The universal eye health imperative for Canada: an inescapable reality of unmet need

Abstract

Universal eye health is a component of universal health care, which member states of the World Health Organization have supported in principle through their endorsement of the Global Action Plan for the Prevention of Avoidable Blindness and Visual Impairment (2014–2019). While much of the world’s attention has been on addressing the needs of developing countries which suffer significant shortcomings in terms of effective and accessible eye care services, similar access inequities exist in developed nations such as Canada. The Canadian health system is based on the principle of universal health coverage; yet, for the majority of the population, access to primary eye care services such as an eye examination and spectacles is an out-of-pocket expense. Therefore, despite the global call for universal eye health, Canada has still not made relevant policy shifts in terms of addressing the structural barriers to all its citizens accessing primary eye care services within its health system, despite active advocacy efforts of key stakeholder groups in eye health. There is, therefore, an inescapable reality of unmet eye care needs, which Canada must address if it is to meet the World Health Organization’s goals of universal eye health.

Introduction

The Global Action Plan (GAP) for the Prevention of Avoidable Blindness and Visual Impairment 2014–2019 was endorsed at the 66th World Health Assembly of the World Health Organization in 2013 (World Health Organization 2013). It recognizes the fact that provision of effective and accessible eye care services is key for controlling vision impairment and blindness, and promotes the integration of comprehensive eye care services into primary health care as part of health systems development. The plan broadly aims to reduce avoidable vision impairment as a global public health problem, and recognizes the need for incorporating the prevention of vision impairment into wider health policies and approaches. Its three main objectives are to address the need for generating evidence on the magnitude and causes of vision impairment; to encourage the development and implementation of integrated national eye health policies, plans and programs which enhance universal eye health; and to address the need for multi-sectoral engagement and effective partnerships in this regard (World Health Organization 2013).

Uncorrected refractive error is a major cause of vision impairment worldwide (Holden 2007), yet Canada’s health system does not provide universal coverage for routine vision care services such as eye examinations and spectacles to all its citizens (Canadian Association of Optometrists 2018a). Under the Canada Health Act, each province or territory must ensure that their respective health insurance plans support accessibility, comprehensiveness and universality of care for all “medically necessary” services for the purpose of maintaining health, preventing disease or diagnosing illness (Canadian Nurses Association 2000).

However, there are variations in the coverage provided by Canadian provinces in terms of optometric care. While all provinces provide insurance coverage for “medically necessary” eye care services, the coverage for routine eye examinations is usually restricted to designated groups (Canadian Association of Optometrists 2018a). Therefore, citizens and permanent residents outside of these designated groupings who may not have supplemental vision insurance to cover routine eye examinations, and/or for whom affordability may be an issue, consequently face an access barrier. Routine eye examinations play an important role in diagnosis and management of systemic illness, since the eyes are connected to many other systems in the human body. This makes routine eye exams an important part of preventive healthcare, regardless of age or physical health status (Alberta Association of Optometrists n.d.). Fundamentally, therefore, this inequity in access goes against the principles of universal eye health (World Health Organization 2013) and the conditions of accessibility, comprehensiveness of care and universality as stipulated under the Canada Health Act.

By endorsing the GAP at the 66th World Health Assembly, member states agreed to jointly work towards a 25% reduction in prevalence of avoidable visual impairment by 2019 from the baseline established by WHO in 2010 (World Health Organization 2013). However, it is unclear what policies or strategies Canada has put in place to address this inequity and achieve the goal of universal eye health (Canadian Association of Optometrists et al. n.d.).

Canada’s unmet eye health needs

The Canada Health Act is based on the principle of universal health coverage (Martin et al. 2018), with universal eye health embedded in universal health coverage (Blanchet et al. 2014). While much of the world’s focus in response to the GAP has been on developing eye health systems in low- and middle-income countries where access to eye health services has, in many cases, been non-existent (Blanchet et al. 2014), developed countries such as Canada are equally accountable to the WHO for implementing approaches that support universal eye health. Vision impairment is known to have a significant impact on the lives of those who experience it, as well as their family, friends and society at large (Welp 2016). Blindness and visual impairment are also significantly associated with higher medical care expenditures, a greater number of informal care days and a decrease in health utility (Frick et al. 2007). Therefore, the limitations to coverage for eye health services by the Canadian health system will potentially result in greater economic costs to the government and society as a whole if routine eye examinations, which promote early detection and treatment of potentially serious conditions, are not available to all citizens and residents (Valle 2016). Of concern also is that only half of Canadians seek treatment for symptoms of potential disease that may result in vision loss (Canadian Ophthalmological Society 2018). Even more concerning is that the lowest utilization rates occur in people of productive working age, i.e., 30–39 years old (Jin and Trope 2011). The main factors influencing access to eye health care have been identified as workforce supply, public awareness, availability and regularity of services (particularly in rural and remote areas), affordability of services and physical accessibility (Canadian Association of Optometrists et al. n.d.).

For any economy, productivity losses associated with visual impairment (Smith et al. 2009) should be of concern. Early detection and treatment are therefore key to preventing disease progression and avoiding vision loss or blindness (Welp 2016), both of which impose huge rehabilitation costs on the health system (Frick et al. 2007). Good vision ultimately has a positive impact on educational attainment, employment rates, productivity and economic growth (Canadian Association of Optometrists 2018a). People with vision impairment are also at greater risk of social isolation and reduced community participation (Canadian Association of Optometrists et al. n.d.). Indigenous Canadians represent the fastest growing segment of the Canadian population, increasing at a rate six times faster than non-Indigenous people (Canadian Association of Optometrists et al. n.d.). Risk factors for major blinding diseases, which include diabetes mellitus, smoking and premature birth, have all been highlighted as public health concerns among Indigenous Canadians (Crowshoe et al. 2018). Subsequently, a lack of availability and challenges accessing primary eye care in these communities (Brise and de Leeuw 2015) could impede Canada’s efforts towards the inclusion of Indigenous people, while efforts towards making eye health services more accessible to all Canadians hold potential in terms of fostering broader social and economic benefits.

Optometrists provide a significant volume of primary eye care to the Canadian population (Ali et al. 2015), yet routine eye examinations have been “privatized” as they do not form part of the standard health insurance benefits in most provinces. Unlike the reality in many developing countries (Ntsoane and Oduntan 2010), Canadians should not be required to travel long distances to receive eye care, nor be restricted from accessing treatment for primary eye conditions (Ali et al. 2015). “Towards Universal Eye Health” is therefore a call to action for member states to address major causes of visual impairment and unmet eye health needs through better integrating eye health into national health plans and health service delivery, using a life course approach. More research is needed, however, in order to design appropriate models for universal access to primary eye care (Liberman 2019).

A national imperative

The Global Action Plan (GAP) for the Prevention of Avoidable Blindness and Visual Impairment 2014–2019 envisages a world in which nobody is needlessly visually impaired, where those with unavoidable vision loss can achieve their full potential and where there is universal access to comprehensive eye care services (World Health Organization 2013). Cost is however an access barrier for some, even in the developed world. Therefore, primary eye care must form part of the health insurance system in Canada for improved visual health of the nation and to avoid longer-term costs associated with treating avoidable causes of vision impairment such as diabetic retinopathy and glaucoma, which if identified early can be effectively managed to prevent long-term blindness.

While Canada is a signatory to GAP, not much has been done by way of policy or program development to improve access to eye health services for all Canadians, despite efforts by professional and service organizations in Canada to engage lawmakers (Canadian Association of Optometrists et al. n.d.; Canadian Association of Optometrists 2018b; Canadian Ophthalmological Society 2018). Concerns have repeatedly been raised by both the ophthalmology and optometry fraternities in Canada, who have both advocated for improved access to routine eye examinations for all Canadian citizens (Canadian Association of Optometrists et al. n.d.; Canadian Association of Optometrists 2018b; Canadian Ophthalmological Society 2018).

The World Health Organization (WHO) also recently adopted a global strategy on people-centred and integrated health services (World Health Organization 2015). It called for a fundamental paradigm shift in the way health services are funded, managed and delivered, building on the principles of universal health coverage and primary health care. The report presents an emphatic vision of a future in which people all over the world have access to health services that are coordinated around their individual needs and where services available are better able to provide a continuum of care that meets all their health needs, in an integrated way, throughout the course of their lives (World Health Organization 2015). Achieving people-centred and integrated health services therefore has the potential to generate significant benefits in all countries, whether low-, middle- or high-income countries (World Health Organization 2015).

Eye care is health care. The eye care agenda, however, has frequently been planned and delivered as a parallel system and not as an integral part of mainstream health care services. As such, in many countries, a high percentage of eye care services are delivered by the private sector, with little synergy between the private and public health systems (Liberman 2019). While access to eye care services, and integration into universal health coverage, is one of the things that the WHO is strongly advocating, it is still not a reality in many countries of the world, including Canada (Liberman 2019). Canada therefore needs to identify new models of eye health service delivery, if it is to realize equal access to health care for all Canadians, as advocated for in the World Health Organization’s Global Action Plan and promised in the Canada Health Act (Ali et al. 2015). Should Canada fail to address its unmet eye health needs, citizens who are denied access to these services, either due to cost or accessibility barriers, will potentially suffer social and economic exclusion, as well as ongoing visual disability which impose resultant rehabilitation and social support costs to the economy (Canadian Association of Optometrists n.d.).

Finally, further evidence relating to the unmet need for eye health services in Canada is necessary. Unless a people-centred and integrated health services approach is adopted, eye health care in Canada will become increasingly fragmented, inefficient and unsustainable (Canadian Association of Optometrists n.d.). Therefore, Canada must identify and overcome its roadblocks to implementing universal eye health coverage by identifying strategies to enhance access to primary eye care services and eliminate ability to pay as a barrier to achieving universal eye health.

Compliance with ethical standards

Conflict of interest

The author declares that there is no conflict of interest.