Fatima Kalabi

Why equity is the central performance problem in eye health

The global ophthalmology community is not short of effective interventions; it is short of equitable delivery. The Lancet Global Health Commission on Global Eye Health positioned eye health as integral to universal health coverage (UHC), arguing that progress depends on shifting from vertical, disease-specific activity to health-system strengthening with explicit attention to equity and quality (1). The WHO World report on vision similarly frames the challenge as one of access, affordability, quality, and people-centred systems rather than a lack of clinical solutions (2).

A key implication for ophthalmologists is that “more services” does not necessarily mean “fairer outcomes.” Equity gaps can persist even when crude coverage improves, because barriers accumulate across the pathway from detection to effective treatment and follow-up.

From coverage to effective coverage: how inequity hides in plain sight

Global monitoring has moved toward effective coverage—coverage adjusted for whether care achieves a good outcome. Two indicators endorsed by WHO Member States are now central:

• Effective cataract surgical coverage (eCSC): cataract surgical coverage adjusted for post-operative visual outcome (3).

• Effective refractive error coverage (eREC): refractive coverage adjusted for whether correction achieves a functional visual threshold (4).

These metrics matter for equity because disadvantaged groups often experience a quality gap: they may reach care later, receive lower-quality surgery or refraction, or lack access to post-operative refraction and complication management. eCSC, for example, was designed specifically to quantify access and quality together, using population-based survey data across dozens of countries (3). The WHO’s report on 2030 effective coverage targets further emphasises the “quality gap” between coverage and effective coverage and presents estimates stratified by region, sex, and income group (5).

The Main Barriers to Equity in Global Eye Care

1) Financial hardship and affordability (direct and indirect costs)

User fees, the price of spectacles, transport costs, and lost wages can deter care even when services exist. The WHO World report on vision explicitly highlights financial hardship as a barrier and calls for inclusion of eye care within essential health service packages as part of the UHC journey (2).

What works:

• Embed priority eye care (cataract surgery, refraction/spectacles, chronic eye disease management and follow-up) in UHC benefit packages, with explicit financial protection.
• Reduce indirect costs through “one-stop” models (assessment-to-surgery planning; post-op pathways with refraction) and transport support coordinated via community health structures (where relevant) (2).

2) Geography, service distribution, and fragmented referral pathways

Eye care remains concentrated in urban centres in many settings. Travel time and poor referral continuity disproportionately affect rural populations and those in vulnerable circumstances. The WHO’s recommended approach—integrated people-centred eye care (IPEC)—addresses this by embedding eye care into broader health systems and strengthening primary care interfaces rather than relying on episodic outreach alone (2).

What works:

• Hub-and-spoke networks: decentralise triage, refraction, stable follow-up, and screening; centralise complex diagnostics and surgery with robust referral completion mechanisms.
• Treat outreach as an extension of the system (with data, referral tracking, and quality assurance), not a substitute for it (2).

3) Workforce shortages and suboptimal skill-mix

Equity is constrained not only by the number of ophthalmologists but by the team configuration—including optometrists, ophthalmic nurses, technicians, and community workers—and their distribution. The Commission and WHO report both stress the need for workforce strategies aligned with system integration and population needs (1,2).

What works:

• Task-sharing within a governance and competency framework (e.g., expanding roles in refraction, screening support, post-op follow-up, and chronic disease monitoring).
• Structured career pathways and incentives for rural and underserved areas, coupled with supervision and audit (2).

4) Quality gaps: “access without outcomes”

Quality is a primary equity issue. eCSC exists because cataract services can scale without delivering good vision outcomes, especially where biometry, IOL selection, infection prevention, complication management, and post-op refraction pathways are inconsistent (3). The WHO 2030 targets report similarly frames effective coverage as a combined access-and-quality measure to support accountability (5).

What works:

• Routine, clinic-level outcomes audit (visual outcomes and refractive outcomes), with complication review and feedback loops (3).
• Link programme targets to effective outcomes where feasible (not just volume), aligning with the global effective coverage agenda (3-5).

5) Social and gender inequities, marginalisation, and disability inclusion

The Commission highlights that vision impairment and access to services are shaped by social determinants and marginalisation (1). Women, ethnic minorities, migrants, people with disabilities, and the poorest households frequently face compounded barriers: limited autonomy, lower health literacy, caregiving constraints, stigma, and reduced ability to travel or pay.

What works:

• “Equity-by-design” service planning: clinic hours compatible with caregiving, women-focused outreach where appropriate, accessible facilities and communication, and patient navigation to reduce drop-off at referral points (1,2).
• Community engagement as an implementation strategy: evidence mapping of IPEC emphasises empowering and engaging communities to improve access and continuity (6).

6) Data blindness and weak accountability

Equity problems persist when systems cannot see them. Many services track activity (number of surgeries) without stratifying outcomes by sex, geography, socioeconomic status, or disability. Effective coverage indicators provide a mechanism for accountability, but only if implemented with disaggregation and continuous monitoring (3-5).

What works:

• Minimum datasets that include equity stratifiers and outcome measures; routine review in clinical governance meetings.
• Align local indicators to global effective coverage targets to make performance comparable and policy-relevant (5).

7) Digital transformation and AI: equity accelerant or amplifier?

Teleophthalmology and AI can extend reach, but they can also widen inequity if tools are developed using unrepresentative data, or if downstream referral and treatment capacity is absent. A major review of publicly available ophthalmic imaging datasets highlights geographic skew and metadata limitations that can undermine generalisability and fairness (7).

What works:

• Require external validation in target populations; report subgroup performance; monitor drift post-deployment (7).
• Treat digital screening as a pathway (screening → referral completion → treatment), not a standalone pilot (2,7).

Conclusion

Equitable eye care is achievable, but it requires shifting from episodic service expansion to system-level delivery that prioritises affordability, referral continuity, workforce design, and – importantly – quality. Effective coverage indicators (eCSC/eREC) help make inequity measurable and actionable, while IPEC provides the service architecture to embed eye care within stronger health systems (1–5).

References

1. Burton MJ, Ramke J, Marques AP, Bourne RRA, Congdon N, Jones I, et al. The Lancet Global Health Commission on Global Eye Health: vision beyond 2020. Lancet Glob Health. 2021;9(4):e489–e551. doi:10.1016/S2214-109X(20)30488-5.
2. World Health Organization. World report on vision. Geneva: World Health Organization; 2019.
3. McCormick I, Butcher R, Evans JR, Mactaggart IZ, Limburg H, Jolley E, et al. Effective cataract surgical coverage in adults aged 50 years and older: estimates from population-based surveys in 55 countries. Lancet Glob Health. 2022;10(12):e1744–e1753. doi:10.1016/S2214-109X(22)00419-3.
4. Bourne RRA, Cicinelli MV, Sedighi T, Tapply IH, McCormick I, Jonas JB, et al. Effective refractive error coverage in adults aged 50 years and older: estimates from population-based surveys in 61 countries. Lancet Glob Health. 2022;10(12):e1754–e1763. doi:10.1016/S2214-109X(22)00433-8.
5. World Health Organization. Report of the 2030 targets on effective coverage of eye care. Geneva: World Health Organization; 2022.
6. Lee L, Moo E, Angelopoulos T, Yashadhana A. Integrated people-centered eye care: A scoping review on engaging communities in eye care in low- and middle-income settings. PLoS One. 2023;18(1):e0278969. doi:10.1371/journal.pone.0278969.
7. Khan SM, Liu X, Nath S, Korot E, Faes L, Wagner SK, et al. A global review of publicly available datasets for ophthalmological imaging: barriers to access, usability, and generalisability. Lancet Digit Health. 2021;3(1):e51–e66. doi:10.1016/S2589-7500(20)30240-5.