There is a dearth of knowledge on delivering universal eye health due to the presence of limited evidence on what works for each circumstance. In order to bridge the evidence gap, implementation research has to be undertaken and disseminated. Moreover, researchers have to expand primary data collection to provide comprehensive vision assessments which can prove to be beneficial in the implementation process. World Health Organization (WHO) has committed to strengthening health information systems so that the capacity of local areas to collect, analyze and use data can be boosted and in turn, effective and equitable eye health services can be implemented.
One of the key recommendations presented in the WHO World Report on Vision is to include eye care as an integral part of universal health coverage by implementing integrated people-centered eye care but this has not been achieved until now. The Lancet Global Health Commission on Global Eye Health: vision beyond 2020 proposes a framework for integrating eye health services with the mainstream health system.
The Commission adopted the cube from WHO 2015 in order to contextualize eye health services which have to develop with changing health needs of the population. The colour gradation of the cube indicates the range in the quality of delivered services with the shift from blue to green portraying an increase in effective services.
Universal and Quality Eye Care
The progress towards the delivery of quality eye care is imperative but far from being ubiquitous. Usually, clinical outcome measures are used to track and comprehend service effectiveness but they can only offer a narrow perspective of the quality of care. Thus, a framework inclusive of seven components – effectiveness, efficiency, people-centredness, safety, timeliness, equity, and integration – has been favored by WHO in order to ensure effective deliverance of quality eye care.
At the 66th World Health Assembly, “Towards universal eye health: a global action plan 2014-2019” was endorsed. One of the major objectives of this action plan pertains to encouraging the development and implementation of integrated national eye health policies to enhance universal eye health. Examining the current status of eye care service delivery in India, it has been found that about 65% of surgical procedures are performed in the private and voluntary sector while only 35% is done in the government sector.
In 1976, India became the first country in the world to start the National Programme for Control of Blindness (NPCB) but this still continues to be a compelling development challenge for the nation. Over time, various multilateral and bilateral development agencies such as WHO, World Bank, Danida, DFID, and international NGOs such as ORBIS International, Sightsavers International, OEU, CBM, Lion’s International have extended support to further strengthen the blindness prevention initiatives. Moreover, the national program developments in India for the prevention and control of blindness have served as a blueprint for many other countries.
NPCB consists of several tools for effective monitoring of the program:
(i) standard prototypes for reporting performance and expenditure by district blindness control societies; usage of standard cataract surgery records and patients discharge cards; standard referral cards for children having refractive errors; specific software to facilitate computerized Management Information Systems (MIS) at various levels
(ii) 25 Sentinel Surveillance Units in the departments of Ophthalmology and Preventive and Social Medicine in medical colleges for assessment of beneficiary profile, visual outcomes based on cataract surgical records and follow-up of a sub-sample of operated cases to assess visual outcomes; Ocular Morbidity data to assess patterns and trends of eye diseases
(iii) Independent studies including communication need assessment and beneficiaries assessment to evaluate the program activities; evaluation of trained eye surgeons; rapid assessment of prevalence, coverage, and outcome; Epidemiological survey on blindness in 50+ populations in 15 districts.
Presently, Ayushman Bharat – Pradhan Mantri Jan Arogya Yojana (AB – PMJAY) covers 6 packages for Cataract Care, depending on the technique used to remove the cataract and severity of the condition. The two most widely offered packages for cataracts are Phacoemulsification (PHACO) and Small Incision Cataract Surgery (SICS). In the very first five months after the implementation of this scheme, around 1 L claims for cataract surgery have been raised, indicating both the extensive prevalence of the condition as well as the previously unmet need for cataract surgeries. It has been recognized that the cataract burden is disproportionate and a daunting proportion with lower socioeconomic conditions bear the brunt of the issue.
Additionally, urban-rural imbalances in the distribution of ophthalmologists and suboptimal training of residents in cataract surgery (shortage of adequately trained workforce) add to the problems. In this context, AB – PMJAY enables free-of-cost access to the poor and vulnerable to quality cataract treatment. It remains to be seen if this will result in improving the CSR in the country to help in achieving the estimated CSR required to eliminate preventive blindness.
In the future, it will be necessary to ensure structured delivery of eye care and ameliorate Management Information Systems to comprehensively manage data and effectively implement policies.
Currently, there are 3 notable centres in the peninsular region that are involved rigorously in their effort to reduce needless blindness in India- the Aravind Eye Care System at Madurai, Sankara Nethralaya in Chennai (and Bengaluru), and the L.V Prasad Eye Institute in Hyderabad. They cater to the needs of blind people in the city and its suburbs through mobile facilities and free treatment for the needy.
LV Prasad Eye Centre has set up a system by establishing Rural Eye Health Pyramid. This pyramid comprises over 208 rural “Vision Centres”, situated at the bottom of the pyramid, each of which offers eye care service to a local rural population free of charge. A crucial link to the communities is the number of ‘vision guardians’, individuals trained to be involved in their local environment and communicate with people about eye health. In the second tier of the pyramid are 21 Secondary Centres such as rural eye care clinics, for people in the districts. There are 3 tertiary centres that also do research work in ophthalmology, besides their regular clinical activities. The Quaternary centre at the top of the pyramid oversees and monitors in real-time the work being carried out at the tiers and corrects what needs to be done, round the clock.
It thus becomes imperative to integrate these grassroots level interventions with the national health programs and scale up and expand their services across the nation towards Universal Health Coverage. Further, institutional collaborations and support are equally necessary for leveraging new technologies and ensuring that these become commercially viable. The state will have to provide their support- through funds or infrastructure- to help research councils develop new technologies. The level of expenditure on Research and Development (R&D) in India is already very bleak. Public institutions need to increase their spending on R&D and collaborate with the private and NGO sectors to adopt best case practices generated across the country and worldwide.
Despite several developments, changing population demographics, the lack of implementation research and lack of inclusion of eye care in health plans are some of the challenges that need to be tackled. The paucity of research related to implementation can hinder the evidence-based planning of eye care programmes and services. Several interventions are available but further research has to be undertaken to improve implementation. Besides, many interventions are out of reach for the marginalized and disadvantaged populations.
Acknowledgment: Ritheka Sundar is a Research Intern at IMPRI.