ALICANTE, Spain — Often seen as separate from wider health systems, eye health services can get left behind when it comes to subsidized health care. But experts argue that such services should be free, given bad vision's impact on a person’s ability to learn, earn, and contribute to society.
In many places, eye health services — whether for treatment of a disease, like trachoma, or the provision of spectacles — means out-of-pocket costs. Sometimes the cost of cataract surgery can be a substantial portion of a person’s salary and push them into poverty, Jessica Crofts-Lawrence, head of policy and advocacy at the International Agency for the Prevention of Blindness explained. This is why there should be government ownership of eye care services, she said.
Part of our series Focus on: Vision
This focus area, powered by Essilor, explores challenges, solutions, and innovations in eye care and vision.
For the 2.2 billion people thought to be living with a vision impairment or blindness — of which almost half could be preventable or yet to be treated — this kind of prioritization could be life-changing.
In 2019, heads of state at the United Nations High-Level Meeting on Universal Health Coverage committed to “strengthening efforts to address eye health conditions” following the inclusion of “effective coverage” of refractive error and cataract surgery in the World Health Organization’s universal health coverage index. And in the “World Report on Vision,” WHO called for “integrated people-centered eye care” as part of UHC.
“The really important thing is that eye health is included in broader national strategic plans and financing.”— Jessica Crofts-Lawrence, head of policy and advocacy, International Agency for the Prevention of Blindness
The rollout and expansion of insurance
In countries such as Vietnam, the Philippines, and Rwanda that have a government social insurance scheme, certain eye care services are available and free of charge. In Ghana, however, insurance is limited to hospital-based services while outreach eye services and preventive care are excluded, according to Dr. James Clarke, director of the country’s Crystal Eye Clinic in Adenta. Yet someone living in a remote community may not be able to afford the cost of outreach services, no matter how low, Clarke explained.
“If eye services are included in social insurance schemes, it will increase coverage of services,” he said, adding that this should include preventive care, not just treatment.
He cited chronic glaucoma, which is largely asymptomatic when it begins, and causes irreversible but preventable blindness.
“Its treatment is included in the health insurance scheme, but its detection through screening during outreach is not,” Clarke said.
If people cannot afford prevention measures and regular screening, they are more likely to need more serious interventions that could end up costing governments more long-term. Comprehensive social insurance schemes would mean the detection of many preventable diseases and the prevention of early and avoidable blindness — especially for people in areas where services are not affordable, not available, and not accessible, Clarke said.
According to a report by PwC, an investment of $2.20 per person per year between 2011 and 2020 in low- and middle-income countries could have eliminated avoidable blindness. Without it, vision loss continues to cost the global economy an estimated $168 billion a year in lost productivity.
Inclusion in UHC
Insurance is just one component of financing that needs to exist for eye care, Crofts-Lawrence said. “The really important thing is that eye health is included in broader national strategic plans and financing,” she said, adding that eye health services have always been quite siloed from the rest of mainstream health delivery. While Vision 2020 — a global initiative meant to eliminate avoidable blindness by 2020 — saw the production of many national eye care plans, they were often developed outside broader strategic plans, she said.
Such plans also come with difficulties in moving from the plan to implementation by the government, said Ronnie Graham, trustee and chair of the program subcommittee of the board at Vision Aid Overseas.
For Graham, steps should be taken to integrate the eye health workforce into national health workforce plans as well as integrating eye health data into the national health data system. He cited Ethiopia and Senegal as good examples of having integrated workforce plans.
“From now on, the training of more ophthalmologists, optometrists, ophthalmic nurses, and frontline primary eye care workers is part and parcel and budgeted in the national health workforce plan and I think that’s the way to move this agenda forward,” he said.
Kenya is another example where eye care has been “annexed” to the broader national health sector strategic plan. Annual operational plans and budgets produced by an ophthalmic services unit at the health ministry help to identify and address any gaps in funding there might be for eye care helping to ensure its accessibility.
One reason for the often siloed nature of eye care could be due to the support of NGOs over the years. Crofts-Lawrence said some governments had come to expect that NGOs would continue to do the work thus opting to leave eye care outside the health care systems.
The more the agencies do to address eye health needs, the more prepared some governments are to step back and claim it’s been taken care of by philanthropic, charitable, or civil society efforts, Graham explained. “We’ve got to get over that somehow,” he said, adding that agencies should collaborate and put pressure on governments to do more.
Evidence and data critical
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According to Juliet Milgate, Sightsavers’ director of policy and global advocacy governments have difficult decisions to make and the deprioritization of eye health could have been the result of certain trade-offs.
The benefits eye health can have on overall health outcomes, broader goals, and economic benefits need to be demonstrated, Milgate said, adding that NGOs must hold governments accountable while helping them to provide solutions.
“Governments don’t have all the answers or all the solutions,” she said. For Milgate, NGOs and their programs have a role to play in helping to determine what interventions work best and in which contexts so that this can be used to inform government responses.
Evidence and data are also critical in lobbying government partners and other stakeholders, said Reshma Dabideen, global medical leader and director of Africa programming at nonprofit OneSight. Data on cost-effective interventions can help them to make better-informed decisions.
For example, a World Bank report called cataract surgery one of the most cost-effective public health interventions, even in contexts where resources may be constrained. And a study among tea-pickers in Assam, India, revealed that providing a pair of glasses to those with an age-related decline in near vision, led to improvements in productivity and earning. WHO is also working to create a package of eye care interventions aimed at supporting the integration of eye care into UHC. Such information could help decision-makers better see the value of investing in eye care services.
Dabideen said this has paid off in Zambia, where OneSight helped to provide data around the affordability of spectacles. As a result, last month, the national health insurance system began taking steps to include spectacle care as part of its national insurance package, she said.
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