Challenges for Human Resources in Eye Care in the Context of South America

Julio Yangela Rodilla. MD.
Coordinador del Proyecto de Lucha contra la Ceguera Sostenible en Bolivia.
Fundacin Vision Mundi. Calvo Sotelo 14 pral. 26003. Logroo. La Rioja. Spain.
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The goal of any high quality program designed to reduce blindness is to make eye care services available, accessible and affordable to all, through a sustainable delivery system. One of the key pre-requisites is the development of adequate, appropriate human resources. An analysis of current situation and in Latin-American Countries reveals several problems:

In many of these countries blindness is not perceived as a health priority:
  • It is often difficult to get support from ministries of health in the form of staff, salaries, or trained personnel. Many of the sanitary and educational services are provided and directed by foreign Institutions and professionals. They are funded from abroad and usually do pure assistance or charity.
  • Subsidy culture is very extended. We have used people to get services free.
There is a lack of high quality sustainable cooperation programs
  • There is a good number of foreign agencies doing free cataract surgery campaigns. A classic model is a group of foreign ophthalmologists that arrive to a poor area, perform about 50- 100 cataract in two weeks totally free and go back to their country. They dont create sustainable structures or train local people, something essential to promote sustainable development for the future.
  • We also know some projects, were one or two local ophthalmologists are provided with IOLs and surgical materials. In general they are quite inefficient. Many times, local surgeons perceive it as an opportunity to improve their salaries or their surgical training. A complement to their private activity. The lack of a good supervision, vocation of service and additional training, limits the chance of developing really good quality programs.
It is difficult to find technical personnel sufficiently formed and ready to work for the poor. There is a lack of vocation of service culture.
  • Only in some countries (Brazil, Argentina, Mexico, Colombia, Cuba�) ophthalmic training programs are available. Many of the candidates belong to rich families or to ophthalmologists sages and are not interested in work in our eye care models.
  • Ophthalmic training is based in USA or European models.
  • There are enough ophthalmologists in most of these countries, but their surgical and clinical training is scarce. The reason is that most of them have done their training abroad, were they were not allowed to practice surgery and the training process was not adequately monitored. Some private institutions even offer qualifications in Ophthalmology without doing a single cataract surgery.
  • People are happy to attend training courses or meetings for the prevention of blindness. However they are usually reluctant to joint projects were their work could be closely supervised or to earn a fixed salary, they prefer to work alone.
There is a tremendous shortage of all eye care professionals globally for categories other than ophthalmologists.
  • Most countries either have very poor or no infrastructure for that training. In such circumstances, ophthalmologists perform tasks that do not require their level of training.
  • Most of the eye- care professionals live in the cities. In the rural areas ophthalmic their presence is almost null.
Corruption is high.
  • There is a risk of thefts of funds or detours to other aims different from the expressed ones in project ... understandable in contexts of great need.
  • Some times the authorities see us as a way to get the resources they should be providing. The professionals, as a way for the own promotion.
  • The risk of fugue of personnel to private activities once we have trained them is high, since the ONGs cannot pay such high wages of the private company.
Language is a barrier.
  • Most of the educational materials, agencies for the prevention of blindness, sustainable Eye Care Models and SICS training centers are from English speaking countries.
There is lack of network, leadership and planning culture.

The previous ideas are based in our experience in Bolivia:
We are working in Hospital Primero de Mayo in Santa Cruz de La Sierra, Bolivia since 1993. This is a good second level hospital conducted by a Spanish Catholic Institution I.S.C.E.

In 2002 we had two local ophthalmologist doing clinics only, about 3000 patients /year. 50 cataract and other 50 minor surgeries/ year were been done by two foreign ophthalmologists. No other staff was available.

In 2003 we decided to change to a sustainable model after a visit to Aravind Eye Hospital in India.

We are a cluster of NGOs form Spain (Medicus Mundi Rioja, Fundacion Mundo en Armona, Fundacin Vision Mundi). We also get funds from La Rioja Government (Spain) Development Cooperation Program.

We spent one year to find a local leader (senior surgeon). Although we intend to arrange a full time dedication, we had to agree a part time dedication (80% time) and private activity out of our Hospital.

We tried to contract two Ophthalmologists who had attended a Community Eye Health Course promoted by Vision 2020. We offered a good salary, additional training in Europe an India if necessary� but they refused.

To select two junior ophthalmologists, we put advertisements in national newspapers. We got 9 candidates. Even the two we selected were not able to do a standard EECC surgery unaided. The clinical training was in parallel with surgical skills. They need at least two years more of intensive training.

In February 2004 our group (one senior, one junior ophthalmologists, social worker and one nurse), attended a course in India (LAICO Institute in Aravind Eye Hospital). In November 2004 a group from LAICO visited our project in Bolivia for three weeks. We had to support them with English>Spanish translations during the whole process.

As local optometrists were not available, we sent an Optometrist from Spain. After a 6 months of intensive training course in sales and refraction, in July 2005 we started our optical shop with two local people. Our glasses (frames & glasses) are provided to us daily by a local Essilor Optical workshop at a cost of less than 8 $.

By November 2005 our team are:
  • One senior ophthalmologist.
  • Two junior ophthalmologists in training
  • One social worker.
  • One secretary.
  • Two Optometrists.
  • Two ophthalmic nurses.
  • One accounts manger.
  • Support Services: Patient support, Housekeeping, Security, Transport, provided by the Hospital.
  • Operation theatre and optical shop.
Our current figures are:
Year 2003 2004 2005
PATIENTS 4200 6700 9423
GLASSES - - 2000

We are very happy with the team:
They have learned to work together with a good quality. They organize their own weekly meeting for supervision, the young professionals are anxious to learn�

We receive a monthly report and we travel from Spain every six months for supervision and training. There is a close supervision from de Hospital Primero de Mayo Staff.

For those who are planning to start a new project in the region we suggest:
  • Visit a sustainable Eye care model in a developing country, to learn what can be done.
  • Develop a realistic plan and be patient. Probably at least five years are necessary to develop a good project.
  • Do not start without a good local support. Find a local partner (local or foreign NGO working in the area for a long time) before stating your program. It will help you in your negotiations with local authorities, to select the personal, to do the follow up, to decrease corruption and to linkage with the local community.
  • Help your local partner to know and move to sustainable development models.
  • Select a small initial group with clear leather. It is better to select an honest, committed group that people that could put sticks on the wheels.
  • Confirm the real training and the real surgical skills of every body. Dont be afraid if their results are lower that what you though.
  • Develop training programs for all categories of professionals. Dont try to increase your number of patients or surgeries fast, until your basic team is perfectly oiled and trained.
  • Training courses abroad can be very useful, especially if people visit other sustainable Eye care models.
  • If you send people abroad to Europe or USA, send them for a short time and always to learn something specific. Otherwise you could lose them.
  • In you cant get optometrists, send one from your country and do the training locally. An intensive 6 months training course in sales and refraction, can be enough to start a local optical shop. Probably you can contact a local optical workshop to provide you.
  • Change subsidies culture and develop leadership. Encourage your team to believe that they can and must be the engines of their own development.
  • Ask them to find local models that they could follow as a reference (writer, artist, sportsman, and actress�). Convince them that can become in a model for others and a motive of pride for their countries.
  • A primary eye care network is vital. Build a stable and committed team. Define together the debilities, strengths, menaces and opportunities. Speak and listen to everybody. Define specific functions to every member of the team. Give real responsibility to all in their fields of action.
  • Outputs, outcomes and costs should be monitored. A computerized information, including the clinical histories and accounting system is essential to control the quality of the work and reduce corruption.
  • Quality is your first goal, not figures. Adopt measures to ensure quality since the first day of work. Develop guidelines to ensure basic minimum standards.
  • Consensual all the protocols with the team (clinical history, circulation of patients, surgical consent, stock, reports, sterilization�)
  • Pay bonus to your team for quality. Do not pay bonus for amount of surgery or patients revised. I.e. we pay a bonus if all the patients attending the clinic are properly registered in the computer plus if all patients requiring surgery have signed up the surgical consent.
  • To decrease frequent transfers of staff, include a compensation fee for the training in your contracts in they leave the project before3-5 years., and pay fair salaries.
  • If possible, contract personal with exclusive dedication. Try to avoid people that share the project with their private activity. It also decreases corruption. Offer other stimuli as the permanent training or travel on the outside.
  • To decrease corruption, extreme the care in the follow-up of the work in area: financial follow-up with audits and economic reports and technical intervals, technical continued follow-up and frequent visits,
Finally, Id like to add:

The selection of the personnel based on the deep motivations to be employed at the position is vital.

A " vocation of service �, demonstrated with previous works to the more unfavorable population, might be a good indicator.

We must develop our own training centers, were to train new ophthalmologists and another personal that have demonstrated before vocation of service.

Our local associates and communities should do the selection of these personnel. It would also allow us to form persons from the zones in which the ocular assistance is more scanty and necessary.
I believe that would be the best way of assuring a high quality struggle against blindness in Latin America in the future

Latin America needs reference Eye Care Models in the region.

Our visit to Aravind Hospital in India was crucial.
We all learned that it is really possible to develop high quality Eye Care Programs in developing countries. Those members of the team that came to India are the most committed with the project.
We need these model conducted by Spanish speaking people.
If we are lucky, I hope we will be able to offer it in Hospital Primero de Mayo, Santa Cruz de la Sierra, Bolivia, in a few years.