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What main factors are associated with inequity in eye health?
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Gender and demographics
For many years in eye care, gender differences were overlooked. Both at a program level and the national level, this issue was not actively addressed. In my experience as manager of the Seeing is Believing (SiB) program at the International Agency for the Prevention of Blindness, I was surprised that project managers had to be challenged to consider gender. Once SiB projects managed to collect and report with gender disaggregated data, project reports still arrived with the statement: “Cataract surgery outputs of men and women are 50:50; therefore, we are doing fine.” Unfortunately, this was not and is not the case. There are many reasons why not. One is demographics: Women tend to live longer than men. According to the World Population Ageing (WPA) 2019 report of the United Nations, at the global level, in 2015 to 2020, women’s life expectancy at birth exceeds that of men by 4.8 years. Longer life expectancy results in a higher proportion of older women as compared with men, and this disparity increases in older age groups. The sex ratio at older ages can be stark. In Europe, at older than 80 years, the ratio is 53 men to 100 women; in Asia, 71 men to 100 women, according to WPA 2017 data. Also, gender intersects with other causes of inequality and inequity. Therefore, if eye care is being delivered in a ratio 50:50 at many locations, we are not “doing fine.”
Demographics are important, so we need to collect gender disaggregated baseline and service delivery data and then reflect on this local, relevant data to plan and to deliver services in a more equitable manner for women and men, boys and girls. To overcome gender inequity, eye care providers and planners have to uncover the needs and issues including those that are specific to women and girls to address any barriers that are preventing them from accessing eye care.
Communities are often fatalistic about their eye health and perceive loss of vision as an inevitable consequence of aging. Women with lower access to resources, lower levels of literacy or who live farther from services are further disadvantaged. Illiteracy can affect women from accessing refraction services across their life course, for example, if they believe that eye care services are for people who need their eyesight to do their job, who can read and write. Even when younger, girls can be discouraged from getting their eyesight sorted with a pair of spectacles. As they age, women may have less access to financial resources or be reluctant to ask for it from the wider family as they prioritize the needs of their children and other family members. Women put themselves on the back of the queue because of previous discrimination they experienced, and families do not challenge that view. Disaggregated data will inform the wider delivery or introduction of eye care services, health insurance and other safety nets to help address issues around access and equity. The whole community must also be informed that eye care services are included within schemes or packages and that the services are provided for both men and women. Analyzing the issue of gender in eye health need and service provision is key to enabling the planning and delivery of equitable and accessible solutions.
Sally Crook is IAPB Seeing is Believing program manager. Disclosure: Crook reports no relevant financial disclosures.
Geographical imbalances
The shortage of health workers is a global problem, which involves eye health as well, and is larger in regions such as Africa. In this area overall, we have less than 50% of the minimum number of ophthalmologists required to meet the needs of care. However, the crisis in eye health extends beyond just the numerical shortfall. Even if we were able to successfully mobilize the additional resources necessary to address this gap, imbalances would remain in the distribution of eye health workers, with the associated challenges of retention in underserved areas.
The concern is particularly pronounced in relation to the distribution of ophthalmologists between urban and rural areas. Even if the bulk of the population with the greatest needs resides in the rural areas, urban areas are more attractive to health care professionals. They may come from rural areas themselves, but once they go to the cities to study at universities, they tend to settle there. In Africa and elsewhere, there are regions that have what appears to be an adequate number of eye health workers, but once we dig deeper, we find they are all concentrated in the urban areas while rural areas remain underserved.
Countries in Africa are particularly large, and many fall into the low-income bracket. It is therefore difficult for those in need of eye care to gain access to eye health services. It is difficult to take leave from work and to afford the costs of traveling long distances. Some of the most vulnerable, such as children and the elderly, also require an accompanying person, and that means transport costs for two people. Sometimes hospitals are so far that they need to stay overnight, which adds to the cost for accommodation and food. This is an enormous burden for people who are often living below the poverty line. Women are also massively disadvantaged because they are less independent and tend to overlook their needs in favor of children and family. Lack of equipment and supplies is yet another dimension of the same problem. Even when health workers are placed in a rural facility, they often do not have the resources they need to provide adequate services, and this is a further deterrent for professionals to accept positions in underserved areas.
Simon Day is IAPB regional program coordinator for the Africa region. Disclosure: Day reports no relevant financial disclosures.