Thailand’s Universal Eye Screening in Action

Ariella Rotenberg is a research associate in U.S. Foreign Policy at the Council on Foreign Relations.

As of January 9, 2016, Thailand has implemented refractive error eye screening in first-grade classrooms nationwide. Additionally, any student that is identified with vision impairment through the refractive error screening, is guaranteed to be seen at the local hospital by an ophthalmologist and provided with glasses to correct for their impaired vision. Under this policy, it is estimated that 260,000 Thai children will be able to access spectacles that they need but may not have otherwise received. With the exceptions of South Korea and Iran, Thailand stands way ahead of the pack among Asian countries in having universal eye screening for children. Last September, the World Health Organization (WHO) hosted a meeting focused on promoting universal eye health across the Western Pacific region specifically because the region lags in providing universal vision care.

Thailand’s new nationally-approved program for testing and treating children with vision impairment exemplifies the shift in the global health agenda from the Millennium Development Goals (MDGs) to the Sustainable Development Goals (SDGs). As Yanzhong Huang explained in his Expert Brief, the new agenda entails a widening of the scope of global health initiatives to include issues such as non-communicable diseases (NCDs) and social determinants of health. Vision impairment fits neither into the category of infectious disease nor in the category of non-communicable disease, at least not in the way is it typically defined. It is, however, encapsulated in the broad mandate of the third SDG, namely, “ensure health lives and promote well-being for all at all ages.”  It is the very fact that vision impairment fails to fit neatly into either category, perhaps, that it has remained so underfunded and under-addressed, despite the fact that one third of the blind children in Thailand between the ages of one and fourteen became blind from untreated refractive error—nearsightedness, farsightedness, and astigmatism. These conditions, if uncorrected, can cause learning disabilities, may result in behavioral problems from an inability to focus, and even cause blindness.

Thailand’s government demonstrated the success of evidence-based health policy making with its eye screening intervention. The eye screening program was piloted by Thailand’s semi-autonomous Health Intervention and Technology Assessment Program (HITAP) in order to decide whether or not the government should include this health service in their universal health coverage (UHC) package. In order to decide about new health services, the Ministry of Public Health deploys HITAP to assess pilot interventions based on cost-effectiveness and impact. A cross-sectional study of the refractive eye screening was conducted in seventeen schools spread out over four provinces. The results of the study showed that the detection rate for primary school children of visual impairment was relatively high: 52 percent for mild visual impairment and 74 percent for moderate visual impairment. The study also revealed significant willingness on the part of teachers to perform the screening and that parents trusted teachers to conduct the screening given the limited number of health professionals available. Furthermore, the study found the cost of the screening conducted by teachers to be relatively low–low enough to be funded by current revenue raised for the UHC services.

The universal treatment of refractive error in Thailand addresses not only a health risk, but also works to counteract detrimental social determinants of health. The third SDG has been interpreted to address not only medical conditions, but also the underlying social and economic factors that allow many easily-treated conditions to go untreated in underserved populations. Access to something as simple as an eye screening, ophthalmologists, or eye glasses is commonplace in developed countries where routine clinic visits are typical, but not in developing countries where a large majority of the population does not have access to reasonable quality eye care services. In Thailand specifically, awareness of refractive errors is associated with higher income and urban residence. Furthermore, according to a World Health Organization (WHO) report, uncorrected refractive error in a child who needs glasses and later becomes blind due to lack of treatment “can hinder education, personality development, and career opportunities, in addition to causing an economic burden on society.” Incorporating early detection and treatment of refractive error in Thailand not only addresses the immediate health concern of vision impairment and possibly vision loss, but it helps in that respect to equalize opportunities for successful education, development, and career opportunities.

Two weeks ago, I had the chance to travel to the eastern Thailand province of Samutprakan—one of the pilot provinces for the eye screening intervention. The photo for this post features three young girls at Samutprakan elementary school, one of whom was fitted for glasses as part of the pilot program. The site visit reminded me that UHC and other health-related SDG targets are not just words on paper, but they drive forward actions across the world that have the potential to significantly improve access and health outcomes. The health problems the eye screening program seeks to address, the negative social determinants of health it intends to counteract, and the fact that it is cost-effective, impactful, and funded sustainably, offer clues on how health-related SDGs can be effectively pursued at the country level.