Done right, Universal Health Coverage will be vital to making sustainable inroads to reduce avoidable vision impairment.
Progressing on Universal Eye Health will require maximising financing opportunities and holding governments to account for their responsibilities to provide affordable and accessible health services. Inclusion of eye health services in insurance can be the most effective means to promote scale-up and better reach those most in need. As health systems are increasingly financed from domestic sources, and as schemes advance and availability of services increases, this will be vital to reducing avoidable blindness.
The following countries should be applauded for their efforts towards achieving access to health for all people and having incorporated eye health within their UHC financing mechanisms. These case studies highlight some progress these countries are making as well as many of the challenges that have yet to be overcome. They emphasize the importance of ensuring that delivery is pro-poor and how strengthening health systems is fundamental to increase coverage.
Vietnam has a single-fund national health insurance scheme administered by Vietnam Social Security, which now covers more than 70% of the population . A health financing review from 2011 found that Vietnam was taking important steps towards Universal Health Coverage and that equity is emphasised. Following pilots that began in 1989, Vietnam consolidated various schemes with a new law adopted in 2008 and passed further reforms in 2012.
million poor people and ethnic minorities’
health insurance premiums are now subsidised
by the Vietnamese government
of Cataract surgeries
are now financed through
Subsidising the poor and ethnic minorities
Around 15 million poor people and ethnic minorities’ premiums are now subsidised by the government , but considerable effort is needed to extend coverage to workers in the informal sector and people with a disability. According to Palmer and Nguyen 2012, 66%-80% of people with disabilities are not enrolled . Further, although the level of out-of-pocket health payments have been decreasing in recent years, as of 2012 out-of-pocket payments as a proportion of total health expenditure remained very high at 48.8% .
In eye health, very positively, most inpatient services are included in national health insurance, including Cataract surgery, Trichiasis surgery, eye care emergency procedures and trauma. Unlike some other countries of the region and elsewhere, the cost of the intra-ocular lenses for cataract surgery is fully reimbursed. Data from 14 provinces indicates that 72% of Cataract surgeries are now financed through health insurance .
The cost of the intra-ocular lenses for cataract surgery is fully reimbursed. Data collected by the Fred Hollows Foundation from 14 provinces indicates that 72% of Cataract surgeries are now financed through health insurance
Overcoming the hurdles
In a speech in 2015, the health minister acknowledged that administrative procedures for purchasing health insurance presented a barrier and many people lacked information on the options available . In eye health, some patients bypass referral from their local primary health service, due to concerns about inadequacy of services, and seek treatment instead directly from tertiary hospitals, which is against insurance regulations and cannot be reimbursed . There are also co-payments and additional hospital fees and indirect costs, such as transport, food and accommodation for the patient and anyone accompanying the patient, increasing costs further . People with disabilities may face even higher costs and the cost for those who have to miss work can also be underestimated.
Progress still to be made
While Cataract surgery volumes have increased in recent years and ophthalmic training has developed significantly, quality of surgery remains a concern . There are also challenges around the lack of regulation of private spectacle shops and a need for strengthening optometry to ensure access to quality refractive error services. Low-vision aids and spectacles are not yet covered by insurance, though the government has expressed interest in including these in the list for reimbursements, particularly for people with disabilities and children .
Vietnam’s draft National Strategy for the Prevention of Blindness for 2016 to 2020 calls on authorities to actively encourage people to join health insurance schemes, and with further reforms and increased public awareness this should expand coverage. Other steps needed to improve progress towards Universal Eye Health include improving referral pathways, and strengthening the eye health workforce.
Introduced in 2004, Rwanda’s Community-Based Health Insurance (CBHI), or ‘Mutuelle de Sante’, is open to the whole population. It is a voluntary scheme, particularly targeting those on lower incomes. A wide range of eye conditions and services are covered. The Rwandan government’s commitment to promote health access is evident in that 23.8% of total government expenditure is spent on health (considerably above Abuja Declaration ) with a total of $Int135 per capita. Yet 43% of health expenditure is covered by private health insurance, with 21% of health expenditure from out-of-pocket expenses .
Looking after everyone
CBHI requires middle- and higher-income patients to pay an annual membership fee and contribute 10% of tariff price at the point of service. However, for patients who cannot afford it (approximately 25% of the population), health insurance and services at public facilities are free . After peaking at 91% in 2011-12, coverage of the CBHI service was 74% during 2013-14 . A major factor in this was increasing subscription charges from Rwf 1,000 to Rwf. 3,000 minimum per person, particularly affecting larger families. The revised categories of ‘ubudehe’ (means-testing), meant many families were put into categories with higher costs than they were prepared to pay.
Under the CBHI at the primary level (health centre) services can treat common eye allergies, up to 80% of eye cases in Rwanda, and low-cost Presbyopia glasses are made available to the public at a fixed price of US$2 equivalent, and free for the poorest. All other conditions are referred to the nearest district hospital where the ophthalmic technician can diagnose, take care of minor external surgeries, and refer surgery patients to the nearest provincial hospital for specialist surgery and other treatments. For Cataract surgery, patients are required to pay for consumables, around US$18 equivalent, which could deter people from treatment.
Cataract Surgical Rate up but challenges remain
In recent years, with the inclusion of eye health in the Non Communicable Disease Strategy in 2011, and due to joint MoH / NGO efforts, service availability has increased, expanding the reach of insurance coverage. The Cataract Surgical Rate (CSR) has increased from an average 300 over the past 10 years to 400 in 2015. A major factor for the CSR rise is the increased number of provincial hospitals, and as such the CSR is expected to continue to rise. In 2015 in Rwanda, 68.4% of people who needed cataract surgery at <3/60 received it , a significant increase from 47% coverage for bilateral cataract blindness in 2006.
A number of challenges remain for eye health. A major factor is the need for more eye health personnel. There is also very limited availability of refractive services, meaning access is low with a prevalence of refractive errors of 4.5% . Progress is occurring on this, however, with the joint MoH/OneSight investment to add Vision Centres to all Departments of Ophthalmology in provincial hospitals and then in district hospitals. Further, a high proportion of people are unaware of common eye problems, that treatment is possible and that services are increasingly available and campaigns are needed to address this.
In 2015 in Rwanda, 68.4% of people who needed Cataract surgery at <3/60 received it, a significant increase from 47% coverage for bilateral Cataract blindness in 2006
of total Rwandan government
expenditure is spent on health
of the population cannot
afford health insurance
of health expenditure is
covered by private
Low-cost Presbyopia glasses are made
available to the public at a fixed price of
US$2 equivalent, and free for the poorest
Much of the information on Vietnam was provided by Damian Facciolo, IAPB, and on Rwanda by David Gasatura and Max Presente, Fred Hollows Foundation.