October 2003
Oamodar Bachani and Rachel Jose
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October 2003
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Oamodar Bachani and Rachel Jose |
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The Scenario, 1976-1993 India was the first country to launch a vertical programme to control blindness in 1976. With its socioeconomic diversity, and the distinction of having highest number of blind persons in a single country, India poses a certain challenge to blindness prevention efforts, despite the fact that most causes of blindness are preventable or easily curable. The main challenges between 1976 and 1992 were inequitable distribution of eye surgeons, most of whom worked in urban areas, the low quality of services with conventional ICCE as the main procedure for cataract surgery, and the lack of a focal point at the district level to manage eye care services. Most blind persons were from lower socio-economic strata of society, unaware of the benefits of sight-restoring interventions and having limited resources to seek services. In addition, this vertical programme received very limited funds from the Central Government. Revamping the Programme The National Survey of Blindness in 1986-89 revealed that prevalence of blindness (VS<6/60) remained high at 1.49% and cataract continued to be leading cause, accounting for 80% of blindness. This survey prompted a rethinking of the strategy and structure of this programme. In 1994, World Bank assistance was sought by the Indian Government to address the needs of the programme. |
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Achievements, 1993-2002 In the last 10 years, there has been a significant change not only in terms of enhancing eye care service delivery but also in improving the uptake of eye care services. The use of Intraocular Lens (IOL) has helped in this regard. The increase in number of cataract operations from 1.5 million in 1993 to 3.8 million in 2002 is significant, though there was a corresponding rise in population figures, particularly of the 50+ age group. The cataract surgery rate of 3700 surgeries per million population is one of highest in the developing world. A qualitative change in visual outcome following cataract surgery has come about mainly because of improvements in surgical procedure. IOL implantation increased from just 3% of all cataract surgeries in 1993 to 77% in 2002, astonishing even policy makers. There is now a demand for high quality eye care. Keys to Success How was this possible? This is a commonly asked question. The basic approach was to identify the weak areas and limitations of earlier interventions and specifically target the backlog of cataract blind cases. The following were major inputs during the last decade: 1. Training of eye surgeons in ECCE/IOL surgery: Faculty of Medical Colleges and District Eye Surgeons were trained in 25 selected institutions across the country. Over 1100 eye surgeons have so far been trained in the Public Sector. Hundreds of surgeons from the Voluntary and Private sectors also received similar training either through their own programmes or with the support of INGOs. The training was for a minimum of 8 weeks and focused on developing skills required for ECCE/ IOL. This increased the accessibility of IOL surgery to the masses. 2. Increase in institutional capacity for eye care: Dedicated Eye Wards and Eye Operation Theatres were constructed in district towns and some sub-district level facilities. Over 400 such units in the Public Sector have increased the inpatient capacity by over 5000 beds. Hundreds of such units also came up in the voluntary sector supported by the Government of India or INGOs. These and previously existing facilities were provided with high tech ophthalmic equipment including operating microscopes, slitlamps, A-Scans and Yag Lasers. Provisions were made to maintain the equipment. 3. Initiatives to improve quality of cataract surgery: Besides training surgeons and providing ophthalmic equipment, the following initiatives improved the quality of services and the visual outcome: |
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Shift in approach from surgical eye
camps to fixed facilities: Studies indicated that visual outcome after surgery in makeshift eye camps left much to be desired. This led to a strategic shift from camps to fixed facilities where a sterile OT environment and the required equipment were available. Focus on sight restoration through improved follow-up after surgery: Studies indicated that more than 70% of the ICCE cases with poor visual outcome improved with corrective glasses following refraction. Provision of +100 aphakic glasses at the time of discharge was discouraged after conventional surgery. Strengthening monitoring and evaluation: Standard Cataract Surgery Records were maintained for all operated persons, including details of preoperative and postoperative visual acuity and complication, if any. Sentinel Surveillance Units were set up in different parts of the country to assess visual outcomes. A Computerised Management Information System was developed to monitor various aspects of the programme. The following independent studies were undertaken over the last 8 years to evaluate the programme: Rapid Assessment of Cataract Blindness Beneficiary Assessment Surveys Communication Assessment Study Evaluation of Training of Eye Surgeons in ECCE/IOL Surgery Cost-Benefit Analysis of World Bank Project Evaluation of NGOs National Survey on Blindness 2001-02. |
4. Expanding coverage to underprivileged areas: Villagebased link workers were oriented to identify blind persons and motivate them to seek services. With this innovative approach, untreated cataracts were identified and treated. Government or local NGOs organised screening camps with the active participation of community and local governing bodies (Panchayats). NGOs were subsidised to provide free cataract surgery. These initiatives enhanced coverage. Public awareness through mass media, traditional channels and interpersonal communication led to an increase in utilisation of eye care services. 5. Decentralisation in implementation: Establishment of the District Blindness Control Society (DBCS) as the nodal implementing body was quite successful. With this approach, funds were made directly available to the societies. Grants to NGOs were also decentralised. The DB CS included representatives from the NGOs and Private Sector, which gave them a sense of ownership and partnership. 6. Creating an enabling environment for NGOs in eye care: In initial phases of the programme, there was an over-dependence on the Government sector. In the last 10 years, there has been large-scale participation of NGOs in various activities. Government and INGOs assisted local NGOs with funding for the following activities:
The government of India has decided to continue support the National Programme for Control of Blindness so that the momentum generated during last one decade is sustained. India has already committed to VISION 2020: The Right to Sight Initiative. A plan of action has been formulated to control target diseases, develop human resources and infrastructure required for the country. Besides continuing activities to control cataract blindness, the programme would lay more emphasis on childhood blindness, corneal blindness, refractive errors, low vision and emerging disorders like Diabetic Retinopathy and Glaucoma. To begin with, Rs. 4450 million (approx. US$ 96 million) have been allocated for the period 2002-07. In addition, various INGOs like Sight Savers, Christoffel Blindenmission, Lions SightFirst and many national NGOs have been continuing assistance to prevent and control avoidable blindness in India. The last decade has sparked an eye care movement which will allow India to take up a leadership role in eliminating avoidable blindness. Dr. Damodar Bachani Asstt.Director (Ophth.) National Programme for Control of Blindness Directorate General of Health Services Ministry of Health & Family Welfare 756-A, DGHS, Nirman Bhavan New Delhi -110 011, INDIA Tel: +91-11-2301 8510 Fax: +91-11-2301 4594 Email: adgo@nb.nic.in |