|COMMUNITY EYE CARE
|Year : 1996 | Volume
| Issue : 2 | Page : 117-121
Experience in pilot project in Purnea District
Hans Limburg, YN Pathak
From Danish Assistance to the National Programme for Control of Blindness, Danish International Development Agency (DANIDA), New Delhi, India
DANIDA Support Unit, A1/148, Safdarjung Enclave, New Delhi -110 029
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Limburg H, Pathak Y N. Experience in pilot project in Purnea District. Indian J Ophthalmol 1996;44:117-21
| PURNEA DISTRICT, BIHAR|| |
Purnea district is situated in the far north-east corner of the Indian State of Bihar, close to Nepal in the north and bordering West Bengal on the eastern side. It is one of the most underdeveloped districts of Bihar. The population is nearly 1.9 million, of which 81.9% is rural, 10.1% urban and 8% tribal. An estimated 50% of the population lives below the poverty line. The district has 2 sub-divisions and 11 blocks. The transportation across the district is poor due to bad condition of the roads and scarce public transportation.
On the basis of the WHO-NPCB National Blindness Survey (1986), it was estimated that Purnea District had 10,500 persons bilaterally blind due to cataract (VA<3/60) and over 26,000 eyes requiring cataract surgery (VA<3/60). Other eye problems included refractive errors, xerophthalmia and trachoma.
The initial task of DANPCB was to have complete information on the problem and the existing situation of all eye care services. A District Blindness Control Society (DBCS) was formed and a plan of action was developed. A definite time schedule was made, all the necessary supplies procured, the services extensively publicised and the eye camps started. This program was very successful. The major constraints identified at the outset were the lack of a well organized and fully equipped mobile eye unit, shortage of trained staff to assist in cataract surgery and limited facilities to provide basic eye care in the rural areas.
Initially, the DBCS, Purnea decided to focus on cataract blindness. At the end of 1991, an effort was made to streamline the organization of eye camps. The DBCS was able to organize the eye surgeons, including 3 out of the 4 ophthalmologists, posted at PHCs.
| Design of project|| |
In 1992, a detailed plan of action was made during a 4-day workshop with DBCS resources. The following activities were identified for the initial phase.
- 1. To increase cataract surgery through regular eye camps.
- 2. To make basic eye care services available at all block level PHCs by training Health Workers (male) in basic eye care.
- 3. To increase awareness through publicity campaigns.
- 4. To perform a sample survey to estimate the backlog of cataract blindness.
Activities 1 and 3 were implemented in a very enthusiastic way. The planning was very detailed, describing each and every sub-activity, including individual responsibilities and time frames for each task. Activity 2 was not approved by the Bihar Govt. and was therefore cancelled. Activity 4 was postponed because of the workload coming from 1 and 3.
| Performance over the years|| |
In just 3 years time, the output in cataract operations in Purnea District rose from 600 to over 4000 per year [Figure - 1], an increase of more than 600%. The increase was mainly on account of the operations done in eye camps through the District Mobile Unit.
| Factors that lead to success|| |
- 1. Allocation of funds to ensure availability of all necessary instruments, drugs and other surgical supplies from DBCS.
- 2. The preparation of a detailed time table, well in advance, and strict adherance to such schedule.
- 3. Good publicity campaigns.
- 4. Support from district Magistrate.
- 5. The Role of DBCS: The DBCS had meetings every quarter, and, if circumstances required, more frequently. The composition of the DBCS was balanced with good representation from both governmental and non-governmental agencies.
- 6. Involvement of local organizations.
- 7. Enhanced exposure of eye surgeon throughout the district.
| Other Eye Care Activities|| |
School Eye Screening (SES) was initiated in 1994. The reason for the delayed implementation was the shortage of PMOAs and the lack of refraction facilities. The SES programme was implemented in 3 blocks and covered 8,831 of the 12,419 registered students of middle schools in Krityanand Nagar, Kasba and Purnea East.
| Utilization of Resources|| |
Shortage of trained manpower was already identified at the start to be a major constraint. Initial proposals to train male Health Workers to provide basic eye care services at all PHCs and additional PHCs were not agreed to by the State Government. The proposed training of one Medical Officer per PHC in basic eye care did not materialize.
The in house training of PMO As hoped to enhance those skills which later helped the programme in screening, assist in operation theatre, anaesthesia and postoperative care in addition to School Eye Screening.
| Eye Camps|| |
[Table - 2] indicates the number of operations done in eye camps only, in relation to the number of camps conducted and eye surgeons involved. It is clear from [Table - 1] and [Table - 2] that the output of the DMU has increased to nearly 3500 surgeries per year. Realizing that this output is achieved in 6 months only [Figure - 3] makes it all the more impressive.
[Table - 2] shows a few interesting observations. Initially, the number of operations per camp was high. The following year, the DBCS decided to double the number of camps, but the number of cases per camp reduced to half. It may have been due to poor publicity, or doing eye camps too often at the same place. In 1993-94, the number of camps was increased again to 69, while the total number of surgeries increased by 240 % in the eye camps. In 1994-95, the efficiency in the camps increased further, also because camps have been organized in more peripheral places than before. The number of operations per surgeon is over 700 on average. In fact, one eye surgeon has already done more than 1700 surgeries this year.
Concerned about the higher expenditure with so many camps, the DBCS decided to reduce the number of camps again and focus case finding much more on the interior villages of the district.
| District Hospital|| |
The District Hospital figures on cataract surgery are low [Table - 1]. With 10 beds, the maximum capacity is 500 surgeries a year, assuming that patients stay a week on average. Only 100 operations per year were done, indicating a utilization of only 20% of the bed capacity. The operation theatre facilities in the district hospital were extremely poor. This was renovated and excellent facilities have now become available. This should provide an opportunity for base hospital approach during the summer and rainy season, when conditions for outreach surgical camps are not conducive.
| Rapid Assessment on Prevalence of Cataract Blindness and Impact of Cataract Surgical Services|| |
In July 1994, a rapid assessment was conducted on an experimental basis, to estimate the prevalence of cataract blindness (VA<3/60) in Purnea District in persons of 50 years and older. An estimate was made on how many bilaterally blind persons had access to and availed of cataract surgery. Service facilities were identified, as well as reasons for not availing cataract surgical services. This rapid assessment was conducted in one week, covering nearly 800 randomly selected persons of 50 years and older. Five surveyors and two supervisors were involved. In this way, it was possible to obtain district data on prevalence of cataract blindness in the population at risk (50+) and to assess the coverage of the problem of cataract blindness by the programme.
The high prevalence of cataract blind eyes indicates that many bilaterally blind persons in Purnea are already satisfied when only one eye was operated. The last indicator, Aphakic Coverage (22.5%), means that out of every 4 cataract blind eyes, only one has been operated and three have not been operated.
[Figure - 4] illustrates the different reasons for not performing surgery. The reasons "Waiting to Mature" and "Operation Denied" are due to the fact that in most eye camps, cataract surgery was only performed when the visual acuity is less than 1/60. On the other hand, "Need not Felt" and "One Eye Operated" indicated that patients demand mainly functional eyesight. "No Info on Eye Camps", "Fear" and "Need not Felt" are reasons for not utilizing eye care services that can be addressed by health education.
Of those patients operated, an analysis was made where and by whom surgical services were provided. The eye camps and the private clinics are the main locations for surgery. In Purnea, the Government surgeons and the private surgeons are the same. [Figure - 5] illustrates the location of surgery and the type of surgeon.
The study also revealed that the outcome of the cataract surgery was fairly good, with 77% of the operated patients having a VA of better than 6/60 at the time of the survey. Majority of the operated patients (80%) had aphakic glasses provided and were using them. The condition of the glasses was good in 72%; 85% of the operated patients indicated that their life had improved after surgery.
The analysis of the costs of cataract surgery in Purnea District, is quite illustrative [Table - 3]. It indicates that in the initial years ('91-'93) the costs of sutures, drugs and surgical instruments were relatively high, but subsequently the cost came down considerably. This is due to the investment in instruments, equipment and drugs at the early stage of the project, which were also used in subsequent years. Expenditure on POL and publicity was high in '92-'93, due to an extensive publicity campaign through mobile teams in jeeps with loudspeakers. Many posters were printed, which were also used in subsequent years. This expenditure has shifted in '94-'95 to the heads of Grant in Aid and Incentives.
The costs per patient were highest with Rs.386/- in '92-'93. In '93-'94 and in '94-'95 the costs per patient came down to Rs. 187/- and Rs.122/- respectively. The average costs over the 4 years period was Rs.199/- per operation. The costs of a jeep for the DMU and the renovation of the operation theatre are not included in the costs, since these components are normally covered under Central Assistance.
| Constraints|| |
Several factors continue to limit the performance in the district under NPCB.
- 1. Poor infrastructure in the district and consequent difficulty to reach the remote villages in the district.
- 2. Shortage of trained staff, especially PMO As.
- 3. Poor cooperation and participation of the Medical Officers in charge of PHCs.
- 4. Poor support from field staff.
- 5. Low literacy rate requiring very intensive IEC campaigns.
- 6. Other causes of blindness such as Vitamin A deficiency: Due to the poor medical infrastructure, the Vitamin A supplementation programme was not implemented in all parts of the district.
- 7. Limited support from the State Government.
| Future directions|| |
- With the limited capacity of institutionalized services, eye camps will have to continue as the main strategy in the future. More emphasis will be given to organize services in peripheral and underserved areas.
- With the completion of the renovation of the operation theatre at the District Hospital, the capacity for surgery has increased. It also facilitates base hospital approach during the summer season or during the rains.
- Purnea District has a lot of experience to share with other districts in Bihar and adjoining districts in Uttar Pradesh, who have established a DBCS and appointed the District Programme Manager. An Orientation Workshop in Purnea will facilitate DBCSs of other districts of Bihar to initiate similar eye care activities.
| Acknowledgements|| |
The authors wish to thank the following persons for their valuable information and contributions: Mr. S.S. Kumar, former District Magistrate; Mr. Sukhdeo Singh, present District Magistrate; Dr. B.P. Singh, Civil Surgeon/CMO; Dr. S.K. Verma, Dr. R.D. Raman, Dr. R.N. Kumar and Dr. Milind, eye surgeons; Dr.(Lt. Col.) P.N. Singh, member DBCS; PMOAs and members of the District Mobile Unit, Purnea. The views and opinions expressed in this report remain the sole responsibility of the authors.
[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6]
[Table - 1], [Table - 2], [Table - 3], [Table - 4]