Chapter 1: Market Landscape

3.1 At least 1 billion people worldwide have a vision impairment that is uncorrected or could have been prevented

Globally, at least 1 billion people have a vision impairment that is uncorrected or could have been prevented.³ Myopia and presbyopia, the two most common causes of vision impairment, affect 2.6 and 1.8 billion people respectively.⁴ These numbers will continue to increase due to population growth, ageing, and lifestyle changes.

Refractive error is the most common cause of vision impairment. Vision impairment occurs when an eye condition affects the visual system and one or more of its vision functions.⁵ Various eye conditions can cause vision impairment, including refractive error, cataracts, age-related macular degeneration, glaucoma, diabetic retinopathy, corneal opacity, and trachoma (see Appendix B). Refractive error occurs when the shape or length of the eye prevents light from focusing directly on the retina, resulting in blurred vision.⁶ Table 1 presents the four types of refractive error.

Visual acuity is the typical measure for vision impairment severity (see Figure 2).

• Distance visual acuity is assessed using a vision chart at a fixed distance, commonly 6 metres / 20 feet. The smallest line read on the chart is written as a fraction, where the numerator refers to the distance at which the chart is viewed, and the denominator is the distance at which a “healthy” eye is able to read that line of the vision chart. For example, a visual acuity of 6/18 means that at 6 metres from the vision chart, a person can read a letter that someone with normal vision would be able to see at 18 metres. “Normal” vision is taken to be 6/6 or otherwise referred to as 20/20.⁹ A ‘tumbling E’ chart, which contains rows of the letter E in various kinds of rotation, is used for illiterate populations.

• Near visual acuity is measured according to the smallest print size that a person can discern at a given test distance. Near vision impairment is commonly classified as a near visual acuity less than N6 at 40cm, where N6 refers to a font size equivalent to newspaper print.¹⁰

Myopia and presbyopia affect 2.6 billion¹² and 1.8 billion¹³ people respectively. About 66% of people with myopia live in Asia, and prevalence of myopia is as high as 52% in East Asia.¹⁴ In Sub-Saharan Africa, myopia prevalence is lower at approximately 9%.¹⁵ Myopia is the most common type of refractive error in children: estimates suggest that 312 million children suffer from myopia worldwide.¹⁶ On the other hand, prevalence of presbyopia reaches approximately 70% in populations over 50 years old worldwide.¹⁷ Since a person can have more than one eye condition, it is difficult to estimate the total number of people with refractive errors as the figures for presbyopia and myopia cannot simply be summed to derive a global estimate (see Appendix C).¹⁸

The number of people with refractive errors is projected to grow significantly in the next decade. 3.4 billion people are projected to have myopia by 2030, due to population growth and lifestyle changes such as reduced time spent outdoors, increased near work, and increased rates of urbanisation as children in urban areas spend less time outdoors, among other factors.¹⁹ The number of people with presbyopia is projected to increase to 2.1 billion by 2030 due to population growth and aging.²⁰

3.2 Unaddressed vision impairment has a profound negative effect on individuals and society.

Negative outcomes on education, the economy, and health are associated with unaddressed vision impairment, both for individuals and society:

• High productivity loss: uncorrected myopia and presbyopia cost the global economy approximately USD270 billion in lost productivity per year due to diminished educational and job prospects, and reduced on-the-job efficiency.²¹

• Increase in road accidents: several studies demonstrate a correlation between road accidents and unaddressed vision impairment. For example in India, drivers with poor vision have up to 30% higher incidence of road accidents.²² In the UK, it is estimated that poor vision leads to over 2,800 traffic-related casualties and costs over USD50 million per year.²³

• Lower quality of life: adults with unaddressed vision impairment are more likely to suffer from a lower quality of life, including higher rates of depression and anxiety, social isolation, higher risk of falls and fractures, limited mobility, higher rates of bullying, and cognitive decline.²⁴

• Lower education outcomes: in LMICs, children with unaddressed vision impairment are less likely to enrol in school, complete primary education, and be literate.²⁵ The probability of enrolling in school, completing primary school, or being literate are estimated between 5 to 7.3 percentage points below average for children with vision impairment, depending on the indicator and sample of countries. In addition, students with vision impairment tend to have lower academic performance.²⁶

3.3 Refractive errors could be easily addressed with eyeglasses, but at least 826 million people worldwide live with uncorrected refractive errors.²⁷

Correcting refractive errors with eyeglasses is a simple and effective intervention. As the most common corrective intervention, eyeglasses are included on the WHO Priority Assistive Products List.²⁸ Other interventions include contact lenses and laser eye surgery. Peer-reviewed research revealed that correcting presbyopia with eyeglasses increased productivity of tea-pickers by 22%, and up to 32% for those aged over 50 years old.²⁹ Research in China also showed that providing eyeglasses to primary school students has a significant positive impact on academic tests.³⁰ Eyeglasses are considered functioning interventions, which means that they do not eliminate refractive errors by treating their causes, but rather provide compensation for them.³¹ Three types of eyeglasses exist:

• Prescription eyeglasses are used to treat all types of refractive errors – myopia, hyperopia, astigmatism, and presbyopia. Prescription eyeglasses are customised products made to the specific need of each individual eye. In most countries they are sold in optical shops or vision centres, and users need a prescription from an accredited eye care professional (see Appendix D).

• Reading eyeglasses – also known a near vision eyeglasses or ready-made readers – are used to treat presbyopia only. Reading eyeglasses are generic products that have the same corrective power on both lenses. Individuals put them on to do near tasks and take them off to look into the distance. In most HICs they can be purchased over the counter without a prescription from an accredited eye care professional. In some cases, a prescription is still required to buy reading eyeglasses – e.g. due to regulation or when individuals have presbyopia combined with myopia, hyperopia, or strong astigmatism – these cases will be considered as prescription eyeglasses in this report.

• Multifocal eyeglasses are used to treat patients with both myopia/hyperopia and presbyopia. The lenses are divided into two (bifocals) or three (trifocals) parts, or into a continuum of different corrective powers (progressive lenses). Individuals can look through the top part to see into the distance and look through the bottom part to see up close – therefore removing the need for taking reading eyeglasses on and off. They follow a similar supply chain as prescription eyeglasses but are not a focus of this report.

An appropriate pair of eyeglasses is defined as one that matches the person’s prescription for both eyes while being comfortable to look through, fits the face of the user, and is durable, but also acceptable in terms of style. At a minimum, eyeglasses procured in a country should meet ISO quality standards or their equivalent.³² Additionally, eyeglasses are often considered by users as a fashion accessory rather than a medical device. Therefore, it is important to ensure choice of frames to support longer-term compliance and provide dignity of choice to end users.

WHO estimates that at least 1 billion people have a vision impairment that is unaddressed or could have been prevented, including at least 826 million people suffering from vision impairment due to unaddressed presbyopia and at least 124 million people suffering from moderate to severe distance vision impairment or blindness due to unaddressed myopia or hyperopia.³³ Others estimate that this could be closer to 2.7 billion people with uncorrected refractive errors when including those with milder vision loss.^34,35 Rates of unaddressed presbyopia are estimated to be greater than 85% in Sub-Saharan Africa, while comparative rates in high-income regions like North America and Western Europe are reported to be around 1% (see Figure 3).³⁶

For references please see footnote ³⁷

3.4 Eyeglasses should be provided within the context of comprehensive eye care and integrated within the healthcare system and national health plans.³⁸

Providing eyeglasses is only one component of comprehensive eye care. As previously mentioned, vision impairment can be caused by a variety of eye conditions that in some cases require more specialised care. For example, cataracts, which are treated surgically, account for approximately 25-35% of moderate and severe vision impairment for people above 50 years old in Sub-Saharan Africa.³⁹ Health personnel trained for vision screening or refraction should be able to conduct a basic eye health assessment, identify signs and symptoms of common eye diseases, and refer patients to the relevant level of care. In addition, refraction services are often required as a component of rehabilitation services following eye surgeries such as cataract surgery.^40,41

The WHO recommends an integrated approach to public eye care with services delivered across all levels of a health system in its 2019 World Report on Vision.⁴² Countries are encouraged to integrate eye care into national health plans and health service delivery, rather than through a separate vertical programme approach. This aims to ensure eye care is integrated into health system planning and included across all service delivery platforms.⁴³ While many LMICs have developed national eye health plans leveraging WHO’s most recent action plan, most have not yet integrated eye health into the national health plan, leading to a lack of appropriate strategic planning and budgeting.⁴⁴ Beyond healthcare, integrating eye care with other sectors such as education is also key to delivering high quality, cost-effective interventions such as school eye health programmes (see section 4.9).⁴⁵

3.5 Capacity to deliver services for refractive errors in LMICs is limited due to the high cost of equipment and human resources required.

Guidelines for provision of eyeglasses are generally developed at the country level by professional associations and follow a common process in HICs (see Figure 4). In the US for example, the Optometric Clinical Practice Guidelines are defined by the American Optometric Association.

In most HICs, the provision process for reading eyeglasses can be completed with minimal training. Users can self-identify a vision loss and buy reading eyeglasses at retail points, such as pharmacies, without a prescription. On the other hand, the provision process for prescription eyeglasses relies on trained professionals. Traditional refraction devices are complex to operate, expensive, and stationary. The estimated cost for setting up an optical assembly lab is approximately USD200,000-USD250,000 in LMICs, with the highest costs allocated to lab equipment (approximately USD75,000, e.g. for lens centring, lens edger, and frame heater machines), and personnel training (approximately USD50,000). Due to the high cost of equipment and human resources required, points of access for eye care services in LMICs are scarce and principally located in urban areas.⁴⁷ Limited service points contribute to high drop-out rates when individuals are referred to a vision centre after being screened in more remote locations. Direct costs to access eye care, such as transport to appointments, are primary barriers to accessing care in LMICs.⁴⁸ Indirect costs of care, including the loss of productivity and foregone earnings for the patient and caregiver, are also common reasons to skip eye care appointments.⁴⁹

Limited policy documents guide the provision of refraction services and eyeglasses in LMICs. Recent efforts to support LMICs include the Standard School Eye Health Guidelines for Low and Middle-Income Countries⁵⁰ (see section 4.9) and the International Agency for the Prevention of Blindness’s (IAPB)⁵¹ Standard List / Valued Supplier Scheme for refraction services and eyeglasses. The Standard List provides information on where to source the most cost-effective and appropriate equipment, including a comprehensive list of different products from tried and tested global manufacturers. The list is focused on LMIC settings and is a free source.⁵²

3.6 There is a general shortage of ophthalmologists and optometrists in LMICs, and mid-level eye care workers are not effectively deployed.

LMICs lack trained personnel to deliver refraction services. In many countries, highly trained ophthalmologists are the only personnel legally allowed to prescribe eyeglasses. Ophthalmologists are responsible for performing eye surgery and treating all common eye conditions, including providing refraction services. They are medical doctors who have completed at least 7 years of medical study. There is a shortage of ophthalmologists in LMICs: for example, there are only 2.5 ophthalmologists per million population in Sub-Saharan Africa, below the WHO recommended ratio of 4 per million population.^53,54 Most importantly, the distribution of ophthalmologists is unequal, with most concentrated in urban areas and secondary or tertiary health facilities in LMICs.⁵⁵

Optometrists and mid-level eye care workers are involved in the management of refractive error worldwide, but are often not accredited to carry out eye care services independently. Optometrists provide diagnosis, management, and treatment services for eye conditions. At a minimum, an optometrist has completed a bachelor’s degree and is licensed or registered.⁵⁶ They are not medical doctors. The acceptance of optometrists remains an issue in many countries, either because optometry is not recognised as a profession or because there is no established educational requirement for optometrists.⁵⁷ There is also a shortage of optometrists in most LMICs, with for example only 7.5 optometrists per million population in Sub-Saharan Africa, which is below the WHO recommended ratio of 10 per million population.⁵⁸ A disparity in distribution between rural and urban areas also exists. Mid-level eye care workers are a heterogeneous group of staff with specialist ophthalmic training, but who can perform fewer competencies than an optometrist. The cadre name, time spent in training, and competencies may vary by country, based on regulations, but may include opticians, refractionists, orthoptists, optometric/ophthalmic technicians and assistants, ophthalmic nurses, etc. (this list is non-exhaustive).⁵⁹ They diagnose and treat some eye conditions, and refer patients with conditions beyond their scope of practice. In contrast to ophthalmologists and optometrists, they often serve in rural areas and provide a bridge between ophthalmologists and primary or community-level workers⁶⁰ (see Appendix F).

Task-shifting to optometrists and mid-level eye care workers can support the detection and treatment of refractive errors and other eye conditions in LMICs.⁶¹ The LV Prasad Eye Institute, an Indian NGO, developed a pyramid model of eye care delivery relying on a large network of primary health workers and a strong referral network between the tiers of care to address the lack of available highly trained personnel (see Case study 1).^62,63 Standardisation of accreditation mechanisms for optometrists and mid-level eye care workers is needed to support task-shifting. WHO recommends moving from a pre-defined set of eye health workers to a competency-based approach, where ‘competencies’ refer to the specific tasks an individual must be able to perform to a specified standard to qualify as a professional.⁶⁴ Several core competency frameworks were published by the International Council of Ophthalmology,⁶⁵ the World Council of Optometry⁶⁶ and the WHO Regional Office for Africa.⁶⁷ However, there is no common understanding of how to translate these competencies into training programmes – e.g. steps to learn a competency, expected level of quality, programme length, trainer background, practice on users – leading to a lack of uniformity of both training programmes and service quality across the world. More research is also needed to assess how the additional workload related to refractive errors is impacting mid-level eye care workers’ current scope of practice and the risks around potentially over-burdening them.

3.7 Donor funding to address uncorrected refractive errors in LMICs is only a fraction of the funding spent on eye health and comes from a limited number of donors.

NGOs play a critical role in the provision of refraction services and eyeglasses in LMICs.^69,70 The spending per year addressing uncorrected refractive errors is not typically tracked, but EYElliance - a coalition of multi-sector stakeholders looking to address the unmet need for eyeglasses - estimated that USD37 million was spent across fewer than 50 NGOs on uncorrected refractive errors in 2015.⁷¹ This represents a small fraction of the funding spent on overall eye health: for example, trachoma eradication is supported by a USD105 million philanthropic fund⁷² and also receives multi-million funding as part of neglected tropical diseases programmes.⁷³ Funding for uncorrected refractive errors remains insufficient to address the gap: with USD37 million, NGOs could only reach 7.8 million people,⁷⁴ addressing less than 1% of the need for eyeglasses.

The donor landscape for uncorrected refractive errors is limited: the largest donors include the Standard Charter Bank, Lions Club International, L’Occitane Foundation, and corporate social responsibility programmes – mostly from leading eyeglasses manufacturer EssilorLuxottica. Institutional donors account for only approximately 10% of the funding dedicated to uncorrected refractive errors. For example, uncorrected refractive errors benefit from funding through USAID’s Child Blindness Program, which currently offers grants for projects focused on preventing and treating blindness among children. In-kind donations also account for an important part of NGO funding as there is a preference from a number of donors on providing eyeglasses to individuals instead of building a sustainable provision system.⁷⁵

Essilor estimates that approximately USD14 billion is needed over the next 30 years to eliminate uncorrected refractive errors globally – a significant portion of which is allocated for demand creation activities.⁷⁶ Recent momentum has been gained for uncorrected refractive errors with a few large initiatives being announced:

• The Vision Catalyst Fund: was announced in 2018. It aims to launch in 2020 and to allocate over USD1 billion in funding over 30 years. Although it is unclear how much will be allocated to uncorrected refractive errors, the fund aims to work directly with governments to accelerate systems change and expand universal eye health services. The fund gathers together public and private sector partners.⁷⁷

• Vision for Life: In 2015, Essilor launched a EUR30 million social impact fund, dedicated to supporting sustainable vision care infrastructure and programmes to eradicate uncorrected refractive errors.^78,79

4.1 The global eyewear market is valued at USD130 billion, has a clear market leader and caters to HIC markets.

The global eyewear market is estimated at approximately USD130 billion with lenses accounting for approximately 39% of the market and frames for approximately 37%.^80,81 EssilorLuxottica is the leading global provider of lenses and frames, following the merger of Essilor and Luxottica in 2018. Essilor (France) is the leading lenses supplier, with an estimated 45% of the lenses market.⁸² Other lenses suppliers, such as Hoya (Japan) and Carl Zeiss (Germany) have each less than 10% market share.⁸³ Luxottica (Italy) is the top frames manufacturer, with an estimated 25% market share,⁸⁴ also well ahead of other market players such as Safilo (Italy) which have less than 10% market share.⁸⁵

The global eyewear market is largely focused on highincome markets. Europe and North America accounted for approximately 80% of Luxottica net sales⁸⁶ and approximately 75% of Essilor revenue^87,88 in 2018. In LMICs, expensive branded eyeglasses are often the only available products.⁸⁹ Private optical companies target high-income urban customers with prices of prescription eyeglasses ranging from approximately USD50 to more than USD200. Pricing differs considerably, depending on the mark-ups in the value chain (see section 4.4). Reading eyeglasses are less expensive, with prices ranging from approximately USD3 to approximately USD20.

Manufacturing of lenses and frames is concentrated in four regional clusters within China, with over 3,000 business enterprises involved in the manufacturing of eyeglasses and related products. Most Chinese manufacturers produce unbranded products or serve as contract manufacturers for international brands. Only recently have Chinese manufacturers begun marketing their own brands, backed by in-house research and development.⁹⁰

Lenses and frames manufacturers control the value chain to the end user. For example, Luxottica owns almost 9,000 stores and contracts with a further 100,000 opticians around the world.⁹¹ Essilor owns optical assembly labs and supplies between 300,000 and 400,000 optical stores worldwide.⁹² EssilorLuxottica continues to expand its control over the chain through the acquisition of retail networks.⁹³

4.2 Demand for eyeglasses in LMICs remains low due to low awareness around vision impairment and stigma around wearing eyeglasses.

In LMIC, demand generation for eyeglasses is an under-funded area due to the misconception among donors that individuals are aware of their poor vision and will seek treatment when they can. In reality, even with a well-established supply in an area, demand for eyeglasses remains low due to poor awareness of vision issues and available treatments, and low acceptability of available eyeglasses.

• Low awareness: Many individuals either do not know they have a problem with vision or are not aware that simple and affordable treatments exist. For example, older people often consider a reduction in vision as part of normal ageing and are unaware that it can be corrected with eyeglasses.⁹⁴ A study in Ghana determined that primary reasons for not correcting near vision loss among adults aged 35 years and older were ‘lack of felt need for near vision correction’ (26%) and being ‘unaware of available interventions/correction’ (22%).⁹⁵

• Stigma and low acceptability: When individuals are provided with eyeglasses, wearing compliance remains an issue due to style, cultural stigma, or misconceptions around eyeglasses. Among adults, a study in East Timor found that the primary reasons for unwillingness to use eyeglasses were cosmetic (41%) and embarrassment (38%).⁹⁶ Children can also be reluctant to wearing eyeglasses due to the fear of being victimised at school: in the UK, children wearing eyeglasses are indeed 35% to 37% more likely to be bullied.⁹⁷ Caregivers also play a role in wearing compliance of children: in China, parents and teachers commonly believe that wearing eyeglasses will worsen children’s vision.⁹⁸

4.3 LMIC markets generally lack effective public procurement systems for eyeglasses; NGOs have traditionally aimed to fill the gap by distributing refurbished donated eyeglasses.

Procurement and provision of eyeglasses by the public sector is low to non-existent. Vision impairment straddles health, education, and social welfare agencies that address disability, but it is rarely a priority for any of these ministries, due to limited budgets, competitive priorities, a focus on mortality and morbidity indicators, and low awareness around the burden of uncorrected refractive errors. When procurement occurs, it is poorly coordinated across different ministries and no singular ministry has complete oversight on procurement and provision. When the product is procured, this may be done at sub-national levels where capacity is lacking. In South Africa, provision of eyeglasses is the responsibility of each province. In Zambia and Sierra Leone, each district has their own procedures around procurement. Some districts lack the capabilities and capacity to procure and stock products, or some wait to order until volume thresholds for lenses and frames are met, which contributes to products being out of stock and long waiting lists.

For a long time, NGOs aimed to fill the gap in public procurement through in-kind donations. Provision would take place through one-off vision camps where eyeglasses were distributed without establishing sustainable provision points. These provision models often relied on recycled eyeglasses, whereby a beneficiary’s prescription was matched to the best available donated eyeglasses. But the practice of recycling donated eyeglasses is expensive, costing approximately USD21 per pair.⁹⁹ Recognising the limitations within this model and following IAPB recommendations on this topic,¹⁰⁰ many NGOs and inclusive businesses now focus on capacity building for the provision of appropriate eyeglasses within the public sector or through the sale of affordable or subsidised eyeglasses, often with eyeglasses available for less than USD20. These models are explored in the following sections.

4.4 The supply chain for prescription eyeglasses is complex due to the level of customisation required which adds cost to the user; reading eyeglasses are easier and cheaper to obtain.

Prescription eyeglasses sold in the traditional private optical sector in LMICs have a costly and complex supply chain (see Table 2).

(1 & 2) Sourcing products: uncut lenses and frames are manufactured and shipped to ports of import for less than USD1.50 altogether. Most is mass production and situated in China.

(3) Import: eyeglasses are often considered as cosmetic products rather than medical devices by authorities, leading to long clearing processes at customs and higher import duties.^102,103 For example, import duties reach 76% for frames and 32% for corrective lenses in Bangladesh.¹⁰⁴

(4) Distribution: in-country delivery costs are typically high and options limited, especially to reach remote areas. Often users do not leave points of sale with their prescription eyeglasses on the day of refraction assessment as the order needs to be sent to an optical lab, which is often centrally located. Once assembled, eyeglasses are sent to the point of sale where the user returns to pick them up.

(5) Optical assembly lab: in LMICs, optical shops typically contract out to private optical assembly labs, which can add significant margins to the sale price.

(6) Retail: optical shops often have high infrastructure and overhead costs – including brand licensing fees – and charge a significant margin. Branded frames, such as those supplied by Luxottica under the Ray-Ban, Vogue, or Prada brands, carry a significant price premium and can lead to a final price 40 times higher than the cost of the frame.¹⁰⁵ Customer preferences related to frame style also play an important role in the purchase of eyeglasses. Retail points must create product assortments that offer choice in sizes, colours, and shapes of frames. This makes ordering and stock management complex and can lead to small volume orders spread across various frame models.

The following cost reduction opportunities exist along the supply chain:

• Disintermediating the supply chain – commonly known as ‘cutting out the middleman’ – by handling distribution and optical assembly lab activities. A hub-and-spoke model can be a cost-effective option where the hub is the optical assembly lab and the spokes are the shops of a retail optical chain or the vision centres in different hospitals. In North America, vertically integrated e-commerce player Warby Parker disrupted the eyewear industry by designing, manufacturing, and selling their eyeglasses directly to customers. They were able to offer eyeglasses for less than USD100, significantly below the average cost in the US.¹⁰⁶

• Eliminating or reducing import duties on low-cost, non-branded frames and ready-made reading eyeglasses.¹⁰⁷ In Pakistan, NGOs successfully lobbied the Ministry of Commerce and saw import duties lowered from 11% to 3% on low-cost, non-branded eyewear.¹⁰⁸

Reading eyeglasses have a simpler supply chain compared to prescription eyeglasses as they are generic and have the same prescription on both lenses. They are shipped to LMICs as ready-made eyeglasses and therefore can be purchased directly at points of sale without requiring an in-country optical assembly lab.

4.5 Ready-to-assemble eyeglasses can alleviate supply chain challenges for 80% of the need for eyeglasses.

A new model of eyeglasses adapted to low-resource settings, called ready-to-assemble eyeglasses, entered the market in 2015. Pre-edged lenses are clipped into the frame. Lenses are interchangeable between right and left and allow eyeglasses to be adapted to the specific left- and right-eye prescription. Two main suppliers of ready-to-assemble models are: 1) Essilor, through its inclusive business arm 2.5 New Vision Generation (Ready2Clip model); and 2) VisionSpring, a social enterprise. Ready-to-assemble eyeglasses have a limited range of corrective power, from -6.00D to +6.00D, do not correct for astigmatism and offer limited interpupillary distance adjustment compared to customised eyeglasses. Despite those limitations, they can still address 80% of the population need while alleviating supply chain challenges: ¹⁰⁹

• Faster, simplified delivery: ready-to-assemble eyeglasses can, with limited training, be mounted on the spot in less than 5 minutes. On-the-spot delivery is more cost-effective than custom eyeglasses because it does not require an optical assembly lab and reduces referral and loss to follow-up barriers. Users in low-resource settings are significantly more likely to acquire a pair of eyeglasses when delivered on the spot compared to when issued by prescription only.¹¹⁰

• Appropriate design: ready-to-assemble eyeglasses come with different styles and models adapted to different face shapes. For example, Ready2Clip offers over 30 different styles. Products are certified according to European quality standards (CE marking) and/or ISO standards, and are durable, with spring hinges allowing for flexibility, lightweight resin for frames, and scratch-resistant lenses. Studies show no difference in satisfaction and wearing compliance compared with traditional custom-made eyeglasses.

• Affordable: the price offering for ready-to-assemble eyeglasses typically ranges between approximately USD5 for a basic model to approximately USD15 for more specialised lenses, such as photochromatic.¹¹¹ This price point is lower than the price of the majority of customised eyeglasses currently available in LMICs.

Ready-to-assemble eyeglasses are considered by experts as an appropriate solution for LMICs: Ready2Clip and VisionSpring ready-to-assemble eyeglasses are listed on the IAPB list of recommended products for LMICs.¹¹² However, they have received pushback from optometric professional associations in various countries, mainly due to concerns around poor fitting^113,114 and inequality of treatment between people receiving ready-to-assemble eyeglasses and those receiving fully customised eyeglasses, thereby limiting their uptake.

Other social enterprises are trying to enter this space. DOT Glasses similarly offers ready-to-assemble eyeglasses with a unique model and an adjustable bridge. DOT Glasses further simplifies the supply chain by providing only 5 different corrective powers, matching the refractive error to the best available lenses. OneDollarGlasses and TwoBillionEyes offer on-the-spot production of handcrafted eyeglasses. In the OneDollarGlasses model, a flexible spring steel is bent on the spot to create a frame where pre-edged lenses are inserted. However, these products have varying levels of quality, limited customisation options, and have also not been tested for acceptance by end users.

4.6 New technologies for vision screening and refraction create opportunities to reach more people.

The new technologies mentioned below represent some of the most promising changes to the delivery landscape:

• Smartphone-based visual acuity tests: visual acuity apps offer an alternative to the traditional paper-based eye chart. Among providers, Peek Vision (UK) offers a smartphone-based vision screening app called Peek Acuity which enables data-driven health programmes. The app has shown to be as accurate as conventional paper-based vision tests.¹¹⁵ It is integrated with data capture tools – called Peek Solutions – for visualising patient flow along the health system. One of the features is text message reminders of follow-up appointments, which are sent to the care giver in the local language. In a school screening programme in Kenya, the use of Peek Acuity nearly tripled the number of children who attended follow-up appointments compared to conventional eye health screening.¹¹⁶ Peek Solutions enables the analysis of population-based data, which allows health services to identify challenges along the pathway to care and to optimise programme designs. Peek Vision partners with governments, NGOs or major eye hospitals and provides consulting support to improve programme design based on best practices. Peek Vision provides partners with training and consulting on use of the data generated to identify programme gaps and optimise the impact in an iterative process, and to achieve continuous improvement.

• Handheld, easy-to-use refraction devices adapted to low-resource settings: these devices can be operated by a technician with minimal training, can be taken to the field, and typically require less time to do the refraction compared to traditional refraction devices. They vary by technology, cost, and accuracy (see Appendix G).

  • Promising handheld autorefractors perform objective refraction using wavefront aberrometry technology, which makes them as accurate as top traditional desktop autorefractors, but they cost 2 to 3 times less. Prices range from approximately USD4,000 to USD7,000. A few options exist that are adapted to LMICs, such as the Plenoptika ‘QuickSeeFlip’ or ‘e-see’, the Smart Vision Lab ‘SVOne’, or the Ovitz ‘EyeProfiler’.

  • Other refraction devices are offered at prices starting from approximately USD50 to around USD1,300, but they do not meet the accuracy levels of traditional desktop autorefractors. Promising innovations include the Essilor ‘ClickCheck’ and EyeNetra ‘Netra’. They rely on a self-refraction technique where the user looks into a mechanical or mobile-powered device and turns a knob or a dial to align bars or bring an image into focus. The device then allows a prescription to be determined by comparing the user’s assessment with the ideal alignment.

Depending on the accuracy of the device and the regulations in place, these devices can help reach more people in different ways. One way is to increase the efficiency of existing optometrists or ophthalmologists – by using handheld autorefractors, existing eye professionals can see more patients and travel more easily to remote communities. These devices also support task-shifting as they allow mid-level eye care workers to perform refraction. Mid-level eye care workers can triage patients, identify complicated cases to be referred to an eye professional, and provide eye professionals with an initial starting point for refraction, or even prescribe the eyeglasses themselves if they are using a reliable handheld autorefractor and if national regulations allow. Some studies show a good alignment between the prescription determined with wavefront aberrometery and subjective refraction, potentially opening the way for objective refraction using this technology to be sufficient to prescribe eyeglasses.¹¹⁷

• Self-refraction devices integrated with the delivery of eyeglasses: this self-refraction technique allows the user to self-adjust the lens power they need to arrive at an adequate level of vision.¹¹⁸ Global Vision 2020 has developed a simple portable mechanical self-refraction device – the ‘USee’ – which can determine a prescription based on subjective refraction only. Concerns were raised among vision experts about the fact that using only subjective refraction could lead to over-correction among children, and these concerns are currently being addressed by GV2020.¹¹⁹ The device is used in combination with ready-to-assemble eyeglasses that can be delivered on the spot (see Case study 2). Other examples of self-refraction innovations include adjustable eyeglasses, such as the Adlens and Adspecs eyeglasses, but these products have had limited success in the vision space, mainly due to unsatisfactory cosmetic appearance.¹²⁰

• Photoscreeners: these devices rely on a camera to estimate refractive error. They are used to triage patients and provide an initial diagnostic for young children or uncooperative patients as they can be used from a 1 metre distance and take less than 1 minute to complete. Cost is similar to handheld autorefractors, from approximately USD5,000 to around USD8,000, but they have a lower level of accuracy than refraction devices. Examples of photoscreeners include the ‘plusoptiX A12R and S12R’ by plusoptiX – listed on the IAPB standard list – ‘Spot’ by Welch Allyn, ‘iScreen’ by iscreen Vision, or the ‘GoCheckKids’ app by Gobiquity.

• Teleoptometry/ophthalmology: mid-level eye care workers send eye images to an accredited eye care professional who can then confirm the initial diagnosis and prescription remotely. Teleophthalmology has the same desired clinical outcome as the traditional system, especially for eye conditions where a digital imaging system is useful.¹²¹ Teleophthalmology can be useful in countries where regulations require ophthalmologists or optometrists to write the prescription, and it has the potential to engage established eye care professionals to support the development of mid-level eye care workers in countries where capacity is constrained. Forus Health – an Indian medical equipment company – developed a handheld autorefractor called ‘3nethra aberro’ integrated with a teleophthalmology platform. Images collected from ‘3nethra aberro’ are sent to the platform and can be accessed by an eye care professional remotely. Essilor’s EyeMitra programme (see section 4.11) is currently using this platform where an EyeMitra – a mid-level eye care worker trained by Essilor – can connect to an available optometrist in a (peri-)urban area. The optometrist accesses the details of the refraction and guides the EyeMitra to prescribe the eyeglasses. Users are charged on a per-screening basis for platform usage.

Uptake of these technologies has been limited by a lack of standards around implementation evidence, low acceptance by optometric professional associations, and price. Consensus around clinical, economic, and implementation evidence is needed to demonstrate that these technologies support a cost-effective, simplified service delivery model versus traditional refraction devices, and that they can be used in low-resource settings at scale. Optometric professional associations may identify innovative devices allowing for delegation of tasks to lower-skilled workers as a threat to their scope of practice. Core competency frameworks currently do not consider innovative devices to support task-shifting. In addition, handheld autorefractors, based on their current price, still represent a significant investment in LMICs, in particular if they are meant to be operated by the larger pool of mid-level eye care workers.

4.7 Successful and sustainable public sector procurement and delivery models exist.

Proven models exist to increase access to refraction services and eyeglasses within the public sector. One of these models is to establish vision centres within existing public health facilities, operated and managed by the Ministry of Health (see Case study 3). Vision centres offer refraction and general eye care services, and sell affordable prescription and reading eyeglasses. Setting up a vision centre requires significant upfront investments in terms of infrastructure, equipment, supply chain setup, and human resources training. A public-private partnership approach can help spread the costs across the different stakeholders (see Table 3) and build technical capacity at the Ministry of Health for eyeglasses procurement and supply chain management. Vision centres represent a sustainable solution for public sector provision of affordable eyeglasses:

• Self-sustaining: vision centres operate as stand-alone businesses, with revenue from eyeglasses sales covering operational costs, ensuring long-term sustainability. In some settings, profits from vision centres are transferred to public health facilities.

• Government ownership: vision centre operations and product procurement and distribution are handled by the Ministry of Health, ensuring operations are sustained after NGOs or private partners exit the programme.

• Catering to base of the pyramid customers: different tiers of pricing and product offering enable a cross-subsidy type of model, with higher-income users paying higher rates based on a sliding scale or purchasing higher-tiered products that may carry higher margins, thereby subsidising lower-priced options for those less able to pay.

• Proximity with a local hospital: referral networks are strengthened to treat other types of eye conditions, such as cataracts requiring surgery.

Other initiatives to support provision of eyeglasses within the public sector include setting up local optical assembly labs. The Ministry of Health of Uganda, jointly with the Australian NGOs Light for the World and the Brien Holden Vision Institute, established a national optical lab to assemble prescription eyeglasses.¹²⁷ Assembled eyeglasses are delivered by local transport within 3 working days to users, who pay approximately USD12. Eyeglasses are free for children. About 2,500 eyeglasses are ordered per year. One of the main challenges of the project is to find a sustainable way to procure frames and lenses, which are currently donated products. In South Africa, the KwaZulu Natal province identified the setup of a local optical lab integrated into government systems as a cost-effective and sustainable solution to provide eyeglasses. So far, the province has relied on the Brien Holden Vision Institute to compliment the manufacture and supply of eyeglasses at subsidised cost. The project aims to create a hub-and-spoke model that establishes an on-site optical assembly lab at one of the provincial eye care hospitals. It is expected that eyeglasses manufacturing costs will be lowered, turnaround times will be reduced to same-day delivery in some instances, and KwaZulu Natal will be able to provide services to its marginalised poor population. In parallel, the province and the National Department of Health are working on setting up a provincial and national tendering system for the procurement of eyeglasses.

4.8 Most users in LMICs pay out-of-pocket for services, but public financing mechanisms can be leveraged to ensure better access and quality.

In many LMICs, especially in Asia and Africa, provision of eyeglasses is not integrated into the benefits package of public health services or national health insurance schemes.¹²⁸ A WHO survey among 29 countries reported that more than 20% of them did not provide coverage for any eye care services. If coverage does exist, it often only covers the vision assessment and diagnosis, but excludes the eyeglasses themselves. Other countries in the WHO survey reported that eye care services were only minimally covered or restricted to some categories, such as children.¹²⁹ Potential users without health insurance have lower rates of use of eye care services or rely on lower-quality options.¹³⁰ As mentioned previously, most prescription eyeglasses are unaffordable or lead to high out-of-pocket costs. As a result, users rely on offerings from lower-quality and unregulated private sector optical services. For instance, there has been a proliferation of small private optical shops in Asia that have limited government oversight and clinical regulation.

WHO recommends including eye care provision in public financing. Countries should shift from out-of-pocket payments towards mandatory prepayments with pooling of funds.¹³¹ This should ensure that the inability to pay is not a barrier to coverage, and therefore makes eye care an integral part of universal health coverage.¹³² To support countries in implementing eye care within universal health coverage, WHO is currently developing costing tools and recommendations within the OneHealth tool to support the inclusion of eye care interventions in a health benefits package.¹³³

Coverage and financing decisions will impact uptake, access, quality, and cost efficiency of eyeglasses provision, but more research is needed to support decision-makers. Countries will need to decide whether and at what level of coverage they will finance eyeglasses as part of emerging insurance schemes, often based on cost efficiency and effectiveness thresholds. Countries may choose to cover the full cost of eye exams, lenses, and frames up to a capped amount for different portions of the population, or may only cover a subset of the provision. For example, the Philippines insurance programme PhilHealth provides reimbursement for services and eyeglasses up to a set amount for children under 18, and the community-based insurance programme in Rwanda covers the exam and the first tier of eyeglasses (ready-to-assemble) for all members, but then further subsidises services by selling additional tiers of eyeglasses through the public vision centre. Some public vision centres and financing schemes cover the exam only, with eyeglasses sold through the public institution. Governments may also choose to leverage the already existing private sector to support financing and delivery of services. Indonesia’s national scheme, Jaminan Keshatan Nasionale, provides for a mix of public and private services, whereby members receive an initial assessment and prescription from a public hospital eye clinic and then eyeglasses are provided by contracted private optical shops.

Similar to the Indonesian model, novel financing mechanisms that leverage the private sector exist. A voucher-based model that provides government reimbursement to a private provider can support increased access to quality services. Such a model has been explored as part of the school health programme in Trinidad and Tobago. In other health areas, vouchers have successfully been used to increase access, limit out-of-pocket expenses, and drive quality for family planning services.¹³⁴ Coverage under UHC often assumes that the public sector provides the service; however in many LMICs, refraction services are primarily available in the private sector. Vouchers are paper or electronic referral coupons that are provided to beneficiaries for free or at a highly subsidised cost. Voucher holders can then choose when and where they seek care from a contracted government-accredited provider. The provider then receives payment from the government once services are delivered in accordance with the voucher programme standards and guidelines.

4.9 School eye health (SEH) is an effective delivery platform for eyeglasses and opportunities exist to expand across LMICs.

With a shortage of eye care professionals and infrastructure in LMICs, school-based eye health programmes are cost-effective interventions that leverage existing institutions to screen and deliver eye care services. School-age children are a key target group for eye care services; children with vision impairment lag behind in school enrolment, learning outcomes, and completion of primary school as 80% of all learning during a child’s first 12 years occurs through vision.¹³⁵ NGOs and governments have proven that SEH can safely and accurately identify children with vision impairment. SEH is based on three main activities: 1) teachers, school nurses, or other trained personnel screen children for vision problems on-site at schools; 2) children identified with vision problems are examined by an eye health professional who determines an eyeglasses prescription or refers them for more advanced care; 3) children who are in need of eyeglasses are provided with a pair. Evidence shows that teachers can adequately identify children with vision impairment.¹³⁶ The Disease Control Priorities (DCP-3) considers school vision screenings to be an essential and cost-effective intervention, with a cost of USD3.6 per child who benefits.¹³⁷ The World Bank declared the intervention low cost and affordable for many governments in December 2019.¹³⁸ Governments are increasingly recognising that SEH is possible, but only few LMICs are implementing it (see Case study 4).

A set of best practices and guiding principles were published to ensure the long-term sustainability and success of school-based eye health interventions:¹³⁹

• Integration of SEH: integrate SEH into existing school health or inclusive education programmes, e.g. combine vision screening and basic eye care training with existing school health training, such as deworming, and leverage existing school health budgets.

• Collaboration between Ministries of Health and Education: agreements between ministries need to be in place to allow teachers to screen school children and to take time away from work to be trained in vision screening and basic eye health. The Ministry of Health remains in charge of the quality of health interventions in school.

• Engagement of school leadership: teachers or school nurses – in settings where screening can be performed by these two cadres – need to be trained to screen children and identify those with vision issues.

• Education of teachers and parents on eye health and treatment: teachers and parents play an important role in eyeglasses wearing compliance for children.

• Sufficient trained eye professionals, infrastructure, and referral systems in place: sufficient eye exam professionals and a continuous supply of eyeglasses in the country is needed to ensure eyeglasses can be replaced when needed, and strong referral systems should be in place to connect children in need of specialist assistance to the correct level of care.

Task-shifting, using new screening or diagnostic devices, and ready-to-assemble eyeglasses can help programmes reach further cost-effectiveness. Scaling existing initiatives to a national scale can also help achieve economies of scale (mainly due to absorption of coordination costs).

4.10 Models to distribute reading eyeglasses through the public or private sector have been explored but their sustainability has not yet been proven.

Despite reading eyeglasses having a simplified supply chain, last mile delivery models have encountered many challenges and struggle to be sustainable. The following represent promising models to deliver reading eyeglasses, but more testing is needed to identify key sustainability factors:

• Community health workers (CHW): pilot models show that an individual with no prior health training can learn in a few hours to conduct basic vision screenings and dispense reading eyeglasses. This approach has been implemented for over 10 years as part of private CHW initiatives, initially proven in Bangladesh (see Case study 5) and replicated by multiple NGOs in China, Kenya, Uganda, and Pakistan. It shows there is an opportunity to integrate basic vision screenings and delivery of reading eyeglasses as a new service offering in government-managed CHW programmes. Evidence needs to be generated on the inclusion of eyeglasses in supply chains and the incremental cost involved with adding this new service to the existing system. There are also concerns that adding reading eyeglasses to a CHW’s portfolio of products and services would stretch their capacity.

• Last mile retailers: reading eyeglasses are sold in kiosks, pharmacies, or other last mile retail outlets. More operational evidence needs to be generated on what is needed to incentivise retailers to carry reading eyeglasses, given that they take up shelf space with low profit margins. The profit margin of a pair of reading eyeglasses is equivalent to that of a bar of soap, but individuals only need to buy eyeglasses every couple of years versus the frequent need for soap. Demand generation interventions are key to support sales of reading eyeglasses at last mile retailers and pharmacies.

• Sale of affordable or subsidised eyeglasses by small entrepreneurs: local entrepreneurs are trained to conduct near vision screenings and sell reading eyeglasses in remote areas to underserved populations. Several pilots of this model showed that entrepreneurs struggle to create a sustainable income when relying on reading eyeglasses only. They typically run out of territory after approximately 18 months and margins are low. As stand-alone entrepreneurs, they are also not well integrated with higher levels of care, with weak referral networks for other eye conditions.

• Workplace screening: companies organise regular vision camps to screen their employees for vision loss, provide them with reading eyeglasses if needed, and refer them to specialised care when relevant. VisionSpring established a Clear Vision Workplace alliance to promote workplace screenings, partnering with companies from the textile, transport, and tea industries. VisionSpring selects ‘Vision champions’ from the workforce to run the vision camps and trains them in near vision screening, reading eyeglasses dispensing, and counselling. For example, VisionSpring announced a partnership with Shell India and the New Mangalore Port Trust – owned by the Ministry of Shipping – to provide free vision screenings to truck drivers, deliver low-cost eyeglasses, and refer those who need it to specialised care. Sustainably of the programme beyond VisionSpring’s engagement and integration of the cost of reading eyeglasses in employees’ health benefits has not yet been fully validated and would benefit from further research.

4.11 Inclusive businesses exist that provide quality eyeglasses to base of the pyramid customers and are economically viable, but they require upfront investment to be replicated and scaled.

Different models of inclusive optical businesses exist and have proven successful:

• Urban model: Private optical businesses have managed to set up profitable stores in urban areas selling high-quality eyeglasses in a range of prices, including affordable eyeglasses. These inclusive businesses manage to offer eyeglasses starting at approximately USD10 for prescription lenses and frames by relying on: 1) rapid scale; 2) a tiered pricing model targeting the large and underserved market of middle- to low-income customers with a range of margins based on product category; 3) establishing a repeat customer base through innovative marketing strategies; 4) selling directly to customers, cutting out the middlemen for distribution and optical assembling activities; and 5) developing house brands, thereby avoiding branding fees. Successful examples in LMICs include Lenskart in India and Ver de Verdad in Mexico (see Case Study 6). Further research needs to be conducted to understand the replication potential of such initiatives and mobilise private sector investment to support scale-up in less dense areas.

• Mixed model: High throughput volume is rare in LMICs; therefore, social entrepreneurs and start-ups are looking into other models to generate demand and reach middle-income and base of the pyramid customers, especially in remote areas. In Uganda, Wazi Vision relies on a cross-subsidy business model to sell eyeglasses made with frames locally manufactured from recycled plastic. Sales of USD20-USD25 eyeglasses to middle-income customers can subsidise outreach programmes in remote communities where they sell eyeglasses at USD2-USD3. As demand and volume grows, Wazi Vision is hopping to offer a tiered pricing model and increase the number of delivery points.

• Rural/last mile entrepreneurial model: Setting up a rural network of optical shops selling affordable eyeglasses appears more challenging, due to the lower population density and reduced customer mix. Models do exist, where un(der-)employed youth are trained to become primary eye care providers and run an optical shop (see Case Study 7) or an entrepreneurial ‘vision-in-a-box’ type of business. In the latter, individuals are equipped with a vision kit which contains the necessary screening tools and materials (e.g. lenses, frames) to deliver prescription eyeglasses on the spot. For example, Vision Vijana, a Kenyan social enterprise, equips each pair of entrepreneurs with the innovative handheld autorefractor ‘QuickSee Flip’ by Plenoptika and the TwoBillionEyes eyeglasses assembly kit. Vision Vijana currently works in partnership with truck companies offering eye care coverage for their employees.

This rural/last mile entrepreneurial model requires start-up capital that entrepreneurs may not be able to cover alone. Required capital may cover: 1) training in basic eye health assessment, refraction, referrals for non-refractive issues, and edging of and mounting of eyeglasses; 2) business training around stock management, marketing, or brand-building; 3) set up of the supply chain, procurement and distribution systems and processes; and 4) investment in medical equipment and infrastructure. Novel financing mechanisms, such as development impact bonds or blended finance, may represent an opportunity to crowd in private funding to support the early-stage investment of entrepreneurs and contribute to the expansion of these models. Different mechanisms can ensure that other eye conditions are detected, and patients referred to the relevant level of care. This may include ensuring regular meetings with the local hospital or providing entrepreneurs with compensation – such as a commission for each referral. An important consideration of any of these models is how they are connected into referral systems for more complex eye care needs.

5.1 Demand

5.2 Supply

5.3 Enablers