Tackling vision care in a resource-limited world
As the world experiences various stages of the Covid-19 pandemic, focus on other public health issues, including vision, is reduced. This is understandable as we must save lives and address the immediacy of the moment.
Is it possible, though, to take an approach that allows for the allocation of resources for other public health issues, including vision, while at the same time continuing to fight the pandemic?
We recently talked to Allyala Nandakumar, Professor of the Practice, Brandeis University, Chief Economist at the Office of the Global AIDS Coordinator, USA and VII Advisory Board Member to get his thoughts on this challenging scenario.
VII: Much of your work has been focused on how to allocate resources for the biggest health challenges of our time. What does the resource landscape look like as we currently deal with a global pandemic?
AN: We are entering an extremely resource-constrained environment. Even prior to the pandemic, we were seeing an increase in the debt-to-GDP ratios of many low- and even middle-income countries. The pandemic will lead to a decline in economic growth, with countries dependent on tourism, mineral exports, and global supply chains being the most affected. It’s also likely we’ll see the demise of many small businesses.
At the same time, the pandemic will require increased investments in health. There will be pressure to increase spending on social safety nets like unemployment benefits, food assistance, and loan write-offs. This will further limit resources and the ability of countries to fund new areas in health.
It is important to note that, in the African context, the traditional institutions no longer hold the majority of the debt, so finding debt solutions through groups like the Paris Club (which traditionally helped institutions reduce debt) will be unavailable.
VII: How do we ensure that poor vision continues to remain on the financing agenda?
AN: The most important thing to do is ensure that we sustain the gains that have already been made. In some instances, it has taken decades to achieve these gains and the disruptions to health care systems has the potential to wipe them out. It is important to keep in mind that during past crises, like Ebola, more people died due to the disruption of routine services than from the disease itself.
Pandemics kill in three ways: through the virus itself; through disruptions to the health care system, and through the economic stress and crisis. If we do not stay laser-focused on sustaining and protecting the gains we have made in improving access to vision care services, we run the risk of undoing decades of hard work in a very short time.
VII: There have always been competing health priorities around the world. Are there examples where those competing priorities were tackled together as a result of limited funding?
AN: The way forward is not just to see how to bundle different aspects of health, but to ensure that we take a more holistic view of the “wellbeing of the household.” The lesson from global health is that one needs champions to put issues on the agenda of donors, global institutions, and country governments. Think of primary health care, HIV, tuberculosis, malaria, vaccine development, child health, and family planning. Each has a strong constituency that advocates and puts pressure on all actors to invest in these areas.
An interesting development in global health has been the rise of individual philanthropies that are becoming increasingly influential in shaping and driving the global agenda. The Gates Foundation is an example of philanthropy that has brought attention and investments to key areas of global health. As donor assistance is reaching a plateau, we’ll see an increase in the influence of these philanthropies at the global institution and country levels. Countries are deciding on their own priorities, and the influence of donors is declining. With these realities, there needs to be a reset in the dynamics between donors and countries, between international agencies and their funders, and most importantly between the people and their governments.
In the past, we have been too focused on working through governments. We’ve seen that communities have great strength in defining health priorities. For critical issues in health, including in vision, to come to the fore, we need to figure out how to use the “demand-side lever” from these communities to push for change.
VII: Is there an opportunity to integrate vision care into another complementary health issue when it comes to funding?
AN: Absolutely. Many countries have committed to achieving Universal Health Care (UHC). There has to be a concerted effort to make vision care part of the UHC benefit package and part of insurance benefits. There is a proven link between vision care, individual productivity, and economic growth.
We have spent a lot of time talking to Ministries of Health. We need to engage Ministries of Finance, the office of the President or Prime Minister. Vision care is viewed today as a “private good.” We need to change the dialogue to emphasize that this is a “merit good.” In other words, while there is a benefit to the individual, there is an even greater benefit to society. We need to be smart, strategic, and focused.
VII: How should we position vision as a priority when it comes to attention, time, and money?
AN: There is a very important equity dimension to this. The poor, vulnerable populations, girls and women, are disproportionately affected. The rich have the resources to take care of themselves. Market segmentation and domestic resource mobilization will be key to ensuring resources are available for vision care. Unlike other health issues, depending on donors to fund the response might not be a prudent approach. We must focus on countries where we think there is the possibility of achieving results at scale. Essilor, One Sight, and VII have demonstrated that with strategic investments and high level engagement one can achieve results.
VII: How can the public and private sectors work together to bring solutions to poor vision?
AN: This has to be an “all-of-domestic” and “all-of-market” approach. The private sector can bring new technologies, new service delivery models (e.g. Eye Mitra), and global supply chains to increase access and reduce costs. What we need from governments is to create the enabling environment, regulations that foster innovation, and the push to integrate vision care services into government programs
VII: How can governments ensure that vision care becomes part of country-owned health systems?
AN: It’s clear we need strategic engagement at the highest levels of governments and an actionable plan. It’s also critical to include vision care as part of UHC and social and private insurance plans, develop clear messaging that highlights the importance of vision care for the population, and work with donors to leverage innovative financing vehicles. The bold vision that was released last year during UNGA was a major step. We now need to take advantage of the window of opportunity.
While it is important to focus on global institutions, we should never lose sight of the fact that decisions are ultimately made at the country level, and the success of getting vision care to the billions that need it will be a country-by-country effort.