Vision Center

Vision Centre: A concept for the elimination of unnecessary blindness & visual impairment at 50,000 population level Implemented by : L. V. Prasad Eye Institute & partners Prepared By: Gullapalli N Rao, MD and Vilas Kovai, M.Phil International Centre for Advancement of Rural Eye Care. L. V. Prasad Eye Institute, L.V. Prasad Marg, Banjara Hills, Hyderabad, India. Background It took a few generations for the eye health professionals to understand that the treatment of later stages of disease is much more costly than prevention of its very occurrence and promotion for seeking early interventions before it gets untreated. The L V Prasad Eye Institute has realized that better eye health can be achieved through establishing more accessible services as a first contact and continues services in lifetime through developing vertical linkages with Service Centres and Tertiary Centres and horizontal linkages with community. Why this shift towards primary eye care ? The shift towards an emphasis on primary care in the organization and financing of eye health care is intended to achieve better health through more accessibility to needed services reduced cost and improved coordination. In the realm of eye care, patients can self-refer accurately and discern symptoms readily that are related to their eyes and vision. A clearer understanding of the attributes of primary eye care will help guide policymakers, organizations and the public as they plan, evaluate and develop eye care delivery systems. Why primary eye care services (Vision Centers)? Blindness is developing countries, as well as in India, is most commonly found in rural and often remote underserved areas. The Andhra Pradesh Eye Disease Study, a population based epidemiological survey in the year 2000, found that the prevalence of blindness in the Indian state of Andhra Pradesh is quite high at 1.84% in the population. It is 2.4% in the rural areas, 80% of which is treatable of preventable. Based on the Andhra Pradesh Eye Diseases Study data, it is estimated that in a population of 50,000 the following eye care services are required: 1000 people are blind (6/60 NPL). Of these, 555 are blind due to cataracts (0.8%) and refractive errors (0.3%) which are avoidable causes of blindness. 75% of these do not seek eye care. Majority of those with corneal, retinal and glaucoma disease can avoid blindness if they can access to a system that can identify potential blinding conditions and refer for further management. Approximately 10,000 people require refraction services and spectacles. Against this only 25% of the needy use spectacles. Why and what are the important bottlenecks of eye are? Non availability of a system that timely intervenes and provide affordable simple basic eye examination by using advanced and appropriate technology to: correct uncorrected refractive errors with affordable low cost spectacles identify potential avoidable blinding conditions and refer to the linked service centre for medical and surgical management. What happens if this situation is not addressed? The lack of refraction and spectacle provision in eye care services in underserved areas has important negative consequences in terms of lost educational and employment opportunities, placing a substantial burden on the individual and in turn on the society. What is the solution? May be the Vision Centre Model These centres, each serving a population unit of 50,000, are integrated vertically with Service Centres and horizontally to the primary health care, community development agencies in rural areas, local non-governmental agencies and the local governmental structure. The infrastructure of Vision Center includes: A rented building that has waiting area for patients with sitting arrangements A screening room for Vision Technician to take history and perform initial examination including refraction, slit lamp examination and prescription through counseling. Within the screening room, a section for dispensing glasses at affordable prices. Each Vision Centre is manned by a trained Vision Technician, product of one year training program at the LVPEI after a selection forces from the geographical area when Vision Centre is located. This promotes local community ownership and involvement while making minor contribution to the employment of local youth. The Vision Technicians are trained in good history taking, refraction, initial eye examination including slit lamp and applanation tonometry. These Vision Technicians have an opportunity for career advancement through admission to a degree program in optometry, should they wish to pursue this. These centres are provided with adequate infrastructure to provide all primary eye care services that Correct refractive errors and provide low cost spectacles Detect potentially blinding problems such as cataract, glaucoma etc. and refer them to appropriate care centre. Detect signs of Vitamin A deficiency and make appropriate referrals as well as share the information with local primary health care authorities for necessary action. Help in the development of comprehensive Health Care Services in the community served. Explore and develop the possibilities of Self Financing of Eye Care Services through Low Cost Insurance Schemes. The optician at the service centre helps to fit the lenses in to the frames and keep ready for dispensing. The coordinator of Vision Centres deals with the day to day monitoring of the Vision Centres. Two social scientists and a senior optometrist provide the technical support to plan, monitor and implement the Vision Centre model. The director of LVPEI oversees the project planning, monitoring and implementation. Our experience with service delivery: With the above infrastructure and human resources, five Vision centres, were started in Wanaparthy, Achampet, Nagarkarnul, Kottakota, Kollapur of underserved Mahabubnagar district and Bhainsa, Kubeer, Naveepet and Nandipet of underserved Adilabad and Nizamabad districts in Andhra Pradesh, in 2003 and 2004. Chagallu, another vision centre in West Godavari district was started in December 2002. To illustrate the service delivery at Vision Centre, we would like to share our experience with two of our old Vision centres for the latest 9 months as follows: The successful Vision Centre Wanaparthy could see 5,779 people (without school screening activities), dispense 958 spectacles, refer 1,472 people cost to the service centre and recover 99% of the recurrent cost. On the other hand the centre, with reasonable performance could screen 5,460 people (with school screening activities), dispense 847 spectacles, refer 938 people to the Service Centre and recover 57% recurrent cost. A good quality primary eye care system is essential for delivery of basic eye care in underserved areas of the developing world. LVPEI proposed a 4-tire pyramidal infrastructure for eye care delivery in developing countries encompassing primary, secondary and tertiary levels of care with the goal and objectives as fellows. Specific Activities: To screen initially a minimum of 4,000 subjects per 300 working days and gradually increase the numbers by 10% per annum To dispense a minimum of 750 spectacles per 300 working days and increase by 10% per annum. To refer at least 1000 people per 300 days to the base hospital for cataract and other complicated eye problems and increase by 10% per annum. To investigate the impact of services rendered through Vision Centre, utilization pattern of eye care services and reasons for not utilization of referred services. Project implementation: This project will have two stages of implementation. In the pilot phase (one year) Vision Centers will be established in partnership with LVP and like-minded partners. In the subsequent stage (after the successful experience of Vision Centre), these type of vision centres will be expanded in other parts of Andhra Pradesh and Rural India as well. The place for the Vision Centre will be carefully chosen based on three criteria. Underserved area Availability of surgical facilities for the referred cases. Availability of Vision Technician. Initially the program co-coordinator visits two times in a month and these field visits will be gradually reduced as we progress. Part of the recurring cost of the Vision Centre will be done through sale of spectacles and referred surgeries. Steps: Project implementation, monitoring and evaluation. Identifying and procuring the inventory, including eye charts, eye glasses, carrying cases at reasonable costs (costs identified at the beginning of the project) Conducting Vision Technician training. Inventory storage and supply as needed In the Vision Center. Develop an accurate database to establish initial inventory levels, subsequent inventory movements, re-ordering flags, returns etc and link to accounting / financial system to determine whether the system is cost effective (profitable and sustainable). Provide tertiary eye care services to eligible referrals (those holding white ration cards) Participate in planning for expansion and communications between members.

S.No Particulars Quantity for one Vision Centre Amount per piece(INR) Total amount for one vision center in Rs.   US$   Capital A Training of Vision Technicians 1 50,000 50,000 1,136 B Equipment: 1 Slit lamp 1 3,07,040 2 Trial set 1 7,500 7,020 3 Vision drum 1 1,200 1026 4 Occluder 1 55 45 5 Near Vision chart 1 55 38 6 Retinoscope 1 55 9,500 7 Direct Ophthalmoscope 1 8,500 9,400 9 Table for slit lamp 1 15,000 17,500 10 Stool with wheels 2 550 702 11 Stool without wheels 1 1,134 1,134 12 Mirror 1 350 350 13 KV inverter 1 26,000 26,000 15 Batteries 5,000 7,000 16 Renovation of space for Vision Centres 40,000 40,000 Total 4,60,855 10,473 C Furniture 15,000 341 Total (A+B+C) 5,25,829 11,951 D Possible Variation in cost (5%)-contingencies 25,000 568 Grand total (A+B+C+D) 5,50,829 12,519

BUDGET FOR ONE VISION CENTRE US$ TWELVE THOUSAND AND FIVE HUNDRED NINTEEN ONLY Indian Rupees Five Hundred and Fifty Thousands and Eight Hundred (Indian Rupees 5,24,829 or US$ 12,519) 12,519