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REVIEW The challenge of uncorrected refractive error: driving the agenda of the Durban Declaration on refractive error and service development Clin Exp Optom 2010; 93: 3: 131–136 DOI:10.1111/j.1444-0938.2010.00455.x Kovin S Naidoo* BSc BOptom MPH OD Diane B Wallace* BOptom MPA Brien A Holden* PhD DSc OAM Hasan Minto § DipOpt FAAO Hannah B Faal †§ FRCOphth FWACS DCEH Palesa Dube* BOptom *International Centre for Eyecare Education African Vision Research Institute (UKZN) § Sightsavers International E-mail: [email protected] The purpose of this article is to highlight the challenge of uncorrected refractive error globally, as well as to discuss recent advocacy successes and innovative programs designed to address the need for broader refractive error service development, particularly in developing countries. The World Health Organization’s VISION 2020: The Right to Sight program first posed the challenge to national governments to give priority to strategies and resources targeted towards avoidable causes of blindness and visual impair- ment, so that these unnecessary forms of blindness or visual impairment can be elimi- nated globally by the year 2020. The blindness prevention community is challenged to increase in scale its initiatives, which support the attainment of VISION 2020: The Right to Sight goals primarily and the United Nation’s Millennium Development Goals indi- rectly. The Durban Declaration on Refractive Error and Service Development was the outcome of a meeting of eye-care professionals, researchers, governments, civil society and industry in March 2007 and still stands as a guiding document to the blindness prevention community for the elimination of avoidable blindness due to uncorrected refractive error. Submitted: 12 August 2009 Revised: 29 October 2009 Accepted for publication: 24 November 2009 Key words: Durban, uncorrected refractive error GRC Global Resource Centre IAPB International Agency for the Prevention of Blindness ICEE International Centre for Eyecare Education IOTA Institut d’Ophtalmologie Tropicale d’Afrique MDG Millennium Development Goals NGO Non-government organisations RESC Refractive error studies in children REWG Refractive Error Working Group UN United Nations WCO World Council of Optometry WCRE World Congress on Refractive Error WHA World Health Assembly WHO World Health Organization In February 1999, the World Health Orga- nization (WHO) initiated the ‘VISION 2020: The Right to Sight’ program to accelerate efforts towards eliminating global avoidable blindness and visual impairment by 2020. 1 This initiative, emphasising the fact that many causes of blindness and impaired vision are either avoidable or treatable, brought together international bodies, including non- government and professional organ- isations, educational institutions and inter- ested individuals under the umbrella of the International Agency for the Preven- tion of Blindness (IAPB)-WHO partner- ship. As the global co-ordinating body, IAPB conducts advocacy and mobilises resources in support of national blindness prevention programs. Initially, the priorities identified by the VISION 2020 program were cataract, tra- choma, onchocerciasis, childhood blind- ness and low vision. 2 These received much of the resources and attention from stake- holders in the eye-care field. Later, refrac- tive error programs gained momentum as CLINICAL AND EXPERIMENTAL OPTOMETRY © 2010 The Authors Clinical and Experimental Optometry 93.3 May 2010 Journal compilation © 2010 Optometrists Association Australia 131

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cxo_455 131..136

REVIEW

The challenge of uncorrected refractive error: driving the agendaof the Durban Declaration on refractive error and

service development

Clin Exp Optom 2010; 93: 3: 131–136 DOI:10.1111/j.1444-0938.2010.00455.x

Kovin S Naidoo*† BSc BOptom MPH ODDiane B Wallace*† BOptom MPABrien A Holden*† PhD DSc OAMHasan Minto§ DipOpt FAAOHannah B Faal†§ FRCOphth FWACSDCEHPalesa Dube* BOptom*International Centre for EyecareEducation†African Vision Research Institute(UKZN)§Sightsavers InternationalE-mail: [email protected]

The purpose of this article is to highlight the challenge of uncorrected refractive errorglobally, as well as to discuss recent advocacy successes and innovative programs designedto address the need for broader refractive error service development, particularly indeveloping countries. The World Health Organization’s VISION 2020: The Right toSight program first posed the challenge to national governments to give priority tostrategies and resources targeted towards avoidable causes of blindness and visual impair-ment, so that these unnecessary forms of blindness or visual impairment can be elimi-nated globally by the year 2020. The blindness prevention community is challenged toincrease in scale its initiatives, which support the attainment of VISION 2020: The Rightto Sight goals primarily and the United Nation’s Millennium Development Goals indi-rectly. The Durban Declaration on Refractive Error and Service Development was theoutcome of a meeting of eye-care professionals, researchers, governments, civil societyand industry in March 2007 and still stands as a guiding document to the blindnessprevention community for the elimination of avoidable blindness due to uncorrectedrefractive error.Submitted: 12 August 2009

Revised: 29 October 2009Accepted for publication: 24 November2009

Key words: Durban, uncorrected refractive error

GRC Global Resource CentreIAPB International Agency for the

Prevention of BlindnessICEE International Centre for Eyecare

EducationIOTA Institut d’Ophtalmologie Tropicale

d’AfriqueMDG Millennium Development GoalsNGO Non-government organisationsRESC Refractive error studies in childrenREWG Refractive Error Working GroupUN United NationsWCO World Council of OptometryWCRE World Congress on Refractive ErrorWHA World Health AssemblyWHO World Health Organization

In February 1999, the World Health Orga-nization (WHO) initiated the ‘VISION2020: The Right to Sight’ program toaccelerate efforts towards eliminatingglobal avoidable blindness and visualimpairment by 2020.1 This initiative,emphasising the fact that many causes ofblindness and impaired vision are eitheravoidable or treatable, brought togetherinternational bodies, including non-government and professional organ-isations, educational institutions and inter-ested individuals under the umbrella of

the International Agency for the Preven-tion of Blindness (IAPB)-WHO partner-ship. As the global co-ordinating body,IAPB conducts advocacy and mobilisesresources in support of national blindnessprevention programs.

Initially, the priorities identified by theVISION 2020 program were cataract, tra-choma, onchocerciasis, childhood blind-ness and low vision.2 These received muchof the resources and attention from stake-holders in the eye-care field. Later, refrac-tive error programs gained momentum as

C L I N I C A L A N D E X P E R I M E N T A L

OPTOMETRY

© 2010 The Authors Clinical and Experimental Optometry 93.3 May 2010

Journal compilation © 2010 Optometrists Association Australia 131

research data, which showed that uncor-rected refractive error was the major causeof vision impairment, emerged with subse-quent advocacy efforts highlighting itssignificance.

According to the latest WHO estimates,about 314 million people worldwide livewith visual impairment due to either eyedisease or uncorrected refractive error, ofwhom 45 million are blind.3 Seventy-fiveper cent of blindness is avoidable andresults from conditions that could havebeen prevented or controlled throughappropriate interventions.4 Globally, 153million people are either blind or visuallyimpaired due to uncorrected distancerefractive error.5 Visual impairment due touncorrected refractive error, easily cor-rectable by a pair of spectacles, is poten-tially debilitating and limits the affectedindividuals’ opportunities in educationand employment.6 In addition, studies7–9

have shown that on average in developingcountries, only 20 per cent of those requir-ing distance visual correction have accessto spectacles. The Refractive Error Studiesin Children (RESC)7 and the formation ofthe Refractive Error Working Group(REWG) by the WHO (an expert technicalcommittee to advise on policy, technicaland strategy issues regarding uncorrectedrefractive error) gave further impetus to aglobal prioritisation of eradicating visualimpairment due to uncorrected refractiveerror.

Furthermore, presbyopia, which neces-sitates spectacle correction for near vision,was long considered ‘not as important’due to the assumption that reading spec-tacles were readily available and relativelyinexpensive. Recent studies10 have high-lighted presbyopia as a significant refrac-tive problem due to the followingevidence:• 1.04 billion people worldwide have

presbyopia (2005)• Of those, 517 million people (49 per

cent) have either no or inadequatecorrection

• As a result, 410 million of these areprevented from performing neartasks.

Presbyopia has become a focus of inter-national public health efforts and has

been recognised by the WHO as a majorhealth issue, with potential negative con-sequences for the productivity and qualityof life of affected individuals, their familiesand communities.11,12 Currently, most ofthe burden of uncorrected refractive errorfalls on developing countries, many ofwhich continue to lack the basic infra-structure, equipment and personnel toprovide refractive services as part ofgeneral health service provision.12

IMPETUS GENERATED BY THEDURBAN DECLARATION

The inaugural World Congress on Refrac-tive Error (WCRE) was held in Durban,South Africa, in March 2007. Themeeting, hosted by the InternationalCentre for Eyecare Education (ICEE), wasattended by officials of the WHO, theIAPB, the World Council of Optometry(WCO) and other stakeholders in blind-ness prevention. The aim of the congresswas to advocate public health strategies toend avoidable blindness due to uncor-rected refractive error. This historic gath-ering of more than 650 internationaldelegates representing eye-care profes-sionals, researchers, governments, civilsociety and industry, culminated in thesigning of the Durban Declaration onRefractive Error and Service Develop-ment. The Congress highlighted uncor-rected refractive error as a leading causeof avoidable blindness and visual impair-ment across the world and acknowledgedthe link between poverty and visualimpairment, which places an economicburden on individuals, their families andthe affected nations.

The Declaration (Appendix 1) resolvedto prioritise solutions towards refractiveservice development by:• Increasing awareness of the magnitude

of the unmet need for refractive ser-vices globally

• Influencing the policies of national andworld health bodies with regard to ser-vices and resources required to meetthe refractive care needs

• Addressing the present paucity of ser-vices, personnel, training institutions

and affordable spectacles in developingcountries

• Addressing the barriers that preventthose in developing countries fromaccessing refractive error and lowvision services

• Working towards collaborationsbetween professions and the formationof partnerships to achieve the VISION2020 goals

• Investing in training and the develop-ment of eye-care teams to meet theneeds of underserved populations

• Supporting the establishment of globalprocurement and distribution systemsto make optical appliances and devicesavailable to communities in need

• Creating and disseminating evidence-based information on best practicesin refractive service development anddelivery.

The Declaration also called for thestrengthening and optimal use of infra-structure and appropriate technology,both in relation to comprehensive eye-health services and community participa-tion, which are key components of thesuccess of any VISION 2020 endeavour.Such a comprehensive approach towardsthe reduction of visual impairment, withthe inclusion of uncorrected refractiveerror, should be co-ordinated, appropri-ate to identified needs and sustainable,with relevant resource planning strategiesto ensure effective implementation.

Population growth factors, as well as themaldistribution of available ophthalmicpersonnel in developing countries, makeit difficult to keep pace with eye-careneeds in much of the developing world.Many developing countries lack the basicresources such as trained personnel andappropriate or adequate infrastructure todeliver eye-care services to the populationsthey serve.13 Furthermore, their eye-careservices (in particular, refractive services)do not form part of the general publichealth system, resulting in potentiallyblinding conditions going undetected.National governments should identifypriority actions necessary to reduce theburden of avoidable blindness on theirsociety and ensure effective policyimplementation.

The challenge of uncorrected refractive error Naidoo, Wallace, Holden, Minto, Faal and Dube

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132 Journal compilation © 2010 Optometrists Association Australia

One of the objectives of the WCRE wasto bring stakeholders together and drawattention to key challenges facing theblindness prevention community. Nat-ional Ministries of Health are the primaryhealth service providers and are respon-sible for allocating resources within theirrespective countries. Therefore, the Dec-laration called on governments to:• Make refractive services a priority• Support the development and employ-

ment of appropriate human resourcesand the acquisition of infrastructureand technology for the effective deliv-ery of refractive services within thepublic sector

• Support organisations working to-wards the elimination of avoidableblindness due to uncorrected refractiveerror.

Meeting the VISION 2020 goals in thedeveloping world requires effective policydevelopment and implementation, as wellas a co-ordinated national effort towardsthe development of resources neededfor refractive service delivery. AligningVISION 2020 plans with national healthplans will ensure the availability of refrac-tive service at the point of need.

OPPORTUNITIES FOR ADVOCACY

Since the inception of VISION 2020,two resolutions were passed by theWorld Health Assembly (WHA), whichaddresses the elimination of avoidableblindness (WHA56.26 in 2003 andWHA59.25 in 2006). In addition, the Pre-vention of Blindness Action Plan3 wastabled by the WHO in an attempt toexpand efforts by international partnersin preventing blindness and visual im-pairment. The 62nd WHA of May 2009,in its resolutions on public health,approved a resolution endorsing anaction plan by member states, partnersand the WHO to expand efforts to elimi-nate avoidable blindness by strengthen-ing national eye health programs.14 TheWHA also endorsed the inclusion of pre-vention of blindness, including visualimpairment, in the strategic objectives(Objective 3, Non-Communicable Dis-

eases) of the WHO Medium Term Strate-gic Plan 2008–2013.15

The impetus generated by the WHAresolutions and the Durban Declarationon Refractive Error and Service Develop-ment should encourage regional bodies touse these guiding documents as a basis toadvocate a more comprehensive strategytowards attaining VISION 2020 goals. TheDurban Declaration empowers eye-careadvocates to convince governmentsthat refractive error has been identifiedas a major international public healthchallenge. The United Nations (UN)developed an action plan termed theMillennium Development Goals (MDGs)to lift the world’s population out ofextreme poverty by 2015. Worldwide, gov-ernments of low- and middle-incomecountries are under considerable pressureto achieve the MDG, with seven of theeight MDGs being linked to the prioritiesand implementation of VISION 2020.15

Particular reference to the impact ofuncorrected refractive error on educa-tional and employment opportunitiesneeds to be highlighted to extend thescope of the advocacy efforts to appeal to abroader national development agenda inline with attaining the MDGs.15

The development of comprehensive eyehealth programs at national and sub-national levels creates an opportunity toexpand refractive services and incorporatean integrated refractive error strategy intothe national activities of member coun-tries. The integration of eye-care services(including refractive error services) ingeneral health services will not only allowprevention, early detection and manage-ment of diseases but will contribute to thegeneral strengthening of health systems.Its link to and collaboration with educa-tional services on school health programswill contribute to achieving the secondMDG, which is to achieve universalprimary education.

CURRENT EFFORTS ANDCOLLABORATIVE APPROACHES

Multi-country training initiativesCurrent human resources for refractiveerror are insufficient to meet the growingneed and demand for refractive error ser-vices.16 The Durban Declaration recogn-ises that the greatest contribution to asevere shortage of these services in devel-oping countries is the lack of appropri-ately trained personnel.

An approach to the training of mid-leveland professional optometric personnelwas proposed by Naidoo in 1998.17 In thismultiple entry/exit approach, studentsentering a four-year program have theoption to exit after two years to work atprimary health level in the public serviceand to return to complete an additionaltwo years towards a Bachelor of Optom-etry degree at a later stage. Studentsparticipating in the two-year mid-levelprogram complete a one-year foundationcourse in basic sciences and one year ofoptometric and dispensing training toprovide strategies aimed at encouragingpeople to seek eye-care services, includinghealth promotion tools such as posters,public service announcements andgeneral eye health awareness campaigns atcommunity level, as well as provide basicrefraction and dispensing services. Thesegraduates are able to screen and refer forany obvious ocular pathology. A selectnumber of diploma graduates are allowedto continue towards the completion of afour-year bachelor’s degree. Degree stu-dents will not be restricted to working inthe public service. This approach, which iscurrently being implemented in Malawiand Mozambique through a consortium ofpartners, will have a strong public healthfocus, with graduates being absorbed intoservice within public health facilities.

Elsewhere in Africa, the Institutd’Ophtalmologie Tropicale d’Afrique(IOTA) in Mali has recently implementeda regional training program in optometryfor French-speaking West Africa. Similarly,The Gambia has started a two-yearoptometric technician program within itsRegional Ophthalmic Training program.

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New schools of optometry are being estab-lished in Asia to meet the higher needsand to train educators for the future, whileestablished schools are paying greaterattention to public health eye-care needs.

Infrastructure developmentAn increase in available human resourcesfor optometric service provision alone willnot reduce the prevalence of uncorrectedrefractive error. Establishing well-equipped eye-care service centres that areaccessible to communities is linked toclinical service provision by trained gradu-ates. This strategy could include servicedelivery models such as ‘vision centres’,which are an appropriate, flexible and sus-tainable way of delivering eye care andvision correction at the community level,providing basic eye examinations andspectacles, an essential element of whichis the detection and referral of sight-threatening conditions. This ‘visioncentre’ model was pioneered initially bythe LV Prasad Eye Institute. ‘Visioncentres’ are now being strategically placedin public hospitals and clinics, by non-government organisations (NGOs) orthrough private sector partnership initia-tives, where they provide the necessaryinfrastructure for the delivery of refrac-tion and spectacle service provision.

Strategies for eye care service provisionin the developing world must address thefollowing considerations in planning theiroutcomes:• Integration of the service within exist-

ing eye and health care services• Provision of quality service and

products• Ensure affordability of the service and

service products• Ensure sustainable services through

cost-recovery measures• Empower local people through job

creation• Promote community participation.

Establishing global distribution chan-nels that ensure a supply of affordableoptical products such as spectacles, lensesand equipment to these ‘vision centres’ isan important component of creatingaccess to eye care for people in need. Costrecovery and sustainability of the service

necessitate that these distribution chan-nels reduce handling fees and third-partyoverheads as far as possible, without com-promising equity, affordability or quality.The Global Resource Centre (GRC) is acollaborative effort of various eye-careNGOs aimed at creating direct access tooptical products for non-profit organisa-tions and governments. Initiatives such asthe GRC, which make high quality, lowcost spectacles and optical devices avail-able to public sector programs, will ensurethat cost is not an impediment to eye-careservice expansion.

Research and modeldevelopmentThe Durban Declaration encouragesresearch in refractive services as well as theapplication of research results to achievethe most effective solutions to servicedelivery using best practice models.Appropriate research should enable theidentification of community needs basedon epidemiological investigations and situ-ational analyses. The findings of suchresearch will aid in planning and imple-menting appropriate public health efforts.

Therefore, it is necessary to developevidence-based models for cost-effectiveinterventions in refractive service deliveryand related technology, as well as toexplore possible relationships with theprivate sector and other service providersto expand the availability and ensure thesustainability of refractive services to com-munities in need. It is the responsibility ofall stakeholders to undertake and promoteresearch in the field of uncorrected refrac-tive error, to identify the barriers to itscorrection, the most appropriate servicedelivery models and to ensure co-ordinated efforts toward appropriate inter-ventions with maximum benefit.

CONCLUSION

For the blindness prevention community,the next decade of VISION 2020: TheRight to Sight represents an urgent call toestablish eye-care programs that delivertangible results in eye health promotion,ocular disease recognition and treatment,and service provision, as well as a

co-ordinated approach to a broader devel-opment agenda. Significant escalation inthe pace of delivery must take place, par-ticularly to improve eye-care services in thedeveloping world, if the goals of VISION2020 are to be realised.

To address the identified needs, innova-tive and sustainable strategies to reducewidespread uncorrected refractive errormust continue to be developed and imple-mented, with greater resources being allo-cated to train the personnel, who willprovide eye-care services within the healthsystem. Reducing the burden of avoidableblindness due to uncorrected refractiveerror will remove barriers to educationand employment and thereby improve thequality of life for millions of disadvantagedpeople, ultimately contributing to attain-ing the United Nation’s MDGs. Relatedresearch findings must be published toidentify significant problems and provideevidence-based models.

The Durban Declaration urges publicand private organisations involved in eye-care service development to co-ordinatetheir efforts towards greater impact andoutcomes. The commitment and momen-tum initiated at the WCRE in Durban, inMarch 2007, needs to be maintained bythe members of the international eyehealth community, if the challenges facingthe sector are to be addressed. The goalsof the Durban Declaration need to beadopted and implemented to effectivelyaddress the global refractive errorchallenge.

ACKNOWLEDGEMENT

The authors would like to acknowledgethe writing and technical assistance ofCarrin Martin, Research Manager for theAfrican Vision Research Institute in thepreparation of this paper.

REFERENCES

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The challenge of uncorrected refractive error Naidoo, Wallace, Holden, Minto, Faal and Dube

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3. World Health Organization. Prevention ofavoidable blindness and visual impairment.2009. Available from http://apps.who.int/gb/ebwha/pdf_files/A62/A62_7-en.pdf.

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Corresponding author:Diane WallaceInternational Centre for EyecareEducation272 Umbilo RoadDurban 4000SOUTH AFRICAE-mail: [email protected]

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APPENDIX

The challenge of uncorrected refractive error Naidoo, Wallace, Holden, Minto, Faal and Dube

Clinical and Experimental Optometry 93.3 May 2010 © 2010 The Authors

136 Journal compilation © 2010 Optometrists Association Australia