Challenges in getting Human Resources in Eye Care

Manger HRD
Aravind Eye Care System

The health sector is a human resource intensive service. With the increasing need to provide multi-disciplinary services to an ever increasing population, the availability of well-trained and qualified workers to deliver services is of paramount importance. Lack of adequately trained health care personnel, both in number and distribution, poses a challenge to the health care system, particularly in delivery of services: Opthalmalogy, pharmacy, laboratory, radiography and environmental health, as well as in management of the system

Difficulties are also experienced in recruitment, retention, training, development and utilization of staff. Low salaries and benefits; poor working conditions; little in-service training; the lack of career opportunities; poor coordination of training; a shortage of adequately trained teaching staff and teaching materials, and the absence of a comprehensive human resources development and management plan are underlying causes.

It is a known fact that lack of manpower is a major factor in the persistence of this disappropriate burden of blindness. Manpower development in the poorest countries is now a priority that must be urgently addressed. The human resource available are not only inadequate in quantity but in quality also.

Challenges in Africa

Constraints identified include: inadequate human resources; poor co-ordination between all stake holders; inadequate co-ownership by government; low productivity; inadequate planning with weak integration of eye care services.

There are nearly as many eye surgeons in the San Francisco metropolitan area as there are in the entire continent of Africa. Some African nations do not even have a single ophthalmologist.

There are 275 ophthalmologists in the whole of South Africa: 250 of them work in the private sector catering for the needs of 8 million people, whilst only 25 work in the government practice that services 32 million people. The CSR for the indigent population is 850 per million of the general population per year. In order to eliminate blindness due to cataract, it should be 3000 for South Africa (Source:


Human resources for health remain perhaps the main constraint in the struggle to improve health status in Uganda. Health personnel with the right skills and attitudes remain grossly inadequate.

  1. Shortage of personnel
  2. Poor staff remuneration leading to poor motivation in the Government sector
Human Resources

The total number of ophthalmologists in the country is 50. Thirty of these are in Nairobi City. The ophthalmologist per population ratio in Kenya is 1: 600,000. The total number of Ophthalmic Clinical Officers [including cataract surgeons] is 100. The OCO per population ratio in Kenya is 1:300,000. The OCOs are the key workers in public service and in the rural areas. (Source:


The available eye care personnel in Ethiopia are: 76 ophthalmologists, 4 cataract surgeons, 93 ophthalmic nurses and ophthalmic medical assistants and 258 integrated eye care workers. The ophthalmologist population ratio is 1:1 million nationally. However, this ratio is 1:4-6 million of the population in rural areas. There is 1 ophthalmologist training institute (Department of Ophthalmology, Medical Faculty, Addis Ababa University), which graduates only 3-4 ophthalmologists per year, and there are only 2 ophthalmic nurse training schools

There are only 76 ophthalmologists in the country and 85% of these live in Addis Ababa. This works out to be 1 per 6 million, the WHO standard is 1 per million A typical journey just to reach a health care centre to be seen by an eye doctor can take between 4-5 days. Whilst the cost of treatment may be affordable, the high ancillary costs put eye care out of the reach of the majority. (Source:

Ethiopia is really not well equipped for medical care. There is only one centre for training ophthalmologists, and that is in the capital, Addis Ababa" Dr Mulu Hailu

Challenges in Asia

There is a general shortage of all categories of eye care personnel in most countries of the South East Asia. Their inadequate number is not the only concern. Inappropriate mix (the Region has 11 000 ophthalmologists and only 9 000 optometrists), inequitable distribution (80 per cent of human resources are concentrated in urban areas), low productivity (in some countries ophthalmologists perform two cataract operations or even less in a week) and the lack of public health skills are among other major concerns. (Source:


There is shortage and maldistribution of health manpower; infrastructures and facilities to tackle the identified eye care problem. The lack of training programmes in the country also compounds this problem.

Review of the manpower requirements shows that 9 Ophthalmologists, 17 Ophthalmic Nurses, 7 Optometrists, 28 Basic Eye Doctors, 56 Basic Eye Nurses, 45 Optometry Technicians, 132 Ophthalmic Assistants, 230 Primary Eye Care Trainers and 2215 PEC Workers will need to be trained between now and 2005. This excludes two doctors currently undergoing residency training and 3 nurses who had been trained as Ophthalmic Nurses in Thailand. However, the availability of training centers, trainers and financial resources may preclude the achievement of this very worthwhile objective in the development of eye care in Cambodia. (Source:


76% of the populations live in the rural areas, there are 650 ophthalmologists in the country but over half of these are unable to perform surgery and the majority live in urban areas. (Source:


80% of these people live in rural areas whilst 70% of her 24,000 eye doctors work in urban hospitals. (Source:


India shoulders the largest burden of global blindness. Almost 15 million of the 1.08 billion population are visually challenged, 52 million visually impaired and childhood blindness running at 270,000. India is the first country in the world to initiate a dedicated program for the eradicating avoidable blindness, however, the magnitude of the problem is large and the government resources meager 50% of this blindness is preventable or treatable, but there is a huge lack of trained pediatric ophthalmic professionals as well as essential equipment.

Despite the high concentration of academic institutions -- 196 universities, 8,111 colleges and 887 polytechnics India only has 3,000 optometrists. Given that the population is nearing one billion individuals, approximately 100,000 more optometrists are needed to adequately care for those in need.(Source: Out of Indias 900 hospitals, only 10 have separate pediatric ophthalmic units and there are just 150 pediatric ophthalmologists in the entire country to look after Indias 350 million children (Source:

In India there is a backlog of 6,000,000 totally blind. Fully 80% of this blindness is preventable or curable. Aravind Eye Hospital in southern India provides the highest volume of ophthalmic surgery in the world, and has restored sight to over 130,000 people in just ten years. Even at this rate, Aravind Eye Hospital will cover the backlog in 500 years, a fact that emphasizes the need for more immediate solutions. (Source: www.


There are four million blind people in Pakistan, 1.5 million in the Punjab alone, . "If proper measures are not taken, that figure will reach three million by the year 2020."

The major reasons accounting for the prevalence of blindness in Pakistan are lack of human resources, coupled with a lack of training facilities for qualified ophthalmologists.

World Health Organization (WHO) recommends a ratio of one ophthalmologist per 100,000 populations, while Pakistan has only one eighth of the required number. (Source:


There are 1,451 ophthalmologists & cataract surgeons in the country and the majorities are urban based. Although there is a Vietnamese National Health Service, both eye examinations and surgery have to be paid for. (Source:


There are 16 eye hospitals/clinics in the present infrastructure most of which are in the cities with the country's 80 eye doctors serving the population at the ratio of 1:400,000. A large part of its territory remained inaccessible by modern transport and communications and hence distribution of ophthalmologist is not equal within the country. For eg., Taplejung is one of the remote hilly districts of eastern Nepal with a population of 135,000 and a catchments area of 3 million Nepalese. The nearest eye care facility to Taplejung is a three-day journey on difficult road conditions. (Source:

Challenges in Europe

A review of the current status of eye care services in Europe indicates that the situation varies remarkably between various parts of the continent. Western Europe is composed of highly industrialized countries, the central European region showing a more economically successful transition from the former socialist system, and the eastern European region still going though serious economic difficulties while transforming their healthcare systems under the new economic conditions. Therefore, specific strategies have to be designed in order to take into consideration local constraints and opportunities. (Source: www.


Revamping Medical Education
  • There is need for strengthening and standardizing the training in ophthalmology during undergraduate and post-graduate courses. The curriculum should keep pace with technology particularly in the fields of Glaucoma, Diabetic Retinopathy, Pediatric Ophthalmology, managing corneal infection and Keratoplasty.
  • Uniform curriculum and assessment during MS/MD courses including assessment of skills, maintenance of log-book (minimum 50 IOL microsurgical operations of reasonable quality during postgraduate training) and evaluation of the capacity of the existing PG training centres is advocated.
  • Training of postgraduates of ophthalmology in direct ophthalmoscopy, slit-lamp examination, gonioscopy, applanation tonometry, field charting, biomicroscopy is recommended.
  • All trained Ophthalmologists should mandatorily undergo CME every three years.
  • In case of Paramedics, CME every two years should be encouraged.
Ensuring optimal utilization of Human Resources

Efforts to be taken to ensure optimal utilization of Human Resources by redeployment of Eye surgeons to eye care facilities. Mechanism to be evolved to utilize the large number of private ophthalmologists so as to enhance capacities and surgical rates by contracting out service delivery. System also to be evolved for equal distribution of ophthalmologist in urban and rural areas. Development of dedicated District Programme Managers (DPMs) and Hospital Managers will be required to optimally utilize the available resources.

Improving Quality of Services

There is need to adopt and enforce standard ophthalmic procedures to maintain high quality of pre-operative, operative and post-operative services. Surgical eye camps will be phased out at the earliest and monitoring tools strengthened for quality assurance.