Delivering universal eye health coverage: a call for more and better eye health funding.

Additional resources are urgently needed to tackle the increasing burden of vision impairment, to support the delivery of the Sustainable Development Goals, and to live up to the promise to leave no one behind. This commentary reflects on eye health funding in developing economies and calls for a step change in delivering more and better financing and the integration of eye health into universal health coverage. The transformation in funding will need to be done carefully, creatively and collaboratively to ensure that funding results in faster and more sustainable delivery of high quality, affordable eye healthcare for all.

Introduction

At least 2.2 billion people have a vision impairment, of whom 1 billion have an impairment that is preventable or treatable yet remains unaddressed.[1] Women and girls, people with disabilities and people living in low- and middle-income countries (LMICs) are disproportionally affected. Providing equitable access to quality eye health services will require many things, including political will, responsive governments, effective health systems and multisector collaboration. It will also need more and better funding, as the amount and use of eye health funding affects not only the scale, scope and depth of coverage, but also the quality of services, the sustainability and the equity of eye health programmes.[2]

Good vision: a development ‘best-buy’

Everyone will experience some form of vision impairment at some point in their life.[1] Vision loss can push people into poverty, reduce quality of life, affect educational performance and worsen mental health.[1,3] Poor vision also has a large economic impact, with the annual global productivity loss due to blindness and vision impairment estimated at US$411 billion.[4]

Improved eye health will be critical to achieving many global commitments, including the United Nations Convention on the Rights of Persons with Disabilities and the promise to ‘leave no one behind’. Universal eye health, affordable high-quality eye care that is accessible to all, is critical to universal health coverage (UHC) and there is evidence that good vision contributes to achieving many of the Sustainable Development Goals, not only the health-related targets.[3]

Interventions to prevent and treat common eye health conditions are well known; many of them are cost-effective and efficient delivery models have been tested in various settings. This makes good vision a development ‘best buy’. The case for increasing the availability, accessibility and affordability of eye health services would seem to be clear cut. Yet eye health remains underfunded in many LMICs.

Eye health funding in LMICs

Estimating eye health funding is challenging due to data limitations. The information that is available on the main funding sources (government expenditure, out-of-pocket [OOP] expenditure, external development assistance and alternative financing) supports the call for more funding.

It is recognised that public spending is central to making progress towards UHC[5] and that domestic financing is critical to promote coverage, equity, financial protection and sustainability.[6-9] This is true for eye health, as well as general health. However, in most LMICs, eye health is poorly integrated in national health plans, budgets and health information systems.[1] Comprehensive analysis of government expenditure on eye health is therefore difficult. Eye health system assessments[10] and the eye care system assessment tool[11] contain some information: national eye health plans are insufficiently financed; resources are limited in many countries; and the scope of eye health coverage within social health insurance schemes varies significantly.[12]

Private financing, such as OOP fees and private health insurance, can be a significant source of eye health funding in many LMICs,[1] but the scale is difficult to quantify. In many LMICs, private sector providers represent a substantial share of the eye care market, yet publicly accessible information on the scale of their operations, their revenues and pricing structures, is limited. The perceived and actual OOP costs of eye care interventions can be a significant barrier to accessing eye care services, particularly for the poorest, undermining coverage and equity. More evidence needs to be generated to examine the direct and indirect costs to individuals who access various eye health services to make eye care affordable to all.

External financing is an important source of health funding in some countries.[5,13] However, analysis undertaken by Sightsavers[14] indicates that very little bilateral and multilateral aid has been directed to eye health. During 2010–2019, the average aid to eye health is estimated at US$69 million per year,[15] meaning only 0.04% of total official development assistance from all official donors[16] supported eye health programmes.[17]

Alternative financing mechanisms (e.g. blended finance, public-private partnerships and development impact bonds) can provide additional health funding. A few initiatives in eye health exist, including the provision of spectacles through the Essilor Eye Mitra initiative,[18] providing sustainable financing of cataract surgeries from the Cameroon Cataract Bond[19] and a public-private partnership supporting the elimination of blinding trachoma. Yet the amount of new and additional funding provided by these initiatives and the sustainability of the investment is difficult to assess.

More and better funding is urgently needed

Although data on eye health expenditure remain limited, the available evidence and the scale of unaddressed vision impairment suggests a significant need for more funding. Governments need to take the lead: eye health should be included in government health plans and budgets through the integration of comprehensive eye care services in broader health systems and health financing for UHC. The COVID-19 pandemic has put government budgets under increased pressure and will severely limit health budgets for many years to come.[20] While increases in public spending on UHC (including eye health) may be unlikely in the short term, the response to the pandemic is an opportunity for innovative thinking, creating new partnerships and maximising the efficient use of the limited resources available.

Providing quality eye care in some countries will require greater support from external sources. Without a significant shift in international support, external partners will neglect an important aspect of UHC, universal eye health, and fail to live up to their commitment to leave no one behind. While it is unlikely that external partners will be able to rapidly increase aid, eye health needs to be a higher donor priority. External support to eye health programmes and complementary investments on systems strengthening, supporting innovation and improving data, will be critical for accelerating government commitments to eye health.

Alternative financing mechanisms could provide additional funding to eye health. Ongoing pilots need to be evaluated on the ability to raise additional resources, the cost of the mechanisms, the sustainability of the financing and the equity of the delivered results.[3] Alternative financing mechanisms, like aid, will not address all of the unmet resource needs in eye health in the future, but they could complement domestic efforts.

It is clear more resources for eye health are urgently required in LMICs, but it is equally important that existing and new resources are used wisely. This includes allocating resources to cost-effective interventions, supporting platforms that deliver interventions efficiently to those in need, and ensuring equitable access to services. Expanding the evidence base on the costs, effectiveness and affordability of eye health services will be needed to inform decision-making. Failure to improve the efficiency and effective coverage of eye health services will undermine ongoing efforts to increase funding and may weaken the sustainability and impact of eye health programmes.

A call to action

More and better eye health funding is vital to make progress to universal eye health, but it will need to be delivered carefully. Additional eye health funding, whatever the source, will need to take into account the strength, capacity and the complexity of the health system and where the country is on the journey to UHC. Eye health funders will need to think carefully about making services accessible and affordable, especially for the poorest and most vulnerable. Funding needs to be allocated and used well, requiring careful consideration of data and evidence on the value for money of interventions and delivery models.

Stakeholders will also need to deliver more and better funding for eye health creatively. Raising and allocating additional money will require innovative approaches and flexible and adaptable programming. Creative financing mechanisms, new ways to raise and deliver funding, and new sources of finance for UHC, should be considered. Stakeholders will need to learn, adapt and evolve financing mechanisms to ensure a move from interesting pilots to national eye health programmes at scale. Funding will need to support efforts to leave no one behind, be creative in reaching the most marginalised and ensure no one goes without eye care because they cannot afford it.

More and better eye health funding will need to be delivered collaboratively. No one source of funding will be able to address all eye health needs. At the heart of this collaboration should be domestic governments, requiring greater political and financial commitments to eye health. They will need to be supported by other national stakeholders, the private sector, external partners and communities in raising additional resources and using the funds wisely. Working together will be key to delivering universal eye health, creating sustainable change and tackling unaddressed vision loss.

Given the scale of need, the economic and social impacts of vision loss, and the limited resources dedicated to providing comprehensive eye health, there needs to be a step change in the amount of funding for eye health in LMICs and greater effort to integrate eye health into UHC. This needs to go hand-in-hand with a commitment from all partners to ensure more eye health for the money. This transformation in eye health funding needs to happen carefully, creatively and collaboratively to ensure we make sustainable progress in delivering high-quality universal eye healthcare for all. For the 1 billion people living with unaddressed vision impairment, it also needs to happen urgently.