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“For just a hospital appointment it costs 20 taka, but any tests or medicine are extra. We cannot afford it and we come back without being treated.”
–Mohammad Akkas Molla.
Each year around 150 million people are impoverished because of high, often catastrophic health care costs. 100 million people each year are pushed into poverty and many millions more like Mohammad simply avoid seeking health care in the first place because it is unaffordable, or the quality health services people need, including eye health services, are not there.
[My Son’s Father] has been sick these last three years. We’ve spent a lot of money on his treatment. We hardly pass a day without borrowing money from people. That’s why we haven’t taken my son for treatment.”
–Mother of seven-year-old Parvez who has a speech impairment.
Universal Health Coverage (UHC) is quite simple – it says that all people should have access to the health services that they need, when they need them and that those services must be affordable. It is estimated that one billion people don’t have access to health care services[1].
To people like Parvez’s Mother and Mohammad – two participants in our Voices of the Marginalised research projects[2]– UHC is not a technical concept for health coverage and financial risk protection, but a real life, damaging and disastrous experience of what it feels like for many people, not just people with disabilities, to live without access to health care and good eye care services they need today, right now.
Sightsavers programmes work to strengthen health systems so that they can deliver effective, quality, affordable eye care services. If health systems are strong then people can thrive and go to school or work and live productive, socially inclusive lives. Evidence is showing that people with disabilities, including people who are visually impaired or blind, experience poorer levels of health than other people, while some of this is related to their impairments, a significant amount of ill health is due to barriers in accessing quality health services.
If we are to reach people like Mohammad and Parveen, and deliver UHC for all, then we need to understand better who is accessing our services, and as a consequence who is not. This need for greater understanding is driving our work on data disaggregation.
Sightsavers routinely disaggregates programme data by sex and age in order to monitor whether our interventions and strategies are reaching the right people. In addition, we have been testing approaches to disaggregation of data by disability using the Washington Group Short Set of Questions (WGSS). Increasingly this has been alongside economic status using the Equity Tool (ET) alongside the WGSS in a number of countries across Africa and Asia. This is enabling us to analyse the relationship between poverty and disability affecting people accessing our programmes.
In 2016 and 2017 Sightsavers integrated equity measurement in to Rapid Assessments of Avoidable Blindness (RAAB) – population-based eye health surveys – in Tanzania and India. This enabled us to measure wealth and disability alongside the typical measures captured in RAABs of sex, age, and location. This has allowed us to investigate how wealth and disability interplay with access to health services in our programme districts.
Overall, the integration of additional tools to disaggregate RAAB data provided important evidence on how access to quality cataract services differs by sex, disability and wealth in different settings. The results also suggest that the assumption that certain population subgroups experience disadvantage cannot be generalised, and it is important to understand the factors at play in any particular context.
Sightsavers also piloted the use of the WGSS in an urban eye health project in India. This led to the development of an Inclusive Eye Health (IEH) initiative with the goal of mainstreaming inclusion in the existing eye health programme. Accessibility is a critical aspect of inclusive healthcare, and access to health facilities, workers and medicines is critical to achieving UHC. In our India programme we worked with an organisation led by people with disabilities to conduct participatory accessibility audits of all our project facilities, and together identified infrastructural barriers to address. We then carried out several interventions, transforming primary and tertiary health facilities into more accessible and inclusive environments for all.
Recognising that exclusion is often a result of discrimination, we also trained eye health staff on gender equity and disability inclusion and raised awareness on inclusive practice at community level, closely collaborating with the government to strengthen the local health system.
A learning review of the IEH programme conducted in 2017 identified three major areas of success: improved knowledge, skills and attitude of eye health workers on disability inclusion and gender mainstreaming; increased accessibility of local eye health infrastructure; and successful targeted outreach to provide services to marginalised groups in collaboration with government and local development stakeholders. Analysis from data collected during the first 18 months of the IEH programme indicates an increase in the number of people with disabilities and women accessing eye health services.
In our experience, the process of disaggregating data by sex, age, disability, wealth and location was the initial spark that stimulated positive change and led to the development of more inclusive approaches to health care. If we are to successfully implement Agenda 2030, leaving no one behind, and achieve UHC, then equity and data disaggregation must be at the top of our list of priorities
[1]WHO World Report on Health Systems Financing (2010) http://www.who.int/whr/2010/en/
[2]Voices of the Marginalised: https://www.sightsavers.org/programmes/voices-of-the-marginalised/
Photo: “Envisioning a better tomorrow”. Submitted by Vaebhav Badola, Sightsavers India for the WSD photo competition.
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