Year : 1995 | Volume
: 43 | Issue : 1 | Page : 35--43
World bank-assisted cataract blindness control project
R Jose, Damodar Bachani
From Directorate General of Health Services, Nirman Bhawan, New Delhi, India
Nirman Bhawan, New Delhi 110 011
|How to cite this article:|
Jose R, Bachani D. World bank-assisted cataract blindness control project.Indian J Ophthalmol 1995;43:35-43
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Jose R, Bachani D. World bank-assisted cataract blindness control project. Indian J Ophthalmol [serial online] 1995 [cited 2013 May 25 ];43:35-43
Available from: http://www.ijo.in/text.asp?1995/43/1/35/25277
A. AN OVERVIEW
The WHO-NPCB (National Programme for Control of Blindness) survey (1986-89) has shown that there is a backlog of over 22 million blind eyes/12 million blind people in India. The survey has also revealed that 80.1% of these people are blind due to cataract. Refractive errors, glaucoma, trachoma and central corneal opacities account for the rest of the blind population.
The annual incidence of cataract blindness is about 3.8 million. The present annual level of performance is of the order of about 1.6 to 1.9 million cataract operations. Consequently, the backlog is increasing in magnitude with no prospect of reducing the prevailing rate from 1.49 to 0.3 as set out in the targets for the year 2000. As such, the number of cataract surgeries have to be increased to at least 3 to 4 million annually to have a significant impact on the backlog of cataract cases.
Rationale for Selection of the Project States
Based on the high prevalence levels, the states of Maharashtra, Uttar Pradesh, Madhya Pradesh, Orissa, Rajasthan, Andhra Pradesh and Tamilnadu were selected to be covered under the project. The WHO/NPCB survey (1986-89) has shown that these seven states have the highest prevalence of blindness in the country after the state of Jammu and Kashmir. They account for approximately 2/3rd of the blind population in the country and l/4th of the blind population in the world. Going by current levels of efficiency and performance, it would not have been possible to make any significant change in the situation which necessitated the adoption of new and more focussed strategies to contain the problem. The state-wise prevalence rates are given in Annexure-I. The state of Jammu and Kashmir was excluded because of the conditions prevailing there.
The main objectives of the project are:
1. To improve the quality of cataract surgery and reduce the prevalence of blindness by reducing the backlog of cataract blindness in the states of Madhya Pradesh, Uttar Pradesh, Andhra Pradesh, Rajasthan, Tamilnadu, Orissa and Maharashtra. To achieve this objective, the seven states will perform over 11 million sight restoration surgeries during the 7-year project.
2. To strengthen India's capacity to provide high volume, high quality and low cost eye care by upgrading health and management skills for eye care personnel and improve service delivery through non-governmental and public sector collaboration.
3. To increase the coverage of eye care delivery among the underprivileged population groups like tribal areas, women, and in geographically inaccessible and remote terrains.
1. Emphasizing high volume, quality outcomes by introducing cost effective systems of managing hospital and camp-based operations and maintaining high standards of care.
2. Strengthening the states' technological capacity by upgrading the skills of ophthalmic personnel through expanding training in extracapsular cataract surgery (ECCE) with intraocular lens implants (IOL), and on diagnostic techniques.
3. Developing institutional capacity and appropriate coordination mechanisms for collaboration between the non-government organizations and the public sector to expand coverage to the most disadvantaged populations.
4. Carry out intensive campaigns at the state and national levels against cataract blindness, in order to substantially increase the demand for cataract services. Simultaneously carry out similar campaigns to link the demand with the service delivery areas.
Under the project, 11.03 million cataract operations are proposed to be undertaken in the seven project states as per details given below:
The proposed project aims at reducing inequalities by improving access to eye care services for schedule castes, schedule tribes and women. The project is economically viable as it would direct resources to one of the most cost effective health interventions. This has a special significance in our country in view of the onset of cataract at a much younger age in our population.
The total cost of the project is estimated at Rs.554.36 crores, which is equivalent to US $ 135.5 million. The International Development Agency has agreed to extend assistance worth US $ 117.8 million which represents 89.8% of the project cost excluding taxes. The remaining incremental cost over and above the budget allocated under the National Programme for Control of Blindness which represents 10.2% of the project cost would be the contribution of the Government of India. The state-wise project costs during the entire project period, i.e., 1994-2001 have been estimated to be: A.P.- Rs.56 crores, M.P.-Rs.100 crores, Maharashtra -Rs.83 crores, Orissa -Rs.68 crores, Rajasthan - Rs.68 crores, Tamil Nadu -Rs.59 crores and U.P.- Rs.106 crores. The remaining project costs would be for central activities like training, publicity services, non-recurring grants to nongovernment organisations, monitoring and evaluation of the project and for operational research. These project costs include physical and price contingencies and adjustment for inflation.
B. POLICY NORMS AND TECHNICAL STANDARDS
The National Programme for Control of Blindness has been strengthened by support from the World Health Organisation and Danish International Development Agency (DANIDA). While we look forward for their continuous support, a new dimension has been added to the programme with the launching of the World Bank-assisted Cataract Blindness Control Project. It will not only solve the problem of resource crunch that this programme had experienced in the past, but also bring about technological advancement in eye care services in India.
The revised strategies drawn for this project and incorporated in the National Programme for Control of Blindness include:
1. High Standard of Care: The emphasis would be on high volume, quality outcomes by introducing high standards of care.
2. Technological Advancement: There will be stress on strengthening the states technological capacity by upgrading the skills of ophthalmic personnel through training in modern diagonistic techniques, high volume cataract surgery and extracapsular cataract surgery (ECCE) with intraocular lens implants (IOL).
3. Coordinated Effort: Besides the project seeks for developing institutional capacity, appropriate coordination mechanisms for collaboration between the non-government, public and private sectors to expand coverage, to the most disadvantaged populations.
4. Demand Generation: There is need to carry out intense campaigns at state and national levels against cataract blindness, in order to substantially increase the demand for cataract services and simultaneously carry out similar campaigns at the level of service delivery areas to link such a demand with service delivery.
5. Team Approach: All surgeries would be performed with the support of a surgical team consisting of one ophthalmologist, two nurses and an operating theatre assistant. Surgeries would not be performed unless the required medical staff, equipment and consumables are available to ensure the highest quality of outcomes.
6. Technical Standards: New technical standards will be developed and adopted for all methods of service delivery. The most salient features of these technical norms include:
i) diagnostic guidelines and screening techniques;
ii) minimum acceptable surgical standards, including number of sutures required;
iii) treating unilateral cases only if ECCE with IOL can be done;
iv) limiting ECCE/IOL surgeries to fixed facilities;
v) establishing operational guidelines for conducting eye camps.
7. Quality Visual Outcomes: The programme's effectiveness would be assessed primarily in terms of visual outcomes, not only by the number of surgeries performed. Beneficiary assessments will be carried out to monitor patient satisfaction.
8. Grievance Committees: The states would request each District Blindness Control Society (DBCS) to establish a body to which any patient treated under the project may lodge any grievance relating to the treatment provided. Such a body shall have adequate capacity to effectively assist such patients.
Guidelines to Organise Eye Camps
The Programme Division has, from time to time, issued guidelines for organising eye camps to maintain minimum standards in service delivery. On the recommendations of "Consensus Workshop for Norms and Standards" organised in November 1992, during the preparation of the project, some additions have been made in these guidelines to further improve standards of eye care services in camps. Some of the major recommendations are:
1. As far as possible the camp should be held at CHC/PHC so that the O.T. facilities are used.
2. Constant supervision, monitoring and evaluation should be emphasized in all activities to ensure high quality clinical outcome.
3. Follow-up after 4 to 6 weeks should be arranged for examination, refraction and distribution of aphakic glasses.
4. Assistance for holding eye camps shall be applicable in rural areas and urban slums.
5. The minimum duration of eye camps shall be 7 days, of which, 5 days would be postoperative and one day for pre-operative care.
6. A surgeon must not perform more than 50 operations per day.
7. There is need to instill local antibiotic drops before surgery. It is recommended that dilute betadine solution should also be used before surgery.
8. It is recommended that a minimum of 5 corneoscleral sutures must be applied with 8/0 virgin silk.
9. A "fixed day" approach or a yearly camp schedule would facilitate organization of services.
Guidelines for Involvement of NGOs
The participation of NGOs is to be limited to organizations incorporated under the Societies Registration Act, charitable institutions, public trusts, statutory bodies and cooperative professional bodies.
Criteria for Selection
1. Track record of good performance in the area of eye care delivery services.
2. Experience in coordinating and supporting high quality cataract operations in terms of vision restoration.
3. Having available well-trained staff.
4. Having available the requisite managerial expertise to organize and carry out cataract control programme.
5. Having standing or experience in the community where they would be involved.
6. Agreeing to abide by the essential norms of the programme.
Every effort should be made to assign geographic areas to NGOs and provide them with adequate funding to carry out such assignments.
It has now been decided that 50% of the cost of cataract operations will be reimbursed after the surgical camp, and the balance after follow-up. This has been done to promote proper follow-up after surgery.
Payment to NGOs on a unit case basis should be done according to cost estimates established by the Central Government from time to time. The NGO is eligible for such an assistance only if such funds are not received from any other source including other NGOs.
Reimbursement rates for grants-in-aid for performing cataract surgery have now been substantially increased due to escalation in cost of consumables and mobility.
NGOs not using government facilities, vehicles and personnel: Rs.250 per operated case (Rs.150 for consumables, Rs.100 for screening, motivation, transport, follow-up and miscellaneous expenses).
NGOs using government facilities, vehicles and personnel: Rs.175 per operated case. (Rs.150 for consumables, Rs.25 for screening, motivation and miscellaneous expenses).
NGOs working in difficult terrains as identified by the State Government would get an additional Rs.50 per operated case, i.e., Rs.300. Each State will identify difficult terrains where mobility is not easy. This includes flood-prone areas, deserts, thick forests, isolated villages, tribal areas and where general transportation is inadequate.
The cost of spectacles is not included in these payments and would be made available from the agencies selected through LCB. It is desirable to perform refraction in as many cases as possible. The cost of glasses can be borne by DBCS, if it is not possible by the NGO.
It has also been decided that the payment of such an assistance would be made to NGOs through DBCS, wherever established. This would avoid delays in payment and bring about coordinated efforts in DBCS.
In addition, new schemes for non-recurring grants to NGOs for expansion in rural areas and schemes for involvement of Private Surgeons on Area-specific Contracts are being worked out. Ophthalmologists wanting to establish surgical units in rural areas and small townships are proposed to be provided Seed Capital and Soft Loans, for which, a scheme is being prepared.
Standards for Efficient Ophthalmic Services
The three important resources for efficient ophthalmic services are human resource, equipments and consumables. The minimum facilities available at various facilities should be as mentioned hereunder:
Standard lists of equipments with specifications have also been made for each facility.
Standard Patient Card for preoperative, operative and post-operative care:
A Standard Patient Card is being prepared that would be used throughout the country to collect relevant information for every case operated upon for cataract surgery.
Guidelines for Type of Cataract Surgery
While the final decision would be taken by the operating ophthalmic surgeon on the basis of the potential of sight restoration, the patient's condition and the overall feasibility for surgery, some guidelines on choices have now been framed:
Indication Choice of Surgery
Unilateral Cataract 1. ECCE/IOL (referral to appropriate facility)
(Better eye ≥ 6/24) 2. Do not operate
3. ICCE (only when medically indicated e.g. hypermature cataract, phacolytic glaucoma
Unilateral Cataract 1. ECCE/IOL
Blindness 2. ICCE (if facilities are
(Better eye 6/36) not available and refer-ral is not possible)
Unilateral Cataract 1. ICCE
Blindness (Better 2. Do not operate
eye ≥ 6/36 + aphakia)
Unilateral Cataract 1. ECCE/IOL
Blindness 2. Do not operate
(Better eye ≥ 6/36 + pseudophakia IOL)
One eyed patient 1. ECCE/IOL
(permanently blind ' 2. ICCE
in one eye)
Bilateral Cataract 1. ECCE/IOL
Blindness (Better 2. ICCE
eye ≥ 3/60 ≥ 6/60
Bilateral Cataract 1. ECCE/IOL
Blindness (Better 2. ICCE
eye < 3/60)
Criteria for Monitoring Performance
Currently, parameters to evaluate the performance are based on number of cataract operations performed against set targets. This crude method of evaluation does not indicate actual number of sight restoring operations. Performance in terms of percent achievement of targets could be misleading if targets are not realistic. No parameters are used to assess performance reflecting optimal utilization of surgeons, efficient bed occupancy of eye beds and performance of mobile units.
New parameters that would be used under the project include the following:
Quality of Eye Care Services:
It is expected that training of service providers, supply of quality ophthalmic equipments and regular maintenance thereof and adequate supply of consumables would improve the quality of services provided. This would be followed by proper supervision and follow up. Success would be measured only by sight restoration.
To conclude, the project emphasizes the need for efforts to keep high standards of care for quality visual outcomes and patients' satisfaction; which would be vital for the success of the programme. There should be no scope for complacency. Restoring vision of the affected person should be the sole objective of the providers.
C. ROLE OF DISTRICT BLINDNESS CONTROL SOCIETIES
There has been a major thrust in the government policy in designing the district as the unit for implementing various developmental programmes including national health programmes. This would give the district more authority and scope for flexibility in the implementation of the programme.
The District Blindness Control Societies (DBCS) were set up in five pilot districts funded by DANIDA in 1991-92. The performance in the pilot districts has gone up significantly after the formation of DBCSs. This pattern has been replicated at the national level. This organisational structure is proposed in the World Bank-assisted project, DANIDA, which is assisted by the Pilot State Karnataka Project and Intensified Programme in Jammu and Kashmir.
Since a large part of the services provided under the National Programme for Control of Blindness (NPCB) is curative, coordinated efforts of the government, voluntary organizations and private sector are essential to steer the programme in a focused manner. Such a coordination is possible only at the district level. The DBCS provides the forum for such a coordination.
The district officials and citizens are the best people to decide how to implement and achieve the targets. The diversity in economic status, population size, terrain and communication amongst the states and districts makes it imperative that the districts have to adopt different and locally relevant strategies to achieve a common objective.
The main objective for setting up DBCS is to achieve maximum reduction in avoidable blindness through optimal utilisation of available resources in the district.
Functions of DBCS
The primary purpose of the District Blindness Control Society is to plan, implement and monitor all the blindness control activities in the district under overall guidance of the state/central organization for the National Programme for Control of Blindness. Important functions related to the project are:
Situational Analysis and Planning
1. To assess the magnitude of the problem of cataract blindness.
2. To assess the status of available facilities and resources.
3. To assess the needs of the district for eye care.
4. To prepare an annual plan of action for eye care services.
5. To receive and monitor use of funds, equipments and materials from the government and other agencies/donors.
6. To raise funds from philanthropists and other donors.
7. To involve voluntary organizations and private sector in NPCB activities.
8. To coordinate the activities between health and other government departments (social welfare, education, etc.).
9. To liaise with health functionaries in the district, such as Primary Health Centres (PHC), District Mobile Unit (DMU), District Hospital, etc., for ophthalmic services.
10. To strengthen existing and potential resources, and facilities.
11. To plan and organise screening, surgical and follow-up eye camps in rural areas with District/ Central Mobile Unit and voluntary organisations.
12. To provide free spectacles to the poor patients.
13. To undertake information, education and communication activities.
14. To collect, compile and report information on NPCB activities.
Composition of DBCS
Composition of DBCS has been so designed to include prominent people from government, private organizations and voluntary sector. Efforts to make DBCS a parallel government organisation would fail the very purpose of setting up autonomous DBCS. The DBCS may have maximum of 20 members, consisting of not more than 10 ex-officio and 10 other members. The composition will be:
Chairman: District Collector/District Magistrate/Deputy Commissioner
Vice-Chairman: Chief Executive Officer/District Development Officer, Zilla Parishad
Member Secretary: District Programme Manager (Coordinator)
Technical Advisor: Chief Ophthalmic Surgeon, District hospital
Chief Medical Officer/District Health Officer
Medical Superintendent/Civil Surgeon of Distt. hospital
District Education Officer
State Programme Officer or his representative
Head of Ophthalmology Department of local Medical College
President, Indian Medical Association (Local)
District Governor, Local Lions Club (If more than one club exists in the district, then by rotation)
President, Local Rotary Club (-do-)
Representatives of other NGOs performing eye operations in the district
Representative of the local voluntary action group
Prominent practising ophthalmic surgeons
Prominent people's representatives from the district
The two key members of the DBCS are the district ophthalmic surgeon and the district programme manager. For efficient functioning of the DBCS, both members have to work as a team and have mutual understanding about their job responsibilities.
District Ophthalmic Surgeon
The District Ophthalmic Surgeon will provide technical leadership in the implementation of the programme in the district. Ophthalmic surgeons are the only resource persons who can deliver the surgeries, notably cataract operations. Efficient utilization of their expertise would be a key factor in the success of the project. It would be in the interest of the programme as well as the surgeons themselves, if they are spared of administrative and support services. For administrative functions, a full-time District Programme Manager would be facilitative and should not be viewed as competitive. The objective is to develop a team consisting of provider (surgeon), facilitator (DPM) and support staff. All surgeons in the district are expected to:
1. Attend to the patients in the OPD and referrals from mobile eye-care units and peripheral facilities like PHCs, CHCs.
2. Perform intraocular and extraocular surgical interventions.
3. Supervise screening programmes of the population.
4. Assess requirements of ophthalmic equipments (including equipments required in operation theatres), drugs and other consumable items in all facilities in the district.
5. Assess fitness of holding of eye camps by Govt./NGOs (before approval of the Chief Medical Officer)
6. Monitor quality of ophthalmic services being provided in facilities and mobile camps.
7. Conduct training courses for medical and paramedical staff engaged in eye health care work.
8. Take all steps to minimize complications during/after surgical interventions in facilities as well as during mobile camps (government/ NGO).
9. Organize follow-up services of operated cases in facilities as well as through mobile services.
10. Investigate any complications following surgery, if any, in the district and take all steps to prevent these in future.
District Programme Manager (DPM)
The District Programme Manager (DPM), would primarily be responsible for planning, organising and coordinating eye care services in the district. An ideal DPM should be an experienced person, who knows the district well, has credibility and respect in the society and is equipped with managerial skills required for eye care services. Selection and induction training of DPMs are two crucial activities which can be vital determinant factors for functioning of the society. The main responsibilities of a DPM are:
1. To understand the problem of blindness in the district in terms of its causes, backlog and new cases, past performance and priorities.
2. To assess all resources like infrastructure, manpower and beds in government, voluntary (NGO) and private sector in respect of availability, capacity and utilization.
3. To analyze the performance against capacity and identify factors responsible for low utilization and low level of acceptance.
4. To be responsible for the preparation of the annual plan of action and budget for approval by the DBCS.
5. As the Member Secretary of the DBCS and to perform all duties pertaining to this position.
6. To liaison with the central and state governments on behalf of the DBCS.
7. To ensure the involvement of the government, NGOs and private organizations from health and other relevant sectors related to blindness control activities.
8. To promote Information, Education and Communication (IEC), Social Marketing and Community participation approaches, leading to mobilization of patients to eye care services.
9. To enable smooth functioning of eye care services by providing/procuring adequate supplies like consumable items, instruments and equipments and maintenance thereof.
10. To ensure the training of different categories of manpower involved with the programme.
11. To maintain financial accounts as per the guidelines of the DBCS.
12. To organise implementation of all activities as per the district plan of action under the broad framework of NPCB.
13. To take initiative, assist and support any other activity of NPCB in the district.
14. To implement the Management Information System and ensure that reports are available on due dates.
15. To review monthly progress and organize quarterly review meetings with implementing agencies to monitor quantity and quality of eye care services.
16. To facilitate evaluation as and when required.
Utilization of Government Grants
The Government of India gives grants-in-aid to DBCS in installation of Rs. 3 lakhs each. It is for the first time in the programme, that recurrent grants would be linked with performance. It would be desirable that DBCS uses these funds as per guidelines issued by Government of India. The guidelines have been framed in a manner which allows adaptability and flexibility in implementation. The recurring grant should be used to meet the following expenditures:
i. Cost of consumables for cataract operations performed in the district over and above current performance.
ii. Cost of spectacles to operated cataract patients and students with refractive errors, who cannot afford to pay for spectacles.
iii. Cost of POL, maintenance of vehicle of DMU/ CMU (Central Mobile Unit) and in case the vehicle is not available, on hiring vehicles.
iv. Activities related to local Information, Education and Communication (IEC) at the district level. Local IEC activities include identification and motivation of potential beneficiaries, information through local media including folk methods, educating voluntary groups and teachers, and other relevant activities.
v. Remuneration of the District Programme Manager, appointed by DBCS, on contractual basis @ Rs. 5000 per month.
vi. Grant-in-aid to voluntary organisations for cataract surgery in camps.
vii. Other contingent expenditure towards secretarial assistance, stationary, printing, postage, expenses on communication, organising meetings, TA/DA to DPM for programme related tours. TA/DA to DPMs should be given as applicable to Class I officers in the state at the point of entry.
Selection of District Programme Manager
The position of the District Programme Manager is very crucial in implementing the programme within the district. A medical degree with a postgraduate degree or diploma preferably in ophthalmology or public health or graduate degree in social sciences with a degree or diploma in management would be necessary for the jobs that are envisaged for DPM. Experience in administration or management in health or other related sectors would be an asset. The person should be good in the language used in the district and if he belongs to that district or region, he would understand social dimensions of the problems in a better manner. Success or failure of efficient functioning of DBCS would depend on the procedure for selection without any political or other preferences. The sole criteria for DPM to continue the job should be performance.
Training in District Programme Management
Keeping in view the job responsibilities of the DPM, a two-week training course is being organised in batches of 15-25 DPMs with the following learning objectives:
1. To understand the concept of decentralization process
2. To know the job responsibilities
3. To have an understanding of the magnitude of the problem of blindness in the country.
4. To understand basic principles of management such as organization, planning and management, financing and resource allocation, intersectoral coordination, community involvement and development of human resources.
5. To undertake a district needs assessment.
6. To develop a District Work Plan that integrates the various elements of a district plan.
7. To implement a Management Information System for Eye Care in a district.
8. To plan and implement an IEC programme in a district.
9. To have a vision to develop the DBCS to achieve the goal of blindness prevention and control.
The training comprises of discussions, case studies, learning exercises, subgroup activities and field exposure to PHC, hospital and eye camp. So far, 6 courses have been organised and over 100 DPMs have been trained in Madurai, Bangalore, Pune, Nainital and Delhi.
After successful experimentation in pilot districts, the scheme of setting up of the DBCS has been rapidly expanded throughout the country. More than 372 districts have been covered including more than 200 in states covered by the World Bank-assisted project. About 200 DPMs are in position. More than 300 DBCs have been given funds to initiate the activities. So far, the response is enthusiastic. But a lot more is to be done to see that these DBCSs meet the set objectives and not only generate demand but meet the goal of reducing the prevalence of blindness by the turn of the century.