Q&A: Ensuring equity in eye care through innovation

Globally, at least 2.2 billion people have a vision impairment — more than 1 billion of which could have been prevented with access to adequate eye care, according to the World Health Organization’s 2019 “World report on vision.”

Right now, the burden of poor eye health falls unequally on low-income countries and underserved populations, including people in rural areas, women, older populations, people with disabilities, ethnic minorities, and indigenous communities, according to the WHO report.

The first "Inclusive Eye Health Report" released by CBM, an international Christian development organization, in December 2020, highlights that while the global Vision 2020 initiative for the elimination of avoidable blindness has helped, more needs to be done to ensure equitable access to eye care, especially as global demand is predicted to surge in the coming years as a result of population growth, aging, and lifestyle changes.

Devex spoke to CBM Director of Inclusive Eye Health and Neglected Tropical Diseases Dr. Babar Qureshi about how the organization is working with partners to expand access to quality eye care in the 35 countries where it operates.

This conversation has been edited for length and clarity.

Vision is not just about sight, having a much bigger impact on health care, education, and development. Yet, a workshop hosted by Devex and CBM at Devex World in December, highlighted that vision has been sidelined in the wider development agenda — how is CBM working with partners to solve this issue?

The critical thing is that vision is recognized — first of all — as part of health care, and then as part of the development agenda. The way we've approached it, on the one hand, is through national advocacy … and, on the other, by developing model programs that actually show the results we’re advocating for. An example is something like a school screening program that takes us beyond eye care, into health care, into education, and into the quality of education.

Similarly, when we are looking at cataract surgery, it's not just about people regaining sight, but also about them becoming economically active and freeing up the time of other people that need to look after them when they're blind. These are very clear indicators and motivators of the fact that we are not just bringing sight back, but we’re actually making a difference in the quality of people’s lives.

Whenever we talk about the restoration of sight, we also have to view it in the context of other diseases. Maternal and child health issues, for example, where you're not talking about sight-saving, but about life-saving; and where you're not only talking about one life, but two. So you've got to put that into context when you advocate for vision ... it becomes very difficult for governments to recognize why they need to invest in vision when they have other much bigger issues to deal with.

There’s not only a need for innovation in technology for eye care, but also for innovation in delivery. Why is this so important and how is CBM approaching it?

When we talk about innovation we tend to think of technology, but at CBM we have made it very clear that innovation can also be in programs, or even in funding. In the past, our delivery model was to develop eye hospitals with large volumes. Over the years, we developed “islands of excellence” where we had lots of people being treated and lots of people getting surgeries. But what that led to was people traveling huge distances to get surgeries.

We then moved to work with the government at the district level, trying to provide care closer to the communities. We were not able to do as many surgeries — if we were doing 5,000 there, we were probably now doing 1,000 — but we were doing 1,000 surgeries in 10 districts, so the equity piece came in. We were able to equally divide [the surgeries] and we began to see the uptake of women increase.

So that's a kind of delivery in innovation, but I don't think we need to stop there. We need to strengthen primary care as well so that 80% of community needs can actually be taken care of at the community level. Simple, small things can all be dealt with [at community level] and only major things referred to secondary care. That kind of screening and referral will leave behind a sustainable program in any country. That's the next step in the innovation of service delivery.

Technology, like the app we’ve developed with Peek, can help us improve our understanding of the people getting lost between [vision] screenings and treatment at the secondary level. So for me as CBM, as a donor, when I see that 70% of [referred] people do not reach the secondary center — I need to focus on those 70%, find out why, and then find solutions.

How does CBM promote more health-seeking behavior among people with eye health problems, who are often unaware of existing treatments and sometimes even of their vision impairment?

Some of the key work we do at the primary health care level is bringing about awareness, explaining things to people one-to-one, and giving them health education. Then there are radio messages and print media as well, but that is normally not enough. For decades, people have been unaware of their sight problems, especially children, until they're quite old and they suddenly find out.

A couple of years back we did a program in Nigeria and Uganda where we drew up an eye testing chart on the walls of schools and put a line up about 6 meters from it. It was not to actually check for vision — it wasn't the correct way of doing so — but it was to actually educate kids [about vision impairments]. And you would see kids lining up during their breaks, closing one eye and looking at the chart.

We also started teaching the teachers to screen children, and these children then go back home and talk to their parents, so that's a whole different process of bringing about change in health-seeking behavior. Another very strong area is the community health workers, who are being given very short, clear messages so that they can speak to people and make them understand things like “you have a cataract, but you can go and get it treated.”

How do you work to promote government ownership of programs to ensure they have both the reach and sustainability needed? 

We have a very successful example from Pakistan where we went to a district and supported the government to develop their district hospital, their community work — they went from doing 150 surgeries to 1,000 surgeries a year. Then from one [hospital] we supported 10 more, and then showed [the results] to the government. We were also able to show the impact on the magnitude of blindness in the country, comparing the numbers in 1998 and then the reduction by 2004. That's what the government then took on board and [they] actually replicated the district program in the whole country. So from 10 districts, they went to all 104 districts at that time.

Today, every district in the country has a good district eye care unit, fully equipped, with human resources, and that's how you go district by district until you cover the whole country. You can never cover the country in one day, it will take time.

It's basically about first producing successful models within the system that address the needs of the community, and second, ensuring the model is able to develop with things that are available locally — and one of the biggest challenges there is human resources. You need eye care teams, not only ophthalmologists but nurses, paramedics, optometrists … and these teams need to be developed, they're not just lying around. Thirdly, you need good equipment, good infrastructure, and patience. Finally, you need to do that awareness program in the community so that these services are then very well utilized.

It goes faster in some countries and it goes slower in some countries. The approach will need to be different and will lead to different results at a different pace, but the end result is always the same: that you reduce the visual impairment of people in that country.