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Everyone matters Inequality and inequity in eye health - Community Eye Health Journal
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
Everyone matters Inequality and inequity in eye health - Community Eye Health Journal
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

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2                                                     COMMUNITY EYE HEALTH JOURNAL | VOLUME 29 ISSUE 93 | 2016
Everyone matters Inequality and inequity in eye health - Community Eye Health Journal
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.
Everyone matters Inequality and inequity in eye health - Community Eye Health Journal
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.
Everyone matters Inequality and inequity in eye health - Community Eye Health Journal
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.
Everyone matters Inequality and inequity in eye health - Community Eye Health Journal
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
Everyone matters Inequality and inequity in eye health - Community Eye Health Journal
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.
Everyone matters Inequality and inequity in eye health - Community Eye Health Journal
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.
Everyone matters Inequality and inequity in eye health - Community Eye Health Journal
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

© The author/s and Community Eye Health Journal 2016. This is an Open Access              COMMUNITY EYE HEALTH JOURNAL | VOLUME 29 ISSUE 93 | 2016 9
article distributed under the Creative Commons Attribution Non-Commercial License.
Everyone matters Inequality and inequity in eye health - Community Eye Health Journal
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