Draft Action Plan

Eye Health Aotearoa has developed a "Draft Action Plan for Eye Health in Aotearoa New Zealand".

It is based on findings from the ‘Eye Care in Aotearoa New Zealand 2022: Eye Care Situation Analysis Tool (ECSAT)’ report we commissioned.

The Draft Action Plan focuses on underlying issues common to the prevention and treatment of eye diseases and vision loss in general, rather than a specific eye condition, and includes seven recommended actions.

The Draft Action Plan is a work in progress. Eye Health Aotearoa invites all stakeholders, leaders in government, health care organisations and community groups to contribute to the plan.

By working together, we can address avoidable vision loss and empower people who are blind, deafblind or have low vision to live the life they choose.

Invest in the vision by providing your suggestions at [email protected]

Closing date: 28 July 2023

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DRAFT ACTION PLAN FOR EYE HEALTH IN AOTEAROA NEW ZEALAND

 

Purpose

 

Aotearoa New Zealand has made international commitments to the World Health Organization (WHO)[i] and to the United Nations (UN)[ii] to implement integrated people-centred eye care (IPEC). The International Agency for the Prevention of Blindness defines IPEC as services that are managed and delivered so that people receive a continuum of health interventions covering promotion, prevention, early diagnosis, treatment, and rehabilitation. Eye Health Aotearoa’s vision is to advance IPEC in Aotearoa New Zealand.

In this context, and aligned with our vision, Eye Health Aotearoa has developed a draft action plan for eye health in Aotearoa New Zealand to address challenges within the eye health system. This plan is based on findings from the ‘Eye Care in Aotearoa New Zealand 2022: Eye Care Situation Analysis Tool (ECSAT)’ report we commissioned. The draft action plan focuses on underlying issues common to the prevention and treatment of eye diseases and vision loss in general, rather than a specific eye condition.

We present this draft action plan to stimulate conversation across the eye health sector and gather input from various stakeholders. This plan is aligned with the Royal Australian and New Zealand College of Ophthalmologists (RANZCO) “RANZCO’s Vision for Aotearoa New Zealand’s Eye Healthcare to 2030 and beyond” strategy[iii].

A sector-wide discussion is crucial for reaching a consensus on the actions to improve New Zealanders' access to treatments that prevent avoidable blindness. Implementing the proposed actions requires collaboration among government agencies, healthcare professionals, non-government organisations (NGOs), training institutions, the private sector, and other interested parties.

By working together, we can address avoidable vision loss and support those who experience blindness, deafblindness or vision loss to live the life they choose.

Summary - Recommended Actions

 

No.

Action

Timeline

1

Appoint a Clinical Director of Eye Health within Manatū Hauora's (Ministry of Health)

2024–2025

2

Establish a National Eye Health and Vision Loss Prevention Leadership Group within Manatū Hauora's (Ministry of Health)

2024–2025

3

Map the pathway for social inclusion in eye care by identifying barriers and effective solutions

2024–2025

4

Fund Aotearoa New Zealand’s first National Eye Health Survey

2024–2025

5

Increase general education on the importance of eye health through sector collaboration and using existing budgets

2024–2025

6

Integrate patient-centred referral processes in the new Health Information System

2024-2025

7

Use the improved evidence to develop, implement, and evaluate the 2027–2030 Eye Health Action Plan

2026–2035

 

Context

 

Focus on Māori and Pasifika Eye Health

Eye Health Aotearoa recognises Māori as the Tangata Whenua of Aotearoa New Zealand and Te Tiriti o Waitangi as Aotearoa’s founding document, with its associated responsibilities and obligations.

 

There is growing evidence of inequity in eye care and service coverage, with underserved groups including Māori and Pasifika people. Generally, this evidence has not been used to advocate for improved equity of eye services, although there has been recent activity in this area.

Global and Aotearoa New Zealand commitments for eye health

In October 2019, WHO launched the first-ever World Report on Vision, outlining the scope of visual impairment and proposing strategies to address the issue. The key recommendation is for countries to implement IPEC.

In 2020, during the 73rd World Health Assembly, WHO Member States, including New Zealand, endorsed a resolution on 'Integrated People-centred Eye Care, Including Preventable Vision Impairment and Blindness', requesting countries to strengthen IPEC. The ‘Eye Care in Aotearoa New Zealand 2022: Eye Care Situation Analysis Tool (ECSAT)’ report expands on this resolution:

“World Health Assembly resolution WHA73.4 (August 2020) on Integrated people-centred eye care (IPEC), urged Member States to make eye care an integral part of universal health coverage and to implement people-centred eye care in health systems. Integrated people-centred eye care refers to eye care services that are managed and delivered to assure a continuum of promotive, preventive, treatment, and rehabilitative interventions against the spectrum of eye conditions, coordinated across the different levels and sites of care within and beyond the health sector, and according to people’s needs throughout the life course.

To develop integrated people-centred eye care, countries will need to understand which aspects of eye care services need to be strengthened. WHO has recently revised the Eye Care Situation Analysis Tool (ECSAT) to assist countries to summarise the current situation for eye health and support subsequent planning. We have used this tool to prepare this report.”[iv]

On 14 October 2021, the World Sight Day, WHO launched the revised ECSAT, featuring 178 questions across 31 items, organised under six health system building blocks[v]. The Eye Health Aotearoa commissioned the ‘Eye Care in Aotearoa New Zealand 2022: Eye Care Situation Analysis Tool (ECSAT)’ report, making New Zealand the first high-income country to utilise the revised ECSAT.

In addition to IPEC, WHO has identified two eye care global targets:

  1. 40% increase in effective coverage of refractive error by 2030
  2. 30% increase in effective coverage of cataract surgery by 2030.

During the 74th World Health Assembly in April 2021, WHO Member States, including New Zealand, endorsed these two global targets.

In July 2021, at its 75th session, the UN General Assembly adopted a resolution on vision ('Vision for everyone: accelerating action to achieve the Sustainable Development Goals’), calling for consideration of the two global eye care targets as a mechanism for monitoring and reporting on the contribution to the 2030 Agenda for Sustainable Development.

The prevalence of eye disease in Aotearoa New Zealand

Currently, around 180,000 New Zealanders are blind, deafblind, or have low vision. Projections suggest that this number will increase to 225,000 by 2028[vi]. However, no formal data on the prevalence or causes of blindness and visual impairment in Aotearoa New Zealand is available[vii]. Previous estimates have relied on extrapolations from Australian and US surveys.

The full extent of avoidable blindness in the country remains unknown. It is estimated that 75% of blindness and low vision cases could be prevented[viii]. Still, many people continue to experience unnecessary vision loss and a decrease in independence due to conditions such as refractive error, age-related macular degeneration, diabetic retinopathy, glaucoma, and cataracts. Vision loss can be prevented through early detection and cost-effective treatment.

Every day, New Zealanders lose their sight from preventable causes. The lack of eye health data puts individuals at risk of losing their vision and means the country is lagging in global eye health standards.

Social and economic cost of vision disorders

Vision loss in Aotearoa New Zealand carries a significant economic burden, estimated at NZ$3.74 billion[ix] and growing each year. Individuals with vision loss face considerable challenges, including a reduced likelihood of employment[x], a threefold increase in the risk of clinical depression[xi], and double the risk of falls and quadruple the risk of hip fractures[xii]. This issue affects not only those who experience vision loss but also their friends and whānau who support them.

The ‘Eye Care in Aotearoa New Zealand 2022: Eye Care Situation Analysis Tool (ECSAT)’ report emphasises additional social and economic consequences of vision loss:

“The recent Lancet Global Health Commission on Global Eye Health highlighted that vision impairment reduces mobility, affects mental well-being, exacerbates risk of dementia, increases likelihood of falls and road traffic crashes, increases need for social care, and ultimately leads to higher mortality rates. Further, the Commission showed that poor eye health has a negative impact on quality of life, education, and work, and estimated that addressing vision impairment through the provision of good eye health treatment and rehabilitation services would result in annual productivity gains of more than US$410 billion.

The Commission collated evidence that good vision and eye health unlocks human potential and reduces inequality by facilitating many activities of daily life, enabling better educational outcomes, and increasing work productivity. An increasingly compelling body of evidence demonstrates the potential for eye health services to advance the Sustainable Development Goals (SDGs), by contributing towards Poverty Reduction, Zero Hunger, Good Health and Well-Being, Quality Education, Gender Equality, and Decent Work.”[xiii]

By providing timely access to vision rehabilitation and other support services, those who are blind, deafblind, or have low vision can maintain their independence and continue to enjoy life in their communities. Investing in rapid access to comprehensive vision rehabilitation could yield social returns as high as $3 for every $1 invested[xiv].

Challenges in the eye health sector in Aotearoa New Zealand

The ‘Eye Care in Aotearoa New Zealand 2022: Eye Care Situation Analysis Tool (ECSAT)’ report highlights key challenges for the eye health sector in Aotearoa New Zealand, as outlined below.

Governance structure and coordination mechanism

Eye care lacks a dedicated governance structure within Manatū Hauora (Ministry of Health), with no specific unit or coordinator assigned to it [xv].The government's political and financial commitment to eye care has remained largely unchanged in the past five years[xvi].

There are no formal coordination mechanisms for eye care between ministries, and a non-communicable diseases (NCD) multisectoral committee has only been proposed, but not established.

The main coalitions of stakeholders for eye care include NGOs such as Blind Low Vision NZ, Eye Health Aotearoa, and professional bodies like RANZCO and the NZ Association of Optometrists. However, the representatives from relevant non-health sectors and the eye care sector seldom engage in policy development, as do representatives from relevant health programmes[xvii].

Evidence based policy and planning

Eye care is not specifically included in the national health strategic plan, and there is no national eye care strategy or action plan and therefore we do not have goals and targets for eye health[xviii]. This is despite New Zealand's commitment to the World Health Assembly resolution WHA73.4 (August 2020) on IPEC, which urges Member States to integrate eye care into universal health coverage and implement people-centred eye care in health systems[xix].

The existing NCD plan does not include eye care. While there are several NCD-related guidelines, such as one on diabetic retinal screening, the Healthy Ageing Strategy does not explicitly cover cataract services or refractive and optical services. Primary eye care is not prioritised within wider eye care service planning[xx].

Eye health research

Aotearoa New Zealand lacks formal data on vision loss prevalence and causation, leading to an absence of comprehensive eye health strategies, policies, and frameworks. In contrast, countries like Australia have established strategies and frameworks that provide representative data on eye health conditions.

The Pae Ora (Healthy Futures) Act 2022[xxi] allows Te Aka Whai Ora (Māori Health Authority) and Te Whatu Ora (Health New Zealand) to undertake and support health research. The Ophthalmic Research Institute of Australia (ORIA) found that every $1 invested in eye health research generated a return of $10 (2009 figures)[xxii]. Despite these gains, investment in eye health research remains low compared to other medical research areas.

Access to eye care

In Aotearoa New Zealand, nearly 100% of primary eye care is provided by the private-for-profit sector[xxiii]. Optometrists in the private sector primarily provide refractive services, operating on a fee-for-service basis. The number of spectacles dispensed in the last calendar year is not monitored; an unofficial estimate is around 1.1 million pairs per year, valued at about NZ$350 million. In the government sector, the figure is close to zero, and the private not-for-profit sector is also extremely low or negligible.

Although refractive and optical services are widespread, limited financial protection may result in significant unmet needs among underserved groups[xxiv]. The eye care financing mechanisms and available expenditure for optometry and spectacles are limited, covering only a few people for the services they need[xxv].

The out-of-pocket payment for basic good quality spectacles ranges from NZ$150-250 (single vision) to NZ$600-900 (progressive lenses) in the private sector (main provider). There is no financial protection for people needing to see an optometrist and very limited protection for those needing to access spectacles, leaving most people uncovered[xxvi].

Despite the good quality of cataract surgical services and financial protection, the waiting time for surgery is long in many former District Health Boards (DHB), with significant differences based on the former DHB in which patients live[xxvii].

All New Zealand residents and citizens are eligible for public services with no out-of-pocket costs. Private health insurance is available, with 34.7% coverage among people aged 15 years and older. The main reason people do not have private health insurance is the cost. Information about the social distribution of private insurance coverage, quality, and satisfaction is unknown.

Coverage and social inclusion

Some systems and strategies exist to ensure primary health care effectively serves the most marginalised and underserved groups (e.g., Zero Fees, Very Low Cost Access scheme, Services to Improve Access, Rural Primary Health Care); however, no strategies are in place to improve access to primary eye care consultations with optometrists. There is a subsidy for high prescription spectacles and contact lenses, but few people are eligible[xxviii].

There are examples of government-funded eye care services delivered in the community, but these usually target specific population groups, such as Year 7 Vision Checks at school for children aged 11 or 12 years. Some community-delivered eye care services are part of wider community health care programmes, e.g., the Well Child/Tamariki Ora service (delivered by Plunket and other Well Child providers) is offered free to children aged from 4–6 weeks up to five years and includes questions about the child’s vision, and vision screening as part of the B4 School Check. This service is distributed evenly across geographic areas but is only for children under five years old. Community optometrists provide refractive services on a fee-for-service

basis[xxix].

Vision screening includes formal vision screening at birth, six weeks, four years, and 11 years[xxx].

  • There are guidelines for screening school-aged children at 11 and 12 years of age.
  • Screening for eye conditions, including amblyopia, is part of the B4 school check, which is conducted in pre-school and had coverage of 92% in 2019.
  • Children at primary or secondary school undergo vision screening via a national programme at 11 and 12 years old, but this does not include specific tests for uncorrected refractive error. Non-profit providers deliver a small number of additional services, but not in a systematic, coordinated way, and data is not collated to monitor coverage or outcomes. Providers include Essilor Vision Foundation, Mr Foureyes, OneSight (school screening), and SOVS screening programme[xxxi].

The government provides free inpatient and outpatient public hospital services, as well as free/subsidised primary care for some population groups, including children under 14 years and people with a Community Services or High Use Health Card[xxxii].

Services and medicines partly covered by the government include:

  • Eye care medication (e.g., glaucoma drops) requires a co-payment of NZ$5 per prescription[xxxiii].
  • Eye examinations, including refraction and spectacles, are mostly paid out-of-pocket, but the government funds these for children aged 15 years or younger with a High Health Use Card or whose parents receive social support. The government also funds contact lenses for people with certain conditions (e.g., keratoconus) and people with vision impairment unable to be corrected to 6/24 visual acuity.

Services and medicines not covered by the government include comprehensive eye examinations by optometrists (except for children aged 15 years or younger with a High Health Use Card or whose parents receive social support–costs for this group are partly covered as outlined above) [xxxiv].

Principles for the draft action plan

 

In addition to the recommended actions in the ‘Eye Care in Aotearoa New Zealand 2022: Eye Care Situation Analysis Tool (ECSAT)’ report commissioned by Eye Health Aotearoa, we believe that the actions must:

  1. Give effect to Te Tiriti o Waitangi, and the three principles of Protection, Participation and Partnership.
  2. Adopt a patient-oriented approach, acknowledging that current and future patients should be the starting point for policies and programmes aimed at preventing blindness and vision loss.
  3. Focus on high-risk groups, recognising that specific population groups are particularly vulnerable to avoidable blindness and vision loss.
  4. Prioritise primary prevention, acknowledging that many eye disease risk factors can be modified.
  5. Take a holistic approach, understanding that eye health is linked to a person's overall health and that vision loss may affect their emotional, social, and physical wellbeing.
  6. Apply a life course approach, considering that complex interactions between life events, biological risks, and health determinants produce varying patterns of vision function, eye disease, and vision impairment at each stage of an individual's life.
  7. Base actions on evidence, ideally from peer-reviewed research and evaluation, showing that the proposed actions will lead to a decrease in preventable blindness and vision loss. When research is not available, assess the potential of action items to reduce blindness and vision loss based on current knowledge and experience.
  8. Establish a partnership approach, recognising that the best outcomes will be achieved when all stakeholders work together towards commonly agreed objectives.
  9. Maximise linkages across the health and eye care sector to relevant national public health strategies and initiatives.

Eye Health Aotearoa’s recommendations

 

The authors of the ‘Eye Care in Aotearoa New Zealand 2022: Eye Care Situation Analysis Tool (ECSAT)’ report summarised their findings as follows: "The areas of Quality (Block 3) and Workforce and Infrastructure (Block 4) are strong or need only minor strengthening, while the areas of Leadership and Governance (Block 1), Financing (Block 5), and Information (Block 6) need major strengthening” [xxxv].

Eye Health Aotearoa recommends seven actions to address the report’s recommendations. Developing strategic partnerships and maximising connections to relevant national strategies and initiatives that impact eye health is a crucial part of each action. For the full list of ECSAT recommendations, see the "Recommended actions to strengthen eye care services in Aotearoa New Zealand" section of the ‘Eye Care in Aotearoa New Zealand 2022: Eye Care Situation Analysis Tool (ECSAT)’.

Immediate-short term Actions (2024–2025)

 

Action 1–Appoint a Clinical Director of Eye Health within Manatū Hauora (Ministry of Health)

 

The Chief Allied Health Professions Officer is responsible for optometry[xxxvi], but it is unclear how other eye health professions align with governance structures within Manatū Hauora (Ministry of Health).

The United Kingdom's National Health Service (NHS) recently appointed a National Clinical Director for eye care[xxxvii], a position advocated by the Macular Society, a charity organisation. The Macular Society first revealed plans to recruit the position in November 2021, after campaigning for the role for several years. National Clinical Directors are part-time clinicians who provide leadership, advice, and support across various health conditions and services.

We recommend appointing a Clinical Director of Eye Health within Manatū Hauora (Ministry of Health) who would:

  • Give effect to Te Tiriti o Waitangi, and the three principles of Protection, Participation and Partnership
  • Advocate to increase the evidence base for eye health planning
  • Raise awareness about the unmet need for eye care and support the Ministry of Health to advocate internally for eye care
  • Develop capacity and political support for eye care within the Ministry of Health
  • Create or strengthen intersectoral dialogue mechanisms; define roles and responsibilities of each agency
  • Create clear coordination mechanisms for eye care, such as steering groups, technical working groups, or committees, and support them to function effectively
  • Identify priority sectors and programmes
  • Engage stakeholders from relevant sectors and programmes in eye care planning
  • Ensure representatives from the eye care sector contribute to strategy planning and discussions among all relevant sectors and programmes
  • Ensure eye care indicators are incorporated within frameworks of relevant sectors and programmes, including long-term conditions and noncommunicable diseases[xxxviii]
  • Facilitate the integration of eye care into relevant legislation, policies, and plans.

 

Action 2–Establish a National Eye Health and Vision Loss Prevention Leadership Group within Manatū Hauora (Ministry of Health)

 

Manatū Hauora (Ministry of Health) has expert groups that offer leadership in key health areas and monitor services in the country[xxxix]. We believe it is time to establish an expert group focusing on eye health and vision loss prevention.

The National Eye Health and Vision Loss Prevention Leadership Group would:

  • Support best practices in eye health and vision loss prevention within the health sector.
  • Provide leadership and governance to enable the development of a National Action Plan for implementing person-centred integrated eye care
  • Give effect to Te Tiriti o Waitangi, and the three principles of Protection, Participation and Partnership.

By forming this group, we aim to ensure that eye health and vision loss prevention receive the necessary attention and expertise to improve care and outcomes for all people in Aotearoa New Zealand.

 

Action 3–Map the pathway for social inclusion in eye care by identifying barriers and effective solutions

 

High quality eye health services are not universally delivered; concerted action is needed to improve quality and outcomes, providing effective, efficient, safe, timely, equitable, and people-centred care. Use of effective service coverage indicators for cataract and refractive error highlight the delivery gap between population eye health needs and the delivery of good outcomes. We urge eye health providers to take a holistic view to emphasise quality and design service delivery based on individual and population needs: a people-centred approach. Services need to be characterised by inclusiveness and equity in design and delivery, proactively addressing the needs of marginalised and vulnerable groups through targeted interventions.

To do this, we propose that in 2024, Manatū Hauora (Ministry of Health) conduct a comprehensive review to:

  • Identify existing programmes that remove barriers to people getting regular comprehensive eye health examinations
  • Assess which programmes are effective
  • Determine if these programmes can be made available for Māori and Pasifika Peoples 10 years earlier, as eye diseases present sooner in these populations
  • Recommend ways to expand effective programmes and provide a timeline for implementation.

By implementing some of the recommendations from the review starting in 2025, we aim to improve access to eye health services and ensure better outcomes for all, especially for Māori and Pasifika Peoples.

 

Action 4–Fund Aotearoa New Zealand’s first National Eye Health Survey

 

Eye health policy, planning, and programmes need to be supported by high-quality research and data collection systems. The first step to address this issue is to gather representative and current Aotearoa New Zealand population-based data on vision impairment prevalence and causes. Establishing a dedicated eye health medical research fund could help prevent avoidable vision loss and improve outcomes for people who are blind, deafblind, or have low vision. This fund should finance a National Eye Health Survey to provide an evidence base to determine which services are most needed and where. This information will guide future policy formulation and economic analysis for effective service delivery in Aotearoa New Zealand, resulting in:

  • Reduced rates of avoidable blindness
  • Decreased inequity in eye health and service delivery
  • Lowered economic cost of vision loss (including wellbeing losses), estimated at NZ$3.74 billion in 2021 and increasing each year.[xl]

This initiative should only be the first step in investing further in eye health research.

 

Action 5–Increase general education on the importance of eye health through sector collaboration and utilising existing budgets

 

Every New Zealander should understand the importance of protecting their eyes against injury and disease, and how to maintain eye health throughout their lives. The New Zealand Association of Optometrists recommends comprehensive eye examinations every two to three years or sooner if any concerns arise. However, many New Zealanders do not undergo regular eye examinations, primarily due to a lack of awareness about their significance in maintaining eye health. Increasing awareness about the need for regular eye examinations would help detect eye conditions earlier and ensure people receive the necessary treatment.

Te Pou Hauora Tūmatanui (Public Health Agency) collaborates with non-government organisations (NGOs) and other sector leaders to promote healthy lifestyles and prevent non-communicable diseases within whānau and communities. Some chronic eye conditions related to non-communicable diseases include diabetic retinopathy, glaucoma, age-related macular degeneration, high myopia complications, and retinopathy of prematurity.[xli]

Te Pou Hauora Tūmatanui could integrate eye health education into their existing community public health programmes, such as incorporating eye health education into diabetic programmes to address diabetic retinopathy. By partnering with Eye Health Aotearoa and patient groups in the eye health sector, Te Pou Hauora Tūmatanui could scale up effective education and awareness-raising programmes to improve overall eye health in New Zealand.

 

Action 6–Integrate patient centred referral processes in the new Health Information System

 

Currently, eye health patient support groups receive referrals in an ad hoc manner. These groups report that they only receive referrals from a select few eye health professionals at the patient's first appointment. While patient support groups and vision rehabilitation providers strive to reach those in need, people still fall through the cracks due to inconsistent referral processes. A comprehensive health data system is crucial for enhancing the patient care pathway and ensuring patients are informed about available support resources early in their eye health journey.

The new Health Information System could incorporate an 'opt-in' feature for patients to receive support resources from appropriate organisations such as Blind Low Vision NZ, Glaucoma NZ, Kāpō Māori Aotearoa, and Macular Degeneration NZ, either before or after their consultation with a health professional when health administrators are entering patient data.

Eye health professionals could make referrals at the diagnosis and risk classification stage, as education and support are relevant for patients with suspected or confirmed risk of vision loss. A consistent referral process within the Health Information System would help preserve New Zealanders' sight and ensure they maintain their independence.

An example of an effective system is Oculo[xlii], which is widely used in Australia. Integrating patient-centred referral processes in the new Health Information System will help bridge the gap and provide essential support to those in need of eye health services.

Medium-long term Action (2026–2035)

 

Action 7–Use the improved evidence base to develop, implement, and evaluate the 2027–2030 Eye Health Action Plan

 

We propose developing the Eye Health Action Plan in 2026 and implementing it from 2027 to 2030. The action plan could focus on key areas such as:

  • Reducing the risk of eye disease and injury
  • Increasing early detection
  • Improving access to eye health care services
  • Enhancing system quality and care
  • Strengthening the underlying evidence base
  • Investing in independence for people after vision loss.

The outcomes of the 2027-2030 Eye Health Action Plan should be evaluated to inform the subsequent five-year plan.

The Eye Health Action Plan could integrate with the following strategies and action plans:

  • Living Well with Diabetes (October 2015)[xliii]
  • Ola Manuia Pacific Health and Wellbeing Action Plan 2020-2025 (June 2020)[xliv]
  • He Korowai Oranga – Māori Health Strategy (November 2002)[xlv]
  • Whakamaua Māori Health Action Plan 2020–2025 (July 2020)[xlvi]
  • Healthy Ageing Strategy (December 2016)[xlvii]
  • An interim Hauora Māori Strategy, Pacific Health Strategy, and the Rural Health Strategy expected to be published by July 2023.

These strategies are particularly relevant to eye health and vision care, but this list is not exhaustive.

Eye Health Aotearoa proposes three priorities for the 2027-2030 Eye Health Action Plan: 1) reduce the risk of eye disease and injury and increase early detection; 2) improve access to eye health care services; and 3) invest in independence for people after vision loss. By focusing on these three priorities, the Eye Health Action Plan can significantly improve eye health outcomes for the people of New Zealand.

These priority actions are outlined below.

1.     Reduce the risk of eye disease and injury, and increase early detection

To achieve this goal, funding should be allocated to expand existing education and awareness campaigns and integrate eye health into other public health programmes. Steps for investing in education could include:

  • Nationwide awareness and education campaigns for the public via mass media about eye health and regular eye checks e.g. advertising campaigns
  • Free patient resources readily available on eye health, eye diseases and how to care for your eyes
  • Free patient and caregiver support for people diagnosed with eye disease
  • Expanding the knowledge of primary health professionals (e.g., General Practitioners (GPs)) to incorporate eye health into patients' regular check-ups (for instance, by asking questions like, "When did you last have an eye check?”)[xlviii]

Many people are aware of heart health, obesity, skin health, and certain types of cancer, but they know little about eye health and how to maintain it. Education and awareness are crucial for improving eye health and reducing long-term costs[xlix].

The authors of the Deloitte Access Economics 2016 “Socioeconomic cost of macular degeneration in New Zealand” report found that:

“Awareness raising campaigns are aimed at increasing the number of individuals with Age related Macular Degeneration (AMD) receiving timely treatment, which can prevent further degradation of visual acuity. Historically, awareness and education of AMD has been driven by Macular Degeneration New Zealand, who are the national charity for AMD.

Total costs of awareness raising campaigns were derived from Macular Degeneration New Zealand accounts and were estimated to be $1.2 million for the two years 2015 and 2016, including pro-bono support. The benefits of awareness were based on an efficacy rate of 11%. In other words, an 11% increase in awareness was assumed to translate to an 11% increase in early treatment. The 11% increase in awareness was based on the Galaxy survey results provided by Macular Degeneration New Zealand. Overall:

  • the total benefits of awareness raising campaigns were estimated to be $6.4 million; and
  • the cost effectiveness of awareness raising campaigns was estimated to be $42,062 per Daily Adjusted Life Years (DALY) averted, which is considered cost effective based on World Health Organization benchmarks.”[l]

 

2.     Improve access to eye health care services

Modelling has been completed in the “Age-related Macular Degeneration Model of care assessment and recommendations” report[li] and the RANZCO Referral Pathway for Glaucoma Management[lii].

Current vision screening for children is insufficient and should be expanded to include comprehensive eye health examinations for children before they start school.

Availability of other treatments also needs consideration. For example, people may go blind if they do not receive timely access to anti-VEGF treatments. Anti-angiogenic (anti-VEGF) drug treatments involve having an injection into your eye to treat certain retinal conditions, such as wet macular degeneration, that cause abnormal blood vessels to grow and leak under the retina[liii].

Inequitable access and delays to treatments are likely to cause vision loss and increase costs to the individual and the health system. If treatments for age related macular degeneration (AMD) are started later, more treatments are needed to reach the same result, increasing the cost of treatment per person (treatment costs and staff resourcing). Additionally, once vision is lost, the cost of vision rehabilitation and treatment of co-morbidities (e.g. fractures, early aged care admission), is significantly higher than ongoing anti-VEGF treatments[liv].

The authors of the EY 2017 “Age-related Macular Degeneration Model of care assessment and recommendations” report made the following conclusions about how access to eye health care services affects outcomes for people:

  • Varied treatment approaches result in apparent inequitable access across the country. Opportunities exist to improve access for patients.”[lv]
  • “Slow access to treatment has been indicated as a concern for DHBs, especially with ageing population pressures, as it risks poor health outcomes and escalating health system costs. As soon as slow access occurs, potential visual acuity (VA) gain is diminished, and therefore the gain in quality-adjusted life year (QALY) received from treatment is extremely limited. To try and maintain VA, a greater amount of treatments are required per year when the eye lesions are more advanced – for example if access to treatment is delayed.”[lvi]
  • ‘Slow access’ conditions would cause total injection numbers over 10 years to increase by 17%, and session numbers would have to increase by 12%. As a result costs would increase by 21% for a QALY gain of only 10,400, compared to that of ‘constrained’ at 19,900 QALYs gained. This means this scenario is significantly cost adding ($8m over 10 years), and delivers less quality of life than the current, ‘constrained’ state. Ergo avoiding a ‘slow access’ scenario is critical to avoid inflated health care costs and significant pressure on an already tightly constrained workforce. This scenario could lead to a larger group of AMD patients who are untreated, which would add significant flow on costs to rehabilitation services and co-morbidities (fractures, early aged care admissions) associated with significant loss of vision.”[lvii]

 

3.     Invest in independence for people after vision loss

The WHO’s ‘Rehabilitation 2030: a Call for Action’ defines rehabilitation as a set of interventions designed to optimise functioning and reduce disability in individuals with health conditions, interacting with their environment[lviii]. Additional funding is needed to deliver core vision rehabilitation services to those who qualify but currently do not access them[lix]. An independent 2019 policy and advice report suggested that expanding Blind Low Vision NZ service provision to all eligible individuals in 2024 would require an additional NZ$14.0 million, considering cost pressures[lx]. The report also presents three funding models.

Timely access to vision rehabilitation and other support can help people who are blind, deafblind, or have low vision remain independent and engaged in their communities. Rapid access to comprehensive vision rehabilitation could provide social returns on investment as high as $3 for every $1 invested[lxi]. Trained rehabilitation professionals work directly with people to assess their needs, develop, and deliver individualised service programmes[lxii]. This funding should be complemented by strategies to grow the specialist workforce required.

There are approximately 30,000[lxiii],[lxiv] New Zealanders who have a best corrected visual acuity (BCVA) ≤ 6/24 in the better seeing eye. Within this community, support needs vary:

  • Children who are blind or vision impaired face significant challenges on the path to independence and lifelong success. They and their families require intensive support throughout the early years to grow and thrive.
  • For adults who are blind or vision impaired, community life participation includes workforce success. Specialised technology training can enable them to contribute to the economy alongside their sighted peers.
  • Older adults, particularly seniors with age-related vision loss, focus on achieving or maintaining personal safety and independence. Basic skills training to adapt to vision loss, as well as emotional support and social inclusion opportunities, are essential.

Vision rehabilitation offers numerous benefits, including increased employment retention, support for new workforce entrants, improved wellbeing, maximised remaining vision, independence, physical activity and community participation, reduced risk of falls, and decreased social isolation.

 

Conclusion

 

Aotearoa New Zealand is committed to fulfilling its international obligations to the WHO and the UN by implementing the IPEC initiative.

Eye Health Aotearoa commissioned the ‘Eye Care in Aotearoa New Zealand 2022: Eye Care Situation Analysis Tool (ECSAT)’ report and used its findings to frame this discussion document for eye health in New Zealand.

Our vision for this draft action plan is to spark constructive dialogue across the eye health sector, ultimately leading to a consensus on immediate, medium, and long-term actions to enhance access and prevent avoidable blindness for New Zealanders. Successful implementation of these actions will require collaboration among government agencies, healthcare professionals, NGOs, training institutions, the private sector, and other stakeholders.

The draft action plan addresses underlying issues common to the prevention and treatment of eye disease and vision loss, without focusing on any specific eye condition. It recommends seven actions to address ECSAT report recommendations, all of which emphasise the importance of strategic partnerships and maximising linkages to relevant national strategies and initiatives:

 

No.

Action

Timeline

1

Appoint a Clinical Director of Eye Health within Manatū Hauora's (Ministry of Health)

2024–2025

2

Establish a National Eye Health and Vision Loss Prevention Leadership Group within Manatū Hauora's (Ministry of Health)

2024–2025

3

Map the pathway for social inclusion in eye care by identifying barriers and effective solutions

2024–2025

4

Fund Aotearoa New Zealand’s first National Eye Health Survey

2024–2025

5

Increase general education on the importance of eye health through sector collaboration and using existing budgets

2024–2025

6

Integrate patient-centred referral processes in the new Health Information System

2024-2025

7

Use the improved evidence to develop, implement, and evaluate the 2027–2030 Eye Health Action Plan

2026–2035

By working together, we can combat avoidable vision loss and empower those who experience blindness, deafblindness or vision loss to live the lives they choose.

For the full menu of ECSAT recommendations, please see the “Recommended actions to strengthen eye care services in Aotearoa New Zealand” section of the ‘Eye Care in Aotearoa New Zealand 2022: Eye Care Situation Analysis Tool (ECSAT)’ report.

 

Footnotes

[i] In October 2019, the World Health Organization (WHO) launched the first ever World Report on Vision (WRV). The report outlines the scope of visual impairment and proposes strategies to address the issue. The key strategy recommendation refers to Integrated People-centred Eye Care (IPEC). At the 73rd World Health Assembly in 2020, WHO Member States (including New Zealand) endorsed a specific resolution named ‘Integrated people-centred eye care, including preventable vision impairment and blindness’, requesting countries to strengthen IPEC. WHO has developed the Eye Care Service Assessment Tool (ECSAT) to support countries on strategic planning for IPEC, with the key objective to use the tool for an evidence based analysis of the current strengths and weaknesses of the eye care system in the country. The ECSAT findings will then be used for strategic planning. In addition to IPEC, WHO has defined two global eye care targets. The two targets are a 40 per cent increase in effective coverage of refractive errors and a 30 per cent increase in effective coverage of cataract surgery by 2030. At the 74th World Health Assembly in 2021, WHO Member States (including New Zealand) endorsed the two targets.

[ii] The UN General Assembly has adopted a resolution on vision (‘Vision for Everyone: Accelerating action to achieve the Sustainable Development Goals’). The resolution calls to consider the two global eye care targets as a mechanism for monitoring and reporting on the global contribution to the 2030 Agenda for Sustainable Development.

[iii] RANZCO’s Vision for Aotearoa New Zealand’s Eye Healthcare to 2030 and beyond. https://ranzco.edu/home/community-engagement/vision2030-beyond/ . Last updated 4 May 2023. Accessed on 9 May 2023.

[iv] Page iii. Silwal P, Watene R, Cowan C, Cunningham W, Harwood M, Korau J, Sue W, Wilson G, Ramke J. Eye care in Aotearoa New Zealand 2022: Eye care situation analysis tool (ECSAT). Auckland: University of Auckland, 2022. Available at: https://doi.org/10.17605/OSF.IO/R75ZS

[v] World Health Organization. Eye Care Situation Analysis Tool (Ecsat) Geneva: 2019, accessed 03 Nov 2021. https://www.who.int/news/item/14-10-2021-eye-care-situation-analysis-tool-(ecsat)-launch.   

[vi] Moore, David; Rippon, Rebecca; and Niemi, Malin. Vision Rehabilitation in New Zealand. 27 February 2019. Sapere Research Group. Available on request from [email protected]. Page 14, Section 4.4.

[vii] Figure 11. Most recent population-based eye health surveys globally. The Lancet Global Health Commission. “The Lancet Global Health Commission on Global Eye Health: vision beyond 2020”. Full text at https://www.thelancet.com/pdfs/journals/langlo/PIIS2214-109X(20)30488-5.pdf

[viii] Taylor HR, Pezzullo ML, Keeffe JE. The economic impact and cost of visual  impairment in Australia. Br J Ophthalmol 2006;90:272-275

[ix] Blind Low Vision NZ. Cost of Vision Loss in 2021. 27 January 2021. https://blindlowvision.org.nz/news/cost-of-vision-loss-in-2021/. Accessed on 26 April 2023.

[x] Gail Pacheco and De Wet van der Westhuizen, “Disability, Education and the Labour Market: A Longitudinal Portrait for New Zealand” (AUT, 2016).

[xi] Rovner B, Ganguli M. Depression and disability associated with impaired vision: the Movies Project. Journal of the American Geriatrics Society 1998;46:617-9.

[xii] Klein BEK, Moss SE, Klein R et al. Associations of visual function with physical outcomes and limitations 5 years later in an older population. The Beaver Dam Eye Study. Ophthalmol 2003;110:644-650 Klein BEK, Klein R, Lee KE et al. Performance-based and self-assessed measures of visual function as related to history of falls, hip fractures and measured gait time. The Beaver Dam Eye Study. Ophthalmol, 1998; 105:160-164

[xiii] Page iii. Silwal P, Watene R, Cowan C, Cunningham W, Harwood M, Korau J, Sue W, Wilson G, Ramke J. Eye care in Aotearoa New Zealand 2022: Eye care situation analysis tool (ECSAT). Auckland: University of Auckland, 2022. Available at: https://doi.org/10.17605/OSF.IO/R75ZS

[xiv] Demonstrating the impact and value of vision rehabilitation: A report to RNIB. August 2017. Completed by the OPM Group. Authors Melissa Ronca, Bethan Peach, Ian Thompson, Dr Chih Hoong Sin. Available to download from https://www.rnib.org.uk/professionals/health-social-care-education-professionals/knowledge-and-research-hub/research-archive/demonstrating-the-impact-and-value-of-vision-rehabilitation/

[xv] Page 3. Silwal P, Watene R, Cowan C, Cunningham W, Harwood M, Korau J, Sue W, Wilson G, Ramke J. Eye care in Aotearoa New Zealand 2022: Eye care situation analysis tool (ECSAT). Auckland: University of Auckland, 2022. Available at: https://doi.org/10.17605/OSF.IO/R75ZS

[xvi] Page 2. Silwal P, Watene R, Cowan C, Cunningham W, Harwood M, Korau J, Sue W, Wilson G, Ramke J. Eye care in Aotearoa New Zealand 2022: Eye care situation analysis tool (ECSAT). Auckland: University of Auckland, 2022. Available at: https://doi.org/10.17605/OSF.IO/R75ZS

[xvii] Page 4. Silwal P, Watene R, Cowan C, Cunningham W, Harwood M, Korau J, Sue W, Wilson G, Ramke J. Eye care in Aotearoa New Zealand 2022: Eye care situation analysis tool (ECSAT). Auckland: University of Auckland, 2022. Available at: https://doi.org/10.17605/OSF.IO/R75ZS

[xviii] Page 19. Silwal P, Watene R, Cowan C, Cunningham W, Harwood M, Korau J, Sue W, Wilson G, Ramke J. Eye care in Aotearoa New Zealand 2022: Eye care situation analysis tool (ECSAT). Auckland: University of Auckland, 2022. Available at: https://doi.org/10.17605/OSF.IO/R75ZS

[xix] Page iii. Silwal P, Watene R, Cowan C, Cunningham W, Harwood M, Korau J, Sue W, Wilson G, Ramke J. Eye care in Aotearoa New Zealand 2022: Eye care situation analysis tool (ECSAT). Auckland: University of Auckland, 2022. Available at: https://doi.org/10.17605/OSF.IO/R75ZS .

[xx] Page 5. Silwal P, Watene R, Cowan C, Cunningham W, Harwood M, Korau J, Sue W, Wilson G, Ramke J. Eye care in Aotearoa New Zealand 2022: Eye care situation analysis tool (ECSAT). Auckland: University of Auckland, 2022. Available at: https://doi.org/10.17605/OSF.IO/R75ZS

[xxi] https://www.legislation.govt.nz/act/public/2022/0030/latest/whole.html#LMS575499

[xxii]  Ophthalmic Research Institute of Australia, 2019. ORIA Research Funding & Impact. https://oria.org.au/wp-content/uploads/2012/02/ORIA-RESEARCH-IMPACT-REPORT-20191.pdf

[xxiii] Table, page 2, Silwal P, Watene R, Cowan C, Cunningham W, Harwood M, Korau J, Sue W, Wilson G, Ramke J. Eye care in Aotearoa New Zealand 2022: Eye care situation analysis tool (ECSAT). Auckland: University of Auckland, 2022. Available at: https://doi.org/10.17605/OSF.IO/R75ZS

[xxiv] Page 12. Silwal P, Watene R, Cowan C, Cunningham W, Harwood M, Korau J, Sue W, Wilson G, Ramke J. Eye care in Aotearoa New Zealand 2022: Eye care situation analysis tool (ECSAT). Auckland: University of Auckland, 2022. Available at: https://doi.org/10.17605/OSF.IO/R75ZS

[xxv] Page 27. Silwal P, Watene R, Cowan C, Cunningham W, Harwood M, Korau J, Sue W, Wilson G, Ramke J. Eye care in Aotearoa New Zealand 2022: Eye care situation analysis tool (ECSAT). Auckland: University of Auckland, 2022. Available at: https://doi.org/10.17605/OSF.IO/R75ZS

[xxvi] Page 29. Silwal P, Watene R, Cowan C, Cunningham W, Harwood M, Korau J, Sue W, Wilson G, Ramke J. Eye care in Aotearoa New Zealand 2022: Eye care situation analysis tool (ECSAT). Auckland: University of Auckland, 2022. Available at: https://doi.org/10.17605/OSF.IO/R75ZS

[xxvii] Page 10. Silwal P, Watene R, Cowan C, Cunningham W, Harwood M, Korau J, Sue W, Wilson G, Ramke J. Eye care in Aotearoa New Zealand 2022: Eye care situation analysis tool (ECSAT). Auckland: University of Auckland, 2022. Available at: https://doi.org/10.17605/OSF.IO/R75ZS

[xxviii] Page 6. Silwal P, Watene R, Cowan C, Cunningham W, Harwood M, Korau J, Sue W, Wilson G, Ramke J. Eye care in Aotearoa New Zealand 2022: Eye care situation analysis tool (ECSAT). Auckland: University of Auckland, 2022. Available at: https://doi.org/10.17605/OSF.IO/R75ZS

[xxix] Page 8. Silwal P, Watene R, Cowan C, Cunningham W, Harwood M, Korau J, Sue W, Wilson G, Ramke J. Eye care in Aotearoa New Zealand 2022: Eye care situation analysis tool (ECSAT). Auckland: University of Auckland, 2022. Available at: https://doi.org/10.17605/OSF.IO/R75ZS

[xxx] Page 9. Silwal P, Watene R, Cowan C, Cunningham W, Harwood M, Korau J, Sue W, Wilson G, Ramke J. Eye care in Aotearoa New Zealand 2022: Eye care situation analysis tool (ECSAT). Auckland: University of Auckland, 2022. Available at: https://doi.org/10.17605/OSF.IO/R75ZS .

[xxxi] Page 9. Silwal P, Watene R, Cowan C, Cunningham W, Harwood M, Korau J, Sue W, Wilson G, Ramke J. Eye care in Aotearoa New Zealand 2022: Eye care situation analysis tool (ECSAT). Auckland: University of Auckland, 2022. Available at: https://doi.org/10.17605/OSF.IO/R75ZS

[xxxii] Page 27. Silwal P, Watene R, Cowan C, Cunningham W, Harwood M, Korau J, Sue W, Wilson G, Ramke J. Eye care in Aotearoa New Zealand 2022: Eye care situation analysis tool (ECSAT). Auckland: University of Auckland, 2022. Available at: https://doi.org/10.17605/OSF.IO/R75ZS

[xxxiii] Note that Budget 2023 included “Scrapping the $5 prescription co‑payment, making medicine cheaper for over 3 million Kiwis and taking pressure off our health system”. Find more information about this in Budget 2023. https://www.treasury.govt.nz/publications/budgets/budget-2023. Accessed 23 May 2023.

[xxxiv] Page 28. Silwal P, Watene R, Cowan C, Cunningham W, Harwood M, Korau J, Sue W, Wilson G, Ramke J. Eye care in Aotearoa New Zealand 2022: Eye care situation analysis tool (ECSAT). Auckland: University of Auckland, 2022. Available at: https://doi.org/10.17605/OSF.IO/R75ZS

[xxxv] Page 1. Silwal P, Watene R, Cowan C, Cunningham W, Harwood M, Korau J, Sue W, Wilson G, Ramke J. Eye care in Aotearoa New Zealand 2022: Eye care situation analysis tool (ECSAT). Auckland: University of Auckland, 2022. Available at: https://doi.org/10.17605/OSF.IO/R75ZS

[xxxvi] Ministry of Health. Allied Health. Last modified 21 September 2021. Accessed 13 April 2023. https://www.health.govt.nz/about-ministry/leadership-ministry/allied-health

[xxxvii] National Health Service. Accessed 13 April 2023. https://www.england.nhs.uk/about/ncd/#eye-care

[xxxviii] Bullet points copied verbatim from Tables on Pages 3 and 4. Silwal P, Watene R, Cowan C, Cunningham W, Harwood M, Korau J, Sue W, Wilson G, Ramke J. Eye care in Aotearoa New Zealand 2022: Eye care situation analysis tool (ECSAT). Auckland: University of Auckland, 2022. Available at: https://doi.org/10.17605/OSF.IO/R75ZS

[xxxix] Ministry of Health. Expert Groups. Accessed 13 April 2023. https://www.health.govt.nz/about-ministry/leadership-ministry/expert-groups

[xl] The Economic Cost of Vision Loss in New Zealand 2021. A Report prepared for Blind Low Vision NZ by Keith Gordon Ph.D. December, 2021. Vision Research International 2021.

[xli] World report on vision. Geneva: World Health Organization; 2019. Licence: CC BY-NC-SA 3.0 IGO. Page 78

[xlii]  https://www.oculo.com.au/

[xliii] Accessed 17 April 2023. https://www.health.govt.nz/system/files/documents/publications/living-well-with-diabetes-oct15.pdf

[xliv] Accessed 17 April 2023. https://www.health.govt.nz/system/files/documents/publications/ola_manuia-phwap-22june.pdf

[xlv] Accessed 17 April 2023. https://www.health.govt.nz/system/files/documents/publications/mhs-english.pdf

[xlvi] Accessed 17 April 2023. https://www.health.govt.nz/system/files/documents/publications/whakamaua-maori-health-action-plan-2020-2025-2.pdf

[xlvii] Accessed 17 April 2023. https://www.health.govt.nz/system/files/documents/publications/healthy-ageing-strategy_june_2017.pdf

[xlviii] Feedback received from Macular Degeneration New Zealand and Glaucoma New Zealand

[xlix] Page iv. Deloitte Access Economics. Socioeconomic cost of macular degeneration in New Zealand. 2016.

[l] Page v. Deloitte Access Economics. Socioeconomic cost of macular degeneration in New Zealand. 2016.

[li] EY. Age-related Macular Degeneration Model of care assessment and recommendations. 31 August 2017.

[lii] Last updated 9 February 2021. RANZCO Referral pathway for Glaucoma Management. https://ranzco.edu/policies_and_guideli/ranzco-referral-pathway-for-glaucoma-management/ . Accessed on 17 April 2023

[liii] Moorfields Eye Hospital, NHS Foundation Trust. Patient Information Anti-VEGF intravitreal injection treatment. https://www.moorfields.nhs.uk/sites/default/files/uploads/documents/Patient%20information%20-%20intravitreal%20injections%20for%20AMD.pdf . Accessed 26 April 2023.

[liv] EY. Age-related Macular Degeneration Model of care assessment and recommendations. 31 August 2017.

[lv] EY. Age-related Macular Degeneration Model of care assessment and recommendations. 31 August 2017. Page 25, pop out box titled “Treatment: why change?”

[lvi] EY. Age-related Macular Degeneration Model of care assessment and recommendations. 31 August 2017. Page 147.

[lvii] EY. Age-related Macular Degeneration Model of care assessment and recommendations. 31 August 2017. Page 149.

[lviii] WHO World report on vision, Draft for consultation. Page 35. Reference 142. Available for download at https://www.who.int/blindness/vision-report/consultation/en/.

[lix] Moore, David and Boyle, Rohan; Comprehensive Vision Rehabilitation in New Zealand: Research and Policy Advice for Blind Low Vision NZ. 2019. Sapere Research Group. Page 14.

[lx] Moore, David and Boyle, Rohan; Comprehensive Vision Rehabilitation in New Zealand: Research and Policy Advice for Blind Low Vision NZ. 2019. Sapere Research Group. Page 14.

[lxi] Demonstrating the impact and value of vision rehabilitation: A report to RNIB. August 2017. Completed by the OPM Group. Authors Melissa Ronca, Bethan Peach, Ian Thompson, Dr Chih Hoong Sin. Available to download from https://www.rnib.org.uk/professionals/health-social-care-education-professionals/knowledge-and-research-hub/research-archive/demonstrating-the-impact-and-value-of-vision-rehabilitation/

[lxii]Gordon, K., Bonfanti, A., Pearson, V., Morkowitz, S., Jackson, M. L. & Small, L. (2015). Letter to the Editor: Comprehensive vision rehabilitation. Canadian Journal of Ophthalmology, 50, 85–86. P. 85 Retrieved from https://www.canadianjournalofophthalmology.ca/article/S0008-4182(14)00393-7/pdf

[lxiii]Thornley, S. J., Gordon, K., Shelton, C., Marshall, R. (2015). The prevalence of visual impairment: a capture-recapture study of potential recipients of vision rehabilitation in three New Zealand urban regions. Blind Low Vision NZ’s Prevalence of Blindness Study, see https://blindfoundation.org.nz/eye-info/research/

[lxiv] Gordon, K., Crewe, J., Ramos, P., Macedo, A., Morgan, w. (2017). Capture-Recapture; A method for determining the prevalence of Vision Impairment in the Population. Clinical and Experimental Ophthalmology; (Suppl 1): 88-148.

 


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