“Right to Sight” in Africa: The Fight Goes On

In 1999, the World Health Organization and International Agency for Prevention of Blindness established the “Vision 2020: Right to Sight” initiative with the goal of eliminating preventable blindness by the year 2020. This saw the creation and adoption of national eye health action plans, increased allocation of resources, as well as ophthalmology training in underserved countries worldwide – from which, many African countries agreed to partake. This is particularly relevant given the fact that cataracts is the leading cause of blindness in individuals over the age of 50 in the continent’s sub-Saharan regions.

Three countries that failed to meet several of their targets, however, were Ethiopia, Ghana, and Zambia. Scott Herrod, a Harvard Medical student and the study's lead author, points to “a variety of barriers for both patients accessing care and providers administering care – including physical, social, resource, and financial factors.” These countries have concentrated eye care personnel in urban areas, which, in turn, limits surgical access to those in more rural communities. Civil unrest and security concerns were also identified as factors that hindered efforts to improve patient uptake.

“In our research, some of the most commonly perceived barriers to cataract surgery reported by ophthalmologists were distance to a cataract surgical center, lack of surgical centers, and lack of surgical equipment,” said study co-author Sadik Taju Sherief, Associate Professor of Ophthalmology at Addis Ababa University. While increased funding would address some of these barriers, it is unlikely that sustainability can be achieved from outside donors alone.

In Herrod’s view, one short-term solution could be “an increased number of cataract surgical outreaches led by local clinical teams, combined with strict monitoring for surgical outcomes, which would help address the immediate need until further expansion of eye care services.” The study participants also provided several suggestions for what could be done to increase cataract surgical uptake within their region, i.e., improvements in screening and outreaches, public education about cataract surgery, the number of resources, and economic aspects of providing surgery. “It is critical that colleagues working daily in these countries are brought to the table to guide changes to improve cataract surgical rate,” says Sherief.

A prevalent disparity in each country was the standard-of-care and job satisfaction experienced in private practice settings when compared with government hospital settings. If many ophthalmologists in these countries are drawn to private practice, it may leave poorer patients reliant on the government with less access to cataract surgery. “A possible solution to this could be dual public and private practices,” said Herrod. “Ophthalmologists would then be able to provide care to patients that require it most in the government sector, while also having a private practice to provide most of the financial support for themselves and their families,” he adds.

The Lancet Commision on Global Eye Health recommends that timely refraction and eyeglasses disbursement are essential to achieving comparable surgical outcomes in manual small incision cataract surgery – the most commonly utilized technique in sub-Saharan Africa – and phacoemulsification. However, Herrod and Sherief’s study found that only a median of 80 percent of patients reportedly undergo refraction and 50 percent receive eyeglasses within six months of surgery. Improving post-operative management of patients will be necessary for better surgical outcomes in the future.

“We hope to highlight the importance for all stakeholders in soliciting the leadership and perspectives of ophthalmologists practicing in Africa to the decision-making table for policy-making, resource allocation, and program development,” said Herrod. Oftentimes, such perspectives are underrepresented; change is reliant upon policy and structuring, which reaches beyond the remit of one opinion alone. This is why Sadik Taju Sherief sent their findings to policymakers in his country, Ethiopia, to ensure they are attuned to the opinions of ophthalmologists for the management of cataracts. “Though studies like ours are an important step, nothing compares to the real-time perspectives of these providers when their leadership is solicited as decisions are made,” Sherief added.

Many perceived barriers in Ethiopia, Ghana, and Zamba (and beyond) can be mitigated through greater financial investment in infrastructure, such as increasing the number of trained ophthalmologists, expanding eye care centers, improving referral systems, and cost recovery mechanisms. While structural changes to the financial reimbursement model for ophthalmologists may also be necessary: “respondents indicated a lack of financial incentives to maximize surgical productivity, leading some to prefer private practice and thereby limiting access for lower-income patients,” says Herrod. These changes extend to post-operative care too, as refraction and eyeglasses disbursement rates are currently suboptimal; improving policies and follow-up procedures in these areas will be necessary to achieve the goals set out in the Right to Sight initiative.