THE AIM OF VISION 2020
The three major strategies by which Vision 2020 intends to achieve its objective are (1) disease control,
(2) human resource development, and (3) the advancement of infrastructure and appropriate technology.
The steps this global partnership takes to address the problem of blindness include:
1. increasing awareness of blindness as a major public health issue and campaigning for the right to sight for all people;
2. boosting consciousness among policy makers, donor agencies, and government health functionaries to allocate more resources to eliminate avoidable and treatable blindness;
3. implementing and monitoring specific programs to control and treat the major causes of blindness;
4. training various cadres of eye care professionals, particularly in the developing regions of the world;
5. creating an infrastructure for the delivery eye care service;
6. developing and disseminating appropriate and accessible technology; and
7. integrating eye care into general healthcare services.
These goals express the vision of the initiative, and they are supported by an understanding of global blindness gained through population-based studies and educated estimates.
ESTIMATES OF GLOBAL BLINDNESS
The very first estimate of global blindness, made in 1972 by the WHO,1 was 10 million to 15 million people, a figure thought to be a gross underestimate at the time. Nearly 80% of the visual impairment cited was treatable or preventable, and 90% of the world's visually impaired lived in developing countries. The latest estimate by the WHO, released in 2004 and based on the 2002 world population,2 documents that significant changes have taken place in the prevalence and magnitude of visual impairment—some encouraging, and some not so encouraging. The new statistics claimed that 37 million people around the world were blind, including 1.4 million children (under the age of 15), and that 124 million had low vision that resulted in a total (in excess) of 161 million visually impaired people. This number does not include those with vision impairment due to uncorrected refractive error.
The WHO suggests that 75% of visual impairment is avoidable, much of which is caused by four specific, aging-related conditions. Unoperated cataract is still the leading cause of blindness (47.8%), particularly in developing countries. Glaucoma (12.3%), age-related macular degeneration (8.7%), and diabetic retinopathy (4.8%) have become major causes of avoidable blindness as well. The pattern of visual impairment varies from region to region, necessitating a more context- and geography-based approach to programs aimed at reducing the incidence.
REFOCUSING VISION 2020
When the WHO set goals in 1999 for the Vision 2020 initiative, its objective was based on available statistics. The priority diseases were cataract, trachoma, onchocerciasis, corneal opacity, childhood blindness, and glaucoma—all potentially preventable or treatable causes of blindness. The new statistics, however, have prompted a reconsideration of the goals and a redefinition of Vision 2020, which includes the recognition that blindness prevention must also encompass the rehabilitation and education of persons with irreversible and unavoidable vision loss.
In the 5 years since Vision 2020's initiation, there has been a documented decrease in global blindness.2 However, much remains to be done, particularly in regions of the world where the magnitude of vision loss is greatest and the human and material resources are minimal or completely absent. Although changing demographics have increased certain kinds of blinding conditions in the developed world, they have placed additional stresses on the poorest countries, where the health sector has always been under strain. These countries have also to deal with the attendant problems of globalization—changing lifestyles, pollution, a higher risk of trauma, displaced communities, and skewed development priorities.
A significant achievement for Vision 2020 has been the involvement of national and local groups in the eye health movement. We hope to move forward with this involvement and develop a high-quality, sustainable eye care delivery system. A four-tier pyramid model that encompasses the creation of a permanent and collaborative infrastructure at every level of eye care has been proposed and is being developed by L V Prasad Eye Institute in Hyderabad, India. The base of the pyramid represents crucial community involvement. “Vision guardians” from the community are trained to monitor the eye health of a population of 5,000, which is usually spread across a cluster of villages. At the next level are “vision technicians,” who work at vision centers that operate independently or are attached to specialized primary health centers. The vision centers' staff are trained to perform refraction and to screen for vision-threatening conditions. One such center is developed for 50,000 people. The next level of secondary care, the “service center” (rural or urban), includes a staff of ophthalmologists, ophthalmic technicians, ophthalmic nurses, rehabilitation professionals, and management personnel. The focus of this level is comprehensive eye care and includes modern cataract surgery, the diagnosis of all eye diseases, prevention programs, and community-based rehabilitation. This level assists a population of 0.5 to 1.0 million. The training center, which serves a population of 5.0 million, combines service delivery at the tertiary level with training and research. Beyond this is the “center of excellence,” which performs the entire gamut of eye healthcare functions. At this level, the emphasis is on providing a model of excellence in all respects of eye care and active participation in formulating eye care policy. Essentially, the levels at the bottom of the pyramid emphasize service delivery, the upper two levels emphasize training, and the “center of excellence” level incorporates research, innovation, and policy.
Although Vision 2020's focus remains on controlling the major causes of avoidable blindness, it cannot ignore the larger context of the causes that lead to blindness. Encouraging systems of governance from the national down to the community level to “buy in” to these efforts is a priority. Another goal is the mobilization of resources in more creative ways, such as widening the network of stakeholders, which involves including more corporate partners to share resources in Vision 2020 and the sharing of local knowledge and experience by community-level organizations that should work in closer coordination with each other. The idea of and approach to training caregivers have undergone a shift, from a concentration on medical professionals to the development of “eye care teams” that combine medical, research, technological, and community mobilization skills to deliver high-quality eye care in poor conditions. As evidenced by the pyramid model, there is a renewed commitment encouraging countries and communities to establish permanent infrastructure to enable eye care to be delivered in a sustainable manner. Finally, every Vision 2020 program conveys the idea that better eye health is not just about improving visual acuity, but improving lives.
Gullapalli N. Rao, MD, is Chairman, Board of Trustees, and President of the International Agency for the Prevention of Blindness, and Distinguished Chair of Eye Health, at the L V Prasad Eye Institute in Hyderabad, India. Dr. Rao may be reached at +91 40 3061 2345; gnrao@lvpei.org.
Usha Raman, PhD, is a Communications Consultant with the International Agency for the Prevention of Blindness and L V Prasad Eye Institute in Hyderabad, India. She may be reached at +91 40 3061 2567;
usharaman@lvpei.org.
1. Thylefors B, Négrel A-D, Pararajasegaram R, Dadzie KY. Global data on blindness. Bull World Health Organ. 1995;73:1:115-121.
2. Resnikoff S, Pascolini D, Etya'ale D, et al. Global data on visual impairment in 2002. Bull World Health Organ. 2004;82:11:844-851.
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