We need to raise awareness about the low use of cataract services, and adopt strategies which promote equality in eye service delivery, access and use. People who do not use eye services know why they do not seek treatment. It is therefore critical that providers ask and listen to the views of their community.
Motivating potential treatment beneficiaries via health education, and social marketing strategies, such as the 'aphakic motivator', have been favoured strategies to improve cataract uptake. It would be a mistake to overlook the importance of social marketing but it is by no means a 'magic bullet'. The test of time plus some evidence3ýhas shown that the power of example is not enough. The interplay between social, economic and cultural factors is key to understanding service utilisation, and to developing effective intervention strategies. Many of the reasons specified for poor servÈce use are largely a consequence of poverty, gender inequality and lack of participation in decision-making. Tackling these causes is fundamentally challenging. At a practical level we can begin by:
improving the evaluation of cataract surgical outcomes.
providing 'fast track' consultation and follow-up in the community.
modifying post-operative surgery Necommendations to facilitate a quick return to day-to-day responsibilities.
promoting the benefits of cataract treatment for elderly people.
maintaining better service information systems so that planners know who uses, and does not use their services.
Central to the success of these efforts is a move from an approach of 'do unto communities' to 'do with communities.'
This article has been greatly influenced by other people, and my research experience in Tamil Nadu, India. Many thanks to the rural communities in Tamil Nadu who so readily shared their views with my colleagues and I from the London School of Hygiene & Týopical Medicine, Aravind Eye Hospital and SPEECH (a local NGO). A special thanks to Professor Astrid Fletcher who has given me the benefit of her expertise on countless occasions, and also made incisive comments on this article. Our research in Tamil Nadu was funded by the Department for International Development (UK Government).
World Health Organization. Vision 2020: The Right To Sight. Press Release WHO/12,
18 February 1999. WHO, Geneva.
Fletcher AE, Donoghue M, Devavaram J, Thulasiraj RD, Scott S, Abdalla M, Shanmugham CAK, Bala Murugan P. Low Uptake of Eye Services in Rural India: A Challenge for Programmes of Blindness Prevention. Arch Ophthalmol 1999: 117: 1393-9.
Brilliant GE, Lepkowski JM, Zurita B, Thulasiraj RD. Social Determinants of Cataract Surgery Utilization in South India. rch Ophthalmol 1991; 109: 584-9.
Šrilliant GE, Brilliant LB. Using Social Epidemiology to Understand Who Stays Blind and Who Gets Operated for Cataract in a Rural Setting. Soc Sci Med 1985; 21(5): 553-8.
Johnson JG, Goode V, Faal H. Barriers to the Uptake of Cataract Surgery. Tropical Doctor 1998; 28(4): 218-20.
World Health Organization. Cnformal Consultation on Analysis of Blindness Prevention Outcomes. 16-18 February 1998. WHO, Geneva.
National Prevention of Blindness Programmes and VISION 2020 http://www.jceh.co.uk/journal/36_1.asp
Serge Resnikoff MD
Coordinator, Prevention of Blindness and Deafness
World Health Organization Geneva
The goal of VISION 2020 : The Right to Sight can be achieved only through action at the national level, in accordance with the dictum, ‘Plan globally, Act locally’.
One of the critical functions of the World Health Organization’s Programme for the Prevention of Blindness, under its mandate of providing technical cooperation to Member countries, has been assisting the establishment of national programmes and committees for the prevention of blindness. To date there are over 100 such national programmes/committees/focal points in countries where blindness is a public health problem. These are in various stages of development and activity. While political will and the commitment of ministries of health is an important determinant of how well these function, professional groups and non-governmental organisations can also play a major role, as demonstrated by the importance of advocacy.
Despite varying efforts, often hampered also by resource constraints, there has been a deterioration in the blindness situation in some countries, because of population growth and ageing and the paucity of eye care services where they are needed most.
VISION 2020 represents an unique opportunity to revitalise and strengthen existing programmes/committees and to create new ones where they are lacking.
There is a need to translate global and regional strategies into nationally applicable activities through defining national plans of action, focusing preferably on the most peripheral level possible, perhaps the district level. Such plans of action should fit the situation in which activities would be implemented.
Prior to planning, a situation analysis would be necessary, as well as a detailed needs assessment, taking into account:
the epidemiological situation, ideally through population-based surveys or ‘rapid assessment’ techniques, or appropriately extrapolating from available data
human resources, in terms of numbers and cadres (including the private sector), geographical distribution and ‘quality’ (i.e., the need for re-training)
infrastructure, in terms also of quantity, quality and distribution.
This will facilitate the setting of priorities based on: unmet needs; the magnitude of the disease burden; and the feasibility and cost-effectiveness of interventions. Rele vant and realistic targets need to be set, indicators defined and data recording and reporting systems put in place. As far as possible, data should be collected at district level or other defined areas, to measure and ensure equity in service delivery.
Given the time frame of VISION 2020, it would be useful to have, in the first instance, a five-year plan of action, with subsequent more detailed annual plans of work, to enable monitoring and evaluation.
Finally, VISION 2020 must not be considered a vertical programme with a limited time frame. The national programme plan should be an integral part of the health delivery system, work towards long-term sustainability and address, among others, the key issues of quality and equity.
WHO, the International Agency for the Prevention of Blindness (IAPB) and its constituents, working in partnership, need to support Member countries in the development and implementation of their national plans.
These plans should be as decentralised as possible in order to reflect the actual level of implementation of the different activities. The empowering of local communities is another essential aspect that should not be overlooked. Lessons learned from community-directed treatment programmes, in the case of onchocerciasis control, have demonstrated how much can be achieved even in the most underserved areas when all those concerned join hands and work together.
National Prevention of Blindness Programmes http://www.jceh.co.uk/journal/36_2.asp
David Yorston responds to questions (Q) on National Prevention of Blindness Programmes, providing answers (A) based on his experience in Africa and elsewhere. Dr Yorston (Christian Blind Mission International: CBMI) was formerly Ophthalmologist at Kikuyu Eye Unit, Kenya, and is now practising at Moorfields Eye Hospital, LondonQ: Are National Programmes relevant to Vision 2020?
A: A key part of Vision 2020 is devolving decision making and planning to district level – the idea of planning services for units of one million people. Generally, when we have tried to plan for larger populations, we have not been successful. This has led some people to question whether national prevention of blindness programmes have any role in Vision 2020. Well managed national programmes can play a major part in implementing Vision 2020. However, ineffective programmes risk becoming irrelevant as the focus of activity will inevitably shift to the districts.
Q: What should National Programmes focus on?
A: The main task of a national prevention of blindness programme should be to provide a framework for Vision 2020 at the district level. Globally, Vision 2020 is successful because it has pooled experience and expertise from many sources, and we have all agreed to pursue some clearly defined goals rather than independently pursuing our own priorities. In the same way, at national level, a multitude of isolated, independent programmes will not be the most efficient way to eliminate avoidable blindness. A national progra m me can help by providing guidelines in response to a variety of questions – for example:
How should we monitor cataract outcomes?
Which districts should have the highest priority for full implementation of SAFE?
What is the minimum standard of equipment and supplies for district eye clinics?
All of these issues are best decided at national level.
Secondly, national programmes are vital for human resource development. They must advise the government about the numbers and cadres of eye workers that are needed, how they should be trained, and what they should do. Again, this must be done at national level. It would be unacceptable if ophthalmic assistants were permitted to do cataract surgery in one district, but not in another. The programme should ensure that eye workers are not only trained, but also empowered – that is:
They are suitably equipped and supplied
They have a realistic job description
They have authority to plan their work within the limits of the job description
They receive continuing medical education
Finally, national programmes should act as channels of communication. They should be constantly sharing good ideas, spreading the message that avoidable blindness can be defeated, encouraging the best programmes, and helping the rest to improve. An effective national programme will ensure that there is no such thing as an isolated eye worker.
Q: Who are the key players in National Programmes?
A: National prevention of blindness programmes are usually planned and run by prevention of blindness committees (PBC). Ideally all groups contributing to prevention of blindness should be represented on the PBC.
Ministry of Health
An effective prevention of blindness programme needs official government support. The MoH representative should be sufficiently senior to act as an effective advocate for prevention of blindness within the Ministry. They should have the authority to make decisions that will affect prevention of blindness. It can be very frustrating to spend long periods formulating plans and proposals, only to have them ignored by the MoH.
Eye care professionals
These should include not only ophthalmologists, but also para-medical eye workers, optometrists, eye nurses, and orthoptists. All of us are involved in prevention of blindness, and we all have different insights and priorities. An effective programme will make good use of all these differing skills.
The international non-government development organisations usually provide the funds for prevention of blindness in developing countries. Sadly, INGDO’s may be viewed solely as a source of cash! Major INGDO’s, such as Sight Savers International, and CBMI, have many years of experience of prevention of blindness programmes in many different countries. This expertise is at least as important as their money. The ideal is partnership, in which the PBC and the INGDO sit together and plan how the INGDO can contribute most effectively.
In some countries service clubs, such as Lions and Rotary, make a major contribution to prevention of blindness. Sometimes this can lead to problems, as service club eye clinics may take place outside the framework of the national programme. The best way to handle this is not to ban eye camps (which is usually impossible!) but to include the service clubs in the national programme, by involving them in the development of eye services.
Major teaching institutions, and other successful centres of excellence, should be represented on the PBC. Other programmes may be able to learn from their experience, and decisions about human resource development will have important implications for their training programmes.
Few PBC have any lay representatives, which is a pity. We need to be reminded that we are not dealing with a million cataracts, but with a million people, and their families, every one of whom is experiencing different problems because of their visual disability.
Other expertise / celebrities
The main obstacles to prevention of blindness are not technical or clinical, but are due to failures in management and administration. More skilled managers and business people should be appointed to PBC’s, not because they are interested in prevention of blindness, but because they know how to manage a large enterprise successfully and profitably.
We need advocates who will raise awareness of prevention of blindness. This is most likely to be achieved by involving a local celebrity – a sporting personality, a film star or entertainer, or a traditional leader.
In general, we should be more imaginative and appoint people to national PBC’s who would not normally sit on MoH committees.
Q: What are the problems facing National Programmes?
A: Sometimes national programmes try to do the wrong things. The prim ary focus for implementation of Vision 2020 is at the district level. National programmes cannot micro-manage individual district eye care teams. The national PBC has to give the guidelines to the districts and then let them do the work.
Secondly, national pro gram mes are often perceived as being remote and out of touch. One of the most important tasks of the national programme is to promote networking and sharing of ideas. If this is done effectively, then the national programme will be close to every eye worker.
Finally, prevention of blindness on a national scale is bound to be a political issue. Sadly, care for blind people is frequently hampered by rivalry between different eye care professions, government departments, and NGO’s. It has been said that if we spent as much energy fighting blindness as we expend on fighting each other, we could achieve the goals of Vision 2020 by 2015! We must bury past differences, and work together for a common programme. National programmes which can do that effectively will make a huge contribution to eradicating avoidable blindness.
Cambodia's National Eye Care Programme and V I S I O N 2020: The Right to Sight
http://www.jceh.co.uk/journal/36_5.asp Enitan Sogbesan MD
4514/4516 Old Orchard
Canada Uch Yutho MD
Ang Doung Hospital
PO Box 2027