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Middle East Afr J Ophthalmol. 2012 Jan-Mar; 19(1): 75–82.
PMCID: PMC3277028

Enhancing Advocacy for Eye Care at National Levels: What Steps to Take for the Next Decade?

Abstract

The global initiative for the elimination of avoidable blindness by the year 2020-(VISION 2020- The Right to Sight), established in 1999, is a partnership of nongovernmental organizations (NGOs), governments, bilateral organizations, corporate bodies and the World Health Organization. The goal is to eliminate the major causes of avoidable blindness by the year 2020. Significant progress has been made in the last decade. For example, the adoption of three major World Health Assembly resolutions (WHA 56.26, 59.25 and 62.1) requesting governments to increase support and funding for the prevention of blindness and eye care. Additionally, the approval of the VISION 2020 declaration, development of plans and establishment of prevention of blindness committees and a designation of a coordinator by most participating countries represent other major achievements. Furthermore there has been increased political and professional commitment to the prevention of visual impairment and an increase in the provision of high-quality, sustainable eye care. Most of these achievements have been attributed to the advocacy efforts of VISION 2020 at the international level. The full success of this global initiative will likely depend on the extent to which the WHA resolutions are implemented in each country. However, most ratifying countries have not moved forward with implementation of these resolutions. To date, only few countries have shown consistent government support and funding for eye care pursuant to the resolutions. One of the main reasons for this may be inadequate and inappropriate advocacy for eye care at the national level. As such it is believed that the success of VISION 2020 in the next decade will depend on intense advocacy campaigns at national levels. This review identified some of the countries and health programs that have had fruitful advocacy efforts, to determine the factors that dictated success. The review highlights the factors of successful advocacy in two countries (Australia and Pakistan) that secured continued government support. The review further explores the achievements of the HIV/AIDs control network advocacy in securing global and national government support. Common factors for successful advocacy at the national level were identified to include generation of evidence data and effective utilization of the data with an appropriate forum and media to develop a credible relationship with prominent decision makers. Aligning eye care programming to the broad health and development agendas was a useful advocacy effort. Also a broad all-encompassing coalition of all stakeholders provides a solid platform for effective and persistent advocacy for government support of eye care.

Keywords: Advocacy, Eye Care, Vision 2020

INTRODUCTION

What is advocacy?

There are many definitions of advocacy. According to Webster's dictionary, to advocate means to support, uphold, back or champion a cause or proposal. The word advocacy was derived from the Latin word “to call” or “to voice”.

There is no internationally agreed definition of advocacy. Different organizations and groups coin their definitions. There are differences as to which one is the most appropriate to use. Generally the definition that best suites the purpose of the advocacy is used. Here are some of the readily used definitions as developed by different groups and organizations:

  • Action for Advocacy Development and Australian National Advocacy Workshop in Sydney in June 1994 defined Advocacy as ‘speaking, acting and writing with minimal conflict of interest on behalf of the sincerely perceived interests of a disadvantaged person or group to promote, protect and defend their welfare and justice’.1
  • A workshop of the India HIV/AIDS Alliance, held in India, November 2002 had the following description “- Advocacy is an ongoing process aiming at change of attitudes, actions, policies and laws by influencing people and organizations with power, systems and structures at different levels for the betterment of people affected by the issue.”2 /AIDS Alliance, 2003
  • While a document of SARA (Support for Analysis and Research in Africa) project titled ‘An Introduction to Advocacy, Training Guide’ had the following definition for advocacy “- is an action directed at changing the policies, positions and programs of any type of institution.”3

It is important to differentiate between different terminologies that are often confused with Advocacy. These includes lobbying, Information Education and Communication (IEC) and community mobilization. Lobbying involves attempts to influence legislation at the federal and state level of governance, whereas advocacy is a much broader range of activities which may or may not include lobbying. IEC and community mobilization, are more about working with the general public or specific groups of people to educate, enlighten and possibly direct. IEC and community mobilization can also involve influencing, persuading and mobilizing people into action – which are all key advocacy ‘terms’.

TYPES OF ADVOCACY

Various types of advocacy exist. The Scottish Independent Advocacy Alliance4 classifies advocacy into Independent Professional Advocacy, Citizen Advocacy, Collective/Group Advocacy, Self Advocacy and Peer Advocacy.

But a simpler classification divides advocacy into two common types based on the Tristate Resources and Advocacy Corporation5 (TRAC) classification - individual and systems advocacy. These two common types of advocacy seem more relevant to eye health and will be considered here.

In Individual Advocacy the advocates concentrate their efforts on one or two people only. There are two common forms of individual advocacy. Informal advocacy includes parents, brothers and sisters, relatives, friends who often take on advocacy roles subconsciously. Voluntary community-based organizations that pay staff to advocate for individuals, is another form of individual advocacy. But Systems Advocacy is primarily concerned with influencing and changing the system in ways that will benefit a group of people e.g., people with a disability as a group within society. Systems advocates will encourage changes to the law, government and service policies and community attitudes. Usually systems advocates do not perform individual advocacy.

VISION 2020

The Global initiative for the elimination of avoidable blindness by the year 2020: Vision 2020: The Right to Sight, is a program of the World Health Organization (WHO) and the International Agency for the Prevention of Blindness [an international body of nongovernmental organizations (NGOs), professional bodies, academia, and industries] [Figure 1] Vision 2020 logo. The initiative was established in 1999 to reverse the global blindness which was projected to double from an estimated 36 million blind people in the early 1990s to over 76 million by the year 2020, if the current state of resources and services for eye care remain static.6

Figure 1
The Vision 2020 logo

The aim of the initiative is to eliminate the main causes of all preventable and treatable blindness as a public health issue by the year 2020. Efforts to reach the goal involve raising the profile of eye care to key decision makers by highlighting the causes of avoidable blindness and suggesting solutions that will help to eliminate the problem, identifying and securing the necessary resources around the world in order to provide an increased level of prevention and treatment programs and facilitating the planning, development and implementation of the three core strategies by national programs. The core strategies are disease control, human resource development and infrastructure and technology development.7

SUCCESSES OF VISION 2020 AND ADVOCACY

The global initiative had made remarkable achievements in the last decade especially at the international level. Most of the major achievements can be attributed to the strong and persistent advocacy that was achieved through strong leadership and strong broad partnerships involving all major stakeholders including professionals, academic institutions, NGOs, corporate bodies, civil societies, WHO, etc.

Some of the major successes included securing two World Health Assembly (WHA) resolutions – WHA 56.26 resolution in 2003 and WHA 59.25 in the year 2006. The resolutions recommended a unified approach to blindness prevention activities urging member states of the WHO to establish national committees, set up national blindness prevention plans and establish monitoring and evaluating mechanisms. Further in 2009 the WHA adopted resolution WHA 62.1 endorsing and urging the implementation of the Action plan for the prevention of avoidable blindness and visual impairment [Figure 2].

Figure 2
The Action plan document

Since the launch of the initiative more than 100 Member States have been directly involved in the activities of VISION 2020. Most countries have approved the Global declaration, developed plan and have a (PB) Prevention of Blindness committee and a coordinator. One hundred and five countries have formed national VISION 2020 committees. One hundred and thirty-five countries have done a VISION 2020 workshop, 91 countries have a national eye care plan.8

There has been increasing political and professional commitment to the prevention of visual impairment; increasing the provision of high-quality, sustainable eye care; increasing public awareness and use of eye health-care services; and encouraging commitment and support of NGOs and the private sector.8

Some countries have reported impressive success in the prevention of blindness. These countries include Gambia, India, Morocco, Nepal, Pakistan and Philippines. In Gambia the prevalence of blindness has decrease by 40% between 1986 and 1996. In India number of blind people had decreased by 25% in 2002 (8.9-6.7 million).8

CHALLENGES TO VISION 2020 AT THE COUNTRY LEVEL AND ADVOCACY

However the Vision 2020 program is facing serious unaddressed challenges, which may hamper the attainment of the goals of the initiative by the year 2020. Although the majority of countries had ratified the WHA resolutions relating to Vision 2020 and set up a plan and a national committee for prevention of blindness, the implementation of these plans have been lacking in most countries. Without the execution at national levels, elimination of the major causes of treatable or preventable causes of blindness cannot be achieved.

Most of the successes of Vision 2020 were at international levels, at the regional and country levels little has been achieved in many countries in terms of implementation of the WHA resolutions 56.26, 56.25 and 62.1, which all the countries had ratified. This point was highlighted by a discussion paper at a WHO and IAPB meeting held in Geneva in October 2010.9

Recognizing the importance of getting national governments to commit to supporting and funding national care programs, the IAPB Board endorsed the IAPB Strategic Plan 2009-1310 which includes increased emphasis on advocacy. This plan requires IAPB to advocate and hold governments accountable for the implementation of the WHA resolutions and the WHA Action Plan on the elimination of avoidable blindness and visual impairment; and the implementation of individual government national eye health plans (Strategic Objective 1). Additionally it recommends advocacy for resources to be made available from governments, foundations and other major donors to support national eye health plans (Strategic Objective 2).10

Possible reasons for the slow progress in implementing eye care at country levels may include inadequate resources due to competing health demands in each country and ignorance on the part of policy makers on the burden, economic impact and cost effectiveness of eye care interventions. Other factors include a lack of awareness by policy makers, public health practitioners and eye health professionals to the fact that eye health is readily compatible and compliant with many development, poverty alleviation and health agendas. Lack of adequate technical knowledge on the implementation of effective eye care programs by health administrators and professionals represent other factors for the lack of progress.

To address these issues a greater focus on advocacy at regional and specifically, at national levels is what is currently required. Advocacy for eye care at national levels is fundamental to the success of Vision 2020 in the last decade of the program. These advocacy activities should be directed at mobilizing leaders and groups to take action.

THE SUCCESS OF ADVOCACY AT NATIONAL LEVELS

Successful advocacy can result in greater government understanding, securing support and resources for health intervention. For example, successful advocacy has resulted in commitments from the Australian government to support eye care in Australia and the Asia-Pacific region, a commitment from the Pakistani government to support eye care since 2005 and a tripling of the eye care budget in India for the 11th five-year plan.11 Global support for HIV/AIDS intervention programs by most governments and the control of neglected tropical diseases (NTD) in many countries are examples of successful advocacy in other health sectors.

In order to understand the factors that comprise success in advocacy for health interventions at national levels, we studied previous examples of success.

METHODOLOGY

IAPB and WHO reports relating to Vision 2020 programs within the last decade were reviewed. We identified successes, challenges and advocacy efforts at national levels. Furthermore we interviewed some key groups in the global prevention of blindness community to identify some of the countries that have made significant strides in advocacy that had resulted in positive results. Out of the candidate countries, we selected Australia and Pakistan because data was readily available. We contacted the national organizations in charge of Vision 2020 activities or key groups in the prevention of blindness in these countries. We interviewed these national organizations and groups with a focus on the major advocacy activities that resulted in the success.

For comparison, we selected two major global health initiatives that had successfully secured governments support especially in developing countries. These initiatives were HIV/AIDS control programs and neglected tropical diseases control programs. Extensive literature searches were performed on the advocacy efforts of these health control networks. Personal interviews were conducted with some national groups or organizations in these health control programs in some developing countries.

All documents, searches and personal communications from the prevention of blindness organizations of Pakistan and Australia, and that of the HIV/AIDs and NTD control programs were reviewed and summarized to highlight the major activities and experiences that had culminated in smooth and fruitful advocacy outcomes especially in relation to the developing countries where there is an acute need for the Vision 2020 programs. The data are presented as case studies of these countries and control programs.

CASE STUDY 1: VISION 2020 AUSTRALIA: ADVOCACY FOR EYE CARE

Over the past decade, Australia has established itself as a global leader in efforts to eliminate avoidable blindness. Vision 2020 Australia, as the primary body for Australia's eye health and vision care sector, has been at the forefront of these efforts using novel advocacy strategies.

Following a well-coordinated advocacy approach targeting both the Australian Government and the Opposition in the lead up to the 2007 Australian federal election, Vision 2020 Australia secured a commitment from the Australian Labor Party for a $45m Avoidable Blindness Initiative (ABI).12 The party went on to win the election and the ABI (as it is commonly known) is currently being implemented in the Asia-Pacific region. Their advocacy approach was based on four key pillars:

Facilitating and strengthening partnership and collaboration among member organizations

Effective communication and the facilitation of member collaboration is a key element of the approach. Vision 2020 Australia encourages collaboration through a variety of mechanisms, including convening committees and working groups that provide specialized forums for policy areas and allow collaboration of members from varying areas of expertise to share knowledge.

Establishing and maintaining credibility with government

Vision 2020 Australia works closely with the Australian Government to ensure good policy outcomes. Achieving credibility has been a vital element of the success. Currently Vision 2020 Australia acts as a conduit for government seeking information or advice. Additionally, the effective relationship with Australia's previous Parliamentary Secretary for International Development Assistance, Bob McMullan, and the resulting outcomes, illustrates how partnership is central to these achievements. In this case, success was largely due to the fact that Vision 2020 Australia was able to demonstrate unity within the sector and a clear action plan that would deliver results.

In 2009 and 2010, Vision 2020 Australia engaged in extensive discussions with the Committee for Health and Ageing during an inquiry of health challenges facing Australia and the Pacific. During this inquiry, Vision 2020 Australia provided a private briefing on eye health issues, and participated in roundtable discussions with other leading public health and development agencies across Australia. As a result, eye health featured prominently in the Committee's final report, resulting in further pressure on the Australian Government to enhance funding commitments.

Vision 2020 Australia continued to engage politicians and government officials to ensure that eye health remained a priority for the Government. This continued effort resulted in avoidable blindness being included in the Government's International Development Assistance policy during the lead up to the 2010 election. This was a major achievement considering the other (competing) challenges included education, maternal health, water and sanitation and climate change.

Effectively utilizing the available evidence

One key element in convincing governments to fund eye health interventions is the effective use of available evidence. Fundamental to this strategy is explaining to members of Parliament and other stakeholders, the significant savings to national health care budgets due to cost effective eye health interventions.13 Furthermore, it is crucial that the decision makers understand the relationship between vision impairment and achieving the Millennium Development Goals. With so much attention being paid by governments to improving the lives of people living in poverty in the developing world, it was vital that vision impairment is tied to this broader issue.

How the evidence is used is equally as important as the evidence itself. In 2011, Vision 2020 Australia members collaborated in the development of ‘Towards 2020’,14 a professional document that outlines what has been achieved so far under the ABI and what can be achieved in years to come with further funding. It is important to understand how and where to use this evidence and related documents. Vision 2020 Australia engaged the various Committees of Australia's Parliament. Committees, consisting of parliamentarians who have a particular interest in certain areas, conduct inquiries and release reports of findings and recommendations that are tabled before the Parliament to assist with decision making.

Engaging the wider international agencies and groups

It is vital that key stakeholders see avoidable blindness as being much more than a fringe issue, and forums such as the United Nations Conference are an important way of achieving this. The most recent United Nations Department of Public Information/NGO Conference in Melbourne, which focused on global health and was attended by 1600 people, is another example of how Vision 2020 Australia, in partnership with its members, can influence key events. This conference, held annually in different cities around the world, is a key platform for the UN to engage with civil society and a big opportunity to raise awareness about eye health issues. Vision 2020 Australia was involved in two workshops, and managed an exhibit to raise awareness.15

Partnerships —in policy development and program implementation; between agencies and with governments and other stakeholders - are vital, if the global eye health sector is to move forward and capitalize on the momentum that has been achieved so far. By strengthening existing partnerships and building new ones, Vision 2020 efforts in any country can maximize the effectiveness of eye care programs, and speak with a forceful and convincing voice to governments and other donors. Partnership and alignment will result in resource mobilization which, in turn, will achieve the goal of eliminating avoidable blindness.

Main success points:

  • Gathering and using evidence
  • Lobbying for political commitment
  • Inclusion of blindness and visual impairment control in the Australian development aid agenda

CASE STUDY 2: NATIONAL PROGRAM FOR PREVENTION OF BLINDNESS PAKISTAN: ADVOCACY FOR EYE CARE

In 2005 the Pakistani Government allocated $51 million for prevention of blindness for 5 years. Additionally, the government upgraded eye departments in 27 teaching, 63 districts and 147 subdistrict Hospitals and a total of 2,719 posts were created for eye care at teaching hospital, district and sub-district levels.16 Furthermore, primary eye care was recognized as a prevention and health promotion strategy and included within the health system. This has resulted in the establishment of a modest annual budget directed to prevention and control of blindness.16 Thus the Pakistan National Eye Care Program has become a model of National eye care program in the Eastern Mediterranean Region. These successes were attributed to an affective advocacy strategy evolved by the Pakistani National program for the prevention of blindness which resulted in active involvement and financial commitment from the Pakistani Government. The following were some of the advocacy strategies used.

Use of evidence data and demonstration of success

The Pakistani national blindness survey data of 1988 and 2004 reported the prevalence of blindness at 1.78% and 0.9%, respectively.17 This reduction (approximately 50%) in blindness in less than two decades was effectively used to demonstrate the importance of the prevention of blindness and visual impairment control strategies. And how much more reduction can be achieved with more active government involvement. The effective use of these tools requires a team of charismatic, credible and focused leaders for the prevention of blindness program. This was provided by imminent personalities within the Pakistani eye care community.

Engagement with government and policy makers

The national committee for the prevention of blindness engaged the government and policy makers by using evidence-based data. This data allowed the leadership of the committee to demonstrate that blindness and visual impairment are important public health issues that warrant more attention and the cost effectiveness of controlling visual impairment and blindness was demonstrated. For this national situational analysis, policy studies and blindness survey reports17,18 were used, and field visits to district community eye care programs were arranged for some prominent policy makers. The reports and field visits created credibility for the committee which resulted in a good working relationship with the National health policy forum and the National planning division of the government – key agencies that decide the funding for government programs.

Engagement of all stakeholders and decentralization of the prevention of blindness program

Decentralization of the prevention of blindness (PB) program to the different provinces ensured the involvement of provincial health secretaries and ownership of the PB programs. Furthermore engagement of all major stakeholders including all professional associations, governmental agencies, district health administrators and the communities provided a wider platform for advocacy at the district level. This was enhanced by building the leadership and management skills of the district ophthalmologists and health officials.

Main success points

  • Generation of evidence and demonstration of success
  • Establishing relationship with appropriate policy makers
  • Unified engagement of all stakeholders
  • Creditability and continuity of national leadership for eye care.

CASE STUDY 3: GLOBAL HIV/AIDS CONTROL NATIONAL ADVOCACY STRATEGIES

Significant information can be garnered from the advocacy movements and activities of HIV control programs in view of their ability to secure support and resources from governments, NGOs, unilateral and multilateral organizations.

One effective method to secure political commitments at subnational and regional levels was highlighted by ‘Policy project’ a program of USAID which developed and implemented a toolkit for ‘Building Political Commitment for Effective HIV/AIDS Policies and Programs’.19

AIM –AIDS Impact model19

AIM was designed to raise awareness and place HIV/AIDS on the political agenda. It uses a computer model that utilizes demographic, sentinel surveillance and other data to project the future number of HIV infections, AIDS cases and AIDS deaths, given an assumption about adult HIV prevalence in a country. The program also projects the demographic, economic and social impacts of the epidemic. The analysis of the current situation and the projections of the future course of the epidemic are used to make an attractive multimedia AIM presentation that is targeted at leaders, policy makers and other influential individuals. Anecdotal reports suggests that part of the successes in getting many governments committed to funding HIV/AID programs at least in part was the application of this tool to key policy makers, opinion leaders and the press. Can IAPB and its partners support the development of similar computer model – Blindness Impact Model (BIM) for advocacy in various countries?

Innovative media strategy

Another example is the Innovative media advocacy- strategy that was extremely effective at utilizing the press to maintain HIV/AIDs on the public agenda . This strategy included increased national media coverage in the developed countries that comprise the majority of funding donor organizations. Such an approach may include reporting field activities to newspapers. The establishment of fellowships, awards and grants for reporting is also an effective tool. An example is the HIV- Kaiser Family Foundation20 which supports HIV/AIDS reporting projects. NGOs and eye care programs can sponsor journalists to the field to witness and document the ‘human component’ of blindness. Formation of ‘Networks of voices’ by identifying media champions for blindness and the establishment of an editor's forum for eye care that can encourage coverage in the media are also important.

Main success points

  • Use of disease projections and impact to society
  • Effective use of communication modalities
  • Creating public agenda through Innovative media approach

OTHER CASE STUDIES AND APPROACHES

These are some other approaches that may assist national advocacy efforts for eye care.

Designation of National Vision ambassadors

Use of high profile international and national personalities as ‘door openers’ e.g., the use of NTD ambassadors in the US had significantly increased the profile and visibility of the NTD control movements in securing the support of governments, multilateral organizations and international donors.21 Politicians and celebrities have been successfully used for NTD control movement. However, the use of such ambassadors in specific countries should be customized to the existing sociocultutal values and practices. In some countries actors, musicians and other celebrities are appropriate, in others National leaders and religious leaders are more appropriate. IAPB regional offices may assist National eye care programs in identifying potential national ambassadors for engagement.

Generation of more evidence on the economic impact of visual impairment and strategies for tackling emerging challenges

It is commonly believed that the availability of appropriate blindness and visual impairment data was fundamental to eye care movements securing more funding from some countries. Common to the examples of Australia and Pakistan were the generation of reliable estimates of the status of blindness and visual impairment and the economic cost of blindness.13,18

It is imperative to generate more data on the relevance and economic returns of investing in eye care. A recent research workshop held in September 2010 in India 22 has been able to generate ideas on the global and regional research priorities for advocacy and planning. IAPB, Professional bodies, NGDOs and WHO collaboration centers should take the lead in ensuring the conduct and adequate interpretation, dissemination and utilization of data for advocacy.

Multifaceted approach to eye care programs

All eye-care planning and programs needs to be aligned with poverty, development, disability , gender agendas to be easily ‘sellable’ to policy makers. For each country priority focus will depend on the focus of the national governments and the strength of the different agendas/movements. For this eye care program managers and those implementing strategies need to target officials of in –country Millennium development goals (MDGs) implementing offices. Some have suggested that 7 out of 8 of the MDG goals are directly or indirectly connected to implementation of eye care.23

Eye care programs may also have to target the country Poverty Reduction Strategies Papers (PRSP) strategies. In order to qualify for multilateral debt relief or to access concessional funds from International Monetary Funds (IMF) and World Bank, many developing countries had to develop a PRSP. PRSP are macroeconomic, structural, and social policy programs that promote growth and reduce poverty. WHO had reported that most PRSP often contain health programs. An IMF publication reported that the PRSP of the 23 Heavily Indebted Poor Countries (HIPCs) that have reached the decision point, all include measures designed to increase the poor's access to primary and preventive health care and to primary education. This can be a potential resource which eye care can tap into for many developing countries arguing the role of eye care in enhancing overall socioeconomics of the visually impaired, their families and communities. Currently over 66 countries in the developing world have a PRSP.24,25

National Coordinators for eye care programs and National ophthalmic society leaders need to be educated in advocacy skills, to engage governments, bilateral and multilateral agencies and the public.

Local network and coalition-building for supporting links among service organizations at national levels

For all stakeholders in eye care and prevention of blindness in different countries, sharing ownership of common goals, and supporting one another's efforts by information sharing and undertaking joint activities, such as advocacy and information dissemination campaigns and support from non-health related groups and actors are reliable methods to strengthen advocacy efforts.

Networks can be developed whether formal or informal - professional networks, informal friendships for recreation, voluntary work and social activities. Online networks such as Facebook, Twitter, etc. that had gained popularity in many countries in galvanizing ideas and movements can be explored in developing these coalitions.

Main success points

  • Use of high profile, respected individuals as eye care ambassadors
  • Generation of more evidence including economic analyses
  • Development and presenting eye care as complementary to health and development goals
  • Developing a broad base all encompassing national platform for advocacy

CONCLUSIONS

Some of the common denominators for successful advocacy efforts at national levels include the generation of reliable data and effective utilization of data in appropriate media and forums to appropriate personalities. This will assist in developing reputable relationships with prominent decision makers. These data may include survey data, economic analysis and projections, as well as highlighting the relevance of eye care in the public health system and development agendas. There is also the need to directly associate eye care programs with health and development agenda. A wide all-encompassing forum that involves all major stakeholders at all levels including the community level provides a solid platform for effective and persistent advocacy for government support for eye care [Figure 3].

Figure 3
Some of the key factors identified for successful advocacy

Footnotes

Source of Support: Nil

Conflict of Interest: None declared.

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