The Lancet Global Health Commission on Global Eye Health: vision beyond 2020

Abstract

Eye health and vision have widespread and profound implications for many aspects of life, health, sustainable development, and the economy. Yet nowadays, many people, families, and populations continue to suffer the consequences of poor access to high-quality, affordable eye care, leading to vision impairment and blindness. In 2020, an estimated 596 million people had distance vision impairment worldwide, of whom 43 million were blind. Another 510 million people had uncorrected near vision impairment, simply because of not having reading spectacles. A large proportion of those affected (90%), live in low-income and middle-income countries (LMICs). However, encouragingly, more than 90% of people with vision impairment have a preventable or treatable cause with existing highly cost-effective interventions. Eye conditions affect all stages of life, with young children and older people being particularly affected. Crucially, women, rural populations, and ethnic minority groups are more likely to have vision impairment, and this pervasive inequality needs to be addressed. By 2050, population ageing, growth, and urbanisation might lead to an estimated 895 million people with distance vision impairment, of whom 61 million will be blind. Action to prioritise eye health is needed now. This Commission defines eye health as maximised vision, ocular health, and functional ability, thereby contributing to overall health and wellbeing, social inclusion, and quality of life. Eye health is essential to achieve many of the Sustainable Development Goals (SDGs). Poor eye health and impaired vision have a negative effect on quality of life and restrict equitable access to and achievement in education and the workplace. Vision loss has substantial financial implications for affected individuals, families, and communities. Although high-quality data for global economic estimates are scarce, particularly for LMICs, conservative assessments based on the latest prevalence figures for 2020 suggest that annual global productivity loss from vision impairment is approximately US$410·7 billion purchasing power parity. Vision impairment reduces mobility, affects mental wellbeing, exacerbates risk of dementia, increases likelihood of falls and road traffic crashes, increases the need for social care, and ultimately leads to higher mortality rates. By contrast, vision facilitates many daily life activities, enables better educational outcomes, and increases work productivity, reducing inequality. An increasing amount of evidence shows the potential for vision to advance the SDGs, by contributing towards poverty reduction, zero hunger, good health and wellbeing, quality education, gender equality, and decent work. Eye health is a global public priority, transforming lives in both poor and wealthy communities. Therefore, eye health needs to be reframed as a development as well as a health issue and given greater prominence within the global development and health agendas. Vision loss has many causes that require promotional, preventive, treatment, and rehabilitative interventions. Cataract, uncorrected refractive error, glaucoma, age-related macular degeneration, and diabetic retinopathy are responsible for most global vision impairment. Research has identified treatments to reduce or eliminate blindness from all these conditions; the priority is to deliver treatments where they are most needed. Proven eye care interventions, such as cataract surgery and spectacle provision, are among the most cost-effective in all of health care. Greater financial investment is needed so that millions of people living with unnecessary vision impairment and blindness can benefit from these interventions. Lessons from the past three decades give hope that this challenge can be met. Between 1990 and 2020, the age-standardised global prevalence of blindness fell by 28·5%. Since the 1990s, prevalence of major infectious causes of blindness—onchocerciasis and trachoma—have declined substantially. Hope remains that by 2030, the transmission of onchocerciasis will be interrupted, and trachoma will be eliminated as a public health problem in every country worldwide. However, the ageing population has led to a higher crude prevalence of age-related causes of blindness, and thus an increased total number of people with blindness in some regions. Key messagesEye health is essential to achieve the Sustainable Development Goals; vision needs to be reframed as a development issueThere is extensive evidence showing that improving eye health contributes directly and indirectly to achieving many Sustainable Development Goals, including reducing poverty and improving work productivity, general and mental health, and education and equity. Improving eye health is a practical and cost-effective way of unlocking human potential. Eye health needs to be reframed as an enabling, cross-cutting issue within the sustainable development framework.Almost everyone will experience impaired vision or an eye condition during their lifetime and require eye care services; urgent action is necessary to meet the rapidly growing eye health needIn 2020, 1·1 billion people had distance vision impairment or uncorrected presbyopia. By 2050, this figure is expected to rise to 1·8 billion. Most affected people live in low-income and middle-income countries (LMICs) with avoidable causes of vision impairment. During the life course, most people will experience vision impairment, even if just the need for reading glasses. Because of unmet needs and an ageing global population, eye health is a major public health and sustainable development concern which warrants urgent political action.Eye health is an essential component of universal health coverage; it must be included in planning, resourcing, and delivery of health careUniversal health coverage is not universal without affordable, high quality, equitable eye care. In line with the WHO World report on vision, we urge countries to consider eye care as an essential service within universal health coverage. To deliver comprehensive services including promotion, prevention, treatment, and rehabilitation, eye care needs to be included in national strategic health plans and development policies, health financing structures, and health workforce planning. Coordinated intersectoral action is needed to systematically improve population eye health, also within healthy ageing initiatives, schools, and the workplace. Integration of eye health services with multiple relevant components of health service delivery and at all levels of the health system is of central importance.High quality eye health services are not universally delivered; concerted action is needed to improve quality and outcomes, providing effective, efficient, safe, timely, equitable, and people-centred careUse of effective service coverage indicators for cataract and refractive error highlight the delivery gap between population eye health needs and the delivery of good outcomes. We urge eye health providers to take a holistic view to emphasise quality and design service delivery based on individual and population needs: a people-centred approach. Services need to be characterised by inclusiveness and equity in design and delivery, proactively addressing the needs of marginalised and vulnerable groups through targeted interventions. To encourage improved quality in cataract surgery, we support redefining a good vision outcome threshold as 6/12 or better.Highly cost-effective vision-restoring interventions offer enormous potential to improve the economic outlook of individuals and nations; a major scale up of financial investment in eye health is requiredFor 2020, we estimate that vision impairment resulted in $410·7 billion lost economic productivity; the full cost is most likely higher. Treatments for cataract and refractive error would meet more than 90% of unmet needs and are highly cost-effective. The case for countries to invest in improving population eye health is compelling and more financial resources are urgently required.Financial barriers to accessing eye care leave many people behind; eye health needs to be included in national health financing to pool the riskHealth-care costs prevent many people from accessing essential eye health services. Eye care needs to be integrated into general health system financing to remove cost barriers. To improve access for the whole population and mitigate eye care expenditure, mechanisms that pool risk are highly desirable.Technology and treatment developments offer new tools to improve eye health; thoughtful application is needed to maximise the potential to improve coverage, accessibility, quality, efficiency, and affordabilityTechnological developments such as telemedicine, mHealth, and artificial intelligence offer the potential to revolutionise eye health care in the next decade by delivering affordable, high-quality services to remote areas. However, caution is needed to ensure all populations benefit from these developments.The eye health workforce is unable to meet population needs in many countries; major expansion in service capacity is required through increased numbers, sharing tasks, strengthened training, enabling work environments, and effective leadershipMany areas have major shortages of personnel working in eye health. The available workforce needs to be distributed according to population need. Quality of training for the workforce needs to be updated, with renewed emphasis on competency. Enabling working environments need to be created, including appropriate support, supervision, and equipment. Long-standing issues of low productivity need to be systematically resolved. Mentoring and other programmes to cultivate an emerging generation of eye health leaders are needed.Reliable survey and service data are key to progress in eye health; robust indicator data are needed to shape change and drive actionTo monitor progress in delivering improved eye health within universal health coverage, a balanced set of robust indicators are needed, which we outlined in this Commission. Service data should be available and used by implementers and policy makers to drive change. We highlight the scarcity of epidemiological data in several regions, which should be addressed as a priority.Research has been crucial to advances in understanding and treating eye disease; solution-focused, contextually relevant research is urgently needed to deliver innovative prevention and treatment strategies and inform implementation of eye health within universal health coverageImplementation research is needed, particularly in LMICs, to guide effective delivery of services within universal health coverage. Discovery research is needed for specific areas that remain without efficacious interventions. The economic impact of vision impairment, and the costs and benefits of interventions are only partly understood; a coordinated global effort to systematically collect data is needed. A step-change in the capacity of LMICs to do contextually relevant eye health research and a greater commitment are needed to improve diversity and inclusion in the research community. Eye health is essential to achieve the Sustainable Development Goals; vision needs to be reframed as a development issue There is extensive evidence showing that improving eye health contributes directly and indirectly to achieving many Sustainable Development Goals, including reducing poverty and improving work productivity, general and mental health, and education and equity. Improving eye health is a practical and cost-effective way of unlocking human potential. Eye health needs to be reframed as an enabling, cross-cutting issue within the sustainable development framework. Almost everyone will experience impaired vision or an eye condition during their lifetime and require eye care services; urgent action is necessary to meet the rapidly growing eye health need In 2020, 1·1 billion people had distance vision impairment or uncorrected presbyopia. By 2050, this figure is expected to rise to 1·8 billion. Most affected people live in low-income and middle-income countries (LMICs) with avoidable causes of vision impairment. During the life course, most people will experience vision impairment, even if just the need for reading glasses. Because of unmet needs and an ageing global population, eye health is a major public health and sustainable development concern which warrants urgent political action. Eye health is an essential component of universal health coverage; it must be included in planning, resourcing, and delivery of health care Universal health coverage is not universal without affordable, high quality, equitable eye care. In line with the WHO World report on vision, we urge countries to consider eye care as an essential service within universal health coverage. To deliver comprehensive services including promotion, prevention, treatment, and rehabilitation, eye care needs to be included in national strategic health plans and development policies, health financing structures, and health workforce planning. Coordinated intersectoral action is needed to systematically improve population eye health, also within healthy ageing initiatives, schools, and the workplace. Integration of eye health services with multiple relevant components of health service delivery and at all levels of the health system is of central importance. High quality eye health services are not universally delivered; concerted action is needed to improve quality and outcomes, providing effective, efficient, safe, timely, equitable, and people-centred care Use of effective service coverage indicators for cataract and refractive error highlight the delivery gap between population eye health needs and the delivery of good outcomes. We urge eye health providers to take a holistic view to emphasise quality and design service delivery based on individual and population needs: a people-centred approach. Services need to be characterised by inclusiveness and equity in design and delivery, proactively addressing the needs of marginalised and vulnerable groups through targeted interventions. To encourage improved quality in cataract surgery, we support redefining a good vision outcome threshold as 6/12 or better. Highly cost-effective vision-restoring interventions offer enormous potential to improve the economic outlook of individuals and nations; a major scale up of financial investment in eye health is required For 2020, we estimate that vision impairment resulted in $410·7 billion lost economic productivity; the full cost is most likely higher. Treatments for cataract and refractive error would meet more than 90% of unmet needs and are highly cost-effective. The case for countries to invest in improving population eye health is compelling and more financial resources are urgently required. Financial barriers to accessing eye care leave many people behind; eye health needs to be included in national health financing to pool the risk Health-care costs prevent many people from accessing essential eye health services. Eye care needs to be integrated into general health system financing to remove cost barriers. To improve access for the whole population and mitigate eye care expenditure, mechanisms that pool risk are highly desirable. Technology and treatment developments offer new tools to improve eye health; thoughtful application is needed to maximise the potential to improve coverage, accessibility, quality, efficiency, and affordability Technological developments such as telemedicine, mHealth, and artificial intelligence offer the potential to revolutionise eye health care in the next decade by delivering affordable, high-quality services to remote areas. However, caution is needed to ensure all populations benefit from these developments. The eye health workforce is unable to meet population needs in many countries; major expansion in service capacity is required through increased numbers, sharing tasks, strengthened training, enabling work environments, and effective leadership Many areas have major shortages of personnel working in eye health. The available workforce needs to be distributed according to population need. Quality of training for the workforce needs to be updated, with renewed emphasis on competency. Enabling working environments need to be created, including appropriate support, supervision, and equipment. Long-standing issues of low productivity need to be systematically resolved. Mentoring and other programmes to cultivate an emerging generation of eye health leaders are needed. Reliable survey and service data are key to progress in eye health; robust indicator data are needed to shape change and drive action To monitor progress in delivering improved eye health within universal health coverage, a balanced set of robust indicators are needed, which we outlined in this Commission. Service data should be available and used by implementers and policy makers to drive change. We highlight the scarcity of epidemiological data in several regions, which should be addressed as a priority. Research has been crucial to advances in understanding and treating eye disease; solution-focused, contextually relevant research is urgently needed to deliver innovative prevention and treatment strategies and inform implementation of eye health within universal health coverage Implementation research is needed, particularly in LMICs, to guide effective delivery of services within universal health coverage. Discovery research is needed for specific areas that remain without efficacious interventions. The economic impact of vision impairment, and the costs and benefits of interventions are only partly understood; a coordinated global effort to systematically collect data is needed. A step-change in the capacity of LMICs to do contextually relevant eye health research and a greater commitment are needed to improve diversity and inclusion in the research community. Despite this progress, business as usual will not keep pace with the demographic trends of an ageing global population or address the inequities that persist in each country. New threats to eye health are emerging, including the worldwide increase in diabetic retinopathy, high myopia, retinopathy of prematurity, and chronic eye diseases of ageing such as glaucoma and age-related macular degeneration. With the projected increase in such conditions and their associated vision loss over the coming decades, urgent action is needed to develop innovative treatments and deliver services at a greater scale than previously achieved. Good eye health at the community and national level has been marginalised as a luxury available to only wealthy or urban areas. Eye health needs to be urgently brought into the mainstream of national health and development policy, planning, financing, and action. The challenge is to develop and deliver comprehensive eye health services (promotion, prevention, treatment, rehabilitation) that address the full range of eye conditions within the context of universal health coverage. Accessing services should not bring the risk of falling into poverty and services should be of high quality, as envisaged by the WHO framework for health-care quality: effective, safe, people-centred, timely, equitable, integrated, and efficient. To this framework we add the need for services to be environmentally sustainable. Universal health coverage is not universal without eye care. Multiple obstacles need to be overcome to achieve universal coverage for eye health. Important issues include complex barriers to availability and access to quality services, cost, major shortages and maldistribution of well-trained personnel, and lack of suitable, well maintained equipment and consumables. These issues are particularly widespread in LMICs, but also occur in underserved communities in high-income countries. Strong partnerships need to be formed with natural allies working in areas affected by eye health, such as non-communicable diseases, neglected tropical diseases, healthy ageing, children's services, education, disability, and rehabilitation. The eye health sector has traditionally focused on treatment and rehabilitation, and underused health promotion and prevention strategies to lessen the impact of eye disease and reduce inequality. Solving these problems will depend on solutions established from high quality evidence that can guide more effective implementation at scale. Evidence-based approaches will need to address existing deficiencies in the supply and demand. Strategic investments in discovery research, harnessing new findings from diverse fields, and implementation research to guide effective scale up are needed globally. Encouragingly, developments in telemedicine, mobile health, artificial intelligence, and distance learning could potentially enable eye care professionals to deliver higher quality care that is more plentiful, equitable, and cost-effective. This Commission did a Grand Challenges in Global Eye Health prioritisation exercise to highlight key areas for concerted research and action. This exercise has identified a broad set of challenges spanning the fields of epidemiology, health systems, diagnostics, therapeutics, and implementation. The most compelling of these issues, picked from among 3400 suggestions proposed by 336 people from 118 countries, can help to frame the future research agenda for global eye health. In this Commission, we harness lessons learned from over two decades, present the growing evidence for the life-transforming impact of eye care, and provide a thorough understanding of rapid developments in the field. This report was created through a broad consultation involving experts within and outside the eye care sector to help inform governments and other stakeholders about the path forward for eye health beyond 2020, to further the SDGs (including universal health coverage), and work towards a world without avoidable vision loss. The next few years are a crucial time for the global eye health community and its partners in health care, government, and other sectors to consider the successes and challenges encountered in the past two decades, and at the same time to chart a way forward for the upcoming decades. Moving forward requires building on the strong foundation laid by WHO and partners in VISION 2020 with renewed impetus to ultimately deliver high quality universal eye health care for all. In 2020, an estimated 596 million people worldwide had distance vision impairment and a further 510 million had uncorrected near vision impairment.1GBD 2019 Blindness and Vision Impairment Collaboratorson behalf of the Vision Loss Expert Group of the Global Burden of Disease Study (VLEG–GBD)Trends in prevalence of blindness and distance and near vision impairment over 30 years: an analysis for the Global Burden of Disease Study.Lancet Glob Health. 2021; 9: e130-e143Summary Full Text Full Text PDF PubMed Scopus (18) Google Scholar Most of these people live in low-income and middle-income countries (LMIC). Eye health is also affected by conditions that do not, at least initially, impair vision. Although these conditions are not currently included in global prevalence estimates, they contribute substantially to the unmet need for eye health services. Vision is important for many aspects of life, and vision impairment can profoundly affect individuals, families, and society. Eye health touches all lives, either directly or indirectly, through its impact on those close to us. The year 2020 marks the culmination of the global initiative to eliminate avoidable blindness, VISION 2020: The Right to Sight (appendix 1 p 7). This initiative provided the framework for national programmes to address eye health over the past 20 years. In 2019, WHO published the World report on vision,2WHOWorld report on vision.https://www.who.int/publications/i/item/world-report-on-visionDate: 2019Date accessed: December 17, 2020Google Scholar which was endorsed by the 73rd World Health Assembly in 2020. The report and resolution call for the advancing of eye health as an integral part of universal health coverage, by implementation of integrated people-centred eye care, following the approach outlined in a broader health services framework.3WHOFramework on integrated people-centred health services.https://apps.who.int/gb/ebwha/pdf_files/WHA69/A69_39-en.pdf?ua=1&ua=1Date: 2016Date accessed: December 30, 2020Google Scholar The Lancet Global Health Commission on Global Eye Health contends that eye health should be part of the mainstream agenda to achieve universal health coverage and sustainable development. We define eye health as the state in which vision, ocular health, and functional ability are maximised, thereby contributing to overall health and wellbeing, social inclusion, and quality of life. Eye health can be considered both a process and an outcome. We define eye care services as those that contribute to any of vision, ocular health, or functional ability being maximised. This report broadly divides into two halves. First, we present evidence for the importance of eye health, supporting the case for urgent action. Second, looking beyond 2020, we examine approaches to enable delivery of eye health services within universal health coverage. In section 1 we summarise the visual system, vision impairment, and common conditions. In section 2, we synthesise several reviews done by the Commission on the relevance of eye health to the Sustainable Development Goals (SDGs), as well as its impact on quality of life, general health, and mortality. In section 3, we describe the magnitude and causes of vision impairment in 2020 and projected global and regional trends. We explore service needs of people with non-vision impairing eye conditions. We propose a more standardised approach to reporting population-based eye health surveys and examine the disability weights applied to vision impairment. In section 4, we summarise findings from a systematic review of eye health economics, identifying important areas for future work. We present a new estimate of global lost productivity associated with vision impairment for 2020, and an analysis of the cost-effectiveness ratios for cataract surgery and refractive error services. In section 5, we outline a bibliometric analysis of eye health research since 2000, and report a global Grand Challenges project, highlighting crucial issues for concerted research and action. Lastly, we address the question of how health systems can practically advance towards delivering high quality integrated people-centred eye care within universal health coverage.2WHOWorld report on vision.https://www.who.int/publications/i/item/world-report-on-visionDate: 2019Date accessed: December 17, 2020Google Scholar We argue that business as usual will be insufficient, as evidenced by new analysis of effective cataract surgical coverage data. We examine service delivery components: primary eye care and integration with general health services, workforce strengthening, financing, health information systems, indicators, advocacy, and approaches to increase quality and equity. This Commission views global eye health through the global health framework articulated by Koplan and colleagues.4Koplan JP Bond TC Merson MH et al.Towards a common definition of global health.Lancet. 2009; 373: 1993-1995Summary Full Text Full Text PDF PubMed Scopus (686) Google Scholar Eye health started with an understanding of the anatomy, physiology, diseases of the eye, and the development of clinical ophthalmology, the medical and surgical discipline for diagnosis and treatment of eye diseases. From the mid-20th century onwards (figure 1), there have been major technological advances in microsurgical techniques for cataract and other conditions, and equipment for diagnosis and treatment of major non-communicable eye diseases, resulting in more effective interventions. There has been an enormous demographic transition, with ageing populations and epidemiological changes from infectious diseases and towards non-communicable diseases, requiring accessible and affordable eye services with long-term follow-up. The increase in demand, emphasis on better quality, and higher cost of more sophisticated diagnostic and treatment services is requiring an increase in resources, which presents enormous public health challenges. There are many lessons from the past 70 years that are instructive for the future of global eye health (appendix 1 p 8). First, the importance of advocacy in creating global platforms to address a public health issue. Second, the value of common definitions, high quality data and research to develop global, regional, and national health programmes. Third, the importance of identifying and addressing specific eye diseases of public health importance that can be eliminated through public–private partnerships. Fourth, that the VISION 2020 initiative created an easily understood message for advocacy and planning services, and a global partnership involving different stakeholders in public health, including the private sector and non-governmental organisations, which resulted in extra resources and a common goal and focus. Fifth, that in promoting a global programme, inadequate attention was given to the engagement and partnership with ministries of health to ensure national ownership. There remains a need to integrate eye care planning and resource allocation into national health systems and share the achievements and successes. Sixth, that the transition from elimination of focal eye diseases with regional programmes and international funding to the development of comprehensive services to achieve universal eye health requires engagement, commitment, and leadership by the ministries of health and the willingn