Primary eye care – Key to universal eye health

Rationale for vision centers

The recent World Report on Vision[1] by the World Health Organization (WHO) focuses on achieving universal eye health through integrated people-centered eye care (IPCEC). Subsequent to this report, WHO also has, for the very first-time, proposed thresholds for intervention as well as outcomes for cataract surgery and refractive error interventions.[2] It recommends that the coverage of cataract surgery and refractive error should be monitored for all those with presenting vision in the better eye <6/12 due to cataract or refractive error. For the interventions to be considered effective, the post-intervention visual outcome has to be 6/12 or better. Further, WHO has proposed a goal that the current effective coverage for cataract surgery and refractive errors should be increased by 30% and 40%, respectively, by the year 2030. India is among the countries that have agreed to adopt these new guidelines and the goals proposed. This exacerbates the existing challenge of providing timely eye care to rural and poor communities. Eye care services in India are essentially urban-centric, seldom reaching below the district capitals. The only approach used at scale across the country to reach the rural masses is eye camps. While they reach and serve a significant number of people, a study in the late 1990s demonstrated this to be less than 7% of those in need of eye care.[3] It is in this context that an urgent need was felt for new approaches to make eye care more universal. A strategy that is actively explored is establishing permanent primary eye care facilities to supplement the eye camps that happen periodically.

Vision centers (VCs) and their impact

Adopting the global initiative, VISION 2020 the Right to Sight, in early 2000, India planned on establishing 20,000 VCs across the country by 2020, both in the government and non-government sectors.[4] Budgetary provisions had been made in subsequent five-year plans. Though this goal is yet to be achieved, there is growing appreciation for this concept and interest in establishing VCs across the country. Several state governments have set up VCs, with Tripura state pioneering the effort by establishing 40 centers, covering the entire state, way back in 2007. Several NGO eye hospitals have established large networks of VCs with funding support from international eye-care NGOs and corporate social responsibility funding. While there is a growing network of VCs, there has not been much evidence on their impact at the population level. This article in this issue by Gogate et al.[5] is probably the first publication to document the impact of VC services on blindness and vision impairment. The authors have leveraged their service delivery model that integrated door-to-door visual acuity assessment, documentation, case finding, and referral to the VC that was being established. This well-documented, population-level data served as the baseline. The same cohort was followed up 3–4 years later in 2018–19, resulting in a longitudinal study, which is the ideal design for impact assessment. Because the community health workers were regularly visiting the families, they had a very high follow-up rate. Though the subjects during the second survey would have been 3–4 years older in this longitudinal study, the prevalence of blindness and visual impairment decreased in spite of the aging cohort. Though the study covered subjects in an urban slum, served by just one VC, it still unambiguously establishes the potential impact of this approach and thus provides the confidence for rapid scaling of VCs across the country.

Looking ahead and the need for enabling policies

We need to recognize that primary eye care centers (VCs) are a novel initiative and that they will be effective only when they can resolve common eye conditions such as refractive errors at the VC level itself. They should not just serve as outposts for referring all patients to secondary or tertiary level eye hospitals. Because these VCs will be staffed by allied ophthalmic personnel or optometrists, technologies such as telemedicine or artificial intelligence should be harnessed to enhance the quality of diagnosis and treatment plan to ensure comprehensiveness of care, which is one of the three elements of universal health coverage. Using technology at the primary level will be another new initiative. As we are breaking new ground with respect to access and comprehensiveness in care, the policy framework has to catch up. We need to give clarity on what services can and should be provided at the VC level, keeping in mind that care loop should be completed for most of those presenting at these centers.

Ophthalmology for long has been a curative specialty, with eye care delivered largely by secondary or tertiary level providers. As a consequence, all current policies and practices are for care delivery at these levels. Studies such as this one establish the potential for building a truly inclusive care delivery model. The ophthalmologists and the eye care community have to recognize this potential of VCs in achieving true universal eye care and work with policymakers within the ophthalmic community and the government to enact enabling policies.[6]

About the author

Thulasiraj Ravilla

One of the founding members of Aravind Eye Care System, Thulasiraj Ravilla is currently the Executive Director of Lions Aravind Institute of Community Ophthalmology (LAICO) as well as the Director – Operations for Aravind Eye Care System.

An MBA from Indian Institute of Management Calcutta, he was visiting scholar at University of Michigan, Ann Arbor, USA and University of Pennsylvania, Philadelphia, USA, as well as guest faculty in many academic institutions in India and other countries. He is the Founder President of VISION 2020: The Right to Sight-India and now, one of the honorary member in Management Board. He is a Board Member of Acumen Fund – USA, Aravind Eye Foundation – USA, Indian Institute of Health Management and Research, Bangalore as well as the President of Aurolab Trust. He has served on several task force groups at the national level and at the World Health Organization. He was earlier on the boards of Seva Foundation – USA, Dhan Foundation and Indian Institute of Management, Calcutta.