Going where the need is greatest: eye care in Lahore, Pakistan

Our aim through this study was to evaluate and understand the situation in urban ‘slums’ or informal settlements: a growing area of interest and concern given the high urbanisation rates globally. Even though availability of eye care services is less of an issue in urban than rural areas, these services are not always accessible, particularly for marginalised populations like the urban poor. Population projections show that the number of people living in urban slums will increase at a faster rate than the general population, and health access disparities are expected to further increase as a result. It’s vitally important to investigate and address these health disparities in urban areas.

Following two successful research projects carried out in Bangladesh and India, our study is intended to contribute to the evidence base for programming and give a better understanding on the demand and provision of eye care services to people living in urban slums.

The process of collecting the data was challenging for two main reasons. Firstly, it was very difficult as the last census in Lahore was conducted in 1998 (results of the new census conducted in 2017 were released in August), so we had to improvise, collecting demographic data ourselves through the mapping of some ‘slums’ and eye health facilities.

Secondly, the situation in Pakistan was very tense due to a series of terrorist attacks occurring in different regions, including one in Lahore during the training, and one which targeted a government census team. As a result, some areas were too dangerous to be surveyed.

Despite these challenges, the research team, with the help of Sightsavers’ Pakistan country office and our local partners, collected data from 61 ‘slums’ (called ‘katchi abadi’ in Pakistan) previously identified by a mapping team. The data collection team was composed of clinical and non-clinical staff who asked selected household members to complete a questionnaire about their socio-economic level, eye health seeking behaviour and their willingness to pay for spectacles or cataract surgery. Each team was accompanied by an optometrist and an ophthalmologist – this meant that assessments could be provided immediately for refractive error and other visual impairments. At the same time, around 20 inhabitants of registered and unregistered settlements were interviewed about their experiences related to eye care and eye health seeking behaviour.

The surveys returned interesting results, and the quantitative and qualitative data collected gave us a hint on the eye health seeking behaviour of people living in the urban slums of Lahore. From the in-depth interviews we learnt that there is still stigma around wearing spectacles (though it is marginal). We also found that many women interviewed had to be accompanied by their husbands to receive consultation about health issues.

We’ve learnt that while some respondents were not accessing eye care services, more than half of the participants with eye problems (ranging from minor issues to severe visual impairment) have consulted and in most of the cases complied with the treatment prescribed.

Our ‘willingness to pay’ study has shown that a large proportion of the people living in slum areas would be willing to pay for spectacles or for cataract surgeries, with some important inequalities in terms of how much they can afford to pay. Overall, the eye health seeking behaviour does not seem to be drastically different from the rest of the urban population, but the results showed there is still a portion of the population that does not access eye care services due to a lack of awareness, and because of financial barriers.

The clinical assessment showed a higher prevalence of blindness among women and among the poorest households. It also showed that the prevalence of blindness was lower in the urban slums than in the rest of the country.

On top of clinical results, the sociodemographic information collected showed that urban slums or ‘katchi abadi’ are not necessarily inhabited by the poorest people. The diverse level of education (almost 50 per cent of respondents had at least primary education), the occupation level, and the relative level of wealth, confirmed the unequal access to education and wealth among slums.

The Urban Eye Health study in Lahore demonstrated that there is still a need to raise awareness on the importance of eye care, and that eye health services should be made available freely for the urban poor. And my hope is that through our study, we’ll have a better understanding of urban settings in South Asia. ‘Slums’ are diverse areas in terms of wealth, accessibility to education and health services, and this calls for a more tailored approach for our future programmes – we need better segmentation of urban areas (this is an area where Sightsavers’ equity tool, which measures the relative wealth of households, could prove very valuable). If we want to reach the people most in need of services, simply surveying ‘slum’ areas is not sufficient.

1 Stevens et al. 2014

*We acknowledge that the word ‘slum’ can be problematic. UN-HABITAT makes clear that the term ‘slum’ refers to living conditions, not people. It defines a slum household as one that lacks one or more of the following: 1. Durable housing of a permanent nature that protects against extreme climate conditions. 2. Sufficient living space which means not more than three people sharing the same room. 3. Easy access to safe water in sufficient amounts at an affordable price. 4. Access to adequate sanitation in the form of a private or public toilet shared by a reasonable number of people. 5. Security of tenure that prevents forced evictions.