Windows to the world: How eye care is about more than health

Essilor Vision Foundation screening event in China. Photo by: Essilor

Around 2.5 billion people with poor vision, of whom 80 percent live in developing countries, do not have eyeglasses, which could vastly improve their vision. The leading causes of blindness — cataract, uncorrected refractive error, glaucoma, age-related macular degeneration, blinding complications from diabetes, and corneal blindness caused by neglected tropical diseases — affect developing countries disproportionately. The consequences are far-reaching. Poor vision impacts people throughout their lives, preventing children from succeeding at school and adults from reaching their economic potential. Lost productivity from poor vision costs the global economy $227 billion every year, according to the World Economic Forum. It’s a major public health issue that hasn’t yet harnessed as much attention from the development community as it might have.

However, it’s not all doom and gloom; data shows that advances in medicine and product technology have led the prevalence of vision loss to drop from 4.58 percent in 1995 to 3.37 percent in 2015. But as the world’s population grows, so does the total population of visually impaired people, as well as health concerns tied to population growth and economic development. Conditions linked to diabetes, ageing, and sedentary lifestyles are set to dramatically increase in the next decades. By 2050, half of the worlds population will be affected by myopia — or nearsightedness — according to current estimates.

“These three areas are ticking time bombs,” Johannes Trimmel, interim CEO and director of advocacy at the International Agency for the Prevention of Blindness, told Devex. “We need to act now to have health systems in place that are able to tackle these issues.”

“So much of the development community has focused on a number of other services and other forms of developmental assistance such as health care more broadly, education, and financial inclusion. It’s important to remember that if you cannot see, then even with the best education, there is so much you can’t do with poor eyesight.”

— Bhaskar Chakravorti, senior associate dean of international business and finance at The Fletcher School, Tufts University

It’s easy to see why eye health doesn’t rank high among development priorities for everyone: It isn’t specifically mentioned in the Sustainable Development Goals. Yet a number of SDGs will not be reached without seeking to improve vision among the world’s most vulnerable: health, of course, but also poverty, economic growth, and education, to name a few. Water and sanitation, being connected to water-borne diseases causing blindness such as trachoma and onchocerciasis, are equally essential to promoting good eyesight, as well as forming partnerships with other development organizations working on connected issues, governments, and the private sector.  

Strengthening health systems

Eye health shouldn’t necessarily be seen as a specialization within health care. Some of the leading factors of vision loss, such as premature birth, diabetes, and vitamin A deficiency, could indeed be addressed through primary health care services.

“Many of the things that are leading to vision impairment and disability are easy to treat when treated in time and by the right people,” said Trimmel. “Eye health is a very good indicator of whether health systems work, and whether at the time you’re in need of treatment, you have a chance to access that treatment.”

That is why the World Health Organization, in its Global Action Plan 2014-2019 for eye health, is advocating the strengthening of health systems and integrating eye care services into primary health care, rather than pursuing vertical programs.

Essilor, a leading manufacturer of ophthalmic lenses and optical equipment, is running various programs through its nonprofit and inclusive business branches in partnership with international nongovernmental organizations, local governments, and civil society organizations. “All our focus is around raising awareness for the cause and creating access,” said Jayanth Bhuvaraghan, Essilor’s chief mission officer.

The company wants to eradicate poor vision by 2050. Along with the Brien Holden Institute, it co-founded Our Children’s Vision, a coalition of NGOs, governments, aid organizations, and local communities working to improve children’s access to eye health services. And it works with governments around the world to bring eye care services to schoolchildren and low-income communities, adjusting its activities — from skills buildings to advocacy — to local needs. “We run different activities in different places,” said Bhuvaraghan. “Adopting our programs according to the needs of the country helps to ensure we’re building sustainable vision care programs.”

Sightsavers, an international NGO working toward treating and preventing avoidable blindness, as well as advocating for the rights of people with disabilities, has also adopted a multi-pronged approach that includes human resources, physical infrastructure, health financing, and awareness-raising.

Q&A: Opening eyes on the impact of poor vision

Good eyesight is critical to so many components of a person’s daily life and without it, many are unable to learn, earn, and be included in society. In this Q&A, Jayanth Bhuvaraghan from Essilor, a world leader in ophthalmic optics, explains how access to eye care affects every Sustainable Development Goal and why governments must make it a part of their national agendas.

Government engagement and ownership of eye health interventions is critical to making these programs sustainable, explained Imran Khan, chief global technical lead at Sightsavers. In Cambodia, Ethiopia, Ghana, and Senegal, Sightsavers ran the School Health Integrated Program, or SHIP, throughout 2016 to raise awareness about the impact of poor vision on student performance and attendance rates and to provide eyeglasses to children in need.

The program also integrated screening and treatment for worm infections and encouraged governments to improve nutrition in schools — two interventions that have been proven highly effective in increasing the performance of schoolchildren. In each country, Sightsavers worked with ministries of health and education.

“We’re looking at some ways of thinking outside the health box,” said Khan. “We act as a catalyst to help bring these ministries together to collaborate on these projects.”

Making poor eyesight visible

Lack of high-quality, disaggregated data is a major barrier to building efficient interventions. We know that women and children are disproportionately affected by poor eye health — women represent 55 percent of visually impaired people and 60 percent of blind people worldwide — but more information is needed on other marginalized populations such as ethnic minorities and migrants to uncover how people are actually impacted by poor eyesight.

The causes of poor vision

Vision impairment, also known as visual impairment or vision loss, refers to a moderate-to-severe reduction in vision that cannot be corrected with eyeglasses or contact lenses.

Blindness is defined as a near complete (20/1000) or complete (no light perception at all) vision loss.

Refractive error occurs when the shape of the eye causes light to bend incorrectly, resulting in blurred vision. Uncorrected refractive error is the leading cause (53 percent) of vision impairment worldwide. The main types of refractive error are myopia, hyperopia, presbyopia, and astigmatism.

Un-operated cataracts (25 percent) is the second-leading cause of vision impairment, followed by age-related macular degeneration (4 percent) and glaucoma (2 percent).

Trachoma and onchocerciasis (also known as river blindness) are the two leading causes of blindness due to infection. Both are listed as neglected tropical diseases and primarily affect people living in developing countries.

In Bhopal, India, Sightsavers used the Washington Group questions — which ask responders to rate their ability to perform simple tasks, such as seeing someone’s face across the room — to survey 24,000 patients in a local eyecare program.

“We found that out of the respondents, something like 16.7 percent said they experienced severe difficulties functioning. However, only about 0.6 percent responded to a question on the census that asked: Are you disabled?” Khan told Devex. “That showed us that there are more people who are disabled within these countries than are being picked up on census data. But it also gives us a baseline that allows us to measure what percentage of people with disabilities are accessing those health services.”

People with poor vision may often not be aware they should seek treatment, with some considering their difficulties or illnesses to be a normal part of life.

Others have no one to go to for help.

“There is a big gap in human resources for eye health, not only on the specialist side, like ophthalmologists and optometrists, but also when it comes to primary health care mid-level staff,” said Trimmel, adding that in developing countries, specialists are few and far between, and work mostly in cities, while non-specialists aren’t always trained on basic screening and treatment procedures.

Treatment may not be available either. Affordable eyeglasses are not yet universally available — even in higher income countries, where the cost of spectacles can be prohibitive for people who don’t have private insurance — and the value chains are not always in place to deliver these products.

Inclusive businesses

Development organizations are now looking at innovative business models to increase the availability of eyeglasses. VisionSpring has set up optical shops and sells subsidized glasses in more than 40 countries. The Brien Holden Vision Institute uses cross-subsidies, a tiered pricing system that covers the cost of eyeglasses for patients who can’t afford them and finances outreach campaigns, in some of its vision centers in sub-Saharan Africa and Asia.

Increasingly, partnerships with the private sector are evolving in scope and nature, as companies are embracing the SDGs and seeing the long-term value of serving the bottom of the pyramid.

“The emerging markets, and even the frontier markets, are the future source of growth for many companies,” said Dr. Bhaskar Chakravorti, senior associate dean of international business and finance at The Fletcher School of Tufts University. “The underlying logic here would be that if you do not invest in those markets today, you will not have them available to you as a source of revenue in the future.”

That’s the case with Essilor. While the company runs a number of nonprofit programs, most of its high-impact activities in emerging markets are conducted under for-profit models, in partnership with NGOs and governments.

“We believe that 80 percent of what we do has to come from inclusive businesses, simply because that’s the only way it can be sustainable, long lasting, and impactful,” said Essilor’s Jayanth Bhuvaraghan.

One of these programs is Eye Mitra, which trains unemployed and underemployed youth in India to become micro-entrepreneurs, performing eye screenings and selling low-cost eyeglasses in their communities. Through its 2.5 New Vision Generation inclusive business division, Essilor has developed and implemented more than three dozen business models in as many communities around the world. Beyond emerging markets, the company considers the impacts on sustainability of all its activities along the value chain; it tracks and reports on its contribution to the SDGs.

“A problem of this nature cannot be left to the governments and the international aid agencies to go and find solutions alone,” said Bhuvaraghan. “As responsible corporations, we have a role to play.”

New forms of partnerships

Partnerships with the development sector are essential to multinational companies that seek to enter emerging markets, Chakravorti explained. NGOs can bring a deep understanding of the complexities of the local market, as well as making multinationals more credible in the eyes of local governments. He also sees an important role for the development sector to act as convener and catalyst for sector-wide adoption of best practices, in cases where competition is hindering collaboration between companies.

“So much of the development community has focused on a number of other services and other forms of developmental assistance, such as health care more broadly, education, and financial inclusion,” Chakravorti said. “It’s important to remember that if you cannot see, then even with the best education, there is so much you can’t do with poor eyesight.”

To learn more about the work Essilor is doing to improve vision care worldwide and how that contributes to the wider 2030 sustainable development agenda, click here.

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