Discussion
This paper presents the methodology for the development of the WHO evidence-based PECI. In brief, the PECI will support countries to determine the (1) eye care interventions to prioritise, (2) workforce competencies, equipment, medicines, consumables and assistive technologies necessary for the implementation of eye care interventions and (3) costs associated with the implementation of evidence-based eye care interventions. It is anticipated that the PECI will be available for use in 2021.
Eye care medicines and interventions are not integrated into the health insurance schemes in many low-income and middle-income countries4 . An important component of UHC for eye care is that all people obtain the eye care services they need without risking financial hardship from unaffordable out-of-pocket payments. Thus, in order to promote equitable access to services, including protection against financial hardship, a shift is required to ensure that high-priority eye care interventions are included in service packages covered by prepaid pooled financing. This is particularly important for the poor. Once finalised, the PECI will be integrated in the WHO’s UHC compendium of interventions, containing interventions across all of WHO’s programmatic health areas, and linked with the WHO OneHealth Tool, a single framework for planning, costing, impact analysis, budgeting and financing. When considered together with reliable data about the population eye care needs, these resources will facilitate discussions in low-income and middle-income countries around what eye care services to provide within their national health services packages.
While the primary audience for the PECI will be Ministries of Health (MoH) and other ministries involved in eye care service delivery in low-income and middle-income settings, there are a number of other potential end-users of the PECI. Government service providers will be able to use the PECI to plan and implement specific eye care interventions in their service programmes. Training facilities can use the PECI to develop their curricula for the training of health workers involved in eye care. In addition, based on the results of stage 2 of the development process—the systematic identification and quality appraisal of CPGs and systematic reviews—researchers will be able to identify current gaps in evidence and define research strategies to address these gaps.
The scope of eye conditions included in the PECI goes beyond the leading causes of vision impairment and blindness. The inclusion of eye conditions that may not typically cause vision impairment, such as dry eye disease, conjunctivitis, pterygium and blepharitis, is important for several reasons. First, these conditions are troublesome and painful and often severely impact on quality of life.13–15 Second, these conditions are frequently among the leading reasons for presentation to eye care services in all countries and thus expose individuals to financial burden.16–20 The list of eye conditions included in the priority PECI is not meant to be exhaustive or exclusive, but rather represent a selection of conditions and eye care interventions that are supported by high-quality evidence and that are applicable to most low and intermediate resource settings. Future work will involve refining and expanding the PECI, drawing on newly available evidence and newly collected data on service provision. It is important to note that intervention packages for vision rehabilitation, trachoma, onchocerciasis, vitamin A deficiency, measles and rubella were not considered in the PECI as they are encompassed under the WHO Department of Neglected Tropical Diseases and WHO’s Programmes on Nutrition and Rehabilitation, respectively. Once finalised, the selected interventions will undergo a process of prioritisation, with input from clinical and public health specialists from all WHO regions, in order to develop recommendations for a ‘basic’ package of interventions to assist countries when making choices of which interventions to prioritise in their service packages.
Some potential limitations should be considered regarding the methodology employed for the development of the PECI. First, the utilisation of CPGs as the primary source of evidence for the selection of interventions may be viewed as controversial given that the vast majority of scientific evidence forming the basis of the CPGs often originates from high-income settings, and therefore may not be pertinent to low resource settings. To address this, eye care experts from low-income and middle-income settings will be involved in all stages of development of the package, including during the process of defining the workforce competencies and resource requirements for the delivery of interventions. Second, limiting the search of CPGs and systematic reviews to the English language (only) will result in relevant CPGs published in other languages being overlooked. This decision was one of feasibility given the labour-intensive nature of screening CPGs published in all official WHO languages and later translation of the extracted information. In instances where there is an absence of evidence, WHO representatives will consult specific TAG members to determine benefit and feasibility of identifying evidence from CPGs published in other languages. Lastly, using the eye condition as a starting point for the PECI development may be perceived as counterintuitive for the integration of eye care interventions within the broader health system. As mentioned previously, the PECI will be integrated in the WHO’s UHC compendium of interventions, containing interventions across all of WHO’s programmatic health areas. In addition, the WHO VP will work closely with representatives from other related WHO programmes, including ageing, primary care, diabetes and maternal and child health, to ensure relevant PECI are aligned and integrated within the care packages of these programmes.
To address many of the challenges facing the eye care sector, including those relating to changing demographics, inequities in access, and lack of integration—eye care needs to be an integral part of UHC. In summary, the development of the PECI described herein aims to move forward the agenda of eye care as part of UHC by providing countries with information on evidence-based eye care interventions, including resource requirements for their implementation, to facilitate the integration of eye care into national health services packages and policies. It is therefore the intention that the PECI will take an important step to strengthening eye care within health systems, enabling more people to benefit from eye care interventions.