Universal eye health coverage: from global policy to country action.

The year 2020 marked the end of the global initiative Vision 2020: The Right to Sight launched by World Health Organization (WHO) in 1999 to intensify and accelerate activities to tackle avoidable blindness. Over the three decades of this initiative, four resolutions on avoidable blindness and vision impairment were adopted by the World Health Assembly (WHA; 56.26 [2003], 59.25 [2006], 62.1 [2009] and 66.4 [2013]). Evidence of the impact of these concerted efforts is clear, with a significant reduction in the age-adjusted prevalence of blindness (27% reduction between 1990 and 2020) and a substantial reduction in the number of children and adults who are blind due to vitamin A deficiency and infectious causes, such as onchocerciasis and trachoma.[1,2]

Despite the successes, eye care services in many countries have been unable to keep pace with the increasing need associated with demographic, behavioural and lifestyle trends that have led, and will continue to lead, to an increase in the number of non-communicable eye conditions. As a result, >1 billion people worldwide have vision impairment that could have been prevented or has yet to be addressed due to causes such as cataracts, myopia, glaucoma and diabetic retinopathy.[2] To accentuate these challenges, significant inequalities in access to eye care services exist—the burden of eye conditions and vision impairment is greater in low- and middle-income countries and underserved populations, such as people living in rural areas, those with low incomes, women, older people, indigenous populations and ethnic minorities.[2]

As the eye care sector transitions from Vision 2020: The Right to Sight, it is clear that new strategies are needed to address the current and projected eye care needs.

United Nations developments for the new eye care agenda

Over the past 2 y, eye care has gained significant momentum in the global public health agenda (Figure 1). In October 2019, WHO launched the first World report on vision, highlighting the role of eye care in contributing to achieving Sustainable Development Goal (SDG) 3 (Ensure healthy lives and promote well-being for all at all ages) and its target 3.8 of achieving universal health coverage (UHC; ensuring all people have access to the promotive, preventive, curative and rehabilitative services they need, when and where they need them, without being exposed to financial hardship).[2,3] The report puts forward a set of recommendations, namely making eye care an integral part of UHC and implementing integrated people-centred eye care (IPEC).

Figure 1.

Timeline of global United Nations documents and decisions since 2019.

In November 2020, member states endorsed the recommendations of the World report on vision with the adoption of the resolution titled ‘Integrated people-centred eye care, including preventable vision impairment and blindness’ at the 73rd World Health Assembly (WHA 73.4).[4] This resolution sets forth several actions that governments, non-state actors and the WHO can take to address the key challenges facing the eye care sector. One of the actions agreed on in resolution WHA 73.4 was for the WHO, in consultation with member states, to prepare recommendations on feasible global targets for 2030 focusing on two global tracer eye care indicators, effective cataract surgery coverage (eCSC) and effective refractive error coverage (eREC). To this end, the WHO undertook a consultative process with member states and experts from the field to develop global targets for eCSC and eREC that were endorsed by the 74th WHA in May 2021.[5] The two new ambitious global eye care targets for 2030 are a 40% increase in eREC and a 30% increase in eCSC.[6] The essential purpose of these indicators and related targets is to drive eye health coverage while delivering quality care. The ability to collect a large volume of high-quality data, periodically and across all relevant target populations and WHO regions, will be critical to ensure robust monitoring of progress towards achieving these new targets.

In recognition of the growing evidence that improving eye health and preventing vision impairment can directly contribute to achievement of many other SDGs,[7] including the goals on quality education (SDG4), gender equity (SDG5), work and economic growth (SDG8) and reduced inequities (SDG10), the first United Nations General Assembly (UNGA) resolution on vision was adopted by member states in July 2021. This resolution frames vision as a cross-cutting issue within the sustainable development framework and encourages greater coordination on vision with other global development priorities.

These high-level documents and global commitments provide important advocacy support for national efforts to strengthen eye care service delivery and set forth a strategic framework to support relevant stakeholders (i.e. policymakers, managers and service providers) in achieving this objective.

Priority areas of actions toward achieving universal eye health coverage within countries

In order to address the inequities in access to and provision of eye care services across the population, the delivery of eye care needs to be strengthened within universal healthcare. As outlined in the World report on vision,[2] there are a number of actions that need to be taken in order to make this a reality. First, and most importantly, eye care needs to be included in national health strategic plans and development policies, so it is better prioritized within countries. Second, eye care services and interventions need to be integrated in benefit packages covered under social health insurance and there is a need to reorientate the model of care towards strengthening eye care within primary health care. Third, given the challenges relating to the growing population needs and shortage of eye health workers, eye care workforce planning needs to be an integral part of health workforce planning and a competency-based care approach needs to be adopted. Lastly, opportunities exist to strengthen intersectoral partnerships with education, the private sector, social services and labour to improve eye health.

It should also be acknowledged that the generation of new evidence will be critical to the achievement of universal eye health coverage. For example, health services and implementation research is required to ensure that innovative workforce models (e.g. task sharing) and technological advances can be scaled up and return-on-investment studies will also be important to provide evidence on how investing in eye care interventions can secure health, social and economic returns. In order to effectively drive policy decisions about eye care service planning, health information systems must also to be strengthened to include a balanced set of robust eye health indicators and evidence on the total population’s eye care needs, both met and unmet.

WHO’s support for implementing universal eye health coverage within countries

Resolution WHA 73.4 provides the WHO with a mandate to provide technical support to member states and other stakeholders in achieving the aforementioned actions. In view of this, the WHO, with the involvement of international experts, is developing relevant technical guidance and tools, including a package of evidence-based eye care interventions to assist countries in making decisions on which interventions to prioritize, how these can be budgeted and how they can be integrated into national health services packages and policies[8]; a comprehensive guide for action to assist governments through a phased process of situation assessment, strategic planning, monitoring and evaluation and implementation of the strategic plan; and an eye care competency framework to assist in workforce planning and development, informing education institutions in preparing workers for practice and setting practice standards for employers, policymakers and regulatory bodies.

Conclusions

Building on the previous achievements of the eye care sector, the recent high-level documents and global commitments arising from the WHA and UNGA provide a solid foundation to move a ‘new’ eye care agenda forward in the coming decade. Achieving the proposed actions and targets will require the combined and proactive efforts of all stakeholders, including governments, the WHO, multilateral institutions, non-governmental organizations, the private sector and the community, to provide the long-term investment and management capacity needed to ensure that all people can receive quality eye care services without risking financial hardship. The generation of high-quality evidence and data will be instrumental for the realization of universal eye health coverage.