.38 percent in 2015, according to data from the Vision Atlas, a project by the International Agency for the Prevention of Blindness, an umbrella organization leading and coordinating efforts to prevent blindness. But a growing population and demographic changes, particularly an increase in the number of elderly, could cancel out early successes. Between 2020-2050, the number of blind people and those with medium to severe visual impairment could reach as much as 703 million, almost triple the projected 276 million by 2020, according to IAPB estimates.

Haslam referred to it as a “ticking time bomb,” but noted the information could help inform the sector on what next steps to take. The impending end of Vision 2020, the global initiative jointly launched by WHO and IAPB in 1999, has provided the sector with an opportunity to “come together and think about what needs to be different and what needs to change,” he said.

Part of that relates to integrating eye care services into countries’ health systems, thus ensuring they’re part of essential health benefits packages, instead of being treated as a standalone health issue. It also requires raising visibility and financing for eye care outside the sector, as well as outside the traditional donor aid model.

To do that, Sightsavers has tried linking eye health and other development issues, such as education and road safety, to their projects. In 2016, the charity worked with the Partnership for Child Development on an initiative called School Health Integrated Programming to demonstrate how schools can be a platform to deliver health interventions. The overarching goal was to raise awareness and increase the engagement of entities within government on the issue.

For SHIP, countries’ ministries of health and education were brought together to co-own and co-design the health interventions in school, which involved vision screening and deworming. The initiative was funded by the World Bank and the Global Partnership for Education.

More recently, Sightsavers launched a program in India addressing poor vision among commercial truck drivers. The goal was to reduce road traffic accidents by reaching half a million drivers in 27 locations in India. They were able to convince insurance companies to help fund the program.

“By preventing road traffic accidents due to poor vision, that's actually helping increase road safety but also saving the insurance company's money,” said Imran Khan, chief global technical lead at Sightsavers.

Some of these linkages have been successful, but others are still work in progress.

The World Diabetes Foundation, which works to alleviate people’s suffering from the disease and its complications in developing countries, recognizes the links between eye health and diabetes, and considers the prevention of diabetic retinopathy as one of its main focus areas. The foundation estimates diabetic retinopathy affects 2.5 million people worldwide, and is becoming a leading cause of blindness.

When the foundation started two decades ago, it was one of the two most common diabetes complications, but which received little care due to lack of awareness, knowledge, diagnostic tools, and equipped health care staff, said Anil Kapur, chairman of the foundation’s board of directors. A number of international NGOs working on eye health didn’t have much focus on diabetic retinopathy either, he added.

But they received grant applications from some of India’s leading eye care institutions, raising their understanding of the problem and the types of interventions needed.

“The lack of trained capacity, in particular lack of ophthalmologists and those with training to deal with diabetes retinopathy, is a big barrier ... When services are not available to address the problem, people tend to focus less on the issue and, as a consequence, awareness suffers,” he explained.

Meanwhile, a 2016 resolution calling for the creation of a trust fund set up by the United Nations to address road accidents failed to mention the significance of poor vision as a priority intervention. Bloomberg Philanthropies, which is active in supporting policies related to road safety, doesn’t work on eye health.

Future vision

WHO is currently working on the “World Report on Vision,” which was supposed to come out on World Sight Day this Oct. 11, but has been deferred to next year. It will be the first world report on vision, and many of the organizations working in the eye health sector are placing their hopes on its publication.

The report will set a new strategic framework for eye care, and recommendations as to how countries can fully integrate it into their health systems, meaning that eye care is present in health ministries’ regular planning and budget processes.

“The reason why we're focusing so much on integration is because we know that that is how you get sustainable eye care services, and it's also how you get services that are better able to meet people's needs,” said WHO’s technical lead McCoy.

WHO has also started planning developing tools and guidelines to help countries implement the recommendations in the report, although McCoy was quick to point out this is in very early stages.

“We've produced a number of world reports over the years and they tend to have a catalytic effect on the topic, either in terms of drawing attention to something that may not necessarily have been on the global public health agenda or perhaps changing the way that we think about a topic. Those are our sort of high expectations for this ‘World Report on Vision.’ And that's certainly what we hear from the eye care sector, that that's what they are looking for: A new strategic direction, a new framework, a new vision for this work,” she said.

Haslam shared the same optimism, referencing the impact the “World Report on Disability” has had within and outside the sector since it came out in 2011.

“They started to take disability seriously as an issue and I think without that world report from WHO and the World Bank, we wouldn't have had the progress within the SDGs on disability that we've seen,” he said.

But if there’s one thing the “World Report on Vision” won’t do, it’s setting specific targets or goals, McCoy said. That is something that member states will need to consider and decide on through a resolution in the future, or after the report comes out.

Choosing targets is not an exact science. Most of the time, stakeholders have to strike the balance between ambition and feasibility. The earlier goals set for eye care were likely chosen based on the best information they had at the time, McCoy suggested.

If member states do decide to set new targets and goals, however, the eye health community has now more experience and lessons to pull from.

“That'll be a really interesting discussion because we have lots more experience now in this field about what's the value of goals and targets, how do you pick the right ones, how do you want it to progress,” McCoy said.

Devex, with financial support from our partner Essilor, is exploring challenges, solutions, and innovations in eye care and vision. Visit the Focus on: Vision page for more.