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Disruption in eye care progress during Covid? Govt of India 'forced to revise' targets

By Arjun Kumar, Anshula Mehta, Simi Mehta, Kuldeep Singh* 

Vision loss and impairment affects more than how people see; it has implications for inequities in employment, healthcare access, and income. According to the World Health Organization (WHO), it has been estimated that 80% of vision loss is preventable or treatable. Yet, many populations do not have access to good-quality, affordable eye care.
The WHO in its 2021 Factsheet on Blindness and Visual Impairment suggests that approximately 2.2 billion people across the world suffer from vision impairment or blindness. Of these, at least a billion people have a vision impairment that could have been prevented or is yet to be addressed. According to their evaluations, 90% of vision loss is concentrated in low- and middle-income countries.
India has been a frontrunner in ensuring eye care for its population, by instituting programmes like the National Programme for Control of Blindness and Visual Impairment (NPCBVI) (1976), under the Directorate General of Health Services (DGHS), Ministry of Health and Family Welfare (MoHFW), and subsequently has made remarkable progress. However, owing to the challenges in catering to a large population, and evident gaps, a renewed thrust towards comprehensive and universal eye care is required.

Eyecare statistics

According to the Population Census of 2011, 2.2% of the population had disabilities, and the percentage of persons with Disability In Seeing (excluding those with multiple disabilities) was 0.4%.
The Survey of Persons with Disabilities in India conducted under the 76th Round (July – September 2018) of the National Sample Survey also reported a 2.2% prevalence of disability in the population, similar to the 2011 Census. The percentage of persons with Visual Disability (with or without any other disability) stood at 0.2% according to this Survey.
The Rapid Survey on Avoidable Blindness and the National Blindness and Visual Impairment Survey, conducted under the NPCBVI report the prevalence of blindness over several years.
It is important to note that over time there has been improvement. The National Blindness and Visual Impairment Survey India 2015-19 indicates a 0.36% prevalence of blindness and 2.55% prevalence of visual impairment in the country. This survey uses better techniques and indicators at par with global standards, incorporating more inclusionary criteria.
Key findings from the Survey suggest that cataracts are the leading cause of blindness and visual impairment among the population aged 50 years or over, accounting for blindness in 2 out of 3 persons and vision impairment in 7 out of 10 persons in this segment.
The Survey also puts forth that
“The WHO Global Action Plan for Universal Eye Health 2014-2019 targets a reduction in the prevalence of visual impairment by 25% by 2019 from the baseline level of 2010. The WHO estimated a prevalence of blindness, MSVI and VI as 0.68%, 4.62% and 5.30% respectively in India for the year 2010. The current survey shows a reduction of 47.1% in blindness, 52.6% in MSVI and 51.9% in VI compared to the baseline levels. This shows that the target of 25% reduction in visual impairment have been achieved successfully by India.”
However, it is important to note that the International Agency for the Prevention of Blindness (IAPB), on the basis of the VLEG/GBD (Vision Loss Expert Group/Global Burden of Disease study) 2020 Model, reports that in 2020 in India, there were an estimated 270 million people with vision loss, of which, 9.2 million people were blind. Notwithstanding the recent national figures, these estimates by IAPB are multiple times, which raises questions and requires further scrutiny.

National programme: progress and issues

The National Programme for Control of Blindness (NPCB) was launched as a 100% Centrally Sponsored scheme in 1976 with the aim of reducing the prevalence of blindness from 1.4% to 0.3 % (by 2020). It was later renamed as National Programme for Control of Blindness and Visual Impairment (NPCBVI) in 2017.
According to the 2021-22 Annual Report of MoHFW, the programme currently provides primary and secondary eye care services within the National Health Mission (NHM) framework with cost-sharing between Centre and States. Under the National Health Policy (NHP), the target is to reduce the prevalence of blindness to 0.25% by 2025 . The MoHFW fixed a target of 330 lakh cataract surgeries with an annual target of 66 lakh cataract surgeries under NPCB during the 12th Five Year Plan (2012-2017).
The Quarterly Review of the Programme (September 2019) highlights major issues such as low utilization of allotted funds by most states, poor physical performance by many states, and delay in NGO payments (for performing cataract and treatment of other eye diseases) by District Programme Officers.
Over time, the programme has maintained a phenomenal pace in achieving its targets for cataract operations. However, with the onset of the COVID-19 pandemic in 2020, the programme performance has seen a decline. Several media reports bring to light the backlog of cataract surgeries and the government’s push to clear it, with a proposed total of 270 lakh surgeries to be carried out over the next three financial years (2022-23 to 2024-25).
Similarly, other programme activities – provision of free spectacles to school children suffering from refractive errors, treatment and management of other eye diseases, collection of donated eyes, and training of eye surgeons – have been carried out at a rapid pace over the years, but have seen a dip amid the pandemic.
Further, a Parliamentary Standing Committee on Health and Family Welfare in March 2021 noted that there had been underutilisation of funds earmarked for the purposes of capacity building of personnel, which requires attention. (See: One Hundred and Twenty-Sixth Report on Demands for Grants 2021-22 [Demand No 44] of the Department of Health and Family Welfare – March 2021.)
A cursory look at the expenditure of the NPCBVI, as reported in a 2022 release by the Press Information Bureau, suggests the backlog and impact of COVID-19 on the financial aspects. The total expenditure for the FY 2018-19, 2019-20 and 2020-21 was ₹ 396.8, 331.6 and 227.4 crore respectively. Moreover, the approval of expenditure for FY 2021-22 was increased to a whopping ₹ 724 crore.
However, owing to the second and third wave of the COVID-19 pandemic in 2021-22, the utilisation has been a mere ₹ 140.5 crore, or around one-fifth of the approved expenditure. There are also state-wise variations in the achievement levels as elucidated in the press release. Thus, there is an urgent need to reinvigorate NPCBVI and the eye care sector by the Central and State Governments, addressing unmet target demands and unspent funds.

Way forward

The COVID-19 pandemic has disrupted India’s progress in the provision of eye care over the past two years. The government has revised programme targets and set out to clear the backlog of cataract surgeries with a plan for the next three years.
However, concerns regarding administrative and logistical glitches, and delays in payments to voluntary and private organisations under the NPCBVI remain a roadblock in strengthening its reach and achievement. The renewed focus on universal and timely eye care intervention must be taken forward as a priority - implementation remains the crucial challenge.
The available data on vision loss and eye care is, for the major part, programme related, from various official sources. There is a need for a centralised real-time data system, which takes into account eye care interventions in the private and NGO sector, to arrive at a complete picture. Moving ahead, initiatives such as Digital India and Ayushman Bharat Digital Mission must take the lead in integrating health and eye care records with findings from regular, periodic, dynamic and real-time surveys, to build a comprehensive statistical repository on eye care.
Government figures reflect a reduction in prevalence of blindness and visual impairment in the country over the years, however, it is also seen that data, such as that from the VLEG/GBD 2020 Model, presents the current prevalence to be multiple times of the official figures. This requires further assessment.
Existing eye care programmes must be strengthened and expanded, and infrastructure and ophthalmic equipment be maintained and upgraded. Availability, accessibility, and affordability must be at the centre of efforts in ensuring universal eye health.
As the country’s population grows and ages, the burden of vision impairment and blindness will continue to increase, if mechanisms for timely and effective intervention are not maintained and strengthened. With India at 75, and moving towards India@2047, the importance accorded to eye care and eye health will be crucial in the coming years.
Policy must move forward with a view to maintain India’s eye care ecosystem as a strength and asset, towards shaping the growth, wellbeing and self-reliance of the country and its ageing population in the years to come.
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*Arjun Kumar, Anshula Mehta and Simi Mehta are with IMPRI Impact and Policy Research Institute, New Delhi, and Kuldeep Singh is Program Manager, India and Bangladesh, Seva Foundation, USA. This article is an outcome of a research project supported by Seva Foundation, USA. For full report click here

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