REFRACTIVE ERROR CHANGE IN APPROACH Overview of Refractive Error Prevalence and Delivery Models

Kocur, 2008

Refractive Error Working Group: Significant Refractive Error < 6/12 in children in the better eye < 6/18 in adults in the better eye. Myopia >= 0.50 Ds. Astigmatism >= 1.50 Dcyl Hyperopia >= 2.0 Ds ( >=1.0 Ds in > 40 yrs) Anisometropia >= 2.0 Ds (children)

Country Hyperopia >2.0 (%) Myopia > 0.50 (%) Astig. >0.75 (%) S Africa - Urban India - Rural India - Urban China - Rural China - Urban Chile - Urban Malaysia - Urban Nepal - Rural Refractive Errors in Children(RESC)

Burden of URE Resnikoff S, et al. (2008). "Global magnitude of visual impairment caused by uncorrected refractive errors in " Bull World Health Organ 86(1): 8.

Burden of URE - Regions *millions Resnikoff S, et al., 2008

Global Estimates Reference: Global estimates of visual impairment: 2010; Pascolini and Mariotti. BJO 2012, 96: December 2011

Major cause of VI - Uncorrected refractive errors 43% Global Estimates 2010 … Pascolini, D. and S. P. Mariotti "Global estimates of visual impairment: 2010." Br J Ophthalmol. 43 % (123 million)

1.04 billion people globally 517 million of whom had no spectacles or inadequate spectacles. 410 million prevented from performing near tasks in the way required. 94% from less and least-developed countries Presbyopia - Estimates Holden, B et al., (2008) Global Vision Impairment Due to Uncorrected Presbyopia. Arch Ophthalmol. 26(12):

Mingguang et al, 2012

Mingguang et al, 2012

Mingguang et al, 2012

Global Visual Impairment (<6/18) 123 Mil Dist 517 Mil Near 640 million

The vicious cycle of uncorrected refractive error Visual Impairment Limits Educational Oppotunities Unemployment PovertyQuality of Life

International Centre for Eyecare Education (ICEE) 269 billion dollars lost productivity Smith et al, 2009 >50 yrs No Producitivity billion dollars

How many Optometrists are there? Global Estimate (D. Wilson et al., BHVI 2010) Varies tremendously from country to country −from 0.1 per million population −to 600 per million population

Number of Optometrists per Million population

Number of Optometrists and Ophthalmologists per Million population

RE Programs: Core Activities Sustainable, Accessible, Affordable SCALABLE

Community Regional National Global WHO, IAPB, NGOs Regional IAPB offices MOH, NGOs, Professional bodies Local government bodies, Community clinic setting, Community bodies, Advocacy

Human Resource Development Who is the refractive services workforce? Individuals with clearly defined: −Roles and responsibilities −Job descriptions −Career structure All cadres, should possess: −Competencies and skills −Complementary functions with other cadres −TEAM APPROACH

Who is the refractive services workforce Optometrists Ophthalmologists Mid-level personnel Primary level personnel Optical dispensers Spectacle technicians Optical Dispensary Staff

The strategy for eye care delivery determines where the work force operates Community Level Vision Centre Training Centre Specialists Service Centre Mid-level personnel Vision 2020 WHO, IAPB, NGOs Specialists – Ophthalmologists, Optometrists, Disp & Manuf technicians Optometrists, Ophthalmics Nurses Ophthalmic technicians Vision technicians Community Worker, Teachers, Primary health care worker Case finding Screening Refraction Dispensing Refraction Diagnosis & Management

Challenges to HRD Personnel retention Multi-tasking Sustainability Career path Remote communities Maintaining standards Changing scope of practice

Providing refractive correction Providing the refractive correction depends on local conditions and resources Accessibility −Providing a supply chain Quality −Equipment sourced and incorporated into service delivery programmes −Ready made spectacles Lower cost Rapid treatment −Adaptive Spectacles

An optical supply chain with social and economic benefit GLOBAL RESOURCE CENTRE GLOBAL RESOURCE CENTRE SUPPLIER PATIENTS VISION CENTRES VISION CENTRES NGOs & PUBLIC HEALTH SECTOR Cost Recovery / Minimum Markup = Affordable to Pts Purchase in bulk (no middle man) = reduced product cost Purchase in bulk (no middle man) = reduced product cost Minimum Price Mark Up Minimum Price Mark Up

Service Delivery Refractive Service/Vision Centres/Refraction Clinics Partnerships with governments NGO led Entrepreneurship

NON- SPECIALIST HEALTH DISTRICT 3 o LEVEL CARE SPECIALISED SERVICES SPECIALIST & SUPER- SPECIALIST CARE (4 0 ) Fig 1. CLINIC DISTRICT HOSPITAL COMMUNITY HEALTH CENTRE PROVINCIAL HOSPITAL REGIONAL HOSPITAL District Health System COMMUNITY HEALTH CENTRE DISTRICT HOSPITAL REGIONAL HOSPITAL

Primary Eye Care Integration of primary eye care into primary health care Strong primary health care development = strong eye care programmes Different personnel in different contexts Roles and tasks need to be clarified

Service Delivery in KZN optometrists 11 Districts 123 clinics patients

Social Entrepreneurship and Public Private Partnership Addressing Poverty and Eye Health through entrepreneurship and within a health systems perspective Have to balance public protection with profitability and a purely financial model cannot be adopted

Infrastructure & Service Development Vision Centres LVPEI model An eye care facility that provides a range of eye care services, including: Eye examinations Refraction (i.e. determining the spectacle prescription required) Supply and dispensing of affordable spectacles Detection of potentially blinding diseases Treatment of minor eye diseases

Tanzania Vision Centers

Enterprise for Sight Program in South Africa

Partnerships with private practitioners D Get private optometrists involved for our mission Package of 20 to 30 affordable frames and ready-made spectacles Supported by Optometry Associations CPD for participating optometrists Target customers: Low income consumers (working poor)

Vision screening in China Screening in Lechang, China, 2010 SCHOOL HEALTH AND SCHOOL EYE HEALTH

Strategic partnerships to support sustainability Governments Major Development Agencies Rural agencies Women's Groups Professional Associations Business Development Units Micro-finance Groups

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