Chapter 2: Strategic Approach to Market Shaping

Barriers addressed

• Lack of global awareness and consistent data on the prevalence and impact of uncorrected refractive errors.

• Lack of data on quality of eye care and eye care capacity in countries.

• Fragmentation of efforts to address uncorrected refractive errors, often led by a variety of NGO implementers.

Rationale

A coordinated effort that is informed by better data will ensure a more effective use of available resources and achieve better outcomes.

Proposed activities

• Standardise data collection across countries – on the magnitude of refractive errors, uncorrected refractive errors, and the quality of eye care – to monitor progress to reduce the global burden of uncorrected refractive errors and integrate indicators into health management information systems.

• Consolidate existing market intelligence and conduct further market research around low-cost suppliers and demand in LMICs.

• Develop global cross-sector collaborations around proven delivery platforms – such as school eye health – to 1) coordinate and accelerate global efforts; 2) mobilise political will; 3) increase donor commitment to address uncorrected refractive errors; and 4) enhance exchange of learning across countries.

Target outputs

• Increase in quality data to guide investment and prioritisation.

• Cross-sector collaborations to accelerate national-scale solutions that have been proven at the district level.

• Quality data influences activities under Strategic Objective 2.

Long-term outcome

Governments and donors prioritise efforts to address uncorrected refractive errors and support scaling of proven models.

Barriers addressed

Refraction services (human resources)

• Shortage of qualified professionals to provide refraction services.

• Lack of standardisation of training standards, accreditation mechanisms, and clear legislation to allow for refraction and dispensing of eyeglasses across countries.

Refraction services (devices)

• Limited uptake of innovative devices for screening and diagnosis that are mobile, less expensive, and require less training.

Customised eyeglasses

• Complex and expensive supply chain for customised eyeglasses.

• Limited uptake of ready-to-assemble solutions that can serve 80% of the need.

Rationale

• A simplified delivery model supported by global guidelines has the potential to standardise provision requirements at multiple levels and to resolve questions around the appropriate use of new screening and refraction devices.

• Decentralising screening and refraction through task-shifting and new technology can lead to a reduction in barriers related to personnel, infrastructure, costs, and reach of services.

• Evidence is needed to show that increasing trained mid-level eye care workers does not impact the business of current practitioners, who often lobby through professional bodies against task-shifting.

Proposed activities

• Develop guidance on a simplified delivery model, and on minimum competencies and training standards to refract, prescribe, and dispense eyeglasses in LMICs, leveraging a consensus-driven process with relevant stakeholders.

• Support uptake of innovative screening and refraction devices that simplify service delivery by achieving consensus on research standards and generating additional implementation and cost-effectiveness evidence.

• Build partnerships with optometric professional associations in various countries to promote uptake of ready-to-assemble eyeglasses, and new screening and refraction devices.

• Analyse impact of increasing the number of mid-level eye workers trained in refraction on ophthalmologists/optometrists’ existing demand.

• Develop advocacy tools to lobby governments for tax exemption or lower import duties on low-cost unbranded lenses and frames.

Target outputs

• Global guidance on task-shifting and required training standards in service delivery for low-resource settings.

• Accelerated adoption of innovative screening and refraction devices, and ready-to-assemble eyeglasses.

• Advocacy points to support task-shifting with optometric professional bodies.

• Global guidance influences activities under Strategic Objectives 3 and 4.

Long-term outcome

• Enhanced access to refraction services and eyeglasses for individuals, due to the broad adoption of simplified service delivery models that are more affordable and effective in addressing uncorrected refractive errors.

• Global guidance is utilised by relevant bodies, such as Higher Education Commissions, to increase number of individuals who can refract, prescribe, and dispense eyeglasses.

Barriers addressed

• Lack of planning, budgeting, and low levels of government procurement for vision services.

• Limited service delivery points, due to high-cost equipment and limited number of trained personnel, leading to vision centres being concentrated in urban centres.

• Limited public financing for eye care and provision of eyeglasses.

Rationale

• Use of eyeglasses has a measurable impact on education, literacy, road safety, and productivity.

• Inclusion in UHC or insurance schemes can drive uptake and access.

• Proven models to increase access to eyeglasses exist, such as school eye health and integration of vision centres into public facilities. Scaling up these models will require government leadership to create an enabling environment (e.g. regulation and logistics).

• CHWs can serve as an access point for reading eyeglasses with minimal training, but more operational evidence is needed to prove this model is sustainable.

Proposed activities

• Advise LMIC governments on WHO-recommended eye care interventions and public financing schemes to promote coverage of part or total costs of screening, refraction, and eyeglasses provision in low-resource settings.

• Support LMIC governments to develop and implement a costed plan for eye care, integrated in national health strategic plans and aligned with UHC objectives – the plan should incorporate proven cost-effective interventions, such as school eye health programmes and vision centres providing refraction services in public facilities.

• Build operational evidence on the role of government-managed CHWs to serve as points of triage to dispense reading eyeglasses and identify individuals in need of more advanced eye care – in particular, generate evidence on integration of eyeglasses into government-managed supply chains, and analysis of the incremental cost of adding this service offering to existing programmes.

Target outputs

• National eye health programmes that include refraction services and eyeglasses.

• Increased number of access points offering refraction services and eyeglasses.

• New screening and service delivery models developed and implemented through the public sector.

• Increased procurement of eyeglasses in the public sector.

Long-term outcome

Increased access to refraction services and affordable eyeglasses through sustainable public sector programmes.

Barriers addressed

• Focus on high-income segments by private sector.

• Lack of affordable products in LMICs.

• Limited service points, especially in rural areas of LMICs.

Rationale

• Regulatory barriers (as addressed in Strategy Objective 2), especially around who can prescribe eyeglasses as well as high internal distribution costs, make LMIC markets less attractive to suppliers in terms of price, logistics, and availability of trained human resources.

• Inclusive business models exist that show promise to reach the base of the pyramid and other market segments with affordable high-quality eyeglasses and appear economically viable.

• Catalytic investment in pipeline development, refraction, and business training can increase the availability of a workforce to attract and support private sector businesses.

Proposed activities

• Leverage existing last mile retail or pharmacy chains to sell reading glasses, e.g. providing them with tools on procurement and inventory management, and market data around reading eyeglasses, such as pricing and regional style preference.

• Develop business cases to replicate and scale successful inclusive optical business models to other regions.

• Set up blended finance vehicle to support start-up of inclusive optical businesses and scaling of high potential innovators in LMICs.

Target outputs

• Create a competitive business environment that can drive prices down while maintaining high quality.

• Increased access points through the private sector.

Long-term outcome

A sustainable and inclusive private sector providing quality products and service at low cost to remote and/or low-income communities.

Barriers addressed

• Low awareness: Many individuals either do not recognise they have a vision problem or are not aware that simple corrective treatments exist.

• Low acceptance: When individuals are provided with eyeglasses, compliance remains an issue due to style and attractiveness, cultural biases, stigma, or misconceptions around eyeglasses.

Lack of understanding of the economic benefits of correcting vision impairment by private stakeholders.

Rationale

• Additional evidence is required to better understand the causes of and mechanisms to overcome compliance challenged

• Demand generation is under-funded due to the misconception that individuals are aware of their poor vision and will seek treatment when they can.

Proposed activities

• Develop an investment case and toolkit for demand generation at the global level – this can include guidance on how funds could be deployed, lay out best practices, and consolidate the available evidence on behavioural change communication and compliance.

• Integrate and contextualise demand generation activities into governments’ national plans and mobilise funding around them.

• Engage with regional industry federations (e.g. in textiles and transport) to include workplace vision screening in employee health programmes, provide technical support, and understand how workplace vision screenings generate demand in the marketplace.

Target outputs

• Increased awareness and care-seeking for poor vision.

• Increased compliance with eyeglasses wearing.

• Demand generation activities supporting activities under Strategic Objectives 3 and 4.

Long-term outcome

Decreased prevalence of uncorrected refractive errors as populations in need become aware of eyeglasses as a potential solution to vision problems, are care-seeking for eyeglasses, and are regularly wearing eyeglasses.