Are You a Policy Maker? (Yes)

As its central objective, The World Health Organization (WHO) has a commitment to “the attainment by all people of the highest possible level of health” (1). To deliver this objective, the WHO develops and engages in the partnerships necessary for action. We recently had the privilege of being part of the multinational Expert Development Group that shaped the recommendations relating to children and paediatric eye disorders within the WHO’s recently published Package of Eye Care Interventions (PECI). This landmark publication comprises a “set of evidenced-based eye care interventions across the continuum of care and the material resources required for implementation. The PECI serves to facilitate policy-makers and technical decision-makers in low- and middle-income countries to integrate eye care into the packages and policies of their health services. Service providers can use the PECI to plan and implement eye care interventions in their service programmes; and the donor and development agencies can use it as a blueprint for eye care programmes.” (2)

Though this guidance is targeted at low- and middle-income countries, the approach used to develop it and much of the evidence base for the recommendations either derives from, or applies to, high-income countries. This principle of using the best evidence to inform practice and policy decisions is universal. And our experience of being involved in the development of the PECI certainly reminded us that we are, in the end, all one world – it’s just a question of where you choose to set your professional horizon.

Our work on the PECI also reminded us that, despite its value, contributing to eye health strategy isn’t part of the “day job” for most ophthalmologists. We are instead trained to provide service delivery, focusing on the patient in front of us and the decisions we need to make about their care. Few of us receive training in (or gain experience of) the wider role that all ophthalmologists could – and we argue, should – have in shaping the policies and services that affect the care of the population of patients we serve collectively.

Conventionally, decisions about individual patients are generally thought of as being “bespoke” – for example, we assess the risks and benefits of a particular drug or surgical procedure in the context of the individual’s other health issues.  By contrast, decisions about policy or services are about populations, considering the “average” patient in the context of the society in which they live, which requires different and additional sources of evidence to balance wider risks and benefits at both a societal and individual level.

But health care resources – be they financial, technical, manpower, facilities – are always finite, even in the highest income countries. As clinicians, when we offer a resource to one patient, we are affecting that resource’s availability for someone else. We just don’t usually see this system of ranking until we are forced to prioritise explicitly. For example, when we decide which patient moves up a waiting list for a non-urgent procedure, we are making a policy decision as much as a clinical decision. And policy makers, unlike clinicians, must always consider the “zero sum” scenario in their decision making.

The pace of innovation in ophthalmology is fast, with new potential diagnostic and therapeutic interventions always on the horizon. In response to this rapid rate of change, the natural inclination for some clinicians is to adopt new interventions as early as possible whilst others wait until the case for the intervention is unequivocal. Policy makers must, by necessity, wait for a solid evidence base to justify their choices. Their decisions are at scale and so are the implications of getting it wrong. But critically, in many areas of ophthalmology the evidence base is incomplete – as exemplified by the conclusion of the systematic review which itself underpinned the WHO PECI, stating, “The review identified some important gaps, including a paucity of high-quality, English-language Clinical Practice Guidelines for several eye diseases and a dearth of evidence-based recommendations on eye health promotion and prevention within existing Clinical Practice Guidelines.” (3)

The lack of high-quality guidelines for clinical practice is due mainly to the paucity of the robust primary research on which they rely. We must collectively take responsibility for addressing this evidence deficit, especially in high-income countries where the resources needed for research are more plentiful. This evidence-deficit – which is the shared responsibility of all ophthalmologists – is also the main reason why ophthalmologists should engage with eye care and eye health policy making.

This additional effort is even more important in relation to rare (versus common) eye conditions, which collectively affect around five percent of individuals, and where national or international studies are necessary to produce robust evidence (4).  As clinicians, we produce and gate-keep the expertise and information necessary for impactful medical research. And though we may not all be best placed to partner with national or supranational health organisations, we are all able to have impact at local level through our partnerships with our patients to generate the key research questions which must be answered to grow the evidence base.

Ultimately, as clinicians we work to deliver the best outcomes for our patients. If we remember that our patients are part of a population, and the clinical care we provide to them at an individual level is part of a wider health ecosystem, it isn’t a big leap to think of ourselves as policy makers. The different ways in which we can engage with and support local, national, and global eye care health policy are articulated in the first Lancet Global Health Commission on Global Eye Health, Vision Beyond 2020 (5). We all have a role to play in achieving its rightly ambitious aims, regardless of where or how we work in clinical practice.