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

3. Kocur, 2008

4. 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)

5. Country Hyperopia >2.0 (%) Myopia > 0.50 (%) Astig. >0.75 (%) S Africa - Urban1.82.99.2 India - Rural0.84.12.8 India - Urban7.77.45.4 China - Rural3.516.215.0 China - Urban5.835.133.6 Chile - Urban16.36.819.0 Malaysia - Urban1.319.315.7 Nepal - Rural1.41.22.2 Refractive Errors in Children(RESC)

6. Burden of URE Resnikoff S, et al. (2008). "Global magnitude of visual impairment caused by uncorrected refractive errors in 2004.." Bull World Health Organ 86(1): 8.

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

8. Global Estimates Reference: Global estimates of visual impairment: 2010; Pascolini and Mariotti. BJO 2012, 96: 614 -618 December 2011

9. 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)

10. 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):1731-1739

11. 25.8-39.8 17.4-43.3 26.8-39.1 14.6-66.3 15.4-47.8 7.6-49.6 29.0-35.3 Mingguang et al, 2012

12. 0.07-98.7 4.62-63.3 2.38-92.31.34-93.6 0.32-95.4 1.1-87.7 0.84-39.3 Mingguang et al, 2012

13. 0.1-98.4 4.67-50.8 2.3-89.1 0.44-86.9 0.67-93.8 0.72-91.4 0.84-69.2 Mingguang et al, 2012

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

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

16. International Centre for Eyecare Education (ICEE) 269 billion dollars lost productivity Smith et al, 2009 >50 yrs No Producitivity 121.4 billion dollars

17. How many Optometrists are there? Global Estimate (D. Wilson et al., BHVI 2010) 281 748 Varies tremendously from country to country −from 0.1 per million population −to 600 per million population 281 748

18. Number of Optometrists per Million population 0.9 194 14

19. Number of Optometrists and Ophthalmologists per Million population

20. RE Programs: Core Activities Sustainable, Accessible, Affordable SCALABLE

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

22. 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

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

24. 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

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

26. 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

27. 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

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

29. 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

30. 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

31. Service Delivery in KZN 3 3 2 4 2 2 1 2 3 3 8 33 optometrists 11 Districts 123 clinics 1000 000 patients

32. 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

33. 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

35. Tanzania Vision Centers

36. Enterprise for Sight Program in South Africa

37. 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)

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

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

40. THANK YOU k.naidoo@brienholdenvision.org