Childhood Blindness Mohammad Muhit PhD Child Sight Foundation & University of South Asia

Country profile: Bangladesh Area: 144,000 sqkm Population: 140 million, 50m children Health budget : 1.7% of total budget Life expectancy 58.9 Per capita GDP: US$1,483 Population below poverty line: 35.6% Literacy rate: M- 51.1%; F- 28.6% Rural population: 53.6% Human Development Index rank: 132 (out of 162 countries)

Causes of childhood blindness in Bangladesh Childhood blindness due to Cataract

Childhood Blindness Profile National Childhood Blindness Study by ICEH- Prevalence of CHB: 0.7/1,000 children 40,000 blind children in Bangladesh 36% treatable     32% preventable Childhood cataract (31%) Treatable cataract -12,000 blind children! Innovative approach to case detection (KIM). Potential of further development of services using ‘register for blind children’.

Situation in 2003 Paediatric Cataract Backlog! 12,000 children with bilateral cataract 50 million children in the country. 1 fully trained paediatric ophthalmologist. Absolute lack of awareness about cataract in children – Public and Professionals. Services for children’s eye care-limited, expensive, inaccessible. No programme for childhood cataract.

Way Forward- Research – Causes, Barriers, SA. Advocacy-Childhood Blindness Workshop 2003 Alliances- GO, NGO, policy makers, media.. Establish the Need Provide a Framework for Action Develop appropriate tools (KIM) Mobilise resources

BCCC: Partnership in Practice Sight Savers International ORBIS International International Centre for Eye Health Child Sight Foundation Uttaran YPSA CBR projects Islamia Eye Hospital BNSB Sirajgonj Eye Hospital BNSB Khulna Eye Hospital CEITC, Chittagong Eye Hospital BJAKS Comilla Eye Hospital MOH & MOSW, Govt. of Bangladesh

Goal & objectives of the campaign The Goal is to contribute to the elimination of avoidable Child Blindness by the year 2020, as part of the V2020 programme. Objectives are- To eliminate 90% of the backlog of Childhood cataract in Bangladesh by the year 2008 To contribute to the development of long term systems that will ensure that future incidence of childhood cataract in Bangladesh is adequately dealt with To support the development of long term systems to ensure that all irreversibly blind children receive the services to which they are entitled To provide lessons that can be used to inform similar programmes elsewhere

Bangladesh Childhood Cataract Campaign Identify 40,000 blind children Treat 10,000 cataract blind children 20,000 cataract surgery in children Raise awareness throughout the country Develop paediatric ophthalmic centres Develop and maintain a database of blind children in the country for future services Document & disseminate programme learning. In 4 years! With £2 million programme budget. Campaign was launched in 2004 World Sight Day

Focal areas of action FIND all blind children EXAMINE at the sub-district/district REFER for surgery to specialized units OPERATE by trained surgeons FOLLOWUP regularly and long term. National register & database of blind children Develop Systems for Long-term impact.

Training on ‘how to identify a blind child’ Health education Community based eye care services for children Awareness campaign Training on ‘how to identify a blind child’ Health education Empowering communities & key informants Community Mobilizer for Child Sight Working with key informants, volunteers and other organisations to develop linkages and to overcome barriers. Blind Children in their home Assessment, counselling & referral by mobile team Incurable Treatable Eye hospital Schools Rehabilitation

Harun-Ur-Rashid, with children Ahsanullah, Fazar Ali, Osman Gani, Khadija, and Yunus, who all can now see thanks to a simple operation. Salma and Shetu after cataract surgery; with their mother Photo courtesy: : Ian Rutherford, Daily Scotsman Photo courtesy: : Pany Petro CSF

Achievements in the first year: 2005 2 Paed Ophth teams trained in India & Tanzania 5 Centres has been enhanced with equipments Over 3,000 cataract surgery in nearly 1,500 cataract blind children 3 ‘case finding’ NGOs are working in 3 divisions Database for blind children designed & tested Working Group of BCCC partners formed & active Standard data recording forms have been designed and trained for Child Cataract clinical data Baseline data collected on KAP and SA Key Performance Indicators for programme monitoring

Challenges and lesson in the first year Broad based partnership is challenging Case finding in remote areas Training of Paed Ophth team- expensive, training centres, time Procurement of IOL, glasses and LVA for children Follow-up: long term and regular? Multiple donors, hospitals, MOUs etc. Programme monitoring system Engaging media for awareness campaign Competition between partners Transparent and democratic decision making BCCC partner hospitals- inclusive or exclusive? Linkage with education and rehabilitation

Strategic Evaluation: BCCC 2010 Effectiveness: BCCC was effective, as the objectives and targets were met or almost met. Blind children Cataract blind children Traced Operated Target Identified N % of those traced BCCC 28,520 9,373 33% Non-BCCC1 4,456 1,286 29% Total: 40,000 32,976 (82%) 10,659 32% 10,000 7,674 (77%)

BCCC Efficiency: efficiency of the different types of case finding financial efficiency i.e. the cost per blind child and cataract blind child found whether the project was good value for money. Next slide: Number of blind children and cataract blind children expected, and identified, by case finding partner.

Population allocated (millions)  Case finding partner Population allocated (millions) Population estimates Cases identified Cases operated Method All ages Child pop Blind1 Cat blind (30%) Blind found % of est-imate Cat blind From CFP Uptake (%) Walk-in CSF KI 38.2 15.7 10,960 3,288 10,492 96% 3,439 105% 2,361 69% 49 All CBR CBR 26.7 11.0 7,670 2,301 1,438 19% 1,147 50% 1,083 94% 387 YPSA H-t-H 17.7 7.3 5,087 1,526 4,992 98% 607 40% 587 97% 82 Uttaran 15.9 6.5 4,557 1,367 6,433 141% 1,517 111% 708 47% RDSS 11.4 4.7 3,268 980 2,018 62% 1,046 107% 819 78% 108 VARD 9.1 3.7 2,612 783 2,287 88% 1,133 145% 530 Not clear 9.9 4.1 2,848 854 510 18% 147 17% 100% 233 1.5 0.61 426 128 15 4% 12% 32 Subtotal: 37,428 11,227 28,185 75% 9,051 81% 6,250 891   CSF MA 12.2 5.0 3,509 1,053 4,456 127% 332 32% 322 211 TOTAL 42.6 8.8 40,937 12,280 32,641 80% 9,383 76% 6,572 70% 1,102

Time efficiency Months Cataract blind found Cataract blind/month Under BCCC:   CSF Dhaka 20 2,567 1281 CSF Barisal 24 827 35 Uttaran 42 1,517 36 YPSA Chittagong 560 16 YPSA Chittagong HTs 29 47 2 VARD Sylhet 26 1,133 44 RDSS 1,046 40

Acceptance of surgery among bilaterally cataract blind children Uptake of cataract surgery among cataract blind children identified, by case finding partner Case finding partner Acceptance of surgery among bilaterally cataract blind children CBR 94% CSF 69% RDSS 78% Uttaran 47% VARD YPSA 97%

Cost efficiency in case finding Case finding partner Total reimbursed (BDT) Blind children found Reimbursed per blind child found Cataract blind children found Reimbursed per cataract blind child found CSF 22,012,048 10,492 2,098 3,439 6,401 Uttaran 9,699,355 6,433 1,508 1,517 6,394 YPSA 4,992 607 VARD 6,549,507 2,287 2,864 1,133 5,781 RDSS 9,569,689 2,018 4,742 1,046 9,149 CBR partners 848,594 1,438 590 1,147 740 Others 115,724 860 135 494 234 Sub-total 59,528,517 28,520 2,087 9,383 6344

Reimbursement of clinical partners for managing cataract in children. Surgeries Total reimbursed Reimbursed per surgery (BDT)   BNSB Mymensing 499 4,652,548 9,320 BJAKS 1,605 14,669,112 9,140 BNSB Moulavibazar 722 5,631,687 7,800 BNSB Dinajpur 3173 19,150,605 6,040 BNSB Khulna 2202 12,554,893 5,700 BNSB Sirajgang 5994 33,805,763 5,640 CEITC 2000 9,077,197 4,540 Islamia Eye Hospital 8398 36,965,653 4,400 Others 218 360,355 1,650 Sub-total 24,811 136,867,813 5,520

Beyond BCCC Unique programme for Child Cataract Replicable in other Asian, African and LA? 200,000 cataract blind children globally Development of more training centres Technical input & collaboration –ICEH Standard data recording forms and software available – childhood blindness & childhood cataract Sustainability- Technical, managerial, financial

Thank you!