Delivering primary eye care in the 21st century
The changing epidemiology of eye conditions calls for reimagining primary eye health care services with strong referral linkages.
The World Health Organization (WHO) made a clear, strong call for equity in health care in the ambitious Alma-Ata Declaration (1978), which recognised primary health care as an essential means to achieve health for all by 2000.1 Forty years on, despite the changes in the epidemiology of health conditions, the 2018 Astana Declaration reiterated that universally accessible, safe, quality, and affordable primary health care is an integral part of a health system.2,3 Primary health care was upheld as the foundation for universal health coverage and the Sustainable Development Goals. The use of technology in primary health care was also felt to be important in the current and future contexts.
Primary eye health care and changing needs
The WHO describes the basic clinical care provided in frontline health facilities as ‘primary care’. Applying this to eye care, the clinical eye health services in primary level facilities should be called ‘primary eye care’ (PEC). We should broaden the scope to achieve ‘primary eye health care’ (PEHC), which includes health promotion, disease prevention, and rehabilitation of the visually impaired. The health systems framework is a helpful template, which can be adapted for assessing primary eye care needs and delivery, as depicted in Table 1.4 For example, a district in India has an average population of 1.25 million. For every 100,000 population, there is a health facility called a community health centre, where a paramedical ophthalmic officer/ophthalmic assistant is posted. The person provides refraction services, follow-up services for those who have undergone cataract operation, and clinical support to diagnose eye problems such as a red eye. This function is purely an individual patient-related service at a frontline health facility and can be aptly called ‘primary care’. Such individual patient-related services are also provided by other trained personnel in the private sector. However, the paramedical ophthalmic officer or assistant also provides school vision screening services, engages in health education and communication with the trained general health personnel working in the public health system, and provides other eye care activities at the population level. Such services, which are more comprehensive than pure clinical work, constitute primary eye health care activities.
Table 1 Primary eye health care in the health systems framework
|Health systems building blocks
|Possible primary eye care activities
|Health information management systems
|Medical products and technology
Social determinants of health and eye care
Primary health care addresses the social determinants of health and the direct medical causes of disease causation. Social determinants of health are the factors that influence everyday life and health: education, housing and the environment, income and social protection, working life conditions, and social inclusion. Indeed, it has been estimated that these factors account for between a third and half of health outcomes.5 These factors are also relevant to eye care. They can influence whether or not an individual develops an eye condition and is able to access services for treatment; as well as the prognosis and outcomes.
As the major causes of visual impairment can change over time, PEHC needs to evolve to remain relevant to the current eye health needs of the population (as outlined in Table 2). For example, the dramatic increase in diabetes increases the risk of visual loss from diabetic retinopathy (DR), and an increasingly ageing population is at increased risk of glaucoma. Additionally, there is an epidemic of retinopathy of prematurity (ROP) in low- and middle-income countries because of the increased chances of survival of preterm babies. The changing epidemiology of eye conditions calls for reimagining primary eye care service with a robust referral mechanism to link to secondary and tertiary levels of care (Table 3).
Table 2 Adapting primary eye health care to current needs
|Elements of primary eye health care
|Current needs and adaptation
|Imparting education on eye health problems and their prevention and control
|Ensuring proper food and nutrition, especially in low- and middle-income countries
|An adequate supply of safe water and basic sanitation
|Maternal and child healthcare, including family planning
|Immunisation against major infectious diseases
|Prevention and control of locally endemic diseases
|Appropriate treatment of common diseases and injuries, and referral
|Provision of essential drugs
Table 3 Suggestions to tackle emerging eye care challenges
|Eye conditions/ disease focused services
|Primary eye care approaches
|Near vision correction facilities
|Distance vision correction facilities, including low vision
|Paediatric cataract, strabismus, and congenital anomalies
|Retinopathy of prematurity
|Health communication in primary clinics and the community
The impact of COVID on primary eye care services
COVID-19 has impacted all levels of the health system, particularly primary health care and primary eye care services. Elective services like school vision screening and screening for ROP and DR have been shut down. With the COVID vaccine drive under way in many low-and middle-income countries, all primary health personnel, including eye care personnel, will continue to shoulder COVID-related responsibilities. Also, service users are apprehensive about visiting health facilities. All of this will have a catastrophic cascading effect as those not screened and managed in time may become visually impaired.
In the South Asia region, some services had resumed towards the last quarter of 2020. However, most were suspended during the first quarter of 2021 due to the second surge of COVID from March 2021. Going forward, there is a huge need to reduce risks to both users and providers of primary eye care. There is an urgent need to employ teleconsultation in eye care. Its effectiveness, though, will depend on developing smartphone-based applications to capture images of the back of the eye, which could be shared from the service user’s home. Technology, like PEEK,6 will need to be used more widely. Each country should look at what works best in its context and plan accordingly.
1 White F. Primary health care and public health: foundations of universal health systems. Med Princ Pract. 2015;24(2):103-16.
2 World Health Organization. Global conference on primary health care: from Alma-Ata towards universal health coverage and the sustainable development goals, Astana, Kazakhstan, 25 and 26 October 2018. Astana: World Health Organization; 2018. Available from: https://bit.ly/3oSvCJ7 (accessed 10 June 2021).
3 World Health Organization. Declaration of Alma-Ata international conference on primary health care, Alma-Ata, USSR, 6-12 September 1978. Available from: https://bit.ly/3zBs7M7 (accessed 10 June 2021).
4 World Health Organization. Everybody’s business: strengthening health systems to improve health outcomes, WHOs framework for action. Geneva: World Health Organization; 2007. Available from: https://bit.ly/3gJQEpo (accessed 10 June 2021).
5 World Health Organization. Social determinants of health. Available from: https://bit.ly/35vPPLL (accessed 10 June 2021).
6 Bastawrous A. Increasing access to eye care … there’s an app for that. Peek: smartphone technology for eye health. International J Epidemiol. 2016;45:1040-3 (accessed 10 June 2021).