Scaling-up provision of eyeglasses in low- and middle-income countries.

Globally, at least 2.2 billion people have a vision impairment or blindness, and at least one billion of these individuals have an impairment that could have been prevented or has not yet been addressed.[1] Refractive error is the most common cause of visual impairment – and at least 826 million people living with a visual impairment due to uncorrected refractive error would benefit from eyeglasses. Some estimates which include milder vision loss place this number at more than 2 billion.[2] 

As vision plays a crucial role in so many aspects of our lives, uncorrected refractive error can have a negative impact on the health, education, productivity, quality of life, and general wellbeing of individuals. Yet, correcting refractive error with eyeglasses is a highly effective intervention. As the most common corrective intervention, eyeglasses are included on the WHO Priority Assistive Products List. Eyeglasses are considered functioning interventions, which means they provide compensation for refractive errors, rather than eliminating them by treating their causes, to improve functioning and independence of an individual to facilitate participation and to enhance general well-being.[1]

The primary focus of this work will be on eyeglasses that are prescribed, though it is envisioned that positively strengthening systems that support provision of prescription eyeglasses could positively impact other systems as well.

There are many factors contributing to the low uptake of eyeglasses, particularly in low- and middle-income countries (LMICs) where the unmet need is concentrated. These are multi-fold and require a series of targeted, coordinated interventions to overcome them. The World Health Organization’s 2019 World Report on Vision articulates the current global situation, as well as overarching recommendations to support countries, including integrating eye care into national health plans and health service delivery to support integration of eye care into fundamental health system planning and included across all appropriate service delivery platforms. Addressing eye care can support achieving the Sustainable Development Goals (SDG), particularly SDG 3, in addition to addressing Universal Health Coverage targets. Further, beyond healthcare, the WHO highlights integrating eye care with other sectors such as education is also key to delivering high quality, cost-effective interventions such as school eye health programmes. [1] 

Improving access to appropriate, affordable eyeglasses and related services is going to require innovative and ambitious efforts from multiple perspectives to achieve national scale. The current market landscape and relevant strategic objectives are described in the Product Narrative: Eyeglasses, published in 2020 by ATscale, the Global Partnership for Assistive Technology, together with the AT2030 Programme. This document provides a foundation for ATscale’s investment to improve access to eyeglasses globally.

ATscale, the Global Partnership for Assistive Technology, was launched at the Global Disability Summit in July 2018, with the goal of reaching 500 million additional people with life-changing assistive technology by 2030. ATscale is a cross-sector partnership that brings new energy and strategic focus to a significant global challenge. 

ATscale has two primary strategic objectives driving its initial work including: (1) developing an enabling ecosystem for increased access to assistive technology by galvanizing political will, mobilising investment, driving policy reform, and strengthening targeted, cross-product systems, particularly at country level; and, (2) building and shaping markets for priority products and their related services by identifying and investing in interventions to overcome specific supply and demand-side market barriers. This market-shaping work is initially focused on five priority products: wheelchairs, hearing aids, prostheses, eyeglasses and assistive digital devices and software. 

The United Nations Office for Project Services (UNOPS) is an operational arm of the United Nations, supporting the successful implementation of its partners' peacebuilding, humanitarian and development projects around the world. Mandated as a central resource of the United Nations, UNOPS provides sustainable project management, procurement and infrastructure services to a wide range of governments, donors and United Nations organizations. In light of this, the United States Agency for International Development (USAID) has entered into an agreement with UNOPS in support of the program entitled, “Assistive Technologies - Grant Management and Support to Operations” which is aimed at improving access to assistive technology worldwide.

USAID through the Inclusive Development Hub in the Bureau for Development, Democracy and Innovation has been investing in improving access to assistive technology and rehabilitation services for over 30 years through the Leahy War Victims Fund and the Wheelchair Program. Beginning in fiscal year 2019, a specific fund was mandated by Congress to improve access to low-cost eyeglasses. USAID is investing these funds in partnership with ATscale to implement the strategy outlined within the Product Narrative: Eyeglasses.

Project description

The United States Agency for International Development (USAID) is funding a two-year grant for up to USD 2.2 million in support of ATscale, the Global Partnership for Assistive Technology. These funds are intended to catalyse the scale-up of promising, holistic approaches to increasing provision of eyeglasses in low and middle-income countries (LMICs) and translating them into integrated, system-based, sustainable national programs.

Project objectives and elements

The overall objective of this project is to support the effective scale-up of screening, refractive services and eyeglasses provision and integration of these approaches into national, government-led programs. It is essential that solutions proposed are locally owned, based on proven models, are integrated into a broader, coordinated system that leverages the strengths of both the public and private sectors, and are developed with a clear pathway to achieve national scale in the short to medium term. 

Initiatives should be proposed in LMICs where there is already a good foundation for the work, including strong political will. Given the scope and duration of funding, it is envisioned that this grant will be utilized to catalyze important advancement towards national scale, accelerating what is currently possible, and will be accompanied by other activities, investments, and partnerships to accommodate a comprehensive national approach to addressing refractive error and comprehensive eye care, integrated within the national health system and related sectors (e.g. education).

To ensure that the work proposed to be funded by this grant will have the impact intended, including scale-up potential and sustainability, the applicant should clearly describe a roadmap for all components necessary to achieve eyeglasses provision on a national scale and integrated within a national program, including those elements funded through other sources and/or that will build on the achievements of this project. 

This roadmap will likely include a comprehensive approach to human resource development, service delivery, supply chain management and procurement, links with the private sector, policy development and implementation, and financing. The pathways described may include existing systems and initiatives, or those planned for the future – most important is that applicants demonstrate a clear vision and a thorough understanding of what is needed and what is anticipated to happen in the medium-term in the country of focus. These should be based on evidence articulated in relevant guiding documents such as WHO’s World Report on Vision, the subsequent package of evidence-based interventions, and the Eyeglasses Product Narrative, and should cover the following areas:  

• Human resource development: To effectively provide quality, low-cost eyeglasses, it is necessary to define, develop, and empower the workforce to screen, prescribe and provide eyeglasses safely and effectively. The roadmap related to human resources should address the relevant national policy framework, clear knowledge and skill standards necessary, and plans for development of a coordinated and appropriately sized workforce, with a special regard to ensuring gender balance.

• Service delivery: Service delivery models proposed within the grant, as well as the complementary initiatives (outside the scope of the grant) described, should have already demonstrated success in a similar context and should include a clear pathway for scale-up. The service delivery model(s) must address the necessary points of screening, prescription, and delivery of eyeglasses. Further, it must be clear how these models are, or will be, integrated into government-led health, education, or other national systems and how public and private sector models will interact. 

• Tools to simplify service delivery: The overall proposal must describe the use of an appropriate suite of validated screening and refractive devices. There are, of course, new technologies that support improved simplified delivery of eyeglasses and related services by: (1) requiring less training to use them; (2) having features that make them amenable to low-resource settings such as being portable or not requiring electricity; and/or (3) reducing the time for screening; and/or, addressing a new population. Using new technologies is not a requirement, but if applicants plan to validate any new technologies, it is necessary to provide an overview of the new technology, the barrier it addresses and value it will bring to the program, and the proposed validation process. It is important also to articulate how the success of these will be measured and scaled-up in the context of a national program.

• Awareness and acceptance of eye care needs and interventions: In many contexts, it is necessary and important to engage with communities to develop approaches to address existing attitudes and behaviors that are limiting people’s engagement with eye care services. The proposed activities and the related roadmap described should include any necessary culturally and community-relevant interventions to be implemented to support greater awareness and acceptance of the availability and importance of the relevant services and products.

• Supply management and procurement: Procurement of eyeglasses may be achieved through multiple channels, but it is imperative that eyeglasses meet International Organization for Standardization quality standards or their equivalent. There must also be a comprehensive procurement plan, which articulates the standards and specifications required and also indicates how longer-term procurement of eyeglasses will be conducted and financed. Any in-country policies that need to be addressed or supply chain or procurement system strengthening that needs to happen in the context of eyeglasses should be described and planned, either in the context of what is requested in the grant, or what will be strengthened in a complementary way.

• Integration with the private sector: To successfully reach an entire population with appropriate screening and refractive services, as well as provision of eyeglasses, varied approaches and partnerships are critical. The private sector plays an important role in improving access to eyeglasses globally and it is imperative that synergies between the public and private sectors are identified, partnerships are implemented, and these approaches are brought together under clear national strategies and costed plans. The role the private sector will play in the context of national scale-up in the proposed country should be specified.

• Financing and governance: While different elements of the roadmap will lend themselves to discussing longer-term financing, applicants should also include a discussion of plans for integration of each component into costed national plans or integration into existing health plans, and opportunities for securing sustainable financing. This could involve costing the inclusion of screening and refractive services and eyeglasses provision into the health benefits package, for example. It will be important also to articulate how long-term investments from across various Ministries and across sectors to fund, plan, and sustain services will be coordinated.

• Policy development and implementation: There may be policy-related elements that need to be addressed in the context of human resources development and recognition, procurement and financing, for example, as described above. Please describe policy-related elements that need to be addressed in the context of ensuring the proposed project becomes part of an integrated, sustainable national program.

Application guidelines (maximum 21 pages plus appendices)

The Application should describe the current national context, the specific activities proposed to be funded, the other elements critical to a comprehensive, integrated national program, and the applicant’s existing technical and organizational capacity. It should be concise, specific, and holistic in its perspective, and should demonstrate a clear understanding of the national context as well as the objectives of the project.

Cover page (~1 page)

Include the name of the organization submitting the Application, project title, country where the proposed project will be implemented, proposed project dates (estimated timeframe for implementation available is March 2021 – February 2023), requested amount (in USD) of USAID funding, and name, office address, phone and email of the primary individual responsible for the Application (as well as one alternate).

Executive Summary (~1.5 pages)

The Executive Summary should provide an overview of critical features of the proposed project, including the national context, program activities, and anticipated results.

Situational Analysis and National Commitment (~2.5 pages + appendices)

The Situational Analysis should present a comprehensive understanding of the current context as it relates to provision of eyeglasses in the specific country being proposed and a clear justification for why the country was selected. Countries proposed must be eligible to receive Overseas Development Assistance. In the selection of countries, applicants should consider factors such as the status of the health sector overall, estimated number of individuals in need of eyeglasses, and the existence of partners on the ground.

The situational analysis should create a sound basis for the proposed interventions, including an understanding of what exists, as well as where there are gaps in the policy landscape, capacities and services, procurement capabilities, funding, human resources, and management related to the provision of eyeglasses. This section should establish that the applicant has sufficient understanding of the current and evolving situation in which the project would be implemented, and that the country has the appropriate environment for implementation. 

As highlighted previously, comprehensive, integrated national approaches to provision of eyeglasses can only be achieved with leadership, ownership, and support from the national government. Provide evidence of national commitment in a form that clearly articulates the government’s awareness and support of the proposed activities. Evidence can be provided in the form of a letter of support from the relevant Ministry or any other form in which the applicant is able to demonstrate commitment. Evidence may be incorporated into an appendix.

Project Approach (~5 pages)

The Project Approach should describe the specific activities that are being proposed to be supported through this grant. It is expected that the proposed activities will include those that will be the most catalytic in moving the country from the existing situation towards achieving the desired national scale, incorporated within a national program. Describe in detail the proposed activities, why these are the most critical to implement as evidenced by past implementation, and how these will contribute towards achieving a comprehensive program integrated within national systems. If any of the key elements for success are not addressed, it should be clear from the following section how these needs are proposed to be met.

Roadmap to National Program (~5 pages)

Given that the grant can only support a portion of what is needed to bring screening, refractive services, and provision of eyeglasses to a national scale, applicants must describe in this section the Roadmap of how the proposed country will achieve a comprehensive and sustainable program to address provision of eyeglasses within the national system. This plan is not confined to the specific elements of the proposed project, but it should encompass a more thorough description of how the country will evolve from the existing context, as described in the Situational Analysis, to a system that provides access to eyeglasses for the majority of the population. Within the Roadmap, the key elements of human resource development, service delivery, tools for service delivery, supply management and procurement, integration with the private sector, policy development and implementation, and financing should each be addressed.

Organizational Capacity, Management, Implementation and Staffing (~2 pages)

Provide an overview of the applicant organization’s prior experience that demonstrates its capacity to effectively implement the proposed project. Identify up to three key personnel for this project and briefly describe their areas of responsibility and how the proposed project will be managed. 

For any proposed sub-agreements, applicants must identify those organizations and provide a brief justification for their selection and demonstrate their organizational capacity to fulfil the role defined.  

Data and monitoring (~3 pages)

The application should include a concise overview of the timeline for the major stages of the proposed project’s initiation and implementation. 

The applicant should propose a clear performance matrix for what can be achieved and should highlight a robust monitoring system not only in the context of this grant, but also for longer-term implementation at a national level. Wherever possible, country data and monitoring systems should be used to report success of the programme. Further, the applicant should make an effort to align monitoring and evaluation plans with global indicators and targets, such as those the World Health Organization is establishing for monitoring success in effective coverage of the correction of refractive error globally [1]. 

Summary Budget (~1 page plus appendices)

The funding available for this grant is up to USD 2.2 million. Applicants should provide a high-level summary budget including a breakdown of key personnel, operating costs, direct and indirect costs, etc., as further articulated in the Grant Application Template (Annex 1). Please include an appendix that outlines in greater detail the components of the proposed cost categories and the general basis for these estimates which may be the local market, quotations received from vendors, historical records, ongoing activities, your organization's (or sub-grantee’s) policies and procedures, etc 

Risks (~1 page)

Identify and list any major risk factors that could result in the grant activities not producing the expected results. These should include both internal factors (for example, the technology involved fails to work as projected) and external factors (for example, significant currency fluctuations resulting into changes in the economics of the grant project).

Grant Implementation

Grant Management 

UNOPS will be responsible for day-to-day financial and contract management of the grant. ATscale and USAID will be responsible for programmatic guidance. 

Management and Operational Capacity

The Grantee is expected to hold regular check-in meetings with ATscale and USAID to align on the workplan, progress updates, project risks, and other considerations, as necessary. 

Integrating persons with disabilities and/or users of assistive technology as part of the project team is strongly encouraged. 

Timing

The expected start date for the work is 15 March 2021 and the anticipated ending date is 15 February 2023. The closing date is constrained by existing contracts.

Project Deliverables

• An updated situational analysis highlighting progress in the country relative to the country’s overall ability to provide quality eyeglasses. 

• Demonstration of the achievements and improvement in the elements of the roadmap strengthened specifically by the project activities. 

• A clear indication of the increase in the number of people reached with quality screening, refractive services, and eyeglasses. 

Please note that more details regarding deliverables should be discussed and jointly confirmed during the contracting period based on the activities of the successful proposal.

Expected Reporting Milestones 

• Initial kick-off meeting with all partners, ATscale and USAID within first two weeks of project

• Quarterly project update meetings with ATscale and USAID 

• Quarterly narrative and financial reports 

• Final report is due within 45 days of the final day of implementation

These milestones are to be confirmed with the selected grantee during the contracting period

References

[1] World Health Organization, World Report on Vision, (2019), accessible at https://www.who.int/publications/i/item/world-report-on-vision 

[2] Essilor, Eliminating Poor Vision in a Generation, (2019), accessible at https://www.essilorseechange.com/wp-content/uploads/2020/02/Eliminating-Poor-Vision-in-a-Generation-Report.pdf