Management Challenges in Primary & Secondary Eye Care in India Prof. R.S. Goyal Institute of Health Management Research, Jaipur

Eye care scenario in India Prevalence of blindness in India is relatively large (0.7%) as compared to world as a whole (0.57% ). Prevalence of blindness in India is relatively large (0.7%) as compared to world as a whole (0.57% ). Country has 15 – 18.6 million people with blindness accounting for one fourth of the world’s blind population. Country has 15 – 18.6 million people with blindness accounting for one fourth of the world’s blind population. India has highest burden of blindness in the world. India has highest burden of blindness in the world.

Regional Burden of Blindness (RBB) Region % of global population (A) % of global blindness burden (B) RBB (B/A) Established Market Economies Former Socialist Economies of Europe India China Other Asia and Islands Sub-Saharan Africa Latin America and the Caribbean Middle-Eastern Crescent

Recent trends indicates that prevalence of blindness due to infectious diseases is decreasing, but age-related impairment is growing. Recent trends indicates that prevalence of blindness due to infectious diseases is decreasing, but age-related impairment is growing. Around 82 % blind people are above 50 years of age. Around 82 % blind people are above 50 years of age. Visual impairment is relatively higher among women ( in all ages) than males. Visual impairment is relatively higher among women ( in all ages) than males.

Cataract has been recognized as the major cause of blindness in the country. Cataract has been recognized as the major cause of blindness in the country. Around 3.8 million people become blind due to cataract every year. It is also the leading cause of blindness, globally. Around 3.8 million people become blind due to cataract every year. It is also the leading cause of blindness, globally. Under the current demographic scenario (rapid aging of population), it is feared that prevalence of visual impairment in India will further increase in coming years. Under the current demographic scenario (rapid aging of population), it is feared that prevalence of visual impairment in India will further increase in coming years. There are also regional imbalances in prevalence of blindness across states in India. There are also regional imbalances in prevalence of blindness across states in India.

Status of prevalence of blindness in states of India CategoryPrevalence (%)States & regions of the country Low Prevalence< 1Punjab, Himachal Pradesh, Delhi, West Bengal, & N.E. States Moderate Prevalence 1 to 1.49Gujarat, Haryana, Kerala, Bihar, Karnataka, Andhra Pradesh and Assam High Prevalence1.5 to 1.99Maharashtra, Orissa, Tamil Nadu & Uttar Pradesh Very High Prevalence2 and aboveMadhya Pradesh, Rajasthan and Jammu & Kashmir

Current status of eye care in India The National Program of Control of Blindness ( NPCB) was launched in the year 1976 as a 100 percent centrally sponsored program. The National Program of Control of Blindness ( NPCB) was launched in the year 1976 as a 100 percent centrally sponsored program. The objectives of NPCB include; The objectives of NPCB include; To provide high quality of Eye Care To provide high quality of Eye Care To expand coverage of eye care services To expand coverage of eye care services To reduce backlog of blindness To reduce backlog of blindness To develop institutional capacity for eye care services. To develop institutional capacity for eye care services. The program also extended assistance to voluntary organizations for cataract operations and eye banking.

The NPCB sought to bring down prevalence of blindness in the country to 0.3 % by 2010 by promoting ; The NPCB sought to bring down prevalence of blindness in the country to 0.3 % by 2010 by promoting ; 1. Cataract Operations 1. Cataract Operations 2. School Eye Screening ( Preventive measures & Screening Program) Screening Program) 3. Eye bank 4. Strengthening of Infrastructure 5. Operationalization of Tele-Ophthalmic Vision Centers Centers 6. Capacity Building

A global initiative Vision 2020: The right t o sight” A global initiative Vision 2020: The right t o sight” by WHO & IAPB to eliminate avoidable blindness by the year 2020, was launched in India in by WHO & IAPB to eliminate avoidable blindness by the year 2020, was launched in India in Its strategy focused on; Its strategy focused on; disease prevention and control, training of personnel, strengthening of the existing eye care infrastructure, use of appropriate and affordable technology and, mobilisation of resources. disease prevention and control, training of personnel, strengthening of the existing eye care infrastructure, use of appropriate and affordable technology and, mobilisation of resources.

Goals and strategy of NPCB and Vision 2020 complemented each other in India. Goals and strategy of NPCB and Vision 2020 complemented each other in India. A host of international NGOs are contributing to Eye Care in India. These include; A host of international NGOs are contributing to Eye Care in India. These include; Sight Savers International, Christoffel- Blindenmission (CBM), ORBIS International, Operation Eyesight Universal, Rotary International, International Eye Foundation, Lions Clubs International Foundation, Help Age India, Seva Foundation and many others. Sight Savers International, Christoffel- Blindenmission (CBM), ORBIS International, Operation Eyesight Universal, Rotary International, International Eye Foundation, Lions Clubs International Foundation, Help Age India, Seva Foundation and many others.

L.V. Prasad Eye Institute, Hyderabad L.V. Prasad Eye Institute, Hyderabad Sankara Nethralaya, Chennai Sankara Nethralaya, Chennai Arvind Eye Care System Arvind Eye Care System All India ophthalmological Society All India ophthalmological Society Eye Bank Association of India Eye Bank Association of India Venu Eye Institute and Charitable Society Venu Eye Institute and Charitable Society are some of the leading national NGOs providing primary and secondary eye care in India. are some of the leading national NGOs providing primary and secondary eye care in India.

NPCB supported a large increase in the infrastructure for eye care in the country- NPCB supported a large increase in the infrastructure for eye care in the country- Regional Institute of Ophthalmology, Eye Banks, Mobile Units, up gradation of PHCs, construction of Eye Wards and dedicated Eye OTs etc. Regional Institute of Ophthalmology, Eye Banks, Mobile Units, up gradation of PHCs, construction of Eye Wards and dedicated Eye OTs etc. The NPCB has also established 590 District Blindness Control Societies (DBCS) to strengthen the eye care delivery at the district level. The NPCB has also established 590 District Blindness Control Societies (DBCS) to strengthen the eye care delivery at the district level. NPCB gave particular emphasis on promoting cataract surgeries in the country. NPCB gave particular emphasis on promoting cataract surgeries in the country.

Yet, voluntary and private sectors are shouldering the major burden of corrective eye surgeries (65%) in the country. Yet, voluntary and private sectors are shouldering the major burden of corrective eye surgeries (65%) in the country. About 11,000 ophthalmologists and an equal number of trained and recognized mild level personnel (MLP) are currently available in the country against the desired ratio of at least 4 ‐ 5 MLP for each ophthalmologist. About 11,000 ophthalmologists and an equal number of trained and recognized mild level personnel (MLP) are currently available in the country against the desired ratio of at least 4 ‐ 5 MLP for each ophthalmologist. Nearly half of the ophthalmologists in the country are surgically inactive. Nearly half of the ophthalmologists in the country are surgically inactive.

The ophthalmologist to population ratio in urban India is 1:25,000 but in rural India it is about 1:250,000. The ophthalmologist to population ratio in urban India is 1:25,000 but in rural India it is about 1:250,000. Yet a rapid assessment in 14 districts in the country has pegged the coverage of eye care services at around 70%. Yet a rapid assessment in 14 districts in the country has pegged the coverage of eye care services at around 70%. Also, IOL implantation rates gone up to 90% ( of all surgeries) in 2006 ‐ 07. Also, IOL implantation rates gone up to 90% ( of all surgeries) in 2006 ‐ 07.

The number of cataract surgeries performed has grown to 5 million in a year. A rapid assessment (2001-2) of the coverage of surgical interventions for cataract blind shows 70% reach. The number of cataract surgeries performed has grown to 5 million in a year. A rapid assessment (2001-2) of the coverage of surgical interventions for cataract blind shows 70% reach. There are also evidence of improving visual outcomes as assessed by the rapid assessment surveys among cataract operated. There are also evidence of improving visual outcomes as assessed by the rapid assessment surveys among cataract operated.

Issues in childhood blindness.. Specific infrastructure for detection and management of childhood blindness is not available at most primary and secondary health care facilities in the country. Specific infrastructure for detection and management of childhood blindness is not available at most primary and secondary health care facilities in the country. Human Resources particularly the trained personnel are inadequate at the PHC/CHC level. Human Resources particularly the trained personnel are inadequate at the PHC/CHC level.

At the tertiary level, very few centers (both Govt. and NGO) are equipped to manage childhood blindness. At the tertiary level, very few centers (both Govt. and NGO) are equipped to manage childhood blindness. Because of inadequate trained ophthalmic human resources, many conditions like ocular injuries are treated by non ‐ ophthalmologists like general surgeons or physicians in most places. Because of inadequate trained ophthalmic human resources, many conditions like ocular injuries are treated by non ‐ ophthalmologists like general surgeons or physicians in most places. Posterior segment care is grossly inadequate. Only 150 ophthalmologists (including govt. and private sector) are trained to deal with posterior segment disorders. Posterior segment care is grossly inadequate. Only 150 ophthalmologists (including govt. and private sector) are trained to deal with posterior segment disorders.

From a Socio ‐ economic Perspective.. There is a bias in the reach of cataract services. The urban, literate population is getting a better coverage. There is a bias in the reach of cataract services. The urban, literate population is getting a better coverage. Lack of escort/care providers, fatalistic attitude and fear in spite of increased commonness of services, and long waiting in decision making to undergo surgery in the average Indian household are also important barriers. Lack of escort/care providers, fatalistic attitude and fear in spite of increased commonness of services, and long waiting in decision making to undergo surgery in the average Indian household are also important barriers.

The Gender Issues.. Several studies have shown that the female carry a 40% higher burden of cataract than the male. Several studies have shown that the female carry a 40% higher burden of cataract than the male. However, women access/use of cataract corrective services is either less or at the best equal to men. However, women access/use of cataract corrective services is either less or at the best equal to men. To achieve equity in the backlog, there is a need to ensure that 60% of all cataract surgeries are performed on women. To achieve equity in the backlog, there is a need to ensure that 60% of all cataract surgeries are performed on women.

Challenges in Blindness Control in India A strategic approach to program management is missing A strategic approach to program management is missing Isolated efforts by the private, voluntary and public sectors Isolated efforts by the private, voluntary and public sectors Poor balancing between the quantity and quality of care Poor balancing between the quantity and quality of care Deficiencies in the cycle of care Deficiencies in the cycle of care In appropriate utilization of existing facilities In appropriate utilization of existing facilities

Lack of trained human resources and their unequal distribution in rural and urban areas Lack of trained human resources and their unequal distribution in rural and urban areas Large gap in ophthalmic training & education Large gap in ophthalmic training & education Socio ‐ cultural, logistic and financial issues Socio ‐ cultural, logistic and financial issues Lack of general seriousness towards the eye care Lack of general seriousness towards the eye care Low level of awareness for eye care in the community Low level of awareness for eye care in the community

22 Strategic Management Process for Eye Care interventions

Priority areas for Strategic Management of Eye Care Comprehensive BCC / IEC strategy for eye care Comprehensive BCC / IEC strategy for eye care Capacity building of existing human resources Capacity building of existing human resources Increase uptake in eye care training institutions through expanding infrastructure for addressing HR shortage Increase uptake in eye care training institutions through expanding infrastructure for addressing HR shortage Formulate efficient PPP model using SWOT analysis of Government and Private sector Formulate efficient PPP model using SWOT analysis of Government and Private sector

Develop quality norms for primary and secondary eye care and procedures ensuring adherence for quality control Develop quality norms for primary and secondary eye care and procedures ensuring adherence for quality control Efficient MIS to be developed for quality implementation and monitoring of eye care interventions Efficient MIS to be developed for quality implementation and monitoring of eye care interventions Evaluate the interventions based upon baseline and goals envisaged Evaluate the interventions based upon baseline and goals envisaged

Suggested areas for efficient management of NPCB Proper completion of Surgical Records for cataract surgery and other services needs to be maintained with complete, correct and reliable information; Proper completion of Surgical Records for cataract surgery and other services needs to be maintained with complete, correct and reliable information; Standard referral cards from primary to secondary/tertiary level of care; Standard referral cards from primary to secondary/tertiary level of care;

Development of Management Information Systems at various levels so as to plan, monitor and evaluate the programme in an efficient manner; Development of Management Information Systems at various levels so as to plan, monitor and evaluate the programme in an efficient manner; Network of Sentinel Surveillance Units to be established to study profile of beneficiaries and outcome of interventions; Network of Sentinel Surveillance Units to be established to study profile of beneficiaries and outcome of interventions; Independent evaluation on various programme activities and outcomes with standard protocols comparable with other nations. Independent evaluation on various programme activities and outcomes with standard protocols comparable with other nations.

PEC through PHC 1. Better nutrition-Prevents vitamin A deficiency 2. Safe drinking water and sanitation programmes- Contribute to trachoma control 3.Quality maternal and child health care-Reduce retinopathy of prematurity 4. Health education-Prevention of eye trauma

Effective management of eye care programs in outreach Strong leaders who build vision, commitment, positive attitudes, and a sense of mission Strong leaders who build vision, commitment, positive attitudes, and a sense of mission Increasing the uptake for eye care services through outreach and demand Increasing the uptake for eye care services through outreach and demand Generation activities, health education, and social/service marketing Generation activities, health education, and social/service marketing

Quality and size of human and other infrastructure resources Quality and size of human and other infrastructure resources Quality and number of instruments, equipment and supplies Quality and number of instruments, equipment and supplies Systems and procedures that optimizes the utilization of all of the above resources Systems and procedures that optimizes the utilization of all of the above resources

Efforts required for preventive Eye Care Increased availability and affordability of eye care services; Increased availability and affordability of eye care services; Increased commitment to prevention from national program leaders, medical professionals and private and corporate partners; Increased commitment to prevention from national program leaders, medical professionals and private and corporate partners; Creation of awareness for increased use of eye health care services; Creation of awareness for increased use of eye health care services; Implementation of effective eye care strategies to eliminate infectious causes of vision loss. Implementation of effective eye care strategies to eliminate infectious causes of vision loss.

Recommendations Collaborative approach is required from Government and private sector to achieve the NPCB and Vision 2020 goals Collaborative approach is required from Government and private sector to achieve the NPCB and Vision 2020 goals Government may focus on increasing outreach services and providing primary eye care services at PHCs while Private sector may focus on quality secondary eye care Government may focus on increasing outreach services and providing primary eye care services at PHCs while Private sector may focus on quality secondary eye care Efficient PPP models may be developed after mapping of present facilities and need assessment Efficient PPP models may be developed after mapping of present facilities and need assessment

Strengthening of preventive eye care through school screenings, awareness and community participation Strengthening of preventive eye care through school screenings, awareness and community participation Minimum quality norms should be laid down for government and private eye care facilities Minimum quality norms should be laid down for government and private eye care facilities Capacity building of medical & paramedical staff for primary eye care Capacity building of medical & paramedical staff for primary eye care