VISION 2020: THE RIGHT TO SIGHT

AURTHOR (S)

Kovin S Naidoo: Brien Holden Vision Institute, Public Health Division, Durban, South Africa; University of KwaZulu
Natal (UKZN), Durban, South Africa
Brien Holden: Brien Holden Vision Institute, University of New South Wales (UNSW), Australia

PEER REVIEWER (S)

Ron Fyfe:Past Chairman of the Public Health Committee of WCO; Currently: Asia Pacific representative on WCO
Public Health Committee and member of the board of Vision 2020 New Zealand

THIS CHAPTER WILL INCLUDE A REVIEW OF:

 Vision 2020
 Human resources
 Coordination of vision 2020
 Millenium development goals (MDG) and vision 2020
 Impact of vision 2020
All resources for the Vision 2020: Right to Sight Campaign can be accessed at:
http://www.who.int/ncd/vision2020_actionplan/contents/contents.htm

VISION 2020

In 1998, the World Health Organisation and the International Agency for the Prevention of Blindness (IAPB)
launched VISION 2020: The Right to Sight. This program brought together a range of participants including non
governmental organisations, governments, professional associations, the optical industry and educational institutions
(World Health Organisation, 1998).
The aim of VISION 2020 is to eliminate avoidable blindness by the year 2020. Recognising the difficulties with
targeting all ocular diseases and causes of blindness, the program identified key priority areas that included:
cataracts, trachoma, onchocerciasis, childhood blindness and refractive errors. These conditions are the major
causes of blindness in the developing world and effective screening and treatment modalities are available for these
conditions. Screening techniques, in particular, for these conditions have displayed high sensitivity and specificity
making them ideal for the efficient utilisation of sparse resources.

BASIS OF PRIORITIES FOR VISION 2020

 75% of blindness and visual impairment occurs in the poor and very poor communities of the world
 75% of blindness and visual impairment is a result of five preventable or treatable conditions (cataract, refractive
errors and low vision, trachoma, onchocerciasis and causes of childhood blindness). For each of them there is a
cost-effective intervention.
If priority is given, at the global level, to improving eye care services for neglected communities, and to targeting
these five diseases, then in 2020, it is calculated that instead of more than 75 million blind people the number can be
reduced to less than 25 million.
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 Vision 2020: The Right to Sight

VISION 2020(CONT.)

Primary health care workers are ideally placed to identify blind and visually impaired people in the community. With
additional training they can diagnose and refer patients to the appropriate eye care workers and provide basic
treatment for simple eye diseases.

GUIDING PRINCIPLES OF VISION 2020

These can be summarized in the acronym “ISEE”:
 Integrated into existing health care systems
 Sustainable in terms of money and other resources
 Equitable care and services available to all, not just the wealthy
 Excellence – a high standard of care throughout
The VISION 2020 program identified key areas for planning namely, Human Resources, Infrastructure development
and Disease Control.
VISION 2020 member countries are urged to develop and implement country specific VISION 2020 plans.Inherent in
the strategy of Vision 2020 is the recognition that those countries which do not recognise chosen ocular conditions
as priorities, could focus on alternate conditions which may differ from country to country-based on the most
prevalent causes of avoidable blindness within the country. Furthermore the focus on particular ocular conditions
does not preclude programs from treating and managing glaucoma, diabetic retinopathy, hypertensive retinopathy
and other leading causes of blindness. VISION 2020 in defining a collective strategy focuses energy on a particular
group of diseases. The regular programmes aimed at treating and managing those conditions which are not defined
in the priority list, need to continue. It can also be argued that screening and treating patients with cataract, refractive
errors and the other priorities will inevitably lead to the detection of other potentially blinding disease and could serve
as ideal case finders for those difficult to screen for conditions.

HUMAN RESOURCES 

Human Resources remain a key challenge to VISION 2020. The lack of trained personnel in developing countries
and the propensity of individuals to emigrate remains a constant challenge to planning and development.
Furthermore many skilled ophthalmic nurses are often deployed into other hospital departments in order to meet
more urgent needs e.g. management of patients with HIV. Central to the strategy of VISION 2020 is the mobilisation
of all available human resources. There is also a recognition that different cadres of eye care workers are needed
based on the local conditions. In addition the same group of eye care workers may be deployed differently in various
countries based on the local circumstances.

HUMAN RESOURCE NEEDS

The basic premise in determining human resources according the WHO is a population to practitioner ratio. This
usually ranges from a high to a low figure based on existing resources.2 A point in example is the ratio of
optometrists to population is realistically set at 1:250 000 because of the difficulties with recruiting practitioners into
the public sector. A vibrant private sector coupled with poor working conditions and salaries works against the
successful integration of the profession into the public sector. Further the overwhelming orientation of the training to
a private sector ethos has produced limited number of practitioners with the willingness to work for the public sector.

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 Vision 2020: The Right to Sight

HUMAN RESOURCES(CONT.) 

The WHO has recommended specific ratios for human resources in Africa. In Table 3.1 are the recommended ratios
for human resources in Sub-Saharan Africa:

Table 3-1: Recommended ratios for human resources in Sub-Saharan Africa

EYE PROFESSIONAL RATIO
Ophthalmologists 1:400 000 by 2010 and 1: 250 000 by 2020
Optometrists no definite ratio is provided but can use refractionist ratio
Ophthalmic Nurses 1: 200 000 by 2010 and 1: 100 000 by 2020
Ophthalmic Medical Assistant 1: 200 000 by 2010 and 1: 100 000 by 2020
Refractionist 1: 100 000 by 2010 and 1: 50 000 by 2020

INFRASTRUCTURE DEVELOPMENT
Much of the developing world is confronted by a lack of eye clinics and the appropriate equipment to cater for
patients. There is a need therefore to develop such infrastructure. However the capacity for infrastructure growth is
limited in most developing countries. There is a constant battle between competing priorities. This reality has been
further complicated by the aids pandemic. The lack of infrastructure both in terms of buildings and equipment often
challenges eye care programs to be innovative and develop cost effective strategies with the least capital
expenditure.

DISEASE CONTROL
Disease control is dependant on the human resources, infrastructure as well as the prevalence data. The prevalence
data assists in determining priorities for treatment as well as health promotion efforts.
VISION 2020 defines priorities namely, cataract, trachoma, onchocerciasis, childhood blindness and refractive
errors, based on the data currently available as well as the existence of appropriate screening and prevention
techniques. However this reality changes at a micro (country, province, district) level whereby great variation in eye
disease profile manifests, even among developing countries.
The development of appropriate screening and clinical techniques and defining protocols for the management of
ocular conditions, is a priority of disease control.

COORDINATION OF VISION 2020 

Formatting a National Coordinating Body for VISION 2020

A national VISION 2020 Committee should have representation from all the relevant stakeholders:
1. Ministries of Health
2. Ophthalmologists, optometrists and other eye care practitioners
3. Local and international non-governmental eye care providers
4. Private sector
If a National Prevention of Blindness Committee already exists, it need not be dissolved, but could be made “VISION
2020 compliant”.
The committee should be well integrated in the existing health care structure with the Ministry of Health in a
coordinating role, and should meet at least twice annually.
It is advisable to have a small taskforce or executive committee under the Ministry of Health, made up of the key
individuals in national eye care, which meets once every 1–3 months and reports to the National VISION 2020
Committee. A dedicated full-time National VISION 2020 Coordinator would be ideal.

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 Vision 2020: The Right to Sight

COORDINATION OF VISION 2020(CONT.) 

It is important to develop a good collaboration and co-ordination between all the relevant stakeholders, including the
private sector. A national plan is needed to identify the priorities for action and who will be responsible for each
activity (see Fig. 3-1).

National level (VISION 2020 committee)

Identifies VISION 2020 priorities for the country, develops strategies, sets targets
Identifies issues of resources and coordinates support
Secures funding - Develops budgets
Monitors and evaluates the programme at all levels

District Level
VISION 2020 action plan for a specific population and
priority diseases
Monitors local progress and reports to national level

Primary eye care Curative services Rehabilitation

Figure 3-1: A national plan is needed to identify the priorities for action and who will be responsible for each activity

A planning committee may be at national level, provincial level or project level. The committee will be small and
active and may be structured to include members from the Ministry of Health; Public health; Ophthalmology/eye care
services; the community; local NGO/Service Organisation; International Non-governmental Development
Organisations (INGDO) and United Nations (UN) agencies.

FUNCTIONS OF THE COMMITTEE

 Plan a Prevention of Blindness (PBL) / eye care programme
 Mobilise resources / funding for the programme
 Implement activities
 Evaluate progress and results

WORLD HEALTH ASSEMBLY RESOLUTIONS WHA56.26 AND WHA59.25

In 2003, global political commitment to VISION 2020 was reaffirmed through the adoption of resolution WHA56.26
by the World Health Assembly, urging each member state to:
 Support the global initiative for the elimination of avoidable blindness by drafting, by 2005 at the latest, a national
VISION 2020 plan – in partnership with WHO and in collaboration with NGOs and the private sector
 Commence implementation of such plans by 2007 (at the latest)
 Include effective information systems in national plans – with standardized indicators and periodic monitoring
and evaluation, with the aim of showing a reduction in the magnitude of avoidable blindness by 2010
In 2006, resolution WHA59.25, “Prevention of avoidable blindness and visual impairment” was adopted – expanding
on the base laid down in resolution WHA 56.26 (World Health Organisation, 2010).
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COORDINATION OF VISION 2020(CONT.) 

IMPLEMENTATION OF VISION 2020 TO DATE

As of December 2007, 135 WHO member states have participated in a VISION 2020 workshop, 107 have formed
national committees, and 91 have drafted VISION 2020 national plans.

MILLENNIUM DEVELOPMENT GOALS (MDG) AND VISION 2020 

THE MILLENNIUM DEVELOPMENT GOALS

The Millennium Development Goals (MDGs) were developed out of the eight chapters of the United Nations
Millennium Declaration, which in September 2000 was signed by 189 countries, including 147 Heads of State
(United Nations, 2000).The MDGs include goals and concrete targets for development, representing the
commitments of member nations to reduce poverty and hunger, and to tackle ill-health, gender inequality, illiteracy,
lack of access to clean water and environmental degradation by the year 2015.They also represent the basic rights
of each person on earth to health, education, shelter and security.
Eight goals and 21 ambitious targets of the MDGs
1. Eradicate extreme poverty and hunger
 Halve, between 1990 and 2015, the proportion of people whose income is less than one dollar a day
 Achieve full and productive employment and decent work for all, including women and young people
 Halve, between 1990 and 2015, the proportion of people who suffer from hunger
2. Achieve universal primary education
 Ensure that, by 2015, children everywhere, boys and girls alike, will be able to complete a full course of primary
schooling
3. Promote gender equality and empower women
 Eliminate gender disparity in primary and secondary education preferably by 2005, and at all levels by 2015.
4. Reduce child mortality
 Reduce by two-thirds, between 1990 and 2015, the under-five mortality rate
5. Improve maternal health
 Reduce by three quarters, between 1990 and 2015, the maternal mortality ratio
 Achieve, by 2015, universal access to reproductive health
6. Combat HIV/AIDS, malaria, and other diseases
 Have halted by 2015 and begun to reverse the spread of HIV/AIDS
 Achieve, by 2010, universal access to treatment for HIV/AIDS for all those who need it
 Have halted by 2015 and begun to reverse the incidence of malaria and other major diseases
7. Ensure environmental sustainability
 Integrate the principles of sustainable development into country policies and programs; reverse loss of
environmental resources
 Reduce biodiversity loss, achieving, by 2010, a significant reduction in the rate of loss
 Halve, by 2015, the proportion of people without sustainable access to safe drinking water and basic sanitation
 By 2020, to have achieved a significant improvement in the lives of at least 100 million slum-dwellers
8. Develop a global partnership for development
 Develop further an open trading and financial system that is rule-based, predictable and non-discriminatory.
Includes a commitment to good governance, development and poverty reduction—nationally and internationally
 Address the special needs of the least developed countries. This includes tariff and quota free access for their
exports; enhanced programme of debt relief for heavily indebted poor countries; and cancellation of official
bilateral debt; and more generous official development assistance for countries committed to poverty reduction
 Address the special needs of landlocked and small island developing States

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MILLENNIUM DEVELOPMENT GOALS (MDG) AND VISION 2020(CONT.) 

 Deal comprehensively with the debt problems of developing countries through national and international
measures in order to make debt sustainable in the long term
 In cooperation with developing countries, develop and implement strategies for decent and productive work for
youth
 In cooperation with pharmaceutical companies, provide access to affordable essential drugs in developing
countries
 In cooperation with the private sector, make available the benefits of new technologies, especially information
and communications

VISION FOR AFRICA PROPOSAL

Faal & Gilbert, 2007, The VISION FOR AFRICA proposal summarizes the link between vision impairment and the
millennium development goals as follows:
MDG 1: Eradicate extreme poverty and hunger
Studies have demonstrated that vision impairment is both a cause and consequence of poverty. Globally, the
prevalence of blindness is five-fold higher in poor than rich countries, and research in India and Pakistan has shown
that poor people are more likely to be blind. In 2005-2006, a study by Kuper et al (2008) showed that people with
cataract in Kenya, the Philippines and Bangladesh were poorer than those with normal sight, and demonstrated the
need for increased cataract surgeries for poor people. In Cambodia, a survey conducted with post-operative cataract
patients showed that over 90 per cent of respondents said their quality of life had improved after sight-restoring
surgery, that they no longer needed anyone to look after them, and that they could assist in cultivating crops and
working around the house.
Extrapolations at a global level have shown that a successful global VISION 2020 eye care program could prevent
more than 100 million cases of blindness between 2000 and 2020, with savings of at least US$102 billion, which
would otherwise be lost to reductions in productivity associated with blindness. And in 2007, the global economic
productivity loss in international dollars (I$) associated with the burden of vision impairment was approximately I$
427.7 billion before, and I$ 268.8 billion after, adjustment for country-specific labour force participation and
employment rates. With the same adjustment, but assuming no economic productivity for individuals aged ≥ 50
years, the potential productivity loss was approximately I$ 121.4 billion.
With appropriate funding, vision impairment can be substantially reduced and certain conditions can be effectively
eliminated. In Vietnam and Morocco, for instance, sustained effort by governments, international agencies and the
eye care sector has resulted in the elimination of trachoma as a major public health problem. In Gambia, the 10-year
National Eye Care Program from 1986 to 1996 led to reductions of 40 per cent in the prevalence of blindness,
including the elimination of over half of all trachoma.
MDG 2: Achieve universal education
Approximately 90 per cent of vision impaired children in developing countries are deprived of schooling. Lack of
infrastructure, affordable health care, accessible and suitable school materials and qualified teachers prevent vision
impaired children from attending school in many low income countries. Blindness among adults in the family may
also result in decreased school attendance and performance, as blind adults are dependant on school aged children
for care.
MDG 3: Promote gender equality and empower women
Women are affected by blindness and vision impairment to a much greater degree than men. A review of population-
based surveys carried out between 1980 and 2000 showed that, in people aged older than 50 years, blindness is
about 40 per cent more common in women than men. Since then, a large number of national surveys and
assessments have confirmed these earlier findings. Surveys have revealed that women account for approximately
64 per cent of the total number of blind people globally, and that in some areas women are half as likely to be able to
access eye care (Courtright & Lewallen, 2009). Studies indicate that women generally have less access to cataract
services, and that girls are more likely to have trachoma than boys.
MDG 4: Reduce child mortality
Up to 60 per cent of children in low income countries die within two years of becoming blind, and approximately
500,000 children become blind each year (Faal & Gilbert, 2007). Many of the conditions associated with child
blindness are also causes of child mortality (premature birth, measles, congenital rubella, vitamin A deficiency, and
meningitis).
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MILLENNIUM DEVELOPMENT GOALS (MDG) AND VISION 2020(CONT.) 

The Australian Government has acknowledged that MDG 4 will not be met unless there is an increase in funding and
development of national strategies to ensure effective allocation of resources. By providing further funding for the
elimination of avoidable blindness, the Australian Government can continue to lead by example in reducing vision
impairment among children, thereby reducing child mortality.
MDG 6: Combat HIV/AIDS, malaria and other diseases
Hundreds of millions of people experience vision impairment and blindness caused by diseases including cataract,
glaucoma, river blindness and trachoma. The reference to ‘other diseases’ in MDG 6 provides a direct opportunity
for concerted action to recognise and address these diseases.
Additionally, people living with disability are equally, or more, exposed to risk factors that lead to infectious diseases
and have limited access to outreach and treatment services. Global Consortium programs address this by reducing
the prevalence of vision impairment, and by addressing the needs of people with disabilities. Global Consortium
programs also contribute to reducing the impact of HIV/AIDS, malaria and other diseases by utilising a public health
approach which improves eye health services, and by providing that includes maternal and child health care, health
education, and good nutrition.
MDG 7: Ensure environmental sustainability
People in low-income countries living with a disability are likely to have lower standards of housing conditions and
have less access to clean water and sanitation. Facilitating access to clean water and sanitation is one element of
Global Consortium programs, particularly in efforts to eliminate trachoma in the Pacific.
MDG 8: Develop a global partnership for development
The global VISION 2020 initiative, Vision 2020 Australia’s Global Consortium, and the Vision for Africa Consortium
each represent unique and effective responses to MDG 8. The fostering of strong partnerships between Ministries of
Health, international and national organisations, professional organisations and civil society groups, ensures that the
benefits of partnership are experienced at national, regional and community levels. They directly benefit the poorest
of the poor, enable expertise to be shared and built upon, and by minimising program overlap and inefficiency
contribute to the goals of the Paris Declaration and Accra Agenda for Action. Table 3.2 outlines VISION 2020’s
approach to addressing the millennium development goals.

Table 3-2: Summary – VISION 2020 Addressing the Millennium Development Goals
Treating blind will decrease burden to society which in turn increases income
ALLEVIATING POVERTY
generation
Childhood blindness programmes and rehabilitation would increase education
EDUCATION FOR ALL
opportunities
FEMALE EMPOWERMENT RE services/ Health education to mothers/ VAD/ Treating mother and child
ENVIRONMENT Trachoma/ Onchocerciasis/VAD influenced by sanitation and H2O supply
LIMIT DISEASE SPREAD Community based programmes- Trachoma/ onchocerciasis/ school screening
LIMIT MALNUTRITION VAD lobby for programmes including fortification/supplementation
LIMIT CHILDHOOD MORTALITY VAD/Measles/ Corneal Opacity
YOUTH IN EMPLOYMENT HR development equates to creation of mid level training - PHC/ Case finding.

One should note that the VISION FOR AFRICA proposal can be a guide for every other region and their own
developing countries.

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 Vision 2020: The Right to Sight

IMPACT OF VISION 2020 

An estimated 314 million in the world suffer visual impairment, of which about 45 million are blind.Without effective,
major intervention, the number of blind people is projected to increase to 76 million by the year 2020.
Seventy five percent of all global blindness is caused by five treatable or preventable conditions, namely:
1. Cataract
2. Refractive errors and low vision
3. Trachoma
4. Onchocerciasis
5. Childhood blindness (mainly due to vitamin A deficiency)
If the VISION 2020 initiative is successful in eliminating these causes of avoidable blindness by the year 2020, the
number of blind people will be limited to 24 million.
The successful implementation of VISION 2020 would not only reduce the suffering of individuals with visual
impairment, but would also provide significant social and economic benefits for society at large.

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 Vision 2020: The Right to Sight

SELECTED READING

 Foster A and Resnikoff S, 2005. The impact of Vision 2020 on global blindness. Eye.19, 1133-1135
Source: http://www.nature.com/eye/journal/v19/n10/pdf/6701973a.pdf Retrieved 14 August 2012

SELECTED REFERENCES 

 Courtright P and Lewallen S, 2009.Why are we addressing gender issues in vision loss?Journal of
Community Eye Health 22(70):17-19
 Faal H and Gilbert C,2007.Convincing governments to act: Vision 2020 and the Millennium Development
Goals.Journal of Community Eye Health, 20(64): 62-64.Kuper H, Polack S, Eusebio C, Mathenge W, Wadud Z
and Foster A, 2008.A case-control study to assess the relationship between poverty and visual impairment from
cataract in Kenya, the Philippines, and Bangladesh.PLoS Medicine 5(12):
1716-1728
 United Nations, 2000.United National Millennium Declaration: Resolution A55/2.United Nations, New
York.Source: http://www.un.org/millennium/declaration/ares552e.pdf.Retrieved 16 Auguest 2012
 Vision 2020: Right to Sight Initiative, 2004.Vision 2020 Toolkit.Source:
http://www.vision2020.org/main.cfm?type=V2020TK.Retrieved: 16 August 2012
 World Health Organisation. Informal Consultation on Analysis of Blindness Prevention Outcomes.
WHO/PBL/98.68 Geneva: World Health Organisation, 1998; v. 1998
 World Health Organisation.2010.Action plan for the preventionof avoidable blindness and visual
impairment: 2009-2013.WHO Press, Geneva

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