Advocacy for eye health
Advocacy is a crucial component of VISION 2020: The Right To Sight. It has in fact been an important part of global health promotion initiatives for the past twenty years, since the nations of the world came together in Canada for the first International Conference on Health Promotion in 1986. The resulting ‘Ottawa Charter for Health Promotion’ specified three strategies to promote the health of all people of the globe: enabling people to take control of the things which affect their health; mediating between groups who may have different interests, in the pursuit of health for society as a whole; and advocating actions that will have a positive impact on the political, economic, social, cultural, environmental, behavioural, and biological factors which affect health. Advocacy has been emphasised at international conferences on health promotion ever since.
What is advocacy?
What do we mean by ‘advocacy’? Advocacy is the act of arguing on behalf of a particular issue, so that it gets the attention it deserves, or on behalf of particular groups of people, so that their voices are heard and their interests are taken into account. Usually these groups are vulnerable or disadvantaged in some way,1 for example: women, children,2 the elderly,3 and the visually impaired. The aim of advocacy is to persuade those in authority or those with influence to use their authority to promote actions that are desirable and beneficial for a particular group of persons. A related word is ‘lobbying'; it is used when people work to achieve a specific goal (often in their own interests) by influencing authorities or elected officials. ‘Health activism’ is another related concept, which describes people actively striving for better health, on behalf of themselves and others.
Why is advocacy needed?
There are a number of reasons for becoming involved in advocacy. Advocacy can help to draw attention to patients’ needs. For example, it can lead to better provision of services or ensure that patients and their families have more say in the way they are treated.4,5,6 Eye care workers can and should act as advocates for their patients in this regard.
Advocacy can also raise public awareness of eye health problems and their impact. A public that is aware is more likely to contribute, to participate, and to put pressure on authorities and policy makers to allocate resources to eye health.
A further important reason for doing advocacy is that it can help organisations to gain access to the human, material, and financial resources that are needed to bring about improvements in eye health.
As mentioned above, controlling the causes of avoidable blindness requires the development of human resources and infrastructure – both of which cost money. Another reason for doing advocacy is therefore to influence policy, since policies affect the way in which resources are allocated. The policies supported by advocacy may deal with the prevention of eye disease (e.g. improved water supply, the provision of vitamin A supplements), eye health promotion (e.g. screening for glaucoma and diabetic retinopathy), or the provision of eye care services (e.g. cataract surgery or medication for glaucoma). Lastly, advocacy can inform eye health practitioners of best practice so that they may avoid malpractice.7
‘Doing what is good’ is not enough
When we advocate for eye health, we are asking people to become more involved in something that is intrinsically good – what could be better than preventing blindness? It is not that simple, though. Resources are always limited and policy makers often have to choose between two good things. For example, one may find, in a given country, that onchocerciasis (river blindness) is non-blinding and occurs in a few districts only, but that infant mortality is high. If resources are limited, it could be said that advocacy should in this case be focused on measures to reduce infant mortality, rather than on the distribution of ivermectin to treat onchocerciasis.
Uncontrolled advocacy can lead to conflict between organisations looking for resources and may even lead to irrational decisions being taken. That is why, in some countries, there are laws which regulate which kind of advocacy may be done and which may not.8
To be effective, advocacy must be supported by high-quality information. We usually obtain this through research – for example, research into the extent of an eye health problem and the effectiveness of the strategies that can overcome it. In the past, advocacy has been held back by the lack of such information,9 but this is being overcome by studies such as the mapping of the global distribution of trachoma10 and the World Health Organization global database on blindness.11 At a more local level, research can establish the prevalence of eye conditions and whether the necessary resources are available to visually impaired people.13,14 Research can also create evaluation tools or questionnaires that can be used to measure the impact of visual impairment on people’s lives.15 Once the information is available, it can be used to develop appropriate messages or arguments to support the aims of advocacy. These messages should then be communicated to those in authority or those with influence. One way of doing this is to approach governments officially and talk to them about the area of concern, e.g. vitamin A supplementation and food fortification.16,17 Another method is to arrange workshops with individuals and organisations with an interest in the elimination of avoidable blindness; one example is the VISION 2020 workshops that have been taking place in many countries in the world.
What is advocacy for eye health?
Advocating for eye health means working to change the policies and practices of those institutions, and the attitudes and behaviours of those individuals, whose actions affect the elimination of avoidable blindness.
Advocacy involves lobbying – speaking directly to key decision makers and those who influence these decision makers – and campaigning, which aims to mobilise public and media support for an issue.
Where needed, advocacy can be supported by information, communication, education, publicity, and fundraising.
A further strategy is to make use of personal contacts (formal and informal) with key decision makers. Both the International Association for the Prevention of Blindness (IAPB) and the VISION 2020 initiative urge members and supporters to talk with friends and acquaintances, including health ministers, about avoidable blindness. Eye health practitioners can also volunteer to become members of committees with eye health responsibilities and can use their position and influence to talk about areas of concern. National and local advocacy bodies can use the mass media to sensitise communities about the needs of those with low vision – through television documentaries and drama, the radio, magazines, and leafets.
To be successful, advocacy needs to be sustained. Even if progress has been made (for example, towards the global elimination of trachoma), advocacy efforts should continue as before.18 The African Programme for Onchocerciasis Control has long been aware that effective, ongoing advocacy is essential if its national and local programmes are to be sustained.19 Advocacy is more effective if it is undertaken by a team of interested individuals and organisations, working together according to a plan.20 Advocacy efforts are also more likely to be effective if they are aimed at a wide audience, including individuals and organisations outside the health sector.21 In order to maximise the impact of advocacy for eye care, we should explore the possibility of forming alliances with other causes. These alliances could be with the wider disability movement, general development and anti-poverty initiatives, other health programmes, or appropriate organisations in civil society (such as non-governmental organisations). We should carefully consider the role of a potential alliance in the context of the specific objectives of planned advocacy activities. The potential benefits should also be assessed against the possible dilution of the VISION 2020 message. However, more often than not, working together creates opportunities for more effective advocacy.
A final requirement for effective advocacy is that it must be done rigorously. Health promotion has often been undertaken in a relatively haphazard way, by doing what seemed to be ‘the right thing’ without rigorous planning and subsequent monitoring. This is now being rectified by the use of approaches such as PRECEDE-PROCEED22 and intervention mapping.23 The local eye care team should plan its advocacy campaign carefully, after studying the local social and political situation. The team should obtain high-quality information about the approach it plans to use, in particular whether this approach is appropriate and whether it is likely to succeed. The team should cooperate closely with other groups advocating for resources in the same field (in this case the promotion of eye health) and it should carefully monitor the effect of its advocacy efforts.
Levels of advocacy
Advocacy is needed at different levels: local, national, and international. At the international level, the World Health Assembly has endorsed the VISION 2020 initiative; this endorsement is the result of intensive advocacy by bodies such as IAPB. Following on this good result, advocacy has been carried out at the regional and national levels. International non-governmental organisations such as Sightsavers International, Christian Blind Mission (CBM), ORBIS, the World Blind Union, the Seva Foundation, and their national branches, are constantly engaged in advocacy. Finally, we need advocacy at the local level: this is where actual programme implementation takes place and where people either receive the benefits of eye care or suffer due to a lack of such services.
Who should advocate?
Those with connections at higher levels can advocate nationally or internationally, at the policy level. Those working at the district level can advocate for the full implementation of the national VISION 2020 plan and other eye health policies in their districts. Finally, those providing a service locally can be equally effective in advocating for their patients’ treatment needs or in advocating for increased community support for persons with low vision.
This means that everyone involved in promoting eye health is a potential advocate. This should challenge each one of us to see advocacy as part of our work and to think carefully where, and how, we can be advocates for promoting eye health and preventing blindness.
A framework for advocacy
- Identify the issue and context. What is the problem that requires a solution? Gather high-quality information (evidence) about the problem.
- Decide on a goal. What is the result you want to achieve? What should the solution to the problem look like? Narrow it down to something achievable.
- Identify the target audience(s) and analyse them. Who are the people with decision-making power? How do they make decisions? Who do they listen to? It is often helpful to identify the people who can inf uence these decision makers and include them in your plans.
- Build support. Build alliances with other groups, organisations, or individuals who can support you and/or are in a position to influence your target audience. Cooperate closely with other groups advocating for resources in the same field (in this case the promotion of eye health).
- Develop your message. What is the local social and political situation? Prepare messages tailored to the target audience that define the issue, state solutions, and describe the actions that need to be taken. Support this with relevant facts and evidence that your audience will relate to.
- Choose channels of communication. How can you or your organisation get to speak to key decision makers? Who in your organisation would be best placed to do this?
- Carry out your plan and monitor your success.
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