Financial protection is essential to increase effective refractive error coverage equitably.

Abstract

Financial protection is essential to increase effective refractive error coverage equitably We were pleased to read the letter from Fardow highlighting the need for public funding to improve access to refractive error services. Fardow's call speaks to the ambitious targets for effective service coverage for refractive error (eREC) all countries signed up to at the World Health Assembly in 2021 (alongside targets for effective service coverage for cataract [eCSC]). Depending on the context in each country, increasing eREC will involve improving refractive error services in terms of one or more of access, quality or financial protection— the latter of which can be provided via public funding. It remains unclear how increasing eREC might happen, with very little evidence on how to improve access to refractive error services equitably. Fardow outlines the situation in the UK and Sweden. However, we clarify that the four devolved nations within the UK each take a different approach to eye care services and funding. In England, only those who meet certain criteria are eligible to have their eye examination covered by the National Health Service (NHS), predominantly children, those on a low income, people with diabetes, those at risk of glaucoma or who have a high refractive error. For all others there is a charge, whereas in Scotland eye examinations are covered by the NHS for all UK residents. Optical vouchers of different values dependant on prescription level are issued to certain eligible groups. The constant underfunding of NHS sight test fees is increasingly taken as evidence that the UK government is not taking seriously prevention, eye care or the current crisis in ophthalmology (due to a shortage in the number of ophthalmologists being trained and a backlog in ophthalmology services due to Covid19). Yet despite the NHS covering the cost of both vision tests and provision of vouchers for spectacles for children, the refractive requirements of children are not being fully met. Two examples of this within the UK are the Born in Bradford study and the Villa Vision project. Born in Bradford has a ‘Glasses in Classes’ project that was designed to explore if schools could support children wearing their glasses. 15% of a large cohort of over 16,000 children aged 4 to 5 years failed vision screening with 4.4% identified as having vision impairment. Villa Vision is a partnership between Aston Villa Football Club, Aston University and Essilor. This project aims to raise awareness of the importance of eye examinations and eye health, and crucially how to access it. Over 2,100 children have participated in the Villa Vision interactive classroom workshop. Around 1,700 children have been vision and colour vision screened within their school setting and 100 pairs of spectacles have been dispensed to those children who need them. The critical aspect alongside the lack of government funding for universal primary eye care and provision of refractive correction is that awareness of the importance also needs to be addressed primarily in those underserved communities. Both these initiatives are striving towards this goal. To these observations we would like to add some reflections from Aotearoa/New Zealand, which has even less financial protection for refractive error care, with only two publicly funded schemes operating. One scheme covers the cost of an annual eye examination and subsequent spectacles for children ≤15 years whose parents receive social support and who have agespecific levels of refractive error or at least mild vision impairment (6/12 or worse in the better eye) due to refractive error. The second is an annual subsidy for contact lenses for anyone with ≥10D of refractive error or with keratoconus. In the context of these very limited protections, it is unsurprising that we recently identified a substantial unmet need for refractive error care in a suburb with high arealevel deprivation in Auckland, the largest city in Aotearoa. We offered a full eye examination and subsequent treatment— including referral and refractive error correction as indicated— for adults ≥40 years of age identified with distance or near vision impairment during a pilot populationbased study that recruited people doortodoor. A Covid19 lockdown has suspended the project, but we have so far examined just over 200 people (60% female, median age 63 years). Among this population— all of whom were vision impaired and lived within 4km of an optometrist— half had never had an eye examination and almost threequarters had never owned custommade spectacles; more than twothirds of these participants reported cost as the main barrier to accessing eye care. Aotearoa has never had a populationbased survey to estimate eREC, but these findings suggest refractive error services must become much more accessible for the World Health Assembly targets to be met by 2030. To identify potential strategies we can look to Australia, where a recent national survey found that more than 9 in 10 nonIndigenous and more than 8 in 10 Indigenous Australians had the refractive error correction they required (eREC of 93.5% and 82.2% respectively). While this inequity Published online: 3 December 2021