Access matters

The 2030 IN SIGHT LIVE high-level meeting in Singapore has been an invigorating experience. Indeed, the unique success of IAPB is in convening the disparate groups of the eye health sector and focusing our combined efforts towards a common set of problems. As the session on the global targets notes, we have critical quantitative and qualitative gaps in our ability to meet the targets enshrined in the World Health Assembly’s (WHA) IPEC resolution. One of the central truths of eye care delivery is that we have low-cost and effective solutions to address the key causes of vision impairment and blindness. However, there is a chasm separating these solutions from the people who need it.

The WHA resolution 73.4 too had noted this:
…early detection and timely management, and […] cost-effective interventions – covering promotion of eye health and prevention, treatment and rehabilitation – can be made available at primary health care level … but that there are significant variations in use of, and access to, eye care services between and within populations.

I experienced the consequences and trauma of a poorly run healthcare delivery system in my childhood, which I spent in a small village near Jaipur in Rajasthan. The village had a primary health centre, but the doctor was mostly unavailable. The village had to depend on a nurse or quacks for our health needs. Many a time we had to travel 60 kilometers to seek medical care at a medical college hospital in Jaipur. 40 years ago, this was not an easy task. I still distinctly remember conversations among my parents and their friends worrying about delayed diagnosis and inappropriate primary management. The burden of poor health access continues to haunt many parts of India and other low-income countries even today.

Our experience
There is hope. I have built my career in, and am currently responsible for, a model of eye care delivery that has been pioneered at the L V Prasad Eye Institute (LVPEI). The World Health Organization too had endorsed it during the VISION 2020: The Right to Sight plan period. Starting as an advanced tertiary eye care centre in an urban setting, we spent 36 years creating this large and interconnected pyramidal network, providing the full spectrum of eye health: from promoting eye health, to treating complex eye diseases, and to offering rehabilitation for those with irreversible vision loss.

This has been a fascinating and most satisfying journey for us. Every year, the LVPEI network services over 1.5 million outpatients, performs nearly 150,000 surgeries and trains over 15,000 eye care professionals. Over half of all services are offered free-of-cost to those who cannot afford them. Our services have reached about 13,000 villages in India, while we have a physical presence in 252 villages. We now have a tertiary facility in Monrovia, Liberia and are keen to develop the pyramid there as well. The LVPEI pyramid addresses the twin challenges most low-income countries are struggling with, to achieve universal health coverage: a severe shortage of trained human resources, and a robust healthcare delivery system.

Local access
Few months ago, my colleague, Varsha Rathi, and a group from the University of Sheffield evaluated the economic and clinical outcomes of the early treatment of corneal abrasions and ulcers. Corneal abrasions are small scrapes, perhaps due to agricultural work, that people get on the surface of the eye, which when untreated becomes infected. The study was conducted in our primary and secondary centres. Published in The Lancet Regional Health – Southeast Asia journal, the study found that prompt treatment of corneal abrasions at a local health centre helps prevent the development of far more serious corneal ulceration – a leading cause of vision loss in India for those under 50 years of age. Topical eye drops for abrasions can be given out at primary care centres with good outcomes. But corneal ulcers require specialized care at urban centres with relatively poor outcomes, and the cost of treating ulcers, the travel, and the loss of a daily wage to the patient compound the problem. So, the sooner we treat, the better it is for our patients.

This is one more line of evidence that highlights the value of LVPEI’s eye health pyramid and its ability to address the key gap in healthcare delivery: access. The model brings appropriate, affordable, and high-quality primary care to remote rural areas. It also interconnects between different tiers of service, so that even the most complex cases can be identified and managed timely and seamlessly. Both these aspects: the availability of primary care and appropriate referral mechanism are crucial to an efficient healthcare system.

High-quality telehealth
When Varun was 3 months old, his mother noticed that his left eye had turned blue. The parents rushed Varun to LVPEI’s vision centre in Nagarkurnool village. The Vision Technician suspected glaucoma, where due to an increase in eye pressure the colour of the eye turns blue. The VT immediately connected to an ophthalmologist at the nearest rural secondary eye care centre in Thoodukurthy, through teleconsultation.  A detailed eye examination was arranged for Varun at the secondary centre the same day. Through a priority referral system, Varun was referred to the centre of excellence in Hyderabad where Anil Mandal, our childhood glaucoma specialist, successfully performed glaucoma surgery on him. Varun required follow up care that was provided through teleconsultation with a few physical visits to LVPEI’s secondary centre, saving the family time and money on frequent travel.

Varun’s follow-up plan exemplifies LVPEI’s high-quality network. Think about it: a vision technician running a primary care centre in a village quickly identified a difficult and complex eye condition, sought expert advice, then ensured care over time. Over these 36 years, the pyramid established a network of nodes for public access, but our investments in teleconsultation and referral have super-charged these nodes. In this case, they have empowered the technician to supplement their skills—all to the benefit of this young patient. Varun’s parents do not have to think of the opportunity cost of visiting Hyderabad; high-quality, advanced care is only a teleconsult away from their village.

Today, we are exploring new segments who could benefit from these services. Geriatric patients and patients with disabilities in rural and urban areas, for example, benefit from Homecare, an innovative, digital form of telecare. We even have had some success with telerehabilitation. In just the past year, we’ve conducted over 60,000 primary level teleconsults that allowed us to manage 84% of our caseload at primary care centers with only 16% of patients requiring referral to a higher level of care. In the last three years, ConnectCare, our telehealth app, has been embraced at every level of LVPEI’s pyramid resulting in over 250,000 teleconsultations.

The LVPEI model has the promise and experience to address access issues in eye care. I invite the delegates at 2030 IN SIGHT LIVE who are keen to understand how to address the problem of eye care access to visit us in Hyderabad, India. Together, we can work towards a world free of needless vision impairment. It will be a world where every human being, regardless of their ability to see, realises their full potential.