The Lancet Global Health Commission on Global Eye Health: vision beyond 2020
Authors: Matthew J Burton, Jacqueline Ramke, Ana Patricia Marques, Rupert R A Bourne, Nathan Congdon, Iain Jones, Brandon A M Ah Tong, Simon Arunga, Damodar Bachani, Covadonga Bascaran, Andrew Bastawrous, Karl Blanchet, Tasanee Braithwaite, John C Buchan, John Cairns, Anasaini Cama, Margarida Chagunda, Chimgee Chuluunkhuu, Andrew Cooper, Jessica Crofts-Lawrence, William H Dean, Alastair K Denniston, Joshua R Ehrlich, Paul M Emerson, Jennifer R Evans, Kevin D Frick, David S Friedman, João M Furtado, Michael M Gichangi, Stephen Gichuhi, Suzanne S Gilbert, Reeta Gurung, Esmael Habtamu, Peter Holland, Jost B Jonas, Pearse A Keane, Lisa Keay, Rohit C Khanna, Peng Tee Khaw, Hannah Kuper, Fatima Kyari, Van C Lansingh, Islay Mactaggart, Milka M Mafwiri, Wanjiku Mathenge, Ian McCormick, Priya Morjaria, Lizette Mowatt, Debbie Muirhead, Gudlavalleti V S Murthy, Nyawira Mwangi, Daksha B Patel, Tunde Peto, Babar M Qureshi, Solange R Salomão, Virginia Sarah, Bernadetha R Shilio, Anthony W Solomon, Bonnielin K Swenor, Hugh R Taylor, Ningli Wang, Aubrey Webson, Sheila K West, Tien Yin Wong, Richard Wormald, Sumrana Yasmin, Mayinuer Yusufu, Juan Carlos Silva, Serge Resnikoff, Thulasiraj Ravilla, Clare E Gilbert, Allen Foster, Hannah B Faal
Journal: The Lancet Global Health (2021)

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.