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Community Eye Health
JOURNAL VOLUME 29 | ISSUE 93 | 2016
Everyone matters
EDITORIAL
Inequality and inequity in eye health
Johannes Trimmel
Azahara Sánchez/IAPB
Director: Policy and Advocacy,
International Agency for the Prevention
of Blindness (IAPB), Vienna, Austria.
jtrimmel@iapb.org
According to the 2010 Global Burden of
Disease (GBD) study, the global prevalence
of blindness (age-standardised) has
declined from 0.60% in 1990 to 0.47%
in 2010.1 This seems to indicate that an
increasing number of people have access
to good eye health services.
However, this improvement is not
equally distributed within and across
nations. The GBD study also showed that
60% of blindness worldwide is among
women, underlining that gender equity in
eye health has not yet been achieved.
There are several other studies which
show how inequitable access to eye
health services is worldwide. A recent People living in rural areas or in poverty are often unable to access eye care, even
assessment of avoidable blindness when it is available free of charge. It is important to bring eye care closer to these
and visual impairment in seven Latin communities, for example by offering visual acuity screening in the community. CAMEROON
American countries concluded that the
prevalence of blindness and moderate the high national cataract surgical rate A systematic review of barriers to
visual impairment was concentrated (CSR) of 5,935 cataract operations cataract surgery in Africa4 (which involved
among the most socially disadvantaged, per million population per year. A 2010 reviewing 86 articles, including 12
and that cataract surgical coverage and study in Gujarat, India concluded that, RAAB, 10 quantitative and 5 qualitative
cataract surgery optimal outcome were despite an even higher reported CSR of studies) showed variability in the study
concentrated among the wealthiest.2 10,000, cataract remained the predom- outcomes. In the RAAB studies, barriers
The same study showed that unoperated inant cause of blindness and visual related to awareness and access were
cataract remained the most common impairment and blindness remained a more commonly reported. Other studies
cause of blindness in Argentina, despite significant problem among the elderly.3 reported cost as the most common
barrier. Some qualitative studies
INEQUALITY AND INEQUITY: WHAT ARE WE TALKING ABOUT? tended to report community and family
Elmien Wolvaardt Ellison described as inequities, a word which dynamics as barriers to cataract surgery.
Editor: Community Eye Health
captures the unfairness of the situation. Overall, the systematic review found that
Journal, International Centre for Eye
Health, London, UK. Equal provision of eye health does not the CSR was lower in females in 88.2%
create equity: it is important to ensure of the studies. These major barriers
According to the World Health Organi-
that eye care provision is proportional point to underlying factors of unequal
zation, inequalities in health can exist
to need (see Figure 1 on page 3). For access: illiteracy and low educational
for various reasons, some of which are
example, women are often much more levels, poverty and economic hardship,
biological (e.g. a higher incidence of
likely than men to have age-related no physical access (distance), and the
cataract in people over 60 years of age).
cataract. An equal number of operations socio-cultural situation.
If these inequalities are avoidable,
While, increasingly, data on eye health
however – e.g. if services were made for women and men would therefore be
provision are collected separately by
more affordable – then they are better inequitable, as women’s needs are greater.
Continues overleaf ➤
COMMUNITY EYE HEALTH JOURNAL | VOLUME 29 ISSUE 93 | 2016 1
EDITORIAL Continued
1 Inequality and inequity in eye gender, age and economic situation environment, insecurity and violence,
health (known as ‘disaggregation of data’), social exclusion, lack of participation,
4 Tackling inequalities and inequity there is less information available for disempowerment, a lack of self-esteem,
in eye heath: can the SDGs help ethnic minorities, migrants and people and more.
us? with disabilities. In the United Kingdom, The multidimensional understanding of
5 Overcoming challenges in the people from black and minority ethnic poverty is reflected in the Sustainable
UK’s National Health Service communities are at greater risk of some Development Goals (SDGs, see page 4).
of the leading causes of sight loss, and Adopted by the UN General Assembly in
6 Measuring inequalities in eye care:
adults with learning disabilities are 10 September 2015, they comprehensively
the first step towards change
times more likely to be blind or partially address the economic, social and
8 Putting women’s eyesight first sighted than the general population.5 environmental dimension of sustainable
9 How to ensure equitable access The World Report on Disability6, development. There is a strong focus on
to eye health for children with jointly produced by the World Health tackling the systemic issue of inequity
disabilities Organization (WHO) and the World Bank, and a promise to ‘leave no one behind’.
10 POSTER states that the affordability of health The World Health Organization action plan
Assisting people who are services and transportation are two main called Universal Eye Health: A Global
visually impaired barriers for people with disabilities to Action Plan 2014-20198 has established
12 The importance of assessing access health services. In low-income universal access and equity, human
vision in disabled children – and countries, 36% of non-disabled females rights, and empowerment of people with
how to do it and 40% non-disabled males could visual impairment as core principles.
14 Eye care in rural communities: not afford the visit to the health service
reaching the unreached in provider, compared to 61% (female) and What can we do?
Sunderbans 59% (male) of disabled people. A recent To tackle inequities in eye health, a
15 Improving access to eye care study from Sightsavers on data disaggre- number of measures can be taken. First
for older people: experiences in gation by disability in India and Tanzania7 of all, as eye care providers we should
South Africa showed that, despite the eye health commit to providing eye health services of
programmes being open to all, the level the same quality for everybody,
16 CLINICAL SKILLS
of access of people with disabilities varied irrespective of age, gender, wealth,
Assessing vision in a baby
greatly. ethnicity, place of residence, education or
17 EQUIPMENT AND MAINTENANCE As these examples show, there are disability status. Just as important, as
Understanding and caring for many dimensions to inequity. Inequity can individuals we should treat everyone
the direct ophthalmoscope be understood as a reflection of multidi- equally on a personal level: everybody
18 TRACHOMA UPDATE mensional poverty which, besides income turning up at an eye health clinic or
19 CPD QUIZ poverty, includes poor health, low levels hospital should enjoy the same level of
20 NEWS AND NOTICES of education, lack of water and sanitation, interest, respect and support. As authors
an unhealthy or unsafe residential we recommend awareness training of
Community Eye Health Editor Editorial assistant Anita Shah Address for subscriptions
JOURNAL VOLUME 29 | ISSUE 93 | 2016
Elmien Wolvaardt
editor@cehjournal.org
Design Lance Bellers
Printing Newman Thomson
Anita Shah, International Centre for Eye Health,
London School of Hygiene and Tropical Medicine,
Everyone matters Keppel Street, London
Editorial committee
EDITORIAL
Inequality and inequity in eye health CEHJ online WC1E 7HT, UK.
Allen Foster
Johannes Trimmel
Azahara Sánchez/IAPB
Director: Policy and Advocacy,
Visit the Community Eye Health Journal online.
International Agency for the Prevention
of Blindness (IAPB), Vienna, Austria.
Tel +44 (0)207 958 8336
jtrimmel@iapb.org
According to the 2010 Global Burden of
Clare Gilbert
Disease (GBD) study, the global preva-
All back issues are available as HTML and PDF.
lence of blindness (age-standardised) has
declined from 0.60% in 1990 to 0.47%
Email admin@cehjournal.org
in 2010.1 This seems to indicate that an
increasing number of people have access
Nick Astbury Visit: www.cehjournal.org
to good eye health services.
However, this improvement is not
equally distributed within and across
nations. The GBD study also showed that
60% of blindness worldwide is among
Daksha Patel
women, underlining that gender equity in
eye health has not yet been achieved.
Correspondence articles
There are several other studies which
show how inequitable access to eye
health services is worldwide. A recent People living in rural areas or in poverty are often unable to access eye care, even
Richard Wormald
assessment of avoidable blindness when it is available free of charge. It is important to bring eye care closer to these
Online edition and newsletter
and visual impairment in seven Latin communities, for example by offering visual acuity screening in the community. CAMEROON
We accept submissions of 800 words about
American countries concluded that the
prevalence of blindness and moderate the high national cataract surgical rate A systematic review of barriers to
visual impairment was concentrated (CSR) of 5,935 cataract operations cataract surgery in Africa4 (which involved
among the most socially disadvantaged, per million population per year. A 2010 reviewing 86 articles, including 12
Matthew Burton
and that cataract surgical coverage and study in Gujarat, India concluded that, RAAB, 10 quantitative and 5 qualitative
Sally Parsley: web@cehjournal.org
cataract surgery optimal outcome were despite an even higher reported CSR of studies) showed variability in the study
readers’ experiences. Contact:
concentrated among the wealthiest.2 10,000, cataract remained the predom- outcomes. In the RAAB studies, barriers
The same study showed that unoperated inant cause of blindness and visual related to awareness and access were
cataract remained the most common impairment and blindness remained a more commonly reported. Other studies
Hannah Kuper
cause of blindness in Argentina, despite significant problem among the elderly.3 reported cost as the most common
barrier. Some qualitative studies
INEQUALITY AND INEQUITY: WHAT ARE WE TALKING ABOUT? tended to report community and family
Anita Shah: correspondence@cehjournal.org
Elmien Wolvaardt Ellison described as inequities, a word which dynamics as barriers to cataract surgery.
Editor: Community Eye Health
captures the unfairness of the situation. Overall, the systematic review found that
Journal, International Centre for Eye
Priya Morjaria
the CSR was lower in females in 88.2%
Consulting editor for Issue 93
Health, London, UK. Equal provision of eye health does not
create equity: it is important to ensure of the studies. These major barriers
According to the World Health Organi-
that eye care provision is proportional to point to underlying factors of unequal
zation, inequalities in health can exist
need (see Figure 1 on page 3). For access: illiteracy and low educational
for various reasons, some of which are
example, women are often much more levels, poverty and economic hardship,
biological (e.g. a higher incidence of
no physical access (distance), and the
G V Murthy
cataract in people over 60 years of age). likely than men to have age-related
Sally Crook
cataract. An equal number of operations socio-cultural situation.
If these inequalities are avoidable,
While, increasingly, data on eye health
however – e.g. if services were made for women and men would therefore be
provision are collected separately by
© International Centre for Eye Health, London. Articles
more affordable – then they are better inequitable, as women’s needs are greater.
Continues overleaf ➤
Fatima Kyari
COMMUNITY EYE HEALTH JOURNAL | VOLUME 29 ISSUE 93 | 2016 1
may be photocopied, reproduced or translated provided
“Improving eye health through David Yorston Please support us these are not used for commercial or personal profit.
the delivery of practical Sally Crook We rely on donations/subscriptions from charities Acknowledgements should be made to the author(s) and
high-quality information for Serge Resnikoff and generous individuals to carry out our work. to Community Eye Health Journal. Woodcut-style
the eye care team” Babar Qureshi We need your help. graphics by Victoria Francis and Teresa Dodgson.
Janet Marsden
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2 COMMUNITY EYE HEALTH JOURNAL | VOLUME 29 ISSUE 93 | 2016
means for transport, and other reasons.
Angus Maguire/Interaction Institute for Social Change
Positive and pro-active (affirmative)
action is required to ensure that
upcoming cost-coverage schemes are not
only effective for the educated and
socially included, but also reach out to
the poorest. Affirmative action is not
discriminatory, as the UN Convention on
the Rights of Persons with Disabilities
states in Article 5 (4): ‘Specific measures
which are necessary to accelerate or
achieve de facto equality of persons with
disabilities shall not be considered
discrimination under the terms of the
present convention.’
A popular quote these days is: ‘If you
can’t measure it, you can’t manage it’.
While this rightly can be questioned – as
there are many qualities in life not easily
measurable – evidence also shows that
it is very hard to achieve political support
for addressing inequities in eye health
Figure 1. Providing equal eye care services is not enough – equity is only achieved
unless there is reliable data. Accordingly,
when the eye care services meet the needs of different groups of patients
the SDGs requires that high-quality,
staff members and setting quality identified – ignorance, lack of awareness, timely and reliable data – disaggregated
standards that are monitored regularly. cultural traditions, to name a few – need by income, gender, age, race, ethnicity,
Eye care units can be made more to be effectively addressed at family and migratory status, disability, geographic
accessible for people with disabilities as community level. As these barriers are not location (and other characteristics
outlined in the CBM Guide ‘Inclusion specific to eye health, there needs to be relevant in national contexts) – is made
made easy in eye health programmes’.9 either partnerships with other community- available. This should be standard for the
Eye care providers are also employers based services (primary health care and eye health sector as well.
and can support inclusion and diversity community development in general) or a
by recruiting a wide spectrum of staff policy framework which addresses these Conclusion
members: those with or without disabil- issues effectively. This is particularly relevant Tackling unequal access to eye health
ities, from both genders (and transgender), for eye care providers who implement services and inequity in eye health
all sexual orientations, and all population community outreach activities. requires a people-based view and an
groups. This will not only support In any community initiative, partic- approach that reaches far beyond
communication with patients, but also ipation and empowerment are key. By service provision. Moving outside the
help to increase understanding and specifically addressing people, families eye health sector (or silo) is essential in
awareness among staff members. and groups who are socially excluded in order to reduce inequity in eye health.
local communities we can tackle inequity The current international development
A change in perspective and help to change the behaviour of frameworks (see article on page 4), which
However, offering equal eye health mainstream society. also put a strong emphasis on domestic
services to everyone will not by itself lead resource mobilisation, provide an excellent
to equity in eye health services. Equal A helpful policy framework framework which needs to be used.
services will only be effective at reducing The Sustainable Development Goal on References
inequity if every person in the community health calls for efforts to ensure healthy 1 Bourne R and Ackland P. The Global Burden of Disease
(2010) Study. IAPB Briefing Paper. http://www.iapb.
has the same starting point (Figure 1). lives and wellbeing at all ages. To achieve org/resources/gbd-numbers-and-prevalence
Evidence and life experience show that this, a number of political decisions 2 Silva JC, Mújica OJ et al. A comparative assessment of
this is not the case, and that an equality need to be taken and policy choices avoidable blindness and visual impairment in seven
Latin American countries: prevalence, coverage, and
of service provision alone is insufficient to made. Besides lack of knowledge and inequality. Rev Panam Salud Publica. 2015;37(1).
promote fairness and justice. awareness, cost is the most prominent Available online: http://tinyurl.com/blind-LA
3 Murthy GV, Vashist P et al. Prevalence and causes of visual
What is needed to address inequity factor leading to inequity in eye health. impairment and blindness in older adults in an area of
in eye health effectively is a change of Universal health coverage and social India with a high cataract surgical rate. Ophthalmic
Epidemiol. 2010;17(4):185-95. Available online:
perspective. Rather than putting the insurance (or cost coverage) schemes are http://www.ncbi.nlm.nih.gov/pubmed/20642340
eye care service unit at the centre of currently being put in place in many 4 Aboobaker S, Courtright P. Barriers to cataract surgery
planning and action, it is necessary to countries to help cover the cost of health in Africa: A systematic review. Middle East Afr J
Ophthalmol. 2016;23:145-9. Available online: http://
look at eye health programmes from the care. These must be designed to actively www.meajo.org/text.asp?2016/23/1/145/164615
point of view of the person needing eye and effectively include people from disad- 5 www.rnib.org.uk/knowledge-and-research-hub/
key-information-and-statistics
health services and what they need to vantaged and poor populations. Simply 6 WHO. World report on disability 2011. Available from
enjoy a full and healthy life. The best eye reviewing whether or not these groups are www.who.int/disabilities/world_report/2011/en/
clinic will not deliver what people need equally included is not enough: there is a 7 Sightsavers. Everybody counts: lessons from Sightsavers’
disability data disaggregation project. 2015. Available
when there are barriers that prevent high likelihood that poorer people (under- from http://preview.tinyurl.com/disabilitySS
them from arriving there! stood in terms of multidimensional 8 www.who.int/blindness/actionplan/en/
9 CBM. Inclusion made easy in eye health programmes.
Engagement at the community level is poverty) do not seek the services they Available from www.cbm.org/disability-inclusive-
very much needed. Many of the barriers need due to ignorance, fear, lack of eye-health
© The author/s and Community Eye Health Journal 2016. This is an Open Access COMMUNITY EYE HEALTH JOURNAL | VOLUME 29 ISSUE 93 | 2016 3
article distributed under the Creative Commons Attribution Non-Commercial License.
GLOBAL ACTION
Tackling inequality and inequity in eye
health: can the SDGs help us?
Zoe Gray • Advocating for the inclusion of
Advocacy Manager: eye health services (for example
International Agency for the trichiasis surgery, cataract
Prevention of Blindness
surgery and low vision and
(IAPB), London, UK.
zgray@iapb.org rehabilitation services) within
universal health coverage and
The Sustainable Development social insurance schemes, in a
Goals (SDGs)1 were adopted at way that enables access for the
the United Nations (UN) General poorest and most marginalised.
Assembly in September 2015. • Lobbying to ensure that the
They are a set of goals and targets health workforce indicator is
that all UN member states have taken up at national level and
committed to achieving: ‘to end that there is a specific focus on
poverty, protect the planet, and eye health workers.
ensure prosperity for all’. A major As countries progress on this, there • Lobbying for the inclusion of cataract
emphasis of the SDGs is to ‘leave no one should be opportunities to get eye health surgical coverage (CSC) as a national
behind’; that is, to reach everyone, included within essential packages indicator, which will help prioritise action
including the poor and the marginalised. in social insurance or cost coverage on cataract surgery. CSC is recognised
The health goal (Goal 3: Good health) schemes, which can greatly benefit within the WHO/World Bank universal
is to ensure healthy lives and promote eye health, including helping to reduce eye health monitoring report3 as an
wellbeing for all, at all ages. One of the inequalities by reducing patients’ out-of- important indicator of older people’s
targets within Goal 3 is about universal pocket payments. access to health care, which can help
health coverage (defined as access for all Currently, there is a significant to support arguments for CSC as an
people to health services without suffering political push for countries to mobilise indicator.
financial hardship). There is also consid- their own resources, including financial
erable focus on attending to the needs of resources, in order to meet their popula- The development of plans and
people with disabilities and vulnerable tion’s needs (e.g. health), rather than indicators, and what part of government
groups. Goal 3’s emphasis on tackling relying on international aid. This makes will take the lead, will differ from country
health inequity and promoting access for it critical to get involved with discus- to country. UN country teams, interna-
all people complements the approach of sions about universal health coverage on tional agencies in-country and/or health
the World Health Organization (WHO) national/country level. ministries should be useful points of
action plan called Universal Eye Health: There are other SDG goals and targets, contact to advise about these processes.
A Global Action Plan 2014-2019.2 such as on inclusive education, which Working with other relevant organisa-
may provide scope for advocating at tions, both within and outside eye health,
The importance for eye the national level, such as promoting can be very effective, making it possible
health eye screening in schools as a means to to deliver joint messages and lobby
There are a number of targets and improve access to inclusive education. collectively.
indicators within Goal 3: Good Health
which are very relevant for eye health. Including eye health when Accountability
The inclusion of Neglected Tropical implementing the SDGs Programmes and service delivery must
Diseases (NTDs) in the targets is a major be monitored to ensure that efforts are
UN member countries have all made
achievement: the global indicator is the having the intended impact and reaching
a major commitment to implement
‘number of people requiring interventions those most in need. Monitoring and
the SDGs. They are now starting to
against NTDs’. If this is adequately research is needed to track progress and
develop their own national action plan
addressed in national level indicators, to support calls for new approaches when
or strategy, with national targets and
policies and practices, it can significantly there are challenges or failures.
indicators to measure their progress
support efforts to manage and control It is very likely that some countries
against the SDG goals. National strat-
blinding NTDs such as onchocerciasis and will be selective and prioritise some of
egies and indicators will be particularly
trachoma. These are largely diseases of the SDG goals and targets rather than
important as they will direct funding
poverty and addressing them can help to covering all of them. Advocacy is needed
and government commitment towards
reduce eye health inequalities. to hold governments to account and help
programmes and services.
The indicator for the Goal 3 target on them to achieve the stated ideals and
It is beneficial to get involved in these
health financing and human resources aims of the SDGs.
national processes and ensure that eye
includes a requirement for data collection There is an important role for the eye
health targets and indicators are included
on ophthalmologists at the national level. health community to promote the ideas of
– and that there is adequate action to
This information can help to strengthen ‘leave no-one behind’ and equity, whether
achieve them. Here are a few examples.
advocacy to improving the size and distri- in service delivery or in advocacy.
bution of the eye health workforce – which • Ensuring that the national strategies,
References
is essential to address rural/urban eye implementation and indicators 1 https://sustainabledevelopment.un.org/sdgs
health inequalities. adequately address the NTD indicator 2 www.who.int/blindness/actionplan/en/
3 www.iapb.org/resources/universal-coverage-
The Goal 3 target about universal and target (in countries where blindness gap-action-plan-health-financing-health-systems-
health coverage is very important. caused by NTDs remains a problem). who-documents-othermonitoring report
4 COMMUNITY EYE HEALTH JOURNAL | VOLUME 29 ISSUE 93 | 2016 © The author/s and Community Eye Health Journal 2016. This is an Open Access
article distributed under the Creative Commons Attribution Non-Commercial License.
INEQUALITY IN THE UK
Overcoming challenges in the
UK’s National Health Service
Andy Cassels-Brown Darren Shickle John Buchan We have identified that the number of
andy.cassels-brown people registered as blind in communities
@nhs.net with high levels of deprivation and large
ethnic populations is significantly lower
Leeds Ophthalmic Public Health Team, Academic Unit of Public Health, University of Leeds, UK.
than expected, considering what is known
Working in an eye clinic in Dewsbury, prevalence, late presentation, ethnicity about the incidence of blindness in these
West Yorkshire (with its large South and socio-economic deprivation. These communities. This suggests inequality in
Asian migrant population) in the 1990s, studies were a clear demonstration of the access to the registration system, which
Andy Cassels-Brown noticed the large inequalities present in the UK, despite its in turn excludes people from the state
number of young South Asian patients developed economy and world-renowned support offered to those registered as
who presented with much more advanced National Health Service (NHS), which being visually impaired or blind.
keratoconus than their Caucasian offers universal access to health care. In summary, despite our well-resourced
counterparts, who tended to be detected Along the way, the team has tried National Health Service, there are many
much earlier. This indicated an inequality to honour the well-known adage: examples of inequality in access to
in access to eye care services which, ‘no survey without service’ and has services, and care often depends on where
we discovered, was made worse as the undertaken health promotion campaigns you live (known in the UK as the postcode
Asian patients frequently had preventable for glaucoma, diabetes and smoking lottery). Our biggest challenges now
associated allergic conditions (such as cessation in Leeds, including the use of include increasing detection, prevention
allergic conjunctivitis or eczema) and a community radio and health promotion and curative service capacity to meet
strikingly strong family history of kerato- stands at festivals and carnivals. We the increase in demand for hospital eye
conus.1 Better access to eye care would have also trained link workers in many care in England (due to the ageing of the
permit earlier identification of family locations across the city to talk to population and an increase in treatment
members with the condition and, these community groups, community support options, e.g. for wet ARMD).
days, prevention of progression by means workers, social workers and staff Our response in Leeds, as with much
of cross-linking to stabilise the kerato- members in elderly care homes about the of the rest of the world, is to train our
conic cornea. importance of having regular sight tests. primary care workforce and continue to
After doing a Masters in Community As part of the VISION 2020 Leeds decentralise eye care by dealing with
Eye Health at ICEH London in 2000, programme, we developed consultant-led lower complexity cases in consultant-led,
Andy cycled daily to the eye department multiprofessional Community Eye Centres. multiprofessional community settings,
at St James’s Hospital, through Leeds’ The centres are located in specific rather than in hospital. We are devel-
multi-ethnic suburb of Chapeltown. Andy communities around Leeds. They help oping a multi-disciplinary academy to
started to wonder why there were not to target inequalities by offering eye care train ophthalmic nurses, optometrists,
more African-Caribbean patients with services to people who would otherwise orthoptists, health care assistants and
glaucoma coming to St James’ Hospital, face socio-economic and geographical allied health professionals in line with an
given the higher prevalence and earlier barriers to accessing eye care. emerging ‘competency framework’5 which
onset (but often all-too-late presen- The Leeds Ophthalmic Public Health is currently being developed in the UK.
tation) in this population group. Research Team have continued to research and And finally, before it is too late, we are also
confirmed2 that there were no optometry pilot innovative ways to deliver primary starting to develop strategies to be resilient
practices in this socio-economically eye care in areas of deprivation, including against the impact of environmental
deprived community, and that people the provision of free sight tests and free change and to reduce health care’s
found it difficult and expensive to come prescription spectacles in the community. damaging environmental footprint.
into the city centre for eye tests
Further reading
and to pay for prescription
Leeds Public Health Team
1 Georgiou T, Funnell CL, Cassels-Brown A,
spectacles. O’Conor R. Influence of ethnic origin on the
incidence of keratoconus and associated
The Leeds Ophthalmic Public atopic disease in Asian and white patients.
Health Team (which includes Eye 2004;18(4):379-83.
Darren Shickle, John Buchan 2 Awobem JF, Cassels-Brown A, et al.
Exploring glaucoma awareness and the utili-
and other colleagues) is part of zation of primary eye care services: community
the UK’s National Health Service perceived barriers among elderly African
Caribbeans in Chapeltown, Leeds. Eye.
and is based at the University of 2009;23(1):243.
Leeds. The team undertook a 3 Day F, Buchan J, Cassels-Brown A et al, A
Glaucoma Health Equity Profile Glaucoma Equity Profile: Correlating Disease
Distribution With Service Provision And
needs assessment across Uptake in a Population In Northern England.
the whole city of Leeds, which Eye 2010;9:1478-85.
4 Kliner M, Fell G, et al. Diabetic retinopathy
confirmed that late presentation equity profile in a multi-ethnic, deprived
was highly linked with socio- population in Northern England. Eye
2012;26(5):671-7.
economic deprivation.3 A VISION 5 Competency Framework for expanded
2020 Equity Profile conducted ophthalmic roles for Ophthalmic Nurses,
across Leeds and Bradford4 also The Leeds Ophthalmic Public Health Team and students Optometrists, Orthoptists and Ophthalmic
Clinical Scientists. https://www.rcophth.
confirmed the links between high promoted eye health at Leeds Carnival. UK ac.uk/2016/01/competency-framework/
© The author/s and Community Eye Health Journal 2016. This is an Open Access COMMUNITY EYE HEALTH JOURNAL | VOLUME 29 ISSUE 93 | 2016 5
article distributed under the Creative Commons Attribution Non-Commercial License.
QUANTIFYING INEQUALITY
Measuring inequality in eye care:
the first step towards change
Jacqui Ramke Equality vs equity
University of New South Wales, School
of Social Sciences, Sydney, New South
We must remember that equal rates of
Wales, Australia. treatment between subgroups (such as
surgery) will not necessarily mean we are
‘Health inequalities’ are differences in delivering equitable services. For
health between different subgroups of a example, the Nigerian National
population1, for example women/men, Blindness and Visual Impairment Survey
Lance Bellers/ICEH
people with/without disabilities, and showed that, although women had
urban/rural dwellers. received almost half of all cataract
Many of us have insufficient information surgery (47%), they still suffered from
to understand the nature and extent of the two-thirds of the bilateral cataract
inequalities that exist, and whether our Gathering appropriate information helps blindness (67%)4 in the country. This
services are effective. This lack of information us to understand inequality. TANZANIA means that Nigerian women must receive
restricts our ability to plan appropriate much more than 50% of all the
strategies to reduce inequality, and to track The acronym ‘PROGRESS’ can help us operations in order to reduce this inequity.
our progress towards equitable eye health. to think about which subgroups to
Fortunately, we can obtain this infor- monitor, as it sets out a range of social
mation by monitoring health inequality. factors that are often associated with How do we monitor
Monitoring is a process that helps to health inequality (Figure 1.)2 Some of inequality?
determine whether policies and practices these have obvious subgroup categories We can incorporate inequality monitoring
are working, and whether change is (e.g. age, gender, disability), but others into our hospital or clinic’s existing
needed. There are two main sources of require us to adopt clear and consistent system, whether electronic or manual.
data we can use to monitor inequality – definitions, e.g. socioeconomic status, The monitoring cycle is shown in
population-based surveys, and education level, area of residence (rural Figure 2.
information collected from our clinics. vs urban) or occupation category. We have already selected the relevant
Ideally, we would use information from health and social indicators and chosen
Figure 1. PROGRESS: social factors
both of these data sources. However, few the subgroups we want to monitor. The
associated with health inequality2
of us have the time and money to next step is to collect the data. If we want
implement population-based surveys, so P Place of residence to know if there is inequality in who
this article will focus on monitoring R Race, ethnicity, culture and language receives cataract surgery, for example, we
inequality using clinic-based data. For can begin to record, on a regular basis
O Occupation
example, you may have noticed that, (e.g. monthly), the number of people in
compared to the community served by G Gender and sex each of our selected subgroups who are
your hospital, most of the people under- R Religion receiving surgery.
going cataract surgery are from the E Education
Figure 2: Cycle of health monitoring
families of government employees (and S Socioeconomic status
very few are farmers) or from a ‘wealthy’ S Social capital Select relevant
area in town (and very few from poorer Plus Age, other disability, migratory status health and social
areas, or rural areas), or from the most indicators
powerful ethnic, religious, or language
group (and very few from minority What should we monitor?
groups). Or perhaps you have noticed that Once we have identified the subgroups,
very few of your surgical patients are we can use any of our routinely collected Implement
elderly widows. Collecting clinic-based health indicator(s) to investigate Collect data
changes
information is a way to confirm or uncover inequalities between the subgroups.
these sorts of inequalities. These indicators include:
• The prevalence of conditions (e.g. blind-
Who should we monitor? ness, visual impairment, trachomatous
To reduce inequality, we must identify trichiasis, diabetic retinopathy)
which subgroup(s) of the population Report Analyse
• Quality of care (e.g. visual outcome
(e.g. farmers, people from poorer or results data
after cataract surgery).
urban areas, or minority groups) are less • Access to services by different groups;
able to get access to, and benefit from, e.g. cataract surgical coverage, cataract
Adapted from Figure 1.1 of WHO’s Health Inequality
our services. Some of us work in settings surgical rate, refractive error correction Monitoring Handbook3
where the Ministry of Health and/or coverage, attendance at diabetic
hospital has already identified priority retinopathy screening, ability to pay Once we have collected the data, we
subgroups to monitor, so advice and • Eye care service factors; e.g. the can calculate, and then compare, the
resources may be available locally. For distribution of eye care facilities and the proportion of cataract surgery delivered
others, we will need to decide which eye health workforce, and the availability to each subgroup (e.g. by dividing the
subgroups are most relevant to monitor in of subsidised services or financial number of women by the total number
our particular setting. protection for vulnerable subgroups. of operations). These figures are often
6 COMMUNITY EYE HEALTH JOURNAL | VOLUME 29 ISSUE 93 | 2016
presented as percentages (the proportion feasible and sustainable in your setting. ultimately achieve universal eye health.
multiplied by 100). Another simple way to It is better to begin with a small number For more information on monitoring
quantify inequality is to calculate the gap of indicators (such as uptake of cataract inequality, see WHO’s Health Inequality
between the subgroups (e.g. subtract surgery by gender and urban/rural Monitoring Handbook: http://www.who.
the number of women from the number residence) and collect and analyse int/gho/health_equity/handbook/en/
of men to see how many more men have these accurately and consistently, rather References
received surgery). than introducing many measurements 1 Hosseinpoor AR, Bergen N, Koller T, et al. Equity-
oriented monitoring in the context of universal health
This can be done on a monthly, that take a lot of time and effort; which coverage. PLoS Med 2014;11:e1001727.
quarterly and annual basis, and means it will become unsustainable. 2 O’Neill J, Tabish H, Welch V, et al. Applying an equity
inequality calculations can be reported You can expand your monitoring system lens to interventions: using PROGRESS ensures
consideration of socially stratifying factors to illuminate
alongside the total number of operations with more indicators once it is running inequities in health. J Clin Epidemiol 2014;67:56-64.
in each subgroup in well-designed tables, smoothly. 3 World Health Organization. Handbook on health
inequality monitoring with a special focus on low-and
graphs and maps. The information can Monitoring is essential if we are to middle-income countries. Geneva: World Health
then be communicated to hospital understand the nature and extent of Organization, 2013.
4 Abubakar T, Gudlavalleti MV, Sivasubramaniam S,
administrators and health managers. A inequality in the populations we serve. Gilbert CE, Abdull MM, Imam AU. Coverage of hospital-
worked example is provided below. The information must then be used to based cataract surgery and barriers to the uptake of
surgery among cataract blind persons in Nigeria: The
When expanding your monitoring inform policies, programmes and Nigeria National Blindness and Visual Impairment
process, try to be realistic about what is practices to reduce inequities and Survey. Ophthalmic Epidemiol 2012;19:58-66.
Worked example
Imagine your eye clinic is in an urban centre (population In a report, you would normally include Table 1 (which shows the
150,000) that also serves the surrounding rural district number of operations in each subgroup) and compare the
(population 350,000). You conduct intermittent outreach percentages in each subgroup). In addition, you can use the
services, and would like to conduct more as you think few rural information about the relative ratio to point out that there were
dwellers are coming to your eye clinic. 1.3 times more male than female patients, and 5.3 times more
You begin to monitor who is presenting for cataract surgery. urban than rural patients.
In the first quarter you conduct no outreach trips and your
monitoring data for January to March is shown in Table 1. This information alerts you that rural dwellers, and rural women
in particular (of whom there were only 4), are not accessing your
Table 1. Tally of cataract operations by gender and area of residence services as much as their urban counterparts.
Number of operations You then decide to do more outreach and deliver two outreach
activities in the next quarter. The monitoring data for April to
Women Men Total June is given in Table 3.
Rural 4 31 35 Table 3. Tally of cataract operations after outreach
Urban 91 94 185 Women Men Total
Total 95 125 220
Rural 35 41 76
You can work out and compare what percentage of the total 62 59 121
Urban
number of operations were performed on patients belonging to
each subgroup, e.g.: Total 97 100 197
• 57% of patients (125 ÷ 220 x 100) were men
• 43% of patients (95 ÷ 220 x 100) were women
• 84% of patients (195 ÷ 220 x 100) were urban Table 2. Measures of inequality after outreach
• 16% of patients (35 ÷ 220 x 100) were rural
Absolute gap Relative gap
You can further demonstrate the inequality between women and Difference Ratio
men, and between rural and urban dwellers, by calculating the
absolute gap (subtract the smaller number from the larger number) Gender Men – Women Men ÷ Women
and the relative gap (divide the larger number by the smaller number). 100 – 97=3 100 ÷ 97=1.0
Table 2. Measures of inequality: absolute gap and relative gap
Place of Urban – Rural Urban ÷ Rural
Absolute gap Relative gap residence 121 – 76=45 121 ÷ 76=1.6
Difference Ratio
You might conclude from this that providing outreach services
Gender Men – Women Men ÷ Women has been effective in reducing both gender and place of
125 – 95=30 125 ÷ 95=1.3 residence inequalities. You could use this information to
Place of Urban – Rural Urban ÷ Rural advocate for regular outreach activities and continue to monitor
residence 185 – 35=150 185 ÷ 35=5.3 your services each quarter to identify further changes that are
needed.
© The author/s and Community Eye Health Journal 2016. This is an Open Access COMMUNITY EYE HEALTH JOURNAL | VOLUME 29 ISSUE 93 | 2016 7
article distributed under the Creative Commons Attribution Non-Commercial License.
GENDER
Putting women’s eyesight first
Damian Facciolo sufficient. Some organisa-
Mark Maina/Fred Hollows Foundation
Regional Programme tions already disaggregate
Manager (Western Pacific):
data by gender for analysis,
International Agency for the
Prevention of Blindness, but it is important that all eye
Singapore. care organisations should do
so. Data should be carefully
Camille Neyhouser
Learning and Best Practice
analysed and compared to
Coordinator & Gender the demographics of the
Strategy Coordinator: community. Are there gender
The Fred Hollows Foundation, differences in the number
Sydney, Australia. of patients? Why do they
Two-thirds of blindness and exist? Do the numbers vary
visual impairment occurs in on certain days or in different
women , and recent prevalence
1 locations? How does the
surveys in Vietnam and China gender balance of staff
show an imbalance in the members affect the balance of
A woman waits to have her patch removed after surgery. KENYA
coverage of services across patients? Increasingly, donors
expect this data and expect to see
some areas. We know that, compared to How can we improve?
men, women account for the greater gender issues addressed.4
Although many barriers exist for both men
burden of blindness from cataract.2 4 Create opportunities for women
and women, gender inequalities makes
Women and girls face numerous barriers across the eye health workforce,
access harder for women. In November
in accessing eye care services and are and support them. Although this
2015, a regional forum (meeting) was
less likely to utilise them. varies according to cultural contexts
held in Cambodia to focus on improving
Understanding gender dimensions is and regions, the gender of eye health
eye health for women and girls.
an important aspect of public health and workers can affect access to services
Knowledge from the forum and from other
development. In 2009, Gender was the by female patients. Female eye health
effective models will be used to produce a
theme for World Sight Day and the focus professionals need to be supported
guide for good practice. The forum
and mentored. Women often have to
of articles in this Journal.3 The World highlighted five practical ways to improve
work extra hard to negotiate for
Health Organization action plan called services for women and girls.
resources to do their clinical work and
Universal Eye Health: A Global Action Plan
1 Ensure services are community- must balance family pressures. They
2014-2019’ prioritises equity and it is
based. Screening and appropriate also face a greater risk of overt and
clear that we need to do more to improve
treatment should be provided close to subtle discrimination and violence in
services for women and girls.
home or in the workplace. Outreach the workplace. Managers of
services should be tailored to the programmes, services, clinics and
What are the barriers for specific needs of women and girls and hospitals need to be attentive and
women and girls? be organised at a time and location responsive to ensure female workers
Often, the barriers faced by women are suitable to maximise their participation. are employed, retained and promoted.
not fully understood by health care Schools and market places are two 5 Reach higher. Our approach should
providers. Greater understanding can be possibilities, but the best ideas and be based on equity, not just equality.
achieved through regular data collection advice will come from women In many contexts, it is not enough for
(separately for men and women), themselves – therefore encourage service data to report an equal 50/50
knowledge, attitudes and practice (KAP) female community representatives to split between men and women.
surveys, satisfaction surveys and gender work with you in programme design. Blindness prevalence is generally
analyses. Consultation with both women 2 Tap into the expertise of others. higher for women because they have a
and men helps to ensure that services are Partnerships with women’s organisa- longer life expectancy and are more
delivered in a way that is gender-sensitive tions, the women’s agency or ministry likely to experience non-communicable
and relevant to that community. in the government, maternal and child diseases such as cataract and commu-
Lack of access to household resources health services, gender-focused NGOs nicable diseases such as trachoma.
and opportunity costs (e.g. loss of income and microfinance networks can Some organisations set firm targets
due to the time taken to attend appoint- strengthen and more effectively target that encourage services to reach a
ments) prevent women from accessing programmes for women and girls. In higher number of women than men.
eye care services. As women are often Cambodia, the Fred Hollows References
less educated than men and are less Foundation is working with the Ministry 1 Clayton JA, Davis AF. Sex/Gender Disparities and
Women’s Eye Health Current Eye Research 2015
likely to access information outside the of Women’s Affairs to deliver a project 40(2): 102-109
home due to their caretaking role, they to remove the barriers faced by 2 Grey Z and Ackland P. IAPB Cataract Surgical
are also less aware of eye health treat- women. Coverage. Finding 3. Page 11. August 2015
http://tinyurl.com/IAPB-catarac
ments and services. Women have reduced 3 Disaggregate and analyse data. 3 Courtright P, Lewallen S. Why are we addressing
power to make decisions in the household Disaggregating (or splitting) clinical gender issues in vision loss? Comm Eye Health J
2009 22:17
and sometimes de-prioritise their own data by gender and age is critical 4 Crook S. A View from SiB – Gender. 2015.
health in favour of others in the family. – just collecting the figures is not www.iapb.org/view-sib-gender
8 COMMUNITY EYE HEALTH JOURNAL | VOLUME 29 ISSUE 93 | 2016 © The author/s and Community Eye Health Journal 2016. This is an Open Access
article distributed under the Creative Commons Attribution Non-Commercial License.
CHILDREN WITH DISABILITIES
How to ensure equitable access to
eye health for children with disabilities
Hannah Kuper understand the different difficulties However, many children with disabil-
Co-director: International Centre for Evidence they face in accessing services in your ities are not enrolled in school, and so
in Disability, London School of Hygiene setting. Children with disabilities are will miss out. Linkages can be made with
and Tropical Medicine, London, UK
not all the same. For example, children local community health workers and also
All children need access to good quality who are deaf or hard of hearing will with rehabilitation programmes so that
eye care, and this must include children face different difficulties in accessing children with disabilities who don’t go to
with disabilities. eye services compared to children with school can still be included.
Childhood disability is very common. physical impairments or those with intel- Staff must be trained in disability
The World Health Organization (WHO) lectual impairments. It is therefore awareness to make sure that they interact
estimates that there are at least 93 very important to work with people with well with children with disabilities and
million children with disabilities worldwide, disabilities and their families in the their families. This can include raising
which equates to one in twenty children.1 community to find solutions together. As awareness about the rights of children
Childhood disability is particularly common the disability movement says: ‘Nothing with disabilities to have access to eye
in low- and middle-income countries. about us without us.’ In order to do this,services, challenging negative attitudes,
Children with disabilities may have it is useful to link with a local disabledand offering practical training on commu-
a particularly high need for eye health persons organisation or other people with nication with children with disabilities.
services. This is because eye problems experience of living with disability. Eye health workers can also receive
are a common cause of disability in This consultation process will identify
the encouragement that the care they
children, and children with disabilities are specific things which can be strengthened provide may change the whole life of
particularly vulnerable to eye problems. in your setting, from which a disability those children, resulting in their inclusion
For instance, one in three children plan of action can be made.2 in education, livelihoods and social
with cerebral palsy experiences visual Clinics must be made physically acces-
opportunities. Local Disabled People’s
impairment. sible for children with disabilities. The Organisations may be able to deliver, or
Eye health services will exclude many child should be able to enter the buildingparticipate in, the training.
children if they are not accessible to and access the clinics, toilets and Systems can be strengthened to help
children with disabilities or if they are washing facilities. It is also important that
overcome cost barriers for children with
not proactive about ensuring inclusion. equipment can be used to examine and disabilities, as for other marginalised
Eyesight is very important for all children, treat children with disabilities, so that they
patients. For instance, transport services
even more so when children have other can receive the same quality of treatment may be set up or subsidised to help
impairments, such as those who are deaf as everyone else. Ideally, physical acces-children with disabilities.
or hard of hearing. sibility should be considered when the Formulating a plan is the first step,
Even though children with disabil- clinic is being built, but there is much that
but it must be carried out. It can be
ities have a greater need for eye health, can be done to improve existing facilities.
useful to establish a disability committee
they may not have equal access to these Outreach eye care services for or focal person to oversee the imple-
services, because they face a number of children are often conducted in schools. mentation of the plan and to develop
barriers, including: a specific disability policy. It is
• Financial barriers, e.g. paying for important to designate a budget
CBM
travel or services, since children line for disability inclusion to cover
with disabilities are more likely to the costs. The plan and policy may
come from poor households. 1 evolve over time, so the programme
• Physical barriers that limit must be reviewed regularly to
access to buildings or transport make sure it is constantly being
• Attitudinal barriers, e.g. when strengthened.
children with disabilities are seen VISION 2020: The Right to Sight
as less worthy of attention by their aims for all services to be equitable,
own families or health workers. and so must include children
• Communication, e.g. for with disabilities. Furthermore, if
children who are deaf or hard of children with disabilities do not
hearing or who have intellectual have equal access to eye health
impairments/learning difficulties. then this violates their right to
health care, and may also deprive
Eye health services therefore need Amina is profoundly deaf and then found her eyesight them of life-long opportunities. It is
to be strengthened to ensure that was deteriorating; this made communication difficult the responsibility of all eye health
children with disabilities have equal as she had relied on her sight for lip reading. Following workers to make sure that children
access, and this must cover all the an eye examination, Amina had surgery for congenital with disabilities are fully included in
different activities (e.g. screening, cataracts and received spectacles. She is also their services.
outreach, outpatient, counselling, receiving rehabilitation to assist her with both her References
medical and surgical treatment, and deafness and remaining vision impairment. These 1 World Health Organisation (2011) World Report
referral to other services). intervention activities will greatly improve Amina's on Disability. Geneva: World Health Organization.
The first step in ensuring that ongoing opportunities in social inclusion, education
2 CBM. Inclusion made easy in Eye Health
Programmes. http://www.cbm.org/article/
children with disabilities have and the chance of decent work as an adult. downloads/54741/Inclusion_in_Eye_
equal access to eye health is to Health_Guide.pdf
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