|COMMUNITY EYE CARE
|Year : 1999 | Volume
| Issue : 3 | Page : 199-203
Yavatmal district blindness control society: A case study
SP Rao, RV Dubewar, PG Deotale
Dept. of Preventive and Social Medicine, V.N. Government Medical College, Yavatmal, India
S P Rao
Dept. of Preventive and Social Medicine, V.N. Government Medical College, Yavatmal
Source of Support: None, Conflict of Interest: None
Purpose: To retrospectively study the records and reports available at the District Blindness Control Society (DBCS), Yavatmal in terms of target fixation, performance and utilisation of manpower and equipment. Methods: All the available records, reports, correspondence, and proceedings of meetings from 1981-98 were scrutinized and analyzed. Results: The performance records and reports showed that over the last 10 years the target achievement of DBCS is close to 100%. However, the fixed facility (District hospital/Tertiary hospital where cataract surgeries are being performed under strict aseptic conditions) performance does not match the targets. The district mobile unit camp performance achieved 35-40% of the target in the last quarter of the financial year. Conclusion: The target fixation is irrational and needs improvement, and it is necessary for the program managers in the district to undertake analysis of the available data to ensure performance improvement
Keywords: Cataract, fixed facility, DBCS, targets, performance
|How to cite this article:|
Rao S P, Dubewar R V, Deotale P G. Yavatmal district blindness control society: A case study. Indian J Ophthalmol 1999;47:199-203
|How to cite this URL:|
Rao S P, Dubewar R V, Deotale P G. Yavatmal district blindness control society: A case study. Indian J Ophthalmol [serial online] 1999 [cited 2019 Sep 21];47:199-203. Available from: http://www.ijo.in/text.asp?1999/47/3/199/14912
The National Programme for Control of Blindness (NPCB) was launched in 1976 in Maharashtra. Recently, with a view to increase people's participation, and to involve non-government organisations (NGOs), it was decided to run the programme through District Blindness Control Societies DBCS. Based on its success in the pilot districts, the concept of DBCS was replicated in all the districts of Maharashtra state from 1993-94 with World Bank and assistance.
The objectives of the DBCS included: achievement of maximum reduction in avoidable blindness through optimal utilization of available resources; and restoration of sight through cataract surgery. The concept of high-volume, high-quality, cataract surgery is the cornerstone of the programme., The backlog of cataract cases requiring surgery was estimated in 1990 to be 22 million with an annual increase of 2 million. Despite the annual rate of 2.43 million operations (1995-96), the backlog continues to grow. Thus, there is an immediate need to increase the volume of cataract surgeries to at least 5 million per year. Secondly, the quality of surgery can be enhanced by gradually phasing out the eye camp approach and improving the static (fixed) facilities. However, in India, it is estimated that 60% of cataract surgeries are being performed in makeshift camps in schools, peripheral health centers and community centre (dharmashalas) where quality of care is liable to be compromised. Moreover, the technique used in India for cataract surgery was intracapsular cataract extraction (ICCE) although modern techniques such as extra-capsular cataract extraction (ECCE) with intraocular lens (IOL) implantation have better outcome in terms of vision.
There have been many controversial reports regarding the under-utilisation of manpower and infrastructure in India. [3,8] On the other hand, the target achievment in cataract surgery is shows excellent performance. In view of these conflicting reports, a record-based analytical case study was undertaken for the DBCS at Yavatmal.
The objectives of the study were to analyse the records and reports of the DBCS from 1981-1997 with particular reference to target fixation, performance and manpower and infrastructure utilisation. Both quantitative and qualitative analyses were attempted in this study.
| Materials and Methods|| |
Yavatmal is situated in a hilly area of the Vidharba region of eastern Maharashtra. The total population of the district is 20,77,144 (1991 census); the majority of the people belong to backward and tribal communities. The District Blindness Control Society was established during 1993. It has its office in the district hospital building with a retired medical officer (MBBS) serving as project officer. The earlier project officer, another retired medical officer, worked for less than a year. Every month the project officer conducts a meeting of Para Medical Ophthalmic Assistants (PMOAs) and Ophthalmic Surgeons to collect performance reports and discuss future Plans. These performance reports are compiled into a district performance report which is sent to the state headquarters.
He also prepares, in consultation with the Ophthalmic Surgeon, a monthly schedule for camps to be conducted at the periphery.
All the monthly performance reports and records available at the DBCS center were screened and the figures noted including the year-wise targets for the cataract surgery. The project officer and the ophthalmic surgeon were informally interviewed for their experiences with NPCB. The available correspondence and reports from private practitioners and voluntary agencies were scrutinized to assess content and frequency. The minutes of the monthly meetings were reviewed for camp performances. Thus, a record-based (1981-98) analysis was attempted and the results were analyzed manually.
"Fixed Facility" was defined as the base District hospital/Medical College hospital where cataract surgeries were performed in well-equipped operation theatres under strict aseptic conditions by qualified ophthalmic surgeons. Theatre time was allotted according to demand.
| Results|| |
The Yavatmal DBCS was established during 1993-94 in accordance with a Government of Maharashtra ordinance. However, blindness control and prevention activities had began in 1981-82 under the National Programme on Blindness Control and Prevention (NPBCP). Cataract surgeries were being performed at the base hospital (fixed facility), during outreach operations, by the District Mobile Unit (DMU), and by private practitioners. The targets fixed for the cataract surgeries were communicated to the district every year from the state headquarters. Hence, the activities were directed mainly towards target achievement. [Figure - 1] shows the NPCB performance in cataract operations performed and the targets, which varied every year. Till 1989, the number of ophthalmic surgeons available in the district did not change. During 1989, new Government Medical College was established and 3 new ophthalmic surgeons were recruited. Hence, the following years showed enhanced targets. Higher targets were fixed for 1983-86, and the performance matched them. The targets were increased again after the establishment of DBCS in 1993. The target achievement is a gross indicator of compiled performances of fixed facility, camp, and private practitioners. [Table - 1] shows the breakup of performance since 1993. It may be noted surgical performance in the eye camps was satisfactory whereas performance at the fixed facility ranged from 25 to 84%. The performance of private practitioners routinely exceeded the expected target. The fixed-facility targets and achievements from 1986-98 are shown in [Figure - 2]. Until 1993 the surgical performance matched the expected targets for the fixed facility. However, since then, the enhanced targets have not been achieved.
The quarterly cataract surgery performance excluding that of private practitioners from 1990-98 is shown in [Table - 2]. The performance-reporting year is the financial year, April to March. For the last 7 years, the first quarter performance was minimal, and performance peaked is the last quarter of the year. The cataract surgery performance of Yavatmal district was compared to that of Pune (Maharashtra) and India and is shown in [Table - 3]. The cataract operations per surgeon are 384 in Yavatmal, which is comparatively better than the national average. The number of cataract operations per 100,000 population was also encouraging.
The ophthalmic infrastructure and manpower available at DBCS are shown in [Table - 4]. On one hand, 2 operating microscopes in good working condition were available; on the other, basic equipment like visual acuity testing illuminated drums were lacking. There were 15 ophthalmic surgeon available in the district. The average number of patients operated for cataract per camp is shown in [Table - 5]. Over the last 5 years, the number of camps has been increased. However, the average number of cataract operations per camp has not shown any significant change. There were camps in which virtually no patient was operated for cataract and in a few, as many as 200 or more cases were operated. Based on the Government of India manual, the prevalence of cataract blindness and the performance of ophthalmic surgeons were estimated Table 6. The actual number of cataract surgeries achieved per year is 70% of the expected surgeries.
| Discussion|| |
The performance of NPCB, Yavatmal in terms of cataract operations per year varied from 1981-97. Interestingly, as the targets increased, the achievement showed a corresponding increase except for the years 1983-85. This phenomenal success was entirely due to the regular surgical camps. Ironically, when the performance was poor (in terms of target achievement for 1983-85), the targets fixed for the subsequent years were high and were achieved. These figures are to be interpreted with caution because NPCB data is well known to be over reported. The reasons for the decrease in the targets from 1987-1990 were not known and the available records showed no explanation. The Government of Maharashtra established a new medical college with additional recruitment of ophthalmologists in the year 1989; contrary to the expectation that additional staff would increase the performance, the district performance showed no significant change. The establishment of DBCS in 1993 automatically fixed the target for cataract operations at a higher level. In the last 3 years, the performance of DBCS was short of the targets unlike the earlier experience of 300% boosted performance in other districts. This clearly brings out the fact that target fixation is irrational and situational analysis was never considered. The main emphasis of DBCS was high-volume, high-quality cataract operations. It was stressed that over a period the outreach operations should be minimised and the fixed facilities strengthened. Since the establishment of DBCS, the fixed-facility performance showed minimal increase [Figure - 2]. The target achievement in the 3 categories, namely, DMU, fixed facility, and private practitioners, indicates poor performance of the fixed facility, or the base hospital.
Similar situations were also reported from other districts. The Government of Maharashtra currently has clubbed the DMU and fixed facility as one category for the purposes of target achievement. Thus the target achievement under the fixed facility would show improved performance. The eye camp (DMU) performance from 1993-98 showed no significant increase. It has been pointed out that any district showing stagnant performance for 3 years continuously should cause concern as it indicates poor output due to underutilisation of available resources. The DMU performance in the first quarter was very low, whereas the last quarter performance was around 35-40% of the total target. Pune district also reported a similar trend. The last quarter performance should be cautiously read as it might involve inflating of figures to meet the targets. It is argued that during summer (first quarter), the temperatures in this region reach around 40-45° C and it would be inconvenient to organize camps at the periphery. This results in low performance. The last month of the financial year (March) showed the highest number of cataract operations. It is suggested that the first quarter performance can be improved by conducting the cataract surgery camps in Rural / Cottage hospitals and Primary Health centres where the temperatures can be controlled.
Though the number of ophthalmologists is low, DBCS performance in terms of cataract surgeries per surgeon outweighed that of Pune. However, it is noteworthy that the cataract operations per 100,000 of population was low. This is due to the fact that Yavatmal district is vast in area and consists of a tribal population living in inaccessible, hilly terrain. The ophthalmic infrasructure available at DBCS shows the underutilisation of operating microscopes as the ophthalmic surgeons conduct only ICCE. This corroborates the reports that only 40% of infrasructure, beds and manpower available for DBCS were utilised. It has also been pointed out that this district was fully equipped with more than the required World Bank standards for manpower and equipment. [8,10] It has been suggested that rising older methods of surgery could negate the quality eye-care services. Adopting ECCE with IOL would definitely improve the quality of vision and increase client acceptance.
The average number of patients operated for cataract per camp has been fairly constant over these years; though the number of camps have increased. On further analyses it was found that more cataract operations were performed in camps organised by voluntary agencies. The organisation of publicity campaigns motivating community involvement, and providing cataract surgery facilities nearer to their homes were among the reasons offered by the NGOs for their greater success. Hence, it is suggested that the eye camp organisation in public sector should be preceded by effective publicity campaigns.
The targets for the district show crests and troughs over these years. The World Bank also criticises the fixation of unrealistic targets. Since the establishment of DBCS, the targets have been enhanced with the presumption of improvement in performance. A close look at the targets reveals that the target fixed for private practitioners in Maharashtra ranges from 30-60% of the total, whereas in a model district in Maharashtra, the contribution of private practitioners to the target was limited to 5-7%. When assessed for the total cataract target [Table - 1] the estimated number of cataract surgeries were higher than the actual target. Hence, there is enough room for improvement.
| Acknowledgement|| |
The authors wish to express their gratitude to Dr. D.D. Kamble, Civil Surgeon, for permission to utilise the records.
| References|| |
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[Figure - 1], [Figure - 2]
[Table - 1], [Table - 2], [Table - 3], [Table - 4], [Table - 5]