The Lancet Global Health Commission on Global Eye Health: vision beyond 2020

Abstract

Eye health and vision have widespread and profound implications for many aspects of life, health, sustainable development, and the economy. Yet nowadays, many people, families, and populations continue to suffer the consequences of poor access to high-quality, affordable eye care, leading to vision impairment and blindness. In 2020, an estimated 596 million people had distance vision impairment worldwide, of whom 43 million were blind. Another 510 million people had uncorrected near vision impairment, simply because of not having reading spectacles. A large proportion of those affected (90%), live in low-income and middle-income countries (LMICs). However, encouragingly, more than 90% of people with vision impairment have a preventable or treatable cause with existing highly cost-effective interventions. Eye conditions affect all stages of life, with young children and older people being particularly affected. Crucially, women, rural populations, and ethnic minority groups are more likely to have vision impairment, and this pervasive inequality needs to be addressed. By 2050, population ageing, growth, and urbanisation might lead to an estimated 895 million people with distance vision impairment, of whom 61 million will be blind. Action to prioritise eye health is needed now. This Commission defines eye health as maximised vision, ocular health, and functional ability, thereby contributing to overall health and wellbeing, social inclusion, and quality of life. Eye health is essential to achieve many of the Sustainable Development Goals (SDGs). Poor eye health and impaired vision have a negative effect on quality of life and restrict equitable access to and achievement in education and the workplace. Vision loss has substantial financial implications for affected individuals, families, and communities. Although high-quality data for global economic estimates are scarce, particularly for LMICs, conservative assessments based on the latest prevalence figures for 2020 suggest that annual global productivity loss from vision impairment is approximately US$410·7 billion purchasing power parity. Vision impairment reduces mobility, affects mental wellbeing, exacerbates risk of dementia, increases likelihood of falls and road traffic crashes, increases the need for social care, and ultimately leads to higher mortality rates. By contrast, vision facilitates many daily life activities, enables better educational outcomes, and increases work productivity, reducing inequality. An increasing amount of evidence shows the potential for vision to advance the SDGs, by contributing towards poverty reduction, zero hunger, good health and wellbeing, quality education, gender equality, and decent work. Eye health is a global public priority, transforming lives in both poor and wealthy communities. Therefore, eye health needs to be reframed as a development as well as a health issue and given greater prominence within the global development and health agendas. Vision loss has many causes that require promotional, preventive, treatment, and rehabilitative interventions. Cataract, uncorrected refractive error, glaucoma, age-related macular degeneration, and diabetic retinopathy are responsible for most global vision impairment. Research has identified treatments to reduce or eliminate blindness from all these conditions; the priority is to deliver treatments where they are most needed. Proven eye care interventions, such as cataract surgery and spectacle provision, are among the most cost-effective in all of health care. Greater financial investment is needed so that millions of people living with unnecessary vision impairment and blindness can benefit from these interventions. Lessons from the past three decades give hope that this challenge can be met. Between 1990 and 2020, the age-standardised global prevalence of blindness fell by 28·5%. Since the 1990s, prevalence of major infectious causes of blindness—onchocerciasis and trachoma—have declined substantially. Hope remains that by 2030, the transmission of onchocerciasis will be interrupted, and trachoma will be eliminated as a public health problem in every country worldwide. However, the ageing population has led to a higher crude prevalence of age-related causes of blindness, and thus an increased total number of people with blindness in some regions. Key messagesEye health is essential to achieve the Sustainable Development Goals; vision needs to be reframed as a development issueThere is extensive evidence showing that improving eye health contributes directly and indirectly to achieving many Sustainable Development Goals, including reducing poverty and improving work productivity, general and mental health, and education and equity. Improving eye health is a practical and cost-effective way of unlocking human potential. Eye health needs to be reframed as an enabling, cross-cutting issue within the sustainable development framework.Almost everyone will experience impaired vision or an eye condition during their lifetime and require eye care services; urgent action is necessary to meet the rapidly growing eye health needIn 2020, 1·1 billion people had distance vision impairment or uncorrected presbyopia. By 2050, this figure is expected to rise to 1·8 billion. Most affected people live in low-income and middle-income countries (LMICs) with avoidable causes of vision impairment. During the life course, most people will experience vision impairment, even if just the need for reading glasses. Because of unmet needs and an ageing global population, eye health is a major public health and sustainable development concern which warrants urgent political action.Eye health is an essential component of universal health coverage; it must be included in planning, resourcing, and delivery of health careUniversal health coverage is not universal without affordable, high quality, equitable eye care. In line with the WHO World report on vision, we urge countries to consider eye care as an essential service within universal health coverage. To deliver comprehensive services including promotion, prevention, treatment, and rehabilitation, eye care needs to be included in national strategic health plans and development policies, health financing structures, and health workforce planning. Coordinated intersectoral action is needed to systematically improve population eye health, also within healthy ageing initiatives, schools, and the workplace. Integration of eye health services with multiple relevant components of health service delivery and at all levels of the health system is of central importance.High quality eye health services are not universally delivered; concerted action is needed to improve quality and outcomes, providing effective, efficient, safe, timely, equitable, and people-centred careUse of effective service coverage indicators for cataract and refractive error highlight the delivery gap between population eye health needs and the delivery of good outcomes. We urge eye health providers to take a holistic view to emphasise quality and design service delivery based on individual and population needs: a people-centred approach. Services need to be characterised by inclusiveness and equity in design and delivery, proactively addressing the needs of marginalised and vulnerable groups through targeted interventions. To encourage improved quality in cataract surgery, we support redefining a good vision outcome threshold as 6/12 or better.Highly cost-effective vision-restoring interventions offer enormous potential to improve the economic outlook of individuals and nations; a major scale up of financial investment in eye health is requiredFor 2020, we estimate that vision impairment resulted in $410·7 billion lost economic productivity; the full cost is most likely higher. Treatments for cataract and refractive error would meet more than 90% of unmet needs and are highly cost-effective. The case for countries to invest in improving population eye health is compelling and more financial resources are urgently required.Financial barriers to accessing eye care leave many people behind; eye health needs to be included in national health financing to pool the riskHealth-care costs prevent many people from accessing essential eye health services. Eye care needs to be integrated into general health system financing to remove cost barriers. To improve access for the whole population and mitigate eye care expenditure, mechanisms that pool risk are highly desirable.Technology and treatment developments offer new tools to improve eye health; thoughtful application is needed to maximise the potential to improve coverage, accessibility, quality, efficiency, and affordabilityTechnological developments such as telemedicine, mHealth, and artificial intelligence offer the potential to revolutionise eye health care in the next decade by delivering affordable, high-quality services to remote areas. However, caution is needed to ensure all populations benefit from these developments.The eye health workforce is unable to meet population needs in many countries; major expansion in service capacity is required through increased numbers, sharing tasks, strengthened training, enabling work environments, and effective leadershipMany areas have major shortages of personnel working in eye health. The available workforce needs to be distributed according to population need. Quality of training for the workforce needs to be updated, with renewed emphasis on competency. Enabling working environments need to be created, including appropriate support, supervision, and equipment. Long-standing issues of low productivity need to be systematically resolved. Mentoring and other programmes to cultivate an emerging generation of eye health leaders are needed.Reliable survey and service data are key to progress in eye health; robust indicator data are needed to shape change and drive actionTo monitor progress in delivering

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Affiliated Institutions

• Harvard University US
• The University of Melbourne AU
• London School of Hygiene & Tropical Medicine GB
• University Hospital Heidelberg DE
• Johns Hopkins Medicine US
• Singapore Eye Research Institute SG
• University College London GB
• Ulaanbaatar International University MN
• St Thomas' Hospital GB
• Universidade de São Paulo BR
• Seva Foundation US
• Leeds Teaching Hospitals NHS Trust GB
• Capital Medical University CN
• UNSW Sydney AU
• Aravind Eye Hospital IN
• Health Data Research UK GB
• Massachusetts Eye and Ear Infirmary US
• Kenya Medical Training College KE
• University of Cape Town ZA
• University of Calabar NG
• Brien Holden Vision Institute AU
• Queen's University Belfast GB
• United Nations US
• University of Abuja NG
• London Vision Clinic GB
• International Agency for the Prevention of Blindness GB
• International Trachoma Initiative US
• Tilganga Institute of Ophthalmology NP
• Ministry of Health and Family Welfare IN
• Duke-NUS Medical School SG
• The George Institute for Global Health AU
• Ministry of Health, Community Development, Gender, Elderly and Children TZ
• Ministry of Health KE
• Institute of Molecular and Clinical Ophthalmology Basel CH
• National Institute for Health Research GB
• University of Geneva CH
• Emory University US
• University Hospital of the West Indies JM
• Africa Health Research Institute ZA
• Indian Institute of Public Health Gandhinagar IN
• Sun Yat-sen University CN
• Ministry of Health MZ
• Drugs for Neglected Diseases Initiative CH
• Universidad Mexicana MX
• Cambridge University Hospitals NHS Foundation Trust GB
• Catalyst Health Economics Consultants Ltd GB
• Singapore National Eye Center SG
• Sightsavers GB
• University Hospitals Birmingham NHS Foundation Trust GB
• University of Nairobi KE
• Universidade Federal de São Paulo BR
• University of Michigan US
• Instituto Mexicano de Oftalmología IAP MX
• University Medical Centre Mannheim DE
• University of Auckland NZ
• Johns Hopkins University US
• Anglia Ruskin University GB
• Heidelberg University DE
• Moorfields Eye Hospital NHS Foundation Trust GB
• Mbarara University of Science and Technology UG
• Queen Elizabeth Hospital Birmingham GB
• Muhimbili University of Health and Allied Sciences TZ
• L V Prasad Eye Institute IN
• Beijing Tongren Hospital CN

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