EDITORIAL

Integrated, people-centred eye care: Why South Africa needs to prioritise scaling up refractive services

Vision is our most dominant sense and plays a critical role in every facet of our lives.^[1] People often take vision for granted, yet without it one would struggle to learn to walk, read, participate in school activities or perform certain kinds of work.^[1] The Lancet Global Health Commission on Global Eye Health^[2] defines eye health as maximised vision, ocular health, and functional ability that contributes to overall health and wellbeing, social inclusion and quality of life. Refractive services are focused on maximising vision, and are known to improve quality of life.^[1] However, these services have been a neglected component of South Africa (SA)'s healthcare delivery system. Millions of South Africans affected by refractive error cannot even access a basic pair of spectacles required to see clearly. The reality is that refractive error is a major, yet unnecessary, cause of visual impairment globally, and if adequately addressed, more than half the world's visually impaired people could achieve good vision and improved quality of life.^[2] While this may sound simplistic, refractive error remains a major public eye health challenge for many countries in the developing world, including SA.^[3]

Historically, refractive care has been a private sector-dominated service in SA. More than 80% of the population is dependent on public health services, yet only a small percentage of optometrists practise in the public health sector, mainly owing to lack of available posts in most provinces.^[4] As a consequence, there is insufficient coverage of refractive services nationally, leaving most medically uninsured citizens without access to the basic refractive services required to correct their vision and improve their quality of life. This lack of access to refractive services imposes an unnecessary burden of visual impairment on the country, which in some cases could even lead to preventable blindness. According to the Lancet Global Health Commission on Global Eye Health,^[2] a lack of access to refractive services directly impacts on the ability of affected people to improve their social and economic status by restricting achievement in education and the workplace.

The World Health Organization (WHO) proposes integrated people-centred eye care (IPCEC) as an approach to strengthening health systems towards improved delivery of eye health services.^[1] In essence, to achieve national eye health goals it is necessary to ensure that promotive, preventive, treatment and rehabilitation interventions are available across a spectrum of eye conditions, within and beyond the health sector, according to people's needs throughout their life course. Ensuring that citizens' vision is adequately corrected is imperative for SA, which seeks to reduce barriers to employment and promote socioeconomic inclusion. Central to this, however, is the need to address the unequal distribution of refractive services in the country.

Refractive error can be managed easily by medical devices such as spectacles, contact lenses and low-vision aids. Accelerating progress towards achieving the goals of IPCEC can be achieved by making refractive care services more available, accessible and affordable to all people in SA. The WHO recently revised its global targets for refractive service coverage, proposing a further 40% increase in effective coverage for refractive care at national level.^[5] With this in mind, SA needs to urgently identify strategies to increase refractive service coverage. The current pace of roll-out is simply not enough to ensure equitable access to refractive care for all citizens, meaning that SA will continue to fall short of global health and development targets if refractive services are not adequately and sustainably addressed within its health system. Furthermore, myopia is on the rise globally, with projections indicating that by 2050, almost half of the world's population will be short-sighted,^[6] implying an even greater demand for refractive care as the myopia burden increases and placing further pressure on the country to immediately scale up its refractive care services.

The WHO envisages that IPCEC can help address significant eye care challenges that countries face by creating an enabling environment, specifically the inclusion of eye care in national health strategic plans, the integration of relevant eye care data in health information systems, and the planning of the eye care workforce according to population needs.^[1] Despite free eye tests having become increasingly available in public health facilities over the past few years, corrective optical devices have remained a cost imposed on many of these patients, a legacy of the privatisation of vision care as a pay-for-service component at the point of care. In a country with high unemployment rates and escalating levels of poverty, providing comprehensive eye health services (which includes vision correction) should not place a financial burden on individuals and households. Having a visual assessment with the aim of improving patients' vision is futile if they are unable to afford to purchase the spectacles. It is akin to patients with hypertension being diagnosed at public health facilities but having to purchase their treatment or medication out of pocket. Yet vision, which enhances the life that the hypertensive patient is treated for, is overlooked. The antihypertensive medication is rightfully life-saving, but the corrected vision can be life-enhancing. An important component of improving the eye health of the population is therefore removing cost as a barrier to achieving optimal visual health. The legacy of an apartheid healthcare service favouring the privileged, and using cost as a barrier to accessing basic healthcare, needs to be redressed.

While SA's National Health Insurance is in principle an effort to move towards making health services more available to a broader spectrum of the population, the fact is that its implementation seems a lot further off in reality than is planned by government. There are many economic and structural reasons for this. As such, without a concrete funding structure for IPCEC services, SA will fall short of addressing the burden of demand for refractive care services that continues to plague the country. As a member of the WHO, SA has an obligation to take the necessary steps towards realising the WHO's IPCEC goals. Efforts towards improving the coverage of refractive care nationally, and removing cost barriers to providing corrective devices to patients, must therefore be scaled up. Identifying practical strategies for providing sight-restoring spectacles in order to immediately address the simplest, most preventable cause of vision impairment, namely uncorrected refractive error, may be a good place to start.

Author contributions. DvS and AM equally participated in the conceptualisation, drafting and editing of the manuscript.

Diane van Staden, Alvin Munsamy

Discipline of Optometry, School of Health Sciences, University of KwaZulu-Natal, Durban, South Africa wallaced@ukzn.ac.za

References

1. World Health Organization. World report on vision. Geneva: WHO, 2019. https://www.who.int/docs/default-source/documents/publications/world-vision-report-accessible.pdf?sfvrsn=223f9bf7_2 (accessed 24 June 2021).         [ Links ]

2. Burton MJ, Ramke J, Marques AP, et al. The Lancet Global Health Commission on Global Eye Health: Vision beyond 2020. Lancet Glob Health 2021;9(4):e489-e551. https://doi.org/10.1016/S2214-109X(20)30488-5        [ Links ]

3. Tagoh S, Kyei S, Kwarteng MA, Aboagye E. Prevalence of refractive error and visual impairment among rural dwellers in Mashonaland Central Province, Zimbabwe. J Curr Ophthalmol 2020;32(4):402-407. https://doi.org/10.4103/JOCO.JOCO_224_20        [ Links ]

4. Maake ME, Moodley VR. An evaluation of the public sector optometric service provided within the health districts in KwaZulu-Natal, South Africa. Afr Vision Eye Health 2018;77(1):a407. https://doi.org/10.4102/aveh.v77i1.407        [ Links ]

5. World Health Organization. Global eye care targets endorsed by Member States at the 74th World Health Assembly. 27 May 2021. https://www.who.int/news/item/27-05-2021-global-eye-care-targets-endorsed-by-member-states-at-the-74th-world-health-assembly (accessed 10 June 2021).         [ Links ]

6. Sankaridurg P, Tahhan N, Kandel H, et al. IMI impact of myopia. Investig Ophthalmol Vis Sci 2021;62(5). https://doi.org/10.1167/iovs.62.5.2        [ Links ]