The Duke Elder lecture: the challenge of equitable eye care in Pakistan

Exploring eye care pathways, patient priorities and economics in Pakistan: A scoping review and expert consultation study with thematic analysis

Purpose

As the prevalence of eye diseases increases, demand for effective, accessible and equitable eye care grows worldwide. This is especially true in lower and middle‐income countries, which have variable levels of infrastructure and economic resources to meet this increased demand. In the present study we aimed to review the literature on eye care in Pakistan comprehensively, with a particular focus on eye care pathways, patient priorities and economics.

Methods

A systematic scoping review was performed to identify literature relating to eye care in Pakistan. Searches of relevant electronic databases and grey literature were carried out. The results were analysed through a mixed methods approach encompassing descriptive numerical summary and thematic analysis. To consolidate results and define priority areas for future study, expert consultation exercises with key stakeholders were conducted using qualitative semi‐structured interviews.

Results

One hundred and thirty‐two papers (published and unpublished) were included in the final review. The majority (n = 93) of studies utilised a quantitative design. Seven interlinked themes were identified: eye care pathways, burden of eye disease, public views on eye‐related issues, workforce, barriers to uptake of eye care services, quality of eye care services and economic impact of blindness. Research priorities included investigating the eye care workforce, the quality and efficiency of current eye care services, eye care services available in rural Pakistan and the costs and benefits related to eye care provision and sustaining eye care programmes.

Conclusions

To the best of our knowledge, this is the first review to synthesise evidence from papers across the field relating to eye care in Pakistan. As such, this work provides new insights into the achievements of the national eye health programme, challenges in eye care in Pakistan and priority areas for future research.

Assessment of Horizontal Inequity in Eye Care Utilization in the Iranian Middle-aged Population

PURPOSE

The present study was designed to determine the extent that horizontal inequity was realized regarding eye care utilization in a middle-aged population as well as factors affecting this equity.

METHODS

Data were obtained from a population-based study (Shahroud Eye Cohort Study) in 2009 that included 5190 participants from 40 to 64 years of age. Horizontal inequity was determined based on the following variables: (i) economic status, (ii) eye care service needs, (iii) non-need variables, and (iv) eye care utilization (visiting an ophthalmologist or optometrist). Decomposition analysis of the concentration index based on a nonlinear model and indirect standardization was used to ascertain the contribution of each factor in inequity of eye care utilization.

RESULTS

After adjusting for need variables, the results of our study demonstrated that horizontal inequity in eye care utilization in a middle-aged Iranian population remained positive and significant (horizontal inequity: 0.19; 95% confidence interval: 0.17-0.23) indicating that use of services was focused among participants with a better financial situation. Furthermore, decomposition analysis demonstrated that educational level and economic status had the greatest contribution (54.1% and 41.1%, respectively) in comparison to other variables.

CONCLUSION

This study demonstrated that horizontal inequity exists in eye care utilization among the middle-aged Iranian population.