Commentary: Comprehensive eye care - Issues, challenges, and way forward.

Epidemiological studies pertaining to blindness and low vision suggest that the percentage of blindness because of preventable causes such as cataract, refractive errors, onchocerciasis, vitamin A deficiency, etc. have reduced and that owing to diseases such as diabetic retinopathy, glaucoma, etc. have increased. The reasons for this shift in the paradigm of the diseases leading to blindness include vertical programs like a SAFE strategy for trachoma, Ivermectin for onchocerciasison one hand and increased life expectancy, changes in lifestyle on the other hand leading to increasing number of non-communicable eye diseases (NCEDs). The need of the hour is to build a comprehensive eye care (CEC) system that is available, accessible, and affordable at the grass-root levels including for the underprivileged. According to WHO, CEC is indented as the strategy which “aims to ensure that people have access to eye care services that meet their needs at every stage of life. This includes not only prevention and treatment services but also vision rehabilitation. CEC also aims to address the full spectrum of eye diseases.”[1] In this era of a battle against NCEDs, CEC models are critical in providing eye care according to an integrated multi-level structure.[2] They include

Comprehensive eye examination includes a thorough evaluation of visual acuity, anterior segment structures using a slit-lamp, and a detailed posterior segment evaluation using an indirect ophthalmoscope

Comprehensive eye care services that encompass primordial and primary prevention strategies by executing the guidelines of national eye health programs

Equitable distribution of services in the comprehensive eye care system, designed to cater to people belonging to every strata of the society irrespective of their age, gender, sex, caste, and creed.

WHO has proposed six building blocks, which act as frameworks for development and strengthening of the CEC system:

Human resources: Human resources include well-trained ophthalmologists who are competent to perform comprehensive eye examinations, initiate medical management for the majority of diseases, and conduct surgical procedures for the management of cataract, glaucoma, and perform some corneal and oculoplastic procedures

Service delivery: The CEC services are comprehensive in disease control, population coverage, and referrals; they are also of high-quality, equitable, accessible, and affordable. Eye care providers offer the entire spectrum of eye services, from promotion to treatment, in a continuous manner across levels of care, settings, and providers, rather than as a one-time activity

Consumables and technology: Infrastructure should be designed to match the needs of care. Supply to demand ratio should be ensured while utilizing the resources for producing consumables and making the technology available in providing comprehensive eye care

Health information: An eye health information system allows to register (systematically tracking all patients), relay (facilitate information sharing), and recall (timely review and reassessment) medical data

Finance: An eye health financing system, which provides adequate funds for eye care and ensures that patients with chronic eye conditions do not suffer from the monetary burden of treatment due to a long course of the disease

Governance: CEC relies on solid leadership and governance to guarantee universal eye health coverage and integration within the national health system and to maintain strong public-private partnership in providing health care which will increase the effectiveness of advocacy, influencing policy, and promoting best practices.

Issues and Challenges in Providing CEC

There is a huge gap between the number of patients suffering from causes of preventable blindness and those actually getting treated for it. Social, economic, and demographic factors, such as age, gender, place of residence (state or district), personal incomes, ethnicity, political and health status, also reduce the potential of success of any intervention.[3] Delivering services to underprivileged population and those in outreach areas, including transportation to care centers, distribution logistics, surgical consumables and technology, represent the main challenges in establishing CEC systems.

Outreach camps as a result of efforts by the philanthropic organizations have been a bridge to cover the gap of the unmet needs, but unfortunately, they cannot suffice the needs of all. Shortage of eye care human resources, lack of educational skills, paucity of funds, limited access to instrumentation and treatment modalities, poor outreach, lack of transportation, and fear of surgery may still represent the major barriers to CEC large-scale diffusion.[3]

The vertical model of eye care system has come a long way in eradicating and reducing the burden of preventable blindness. However, CEC system should be the next step in the crusade against causes of preventable blindness and NCEDs. In the current issue of IJO, these challenges were very well depicted by the manuscript Comprehensive eye care – Issues, challenges and way forward.[4]