Long Range Strategy Plan ORBIS INTERNATIONAL– INDIA Highlights of the Situational Analysis Document Keerti Bhusan Pradhan, B R Shamanna, P K Nirmalan

This situational analysis document is a draft document subject to revision & finalization after the deliberations in this workshop. The document aims to provide a framework for discussion to guide the initiatives of ORBIS – India eye care program

Purpose & Methods Main Purpose To drive ORBIS – India country offices’ direction in the eye care milieu of the country. Methodology Primary & Secondary information Discussions Analysis by the consultants based on their experience

GLOBAL BLINDNESS ? Millions

Prevalence of Blindness (Visual Acuity <6/60) as per the National Survey (86-89) Category Prevalence (%) States & regions of the country Low Prevalence Less then 1 Punjab, Himachal Pradesh, Delhi, West Bengal, & N.E. States Moderate Prevalence 1 to 1.49 Gujarat, Haryana, Kerala, Bihar, Karnataka, Andhra Pradesh and Assam High Prevalence 1.5 to 1.99Maharashtra, Orissa, Tamil Nadu & Uttar Pradesh Very High Prevalence 2 and above Madhya Pradesh, Rajasthan and Jammu & Kashmir

Blindness in South East Asia Prevalence 0.8%; Range 0.3 – 1.5% Cataract – Major Cause, 50-80% Other major causes – uncorrected refractive errors, trachoma, childhood blindness, corneal blindness, ocular trauma. Cost of Blindness US$ 5.6 billion annually

Profile of SEA Region 25% of the world’s population 33% of the world’s blind 40% of the world’s poor 50% of the world’s childhood blindness 60% of the cataract backlog

Cataract Ref.error Glaucoma Cornea Others

Eye Care Service Delivery in India  About 65% of surgical performance in the country is performed in the private and voluntary sector and only 35% is within the government sector.  About 11,000 ophthalmologists and an equal number of trained and recognized mid level personnel (MLP) exist as opposed to the ratio of having at least 4-5 MLP for each ophthalmologist. 50% of the ophthalmologists are surgically inactive within the country.  The ophthalmologist to population ratio in urban India is 1:25,000 but in rural India it is about 1:250,000. Eye Care Service Delivery in India  About 65% of surgical performance in the country is performed in the private and voluntary sector and only 35% is within the government sector.  About 11,000 ophthalmologists and an equal number of trained and recognized mid level personnel (MLP) exist as opposed to the ratio of having at least 4-5 MLP for each ophthalmologist. 50% of the ophthalmologists are surgically inactive within the country.  The ophthalmologist to population ratio in urban India is 1:25,000 but in rural India it is about 1:250,000.

Eye Care Service Delivery in India Rapid assessment surveys in 14 districts in the country - coverage at 70% IOL surgery increased to 60% Poor surgical outcomes, as high as 40% post-operatively blind following conventional ICCE & 10% following IOL surgery – population based outcomes

Current situation - India Reasonable facilities and service delivery mechanisms that can be utilized. Demographic and epidemiological transitions – increase and change in disease patterns despite current intervention levels. Unifocal vertical interventions – limited structure at the community level. Need for more public-private coordination efforts in eye care in India

Disease Control Status Cataract –Issues: Major cause for blindness Changing demographics = Increasing prevalence and incidence Only 60% IOL Quality of surgery

Disease Control Status Cataract –Issues: Geographic coverage Socioeconomic issues Gender issues

Disease Control Status Cornea –Issues: Infectious disease Nutritional causes Trauma Awareness, treatment strategies and access Determining the national need for corneas

Disease Control Status Cornea –Issues: Eye banking Availability of grafts, Capability to graft Preservation of graft material Standardized protocols, accreditation & need for appropriate legislation Awareness of eye donation (gap between pledge and actual donation)

Disease Control Status Childhood blindness – estimate – 1.5 million –Issues: Almost 50% of childhood blindness in India Overshadowed by the cataract problem Limited epidemiological details Cause estimates mainly from blind school data

Disease Control Status Childhood blindness –Issues: No service delivery models Few pediatric Ophthalmology Units Cost effectiveness of service delivery Pediatricians and primary care personnel not involved

Disease Control Status Refractive errors –Issues: Uncorrected refractive errors being recently recognized as a problem 60-70% of refractive errors can be corrected by spectacles Accessible, affordable, available spectacles Need for service delivery models including follow-up

Disease Control Status Low Vision –Issues: Low appreciation of need even among eye care professionals Few Centres & trained personnel Cost of devices Availability & acceptability of devices

Disease Control Status Emerging problems –Diabetic Retinopathy –Glaucoma –Age –Related Macular Degeneration

Human resources 11,000 Ophthalmic surgeons Paramedical staff: 15,000 15,000 to 20,000 persons in eye care without any formal training and qualification

Human resources 80 institutions currently training MLOP’s in India 1300 persons each year Fellowship programs Optometry, Ophthalmic techniques, Instrument maintenance, opticians, management courses

Human Resources status and needs in India Category Current Ophthalmologists 11,000 15,000 18,00021,00025,000 Mid Level Personnel 24,00040,000 51,00062,00073,000 Eye Care Managers ,0001,5002,000 Community Eye Health Specialists

Major Issues in Blindness Control in India Limited levels of coordination among Private, Voluntary & Public Sectors Emphasis on Quantity over Quality Excessive reliance on camps and improvised facilities previously did not translate into expected permanent solutions Mismatch in Infrastructure, human resources & limited training Programs unable to redress barriers at the community level

India Vision 2020 Plan of Action Revamping of medical Education Redeployment of human resources Better coordination among all stakeholders Better service quality – standards & protocols Due emphasis on preventive eye care Strengthen advocacy Reduction of disease burden Strengthen physical infrastructure and human resources MIS for better program management Central government – Advisory role in Policy, resource mobilization and program implementation

Targets 2002 – 2007 (India Vision 2020) Increase CSR to 4,500 by % operated cases – good outcomes Increase IOL surgeries to more than 80% Establish at least 50 pediatric eye units Opportunistic high – risk screening for glaucoma and diabetic retinopathy Establish 7,500 more vision centres, 50 more training centres, 325 more service centres & 7 more centres of excellence for eye care service delivery. Integrate components of PEC in PHC and training in PEC 25 fully accredited eye banks, 50 new low vision centres and 20 eye donation centres and networking

Eye Care in the Broader Health Care Agenda of the country National Health Policy 2002 – Reduction of prevalence of blindness to 0.5% by 2010 Establishment of a baseline data for incidence of blindness by 2005 Use data for Evidence Based Policy Mapping of facilities and infrastructure on a country level for comprehensive service delivery approach. Statutory professional council for paramedical personnel

Role of Stakeholders in Eye Care in India Multilateral & Bilateral agencies –WHO –World Bank –UNICEF –DANIDA (DANPCB) –DFID –USAID

Role of Stakeholders in Eye Care in India International NGOs & Service organizations in India –ORBIS International –CBM –OEU –Rotary International –International Eye Foundation –Sight Savers International –Lions Club International Foundation –HelpAge India

Role of Stakeholders in Eye Care in India National Institutions/Agencies in India –Dr. R.P.Centre for Ophthalmic Sciences –ICMR –All IOL training centres –LVPEI –SN –AECS –AIOS –EBAI –VCS –SCEH

Strategic Opportunities We do not present an exhaustive list, but present certain broad areas to stimulate discussion that may determine specific areas of interest for ORBIS-India.

Strategic Opportunities Goals –Disease Control –Developing Human Resources –Strengthening Service Delivery –Promoting outreach activities and public awareness - advocacy –Develop institutional capacity, partnerships and Networking

Strategic Opportunities Potential areas for interventions –Disease Control Approaches –Research to understand risk factors and disease process better –Research to develop and improve service delivery models –Health economics

Disease Control Cataract –Understand risk factors better, gender and socioeconomic factors –Alternate service delivery models

Disease Control Cornea –Develop intervention for corneal abrasions at the primary level –Train ophthalmologists in Mgt of corneal infection –Develop a basic lab set-up –Study national need for corneas –Establish eye banks and accreditation process

Disease Control Childhood blindness –Train Ophthalmologists and a team for pediatric eye care –Establish pediatric eye care units –Develop service delivery mechanism –School screening & screening for school aged children –Research to understand causes and diseases better

Disease Control Refractive errors –Develop service delivery models –Promote refraction training centres –Promote optical ‘dispensing’ training centres (grinding, fitting)

Disease Control Diabetic retinopathy –Strengthen tertiary care centres –Training in management of diabetic retinopathy –Awareness –Service delivery models

Disease Control Glaucoma –Tertiary care centres –Training in management of glaucoma Low Vision –Tertiary care centres –Training in management

Human Resource Development MLOP –Develop curriculum –Training materials in regional languages –Body for accreditation –Develop Management Competence –Standardized Ophthalmologist training, CME

Service delivery models Need to develop working models of primary eye care Strengthen tertiary care models Develop regionally appropriate IEC materials

Advocacy Develop partner institutes to COE Improve networking between stakeholders Low Vision devices production

Technologies Telemedicine GIS