Eye health action plan focuses on improvement strategies, progress monitoring, effective cooperation

The World Health Organization 2014-2019 Global Action Plan for the prevention of avoidable visual impairment, endorsed by the World Health Assembly in May 2013, is being translated into workable programs and practical commitments.

“Our team has met with representatives of the ministries of health in the WHO region of the Americas, Eastern Mediterranean region, in the African region and Western Pacific, and will be shortly in Southeast Asia. In Europe, we have been involved in several international clinical meetings including the action plan in the agenda,” Ivo Kocur, MD, WHO Medical Officer, Prevention of Blindness and Deafness, said.

The first objective, as stated in the Global Action Plan (GAP), is to generate evidence on the magnitude and causes of visual impairment in individual countries or specific areas and assess the availability of eye care services.

“We are currently developing a tool to help individual countries to gauge the progress of the plan in relation to disease control, visual rehabilitation and eye care services capacity. What we expect as a first result at this stage is a brief document following our indicators to describe the situation, what has been already done and what is needed,” Kocur said.

Image: Kocur I

This evidence would then become the basis for the development and implementation of national eye health plans and policies working toward universal eye health.

“We at WHO are just a small team of experts working in partnership with [international nongovernmental organizations], scientific societies and professional associations to support member states in their efforts. We give the input and provide the basic framework and instruments for governments to work according to their specific needs and capacities,” Kocur said.

“Universal eye health,” the title given to the action plan, reflects a vision: a world in which no one is needlessly visually impaired, those with unavoidable vision loss can achieve their full potential and there is universal access to comprehensive eye care services, Kocur said.

The Western Pacific region

The GAP has already achieved some unprecedented goals. For the first time, all 194 WHO member states set a common global target: 25% reduction in the prevalence of avoidable visual impairment by 2019 from baseline data of 2010. Also, a consensus was found on a list of key eye health indicators to assess the current situation of eye health and measure progress.

“The previous action plan set some fine goals, but there was nothing that was measurable around them,” Hugh R. Taylor, AC, president of the International Council of Ophthalmology, said.

“The 25% reduction in avoidable blindness is a clear target to work on, and it means that national governments have to make specific plans. Our government in Australia is looking at it very seriously, and I believe other countries have immediately reacted in a positive way,” he said.

The Western Pacific region is home to more than one-fourth of the global population and includes countries with highly developed economies such as Japan and Singapore and growing economies such as China, as well as some of the poorest areas of the world.

“One of the most exciting initiatives to improve eye care in these areas has been the opening of the Pacific Eye Institute in Suva, Fiji, the Pacific region’s first training facility for eye health professionals. People from the islands are trained there for the specific needs of their environment, and when they go back, they can make a real difference,” Taylor said.

Cambodia has met the first objective of the GAP by producing a comprehensive Eye Health Systems Assessment (EHSA), based on six key areas: governance, financing, service delivery, human resources, supply of medicines and equipment, and monitoring within the national information system. Strengths and weaknesses of the eye health system were identified for each of the aspects.

“The assessment was conducted through interviews with relevant eye health system stakeholders and document review. A national workshop to discuss findings and develop strategies for strengthening the eye health system was then organized,” Do Seiha, MD, said.

Over the last 15 years, the ministry of health of Cambodia has invested in a group effort in cooperation with WHO and international nongovernmental organizations for the prevention of avoidable blindness, leading to a decrease in the prevalence of blindness from 1.3% to 0.3%.

“Blindness remains a major public health issue and is avoidable, according to the EHSA, in 90.2% of the cases,” Seiha said.

Efforts will continue through integration of Cambodia’s national plan for eye health and the GAP to improve service delivery and coordination.

Increasing prioritization and advocacy in Africa

“Following the meetings with the WHO regional office for Africa, we have developed a regional and sub-regional strategy to achieve the objectives of the GAP and have agreed to focus on the HRH [Human Resources for Health] component of the plan,” Kovin Naidoo, OD, PhD, Africa chairperson of the International Agency for the Prevention of Blindness, said.

With the majority of African countries not yet meeting the Abuja Declaration of 2001 to spend 15% of their national budgets on health, the continent has a severe, permanent shortage of human resources for eye care.

“Thirty-six out of 57 HRH crisis countries are in Africa. Besides this, low prioritization is given to eye health due to the existence of so many other threats to health. Despite 80% of blindness and visual impairment being avoidable or preventable, very little is done in terms of prevention,” Naidoo said.

Six African researchers will be trained in the rapid assessment of avoidable blindness methodology so that the appropriate epidemiological data can be generated to monitor progress in terms of meeting the targets of the GAP. In addition, a national advocacy capacity building workshop will be held in Ghana in June for five pilot countries.

Advocacy is key to getting African governments to commit and achieve the targets of the GAP, Naidoo said.

“Given the multitude of priorities Africa governments are confronted with, to elevate eye care on their agenda requires solid planning, effective strategies and high-level advocacy,” he said.

Model strategy for universal coverage in India

The Aravind Eye Hospital network in the south Indian state of Tamil Nadu has established a model strategy for the elimination of avoidable vision loss and universal coverage.

Aravind started as a single hospital in Madurai and now has branches in nine other towns and cities in Tamil Nadu.

“In the rural areas around these 10 base hospitals, we have set up primary care vision centers, with a stable team of one counselor and one ophthalmic technician, all women, from local areas and trained at Aravind,” Kim Ramasamy, MD, chief medical officer at the Aravind Eye Hospital in Madurai, said. “The technician performs a complete eye examination, uploads the data in a simple electronic medical record and is simultaneously available for the ophthalmologist at the base hospital to review. Patients are then able to talk to the ophthalmologist via video conferencing. If more complex investigation or surgery is indicated, they are referred to the base hospital, and these account for only 10% of the patients; the others are taken care of in the primary center.”

Currently, there are 46 vision centers, covering a population of about 3 million people. For the entire consultation process, the patient pays a fee of 20 rupees, which is valid for three visits or 3 months, whichever occurs first. Through this fee and by selling medicines and spectacles, each center is able to sustain itself financially.

“Earlier, the only outreach mode was eye camps, and each year we conducted over 2,500 eye camps, but through a study we learned that these eye camps reached only 7% of the people in need of eye care in that area. This is the reason for establishing the primary care vision centers. Through them, we are now reaching more than 75% of the patients who need eye care in the service area of the vision centers. We are planning to increase the number of centers by another 100 in the next 5 years to ensure universal coverage to a total of 10 million people. We are also exporting our model to other states of India, including the northeast states, which suffer from a severe shortage of services and human power,” Ramasamy said.

Marginalized communities in Europe

Although eye care is well developed in Europe, differences in accessibility and affordability still exist, Kocur said.

“Availability and quality of services are an issue also in some parts of Europe, particularly in countries in transition, such as the east non-EU countries. In EU countries, there might also be areas in eye health which haven’t been fully addressed, such as low vision services or ROP prevention,” he said.

According to Stefan Seregard, MD, PhD, president of the European Society of Ophthalmology, there is a lack of consistently used measurement tools and standardization for quality measures in Europe.

“We don’t know how well or bad we are doing because we cannot rely on consistent, validated data. We need to put all the facts together, and only then we can start identifying the issues and develop pilot projects,” he said.

One area that is likely to need intervention is diabetic retinopathy, which is considerably increasing in Europe.

“We should focus on screening to detect early changes and avoid time- and money-consuming complications,” he said.

Governments, ophthalmological societies and consumer groups should be involved and interact to develop projects around core objectives and monitor progress, Kocur said. The needs of marginalized communities, such as immigrants, Roma and elderly people, should be first on the agenda, and key questions should be considered: What are their needs? Are they aware of what they need and what is available? Are we making it accessible and affordable to them?

According to Taylor, when looking at prevention of blindness and the right to sight, there is a need to “think globally but act locally.”

“When I sit in my office in a town or a city, in Europe, Australia or America, I need to think who are the underserved people in my own community and how I can contribute to make health and life better for them,” he said. – by Michela Cimberle

References:

Sok K, et al. Eye Health System Assessment, Cambodia, 2013. www.iapb.org/sites/iapb.org/files/Eye%20Health%20System%20Assessment%20in%20Cambodia_2013.pdf.

Universal eye health: a global action plan 2014-2019. World Health Organization website. www.who.int/blindness/en/.

Universal eye health: a global action plan 2014-2019. World Health Organization website. www.who.int/blindness/actionplan/en/.

For more information:

Ivo Kocur, MD, can be reached at World Health Organization, Avenue Appia 20, 1211 Geneva 27, Switzerland; email: kocuri@who.int.

Kovin Naidoo, OD, PhD, can be reached at Brien Holden Vision Institute, 272 Unbilo Road, Durban, South Africa, 4000; email: k.naidoo@brienholdenvision.org.

Kim Ramasamy, MD, can be reached at Aravind Eye Hospital, 1 Anna Nagar, 625 020, Madurai, India; email: kim@aravind.org.

Do Seiha, MD, can be reached at 121, Preah Ang Duong (St. 110), 12202 Phnom Penh, Cambodia; email: doseiha@gmail.com.

Stefan Seregard, MD, PhD, can be reached at St. Eriks Eye Hospital, Fleminggatan 22, Stockholm, SE-11282, Sweden; email: stefan.seregard@sankterik.se.

Hugh R. Taylor, AC, can be reached at University of Melbourne, 207 Bouverie St., Carlton, 3053, Australia; email: h.taylor@unimelb.edu.au.

Disclosure: The sources have no relevant financial disclosures.

 

 

Are ophthalmic industries contributing to a sufficient extent and with appropriate strategies toward implementation of eye health policies in your area?

Needs of the Amazon have been poorly addressed

The needs of the Amazon have been poorly addressed so far by the business community, although part of the industry has already perceived that there is the potential here for a huge market. Portable equipment, such as optical coherence tomography systems and retinal cameras, is the most obvious example.

Serving this area requires a major paradigm shift. The concept of “disposables,” for instance, is totally unsuitable. Due to the high cost of the kits, disposables are often reused many times, creating a situation of higher risk for infection. In addition, they produce huge amounts of waste. On the other hand, there is a high potential demand here for “lower-tech” devices, as well as pharmacotherapies, which could be sold at affordable prices but in large quantities for the treatment of many diseases. However, this does not depend entirely on manufacturers. Physicians and health agencies should be more interested in generating outcome-based studies comparing similar treatments that use technologies with different costs. The CATT study is a rare and fantastic exception.

Specific needs for the Amazon include multimodal Internet-based diagnostic and therapeutic systems. Remote retinal imaging by fundus camera and OCT could be used for glaucoma, age-related macular lesions and diabetes screening. Digital photography could be used to screen for corneal diseases and cataract, as well as children for central corneal reflex in strabismus. And refraction using smart phones is underway. All this can be done by mid-level technicians, and images can be sent to reading centers for remote expert interpretation. Unfortunately, ophthalmology care is still too physician-centered with a huge technician shortage. Also unfortunately, most of the Amazon has no Internet coverage. Google is currently testing Project Loon, a network of balloons floating in the stratosphere that would provide this remote part of the planet with access to the Web.

 

Rubens Belfort, MD, PhD, is the head professor of the Vision Institute, Hospital São Paulo, Federal University of São Paulo, Brazil. Disclosure: Belfort has no relevant financial disclosures.

Local industry has played major part in India

Historically, technology and industry were Western-based and predominantly served the Western market, with practically no investment for emerging economies. Major industries such as Alcon did not have a presence in India. The reason for it was that in the emerging markets, not much was happening in health care. However, the scenario is rapidly changing. In the last year in India alone, 6 million cataract surgeries were performed, probably almost one-third of what is done in the world. It is a huge market, but Western industries that do have a presence here tend to apply the same prices that they apply in the West. On the other hand, local industries are growing. They have some catching up to do, but they sell good-quality products at a fraction of the price of Western companies.

In 1992, we set up a manufacturing unit, Aurolab, as an integral part of the Aravind Eye Care System. It is set up as a nonprofit, but its operations are similar to that of a commercial company, complying with the standards of the U.S. Food and Drug Administration and other quality standards. It supplies 140 countries in the world and has an estimated market share of about 8% to 10% of the global IOL market. The price is less than 5 for soft IOLs, 1.50 for rigid lenses and about 50 for toric lenses. Our market is mostly developing countries because our primary intention is to address the eye care problem. There are many manufacturers of a similar nature in India, and our local industry has become an active player in the elimination of visual impairment.

Industries have a major role in scaling up innovation. Their contribution is critical. In the delivery of care, the entire logistic of the supply chain, making medications accessible to patients, is handled by the industry — a role that is sometimes not fully appreciated.

 

Thulasiraj Ravilla is with the Aravind Eye Care System, Madurai, India. Disclosure: Ravilla has no relevant financial disclosures.