Introduction

The World Health Organization (WHO) division of the Southeast Asia region consists of 11 countries, namely Bangladesh, Bhutan, DPR Korea, India, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka, Thailand and Timor-Leste. The population of these 11 countries at 1761 million is approximately 26% of world population. Using the published information, the WHO reported the global data on visual impairment 2010 of all six WHO regions [1]. As per this estimate, 4.24% people of world were visually impaired—0.58% blind (visual acuity <3/60) and 3.65% impaired vision (visual acuity <6/18 ≥ 3/60). This amounted to 39.365 million people blind and 246.024 million people with impaired vision (a total of 285.389 people with any kind of visual impairment). The report also stated that 12.049 million blind people and 78.482 million people with vision impairment live in the Southeast Asian region. This amounts to 30.60 and 35.89% of world’s blind and impaired vision people, respectively. The World Health Organization (WHO) 2010 data [2] documented many key parameters that form the base line data for implementation of the global action plan (GAP) to universal eye health as stipulated by WHO resolution 66.4 [3].

In this midway analysis between 2010 and 2019, we collected data from 10 of 11 member states of the region and added additional information form the recently published papers. The key data were compared with the 2010 WHO data.

Methods

The data collected from the International Agency for Prevention of Blindness (IAPB) country chairs (10 of 11 countries, with exception of DPR Korea) included information regarding the national health policy, national health expenditure, insurance and out-of-pocket expense for eye health care, the strength of eye health personnel, training and future man power planning and presence of the international non-governmental organization (INGO). In addition, we also accessed the PubMed referenced recent articles using the key words “blindness,” “low vision,” “vision impairment,” “south east Asia” from January 2000 to December 2015. This was confined to reports on adult and pediatric population blindness survey and two principal causes of visual impairment—the cataract and the uncorrected refractive error. Other disease specific data such as trachoma, corneal blindness, glaucoma and diabetic retinopathy were not included in the analysis.

Results

A number of population-based survey publications are available on blindness and visual impairment in the Southeast Asia region [4–31]. While all these studies have estimated the prevalence and causes of blindness and visual impairment, few studies have looked at the eye care service profile in the Southeast Asia region [2]. The current situation analysis of eye care service in the Southeast Asia region is as follows.

Health indices

Life expectancy has increased in all member states. In general, females live longer than males. The life expectancy for males at 73.13 years was highest in Maldives and at 64 was lowest in Myanmar; for the females it was highest in Thailand (79 years) and Maldives (74 years) and lowest in India and Myanmar (68 years). The mortality rate under 5 years age was highest in Timor-Leste (54.6/1000 live births) followed by India (52.7/1000 live births) and lowest in Sri Lanka (9.6/1000 live births) and Maldives (10/1000 live births).

Blindness and low vision

The blindness prevalence data were not available from Maldives. It was low in Bhutan (0.33%), Nepal (0.35%), Myanmar (0.58%) and Thailand (0.59%). It was around 1% in Indonesia (0.9%), India (1%) and Bangladesh (1.6%) and apparently high in Timor-Leste (4.2% for 40+ age group).

National eye health policy

The Ministry of Health (MoH) in each country is responsible for all health-related policies and planning. The VISION 2020 is operational in all countries. But only five countries in the region have an established national eye health plan. They include Bangladesh—the Bangladesh National Control of the Blind (BNCB); India—the National Program for Control of Blindness (NPCB); Indonesia—Ministry of Health, National Eye Committee; Nepal—Apex Body of eye health; and Thailand—the National Committee of Eye Care services.

Eye health expenses

The expenditure as percentage of national gross domestic product (GDP) for health in general was highest in Maldives (7.3%) and lowest in Myanmar (0.99%); all other member state expenditure was between 4 and 6% of GDP. There was no knowledge of eye care expenses specifically.

Insurance and out-of-pocket expense

Insurance of eye health care is not uniformly distributed. Eye care is solely provided at the government cost in Bhutan and Myanmar; the government of Maldives has insured all people in the country; primary eye care is delivered at no cost to the patients in Nepal at village level; and the government of India offers incentive to non-government health providers for free eye care. However, a major challenge lies in accessing free eye care in nearly all member states. All the same, there is out-of-pocket expense in most instances; at 20%, it is lowest in Thailand and probably higher in other countries.

Integration with general health delivery system

The eye health is not integrated into general health system in all countries of the region. It is mostly integrated into Bhutan and Sri Lanka at the primary level; the government of India and Nepal is experimenting in few areas of the country.

Strength of eye health personnel

Complete data of all cadres of eye health workers were not available in all countries. This was particularly true for eye care nurses since in many instances there was no clear separation between a general and eye care nurse. Compared to year 2010, the number of ophthalmologists has increased in all countries except Timor-Leste. But the distribution in the general population was appreciable (1:100,000) only in few countries—Bhutan, India, Maldives and Thailand. Most ophthalmologists in all countries are located in urban areas only. Additionally, Bhutan and Maldives have their specific terrain difficulties. In general, the availability of auxiliary ophthalmic personnel (AOP) was insufficient.

Cataract surgery rate as surrogate for eye care services

Cataract surgical rate (CSR) at 5050/million people was highest in India and was followed by Sri Lanka (5030/million). But it was below the target in many countries. The cataract surgical coverage (CSC) at 95% was highest in Thailand followed by Sri Lanka (86%) and Nepal (80%).

International non-governmental organizations

Many international non-governmental organizations (INGOs) work in Bangladesh, India, and Nepal followed by Indonesia and Timor-Leste. None of the INGO currently have presence in Maldives, and one INGO, the Himalayan Cataract Project (HCP), works in Bhutan.

The details are listed in Table 1.

Table 1 Comparative statement of eye care service delivery in year 2010 and 2014 in Southeast Asian countries
Full size table

Discussion

In May 2013, the 66th World Health Assembly (WHA) endorsed resolution WHA 66.4—the “universal eye health: a global action plan (GAP) 2014–2019” [3]. The WHO set a global target of reduction in prevalence of avoidable visual impairment by 25% by 2019 from the baseline of 2010. The GAP 2014–2019 is intended to serve as a road map to consolidate joint efforts aimed at working toward universal eye health in the world. The WHO collected the year 2010 base line data. The Southeast Asian member states exchanged each country data annually, and the information collected here (Table 1) is the current data in key areas. This helps in the region’s preparedness for implementation of universal eye health by year 2019.

Available blindness data are at best patchy in a few countries. While it is possible that blindness will reduce in all countries in the region, it is difficult to forecast the actual number. The high burden of blindness in the Southeast Asia region continues with below target cataract surgery in many countries. Two main causes are the un-operated cataract and uncorrected refractive error, though there is a need to shift the exclusive focus from cataract to other emerging causes of blindness, such as glaucoma and diabetic retinopathy in countries where a good cataract surgical rate and good cataract surgical coverage are already achieved [32]. An effective control of the chronic diseases such as diabetic retinopathy and glaucoma requires a different planning and implementation because both detection and treatment of these diseases are a lot more different than cataract and refractive error-related blindness and visual impairment. This calls for greater emphasis on training and developing the required skills in mid-level ophthalmic personnel and the ophthalmologists in the entire region [33, 34].

The utilization of services in rural population is inadequate in all countries [35, 36]. The healthcare personnel are also mostly urban centric. What is the remedy? One of the ways is the mass community service that is practiced in certain countries in the region, particularly, in India and a few neighboring countries. But this is only a temporary solution. A tier model of eye care service, adequate for the area, affordable and accessible to people is increasingly tried with a greater degree of success [37, 38].

In general, health and disease are linked to poverty; eye disease is no exception [39]. While the various governments will continue to improve the economics of the country, the current eye care delivery model in this region has to be unique that could deliver quality eye care in most equitable manner [40]. The current preparedness in most regions is inadequate and needs a greater thrust to achieve the WHO stated goal by the year 2019.

Conclusion

Provision of comprehensive eye care thorough different models of fixed facility at the district/provincial level coupled with adequate training, both in quantity and in quality, of people possibly help bridge the gap and achieve universal health coverage. Further, increasing financial allocation and periodic monitoring of disease burden are critical for the success of eye care programs across the region.