The Indigenous eye-care gap is closing, but not fast enough

While the Roadmap to Close the Gap for Vision is helping to improve Aboriginal and Torres Strait Island eye health – 2020 has presented several road blocks.

Many of the disadvantages that cause poor eye health outcomes remain, and the COVID-19 global pandemic presented additional challenges. This means that to reach our goals we need more health partnerships, improved housing and environmental health in affected communities.

But there’s also a plus side.

COVID-19 led to a shift in the provision of soap, washing facilities and cleaning in schools and communities – all important in maintaining eye health – which was helped further by community ownership with local leaders.

However, we still have a long way to go.

Launched in 2012, the Roadmap to Close the Gap for Vision followed the National Indigenous Eye Health Survey results that showed Aboriginal and Torres Strait Island adults were six times more likely to experience blindness than other Australians.

Most (around 94 per cent) of their vision loss was unnecessary, preventable or treatable, but more than a third had never had an eye exam. This unmet need was similar across towns, cities and remote areas.

The treatment pathway was likened to a leaky pipe with lots of leaks where the system allowed patients to fall out and, at the time, we identified 42 issues that needed to be addressed.

Progress is being made

This year’s ninth Annual Update shows that more than half (24 out of 42) of the recommendations have been fully implemented, and 116 of 138 intermediary steps taken.

In 2015, the National Eye Health Survey showed the gap for blindness had halved, while Australian Institute of Health and Welfare Indigenous Eye Health reports found outreach eye exams had tripled, and eye examinations for those with diabetes and cataract surgery had more than doubled.

Trachoma rates in children in outback areas dropped from more than 20 per cent to less than five.

So, progress is being made and this is good, but eight years into the five-year Roadmap there’s still so much left to do. Why?

More work needed on trachoma

Australia remains the only developed country with trachoma. Mainstream Australia eliminated it 100 years ago but it is still found in some remote communities.

Australia’s 2009 plan to eliminate trachoma by 2020 has now been pushed out to 2022.

In Australia, we have made good progress examining children, distributing antibiotics, finding and treating older people with in-turned eyelashes and promoting good health. The key message about maintaining facial cleanliness is incorporated in the global hygiene approach: Milpa’s Six Steps to Stop Germs.

Access to soap and washing facilities at home and in school is also crucial.

Although there have been some improvements, housing and environmental health are key here. Overcrowding as well as the poor repair and maintenance of remote Aboriginal housing is a disgrace in some homelands and communities and washing facilities need ongoing, prompt repair and maintenance.

Until this is addressed properly, childhood infections like trachoma, ear infections, respiratory and gastro infections, scabies, and skin infections that lead to rheumatic heart disease and kidney failure will continue at unacceptable levels.

The Aboriginal and Torres Strait Islander community-led approach to controlling COVID-19 helped keep communities safe this year. But it also provided a blueprint for the future - this community-controlled model must be continued and reinforced when it comes to housing if we are to eliminate trachoma.

Community control and leadership

The regional model for appropriate, accessible, affordable and culturally-safe eye services has strong community involvement and links between the Aboriginal Community Controlled Health Organisations and primary care, with specialist services and a hospital hub.

Within the 64 self-defined regions, planning and activity is underway in 59. However, the rollout is incomplete.

Aboriginal and Torres Strait Islander community control and leadership is critical in regional collaborative networks. Developing models of care, workforce support, and training and investment in capacity building are also key to improving Indigenous eye health.

To facilitate these regional partnerships, we need the funding for part-time project officers or regional managers for a year or two. Although the federal government is responsible for Indigenous health and outreach services, it has not supported this critical role.

They are key in establishing regional services and the lack of federal funding has hindered these improvements

In some regions, such as in Victoria, state government funding has supported regional groups. In others, these positions are funded in a variety of ways, including non-government organisations.

The next step is local case-management of eye-related activities in primary care, in addition to outreach or visiting optometry and ophthalmology services.

This funding is a federal responsibility, but has not been forthcoming to meet population needs.

Progress has been made in providing eye-screening equipment and some training has been provided. However, more support is needed to increase capacity to provide basic eye care in primary care.

We also need better public hospital access for eye care such as cataract surgery. Indigenous patients often have to wait years for public surgery having already waited years for the outpatient appointment to put them on the surgical waiting list.

While some states have dragged their feet on their responsibility to provide affordable glasses, Victoria has led the way. Other states have upgraded their service and the Commonwealth recently funded an exploratory program that is leading some improved systems in the remaining jurisdictions.

What are the next steps?

The Aboriginal community-controlled model has shown outstanding leadership in caring for and protecting communities nationally from COVID-19.

This is powerful evidence of the effectiveness and capacity of communities.

Eye-care challenges now include significant service backlogs as a result of community closures, and limited elective surgery and non-urgent care. Any unused funds provide an opportunity to innovate and ensure eye care is incorporated into community health and wellbeing programs.

Although the Roadmap needs are clear, the response of some governments has been tardy, despite the moral and the economic imperatives. For every $A1 spent on eye care there is a $A5 economic return to the community.

Now surely must be the time to finally close the gap for vision – eliminating avoidable blindness and providing equity in Australian eye health.

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