Situation analysis of South East Asia to adopt the UHC eye health indicators: eCSC and eREC

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Last year the World Health Assembly endorsed the resolution on Integrated people-centered eye care. This year they adopted global targets for 2030 focusing on effective coverage of refractive error and effective coverage of cataract surgery.

The targets are:

A 30% percentage point increase in effective coverage of cataract surgery, by 2030.
- Countries with baseline effective coverage rates 70% or higher, strive for universal coverage.
- Countries should aim to achieve an equal increase in effective coverage of cataract surgery in all population sub-groups, independent of baseline estimates.
eCSC definition: The proportion of people who have received cataract surgery and have a resultant good quality outcome (PVA6/12 or better) relative to the number of people in need of cataract surgery having BCVA <6/12 due to cataract).

A 40% percentage point increase in effective coverage of refractive error, by 2030
Countries with baseline effective coverage rates 60% or higher, strive for universal coverage.
Countries should aim to achieve an equal increase in near and distance effective coverage of refractive errors, and in all population sub-groups, independent of baseline estimates.
eREC definition: The proportion of people who have received refractive error services (i.e. spectacles, contact lenses or surgery) and have a resultant good quality outcome (presenting visual acuity 6/12 or better) relative to the number of people in need of refractive error services having presenting visual acuity <6/12 due to refractive error.

It is vital that all countries have baseline data on eCSC and eREC to incorporate to track progress and meet the above mentioned UHC eye health targets for 2030. Unfortunately, most countries in the SEA region do not have this data.

Generating data for eCSC and eREC

As the denominator for these indicators is the population, therefore, the information can only be generated from population based survey. Regular hospital service or programme output data in terms of number of people treated will not be able to give this information. These indicators are relatively new, therefore traditional population-based surveys do not include this in their data collection and report generation.

The most popular population based survey method to obtain this is the Rapid Assessment of Avoidable Blindness (RAAB) survey. RAAB survey version RAAB – 6 provides the information on eCSC only but the new version- RAAB-7 officially launching in 2021 which was trialed in many countries during 2019 and 2020 will provide detailed information on eCSC and eREC for 50 + age group. The RAAB survey methodology provides information on eCSC and eREC for 50 + age group only, as it enrolls the survey participants of that age. It is estimated that more than 80% of cataract occurs in this age group so eCSC data generated from RAAB survey can be considered as representative of the total population. Similarly, the information generated for eREC – near vision impairment/presbyopia will also be representative of all population. However, the distance vision impairment due to refractive error occurs in all ages and myopia is increasing in the age group of 9 to 15 years . So, RAAB survey information of elderly age group needs to be cautiously generalized or may not be representative of all population. Therefore, in addition a Refractive Error Study in School Children (RESC) using WHO-RESC survey method can be used to generate eREC information in children. In countries where school enrollment is more than 90%, a well designed school children survey is considered as an equivalent to population based surveys in school going children.

The data availability situation of SEA countries are as provided in Table given below:


Description	SEA Countries
	Bangladesh	Bhutan[1]		India[2]	Indonesia[3]		Maldives[4]	Myanmar	Nepal	Sri Lanka[5]	Thailand[6]	Timor-Leste[7]
Year	2021	2019		2018	2017		2016	2017	2021	2015	2013	2017
Area Covered	National	National		National	15 Province		National	National	National	National	National	National
Sample Size	Survey completed data analysis in process	4970		93,108	45822		3020	35710		6713	20044	3253
Age Group		50+		50+	50+		50+	50+	50+	40+	50+	50+
Number of Survey Sampling Frame		1		31	15		1	11	7	1	5	1
Prevalence of Blindness (Person)		1.0%		2.0%	3.0%		2.0%	Data still not released by MoH	Data analysis in process	1.7%	0.6%	2.8%
Prevalence of Blind eyes		3.8%					5.0%					4.6%
Prevalence of SVI (Person)		0.6%%		2.0%	2.4%		1.9%			1.6%	1.3%	1.7%
Prevalence of MVI (Person)		5.1%%		9.8%	9.1%		11.4%			15.4%	12.6%	8.1%
Prevalence of EVI (Person)		7.6%		12.9%	11.3%		N/A					N/A
Major Cause Blind (Person)		Cataract 53.8%		Cataract 66.2%	Cataract 81.2%		Cataract 51.4%			Cataract 66.7%	Cataract 69.7%	Cataract 79.4%
Major Cause SVI (Person)		Cataract 57.1%		Cataract 80.7%	Cataract 81.2%		Cataract 64.6%				Cataract 77.1%	Cataract 96.4%
Major Cause MVI (Person)		Cataract 65.3		Cataract 70.2%	Cataract 64.0%		URE 50.9%				Cataract 60.7%	Cataract 64.4%
Major Cause of EVI (Person)		URE 46.7%	URE 70.6%			N/A
CSC Person
<3/60		86..1%		93..2%	47.0%		93.5%			85.4%	95.1%	45.9%
<6/60		83.2%		89.0%	37.4%		89.7%			79.1%	85.3%	36.1%
<6/18		55.6%		74.0%	21.6%		69.0%			54.4%	46.6%	21.4%
CSC eyes
<3/60		74.7%			28.9%		86.9%				79.6%	41.0%
<6/60		69.5%			23.0%		80.8%				69.2%	30.3%
<6/18		46.2%			12.8%		61.9%				33.0%	16.4%
eCSC (Person)
<3/60		67.30%		eCSC data can be worked out with further analysis of raw data			73.0%					35.3%
<6/60		62.7%					69.5%					27.3%
<6/18		39.5%					52.3%					15.3%
Prevalence of RE		12.8%					28.6%					4.9%
Prevalence of URE		4.7%		11.5%			22.3%					2.7%
Uncorrected Presbyopia		84.4%		74.2%			36.4%					86.8%

The population-based survey data older than five years is considered as older evidence and it is recommended to carry out a new survey for fresh evidence. The data shown in the above table, shows Thailand and Sri Lanka’s data is older than five years. Therefore, these countries need to plan a nationwide population survey such as RAAB as soon as possible to assess their current situation. This survey information can also serve as a baseline information to set the WHA 73.4 resolution on IPEC and eCSC target for 2030.

The eREC data is only available in Bhutan[8], and not for other nine countries of the region. So, in addition to RAAB survey there is a need to carry out RESC survey in nine countries of the region.

Now the priority of WHO, IAPB, our members, other stakeholders and respective member states is the need to work collaboratively to implement IPEC and develop a strategic plan incorporating the new global targets.

[1] Lepcha NT, Sharma IP, Sapkota YD, Das T, Phuntsho T, Tenzin N, et al. (2019) Changing trends of blindness, visual impairment and cataract surgery in Bhutan: 2009–2018. PLoS ONE 14(5): e0216398. https://doi.org/10.1371/journal. pone.0216398

[2] National Blindness and Visual Impairment Survey India, 2015-2019 – A summary Report, National Programme for Control of Blindness and Visual Impairment, Director General of Health Services, Ministry of Health and family Welfare, Government of India, New Delhi

[3] Lutfah Rif’Ati , Aldiana Halim , Yeni Dwi Lestari , Nila F Moeloek & Hans Limburg (2020): Blindness and Visual Impairment Situation in Indonesia Based on Rapid Assessment of Avoidable Blindness Surveys in 15 Provinces, Ophthalmic Epidemiology, DOI: 10.1080/09286586.2020.1853178

[4] Ubeydulla Thoufeeq, Taraprasad Das, Hans Limburg et al; First Rapid Assessment of Avoidable Blindess Survey in the Maldives: Prevelance and cause of blindness and Cataract surgery; Asia-Pacific Journal of Ophthalmology: Volume 0 Number 0 2017

[5] National Survey of Blindess, Visual Impairment, Ocular Morbidity and Disability in Sri Lanka – A Report (2014-2015) Vision 2020 Secretariate, Ministry of Health , Sri Lanka

[6] Isipradit S, Sirimaharaj M, Charukamnoetkanok P, Thonginnetra O, Wongsawad W, et al. (2014) The First Rapid Assessment of Avoidable Blindness (RAAB) in Thailand. PLoS ONE 9(12): e114245. doi:10.1371/ journal.pone.0114245

[7] Marcelino Correia, Taraprasad Das, Julia Magno, Bernadette M Pereira, Valerio Andrade, Hans Limburg, John Trevelyan Jill Keeffe, Nitin Verma, Yuddha Sapkota; Prevalence and causes of blindness, visual impairment, and cataract surgery in Timor-Leste; Clinical Ophthalmology 2017:II 2125-2131.

[8] Sharma IP, Lepcha NT, Lhamo T, Ellwein LB, Pokharel GP, Das T, et al. (2020) Visual impairment and refractive error in school children

in Bhutan: The findings from the Bhutan School Sight Survey (BSSS 2019). PLoS ONE 15(9): e0239117. https://doi.org/10.1371/journal.pone.0239117

Image on top: A man puts on a school boy’s glasses/ Amal Gupta