Fund someone’s reading glasses

Civil Society News, New Delhi

IT is comforting to end the year by giving. Yet, even as you get your debit card out, choosing a beneficiary can be a challenge. Putting money where it works well for someone is invariably a complicated call.

But it is possible with just one modest donation, well directed, to help transform a life forever. For instance, a few hundred rupees spent on an eye check-up and reading glasses can instantly improve the quality of life of someone afflicted with presbyopia or the inability to read and focus on nearby objects.

It is estimated that close to 300 million Indians suffer from presbyopia which has not been addressed. The reason they live with weak vision is that there aren’t the facilities where they can easily get their eyes tested and have access to an affordable pair of spectacles.

Presbyopia has a direct impact on livelihoods. It diminishes the capacity to work. People begin fumbling around — be it an artisan, farmer, security guard, machine operator or tea garden labourer. Since presbyopia sets in mostly after the age of 40 it accompanies the other effects of ageing and is doubly unnerving for people who might want to feel reassured that they can continue to be independent and bring in an income.

Presbyopia has all the makings of a public health crisis given the numbers and the disruption that it is causing in people’s lives. But it passes under the radar with government taking scant note of it.

Some amount of attention is paid to presbyopia in the voluntary sector. But no effort is really known to be on a scale that is significant and it is not among the hot buttons that private donors press.

There is a shortage of optometrists in the country and the task of testing vision and dispensing glasses needs to be passed on to grassroots-level health workers

A combination of government and voluntary sector initiatives and private enterprise could address the problem. But such a combined effort is as yet not happening, perhaps for want of an effective catalyst.

The spectacles business has gone through pathbreaking changes. New-age ventures by dynamic entrepreneurs make it easy to get a pair of spectacles. They are delivered home, frames are stylish, lenses are state-of-the-art, and prices have come down. These are start-ups on steroids. They have changed the way spectacles are bought and sold but they don’t address the base of the market where poor vision impacts the capacity to earn.

Chains of eye-care clinics are flourishing. But these businesses are all geared to serving the middle class. Left out of the market are millions of Indians who don’t have the money or the social reach to be counted in as consumers.

| Five facilities to donate to: CLICK HERE |

There are systemic problems that result in their exclusion. For instance, India suffers from a serious shortage of optometrists — one for every 180,000 population or thereabouts. In the developed world it is one for 10,000. Even in their paltry number, optometrists in India are skewed to cities. The rural population, as a result, is at a disadvantage. Someone in a remote village has to trek to a town or city for an eye-check and then wait for glasses. It all becomes too much. Consequently, they live with sub-optimal vision.

In cities, the middle class and well-off have the awareness and know where to go to get their eyes checked. But those lower down the economic ladder, workers in the unorganized sector, for instance, tend to ignore vision problems and even when they do want them attended to, they don’t have ready access to vision testing facilities and a basic pair of glasses.

The/Nudge Institute, based in Bengaluru, has put together a paper on presbyopia to set rolling an effort to do something about it. We are told that the World Health Organization (WHO) estimates there are 800 million cases of uncorrected presbyopia in the world of which 150 million to 300 million are in India.

Amit Gupta of The/Nudge Institute

“Looks like it would be closer to 300 million because we are such a populous country,” says Amit Gupta, COO of The/Nudge Institute.

In the absence of a detailed study, the numbers are all estimates. Since the industrialized world has dealt with presbyopia, it can be assumed that the majority of the 800 million cases would be in the developing world. Of which India’s share would be around 300 million.

Gupta goes on to say that the global loss in productivity because of presbyopia is estimated at $24 billion annually. Of which India is seen as accounting for $14 billion. Once again, this is a back-of-the-envelope calculation that comes from the Indian Journal of Ophthalmology. But, inexact as these figures might be, it can be safely assumed that presbyopia, as so many other health conditions, has a sizeable impact on India’s GDP. It is a truism that for an economy to shine people have to be healthy. 

Should presbyopia be seen as a public health or livelihoods issue? It ranks among a range of eye diseases such as cataract, glaucoma and diabetes-related loss of vision.

Of these, presbyopia is the easiest to deal with but if left to a lumbering and ill-funded public health system, the solutions might just never show up. On the contrary, categorized as a livelihoods issue, lithe ways forward are possible. 

Says Gupta: “People have other vision problems. Those things need to be solved, for sure. However, if we look at presbyopia as low-hanging fruit we can deal with it while working on solving other problems, right? So, there’s no adverse effect as such on other problems.”

Livelihoods are affected by presbyopia

The social returns on spending on presbyopia are immediate and not inconsequential, explains Gupta. A dollar invested in reading glasses is around $36 in returns, according to WHO. In India it would be closer to $50, taking into account various sources of income including the rural employment scheme, he explains.

On the other hand, waiting for the healthcare system to come up to scratch and perform will mean passing up the opportunity to deal with the problem quickly and simply.

India’s per capita expenditure on health is notoriously low. It has the largest number of cases of preventable blindness in the world, but of the entire amount spent on healthcare no more than $100 million gets spent on vision care.

Says Gupta: “Now out of this $100 million within vision care from a public health standpoint are cataract, glaucoma, myopia — those are the things which are more important. Quite frankly, they will cause bigger problems than presbyopia. So, while presbyopia is a health issue, there are bigger issues which will get precedence over it.”

He continues: “If we will rely solely on the healthcare system, I’m afraid that we will not be able to solve the problem at scale. To give you a few more numbers, in India on average, there’s one trained optometrist for 180,000 people versus about 10,000 in the developed countries. We don’t produce as many optometrists in the country. Even if you do, it’s not a sustainable livelihood for them to just focus on presbyopia and then, too, go to rural areas. It’s just not possible.”

The/Nudge Institute would like to see a few targeted moves making a difference. Since glasses are not on the list of medical devices, the process of screening for presbyopia and dispensing of glasses can be handled by the large number of community workers who are already meeting the health needs of communities. There are millions of self-help groups, ANMs (Auxiliary Nurse Midwife) and ASHA (Accredited Social Health Activist) workers who can be trained to fulfil this role.

“They are working in the community already. They have that trust and if we leverage that then we can scale. And that’s the model we are trying at Nudge. We are not depending only on the healthcare system which has currently many other things to worry about,” says Gupta.

With presbyopia there is the possibility of quickly dealing with a health issue and providing relief. The numbers are so large that speed is of essence for a meaningful impact to be made. Going through the healthcare system slows things down. It is even so in the southern states where there are higher and more efficient standards of public healthcare.

“The moment one (goes through the health system) one requires far more trained people. An ASHA can do the initial level of screening, then somebody will have to go for a second screening, or somebody will have to go for surgery and so on and so forth. That addresses the problem (of providing eye care holistically), but it puts a constraint on how rapidly we can solve the problem (of presbyopia),” Gupta explains.

Loans can be given to microentrepreneurs to set themselves up in screening vision and providing spectacles

What is The/Nudge Institute’s strategy? It is seeking to bring about policy changes, more government funding, community initiatives and partnerships.   

 

POLICY CHANGES

Currently, most government schemes require a doctor’s prescription if one is to avail of a pair of glasses under the scheme. Nudge, through advocacy and citing of examples from other countries, is trying to bring about a policy change.

 

FUNDING

The Centre and state governments should allocate funds for presbyopia for helping meet the cost of a pair of glasses and investing in community initiatives. It could be through the health ministry or the livelihood-centric ministries. It should be at the Central and state levels.

 

PARTNERSHIPS

The government and other players can together experiment with different screening and distribution models and see which one will scale right. One way would be through the community and the use of health workers. Another would be an entrepreneurship-based model in which loans are given for two-wheelers and smartphones to microentrepreneurs to set themselves up in screening and dispensing of spectacles.

 

CATALYTIC PHILANTHROPY

Nudge is ready to commit its own resources to initiatives in which it is partnering with the government. It will do capacity building for screening and distribution, provide programme management support and finally invest in technology solutions that bring scale.

A robust funding model will have to be at the heart of any plan. A mix of government and philanthropic funding together with a market-driven model is envisaged. But any such coalescing of resources would have to be first driven by philanthropy.

Gupta explains: “Let’s assume that there are 300 million people who need a pair of reading glasses, right? And then these people will need another one in two years. And so on and so forth.

“Let’s think of it as a two-phased approach. Phase 1 will be the first five years. We look at the unmet demand for, let’s say, about 150 million pairs of glasses. We believe that there can be 10-12 × leveraging from the catalytic philanthropy to unlock government funding and to utilize government community cadres. And we believe that we should also experiment during this time with a market-based model. It will generate some revenue even if it will not be significant.”

In Phase 2, when the demand for the next 50 percent — 150 million — will be met, the market-based solution would have begun to generate more funds. “Again, we require catalytic philanthropy and unlocking of government funds. But by this time there would be an increase in revenue from the market-based model,”  says Gupta.

Government funding alone cannot hope to cover the costs of getting spectacles to people together with replacements and repairs over time. Clearly, the answer lies in creating a market through which spectacles become available, eyes are tested and costs come down. Kickstarting such a market with government, community and private engagement is the present challenge in dealing with presbyopia. 

Such a market hasn’t come about despite its potential size because major companies in the eye care business don’t see value in it. They have left it to small players and stand-alone opticians. There has also been no government intervention to create a business environment in which entrepreneurs might see a profitable and socially relevant opportunity.

Nudge cites Euromonitor figures saying that the size of the spectacles market in India is $3.3 billion and is growing at five percent annually. By comparison, with a much smaller population, the spectacles business in the US is worth $37 billion annually.

What this would indicate is that the Indian market is seriously underserved. Opportunities exist but a stimulus is needed to get commercial players to jump in. It is also a market that calls for innovations in pricing, technology and social marketing.

But there is enough scope for straightforward philanthropy as well. Helping someone get their eyes checked or funding a pair of spectacles is an incomparable good turn. Clear vision is a wonderful gift not just in terms of what it means for the quality of life but in how it enhances income.

A study cited by Nudge says that when vision is corrected income can rise by as much as 20 percent. This data comes from the World Economic Forum and the EyElliance. Another such study shows that wearing glasses made certain categories of workers more efficient at what they were doing.

Similarly, the PROSPER trial conducted by VisionSpring among a sample of tea garden workers showed that their productivity went up by 20 percent when they were given corrective glasses.

Any number of such studies are available. Without doubt they come with their contexts and margins of error. But what they all seem to accurately underline is that correcting vision and helping people get spectacles is a cause that should be taken up quickly and as widely as possible. Addressing presbyopia effectively is a public health issue and not something governments alone can solve fast enough. It needs everyone to get involved.

Businesses like Lenskart and Tata Eye have rapidly grown their reach using digital technology and online payments mechanisms. They have built platforms on which consumers can be served. Similar innovations are required for those whom the market doesn’t currently cater to.